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 http://www.archive.org/details/cu31924014123180 
 
THE NEW SYDENHAM 
 SOCIETY. 
 
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CLINICAL TREATISE 
 
 DISEASES OF THE LIVER 
 
 DR. FRIED. THEOD. FRERICHS, 
 
 rBOFESSOR OF CLIMCiL MEDICINE, TORMEELT IS THE UNIVERSITY OF BRESUU, AND NOW Of THE UNTTEBSITT 
 OT BERLIN ; ETC.. ETC 
 
 IN TWO VOLUMES. 
 
 VOL. I. 
 TRANSLATED BY 
 
 CHAELES MURCHISON, M.D., 
 
 FELLOW or THE ROTAL COLLEOB OF PHTSICIASS, LOXPOS , At?S ISIiST PHI 51 C IAN TO SING'S COLLEGE HOSFITAL, 
 AND TO TBE LOS DOM JEYBB. HOSPITAL. 
 
 THE NEW SYDENHAM SOCIETY, 
 LONDON. 
 
 MDCCCLX. 
 

 LONDON : 
 
 Printed by Jxmzs Williah Roche. 5, Klrby Street, 
 
 Hatton Garden. 
 
 <lwy 
 
AUTHOR'S PREFACE. 
 
 With the present Clinical Treatise on Diseases of the Liver, it is 
 intended to commence a series of Works 'which shall contain the 
 results of my clinical experience and pathological observations. The 
 manner in which I propose to treat the subject, will appear from the 
 works themselves ; and it, therefore, seems needless to discuss this 
 any more in detail at present j it is only necessary for me to make a 
 few brief explanatory remarks. 
 
 At the present day, it is agreed, that the science of life is 
 undivided, and that no real defined limits exist between the varying 
 phenomena of health and disease, but that both are governed by the 
 same laws. We endeavour to investigate the conditions under which 
 disease takes place in the same rigidly empirical manner, that we 
 study the general vital processes of which disease is merely a frag- 
 mentary constituent. In addition to simple observation at the 
 bedside of the patient, we have recourse to the assistance of physical, 
 chemical, microscopical, and experimental modes of investigation, in 
 order to coDect materials for the construction of a scientific system 
 of medicine. 
 
 There can be no doubt, that a great advance has been made by 
 this mode of research, which, although not novel, has at no time 
 been adopted to the same extent, and with such ample means at our 
 disposal, or attended by equally important results, as during the last 
 ten years. Our general views of disease have been simplified since 
 we have ceased to disconnect it from the phenomena of life, as 
 something foreign and endowed with a peculiar and individual exist- 
 
vi AUTHOR'S PREFACE. 
 
 ence; while the several pathological processes have been rendered 
 more intelligible, since they have been referred back to their physio- 
 logical origin, and since their fundamental structural lesions have 
 been carefully and thoroughly examined. The volume of the work 
 now presented to the public, furnishes ample stores of individual 
 facts, difficult to understand and arrange, and still more difficult to 
 turn to practical account. It is a characteristic of human nature to 
 exhibit partialities, and to elaborate and make use of sometimes 
 one, and sometimes another mode of investigation in preference 
 to any other : " Suo quisque studio delectatus alteram contemnit ; " 
 but no permanent injury results from this. 
 
 Clinical and practical medicine have made a difficult stand in oppo- 
 sition to the results arrived at by modern means of scientific research. 
 Their representatives, from the very tendency of their studies, have, 
 put of their much-trodden field of observation, been unable to con- 
 tribute so much as the auxiliary sciences, towards the completion 
 of the entire edifice of medicine ; hence, literature is made up almost 
 exclusively of these auxiliary sciences. The field of actual medi- 
 cal practice has become overgrown by foreign elements, which, owing 
 to the constantly increasing gap between science and practice have 
 shot up luxuriantly. As at other times of remarkable scientific 
 progress, and as was particularly the case at the commencement of 
 the seventeenth century, so likewise at the present day, very 
 different views are entertained as to the relations which ought to 
 subsist between scientific and practical medicine. 
 
 A large proportion of medical men are upholders of the system of 
 practice transmitted from the ancients. They have regard solely 
 to the empirical method of treatment, and take little cognizance 
 of medical science. They look upon this as something extraneous, 
 from which they select what is practically useful, or what may serve 
 for assisting diagnosis, or for the elucidation of individual sym- 
 ptoms,' or some kindred purpose ; but their general views are not 
 at all . influenced by it. 
 
 Others again maintain, that clinical studies should have reference 
 solely to scientific medicine, or to some individual department of it, 
 
AUTHOR'S PREFACE, vii 
 
 such as pathological anatomy ; they throw treatment into the back- 
 ground, inasmuch as the traditional systems of treatment have 
 appeared untenable when subjected to critical examination. Obser- 
 vations in pathological anatomy have been misconstrued by such 
 persons, and this, on the one hand, has led to complete discourage- 
 ment as to the effects of remedies, and to a system of doing nothing, 
 whilst on the other hand, an excess of scientific acquirements, has, 
 notwithstanding all the warnings of history, misled some physicians 
 into the adoption of the so-called rational system of therapeutics, as 
 the only correct system of treatment. 
 
 In addition to these main directions taken by scientific medicine, 
 of which there are many varieties, according as the anatomical, the 
 chemical, or the physical side of the question has been most studied 
 and followed out, numerous therapeutic sects have made their ap- 
 pearance, which, renouncing all traditional experience as well as 
 science, have endeavoured to construct systems of treatment of 
 their own. 
 
 The point of view in which the subject of clinical research has 
 been considered in the present work is different from any yet 
 alluded to. Scientific medicine in its entire extent constitutes its 
 groundwork; this paves the way for clinical observation without 
 reference to any practical results. Just as Natural Philosophy and 
 Chemistry did not yield any practical fruits, until these sciences 
 were studied without any regard to immediate benefits to be derived 
 from them, so i.t is with Medicine. Isolated phenomena of disease, or 
 more or less artificial groups of these phenomena, do not constitute 
 objects of clinical observation, but the diseased individual himself, 
 in all his aspects ; every phase of the varying processes of life, is to 
 be investigated by means of the auxiliaries which natural science has 
 placed at our disposal. The object of clinical medicine is to con- 
 centrate into one focus the results which are obtained from these 
 various modes of investigation, and to reconcile and perfect the 
 one-sided views resulting from the division of labour. 
 
 Between the scientific department of clinical medicine, and that of 
 real practice, there exists a chasm, which is bridged over in a doubt- 
 
viii AUTHOR'S PREFACE. 
 
 fill manner, at a few places only. It is true, that our treatment 
 at the bedside, always becomes more firmly based, the more our 
 insight into morbid processes is extended ; but we are still far from 
 being able to direct it solely by the indications of our pathological 
 knowledge, and precipitation in this matter has always been at- 
 tended by serious results. The main part of the science of disease 
 is of a purely descriptive character ; a scientific interpretation of 
 facts and a clear insight into the intimate connection subsisting 
 between different phenomena, which must precede all attempts at a 
 rational method of cure, having been attained in a few instances only. 
 Hence, treatment is still, as heretofore, handed over, for the most 
 part, to empiricism, but not, however, to that traditional so-called 
 experience, which has no clear knowledge of the subject, which is 
 followed by no certain results, and which does not make any rigid 
 discrimination between the heterogeneous elements which are jumbled 
 together, or between one form of disease and another. Therapeutic 
 researches must be regulated in the same manner as pathological. 
 Scientific medicine, although it has not rendered a rational system of 
 treatment possible, has already furnished us with important data in 
 anticipation of such a system. The more careful tracing of the pro- 
 gress of morbid processes, and the insight into their modes of origin 
 and retrogression, enable us to determine the principles of treatment 
 with greater clearness than formerly; a more accurate diagnosis 
 secures to us the homogeneous nature of the quantities that we have 
 to deal with, while the study of pharmacy provides us with the first 
 materials for an insight into the mode of action of drugs. 
 
 In treatment, we have not to do with such a novel subject as 
 pathology, but we have first to prove the correctness, and ascertain 
 the value, of the observations which have been transmitted to us. 
 The materials which scientific medicine at first encountered, resem- 
 bled in many points the labours of the alchemists in anticipation of 
 modern chemistry. In both cases there were observations which, 
 from being collected with a limited object in view, were consequently 
 defective, and frequently not to be depended on. In the one case 
 there was the idea of the philosopher's stone, and in the other there 
 
AUTHOR'S PREFACE. ix 
 
 was the supposition of a cure, which an unprejudiced and rational 
 interpretation of facts would have entirely dispelled. Medicine 
 ought not, any more than chemistry, to neglect the labours of our 
 forefathers, but must continue to build upon the foundation of 
 history. The therapeutic observations of the ancients are in many 
 respects more valuable than the pathological, because treatment has 
 to do less with the details of local processes than with the examina- 
 tion of the general condition of the body, to which the ancients paid 
 particular attention. 
 
 These are the principles which I have endeavoured to carry out in. 
 the present Clinical Treatise on Diseases of the Liver, and which shall 
 also be followed in the subsequent volumes of this series. I know 
 that it is an easier matter to enunciate principles than it always is 
 to remain true to them. Perhaps the will is better than the deed. 
 
 The difficulties which surround the pathology of the liver are well 
 known. The minute structure and the physiological functions of 
 this gland are only partially understood, and it is only in recent 
 years that some light has been thrown upon its relations to the 
 metamorphosis of matters within the body. A large proportion 
 of the abnormal conditions of the liver give rise to no marked 
 derangements of the bodily functions obvious to the eye, but they 
 produce alterations in the animal economy, which do not declare 
 themselves in a prominent manner until they have reached a certain 
 height. Hence, in hepatic disease, we do not always expect to meet 
 with accuratelyrdefined symptoms, such as we are wont to observe 
 in affections of the lungs, heart, brain, &c. 
 
 Where I have enunciated novel views, which as yet it has 
 been impossible to establish with certainty, as in accounting for 
 icterus in cases where there is no structural lesion of the liver, 
 I solicit a careful examination. I have endeavoured to distinguish 
 between statements based upon facts and individual opinion. 
 Experiments in support of my opinions will be appended to the 
 close of the volume. 
 
 As regards the plan of the work, I have in the distribution of my 
 materials, had anatomy and physiology less in view than medical 
 
x AUTHOR'S PREFACE. 
 
 practice. Thia explains why the subject of icterus is treated at 
 such length; and why I have annexed to this the consideration of 
 acholia and of acute atrophy of the liver, which last might with 
 more propriety have been considered under the head of inflammation 
 of the organ. At the end of the work, I shall classify the various 
 morbid processes according to their mutual relations. 
 
 The present volume contains the historical account of diseases of 
 the liver, the definition of the dimensions and weight of the organ, 
 physical diagnosis, the chapters on icterus, acholia, acute and chronic 
 atrophy, the fatty liver, the pigment-liver,* and the hypereemias and 
 haemorrhages of the liver. 
 
 The more important diseases of the liver will find a place in 
 the second volume: — Inflammation with its consequences, cir- 
 rhosis, the colloid or lardaceous degeneration, morbid growths, 
 the diseases of the bile ducts and of the portal veins, &c. At the 
 conclusion of the entire work, I purpose to collect the general 
 results derived from the isolated data, and to point out their value in 
 reference to the pathology and treatment of the organ. 
 
 Lastly, I would desire to thank those gentlemen who have aided 
 me in the preparation of this work, and particularly my friends and 
 colleagues, Herr Eeichert, councillor of state, and Professor G. 
 Staedeler of Zurich. I am indebted to the former gentleman's 
 extensive acquaintance with the entire subject of minute anatomy 
 for repeated suggestions and assistance, while his skill in making 
 preparations has essentially contributed to the success of the Atlas of 
 Plates drawn by Herr Assmann. My friend Staedeler has assisted 
 me on many occasions with chemical advice, and I have to thank 
 him for the elementary analyses of the abnormal products of meta- 
 morphosis detected in the liver and in the urine. 
 
 Dr.. Valentin has performed a large proportion of the chemical 
 
 * Under the head of the pigment-liver, I have been compelled to expa- 
 tiate and to describe derangements, which may be said to have no direct 
 connection with hepatic disease. I trust that the rare opportunities which 
 I have enjoyed of observing large accumulations of pigment in the blood, 
 and the small number of cases which as yet have been accurately de- 
 scribed, will be regarded as an excuse for this digression. 
 
AUTHOR'S PREFACE. xi 
 
 researches in my laboratory. Messrs. Professor Riihle, Graetzer, 
 Dr. Hasse, Cohn, and other physicians of All Saints' Hospital 
 have assisted me, by supplying numerous measurements and 
 weights of the viscera, or by calling my attention to interesting 
 cases of disease. To all of them I beg to express my warmest 
 thanks. 
 
 THE AUTHOR. 
 
 Breslau, March, 1858. 
 
TRANSLATOR'S PREFACE. 
 
 The manner in which the author has treated the subject of " Dis- 
 eases of the Liver," must be judged of upon its own merits. Many 
 of the facts and views which have been brought forward will be 
 found of much interest and novelty to the English reader. There are 
 one or two topics, however, which, since the publication of the 
 German edition of the work, have been the subject of renewed in- 
 vestigations and of considerable discussion, and which, therefore, 
 demand special notice in this place. 
 
 The author endeavours to explain certain obscure forms of jaun- 
 dice, where there is no mechanical obstruction to the excretory ducts 
 of the liver, such for instance, as the jaundice which has been 
 observed in pyeemia, typhus, and after snake bites, on the supposi- 
 tion of an arrested consumption of the biliary acids which have been 
 re-absorbed into the blood, either from the intestine, or directly 
 from the liver. Arguments are brought forward which render it 
 probable, that, ev«n in a state of health, all the bile formed in the 
 liver does not pass into the bile ducts, but that a portion of it enters 
 the hepatic veins along with the sugar, the quantity which thus 
 enters, varying with the distribution of the blood in the gland, and 
 with the relative degrees of pressure exerted by the contents of the 
 
TRANSLATOR'S PREFACE. xiii 
 
 veins, and of the minute bile ducts upon the secreting cells, being 
 largest, when the pressure on the sides of the veins is least, and 
 when that on the side of the ducts is greatest. The biliary acids 
 which thus enter the blood, or which are re-absorbed from the intes- 
 tine, are supposed to undergo certain changes from oxydatkro, and 
 may thus account for the large quantity of taurine which has been 
 found in the healthy lung, and for the pigments which are naturally 
 voided in the urine. When, however, anything, interferes with these 
 normal metamorphoses in the blood, as when this fluid becomes 
 contaminated by the purulent infection, or by any other poison, it is 
 supposed, that the complete metamorphosis of the colourless bile 
 into urinary pigments is arrested, and that the intermediate sub- 
 stance, bile-pigment, is formed in the blood, so as to colour the 
 various tissues and secretions. The arrested metamorphosis of the 
 biliary acids, under such circumstances, is thought to be analogous 
 to the arrested metamorphosis of the sugar formed in the liver, 
 which leads to diabetes. 
 
 This view as to the origin of jaundice is supported by two experi- 
 ments, tending to show that the colourless biliary acids may become 
 converted into bile pigment. 1. The colouring-matter of bile may be 
 formed artificially out of compounds of the biliary acids with soda. 
 If the glycho-cholate or tauro-cholate of soda be digested for a long 
 time, at an ordinary temperature, with concentrated sulphuric acid, 
 the solution gradually assumes several different colours, and after a 
 certain time, on the addition of water, a flaky precipitate, resem- 
 bling the colouring-matter of bile, is produced. 2. Frerichs 
 found, that on injecting ox-bile, entirely freed from its colouring- 
 matter and mucus, into the veins of dogs, the urine afterwards 
 secreted became deeply coloured with a substance, which was 
 ascertained on chemical analysis to be bile-pigment. None of 
 the biliary acids injected were found in the urine, and, indeed, 
 Frerichs denies that these acids are ever found in the urine along 
 with bile-pigment, although they are sometimes present in urine 
 having no jaundiced hue. !Prom these experiments, which were 
 
xW TRANSLATOR'S PREFACE. 
 
 repeatedly confirmed, it has been concluded, that there is ah intimate 
 relation between the biliary acids and the bile-pigment, and that in 
 fact the former become converted into the latter when subjected to 
 the influence of certain agencies; and it has been thought, that, 
 under certain pathological conditions, the biliary acids normally 
 present in the blood are transformed into bile-pigment. The de- 
 tailed account of French's experiments will be found in the section 
 which treats of the Theory of Jaundice, and in the Appendix to the 
 present volume. 
 
 Since the appearance of French's work, these views as well as the 
 facts upon which they are founded, have been called in question by 
 Dr. Kuhne, (Vvrchow'a Archiv., 3rd and Uh Part of Vol. XIV., 
 Sept. 1858) ; and as an abstract of Kiihne's paper has lately appeard 
 in an English Medical Journal, and may have some influence with 
 English readers {Archives of Medicine, edited by Br. Beale, Vol. I., 
 p. 342, March, 1859), it demands a brief notice here. Kuhne 
 maintains that biliary acids do constitute an integral part of jaun- 
 diced urine, and he attributes the circumstance of their not having 
 been hitherto demonstrated, to the insufficiency of the tests em- 
 ployed for the purpose. The method which he has followed has 
 been that of Dr. Felix Hoppe, an account of which will be found 
 in the thirteenth volume of " Virchow's Archives," and in the first 
 volume of the "Archives of Medicine," edited by Dr. Beale (p. 
 844). The following conclusions are arrived at by Kuhne as the 
 result of his investigations. 
 
 1. In jaundice resulting from closure of the ductus communis 
 choledochus, the urine always contains biliary acid as well as bile- 
 pigment. 
 
 2. The presence of biliary acids is a peculiarity of jaundiced 
 urine only. They are never present in normal urine. 
 
 3. The biliary acids are not decomposed in the blood. In what- 
 ever manner they find their way into this fluid, they are afterwards 
 excreted unchanged by the kidneys. Glyco-cholate of soda injected 
 into the veins passes out in the urine unchanged. On the other 
 
TRANSLATOR'S PREFACE. xv 
 
 hand, according to Frerichs, when glycd-cholate of soda or any 
 other pure bile-acid salt is thrown into the veins, bile-pigment 
 appears in the urine, while unchanged biliary acids can never be 
 detected. 
 
 4. After the injection into the veins of colourless solutions of the 
 biliary acids or of their salts, bile-pigment may appear in the urine, 
 as stated by Frerichs ; but the colouring-matter which is developed 
 under such circumstances is due to the property possessed by the 
 biliary acids of dissolving the blood-corpuscles and of thus setting 
 free a quantity of haematine, which, being acted on in some un- 
 explained way by the biliary acids or their salts, is converted into 
 bile-pigment. In support of this view, Kiihne appeals to the circum- 
 stance of albuminuria or hsematuria having been usually observed 
 after the injection of biliary acids into the blood, and to the 
 following experiment. A solution of haemato-globuline containing 
 a minute trace of glyco-cholate of soda was injected into the 
 veins of a dog, and it was found that the urine subsequently 
 secreted gave a splendid reaction of bile-pigment with nitric 
 acid. Kiihne even thinks it highly probable, that a consider- 
 able number of blood corpuscles is, under ordinary circum- 
 stances, destroyed in the liver, and that the colouring-matter 
 of bile is derived from the hsematine set free by the solution of 
 these corpuscles. 
 
 5. The bile acids all pass off with the faeces, and are not re- 
 absorbed from the intestine. 
 
 Quite apart from the correctness of Frerichs 5 s theory of icterus, 
 which, by the way, is only advanced as one that is highly probable, 
 it is obvious that we have here to do with a question of facts, and 
 that Kuhne's facts are diametrically opposed to those brought for- 
 ward by Frerichs. It is due, however, to Frerichs to state, that the 
 results arrived at by him have been confirmed by several subsequent 
 observers. Dr. Folwarczny, of Yienna (Zeitschrift der kwlserl. 
 Mniffl. Qeselhchaft der Aerzte zu Wien. 1859. No. 15, p. 225), 
 examined the urine in three cases of jaundice in Prof. Oppolzer's 
 
xvi TRANSLATOR'S PREFACE. 
 
 Clinique, but in all he failed to detect any trace of the biliary acids, 
 although the examination was performed repeatedly, and Hoppe's 
 process adopted in each case. 
 
 Professor Staedeler of Zurich, and Dr. Neukomm, have likewise 
 arrived at results similar to those of Frerichs, and have in Frerichs's 
 opinion, completely refuted the statements made by Kuhne. The 
 results of their researches are about to be published (ArcMv. fur 
 Anatomie, Phys. und Wissenschaftliche Med. von Br. C. B. Reichert 
 und Br. E. Bu Bois Reymond. 1860. TJeber die Nachweisung der 
 Gotten Sduren und die Umwandlung derselben in der Blutlahn. 
 Von Br. F. Neukomm) ; and I am indebted to Professor Frerichs 
 for a manuscript copy of the Memoir in which they are embodied. 
 The first portion of this Memoir is devoted to a comparison of the 
 delicacy of the several tests for the biliary acids, Pettenkofer's, 
 Hoppe's, and that of another recommended by the author, which is 
 a modification of the ordinary process by precipitation with acetate 
 of lead. It is shown that the last of these processes is much more 
 delicate than that of Hoppe's. These several processes are then 
 applied to the examination of two specimens of jaundiced urine from 
 the human subject, and to that of the urine of seven dogs, into whose 
 blood solutions of the biliary acids had previously been injected. In 
 both the specimens of jaundiced urine, Pettenkofer's test gave a negar 
 tive result, but the author's process indicated the presence of minute 
 traces of the biliary acids. It is shown, however, that the quantity 
 of these acids was so small (in one instance, only 5 milligrammes in 
 1200 cubic centimetres of urine, or less than n of a grain troy in 42 
 fluid ounces) as to bear a very small proportion to the amount which 
 must have entered the blood. Of the seven dogs into whose blood 
 large quantities of the colourless solutions of the biliary acids were 
 injected, in all the urine became coloured with bile-pigment within 
 a certain number of hours after the operation ; in none could any 
 bitter taste be distinguished in the urine; in none did the urine 
 exhibit the slightest reaction with Pettenkofer's test; and in two 
 cases only did the author's test indicate the presence of traces of the 
 biliary acids in this secretion. It is contended that these cases 
 
TRANSLATOR'S PREFACE. xvii 
 
 confirm the statements made by Frerichs to the effect that the biliary 
 acids are converted in the blood into bile-pigment. 
 
 There would appear to have been some important difference between 
 Kuhne's experiments and those of Frerichs. Kuhne tells us, that 
 in his experiments, the dogs died suddenly soon after the injection 
 into the veins of the colourless biliary acids ; whereas it is distinctly 
 stated by Ererichs that the injection of these substances produced 
 little or no change in the deportment of the animals> and that in 
 one case the experiment was repeated four times without entailing 
 any lasting injury. Moreover, the co-existence of a small quantity 
 of biliary acid along with bile-pigment in jaundiced urine,- when it 
 does occur, is not opposed to the correctness of Frerichs's theory, 
 for it may easily be supposed that a portion of the biliary acid may 
 remain unconverted into bile-pigment. As to Kiihne's opinion, that, 
 the colouring-matter which appears in the urine, after the injection 
 into the veins of the colourless biliary acids, is derived from the 
 hsematine of the blood, it may be observed that, although it is 
 possible that the colouring-matter of the blood may become trans- 
 formed into bile-pigment, positive proofs are still wanting to show, 
 that such a transformation really takes place. No one has yet 
 succeeded in obtaining bile-pigment from the colouring-matter of 
 the blood. At all events, Kuhne's experiments fail in proving that 
 the colouring-matter in the urine originates from this source, and 
 not from a transformation of the biliary acids ; and they, likewise 
 fail in accounting for the disappearance of the biliary acids injected 
 into the blood, in any other manner than that suggested by 
 Ererichs. 
 
 , Further observations and experiments on the whole subject are 
 still required ; but in the meantime, it should be understood, that 
 the main facts adduced by Frerichs in support of his theory of 
 Icterus have received confirmation at the hands of most subsequent 
 observers. 
 
 Since the publication of the German edition of the first volume, cer- 
 tain experiments have been performed in Frerichs's laboratory by his 
 assistant, Dr. Valentin, which tend to show, that one of the colouring- 
 
xviii TRANSLATOR'S PREFACE. 
 
 matters of bile consists of hsematine, the substance which is known 
 to be derived from, blood-pigment. Vahmtin has succeeded in de- 
 tecting crystals of hsematine in gall-stones, in the bile of men and 
 animals, and in the tissues and secretions of jaundiced patients. 
 The addition of chloroform is found to dissolve the hsematine with a 
 yellow colour, and from this solution red and brownish-red, lancet- 
 shaped, andrhomboidal prismatic crystals separate, which correspond 
 in every respect with those of hsematine ( Giinsbmg's Zeitschrift, Bee. 
 1858). From these experiments, Frerichs admits there is an intimate 
 relation between bile-pigment and the colouring-matter of the blood, 
 and even thinks it probable, that the former substance may be 
 developed from the latter. Still he urges, that no one has succeeded 
 in obtaining bile-pigment from the red matter of the blood, and that 
 Valentin's results are not at all opposed to his theory of the con- 
 vertibility of the colourless biliary acids into bile-pigment. 
 
 It may be mentioned, that although only the first German edition 
 has as yet been published, most of the corrections and additions for 
 the second edition, have, through the kind co-operation of the author, 
 been incorporated in the present English translation. Unfortunately, 
 the alterations for the section on the " Theory of Jaundice," which 
 have been suggested by the statements of Kiihne, and by the recent 
 observations of Staedeler, Neukomm and Valentin, were not received 
 until long after that portion of the translation had passed through 
 the press. A list of these alterations will be found immediately 
 after the Table of Contents. 
 
 The German edition of the work is illustrated by forty-two wood- 
 cuts and by an Atlas of twelve coloured plates. Twenty-nine of the 
 more important woodcuts have been reproduced by Dr. Westmacott, 
 who has succeeded in improving the style of their execution, without 
 at all interfering with the objects they are designed to represent. 
 The republication of the Atlas would have involved too great an 
 outlay, but Messrs. Williams and Norgate of 16, Henrietta Street, 
 Covent Garden, will supply copies of it to any members of the 
 New Sydenham Society. A few figures representing the crystalline 
 forms presented by leucine and tyrosine have been copied from the 
 
TRANSLATOR'S PREFACE. xix 
 
 Atlas, and form the frontispiece to this translation. Three other 
 figures (Figs. 30, 31, and 32) have been copied from the same 
 source, and added to the list of woodcuts. 
 
 It has been the object of the translator to adhere as closely as 
 possible to the original text, so far as this was compatible with 
 readable English. Throughout the work, the measurements and 
 weights adopted by the author have been retained; but their 
 equivalents in English measurements and weights have everywhere 
 been added within brackets. A similar plan has been followed in 
 cases where the size of objects is compared to that of Prussian 
 coins. Notes have been appended to the various tables of weights 
 and measurements, showing how these may readily be reduced to 
 their corresponding English equivalents. A few other short notes 
 have been added, giving an account of the composition and pro- 
 perties of the German Spas, and of various preparations of the 
 Prussian Pharmacopoeia, and also explaining several matters referred 
 to in the work, with which few English readers can be expected 
 to be familiar. It has been thought that, by these notes of expla- 
 nation, the practical utility of the work might be enhance d. 
 
 79, Wimpole Street, W., 
 
 June, 1860. 
 
 42 
 
EXPLANATION OE FEONTISPIECE. 
 
 Fig. 1. Disintegrating glandular cells of liver (6) and bundles of needle- 
 shaped crystals of tyrosine (s)> from a case of acute atrophy of the liver. 
 See Observation XIV., page 202. 
 
 Fig. 2. Blood from the hepatic vein of the same case as Fig. ] : a, cry- 
 stals of tyrosine adhering in radiating bundles ; b, normal blood-corpuscles. 
 
 Fig. 3. Crystals of tyrosine which separated from a decoction of the 
 liver upon cooling; from the same case as Figs. 1 and 2: a, crystalline 
 masses impregnated with colouring-matter ; b, long needle-shaped crystals. 
 
 Fig. 4. A fragment of the parenchyma of the liver, from a case of acholia 
 arising from impermeability of the bile ducts. The secreting cells have 
 become almost entirely disintegrated, and their place is supplied by 
 bundles of acicular crystals of tyrosine, and globular masses of leucine 
 deposited in concentric layers. See Observation XIX., p. 240. 
 
 Fig. 5. A drop of urine passed by a patient labouring under acute 
 atrophy of the liver, and evaporated upon an object-glass. It exhibits 
 leucine deposited partly in globular masses, with concentrically-thickened 
 walls and fissured surfaces, and partly, in finely-striated laminae, and also 
 greenish-yellow crystals of tyrosine. See Observation XV., p. 204. • 
 
 Fig. 6. Greenish-yellow globular masses of crystals of tyrosine deposited 
 spontaneously from the urine of the same case as Fig. 5, after standing in 
 the cold for twenty-four hours. 
 
 Fig. 7. Crystals of pure tyrosine obtained by re-crystallization from the 
 same sediment as mentioned in the description of Fig. 6. 
 
 N.B. — A List of the Woodcuts is appended to the end of the volume, 
 page 401. 
 
TABLE OF CONTENTS. 
 
 CHAP. I. 
 
 Historical Introduction ....... 1 
 
 History of the physiology of the liver .... 1 
 
 History of the pathology of do. ..... 6 
 
 Present condition of our knowledge and new questions for investi- 
 gation ........ 13 
 
 The most important literature on the subject . . .14 
 
 CHAP. II. 
 
 The relative size and weight of the Liver in health and in disease . 15 
 
 A. In health .... .... 16 
 
 1. Period of life ....... 16 
 
 Table I., weight, feci of liver in normal state . .18 
 
 2. Sex . . . . . . . .19 
 
 3. Ingestion of food . . . . . .19 
 
 4. Degree of congestion of the liver . . . .20 
 
 B. Relative weight and dimensions of the liver in disease . . 21 
 
 Table II., acute diseases without any direct implication of 
 the liver ....... 22 
 
 Table III., chronic diseases without any direct implication of 
 the liver . . . . . .24 
 
 Table IV., relative size and weight of the liver when it is 
 itself diseased . . . . . .26 
 
 CHAP. III. 
 
 A sketch of the relative sizes and forms of the Liver in its morbid condi- 
 tions, and of their diagnostic value .... 
 A. The situation and boundaries of the liver in health 
 
 1. In males ...... 
 
 2.- In females ...... 
 
 3, Average measurements according to stature . 
 
 4. Do. according to age 
 
 28 
 29 
 29 
 31 
 34 
 36 
 
TABLE OF CONTENTS. 
 
 5. Comparison of the sexes 
 
 6. Value of palpation .... 
 
 7. Do. inspection .... 
 
 8. Do. auscultation . 
 B. The application to diagnosis of the results of observation 
 
 1. Congenital and acquired malformations of the liver 
 
 2. Abnormal position .... 
 
 3. Abnormal situation. Dislocation 
 
 a. From emphysema, pleurisy, and pericarditis, 
 
 b. From diseases of the abdominal organs 
 
 4. Difficulties in determining the boundaries of the liver arising 
 from pathological conditions of the adjoining parts 
 
 a. From the abdominal parietes 
 
 b. From diseases of the peritoneum . 
 
 c. From diseases of the small and great omentum 
 
 d. From abnormal conditions of the stomach and intestine 
 
 e. From diseases of the kidneys 
 
 Pago 
 36 
 37 
 38 
 39 
 39 
 40 
 45 
 50 
 50 
 61 
 
 62 
 63 
 64 
 65 
 68 
 72 
 
 CHAP. IV. 
 
 Jaundice 
 
 1. Historical account ...... 
 
 2. Theory of jaundice ...... 
 
 i. Increased absorption of bile from the liver into the blood 
 ii. Some alteration in the metamorphosis of substances con- 
 tained in the blood . 
 
 3. Symptoms of jaundice . 
 State of the tissues, organs, and secretions 
 State of the functions of the nervous system 
 
 4. Duration of jaundiee 
 
 5. Modes of termination . 
 
 6. Diagnosis 
 
 7. Prognosis 
 
 8. Treatment 
 Therapeutic indications 
 Empirical treatment 
 
 9. Different forms of jaundice and their special etiology, 
 I. Jaundice resulting from stoppage to the flow of bile in 
 
 consequence of diseases of the liver and bile ducts 
 
 A. Jaundice from constriction of the ductus choledochus 
 
 and ductus hepaticus . 
 
 B. Jaundice from closure of do., do 
 c. Jaundice from constriction or occlusion of the bile 
 
 ducts within the liver 
 Illustrative cases . 
 
 76 
 76 
 81 
 85 
 
 89 
 93 
 93 
 107 
 113 
 114 
 118 
 119 
 119 
 119 
 122 
 126 
 
 127 
 
 127 
 129 
 
 131 
 132 
 
TABLE OF CONTENTS. 
 
 ii. Jaundice without any obvious mechanical impediment to 
 the escape of the bile 
 A. Jaundice from mental emotions 
 
 b. Jaundice from the effects of ether and chloroform 
 
 c. Jaundice from snake bites .... 
 
 d. Jaundice from pyaemic infection of the blood 
 
 e. Jaundice from typhus ..... 
 F. Bilious fevers and the epidemic forms of jaundice 
 
 a. The intermittent and remittent malarious fevers 
 
 b. The recurrent fever (" relapsing fever") 
 
 c. The yellow fever 
 
 The causes of nervous symptoms in the bilious forms 
 of fever and the effects of bile introduced into the 
 blood ...... 
 
 d. The most important epidemics of. jaundice . 
 Appendix to chap. IV. ....... 
 
 1 . Jaundice in new-born infants ..... 
 
 2. Jaundice in pregnant females ..... 
 
 Page 
 
 157 
 158 
 160 
 160 
 161 
 167 
 177 
 179 
 181 
 183 
 
 185 
 188 
 189 
 189 
 191 
 
 CHAP. V. 
 
 Suppression of the functions of the Liver. — Acholia and its consequences 193 
 A. The acute or yellow atrophy of the liver . . . .194 
 
 I. History and literature . . . . . .194 
 
 II. Symptoms . . . . . . .196 
 
 III. Illustrative cases of the disease . . . .199 
 
 IV. Analysis of the symptoms . . . . .216 
 
 1. The premonitory symptoms .... 217 
 
 2. The skin . . . . . . .217 
 
 3. The organs of circulation ..... 218 
 
 4. The organs of respiration . . . . .219 
 
 5. The organs of digestion ..... 219 
 
 6. The urinary organs ..... 220 
 
 7. The nervous system ..... 221 
 
 v. Duration and modes of termination .... 223 
 
 VI. Anatomical lesions- . . . . . .224 
 
 vn. Theory of the disease ..... 227 
 
 vm. Etiology . . . . . . .233 
 
 IX. Diagnosis ....... 235 
 
 X. Treatment ....... 236 
 
 Acholia resulting from other structural diseases of the liver 237 
 
 b. From softening of the liver supervening upon obstruction to the 
 flow of bile ........ 237 
 
 c. From cirrhosis ....... 241 
 
 d. From fatty degeneration ...... 244 
 
TABLE OF CONTENTS. 
 
 CHAP. VI. 
 
 Pane 
 
 Chronic Atrophy of the Liver ..■■•• 247 
 
 i. Causes and mode of production . 247 
 Various forms of this dependent upon structural changes in the 
 
 liver, compression, &c. ...••• 247 
 
 Atrophy resulting from obliteration of the capillaries of the 
 
 liver in consequence of inflammation of Glisson's capsule . 251 
 Atrophy resulting from occlusion of the hepatic capillaries by 
 
 pigment ......•• 258 
 
 Atrophy of the liver accompanied by chronic inflammation of 
 
 the intestine ...... . • 261 
 
 Effect of obliteration of the portal vein upon the nutrition of the 
 
 liver ........ 267 
 
 ii. Consequences of chronic atrophy of the liver : its symptoms . 275 
 
 ill. Modes of termination ...... 276 
 
 iv. Diagnosis ........ 276 
 
 v. Treatment ........ 276 
 
 CHAP. VII. 
 
 The Fatty Liver ....... 278 
 
 i. Pathology of fatty liver ...... 279 
 
 Occurrence of fat in the liver, under normal circumstances, in 
 
 the lower animals, and in man .... 279 
 
 Influence of diet ....... 280 
 
 Experiments by feeding animals ..... 281 
 
 The injection of oil into the portal vein .... 282 
 
 Constitutional predisposition to the deposit of fat . . 284 
 The fatty liver which accompanies pulmonary tubercle and other 
 
 consumptive processes, and which occurs in drunkards . 284 
 Fatty degeneration resulting from disordered nutrition of the 
 liver . . . . . . . .286 
 
 II. Structural characters of fatty liver .... 287 
 
 in. The amount of fat ...... 292 
 
 iv. The general anatomy of fatty liver .... 293 
 
 v. Frequency with which fatty liver occurs .... 297 
 
 Tabular view of the occurrence of fatty deposit in the liver in 
 
 different diseases, determined by microscopic examination . 298 
 
 vi. Pathological importance of fatty liver .... 300 
 
 vii. Effect of the deposited fat upon the function of the liver and 
 
 upon the entire system — Symptoms of fatty liver . . 302 
 vm. Diagnosis ..... 
 
 ix. Treatment . 
 
 306 
 311 
 
TABLE OF CONTENTS. 
 
 CHAP. VIII. 
 
 The Pigment-Liver ....... 314 
 
 I. Historical account ....... 314 
 
 II. Anatomy of the pigment-liver ..... 317 
 Occurrence of pigment in the spleen, brain, kidneys, and blood . 319 
 
 III. Place and mode of origin of the pigment .... 322 
 
 IV. Effects of the deposit of pigment upon the structure and functions 
 
 of the different organs of the body .... 325 
 
 Derangements in the liver ..... 326 
 
 „ in the brain ..... 326 
 
 „ in the kidneys ..... 330 
 
 v. Forms of fever which accompany these morbid processes . 332 
 
 Their progress ....... 333 
 
 Account of their anatomical lesions .... 334 
 
 I. Forms with cerebral disturbance .... 334 
 
 II. Forms with predominant affection of the kidneys . . 342 
 
 III. Forms in which the liver and the gastrointestinal canal are 
 
 pre-eminently involved . . . . .346 
 
 vi. Etiology of pigment-liver ...... 354 
 
 VII. Diagnosis ........ 355 
 
 vm. Prognosis ........ 355 
 
 IX. Treatment ........ 356 
 
 CHAP. IX. 
 
 Hyperemia of the liver and its consequences . . . .359 
 
 General observations on the conditions of the circulation of the 
 
 blood in the liver ....... 359 
 
 A. Hyperaemia of the liver from obstructed circulation . . 361 
 
 i. Pathology . . . . . . .361 
 
 Wasting of the liver consequent upon this . . . 363 
 
 Its effects upon the organs included in the portal system . 364 
 
 II. Symptoms ..... . . 365 
 
 III. Treatment ....... 366 
 
 Mechanical hyperaemia in consequence of constriction of the 
 
 vena cava and of the hepatic veins .... 372 
 
 B. Congestive conditions and atonic hyperemias of the liver . 373 
 
 a. Congestions dependent upon the processes of digestion . 374 
 The effects of irritating ingesta upon the liver . . 375 
 Chronic hyperaemia of the liver resulting from over-feeding 376 
 Its treatment ....... 376 
 
 b. Traumatic hyperaemia ...... 377 
 
TABLE OF CONTENTS. 
 
 Page 
 
 c. Hyperemias dependent upon the effects of high temperature 
 
 and miasmatic effluvia . J_ 
 
 Acute and chronic forms— Their consequences . • 379 
 
 Treatment ..-■•■• 
 
 Hyperaemia of the liver in scurvy . . • .381 
 
 d. Hyperemias of the liver resulting from the suppression of 
 
 habitual haemorrhages, &c. . • • • • 
 
 Hepatic hemorrhage, apoplexy, and hemorrhagic softening 
 of the liver . .... 383 
 
 APPENDIX 
 
 OP OBSERVATIONS AND EXPERIMENTS IN SUPPORT OF STATEMENTS 
 MADE IN THE BODY OF THE WORK. 
 
 I. Observations of disease ...... 388 
 
 II. Experiments in support of the theory of icterus — Injection of 
 
 pure bile into the blood of living animals . . . 394 
 
 1. Effects of bile introduced into the blood upon the functions 
 
 of the nervous system ..... 395 
 
 2. Changes in the urinary secretion. — Appearance of bile pig- 
 
 ment, &c. ..•••• • 395 
 
 3. Chemical examination of the urine passed within 24 hours 
 
 after the injection of bile into the blood . . . 396 
 
 a. Examination of urine containing colouring-matter . 396 
 
 b. Examination of urine passed free from colouring-matter, 
 
 after the injection of bile into the blood . . . 397 
 
 in. Experiments on the rapidity of the absorption of bile after liga- 
 ture of the ductus choledochus (see page 94) . . . 400 
 
 iv. Experiments on the influence of a fatty diet on the generation 
 
 of fatty liver (seepage 281) ..... 400 
 
 v. Experiments on the injection of oil into the portal vein (see page 
 
 282, note) ........ 400 
 
 vi. List of Woodcuts ....... 401 
 
ALTERATIONS FOR SECOND EDITION. 
 
 Page 85, lines 18 and 19; page 89, lines 18 and 19, and page 93, lines 11 
 and 12 ; substitute, " Through some alteration in the metamorphosis of 
 substances contained in the blood." 
 
 Page 89, For paragraph commencing line 20, substitute : — 
 
 " The bile-pigment is so intimately related on the one hand to the red 
 " matter of the blood, and, on the other, to the colourless biliary acids, as 
 " to justify us in referring its origin to one or the other of these sources. 
 
 " The intimate relation subsisting between the bile-pigment and the 
 " colouring-matter of the blood is indicated by facts which have been 
 " already mentioned, but more particularly by observations which have 
 " been recently made in my laboratory by Dr. Valentin ( GUmburg's 
 " Zeitschrift, Dec. 1858), according to whom a portion of the colouring- 
 " matter of the bile dissolves in chloroform, and from this solution a 
 " crystalline substance may be obtained presenting all the characters of 
 " hasmatoidine. From this it appears possible, nay probable, that, as in 
 " extravasations, hsematoidine may be developed from blood-pigment, so 
 " in like manner, in the vascular system and in the liver, the colouring- 
 " matter of bile may originate from the same source. Hitherto, how- 
 " ever, no one has succeeded in obtaining bile-pigment directly from 
 " the red matter of the blood." 
 
 Page 89, at commencement of last paragraph, for " This view,'' substi- 
 tute " The second view.'' 
 
 Page 91, to end of note which commences on page 90, add, "The state- 
 " ments which have been made by Dr. Klihne {Virchovfs Archiv, xiv., p. 
 " 310) in opposition to the correctness of this view, have been completely 
 " refuted by Dr Neukomm (Archiv fur Anatomie und Physiologic Leipzig, 
 "1820)." 
 
 Page 96, at end of note which commences on preceding page, add, " The 
 " assertions of Kuhne and Hoppe to the effect that the biliary acids pass 
 " unchanged from the blood into the urine, have been completely refuted 
 " by Neukomm and Staedeler." 
 
A 
 
 CLINICAL TREATISE 
 
 ON 
 
 DISEASES OF THE LIVEE. 
 
 CHAPTER I. 
 
 HISTORICAL INTRODUCTION. 
 
 It is very interesting to trace historically the views which medical 
 men at different periods have formed concerning the functions of 
 individual organs of the body, and the diseases to which these 
 organs are liable. The tree of knowledge, with its flowers and fruit, 
 appears less strange to us, when we follow its roots, as they branch 
 out, at one time more deeply, and at other times less so, into the 
 region of history, and when we search out the springs which have 
 made it bear fruit. That which at the present day is brought forward 
 as new has not unfrequently been known centuries ago. 
 
 With regard to no organ does history attest a change of views 
 in a more remarkable manner than in the case of the liver.* This 
 organ and the portal venous system attracted at a very early period 
 the attention of physicians. More from vague conjectures than 
 upon clearly established grounds, the seat of various functions, of 
 great importance both in health and in disease, was transferred to 
 this powerful glandular organ, and to the extensive system of 
 vessels, which is intimately connected with the gastro-intestinal 
 canal. By the ancients the Hver was regarded as the central 
 organ of vegetative life.t Galen looked upon it as the focus of 
 
 * See Beau, Arch, gener. de M6d. 1851. 
 
 t Plato, in his Timaeus, calls the liver a 8pepfm Sypiov, on account of 
 
 B 
 
2 HISTORICAL INTRODUCTION- 
 
 animal heat, and as the organ intended for the formation of blood, 
 and for the origin of the veins* According to him, the metamor- 
 phosis of chyle into blood commenced in the portal veins, but was 
 completed in the liver, which organ, during the process, separated 
 as waste, matter from the blood the yellow and the black bile, the 
 former passing to the gall-bladder, the latter to the spleen, t 
 
 Galen's views underwent scarcely any modification by the Arabian 
 physicians, and remained undisputed until the middle of the seven- 
 teenth century. Even Yesalius, who, by his anatomical researches, 
 contributed more than any one else to the overthrow of the doctrines 
 of Galen, did not venture to oppose his physiological' theories re- 
 specting the liver; he only, denied the assimilative property attri- 
 buted to the portal veins. J 
 
 The attempts of Argentieri § to restrict the functional importance 
 of the organ met with no support. 
 
 The discovery of the lacteal vessels by Aselli in 1622, and of the 
 thoracic duct by Prequet in 1647, first imparted a severe shock to 
 the views of Galen. A way had been discovered, by which the 
 chyle was conveyed from the bowel into the blood quite independ- 
 ently of the portal vein and of the liver ; henceforth, neither of these 
 structures appeared to serve any purpose in sanguification. Bar- 
 tholin || and Glissonlf were the -first who enunciated in a decided 
 manner this opinion. It rapidly spread ; and the more readily, 
 inasmuch as the revolutions, just effected in the views of physiolo- 
 
 its importance in vegetative life, and in opposition to its asserted spiritual 
 signification. See Galen, de dogm. Hippocr. et Platonis. 
 
 * De usu partium, libr. IV. In he'pate, quod supponitur venarum prin- 
 cipium esse, primum sanguificationis instrumentura. 
 
 f Prius elaboratum in ventriculo alimentum venae ipsae deferunt ad 
 aliquem concoctionis locum communem totius corporis, quem hepar nomi- 
 namus. De usu partium, libr. IV. 
 
 X De corporis humani fabrica, 1542, libr. III. 267, libr. V. 508. Quod 
 vero iidem rami, priusquam jecori succulentum id porrigant, rudem 
 aliquam sanguinis formam cremori seu succulento illi conferant, et ut 
 Galenus attestatur, modo jecori simillimo istud prseparent, non facile 
 concessero. 
 
 § De erroribus veter. med., Flor. 1553 ; and, Comment, tres in art. med., 
 Galeni. Paris, 1553. 
 
 || Vasa lymphatica nuper in animantibus inventa et hepatis exequiae. 
 Paris, 1653. 
 
 H Anat. hepat., p. 289. Edit nova. Amstelodami, 1665. 
 
HISTORICAL INTRODUCTION. 3 
 
 gists by the labours of Harvey,* bestowed an importance hitherto 
 unknown upon the organs of the chest. 
 
 Biolan, indeed, and after him De Bils, endeavoured to defend the 
 important part played by the liver in sanguification, in opposition to 
 the views of Bartholin ; but Bartholin came victoriously out of the 
 contest, and wrote for the liver a humorous epitaph, in which the 
 end of its dominion was announced, and in which its function was 
 declared to be henceforth limited to the secretion of bile.f 
 
 For almost two centuries this opinion continued generally to pre-, 
 vail. Swammerdamm, it is true, endeavoured to advocate once 
 more the ancient theory, yet with so little success, that Boerbaave 
 observed : " Dudum in meliori parte Europse obsolevit hsec sangui- 
 ficatio nunquam ab eo viscere expectanda." 
 
 It was reserved, for the experimental physiology of the present 
 century to extend the boundaries of our knowledge in this matter, 
 and to reproduce, in a more novel and exact form, opinions which, 
 for a long period, had appeared buried in oblivion. The first step 
 in this direction was made by Magendief and Tiede'mann,§ who 
 • furnished the proof that the absorption of nutritive matters is not 
 solely the work of the lacteal vessels, but that a part of the food 
 digested in the gastro-intestinal canal is taken into the blood 
 through the portal vein. Tiedemann and Gmelin moreover, by a 
 series of careful experiments, arrived at the result, that "the 
 liver must also be regarded as the organ for the assimilation of 
 substances which have been absorbed from the intestine." 
 
 The more recent investigators who have paid attention to this sub- 
 ject, such as Blondlot,]| Claude Bernard^ Lehmann,** C. Schmidt, 
 and others, have been obliged to corroborate the opinion as to the 
 
 * Harvey himself attached little weight to the lacteals, and upheld the 
 views of Galen in respect to the liver. 
 
 t Defensio lacteorum et lymphaticorum contra Riolanum. Hafhise, 1655 . 
 Bartholini responsio de experimentis Bilsianis et difficili hepatis resurrec- 
 . tione. Hafniae, 1661. 
 
 X Precis elementaire de physiol. Tom. II., p. 268. 
 
 § Tiedemann et Gmelin, Versuche iiber die Wege auf welchen Sub- 
 stanzen aus dem Magen-und Darmcanal ins Blut gelangen. Heidelberg, 
 1820. 
 
 || Essai sur les fonctions du foie. Paris, 1846. 
 
 IT Lecons de physiologie expcrimentale appliquee a la medecine. 
 Paris, 1855. 
 
 ** Physiolog. Chemie., Bd. III. 
 
 B2 
 
4 HISTORICAL INTRODUCTION. 
 
 participation of the portal vein in the absorption of materials from 
 the intestine into the system, although much remains doubtful as 
 regards the extent and importance of this participation. It is to be 
 regarded as clearly proved that water, salts, sugar, odoriferous and 
 colouring-matters are, for the most part, conveyed to the blood by 
 venous absorption, as also that the greatest part of the fat reaches 
 the blood through the lacteals. But it is still a matter of question, 
 in what way the most important principles of nutrition, the 
 albuminous, are absorbed. Claude Bernard and the majority of 
 the French investigators make their absorption take place through 
 the veins, whilst Lehmann, Schmidt, and Ludwig are convinced 
 that it is through the lacteals. 
 
 Another point which has not been sufficiently investigated, is the 
 influence which the hepatic parenchyma exercises over the substances 
 which pass through it. According to the experiments of Claude 
 Bernard, Mialhe, and others, the carbo-hydrogens, no less than the 
 albuminous principles, in their passage through the portal system, 
 undergo important changes from the action of the liver, by means 
 of which they first become fitted for the . formation of blood. A " 
 detailed proof of this metamorphosis has not, however, as yet been 
 given with sufficient clearness. 
 
 At the conclusion of the work, we shall return to this and to 
 other physiological questions of a general nature, and shall bring 
 together such materials for their solution as present themselves; 
 in the meantime we shall only make a few historical remarks, show- 
 ing how the important part played by the liver in the absorption 
 and elaboration of the products of digestion came by degrees to, 
 be again recognised. 
 
 . Whilst experiment proves that the liver exercises an indirect 
 influence over the formation of the blood, there are not wanting 
 observations which seem to indicate that it participates directly in 
 the generation of the elementary principles of this fluid, although, 
 taking everything into consideration, these observations cannot be 
 regarded as decisive. Among these may be mentioned the obser- 
 vations which Beichert,* E. H. Weber,t and Kolliker J have made 
 upon embryos, and upon frogs wakened up out of their winter's 
 
 * Entwickelungsleben in Wirbelthierreiche. S. 22. 
 t Berichte der koniglich sachsischen Gesellschaft der Wissenschaften- 
 zu Leipzig, 1850. S. 15, bis. 20. 
 
 X Henle's und Pfeufers Zeitschrift. Bd. IV., S. 147, ff. 
 
HISTORICAL INTRODUCTION, 3 
 
 sleep, in reference to the development of blood-corpuscles in the 
 liver. These observers found in this way a remarkable confirmation 
 of the differences between the blood of the portal and hepatic 
 veins, which had been authenticated by the carefully repeated 
 chemical analyses of Lehmann,* and by the changes which, accord- 
 ing to the observations of Moleschott, the entire blood undergoes 
 after the extirpation of the liver. 
 
 Besides this direct and indirect participation in the formation 
 of blood, we have very recently become acquainted with the part 
 played by the liver in certain metamorphic processes of an inter- 
 mediate nature, which are of the greatest importance, as furnishing 
 a deeper insight into health and disease. Bernard f has shown, 
 by a series of accurate and precise experiments, that, notwithstand- 
 ing that an animal is fed upon nitrogenous food solely, there is 
 always formed in the liver, in addition to bile, a considerable 
 quantity of sugar, which passes into the mass of the blood, to serve 
 an ulterior object, and which appears as necessary for the healthy 
 performance of vital processes as are other metamorphoses, the pro- 
 ducts of which are thrown off from the system by secreting organs. 
 
 In addition to this elimiuation of sugar from the complex atoms 
 of the albuminous principles, other chemical changes take place in 
 the liver, of' which we will hereafter learn the importance. This is 
 shown by the existence in the gland of inosite, hypoxanthine, and 
 uric acid, and further by observing in it in the course of many 
 diseases, the occurrence of cystine, and large quantities of leucine 
 and tyrosine, and lastly, by the remarkable abnormalities in the 
 composition of the urine which are observed in certain diseases of 
 the liver. Besides all this, the important part which the liver plays 
 in the production of animal heat has found a new defender in Claude 
 Bernard. J 
 
 The liver has consequently again ceased to be regarded as merely 
 an organ for secreting bile. The views of Galen, which Bartholin 
 believed he had overthrown for ever, although modified and cir- 
 cumscribed, have risen into new life and significance. There can 
 now be no doubt, that in this gland processes go on, which exercise 
 an important influence over the principal vegetative functions — 
 
 * Berichte der konigUch sachsischen Gesellschaft der Wissenschaften. 
 1851. S. 131, ff. 
 
 t Nouvelle fonction du foie, &c. Paris, 1853. 
 X Lemons de physiol., Experim. I., p. 199. 
 
6 HISTORICAL INTRODUCTION. 
 
 sanguification and the .metamorphosis of tissues ; what remains to be 
 done is to ascertain at the sick bedside, and by means of experiment, 
 the extent of these processes, and to fix with precision their influ- 
 ence upon health and disease. 
 
 As might have been expected, this change of opinions concerning 
 the physiological relations of the liver could not fail to react upon the 
 views, entertained as to its pathology. In these views similar changes 
 are met with; only they are less remarkable than in the case of 
 the physiological opinions, because clinical observation must always 
 be directed to the secretion of bile as the chief function of the liver. 
 
 In the pathology of the ancients, and particularly of Galen, the 
 liver and the portal system served as the starting-point of manifold 
 disturbances. There were described not only a host of anatomical 
 and functional lesions of the organ itself, such as inflammation, 
 abscess, obstruction of the ducts, and the different conditions re- 
 sulting from intemperance, but a large proportion of constitutional 
 diseases were referred to the same source. Abnormal conditions of 
 the liver were regarded as the principal cause of changes in the 
 constitution of the blood. " Sanguificatio vitidtv/r Aepate vitiato." 
 Plethora, anaemia, cachexia, and dropsy, were attributed to certain 
 changes in the activity of this gland. A further cause of general 
 diseases was found in the products of the secretion of the organ, the 
 yellow and the black bile, which under a humoral pathology, had a 
 mighty importance as elementary constituents of the organism. The 
 yellow bile, it was thought, would' induce acute diseases, running a 
 rapid course and accompanied by a high temperature, such as 
 erysipelas, &c.j while, on the other hand, black bile was believed to 
 give rise to chronic diseases, such as mental derangement, apoplexy, 
 convulsions, &c. No wonder that in this way, the liver came to 
 be regarded as the centre of a large proportion of pathological pro- 
 cesses. Throughout the pathological works which appeared from 
 the time of Galen down to the middle of the seventeenth cen- 
 tury, this organ was looked upon as the seat of the mind itself. 
 No one dared to question the grounds of this dogma, although in a 
 few instances it was extended or modified. Even in the year 1626, 
 Riolan called upon physicians diligently to study the liver, as the 
 vita et nutricatus fundamentum. 
 
 The discovery of the lacteals, effected a change in physiological 
 views, which was necessarily followed by a reaction in the theories 
 of disease. One of the foundation-stones upon which the artificial 
 
HISTORICAL INTRODUCTION. 7 
 
 fabric of Galenic pathology had rested, was removed; opinions, 
 which through a lengthened period had apparently acquired the 
 value of facts, became untenable; and novel points of inquiry were 
 opened up. Although the functional importance of the liver had 
 necessarily become circumscribed, other channels of absorption 
 before unknown had been discovered. Simultaneously with this, 
 the brilliant work of Harvey upon the circulation of the blood was 
 attracting much attention, and promised an explanation of many 
 phenomena. 
 
 It was Bartholin,* the strenuous opponent of the Galenic 
 theories, who had the merit of undertaking a revision of the science 
 of medicine under the light of the, new discoveries in physiology. 
 "With a degree of caution worthy of all praise, he declared that the 
 ancient medical doctrines were not overthrown, but only elucidated"; 
 that the causes of disease were better understood and more correct 
 than formerly, and therefore more easily obviated ; and that especial 
 attention was to be given to the heart as the .organ for the cir- 
 culation of the blood. It was, however, admitted that abnormal 
 conditions of the blood might result from obstruction and other 
 diseases of the liver, although this organ did not take any part in 
 sanguification. The obstinate adherents of Galenic medicine in 
 vain endeavoured to combat these innovations; the views of phy- 
 sicians became modified more and more, and as a substitute for the 
 dogmas formerly prevalent, they hastened to turn the discoveries 
 of the day to a theoretical and practical account. 
 
 There is a tendency in the human mind' to overrate the import- 
 ance of new discoveries, and in this way to make an improper use 
 of them. Hence, we can quite understand how crude medical theo- 
 ries should have succeeded the revolutions above-mentioned, in the 
 departments of anatomy and physiology, and the more so, as, at the 
 same time, a more correct knowledge of natural philosophy and 
 chemistry was beginning to shed a new but deceitful light upon 
 many questions. For practical medicine in general, and for the 
 study of diseases of the liver in particular, there commenced an 
 unproductive period, which, trusting to theory more than to actual 
 observation, always failed in obtaining a firm foundation in facts. 
 The followers of , Sylvius, the Iatrochemists, as well as the Iatro- 
 physicists, left behind them no fruits of direct investigation on the 
 subject with which we are now engaged. The theory of Franz de 
 
 * An hepatis funus immutet medendi mcthodum. Haf'niae, 1653. 
 
8 HISTORICAL INTRODUCTION. 
 
 le Boe Sylvius, who maintained thai the fermentation of the juices 
 secreted by the spleen, pancreas, and^liver, was of great importance 
 for chylification and sanguification, both in health and in disease, 
 acquired a wide-spread influence, only because it compensated for the 
 opposition bestowed, since the discovery of the thoracic-duct, upon 
 the Galenic method of explaining many diseases, which, it was be- 
 lieved, must necessarily result from a disturbance in the functions 
 of the liver. Not much more resulted from the writings of Syden- 
 ham, except that he re-established the Hippocratic method of clini- 
 cal observation, and removed the abuses which had resulted from 
 crude sources of information. Considering his great distinction in 
 the practice of medicine generally, he bestowed but little attention 
 upon the diseases of the liver. 
 
 Meanwhile, and partly even before this period, a better future 
 was gradually being opened up through the anatomical and patho- 
 logical investigations to which physicians had begun to devote 
 themselves with increasing zeal. In this way there was accumulated 
 by degrees materials, from which a future age was able to construct 
 the foundation of a pathology of liver-diseases founded upon facts, 
 although, certainly, one-sided. Even before the general revolution 
 in medical opinions, Benivieni,* "Vesalius,t and FallopiusJ had, from 
 their anatomical studies, collected contributions which served to cast 
 a new light over several forms of hepatic disease. They were the 
 first to give accurate descriptions of gall-stones,- and of the conse- 
 quences which resulted from their detention in the gall-bladder. 
 Vesalius reported a case of bursting of the portal vein in conse- 
 quence of cirrhotic degeneration of the liver ; he noted the prejudi- 
 cial effects of spirituous liquors upon this organ, and the connection 
 between intumescence of the spleen and disease of the liver. 
 
 The writings of Glisson § contained some valuable observations 
 upon the subject of tumours of the liver in rachitis ; abscesses and 
 concretions were treated of by Bartholin ; || malignant jaundice by 
 Baillou,ir a very able physician, and especially by Th. Bonnet, in 
 his large and comprehensive work.** The last of these authors re- 
 
 * De abditis morborum causis. Cap. 3, pp. 94, 140, 263. 
 
 f Epistola de radie. Chin. Basil., 1546, p. 642. 
 
 t Observ. Anatom., p. 401. 
 
 § Anatom. hepat. 
 
 || Historia anat., Cent. VI. 
 
 f Ballonii opera, om. Genev., 1662, Tom. I., p. 188. 
 
 ** Sepulchretum anat. Genevse, 1679. 
 
HISTORICAL INTRODUCTION. 9 
 
 corded an instructive series of cases of jaundice depending upon 
 obstruction, and divided his observations under the heads of Inflam- 
 mations, Tumours, Scirrhus, Obstructions, Cysts, Calculi, &c, of the 
 Liver. It is true that these observations, in many places, require 
 sharp criticism ; yet, as the first rudiments of our knowledge, they 
 are of much interest. Bonnet's description of Cirrhosis, indeed 
 (Sect. I., Observ. 4), leaves little more to be desired. Sylvius, and 
 afterwards Bonnet, discussed at full-length the importance of the 
 liver in general pathology.* 
 
 Although, in the present state of our knowledge, these early 
 dawnings of anatomico-pathological investigation may appear incom- 
 .plete and defective, yet they were of great weight at a time when 
 every well-grounded fact removed entire series of false theories, and 
 formed starting-points for new studies rich in results. 
 
 All the information concerning diseases of the liver, which, in the 
 course of time had been obtained through these investigations, 
 J. B. Bianchi endeavoured to bring together in his work entitled, 
 Historia hepatica sew Theories et Praxis omnium, morborum Aepatis et 
 bills. This work, although it went through three editions, con- 
 tained much that was crude and carelessly done, and therefore 
 deserved the severe criticism which it suffered at the hands of Mor- 
 gagni and Haller. Its influence upon the further study of hepatic 
 diseases was limited, and the more so, as, soon after its appearance, 
 transcendent geniuses brought facts to light which necessarily 
 eclipsed all that had gone before. H. Boerhaave and G. E. StaB. 
 appeared in the field of clinical medicine ; J. B. Morgagni in that 
 of pathological anatomy. 
 
 H. Boerhaave, who, in combining the artificial system of Syden- 
 ham with the fundamental investigation of nature, was a bright 
 example to later times, paid particular attention to the diseases of 
 the liver, because in them he believed he had discovered the source 
 of a large proportion of chronic diseases.f A disturbance of diges- 
 
 * Wenn die Leber kalt sei und die sauren Safte, die von der Milz her- 
 kamen, nicht verarbeite, so entstehe eine mangelhafte Fermentation, der 
 Chylus werde unvollkommen, das Blut bleibe seros und Wassersucht 
 bilde sich. Wenn die Leber heiss sei, so entstehe unpassende Fermenta- 
 tion, welcne Fieber, Entzundurig Putrescenz bedinge, unter Umstanden 
 Icterus, Diarrhoe, Cholera, Dysenterie einleite. Bei verstopfter und 
 scirrhotischer Leber entstanden Cruditaten verschiedener Art (p. 26, 
 et seq). 
 
 + Prselect. academ. Ed. Haller, Vol. III., p. 186. Duo viscera sunt, a 
 
10 HISTORICAL INTRODUCTION. 
 
 tion, resulting from a deficient secretion of bile, Boerhaave believed 
 to be the cause of a faulty chylification, from which proceeded 
 dropsy, cachexia, leucophlegmasia, &c* In addition to defective 
 assimilation, the stagnation of blood in the portal vein was considered- 
 as a second source of morbid conditions of the liver. The retarda- 
 tion of the blood at this part of the vascular system was, in Boer- 
 haave' s opinion, independent of the heart's action,t and was brought 
 about by the contractility of Glisson's capsule, and the pressure of 
 the abdominal viscera. Hence, it was thought, stagnations of blood 
 often occurred at this place, and black bile was formed, which 
 gave rise to obstruction of the viscera, especially of the liver, to 
 hypochondriasis, melancholia, and many other diseases. J In his trea- 
 tise Hepatitis et Icterus multiplex y which Boerhaave declared to be 
 one of his best works, there is a comprehensive account of the 
 special pathology of the liver. It is remarkable, however, that the 
 changes in physiological views among ancient physicians should 
 have failed to effect any essential alteration upon pathology. 
 
 Almost at the same time, G. E. Stahl,§ relying less upon 
 facts than upon theoretical reasoning, endeavoured to claim for the 
 liver a very comprehensive pathological importance. He called in 
 question the opinion as to the exclusive participation of the lacteals 
 in the absorption of nutriment, which, since the discovery of the 
 thoracic duct, had gradually become generally admitted ; and, at the 
 same time, he maintained that as large a quantity of chyle was 
 carried with the blood through the mesenteric veins to the liver, as 
 that which found its entrance into the system through the lacteals. 
 The absorption of improper ingesta into the vena porta was regarded 
 by him as an important source of the changes in the contents of 
 this vessel. Neither Stahl nor Boerhaave believed that the circula- 
 
 quibus fere anne omne morborum chronicorum genus oritur, pulrao 
 a quo tabes, hepar, a quo iunumerabiles lenti morbi. Ibid. p. 190. 
 Atqui ex centum morbis chronicis vix unus, cujus princeps sedes non sit 
 in hepate. 
 
 * Quanquam bilis languet, nata est origo morbi alicujus chronici; 
 chylus enim.non potest legitime praeparari, inde hydrops, cachexia, leuco- 
 phlegmasia, &c. 
 
 t Sanguis enim venae Portarum .... amittit omnem a corde 
 acceptum impetum, he. cit. III., 183. Cum sinus Portarum pariter sit 
 cor hepatis uti cor dictum universo corpori. Ibid. p. 115. 
 
 X Prax. medic, pars V., p. 48 et seq. 
 
 § De vena portae, porta malorum hypochondriaco — splenetico — suffoca- 
 tive), hysterico — colico haemorrhoidariorum. Hal., 1698. 
 
HISTORICAL INTRODUCTION. 11 
 
 tion of the blood in the portal vein depended upon the heart's in- 
 fluence, but upon that of the respiratory organs, and upon a peculiar 
 tonic motive power, which was imputed to the abdominal organs, 
 and especially to the spleen, the intestines, and - the mesentery, as 
 well as to the coats of the vessels themselves. 
 
 The diseases of the vena porta — to which Stahl referred those of all 
 the abdominal organs with which this vessel was connected — were 
 reduced to four elementary forms, from which was constructed a 
 theory of the most heterogeneous pathological processes : — 1. Abnor- 
 mal capacity; contraction and dilatation. 2. Increased consistence 
 of the blood, resulting from the absorption of ingesta which are 
 acid, feculent and thick with mucus, from sluggish respiration, &c. 
 8. Passive stagnation. 4. Active stoppages in the circulation of 
 the blood, resulting from the above-mentioned relaxation and con- 
 striction, and from anomalous changes in position of the thickened 
 blood. 
 
 Although the physiological proof of these views, and of the 
 consequences resulting from them, necessarily remained defective, 
 still the doctrines involved in them were not without some influence ■ 
 upon the succeeding age. Stahl, it is true, found but few supporters 
 among his contemporaries, or even afterwards among medical men 
 generally; but the theory of abdominal plethora, and of the stag- 
 nation of blood in the bowels, which at a later period was elevated 
 by Kampf * into the doctrine of Infafctus, remained a standing and 
 important article of pathology, which even at the present day 
 attracts many supporters among physicians, and among the lay 
 public has acquired the power of a confession of faith. The careful 
 study of abdominal diseases was greatly prejudiced through this 
 vague doctrine offering an easy explanation for every case. 
 
 Whilst, on the part of physicians, many things were being done 
 which must have retarded rather than have advanced progress, J. B. 
 Morgagnit was collecting a rich store of anatomical facts and 
 clinical observations, for which he secured an imperishable value, 
 even in recent times, owing to their clearness and to the care with 
 which they were worked out. For most of the diseases of the liver, 
 
 * Abbandlung,von enier neuen Methode, die hartnackigsten Krankheiten, 
 die ihren Sitz im Unterleibe haben, besonders die Hypocbondrie, sicher 
 und griindlich zu heilen. Frankfurt und Leipzig, 1787. 
 
 t De sedibus et causis morborum per anatomiam indagatis. Ebroduni, 
 1779. 
 
12 HISTORICAL INTRODUCTION. 
 
 .we find in his works, the outlines of what is currently accepted at 
 the present day* After the time of Morgagni, anatomical investi- 
 gation was pursued with greater zeal, and acquired increasing 
 importance in the clinical study of diseases generally, and of those of 
 the liver in particular. The several structural changes of this 
 gland became more clearly understood, and distinguished from one 
 another; and their nature and consequences began to be placed 
 upon a surer foundation, for which end the increasing study of the 
 finer tissues by means of the microscope furnished still better and 
 more convenient ways and means. The information upon this sub- 
 ject, which was contained in the works of Lieutaud, A. Portal, 
 JVTathew Baillie, Carswell, Andral, CruveilMer, Eokitansky, and 
 many others, formed a solid nucleus, around which the more modern 
 .pathology of the liver has arranged itself. 
 
 At the very time that the anatomical element was acquiring 
 weight and influence in the investigation of liver-diseases, the 
 pathological importance .of the organ in diseases generally was gra- 
 dually losing ground. It is true, that Yan Swieten and his 
 contemporaries upheld the views of Boerhaave in their essentiality; 
 it is true, likewise, that at a later period, owing to the then prevail- 
 ing epidemic constitution, the bile assumed a degree of importance 
 in pathology such as it never had before; and to such an extent 
 was this importance exaggerated, that even Kampf s doctrine of 
 Infarctus found a hearing. Still all this was of short duration ; the 
 labours of anatomists, the chemical analyses of the bile, the physio- 
 logical experiments upon the secretion and uses of this fluid, and the 
 study of the digestive process, year by year, removed the grounds, 
 on which the comprehensive general importance of the liver, both in 
 health and in disease, had hitherto been based. 
 
 After the discovery of the elementary composition of the bile, the 
 liver came to be regarded as the organ which purified the blood of 
 its carbonaceous products, and as being in this way vicarious with the 
 lungs ; scarcely a trace remained of the views entertained by the old 
 physicians, that the organ exercised a manifold influence over the 
 formation of the blood. The study of liver-diseases acquired in this 
 way the simple anatomical character which we recognise at the pre- 
 sent day : and owing to this study being cultivated more on the 
 dissecting table than at the sick bedside, the investigation of the 
 more obscure functional disturbances of the Hver itself, and of its 
 * Vide Epist. XXXVII., on Jaundice. 
 
HISTORICAL INTRODUCTION. 13 
 
 participation in other acute and chronic diseases was gradually dis- 
 carded. That which had been stated and written by the ancients 
 upon the subject was looked upon as the fictions of an age long past. 
 Modern physiology., however, has effected great changes in this 
 department, and has opened up many new points of view from which 
 to study the question. The secretion of the liver has been carefully' 
 examined; the composition, origin and uses of the bile have been 
 closely investigated, and in it, as a constant result of the secreting 
 activity of the gland, sugar has been detected, although the physio- 
 logical importance of this substance is still obscure. Further, there 
 has been shown to exist in the liver a large quantity of the pro- 
 ducts of retrograde metamorphosis, which indicate a complicated 
 transformation of materials within the organ, the extent and import- 
 ance of which, however, still remain to be determined. Lastly, 
 observations have been made which seem to speak in favour of a 
 direct participation of the liver in the formation of the blood. 
 
 The task of proving and turning to account these new views will 
 belong to pathology ; but there are many difficulties which stand 
 in the way of its performance. Quite independently of the defects 
 which are exhibited almost everywhere in the physiology of the 
 organ before us, and which are sometimes of so important a nature 
 that great caution is necessary in applying our knowledge of its 
 physiology to the investigation of its pathology, the careful study of 
 liver-diseases is impeded by the concealed situation of the organ, 
 by the fact of its secretion being poured high up into the intestinal- 
 canal, by the connection of the organ with those parenchymatous 
 changes, the products of which do not make their appearance 
 directly in the excretions, and by the frequent coexistence of 
 diseases of the liver with diseases of other organs which exercise 
 an influence over sanguification and the metamorphosis of matter, 
 such as the digestive organs, the spleen, &c. 
 
 In the present work, therefore, many questions are merely an- 
 nounced in a preliminary manner, without our being able to solve 
 them while others, again, receive only a fragmentary solution. Our 
 investigations, however, on -this subject, promise to be not without 
 results, provided we pay attention not merely to anatomical lesions, 
 but also to the disturbances in the metamorphosis of matter by 
 which these lesions are accompanied. 
 
 A few references to the most important monographs on Diseases 
 of the Liver are here annexed : — 
 
14 HISTORICAL INTRODUCTION. 
 
 J. B. Bianchi. Historia hepatica seu Theoria et praxis omnium 
 morborum hepatis et bilis. — Tom. I. et II. 
 . Fa. Hoffmann. De morbis hepatis ex anatomia deducendis. 
 Also : De bile medicina et veneno corporis. Opera omnia 
 phys. med. — Tom. Y. 
 
 J. Ande.ee. Considerations on Bilious Diseases and some particu- 
 lar affections of the Liver and Gall-bladder. London, 1790. 
 
 Satjndeus. A Treatise on tbe Structure, Economy, and Diseases of 
 the Liver. _ German translation. Leipsig, 1795. 
 
 A. Postal. Observations sur la nature et le traitement des mala- 
 dies du foie. Paris, 1813. 
 
 J. Abeecbombie. On Diseases of tbe Stomach, &c. Edinburgh. 
 German translation by Busch, 1833. 
 
 Bonnet. Traite des maladies du foie. Paris, 1828 and 1841. 
 
 G. Btjdd. On Diseases of the Liver. London, 1845 and 1851. 
 • German edition by Henoch. 
 
 The works, moreover, which treat of diseases of the tropics are of 
 importance, especially in reference to inflammation of the liver ; 
 such as : — 
 
 Annesley. Researches into the cause, nature, and treatment of 
 the more prevalent diseases of India. Vol. I., II., with plates. 
 
 Cambat. Traite, des maladies des pays chauds, et spe'cialement de 
 l'Algerie. Paris, 1847. 
 
 Haspel. Maladies de l'Algerie. 1852. Tom. II. 
 
SIZE AND WEIGHT OF LIVER IN HEALTH AND DISEASE. 15 
 
 CHAPTEK II. 
 
 THE RELATIVE SIZE AND WEIGHT OE THE LIVER IN HEALTH 
 AND IN DISEASE. 
 
 In order to obtain positive data for the solution of many questions, 
 I have deemed it necessary to ascertain the. size and weight of 
 the liver, both absolutely and in relation to the weight of the entire 
 body, with greater precision than has hitherto been done. We are 
 dependent upon such knowledge, not merely in a diagnostic point 
 of view, for a correct scale from which to judge of the existence of 
 abnormalities in the size of the organ, such as atrophy, &c. ; but we 
 are still more dependent upon it for information as to the manner in 
 which general and local diseases react upon the liver, and as to the 
 extent to which this organ, under the different conditions of the 
 system (resulting from age, sex, and certain diseases), participates 
 in the changes of the nutritive principles. 
 
 It would of course have been preferable to have arrived at a 
 satisfactory elucidation of such obscure and complicated questions 
 without having recourse to the force brutale ties chiffres, yet by 
 such means we may expect to obtain some precise data on which to 
 base further investigation. 
 
 It is necessary to take the' spleen into consideration at the same 
 time as the liver, partly on account of its intimate relation with the 
 organ secreting bile, and partly on account of the changes in volume 
 of this gland which accompany the different species of affections of 
 the liver, and which are of such importance in the diagnosis of 
 obstructions of the vena portse. 
 
 The determination of the value of figures, as applicable to the 
 purposes just mentioned, is a matter of n» small difficulty, inasmuch 
 as, even under normal circumstances, the liver exhibits remarkable 
 differences, which, to a certain extent, cannot easily be accounted 
 for. Hence it is not to be wondered at, that authors should have 
 made widely different statements as to both the absolute* and the 
 
 • The absolute weight of the liver usually rises and falls in proportion 
 
16 SIZE AND WEIGHT OF THE LIVER 
 
 relative weight of the liver in healthy individuals. Bartholin esti- 
 mated the relative weight of the liver in proportion to that of the 
 body as 1 to 36 ; Haller, as 1 to 25 : the average weight of the 
 gland was reckoned by Haller at 45 ounces, or 3.7 pounds, or 1.8 
 kilogramme; by Cruveilhier, at 3 pounds; and by Huschke at 
 from 4 to 6 pounds. According to my experience, the relative 
 weight of the liver in healthy individuals may vary from one-seven- 
 teenth to one-fiftieth of that of the body, and in adults it fluctuates 
 between one-twenty-fourth and one-fortieth ; the absolute weight at 
 this period of life, reaches from 0.82 to 2.1 kil6grammes (1.8 
 to 4.6 English pounds avoird.)* The observations from which 
 these numbers have been derived, were made upon individuals who 
 had died suddenly from accidents without losing any blood, and 
 whose livers, on careful examination, appeared to be healthy. Cases 
 in which there was abundant fatty deposit in the gland were 
 excluded. 
 
 There are, therefore, tolerably wide limits which must be exceeded 
 before we can speak of a simple hypertrophy or atrophy of the liver 
 as a pathological phenomenon. The circumstances upon which 
 these ■ differences in the weight of the liver are dependent, have 
 hitherto been only partially discovered. The most important of 
 them are the following. 
 
 1. Age. 
 
 It is during the first stages of development that the organ is 
 largest in proportion to the size of the entire body ; even in the. 
 later months of foetal life, and still more so soon after birth, its ■ 
 relative weight declines more and more towards that which is ob- 
 served at a more advanced age. It is still undetermined, whether the 
 remarkable diminution observed during foetal rife is, of a uniform 
 nature; many observations are. opposed to such being the case. 
 After birth, the entire gland, but especially the left lobe, t dimi- 
 
 to the weight of the body, so that the term absolute can only be em- 
 ployed in a comparative sense. 
 
 * Similar differences were observed by Bidder and Schmidt (Verdaw- 
 ungsafte, etc., S. 152), in healthy animals, such as cats, in which the ratio 
 was from as 1 to 14, to 1 to 38. 
 
 t According to Portal and Meckel the liver in newly-born children 
 ought to be one-fourth heavier than -in children from eight to ten months" 
 old ; but my experience does not correspond with this. 
 
IN HEALTH AND IN DISEASE. 17 
 
 fishes more rapidly in consequence of the altered supply of blood. 
 During the period of greatest growth, the liver does not become 
 enlarged in a manner proportionate to the increase of the entire 
 body, and its diminution in old age is, for the most part, in 
 advance of that of the body. The substance of the liver, therefore, 
 presents in this respect, a marked contrast to the muscular tissue 
 of the heart, for whilst this, according to Bizot, increases progres- 
 sively up to an advanced age, the mass of the liver diminishes. In 
 old age, as a general rule, there is senile atrophy of the organ. 
 
 Such are the results of weighing the liver in healthy individuals, 
 as well as in numerous instances of persons who have died of other 
 diseases in which the liver has not been at all involved. Exceptions 
 occur, owing to the force of circumstances of an extraneous nature 
 influencing the volume of the gland; but these exceptions disappear 
 on adding together the larger series of figures and calculating the 
 
 * The number of original observations as to the weight and size of the 
 liver from which my calculations have been made, amounts to about 800. 
 A large number of weighings appeared necessary, because numerous acci- 
 dental influences, modifying the weight of the liver as well as of the entire 
 body, such as hyperemia and anaemia of the organ, dropsy, suppression, 
 or profuse secretion of bile must be excluded. Space does not permit us 
 to give here a detailed account of the numbers in each case. In the 
 tables the measurements are indicated by Paris inches j the weights, by 
 kilogrammes. 
 
18 
 
 SIZE AND WEIGHT OF THE LIVER 
 
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 02 
 
 I 
 
 e H 
 
 Ph 
 
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 60 
 
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IN HEALTH AND IN DISEASE. 19 
 
 2. The Sex. 
 
 According to Glisson, the liver, as a general rule, is heavier in 
 men than in women; hut an opinion precisely the reverse is main- 
 tained by Dumas. I myself have been unable to detect any 
 differences dependent upon sex, except that in scrofulous women the 
 liver is usually larger than in men, from the fact, that in the former 
 sex, it is more frequently remarkable for an abundant deposit of 
 fatty matter. 
 
 3. The Ingestion of Wood 
 
 exerts a powerful influence over the volume of the liver. During the 
 second stage of digestion the organ increases in size and weight, partly 
 owing to the state of congestion which then makes its appearance, 
 and partly owing to the abundant deposit of granular and amorphous 
 material in the interior of the hepatic cells. After a protracted fast 
 the gland becomes smaller and lighter. Bidder and Schmidt found 
 that in cats the relative weight of the liver to that of the entire body 
 was as 1 to 30, three hours after a meal; after from twelve to 
 fifteen hours, it was 1 to 25 ; from twenty-four to forty-eight hours 
 after, it was 1 to 31 ; and after seven days' fast, 1 to 37. . I have 
 arrived at similar results in rabbits ; under the influence of a three 
 days' fast, the relative weight, which after a full meal is, generally, 1 
 in 25, or 1 in 27, diminished to 1 in 34, 1 in 37, and 1 in 43, with 
 a total loss in each case of 31.1, 29.6, and 17.8 per cent. The 
 following observations appear to indicate that starvation is followed 
 by similar consequences in men. In a healthy individual aged 27, 
 who, owing to a fall from a scaffold, died with a full stomach, the re- 
 lative weight of the liver was found to be as 1 to 26.5 ; in another 
 person aged 36, who perished under similar circumstances, it was as 
 1 to 37 ; on the other hand, in a man aged 25, who died of trismus, 
 after three days' complete abstinence, it was 1 to 40 ; and in a woman, 
 33 years of age, who died from burning the pharynx with sulphuric 
 acid, after seven days' fasting, it was 1 to 50. 
 
 From what has just been stated it may be concluded, that, in the 
 management of chronic congestions of the liver, a strict diet plays a 
 powerful part in effecting a cure. In cases, however, of protracted 
 
 c2 
 
20 
 
 SIZE AND WEIGHT OF THE LIVER 
 
 starvation, which terminate in death from inanition, the diminution 
 of the liver in proportion to that of the entire body, becomes 
 again equalized. Thus, the following observations were made in 
 four individuals who died of stricture of the oesophagus. 
 
 Age. 
 
 Weight 
 
 Relative 
 
 weight of 
 
 Liver to 
 
 , that of 
 
 Body. 
 
 Weight- 
 of the 
 Spleen. 
 
 Relative weight of 
 Spleen to that of 
 
 Of the 
 Body. 
 
 ;0f the 
 Liver. 
 
 
 Liver. 
 
 Body. 
 
 48 years . 
 50 „ . 
 65 „ . 
 44 „ , 
 
 Kilogr.* 
 32.2 
 30.8 
 39.0 
 39.7 
 
 Kilogr. 
 1.1 
 0.92 
 1.20 
 1.75 
 
 1 : 29.2 
 1:33.47 
 1:32.5 
 1 : 22.7 
 
 Kilogr. 
 a: 13 
 
 0:12 
 
 1 : 8.4. 
 1:10. 
 
 1:247 
 1:325 
 
 Still more remarkable is the influence of diet, when the food is 
 very rich in fat, or when it is too bulky, while at the same time the 
 powers of digestion are impaired. In this case the deposit of fat in 
 the hepatic parenchyma induces an undue proportion in the size of 
 the liver. Bidder and Schmidt found the relative weight under such 
 circumstances to be as 1 to 16. Lereboullet ascertained, that in 
 geese the relative weight of the liver varied from 1 in 26 to 1 in 18, 
 after feeding for two weeks upon maize, and that after four weeks it 
 rose to 1 in 12.8. 
 
 . How greatly the volume of the liver is influenced by nourishment 
 may easily be seen by comparing a large number of observations on 
 the weight of the organ in individuals who have died of pneumonia, 
 typhus, and other febrile complaints. Its relative size under such 
 circumstances is much smaller and more uniform than what it is 
 when death has not been preceded by protracted starvation. (See 
 Table'II.) 
 
 4. The Degree of Congestion of the IAver 
 
 has a marked influence over its size and weight; changes result 
 from this cause, which are of little importance, because the causes of 
 the abnornal distribution of the blood have in a -measure only a 
 transitory and accidental value. We are possessed of no means for 
 completely comprehending the derangements which result from this 
 
 * J Kilogr. = 2.2046 English pounds avoird. 
 
IN HEALTH AND IN DISEASE. 21 
 
 cause, whilst the attempts to separate the blood before weighing, by 
 the injection of water have induced other sources of fallacy. 
 
 It is not improbable, that in addition to the influences just men- 
 tioned, there are still others which operate in changing the volume 
 of the liver, so that the organ will be found sometimes exceeding, 
 and sometimes smaller than, its normal proportions, according to 
 the constitutional peculiarities of the individual. 
 
 No certain proofs, however, can be furnished of the existence of 
 such agencies, because we know not the limits to which other causes, 
 which are at least partially understood, modify the size of the organ, 
 and consequently, in some cases, we are not in a position to exclude 
 these causes. 
 
 The Relative Weight and Size of the Liver m Disease. 
 
 In order to obtain an insight into the manner in which the rela- 
 tive volume of the liver becomes affected in the course of general and 
 local diseases, and as to how the organ becomes altered in size by 
 morbid conditions of its own textures, several special series of 
 measurements have been collected. The most important results of 
 these measurements have been noted in the annexed tables. These 
 observations furnish us with trustworthy data for the solution of 
 many questions, and their value will appear in a subsequent part of 
 this Work. 
 
22 
 
 SIZE AND WEIGHT OF THE LIVER 
 
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 30 „ 59 
 
 18 „ 24 
 
 22 „ 45 
 29 „ 68 
 
 36 „ 55 
 41„54 
 
 
 8 
 1 
 1 
 
 Acute Atrophy- 
 
 Chronic Atrophy — 
 A. Without Dropsy - 
 
 b. With Dropsy 
 
 Cirrhosis of Liver — 
 
 A. Without Dropsy - 
 b. With Dropsy - - - 
 
 Waxy Liver — 
 a. Without Dropsy - 
 
 B. With Dropsy 
 Pigment Liver in In- 
 termittent Fever 
 
 Retention of Bile 
 Carcinoma of Liver - - 
 Diabetes mellitus - - - 
 
IN HEALTH AND IN DISEASE. 
 
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28 DIAGNOSTIC VALUE OF ABNORMAL 
 
 CHAPTER III. 
 
 A SKETCH OP THE RELATIVE SIZES AND POEMS OF THE LIVEE IN 
 ITS MOEBID CONDITIONS, AND OP THEIE DIAGNOSTIC VALUE. 
 
 In the diagnosis of diseases of the liver, an accurate knowledge 
 of the size and form of the organ is one of the first points to be 
 ascertained. Such information furnishes valuable data, which in 
 some cases are of themselves sufficient for the diagnosis, and which 
 in most enables us to refer the disease to a certain group, so as to 
 narrow the field of choice. The positive data which we obtain by 
 this means are always of great value, although we cannot draw any 
 conclusions as to the healthy condition of the organ, from the fact 
 of its form and size being normal. Thus, there may exist deep- 
 seated diseases of the parenchyma of the liver, although on physical 
 examination, no deviation of its external characters can be detected.* 
 Not only functional derangements and the more minute alterations- 
 of tissue, but also the coarser anatomical lesions, such as cancer, 
 echinococci, &c, may not unfrequently attain a considerable develop- 
 ment in the interior of the liver, without modifying in a marked 
 degree its volume and form. As one of many similar instances, I 
 may mention one where a large sac of an echinococcus was situated 
 in the right lobe of the liver underneath the diaphragm, and pene- 
 trated deeply into the parenchyma without altering the extent or 
 form of the organ in any way capable of assisting diagnosis. A 
 similar condition is not unfrequently met with in the case of cancer ; 
 here, indeed, it is sometimes impossible, even after the removal of 
 the organ, to detect upon its surface with closed eyes, and by the 
 sense of touch merely, any nodules existing in its interior. 
 
 With some practice it is not difficult, by means of percussion 
 
 * Even the ancient physicians- were familiar with this fact; Baillou 
 (Consul/ ationes med. T. II., p. 56) justly observes : — " Hepar non desinit 
 male haberi, etsi nihil fores appareat." 
 
 t In the original German edition, a figure is given of the liver here 
 alluded to. — Transl. 
 
SIZES AND FORMS OF THE LIVER. 29 
 
 and palpation, to obtain data which may be of service in diagnosis j 
 it is a far less easy matter to turn these data to a proper account. 
 The impediments which here present themselves cannot be overcome 
 by any general rules, but only by an attentive consideration of all 
 the circumstances of the case, and by a careful sifting of the nume- 
 rous causes of the abnormality in question. Some of these last are 
 owing to the great variety of forms which the healthy liver may 
 exhibit ; others, to the very frequent anomalies in the situation and 
 position of this gland; and lastly, a third class are dependent npon 
 the difficulty which there is in distinguishing, by any diagnostic 
 means placed at our command, between the boundaries of the liver, 
 and those of adjoining organs and pathological growths. 
 
 The Normal Situation, and Size of the Liver. 
 
 The liver is situated in the right hypochondrium, filling up the 
 concavity of the diaphragm upon this side, and is almost completely 
 concealed by the arch of the ribs, which usually leave uncovered the 
 part of the left lobe which projects into the epigastrium. Its con- 
 vex, upper surface corresponds to the vault of the diaphragm, and 
 projects into the right side of the thorax, where it is partially sepa- 
 rated from the walls of the, chest by the intervention of the thin 
 lower margin of the right lung, the greater portion of the organ, 
 however, being in close juxtaposition to these walls. In any investiga- 
 tion, therefore, the upper boundary may be said to be twofold; thus, 
 there is one boundary which corresponds to the limit of the region 
 in which the organ is in close approximation to the walls of the 
 chest, and which is distinguished by a dull percussion-sound ; and 
 there is a second, which represents the absolute height of the liver, 
 which corresponds to the space overlapped by the thin layer of lung, 
 and which is recognised by the transition from a muffled sound, on 
 percussion, to the full clear pulmonary note. In healthy individu- 
 als, the situation of these upper boundaries is tolerably uniform. 
 ; In the median line, at the junction of the ensiform-cartilage with 
 the sternum, the liver is in contact with the walls of the chest, and 
 from this it stretches almost horizontally, yet slightly downwards 
 and backwards, through the right half of the thorax towards the 
 vertebral column. 
 
 In the Imea mammaUs, or a line extending perpendicularly down- 
 wards from the right nipple, the upper boundary (uncovered by 
 
30 DIAGNOSTIC VALUE OF ABNORMAL 
 
 lung) corresponds in most cases to the sixth rib ; along the linea 
 axillaris, to the eighth] and at the side of the vertebral column to 
 the eleventh. The extent of the space covered by the layer of lung 
 amounts to from two to five, usually three, centimetres (3 cent. 
 =1\, or 1.18 English inch), and above this is the true upper 
 margin of the organ ; this space is somewhat more extensive in a 
 line with the axilla than in a line with the mamma, and usually it is 
 larger in tall persons than in those of short stature. It follows, 
 that the true upper margin of the liver, along the linea mammaUs, 
 in most cases, lies in the fifth intercostal space, less frequently be- 
 neath the fifth rib or in the fourth intercostal space ; in the Imea 
 axillaris it is in the seventh intercostal space, or more seldom 
 under the seventh rib j and close to the vertebral column, it is in 
 the tenth intercostal space, or less frequently in the ninth. 
 
 The upper boundary of the liver at the median line cannot usually 
 be distinguished from the lower margin of the heart.* It extends 
 from three to twelve, but in Inost cases about seven centimetres 
 (three English inches), to the_ left beyond the median line. Its 
 upper margin at this part corresponds to the lower margin of the 
 heart, and can only be made out with certainty by percussion, 
 where it projects beyond this organ to the left. 
 
 The position of the lower margin is much less constant than that 
 of the upper. Even in healthy persons, it is very variable, owing 
 to the great varieties in the form of the liver, and to abnormalities in 
 the configuration of the lower -part of the thoracic walls. In a line 
 with the nipple, the lower edge of the liver is found sometimes to 
 coincide with the lower margin of the ribs, and at other times to be 
 from two to four centimetres (four-fifths to one and three-fifths of 
 an English inch) higher up beneath the ribs ; it may, however, ex- 
 tend to seven centimetres (nearly three inches) beyond the lower 
 margin of the ribs, and in certain abnormal forms of the liver, such 
 as in tight-lace-liver (ScMiirleder), still deeper, without being indi- 
 cative of any disease. In the Imea axillaris, the lower margin lies 
 usually in the tenth intercostal space, rarely in the ninth ; it may, 
 however, here also project from two to four centimetres beyond the 
 
 * According to the advice given by Conradi, the upper boundary of the 
 liver at this place may be made out most easily, by drawing a straight 
 line from the point of contact of the right margin of the cardiac dulness 
 with the upper boundary of the liver to the apex of the cardiac dulness on 
 the left. 
 
SIZES AND FORMS OF THE LIVER. 31 
 
 margin of the ribs, and under some circumstances even farther, 
 quite independently of any lesion of the organ. At the side of the 
 vertebral column it is impossible to make out the boundary between 
 the lower margin and the right kidney. The lower edge of the 
 left lobe is from five to fourteen centimetres (two to five and a-half 
 inches) distant from the base of the ensiform cartilage, or more 
 correctly from the line above-mentioned, as corresponding to the 
 lower margin of the heart ; in most cases, it lies somewhat higher 
 than the middle of a line drawn from the umbilicus to the apex of 
 the ensiform cartilage. 
 
 The lower margin as far as the left extremity of the organ is more 
 or less rounded, according to the form of the left lobe, which is very 
 variable. HenCe, to sum up, the position of the lower margin of 
 the liver, and its relation to the edge of the thoracic walls vary 
 so greatly in healthy individuals, that the greatest caution is required 
 in making use of these signs in diagnosis. It is, therefore, only 
 permissible to draw any conclusion as to the enlargement or dis- 
 location of the organ, from the mere fact of its protruding beyond 
 the margin of the walls or the thorax, when the extent of this pro- 
 trusion is considerable. 
 
 The statements just made as to the relative situations of the liver 
 have mostly reference to men from twenty to forty years of age. In 
 females, the same rules hold good in general, as far as regards the 
 upper boundary ; but the lower margin is wont to project somewhat 
 farther beyond the edge of the ribs than in men, owing to the 
 smaller size of the female thorax. 
 
 This remark is still more applicable to children during the first 
 year of life, because in them the organ, and especially the left lobe, 
 is relatively larger,jand because the thorax does not undergo great 
 development until the period of puberty. 
 
 Percussion is of much service for the determination of the rela- 
 tive sizes and situations of the liver at the sick bedside, and its 
 results may be corroborated in some points by palpation, and still 
 more rarely, by auscultation. In order to yield accurate results, 
 percussion demands certain measures of caution, and some amount 
 of technical experience, without which one may easily fall into error. 
 The stomach and intestines must not be loaded with solid matter, 
 otherwise it will always be impossible to make out the lower margin 
 of the liver. Hence observations immediately after a meal are to be 
 avoided; obstinate constipation must first be removed by moans of 
 
32 DIAGNOSTIC VALUE OF ABNORMAL 
 
 purging ; and accumulations of gas must be got rid of. Boundaries 
 which have been determined during a tympanitic distention of the 
 gastro-intestinal canal must be tested subsequently to the dissipa- 
 tion of the tympanitis ; apparent contractions of the liver are often 
 upon this restored to their original size. 
 
 Tor percussion it is best to employ a pleximeter divided into lines 
 or centimetres, and a hammer. In order to ascertain the upper 
 boundary, we ought to percuss from the third intercostal space 
 downwards, until we arrive at a place where the sound is dull. 
 Here the liver is in immediate contact with the wall of the chest; 
 above this lies the convex portion which is covered by a layer of 
 lung gradually increasing in thickness as we proceed upwards. The 
 breadth of this portion, the upper edge of which represents the true 
 upper boundary of the liver, varies from two to five centimetres 
 (four-fifths to two English inches) but usually amounts to three 
 (one and one-fifth of an inch). In a case where precise results 
 are desirable, we must map out the gland all round the right half 
 of the chest, as far as the vertebral column, and indicate its outline 
 with lunar caustic. In ordinary cases, it is sufficient to determine its 
 boundary points in the course of the Tmea mammalis and linea 
 axillaris, as also close to the vertebral column, and in the median 
 line in front : in the last-mentioned situation, this is best done by 
 drawing a line from the point of contact of the right side of the cardiac 
 dulness with the upper boundary of the liver to the apex of the heart. 
 
 In order to define the lower border of the liver, we percuss down- 
 wards until we can distinguish the tympanitic sound of the stomach 
 or intestine. By a percussion stroke of moderate firmness and 
 elasticity this margin is usually made too high,* because the intes- 
 tinal sound is transmitted through the liver, in cases where the 
 margin of this organ is sharply attenuated, or where the underlying 
 parts contain much gas. To define it with any amount of certainty, 
 we must percuss very gently ; and for this purpose, the muffled mode 
 of percussion recommended by Piorry, by making the two or three 
 first fingers strike simultaneously, is of the greatest service. Fine 
 distinctions of sound are in this way more easily recognised. 
 
 A mistake of an opposite character not unfrequently happens, 
 
 * The situation, of this margin can be made out with greatest certainty 
 in cases in which the lower margin can also be felt on palpation ; the 
 latter mode of observation almost always indicates the lower margin as 
 somewhat lower down than percussion, unless this is made with great care. 
 
SIZES AND FORMS OF THE LIVER. 33 
 
 owing to the abdominal walls being rendered very tense in conse- 
 quence of great pain in the epigastric region. Here/ from the 
 great muscular tension, the dulness corresponding to the situation 
 of the liver is extended, an illusion which is increased still more by 
 palpation. The inflammations and enlargements (Ansc&qppwnffen) of 
 the left lobe of the liver, so frequently believed to exist, depend for 
 the most part upon this condition, which in practice is not suffi- 
 ciently attended to. 
 
 In cases where it appears necessary, we may mark out the lower 
 border in its whole extent, from the extremity of the left lobe nearly 
 as far as the spinal column ; but in most cases it is sufficient to 
 determine it in lines corresponding to the nipple, axilla, and ster- 
 num. By ascertaining the upper and lower borders at these three 
 situations, n we learn the measurements of a third part of the organ, 
 from which we may draw conclusions as to its entire volume. 
 
 These measurements, however, in healthy individuals, are liable 
 to variations of considerable extent, the limits of which must be 
 determined, before we can turn the clinical observations to any 
 practical account. A large number of measurements appears to 
 be necessary, in order to become acquainted with the differences 
 arising from age, stature, sex, and other physiological conditions, 
 and in order to ascertain the limits which cannot be transgressed 
 without affording a certain proof of a pathological alteration in 
 the volume of the liver. 
 
34 
 
 DIAGNOSTIC VALUE OF ABNORMAL 
 
 TABLE I. 
 
 Variations in Measurements op Liver according to 
 Age and Stature. 
 
 males." 
 
 
 Age. 
 
 1 
 
 3 co 
 
 II 
 
 a hi 
 
 .a 
 
 la 
 
 xn 
 
 
 Age. 
 
 | 
 
 at 
 
 \i 
 
 la 
 a 
 
 
 
 
 Centim. 
 
 
 
 
 
 
 Centim. 
 
 
 
 
 1. 
 
 10 mon. 
 
 67 
 
 4 
 
 3J 
 
 4 
 
 29. 
 
 22 yrs. 
 
 160 
 
 8 
 
 9 
 
 6 
 
 2. 
 
 10 „ 
 
 69 
 
 5 
 
 3 
 
 2 
 
 30. 
 
 23 „ 
 
 153 
 
 8 
 
 10 
 
 8 
 
 3. 
 
 5 yrs. 
 
 103 
 
 84 
 
 7 
 
 3 
 
 31. 
 
 24 „ 
 
 170 
 
 9 
 
 9 
 
 7 
 
 4. 
 
 6 „ 
 
 99 
 
 6 
 
 6 
 
 4 
 
 32. 
 
 24 „ 
 
 154 
 
 9 
 
 9 
 
 5 
 
 5. 
 
 7 ,. 
 
 98 
 
 81 
 
 7 
 
 3 
 
 33. 
 
 24 „ 
 
 154 
 
 10 
 
 10 
 
 6 
 
 6. 
 
 8 „ 
 
 115 
 
 7 
 
 7 
 
 4 
 
 34. 
 
 25 „ 
 
 150 
 
 10 
 
 10 
 
 6 
 
 7. 
 
 9 „ 
 
 102 
 
 7 
 
 6} 
 
 4 
 
 35. 
 
 25 „ 
 
 151 
 
 6 
 
 9 
 
 5 
 
 8. 
 
 n , 
 
 125 
 
 7 
 
 6 
 
 3 
 
 36. 
 
 25 „ 
 
 158 
 
 9 
 
 10 
 
 6 
 
 9. 
 
 13 „ 
 
 125 
 
 5 
 
 64 
 
 3 
 
 37. 
 
 26 „ 
 
 138 
 
 12 
 
 12 
 
 7 
 
 10. 
 
 14 „ 
 
 124 
 
 7 
 
 6 
 
 6 
 
 38. 
 
 27 „ 
 
 146 
 
 8 
 
 6 
 
 3 
 
 11. 
 
 15 „ 
 
 144 
 
 T 
 
 8 
 
 6 
 
 39. 
 
 27 „ 
 
 160 
 
 10 
 
 9 
 
 5 
 
 12. 
 
 16 „ 
 
 150 
 
 n 
 
 10 
 
 6 
 
 40. 
 
 27 „ 
 
 160 
 
 11 
 
 10 
 
 8 
 
 13. 
 
 17 „ 
 
 142 
 
 n 
 
 9 
 
 5 
 
 41. 
 
 28 „ 
 
 160 
 
 11 
 
 12 
 
 8 
 
 14. 
 
 1? „ 
 
 146 
 
 10 
 
 9 
 
 5 
 
 42. 
 
 29 „ 
 
 150 
 
 9 
 
 8 
 
 6 
 
 IS. 
 
 17 „ 
 
 144 
 
 10 
 
 10 
 
 7 
 
 43. 
 
 29 „ 
 
 150 
 
 11 
 
 11 
 
 7 
 
 16. 
 
 17 „ 
 
 162 
 
 10 
 
 8 
 
 6 
 
 44. 
 
 30 „ 
 
 170 
 
 10 
 
 10 
 
 9 
 
 17. 
 
 17 „ 
 
 149 
 
 8 
 
 7 
 
 5 
 
 45. 
 
 32 „ 
 
 160 
 
 10 
 
 12 
 
 6 
 
 18. 
 
 17 „ 
 
 154 
 
 8 
 
 9 
 
 7 
 
 46. 
 
 32 „ 
 
 154 
 
 11 
 
 11 
 
 6 
 
 19. 
 
 17 „ 
 
 157 
 
 8 
 
 6 
 
 7 
 
 47. 
 
 34 „ 
 
 150 
 
 10 
 
 11 
 
 3 
 
 20. 
 
 18 „ 
 
 151 
 
 8 
 
 7 
 
 4 
 
 48. 
 
 34 „ 
 
 156 
 
 9 
 
 10 
 
 6 
 
 21. 
 
 18 „ 
 
 150 
 
 •10 
 
 9 
 
 7 
 
 49. 
 
 34 „ 
 
 152 
 
 10 
 
 10 
 
 4 
 
 22. 
 
 19 „ 
 
 156 
 
 10 
 
 10 
 
 6 
 
 50. 
 
 37 „ 
 
 160 
 
 8 
 
 11 
 
 5 
 
 23. 
 
 20 „ 
 
 155 
 
 12 
 
 11 
 
 7 
 
 51. 
 
 39 „ 
 
 168 
 
 12 
 
 10 
 
 4 
 
 24. 
 
 20 „ 
 
 168 
 
 9 
 
 9 
 
 7 
 
 52. 
 
 42 „ 
 
 171 
 
 11 
 
 11 
 
 8 
 
 25. 
 
 20 „ 
 
 153 
 
 9 
 
 11 
 
 6 
 
 53. 
 
 44 „ 
 
 150 
 
 10 
 
 9 
 
 4 
 
 26. 
 
 21 „ 
 
 155 
 
 9 
 
 10 
 
 6 
 
 54. 
 
 45 „ 
 
 166 
 
 8 
 
 9 
 
 6 
 
 27. 
 
 21 „ 
 
 155 
 
 8 
 
 9 
 
 5 
 
 55. 
 
 46 „ 
 
 160 
 
 9 
 
 9 
 
 7 
 
 28. 
 
 22 „ 
 
 164 
 
 12 
 
 12 
 
 5 
 
 56. 
 
 55 „ 
 
 155 
 
 10 
 
 10 
 
 4 
 
 * The measurements in this and the following tables are given in cen- 
 timetres. There are about 2J centimetres in an English inch, or more 
 correctly, 1 centimetre = .3937 English inch. — Transl. 
 
SIZES AND FORMS OF THE LIVER. 
 
 35 
 
 TABLE II. 
 
 Variations in Measurements of Liver according to Age 
 and Stature. 
 
 females. 
 
 
 Age. 
 
 ID 
 
 
 
 1 8 
 I 3 
 
 CQ 
 
 
 Age. 
 
 1 
 
 
 a. 
 
 Is 
 
 3 
 
 ■a . 
 II 
 
 
 
 
 Centim. 
 
 
 
 
 
 
 Oentim. 
 
 
 
 
 1. 
 
 11 
 
 yrs. 
 
 68 
 
 4 
 
 4 
 
 24 
 
 30. 
 
 30 yrs. 
 
 136 
 
 91 
 
 9 
 
 6 
 
 2. 
 
 1* 
 
 j) 
 
 67 
 
 4 
 
 5 
 
 44 
 
 31. 
 
 30 „ 
 
 138 
 
 10 
 
 8 
 
 3 
 
 S. 
 
 24 
 
 /j 
 
 80 
 
 24 
 
 14 
 
 2 
 
 32. 
 
 30 „ 
 
 139 
 
 10 
 
 9 
 
 5 
 
 4. 
 
 3 
 
 jj 
 
 90 
 
 54 
 
 44 
 
 44 
 
 33. 
 
 30 „ 
 
 132 
 
 10 
 
 10 
 
 ■1 
 
 5. 
 
 34 
 
 jj 
 
 76i 
 
 4 
 
 4 
 
 5 
 
 34. 
 
 30 „ 
 
 150 
 
 10 
 
 8 
 
 9 
 
 6. 
 
 4 
 
 JJ 
 
 77 
 
 2| 
 
 24 
 
 24 
 
 35. 
 
 30 „ 
 
 150 
 
 11 
 
 10 
 
 ■7 
 
 7. 
 
 5 
 
 j} 
 
 91 
 
 4 
 
 2 
 
 1 
 
 36. 
 
 33 „ 
 
 ^146 
 
 9 
 
 9 
 
 4 
 
 8. 
 
 5 
 
 
 87 
 
 7 
 
 7 
 
 3 
 
 37. 
 
 34 „ 
 
 156 
 
 10 
 
 11 
 
 7 
 
 9. 
 
 6 
 
 )> 
 
 90 
 
 51 
 
 5 
 
 44 
 
 38. 
 
 35 „ 
 
 147 
 
 10 
 
 9 
 
 8 
 
 10. 
 
 11 
 
 jj 
 
 124 
 
 10 
 
 8 
 
 3 
 
 39. 
 
 36 „ 
 
 147 
 
 8 
 
 8 
 
 7 
 
 11. 
 
 12. 
 
 jj 
 
 127 
 
 7 
 
 6 
 
 41 
 
 40. 
 
 38 „ 
 
 148 
 
 11 
 
 9 
 
 6 
 
 12. 
 
 14 
 
 
 127 
 
 8 
 
 9 
 
 4 
 
 41. 
 
 40 „ 
 
 142 
 
 13 
 
 11 
 
 6 
 
 13. 
 
 15 
 
 
 131 
 
 6 
 
 7 
 
 6 
 
 42. 
 
 42 „ 
 
 152- 
 
 8 
 
 9 
 
 5 
 
 14. 
 
 17 
 
 J 7 
 
 150 
 
 9 
 
 9 
 
 6 
 
 43. 
 
 42 „ 
 
 142 
 
 13 
 
 12 
 
 7 
 
 15. 
 
 18 
 
 jj 
 
 139 
 
 10 
 
 10 
 
 5 
 
 44. 
 
 42 „ 
 
 142 
 
 9 
 
 8 
 
 4 
 
 16. 
 
 18 
 
 t) 
 
 154 
 
 6 
 
 8 
 
 7 
 
 45. 
 
 43 „ 
 
 152 
 
 13 
 
 8 
 
 6 
 
 17. 
 
 19 
 
 jj 
 
 136 
 
 8 
 
 9 
 
 7 
 
 46. 
 
 47 „ 
 
 150 
 
 8 
 
 9 
 
 .5 
 
 18. 
 
 20 
 
 J} 
 
 136 
 
 9 
 
 8 
 
 3 
 
 47. 
 
 48 „ 
 
 150 
 
 9 
 
 8 
 
 7 
 
 19. 
 
 21 
 
 jj 
 
 142 
 
 6 
 
 7 
 
 4 
 
 48. 
 
 49 „ 
 
 136 
 
 9 
 
 8 
 
 7 
 
 20. 
 
 21 
 
 jj 
 
 138 
 
 7 
 
 8 
 
 5 
 
 49. 
 
 50 „ 
 
 140 
 
 9 
 
 8 
 
 8 
 
 21. 
 
 22 
 
 j| 
 
 152 
 
 8 
 
 9 
 
 44 
 
 50. 
 
 52 „ 
 
 155 
 
 11 
 
 11 
 
 6 
 
 22. 
 
 23 
 
 jj 
 
 146 
 
 8 
 
 9 
 
 5 
 
 51. 
 
 53 „ 
 
 144 
 
 9 
 
 10 
 
 8 
 
 23. 
 
 23 
 
 jj 
 
 158 
 
 9 
 
 10 
 
 5 
 
 52. 
 
 59 „ 
 
 148 
 
 10 
 
 10 
 
 7 
 
 24. 
 
 24 
 
 jj 
 
 147 
 
 9 
 
 8 
 
 5 
 
 53. 
 
 61 „ 
 
 146 
 
 7 
 
 7 
 
 6 
 
 25. 
 
 24 
 
 jj 
 
 152 
 
 8 
 
 11 
 
 6 
 
 54. 
 
 69 „ 
 
 137 
 
 10 
 
 12 
 
 6 
 
 26. 
 
 26 
 
 jj 
 
 .151 
 
 8 
 
 7 
 
 6 
 
 55. 
 
 76 „ 
 
 146 
 
 9 
 
 7 
 
 4 
 
 27: 
 
 27 
 
 JJ 
 
 150 
 
 6 
 
 8 
 
 5 
 
 56. 
 
 79 „ 
 
 144 
 
 8 
 
 7 
 
 7 
 
 28. 
 
 27 
 
 JJ 
 
 152 
 
 9 
 
 8 
 
 6 
 
 57. 
 
 80 „ 
 
 154 
 
 10' 
 
 8 
 
 5 
 
 29. 
 
 27 
 
 JJ 
 
 142 
 
 9 
 
 9 
 
 7 
 
 58. 
 
 80 „ 
 
 150 
 
 10 
 
 7 
 
 44 
 
 TABLE III. 
 
 Average Measurements according to Stature. 
 
 
 Axillary 
 
 Mammary 
 
 Sternal 
 
 No. of 
 
 
 Line. 
 
 Line. 
 
 Line. 
 
 Individuals. 
 
 From 67 to 100 centimetres - 
 
 5.09 
 
 4.23 
 
 2.71 
 
 13 
 
 „ 100 „ 150 „ 
 
 8.88 
 
 8.55 
 
 5.48 
 
 58 
 
 „ 150 „ 160 „ 
 
 9.17 
 
 9.54 
 
 5.88 
 
 35 
 
 „ 160 „ 170 „ 
 
 10.00 
 
 9.56 
 
 6.28 
 
 7 
 
 „ 170 „ 180 
 
 11.00 
 
 11.00 
 
 8.00 
 
 1 
 
 o2 
 
3& 
 
 DIAGNOSTIC VALUE OF ABNORMAL 
 
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SIZES AND FORMS OF THE LIVER. 37 
 
 Apart from the rough outlines of the liver Which are obtained by 
 means of percussion, palpation of the organ, so far as this is practi- 
 cable, is of service for determining its form. In practising palpa- 
 tion, everything must be avoided which can induce tension of the 
 abdominal muscles, and thus interfere with the free penetration of 
 the hand. It is most advantageously performed when the patient 
 is in a recumbent posture, and then the abdominal muscles are 
 most easily relaxed by extreme flexion of the thigh, and by raising 
 the upper part of the body by means of pillows placed under- 
 neath. The hand, which must of necessity have been previously 
 warmed, should be laid cautiously upon the abdominal wall, and a 
 gradually increasing pressure inwards should be made with the 
 points of the fingers in a rotating manner ; by the hasty application 
 of a cold hand, muscular contraction is excited to such a degree, 
 that deep penetration is impracticable. Several attempts are not 
 unfrequently required before an anxious patient is so far composed 
 as not to render the examination unnecessarily difficult through 
 muscular contraction. Many moveable parts, such as a distended 
 gall-bladder, are felt on light application of the hand more distinctly 
 than on firm pressure, by means of which they are displaced and 
 escape from under the fingers j there is no objection, however, to 
 this last mode of examination in the case of solid tumours on the 
 under surface of the liver, although, in order to be successful, pal- 
 pation must always be practised not abruptly, but with a gradually 
 increasing pressure. The liver is most accessible along the outer 
 margin of the rectus; as far as this muscle extends, its tension 
 causes the organ to be felt with difficulty. Of course, the Tmea 
 transversa must not be mistaken for the margin of the liver. 
 
 "When the margin of the liver has been felt with the points of the 
 fingers, we may, by pressing above and below this margin, ascertain 
 its thickness, and whether it has its normal sharpness or round- 
 ness ; we may also, in this way, observe where the rounded margin, 
 characteristic of the right lobe in its normal condition, commences, 
 whether the upper surface is smooth or rough, and whether there 
 exist large, painful nodules, or painless processes of the lobe itself, 
 surrounded by deep fissures. In this way, too, we may obtain a 
 knowledge of the consistence of the organ, whether it is hard or 
 doughy, and also of the motility of tumours, which, in the case of 
 the lobes separated by tight-lacing, is not unfrequently so great, 
 that we can turn the tumour and lay it upon the upper surface of 
 
38 DIAGNOSTIC VALUE OF ABNORMAL 
 
 the organ. In determining the sizes of tuberosities and excrescences 
 of the liver, we must, of course, before we form an opinion as to 
 their real extent, deduct the thickness of the abdominal walls, 
 one or twofold, according to the mode of examination. The 
 margin of the liver should be traced out, so far as this is prac- 
 ticable, to the right and left, and care should be taken- to make 
 out the position of the fissure of the liver, and of the round liga^ 
 ment, inasmuch as a knowledge of their situation is of great service 
 in the diagnosis of displacements of the organ. 
 
 In many cases, the situation of the liver is so high, that every 
 attempt at palpation is fruitless ; in others, the left lobe only can 
 be felt in the epigastrium, and then the examination must be made 
 with peculiar caution, in consequence of the difficulty occasioned 
 by the rectus muscle. 
 
 Inspection of the hepatic region rarely furnishes data for dia- 
 gnosis, which may not be obtained more accurately and completely 
 by means of percussion and palpation. Visible bulgings of the 
 right hypochondrium, whether smooth or nodulated, not unfre- 
 quently result from lardaceous {specJdg) infiltration, from carcinoma, 
 or from echinococci of the liver ; and they may even attain such 
 a prominence, that the boundaries of the organ may be recognised 
 through the abdominal parietes (see Mg. 14) ; these rare cases, how- 
 ever, only raise new difficulties in diagnosis. In most cases, in- 
 spection fails to afford us any assistance, yet on two points, it will 
 be of great service, viz., when there is enlargement of the veins 
 of the abdominal walls, and in reference to the situation of the 
 umbilicus. 
 
 In great enlargements and in displacements of the liver, the 
 situation of the umbilicus is carried downwards, so that it ap- 
 proaches nearer to the symphysis of the pubes, whereas in tumours 
 which arise from the bottom of the abdomen, and fill up the whole 
 of the abdominal cavity, it is pushed upwards towards the sternum. 
 These changes, upon which Ballard* appears to lay some stress, must 
 only be made use of with great caution, because the distances of the 
 umbilicus from the base of the ensiform cartilage, and from the 
 pubes, are susceptible of remarkable differences, even under normal 
 circumstances, as shown by measurements which have been made in 
 these localities. 
 
 Enlargements of the branches of the epigastric veins may exist 
 
 • The physical Diagnosis of Diseases of the Abdomen. London. 1852. 
 
SIZES AND FORMS OF THE LIVER. 39 
 
 in a moderate degree, when the abdominal walls are much distended 
 and tense; where, however, they attain a considerable degree without 
 these last-mentioned conditions, they indicate an obstruction to the 
 circulation of the blood in the vena cava inferior, or in the vena 
 porta. In most cases it is not difficult to determine which of these 
 two vessels is at fault, for when the obstruction has its seat in the 
 vena cava, the venous roots of this trunk are seen to participate in 
 the enlargement from the beginning, whereas they remain for a long 
 time exempt when the portal vein is contracted or closed up< Sub- 
 sequently, under the heads of cirrhosis of the liver and of diseases of 
 the portal vein, we shall return to this subject, and shall also speak 
 of the enlargement of the veins around the umbilicus, described as 
 the caput medusa. 
 
 Auscultation is of little use for the objects under consideration ; 
 it may be of service by assisting in the determination of the dia- 
 phragmatic boundary of the liver. As a result of the compression of 
 the lower lobe of the right lung by enlargement or elevation of the 
 liver, there may be heard, according to "Walshe, along the line of 
 junction of the two organs, towards the end of a deep inspiration, a 
 dry crepitation, or " hepatic compression rhonchus." In a few cases 
 of this nature, I have heard consonating respiratory murmurs, 
 although, as was proved by postmortem examination, no infiltration 
 of the lungs existed. 
 
 b. The Application to Diagnosis of the Results of Observation. 
 
 This is a less simple matter than might at first sight appear; 
 manifold difficulties, which may lead to mistakes, meet us at every 
 step. 
 
 The surface of the liver, which is in contact with the wall of the 
 chest and abdomen, is the part of the organ upon the size of which 
 we must depend for information. The extent of this surface, how- 
 ever, is very variable, even when there is no alteration in the volume' 
 of the liver, inasmuch as the position of the organ is liable to 
 change. Extension in a downward direction, such as results from 
 the pressure of tight clothing, from deformity of the lower part of 
 the chest, and softening of the hepatic parenchyma, brings a larger 
 portion of the surface into contact with the abdominal wall, and so 
 produces an* apparent enlargement; whilst, on the other hand, eleva- 
 tion of the organ, and the change in position produced by distention 
 
40. DIAGNOSTIC VALUE OF ABNORMAL 
 
 of the lower part of the abdomen, bring the anterior sharp margin 
 of the organ in opposition to the abdominal wall, and thus give 
 rise to an apparent diminution. These conditions, as well as con- 
 genital and acquired malformations of the liver, constitute our first 
 difficulties in diagnosis ; others arise from displacement of the entire 
 organ, and from the obstacles which are experienced in determining 
 its boundaries, owing to pathological changes in the adjoining parts. 
 
 1. Congenital and acquired Malformations of the Liver. 
 
 Prom its first formation the liver is liable to numerous abnormali- 
 ties in form, which may easily lead to mistakes in the examination 
 of the organ at the bedside of a patient. In many cases it appears 
 almost quadrangular (Pig. 1.) ; in others, it is furnished with ab- 
 
 Fig. 1. Fig. 2. 
 
 Fig. 1. Liver of an abnormal, quadrangular form: upper surface. 
 
 Fig. 2. The lower surface of a liver presenting an abnormally , 
 rounded outline, so that when in situ, the left lobe scarcely 
 reached to the median line. The right margin is seen to be 
 abnormally fissured. 
 
 normal fissures and rounded, so that its left margin scarcely reaches 
 to the median line (Pig. 2.) ; whilst in other cases, the left lobe is 
 prolonged in the form of a tongue, and stretches far into the left 
 hypochondrium (Pig. 3.). When this is the case, the liver some- 
 times overlaps the spleen, and contracts firm adhesions with the 
 surface of this organ, so that a definition of the boundaries of each 
 ia impossible. (Fig. 4.) 
 
SIZES AND FORMS OF THE LIVER. 
 
 41 
 
 The size and form of the left lobe are, under normal conditions, 
 so very variable, that the determination of its extent mjist only be 
 employed for clinical purposes with great caution. 
 
 Fig. 3. 
 
 Fig. 4. 
 
 Fig. 3. Liver, with an abnormally prolonged left lobe, and a tight- 
 lace depression. 
 
 Fig. 4. Adhesion of the extremity of the left lobe of the liver to 
 the spleen; a section has been made through the line of 
 junction of the two organs. 
 
 To these congenital malformations, a knowledge of which can only 
 be acquired by frequent post-mortem examinations, are to be added, 
 acquired malformations of a still more variable character, partly result- 
 ing from disease of the hepatic tissue, and partly from compression 
 of the organ from without, by deformities in the thorax, &c. Inde- 
 pendently of tumours, carcinoma, echinococci, and abscesses,- which 
 may extend in any direction, the diseases which especially affect 
 the form of the liver, are those chronic morbid processes, which 
 terminate in cirrhotic degeneration of the gland, and which usually, 
 though by no means invariably, occasion an undue contraction of the 
 left lobe, and a retraction of this towards the right side. The an- 
 nexed figure, reduced to one-fourth of the natural size, shows what 
 a remarkable disproportion of the two lobes may result from such a 
 state of matters. (Kg. 5.) 
 
 Here, also, we must include the lobulation of the organ which 
 arises from obstruction of several branches of the portal vein, and 
 from partial inflammations and cicatrization of the hepatic paren- 
 chyma, as, also those rare cases of congenital lobulation, of a nature 
 similar to what is observed in the case of the kidneys. 
 
42 DIAGNOSTIC VALUE OF ABNORMAL 
 
 Much more frequently than these deformities, we meet with, 
 especially in females, abnormalties in the form of the liver produced 
 by tight-lacing of articles of clothing and lateral distortion of the 
 thorax. Provided there is narrowing of that part of the walls, of 
 
 Fig. 5. 
 
 Cirrhosis of the liver, with remarkable atrophy of the 
 left lobe. 
 
 the chest which encloses the liver, we have, as a result of lateral 
 distortion, either displacement of the organ or an alteration of its 
 form. Sometimes the liver is rolled up into a rounded conical mass, 
 but more frequently it is more or less deeply notched, by the turn- 
 ing inwards of the margin of the ribs. From its daily occurrence, 
 the so-called tight-lace liver [SchnMrleber) has an importance in 
 diagnosis greater than is otherwise its duei 
 
 According to the changes in the fashion of dress, tight-lacing in 
 producing a thin waist, affects sometimes a higher and sometimes a 
 lower part of the thorax, and more rarely the hypochondrium 
 beneath the ribs. Of all the organs, the liver suffers the most from 
 this pressure ; not only is its form altered, but in most cases, if we 
 examine it at a late period, its situation and position also. By the 
 narrowing of the base of the thorax, the organ is first compressed* 
 
SIZES AND FORMS OF THE LIVER. 
 
 43 
 
 from side to side, and as a consequence of this, especially when 
 its transverse diameter is considerable, there not unfrequently, is 
 produced a series of folds, which feel like slightly. prominent nodules 
 (Fig. 3). 
 
 At the same time, as a consequence of the circular contraction, a 
 part of the right, and usually of the left lobe also, becomes separated 
 by a depression, the situation of this depression being sometimes higher 
 and sometimes lower, according to the locality of the lacing. The 
 furrow thus formed often penetrates deeply into the parenchyma, till 
 there remains nothing more than a loose ligamentous connection, 
 which allows a free motion of the separated portion (Fig. 6). 
 
 Fig. 6. 
 
 Abscission of the. right lobe of the liver, with thickening 
 of the capsule. 
 
 The serous covering of this portion always appears thickened, and 
 of an opaque white, and the biliary ducts may be seen through the 
 peritoneal coat, enlarged and full of a brownish mucus, the evacua- 
 tion of which is prevented by the constriction (Fig. 7). The veins 
 are invariably enlarged. The margins of the detached portion are 
 rounded and nodulated (Figs. 6 and 8), and its tissue feels firmer, 
 and exhibits a finely-granular appearance, similar to that which we 
 find throughout the entire organ, when there is an obstruction to 
 the circulation of the blood in consequence of disease of the heart. 
 
 In this way there is produced a moveable nodulated tumour in 
 
44 
 
 DIAGNOSTIC VALUE OF ABNORMAL 
 
 the situation of the right lobe of the liver, which feels hard 
 
 Fig. 7. 
 
 Fig 8. 
 
 Fig. 7. Abscission of both the right and lift lobe of the liver, with 
 enlargement of the bile ducts and of the veins below the 
 iight-lace fissure. 
 
 Fig. 8. Abscission of the right and left lobes of the liver : a sec- 
 tion is made showing enlarged vessels in the tight-lace con- 
 striction. 
 
SIZES AND FORMS OF THE LIVER. 45 
 
 nodulated, and may hence be easily mistaken for a new growth. A 
 smaller tumour which may be grasped in the fingers may also be 
 developed upon the left lobe. The possibility of an error in 
 diagnosis, arising under such circumstances, is still farther increased 
 by the fact, that the situation and position of the entire organ are 
 almost always altered in various manners at the same time. 
 
 2. Abnormal Positions of the Liver. 
 
 By abnormal positions we understand deviations from the normal 
 direction of that axis of the liver, which extends from the anterior 
 sharp margin to the middle of the posterior rounded border. This 
 may incline very much downwards, in which case, a large portion of 
 the convex surface of the organ is opposed to the abdominal parietes, 
 and the liver appears larger ; it may, on the other hand, be elevated 
 to such a degree that the sharp anterior margin alone remains 
 opposed to the abdominal wall, and thus the extent of surface yield- 
 ing a dull percussion sound is reduced to a minimum. The liga- 
 mentum pensorium hepatis restricts the movement of the liver only 
 in cases of enlargement ; as Hyrte justly remarks, this is not to be 
 regarded as the true supporter of the liver. 
 
 There are various causes which give rise to these abnormal 
 positions. Sometimes they are the result of mechanical force acting 
 upon the organ from above, or from below; at other times they result 
 from disease, followed by softening of the hepatic tissue. In many 
 cases, there is simply change in position of the organ ; but more 
 generally, along with this, there is dislocation. 
 
 One frequent cause of abnormal positions of the liver is tight- 
 lacing, the operation of which varies according to the part of the 
 gland which is subjected to compression. When the middle or lower 
 portion of the liver suffers from the circular compression of stays, or 
 more commonly of the petticoat strings, the axis of the organ falls 
 downwards, and the edge of the right lobe protrudes far below the 
 margin of the ribs, so that sometimes it may be felt in the region of 
 the caecum close to the crest of the ilium.* The removal of the he- 
 
 * Cruveilhier(Livr. 40, pi. I. p. 5) asks the question, how a liver which 
 has been altered in position through the operation of a tight-laced chest, 
 may be distinguished from that which results from inflammatory en- 
 largement ; and assumes that the former may be diagnosed from its 
 sharp margin. This is a mistake. The right lobe, which is the only 
 part that comes under observation, has always, as the result of tight- 
 lacing, a nodulated rounded margin. 
 
46 
 
 DIAGNOSTIC VALUE OF ABNORMAL 
 
 patic parenchyma along the groove produced by the tight-lacing, con- 
 tributes also to the widening of this groove. "When the groove is deep, 
 
 Fig. 9. 
 
 Dislocation of the liver towards the median line from tight- 
 lacing ; a depressed farrow on the upper part of the right 
 lobe ; apparent enlargement of the organ. 
 
 coils of intestine not unfrequently he in it, and a round solid tumour 
 may be felt in the right iliac region, separated to all appearances from 
 
SIZES AND FORMS OF THE LIVER. 47 
 
 the liver by a space, yielding on percussion a clear tympanitic sound. 
 If the left hjbe is small, it may remain quite unaffected by the tight- 
 lacing j there may, however, be often found upon its margin a 
 moveable rounded detached portion, which can be pushed backwards 
 or forwards. The upper boundary of the organ is either quite un- 
 affected, or may be carried upwards towards the thorax, owing to 
 the application of a constricting force over the upper portion. 
 
 When, on the other hand, the upper third of the liver, where its 
 substance is of considerable thickness, is compressed, the axis is also 
 carried very much downwards, and in most cases the entire organ 
 is at the same time dragged over towards the middle line. The 
 round ligament may then be found opposite the eighth or ninth left 
 costal cartilage, and the middle of the right lobe may correspond to 
 the linea alba, or may even he to the left of this, whilst the left 
 lobe penetrates deeply into the left hypochondrium (Kg. 9). Upon 
 examination, a liver of about the normal size is then, to all appear- 
 ances, remarkably enlarged, from its filling up the entire upper-half 
 of the abdominal cavity : even upon posb~morteto examination, this 
 may be the first impression, until we are convinced of the contrary, 
 by measuring and weighing the organ. 
 
 When, as at the present day rarely happens, the lacing is made 
 below the Ever, or close to its lower edge, the organ is pushed up 
 towards the cavity of the chest, and its upper boundary is elevated 
 one intercostal space or more. 
 
 The confusion of the alterations in the situation of the liver just 
 alluded to, with real enlargements and tumours of the organ, is, after 
 a little practice, easily avoided, inasmuch as, by means of careful 
 palpation, we may detect the depression produced by the lacing ; 
 the marks of the pressure are also often visible upon the skin. It 
 is not, however, to be supposed, that these tight-lacings should 
 always have a remarkable effect upon the arch of the ribs ; as soon 
 as the tight articles of clothing are loosened, the depression dis- 
 appears in a great measure, and is then easily overlooked, unless 
 the pressure exerted has been very great and prolonged. We shall 
 return at greater length hereafter to the diagnosis between the 
 condition of the liver resulting from tight-lacing, and several real 
 diseases of the organ. 
 
 Under certain circumstances, lateral distortion produces the same 
 effects as stays : tumours also, appearing between the liver and 
 diaphragm (unless they lie very far back), and likewise circumscribed 
 
48 DIAGNOSTIC VALUE OF ABNORMAL 
 
 peritoneal exudations, &c, compress the organ in a downward 
 direction. 
 
 The left lobe of the liver may, when perfectly healthy, undergo 
 slight alterations in position, which may be a source of error, owing 
 to changes in the condition of the stomach. When this organ is 
 empty, the left lobe is much depressed, whilst it is elevated when 
 the stomach is full. 
 
 A change in the position of the entire liver in an opposite direc- 
 tion to that above noticed is observed, when large quantities of gas 
 accumulate in the stomach and intestinal canal, or when from 
 ascites, &c, the parts of the intestine which contain air are pushed 
 upwards against the diaphragm. The anterior margin of the liver 
 is then elevated, so that the surface which is in contact with the 
 abdominal parietes is always reduced in extent. Not unfrequently, 
 the anterior sharp edge is the only part which remains opposed to 
 the abdominal wall. When this is the case, the dull space on per- 
 cussion diminishes more and more, until it becomes difficult to 
 detect the liver at all, at the place where the pulmonary sound 
 passes into that of the intestine. In the mammary and axillary 
 lines, it is often quite impossible to do this, because in these situa- 
 tions the margin is surmounted by the distended intestines, but in 
 the axillary line, such an occurrence is exceptional. 
 
 In this state of matters the liver appears considerably diminished, 
 although in reality, its volume is in no way altered. Hence it is a 
 rule which should never be broken, that diminutions of the 
 hepatic dulness, observed in the course of typanites or ascites, and 
 accompanied by elevation of portions of the bowel containing gas, 
 should only be made use of in diagnosis with great reserve. Oft- 
 repeated observations are here indispensable. After the removal of 
 the gases, the results of percussion are frequently entirely different 
 from what they were before. When there has been protracted con- 
 stipation, the bowels should in the first place, be cleared out by 
 means of purgatives. 
 
 Structural diseases of the hepatic parenchyma give rise to abnor- 
 mal positions of the organ only when they are accompanied by soften- 
 ing. This is the case in fatty degeneration and in acute atrophy. 
 The effects of these diseases vary according to the degree of 
 softening. When this is moderate, as may happen in fatty liver, 
 the axis falls downwards, and the gland protrudes farther below the 
 margin of the ribs. Hence a fatty liver usually appears upon per- 
 
SlZES AND FORMS OF THE LIVER. 
 
 49 
 
 mission to be larger than it really is. When the softening is 
 considerable, as in acute atrophy (in which the gland is flexible 
 like a piece of cloth), the liver folds upon itself, and collapses towards 
 the vertebral column, and the space corresponding to it in front is 
 filled up by intestines containing gas. The. hepatic dulness then dis- 
 
 Fig. 10. 
 
 Fig. 10, represents the situation of the parts in a case of acute 
 atrophy of the liver. The organ has become folded upon 
 itself; collapsed towards the spine, the space corresponding 
 to it being occupied by folds of intestine : a, colon ascendens ; 
 b, sigmoid flexure ; c, jejunum ; d, sixth rib. The details of 
 the ease will be found under Observation XV. 
 
50 DIAGNOSTIC VALUE OF ABNORMAL 
 
 appears entirely in front, whilst posteriorly it may still be detected. 
 Kg. 10 represents the relative position of the different parts in a 
 case of acute atrophy, a. Ascending colon, b. Sigmoid flexure. 
 c. Small intestine, d. Sixth rib. 
 
 3. Abnormal Situations. Dislocations of the IAver. 
 
 The liver is frequently entirely dislodged from its normal situa- 
 tion, through the operation of forces compressing it either from the 
 chest, or upwards from the abdominal cavity ; from the same causes 
 its position is also altered. 
 
 The contents of the thoracic cavity exercise a constant influence 
 over the situation of the liver, inasmuch as with every deep in- 
 spiration the organ is depressed from one to one and a,-half centi- 
 metre (two-fifths to three-fifths of an English inch), and rises again 
 upon expiration. Protracted dislocations downwards are produced by 
 all diseases of the thoracic organs, which permanently depress the 
 diaphragm; but the altered situation varies greatly, according as the 
 pressure operates from the right or the left side of the thorax, and 
 partly also, according to the nature of the disease which occasions 
 this pressure, whether it acts more upon one part of the diaphragm 
 than upon another. 
 
 a. In pulmonary emphysema, when this is so considerable 
 that the lungs exceed their normal dimensions, the liver falls 
 downwards from one to one and a-half intercostal space. The 
 displacement is most remarkable when the right lung is chiefly 
 affected. 
 
 b. In pleurisy, with abundant purulent effusion,* and still more 
 so in pneumothorax, marked dislocations of the liver in a down- 
 ward direction are produced. Not unfrequently under such cir- 
 cumstances, the diaphragm is turned convexly downwards, so that its 
 lowest part projects far beyond the margin of the ribs, pushing the 
 liver before it into the abdomen. The resulting situation of this gland 
 is essentially different, according as the exudation is contained in 
 the right or the left pleural cavity. In pleurisy of the right side, the 
 diaphragm becomes archedVionvexly downwards, and depresses the 
 right lobe of the liver, so that its anterior border reaches several 
 inches beyond the ribs. In the case represented in the annexed 
 
 * Slight fibrinous exudations may exist without any remarkable effects 
 upon the situation of the liver. 
 
SIZES AND FORMS OF THE LIVER. 
 
 51 
 
 figure, the anterior margin of the right lobe of the" liver {b) was 
 eight inches below the apex of the ensiform cartilage. (Kg. 11.) 
 
 Fig. 11. 
 
 Fig. 11. Dislocation of the liver resulting from exudation into 
 the right pleural cavity : a, ensiform cartilage; J, lower mar- 
 gin of the right lobe of the liver; e, diaphragm arched 
 downwards. - 
 
 The liver is at the same time pushed towards the left side, and the 
 suspensory ligament is stretched obliquely to the left of the median 
 line. The left lobe is not usually depressed, but on the contrary, 
 owing to the point of suspension of the organ from the suspensory 
 ligament acting as the fulcrum of a lever, it is pushed upwards and 
 to the -left, the apex of the heart lying in front of it. This elevation 
 is, however, by no means of universal occurrence ; it is completely 
 absent when, as often happens, the left lobe is too thin and soft to 
 overcome the resistance from above, or when the mediastinum is 
 
 £2 
 
52 
 
 DIAGNOSTIC VALUE OF ABNORMAL 
 
 pushed by the pleuritic effusion over towards the left, so that it 
 presses upon the left lobe equally with the right. 
 
 In pleuritic effusion on the left side, the change in the situation 
 of the liver is entirely different. It is true that in this case also, 
 when the diaphragm bulges downwards, and the mediastinum is 
 pushed over towards the right, the liver is slightly depressed; but 
 still, the principal displacement of the organ is towards the right, and 
 is of such a character that the suspensory ligament is transported to 
 opposite the eighth or ninth right rib, and the left lobe of the gland is 
 carried completely beyond the middle line to the right side, and at 
 the same time downwards. (Fig. 12.) 
 
 c. Pericardial effusions and eccentric hypertrophies of the heart 
 
 Fig. 12. 
 
 Fig. 12. Dislocation of the liver towards the right side, resulting 
 from effusion into the left .pleural cavity. In this case, the 
 diaphragm projected 4J inches beyond the lower margin of 
 the ribs. 
 
SIZES AND FORMS OF THE LIVER. 
 
 53 
 
 exercise but little influence over the situation of the liver. The 
 former, however, when considerable, may depress the gland to the 
 extent of half or a whole intercostal space, and in this case it is the 
 left lobe which is chiefly affected. (Eg. 13.) The congestive swelling 
 
 Fig. 13. 
 
 Fig. 13. Dislocation of the liver, especially of the left lobe, 
 downwards, resulting from a remarkable effusion into the 
 pericardium : a, pericardium ; b, sixth rib. 
 
 of the liver which is usually present under such circumstances, in- 
 creases this apparent change of situation, which, therefore, must not be 
 judged of from the degree of bulging of the organ below the margin 
 of the ribs. 
 
 In general, it is not difficult to distinguish between the changes in 
 the situation of the liver just mentioned, and hypertrophies of the 
 organ itself. This is especially an- easy matter in emphysema and 
 pneumothorax, in which the low situation of the upper boundary is 
 at once made out by means of percussion. Errors in diagnosis are 
 at the present day quite unjustifiable ; such, for instance, as I have 
 met with in one consultation, where it had to be decided, whether the,. 
 
54 DIAGNOSTIC VALUE OF ABNORMAL 
 
 recommendation of the Marienbad waters, by two experienced 
 physicians, was suitable for a case of suspected enlargement of the 
 liver, which turned out to be an example of displacement of this 
 gland, resulting from pneumothorax supervening upon pulmonary 
 tubercle. It is a more difficult matter to come to a decision in 
 certain cases of dislocation of the liver from right pleuritic effusion, 
 and especially in cases where the layer of exudation in its height and 
 situation does not exceed limits to which an enlarged liver might 
 possibly have risen.* Under such circumstances, when, from the 
 history of the case, no clear information can be obtained as to the 
 mode of development of the affection, and when we are unable to dis- 
 tinguish the conical form, characteristic of tumours, growing upwards 
 into the cavity of the chest from the horizontal boundary, which in 
 most cases distinguishes pleuritic effusions, we must be guided 
 chiefly by the mobility of the liver upon deep inspiration. When 
 this remains unchanged, as can in most cases be made out without 
 any difficulty,t by means of palpation and percussion during a full 
 inspiration, we conclude that the diaphragm, and with it the liver, 
 are not depressed by pleuritic effusion, but that an increase in the 
 ■ volume of the organ has altered the situation of its upper and lower 
 margin. On the other hand, we must not infer with certainty the 
 existence of empyema from an absence of the natural mobility of 
 the liver, because quite independently of this, the diaphragm may 
 lose its contractility through the fatty or fibrous degeneration, which 
 this muscle so often undergoes, when it becomes adherent to 
 tumours, of the liver. This is very often the case with tumours 
 reaching high up into the thorax, 
 
 In addition to the mobility of the liver upon inspiration, it should 
 be noted, whether the cartilaginous margin of the arch of the ribs on 
 
 * This may be considerable: tumours of the liver, as, for instance, 
 echinococci, which grow from the upper convex surface of the organ, not 
 unfrequently elevate the diaphragm as high as the third or second rib. In 
 such a case, when there is also pleuritic effusion, the definition of the 
 upper margin of the liver will depend upon the slight resistance of the 
 swelling growing on the thoracic side of the diaphragm, as compared 
 with that on the abdominal side. 
 
 + We rely here upon the situation of the lower margin of the liver, inas- 
 much as, even when the diaphragm is inactive, there is an apparent 
 depression of the upper boundary during a deep inspiration, in which, 
 owing to the altered position of the ribs, and the enlargement of the 
 thoracic cavity, the margin of the lung extends downwards between the 
 liver and the wall of the thorax. 
 
SIZES AND FORMS OP THE LIVER. 55 
 
 the right side appears to be turned outwards, a circumstance of fre- 
 quent occurrence in enlargement of the liver, but which is not 
 observed in empyema. 
 
 Stokes places great stress in diagnosis upon the depression, which 
 in cases of effusion into the thorax may be made out between the 
 margin of the ribs, and the convex upper surface of the liver. 
 This (as represented in Kg. 11.) is prpduced in the line of contact 
 of the right half of the diaphragm bulging convexly downwards 
 with the upper surface of the liver, and may be often distinctly felt, 
 and sometimes also seen, during life • but for the purpose of 
 diagnosis, it is for several reasons of little value. In empyema 
 producing a bulging downwards of the diaphragm, where the layer 
 of exudation extends to a considerable height, the diagnosis is 
 in most cases easy, quite independently of the existence of this 
 sign; in the more obscure cases, in which this sign would be 
 of value, it is wanting, because here there is not such a remark- 
 able displacement of the diaphragm as to produce it. fre- 
 quently, moreover, even when the depression exists, it cannot be 
 detected, owing to the tension of the abdominal muscles being so 
 great. Lastly, a similar furrow may exist in the case of all nodu- 
 lated tumours of the liver, such for instance, as in very prominent 
 carcinomatous and hydatid tumours, for by the bulging which they 
 occasion, .the liver is removed from the thoracic wall, and thus 
 there is created a space between it and the ribs large enough to 
 admit the finger. 
 
 The following case, which is also interesting in other respects, 
 shows that the obliteration and fluctuation of the intercostal spaces, 
 with displacement of the mediastinum are not, as has been assumed, 
 certain proofs of the existence of empyema. 
 
 Obseevation No. I. . 
 
 Tertiary Syphilis. — Tumour of the liver, which ascended as high as 
 the second rib, and consisted of echinococci along with- lardaceous 
 infiltration. — Bulging and fluctuation of the intercostal spaces. — 
 Displacement of the heart. — Immobility of the tumour upon deep 
 inspiration. — Diagnostic value of exploration by a trocar. 
 
 Wilhelmina Kohler, aged 38, who had formerly been repeatedly 
 treated for secondary and tertiary syphilis, was admitted into the 
 
56 DIAGNOSTIC VALUE OF ABNORMAL 
 
 clinical wards on January 15th, 1855, with oedema of the feet and 
 ascites. On examination of the abdomen, there was found a re- 
 markable enlargement of the liver and spleen. On the right side 
 there was dulness on percussion, extending from the fourth rib to 
 three centimetres above the umbilicus ; on the left side, it appeared 
 impossible to define the boundaries of the spleen. The surface of 
 the liver was somewhat uneven ; its margins felt hard and resist- 
 ant. The spleen extended as far forwards to the anterior extremities 
 of the tenth and eleventh ribs; higher up, its dulness was continuous 
 with that of the liver. Appetite normal ; bowels regular ; stools of a 
 pale brownish colour ; the urine scanty, and of a dirty-yellow colour, 
 but free from albumen and bile-pigment. The colour of the skin 
 was a yellowish-grey; nutrition was but slightly impaired; the 
 menses had ceased for three months. Upon the shin-bones there 
 were syphilitic nodes, which were painful towards night; and old 
 cicatrices could be seen upon the velum-palati. The diagnosis 
 arrived at was syphilitic lardaceous degeneration of the liver 
 {syphiUtische Speekleber) and spleen. Iodide of iron, along with a 
 diuretic infusion, was prescribed. 
 
 The' oedema of the lower extremities completely disappeared after 
 some days, as did, also, in a great measure, the ascites ; the Hver and 
 spleen, however, underwent no alteration in volume, although the 
 preparations of iodine (iodide of iron, and afterwards iodide of potas- 
 sium) were continued for ten weeks. 
 
 During the vacation, which the patient spent in another part 
 of the, hospital, her condition underwent an essential change. A 
 circumscribed pleuritic effusion, causing displacement of the Hver 
 and of the heart, was reported to have made its appearance in the 
 front of the right side of the chest, without the ordinary subjective 
 phenomena of such a lesion. 
 
 At the end of April, when the patient again came under observa- 
 tion in tht clinical ward, the following facts were noted : — The 
 right side of the thorax was distended; in front, the respiratory 
 murmur was completely absent from the second rib downwards, and 
 there was dulness on percussion from the same place down to a level 
 with the umbilicus, and in a line with the mamma as far as six 
 centimetres (2| English inches) below this; posteriorly, vesicular 
 breathing was audible as low as the ninth rib. The fissure of 
 the Hver lay immediately behind the depression of the umbiH- 
 cus, and from this point the left lobe extended to below the car- 
 
SIZES AND FORMS OF THE LIVER. 
 
 57 
 
 tilage of the tenth left rib, where, in the axillary line, it was 
 bounded by the tympanitic stomach-sound. The heart was pushed 
 
 Fig. 14. 
 
 Fig. 14. The appearance presented during life by a patient suf- 
 fering from echinococci of the liver ; a, ensiform cartilage ; 
 b, symphysis pubis ; c, d, e, contour of the liver ; g, situation 
 of the cardiac impulse. The left lobe of the liver has been 
 represented somewhat too large, and extending too low down. 
 
 upwards and to the left, and its pulsation could be seen and 
 felt in the fourth intercostal space, three centimetres (lj of an 
 inch) to the left of the nipple, g. On the left side of the chest, 
 
58 DIAGNOSTIC VALUE* OF ABNORMAL 
 
 slight dulness on percussion, and bronchial breathing, could he 
 detected at the lower and back part — the remains of a pleuritic effu- 
 sion, for which the patient had been under treatment on a former 
 occasion, but otherwise, there was nothing abnormal. The surface 
 and margins of the liver presented, as formerly, slight unevenness 
 and a firm consistence. No depression of the lower margin of the 
 organ upon a deep inspiration was observable. The general health 
 appeared but little impaired, the digestion was unaffected, and the 
 bowels were regularly moved, after a spontaneous diarrhoea which 
 had lasted for a fortnight ; dyspnoea was only complained of upon 
 moving or upon going up stairs. 
 
 The use, for four weeks, of the Karlsbad Mill Springs * did not 
 result in any remarkable diminution of the liver ; its margin only 
 became softer and more flabby, so that it could be doubled in upon 
 itself. 
 
 From time to time, there appeared symptoms of inflammation of ' 
 the capsule of the liver {perihepatitis), which passed away either 
 spontaneously, or after the application of a warm cataplasm; and 
 there were, also, bleedings from the nose occurring once every 
 month with tolerable regularity. 
 
 Now and then the patient left the Hospital to arrange her domes- 
 tic concerns, her condition, during several months, remaining 
 unchanged, under the influence of simple symptomatic treatment. 
 By degrees, however, the ascites increased, and the veins of the 
 abdominal wall, especially those of the right side,. became enlarged 
 to a considerable extent. There, also appeared below the right 
 hypochondrium, a fluctuating bulging, surrounded by the solid 
 parenchyma of the liver; and a similar fluctuation could be de- 
 tected in the lower intercostal spaces. The nature of this fluid 
 appeared doubtful; whether it was serum which lay circumscribed 
 between the liver and the abdominal wall in the meshes of fibrous 
 bands, resulting from oft-repeated attacks of inflammation of the 
 capsule of the liver, or whether it consisted of pus from a pleuritic 
 
 * The Mill Spring (Miiklbrunn) is one of the sources of the Karlsbad 
 water. The Karlsbad Springs are thermal ;' their temperature varying 
 from 122" to 197° Fahr. Their principal chemical constituents are car- 
 bonic acid, the. sulphate and carbonate of soda, chloride of sodium, the 
 carbonates of lime and magnesia, with traces of iron, manganese, iodine, 
 bromine, &c. They are much resorted to for hepatic diseases, and cal- 
 culous affections. — Transl. 
 
SIZES AND FORMS OF THE LIVER. 59 
 
 effusion pressing down the diaphragm, or from an abscess of the 
 liver, or, lastly, whether it was the thin, watery contents of an 
 hydatid cyst. The data furnished by the history of the case, and by 
 direct examination, were insufficient for determining this question. 
 A specimen of the fluid, therefore, was cautiously drawn off on the 
 8th of June, 1856, by means of a fine exploratory trocar. It consisted 
 of a very yellow, clear water, which deposited scarcely a trace of 
 albumen upon the application of heat or the addition of nitric acid, 
 but which contained leucine, and, so far as might be argued from its 
 reaction with chloride of iron, salts of succinic acid. Thus the fluid 
 must have originated from the cysts of an echinococcus. With the 
 determination of this point, all idea as to the existence of a circum- 
 scribed pleuritic effusion on the right side disappeared^an opinion 
 which had become more than probable, chiefly from the information 
 communicated to us, which had been confirmed by the absence of any 
 change in the situation of the liver dependent upon respiration. 
 The displacement of the liver and heart were sufficiently explained 
 by the extension upwards of the hydatid mass. ' 
 
 On the 16th of July, the patient left the Hospital for some days, 
 and exposed herself injuriously, so as to bring on a fatal termina- 
 tion. By the time of her readmission on the 21st, there had arisen 
 considerable oedema of the feet, and extensive catarrh of the air-pas- 
 sages along with oedema of the lungs. * 
 
 On the morning of the 23rd, shivering, pulse 130, great dyspnoea, 
 expectoration of frothy fluid mixed with blood, general lividity. 
 Death from asphyxia occurred about noon. 
 
 The diaphragm on the right side reached as high as the second 
 rib. Above this, there could only be seen in front a bluish-grey 
 membrane, destitute of air, and compressing the middle (b) and 
 upper lobes of the lung ; the lower lobe lay pushed away to the back , 
 wall of the thorax, firmly adherent to this and to the diaphragm. In 
 the left side of the thorax, the heart (e) was pushed upwards and 
 to the left, and had assumed a transverse position, its apex lying in 
 the third intercostal space. The diaphragm upon this side reached 
 nearly as high as the fourth rib, being pushed upwards by a con- 
 siderably enlarged spleen, which had applied itself horizontally upon 
 the upper surface of the left lobe of the liver and lay in contact with 
 
.60 
 
 DIAGNOSTIC VALUE OF ABNORMAL 
 
 the blunt upper extremity of the suspensory ligament. The surface 
 of the liver was united, at many places, to the abdominal wall and 
 to the diaphragm by adhesions, partly recent, and partly of old date. 
 
 Fig. 15. 
 
 Fig. 15. Arrangement of the viscera from the individual repre- 
 sented in Fig. 14. b, middle lobe of right lung ; c, large 
 hydatid cyst ; d, spleen pressed upwards by the left lobe of 
 the liver ; e, pericardium ; /, stomach. 
 
 • 
 The left lobe was intimately adherent to the spleen. The mus- 
 cular tissue of the diaphragm appeared of a pale-yellow colour] upon 
 closer examination, it proved to be in an advanced stage of fatty 
 degeneration. The upper part of the right lobe of the liver was 
 made up of one cyst, the transverse diameter of which was estimated 
 at 9| inches (10£ English inches). It contained thirteen pounds 
 of a bright-yellow, turbulent fluid, and a single large gelatinous 
 bladder, having its inner surface covered with young echino* 
 cocci. The fluid had undergone a great change in consequence of 
 
SIZES AND FORMS OF THE LIVER. 61 
 
 inflammation induced by the puncture; it now deposited, upon 
 the application of heat, an abundant quantity of albumen, which 
 had not been present in the specimen drawn off during life. The 
 surface of the liver was uneven, its parenchyma granular, of tena- 
 cious [zahe) consistence and of a light greyish-brown colour. The 
 entire weight of the liver amounted to 8.68 kilogrammes (19| 
 English pounds avoirdupois) ; the longitudinal diameter' of the 
 right lobe measured 14| (Paris) inches; the transverse, 8J; the 
 corresponding dimensions of the left lobe were 6 and 4f inches, and 
 the thickness of the organ amounted to 7 inches. The spleen was 
 of firm consistence, and of a reddish-brown colour, with a glisten- 
 ing surface on section; it weighed 0.4 kilogramme (14J ounces 
 avoirdupois) ; its length was 6 inches, and its breadth, 4.* 
 
 In the cranial cavity, there was nothing abnormal ; the mucous 
 membrane of the bronchi was of a bright-yellow colour, and covered 
 with bloody froth ; both lungs were very cedematous ; at the lower 
 margin of the left lung, the pleura was thickened, and the paren- 
 chyma was indurated and traversed by enlarged bronchi. 
 
 The right side of the heart was enlarged, but in other respects 
 the organ was normal. 
 
 The mucous membrane of the stomach and of the intestinal 
 canal was pale, and that of the latter was covered with greyish- 
 yellow faeces ; upon the fundament there was a white cicatrix, 
 extending into the rectum, and measuring \\ centimetre (§ inch). 
 
 The urinary and genital organs presented nothing worthy of notice. 
 
 Other observations of a similar nature will be given when we 
 come to treat of hydatids of the liver. 
 
 d. The displacements of the liver, which are dependent upon 
 abnormal conditions having their seat in the abdominal cavity, 
 take, for the most part, a direction upwards, and are then almost 
 always associated with alterations of the axis of the organ. Every- 
 thing which fills up the abdominal cavity and narrows the space for 
 the intestines, or which distends these to. a great extent, may give 
 rise to such displacements : such, for example, as ascites, pregnancy, 
 ovarian tumours, tumours originating from the omentum, or from 
 the kidneys, and, lastly, tympanites, and accumulations of the faeces 
 in the gastro-intestinal canal. Under such circumstances, displace- 
 ments of the liver almost always ensue from the inflated coils of 
 intestine, rising upwards towards the hypochondrium, and pushing 
 • See Note, page 18. 
 
62 DIAGNOSTIC VALUE OF ABNORMAL 
 
 the gland before them towards the thorax, so that its upper border 
 is found behind the fifth, or sometimes even behind the fourth, rib ; 
 the anterior sharp margin, which is moveable, is especially elevated, 
 and is often nearly in contact with the thoracic wall, so that in this 
 way the extent of dull percussion-sound is always reduced, and in 
 the median and mammary lines is scarcely distinguishable. 
 
 It happens much more rarely, that abdominal tumours originating 
 from below, press the liver directly upwards without altering its axis. 
 Ovarian tumours, however, morbid growths in the kidneys, &c, some- 
 times reach the liver and push the organ upwards, so that we can 
 understand how the direction of its axis should be liable to numerous 
 modifications, according to the more or less lateral operation of the 
 pressure. 
 
 It is only in exceptional cases, that pathological changes within 
 the abdominal cavity displace the liver downwards or laterally. 
 Displacement downwards is observed to result from circumscribed 
 peritoneal exudations lying between the diaphragm and the liver, or 
 from hydatids similarly situated; whilst lateral displacements are 
 chiefly produced by great dilatation of the neighbouring portions 
 of intestine, especially of the colon, as a consequence of constriction 
 or compression of more deeply-situated portions, such as the sigmoid 
 flexure, the left curve of the colon and the rectum. I have myself 
 observed great displacement of the liver towards the right concavity 
 of the diaphragm and the ribs of the same side, with consecutive 
 atrophy of the organ, in one individual, in whom, as a consequence 
 of circumscribed peritoneal exudation in the left hypochondrium 
 resulting from a perforating ulcer of the stomach, the descending 
 colon had been compressed, and an accumulation of faecal matters 
 and gases had taken place in the transverse colon. I have noticed 
 a similar displacement of the liver in the post-mortem examination 
 of a man 60 years of age, who died of carcinomatous stricture 
 of the descending colon. At this very date I have under treatment 
 a female with stricture of the rectum from syphilitic cicatrices, in 
 which the colon is almost always distended by gas, or fseculent 
 matter, and pushes the left lobe of the liver across the median line 
 towards the right side. 
 
 4. Difficulties in determining the boundaries of the liver, arising 
 from pathological conditions of the adjoining parts. 
 
 A large proportion of the mistakes in examining the liver, which 
 
SIZES AND FORMS OF THE LIVER. 63 
 
 are made in practice, arise from these causes. Most of them, indeed, 
 may he entirely avoided by a careful examination of the relations 
 of the parts, and with a little practice and experience ; but in some 
 cases the illusion is so complete, that it is a difficult matter to escape 
 being deceived. In many such cases, a great point is gained if we 
 can only determine with certainty that the enlargement of the liver 
 is merely apparent, although its volume cannot be positively deter- 
 mined at every part. 
 
 . The difficulties in determining the boundaries of the liver may 
 proceed from very various parts and organs. 
 
 a. From the Abdominal Parietes. 
 
 The muscular tissue of the abdomen usually exhibits a remarkable 
 degree of tension at such parts as lie over organs which are the seat 
 of pain. In the hepatic region, such partial muscular contractions 
 are frequently observed as a consequence of catarrh and inflammatory 
 conditions of the pyloric portion of the mucous membrane of the 
 stomach, or of. circumscribed peritonitis, perihepatitis, gall-stones, &c. 
 These contractions render the examination difficult, inasmuch as from 
 their hardness and resistance upon palpation, an inexperienced observer 
 may easily mistake them for enlargements of the liver, especially of 
 the left lobe. Such a mistake is avoided by percussion, which does 
 not yield the dull tone, that might have been expected from the 
 degree of resistance on palpation. The percussion-sound is always, 
 however, in such a condition, somewhat shorter and more muffled 
 than natural, in consequence of the violent contraction — a circum- 
 stance which must not be allowed to lead us into error. 
 
 It is a more difficult matter to avoid mistaking inflammatory 
 infiltrations into the abdominal muscles, for swelling or inflammation 
 of the liver, if$ as now and then happens, the disease of the muscular 
 tissue corresponds to the form and situation of this gland. I have 
 met, with one case of this nature, in which the resemblance was so 
 striking, that an old and experienced physician had, in order to re- 
 move an enlargement of the liver {LeberanscAoppung), made the 
 patient drink of the Karlsbad Springs for many weeks before he 
 presented himself at the Clinique. In this case, cataplasms after 
 eight days brought an abscess to maturity, and that which the Castle 
 Spring* had been unable to remove, was easily emptied by means of 
 
 * The Castle Spring (Schlossbriinn) is the name given to one of the 
 springs at Karlsbad. See note, page 58. — Transl. 
 
64 DIAGNOSTIC VALUE OF ABNORMAL 
 
 a bistoury. The diagnosis between the two conditions is generally 
 not difficult, because muscular inflammation is rarely limited pre- 
 cisely by the contour of the subjacent liver. "Where this happens to 
 be the case, the tightness of the skin over the diseased portion of 
 the parietes, the absence of the other abnormal conditions of the 
 liver, and the insignificance of the general disturbance of the system, 
 enable us to distinguish the true nature of the affection. In 
 addition, a satisfactory confirmation is afforded by the gradually 
 diminishing dulness of percussion, which is much more sharply 
 defined, and terminates more abruptly in cases of enlargement 
 and abscess of the liver. Even Galen was aware of this point of 
 distinction, and by means of it diagnosed the existence of an abscess 
 of the abdominal walls, in a person named Stesianus, in whom other 
 physicians believed there was an abscess of the liver. 
 
 6. From diseases of the Parietal Peritoneum. 
 
 There are likewise certain cases of circumscribed peritoneal exu- 
 dations, and of cancer of the peritoneum, which may puzzle our 
 judgment respecting the volume of the liver. The discrimination of 
 the former of these conditions is especially difficult, when the exuda- 
 tion lies in the hollow of the diaphragm and pushes the liver before 
 it. In such a case, when the previous history does not give us any 
 assistance, the diagnosis may be impossible, as I have myself ex- 
 perienced. When, however, as more generally happens, the exudation 
 extends beyond the boundaries of the liver, the nature of the case 
 may be easily recognised from the thinness of the layer of exudation 
 causing a very gradual diminution of the dulness on percussion — a 
 sign which, in several instances, we have found to be a sure guide in 
 distinguishing the exudations which frequently take place in the left 
 hypochondrium, from tumours of the spleen. Exudations of a con- 
 siderable amount occurring between the liver and the diaphragm 
 produce, also, a bulging of the right hypochondrium, fluctuation in 
 the enlarged intercostal spaces, and paralysis of the diaphragm. 
 Cancer of the peritoneal membrane is in general easily recognised 
 from its irregular distribution. 
 
 General or circumscribed accumulations of gas in the peritoneal 
 cavity, such as result from perforation of the stomach, may partially 
 or entirely cover over the liver, and render it inaccessible to percus- 
 sion. The presence of these accumulations is in general revealed by 
 
SIZES AND FORMS OF THE LIVER. 65 
 
 the equable arching of the abdomen, by the history of the case, 
 and by their being preceded or accompanied by the symptoms of 
 peritonitis from perforation. 
 
 c. From Diseases of the small and large Omentum. 
 
 These are, for the most part, of rare occurrence, and can, only 
 in exceptional cases, embarrass the examination of the liver. I give 
 two examples from my own experience, in one of which the nature 
 of the affection could not be diagnosed. 
 
 Observation No. II. 
 
 Cancer of the lesser Omentum. — Compression of the Portal Vein 
 and Atrophy of the Liver. — Ecchymoses in the serous covering of 
 
 C. Hesse, aged 62, had suffered for -some months from increasing 
 emaciation, oedema of the feet, and derangement of digestion. The 
 abdomen was painful, and there was a semiglobular prominence in 
 the right hypochondrium and epigastrium. Here there could be 
 felt a tumour covered with nodules from the size of a walnut to 
 that of an apple, which could be traced as far as six centimetres 
 (2§ Eng. inches) below the umbilicus, and which extended into the 
 left hypochondrium. In it there could be felt distinctly fluctu- 
 ating cysts, surrounded by a dense margin, some of them of the 
 size of half a walnut, or more. The tumour disappeared beneath 
 the ribs, and by means of percussion could be traced upwards as far 
 as the middle of the fourth intercostal space. Its longitudinal dia- 
 meter in the median line amounted to 32 centimetres (12£ inches). 
 The intestinal canal was full of gas j some fluid effusion could be 
 felt in the lower part of the peritoneal cavity ; the spleen was en- 
 larged, reaching to the margin of the eleventh rib. 
 
 The tongue was covered with a greyish-yellow coat, there was 
 loss of appetite, and a feeling of fulness after every meal. The 
 bowels were inactive, and the stools of a pale-brown colour. Pulse 
 60. No jaundice. 
 
 The tumour, which could nowhere be isolated from the liver, and 
 which, also, formed part of its contour, was of course regarded aa 
 a tumefaction of this organ, and as certainly due either to a cancer 
 
66 DIAGNOSTIC VALUE OF ABNORMAL 
 
 containing cysts, or to an hydatid. The latter opinion was counter- 
 indicated by the great tenderness of the tumour upon pressure, the 
 absence of the tremulousness of hydatids, and the firm Consistence 
 of most of the nodules, the number of which, moreover, greatly 
 exceeded the usual number of hydatids. A small quantity of the 
 fluid contents was carefully drawn off from one of the cysts, with a 
 fine exploratory trocar. This specimen contained blood and abun- 
 dance of albumen. It differed also entirely from the fluid of hydatids. 
 Thus, the only tenable hypothesis was that of cancer. 
 
 Infusion of rhubarb, with cherry-laurel water and acetic ether, 
 were prescribed. On the following day, November 11th, 1854, in 
 consequence of a copious evacuation, the abdomen was less tense, 
 and the tenderness less ; the loss of appetite remained the same. 
 On the 13th, the patient's condition remained unchanged; the 
 exhaustion had increased, and the cysts emptied on the 10 th, had 
 become refilled. Pulse small, 72. 
 
 On the 16th of November, death supervened under symptoms of 
 oedema of the lungs. Upon post-mortem examination, nothing 
 abnormal was found in the cranial and thoracic cavities, except the 
 ordinary changes of old age, and the oedema of the lungs. 
 
 In the abdominal cavity there was an abundant effusion of bloody 
 serous fluid ; the parietal peritoneum, as well as the serous covering 
 of the small intestine, were covered with numerous ecchymoses, from 
 the size of a lentil to that of a pea, which were so densely studded 
 together, that the serous membrane appeared of a reddish-brown 
 colour. The spleen was enlarged by one-half, and contained much 
 blood. The tumour, situated in the right hypochondrium, extended 
 as high as the lower margin of the third rib. It consisted, for the 
 most part, of a soft, greyish-yellow mass of medullary cancer, with 
 numerous cysts, the size of a walnut, scattered through it, which 
 sprung from the small omentum, covered over the stomach and 
 transverse colon, and penetrated from below upwards (in the form 
 of a wedge) into the parenchyma of the liver. This last was con- 
 siderably atrophied, and lay deep in the hollow of the diaphragm. 
 The gall-bladder was visible upon the upper surface of the cancerous 
 mass. The portal vessels, especially the right branch, were com- 
 pletely compressed at one part by the cancer. The pancreas, mesen- 
 teric glands, kidneys, and urinary-bladder were free from disease. 
 
 It is impossible during life to distinguish a new growth of the 
 nature just mentioned, from a tumour of the liver, and the margins 
 
SIZES AND FORMS OF THE LIVER. 67 
 
 of the two pass so insensibly into one another, that we cannot 
 imagine any possibility of isolating the one from the other by means 
 of palpation through the abdominal wall. 
 
 Similar, although usually slighter difficulties in diagnosis, may 
 result from cancer of the great omentum. Here, the problem to be 
 solved is in general simplified from the fact, that the nodulated 
 tumours in the great omentum, almost always leave some parts 
 unaffected, through which the clear intestinal sound is transmitted, 
 so that the absence, of continuity in the dull percussion sound must 
 prevent our mistaking them for new growths in the liver. But to 
 this there are exceptions, although they are of rare occurrence. In 
 Kg. 16. is represented the position of a cancer of the great omentum, 
 
 Fm. 16. 
 
 Fig. 16. Cancer of the great omentum, forming a mass which 
 filled up the entire abdominal cavity. The dulness on per- 
 cussion during life was continuous with that of the liver, and 
 the omentum was so thick that the clear intestinal sound 
 could nowhere*be distinguished through it. 
 
 which extending from the liver, filled up the entire abdominal cavity. 
 The thickness of the omentum was so remarkable, that upon percus- 
 
 F2 
 
68 DIAGNOSTIC VALUE OF ABNORMAL 
 
 sion the intestinal sound could nowhere be detected. Tubercular 
 infiltrations of the omentum also now and then attain a similar 
 thickness. I have found the omentum, from this cause, upwards of 
 an inch in thickness. 
 
 d. From abnormal conditions of the Stomach and Intestine. 
 
 The great mobility of the intestinal tube, which allows of manifold 
 changes in its situation, not unfrequently embarrasses the examina- 
 tion of the liver in a high degree, and the more so as the deter- 
 mination of the situation of the intestine is rendered uncertain from 
 its contents being sometimes gaseous, and sometimes solid.* 
 
 Accumulations of fseces in the transverse colon, if they are 
 limited to the right hypochondrium, may very easily be mistaken for 
 smooth or nodulated tumefactions of the liver. "When the portion 
 of colon which lies below the anterior margin of the liver, is filled 
 with solid excrement, it produces an increase of the dull percussion 
 sound, which is the more readily referred to this gland, as not un- 
 frequently from the bile ducts being at the same time compressed, 
 there is more or less jaundice. Even palpation may appear to con- 
 firm this supposition, and sometimes even to strengthen it, for 
 in addition to the enlargement, nodulated tumours similar to 
 cancer may be felt. The hard knotty scybala which exist under 
 such circumstances may easily be mistaken for cancer by the inex- 
 perienced observer. Cases of this nature are met with most frequently 
 in women; and, were it necessary, I could furnish the details of 
 an entire series of them.f In general, it is not difficult to avoid 
 
 * The situations*of the large intestine, in relation to surrounding parts, 
 are very various, and are hence difficult to determine. Long ago, De 
 Haen, in his "Ratio Medendi," took notice of this circumstance, and gave a 
 number of sketches of abnormal situations of this bowel, which appeared 
 to him of practical importance. Annesley also published some interesting 
 examples in his " Atlas." For some years I have had drawings made of the 
 appearances of this nature, which presented themselves on post-mortem 
 examination, and I shall bring forward the most important of these in a 
 subsequent memoir upon diseases of the large intestine. This circumstance 
 claims our consideration, not only in diagnosis, but also in reference to 
 many other points. 
 
 f One example is here annexed, which is interesting from the fact that 
 a double displacement had taken place. A female, aged 25, living in the 
 country, who had already aborted several times, believed that she was in 
 the family-way, owing to the cessation of menstruation, the presence of 
 
SIZES AND FORMS OF THE LIVER. 69 
 
 mistakes in diagnosis arising from these causes. Swellings due to 
 accumulation of faeces are seldom confined to tlie ordinary boundaries 
 of an enlarged liver; they pass beyond this on one side or another, in 
 such a manner as could not be imagined to take place from increase 
 in the volume of this gland. The abdominal parietes are not too thick 
 to prevent our distinguishing the peculiar doughy feel, upon palpa- 
 tion, furnished by faecal matter, from the firmer consistence of the 
 liver. In doubtful cases, we must not forget the valuable rule, to 
 
 squeamishness, &c. The ordinary medical attendant enjoined the strictest 
 rest, which, from her anxiety to avoid, at any price, a fresh abortion, she 
 maintained by lying for six months upon a sofa. A vaginal examination 
 was not permitted ; it was only by feeling the abdomen, that the medical 
 man recognised a rounded tumour rising up out of the pelvic cavity, 
 and reaching by degrees to the umbilicus. Meanwhile, the anxiously- 
 expected movements of the child did not make their appearance ; and, 
 notwithstanding the most careful nursing, the young woman fell away, 
 became of a pale-yellow colour, lost her appetite, got oedema of the feet, 
 and at length complete jaundice. A second medical man who was called in, 
 declared that the disease was an enormous swelling of the liver, and 
 denied the existence of pregnancy ; in opposition to which, the first medical 
 man urged the fact (which he had observed) of the tumour growing up- 
 wards from below. On my opinion being asked, I examined the abdomen 
 more closely. It was remarkably distended and tender ; a tumour was 
 seen rising up from the left side of the cavity of the pelvis, which felt 
 doughy, and at the umbilicus extended 1 J inch beyond the median line ; 
 the cascal region yielded a clear tympanitic sound as far as the linea alba. 
 The hepatic dulness, in a line with the mamma, extended from the fifth ■ 
 rib to 8 centimetres (3£ inches) below the arch of the ribs, but in the 
 axillary line did not pass beyond the margin of this arch. Transversely, 
 through the epigastric region, there ran a cylindrical swelling, which was 
 tender upon pressure, and which yielded, upon percussion, at some places 
 a clear sound, and at others a dull one. The bowels were moved every second 
 day, and the colour of the stools varied, being sometimes pale and sometimes 
 dark. Hence, I expressed my opinion that pregnancy did not exist (an 
 opinion which was contradicted by the form, and more especially by the 
 doughy consistence of the swelling, which could have only arisen from an 
 unusually long sigmoid flexure distended with faecal matter), and that the 
 condition of the liver could only be judged of after the evacuation of the 
 intestinal canal. By means of clysters, and compound infusion of senna, 
 an extraordinary amount of faeces was evacuated. After eight days, it 
 was reported to me that the lower tumour had disappeared, that the liver 
 was much smaller, and that the jaundice had diminished. Three weeks 
 later, when the patient presented herself to me, after having drunk of the 
 Kreutzbrunnen Springs of Marienbad, no enlargement of the liver was any 
 longer to be detected ; — by means of purgatives she had lost her hope of 
 a child, and, at the same time, her anxiety about a diseased liver. 
 
70 
 
 DIAGNOSTIC VALUE OF ABNORMAL 
 
 clear out the intestinal canal before examining the liver, and not to 
 be deterred from this, by the statements of the patient, to the effect 
 that he has a daily evacuation, or occasional diarrhoea, because con- 
 siderable accumulations may be present notwithstanding. 
 
 The intestinal canal sometimes embarrasses the examination of 
 the liver in another way, namely, from folds of the large intestine, or 
 more rarely of the small, being interposed between the gland and 
 the abdominal wall. In most cases, it is the first curve of the 
 colon which is pressed forward, and lies upon the upper surface, 
 sometimes of the right (Fig. 17.), and sometimes of the left lobe. 
 
 Fig. 17. 
 
 Fig. 17. Represents a case in which the right lobe of the liver 
 was found overlapped by the first curve of the colon. 
 
SIZES AND FORMS OF THE LIVER. 
 
 71 
 
 One must suspect such a superposition of the colon upon the liver, 
 wheu the diameter of the liver at one part is found, upon percus- 
 sion, to be unusually small in comparison with that at an adjoining 
 part. In many cases, almost the entire length of the colon lies over 
 the liver, so that a determination of the size of this, organ is impos- 
 sible. (Eig. 18.) 
 
 Fig. 18. 
 
 Fig. 18. Represents a case in which the entire liver was 
 covered by the colon. 
 
 The large intestine is sometimes of such unusual length, as to 
 assume situations which could scarcely have been expected. I have 
 before me the sketch of a distribution of the parts which I met with 
 some days ago in the post-mortem examination of a man, 33 years 
 of age ; the middle part of the liver is represented as covered by the 
 fold of the sigmoid flexure, whilst the lateral parts are hidden by the 
 transverse colon lying above this fold. Such displacements of the in- 
 testine are usually only temporary. There are cases, however, in which 
 they continue for mouths, and finally lead to atrophy, and to the 
 formation of depressions upon the upper surface of the gland.* 
 
 * An observation of this nature was made in this Clinique, in the case 
 
DIAGNOSTIC VALUE OF ABNORMAL 
 
 The stomach contributes more rarely than the intestinal canal to the 
 ibarrassment of the examination of the liver. The obstacles which 
 stomach distended with food opposes to the determination of the 
 ie of the left lobe of the liver, are easily avoided, if a proper time 
 ) selected for the examination. When the stomach is completely 
 apty, the left lobe, as has already been observed, falls somewhat 
 >wnwards. 
 
 It is much more difficult to distinguish cancer of the stomach, 
 pecially of its pyloric portion, and tumours of the head of the 
 mcreas, from tumours situated on the under surface of the liver, 
 ases occur in which these parts become so intimately united by 
 Ihesions, and in which the diseased pylorus is so completely 
 jvered by the liver, through the greatest part of its extent, that 
 i is impossible to distinguish them by either palpation or per- 
 iission. In such cases, the other symptoms of cancer of the pylorus, 
 ie enlargement of the stomach, the characteristic vomiting, &c, 
 ecide the matter. The jaundice is here but of slight importance 
 s a symptom localising the disease in the liver, because cancerous 
 Kudations in the pylorus and pancreas very often close up the 
 'actus choledochus, without affecting the parenchyma of the liver. 
 
 e. From Diseases of the Kidneys. 
 
 It. is only very extensive tumours of the kidneys, such as medul- 
 iry cancers, echinococci, and hydronephroses, which come to be 
 onsidered here, for the smaller ones are much too deeply situated 
 o be confounded with hepatic affections. In most cases, the dia- 
 uosis is facilitated by the fact that enlargements of the kidneys are 
 overed by folds of intestine containing gas, which is not usually 
 lie case with those of the liver. According to my experience, the 
 welling which depends upon large cancers of the kidneys, is, in 
 lost cases, situated in the caecal region, in contact with the abdo- 
 ainal wall, and is then separated from the liver by portions of 
 iowel. I only remember one patient in whom this was not the 
 ase, and in whom cancer of the kidney had been mistaken for 
 ancer of the liver. The tumour of the kidney, as large as a child's 
 
 f a man, 48 years of age, in whom, during three months, a fold of tie 
 olon covered over the left, and part of the right, lobe of the liver. The 
 isplacement, which was made out during life, was confirmed by post- 
 \ortem examination. 
 
SIZES AND FORMS OF THE LIVER. 73 
 
 head, was in contact with the under surface of the liver, and had 
 pushed this organ upwards almost an entire intercostal space. It 
 was not covered by coils of intestine containing gas. On the 
 patient's back it was easy to pass the finger into a space between 
 the swelling and the margins of the rib, a sign which, as Bright 
 has justly observed, contra-indicates cancer of the liver. In 
 the case just mentioned, the tumour could only be mistaken for 
 cancer of the liver, by assuming that there was a new growth pro- 
 jecting, in an isolated manner, from the posterior part of the liver. 
 But such growths never protrude so far from the parenchyma of the 
 liver, in which they he embedded, as mast have been assumed to be 
 the case in this instance. "When tumours of the kidneys are pre- 
 sent, we must not calculate upon finding, upon that account, a 
 prominence in the lumbar region close to the margin of the qua- 
 dratus muscle, which may serve for distinguishing them from hepatic 
 affections ; such a prominence is usually sought for in vain, because 
 tumours of the kidneys, in their development, take chiefly a direc- 
 tion forwards and downwards. 
 
 The following instructive case may farther illustrate the relative 
 situations of these organs in disease. 
 
 Obseevation No. III. 
 
 Cancer of the Bight Kidney. — Displacement of the Liver upwards 
 and to the left. 
 
 J. Bother, a boy aged 16, a pupil in the Blind Institution, after 
 having been treated for a long period in the surgical division of the 
 Hospital, was removed, on the 19th of August, 1856, to the medi- 
 cal department. Tor three weeks before, there had been observed 
 a tumour, rapidly increasing in extent, which projected from under 
 the right arch of the ribs, and was covered with enlarged cutaneous 
 veins. It was smooth and elastic, appeared to fluctuate in some 
 places, and was notably displaced upon a deep inspiration. Percus- 
 sion in the mammary, as well as in the axillary lines, yielded a dull 
 sound, extending 21 centimetres (8J inches) downwards from the 
 third rib. This dull space stretched backwards as far as the sixth 
 dorsal vertebra ; it could be traced beyond the epigastrium as far as 
 the axillary line on the left side, and upwards as high as the fifth 
 left rib ; the lower intercostal spaces of the left side were widened. 
 
H DIAGNOSTIC VALUE QF ABNORMAL 
 
 Tke impulse of the heart was felt between the third and fourth ribs. 
 Pulse 12.0 to 130 ; respiration free ; appetite moderate ; stools nor- 
 mal ; urine pale, and containing neither albumen nor blood. 
 
 The boy became rapidly anaemic, so that death ensued as early as 
 the 24th of September. Upon post-mortem examination, the liver 
 appeared remarkably enlarged ; it filled up both the hypochondria 
 and the epigastrium, as far as the umbilicus ; the diaphragm was 
 pushed upwards by it as high as the third rib on the right side, and, 
 on the left side as high as the lower border of the fourth ribs. At 
 the same time, the organ was compressed on the right side, so 
 that the suspensory ligament lay in the left mammary line, and the 
 gall-bladder to the left of the linea alba. Upon closer inspection, it 
 was found that the apparent enlargement of the liver depended 
 upon an enormous cancer, which sprung from the right kidney, and 
 had compressed the right lobe of the liver so as to reduce this to 
 the thickness of a mere membrane. This tumour was bounded exter- 
 nally by a firm capsule, and consisted of a white mass of medullary 
 cancer interspersed with numerous apoplectic patches. The tumour 
 weighed 8.7 kilogrammes (19 pounds avoirdupois). Close to the 
 suspensory ligament, there were embedded in the substance of the 
 liver a couple of cancerous nodules, the size of beans. Similar 
 secondary deposits were found in the upper lobe of the left lung; 
 the lower lobe was compressed. The heart was moved upwards, but 
 otherwise normal; the spleen was anaemic, and of moderate size; 
 the stomach and intestinal canal exhibited no important structural 
 change ; the left kidney was hypertrophied. 
 
 It is not my present object to enumerate all the causes of mis- 
 takes in diagnosis, which may throw uncertainty over the results of 
 clinical examinations of the liver. I wish merely to communicate 
 those which my experience in practice, and in the post-nwrtm 
 theatre, has pointed out to me as the most important and the most 
 necessary to be borne in mind. 
 
 He who wishes to master this department of the diagnostic art, so 
 far as it is practicable,* or even he who would avoid with certainty 
 
 * I have not considered here, displacements of the liver by aneurisms 
 of the aorta, or of the hepatic artery, or by retroperitoneal tumours, 
 because I have met with no complete case of this nature, that is to say, 
 in which there was an opportutaity of following it up by post-mortem 
 examination. What has been already communicated must suffice for 
 correcting our diagnosis under such circumstances. 
 
SIZES AND FORMS OF THE LIVER. 75 
 
 the commission of great blunders in diagnosis, must study the rela- 
 tive situation of the abdominal viscera in their pathological condi- 
 tions, have great experience in post-mortem examinations, and 
 neglect no opportunity of rectifying and extending his clinical know- 
 ledge upon this head. The practice of determining with accuracy 
 and certainty the boundaries of solid tumours in the abdominal 
 cavity, by means of the pleximeter, is the school for this work; 
 but he who thinks that this will suffice, must not be surprised if 
 his diagnosis be frequently corrected by post-mortem examination. 
 
76 JAUNDICE. 
 
 CHAPTER IV. 
 
 JAUNDICE. 
 
 {Icterus, Auriga, Morbus Regius, Morbus Arguatus.) 
 
 1. Historical Account. — The yellow-tinging of the skin, and of 
 several of the secretions by bile-pigment, has always greatly engaged 
 the attention of physicians. Accompanying this condition we meet 
 with a series of diseased processes, which, tinder the names of icterus, 
 bilious fever, bilious conditions, &c., even in the infancy of medicine, 
 and from that period through all ages down to our own day, have 
 been studied sometimes more zealously, and at other times less so, 
 according to the prevailing constitution of disease, and local influ- 
 ences. Copious materials have accumulated in the course of time,* 
 and theoretical views of various natures have started up and fallen to 
 the ground, without the most important fundamental questions 
 having received a satisfactory explanation. 
 
 Passing over the detailed history of the subject, we meet with two 
 principal theories concerning the different forms of disease under 
 discussion, Which we shall, in the first place, treat of collectively, be- 
 cause the distinctions between certain varieties of jaundice and 
 bilious fevers t cannot everywhere be accurately defined. Of these 
 two theories, sometimes the one has found its supporters, sometimes 
 the other, and not unfrequently both at the same time. 
 
 1. One of these theories is, that the seat of these diseases is to be 
 looked for in a disturbance of the functions of the liver; that they 
 arise from abnormalities in the secretion, or in the excretion of bile; 
 and that thus they exhibit symptoms indicative of derangement of 
 the liver. 
 
 * See Eisenmann, Krankheitsfamilie Cholosis. Erlaugen, 1836. 
 
 t In order to circumscribe somewhat the extremely vague collection of 
 morbid processes formerly designated by this name, we include here only 
 those forms which are accompanied by a jaundiced-tint of the skin and of 
 the excretions. 
 
HISTORICAL ACCOUNT. 77 
 
 During the time of Hippocrates, and down to the decline of the 
 doctrines of Galen, bile secreted in excessive quantity, or of bad 
 quality, was regarded as a fruitful source of diseases ; its overflow 
 into the body, its passage from the abdomen into the blood, and 
 its abnormal colour, were looked upon as so many etiological im- 
 pulses, from which numerous disturbances took their origin. The 
 cause of these anomalous conditions remained undetermined ; per- 
 sons were contented with collecting observations, and bringing them 
 into harmony with the predominant opinions of the day. 
 
 When, in the sixteenth century, the views concerning the func- 
 tional importance of the liver began to assume another form, these 
 theories underwent a change, and, as usually happens, passed over 
 almost to the opposite extreme. Paracelsus and Yan Holmont 
 rejected almost all the pathogenetic properties of the bile; the 
 former, on the ground that this secretion was nothing more than 
 a useless refuse ; the latter, because he thought it impossible that 
 such an excellent fluid, the very balsam of life, could give rise to 
 disease. 
 
 This change of opinion, however, had but a short duration, and 
 was never generally recognised. Even Sylvius * again, regarded the 
 bile as an important source of disease, in a similar manner to the 
 ancients, except that the theory of its mode of action was transferred 
 to a chemical basis. The opinions concerning jaundice and the allied 
 affections were so far cleared up, that a disturbance in the evacuation 
 of the secretion formed in the liver was always distinctly recognised 
 as the cause of an excess of bile in the blood, the more the zeal 
 for anatomical studies increased. The question as to whether there 
 could be a suppression of the secretion was sometimes affirmed and 
 sometimes denied, according as the liver or the blood was regarded 
 as the seat of the secretion of bile. The supporters of the latter view, 
 who, like Glisson, looked upon the liver as only a peculiar organ for 
 filtering the bile from the blood (peculiare eollatorium), who main- 
 tained that interruption of the functions of the organ was the cause 
 of bilious conditions of the system, and who included among them 
 such weighty names as those of Morgagni, Boerhaave, Van Swieten,t 
 and others, gradually lost ground in opposition to those who, like 
 
 * Opera Omnia, p. 469. 
 
 t Comment, in H. Boerhaave, Aphor. III. 127. Semper autem supponit 
 (icterus) vel impeditam secretionem a sanguine venae portarum vel im- 
 pedimentum tollens liberum exitum bilis secrete in duodenum. 
 
78 JAUNDICE. 
 
 Monro,* Eller,t Werlhof, Selle,t Reil,§ &c, believed that jaundice 
 arose only from an "obstruction to the excretion of bile. The argu- 
 ments, which at that time were urged against jaundice being the re- 
 sult of a suppression of the functions of the liver, have been collected 
 in Marcard's " Medicinischen Versuchen" {Part I. p. 12). 
 
 The same results were arrived at by W. Saunders, || who was the 
 first to investigate experimentally the passage of the bile into the 
 blood. 
 
 In more recent times this theory has acquired a still firmer foun- 
 dation, since the chemical and physical properties of the bile have 
 begun to be examined more carefully, and since the constituent 
 elements of this secretion have been sought for in vain in the blood 
 of the portal vein, and likewise of other vessels. It became, there- 
 fore, necessary in all cases and forms of jaundice to search for causes, 
 which could obstruct the evacuation of the biliary ducts. For most 
 of the forms of jaundice, this could be done without difficulty ; but in 
 other cases, no material proof of such obstructions could be fur- 
 nished, however readily catarrhal constriction of the ducts was 
 assumed to exist ; even the spasmodic contractions and paralysis to 
 which they were supposed to be liable, could not always suffice. 
 
 Such forms consequently remained unexplained, seeing that the 
 experiments of physiologists were not taken into account, and as 
 there was an unwillingness to adopt any new theory. The conse- 
 quence has been, that a large proportion of physicians, such as 
 Darwin, Aiidral,Tf H. Mayo, "Watson,** Budd,ft &c., have maintained 
 that the bile does not originate in the liver, but is previously 
 generated in the blood, and that thus, anything which interferes with 
 its elimination may give rise to jaundice. Even in Germany opinions 
 
 • Account of the Diseases of British Military Hospitals, p. 206. 
 
 t De cognosc. et curand. morb., p. 221. Icterum oriri non posse nisi 
 bills prius a sanguine segregata ejusque circulo deinceps commista. 
 
 % De curand. horn, morb., Ed. Sprengel, p. 184. Secretionis bilis im- 
 pedimenta icterum efficere nequeunt, quum bilis secretione producatur. 
 
 § Icterus est bilis jam in hepate secretse redundantia in sanguinem ex 
 qualicunque excretionis impedimento. 
 
 || Abhandlung iiber die Structur der Leber. Leipzig, 1 795, S. 60. 
 
 II Bullet, des Sciences mSd. 1816. 
 
 ** Prakt. Heilkunde iibers, von Steinau. Bd. IV., S. 264, ff. 
 
 +t Diseases of ttie Liver, p. 374. " In a large proportion, perhaps in the 
 greater number of cases, jaundice results primarily and solely from the 
 secretion of bile being suppressed or deficient." 
 
HISTORICAL ACCOUNT. 79 
 
 have recently been expressed in favour of this view, although the 
 repeated chemical analyses of the blood of the portal vein, as well as 
 the experiments of extirpating the liver, have thrown a new light 
 upon the secreting function of this organ. Many pathologists, how- 
 ever, reject both theories. 
 
 2. The second theory is, that under morbid conditions of the sys- 
 tem, substances are formed in the blood without the co-operation of 
 the liver, which in colour and other properties resemble the ingre- 
 dients of bile, if they are not identical with them; but which only 
 assume a pathological importance from their quantity being in excess. 
 
 This view as to the formation of bile, if we except obscure hints 
 at it, already existing in the writings of Galen, Sydenham, Baillou, 
 &c, was first clearly announced by Bianchi : * " Sunt duo primaria 
 icteri genera, primae classis icterus a vitio hepatis, alterius speciei 
 icteritia a causa solutiva sanguinis." The same view was fully dis- 
 cussed by Grant, f who assumed that the yellow material of the serum 
 consisted of bile, and who attributed the causes of bilious diseases to 
 an excessive quantity, or to alterations in the quality of this fluid, 
 quite independent of the liver. 
 
 This theory was also maintained by Beil in his " Tractatm de 
 Polycholia" published in 1782 ; ten years later, however, he retracted 
 his opinion, in the " Memorabil. Clinic" (Fasc. IV. p. 48), in 
 which he attributed the change of the fluids in question to an ab- 
 normally increased activity of the liver : "Nunquam nisi hepatis ope, 
 neque bilis, neque ipsius analogon conficitur." 
 
 The ideas of Grant were reiterated in the observations published 
 by J. P. Schotte, J " On the Malignant Fever on the Coast of Sene- 
 gal." A. Diel § likewise attributed the cause of bilious diseases not 
 to the bile already formed, but to an increase of the elementary 
 constituents of this substance in the unhealthy juices of the body. 
 
 Senac, || also, thought it probable that the red portion of the 
 blood Was the peculiar material of the bile, and that it assumed a 
 yellow colour when it became putrid or otherwise decomposed. 
 
 More recently, since the subject of pigments has been more care- 
 
 * loc. cit., pp. 75-78, 185, 313. 
 t Observations on Fevers, vol. I., p. 30. 
 
 t Von einem austeckenden schwarzgallichten Fieber, welches im Jahre 
 1778 am Senegal herrschte. Aus dem Englischen. Stendal, 1786. 
 § Baldinger's neues Magazin. Bd. 7, Stuck, 5. 
 II De recondita febrium natura, p. 25. 
 
80 JAUNDICE. 
 
 fully studied, and since the doctrine that the hsematine of the blood 
 forms the basis of all pigments, has become more generally ac- 
 cepted, there has been no lack of observers who, adopting the ideas 
 of Senac, have referred the jaundiced-tint of the skin, which is pre- 
 sent in pyaemia, in putrid infection, and other allied conditions, 
 without any morbid condition of the liver, to a direct metamorphosis 
 of the hsematine into a yellow substance similar to, if not identical 
 with, bile-pigment. Breschet, to whom belonged the merit of 
 having first supported the derivation of the pigment from the blood 
 by direct proofs,* bluntly expressed this view as to the origin of 
 jaundice as follows : — 
 
 " Je presume ainsi, que Tictere est occasional bien moins par la 
 " bile que par le sang." 
 
 A similar expression is made use of by Dubreuil t : — " La teinte 
 " icterique est la suite d'une modification maladive des parties con- 
 " stituantes du sang, peut-etre de la matiere colorante portee sur le 
 " serum/' 
 
 This theory has acquired fresh support from the investigations of 
 Yirchow upon pathological pigments. % These investigations have 
 proved that, under certain circumstances, a yellow substance is 
 formed from the hsematine which, in its relation to solvents and re- 
 agents, bears a close resemblance to cholepyrrhin. 
 
 Zenker and Funke § have brought forward fresh arguments in 
 favour of the intimate relation subsisting between the bile-pigment 
 and the red matter of the blood, by showing that a modification of 
 the colouring-matter of the bile, viz., bilifulvine, can easily he 
 transformed into " hsematoidine," — a derivative of " hsematine/' 
 This would appear to indicate the possibility of a direct transformation 
 of hsematine into cholepyrrhin. 
 
 We shall subsequently see that the observations upon the forma- 
 tion of pigment, however numerous these may be, are not yet suffi- 
 ciently mature for arriving at any conclusion ; but that there exist 
 still other sources of colouring-matter hitherto neglected, which may 
 assign to the brown matter of the bile another place in the series of 
 pigment changes. 
 
 * Considerations sur une alteration organique appelee degeneration 
 noire. Paris, 1821. Journ. de Magendie, Tom. I. 
 t Ephemer. medic. 1826. 
 
 X Virchow, Archiv. fur patholog. Anatomie. Bd. I. 
 § Lehmann, Lehrb. der physiol. Chemie. Bd. I., S. 292. 
 
THEORIES AS ,TO MODE OF PRODUCTION. 81 
 
 The two theories of bilious affections upon which some historical 
 light has just been thrown, have at no time received a universal 
 application. They were employed to explain the origin of those 
 forms of jaundice only, in which no proof existed of any obstruction 
 to the escape of bile. There has been no want of opposition to 
 these theories. I shall content myself by mentioning here the nature 
 and manner in which J. P. Erank, in his time, expressed himself in 
 regard to them : — * 
 
 " Ita quoque cutis flavedinem in ictero non tarn a bile resorpta 
 " quam a cruoris ipsius in vasis metamorphosi aut combinatione, si Diis 
 " placet, chemica aliqui derivant. Sic, eheu! hypothesis in rebus medi- 
 "cis hypothesin trudit; et montem, qui prseoccupatos ante oculos 
 " prominet, in acervis formicini favorem, arenas pro grumulo declarat." 
 
 In addition to the theories just discussed, others have been 
 brought forward from time to time, which require no detailed 
 critical examination. To these belong the view frequently enter- 
 tained by the ancient physicians, that the bile was infiltrated into 
 the tissues, owing to its becoming fluid from the operation of poisons, 
 marsh miasma, putrid substances, &c. , — Eegner de Graaf (Be sueco 
 pancreatico. Cap. Fill.), Godart (Jownal de Medecine. Tom. XVIII., 
 1763).t Among these, also, may be included the view,which made 
 jaundice depend upon a spasmodic condition of the skin, and an 
 obstruction to the circulation of blood through it j and, lastly, the 
 theory of Deyeux ( These de Paris, 1804), and of Gaultier, (These de 
 Paris, 1811), who imagined that the yellow colouring-matter was 
 secreted by the skin, without any necessary participation of the liver. 
 
 2. Theory of Jaundice. 
 
 There can be no doubt that most, although not all, cases of jaundice, 
 are produced by the re-absorption of bile already secreted. In gene- 
 ral, it is not a difficult matter to point out the anatomical nature of 
 the mechanical obstruction to the excretion of bile ; and numerous 
 instances in which the experiment of applying a ligature to the duc- 
 tus choledochus was performed, years ago, by Saunders, Tiedemann, 
 Gmelin, and many others, have thrown some light upon jaundice re- 
 sulting from the passage of the secretion into the lymphatics and veins. 
 
 * Decurand.homin.morbis epitome. Vienna, 1821. Lib.VI.,Pars3,p.336. 
 t Pliny had long before imputed a case of jaundice to a great liquefac- 
 tion of the bile. 
 
82 JAUNDICE. 
 
 Jaundice from re-absorption, therefore, forms the sure starting- 
 point for further pathological inquiry, and in all cases and forms 
 of the affection where it is practicable, the main question is to 
 search for mechanical obstructions preventing the escape of the bile, 
 or for other causes of the passage of this fluid into the blood. It 
 is only when this is impossible, that we can consider other theories 
 of which a positive confirmation has hitherto been impossible, and 
 the main value of which consists in the necessity for some hypothesis 
 for explaining our observations. In such cases can we ascribe the 
 jaundice to an accumulation of bile in the blood, owing to some- 
 thing which interferes with its secretion, or are we to adopt the 
 theory of a direct crumbling down of the blood corpuscles, or red 
 matter of the blood, into bile-pigment ? 
 
 The production of jaundice from an imperfection in the secreting 
 functions of the liver, which Budd and Bamberger * have spoken of 
 in recent times, without, however,, bringing forward any ' striking 
 proofs of the assertion, is opposed by too many well-established 
 facts for us to support it. All the means for detecting traces of 
 the essential elements of the bile in the blood generally, and in that 
 of the portal vein in particular, have been exhausted without any 
 result ; neither the colouring-matter, nor the acids of the bile, t 
 substances for which we possess tests of considerable delicacy, have 
 been found. Even if it be granted that the quantity of hile which 
 circulates with the blood under normal circumstances is immeasur- 
 ably small, owing to the constant performance of the functions of 
 the liver, in the same way as occurs in the case of the urine, % still 
 
 * Handb. der Pathologie und Therapie von Virchow. Bd. VI., p. 518. 
 
 t From the researches of Strecker, the bile would appear to contain 
 two resinous acids., the Cholic {Strecker), or Glycocholic (Lehmann), and 
 the Choleic (Strecker), or Tauro-cholic (Lehmann). According to Lehmann, 
 these acids are formed by the " conjugation" of cholic acid with Glycine 
 (gelatine-sugar) and Taurine respectively ; and they are united in the bile 
 with soda as a base. Lehmann makes the composition of Glycocholic 
 acid C ffl H fi NO u HO, and that of Taurocholic acid C 6 j H^NSu M .— 
 Transl. 
 
 J If we assume, what may not be far from the truth, that 1 kilogramme 
 (2.2046 lbs. avoird.) of bile, containing 6 per cent, of solid matter,is secreted 
 daily by an adult man, the quantity of the acid of the bile contained in 
 the blood must be twice as great as that of the urea, the daily quantity of 
 which is calculated at 30 grammes (463 grains Troy). But Pettenkofer's 
 test indicates the presence of a smaller quantity of the acids of the bile 
 than any test does for urea. Accordingly, the detection of bile in the 
 
Theories as to mode of production. 83 
 
 this argument is of no weight in diseased conditions, in which the 
 disorganisation of the glandular parenchyma limits the 'secreting 
 function, or arrests it to a greater or less degree. In the- same way 
 that urea accumulates in large quantity in the blood in granular 
 degeneration of the kidneys, so ought the biliary acids and bile- 
 pigment to accumulate in the blood in cases of granular liver. Re- 
 peated observations have proved that this is not the case. Further 
 on I shall relate a case of disease (No. XXIX.), where the secre- 
 tion of bile was completely arrested in consequence of fatty dege- 
 neration of the liver, so that the contents of the bowels were 
 found pale, the gall-bladder empty, and the biliary ducts coated 
 with a greyish mucus, notwithstanding which, the skin was of a 
 chalky paleness, and the urine not tinged with bile-pigment.* Still 
 more decided are the proofs of the formation of bile in the liver, 
 which have been furnished by the beautiful investigations of Muller 
 and Kunde, t and likewise of Moleschott. $ In the case of frogs 
 which were kept alive for two or three days, and by Moleschott for 
 several Weeks, after being deprived of their livers, not a trace of the 
 elements of the bile could be detected in the blood, the lymph, the 
 urine, or the musuclar tissue. 
 
 The idea of the pre-existence of bile in the blood is further 
 opposed by the arguments in favour of a conversion of certain 
 elements of the blood into bile within the liver, which may be 
 derived from the different composition of the blood in the portal 
 and hepatic veins. Although the difference of the blood from 
 these two sources indicated by Lehmann's analyses, appears almost 
 too great to be explained by the act of secretion, it, never- 
 theless, opens up interesting points for studying the origin of bile. 
 We shall, hereafter, have an opportunity of adducing fresh data 
 for obtaining a deeper insight into the mode of origin of the 
 hepatic secretion, by showing how certain products of metamorphosis 
 disappear within the liver. 
 
 Bamberger considers that he has found a proof of the pre-exist- 
 blood ought to be an easier matter than that of urea, a circumstance 
 which must increase the value of the above observation. 
 
 • Haspel (Maladies de l'Algerie, Tom. I., p.' 262) observes :—« J'ai en 
 " Toccasion de constater plusieiirs fois l'absence d'ictere dans les cas de 
 "destruction presque complete de l'organe hfipatique. La bile n'gtait 
 "plus secretee, la vesicule ne contenait qu'un mucus blanchatre." 
 
 t Kunde, Dissert, inaug. Berol. 1850. 
 
 X Archiv fur physiol. Heilkunde. Bd. II., S. 479, ff. 
 
 G2 
 
84 JAUNDICE. 
 
 ence of bile in the portal vein in the jaundice, which is observed to 
 accompany inflammation of that vessel The blood of the vena 
 porta, which passes by the collateral vessels into the general circu- 
 lation, it is thought, in such a case, produces jaundice by the spon- 
 taneous elimination of the elements of bile. During the past year, 
 I have met with three cases of complete obstruction of the portal 
 vein, and have availed myself of the opportunity to examine care- 
 fully the clot {Thrombus) taken from the vessel. Leucine could be 
 detected in it, but not a trace of bile-pigment. Moreover, jaundice 
 is pretty frequently absent in cases of obliteration of the ^portal 
 vein.* The conclusions which the same author draws from the 
 presence of buiary matter in the fluid of ascites accompanying cir- 
 rhosis of the liver, will subsequently receive a simpler interpretation; 
 as will also the gall-stones, which have been observed in the interior 
 of the portal vein by Eealdus, Columbus, and Deway. 
 
 As regards the second hypothesis, the spontaneous conversion of 
 the red matter of the blood into bile-pigment in putrid diseases, no 
 objection can be made to the possibility of such an event, consider- 
 ing the intimate relations which have been shown to exist between 
 heematine and cholepyrrhin ; but positive proofs of it are entirely 
 wanting. As yet no one has succeeded in manufacturing bile- 
 pigment from the red colouring-matter of the blood, although the, 
 products of decomposition of both are the same. The yellow matter, 
 however, which in cases of pysemia circulates with the blood, and is 
 voided in the urine, is, at least in most cases, identical with bile- 
 pigment, and participates in all the properties of this substance. 
 But even were the conversion of heematine into cholepyrrhin, under, 
 the operation of certain agencies, possible, still it remains to be 
 proved that this metamorphosis really takes place in the course of 
 putrid diseases within the blood-vessels of the living body. As to 
 the absence of pigment in the interior of the hepatic cells as an 
 argument against the theory of re-absorption in consequence of ob- 
 struction, which has been urged, particularly by Virchow, t it is of 
 no weight, provided ways can be shown in which accumulations of 
 pigment may take place in the blood without any obstruction to the 
 escape of the bile. 
 
 If, after what has been said, we should have legitimate scruples in 
 making use of hypotheses, which rest upon an uncertain fouuda- 
 
 * See Gintrac. Sur l'obliteration de la veine-porte. Bordeaux, 1856. 
 t Virchow, Archiv f. path. Anatomie. Bd. I. 
 
THEORIES AS TO MODE OF PRODUCTION. 85 
 
 fcion, the question comes to be, how those cases of jaundice are to be 
 explained which occur without any remarkable obstruction to the ex- 
 cretion of bile. The number of such cases is not small, for they 
 include, in addition to the jaundice of pyaemia and of the conditions 
 allied to this, those forms of jaundice which result from the narcotism 
 of chloroform and from other forms of intoxication, and lastly, those 
 which are met with in many instances of pneumonia, in intermittent 
 fever, in the bilious fevers of marshy districts, in inflammation of the 
 portal vein, &c. ; we likewise refer to this class the jaundice induced 
 by mental affections, for which spasm of the bile ducts — the cause to 
 which it is usually referred — offers no satisfactory explanation. 
 
 In order to arrive at some clear ideas upon this point, so far as 
 the present state' of circumstances permits, we must examine more 
 closely the causes which can give rise to an accumulation of bile in 
 the blood. These may be said to be twofold, provided the forma- 
 tion of bile is in the first place assumed to be constantly the same.* 
 
 I. Through increased absorption of bile from the liver into the blood. 
 
 ii. Through small consumption, or a sparing change of the bile, 
 which has been taken up into the blood. 
 
 We leave the latter unconsidered at present, and occupy ourselves 
 in the first place with — -1. The conditions upon which the passage of 
 a large quantity of bile into the llood may depend. 
 
 The mechanism of biliary obstruction is much more complicated 
 than it is considered to be by pathologists who usually only pay 
 attention to the condition of the biliary ducts. Obstructions' may 
 exist'during life, which are with difficulty accessible to the knife of 
 the anatomist, and which, to a certain extent, cannot be demon^ 
 strated. It is known that two products of cell-growth, bile and 
 sugar, are simultaneously produced in the liver; the latter passes into 
 the blood of the hepatic vein, the former into the commencement of 
 the bile ducts. The current towards the blood can only result from 
 diffusion, that occurring at the same time towards the bile ducts, from 
 filtration. It is difficult to determine how the separation of the two 
 currents is possible; why the contents of the cells surrounded by 
 capillaries almost like a ring should be distributed partly in one direc- 
 tion, and partly in the other. "We must, as Ludwig t has with justice 
 acutely observed, either assume that the rapidity of diffusion into the 
 
 * We shall subsequently become acquainted with Polycholia, or an ex- 
 cessive secretion of bile, as a cause of several forms of jaundice, 
 t Physiolog. des Menschen. Bd. II., S. 232. 
 
86 JAUNDICE. 
 
 blood of the elements of bile is less than that of sugar, or that the 
 sugar has attractions for some one element in the blood which is 
 wanting to bile. The latter view is highly improbable, for we are 
 acquainted with no substance in the blood for which sugar possesses 
 a pre-eminent affinity. In the former case, the separation of the two 
 substances would not be complete, some bile would always pass into 
 the blood along with the sugar, and some sugar into the bile.* But, 
 whatever view we adopt as to the mode of separation of the sub- 
 stances secreted by the liver, still it is certain, that an increased ab- 
 sorption of bile into the blood may be dependent upon a difference in 
 tension of the contents of the hepatic cells and blood-vessels. Such a 
 condition may arise in two ways : ' 1, from obstruction of the bile ducts 
 by which the pressure on the side of the cell contents is increased, 
 and 2, from obstruction to the flow of blood in the portal system, 
 and consequent diminution of the pressure on the side of this fluid. 
 
 The former mode of production is the more common, and is the 
 only one which as yet has been investigated. All mechanical ob- 
 structions which interfere with, or arrest the flow of bile into the 
 larger or smaller biliary ducts, produce jaundice in this way. A large 
 proportion of these obstructions are of an anatomical nature, and 
 may be detected on dissection, and hence are accurately known; 
 others, however, the existence of which has been maintained, are less 
 clear in their nature, and require further examination. 
 
 The flow of bile through the hepatic ducts is principally owing to the 
 vis a tergo of the secretion constantly pressing onwards ; the ana- 
 tomical element, muscular tissue, necessary for the assumption of the 
 existence of contractility as the exciting cause, does not exist. Mus- 
 cular tissue can only be detected in the gall-bladder, and in the cystic 
 and hepatic ducts, and can, therefore, only be taken into considera- 
 tion in reference to these parts. Muscular contraction was resorted to 
 ages ago for the explanation of many forms of jaundice, and one form 
 of the affection was named icterus spasmoclicus, which was thought to 
 arise from exposure to cold, mental emotions, &c. To this view it 
 is justly objected > that a closing up of the large bile ducts (and it is 
 only in these that muscular fibres capable of giving rise to spasm 
 exist),t does not produce jaundice until after three days, and that 
 
 * According to Stockvis (Bijdragen tot de Kermis der Suikervorming in ie 
 lever, p. 35) sugar ' is always present in the bile ; I have myself detected 
 it in considerable quantity, in many cases. 
 
 t The older physicians transferred the seat of spasm partly to the mus- 
 
THEORIES AS TO MODE OF PRODUCTION. 87 
 
 a spasm lasting for three days, without the operation of any persistent 
 local cause, such as a concretion, is beyond the reach of imagination ; 
 moreover, the jaundiced tint appears much earlier than is compatible 
 with such a theory. At first sight, it seems more probable, that there 
 might be paralysis of the bile ducts, as was long ago assumed by Galen 
 and Darwin, and for which arguments have been adduced more re- 
 cently by Frey,* Henle,t and von Dusch.f It is doubtful, however, 
 whether paralysis of the hepatic and cystic ducts, can really produce 
 such a degree of obstruction as to result in jaundice, while the other 
 agencies concerned in the propulsion of the bile continue in operation. 
 Moreover, no one has brought forward proofs of, the existence of so 
 limited a muscular paralysis without any anatomical lesion : and from 
 what we know of muscular action in the other abdominal organs, 
 such a phenomenon would be quite exceptional. In order to obtain ' 
 more precise information, I have, in conjunction with my colleague, 
 Beichert, divided both the splanchnic nerves of a cat, and extirpated 
 the largest part of the cceliac ganglion according to the method pro- 
 posed by Ludwig. The animal lived three and a-half days after. 
 Upon post-mortem examination we found the liver congested, and 
 the gall-bladder moderately distended. The mucous membrane of 
 the stomach was congested, and presented, at one part, an ulcer 
 of a rounded form, the size of a groschen (somewhat smaller than a 
 sixpence), and having its margins suffused with blood. There was 
 not a trace of jaundice. Division of the spinal cord both above and 
 below the cervical plexus, in the manner practised by Bernard, has 
 been equally unsuccessful in producing an obstruction to the flow of 
 bile. These experiments were made repeatedly by Dr. Valentin, yet 
 always with negative results. 
 
 The compression which the biliary organs undergo from the nar- 
 rowing of the abdominal cavity consequent upon the respiratory 
 movements, has a much greater influence over the flow of bile. This 
 circumstance, was already known to the older physicians. Boerhaave 
 remarks : " Bilis vix movetur, nisi aliunde urgeatur,neque protruditur 
 nisi respirationis efficacia." § Bidder and Schmidt || also state, that 
 
 cular tissue of the duodenum, the contraction of which was thought to 
 close the mouth of the ductus choledochus. 
 
 * Archivfur physiol. Heilk. Bd. IV., 49. t Rationelle Pathol. II., 195. 
 
 \ Untersuchungen und Experimente als Beitrag zur Pathogenese des 
 Icterus. Leipzig, 1854. 
 
 § Praelect. acad. in propr. institution. Ed. Haller, Vol. III., S. 186. 
 
 II Verdaungssafte und Stoffwechsel. S. 210. 
 
88 JAUNDICE. 
 
 in all their experiments, they had repeatedly made the observation, 
 that the respiratory movements exercise a powerful influence over 
 the propulsion of the bile which has been secreted. Although it 
 might be difficult to show, that the want of this influence is sufficient 
 to give rise to jaundice, still this must be borne in mind as a co- 
 operating cause. Jaundice is not unfrequently observed accompany- 
 ing right diaphragmatic pleurisy and perihepatitis of the convex 
 surface of the liver, in which there is certainly a limitation of the 
 free action of the diaphragm, but in which no deeper lesion of the 
 liver or of the bile ducts is to be detected. 
 
 Hence it follows, that in general we must be very cautious in 
 assuming causes of obstruction of bile, for which, as in the case 
 of paralysis of the bile ducts, no anatomical origin can be detected. 
 
 As regards the second mode in which the bile is made to enter 
 the blood, viz., the obstruction of the circulation of the blood, and 
 the diminution of the pressure exerted on the side of the capillaries 
 of the portal vein, it is estimated with difficulty on account of our 
 comparatively small knowledge of the complicated circulation of blood 
 in the interior of the liver ; still it is easy to show that the tension 
 of the stream of blood must be here liable to many variations. 
 There can be no doubt, that from obstruction of the main trunk or 
 of the larger branches of the portal vein, the tension of the capillary 
 vascular system in the liver is diminished, and the entrance of the 
 biliary contents of the hepatic cells into the blood is facilitated. 
 Hence jaundice is of frequent occurrence under such circum- 
 stances.:]: Similar conditions result from obstructions of a large 
 number of the interlobular veins of the liver by means of pigment 
 granules, which is a matter of frequent observation in malignant 
 intermittents. An obstruction to the flow of blood in the liver is 
 here produced ; at one part the pressure of the capillary vessels is 
 diminished ; whilst at another, their tension is greatly increased. In 
 such a case we very often find albumen in the bile as well as jaun- 
 dice, which last only attains a high degree when the majority of the 
 capillary vessels are blocked up. A diminution of the tension of 
 the hepatic vessels also happens in new-born children, directly after 
 birth, when the portal vein ceases to receive blood from the umbi- 
 lical veins : jaundice, very frequently presents itself along with 
 
 t Whether jaundice makes its appearance under such circumstances or 
 not, the secreting function of the gland may become more or less inter- 
 fered with in consequence. 
 
THEORIES AS TO MODE OF PRODUCTION. 89 
 
 defective respiration, especially in children prematurely born, whose 
 fcetal vessels are long in closing up. 
 
 Moreover, variations of no small importance in the pressure 
 exerted by the hepatic vessels occur, when persistent and profuse 
 haemorrhages take place from the roots of the portal vein, as in the 
 case of yellow fever. 
 
 It is obvious, that the nervous system here, as everywhere else, 
 influences . the distribution of blood and its consequences, and, 
 moreover, this has been proved by the experiments of Claude Ber- 
 nard. We are not, however, in a position to make use of this 
 influence, with any degree of certainty, for the explanation of 
 pathological conditions, because the investigations necessary for this 
 purpose are wanting.* It may suflice, as a preliminary matter, to 
 have briefly alluded here to the importance of the distribution of 
 the blood in the liver, as well as to that of obstruction to the flow 
 of bile in the production of jaundice, reserving the subject for 
 further discussion. 
 
 II. Diminished consumption, or a sparing 'metamorphosis of the bile 
 which has been taken up into the blood. 
 
 Hitherto, it has been necessary to attribute the tinging of the 
 tissues and secretions, which is observed in jaundice, either to the 
 absorption of bile-pigment, which has been already secreted, or to 
 the hypothetical decomposition of the blood formerly alluded to. 
 ' There is still another source of bile-pigment in the blood, which is 
 more obvious, of which it may be said that it exists in the blood 
 itself, and which, according to the nature of the transforming causes 
 present in this fluid, must furnish sometimes a greater and some- 
 times a smaller quantity of pigment, without this being necessarily 
 attributed to an obstruction to the escape of bile. 
 
 This view rests upon the following facts : — The pure colourless 
 
 * From the investigations of Claude Bernard {Lemons de pKysiol. expirim. 
 Paris, 1855, p. 333 seq.), it appears to, follow, that on the one hand irrita^' 
 ing causes, which stimulate certain parts of the nervous system, such as 
 punctures in certain regions of the medulla oblongata, and electric stimu- 
 lation of the proximal extremities of the divided pneumogastric nerves, 
 and on the other hand, injuries which reduce the nervous energy of the 
 individual, such as contusions of the head, poisoning with curari, setherisa- 
 tion, &c, give rise to congestion of the liver, whilst division of the spinal 
 cord below the cervical plexus is followed by an opposite result. 
 
90 JAUNDICE. 
 
 acids of the bile may be transformed into bile-pigment with all the 
 properties characterising this substance. Such a transformation 
 takes place not only under the influerrce of re-agents, but it also 
 follows the absorption of the acid substance (into the blood of living 
 animals), and is in a measure dependent upon this.* By the action 
 of concentrated sulphuric acid upon colourless bile, there are 
 
 * If concentrated sulphuric acid is poured upon pure, perfectly colour- 
 less, glycocholate of soda, there is formed- a resinous mass, devoid of 
 colour, which dissolves in the cold with a saffron-yellow colour, and with 
 a reddish colour upon the application of heat. This solution separates 
 into a colourless water, and flakes of a greenish or brownish colour, ac- 
 cording to the temperature at which the solution has been made. Glyco» 
 cholic acid, when changed by sulphuric acid, has the property, upon 
 exposure to the atmosphere, of rapidly taking up acid substances, and of 
 passing into gorgeously-coloured combinations. If the amorphous, 
 colourless mass resulting from the action of sulphuric acid, after it has 
 been deprived, as far as possible, of the adherent acid, is placed upon a 
 piece of filtering paper, it dissolves, and there is produced a ruby-red 
 spot, which soon presents a blue margin, and after a short time assumes 
 an indigo-blue colour. After some days, this colour also disappears, and 
 the spot becomes brown. 
 
 By the continued action of sulphuric acid upon glycocholic acid, a sub- 
 stance is produced, which dissolves in water with a deep green colour, and 
 in a weak solution of soda with a brown colour, and which, upon the 
 addition of nitric acid, assumes first a green, then a reddish, and lastly, a 
 yellow tint. The behaviour of this substance with nitric acid reminds us 
 of that which characterises the natural bile-pigment, although the change 
 of colour is less rapid. When taurocholate of soda is treated in the above 
 manner, there is obtained in its place a product behaving in every respect 
 the same as cholepyrrhin. When dissolved in a little water, and mixed 
 with concentrated sulphuric acid, this assumes a brilliant red colour, and 
 gradually, upon exposure to the air becomes blue. When the red solution 
 is mixed with more sulphuric acid, the colour passes into brown. Upon 
 the addition of water, there is produced a delicate precipitate, gradually 
 becoming pale green ; if the acid fluid is poured off from this, .and what 
 remains i| warmed, intense green, blue, and violet colours are produced. 
 The coloured products dissolve in potash, with a bilious brown colour, 
 and the solution behaves, with nitric acid, in precisely the same manner 
 as a basic solution of cholepyrrhin. 
 
 ^ That the same metamorphoses may take place in the blood of a living 
 individual is proved by injections of colourless solutions of bile into the 
 veins of dogs. The urine passed after such an experiment usually depo- 
 sits, upon standing, green flakes, which, upon the addition of nitric acid, 
 exhibit in a beautiful manner the alternation of green, blue, violet, and 
 red colours, characteristic of bile-pigment. The unchanged acids of the 
 bile may then be sought for in vain by means of Pettenkofer's test. In 
 
THEORIES AS TO MODE OF PRODUCTION. 91 
 
 formed colour-producing substances (CAromoffene),* which, upon 
 exposure to the atmosphere, and still more rapidly on the addition 
 of nitric acid, exhibit alternations of tints corresponding, in every 
 respect with bile-pigment. The same pigments and colour-pro- 
 ducing substances (Chromogene), which in their properties precisely 
 resemble cholepyrrhin, are produced by the injection of large quan- 
 tities of colourless bile into the vascular system of living animals. 
 In this case the acids of the bile are transformed in the blood into 
 pigment under the influence of respiration. That the bile which 
 has been re-absorbed from the intestine, or which has passed directly 
 from the liver into the blood, may, under normal circumstances, 
 experience a similar transformation, is an opinion which is favoured 
 in the first place by the presence of large quantities of taurine in 
 the healthy lung, as shown by Staedeler and Cloetta. The pig- 
 ments, however, which are produced in this way, are not voided with 
 the urine, until the constantly advancing process of transformation 
 to which the colouring-matter is subjected, has gone so far, that the 
 substance is no longer endowed with the properties of bile-pigment. 
 We not unfrequently find such advanced stages of transformation in 
 the slighter forms of jaundice, sometimes, also, in other forms of 
 disease, in which there is no yellow tinge of the skin to indicate an 
 affection of the liver. Thus, I have observed in a case of slight 
 jaundice resulting from intermittent-fever, urine passed repeatedly of 
 a ruby-red colour, which, on the addition of nitric acid, became 
 blood-red, and remained so for a day,t whilst serous effusions of the 
 ordinary bilious brown colour were found in the dead body. Not 
 unfrequently, the urine which is voided in chronic affections of the 
 
 one case only, where an unusually large quantity (about two drachms of 
 dry bile), was injected, a trace of it could be detected. It is worthy of 
 notice, that the quantity of colouring-matter voided in the urine appears 
 greatest, when the animal experimented upon has suffered from dyspnoea, 
 as, for instance, in one dog, which- died from oedema of the lung, conse- 
 quent upon the experiment. In one case, where the quantity of bile 
 injected was small, and the animal remained free from respiratory ail- 
 ments, no pigment was found at all. 
 
 * Chromogen is a term applied by Frerichs to a colourless material, 
 which, when subjected to the action of certain agencies above-mentioned, 
 is transformed into the colouring-matter of bile. The relations of the 
 two substances are somewhat analogous to those of colourless and blue 
 indigo. — Transl. 
 
 + A similar colouring-matter may be produced by the action of sulphuric 
 acid upon tyrosine. 
 
92 JAUNDICE. 
 
 liver, becomes violet or dark blue on the addition of muriatic acid.* 
 In other cases of jaundice, the urine is brown ; but whea treated 
 with nitric acid. exhibits the play of colours either incompletely or 
 not at all. The bright-red urinary sediments occurring in diseases 
 of the liver have long been familiar to practitioners. 
 
 There may thus be detected in the urine very various shades of 
 the same pigment, and it might be difficult, in this intimately-con- 
 nected series, to distinguish between bile-pigment and the colouring- 
 matter of the urine. The quantity and the quality of this colouring- 
 matter are always influenced in an unmistakable manner by the 
 agencies which modify the metamorphosis of matter throughout the 
 system, and by local diseases which circumscribe respiratory action. 
 In hot summer weather, the urine of healthy individuals often con- 
 tains distinct evidences of bile-pigment, — a fact which was mentioned 
 long ago by Scherer, and has been repeatedly confirmed by Valentin. 
 A slight and scarcely observable degree of jaundice increases in in- 
 tensity so soon as any febrile process is lighted up, which restricts, 
 to a considerable extent, the process of oxydation in the blood ; and 
 still more remarkable is the influence of pneumonia. These facts, 
 suggest the supposition, that under certain pathological conditions, 
 the metamorphosis of bile in the blood is incomplete, in the same 
 way as is the case after the injection into this fluid of larger 
 quantities of bile, and that thus a sufficient quantity of bile-pigment 
 remains in the blood to give rise to all the symptoms of jaundice. 
 A powerful influence over the quantity of this pigment is exercised 
 by the secretion of urine, which removes it more or less quietly, 
 and thus regulates its accumulation in the blood. (See Observa- 
 tion No. VII.) There is, in many respects, an analogy between 
 diabetes mellitus and several forms of icterus ; in the same way that 
 in certain states of the system, with which we are still imperfectly 
 acquainted, the sugar which is formed in the liver, in place of being 
 consumed, is voided with the urine, so, under certain conditions, 
 the transformation of the acids of the bile remains incomplete. So 
 far as clinical experience teaches us, this imperfect metamorphosis 
 of bile takes place principally in those diseases which obstruct or 
 interfere with the processes of metamorphosis or oxydation in the 
 blood, such as putrid infection, pyaemia, and its allied conditions, 
 the state of intoxication produced by the bite of serpents, by chloro- 
 
 * See Observations on the relations of blue colouring-matter to Bile and 
 Tyrosine, &c. Mailer's Archiv, 1856. 
 
SYMPTOMS. 93 
 
 form, &c, and also the obstructions to respiration from pneumo- 
 nia, &c.* 
 
 Thus, to sum up, we have become acquainted with three causes 
 of icterus : — 
 
 1. Obstruction to the escape of bile. 
 
 2. Diminished circulation of blood in the liver, and consequent 
 abnormal diffusion. 
 
 Both of these conditions give rise to an increased imbibition of 
 bile into the blood; and, in both cases, the liver is more or less 
 directly implicated. 
 
 3. Obstructed metamorphosis, or a diminished consumption of 
 bile in the blood. 
 
 This cause is independent of the liver, and, so far as we as yet 
 understand the matter, is chiefly influenced by the composition of 
 the blood, and by everything which essentially limits or modifies 
 the processes of metamorphosis within the vascular system. 
 
 3. Symptoms of Jaundice. 
 
 We select as the basis of our description of jaundice, that variety 
 which owes its origin to a mechanical impediment to the excretion 
 of bile. This variety is the more eligible, as in it the conditions 
 take on their simplest form and are less apt to be interfered with by 
 disturbances of an extraneous nature, which owe their origin either 
 to the primary cause of disease, or to some other morbid processes 
 going on at the same time. 
 
 The bile which stagnates in the hepatic cells and bile ducts, in 
 consequence of a mechanical impediment .to its excretion, is carried 
 into the blood by means of the veins and lymphatics. When the 
 impediment has its seat in the. ductus choledochus, the bile first 
 shows itself after three days by a yellow colour of the conjunctiva.t 
 
 * In an analogous manner it appears, that the excretion of sugar in the 
 urine, after puncture of the fourth ventricle of the brain, must be viewed 
 in connection with the obstructions to respiration and to the heart's 
 action which result from this wound. {Berlin, Schroder, XJhh, Stochvis.) 
 Reynoso found sugar in the urine of persons who had been setherised ; 
 Bence Jones in the urine of those who had taken chloroform ; and Garrod 
 in the urine of acute bronchitis. It is obvious, however, that here there 
 are other collateral circumstances of an unknown nature in operation. 
 
 + Tiedemann and Gmelin (Ob Digestion, Vol. II., p. 48), as also Blondlot, 
 observed jaundice commence after three days, and my own investigations. 
 
94 JAUNDICE. 
 
 Its absorption into the blood takes place much earlier j* but in order 
 that the jaundiced colour of the skin should become visible, a certain 
 amount of concentration is necessary. The colour makes its appear- 
 ance in the renal secretion sooner than it does in the skin, and serous 
 effusions in the various cavities of the body become tinged with 
 pigment earlier than the urine. I have repeatedly found cholepyrrhin 
 in the serum of the blood, and in effusions into the abdominal and 
 thoracic cavities, where no traces of a jaundiced tint had been present 
 either in the urine or in the skin.f 
 
 Apart from the tinging of its plasma, the blood undergoes no 
 remarkable change from the absorption of bile; its proximate 
 principles vary, as numerous analyses have shown, ' according 
 
 have usually led me to the same result. After the application of a liga- 
 ture to the common bile duct, the yellow colour of the conjunctiva was 
 first observed between the sixtieth and seventieth hour, and sometimes 
 later. 
 
 * As regards the rapidity of absorption, reference is generally made to 
 the observations of Saunders — {Abhandl. fiber die Structur, fyc, der Leber. 
 Am dem Englischen. Leipzig, 1795, S. 61) — who, so soon as two hours 
 after the application of a ligature to the ductus choledochus, found the 
 lymphatics, as far as the thoracic duct, filled with a yellow fluid, and, in 
 the same space of time, the serum of the blood of the hepatic vein 
 darkly tinged, but that of the jugular vein scarcely at all so. I have not, 
 from my own investigations, been able to confirm these statements. Four- 
 and-twenty hours after the ligature of the ductus choledochus, bile- 
 pigment could not be detected either in the serum of the blood, the 
 lymphatics, or the urine. On one ocasion, it was found in the blood of 
 the jugular vein after twenty-eight hours ; but on another occasion, there 
 was not a trace. After forty-eight hours,, the colouring-matter could he 
 seen almost always in the blood and in the urine, but not, however, in the 
 contents of the thoracic duct. Sixty hours after the ligature, the chyle was 
 still white on one occasion, but on another it was yellow, and contained 
 pigment. Cases have occurred in which, notwithstanding the complete 
 obstruction of the bile ducts, not a trace of colouring-matter had appeared 
 either in the blood or urine at the end of two days, and others, in which 
 the serum was pale, and without the reaction of bile, but in which the 
 blood, when digested in alcohol for some time, yielded a not inconsider- 
 able quantity of cholepyrrhin, which was first formed from chromogen 
 during standing. 
 
 t There are, however, exceptions to this ; sometimes, along with the 
 yellow colour of the skin, the urine contains no bile-pigment of the usual 
 reaction, but colouring-matter of another nature, which is formed from 
 it. Moreover, upon post-mortem examination, the comparative deposit of 
 pigment is found to be greatest, at one time in the skin and at another in 
 the kidneys. 
 
SYMPTOMS. 95 
 
 to the constitution of the individual, &c, without presenting any 
 constant abnormality. Many incorrect statements have been made 
 as to the liquefaction of the blood corpuscles by means of bile; the 
 contents of the gall-bladder possess this property in a less degree 
 than distilled water. Owing to the comparatively small quantity of 
 bile which passes into the blood, for the purpose of undergoing 
 metamorphosis, no liquefying results could- be expected from it, 
 although the pure salts of the biliary acids, according to the experi- 
 ments of von Dusch, are endowed with this property.* It is there- 
 fore intelligible how Becquerel and Eodierf should sometimes have 
 observed even an increase of the red corpuscles : a diminution of 
 the fibrine is, likewise, no proof of the blood having become dis- 
 solved. 
 
 Of the various elements of the bile taken up into the blood, the 
 colouring-matter is the only one which can always be detected; 
 the biliary acids are apparently changed immediately by the influence 
 of the acid ingredients of the blood, and soon disappear, without 
 leaving a single trace, in the same way that the biliary acids disap- 
 pear, which, during digestion, are absorbed from the intestinal 
 canal, and return into the circulation. The numerous investigations 
 which have been undertaken since the time of Thenard, to demon- 
 strate their presence in jaundiced blood, have almost always led to 
 negative results. 
 
 I have myself repeatedly examined jaundiced blood, which has 
 been obtained by venesection, or still more frequently, from the 
 heart and vense cavae of the dead body, for the biliary acids, 
 and their immediate derivatives ; and more recently I have had it 
 examined by my assistant, Dr. Valentin, but always with negative 
 results. No substances could be found in the alcoholic extract of 
 the blood which yielded any indication, by Pettenkofer's test for the 
 biliary, acids, whether this alcoholic extract was directly treated with 
 sulphuric acid and sugar, or whether, in order to get rid of foreign 
 substances, a watery extract of it was first prepared. This coincides 
 with the experience of most of the older and modern observers. { 
 
 * It is worthy of notice, that animals, after the injection of bile into the 
 blood, generally pass urine which contains albumen, and the dissolved red 
 matter of the blood. The admixture of these substances, however, soon 
 disappears. 
 
 t Untersuch. S. 15. 
 
 X Thenard, Chevreul, Bondet, Lecann, Deyeux, Gmelin, &e., have 
 
96 JAUNDICE. 
 
 Thus the biliary acids disappear completely from the blood in a 
 short space of time, not because they are voided by the excreting 
 organs, but because they undergo changes, by which they entirely 
 lose their properties. 
 
 A long series of fruitless attempts to find these substances, or 
 their immediate derivatives in the urine, the sweat, and the saliva, 
 shows that they are not removed from the blood of jaundiced per- 
 sons by any increased action of the glands forming these secretions.* 
 
 searched in vain for the ingredients of bile. The statements of Orfila, 
 Collard de Martigny, and Clarion, to the effect that they had found the resin- 
 ous constituent of bile in the blood, were made at a time when it was impos- 
 sible to distinguish with accuracy between the resin of bile and other similar 
 substances. Since we have obtained in Pettenkofer's test, an easy, although, 
 under certain circumstances, deceitful test for small quantities of biliary 
 acid, it has frequently been resorted to, but in general without results 
 (Scherer, V. Gorup-Besanex, fyc). Lehmann alone mentions his having found 
 a gmall quantity of the acids of the bile in the blood, in the urine, and in 
 exudations. It appears, however, that this was not in jaundice, but in 
 other diseases in which the liver was not at all implicated. Without 
 wishing to call this fact in question, I must observe, that I have often 
 obtained Pettenkofer's colour in serous and inflammatory exudations in 
 the abdominal and thoracic cavities, and for some time I zealously fol- 
 lowed up this observation, until I became convinced that the pure white 
 of egg, when treated with sulphuric acid, often assumes this same violet 
 colour, and that the same exudations which, when employed directly, had 
 yielded a positive result, when dried and extracted with alcohol, ceased to 
 exhibit that reaction. 
 
 * I have made many attempts to find the materials of bile in jaundiced 
 urine ; and, to make the matter more certain, I have operated with large 
 quantities of urine. In order to separate the biliary acids, the urine has 
 been mixed with neutral and basic acetate of lead, and the precipitates have 
 been collected, dried, and then extracted with boiling alcohol. The alco- 
 holic solutions must have contained compounds of lead and the biliary 
 acids, if any of the latter had been present. They were, however, scarcely 
 coloured by the solution of sulphuretted hydrogen, and upon evaporation 
 only a small residue remained, which, with Pettenkofer's test, afforded no 
 indication of biliary acid. 
 
 I have met with no better success in endeavouring to extract, by means 
 of alcohol, from the evaporated urine, a substance exhibiting the reaction 
 of the biliary acids. 
 
 Upon adding alcohol to the condensed urine, crystals have sometimes 
 separated, which, in their form and in their relation towards solvents, have 
 resembled taurine. The crystals, howeyer, have not been sufliciently 
 large to permit of their angles being measured without a special apparatus. 
 Glycine also has been sought for without success. 
 
 In accordance with these results, Griffith, Scherer, Gorup-Besanez, &c, 
 
SYMPTOMS. 97 
 
 Even when we inject large quantities of bile, so as to obviate the 
 difficulties which there might be in detecting a small quantity, we 
 are equally unsuccessful ; it was always the colouring-matter only 
 which could b'e observed. We have, hitherto, been unable to trace 
 in detail wherein consist the changes in the absorbed bile, the occur- 
 rence of which we are thus obliged to admit ; this much only is certain, 
 that they give rise to colour-producing substances, which, under the 
 action of the (respiratory acid) carbpnic acid of respiration, are trans- 
 formed into bile-pigment. This is confirmed, not only by the quantity 
 of the colouring-matter, which, so far as this can be ascertained, 
 stands in no relation to the quantity daily formed in the liver, but 
 also by the already-mentioned results of injecting biliary acids into 
 the blood, and above all, by the direct examination of the blood of 
 jaundiced patients. We find in it, besides the colouring-matter of 
 bile, colour- producing substances [Ghromogene Substanzen) which 
 exhibit the same characters as the similar bodies prepared artificially 
 from the bile, and which, like them, become, upon exposure to the 
 air, blue, green, red, and brown.* 
 
 The bile-pigment itself, which is obtained by the action of alcohol 
 upon the dried blood, is sometimes amorphous, but at other times 
 it separates in a crystalline form. These crystals consist of short 
 rods, which adhere in rows to one another, and sometimes form 
 radiated crystalline masses,t or appear as angular granules, either 
 
 have likewise never succeeded in finding the biliary acids in jaundiced 
 urine. The assertions of Fourcroy and Vauquelin, that such urine be- 
 trays the presence of bile from its bitter taste, are of no importance ; 
 neither need much weight be attached to the statement of Orfila, that 
 jaundiced urine contains picromel ; or to that of Simon, who believed that 
 he had found in it much biliary resin ; because the nature of these bodies 
 has not been established with sufficient accuracy. There appears to be 
 much more importance in the remark of Lehmann, that sometimes a 
 large quantity of biliary acid is to be found in urine, but feebly coloured 
 with pigment, whilst only traces of it occur when the quantity of colour- 
 ing-matter is abundant. In place of the expected biliary substances, I 
 have always found the pigment only, and usually, in addition, a small 
 quantity of leucine. 
 
 * The colour-producing substances were detected in largest quantity in 
 the alcoholic extract of the blood, in those cases where, after the injection 
 of bile, they also appeared in the urine, and likewise in animals two days 
 (see Note, p. 94) after the application of a ligature to the ductus chole- 
 dochus : in other words, under circumstances in which an incomplete 
 metamorphosis might have been expected. 
 
 t These are figured in Table VII., Fig. 7, of the Atlas. — Transl. 
 
 H 
 
98 JAUNDICE. 
 
 isolated or adhering in groups. They are not very durable, and 
 soon lose their properties ; they cannot be re-crystallized ; their solu- 
 tion is of a dark colour ; and the pigment separates from the solu- 
 tion as an amorphous mass.* 
 
 In addition to these colouring-substances, leucine occurs in the 
 blood in considerable quantity, t aud there is also an unusual pro- 
 portion of fat, rich in cholestearine; this last, in some cases, amounts 
 to four or five per cent. J 
 
 Thus the bile-pigment alone remains as the essential substratum 
 of the bilious dyscrasia, resulting from the retention of the hepatic 
 secretion, and to this perhaps may be added, the effects which the 
 metamorphsis of the absorbed biliary acids produces upon the 
 other functions of the blood. It might have been expected, 
 a priori, that the consequences of such a change in the composition 
 of the blood upon the vital functions should not be of a very remark- 
 able nature, and in fact, they are not. The violent disturbances 
 which have been attributed to cholsemia, are not due to this, but to 
 entirely different circumstances, which will be discussed hereafter. 
 
 The most remarkable effect is the tinging with pigment of the 
 various tissues of the body, and of the individual secretions, which 
 is the more striking the more deeply the blood-plasma is coloured, 
 and the longer this condition continues. 
 
 When an obstruction to the excretion of the bile is the cause of 
 the jaundice, the deposit of pigment commences in the hepatic cells. 
 A finely granular, brown or yellow colouring-matter, is first de- 
 posited around the nucleus, or the entire cell becomes filled with 
 pale-yellow contents. The nucleus itself remains pale, or it becomes 
 
 • The crystalline colouring-matter is insoluble in ether, but is soluble 
 in alcohol ; on the addition of nitric acid it exhibits no change of colour; 
 potash dissolves it with a greenish-brown colour. 
 
 t In one case, Staedeler also obtained traces of tyrosine in the blood 
 which had been removed by cupping-glasses from a jaundiced patient. 
 
 % The largest quantity was found in cases of jaundice arising from cancer 
 of the liver, in which it amounted to 3.78 and 4.98 per cent, of the dried 
 blood; in pneumonia with jaundice, there was 1.04 ; in pysemic jaundice, 
 1.97; in typhus with jaundice, 1.93; in cirrhosis of the liver with jaundice, 
 1.10 ; and in catarrhal jaundice, 0.90 per cent. It is doubtful whether the in- 
 crease of fat depends upon the jaundice, or upon the primary affection of 
 the liver : the latter view is the more probable. In cancer of the liver 
 without jaundice, the fat amounted to 3.96 per cent., and was thus more 
 than in simple jaundice. 
 
SYMPTOMS. 99 
 
 greenish-yellow, or sometimes even dark-brown. At a later period, 
 solid deposits of pigment are observed in the form of small 
 rods, either straight or bulging at their extremities, or repeatedly 
 ramified. Here and there also, the pigment appears as rounded 
 globules, or sharply-angular particles, which have a yellow, reddish- 
 brown, pale, or deep-green colour, and which are hard and may be 
 broken tip by means of pressure. 
 
 It is worth observing, that the cells which contain an abundance of 
 pigment are always situated in greatest quantity around the central 
 vein of the lobule, and gradually become less numerous towards the 
 periphery. The co-existence of fat in the cells containing pigment 
 seems to be of rare occurrence, because the cells containing fatty 
 matter have a predilection for the periphery of the lobule. 
 
 The cut surface of the liver assumes, in consequence of the stop- 
 page of bile, a more or less intense brown, or sometimes a brownish 
 or olive-green colour. The central portions of the lobules are more 
 deeply impregnated with the colour, which gradually loses its inten- 
 sity towards their circumference ; for this reason, the colour is never 
 uniform, but speckled like a nutmeg. If the obstruction lasts a long 
 time, the bile ducts, and under certain circumstances, the hepatic 
 tissue also, exhibit changes of structure of a more intimate nature, 
 with which we shall subsequently become acquainted, when we speak 
 of the results of jaundice. 
 
 Next to the liver and the blood, the jaundiced tint is earliest 
 observed in the serous exudations, and then in the secretions, espe- 
 cially those of the kidneys and of the skin; the colour does not mani- 
 fest itself everywhere throughout the tissues, to which the blood- 
 plasma is carried, until the accumulation of the dissolved bile-pigment 
 in the blood becomes considerable. 
 
 The urine becomes changed in colour at an early period, from 
 the admixture of smaller or larger quantities of cholepyrrhin. It 
 becomes saffron-yellow, reddish-brown, dark-brown, greenish-brown, 
 or brownish-black, according to the quantity and the quality of the 
 pigment which enters into it. A practised eye is usually able, with- 
 out further tests, to recognise the presence of the colouring-matter 
 of the bile from the saffron-yellow tint of the froth, or of thin 
 layers of the urine ; yet this is by no means invariably possible. 
 The urine is not unfrequently of a reddish-brown, or of a brownish- 
 black colour, even when it does not contain a trace of cholepyrrhin. 
 Dark shades of colour, similar to 'those of jaundiced urine, may be 
 
 h2 
 
100 JAUNDICE. 
 
 observed in the course of other diseases, especially in impeded respi- 
 ration, when this is not accompanied with impoverished blood, in 
 emphysema, in congestion of the lungs resulting from disease of the 
 mitral valves, and also in haemorrhages of the kidney ; the urine may 
 also assume a bright-red or saffron-yellow colour after the use of 
 preparations of rhubarb, or santonine, or even independently of these. 
 
 Re-agents are almost always necessary, in order to determine with 
 accuracy the presence in the urine of the colouring-matter of bile ; 
 and we possess unequivocal tests of its existence. The best we can 
 employ for the purpose is nitric acid, which is not altogether free 
 from nitrous acid. This produces the well-known play of colours 
 from brown to green, blue, violet, and red, this last ultimately pass- 
 ing into a dirty-yellow. This change is exhibited most distinctly by 
 adding the concentrated acid, drop by drop, to the urine in a 
 small conical glass, taking care not to shake it ; the different colours 
 are then arranged in layers, one above another like a rainbow. It 
 is not always, however, that this reaction can be recognised in 
 the urine containing bile-pigment. It very frequently happens that 
 the pigment undergoes further changes, either before leaving the 
 blood or in the urine, which deprive it of this property. Even the 
 gaseous acids contained in the atmosphere, may produce similar 
 changes in the urine, when it is allowed to stand exposed to the 
 air ; the colour, which at first was brown, gradually becomes green- 
 ish, and at the same time the characteristic effect of nitric acid 
 gradually ceases. The modification of the bile-pigment which is 
 produced under such circumstances, assumes, when acted on by 
 acids, a green, or bluish-green colour, which is particularly distinct, 
 when the urine at the same time contains albumen ; the precipitate 
 formed by nitric acid then exhibits a bluish-green shade. 
 
 However, this reaction may also fail; the colouring-matter may 
 already have passed through all these stages of transformation, and be 
 no longer in a condition to furnish either the one or the other reaction, 
 although, as is proved by the other symptoms of jaundice, it must 
 be regarded as a direct derivative of the bile-pigment. "When this is 
 the case, the urine is at one time of a brown, or brownish-red colour, 
 and becomes red on the addition of nitric acid ; at another time it is 
 of a deep-red, which is converted, by nitric acid, into a dark bluish-red. 
 
 In some cases, the urine contains colour-producing substances 
 {Chromogene), and then it exhibits no trace of the characteristic 
 reaction of cholepyrrhin immediately after being passed, which, 
 
SYMPTOMS. 101 
 
 however, becomes apparent when the urine has stood for some time 
 exposed to the air, and is then treated with nitric acid. It is the 
 same colour-producing substance which is found in the blood of 
 jaundiced patients, and which is formed during the metamorpho- 
 sis of the acids of the bile into pigment. 
 
 The vegetable colouring-matters, which may be mistaken for 
 the pigments of bile, may easily be distinguished by their different 
 behaviour towards re-agents. The colouring-matter of rhubarb and 
 of santonine, which especially come under our notice, become of 
 a blood-red colour when treated with the caustic alkalies or their 
 carbonates, a property which is participated in by no modification 
 of bile-pigment. 
 
 Jaundiced urine is usually clear; but in most cases of febrile 
 jaundice, it deposits sediments of uric acid, which are characterised 
 by a bright brick- or rose-red colour. Occasionally, we find pre- 
 cipitates of another nature, such as the epithelium of the urinary 
 passages and of the kidneys tinged yellow; still more rarely, and 
 only in aggravated cases of jaundice, we find flakes of a yellowish- 
 brown fibrinous substance, or of a crumbling, brownish-black pig- 
 ment, which is sometimes deposited in large quantities in the in- 
 terior of the tubuli-uriniferi of the kidneys. 
 
 A complete examination of jaundiced urine, in reference to the 
 quantity of solids, uric acid, salts, &c, which it contains, has not 
 yet been accomplished on such a scale as to furnish a comprehen- 
 sive view of the metamorphosis which takes place in the course of 
 jaundice. We are equally ignorant of the amount of the products 
 of respiration. It is not improbable that such an investigation 
 would furnish results, which would repay one's trouble. 
 . By. far the largest quantity of the bile-pigment is excreted . by 
 the kidneys; the excretion from these organs takes place in such 
 quantities, that in some cases, their texture is essentially injured 
 thereby. In the more persistent and intense forms of jaundice, 
 changes take place in the kidneys, which hitherto have not re- 
 ceived the attention which they deserve. The organs assume an 
 olive-green appearance; a number of Coiled-up uriniferous tubes 
 of a dark colour may be seen in the cortical substance; and in 
 the pyramidal portion, in addition to brown or sap-green tubuli, 
 there are others which are filled with a black deposit. Upon closer 
 inspection, the paler uriniferous tubules are found to be of a green 
 or brown colour, and their epithebal lining, which is seldom entire, 
 
102 JAUNDICE. 
 
 is of a deep-brown tinge, which is particularly marked in the nuclei. 
 The individual cells appear partly of a blood-red colour, partly 
 green, and partly brown ; some of them contain layers of pigment 
 deposited in a concentric manner around the nucleus; not unfre- 
 quently, we meet with epithelial cells which have undergone fatty 
 degeneration, and are red, brown or black. Where the deposit of 
 pigment is most intense, uriniferous tubes may be observed dis- 
 tended with a coal-black, hard, brittle mass, which, like the material 
 of black gall-stones, is either dissolved in caustic potash, slowly and 
 incompletely, or is quite insoluble. In addition, there may be 
 noticed cylindrical masses, consisting of an amorphous material, 
 brown in the centre, but becoming gradually paler towards the peri- 
 phery. Caustic potash acts upon them more rapidly, dissolving 
 their pigment, and causing the cylinders themselves to become 
 transparent and swell up like coagulated fibrine which has been 
 retained for a long period in the uriniferous tubes.* 
 
 The deposit of pigment under such circumstances extends through- 
 out the entire tissue of the kidneys ; it is even perceptible in the 
 epithelium of the Malpighian bodies ; it is still more evident in the 
 convoluted tubuli uriniferi, and is pre-eminently, distinct in the 
 straight tubules of the pyramids, the calibre of which becomes 
 blocked-up with hard, coal-like masses. It might be imagined, that 
 such a deposit would greatly interfere with the secreting function of 
 the kidneys, and observation proves that it really does so. (See Ob- 
 servation No. VI.) 
 
 Next to the kidneys, the sweat-glands take the most prominent 
 part in the excretion of bile-pigment. Not unfrequently, the 
 secretion of the axilla, and of other parts of the skin remarkable for 
 their secreting properties, colours the white linen distinctly yellow. 
 Chomel was acquainted with this symptom, f and Cheyne J observed 
 a patient who first became cognizant of his complaint from noticing 
 his towel become yellow upon wiping his face. Andral § describes 
 a case in which the sweat coloured the linen yellow, and the urine 
 contained the colouring-matter of bile, although the skin and con- 
 junctivae exhibited no jaundiced tint. 
 
 * These various forms of the pigment-deposit are accurately delineated 
 in the coloured Atlas. Plate I. (Figs. 9, 10, 11, 12). — Transl. 
 t Academ. des Scienc, 1737, p. 69. 
 t Dublin Hospital Reports, Vol. III., p. 269. 
 § Clinique Med., Tom. II., p. 373. 
 
SYMPTOMS. 103 
 
 The quantity of colouring-matter which is excreted by the sweat- 
 glands is always very inconsiderable in comparison with that excreted 
 by the kidneys. The sweat-glands themselves do not undergo any 
 important changes of structure, corresponding to those of the kid- 
 neys. The contents of the cutaneous glands appear of a somewhat 
 yellow tinge, and here and there may be seen brown granules, and dark 
 nuclear formations, but nowhere a considerable deposit of pigment. 
 
 The participation by the remaining secreting organs in the re- 
 moval of the colouring-matter is very insignificant and inconstant. 
 Wright maintained that he had found cholepyrrhin in the saliva, 
 which, after repeated examinations, I have failed in doing} even in 
 the parenchyma of the parotid and submaxillary glands, and of the 
 pancreas, I have only observed a very slight deposit of pigment.* I 
 have been equally unsuccessful in ever detecting the colouring-matter 
 of bile in mucus. The catarrhal sputa of a woman labouring under 
 very intense jaundice, which was expectorated in large quantity, exhi- 
 bited the usual greyish-yellow colour, and gave no reaction on the 
 addition of nitric acid (see Observation No. VII.) ; even the mucus 
 which lined the bile ducts in one case was as clear as water, and with- 
 out a trace of pigment. (Observation No. VI.) The mucous secre- 
 tion of the small and large intestines likewise remains greyish- white, 
 and free from colouring-matter ; in one case only, have I found it 
 to exhibit a bluish colour, which, however, did not proceed from 
 bile-pigment, but from melanotic granules deposited in the cast-off 
 epithelium. I cannot, therefore, agree with those who, like Foureroy 
 and others, assume that the mucus is coloured yellow in jaundice. 
 Albuminous and fibrinous exudations are entirely different in this 
 respect: they always abound in colouring-matter. The sputa in 
 bilious pneumonia have a brown, or usually, a leek-green colour, 
 and, upon the addition of nitric acid, present a lively reaction. 
 This property they retain so long as any exudation is expectorated ; 
 hence, they are sometimes observed to be still green, long after the 
 jaundiced colour of the skin and urine has disappeared. 
 
 * Huxham (Opera physico-mecUca, Tom. III., p. 12) describes the case 
 of a man, aged 40, who, when suffering from jaundice, and colic from a 
 biliary calculus (Steinkolik), became salivated after taking eight grains of 
 calomel, and poured out an enormous quantity of saliva, at first green, and 
 afterwards yellow ; the fauces and the teeth were seen to be covered with a 
 substance resembling verdigris. Mercurial salivation, however, causes a 
 transudation of albumen into the saliva, so that the case proves nothing 
 so far as the normal secretion of the parotid is concerned. 
 
104 JAUNDICE. 
 
 Observation No. IV. 
 
 Pneumonia Duplex, Icterus, Bilious Stools — Green Expectoration 
 continuing for ten days after the cessation of the Pneumonia, and 
 for eight days after the disappearance of the Jaundice from the skin. 
 
 ■ Carl Jansch, a daily labourer, 64 years of age, was admitted on 
 the 7th of December, 1855. On the 3rd, the patient was carrying 
 a heavy load of wood, which, on going up-stairs, he knocked against 
 the ceiling, so as to produce a violent concussion of the thorax. 
 On the 4th, he had pain in the chest, cough, and bloody expectora- 
 tion, accompanied with rigors, &c. 
 
 On the 11th, the patient was admitted into the Clinique. Pulse, 
 118 ; jaundiced colour of skin and conjunctivae ; urine, brownish- 
 black; sputa tenacious, dark-green, and yielding the reaction of 
 bile-pigment. On the right side of the back, there was dulness, 
 with bronchial breathing extending as high as the middle of the 
 scapula ; the same signs were observed on the left side, but extend- 
 ing in an upward direction, one intercostal space less ; the upper 
 lobes of both lungs normal; stools thin, and coloured with bile. 
 Was ordered infusion of digitalis with gum arabic. 
 
 On the 12th, the upper lobe of the right lung was also con- 
 densed. The situation and volume of the liver were normal. 
 
 On the afternoon of the 13th, the fever ceased; on the 14th, 
 perspiration ; pulse, 88. Was ordered infusion of ipecacuanha. 
 
 On the 16th, the jaundice of the skin was no longer visible, the 
 condensation of the lungs was receding, and over the dull spaces 
 there could be heard loud consonant rattles. 
 , Prom the 18th, the urine was free from bile-pigment, but the 
 sputa continued of a dark-green colour, and yielded, with nitric 
 acid, distinct indications of the presence of bile-pigment, until ten 
 days after the cessation of the pneumonia, and eight days after the 
 disappearance of the jaundice from the skin. 
 
 Hence it would appear, that in bilious pneumonia the removal of 
 the exudation by means of the expectoration is peculiarly apt to 
 continue. The case also shows, that the expectoration occurs in 
 much greater abundance, and lasts longer than is generally believed. 
 
 If now and then mucous fluids have contained bile-pigment, this 
 
SYMPTOMS. 105 
 
 has always been when albumen has been present, and when, conse- 
 quently, the mucus has been mixed with exudation. 
 
 The statement, also, of Heberden, to the effect that the tears 
 are coloured yellow, I have not been able to confirm. 
 
 Cases, however, undoubtedly occur, in which the colouring-mat- 
 ter may be observed in the milk of suckling women. This fact 
 was long since mentioned by Mende and J. P. Prank. Marsh drew 
 off from the distended mammae of a female who had died of jaun- 
 dice, a tenacious yellow fluid, which presented all the characters of 
 pure bile ; a similar observation was made by Bright ; * and more 
 recently, Gorup-Besanez, t has detected unmistakable bile-pig- 
 ment in the milk of a jaundiced female. This admixture, however> 
 is not constant. 
 
 Simultaneously with the tinging with pigment of the secretions 
 just mentioned, changes of colour begin to be observed in the tissues. 
 These are first visible in the skin and conjunctiva. 
 
 The skin at first is of a pale sulphur-yellow, and afterwards of 
 a saffron or citron-yellow, or of an olive or bronzed colour {melas 
 icterus). The shade of colour depends partly upon the intensity 
 and duration of the disease, and partly upon the smooth or puck- 
 ered character of the skin, the thickness of its epidermal covering, 
 and the activity of its secreting power. In young persons, whose 
 skin is kept smooth by a thick cushion of fat, we do not find the 
 dark, dirty shades exhibited by the wrinkled skin of older people. 
 The colour is first observed in those places where the epidermis is 
 thin, and the secretion abundant, upon the alee of the nose, at the 
 angles of the mouth, upon the forehead and neck. Sometimes I 
 have seen the upper half of the body very distinctly tinged without 
 any change being visible on the lower. 
 
 Some of the older physicians, such as Morgagni, Behrends, and 
 others, describe a partial jaundice, which in some cases is limited to 
 one-half of the body, and in others is confined to several isolated 
 localities. J. P. Prank, who had an abundant experience in 
 jaundice^never observed cases of this nature. It is probable that 
 pigmentary deposits in the skin of another nature have here been 
 confounded with jaundice ; in none of the cases is there any cer- 
 tain proof of the colouring-matter of bile having been present in 
 the urine at the same time. 
 
 * Guy's Hospital Reports, Vol. I. 
 t Archiv fur physiol. Heilk. 1849. 
 
lOff JAUNDICE. 
 
 The jaundiced colour of the skin proceeds principally from the 
 deeper layers of the epidermis, the rounded cells of which are 
 coloured intensely, and contain brown molecules ; the older flat 
 cells are of a paler tinge. Hence, after the removal of the causes of 
 the jaundice and the disappearance of the colouring-matter from the 
 urine, the colouring of the skin may continue for a long time, until 
 the epidermis is removed by desquamation, and is renewed. This is 
 a circumstance which must not be lost sight of in treatment. 
 
 The mucous ^membranes only exhibit the yellow colour in a slight 
 degree ; hence the lips and tongue, especially the latter, when it is 
 covered* with a grey coat, present a remarkable contrast to the sur- 
 rounding saffron-coloured skin. 
 
 The yellow colour which penetrates into all the tissues along with 
 the blood-plasma, may be observed in almost all the deeper-lying 
 parts, which can only be examined after death. The adipose cellular 
 tissue, as already pointed out by Valsalva, assumes a citron-yellow 
 colour; in like manner, the serous and fibrous membranes, the 
 areolar tissue, the walls of the blood-vessels and of the lymphatics, 
 and the substance of the bones and of the teeth, become more or 
 less intensely coloured ; but cartilage is affected in a less degree. 
 The red colour of the muscles takes on a yellow aspect, owing prin- 
 cipally to the tinging of the perimysium* and of the interstitial 
 areolar tissue. 
 
 A marked yellow tinge is seldom to be observed in the substance 
 of the brain ; I have seen it in a few cases, in which the brain 
 was cedematous, and where the colour proceeded from infiltration of 
 the cerebral substance with yellow serum. The same remark is 
 applicable to the nerves. 
 
 In the eye, in addition to the outer membranes, the humours, 
 especially the corpus vitreum, and to a less extent, the aqueous 
 humour, become tinged with cholepyrrhin in the more intense forms 
 of jaundice; t the vitreous body assumes a pale citron-yellow colour, 
 and, on the addition of nitric acid, exhibits distinctly the reaction of 
 cholephyrrhin, as does also the watery fluid contained in it. I have 
 never observed this character in the lens. 
 
 * The perimysium is the areolar sheath, which envelopes the muscles, as 
 well as their larger and smaller fasciculi and individual fibres. — Transl. 
 
 t It is only in the intense forms of jaundice, that I have been able to 
 detect this change ; as a general rule, there has been no abnormal tinging 
 of the humours of the eyeball. 
 
SYMPTOMS. 107 
 
 In pregnant women, the foetus participates in the yellow colour. 
 Bonetus,* long ago, thus described a foetus born of a jaundiced 
 female : " Ita flavum, ut e cera confectus puer non partus humanus 
 videretur." Similar observations weTe made by Wrisberg and Finke.t 
 In order, however, that the offspring should become jaundiced, a 
 long continuance of the disease is necessary ; in jaundiced females 
 who have aborted from five to fourteen days after the commence- 
 ment of the jaundice, I have been unable to perceive any altera- 
 tion in the colour of the foetus. (See Observations No. XIII. and 
 No. XIV.) 
 
 Along with the alteration of colour, although of less constant 
 occurrence, a series of symptoms are observed which proceed from 
 abnormal conditions of the nervous system. The principal of these 
 are the following : — 
 
 1. Itchiness of the shin, in many cases, although by no means 
 in all (according to my own experience only in one-fifth), ac- 
 companies the commencement of the jaundice. The itchiness is, 
 in most cases, spread generally over the skin, and is especially 
 troublesome in the night-time ; in a few cases it is partial, or con- 
 fined to certain localities of the skin, such as the axilla, the inguinal 
 region, &c. ; it usually disappears after some days, or when the 
 jaundice increases in intensity. Graves observed one case, in which 
 the itchiness showed itself before the commencement of the jaundice, 
 on the outbreak of which it disappeared. In most cases it pro- 
 duces no change in the skin ; sometimes there appears an eruption 
 of pimples or pustules, which are usually scratched at an early 
 period ; and, in exceptional cases, according to the experience of 
 Graves, urticaria may be present. In one person labouring under 
 jaundice, I observed the skin covered with numerous rounded wheals 
 (Quaddeln) the size of a four-groschen piece; % these produced no 
 inconvenience, and disappeared eight days after they first showed 
 themselves. 
 
 2. A second, though also not an invariably concomitant symptom, 
 is derangement of the general sensations: great exhaustion and 
 debility, along with sadness and peevishness of temper, headache, 
 giddiness, &c. These symptoms are often completely wanting in 
 simple jaundice; in other cases, they are sufficiently explained by 
 the coexistence of catarrh of the stomach ; in chronic cases, they are 
 
 * Sepulchret, T. II., p. 333. t De morbis Miosis anomalis. 
 
 X ■£, English inch, or about the size of a shilling. — Transl. 
 
108 JAUNDICE. 
 
 not unfrequently observed to occur independently of any other source, 
 and then they betoken, for the most part, nervous disorders, which 
 depend not upon the jaundice, but upon other derangements of the 
 functions of the liver, which will hereafter come under consideration. 
 Still rarer are, 
 
 3. Abnormal perceptions of the senses, subjective sensations of 
 taste and sight. A bitter taste with a clean tongue, of which com- 
 plaint is now and then made, usually disappears after a few days. 
 That this may depend upon the accumulation of bilious matter in 
 the blood, is proved by the experiment which I have often made of 
 injecting bile into the veins of dogs ; as soon as the fluid enters, the 
 animals keep on continuously licking with their tongues. The bitter 
 taste frequently depends upon the eructation of the bilious contents 
 of the stomach. 
 
 Another delusion of the senses met with in jaundiced people has 
 at all times attracted much notice, yellow sight or xanthopsy. The 
 ancients appear to have been acquainted with this symptom, if we 
 can rely upon a passage in Lucretius.* Pr. Hofmann t mentions 
 two cases : since then it has been several times, although compara- 
 tively seldom, observed. J. P. Prank met with it only in five out of a 
 thousand cases of jaundice ; I myself have never had an opportunity 
 of seeing a case, although I have always made inquiries on the 
 point. % "White objects appear to the patients to be yellow, in 
 most cases, only for some hours, but sometimes for several days. In 
 earlier times, this abnormal condition of the function of vision was 
 considered to be produced by a yellow tinging of the cornea, and of 
 the aqueous humour, which had been observed to accompany this 
 symptom. § In opposition to this view, however, J. P. Prank brought 
 forward the following considerations : that he had met with a yellow 
 
 * " Lurida prseterea fiunt quaecunque videntur arquatis." 
 
 t Med. rat. Syst., Tom. IV., p. 353. 
 
 X In interrogating patients concerning this symptom, especially if we 
 have to do with those ■who are uneducated, we must exercise great 
 caution, if we wish to receive trustworthy answers ; I have sometimes 
 received replies in the affirmative, which, upon closer inquiry, have been 
 withdrawn. 
 
 § See Morgagni, De Sed. et causis morborum, Epist. 37-8; and J. P. 
 Frank, De curandis hominum morhis, lib. VI., pars III., p.< 343. Frank's 
 remark that the vitreous humour does not become partly yellow is 
 erroneous ; I have always found more colouring-matter in it than in the 
 aqueous humour. 
 
SYMPTOMS. 109 
 
 condition of the cornea, without the derangement of vision, just alluded 
 to j secondly, that the yellow vision intermits ; and lastly, that the 
 same symptom is met with in typhus fever without jaundice. Hence, 
 in addition to the jaundiced colour of the membranes and fluids 
 of the eye, Prank blamed a morbid action of the nerves. The latter 
 has in recent times been usually regarded as the sole exciting cause ; 
 first, because this symptom is frequently absent in intense colouring 
 of the tissues of the eye ; and secondly, because other derangements 
 of the faculty of vision, such as day- and night-blindness, present 
 themselves under the same conditions as those which give rise to 
 yellow vision. Stokes considers yellow vision as an indication of 
 impending paralysis, and Bamberger observes, that he has only met 
 with it in jaundiced persons who have died of cirrhosis of the liver. 
 The analogous condition, however, which is observed after the use of 
 santonine appears to me to argue in favour of the importance of the 
 accumulation of colouring-matter in the blood, and in the fluids of 
 the eyeballs. Here also, whilst the santonine is being transformed 
 by the alkalies of the blood into a coloured modification, all ob- 
 jects in a feeble light appear of a greenish-yellow colour, but this 
 coloured vision ceases so soon as the colouring-matter is excreted by 
 the kidneys. Elliotson's case of jaundice, in which the yellow 
 vision was limited to one eye covered with varicose vessels, whilst 
 the other eye saw colours unchanged, might admit of another 
 simpler explanation. 
 
 4. Retardation of the hearts action. Very commonly the fre- 
 quency of the heart's contraction in jaundice falls to a greater or less 
 extent below the normal standard, in most cases to 50 or 40 beats, and 
 now and then to still fewer; in one case I have counted 28 beats, 
 and in another only 21. This retardation, which not unfrequently is 
 accompanied by irregular rhythm of the heart's action; often lasts 
 for several weeks before it disappears ; it ceases immediately, when in- 
 flammatory or other acute processes supervene as complications of 
 the jaundice, and a moderate frequency becomes substituted. "When 
 jaundice appears in the course of any febrile disease, such as acute 
 catarrh of the gastrointestinal canal, typhus fever, &c, there is, in 
 most cases, a remarkable diminution in the frequency of the pulse 
 as soon as the yellow colour shows itself: the pulse sinks from 110 
 to 80 or 70, or even less. 
 
 The slow pulse is no constant symptom of jaundice ; cases occur 
 in which it remains absent during the entire course of the disease: 
 
110 JAUNDICE. 
 
 Why this is so, cannot be determined with, certainty, any more than 
 we can in general explain the cause of the phenomenon in question. 
 It might be assumed, that the bile exercises an influence upon the 
 vagus nerve, or upon the brain, similar to the action of digitalis ; hut 
 we do not possess any positive proofs of such an assumption ; and the 
 complete integrity of all the remaining functions of the nervous sys- 
 tem, as also the condition of respiration, renders it very improbable. 
 Whilst along with the diminished frequency of pulse which follows 
 the use of digitalis, the respiration is wont to become more frequent ; 
 in jaundice, on the other hand, the frequency of respiration diminishes 
 along with that of the pulse, although not in the same ratio. 
 The number of respirations in proportion to the beats of the pulse is, 
 in most cases, as 1 to 3. It is conceivable, that the stimulating 
 action of the blood upon the muscular tissue of the heart may be 
 diminished, or that there may be adhesion of the blood to the coats 
 of the vessels, but at present it is impossible to come to any decision 
 upon the matter. 
 
 5. The temperature in simple jaundice remains unchanged. It 
 varies in the axilla from 36.8 P to 37.25° cent. (98.24° to 98.85° 
 Pahr.) ; such a temperature we find in individuals who have been 
 suffering for a long period from carcinoma of the liver, or from other 
 organic diseases. It is obvious, that the circumstances are different 
 in the cases of febrile jaundice ; in catarrhal jaundice with fever, we 
 have found the temperature 38.5°, &c. (101.3° Fahr., &c.) 
 
 6. Derangements of digestion. The functions of the stomach in 
 jaundiced persons are usually unaffected ; the patients may have a 
 clean tongue, and may enjoy an appetite which leaves nothing to be 
 desired. We meet first with abnormal conditions of those processes, 
 which go on in the intestine, and which are known to depend upon 
 the deficiency or absence of bile in that tube.* Observations made 
 by establishing biliary fistulas, which, in recent times, have so fre- 
 quently been repeated, have certainly proved, that the absence of 
 the hepatic secretion in the intestine produces no derangements of 
 nutrition by any means remarkable, or threatening life ; that, on the 
 contrary, most of the objects of chylification canjbe attained without 
 the presence of bile; still, however, there arises a series of abnormal 
 
 * Sometimes the appetite is morbidly increased, and there is a craving 
 for peculiar articles of diet, such as shellfish, mussels, &c, as in a case 
 observed by Budd. 
 
SYMPTOMS. Ill 
 
 conditions, the influence of which gradually increases, and, in jaundice 
 of long-standing, terminates in defective nutrition. 
 
 The stoppage to the flow of bile first interferes with the processes 
 of diffusion which take place in the upper part of the intestinal 
 canal, between the fluid portion of the chyme and the blood in the 
 interior of the vessels. It must be of some consequence to these 
 processes, whether or not in the space of twenty-four hours 1 kilo- 
 gramme (2.2046 lbs. avoir.) of fluid, more or less, is mixed with the 
 intestinal contents. 
 
 The want of bile of course does not influence in any remarkable 
 manner the digestion of the albuminous and carbonaceous ingredients 
 of the food ; but according to the experiments of all practical inquirers 
 upon this subject, the absorption of fat is considerably restricted. 
 Jaundiced persons have in general an aversion to fatty articles of 
 food, and after eating them a large proportion of the fat appears 
 in the evacuations. The loss in nutrition, which results from this 
 cause, is sufficiently great to become observable in the course of time. 
 Another result of less moment is the loss of the antiseptic influence of 
 the bile, which permits of abnormal transformations of the intestinal 
 contents, and the generation of large quantities of gas. Hence, 
 flatulence is generally complained of by jaundiced patients, especially 
 when they exhibit a preference for animal food ; in such cases the 
 fecal matters emit a putrid odour, they differ greatly from the nor- 
 mal evacuations, and they contain numerous vibriones, and sub- 
 stances which in their chemical characters resemble those which are 
 found in putrefying albumen and caseine. When, on the other hand, 
 the food consists principally of vegetable, amylaceous substances, 
 the evacuations have in general no remarkable odour, and are of an 
 acid nature, because a part of the carbonaceous food undergoes acid 
 fermentation* in its transit through the intestinal canal. This, 
 however, likewise occurs in healthy conditions, so that it might be 
 difficult to determine, whether it is increased in proportion by the 
 removal of the bile. 
 
 Of greater importance in a practical sense are the changes in 
 colour which the faeces are wont to exhibit in jaundice, because from 
 their characters we can most easily draw a conclusion as to the more 
 or less complete exclusion of bile from the intestine. "When the 
 obstruction of the biliary ducts is complete, every trace of bile- 
 
 • Monro and Pringle long ago remarked the sour smell of the faecal 
 matters. 
 
T12 JAUNDICE. 
 
 pigment disappears from the stools;* they assume an ash- or 
 clay-colour, which only varies according to the nature of the food. 
 Their consistence is almost always at the same time increased; 
 they become hard and firm; the bowels are also sluggish and 
 require stimulation by means of purgatives. This tendency to 
 constipation is so constant in jaundice, that the assumption appears 
 completely justified that it is owing to the want of bile in the bowel. 
 Whether the bile favours evacuation by stimulating the peristaltic 
 motions of the intestine, or by increasing the secretion of the intes- 
 tinal glands, or by liquefying the ingesta, are questions which we 
 may leave undecided. Spontaneous diarrhoea in jaundice is of rare 
 occurrence; I have observed it repeatedly as a consequence of 
 dysentery, which now and then mates its appearance in the course of 
 the disease. More frequently we find, that notwithstanding the 
 exclusion of the bile from the bowel, the stools come gradually to be 
 passed regularly.t The characters of the faeces are not always such 
 as have just been described. The colour certainly often appears 
 paler than usual, but still the pigment is not entirely wanting. This 
 is always the case, when the exclusion of the bile is incomplete, 
 whether this be owing to only a portion of the biliary ducts being 
 compressed, or because there is merely constriction of the principal 
 duct, which impedes, but does not completely arrest, the passage of 
 the bile. The former condition frequently happens in cirrhosis, where 
 the extreme ramifications of the biliary ducts are partially obliterated 
 by the compression of the newly-developed areolar tissue ; also in 
 carcinoma and other tumours which are wont to encroach upon cer- 
 tain of the larger branches only ; the latter condition again is 
 observed in catarrh of the ductus choledochus and ductus hepaticus, 
 in which the tumefaction of the mucous membrane entails only an 
 impediment to the flow of bile, in angular. concretions, which cannot 
 completely obstruct the flow, &c. 
 
 Occasionally we find jaundiced persons passing stools of a normal 
 colour, or unusually dark. There may be two reasons for this; 
 Either the cause of the biliary obstruction has been suddenly re- 
 
 * Osborne (Dublin Journal, February, 1853) supposes that the mucous 
 membrane of the intestine can secrete dark bile, like the external integu- 
 ment and the kidneys, and that in this way the faeces may become 
 coloured, notwithstanding the closure of the bile ducts. This, as far as 
 my experience goes, is never the case. 
 
 t Graves and Stokes. Dublin Hosp. Reports, Vol. V., p. 109. 
 
DURATION. 113 
 
 moved, and the bile passes again into the bowel, whilst the colour 
 of the skin remains unchanged, as often happens in the case of con- 
 cretions, and other rapidly-disappearing causes of obstruction; or, 
 there is a sudden cessation of an excessive absorption of bile {Poly- 
 choUa), of which we shall subsequently speak. 
 
 4. Duration of Jaundice. 
 
 The duration of jaundice is very various ; it may fluctuate between 
 a few days and several years. The determination of the longer or 
 shorter duration of the disease depends principally upon its primary 
 causes, the persistence of which may vary, and which may of them- 
 selves help to bring about a fatal termination speedily or slowly. If 
 we except those forms, in which the other consequences which may 
 result from the primary exciting cause of the jaundice, decide the 
 matter, the jaundice which proceeds from simple obstruction to the 
 flow of bile, as when the ductus choledochus is obliterated, may last 
 for years before it terminates fatally. Graves and Stokes* men- 
 tion two cases of jaundice, in one of which the disease lasted 
 for eleven months, and in the other for two years, before the 
 nutrition became impaired; Buddf saw a man, who during an 
 attack of jaundice which lasted four years, with complete obstruc- 
 tion of bile, continued well nourished; DewayJ has described a 
 case of seven years' duration, and Yan Swieten § mentions the case 
 of a female who suffered from jaundice for eleven years, and was 
 ultimately cured by solvent extracts. 
 
 The cases which I have had an opportunity of observing, have 
 terminated much more rapidly, even when the primary causes of the 
 jaundice have not contributed in any other way to the acceleration of 
 the fatal termination of the disease. Thus, one woman with oblitera- 
 tion of the ductus choledochus died eight months after the commence- 
 ment of the jaundice; another died after six months and fourteen 
 days ; one man with a cancerous tumour of the duodenum, the size 
 of a walnut, only survived the first appearance of jaundice nine 
 weeks. In one case only, in which a biliary concretion had closed 
 up the ductus choledochus, did the jaundice persist for two years and 
 a-quarter. 
 
 * Dublin Hospital Reports, Vol. V., p. 103. f Op. cit. p. 371. 
 
 I Gazette m&l. de Paris. 1843. § Comment. III., p. 130. 
 
 I 
 
114 JAUNDICE. 
 
 5. Modes of Termination, of Jaundice. 
 
 The jaundice does not disappear completely until some time after the 
 removal of the causes which, have occasioned the accumulation of 
 colouring-matter in the blood. Where the cause of the jaundice con- 
 sists in an obstruction to the passage of bile into the intestine, 
 the recovery is announced by a return of colour to the stools; 
 their colour becomes darker by degrees when the disappearance of 
 the obstruction is gradual, as in catarrh of the bile ducts ; or they 
 are rapidly overcharged with bile, when from, the sudden removal 
 of the obstruction, the pent-up secretion of the liver at once finds its 
 way into the bowel, as in the case of concretions, &c. At the same 
 time, the pigment begins to disappear from those parts which, under 
 normal circumstances, are free from it. First, it disappears from the 
 blood and from the urine ; the solid tissues remain coloured for a 
 longer period, and particularly those tissues in which the mole- 
 cular changes take place slowly. The colouring matter deposited in 
 the epidermal layer of the skin disappears gradually as this layer 
 becomes regenerated by desquamation and new formation; hence, 
 it may last for weeks, especially in old persons. The colouring- 
 matter appears to be gradually washed out from the other tissues hy 
 the current of the nutritious fluid. Thus the complete removal of 
 the jaundiced colour always occurs much later than the cessation of 
 the disease, — a fact which must not be lost sight of in the application 
 of remedies. 
 
 Not unfrequently jaundice terminates in death, which may be 
 brought about in very various ways. Passing over the influences 
 which the manifold exciting causes of jaundice may, directly or in- 
 directly, exercise in this direction (and indeed the mode of fatal ter- 
 mination is as varying as the etiology of the disease, and in most 
 cases death terminates the process sooner or later), we confine our- 
 selves, for the present, to the consideration of those injurious effects 
 by means of which the simple retention of bile may gradually under- 
 mine the constitution, and lead to death. The accumulation of bile 
 in the blood is followed by no dangerous consequences ; it is only in 
 rare cases that the deposit of pigment in the parenchyma of the kid- 
 neys impairs the functions of these organs to an alarming degree.* 
 The danger to be apprehended almost always proceeds from the con- 
 
 * Deway (Gaz. mid. de Paris, 1843) observed complete suppression 
 
MODES OF TERMINATION. 
 
 115 
 
 secutive changes in the liver itself which result from the retention of 
 bile. The pent-up secretion gradually distends to a greater or less 
 degree, the biliary ducts as far as their finest ramifications ; stretching 
 through the parenchyma may be seen the cylindrical, or not unfre- 
 quently, ampulliforin ducts, which compress the adjacent glandular 
 tissue, and a part of the ultimate ramifications of the portal vein. 
 
 Fig. 19. 
 
 Fig. 19. Enlargement of the bile ducts, and of the pancreatic duct, 
 in consequence of a cancerous tumour in the head of the 
 pancreas. The details of the case from which the prepara- 
 tion was obtained will be afterwards given under Observation 
 No. VII. 
 
 (Kg. 19.) When we make a fine section of the hardened substance 
 of such a liver, and examine it with a moderate magnifying power, 
 numerous deficiencies are seen throughout its tissue, usually situated 
 at the periphery, but sometimes near the centre of the lobules, and 
 here and there forming large empty spaces. (Kg. 20.) 
 
 The walls of these distended ducts are in most cases considerably 
 thickened. Their contents in general consist of a thin fluid bile, 
 
 of the urinary secretion in a case of intense jaundice, during the last 
 three days of life. See further, Observation No. VI. 
 
 12 
 
116 
 
 JAUNDICE. 
 
 which is mixed with a varying quantity of the mucous secretion of 
 the bile ducts. Occasionally it happens, that the bile is thickened 
 and lines the inner surface of the enlarged ducts in the form of a 
 solid, tubular, dark-brown mould. I have seen this in one case, in 
 
 Fig. 20. 
 
 Fig. 20. A thin section of the liver represented in Fig. 19, mag- 
 nified 80 diameters. The large empty spaces are the sections 
 of the enlarged bile ducts, the walls of which are represented 
 as much thickened. The smaller openings, surrounded by 
 dark spaces, are the sections of the hepatic veins, surrounded 
 by cells loaded with bile-pigment. The shading around these 
 openings should have been of a granular character. 
 
 which there was an exuberant cancerous growth upon the mucous 
 membrane of the bile ducts ; and Stoll long ago recorded an instance 
 pf a similar nature. Sometimes, notwithstanding intense jaundice 
 of the liver and other tissues, there is not a trace of bile in the 
 fluid distending the gall-bladder and the excretory ducts. This 
 consists of a colourless transparent liquid, containing a small 
 quantity of mucus along with greyish nocculi and ' mucous cor- 
 puscles. (See Observation VI.) 
 
 Simultaneously with the distention of the bile ducts, a large 
 proportion of the hepatic parenchyma becomes atrophied and 
 
MODES OF TERMINATION. 117 
 
 destroyed in the manner just mentioned; and another portion is 
 rendered incapable of performing its function owing to the accumula- 
 tion of bile within the cells. In this way, the secreting powers of 
 the gland are more and more impaired, and the circulation of the 
 blood in it is obstructed. In some cases, the function of the liver 
 is completely arrested, owing to the glandular cells crumbling down 
 into a finely granular debris, in a similar manner to what is observed 
 in acute atrophy. This last change appears to be brought about by 
 the circulation becoming impeded, and the parenchyma becoming 
 overladen with the products of secretion. 
 
 As a general rule, it seldom happens, and that only when foreign 
 bodies, such as concretions, are present, that the gall-bladder or the 
 distended bile ducts on the upper surface of the liver are destroyed 
 by ulceration, and that their contents, passing into the abdominal 
 cavity, excite severe peritonitis. In a similar manner, extravasations 
 of bile may be supposed to take place within the liver, and to lead 
 to the formation of abscesses. 
 
 Under such circumstances, the case terminates fatally, sometimes 
 by exhaustion, sometimes, on the other hand, with symptoms of 
 blood-poisoning from the so-called cholaemic intoxication, or, lastly, 
 at other times, by perforation and peritonitis, or by suppurative 
 hepatitis. The first mode of death is the most common. The im- 
 paired nutrition, which has been already induced by the defective 
 chylification arising from the exclusion of bile from the intestine, 
 becomes more and more obvious, and the volume of the liver, at 
 first enlarged from the accumulation of the bile, begins to decrease. 
 The organ becomes flabby, shrivelled, and wrinkled, because the 
 absorption of the stagnating bile exceeds the gradually abating 
 secretion.* At the same time, attacks of gastro-intestinal catarrh 
 result from the obstructed circulation of blood, and, in some cases, 
 haemorrhages take place from the stomach and intestine.f Dropsi- 
 cal effusions form in the peritoneal sac, which are wont to be fol- 
 
 * Budd (Op. cit., p. 198) is of opinion that the diminution of the liver is 
 due to the crumbling down of the hepatic cells ; and to prove this, he ap- 
 peals to an examination made hy Williams (Guy's Hospital Reports, Octo- 
 ber, 1843), confirming this disintegration of the cells. This is a mistake ; 
 the liver may become remarkably small, without any destruction of its 
 secreting cells. 
 
 t Observations of this nature have been recorded by Bright (Guy's 
 Hasp. Rep.), Durand, Fardel (Arch, geniral.), Andral (Clinique mid.), Budd 
 (Op. cit., p. 203). 
 
118 JAUNDICE. 
 
 lowed by symptoms of hydremia and general anasarca. In this 
 way the fatal termination approaches imperceptibly j or, as in other 
 conditions of exhaustion, it may be brought about more speedily by 
 inflammatory exudations, such as pneumonia, pleurisy, peritoneal 
 exudations, dysentery, &c. The second form of death, that from 
 intoxication of the blood, takes place when the function of the liver 
 becomes entirely arrested, owing to the disintegration of the hepatic 
 cells. In such cases the patients are restless, complain of headache, 
 and delirium, and convulsions supervene, which may pass on to coma 
 and death. (See Chap. V., on Acholic/,.) When the bile ducts are 
 ruptured, the train of symptoms characteristic of a rapid peritonitis 
 close the scene; or death may be preceded by the symptoms of 
 hepatitis, passing into suppuration. 
 
 6. Dl 
 
 The diagnosis of jaundice is in general not difficult, as, usually, 
 simple inspection in daylight is sufficient.* It is only the slighter 
 degrees of the affection which are overlooked or confounded with 
 changes of colour in the skin depending upon some other cause, as, 
 for instance, with the dark colour which results from sun-burning, 
 with the greyish-yellow colour which is observed in the cancerous 
 cachexia, intermittent fever, lead-poisoning, &c, with the yellowish- 
 green tint of several cases of chlorosis, and with the yellow colour 
 which is wont to supervene upon the erythema of new-born children. 
 All these abnormalities of colour are distinguished from jaundice by 
 the conjunctiva t and the urine remaining free from bile-pigment. 
 It must not, however, be forgotten, that in some individuals the 
 membrane covering the eyes has a yellow appearance dependent upon 
 adipose cellular tissue subjacent to it (which, however, may easily be 
 distinguished from the colour of jaundice by its unequal distribu- 
 tion) ; and it must also be remembered that yellow and brown colour- 
 ing-matters, bearing a striking resemblance to cholepyrrhin, may 
 be present in the urine. We have already discussed how these sub- 
 
 * In artificial light, the jaundiced colour, even when it is intense, is 
 easily overlooked. 
 
 t There are rare exceptions, in which, notwithstanding the jaundiced 
 colour of the skin and the presence of bilious matter in the urine, the con- 
 junctiva remains unaffected. I have seen two attacks of this nature in a 
 very anaemic individual. 
 
PROGNOSIS. 119 
 
 stances may be recognised and distinguished, and how, generally 
 speaking, the urine may be examined so as to detect with certainty 
 any bile-pigment which may be present. 
 
 The real difficulties in diagnosis commence when we come to deter- 
 mine the causes of jaundice. We shall endeavour to solve these 
 difficulties, so far as is possible, in describing the various sorts and 
 forms of jaundice; the diagnosis of many of the etiological causes 
 can be treated of subsequently, under the head of the corresponding 
 diseases of the liver. 
 
 7. Prognosis. 
 
 The prognosis, in jaundice, depends principally upon its causes : 
 the natural course and modes of termination of the primary 
 disease, and the greater or less probability there is of interfer- 
 ing with effect in the way of treatment, constitute the consi- 
 derations which alone will enable us to predict the result. An 
 accurate etiological knowledge of each individual case furnishes us 
 with the prognosis at once; only where this is impossible, are we 
 wont to remain in doubt as to the result. It must not, however, 
 be forgotten, that in apparently simple cases of jaundice, without 
 any organic lesion of the liver, symptoms of blood-poisoning some- 
 times make their appearance suddenly and unexpectedly, and then, 
 as a general rule, death supervenes in a short space of time. "We 
 are not yet in * position, as will subsequently be shown more in 
 detail, to recognise these forms at their commencement, and, for this 
 reason, even in simple jaundice, we can never form a perfectly certain 
 opinion as to the result. 
 
 8. Treatment. 
 
 In the treatment of jaundice, the first point to be considered is 
 the causes which have led to the accumulation of bilious matter in 
 the blood. When these are removed, there is seldom any necessity 
 for further treatment directed against the jaundice itself. 
 
 As might be expected, the means to be employed for accomplish- 
 ing these indications for treatment, vary greatly according to the 
 nature of the primary causes of the disease ; they will subsequently 
 occupy our attention, when we come to treat of the individual forms 
 of jaundice and of the corresponding affections of the liver and of 
 the bile ducts. 
 
120 JAUNDICE. 
 
 Not unfrequently, the cause of the jaundice cannot be influenced 
 by treatment ; and in such cases, what we have to do is to counter- 
 act, in a suitable manner, the injurious influences which the abnor- 
 mal distribution of bile may exercise upon the entire organism, For 
 this object there are three principal indications which we must keep 
 in view : — 
 
 1. The regulation of the functions of the bowels which have 
 become deranged by the stoppage to the flow of bile. 
 
 2. The purifying of the blood from the mass of colouring-matter 
 which has accumulated in it. 
 
 8. The consideration of the further consequences, which may befall 
 the entire system, from the operation of the above abnormal condi- 
 tions, and more especially from the changes in the tissue of the liver 
 resulting from the stoppage of bile : such consequences as anaemia, 
 dropsy, cholsemia, &c. 
 
 The derangement of the functions of the bowels, which manifest 
 themselves principally in the form of obstinate constipation and 
 complaints of flatulence, may be greatly lessened by means of an 
 appropriate choice of diet, by restriction to easily-digested lean meat 
 and vegetable food, and by avoiding all fatty articles and such as 
 are wont to occasion flatulence. The sluggish condition of the bowels 
 is best stimulated by means of the extract or infusion of rhubarb, or 
 by small doses of aloes, or of elixir proprietatis,* or, if necessary, 
 by tincture of colocynth. The saline purgatives are not suitable 
 for constant use in such cases ; they are only adapted for catarrhal 
 jaundice which supervenes upon gastro-intestinal catarrh. "When the 
 flatulence is very troublesome, we may infuse along with the rhubarb 
 the root of the calamus aromaticus, peppermint, &c, or we may add 
 some ether to the infusion. 
 
 As regards the second indication for treatment, the kidneys con- 
 tribute more than any other organ to purify the blood from the 
 colouring-matter of the bile ; and next to them come the cutaneous 
 glands. The secretion of urine — which, in the later stages of the 
 more intense forms of jaundice, is not unfrequently suppressed to 
 an alarming degree, in consequence of the deposit of colouring- 
 matter in the parenchyma of the kidneys — must be stimulated from 
 time to time by means of diuretics. We employ for this purpose 
 
 * The Elixir proprietatis Paracehi is a remedy frequently mentioned in 
 German works on medicine. It is a spirituous solution of aloes, myrrh, 
 and saffron, with the addition of a little dilute sulphuric acid.— Transl. 
 
TREATMENT. 121 
 
 the milder vegetable diuretics, and small doses of the neutral salts, 
 such as borax, tartrate of potass, acetate of potass, &c, and also 
 Seltzer and other mineral waters of a similar nature. Valleix has 
 particularly recommended nitre, in doses of from 4 to 6 grammes 
 (3j to 3jss) in the day. According to my own experience, lemon-juice 
 acts more favourably in doses of 1£ to 3 ounces daily : this agrees 
 best with the digestive organs, and excites an abundant diuresis. 
 
 The cutaneous functions may be stimulated by means of tepid 
 baths and mild diaphoretics ; baths, to which some ounces of soda 
 are added, are particularly suitable for the removal of the deposit of 
 pigment in the epidermal layer of the skin, when this persists long 
 after the removal of the obstruction in the bile ducts. The func- 
 tions of the skin are to be kept within due bounds, by stimulating, 
 at the same time, the secretion of urine ; and every cause that tends 
 to derange the digestive functions must be avoided. 
 
 We experience most difficulty in following out the third thera- 
 peutic indication, the counteraction of the injurious consequences to 
 the system, resulting from the consecutive atrophy of the liver, 
 from the destruction of numerous branches of the portal vein by the 
 pressure of the enlarged bile ducts, and lastly, from the disintegra- 
 tion of the hepatic cells. 
 
 The cachectic and anaemic condition, which is not noticed until 
 the shrinking of the hepatic parenchyma and the obstruction to the 
 circulation in the portal vein have become considerable, is best 
 treated by means of bitter medicines, which assist digestion, and by 
 a carefully selected, easily assimilated diet, both of which remedial 
 measures are the more necessary, the more that the functions of the 
 stomach are embarrassed by the state of passive congestion produced 
 in it by the obstruction to the flow of blood. Mild preparations of 
 iron, such as the carbonate and lactate, and small doses of mineral 
 waters, such as those of Schwalbach and Pyrmont,* are also some- 
 times to be tried. In the case of dropsy, which, in general, com- 
 mences with ascites, we must depend chiefly on the tonic treatment 
 just indicated, alternated with mild diuretics; the use of strong 
 purgatives in such cases is not permissible. 
 
 * The waters of Schwalbach are chalybeate and gaseous, containing car- 
 bonate of iron, held in solution by a great excess of carbonic acid. Their 
 temperature is about 50° Fahr. The Springs of Pyrmont are of a similar 
 nature, and had at one time an unrivalled reputation, although of late, 
 years they have been much less resorted to. — Transl. 
 
122 JAUNDICE. 
 
 Treatment is of no avail in the state of acholia, which, in some 
 cases, supervenes as a consequence of the consecutive softening of 
 the hepatic tissue ; here, a purely symptomatic treatment is all that 
 remains to us. 
 
 A whole series of empirical remedies, which have been tried by 
 various experimenters, have been recommended in the treatment of 
 jaundice. Most of these owe their importance to the relation in 
 which they stand to the causes of the jaundice, although, of course, 
 I do not mean that they have any specific relation to this. Hence, 
 in the choice of these remedies, we can only be guided by the etiology 
 of the disease. 
 
 1. Eirst among these remedies, stand pwrgatives, of which at one 
 time the neutral salts, but especially calomel {MichaeUs, Hi&feland), 
 and at other times the vegetable bitter and drastic purgatives, such 
 as rhubarb, aloes {Pitschaft), colocynth, &c, have been preferred. 
 These act by stimulating the secreting functions of the intestine, and 
 by exciting their peristaltic motions, which, being transmitted to the 
 bile ducts and the liver, promote the excretion of the bile, and so 
 overcome the slighter forms of obstruction, such as catarrhal tume- 
 faction of the mucous membrane, the smaller concretions, &c. These 
 remedies are to be employed in moderation, and every cause of 
 exhaustion is to be avoided. It is still undecided whether the 
 preference ought to be given to calomel ; but at all events it is not 
 advisable to push the use of it as far as salivation. The watery 
 extract of aloes, in doses of from half-a-grain to two grains, or 
 tincture of colocynth, in from five to ten drops, several times in the 
 day, are in most cases sufficient for the object in view. 
 
 2. Emetics of tartar emetic, or ipecacuanha. Er. Hoffmann has 
 especially recommended the former, whilst Bichter and Baldinger 
 have spoken in favour of the latter. More recently, Corrigan has 
 recommended ipecacuanha to be taken in doses of 2 grammes (3ss) 
 every second day. Emetics, when employed under such circum- 
 stances, are certainly very effectual in overcoming the obstruction 
 to the excretion of bile. During their action, the liver and bile 
 ducts are powerfully compressed on three .sides, so that the "fluid 
 contents of the latter are pushed with great force against the ob- 
 struction. In dogs, after violent vomiting has been excited by the 
 
TREATMENT. 123 
 
 injection of tartarized antimony into the veins, I have found the 
 bile ducts, for the most part, completely empty. In the case of 
 catarrhal jaundice and in gall-stones, emetics not unfrequently suc- 
 ceed in freeing the bile ducts, although in the latter case their violent 
 action may be dangerous, inasmuch as it may give rise to rupture 
 of the gall-bladder, and escape of bile into the peritoneal cavity. 
 Hence, under such circumstances, they must be used with caution. 
 
 3. The aohent extracts, such as the extractum graminis, ext. 
 taraxaci ; ext. card. ; ext. chelidon.,* &c, owe their effects partly to the 
 salts which they contain, and partly to the bitter ingredients, by 
 virtue of which they exercise a favourable influence in chronic 
 catarrh of the gastro-duodenal mucous membrane. Whether the 
 compounds of the alkalies with the vegetable acids contained in these 
 extracts can contribute towards the increase, or to any change in 
 the quality of the biliary secretion, must remain uncertain until une- 
 quivocal experiments, by means of biliary fistulse, clear up the matter. 
 
 The ancients attached great importance to these extracts, as also 
 to the freshly-expressed juices of plants. Van Swieten records in 
 detail the cure of a case of very lingering and obstinate jaundice by 
 means of decoction of grass. 
 
 4. The muriate of ammonia has a similar effect upon gastro- 
 duodenal catarrh, and was especially recommended by Baglivit in 
 the treatment of jaundice; the same may be said of the purified 
 tartrate of potash and soda (tartar-depuratws natronat.), and the 
 allied salts. 
 
 5. Narcotics, such as cicuta (Stoerek), belladonna (Sickter), 
 theriacj (Galen), may be employed effectually in those forms of 
 
 * Extractum Graminis is the extract of the root of the Triticum rep ens 
 or Couch Grass, which is said to contain sugar and free oxalic acid. 
 
 Extract. Cardui benedicti is an extract of the leaves of the Carduus 
 benedictus, a species of thistle, the chief constituent of which is a bitter 
 extractive matter. 
 
 Extract. Chelidon. is the extract prepared from the juice of the Chelido- 
 nium majus or celandine. It is acrid and bitter, and sometimes is followed 
 by narcotic effects. — Transl. 
 
 t Prax. medic, lib. I., de ictero flavo. 
 
 X Theriac, is the Electuarium Theriaca, seu opiatum, sen aromatico-opiatum 
 of the Prussian and other Pharmacopoeias. It contains opium along with 
 a number of other ingredients, chiefly aromatics, such as angelica root, 
 serpentaria, valerian, squill, cinnamon, cardamoms, myrrh, flowers of 
 sulphur, &c. One ounce contains about 5 grains of opium. — Transl. 
 
124 JAUNDICE. 
 
 jaundice which depend upon the impaction of concretions, and upon 
 the spasmodic contraction around these masses of the muscular tissue 
 of the bile ducts ; their importance in other forms of jaundice appears 
 very problematical. 
 
 6. The acids, such as the citric and acetic acids, chlorine water 
 {Siebert), and especially nitro-hydrochloric acid, or aqua-regia. 
 
 The last of these was first recommended by Scott,* in the form 
 of foot- and general-baths, and also for internal use, in jaundice and 
 other rather obscure derangements of the functions of the liver, and, 
 subsequently, it has been favourably spoken of by Annesley, Copland, 
 and others. More recently, its effects in obstinate catarrhal jaun- 
 dice have been extolled by Henoch, and justly so- The results which 
 follow its employment in such cases, must be partly owing to the 
 favourable action which it has over the relaxed mucous membrane of 
 the stomach and duodenum, but principally to the influence which 
 the acid ingesta in their passage from the stomach into the duode- 
 num exercises over the excretion of bile. Claude Bernard has made 
 the observation, which may easily be confirmed, that upon applying 
 a glass rod, dipped in diluted acid, to the mouth of the ductus cho- 
 ledochus, a few drops of bile are squirted out, which is never the 
 case when a weak alkaline solution is applied to the same spot. 
 
 The general effects of nitro-hydrochloric acid upon the metamor- 
 phosis of tissue, and the composition of the blood, have not yet 
 been sufficiently cleared up ; and hence, if we except its constricting 
 effect upon the bile ducts, its value in the treatment of chronic 
 affections of the liver, can only be purely empirical ; the materials 
 as yet in our possession are not sufficient for coming to a decision 
 upon the matter. 
 
 7. The Alkalies, soda, potash, and carbonate of ammonia, have 
 been particularly recommended in those forms of jaundice which 
 depend upon impermeability of the bile ducts from thickening of 
 the secretion, or the formation of concretions. It is hoped by their 
 means to liquefy the bile and dissolve the concretions. How far 
 this result may be expected from the alkaline carbonates remains to 
 be seen. They are prescribed either by themselves, or in combina- 
 tion with the extract of rhubarb, aloes, &c. 
 
 8. The Mineral Waters of Karlsbad, Marienbad, Kissingen, Hom- 
 burg, Tichy, Ems, &c.,t independently of the effects of the water 
 
 * Medico. Chirurgical Transactions, "Vol. VIII. 
 
 t The Springs at Karlsbad, in Bohemia, are thermal, their temperature 
 
VARIETIES. 125 
 
 itself, — which, when taken in large quantity, finds its way through 
 the walls of the portal vein and gives rise to an abundant secretion 
 of thin bile, — are chiefly indebted for their action to the soda and 
 neutral salts which they contain. They are with difficulty replaced 
 by any other remedies, in cases where the jaundice owes its origin 
 to chronic congestions of the liver, with obstinate catarrh of the bile 
 ducts and mucous membrane of the stomach and duodenum, to gall- 
 stones, &c. Their selection must always be determined by the 
 nature of the fundamental affection of the liver, and by the consti- 
 tution of the individual patient. The constant use of these waters 
 is prejudicial in the case of new growths, such as cancer, or in more 
 profound degenerations of the organ, such as cirrhosis, &c. They are 
 
 varying from 122° to 197° Fahr. They contain free carbonic acid, sul- 
 phate and carbonate of soda, chloride of sodium, the carbonates of lime 
 and magnesia, with traces of iron, manganese, strontia, phosphate of lime, 
 iodine, bromine, &c. They are much resorted to for biliary and calculous 
 affections. 
 
 Marienbad is also in Bohemia, and only six leagues from Karlsbad. 
 There are two principal springs at Marienbad, the Kreutzbrunn and the 
 Ferdinandsbrunn. The former is the one most resorted to. It contains a 
 large quantity of free carbonic acid, and, in the imperial pint, 75.442 
 grains of solid matter, which consists chiefly of sulphate of soda, with 
 a little chloride of sodium and carbonate of soda, and a small quantity 
 of carbonate of iron. 
 
 At Kissengen, in Bavaria, there are three springs, the most important 
 of which is the Ragocszy. This contains a large quantity of free carbonic 
 acid, and 95.76 grains of solid matter in the imperial pint. These solids 
 consist, for the most part, of chloride of sodium (70.768 grains), with 
 chloride of magnesium (7.543 gr.), carbonate of lime (4.034 gr.), carbonate 
 of iron (0.707 gr.), bromide of magnesium (0.789 gr.), &c. The waters are 
 laxative, tonic, and alterative. 
 
 Homburg, in Hesse, is about three leagues from Frankfort. There 
 are four springs here, the most frequented of which is called the Elizabeth, 
 which contains a very large quantity of chloride of sodium, and is strongly 
 charged with carbonic acid. 
 
 The waters of Vichy, in central France, are perhapsthe most celebrated 
 in the world. They owe their virtues almost exclusively to bicarbonate 
 of soda, which they contain in large quantity, along with much free car- 
 bonic acid. There are eight springs at Vichy, three of which are thermal, 
 one of them, the Puits Carre, having a temperature of 113° Fahr. 
 
 The waters of Ems, in Nassau, are very similar to those of Vichy, con- 
 taining a large quantity of bicarbonate of soda, with free carbonic acid. 
 
 One of the springs, the Kesselbrunn, has a temperature of 114.8° Fahr. 
 
 Transl. 
 
126 JAUNDICE. 
 
 not, therefore, to be resorted to when there is any uncertainty in the 
 diagnosis, or when the indication to be fulfilled in each individual 
 case is not perfectly clear. 
 
 9. The Varieties and Special EUology of Jaundice. 
 
 There have at all times been distinguished numerous varieties and 
 forms of jaundice, which sometimes have been made to proceed from 
 the causes of this condition being nearer or more remote, but at 
 other times have been attributed to the period of life and to other 
 circumstances of the patients. It would be a fruitless undertaking to 
 examine more closely the various classifications which have arisen in 
 this way, because in none of them can any fixed principle be laid 
 hold of, and hence many of them have been gratuitous assumptions, 
 or merely adapted to meet a practical necessity. 
 
 In all of these classifications, jaundice is considered as divisible 
 into two great etiological groups. In the one, there may be detected 
 structural changes of the liver, which furnish a sufficient explanation 
 for the origin of the jaundice, which is then only a symptom of a 
 disease of the liver. In the second group, there can be found no 
 anatomical lesion to account for the development of jaundice through 
 any impediment to the flow of bile; the ducts are here intact, and 
 there is no obstruction to the egress of the secretion. Our views 
 as to the origin of these forms of jaundice, are by no means clear; 
 abnormal distribution of the hepatic secretion from impediments to 
 the circulation of blood, or defective metamorphosis of bile in 
 the blood, furnishes us with a ready explanation, which is certainly 
 supported by facts, but by no means firmly established. Of the 
 forms of jaundice belonging to this class, only a portion are inti- 
 mately related to the proper functions of the liver ; there are others 
 which, on the contrary, proceed from a derangement in the consump- 
 tion of bile in the blood, and are dependent upon influences which 
 modify and interfere with the metamorphosis of matter, upon in- 
 fection of the blood, upon derangements of respiration and of the 
 heart's action, and, indirectly, through the last two, upon disorders 
 of the nervous system. 
 
 Whether the etiological causes included in this category exhaust 
 the various modes in which jaundice may originate, cannot at pre- 
 sent be determined j it is difficult to find among them a definite 
 place for some cases. 
 
VARIETIES. 127 
 
 The complicated relations of jaundice to processes of a local and 
 general nature just alluded to, offer a general classification of the 
 different forms of the affection, as regards. the peculiarities arising 
 from the nature of their primary causes, which will smooth many 
 difficulties in diagnosis in the subsequent chapters on diseases of the 
 liver. 
 
 i. Jaundice resulting from stoppage of bile, owing to diseases of 
 the li/ver and bile duets. 
 
 The obstructions which impede or arrest the excretion of bile 
 from the liver, are of a manifold nature, and are situated sometimes 
 in the large ducts lying external to the liver, the ductus hepaticus 
 and ductus choledochus; sometimes, on the contrary, they are 
 situated in the. smaller ducts within the gland; and lastly, at 
 other times, they he at the commencement of the bile ducts, at the 
 circumference of the lobules. In all cases the passage of bile is 
 obstructed, and jaundice results ; but the intensity of the jaundice, 
 as well as the other effects of the obstruction, may vary greatly. 
 
 A. Jaundice in consequence of constriction of the ductus choledochus 
 
 The evacuation of the larger bile ducts is most frequently impeded 
 by catarrh of their lining mucous membrane ; icterus catarrhalis is 
 the most common form of jaundice. It is ushered in with sym- 
 ptoms of catarrh of the stomach and bowels, which last for some days, 
 and sometimes even for a longer period, before the yellow colour of 
 the conjunctiva and of the skin can be distinguished. At the same 
 time, in most cases, the hepatic region becomes painful upon pres- 
 sure, the dimensions of the organ are increased, and the urine 
 assumes a brownish colour, like beer, whilst the faeces become pale, 
 and sometimes even every trace of the admixture of bile disappears 
 from them. Slowness of the pulse and itchiness of the skin are 
 frequent, but not constant phenomena. The appetite, in most cases, 
 soon returns ; after from eight to fourteen days, the stools again 
 assume by degrees a dark colour, and after three or four weeks 
 every trace of the disease has usually disappeared. 
 
 Occasionally, catarrh of the bile ducts is protracted, and gives rise 
 to enlargements of the ducts and more intimate structural lesions of 
 the hepatic tissue. (See Chapter on Diseases of the Bile Ducts.) 
 
128 JAUNDICE FROM 
 
 A similar impediment to the excretion of bile is observed to arise 
 from compression of the bile ducts on the under surface of the liver, 
 by the accumulation of faecal matters in the large intestine, and by 
 the enlargement of the uterus resulting from pregnancy. The 
 latter, however, is very unusual, because, in addition to the enlarge- 
 ment of the uterus, it is necessary that it should take a certain 
 direction in order to produce this accident. The possibility of such 
 a compression has indeed been doubted, but unjustly so. I have 
 repeatedly observed cases of jaundice attributable to considerable 
 accumulations of fecal matter in the colon, which could be circum- 
 scribed by means of palpation and percussion, and where purgatives 
 effected such a speedy removal of the jaundice, that any other expla- 
 nation of its origin, such for instance, as the existence of catarrh of 
 the bile ducts, appeared inadmissible. 
 
 In like manner, jaundice may be produced by the lymphatic 
 glands in the fissure of the liver, when these become enlarged from 
 lardaceous {specMg), tubercular, or cancerous infiltrations. In this 
 way, jaundice is not so very rarely an accompaniment of lardaceous 
 liver, and it is a mistake, to make the absence of this symptom a 
 diagnostic criterion of lardaceous degeneration of the liver, as has 
 recently been done. 
 
 Constriction, or complete occlusion of the bile ducts, often results 
 from an abnormal condition of their own contents, especially from 
 concretions, less frequently from inspissated bile, and still less fre- 
 quently from foreign bodies passing into the duct from the bowel. 
 
 That form which is produced by concretions, may almost always be 
 recognised by the colic which characterises gall-stones, and, as a 
 general rule, it terminates with the passage of one or several stones 
 from the bowels. The jaundice attains a greater or less degree of 
 intensity, according to the length of time that the gall-stone is im- 
 pacted, and the completeness of the occlusion of the canal; the 
 colour of the skin and conjunctiva is often slight, and after lasting a 
 short time disappears, returning repeatedly after fresh attacks of 
 colic. In exceptional cases, the stone remains impacted for a long 
 period, and then there arise all those symptoms which are wont to 
 accompany obliteration of the bile duct. 
 
 It has been repeatedly asserted, that inspissated bile can give 
 rise to jaundice, although many have doubted the possibility 
 of the affection originating in this way. Cases of this nature are 
 certainly rare, and correspond in frequency to those cases in 
 which, upon post-mortem examination, the bile is found to be thick 
 
MECHANICAL OBSTRUCTION OF DUCTS. 129 
 
 and granular, and requires strong pressure to be applied to the gall- 
 bladder, in order to squeeze it through, the ductus choledochus into 
 the bowel. That certain cases of this nature are met with, I believe I 
 must conclude from one observation, in which, on the abatement of 
 the jaundice, there were found in the clay-coloured stools brownish- 
 black flakes, at first sparingly, but afterwards in increasing quantity, 
 until the motions regained their normal colour. The gall-bladder 
 which had previously been distended and painful, became collapsed, 
 and all attempts to detect any concretions were unsuccessful. 
 
 In very rare instances foreign bodies of another nature are present 
 in the bile ducts, or in the diverticulum Fateri,* and give rise to 
 jaundice. To these belong the round worms, which creep from the 
 bowel into the hepatic ducts ;t and likewise the observation of 
 Saunders,J who found a currant-stone in the mouth of the ductus 
 choledochus, where it opened into the bowel. 
 
 It is still questionable, whether clots of blood and~ solid fibrinous 
 exudations, which, in exceptional cases, are present in the bile ducts, 
 can produce such a persistent closure of these ducts, as to cause 
 jaundice; at all events, I know of no examples of this nature, 
 
 b. Jaundice in consequence of closure of the Ductus choledochus 
 and D. hepaticus. 
 
 This is sometimes the result of adhesions of the walls of the 
 ducts, which may arise from exudative processes, but which in most 
 cases are produced by the cicatrisation of ulcers of the mucous mem- 
 brane; at other times, on the contrary, the occlusion is owing to 
 the firm impaction of foreign bodies, or to the filling up of the 
 canal by carcinomatous growths from its lining membrane; most 
 frequently it is caused by pressure from without. This pressure 
 may be exerted by newly-formed cords of areolar tissue, the products 
 of inflammation of the hepato-duodenal ligament ; or by cancerous 
 tumours of the pylorus, of the duodenum, or of the head of the pan- 
 creas, or by tumours in the liver, growing outwards from its surface. § 
 
 • The diverticulum formed by the junction of the ductus com. chole- 
 dochus and the pancreatic duct. — Transl. 
 
 t Lieutaud (Histor. anatom. med., I., p. 211), Roederer and Wagler, 
 Cruveilhier (Diction, de Mid. et Chir. prat. ; Entoz.), Ltennec (ibid), and 
 Guersant (Diet. deMed.; Vers Tntest.), record observations of round worms 
 in the bile ducts; still, it does not appear that jaundice was invariably 
 present in these cases. J Op. cit. 
 
 § Job van Meckren records a case in which the bile ducts were closed 
 
 K 
 
130 JAUNDICE FROM 
 
 The complete impermeability of the bile ducts, which is produced 
 in this way, and which very generally is of a persistent character, 
 gives rise to jaundice of the most intense form. The jaundiced tint 
 of the tissues and of the excretions here attains a degree which, 
 under other circumstances, is by no means common. In conse- 
 quence of the distention of the bile ducts, the volume of the liver is 
 considerably increased, so that the lower border of the organ pro- 
 jects beyond the margin of the ribs, and may easily be felt on 
 palpation. When the obstruction has its seat below the attachment 
 of the cystic duct, the gall-bladder is also distended to a greater 
 or less degree. In the cases which have come under my own obser- 
 vation, the gall-bladder has not contained above from eight to 
 sixteen ounces of bile, but the older physicians mention cases, in 
 which the quantity was much more considerable: thus De Jonge* 
 found seven, and Van Swieten, eight pints of thick bile, accumulated 
 in the gall-bladder. Upon careful examination, the smooth pear- 
 shaped tumour of the bladder projecting beyond the margin of the 
 liver is in general easily felt ; in a few cases, it may be seen as a 
 prominent tumour.f 
 
 The increase in the volume of the liver and of the gall-bladder 
 usually goes on for some months ; it then comes to a stand-still, and 
 there ensues a more and more observable diminution. This is a 
 proof that the secreting function of the gland is impaired. At the 
 same time, unequivocal symptoms of deranged nutrition, and of 
 obstructed portal circulation manifest themselves, the patients be- 
 come, flabby and thin, the digestion is embarrassed, water col- 
 lects in the abdominal cavity, and sometimes haemorrhages from the 
 stomach and bowels occur. A fatal termination usually ensues, from 
 the gradually increasing exhaustion, or from general dropsy, or from 
 consecutive exudation processes ; less frequently it takes place sud- 
 denly by peritonitis consequent upon perforation, and extravasation of 
 
 by the pressure of an intussusception. Stokes (Diseases of the Heart, p. 638) 
 mentions another, in which it was obstructed by an aneurism of the hepatic 
 artery. 
 
 * Philosoph. Transac, Vol. XXVII. 
 
 + I am at present attending a lady whose gall-bladder reaches down- 
 wards to 1 \ inch below the crest of the ilium, and elevates the abdominal 
 wall in the form of a pear-shaped tumour. Owing to the great tension 
 and pain which it occasioned, it became necessary to puncture it ; and, from 
 the presence of adhesions, there was no danger in effecting this. About 
 ten ounces of bile flowed out. 
 
. MECHANICAL OBSTRUCTION OF DUCTS. 131 
 
 bile ; or death may take place under symptoms of suppurative fever, 
 induced by suppuration of the liver. In some cases, the complete 
 destruction of the hepatic functions leads to cholsemic intoxication. 
 
 " c. Constriction, or Obstruction of the Bile Ducts unihin the Liver. 
 
 It is from the presence of one or other of these conditions that 
 jaundice becomes a frequent symptom of hepatic diseases. All mor- 
 bid alterations of the liver, rendering the larger branches of the 
 excretory ducts impermeable, such as cancer, echinococci, inflamma- 
 tory deposits, &c, induce jaundice, which is always greater in inten- 
 sity, the more extensive the volume of the liver„ and the greater the 
 number of ducts, which are implicated. Hence tumours or inflam- 
 mations on the concave surface of the organ are usually accompanied 
 by jaundice, which is generally wanting when these same lesions 
 have their seat on the convex portion, or in the posterior part of 
 the right lobe. It is seldom that the bile is in this way completely 
 excluded from the intestinal tube, in cases where the new growth, or 
 the inflammatory deposit, does not implicate the hepatic duct ; the 
 faeces almost invariably exhibit an admixture of bile. It is worthy 
 of notice, that the jaundice which arises in this way, although there 
 is no corresponding variation in its generating cause, varies in in- 
 tensity at different times, according to the variations produced upon 
 the bulk of the tumour, as well as upon the secreting functions of 
 the liver and the compensating functions of the kidneys, by the 
 changes in the quantity of blood supplied to these parts. This 
 circumstance must not mislead our diagnosis, which, indeed, is 
 seldom difficult, inasmuch as, in most cases, the situation of the 
 tumour can be detected by palpation. 
 
 The jaundice which is produced by the compression of the bile 
 ducts near their origin is extremely slight. This form is now and 
 then observed as an accompaniment of cirrhosis. Under such cir- 
 cumstances, the results of an obstruction to the excretion are usually 
 limited to a more or less intense jaundice of the hepatic parenchyma, 
 the colour of the skin, conjunctiva, and urine, remaining unchanged. 
 In many cases, however, there may be observed a light-yellow tinge 
 of the conjunctiva, and a darker colour around the eyes, while 
 brownish spots may be seen at the angles of the mouth, upon the 
 forehead, on the temples, and on other parts of the body; at a 
 later period, the pale skin assumes throughout a yellowish colour: 
 
 k 2 
 
132 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 The stools are sometimes clay-coloured, sometimes brown, and there 
 may be often seen in the evacuations dark normally-coloured masses, 
 mixed up with others which are pale and free from bile. Sometimes 
 the urine contains pigment ; at other times it does not. 
 
 The expansion of the hepatic cells in fatty liver operates in ob- 
 structing the excretion of bile in a similar manner to that in which the 
 areolar tissue acts in cirrhosis ; but it is rare for general jaundice to 
 result in the former case. A similar result arises from considerable 
 congestions of the liver, as happens when there is obstruction to 
 the circulation in consequence of disease of the heart, lateral distor- 
 tion of the chest, &c, the origins of the bile ducts being then com- 
 pressed by the enlarged capillaries. The jaundice, in most cases of 
 this nature, is limited to a light-yellow tir 2;e of the conjunctiva and 
 skin, and becomes more distinct after violent attacks of dyspnoea. 
 The yellow colour is easily overlooked when there is a florid or livid 
 complexion. {Icterus pleihoricus of the ancients.)* 
 
 The following observations may be given here as illustrations of 
 the points just discussed : — 
 
 Observation No. V, 
 
 Dyspepsia. — Symptoms of Chronic Simple Ulcer of the Stomach. — 
 Jaundice. — Distention of the Gall-bladder. — Pleurisy of the right 
 side, — Dropsy. — Petechia. — Death. 
 
 Cancer of the Duodenum and Dilatation of the Bile Ducts. — Simple 
 Ulcer of the Stomach. — Exudation, in the Bight Pleural Cavity. 
 
 Marianne Dombrowsky, a female servant, aged 63, was admitted 
 on December 13th, 1853. The patient had been complaining for a 
 year of pains in the epigastrium, which occurred after eating, and 
 were accompanied by heartburn, nausea, and sometimes even 
 vomiting; subsequently, the appetite had completely failed, whilst 
 the pains had extended over the hepatic region. Pour weeks before, 
 jaundice of the skin had gradually become developed. 
 
 * Stokes (Diseases of the Heart, p. 206) has observed repeated attacks of 
 jaundice and hemiplegia to result from incompetence of the mitral valves, 
 these symptoms on each occasion disappearing at the expiration of one 
 day, under the use of stimulants. Not unfrequentiy, the jaundice, in cases 
 of disease of the heart, is the consequence of catarrh of the duodenum, 
 and then it is of longer duration. 
 
ILLUSTRATIVE CASES. 133 
 
 On admission, the patient was emaciated, her skin was dry and 
 flabby, and tinged yellow to a considerable degree. The thoracic 
 organs exhibited nothing abnormal, with the exception of well- 
 marked emphysema of the lungs, especially of the right one. The 
 abdomen was soft, and some portions of the bowel were distended 
 and tympanitic. The liver was deeply situated ; its upper border 
 close to the sternum was on a level with the seventh rib ; the out- 
 line of the opgan was somewhat increased ; its dulness on percussion, 
 in the sternal line amounted to 12 centimetres ; in the mammary, to 
 15 ; and in the axillary, to 13. (4|, 6, 5a Eng. inches.) Close to the 
 umbilicus, on the right side, and two centimetres (I inch) from the 
 surface, there might be felt a rounded, painful tumour, which sank 
 downwards upon a deep inspiration, and could be traced upwards as 
 high as the sharp margin of the liver. The upper and under surfaces 
 of the liver, so far as could be made out by palpation, felt smooth 
 and even. No hard tumour could be detected either upon the liver 
 or in the direction of the ductus choledochus as far as the duodeno- 
 pylorie region, even after repeated and careful examinations, with 
 the abdominal parietes relaxed, and with the patient in different 
 positions. 
 
 The spleen was somewhat enlarged. The stools were clay-coloured 
 and smelt badly. The urine was coloured brown like porter, and 
 when spread out in thin layers, was saffron-yellow. 
 
 The pulse was 60 and weak. There was no itchiness of the skin. 
 
 The patient was ordered infusion of rhubarb with the watery ex- 
 tract of nux vomica, and ethereal tincture of valerian. The appetite; 
 improved, the pains during digestion, as also the flatulence, were di- 
 minished, the motions became regular, but the stools still remained 
 free from bile-pigment. The distended gall-bladder increased in 
 size, but continued smooth, painful and moveable. 
 
 Three weeks after admission, dulness on percussion and absence 
 of the respiratory murmur were detected at the base of the right 
 lung, and extending upwards as high as the fourth rib ; at the 
 same time, the bronchial tubes were observed to become loaded 
 with mucus, the respiration became more frequent, and the patient 
 began to complain of dyspncea, and expectorated with difficulty 
 rounded masses of tenacious mucus. The pulse rose from 8 to 85. 
 The urinary secretion was diminished. 
 
 Decoction of senega and liquor ammoniaci anis.* were prescribed. 
 • The Liquor Ammoniaci anitatits of the Prussian Pharmacopoeia contains 
 
134 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 A turpentine liniment was ordered to be rubbed over the thorax and 
 abdomen ; and in the evening, 2 grains of the watery extract of 
 aloes were administered, to open the bowels. 
 
 The patient became rapidly collapsed; cedema appeared in the 
 feet, and in a few days extended to the pelvis. The abdomen be- 
 came fluctuating and tender upon pressure. The pulse was small, 
 and 110 in the minute. 
 
 On the 26th of January she lost her consciousness, the stools 
 were passed involuntarily, and there were hiccup, dilated pupils, and 
 stertorous respiration. Numerous petechise, varying in size from 
 that of a linseed, to that of a groschen piece,* made their appear- 
 ance upon the skin of the trunk and extremities. 
 
 Death supervened on the 27th, at 9 a.m. 
 
 Autopsy, 26 hours after death. 
 
 The skull cap and dura mater were coloured yellow, but other- 
 wise normal ; there was a small quantity of coagulated blood in the 
 longitudinal sinus. The arachnoid, together with the longitudinal 
 sinus, was considerably thickened. The pia mater was of a blood- 
 red Colour. There was a considerable quantity of clear yellow serum 
 at the base of the skull, and in the lateral ventricles. The brain 
 substance contained but a small quantity of blood, it was of normal 
 consistence, and no yellow tinge could be detected in it. 
 
 The mucous membrane of the pharynx and bronchi was slightly 
 injected. The epiglottis was of a saffron-yellow colour. 
 
 The left side of the thorax contained about a pound of clear 
 yellow serum ; and in the right side there were about four pounds of 
 fluid mixed with fibrinous flakes. The upper part of the left lung 
 was dry and emphysematous, the lower part was compressed; the 
 right lung was very emphysematous, its lower lobe was almost com- 
 pletely compressed. 
 
 There were three ounces of clear yellow fluid in the pericardial 
 sac ; the epicardium exhibited a jaundiced tint ; the cavities of the 
 heart contained some coagulated blood; its valves and muscular 
 tissue were normal. 
 
 Upon opening the abdomen, the stomach was found to be dis- 
 
 rectified spirit (32 parts), liquor ammoniae (8 parts), and anise oil (1 part), 
 — Transl. 
 
 " A silver groschen is somewhat smaller than a sixpence. — Transl. 
 
ILLUSTRATIVE CASES. 
 
 135 
 
 tended with gas, so that the liver was partially covered by it, and 
 pushed towards the right side; close to the pylorus might be seen 
 the distended gall-bladder. The transverse colon was firmly adherent 
 to the liver, and the posterior part of the surface of the gall-bladder. 
 It here formed an angular coil in such a way, that the curvature 
 lying underneath the gall-bladder first took a turn backwards and 
 to the right, and afterwards passed towards the left hypochondrium, 
 along the great curvature of the stomaeh ; there was also an angu- 
 larly bent coil of the sigmoid flexure, firmly glued together by recent 
 
 Fig. 21. 
 
 Fig. 21. An ulcerated cancerous deposit in the duodenum passing 
 into the head of the pancreas. Probes passed into the pan- 
 creatic and common bile ducts are seen to emerge in the 
 centre of the cancerous mass in the duodenum. Upon the 
 mucous membrane of the stomach there is represented a 
 simple ulcer with an adherent clot of blood. 
 
 areolar tissue. In the abdominal cavity there was found a large 
 quantity of serum mixed with fibrinous flakes.* The gall-bladder 
 
 • This exudation had a feeble alkaline reaction, and a greenish colour. 
 Upon the addition of acetic acid to the filtered fluid, there was deposited 
 a precipitate which was insoluble in an excess of the acid, Bile-pigment 
 
136 JAUNDICE FROM OBSTRCTION OF DUCTS. 
 
 was loosened from its adhesions and the ductus choledochus laid 
 bare ; this was distended to the breadth of an inch, as far as its 
 insertion into the duodenum. The stomach contained a brownish- 
 black, greasy fluid ; about an inch and a-half below the cardia there 
 lay upon its posterior wall an oval simple ulcer, almost the size of an 
 eight-groschen (halfpennypieee), and attached to its surface was a 
 blackish tumour, the size of a pigeon's egg, consisting of a firm 
 coagulum of blood. Excepting this, the mucous membrane of the 
 stomach, as well as of the pylorus, showed nothing abnormal. The 
 mucous membrane in the upper part of the duodenum was thickened 
 and spongy; at the part where the ductus choledochus and pan- 
 creatic duct opened, there might be observed an ulcerated surface one 
 inch in breadth, and one inch and a-half in length, surrounded by 
 soft excrescences, which were connected with a medullary fungating 
 tumour extending outwards. This tumour penetrated not merely the 
 coats of the bowel, but also extended into the head of the pancreas, 
 in the substance of which softened masses were found. The liver 
 exhibited a deep tight-lace furrow; its left lobe measured trans- 
 versely 3 centimetres (li inch), and 5J (2 inches) from before back- 
 wards ; the right lobe measured 6 centimetres (2^ inches) transversely, 
 and 8 (3} inches) from before backwards. The gall-bladder ex- 
 tended 1£ centimetre (§ inch) beyond the anterior margin. The 
 parenchyma of the gland was firm and hard, of a greenish-brown 
 colour, and of a nutmeg appearance, and was perforated by the 
 enlarged cylindrical bile ducts. Some of the hepatic cells were pale, 
 others were more or less strongly saturated with colouring-matter, 
 but were otherwise normal. 
 
 The spleen was small, anaemic, and of firm consistence; its cap- 
 sule was much corrugated. 
 
 The pancreas was normal. 
 
 The intestinal canal contained greyish clay-coloured faeces, its 
 mucous membrane was unaltered. 
 
 The kidneys were of normal size; their parenchyma was of a 
 jaundiced tint, but free from deposits of solid pigment. Their more 
 intimate structure exhibited nothing abnormal, with the exception of 
 coloured epithelium. The mucous membrane of the pelves of the 
 kidneys, of the ureters, of the bladder, and of the vagina was of 
 
 was found to be present on testing with nitric acid; the biliary acids and 
 sugar could not be extracted by diluted spirit of wine, from the dried 
 residuum. 
 
ILLUSTRATIVE CASES. 137 
 
 a saffron-yellow colour. In the situation of the uterus were 
 found several aggregated rounded tumours, which had replaced 
 the substance of the organ ; one of these was of stony hardness 
 and of the size of an apple. These tumours also were coloured 
 yellow. 
 
 Kolliker* has recently ascertained, that calcareous matter is 
 deposited in the intestinal arteries, and simple ulcers formed in the 
 stomach of animals, after the application of a ligature to the ductus 
 choledochus ; and he has hinted at the possibility of a dependence 
 of these conditions on the retention of bile. In the preceding case, 
 the gastric ulcer had already existed before the commencement of 
 the jaundice, at least the symptoms indicative of it preceded this j 
 hence it cannot be concluded that, in this case, there was any connec- 
 tion between the jaundice and the ulcer as cause and effect. 
 
 Observation No. VI. 
 
 Cancerous Deposit in the head of the Pancreas and in the Duodenum. 
 — Occlusion and widening of the Bile ducts and of the Pancreatic 
 ducts. — Distention of the Bile ducts with mucus and bile\— Dysen- 
 tery. — Diminished secretion of urine. — Infiltration of the kidneys 
 with solid deposits of bile-pigment. — Death from Exhaustion. 
 
 ■ Carl Bohle, a day-labourer, aged 55, was admitted on the 27th 
 November, 1854, and died on the 10th December. 
 
 The patient, who had enjoyed uninterrupted good health up to 
 six months before admission, began then" to complain of frequent 
 short attacks of severe pain, extending from the region of the gall- 
 bladder towards the epigastrium. Seven weeks before, without any 
 other derangement of the general health, he gradually became jaun- 
 diced, and, for four weeks he had been treated as an out-patient, 
 with rhubarb, aloes, &c. 
 
 On admission, the man was of robust habit of body, his skin was 
 coloured a brownish-yellow, and, when spoken to, he gave slow and 
 surly, but rational answers. The thoracic organs were normal; 
 the pulse 64, and weak; the tongue coated greyish-brown; the 
 appetite poor, and the abdomen was somewhat tympanitic and 
 contained a considerable quantity of fluid. The liver was slightly 
 
 * Wiirzburger Verhandl., Bd. VI., S. 474. 
 
138 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 enlarged; its dulness in the median line amounted to 8 centimetres;' 
 in the mammary line, to 15 ; and in the axillary, to 12. (8J, 6 and 
 4| inches). On palpation, its surface appeared smooth, without any 
 tuberosity, and its margin was sharp. At the outer border of the 
 right rectus abdominis muscle, at the same elevation as the umbili- 
 cus, a smooth, pear-shaped, moveable tumour could be felt, which 
 could be traced up under the margin of the liver. No hard tumour 
 could be detected in the region traversed by the ductus choledochus 
 in its passage to the duodenum. Hence, bearing in mind the early 
 attacks of colic, it was reasonable to attribute the cause of the dila- 
 tation of the bile ducts and of the jaundice to an occlusion of the 
 ductus choledochus by means of a concretion. Still it was impos- 
 sible to make a diagnosis with positive certainty, as to the cause of 
 the obstruction of the bile duct. 
 
 The patient took calomel and opium up to the 2nd of December. 
 The stools were now passed regularly ; they lost their grey colour 
 and became greenish. No gall-stones, however, could be found. 
 
 In order to avoid salivation, the mercury was discontinued, and 
 the bowels were kept open by means of aloes ; and compound tinc- 
 ture of bark with naphtha aceti* was prescribed, with the object of 
 stimulating the sluggish digestion. 
 
 The skin gradually assumed a bronze colour, and the urine became 
 brownish-black. Its quantity was small, and, although the patient 
 complained of some thirst, gradually diminished more and more. 
 The colour of the stools was somewhat brownish, not owing, how- 
 ever, to the admixture of bile-pigment, but, as shown by the micro- 
 scope, to numerous epithelial cells containing pigment, derived from 
 the mucous membrane and glands of the intestine. 
 
 IVom the 4th of December the patient became rapidly more 
 emaciated, his strength sank, and his appetite completely failed; 
 he had also frequent bloody stools, with tenesmus; pulse 70, 
 and weak. The mental faculties became impaired, and he scarcely 
 answered when spoken to. The urine, so far as its quantity could 
 be ascertained, was very scanty, in consequence of the frequent 
 dysenteric stools. 
 
 During the last night of the patient's life, he was very restless, 
 made attempts to get out of bed, and became more exhausted. 
 
 He died on the 10th of December, at 6£ a.m. 
 
 * Naphtha aceti is the aether aceticus of the Prussian Pharmacopoeia, or 
 acetic ether. — Transl. 
 
ILLUSTRATIVE CASES. 
 
 Autopsy, 6 hours after death. 
 
 The skin of the dead body was brownish-yellow, and at some 
 places bronze-coloured, as, for instance, on the inner surface of the 
 thighs, whilst the countenance was paler. There was no oedema. 
 
 The skull-cap was 7 Paris lines thick, with but little diploe. 
 The dura mater was yellow and thickened ; beneath it a thin extra- 
 vasation of blood was found, extending over both hemispheres : the 
 brain substance was of normal colour and consistence. 
 
 The mucous membrane of the pharynx and oesophagus was of a 
 jaundiced colour, but otherwise normal. The bronchi presented a 
 similar appearance ; both lungs were emphysematous at their apices 
 and anterior margins, and posteriorly and inferiorly exhibited hypo- 
 static congestion. The right cavities of the heart contained firmly 
 coagulated masses of fibrin insinuated between the trabecular. The 
 muscular tissue and valvular apparatus on both sides were normal ; 
 the endocardium was coloured dark-yellow. 
 
 Two pounds of reddish-brown fluid, exhibiting the reaction of 
 bile-pigment, were found in the peritoneal cavity. 
 
 The relations of the liver closely corresponded to what had been 
 ascertained by means of percussion and palpation on the patient's 
 admission. Its volume was slightly increased. Its surface was 
 smooth, and its margin sharp. The organ was removed along with 
 the neighbouring parts, so as to ascertain the relations of the bile 
 ducts in situ. These ducts were enormously enlarged; the ductus 
 choledochus just before its entrance into the duodenum measured an 
 inch and a-half in its transverse diameter; the cystic duct, the gall- 
 bladder and the hepatic ducts were distended in a corresponding 
 manner. The cystic duct measured 11 Paris lines; the hepatic, 22 ; 
 and one duct in the right lobe, 17. They were full of a fluid pre- 
 senting a whitish turbidity ; but otherwise transparent. This was 
 feebly alkaline, and, on the addition of nitric acid, presented no 
 trace of the reaction of the colouring-matter of bile ; neither could 
 the bile acids be detected by means of Pettenkofer's test* The 
 
 * In Pettenkofer's test, advantage is taken of the circumstance, that 
 various colours are developed when sulphuric acid and sugar are added to 
 a solution containing any of the bile acids. The fluid to be tested is first 
 evaporated almost to dryness, and the residue extracted with alcohol. The 
 alcoholic solution is again evaporated, and the residue dissolved in a little 
 
140 
 
 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 usual epithelial lining of the bile ducts could nowhere be discovered 
 upon microscopic examination ; but in place of it, there were seen 
 
 Fig, 
 
 Fig. 22. Represents an enormous enlargement of the bile ducts, 
 resulting from cancerous deposit in the head of the pancreas : 
 a, the liver turned back ; b, ligamentum teres ; c, the greatly 
 distended gall-bladder; d, the dilated ductus choledochus; 
 e, the stomach ; /, the pancreas ; g, the duodenum ; h, the 
 right kidney. 
 
 globular mucous corpuscles either isolated or adhering in great 
 numbers in epithelial-like laminae. Nitric acid when added to this 
 fluid produced no precipitate, or one that was scarcely appreciable. 
 On the addition of acetic acid, the fluid became thickish and resem- 
 bled bile. The addition of water produced a slight turbidity. The 
 
 water and placed in a white Berlin china dish. A few drops of a solution of ,, 
 sugar are now to be intimately mixed with the solution in the china dish, 
 and concentrated sulphuric acid added to this mixture in drops. When 
 biliary acids are present, the solution at first becomes a little turbid, then 
 clears, and afterwards assumes a pale cherry-red, then a pink, then a 
 crimson, and at last a saturated purple-violet hue. The intensity of the 
 colours depends upon the quantity of the biliary acids present. — Transl. 
 
ILLUSTRATIVE CASES. 141 
 
 fluid when dried at a temperature of 100° cent. (212° Fahr.) left 
 behind 1.80 per cent, of solid residuum, of which 1.15 consisted of 
 ash, and 0.65 of organic matter; the ash contained 0.08 of earths 
 insoluble in water, and 0.07 of alkaline salts. The composition of 
 the fluid may be represented in a tabular form, thus : — 
 
 Water 98.20 
 
 Solids 1.80 
 
 100. 
 
 Ash 1.15 
 
 Organic matter 65 
 
 Total solids 1.80' 
 
 The ash contained — 
 
 Alkalies . 0.07 
 
 Earths 0.08 
 
 The gall-bladder, in addition to a few very small mulberry con- 
 cretions, contained a fluid precisely similar to that just described, 
 with 1.72 per cent, of solid residuum. 
 
 The parenchyma of the liver was impregnated with a brown colour, 
 scattered through which might be observed the congested ramifica- 
 tions of the hepatic veins. In fine sections of a portion of the organ, 
 after this had been boiled and rendered transparent by a weak 
 solution of caustic potash, numerous enlarged bile ducts with thick- 
 ened walls could be distinguished, some of them rounded, and others 
 ampulliform. (See Kg. 20, page 116.) In many parts of the liver, 
 these ducts might be traced as far as the periphery of the lobules ; 
 but in others, this could not be done. No communication could be 
 made out between the blunted and somewhat club-shaped extremities 
 of the distended ducts, and the more delicate channels in the interior 
 of the lobules, from which these ducts take their origin. This even 
 could not be traced in those places where the sections had passed 
 longitudinally through the distended ducts; in such a case, the 
 sections of the tubes presented distinct sacculated bulgings, but each 
 duct invariably terminated bluntly at the periphery of the lobule, 
 without any finer offshoots. 
 
 The hepatic cells were for the most part normal in their characters ; 
 they appeared pale, contained but a small quantity of granular matter, 
 and the nucleus was distinctly visible only in a few. Some of the 
 cells had pigment deposited in them in the form of isolated brown 
 molecules in the neighbourhood of the nucleus, or round the cir- 
 
142 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 eumference of the cell; these molecules were here and there 
 aggregated in clusters, and occasionally formed large greenish 
 spherical masses like drops. Some of the cells w ere of a uniform brown 
 or greenish colour. Along with these were observed little elongated 
 bodies, shaped like sausages, of a brown or bluish green colour, 
 which were for the most part swimming freely about, but occasion- 
 ally were adherent to the side of a cell : less frequently these bodies 
 were observed to be globular, or ramified in an arborescent manner, 
 or sharply angular. 
 
 The large vessels of the liver, the portal vein, the hepatic veins, 
 and the hepatic artery, did not exhibit anything abnormal. The spleen 
 was small and weighed 0.14 kilogram. (5 oz. avoird.) ; it was 
 wrinkled, contained but little blood, and was of good consistence. 
 The mucous membrane of the stomach was pale-yellow, but other- 
 wise normal. The head of the pancreas was enlarged, and occupied 
 by a mass of scirrhus. The cancer had completely obliterated the 
 ductus choledochus, and extended into the duodenum in the form 
 of a pendulous tumour the size of a walnut. The pancreatic duct 
 was also occluded, and at the same time enlarged to the extent of 4 
 Paris lines in its transverse diameter. (Fig. 23.) 
 
 The mucous membrane of the small intestine was coloured 
 bluish-green, owing to the epithelium of the villi and of the glandu- 
 lar epithelium of Lieberkulm's follicles being loaded with black pig- 
 ment. The mucous membrane of the rectum was tumid and covered 
 with ecchymoses ; this puffiness was still more remarkable at the 
 second curve of the colon and in its transverse portion ; no dysen- 
 teric ulcerations were visible after the removal of the bloody 
 mucus. 
 
 The kidneys were of an olive-green colour. Upon their outer 
 surface there were seen numerous brownish-black ramifications cor- 
 responding in their extent and course with the tortuous uriniferous 
 tubes. These were much more distinctly visible on a cut surface, 
 especially in the pyramids. Here many of the tubes resembled 
 long black stripes, and along with these there were others of 
 a brown, sap-green, or yellow colour. The microscope afforded a 
 deeper insight into this interesting, but hitherto unsufficiently 
 studied, alteration of the renal parenchyma. 
 
 The paler uriniferous tubes were of a uniform green or brown 
 colour; their epithelial cells, which, in a few instances only, were 
 found entire (and these, as a general rule, were the ones in which 
 
ILLUSTRATIVE CASES. 
 
 143 
 
 there was the least pigment), exhibited a deep brown colour ; this 
 was darkest in the nuclei. Some of the cells appeared tinged blood- 
 
 Fig. 23. 
 
 Fig. 23. Cancer of the Dead of the pancreas, penetrating, in the 
 form of a pendulous tumour, into the interior of the duo- 
 denum, and producing occlusion, and consequent dilatation 
 of the pancreatic and bile ducts. 
 
 red ; others were rounded, and contained brown or green colouring- 
 matter, deposited in concentric layers around the nucleus. Here 
 and there might be seen epithelial cells in a state of fatty degenera- 
 tion, some of them red, and others brown or black. In many places 
 brown cell-nuclei, either isolated or adhering in groups, lay upon the 
 wrinkled, greenish-yellow basement-membrane of the tubuli; at other 
 places this membrane was covered by a mass of fine brown granules. 
 Where the deposit of the constituents of bile was most intense, the 
 little tubes were filled with a black, brittle material, which was only 
 slowly and incompletely dissolved on the addition of caustic potash, 
 the solution being of a brown colour. There might also be seen a few 
 small cylindrical masses, consisting of an amorphous, dark-brown 
 
144 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 substance, gradually becoming paler towards the periphery. Causiic 
 potash acted rapidly upon these masses ; their pigment disappeared; 
 they became pale, transparent, and swollen up; and they then 
 resembled old fibrinous clots which had been deposited for a length- 
 ened period in the uriniferous tubes. 
 
 The deposits of pigmentary matter just described were scattered 
 throughout the entire structure of the kidneys. They were even 
 present in the epithelium of the Malpighian capsules, but were 
 most abundant in the tortuous uriniferous tubes ; the darkest depo- 
 sits were found in the straight tubuli of the pyramids. A more 
 careful examination was made as to their precise nature. Nitric acid 
 produced, in most of them, the play of colours known to be charac- 
 teristic of bile-pigment. The black crumbling masses, which were 
 apparently of older date, exhibited no reaction ; in this respect they 
 resembled the cholepyrrhin of black gall-stones, in which the pig- 
 ment is gradually more and more altered, becomes less soluble 
 in caustic potash, and loses its reaction with nitric acid. The other 
 deposits consisted of bile-pigment, partly recent, and partly some- 
 what changed. Pettenkofer's test appeared to indicate the presence 
 of the biliary acids, inasmuch as the uriniferous tubes assumed a 
 deep purple-red colour upon the addition of syrup and concentrated 
 sulphuric acid. In order to make this more certain, the kidneys 
 were boiled in alcohol, and the extract thus obtained was dried and 
 dissolved in water. The test now gave a negative result. Even the 
 alcoholic solution did not present the characteristic reaction. Hence 
 it could not be assumed that the biliary acids were present in the 
 kidneys. 
 
 The urinary bladder contained a little dark urine ; its mucous 
 membrane was jaundiced. The retro-peritoneal glands were yellow 
 and infiltrated with cancerous matter. The firmly coagulated blood 
 taken from the right side of the heart, was examined for the ele- 
 ments of bile ; pigment was found, but not a trace of the biliary 
 acids or of their immediate derivatives. 
 
 The urine, passed by the patient between the 2nd and the 7th of 
 December, was repeatedly examined. It was of a dark, brownish- 
 green colour, acid, and deposited, on standing, a light flocculent 
 sediment, mixed with brownish-black, angular granules; albumen 
 and sugar were repeatedly sought for,' but never detected. It 
 exhibited distinctly the play of colours when treated with nitric 
 acid; but none of the other ingredients of bile could be found 
 
ILLUSTRATIVE CASES. 145 
 
 in it, except a few plates of cholesterine which were observed in the 
 alcoholic extract of the secretion. 
 
 This case is interesting in several respects; first, because the 
 deposit of bile-pigment in the kidneys had attained a rare degree of 
 intensity, inasmuch as the secreting functions of these glands were 
 essentially impaired ; and further, because the bile ducts were not 
 filled with bile, as is usually the case, but with a colourless mucous 
 fluid. A similar case has already been recorded by De Graaf.* All 
 communication between the bile ducts and the hepatic parenchyma 
 was here cut off, so that no new secretion could pass into the ducts 
 after their original contents had become absorbed, and replaced by 
 the mucous secretion of their lining membrane. Thus, whilst almost 
 all the solids and fluids of the body were tinged yellow, the contents 
 of the hepatic ducts were colourless ; — a proof that the mucous mem- 
 brane of these ducts plays no part in the separation of bile from the 
 blood. 
 
 Obseevation No. VII. 
 
 Cancerous Deposit iy, the head of the Pancreas. — Occlusion of the 
 Ductus Choledochus and Pancreatic Duct.' — Enlargement of the 
 Pancreatic Duct, and of the Bile Ducts. — Jaundice. — Intes- 
 tinal hmmorrhage. — Diabetes melUtus. — Dysentery. — Death from 
 
 Wilhelm "Vogel, mason, aged 50, was admitted into the Clinique, 
 on the 13th February, 1854, and died on the 9th of April. 
 
 The patient stated that he had suffered, for the period of a year, 
 from pains in the upper part of the abdomen, which, however, 
 had been transient and had attracted little attention, inasmuch as 
 they produced no remarkable impairment of the general health. 
 Since the beginning of December, or for nearly three months, the 
 skin had been gradually assuming a jaundiced tint, and at the same 
 time the pains in the hepatic region, although still only transient, had 
 become more violent and extended towards the right shoulder. More- 
 over, tar-like masses were repeatedly observed in the stools, which 
 .could not be accounted for by anything in the patient's food. 
 
 On admission, the patient's skin was of a yellow-brown colour • 
 his abdomen was soft and somewhat distended, but not tender upon 
 ■ * Tract, de succo pancreatico, cap. 8. 
 
 L 
 
146 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 pressure. The liver was more deeply situated than usual, and it 
 was somewhat increased in volume. The dulness on percussion 
 amounted in the sternal line to 13 centimetres, in the mammary to 
 12, and in the axillary line to ll (54, 4§ and 4| inches). The sharp 
 margin of the organ could be felt about two inches below the false 
 ribs ; on the left side, this margin was thin and could be pressed 
 inwards ; tracing it along towards the right, we arrived, at* a distance 
 of two and a-half inches to the right of the linea alba, at a pear- 
 shaped, smooth, elastic swelling, the position of which was altered 
 by the respiratory movements, and which was tender upon pressure. 
 The swelling reached seven centimetres (2f inches) beyond the 
 margin of the liver. When the hand was firmly pressed immediately 
 to the left of,- and a little above, this swelling, it came upon a hard, 
 nodulated, immoveable tumour, the form of which, however, could 
 not accurately be made out. A tarry motion, evidently due to the 
 presence of blood, which had just been passed, indicated a haemor- 
 rhage high up in the intestinal canal. The appetite was unimpaired ; 
 there was no vomiting ; and the pulse was 60, and weak. 
 
 The heart was normal. Harsh vesicular breathing and bubbling 
 rales (Rasselgerausehe) could be heard over the apices of both 
 lungs, and there was a limited dulness on percussion. 
 
 The urine was brownish-green, free from albumen, and of average 
 quantity. 
 
 The diagnosis necessarily arrived at was, that there was occlusion 
 of the ductus choledochus from cancerous deposit in the head of the 
 pancreas, which, probably, also involved the pylorus. The opinion 
 that the new growth was situated in the pancreas, was favoured by 
 its situation, its complete immobility, and by the circumstance of its 
 form being more globular than is wont to be the case in simple can- 
 cer of the pylorus. The existence of the latter lesion was also contra- 
 indicated by the absence of vomiting, and by the fact of the ductus 
 choledochus being involved, which is seldom the case in tumours 
 of the pylorus. The tarry character of the stools, which was from 
 time to time observed, appeared to indicate that either the walls of the 
 stomach, in the neighbourhood of the pylorus, or those of the duo- 
 denum, were implicated. We did not, in coming to this conclusion, 
 conceal from ourselves the fact that the haemorrhage from cancer is 
 usually not so copious as to blacken the stools, nor the circumstance 
 that it is wont to be more persistent than it was in this case, where 
 there were long intervals between the different attacks. 
 
ILLUSTRATIVE CASES. 
 
 147 
 
 Under the use of rhubarb, aloes, and the ammonio-chloride of 
 iron, the patient's condition remained for six weeks unchanged in 
 its principal features, except that the emaciation increased, notwith- 
 standing a good appetite and abundance of food. The haemorrhage 
 from the bowel did not return ; the stools were clay-coloured without 
 any admixture of bile. 
 
 Prom the 15th of March, it was observed that the jaundiced colour 
 of the skin became paler, without any bile appearing in the stools. 
 This appeared to depend upon an increased secretion of urine, 
 which, by degrees, became doubled in quantity and lighter in colour ; 
 on closer examination, an abundance of sugar was detected in this 
 fluid. The specific gravity varied from 1009 to 1018. Eepeated 
 careful examinations of the urine were now made, and with the fol- 
 lowing results : — * 
 
 Quantity of Urine in 24 hours. 
 English Fluid Ounces -t 
 
 Specific Gravity 
 
 determined by means of 
 
 weighing, and the 
 
 Gravimeter. 
 
 Per centage of Sugar. 
 
 Remarks. 
 
 Date. 
 
 Fluid 
 Ounces. 
 
 Heavier Urine 
 of Night. 
 
 Lighter 
 Urine 
 of Day. 
 
 The lighter urine (1011.5) 
 contained 1.28 p.c. 
 
 ( 2.88 p.c. (heavier, 1015) 
 \ 1.08 p.c. (lighter, 1010.5) 
 J 2.65 (heavier) 
 \1.00 (lighter) 
 
 2.45 
 
 3.8 (heavier) 
 
 0.822 (lighter) 
 Polariscope. 
 
 The morning 
 urine was 
 the heavi- 
 est. It con- 
 tained most 
 bile - pig- 
 ment, and 
 much mu- 
 cus, and 
 gave the 
 reaction of 
 sugar. 
 
 March 26 to 27 
 
 „ 27 to 28 
 
 „ 28 to 29 
 „ 29 to 30 
 
 „ 30 to 31 
 
 „ 31toAp. 1 
 
 April 1 to 2 
 
 „ 2 to 3 
 
 169. 
 
 172.5 
 
 176. 
 165.5 
 
 158.5 
 
 134. 
 120. 
 98.55 
 
 1018.5 
 
 1017. 
 
 1013. 
 1014.5-1015 
 
 1014.5 
 
 1014. 
 1019. 
 1018. 
 
 1012. 
 
 1011.5 
 
 1010.5 
 1010.5 
 
 1009. 
 
 1014. 
 1010. 
 1009.5 
 
 * To determine the quantity of sugar, the urine was diluted with nine- 
 teen volumes of water, and agitated with a boiling, always recently-pre- 
 pared, solution of sulphate of copper, tartaric acid, and potash, containing 
 a fixed quantity of copper, until a few drops of the filtered fluid yielded 
 no red precipitate with hydrochloric acid and cyanide of potassium, and 
 did not any longer precipitate the copper solution. The average result of 
 three experiments was taken. 
 
 t These have been calculated from cubic centimetres in the original. 
 The specific gravity is remarkably low for diabetic urine ; but Frerichs in- 
 forms me that he has occasionally observed such cases. — Transl. 
 
 L2 
 
148 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 The patient used opium in large doses* to counteract the tor- 
 menting loss of sleep and the diuresis ; and to keep -the bowels 
 open the watery extract of aloes, with steel, was prescribed; 
 attention was paid to the diet, which consisted principally of animal 
 food. 
 
 This change in his diet, Vogel, who in other respects was a quiet 
 and sensible man, found to be insupportable, and, consequently, on 
 the 2nd day of April he demanded his discharge. The distention 
 of the gall-bladder, the hard tumour close to the left of this organ, 
 and the size of the liver remained the same as on admission. 
 
 So soon as the 6th of April, the patient returned in a much 
 altered condition. His features were pale and collapsed; frequent 
 evacuations of the bowels, consisting of mucus, blood, and fibrinous 
 flakes, and accompanied by troublesome tenesmus, had quite exhausted 
 him ; along with this, the pulse was 64 and weak, the extremities 
 were cool, there was complete loss of appetite, an inclination to 
 somnolence, and slow answers. From the 7th to the 8th of April, 
 2,500 cub. cent. (88 fluid ounces) of urine were passed, of which 
 the heaviest had a specific gravity of 1008, and the lightest 1005. 
 It had an acid reaction, and contained bile-pigment, but not a 
 trace of sugar. The quantity of urine passed from the 8th to the 
 9th, amounted to 2000 cubic centimetres (70 fluid ounces) ; had a 
 specific gravity of from 1008 to 1006, and likewise contained no 
 sugar. 
 
 An enema containing nitrate of silver and opium, and, internally, 
 compound tincture of bark with ether, wine, soups, and other ana- 
 leptics, failed in arresting the dysentery and exhaustion. Death 
 ensued at one in the morning of April 9th. 
 
 Autopsy, 10 hours after death. 
 
 The body was jaundice-coloured to a considerable degree ; there 
 was no oedema. The dura mater was yellow, the pia mater was 
 moderately congested, as was also the brain substance, which was 
 somewhat softened, especially in the fornix, the corpora quadrage- 
 mina, the pons Varolii, and the roof of the fourth ventricle. In the 
 substance of the pons Varolii numerous little reddish-brown masses 
 of pigment, the remains of capillary apoplexies, were found. 
 
 The mucous membrane of the mouth and pharynx, and also of 
 * Three grains of opium were insufficient to induce sleep. 
 
ILLUSTRATIVE CASES. 149 
 
 the oesophagus was yellow ; that of the larynx and air-passages was 
 faintly injected. The apex of the left lung contained tubercular 
 deposits of old date, which were surrounded by thickened tissue 
 containing dark pigment, and, in the immediate neighbourhood, 
 were portions of the organ in an emphysematous condition; 
 the lower lobe was in a state of hypostatic congestion. The 
 right lung, likewise, contained some tubercular masses, the size 
 of a bean. 
 
 In the pericardium there were found five ounces of fluid tinged 
 with bile, and highly albuminous, from which, soon after its re- 
 moval, a quantity of fibrinous matter separated in the form of a cake. 
 It contained abundance of bile-pigment ; but sugar, and the biliary 
 acids could not be detected, either directly or in the alcoholic extract 
 of the residuum which remained after drying. There were firm, 
 fibrinous coagula in both sides of the heart ; the muscular tissue and 
 the valvular apparatus were normal. 
 
 The peritoneal sac contained a pound and a-half of fluid, which 
 was paler than that in the pericardium; it was turbid owing to the 
 presence of pus ; the reaction of the colouring-matter of bile was 
 distinct, but more feeble than was the case with the pericardial 
 effusion. Pettenkofer's test for the biliary acids gave a positive, 
 and Trammer's test for sugar, a negative result. 
 
 The spleen was adherent to the flexure of the colon ; its size was 
 normal (4| Paris inches long ; 3 inches broad, and f of an inch 
 thick) ; its capsule was thickened, and its parenchyma was soft and 
 moderately congested. . 
 
 The liver was situated farther down than usual. The anterior 
 margin of the left lobe lay 3 \ inches below the apex of the ensiform 
 cartilage of the sternum, and that of the right lobe extended 2 inches 
 beyond the cartilages of the eighth and ninth ribs, and the apex of 
 the gall-bladder, fully 1 inch beyond this ; the edge of the gall- 
 bladder was 2\ inches distant from the median line. 
 
 The size of the liver was unaltered ; its margins were sharp ; and 
 its surface smooth. The gall-bladder was enormously distended; it 
 contained about eleven ounces of thick, brownish-black bile, in which 
 there glistened many large and remarkably thick plates of cholesterine, 
 but which contained no albumen. The bile ducts were all much dilated, 
 so that at many places over the outer surface of the liver they could 
 be felt to fluctuate. (See Fig. 19, page 115.) Their mucous lining 
 had lost its cylindrical epithelium, and was covered with pavement 
 
150 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 , epithelium, which had partly undergone fatty degeneration. The 
 parenchyma of the liver was very moist, infiltrated with greenish 
 bile, moderately congested, and of somewhat diminished consistence. 
 Nothing unusual could be observed in its vascular apparatus : the 
 circumference of the portal vein measured 4 centimetres (1! English 
 inch) . Some of the hepatic cells were remarkably pale and in a great 
 measure free from fat ; others were completely filled with a bright 
 orange-yellow substance, or with little brown masses, or with green 
 granular pigment; only a few cells contained small drops of oil, 
 which were not confluent. Leucine and tyrosine could only be 
 found in small quantities in the hepatic parenchyma; sugar was not 
 present at all. 
 
 The stomach was much contracted; its muscular tissue was 
 covered with a grey tenacious mucus ; the muscular tissue of the 
 pylorus was thickened and penetrated by the tumour in the 
 pancreas which pressed against it. The duodenum was covered with 
 a thick layer of white mucus ; its inner lining membrane was swollen 
 and of a dirty-grey colour. The place where the ductus choledochus 
 and pancreatic duct opened, projected in the form of a hard white 
 papilla ; there was no ulceration anywhere. 
 
 The head of the pancreas was firmly adherent to the wall of the 
 duodenum, and was occupied by a grey medullary tumour, which at 
 some places was softened. In the interior of the cancerous mass 
 might be seen excavated spaces, resembling cysts, and corresponding 
 to the pancreatic ducts; these contained a colourless mucus, and 
 their walls had been eaten away by the surrounding disease. The 
 remaining portion of the gland, which was exempt from the disease, 
 was atrophied; the pancreatic duct was greatly distended, and fur- 
 nished with numerous sacculated bulgings, shut off by valve-like 
 folds of the lining membrane, and filled with secretion. About a 
 drachm and a-half of fluid could be collected from this duct. The 
 turbid fluid appeared, upon contact with the air, to become partly 
 coagulated; the coagulum consisted of brilliant gelatinous globular 
 masses ; under the microscope there were seen corpuscles similar to 
 those of pus, and cells which had partly undergone fatty degeneration, 
 entangled in a grey striated matrix. The reaction was feebly alkaline; 
 the filtered fluid obtained after trituration with water, yielded no pre- 
 cipitate on being boiled. Nitric acid produced a distinct turbidity, 
 as also acetic acid ; the turbidity in the latter case was partly dissi- 
 pated by an excess of the acid. In the small intestine there was 
 
ILLUSTRATIVE CASES. .151 
 
 nothing abnormal ; at the ileo-caecal valve, the mucous membrane 
 began to be red and swollen, and this condition was much more 
 intense further on in the rectum. In this portion of the bowel the 
 dark-red velvety mucous membrane was covered with a bloody viscid 
 fluid, but there was no ulceration of the surface present. 
 Nothing abnormal could be detected upon microscopic examina- 
 tion in the blood of the portal vein, or in that of the splenic or 
 hepatic veins. 
 
 The kidneys were of normal size and of a smooth surface, and 
 were moderately congested; their minute structure was perfectly 
 normal, with the exception of a faint jaundiced tint of the glandular 
 epithelium. TJrine containing an abundance of bile-pigment, but no 
 sugar, was found in the bladder. 
 
 Eichard Bright had previously described a case in which diabetes 
 manifested itself under similar circumstances to those of the present 
 case. Observations of this nature, prove how little the formation of 
 sugar in the liver is interfered with by a stoppage to the flow of bile. 
 The frequency with which diabetes is accompanied by diseases of the 
 pancreas, has appeared to me remarkable ; out of nine cases I have 
 seen atrophy or fatty degeneration of this gland in five. It is still 
 undetermined, whether these lesions are to be regarded as the ex- 
 citing causes of diabetes, and, if so, in what manner they operate. 
 
 The changes which were observed in the pons Varolii are deserving 
 of notice, in reference to Bernard's experiment of exciting diabetes 
 by irritating the eighth pair of nerves at their origin in the fourth 
 ventricle; whether they stood in etiological relation to the flow of urine 
 could not be ascertained under such a complication of circumstances. 
 
 The great influence exerted by the secretion of urine upon the 
 intensity of the jaundice, is shown by the rapidity with which the 
 patient became pale, from the time the kidneys began, under the 
 operation of the sugar in the blood, to secrete freely. 
 
 Observation No. VJLJLl. 
 
 Closure of the Ductus Choledochus hy newly-formed areolar tissue, 
 resulting from Peri-hepatitis. — Jaundice and Enlargement of the 
 Bile duets. — Dropsy. — Secondary Pneumonia. — Death. 
 
 C. Schmidt, aged 74, a tradesman's wife, for her age was an 
 unusually vigorous and active-minded female, fell ill, as was stated 
 
152 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 by her ordinary medical attendant, in November, 1854. Without 
 any obvious external cause, she was seized with symptoms which 
 indicated the existence of gastro-intestinal catarrh : — loss of appetite, 
 a grey-coated tongue, and diarrhoea alternating with constipation. 
 Along with these symptoms, there was tenderness of the hepatic 
 region, gradually increasing in intensity, so that the patient was 
 obliged to keep her bed. These complaints lasted until the end of 
 the year, when there was some amelioration, although only of a 
 temporary nature. Already, in January, 1855, the patient's sufferings 
 returned with increased intensity : the pains in the right hypochon- 
 drium were so great, that she was unable to sit up or to leave 
 the horizontal posture. The appetite failed completely, and 
 severe diarrhoea set in. This diarrhoea was just arrested, about the 
 middle of February, under the use of astringents, red wine, &c, 
 when jaundice suddenly made its appearance, and continued until 
 death; the stools were completely deprived of colour; the skin 
 became yellow, and by degrees, greenish-brown and bronze- 
 coloured. 
 
 The patient was more carefully examined by Dr. Nega on the 20th 
 of March, five weeks after the commencement 'of the jaundice, and 
 shortly after, by myself. The liver lay deeper than usual; its 
 upper margin, close to the right edge of the sternum, was found to 
 be on ar level with the seventh rib ; the dimensions of the organ, were 
 somewhat reduced in every direction. Its anterior edge, which 
 could be easily made out on palpation, felt sharp, and a cylindrical 
 elastic tumour, five inches long and two inches in breadth, extended 
 beyond it. This tumour was situated at the outer margin of the 
 rectus muscle, and was, of course, assumed to be the distended 
 gall-bladder. Both the convex and the concave surfaces of the 
 liver, as far as they could be felt, were smooth, and free from nodules 
 or projections. The tenderness in the right hypochondrium was 
 completely gone ; but the digestive powers were much impaired, the 
 tongue was covered with a greyish-white coat, there was scarcely any 
 appetite, and there was obstinate constipation with flatulence. The 
 pulse was 60, and never sank below this during the whole duration 
 of the disease. The heart was normal ; the lungs were emphysema- 
 tous ; and there was slight bronchitis, with greyish-white tenacious 
 sputa. There was a great tendency to perspiration ; severe itching 
 had been present, but this symptom had ceased to exist. The urine 
 was scanty, of a beer-brown colour, presenting a lively reaction with 
 
ILLUSTRATIVE CASES. 153 
 
 nitric acid ; it was generally clear, but sometimes turbid, owing to 
 the presence of a red sediment of uric acid. 
 
 The consciousness was unimpaired j and there never were any 
 derangements of the senses, or yellow vision. 
 
 It was obvious, that there was here an occlusion of the ductus cho- 
 ledochus ; the only question was, what was the cause which rendered 
 the duct impermeable ? The propagation of a chronic gastrointesti- 
 nal catarrh did not furnish a satisfactory explanation, inasmuch as 
 a complete and persistent closure is not produced in this way. The 
 idea that the ductus choledochus might be compressed by cancerous 
 deposit, or by a tumour of some other nature in the Liver, was entirely 
 opposed by the smooth surfaces and the uniform sharp margin of the 
 gland. It is seldom that an impacted gall-stone hermetically closes 
 up the duct for a length of time ; moreover, such an event is 
 almost always preceded by attacks of colic. The tenderness in the 
 hepatic region, which lasted for several weeks, and which was un- 
 accompanied by jaundice, by any acute attacks of pain coming on 
 spontaneously, or by vomiting, &c, could not be mistaken for colic ; 
 it indicated, with much greater probability, the existence of peri- 
 hepatitis. Hence we assumed that it was this which had given rise 
 to the closure of the ductus choledochus ; although we did not con- 
 ceal from ourselves that this supposition was only the most probable 
 one of all others, inasmuch, as former experience had taught us,* that 
 small tumours in the neighbourhood of the duodenum and in the head 
 of the pancreas, can obstruct the duct without being perceptible on 
 palpation. An unfavourable prognosis was of course arrived at ; and 
 the treatment consisted in doing little more than alleviate symptoms. 
 
 A mild, vegetable diet, with milk, and Seltzer water was ordered; 
 extract, gratiol.f was given to keep the bowels open. 
 
 No important change in the symptoms took place during the next 
 few weeks, except that the appetite improved, the flatulence was 
 removed, and the stools were passed regularly, but still remained 
 clay-coloured. 
 
 In the middle of May, oedema of the feet and ascites ap- 
 peared, both of which increased with considerable rapidity, and were 
 accompanied with anasarca of the upper half of the body ; the urine 
 was scanty and dark, but continued free from albumen. The bron- 
 
 * See Observation No. V. 
 
 t Extractum Gratiolte, prepared from the herb and root of the Gratiola 
 officinalis, or Hedge-hyssop. — Transl. 
 
154 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 chitis increased and the expectoration became more abundant and 
 puriform;* and percussion indicated the presence of fluid in both 
 pleural sacs. The appetite again fell off ; and the tongue became 
 covered afresh with a thick grey coat. 
 
 She was ordered the compound tincture of bark as a dietetic, and 
 the liq. ammon. anis.f to promote expectoration. 
 
 A transient improvement was obtained, but still the dropsy made 
 progress. The quantity of urine became smaller and smaller, so 
 that fears were entertained that the uriniferous tubes had become 
 extensively blocked up with solid deposits of pigment. An infusion 
 of calamus root, with digitalis and acetate of potash, along with some 
 glasses of the Karlsbad Millspring, J had a beneficial effect upon the 
 quantity and the quality of the urine; it became paler in colour; its 
 quantity was trebled ; and the dropsy was again removed. 
 
 Tor three weeks this favourable change continued under the use 
 of the Millspring, when, notwithstanding a copious flow of urine, 
 the dropsy again made its appearance ; the liver became smaller, the 
 length of the gall-bladder was gradually reduced from five to three 
 inches, with a corresponding diminution in breadth. 
 
 In the middle of July, a pneumonic exudation took place in the 
 right lung, extending upwards as high as the spine of the scapula. 
 The pulse rose therewith to 90 ; the expectoration ceased, and after- 
 wards became purulent ; resolution took place in part of the hepa- 
 tized lung, but the greater portion remained for a long time 
 stationary, and subsequently passed into a state of suppuration. 
 The expectoration was abundant and fetid; the patient grew more and 
 more collapsed ; the dropsy became general, until, on the 11th of 
 August, death took place by exhaustion. Consciousness remained 
 clear to the last. What appeared remarkable was, that throughout 
 her entire illness the patient's temper remained unruffled ; when her 
 sufferings were in some degree bearable, she joked about her colour, 
 felt her liver, and commissioned us to make a careful examination 
 of it after her death. 
 
 Autopsy, 18 hours after death. 
 
 The skin was dark-yellow, and at some places bronze-coloured. 
 
 * The sputa were always free from bile-pigment. They were frequently 
 tested with nitric acid; but no play of colours could ever be observed, 
 t See note, page 133. % See notes, pages 58 and 124. 
 
ILLUSTRATIVE CASES. 155 
 
 There was general anasarca. About twelve pounds of clear, brown 
 fluid, were found in the abdominal cavity. 
 
 The liver extended about three centimetres (1\ inch) beyond the 
 margin of the false ribs ; it was somewhat reduced in size. On 
 applying the fingers along the outer surface, soft places could be 
 felt, varying in size from that of a pea to that of a hazel-nut, 
 which were somewhat, prominent, and, upon section, discharged a 
 greyish-yellow fluid (enlarged bile ducts). The serous covering was 
 at some places thickened ; and the upper surface of the organ was 
 adherent to the diaphragm by newly-formed bands of areolar tissue. 
 The gall-bladder extended about three inches beyond the anterior 
 margin; its breadth amounted to If inch. The walls of the gall- 
 bladder were white and thickened from organised exudation, and 
 its posterior surface was connected to the duodenum by cords of 
 areolar tissue ; the cystic and hepatic ducts were both enlarged to 
 the extent of an inch in their transverse diameter. Three lines 
 below the place where they joined to form the ductus choledochus, 
 the canal was completely obliterated ; there was here a thick, whitely- 
 striated areolar membrane, which constricted {lit. tied off) the duct 
 from without, and bound it firmly to the neighbouring duodenum. 
 The contents of the gall-bladder consisted of a greyish-yellow mucus, 
 in which were suspended brownish-black flakes, presenting an 
 amorphous appearance under the microscope — the residuum of de- 
 composed bile-pigment. The fluid yielded no distinct reaction with 
 nitric acid. A similar fluid, but somewhat browner in colour, was 
 found in the distended bile ducts of the liver. The distention of 
 these ducts was, for the most part, of a uniform character ; but in 
 several places there could be observed ampulliform enlargements. 
 The walls of the ducts were thick and rigid ; they were enveloped 
 externally by layers of white, areolar tissue, which passed inwards 
 along with them through the hepatic fissure. 
 
 The hepatic tissue was of firm consistence, and upon its cut- 
 section the lobules appeared of a greenish-brown colour at their 
 peripheries, brownish-black at their centres. The distribution of the 
 pigment was more minutely examined by making fine sections of 
 the organ after boiling, moistening them with acetic acid, and 
 submitting them to a magnifying power of 80 diameters. The 
 colouring-matter could then be seen to be chiefly accumulated in the 
 vicinity of the central veins of the lobules ; the colour became 
 gradually paler towards their circumference. Dark brown granules 
 
156 JAUNDICE FROM OBSTRUCTION OF DUCTS. 
 
 lay scattered throughout the parenchyma, which, when more highly 
 magnified, were found to be hepatic cells deeply impregnated with 
 colouring-matter. In addition to the greatly distended thick-walled 
 bile ducts, round or elongated spaces of a brown colour were 
 observed at many places, which I regarded as the cross sections 
 of the smallest excretory ducts filled with stagnating bile. The 
 hepatic cells were everywhere intact. Some of them were pale 
 and softened, but in no way abnormal; but most of them were 
 loaded with bile. This consisted of yellow or brown granules, 
 either isolated or adhering in dense groups, in the interior of the 
 cell; in a few of the cells only was a nucleus visible. Many of the 
 cells contained abundant deposits of spherical, angular, or cylin- 
 drical little masses, of a yellow, brown, or green colour. In 
 several, the colouring-matter was distributed in a uniform manner. 
 Where the nucleus was visible it sometimes appeared pale, at other 
 times tinged with green or yellow. 
 
 The deposits of bile external to the cells were of various forms and 
 tints ; most of them were cylindrical, straight, or bent, in some in- 
 stances ramified, and occasionally furnished with bulging prominences; 
 their colour was yellow, brown, ochre, or green. One would have 
 been inclined to have taken these for casts of the most delicate of 
 the bile ducts, had not this supposition been contradicted by the 
 presence of similar formations in the interior of the cells. Along 
 with these elongated forms other deposits were observed, which were 
 rounded, club-shaped or angular. These deposits were of tolerable 
 consistence ; by compression between two glass plates, they could be 
 split up and crushed to pieces. 
 
 Although the substance of the liver was not chemically examined 
 for leucine, until after it had been kept for two days during the 
 warm weather of the month of August, this substance was found in 
 considerable quantity. 
 
 The spleen was somewhat enlarged, and presented a v brownish-red 
 colour and firm consistence. The mucous membrane of the gastro- 
 intestinal canal was covered with a layer of grey mucus of consider- 
 able thickness ; the mucous membrane itself was for the most part 
 pale, and contained but little blood ; at certain spots only was it much 
 congested. Nothing abnormal could be detected in the duodenum. 
 
 The kidneys were of the usual size, their outer surface was 
 smooth, and their parenchyma was of a dirty greenish-yellow colour. 
 The epithelium of the uriniferous tubes had undergone extensive fatty 
 
JAUNDICE WITHOUT OBSTRUCTION OF DUCTS. 157 
 
 degeneration, and they were for the most part, especially their 
 nuclei, infiltrated with brown, green, or red pigment. It was only 
 at a few spots, that copious flake-like deposits of colouring-matter 
 could be observed ; nowhere did these occur to the extent that was 
 noticed in Case No. VI. It appeared as if these deposits had been 
 removed, or at all events, arrested- in their formation, by the use of 
 the highly alkaline Karlsbad water. 
 
 The bronze-coloured skin was subjected to a more minute 
 examination. The pigment was mostly contained in the deepest 
 layer of cells of the rete Malpighi, which were coloured brownish- 
 yellow, and contained dark granular deposits. The more superficial 
 layers of cells exhibited only a pale-yellow tinge. 
 
 The sweat-glands in the axillae were likewise deeply coloured by 
 pigment, and contained a large number of molecules and granules, 
 the size of cell nuclei. The cells of the adipose tissue presented a 
 citron-yellow colour. 
 
 The thorax and skull were not allowed to be opened.* 
 
 The treatment of jaundice from obstruction is always directed 
 chiefly against the cause of the stoppage to the flow of bile, in so far 
 as there is any prospect of this cause being removed. Catarrh of 
 the bile ducts and of the duodenum, gall-stones, and other mechanical 
 obstructions will afterwards be treated in detail under the heads of 
 each of these diseases. Where the causes are irremoveable, we must 
 be guided in the more intense forms of jaundice by the general 
 principles above laid down. In certain incurable organic changes in 
 the structure of the liver, such as cirrhosis, cancer, &c, jaundice of 
 considerable intensity is very often a subordinate symptom, which 
 calls for no special therapeutic treatment. 
 
 ii. Jav/adice without any detectable mechanical impediment to the 
 excretion of Bile. 
 
 The pathological origin of the forms of jaundice included under 
 this head is less clear than that of those hitherto dwelt on. We are 
 acquainted with only two conditions which can give rise to them — 
 abnormal diffusion of bile, arising from some alteration in the supply 
 of blood to the liver, and defective metamorphosis, or impaired 
 
 • The microscopic appearances alluded to in the above description are 
 figured in Plate I. of the coloured Atlas. — Transl. 
 
158 JAUNDICE 
 
 consumption of bile in the blood. Both may be present during life, 
 without leaving behind any certain traces of their existence in the 
 dead body. But, even on these suppositions, it is more difficult and 
 uncertain to form an opinion, and give an explanation of, several 
 of the forms of jaundice belonging to this class, than is the case 
 with the first group j we are obliged to substitute for unequivocal 
 anatomical facts, analogies, the value of which can only be substan- 
 tiated in a general way, but cannot, by any means, always be proved 
 in detail. 
 
 Not a trace is found here of those changes in the structure of the 
 liver, which we meet with in the first group in a more or less marked 
 degree, according to the seat and nature of the obstruction. The 
 bile ducts are either empty or half filled; the hepatic cells, as under 
 normal circumstances, are either free from colouring-matter, or only 
 contain a small quantity ; the parenchyma of the gland is at one 
 time anaemic, pale, and soft, at another time it contains a normal 
 amount of blood, or is congested ; the contents of the bowel are 
 found to be mixed with bile. 
 
 To this class we refer : — 
 
 a. Jaundice from Mental Hmotions. 
 
 Physicians have at all times maintained, that jaundice can be pro- 
 duced by functional derangements of the nervous system. It has been 
 thought that it might result from spasm attacking the bile ducts or the 
 muscular tissue of the duodenum, and so producing an obstruction to 
 the passage of the bile. Various considerations, which are opposed 
 to such an explanation of a stoppage of bile, have already been 
 advanced, quite independently of the fact, that the jaundice from 
 mental emotions is developed much more rapidly than is ever the 
 case in complete closure of the ductus choledochus. Since Claude 
 Bernard proved, that by irritation of the fourth ventricle of the 
 brain, the sugar formed in the liver can be made to pass off by the 
 urine, the view, — according to which deranged innervation may give 
 rise to jaundice, — cannot be regarded as extraordinary, although the 
 difficulty of explaining the phenomenon is not in this way removed. 
 So far as we at present understand the matter, derangements of the 
 nervous functions may lead to accumulations of bile in the blood in 
 two ways : — 
 
 a. By interruptions to the circulation of blood through the liver, 
 
FROM MENTAL EMOTIONS. 159 
 
 arising from the influence exerted by the nerves over the caliber of 
 the branches of the portal vein. 
 
 b. By interruptions to the heart's action, the respiratory move- 
 ments, and the renal secretion. 
 
 The former of these causes ■would entail increased formation and 
 absorption of bile ; the latter, the existence of which appears to be 
 indicated by the circumstances accompanying the outbreak of the 
 jaundice, would give rise to a diminished metamorphosis of bile (in 
 the blood), or would limit its excretion. At present, we can no 
 more determine which of these two influences is the more powerful, 
 than we are able to do in the case of diabetes. 
 
 In violent mental emotions induced by vexation, anger, fright, 
 &c, the epigastrium becomes suddenly compressed, and there is 
 dyspnoea, a feeling of suffocation, and sometimes, also, vomiting ; 
 the skin becomes pale, and soon after of a jaundiced colour, whilst 
 large quantities of urine are secreted still devoid of colour.* In 
 such a case, the jaundice makes its appearance in a few hours, 
 and sometimes, as we are informed by authentic observations, in even 
 a still shorter space of time. Yillerme t mentions a case, in which 
 two young persons quarrelled and drew their swords ; one of them 
 became suddenly yellow, and the other, terrified at this change of 
 colour, dropped his weapon. The same writer relates the case of 
 an abbe who became suddenly yellow, on a mad dog rushing against 
 him. Although one may be inclined to doubt statements of this 
 nature, still there are numerous observations which prove, that under 
 such circumstances as those just mentioned, jaundice may be deve- 
 loped in a much shorter space of time than is wont to happen after 
 the application of a ligature to the ductus choledochus. Patients, 
 whose word cannot be doubted, often make communications of 
 this nature, when we inquire into the previous history of their 
 complaint. J 
 
 Usually, this form of jaundice soon passes off, and is not attended 
 by any further consequences. But to this there are exceptions ; cases 
 
 * This limited excretion of the colouring-matter in the urine is not 
 without some influence upon the rapid increase of the jaundice of the 
 skin. 
 
 t Diet, des Scienc. medic. Art. Icterus, p. 420. 
 
 J One must be very careful in coming to a decision in such cases. 
 There are countries in which the popular belief that jaundice depends 
 on mental emotions is so strong, that almost every case is attributed to 
 that cause. 
 
160 JAUNDICE 
 
 are met with in which the disease takes on a malignant character, 
 and in which death ensues after a. few days, amid severe nervous 
 symptoms, such as delirium, convulsions, &c. Morgagni, in his 
 thirty-seventh epistle, has related cases of this nature, and a similar 
 case is reported by Tillerme.* 
 
 "With the jaundice from mental emotions are closely connected tie 
 few observations which we possess of — 
 
 b. Jaundice from the effects of Ether and Chloroform. 
 
 These are interesting, inasmuch as, under the same circumstances, 
 sugar has been observed to pass off by the urine. 
 
 c. Jaundice from Snake-bites. 
 
 That jaundice of an intense form may arise after the bite of ven- 
 omous snakes, is a fact which was known to the ancients. Galen t 
 relates the case of a slave who became intensely jaundiced after 
 being stung by a viper. MeadJ mentions similar cases, and insists 
 particularly on the rapidity with which the yellow colour may he 
 developed : "intra non integrant horam fit flavus, quasi ejus qui 
 ictero laborat." Under such circumstances, the colour often attains 
 a remarkable intensity. Galen and Lanzoni § make mention of a 
 green tinging, and Portal || records the case of an apothecary known 
 to him whose skin, in consequence of a sting from a viper, became 
 first yellow and subsequently greenish. Eesults similar to those 
 supervening upon the sting of a viper have been observed after the 
 bites of rattlesnakes (Moseley), of scorpions, and of mad animals 
 {Bartholin). 
 
 The older physicians attributed the production of this form of 
 jaundice to a spasm of the bile ducts, or, as Fontana^f did, to a 
 liquefaction of the bile resulting from putrid decomposition. 
 
 More detailed observations are still wanting to enable us to solve 
 this question. That no obstruction to the flow of bile exists, is 
 proved by the bilious character of the evacuations, both by vomiting 
 
 • See chapter on Acute Atrophy of the Liver. 
 
 f De locis affectis, Lib. V., cap. 8. 
 
 X Tentamen de vipera, p. 36. 
 
 § Tractat. de venen., cap. V. || Op. cit., p. 140. 
 
 t Abhandlung iLber das Viperngift. Berlin, 1787, S. 417. 
 
FROM PYjEMIA. 161 
 
 and by stool. Still we are uncertain whether the cause of the accu- 
 mulation of bile in the blood depends upon metamorphoses of a 
 morbid character in the blood itself, or on a deranged innervation 
 acting upon the circulation and respiration, in a manner similar to 
 that which occurs in jaundice arising from mental emotions. In 
 reference to this, the observations made by CI. Bernard as to the 
 action of Curari, are worthy of notice. The administration of this 
 poison was found to give rise to congestion of the liver, and to the 
 excretion of sugar in the urine. 
 
 d. Jaundice from Pymmic Infection of the Blood. 
 
 Marechal * was the first to observe that in individuals, in whose 
 bowels pus exists, the skin and conjunctiva, as well as the various 
 tissues of the body, exhibit a more or less marked yellow colour. 
 Sometimes there was associated with this symptom some anatomi- 
 cal change of the liver, but more frequently no such alteration 
 existed, even when the colour was most intense ; hence, the appear- 
 ance was attributed to the dissemination of pus through the 
 tissues. Since then, this yellow colour has been recognised as by 
 no means a constant, but still a frequent, symptom of pyaemia, and it 
 has been ascribed, at one time, to the transformation of the colouring- 
 matter of the blood into yellow pigment, and at another time has 
 been regarded as jaundice, dependent upon an accumulation in the 
 blood of the colouring-matter of the bile. Berardt believed that 
 this colour could not proceed from bile, because the eyes and the 
 urine were not tinged; and his statements, although erroneous, have 
 been frequently repeated by recent writers. There can be no doubt 
 that the yellow colour arises from the brown matter of the bile, and 
 in every respect agrees with that of jaundice ; unmistakable proofs of 
 this opinion are furnished by the blood, the exudations and the urine. 
 In general, the urine exhibits, upon testing, distinct indications of the 
 presence of bile-pigment, as do likewise the serum of the blood, and 
 the effusions into the serous cavities. Moreover, we can obtain from 
 the blood the same crystalline colouring-matter as in the blood of 
 patients who have become jaundiced from occlusion of the bile ducts. 
 
 The anatomical characters of the liver throw no light upon the 
 
 * Recherches sur certaines alterations, qui se developpent au sein des 
 principaux visceres a la suite des blessures ou des operations. These de 
 Paris, 1828. t Dictionn. de Med., T. XXVI., p. 491. 
 
162 JAUNDICE 
 
 mode of origin of this form of jaundice; the bile ducts are open and 
 usually pour out a little thin secretion; the organ itself is in most 
 cases anaemic and dry ; and throughout its parenchyma products are 
 found which indicate morbid conditions of the secretion, and of the 
 metamorphoses of matter. To all appearances the jaundice is here the 
 result of an impaired consumption of bile in the blood, arising from 
 an abnormal condition of the metamorphic processes which go on in 
 that fluid. 
 
 I annex two cases of pyaemic jaundice, the former of which is simple 
 in its nature, but the second is interesting in many points of view. 
 
 Observation No. IX. 
 
 Contusion of the pelvic tones. — Rigors. — Somnolence. — Jaundice. — 
 Albuminuria. — Death. — Phlebitis of the Pelvic veins. — Metastatic 
 deposits in the lungs. — Soft anaemic liver. 
 
 Gottfried "Wiesner, aged 28, on June 29th, 1854, suffered a con- 
 tusion of the pelvic bones from a beam falling upon him. Retention 
 of urine took place, which rendered it necessary to pass a catheter. 
 Above the left pubes there was a superficial extravasation of blood; 
 the power of progression was impaired; but no mobility of the 
 pelvic bones could be made out. 
 
 All these complaints disappeared, and the patient wished to leave 
 the Hospital, when, on the 8th of July, ten days after the injury, a 
 severe rigor set in, followed by heat and some sweating. This did 
 not return, but the patient was roused with difficulty, coughed, had 
 some diarrhoea, and became very feverish. 
 
 On the 11th he was removed to the medical Clinique. Pulse 120. 
 Kespirations-32, and accompanied by visible movements of the scaleni 
 muscles ; speech indistinct ; skin hot and dry ; no pain upon pres- 
 sure of the injured place, and no crepitation; stools pale and thin; 
 urine albuminous. In the lungs extensive wheezing, and posteriorly, 
 rales could be heard ; but no dulness could be made out upon per- 
 cussion. He was ordered decoction of senega root. 
 
 On the 13th, respirations 40 and panting. Pulse 120; heart's 
 sounds clear; profuse perspiration; the conjunctiva and the angles 
 of the mouth had assumed a yellow colour, which was rapidly 
 increasing in intensity. Spleen enlarged ; thin, involuntary stools ; 
 urine contained a quantity of bile-pigment. 
 
FROM PYEMIA. 163 
 
 On the 14th, the jaundice had increased ; the pulse was irregular; 
 drowsiness ; (Edematous swelling of the lower extremities. 
 Died at one o'clock in the following morning. 
 
 Autopsy. 
 
 Nothing abnormal in the cranial cavity. 
 
 The mucous membrane of the bronchi was vividly injected ; over 
 the surfaces of both lungs there were numerous patches of collapsed 
 tissue, and sub-pleural ecchymoses. The pulmonary tissue was 
 (Edematous and congested; at the lower margin of the left lung, 
 there was found a dark-red mass the size of a walnut, with a yellow 
 softened centre ; there was a similar mass in the apex of the right 
 lung; the lower lobe of the right lung also contained numerous 
 masses of the size of a cherry, furnished with yellow centres. On 
 tracing the branches of the pulmonary artery, granular coagnla, fur- 
 nished with white points, were found in those which were nearest to 
 the masses just mentioned; the lining membrane of the vessel was 
 smooth, and a yellow colour could be seen through it, which was due 
 to the presence of pus in the cellular sheath. 
 
 The heart, stomach, and intestinal canal were normal ; the spleen 
 was large and soft. 
 
 The liver was large, abnormally soft (murbe), anaemic and flabby ; 
 the cells were loaded with finely-granular contents, and some of them 
 with oil globules. 
 
 The bile in the gall-bladder, was scanty, pale, and liquid. 
 
 The kidneys were soft and anaemic ; the mucous membrane of the 
 urinary bladder was covered with ecchymoses ; the areolar tissue at 
 the neck of the bladder was infiltrated with extravasated blood and 
 gelatinous exudations ; and on making a section through this part, 
 numerous veins with thickened walls, and filled with pus, were seen 
 on the cut surface ; the hypogastric and iliac veins contained granular 
 (kriimliehe) coagnla. 
 
 The horizontal ramus of the pubes was comminuted, and the loose 
 fragments of bone lay in an ichorous fluid ; the descending ramus of 
 the pubes on both sides was broken. 
 
 The parenchyma of the liver contained a considerable quantity of 
 leucine ; in the blood of the right ventricle there was found 1.17 
 per cent, of fat, rich in cholesterine ; besides this, there was 
 obtained from the same source a considerable quantity of bile- 
 
 M2 
 
164 JAUNDICE 
 
 pigment deposited in the form of rods, grouped together in drusic 
 masses. 
 
 The urine had a specific gravity of 1012, presented distinctly the 
 reaction of the brown matter of bile, and contained small quantities 
 of leucine. 
 
 Observation No. X. 
 
 Acute Articular Rheumatism. — Endocarditis. — Bepeated Rigors. — 
 Painful enlargement of the Spleen. — Jaundice. — Albuminuria and 
 Hematuria. — Petechias. — Convulsions. — Coma, and Death. 
 
 Recent deposits upon the Mitral Valve. — Splenic Infarctions — Flabby 
 anamic liver. — Ecchymoses upon the mucous membrane of the In- 
 testines, Bronchi, fyc. 
 
 Bosina Peter, aged 24, a servant-maid, who had already been 
 under treatment in the Hospital for incompetence of the mitral 
 valves, was admitted on the 13th of November, 1856, with sym- 
 ptoms of febrile articular rheumatism. The disease had existed 
 for eight days. The left knee and elbow were swollen and 
 painful. Pulse 108 j a loud systolic bruit, heard loudest below the 
 nipple. The urine turbid, loaded with urates, but free from albumen j 
 Profuse sweating. "Was ordered colchicum and phosphate of soda. 
 
 About the 20th, the articular affection and the fever disap- 
 peared. 
 
 On th&22nd, at 4 in the morning, and again at 6 in the evening, 
 there was a severe rigor, which lasted an hour, and was accom- 
 panied with- great frequency of the pulse, and followed by heat and 
 sweating. The joints remained unaffected ; and there was no local 
 pain. 
 
 On the morning of the 30th, there was a fresh rigor ; the spleen 
 was enlarged, and had become painful. 
 
 On the 2nd of December, at 6 in the evening, and on the 3rd, 
 at 5 in the morning, there were fresh rigors ; the spleen extended 
 beyond the margin of the ribs j there was no local affection; the 
 cardiac bruit stronger than when formerly examined. 
 
 On the 7th, great distress and uneasiness ; splenic and hepatic 
 region very painful. 
 
 On the 8th, 10th, 11th, 12th, 13th, 14th, and 16th, there were 
 violent rigors j after this there were no real shiverings, but the 
 
FROM PYEMIA. 165 
 
 pulse was very variable, fluctuating, between 100 and 140 beats ; 
 there was great increase of temperature, and likewise greenish vomit- 
 ing, and acute pains in the spleen. The arteries in the limbs were 
 pervious ; and the joints were normal. 
 
 On the 20th of December, slight jaundice was observed, and bile- 
 pigment was found in the urine. She was ordered phosphoric acid. 
 
 The jaundice increased ; the stools became brown ; but the volume 
 of the liver remained normal. On the 25th, shivering ; pulse 136 ; 
 great restlessness, impaired consciousness; in the evening, two 
 attacks of convulsions. 
 
 On the 26th, violent convulsive fits of the entire body; loss of 
 consciousness ; pulse 140 ; petechia? the size of a linseed upon the 
 face and chest; urine bloody and turbid; in the evening death 
 occurred. 
 
 The dead body was intensely jaundiced, and covered with nume- 
 rous petechias ; upon the outer surfaces of the cerebrum and cere- 
 bellum, there lay extensive extravasations of blood, from two to 
 three lines thick, which sank deeply into the sulci ; the substance of 
 the brain was anaemic and of normal consistence. 
 
 The mucous membrane of the bronchi was ecchymosed; both 
 lungs were infiltrated with yellow serum, but without infarctions. 
 There were numerous ecchymoses beneath the epicardium ; the mus- 
 cular tissue of the heart was very pale and abnormally soft [murbe); 
 The mitral valve was covered with a reddish-brown, dry, friable 
 coagulum, having a thickness, at some places, of five lines; its 
 margin was contracted and thickened; and the chordae tendineae 
 adhered so as to form white cartilaginous-looking bands. The fri- 
 able deposit upon the anterior flap extended into the middle of the 
 tissue of the valve, as shown by a transverse section, and it had 
 no well-defined margin; the intermediate tissue of the valve was 
 loosened in its texture, partly transparent and vascular, and partly 
 of a dirty-grey colour, with yellowish deposits scattered through it. 
 
 The spleen was remarkably enlarged, and its capsule covered at 
 some places with recent exudation ; its parenchyma was congested, 
 and had numerous infarctions of various dates scattered through 
 it. The most recent of these were of a reddish-brown colour ; the 
 older ones were greyish-yellow, and softened in the middle; 
 the largest had a diameter of two and a-half inches. In one of the 
 
166 JAUNDICE 
 
 splenic arteries leading to a diseased spot, there was found a small 
 plug, similar to the deposit upon ihe mitral valve. 
 
 The liver appeared large, pale, and soft; its colour was pale 
 greyish-yellow, without any indication of lobules ; its cells were nor- 
 mal, and filled with a mass of granules, and, in some instances,' with 
 oil globules. The portal vein contained fluid blood, in which there 
 could be observed, even with the naked eye, small coagula of a 
 brownish-black, or reddish-yellow colour; the altered condition of 
 the colouring-matter presented by these coagula showed that they 
 were of an old date; little masses of coagulum of a similar 
 character were present in the splenic parenchyma, and in the blood 
 of the splenic vein. The gall-bladder contained a considerable quan- 
 tity of dark viscid bile ; the bile ducts were unobstructed. 
 
 The mucous membrane of the stomach was covered with nume- 
 rous ecchymoses the size of a linseed; A number of extravasated 
 masses of blood, from one to two hues in thickness, and having an 
 area about equal to the size of a two-thaler piece (crown-piece), lay 
 beneath the mucous membrane of the intestine, as far as the colon ; 
 the contents of the bowel were scanty, and coloured reddish-brown. 
 
 The mesenteric glands were normal. The kidneys were covered 
 with ecchymoses ; their parenchyma was soft, and a greyish-yellow 
 substance was infiltrated through their cortical substance. The 
 urinary bladder contained bloody urine. 
 
 To account for the purulent infection of the blood, — the existence 
 of which we were obliged to assume from the symptoms and course 
 of the disease, as also from the anatomical appearances, — no lesion 
 could be found, with the exception of the morbid changes in the 
 mitral valve and in the spleen. Purulent and ichorous deposits 
 and disintegrating thrombi in the interior of the veins were sought 
 for in vain. There could be no doubt that the masses in the spleen 
 depended upon emboli in the arteries, derived from particles which 
 had been swept along from the deposit on the valves of the heart ; 
 it was questionable, however, whether the purulent infection of the 
 blood arose from the same cause. Yirchow * is of opinion that we 
 cannot entirely deny that symptoms, which closely resemble those 
 of pyaemia, may be produced by the corroding (usurirende) and 
 ulcerating forms of endocarditis ; and he records one case, in which 
 he believed such an explanation to be possible; he thinks, how- 
 ever, that accurate observations are still wanting to corroborate the 
 • Gesammelte Abhjmdl., S. 700 and S. 711. 
 
FROM TYPHUS. 167 
 
 theory. Even the case before us cannot be regarded as one to the 
 point, inasmuch as there is as much, if not greater, probability in 
 the assumption that the purulent infection resulted from the deposits 
 in the spleen. The coloured coagula in the portal and splenic veins 
 showed that pathological products passed into the blood from the 
 spleen ; whether these consisted only of the decomposed red matter 
 of the blood, or whether there were also substances which exerted a 
 chemical action, cannot be determined. Moreover, the course 
 of the disease showed, that the emboli in the splenic artery had 
 existed for a long period without giving rise to any symptoms 
 indicative of blood infection. At the commencement, previous to 
 the rigors, the patient had no bad symptom, and only complained of 
 pain in the enlarged spleen on the eighth day after the first rigor ; 
 not until fourteen days after this same rigor, did the train of sym- 
 ptoms, which are wont to accompany infection of the blood, make 
 their first appearance. 
 
 The morbid changes in the heart, from which the unfavourable 
 progress of the case originated, were partly of old, and partly of 
 recent, date. A fresh endocarditis appeared as a complication of 
 the acute rheumatism in the already diseased and incompetent mitral 
 valve ; this gave rise to the deposits upon the valve, and subsequently, 
 by means of emboli, to the affection of the spleen. 
 
 e. Jaundice from Typhus. 
 
 Jaundice is usually a symptom of much rarer occurrence, in 
 typhus than in pyaemia : in ileo-typhus * it is only observed in ex- 
 ceptional cases; but in petechial typhus t it is of frequent occur- 
 rence, several epidemics of this affection having been charac- 
 terised by the frequency of jaundice. The mode of origin of jaundice 
 under such circumstances has not yet been investigated with any- 
 thing like sufficient care. In many cases, and especially in ileo-typhus, 
 the jaundice appears to be of a catarrhal nature ; usually, however, 
 no obstruction to the excretion of bile can be detected, the existence 
 of which is also contra-indicated during life by the fact of the stools 
 being coloured. The liver does not present any important alteration 
 in its texture; it is in most cases pale, soft, and shrivelled, and has 
 its cells filled with finely-granular contents. I have repeatedly 
 
 * The so-called Typhoid fever, or the Fievre typhoide of Louis. — Transl. 
 t The true epidemic typhus. — Transl. 
 
168 JAUNDICE 
 
 observed yellow or reddish-brown pigment flakes in the blood, of the 
 trunk of the portal vein, or of its capillary branches, which appear 
 to proceed from the enlarged spleen, in a similar manner to what 
 has been described in connection with pyaemia. (Observation No. 
 X.) In one i case, round softened masses were found in the 
 liver, but whether these were produced by emboli or not, could 
 not with certainty be determined. My own opinion is, that 
 the jaundice which accompanies the more severe forms of pete- 
 chial typhus, must be explained in a manner similar to pysemic 
 jaundice. 
 
 The following observations may throw some further light upon 
 the matter. 
 
 Obseevation No. XI. 
 
 ExanthemalicTyphus. — Jaundice. — Albuminuria. — Hcemorrhagefrom 
 
 the Bowels. — Ecchymoses of the Skin. — Parotitis. — Death on the 
 
 twelfth day. 
 Small Spleen. — Anaemic Liver. — Normal hepatic cells. — Unobstructed 
 
 bile ducts. — No disease of the intestine, nor of the Mesenteric 
 
 glands. 
 
 J. Pr. Pechhold, aged 55, was brought to the Hospital from the 
 Workhouse on the 31st day of December, 1855, at a time at which 
 there was admitted from that Institution thirty-one cases of typhus 
 within a period of three days. The patient presented all the sym- 
 ptoms of simple typhus ; a widely-spread exanthem; delirium ; pulse 
 120 ; respirations 29 ; constipation for three days ; urine turbid, free 
 from albumen and bile-pigment. He was ordered castor oil and 
 chlorine water. 
 
 On the 2nd of January, 1856, there was observed a yellow colour 
 of the conjunctiva and of the skin of the face, which increased very 
 rapidly ; the urine was dark brown, and contained an abundance of 
 albumen and bile-pigment ; there was blood in the stools ; pulse 98 ; 
 no enlargement of the spleen ; the hepatic dulness in the mammary 
 line measured 5| centimetres (2b English inches) ; great tympanites; 
 much restlessness and active delirium. Was ordered muriatic 
 acid. 
 
 On January 3rd, there were extensive ecchymoses of the skin ; the 
 exanthem was paler; two thin bloody stools; pulse 76; a quiet 
 
FROM TYPHUS. 169 
 
 apathetic deportment ; tremors of the extremities ; skin dry and dark 
 yellow ; the albnmen in the urine diminished in quantity. 
 
 On the 4th, pulse 68; a thin greenish stool; towards evening, 
 a second stool containing blood ; urine paler, free from albumen ; 
 jaundice very intense ; consciousness unimpaired. Was ordered to 
 continue the muriatic acid. 
 
 On the 5 th, a very bloody evacuation, which was followed by 
 great exhaustion ; pulse 96, small and weak ; hepatic dulness in the 
 mammary line 3 centimetres (I3 inch), and in the axillary 6 cent. 
 (2§ English inches) ; great apathy and loss of memory. 
 
 On the 6th, pulse 88 ; the ecchymoses had increased in extent ; 
 bloody stools ; urine pale and free from albumen ; somnolence. 
 
 On the 7th, there was developed in the left parotid, a tense, 
 painful tumour of very considerable extent, the lower part of which 
 felt soft, and poured out a bloody serum when punctured with a 
 needle. Pulse 96; skin dry and cool; urine brownish-black, loaded 
 with pigment; free from albumen, but containing much urea, and 
 traces of leucine. Slight cough with bloody sputa ; no exudation in 
 the lungs could be detected ; somnolence as before ; pupils normal. 
 Was ordered benzoic acid with camphor. * 
 
 On the 8th, pulse 108, very small, symptoms of pulmonary 
 oedema ; inability to expectorate ; tremers of the extremities. Death 
 ensued on the morning of the 10th, after a long agony. 
 
 Autopsy. 
 
 Brain and cerebral membranes normal. The mucous membrane 
 of the bronchi covered with a yellow frothy serum; the lungs 
 posteriorly hypostatic and oedematous. 
 
 The heart contained a considerable quantity of firmly-coagulated 
 blood ; its valvular apparatus and muscular tissue were normal. 
 
 Spleen small, two and a-half inches broad, and four inches long, 
 anaemic; liver very large, and weighed 1.45 kilogr. (3.196 lbs. 
 avoird.) pale and anaemic, of tolerably firm consistence; the cut 
 surface presented a nutmeg appearance ; the gall-bladder contained 
 a small quantity of thin pale bile; the bile ducts unobstructed. 
 The hepatic cells were normal, but loaded with granular con- 
 tents, and some of them, infiltrated with fat. The blood of the 
 portal vein, as also several of the capillaries of the liver contained 
 reddish-brown, and a few black, flakes of pigment. There was 
 
170 JAUNDICE 
 
 no sugar in the hepatic tissue. Leucine was found in large quantity, 
 but no tyrosine. 
 
 The mucous membrane of the stomach was of a bright-red colour ; 
 that of the intestine was pale, without any deposit in, or ulceration 
 of, the glands; the faecal matter in the caecum was of a green 
 colour; the mesenteric glands were not enlarged; in the rectum 
 were a few hemorrhagic erosions, the size of a linseed. 
 
 The kidneys were congested, and of a jaundiced hue; the 
 glandular epithelium was partly in a state of fatty degeneration, and 
 partly filled with a finely granular substance, which was rendered 
 pale by the action of acetic acid. 
 
 Observation No. XII. 
 
 Petechial Typhus. — Jaundice. — Albuminuria. — Suppression of 
 Urine. — Pneumonia on Bight Side. — Dysentery. — Death on the 
 seventh day. 
 
 Lardaceous Spleen of old date. — Anaemia of the Liver. — Exudation 
 into the Right Lung. — Dysentery. — Recent exudation in the Kid- 
 
 C. Winzig, aged 37, a day-labourer, was admitted on the 1st 
 of July, 1856, with the symptoms of exanthematic typhus; the 
 patient was covered with an extensive roseolar eruption (Roseola- 
 eruption), interspersed with a few petechise ; considerable enlarge- 
 ment of the spleen ; pulse 110. 
 
 On the 3rd, a slight jaundiced-tint of the skin was observed, and 
 the urine contained albumen. 
 
 On the 4th, the patient was brought to the Clinique. Great 
 muscular debility ; numerous petechise upon the skin, which was in- 
 tensely yellow ; stools involuntary, very fetid, and containing blood ; 
 urine very scanty ; only two ounces were drawn off by catheter in 36 
 hours, and the bottle, which constantly lay beside him, remained 
 empty. Pulse 80, small and weak ; respirations 10 ; extremites cool. 
 Was ordered muriatic acid with spirit of nitric ether. 
 
 On the 5th, there was dulness over the lower and posterior part of 
 the right side of the chest ; feeble bronchial breathing; volume of the 
 liver normal ; spleen large ; somnolence. Pulse 90 ; respirations 16. 
 Collapse and cold extremities. Was ordered three grains of musk 
 every hour. 
 
FROM TYPHUS. 171 
 
 On the morning of the 6th he died. 
 
 Autopsy, 12 hours after death. 
 
 The substance of the brain was somewhat congested ; its consist- 
 ence normal. 
 
 Bronchi pale; recent exudation and bloody infarctions in the 
 lower lobe of the right lung. 
 
 The heart contained firmly-coagulated blood ; muscular tissue and 
 valves normal. 
 
 (Esophagus pale ; the mucous membrane of the stomach exhibited 
 bloody suffusions, but no ulceration of the surface; the mucous 
 membrane of the jejunum and ileum was pale, that of the caecum 
 and colon considerably reddened, and covered with firm brown faecal 
 matter; iD the descending colon, and reaching down into the rectum 
 there were dysenteric deposits of an advanced stage, but no ulcera- 
 tion. 
 
 Spleen large and firm, and infiltrated with lardaceous matter. 
 
 Liver of normal sjze, of a pale-brown colour, and exhibiting here 
 and there isolated yellowish-white anaemic patches ; consistence toler- 
 ably firm. Bile ducts unobstructed ; gall-bladder half-filled with a 
 dark secretion. The hepatic cells contained pigment molecules 
 and isolated drops of oil; lardaceous matter, such as existed in 
 the spleen was nowhere to be seen. The chemical examination of 
 the organ showed the presence of an unusually large quantity of 
 sugar, besides much leucine, tyrosine, and hypoxanthine. It was 
 very remarkable that in the spleen leucine was almost entirely 
 absent. This substance could be detected in the thick bile, which 
 also contained crystalline colouring-matter. 
 
 The kidneys were of a deeply jaundiced hue, considerably con- 
 gested, and of soft consistence ; the glandular epithelium was tinged 
 partly greenish-yellow, and partly dark-brown ; some of the tubuli 
 contained cylindrical yellow coagula. Leucine and tyrosine were 
 present in these organs also. 
 
 The urine collected during the last day of life contained an 
 abundance of pigment, but no traces of albumen. 
 
172 JAUNDICE 
 
 Observation No. XIII. 
 
 Abdominal Typhus ; a severe riff or during convalescence; afresh 
 enlargement of the Spleen ; great tenderness of the region of the 
 Liver, and afterwards of tlie entire Abdomen. — Jaundice, — 
 Dyspnoea. — Somnolence. — Death. 
 
 Cicatrizing Typhus ulcers in the Ileum ; recent enlargement of the 
 Spleen ; round softened masses, of a brown colour, and about an 
 inch in diameter, in the Liver. — Bile ducts unobstructed. — Peri- 
 
 Carl Mauche, railway labourer, set. 26, had been complaining 
 since the 17th January, 1854 ; he was compelled to seek assistance 
 from the Hospital, on account of painful sensations in the lower half 
 of the right side of the chest, diarrhoea, and great weakness. 
 
 On his admission, on the 2nd of February, it was ascertained that 
 the patient was labouring under bronchial catarrh ; the pulse was 
 100; the tongue was moist and coated grey; the mental faculties 
 were unimpaired; the spleen appeared to be enlarged in every 
 direction; it extended from the level of the sixth rib downwards 
 to four centimetres (1£ inch) beyond the margin of the eleventh rib. 
 Infusion of ipecacuanha and gum arabic were prescribed. 
 
 On the 3rd, pulse 96. Roseola. Six thin stools, containing but 
 little bile. Heo-csecal pain. No delirium. 
 
 On the 6th, pulse 120, severe cough with viscid sputa; dry, hot 
 skin ; tympanitic abdomen ; more thin stools. "Was ordered chlo- 
 rine water. 
 
 On the 9th, pulse 88, and bisferiens ; the exanthem had extended 
 over the entire body ; no motion of the bowels for two days ; the urine 
 deposited an abundance of urates ; sputa bloody, without any 
 obvious exudation in the lungs ; dulness of hearing; splenic enlarge- 
 ment unchanged. 
 
 On the 11th, pulse 92; the eruption is fading; castor oil was 
 administered on account of a sluggish condition of the bowels. 
 
 On the 13th, pulse 84; the dulness of hearing had ceased; the 
 spleen was reduced in size ; the skin moist, and the appetite had 
 returned. Was ordered infusion of Peruvian bark. 
 
 On the 15th, the patient was convalescent. On the 18th, it was 
 necessary to administer an infusion of senna, on account of obstinate 
 
FROM TYPHUS. 173 
 
 constipation ; this brought away solid, feculent, and afterwards pul- 
 taceous, stools. 
 
 On the 21st, the patient had a sudden violent rigor, lasting 
 for an hour and a-half, and succeeded by an increased temperature 
 of the skin, and frequency of pulse ; the tongue was dry, and there 
 were noises in the ears, great debility, profuse green-coloured 
 evacuations from the bowels ; the abdomen was tender and distended. 
 Was ordered muriatic acid. 
 
 On the 23rd, pulse 136, and respirations 36 ; skin and conjunc- 
 tiva yellow; tongue dry; abdomen tender; thin greenish stools, 
 frequent but scanty. The spleen had again increased in volume, 
 extending 5 centimetres (2 inches) beyond the margin of the ribs. 
 The hepatic region was very painful on percussion, and its dulness in 
 the mammary line amounted to 3 inches. Twelve cupping-glasses 
 were ordered to be applied over the hepatic region. 
 
 On the 26th, the jaundiced-colour had increased; the thin, 
 greenish stools continued, and masses of a greenish-colour were 
 repeatedly vomited. The urine was scanty, and tinged with bile. 
 Pulse very small, and scarcely perceptible. The tenderness in the 
 hepatic region was increasing, and extended over the entire abdo- 
 men; great dyspnoea. On auscultation, widely extended rales 
 were heard, but no consonating phenomena.* Somnolence. Was 
 ordered benzoic acid with camphor, and warm cataplasms over the 
 lower part of the abdomen. 
 
 On the 27th, death supervened under symptoms of pulmonary 
 oedema. 
 
 Autopsy. 
 
 The membranes of the brain and the cerebral substance were con- 
 siderably congested; the latter was of normal consistence. The air- 
 passages in the upper part of the lungs were pale ; in the lower part, 
 the mucous membrane of the bronchi was reddened and relaxed; 
 the pulmonary tissue was cedematous, at some places collapsed, but 
 free from any solid exudation. The mucous membrane of the 
 stomach was pale, with a few isolated ecchymoses. The serous 
 membrane of the intestine was covered with exudation, partly recent 
 and partly breaking down into pus. Some portions of the bowel 
 
 * Bronchophony. For an account of Skoda' s theory of consonance, see 
 Walshe on " Diseases of the Lungs and Heart," 1st Ed., 1851, p. 128. — 
 Transl. 
 
174 JAUNDICE. 
 
 were glued to one another and to the omentum. In the mucous 
 membrane of the ileum a small number of typhous ulcers were 
 found, already exhibiting a perfectly clean surface, and in process 
 of cicatrization ; no traces could be detected of recent deposits, to 
 indicate a relapse of the typhus. The mesenteric glands were mode- 
 rately enlarged. The kidneys were soft and congested. 
 
 The spleen was remarkably hypertrophied, tense, and elastic ; its 
 tissue was soft, pultaceous, and congested ; at its anterior border 
 there was a reddish-brown infarction, the size of a walnut. 
 
 The liver was unusually soft; its surface was smooth and its 
 margins sharp ; its surfaces, on section, appeared of a reddish-brown 
 colour j some spots were darker than the tissue immediately sur- 
 rounding, and of a softer, almost pultaceous consistence. These 
 masses were of a rounded form ; measured from 1 to 1£ inch in 
 their transverse diameter, and were separated from the surrounding 
 more solid tissue, by a tolerably sharp line of demarcation. The 
 bile ducts were pervious ; and the gall-bladder contained a small 
 quantity of thin pale bile. 
 
 The firmer portions of the hepatic tissue, on closer examination, 
 presented everywhere normally-formed granular cells. These existed 
 only in small quantity in the softened portions; here there were 
 chiefly observed finely-granular masses, and the debris of dis- 
 integrated cells, free nuclei, oil globules, &c. The liver, after 
 exposure to the air, yielded considerable deposits of leucine and 
 tyrosine. 
 
 Unfortunately, the examination of the blood of the portal vein, 
 and that of the branches of this vessel leading to the softened portions 
 of the liver, was neglected in this case ; hence, it could not be deter- 
 mined whether or not the blood from these sources exhibited abnor- 
 mal conditions of any importance. 
 
 It is worthy of notice, that when the infectious diseases just 
 alluded to are complicated with jaundice, a group of severe sym- 
 ptoms, such as haemorrhages from the gastro-intestinal mucous mem- 
 brane, &c, albuminuria, hsematuria, suppression of the urine, &c, 
 manifest themselves in a similar manner to what we find to be the 
 case in yellow fever, and in the severe intermittent, remittent, and 
 recurrent forms of fever, which are peculiarly endemic in tropical 
 countries ; — a circumstance which would appear to indicate an inti- 
 mate relation between these morbid processes. The post-mortem 
 
FROM BLOOD-POISONINGS. 175 
 
 appearances which we find under such circumstances, in the forms of 
 fever more common in this country, are enlargements of the spleen and 
 of the hepatic glands, and acute tumefactions of the liver and kidneys;* 
 the glandular epithelium in the two last organs becomes filled with 
 granular masses, and, at a later stage, with deposits of fat ; their 
 secretions diminish, and are sometimes suspended, whilst certain 
 products of metamorphosis accumulate in their tissue. 
 
 In this way the liver participates, more or less actively, in the 
 infectious blood-diseases. In typhus, its secreting function is im- 
 paired at an early period, the evacuations become pale, and upon 
 post-mortem examination, a grey or greenish-yellow fluid, which, 
 as a general rule, contains leucine is found in the gall-bladder.t 
 The circumstances are similar in the so-called pysemia, and its allied 
 conditions. The formation of sugar, as well as the elaboration of 
 bile, is diminished, and usually is soon completely arrested ;% at the 
 same time, substances find their way into the secretion of the gland, 
 which, under normal conditions, or in the course of other diseases, 
 are either absent or exist in much more sparing quantity. "We find 
 leucine, and usually also tyrosine in considerable quantity, together 
 with a substance resembling in its characters xanthine and hypo- 
 xanthine,, also a peculiar yellow substance in the form of yellow 
 globules, and occasionally, according to Scherer, cystine. The 
 secretion is frequently neutral, and contains ammonia. We have 
 examined the liver, for the substances just mentioned, in a large 
 number of diseases, and have arrived at the general result, that in 
 typhus fever, the pysemic or septic infection, the various exanthemata, 
 the malignant intermittents, &c, the substances just mentioned exist 
 in unusual quantity, whereas they are either absent or in very sparing 
 quantity in pneumonia, tubercle, organic diseases of the heart, dysen- 
 
 * Of these three organs, the spleen appears to be the one which is most 
 frequently and most extensively implicated ; then the liver ; and, lastly, 
 the kidneys. It is still uncertain whether this depends only upon the 
 intensity of the infection, or upon different qualities of the poison. In 
 yellow fever the affection of the kidneys is more marked and more con- 
 stant than that of the spleen. 
 
 t There are cases in which a complete suspension of the secretion 
 occurs, followed by all the consequences of acholia. See Observation 
 No. XVIII. 
 
 % It is by no means always suspended. In a third of the cases of tpyhus, 
 the liver still contains sugar, the quantity of which is for the most part 
 small, but sometimes considerable. 
 
176 JAUNDICE 
 
 tery, diabetes, &c. It is impossible, in tbe present state of our know- 
 ledge of the metamorphic processes of matter, to understand all the 
 important bearings of these facts, especially as similar products 
 exist at the same time in other organs, such as the spleen, the lym- 
 phatic glands, and the kidneys. Still, the indications of local 
 derangements in the metamorphosis of matter induced by the blood 
 in the liver, and in other structures becoming infected, which the 
 presence of these substances furnishes, are of importance. There can 
 be no doubt that these derangements react upon the composition of 
 the blood ; the presence in the urine of leucine, the salts of valerianic 
 acid, and sometimes, also, of substances similar to xanthine, shows 
 that these derangements are not of a limited character, but that their 
 products pass into the blood and the excretions. The pathological 
 importance of these processes, however, cannot be determined with 
 any degree of certainty, until the nature and extent of the implica- 
 tion in the general metamorphosis of matter of the parenchyma 
 of the several organs and tissues, the varying character of which has 
 only been. recently investigated, is completely understood both in 
 health and in disease. 
 
 In the last described group of varieties of jaundice, we have learnt 
 to recognise this affection as a consequence of impediments to the 
 diffusion, or to the consumption of bile, which are brought about 
 partly by the influence of the nervous system upon the respiration, 
 circulation and secretions, but chiefly by abnormal conditions of the 
 processes of metamorphosis in the blood. It is only in this point of 
 view that the affection can be regarded as of importance as a 
 symptom, or as an indication for treatment. 
 
 The treatment has to be directed against the derangements of 
 innervation, as well as against the abnormalities of the metamorphic 
 processes upcm which the jaundice depends. In cases where the action 
 of these derangements is of a transient nature, as in mental affections, 
 there is seldom any need for interference in the way of treatment ; the 
 milder antispasmodic stimulants, together with a tranquil deportment, 
 warm baths, &c, are sufficient : when there are symptoms of danger, 
 ether, castoreum, musk, &c, are indicated; and eventually, the 
 measures which are recommended under the head of Acute Atrophy 
 of the liver. In cases of snake-bite, purulent infection, typhus 
 fever, and the allied conditions, it is the primary diseases which 
 must be attended to ; the jaundice, in itself, demands no especial 
 treatment. 
 
BILIOUS FEVERS. 177 
 
 F. Bilious Fevers and the Epidemic Forms of Jaundice. 
 
 This is not the place to describe in detail the various forms 
 fever which are complicated with bilious symptoms ; the sole question 
 for us to investigate here, is the mode of origin of the jaundice, 
 which mates its appearance under such circumstances, and the in- 
 fluence exerted by the admixture of bile with the blood upon the 
 course and symptoms of the primary disease ; and in general terms 
 to explain, so far as reliable materials are in our possession, the part 
 played by the liver and its secretion in the morbid processes 
 in question. 
 
 In ancient pathology, bilious fevers (under which name were 
 included diseases of very diverse character)* comprised those affec- 
 tions in which with disturbance of the vascular system, there were 
 associated yellow colour of the skin and conjunctiva, a bitter taste 
 and bilious evacuations either upwards or downwards ; — they were 
 thus a very comprehensive class. The climatic and telluric agencies 
 of the country, which formed the cradle of our science, as well as 01 
 that in which medical science was subsequently developed, furnished 
 rich materials for observations bearing upon these diseases. They were 
 referred by the ancients, in accordance with the tenets of a humoral 
 pathology, to a faulty condition of the quantity or the quality of 
 the bile, in which fluid, it was believed, the key had been found to 
 explain diseases of the most varying nature. At the close of the 
 seventeenth century, doubts were raised against this, as well as 
 against other Galenic theories. Sydenham was the first who, from 
 observations of the epidemic of 1669-70, ventured to express the 
 view, that bilious evacuations and jaundice often constitute symptoms 
 of only secondary importance, which may complicate diseases of very 
 different characters. This first attempt to limit the class of bilious 
 fevers was not followed by great results, inasmuch as the bilious 
 constitution of the eighteenth century, brought not only the mass of 
 physicians, but also such men as Huxham and others, back into the 
 old beaten track. Selle and Stoll were the first to establish the fact 
 of the participation of the mucous membranes of the stomach and 
 intestines in the origin of these fevers ; but the arbitary manner in 
 
 • " On peut citer comme un rare modele de confusion et de savante 
 " obscurite la doctrine des fifevres dites bilienses." (Pinel, Nosograph. 
 philoi., T. I., p. 41.) 
 
 N 
 
178 JAUNDICE 
 
 which the latter writer attributed the various phenomena of 
 these affections to the metastasis of bile,* was little fitted to favour 
 further progress. Pinel expressed in a more decided manner than 
 any of his predecessors, the opinion that the principal seat of these 
 diseases was to be sought for in the digestive organs, and particularly 
 in the stomach and duodenum. Broussais went a step farther, and 
 declared that these fevers, the idiopathic nature of which he denied, 
 resulted from inflammation of the gastro-intestinal mucous mem- 
 brane, accompanied by an -excessive secretion of bile. This view 
 soon became widely extended ; in Germany, chiefly on the authority 
 of J. P. Prank, it became the custom to regard bilious fevers in gene- 
 ral as a degeneration of gastro-enteric catarrh, and jaundice itself 
 as of a catarrhal nature. There is no doubt that this was a one- 
 sided view. Although there can be no question as to the independent 
 existence of these morbid processes, as Littre has recently endeavoured 
 to prove, still the frequency with which jaundice is met with in these 
 fevers shows that the implication of the liver cannot be looked upon 
 as a merely accidental complication, but that there exists between 
 the two, a more intimate connection as regards their mutual exciting 
 causes. The nature of this connection can only be learnt by a 
 careful analysis of the observations hitherto made. 
 
 The descriptions which have been handed down to us by the older 
 writers, are not of much use for this purpose ; and little more can 
 be said of the accounts which have been left behind by Tissot,t 
 StolLJ Pinke,§ and Pringle, because, as has already been justly 
 observed by Payer, very different morbid processes were grouped 
 together, and but little attention was paid to their anatomical orgin. 
 The best materials are to be found in the works of Annesley,|| 
 P>oudin,ir Haspel,** and especially of Griesinger,tt upon the diseases 
 
 * Ad encephalum delata humoris biliformis portio deliria, phrenitides, 
 apoplexias, genus omne convulsionum facit, ad fauces anginam, ad thora- 
 cem tussin, pleuritidem, &c. 
 
 t TlSSOT, Dissert, defebrib. bilios. anomal. seu histor. epidem. bilios. Lau- 
 sanne, 1758. 
 
 X M. Stoll, Aphorism de cognosc, fyc. 1797. 
 
 § L. FlNKE, De morb. bilios. anom. 
 
 || Annesley, Researches into the causes, nature, and treatment of the most 
 prevalent diseases of India. Vol. II., p. 419. 
 
 I BoUDIN, Traiti desjidvres intermittentes. Paris, 1842. 
 
 •* Haspel, Maladies de VAlgtrie, Tom. II., p. 151. 
 
 ft Griesinger, .Das hiliose Typhoid, Archiv f. phys.Heilk. Von Vierordt. 
 
IN INTERMITTENT AND REMITTENT FEVERS. 179 
 
 of tropical climates, to which may be added, the writings upon yellow 
 fever,* and a portion of the monographs upon the epidemic marsh 
 fever of Holland in the year 1826. 
 
 Although the febrile processes which are most frequently associated 
 with bilious symptoms differ in many respects from one another, 
 still they have many points in common. They belong, without 
 exception, to the group of infectious diseases (Infeetionskrankheiten), 
 which owe their origin to the absorption into the system of dele- 
 terious matters, of miasmata, and partly, also, as appears, of conta- 
 gions. They are, for the most part, endemic in the swampy and 
 marshy districts of hot climates, and only make their appearance in 
 colder regions as extensive epidemics, when conditions arise particu- 
 larly favourable to the development of deleterious effluvia, and to the 
 active operation of these emanations upon the human species. _ They 
 commence with changes in the composition of the blood, with which 
 local lesions, especially of the spleen and liver, and often, also, of the 
 kidneys, become associated. The diseases belonging to this class, 
 when they reach an intense degree of severity, give rise to a train of 
 symptoms having many points in common : — jaundice, haemorrhages 
 from the stomach and bowels, petechise, alarming nervous sym- 
 ptoms, albuminuria, suppression of urine, &c. Moreover, in most 
 cases, the fever runs a certain course, and then suddenly ceases, either 
 without returning (yellow fever), or followed by other paroxysms, 
 which sometimes assume a fixed type (intermittent and remittent 
 forms of fever), or at other times, appear as relapses without any 
 fixed type (relapsing fever). But along with these characters in 
 common, there exist important differences, which necessitate a rigid 
 discrimination of the different forms. 
 
 We observe bilious symptoms as a common accompaniment of, 
 first : — 
 
 a. Intermittent and Remittent Marsh Fevers, 
 
 and especially in those which are met with in tropical countries. 
 The frequency with which jaundice makes its appearance under such 
 circumstances varies at different times and places, without our being 
 able to assign any definite cause for such being the case. In Algeria, 
 
 1853. Heft 1 und 2. Also, Handbuch der Spec. Path, wnd Therapie, redig. von 
 Virchow. 2 Bd. 2 Abth. " Die Infectionskranhheiten" of the same author. 
 * La Roche, Yellow Fever. Philadelphia, 1855. 
 
 N2 
 
180 JAUNDICE 
 
 Boudin sometimes found this symptom present in seven-tenths of the 
 cases of intermittent fever. In colder climates, it is only in excep- 
 tional epidemics that bilious symptoms attain a remarkable frequency, 
 as in the epidemic which, in the year 1826, extended along the coast 
 of the North Sea, from the Eider to the Schelde, and in the epi- 
 demic which is recorded to have prevailed in 1807 between Mende 
 and Greifswald. 
 
 The influence which the supervention of bilious symptoms exer- 
 cises over the course and terminations of fever, has not been suffi- 
 ciently established by observation ; in general, it does not appear to 
 be of much consequence, because almost all the dangerous sym- 
 ptoms which accompany the jaundice may occur without it; it is 
 only where the local changes in the liver attain an advanced stage 
 that they give rise to marked results. Besides this, according to the 
 experience of Annesley, the excessive secretion of the liver passing 
 into the intestine, may give rise to inflammation of the mucous mem- 
 brane, dysentery, &c. In addition to the slighter forms, which, under 
 judicious treatment, rapidly subside, severe cases are met with, 
 accompanied by typhoid symptoms and various local affections, in 
 the course of which petechias appear, and haemorrhages occur from 
 the stomach and bowels, and in which the urine contains albumen 
 or blood, or this secretion becomes completely suppressed. Such 
 malignant cases bear a striking resemblance in their symptoms to 
 yellow fever ; they differ, however, essentially from that disease in 
 their progress and in their anatomical lesions. The milder forms, 
 for the most part, exhibit the single or double tertian type, rarely 
 the quotidian or quartan ; * the more severe cases, such as those 
 which are accompanied by local derangements, generally appear as 
 remittent or continued fevers. 
 
 The jaundice does not always arise in the same way ; in many of 
 the milder epidemics, the jaundice is produced by some impediment 
 to the excretion of bile, owing to the fever being complicated with 
 severe gastro-duodenal catarrh ; in such cases, the bowels are torpid, 
 and the stools are deficient in bile, and usually there are fundamen- 
 tal lesions of a more profound nature. Besides acute enlarge- 
 ment and softening of the spleen, which are often associated with 
 wedge-shaped infarctions, or more frequently with abundant deposits 
 
 * In the quartan type I have observed the jaundice to intermit : during 
 the apyrexial period the colour became pale, and grew darker again with 
 the return of the paroxysm. 
 
IN RELAPSING FEVERS. 181 
 
 of pigment, the liver is usually found to be enlarged from conges- 
 tion and softened, its blood-vessels are seen to be filled with pig- 
 ment flakes, and occasionally we observe extravasations of blood or 
 abscesses in the parenchyma of the gland. In other cases, especi- 
 ally such as run a protracted course, and are accompanied by copious 
 haemorrhages from the stomach and bowels, the liver is found to be 
 anaemic and jaundiced ; the bile ducts are usually pervious, the 
 gall-bladder distended, and the contents of the bowels loaded with 
 bile. Quinine, administered in a suitable manner, exercises a favour- 
 able influence over the progress of these affections. 
 
 Closely allied to the diseases just considered, as regards their 
 anatomical lesions, and the operation of quinine, although in other 
 respects bearing a greater resemblance to typhus, is : — 
 
 b. The Recurrent Fever. 
 
 (Bos recv/rrvrenie Fieber — Relapsing Fever. — Fievre a reeMte), 
 
 which is remarkable for the frequency with which it is accompanied 
 by jaundice. This form of fever making its appearance in distinct, 
 regular fits, has only recently been accurately distinguished from 
 typhus and the intermittents, although we possess many observations 
 of an older date as to its prevalence.* This is the fever which gave 
 rise to the great epidemics which have prevailed in Scotland and in 
 Ireland, and also in London, since 184<3.t Bilious symptoms, 
 such as jaundice, and bilious evacuations both upwards and 
 downwards, occurred during the first or second paroxysm; they 
 varied greatly in frequency ; in certain of the epidemics in Scotland, 
 they were almost of constant occurrence, so that the disease was 
 designated " Mild Yellow Fever ; " in other instances, as in Lon- 
 don, Jenner observed these symptoms in only one-fourth of the 
 cases, and occasionally they have been observed even less frequently. 
 Of the anatomical lesions which in general are not very remarkable, 
 swelling of the spleen is the most conspicuous ; this not unfrequently 
 becomes excessive, and is accompanied by the formation of infarctions. 
 
 * See Hildenbrand, " XJeler den ansteckenden Typhus." Wien, 1815. 
 Larrey, " Memoires de Chirurgie militaire." Paris, 1812. 
 
 t Cormack, Natural History, Pathology, fyc, of the Epidemic Fever. 
 Edinburgh, 1843. Dublin Journal, 1849. Lange, Beobachtungen am 
 Krankenbette. Konigsberg, 1850. The author does not appear to be 
 aware that Relapsing Fever constituted an important feature of many 
 fever epidemics in Scotland and Ireland, before 1843. — Transl. 
 
*82 JAUNDICE 
 
 The liver sometimes becomes tumefied from congestion, and at other 
 times is found soft, pale, and yellow ; along with these conditions, 
 the bile ducts are pervious, and the gall-bladder is, in most cases, 
 filled with dark secretion. Here, as in intermittent and remittent 
 fevers, the jaundice is, under certain circumstances, accompanied by 
 haemorrhages from the stomach, intestines, and other organs, by 
 derangements of the nervous functions, lumbar pains, dysuria, reten- 
 tion of urine, &c, which symptoms are followed by somnolence and 
 coma. The cause of the impaired secretion of urine has not yet been 
 investigated with sufficient accuracy ; Cormack, and other Scotch 
 physicians, have detected urea in the serum of the cerebral ventricles 
 and in the blood, in cases where death has been preceded by coma 
 and convulsions, from which the existence might have been inferred, 
 of more serious lesions of the kidneys than were found upon anato- 
 mical examination, so far as the published descriptions of the cases 
 give us any information upon the point. This retention of urine 
 and its consequences we shall presently find to be of much more 
 frequent occurrence in yellow fever. 
 
 Closely connected with the recurrent fever, both as regards its 
 progress being characterised by the occurrence of one or more parox- 
 ysms, and as to its anatomical lesions, is the fever observed by 
 Griesinger, in Egypt, and first accurately described by him under the 
 name of Bilious Typhoid, which, according to the experience of 
 Lange, at Konigsberg, may also be met with in the epidemic form in 
 this country. In this fever also, morbid conditions of the spleen 
 and of the liver constitute the most important lesions found after 
 death; the spleen, in a few days, becomes enlarged to five or six 
 times its normal size, its tissue is interspersed with large infarc- 
 tions, and the Malpighian corpuscles not unfrequently gradually 
 become filled with fibrinous exudation which is distintegrated into 
 pus. The liver is at first turgid and congested ; but subsequently 
 it is found anaemic, collapsed, and jaundiced; the bile ducts are per- 
 vious, and in most "cases filled with secretion. The kidneys become 
 enlarged at an early period in a similar manner to the liver, and 
 their glandular epithelium, like that of the liver, is filled with 
 drops of oil. In addition to these morbid appearances, we some- 
 times meet with deposits in the mesenteric glands, ulcers of the 
 larynx, such as we find in typhus, and likewise exudations, and col- 
 lections of pus in various organs. Jaundice and bilious evacuations, 
 both upwards and downwards, are common, but not constant, 
 
IN YELLOW FEVER. 183 
 
 accompaniments of this form of fever; hsematemesis occurs occa- 
 sionally, and now and then the urine contains albumen or blood. 
 According to Griesinger's experience, large doses of quinine exer- 
 cise an unmistakeably favourable influence over the progress of 
 bilious typhoid ; but this does not appear to be always the case in 
 the relapsing fevers of Scotland. 
 
 c. Fellow Fever. 
 
 The yellow fever bears a striking resemblance, in many of its 
 symptoms, to bilious typhoid. Here, also, the fever ceases after two 
 or three days, but in most cases not to return. The severe sym- 
 ptoms, such as haemorrhages from the stomach and bowels, symptoms 
 betokening a derangement of the nervous functions, lumbar pains, 
 albuminuria, hematuria, and suppression of urine, going along with 
 the jaundice, which, in the forms of fever hitherto described, have 
 been but rarely met with, are in yellow fever regularly present ; 
 important derangements of the nervous functions also frequently 
 manifest themselves, — for the most part, under circumstances which 
 afford some grounds for conjecturing that they have a urajmic origin. 
 Eoche found only traces of urea in the urine ;* in the blood it was 
 detected in larger quantity. Lallemantf describes a penetrating 
 urinous odour pervading the sweat and other secretions of patients 
 labouring under yellow fever. 
 
 The anatomical lesions are essentially different from those of remit- 
 tent and recurrent fevers, inasmuch as the swelling of the spleen, 
 which in these affections occupy a prominent place, are usually 
 absent in yellow fever. The liver is at first congested and swollen, but 
 afterwards it becomes anaemic, yellow, of normal size, or somewhat 
 smaller ; the hepatic cells are found sometimes pale, in most cases 
 devoid of nuclei, with scanty granular contents, and often filled with 
 oil globules; the bile ducts are pervious ; the gall-bladder is some- 
 times distended and at other times empty. The kidneys, in most 
 cases, exhibit signs of acute exudation. 
 
 There can be no doubt that in the diseases just enumerated 
 
 * More accurate examinations of the urine in yellow fever would be of 
 great interest, and so much the more as, in acute atrophy of the liver 
 very remarkable changes often take place in this secretion. .(Vide Acholia.) 
 
 t Verbal communications. 
 
184 JAUNDICE 
 
 bilious symptoms cannot be regarded as merely accidental complica- 
 tions, but that they are intimately related to the fundamental causes 
 of the maladies in question. The infection of the blood, which we 
 regard as the starting-point of these morbid processes, first makes 
 itself manifest by local lesions of the spleen and liver, and often of 
 the kidneys also, which, again, in their turn, entail derangements of 
 a special character. It is possible that these three organs mutually 
 react upon each other, so that disease of one gives rise to disease of 
 the others. 
 
 The changes which are found in the liver afford no ground for 
 explaining the jaundice by attributing it to catarrh of the bile ducts ; 
 the idea of a suppression of the secretion of bile is equally unten- 
 able ; on the contrary, in intermittent and remittent, and also in 
 recurrent fevers, the appearances presented by the intestinal contents 
 arid of the bile ducts is in favour of the idea of an increased secretion ; 
 or a true polycholia.* Whether these changes can be regarded as 
 entirely the consequence of congestion of the organ, or whether the 
 excessive formation of the products of metamorphosis in the con- 
 gested and swollen spleen contributes towards them, can only be deter- 
 mined with certainty when the relation of the materials found in 
 the spleen to the formation of bile has been more clearly investigated 
 than has hitherto been possible. There are two principal causes 
 which are to be regarded as accounting for the jaundice under the 
 circumstances before us ; first, the increased secretion of bile over- 
 loading the bile ducts, which are insufficient for its removal, and so 
 favouring its re-absorption into the blood ; and secondly, the same 
 conditions which give rise to jaundice in typhus, pyaemia and the 
 allied morbid processes, such as blood infection, diminished secretion 
 of the kidneys, &c. 
 
 The anaemia and the shrinking of the liver, as also the abatement 
 of its secretion, might be accounted for by the consumption of the 
 blood by the splenic tumour, and partly also, by the haemorrhage 
 from the stomach and bowels. I cannot regard these conditions as 
 proving the existence of an acute atrophy, in the strict meaning of 
 that term, such as Griesinger is inclined to think may exist, because 
 the hepatic cells remain unaffected. 
 
 Matters are somewhat different in yellow fever ; in this affection, 
 the morbid alteration of the spleen is usually absent; in general, 
 
 * See Annesley, op. cit., Vol. I., p. 297; Vol. II., p. 429; also, 
 Griesinger, op. cit. 
 
IN YELLOW FEVER. 185 
 
 no certain proofs exist of an excessive secretion of bile, although, on 
 the other hand, the bilious colouring of the evacuations, and the 
 distention of the gall-bladder with dark bile, are opposed to the idea 
 of a suppression of this secretion, which is occasionally resorted to 
 for explaining the existence of jaundice. The anatomical characters 
 of the liver also are not in harmony with such a view ; alterations 
 of its intimate structure have long been sought for in vain. The 
 congestion which is present during the first period of the disease, 
 gives way in its subsequent progress to a state of anaemic collapse, 
 with which is associated an infiltration of bilious matter, but the organ 
 by no means presents the characters of acute atrophy ; the hepatic 
 cells, according to Blache remain unaffected, although they become 
 paler, and some of them contain fat. Excepting the funda- 
 mental changes in the composition of the fluids, so far as our 
 researches as yet extend, the abnormal distribution of the blood, 
 arising from the relative pressure of the blood in the portal vein 
 being diminished by the profuse haemorrhages from the stomach, 
 which tends to propel the bilious contents of the hepatic cells into 
 the vascular system, alone remains to account for production of the 
 jaundice. 
 
 It still remains for us to allude to the causes of the nervous 
 symptoms, the delirium, the somnolence, and the coma, which are 
 frequently observed in fevers complicated with jaundice.* These 
 symptoms have at all times been accounted for by the absorption of 
 bile into the blood; and of late the forms of jaundice associated with 
 typhoid symptoms have been united into one group under the desig- 
 nation of Icterus gravis or typlioides. Whether this view is correct 
 or incorrect, will appear by a consideration of what has been de- 
 nominated cholaemic intoxication. 
 
 According to a tradition handed down from the most ancient 
 humoral pathology, the bile, when it accumulates in the blood or 
 undergoes certain changes, gives rise to nervous derangements of 
 various characters, headache, delirium, convulsions, &c.f With a 
 few interruptions, this view continued generally prevalent, even after 
 the authority of Galen had ceased to exercise any influence. The 
 
 * As regards the causes of these haemorrhages, I would refer to the 
 next chapter. 
 
 t " Bilis ut plurimum hominum insanise causa," Hippocr., edid. Kiihn 
 III., 799. " Bilis ad caput recurrens delirii causa," Galen, Ed. Kiihn XV* 
 741, 598. ' 
 
186 JAUNDICE. 
 
 doubts expressed by Paracelsus and Van Helmont in their day met 
 with little sympathy, for immediately after Sylvius wrote concerning 
 the narcotic properties of the bile, and of its capability to excite 
 comatose fever. Boerhaave and Yan Swieten* appealed to the 
 testimony of the ancients in support of the dangerous effects of this 
 secretion, and Morgagni,t in his description of a case of jaundice 
 which terminated fatally, calls the bile a " materies acrior cerebrum 
 maxime afficiens." In a similar manner, Stoll and Sarcone attri- 
 buted the cause of convulsions and other dangerous symptoms to 
 the hepatic secretion and its derivatives. In more recent times, pains 
 have been taken to distinguish by careful examinations the various 
 qualities of the bile, which the majority of the medical profession 
 have during centuries believed in; but the results arrived at have 
 been so unimportant, that for the future we must not expect that the 
 subject will receive much elucidation from this line of investigation.! 
 The attempts to ascertain more accurately the effects of the bile 
 upon the nervous system by injecting this fluid into the blood, have 
 been followed by such diverse results, that we are unable to draw 
 any certain conclusions from them. It is true, that Deidier§ found 
 that dogs speedily died after the bile of persons labouring under the 
 plague had been injected, or brought in contact with recent wounds; 
 the animals also died into which Magendie|| injected bile; but 
 Goupil made experiments with an opposite result, and Bouissonlf 
 found that death only followed when the fluid had not previously 
 been freed from its coarser ingredients, and when, consequently, there 
 was nothing to prevent the capillaries of the lungs becoming plugged 
 up. More recently, these experiments have been oftentimes repeated 
 by Th. von Dusch,** but the results have been always uncertain ; as 
 
 * Van Swieten, Comment., T. I., p. 141 ; T. II., p. 271 ; T. III., p. 499. 
 
 t Moegagni, De sedibus et causis morb., Epist. 37. 
 
 % I have examined the bile in a large number of dead bodies, and have 
 caused it to be examined in a still larger number by Dr. Valentin. In a 
 few cases we found albumen, or sugar, and, in typhoid diseases, leucine ; 
 but, as a general rule, we could detect nothing abnormal, with the excep- 
 tion of varieties, in its degree of concentration, and differences in the . 
 colouring-matter, which at one time was crystalline, and at another time 
 amorphous. 
 
 § De bile peste emortuorum experimenta. Halleri Bibl. anat. 
 
 || Precis de physiol., T. II., p. 260. 
 
 1 De la bile, 1843, p. 60. 
 
 ** Untersuchungen und Experimente, als Beitrag zur Pathol, des Icterus, 
 &c. Leipzig, 1854. 
 
CAUSE OF NERVOUS SYMPTOMS. 187 
 
 a general rale, rabbits died of tetanic cramps, whereas dogs only 
 suffered from transient indisposition and vomiting. My own expe- 
 rience, which is founded upon an extensive series of injections, is in 
 favour of the complete innocuousness of an accumulation in the 
 blood, of the biliary acids and their derivatives. When bile which 
 had been purified with the necessary amount of caution, and freed 
 from its mucus and epithelium, or a solution of the glyco-cholate of 
 soda, was introduced into the veins, no remarkable derangement of 
 the nervous functions, or indeed of *any function whatever, took 
 place. The only circumstances to be observed were, that the 
 amimals immediately after the injection licked with their tongues, 
 proving the existence of a bitter taste proceeding from the blood, 
 and that they voided urine, which deposited a flocculent precipitate 
 of bile-pigment, and contained the dissolved red colouring-matter of 
 the blood, and leucine.* 
 
 Hence we cannot consider the accumulation of bile in the blood 
 as the cause of typhoid symptoms, and we are under the necessity of 
 calling in question the existence of a cholaemic intoxication. 
 
 In the fevers under consideration, this is the less likely to be 
 the cause, as besides those forms which are accompanied with 
 bilious symptoms, we meet with similar fevers, characterised by 
 the same typhoid phenomena, in which jaundice is absent, and in 
 which the bile cannot therefore be regarded as the explanatory cause 
 of the phenomena in question. Hence we are obliged to attribute 
 these phenomena to those obscure alterations in the composition of the 
 blood, to which we ascribe the origin of malignant intermittents, 
 typhous fevers, &c. Where, as in yellow fever, and occasionally also 
 in the other forms, there is persistent suppression of urine, or where 
 as in bilious typhoid, there is purulent infection, the explanation 
 of the somnolence and coma is not difficult. 
 
 The forms of fever, which we have been discussing, are for the 
 most part peculiar to warm climates; in temperate climates, if 
 
 * Altogether, the number of injection experiments amounted to be- 
 tween 50 and 60, the greater number of which were undertaken, less for 
 the object of observing the influence of the bile upon the nervous functions 
 than in order to trace farther the transformation of the colourless bile- 
 acids into bile-pigment. It is evident that the solution ought to be 
 filtered before being injected; moreover, it ought not to be concentrated 
 because it then assumes a slimy consistence, and easily produces obstruc- 
 tions to the circulation. These circumstances may, perhaps, in part 
 explain the anomalous results obtained by Von Dusch. 
 
188 JAUNDICE. 
 
 we except the Scotch and Irish epidemics of relapsing fever, and the 
 bilious typhoid of Konigsberg, they are rarely met with. 
 
 d. EPIDEMIC JAUNDICE. 
 
 The epidemic forms of jaundice which have been observed in 
 Germany and France differ from the above fevers in many respects. 
 Among the best known are the following : — 
 
 1. The epidemic which prevailed in Essen* in the year 1772, and 
 which was described by Briinning.t It attacked principally children, 
 and assumed an intermittent type ; various spasmodic affections and 
 sometimes also delirium showed themselves in its course. A large 
 number of children perished from it. 
 
 2. The epidemic in Liidenscheid described by Kerksig,J ran a 
 very mild course; less than seventy patients died of it. The 
 jaundice usually appeared without any fever, after the precursory 
 symptoms of gastric catarrh had lasted from eight to fourteen days ; 
 the stools were pale. Children remained completely exempt; 
 of five pregnant women who took the disease, three aborted, two of 
 whom were attacked on the third day after delivery with fever, which 
 was accompanied by delirium and coma, and terminated fatally. 
 
 3. In the epidemic of Greifswald in the years 1807 and 1808, 
 observed by Mende,§ a fourth part of all the patients had jaundice. 
 The jaundice was in some cases unaccompanied by fever, and in 
 other cases it was associated with fever, which was of a remittent or 
 an intermittent character. In the latter case, it was the tertian type 
 which predominated. During the intermission, the yellow colour 
 not unfrequently receded, to reappear during the paroxysm; and 
 in other cases it remained throughout the disease. One patient died 
 under severe nervous symptoms. 
 
 4. The epidemic in Chasselay, which was observed by Chardon,|| 
 was very mild. The jaundice commenced with gastric catarrh, 
 and was unaccompanied by fever ; the stools were in all cases pale. 
 Not a single case proved fatal. 
 
 5. During the epidemic which in the year 1826 prevailed along 
 the Coast of the North West of Germany and of Holland,^ bilious 
 
 * Essen is a market-town in Westphalia. — Transl. 
 
 t De ictero spasmodico epidemico Essendiae. 
 
 J Hufeland's Journ., Bd. VII. § Huf eland's Journ., Bd. XXXI. 
 
 || Bulletin de l'Acad. de Med., 1842, T. I., p. 112. 
 
 f Popken, Historia epidem. maligna:. Jeverae observat., 1826. 
 
EPIDEMIC JAUNDICE AND ICTERUS NEONATORUM. 189 
 
 fevers frequently made their appearance along with intermittents 
 and remittents ; usually they presented a double tertian or a remit- 
 tent type. Even at the present day, similar forms of fevers are 
 occasionally met with in these marshy districts, where I have 
 repeatedly had an opportunity of treating them. 
 
 The anatomical cause of the jaundice in the epidemics just men- 
 tioned is very imperfectly known; and hence the determination 
 of the mode of production of this symptom must in many respects 
 remain uncertain. The predominance of the intermittent type of 
 fever in these cases, and the often observed increase of the jaundice 
 during the paroxysms, are circumstances deserving of notice. In the 
 Coast epidemic of 1826, the most constant lesions were remarkable 
 enlargement and softening of the spleen, together with congestion 
 of the liver, — changes the same as are found in tropical fevers, 
 but in a milder form. After the inundation in . Silesia in the year 
 1854, I had abundant opportunities of collecting observations on 
 malignant intermittent and remittent fevers, some of which were 
 complicated with bilious symptoms. ' Here the post-mortem exami- 
 nation, in addition to congestion of the spleen and liver, disclosed 
 abundant accumulations of black pigment in the spleen and in the 
 blood, as also in the other organs, especially the liver, which in most 
 cases was softened, and had the greater number of its capillary vessels 
 filled with this pigment. Delirium, convulsions, and coma were fre- 
 quently observed during life, but the cases which were complicated 
 with bilious symptoms, were not more remarkable in this respect 
 than those cases in which this complication was absent* The epi- 
 demics in Liidenscheid and Chasselay which ran their course without 
 fever, commenced with catarrh of the stomach and bowels, and were 
 accompanied by light-coloured stools. They were to all appearances 
 examples of simple catarrhal jaundice, and only differed in their 
 extensive prevalence. 
 
 Appendix to Chapter on Jaundice. 
 
 1. Jaundice of newly-born Children. — Icterus neonatorum. 
 
 In a tolerably large number of newly-born children the skin and 
 conjunctiva are tinged yellow, and the urine contains the brown 
 colouring-matter of bile, which here, as elsewhere, indicates the 
 * See chapter VIII., on " The Pigment-Liver." 
 
190 JAUNDICE. 
 
 existence of jaundice, and distinguishes this from all other yellow 
 discolourations. As a general rule, the origin of this appearance is 
 connected with changes which the function and the circulation of the 
 liver undergo during birth. If we except the less frequent causes 
 which may give rise to jaundice at this, as at other periods of life, 
 such as catarrh of the bile ducts, occlusions of the ducts by thick- 
 ened bile or by concretions, — instances of which have been recorded 
 by Lieutaud, Portal, Cruveilhier, and Bouisson,* and farther, con- 
 genital obliteration of the bile ducts,t thickening of Glisson's capsule, 
 and congenital cirrhosis of the liver, J — we find that icterus neona- 
 torum is at one time the consequence of phlebitis wmbilicaUs, but at 
 other times is merely one of the results of the revolutions which 
 take place in the infantile organism during birth : — a twofold origin, 
 which the older authors had already intimated in distinguishing the 
 more severe from the milder forms of this affection. The jaundice 
 which is dependent upon phlebitis wmbilicaUs, is produced by the 
 purulent infection, to which this phlebitis may give rise ; it exhibits 
 all the peculiarities of pysemic jaundice, and terminates, as this almost 
 invariably does, in death. The yellow tinging is here only a subor- 
 dinate phenomenon in the complex train of symptoms of phlebitis. 
 
 The more common form of icterus neonatorum presents very 
 different characters ; it appears as a very mild affection, which in 
 most cases terminates favourably, without any treatment; but 
 which is still a subject of controversy in reference to the condi- 
 tions under which it makes its appearance. It has been attributed 
 to an accumulation of meconium (/. P. Frank), to catarrh of the duo- 
 denum and of the bile ducts, to' spasm of the ducts, polycholia, &c. ; 
 but in most of the cases, the supposition of the existence of such 
 exciting causes is justified as little by the symptoms during life, as 
 by the' post-mortem appearances. 
 
 The mode of production of icterus neonatorum in ordinary cases, 
 must be sought for in the diminished tension of the capillaries in 
 the hepatic tissue, which takes place upon the stoppage of the influx 
 of blood from the umbilical vein, and which gives rise to an increased 
 
 * De la bile, p. 187. 
 
 t DONOP, De ictero speciatim neonatorum Diss. Berol., 1828. CAMPBELL, 
 Northern Journal of Medicine, August, 1844. It is worthy of notice that 
 infants succumb much earlier than adults to the effects of an interruption 
 of the flow of bile into the intestine, and in most cases, indeed, haemor- 
 rhages take place from the umbilical vessels. 
 
 % F. WEBEE, Beitrdge %ur path. Anat. der Neugeborenen, III., Lief., S. 47. 
 
ICTERUS GRAVIDARUM. 191 
 
 transfusion of bile into tie blood. In strong, fully-developed infants, 
 the equilibrium of pressure is soon restored ; but in infants prema- 
 turely born, where the respiration is a long time in becoming esta- 
 blished, and where the foetal vessels remain long open, a more or 
 less intense degree of jaundice is apt to make its appearance. 
 Hence, as Bednar* and Westf have rightly observed, it is infants 
 prematurely born who are peculiarly liable to jaundice. 
 
 Icterus neonatorum usually appears soon after birth, some- 
 times even within a few hours, or the colour becomes most dis- 
 tinct about the third day, and then, as a general rule, lasts one or 
 two weeks. The skin and the eyes, present a more or less dark 
 jaundiced hue ; the urine also is of a deeper yellow than usual, but 
 does not exhibit the dark-brown colour of other forms of jaundice 
 (which may be explained by its greater dilution), and often it does not 
 even present distinctly the reaction of bile-pigment. At first, there 
 is constipation, and the stools are pale, but afterwards they are 
 of a normal colour ; and now and then they are seen more intensely 
 coloured than under ordinary circumstances. The general health 
 remains unaffected ; and in most cases there is no alteration in the 
 frequency of the pulse. Certain external causes of the affection are 
 not usually referred to ; but bad nursing, and the exposure to a cold 
 or polluted atmosphere, exercise a powerful influence, as is shown by 
 the statistics of Foundling Hospitals. 
 
 In this simple form of icterus neonatorum, scarcely any treatment 
 is required. Mild, laxative medicines, such as syrup of rhubarb, 
 and, if necessary, a small dose of calomel with magnesia, and after- 
 wards a few waT-m baths with simple diaphoretics, include all that is 
 usually necessary under such circumstances. 
 
 2. The Jaundice of Pregnant Females — Icterus Gravidarum. 
 
 Pregnancy may give rise to two forms of jaundice, which in their 
 symptoms and results present very different characters: one of 
 these is of very little importance, but the other is associated, with 
 serious lesion of the hepatic tissue, and almost invariably termi- 
 nates in death. 
 
 • Krankh. der Neugeborenen, IV., S. 194. 
 
 t Pathologie der Kinderkrankh. Translated from English by Wagner 
 S. 396. West lays great stress upon the obstructed respiration, and the 
 impeded functions of the skin, as causes of icterus neonatorum. 
 
192 JAUNDICE. 
 
 The first of these forms makes its appearance in the later months of 
 pregnancy, and is produced by the distended uterus, or by the accu- 
 mulation of faecal matter in the colon, exercising a degree of compres- 
 sion upon the bile ducts which impedes the free passage of the bile.* 
 Sometimes the affection is developed in the earlier periods of preg- 
 nancy, and depends upon catarrh of the bile ducts, or upon mental 
 emotions. This simple form of jaundice is attended by no conse- 
 quences ; it disappears upon delivery, if it has not yielded sponta- 
 neously at an earlier period to laxative medicines.t 
 
 The second form is characterised by serious derangements of the 
 nervous system, and, so far as cases of it have as yet been examined, 
 depends upon acute atrophy of the liver, resulting from inflam- 
 mation of the parenchyma of the organ: as a general rule the 
 kidneys' are at the same time diseased. (See Chap. ~V. on Acholia.) 
 
 * This view was long ago expressed by Van Swieten (Comment, ad 
 Boerh. aphor., Tom. III., p. 95). Virchow (Gesammelte Abhandl., S. 757) 
 observed jaundice in one pregnant female, in whom a tighUace lobe of the 
 liver, together with the gall-bladder, was, turned up in such a way that a 
 stoppage of bile' necessarily resulted from the tension of the bile ducts. 
 
 t J. P. Frank, however, met with a case in which a fatal rupture of the 
 gall-bladder took place during delivery. 
 
ACHOLIA. !93 
 
 CHAPTER V. 
 
 SUPPRESSION OP THE FUNCTIONS OF THE LIVER. — ACHOLIA, AND 
 ITS CONSEQUENCES. 
 
 In the last chapter, we became acquainted with a series of morbid 
 processes, in which jaundice was in some instances accompanied by- 
 serious derangements of the nervous functions. In these cases the 
 jaundice was associated with certain forms of fever, proceeding from 
 an infection of the blood, and appearing as epidemics, and rarely in 
 the sporadic form ; usually no important morbid alterations of the 
 liver were present ; the cells of the gland remained unaffected, their 
 secreting activity continued unimpaired, and frequently was even 
 increased ; the typhoid symptoms were independent either of the liver 
 or of its secretion. 
 
 Prom this form of jaundice we must distinguish a second, which 
 always comes on sporadically, and depends upon a suspension of the 
 secretion of bile, and as a general rule is produced by acute atrophy 
 of the liver, and in some instances by other structural diseases, such 
 as cirrhosis, fatty degeneration, &c. It is much more dangerous than 
 the former variety, and almost invariably terminates fatally. In 
 their symptomatology, both have many features in common; and 
 although extreme cases of each may present very different characters, 
 both as regards their progress and anatomical lesions, still, on the 
 other hand, there are cases where it is very difficult to draw a dis- 
 tinction, not only during life, but even on the post-mortem table. 
 The principal cause of this difficulty consists in the fact, that in the 
 first form the enlargement and the excessive secretion of the liver, 
 are followed by an opposite condition of collapse and suppression 
 of secretion, which in many respects resembles atrophy; a second 
 cause is the circumstance that the anatomical diagnosis of simple 
 typhus with jaundice is often difficult, inasmuch as the nervous 
 derangements belonging to typhus may be ascribed to the jaun- 
 dice ; and a third arises from the circumstance that the suspension 
 of the functions of the liver being far from sufficient!}'' known, 
 
194 ACUTE ATROPHY OF LIVER. 
 
 it is only provisionally inferred, that structural lesions of the liver 
 exist. "We have already seen, that enlargement and albuminous 
 infiltration of the liver and kidneys are not unfrequently present in 
 infectious diseases ; this constitutes the commencement, or the first 
 stage of diffuse inflammation, from which proceed destruction of the 
 hepatic cells, and atrophy of the gland. Typhus and the allied 
 morbid processes may in this way become the remote causes of 
 acholia, although this condition has usually a different origin. 
 
 In order to form a clear idea of acholia, we are obliged to be 
 guided by observations of cases, in which there has been a complete 
 stoppage of the functions of the liver owing to an unmistakable 
 general change, in the structure of this organ. The results obtained 
 in this manner may serve as a clue for explaining the more obscure 
 forms.* For this purpose I have selected acute atrophy of the 
 liver as a starting-point, and in my analysis of facts I have only 
 made use of those observations which were undoubtedly examples 
 of this affection. 
 
 A. THE ACUTE OK, YELLOW ATROPHY OE THE LIVES,. 
 
 Atrophia hepatis fiava sive acuta. — Hepatitis diffusa. 
 
 I. History and Literature. 
 
 The first authentic communications on acute atrophy of the liver 
 are found in Morgagni's works.f It is true, that in more ancient 
 literature descriptions of diseases occur which correspond to this 
 affection in their symptoms, but the anatomical, proof was wanting 
 or insufficient. Jacob Yercelloni % gave an account of the disease 
 from which his brother suffered ; being hardly pressed by his cre- 
 ditors one night, he became suddenly jaundiced from fright, and 
 
 * Two mistakes have, in my opinion, been committed in treating of this 
 difficult subject; one, that all cases of severe jaundice have been referred 
 to acute atrophy of the liver (the old school, and especially Horaczek) ; 
 and the other, that sufficient accuracy has not been observed in the selec- 
 tion of cases of typhoid jaundice, and the two groups distinguished by me 
 have been confounded together, or, at all events, doubtful cases have been 
 made use of in the accounts of the disease (Ozanam and Lebert). 
 
 + De sedibus et causis morborum, Epist. X., 7, et Epist. XXXVII., 2, 4. 
 
 % J ac. Vercelloni, de bile aucta et imminnta, Epist. ad Bianchi, p. 194. 
 
HISTORY AND LITERATURE. 195 
 
 soon fell into a restless delirium, with a remarkably irregular pulse 
 and panting respiration, and died on the third day. Francis 
 Rubeus * mentions an analogous case of jaundice where death oc- 
 curred on the fifth day amid severe cerebral symptoms. Of a similar 
 nature is the observation recorded by Baillou f of a boy aged 14, 
 who, on the fifteenth day of an apparently slight attack of jaundice, 
 with white evacuations, suddenly fell into delirium and convulsions, 
 gave utterance to loud inarticulate sounds and died. Upon post- 
 mortem examination, the brain was found healthy, "pulmo vitium 
 insigne contraxerat, vitiosius hepar et velut {meptyhop." 
 
 Bonetf gave the description recorded by Guarinonius, of the 
 history of the disease of Cardinal Sforza, who died on the sixteenth 
 day, of an attack of jaundice, after having suffered, for the last three 
 days of his life, from delirium and convulsions. The liver was 
 yellow ; the blood, dark and fluid. In Morgagni's works we find 
 some of these cases repeated, and, in addition, two more instances 
 from Valsalva's practice, in both of which the jaundice was the 
 result of violent mental emotions. Both patients were young; and 
 died, one, two days, and the other twenty-four hours, after the com- 
 mencement of the jaundice. "-Jecur inventum est flaccidum et ad 
 subpalhdum vergens/' 
 
 All these observations remained for a long period dispersed through 
 the writings of different authors, attracted but little notice, and were 
 not referred to in any systematic work. The larger proportion 
 of the materials in our possession have only been collected in 
 recent times, especially since Eokitansky has accurately described 
 the anatomical characters of acute yellow atrophy of the liver, and 
 since Horaczek, and Budd in England, have given a general descrip- 
 tion of malignant jaundice. The bulk of the observations, however, 
 which have been as yet accumulated, contain very heterogeneous" 
 materials resembling one another only in their external characters, 
 so that in order to make use of them, it appears indispensable to 
 have recourse to a careful sifting, in performing which the ana- 
 tomical lesions must be our sole guide. 
 
 • Fa Rubeus de ictero left. noct. exercit., 1660, p. 195, after Ozanam. 
 
 t Ballomi Ephemerid. lib. II., p. 188. Baillou cites another similar 
 case from Galen; who thus explains the cause of death :-«Non vi 
 ' phremtidis, sed ob dominatum humorum virulentorum, qui sua malirr 
 "mtate virus adsequant." 6 
 
 t Boneti, Sepulchret, p. 1007. 
 
 o2 
 
196 ACUTE ATROPHY OF LIVER. 
 
 Of the modern sources of information upon the subject the most 
 important are the following : — 
 
 Alison. Edinburgh Med. and Surg. Journal. 1835. 
 
 E. Bright. Guy's Hosp. Reports. Vol. I. 
 
 Martinet. Biblioth. Medic. Vol. LXVI. 
 
 Aldis. London Med. Gazette. XIII. 
 
 Rokitansky. Path. Anat. Bd. III. 
 
 Budd. Diseases of the Liver. P. 207. 
 
 Horaczek. Die gallige Dyscrasie, &c. "Wien, 1843. 
 
 Wisshaupt. Prager Vieteljahrsschrift. 19, 38. 
 
 Ozanam. De la forme grave de l'ictere essentiel. Paris, 1849. 
 
 Kiwisch. Geburtskunde. II., S, 51. 
 
 Rtjhle. Gtinsburg's Zeitschr. IV., 1. Hft. 
 
 Prey. Archiv f. phys. Heilk. IV., S. 74. 
 
 Glugk. Atlas der path. Anat. 
 
 Spath. "Wiener med. Wochenschr. 1854. 
 
 Pleischl. Ditto. 1855, No. 1. 
 
 Klinik der Gebrutshiilfe von Chiari, Braun and Spath. 245. 
 
 Buhl. Zeitschr. f. ration. Med. 1854. 
 
 Lebert. Ueber Icterus typhoides. Virchow's Archives. 1854. 
 
 Spengler. Ditto Ditto. 1855. 
 
 "Wertheimber. Pragmente zur Lehre vom Icterus. 
 
 Von Dusch. Untersuch. u. Experimente zur Pathogenese des 
 
 Icterus. 1854. 
 Aertzlicher. Bericht des allgem. Krankenhauses in Wien, vom 
 
 Jahre. 1855. S. 53. 
 Guckelberger. Wiirtemb. Correspondenzblatt. 20. 1856. 
 
 ii. Symptomatology of Acute Atrophy of the Liver. 
 
 The symptoms which accompany acute wasting of the liver are 
 sometimes preceded by a preliminary stage ; but at other times, 
 manifest themselves directly. The precursory symptoms present 
 nothing characteristic; usually they resemble the symptoms of an 
 acute gastro-enteric catarrh; the patients get out of sorts, com- 
 plain of dulness and headache; their tongues are coated, and 
 the bowels are irregular, sometimes relaxed, and at other times 
 confined; the abdomen is tender; the pulse is increased in fre- 
 quency. Sooner or later, sometimes not until after the lapse of 
 
, SYMPTOMS. 197 
 
 several weeks, a slight jaundiced-tint of the skin supervenes upon 
 these derangements. The jaundice may exist in the simple form, 
 from eight to fourteen days, or even longer, before the local changes 
 in the liver and spleen, the haemorrhages and the serious derange- 
 ments of the nervous functions, which characterise the affection, 
 become apparent. These symptoms, however, make their appear- 
 ance about the same time as the jaundice, quite as frequently 
 as they follow in its wake. 
 
 The disease runs a more or less violent course ; in severe cases 
 the scene terminates at the end of twelve or twenty-four hours, 
 in other cases, after two or five days ; it is scarcely ever prolonged 
 to a week. 
 
 The symptoms usually commence with vomiting, by means 
 of which there is thrown up first the contents of the stomach, 
 then grey mucus, and lastly, blood, in the form of dirty-brown, or 
 ultimately, black coffee-ground masses. At the same time, severe 
 pains in the head come on, which, as a general rule, soon pass into 
 delirium. In most cases, this delirium is noisy; the patients scream 
 out and beat themselves, try to leave their beds, and are with diffi- 
 culty restrained. In other instances, they are quieter, and can be 
 roused for a short time by loud shouting. The delirium is usually 
 succeeded by convulsions, which extend over most of the voluntary 
 muscles, or are confined to certain localities, such as the muscles of 
 the face and neck ; now and then also they appear in the form of 
 trismus, and in certain cases one half of the body is implicated to 
 a greater extent than the other. Along with these spasms (which, 
 however, are not invariably present), we observe, as a general rule, a 
 tremulousness of the muscles of the extremities and trunk. The 
 patient after a time becomes by degrees more and more tranquil; 
 the state of excitement passes into stupor, and finally, into deep 
 coma; the pupils become large, react slowly with light, and the 
 respiration becomes sighing, intermittent, and stertorous. 
 
 The pulse, which at first was slow, and continues so as long as 
 the jaundice remains simple, at the outbreak of the nervous sym- 
 ptoms increases in frequency, and gradually rises to 110 or 120 or 
 thereabouts; at the same time, it presents remarkable variations as 
 regards its frequency and volume : sometimes when the patients are 
 roused, the pulse rises from 70 or 80 to 120 or 130, soon again 
 to sink to its normal frequency or below it. These oscillations 
 in the frequency of the pulse, which may also be observed in 
 
198 ACUTE ATROPHY OF LIVER. 
 
 respect to its size and hardness, cease when the disease draws 
 towards a close ; the pulse then always increases in frequency and 
 becomes smaller, until it can no longer be felt. 
 
 The tongue and teeth are covered at an early period with a fuligin- 
 ous crust ; the abdomen is in most cases, but by no means always, 
 tender upon pressure, especially in the hypochondriac regions, and 
 particularly the right one ; even during the coma, when the hand 
 is applied here, it produces distortions of the features, and loud 
 complaints. The extent of the hepatic dulness diminishes more and 
 more as the disease advances, and not unfrequently the dull space 
 disappears completely, without there being any tympanitic disten- 
 tion of the bowels to account for it ; at the same time the spleen 
 is increased in volume. The bowels are almost always confined, and 
 the stools are firm, dry, clay-like, deficient in bile, and, at a later 
 period, not unfrequently dark coloured, and tarry from the presence 
 of blood. 
 
 In the meantime the colour of the skin increases in intensity, 
 and numerous extravasations of blood take place into its tissue in 
 the form of petechia? and more extensive ecchymoses; along with 
 these, there are haemorrhages from the nose, the vagina, the stomach 
 and bowels, and the bronchi. 
 
 The urine is more or less saturated with a brown colouring- 
 matter, presents the reaction of bile-pigment, and deposits a light 
 precipitate, in which with the microscope there may be detected, 
 besides amorphous mucus, the epithelium, of the urinary passages, 
 and sometimes likewise of the kidneys, coloured yellow, and also 
 needle-shaped crystals covered with colouring-matter, either isolated 
 or adhering in crystalline masses. Sometimes the urine contains 
 albumen. 
 
 The various derangements just described, usually terminate after 
 a few days in death, which usually occurs amidst increasing coma, 
 and other symptoms of cerebral paralysis. It very seldom happens 
 (and the observations in proof of such an event are still of a 
 doubtful character) that, after very free evacuation of the bowels, 
 consciousness returns, the jaundice diminishes, and recovery takes 
 place. 
 
ILLUSTRATIVE CASES. 199 
 
 in. Illustrative Gases. 
 Observation No. XIV. 
 
 Repeated attach of Lumbago in the seventh month of Pregnancy. — 
 Gastric Catarrh. — Icterus. — Delirium. — Convulsions. — Coma. — 
 Death under symptoms of Blood-poisoning. 
 
 Acute Atrophy of the Lwer. — Complete disintegration of the hepatic 
 cells, — Crystalline deposits in the tissue of the liver, and m the 
 blood of the hepatic veins.— Enlargement of the Spleen. — Abortion. 
 
 The wife of Dr. Sch., chief Physician at Kiel, 33 years of age, 
 of short stature, delicate, and sensitive, had suffered much distress of 
 mind during the three years' war; she often sat for an entire day in 
 tears; she was in easy circumstances, and the mother of three 
 children. Since her last confinement, there had been a hardness in 
 her left mamma, which had originated under symptoms of inflamma- 
 tion, but subsequently had assumed the characters of scirrhus. The 
 post-mortem examination showed in the sequel the carcinomatous 
 nature of this hardness. In December, 1850, Mrs. Sch. was in the 
 fifth month of pregnancy, and had complained of nothing save the 
 usual symptoms incident to that condition. In consequence of an 
 unforseen excitement, the patient was seized on rising from stool 
 with severe pains in the muscles of the lumbar region of the spine, 
 and was obliged to keep her bed. Although this local suffering was 
 unimportant, still it was the commencement of a' series of complaints 
 which gradually exhausted this delicate lady, and ultimately led to a 
 disease which terminated fatally. Fourteen days elapsed before the 
 pains, which at the first were accompanied by smart fever, disap- 
 peared under local abstraction of blood, and rest in bed, &c. The 
 patient remained for some days well, when on rising from stool, the 
 pain suddenly returned at the same place, and with the same degree 
 of violence. This time the fever was more acute, and the skin very 
 active; the tongue was for a long time thickly coated, and there 
 were at the same time nausea and complete anorexia. ^Fourteen 
 days passed before the patient was freed from her sufferings. A 
 second relapse, which made its appearance in the same way as the 
 first, confined the patient to bed for a third time. Meanwhile she 
 became emaciated; a bed-sore formed over the sacrum, which at 
 
200 ACUTE ATROPHY OF LIVER. 
 
 first took a favourable course, but was very slow in healing. The 
 patient had begun to recover, when suddenly an important change 
 in her condition took place. 
 
 In the first place, pains were complained of in the epigastric region, 
 and in both hypochondria, which were increased by slight pressure ; 
 the hepatic region was particularly tender. Percussion indicated a 
 considerable diminution in the hepatic dulness, which was the more 
 remarkable, as there was no accumulation of gas in the intestinal 
 canal to account for it. By degrees, the dulness in the right hypo- 
 chondrium completely disappeared, whilst an examination of the 
 spleen indicated a rapid increase in the volume of this organ. The 
 tongue again became coated; the appetite diminished; and there 
 was repeated vomiting of a dirty-grey mucous fluid. The bowels 
 were torpid, and had to- be opened by means of senna. The 
 stools were at first of a dark colour, and subsequently they exhibited 
 a grey clay-like appearance. The pulse, which a short time before 
 had been 80 to 90, sank to 64, then rose again to from 75 to 80, 
 and towards the termination of the disease reached 110 to 130. 
 Almost simultaneously with the pain in the hepatic region, the con- 
 junctiva was observed to present a yellowish colour, which soon 
 became more distinct, and extended over the skin, without, however, 
 attaining a high degree of intensity. The cerebral functions, which, 
 with the exception of a gloomy despondent disposition, had hitherto 
 remained normal, underwent a sudden change, twelve hours after the 
 outbreak of the jaundice; the patient complained of violent pains in 
 the head, became restless, made attempts to leave her bed, and 
 wandered in her mind. This excitement soon passed off, to make 
 way for a rapidly-increasing somnolence. The patient lay in a 
 stupefied state with enlarged pupils, and from time to time con- 
 vulsive movements occurred of the muscles of the face, neck, 
 and arms ; she drew short sighing inspirations, each of which was 
 succeeded by a quick expiration and a pause. The pulse was 
 130 ; the urine and stools were passed involuntarily. The skin was 
 covered with clammy sweat. Death took place four days after the ap- 
 pearance of the jaundice. The treatment consisted in the administra- 
 tion of muriatic acid, at first by itself, but subsequently in combina- 
 tion with ether, and latterly with musk : purgatives, senna, and 
 afterwards colocynth, were given along with these remedies, in 
 order to overcome the obstinate constipation. 
 
ILLUSTRATIVE CASES. 201 
 
 Post-mortem examination, 30 hours ccfter death. 
 
 The body was emaciated, and of a moderately dark jaundiced hue. 
 A foetus, enveloped in its membranes, projected from the genital 
 organs. The bronchial tubes and lungs were anaemic, but otherwise 
 normal. The heart was flabby and shrivelled (welk) ; the right ventricle 
 contained a loose reddish-brown coagulum ; and the left, a little thin 
 blood. The spleen was remarkably enlarged ; its parenchyma was of a 
 reddish-brown colour, and of normal consistence. The mucous mem- 
 brane of the stomach was pale, and over the cul-de-sac and posterior 
 wall was softened. The lining membrane of the small and large intes- 
 tine was anaemic, without any marked development of its glandular 
 system ; here and there might be seen sharply-defined patches of the 
 mucous membrane presenting a reddish-brown colour, from passive 
 congestion ; the caecum and colon contained greyish faecal matter. 
 
 In the sac of the peritoneum a pound of reddish-brown fluid 
 was found, which exhibited the reaction of bile-pigment. The 
 peritoneum itself was not injected. The kidneys were flabby and 
 tinged yellow, and a portion of their secreting cells were in a state 
 of fatty degeneration. The urine contained in the bladder was 
 deeply coloured by bile; but contained not a trace of the biliary 
 acids * The uterus, the membranes of the ovum, the placenta, and 
 foetus exhibited nothing unusual. The last appeared free from any 
 jaundiced tint, and presented by its breech. After its removal, a 
 pound and a-half of dark, completely coagulated blood escaped from 
 the uterus. 
 
 The liver was very considerably atrophied, flabby, and shrivelled 
 {welk); it was atrophied especially as regards its thickness, which, 
 close to the suspensory ligament, amounted to half an inch, and at 
 the thickest part of the right lobe to scarcely one inch. The serous 
 covering was puckered; the cut surface of the organ was smooth, 
 shining, and of an ochre-yellow colour; there was no visible sub- 
 division into acini. The gall-bladder contained a small quantity of 
 grumous bile, mingled with a few small black concretions, of a neutral 
 reaction, and exhibiting the ordinary reaction of bile-pigment and 
 glycocholic acid. The aperture of the hepatic artery appeared to 
 present its usual calibre, and there was nothing abnormal about its 
 walls. The portal and hepatic veins were also of normal calibre; 
 • The urine was unfortunately not tested to ascertain the amount of 
 urea, or the presence of the other substances which since then I have 
 found in such cases. 
 
202 ACUTE ATROPHY OF LIVER. 
 
 -the bile ducts were pervious, and their lining membrane was pale. 
 No trace of the hepatic cells could be detected upon microscopic 
 examination of the hepatic tissue. This consisted of fine molecules, 
 partly yellow and partly pale ; and here and there were seen large, 
 dark-brown conglomerate masses, with irregular outlines. Some 
 drops of oil, and rounded, sharply-defined formations, which re- 
 sembled the nuclei of hepatic cells, were also perceived. Amidst 
 this detritus of the secreting apparatus of the liver, there were ob- 
 served numerous needle-shaped crystals adhering together in bundles, 
 or in radiating masses (tyrosine).* 
 
 These crystals were found in much greater abundance in the blood 
 of the hepatic veins, which contained a thin reddish fluid, in which, 
 along with normal blood-corpuscles, there floated numberless crystals 
 in bundles and radiating masses.f They were entirely absent from 
 the blood of the portal vein and hepatic artery. The liver was washed 
 in cold water, to free it from its adherent blood ; it was then cut in 
 pieces, triturated, and boiled. The filtered fluid, upon standing, 
 deposited numerous crystals, adhering partly in bundles, and partly 
 in radiating masses (tyrosine). When farther concentrated, a greyish- 
 yellow film formed at the margins and over the surface of the fluid, 
 and there separated, a large quantity of brown globular masses, made 
 up of concentric layers (leucine). Owing to the smallness of the 
 portion, of the liver which had been subjected to the experiment, the 
 quantity of crystals obtained was unfortunately too minute to deter- 
 mine their nature with complete certainty. 
 
 Obsekvation No. XY. 
 
 Symptoms of Gastric Catarrh and Jaundice m the seventh month of 
 Pregnancy. — Delwium. — Convulsions and Coma. — Abortion. — 
 Death on the seventh day of the disease. — Acute Atrophy of the Liver. 
 — Hcemorrhage from the Intestinal Canal, and from the Mucous 
 Membrane of the Bronchi, fyc. — Peculiar composition of the Urine. 
 
 P. Nitschke, aged 24, a carpenter's wife, was brought in a semi- 
 conscious state to the clinical department of All-Saints' Hospital, 
 on January 21st, 1858. The patient was a robust, well-nourished 
 female, of a florid complexion ; who, according to the statements of 
 her relatives, had previously enjoyed uninterrupted good health; she 
 * Frontispiece, Fig. 1. t Frontispiece, Fig. 2. 
 
ILLUSTRATIVE CASES. 203 
 
 was in the seventh month of pregnancy. On the 17th, she had 
 complained, as we were informed, of symptoms resembling those of 
 acute catarrh of the stomach, loss of appetite, along with constipa- 
 tion, headache, general malaise, and great dejection of spirits, and, 
 in short, derangements which, although not urgent, appeared 
 sufficient to call for medical assistance. On the 20th, she came to 
 Dr. Hasse as an out-patient, and he immediately recognising the 
 importance of the case, directed her to be admitted into one of the 
 medical wards. He then observed a slight yellow tinge of the face. 
 During the ensuing night the patient, after repeated vomiting of a 
 dirty-grey fluid, suddenly became delirious, shouted out disconnected 
 words, and could with difficulty be kept in bed. This state of 
 excitement still continued at the time of the patient's admission 
 into the clinical ward; the pulse was 80 ; respirations 20 ; the tem- 
 perature of the skin was not elevated; the pupils were of normal size, 
 and acted somewhat slowly. The conjunctiva was of a pale-yellow 
 tinge, as also the skin of the face and neck, whilst on the abdomen 
 and lower extremities no jaundiced tinge could be recognised. The 
 abdomen was soft, without any very great accumulation of gas ; both 
 hypochondria and the epigastrium were tender upon pressure. 
 
 On percussing the hepatic region, the dulness in the axillary line 
 
 amounted to only 3 centimetres (1J inch) ; in other situations, there 
 
 was a direct transition from the sound of the intestine to that of the 
 
 lung. No dulness corresponding to the spleen could be made out. 
 
 The thoracic organs remained intact. She was ordered muriatic acid. 
 
 In the night between the 21st and 22nd, the restlessness increased; 
 
 the patient kept constantly uttering loud unmeaning cries ; and the 
 
 eyes remained open, the pupils being normal. The pulse rose to 
 
 112, without any elevation of the temperature, and the respirations, 
 
 which were stertorous, to 26. At eleven o'clock of the 22nd, the 
 
 patient was delivered of a dead seven months' foetus, which presented 
 
 no trace of jaundice. This was followed by a profuse uterine 
 
 haemorrhage. After the abortion, the excitement abated; and the 
 
 patient lay, sometimes, at least, in a quiet, unconscious condition; 
 
 the pulse and respiration remained unchanged; the pupils continued 
 
 to act distinctly, although slowly, upon exposure to the light. The 
 
 jaundice had slightly increased since the day before; the hepatic 
 
 dulness was nowhere more obvious than formerly; and the spleen 
 
 was equally undistinguishable by percussion* The bowels had been 
 
 * I remarked in the Clinique, that this absence of splenic dulness could 
 
204 ACUTE ATROPHY OF LIVER. 
 
 confined for three days ; the urine, which had to be drawn off by 
 catheter, was acid, reddish-yellow, clear, and free from albumen ; its 
 specific gravity amounted to 1018.5. Upon the addition of nitric 
 acid, the colour became darker, but did not exhibit the play of 
 colours characteristic of bile-pigment. Upon standing, it depo- 
 sited a slight sediment, which consisted of numerous needles, partly 
 isolated, and partly adhering in groups, along with the yellow- 
 tinged epithelium of the bladder and of the uriniferous tubes. 
 Tincture of colocynth, and, subsequently, jalap, were administered 
 along with the muriatic acid, to remove the constipation. 
 
 During the night, between the 22nd and 23rd, the patient lay 
 quiet, and in a state of deep coma : muscular tremors were observed 
 in the neck and upper extremities. The haemorrhage from the vagina 
 continued. 
 
 On the morning of the 23rd, the jaundice appeared increased; 
 pulse 108; respirations 24, and stertorous; no elevation of tempera- 
 ture; skin dry. 
 
 From time to time vomiting occurred; by which grey mucus, 
 mingled with brownish-black flakes, were thrown up. The bowels 
 remained confined, notwithstanding the colocynth. The urine was 
 darker in colour, acid, gave distinctly the reaction of bile-pigment, 
 but not of the biliary acids; its specific gravity had risen to 1024. 
 After standing in the cold air, a greenish-yellow, light sediment 
 was deposited, consisting entirely of acicular crystals of tyrosine 
 aggregated together in globular masses. When a drop of urine was 
 evaporated upon the object-glass, it left behind a residuum, which, 
 upon microscopic examination, was found to be almost exclusively 
 composed of the most characteristic possible crystals of leucine and 
 tyrosine, partially saturated with colouring-matter.* A portion of 
 
 not be regarded as incompatible with acute atrophy of the liver, although 
 this affection is more frequently attended by an increase of the volume of 
 the organ, because the spleen not unfrequently lies high up in the hollow 
 of the diaphragm in such a manner that, although enlarged, it is neces- 
 sarily out of the reach of percussion, and, moreover, because old thicken- 
 ings of the capsule may interfere with its enlargement. 
 
 * Plate III., Fig. 4, of the Atlas, exhibits a drop of the urine thus 
 evaporated. The leucine was deposited partly in globular masses, with 
 concentrically thickened walls and fissured surfaces, and partly in finely- 
 striated laminae : along with it there were observed greenish-yellow 
 crystals of tyrosine. This figure has been copied in the Frontispiece of 
 the present Translation, Fig. 5. — Transl. 
 
ILLUSTRATIVE CASES. 205 
 
 the urine, immediately after it was drawn off by catheter, was freed 
 from its colouring and extractive matter, by treating it with an ex- 
 cess of the basic acetate of lead, the excess of lead was then removed, 
 and what remained was condensed and set aside. In twenty-four 
 hours there was obtained a quantity of tyrosine, sufficient for several 
 elementary analyses, in the form of brown and greenish-yellow glo- 
 bular crystallized masses ; * the identity of which was proved, first, 
 by the crystalline form after re-crystallization,t then by Piria's test,$ 
 and, lastly, by Staedeler's process of elementary analysis. The co- 
 matose condition of the patient remained unchanged : there was no 
 enlargement of the pupils. 
 
 In the afternoon, the pulse rose rapidly to 134 ; the skin became 
 covered with clammy-sweat ; and death took place about 7 o'clock. 
 
 During the last two days of life, first ether, and then tincture of 
 musk were administered along with the mineral acid. 
 
 Autopsy, 18 hours after death. 
 
 The body was fat, and showed no signs of incipient decomposition. 
 The skin on the head, neck, and chest was considerably jaundiced, 
 as also the sclerotic ; on the lower extremities the colour was paler. 
 
 * See Frontispiece, Fig. 6. f Frontispiece, Fig. 7. 
 
 t In Piria's test, advantage is taken of the dark-violet colour which is 
 produced when tyrosine is treated with sulphuric acid and perchloride of 
 iron. If a small quantity of tyrosine, or of a substance containing a 
 minute trace of it (& grain is sufficient), be placed in a watch-glass, 
 moistened with one or two drops of sulphuric acid, diluted, after half an 
 hour, with water, then heated and saturated with carbonate of lime, and 
 if to the filtered fluid perchloride of iron (containing no free acid) be 
 added, the presence of tyrosine is indicated by the appearance of a dark 
 violet-blue colour. 
 
 Tyrosine and leucine may be obtained as artificial products of the de- 
 composition of albumen and fibrine, when either of these substances, but 
 particularly the latter, is heated with dry caustic potash, or boiled with a 
 strong solution of potash. They are also obtained in the decomposition 
 of caserne and horn, by the action of alkalies and of acids, and by putre- 
 faction. These substances are regarded as some of the intermediate pro- 
 ducts of the destruction of the animal tissues, between the sanguigenous 
 bodies at one extreme, and the still less complex excreted compounds, 
 such as uric acid, hippuric acid, urea, kreatine, &c, at the other. The 
 composition of leucine is C Ia NH 13 4 ; that of tyrosine is C 18 NH n 6 . 
 The crystalline forms presented by leucine and tyrosine are represented in 
 the frontispiece. — Teansl. 
 
206 ACUTE ATROPHY OF LIVER. 
 
 The skull-cap was normal ; the dura mater, yellow ; the pia 
 mater, bloodless, as also the cerebral substance, which was of 
 normal consistence ; there was only a small quantity of clear serum 
 at the base of the cranium. 
 
 The mucous membrane of the larynx, trachea, and bronchi, was of 
 a dark-red colour from suffusion of blood ; the lungs were normal, 
 moderately congested, and posteriorly and inferiorly slightly hypo- 
 static. The heart was of normal size, and there were numerous 
 ecchymoses beneath the epicardium ; the ventricles contained a small 
 quantity of tar-like blood along with a little colourless coagulum. The 
 tongue, pharynx, and oesophagus were covered with a dirty greyish- 
 brown coat; the stomach presented a pale mucous membrane 
 without any visible ulceration ; it contained a brownish-black coffee- 
 ground-like substance, which was also found throughout the whole 
 of the small intestine, as far as the ileo-csecal valve. The large 
 intestine contained scybala of faecal matter, but faintly tinged with 
 bile. The mucous membrane of the bowel was everywhere pale and 
 anaemic. Numerous ecchymoses were found in the mesentery ; the 
 veins were not enlarged nor distended ; and there was no enlargement 
 of the mesenteric glands. The spleen was fixed in the hollow of the 
 diaphragm by old adhesions; it was enlarged by about one-third, 
 soft, and of a pale-red colour. 
 
 The liver lay collapsed against the posterior wall of the abdominal 
 cavity; anteriorly it was completely covered by the folds of the small 
 and large intestine, which were displaced upwards (Kg. 1 0, page 49) ; 
 it was dry and soft; its capsule was puckered and opaque, and 
 its margin sharp. The dimensions of the organ were diminished in 
 every direction, and particularly in thickness. The gall-bladder 
 contained a small quantity of grey mucus. The tissue of the liver 
 felt flabby and dry; in the right lobe it was at some places 
 congested ; - the ramifications of the portal vein surrounding the 
 lobules were distended, whilst the centre of the lobules presented a 
 citron-yellow colour; here and there were small ecchymoses. A 
 greyish-yellow substance was observed in the spaces between the 
 lobules, which were in this case still distinctly defined, owing to the 
 surrounding network of \ essels being injected. Near the sharp margin 
 of the liver, the capillary injection disappeared, the rounded yellow 
 islets appeared smaller, and consequently the surrounding grey sub- 
 stance seemed wider. In the left lobe, where the morbid process 
 had advanced farthest, this inter-lobular substance was still more 
 
ILLUSTRATIVE CASES. 207 
 
 extensive; the cut surface here presented an ochre-yellow colour, in- 
 terspersed through which were distinct ramifying streaks. The 
 secreting cells were completely disintegrated, and in their place were 
 found numerous drops of oil and brownish-yellow molecules ; it was 
 only in the rounded border of the right lobe that a few isolated cells 
 loaded with oil could be detected. Upon exposure the cut surface 
 of the organ became covered with a greyish film, consisting of 
 globules of leucine mingled here and there with crystalline masses of 
 tyrosine. In the blood of the portal and hepatic veins the blood- 
 corpuscles were normal, and no crystalline deposits could be detected. 
 
 The liver was injected with yellow size; this substance penetrated 
 to the centre of the lobules, and passed thence a short distance into 
 the capillaries, and then became extravasated, without reaching the 
 peripheral vessels of the lobules. In fine sections of the tissue 
 injected in this way, the enlarged central veins of the lobules could 
 be seen surrounded by a yellow partially injected space, in which 
 could be observed the crystalline deposits just mentioned, and this 
 again was surrounded by a paler bluish-grey rim of densly aggregated 
 oil globules. The weight of the liver amounted to 0.82 kilogrammes 
 (1.807 lbs. avoird.), and the weight of the entire body to 56.2 
 kilogr. (123.898 lbs.), making the ratio of the former to the latter 
 as 1 to 68.5. In healthy females of the same age and weight, the 
 weight of the liver is about 2 kilogr. (4.409 lbs.), and the ratio is 
 •as 1 to 28. Thus the organ within six days had lost 1.18 kilogr. 
 (2.601 lbs.) in weight. It was also considerably diminished in size; 
 the left lobe measured 3 inches transversely, and 5 J from before back- 
 wards ; and the right lobe 5£ inches by 5£ ; the thickness was 1£ inch. 
 
 The urine voided during life, was now subjected to a closer 
 examination. It left behind 4.9 per cent of solid residue, and 
 0.14 p. c. of ash. The residuum mainly consisted of leucine, tyro- 
 sine, and a viscid extractive matter, along with traces of uric acid ; 
 urea was sought for in vain; and ammonia was present in such 
 small quantity that the supposition of the urea having disappeared 
 from decomposition could not be entertained. This idea was also, 
 opposed by the circumstance, that the urine examined immediately 
 after it was voided was found to be acid. It was also remarkable, 
 that phosphoric acid and lime were entirely absent from the ash. 
 
 Upon evaporation, the urine deposited a considerable quantity 
 of a greenish-yellow sediment, which was collected and treated with 
 diluted ammonia. From this solution there separated long delicate 
 
208 ACUTE ATROPHY OF LIVER. 
 
 acicular crystals, possessing all the characters of tyrosine; on 
 analysis, they yielded 8.03 per cent, of nitrogenous contents, which 
 coincided with the formula of tyrosine. On evaporation of the 
 ammonia, there remained behind a substance similar to tyrosine, and 
 crystallizing in like manner, but which differed in its being more 
 soluble, and in containing a larger proportion of nitrogenous 
 matter. (8.83 per cent.) 
 
 The residuum of the urine was repeatedly extracted with absolute 
 alcohol, so as to obtain any urea present. This solution upon the ad- 
 dition of half its volume of ether, deposited an amorphous substance, 
 from which crystals of leucine gradually separated. The ether was 
 evaporated from the filtrate, which was then treated with an alcoholic 
 solution of oxalate of lime. A crystalline precipitate was formed, 
 which was dissolved in water and decomposed by carbonate of lime. 
 The filtered fluid when evaporated, left behind a very scanty re- 
 siduum, in which, on testing with nitric acid, no trace of urea could 
 be detected. The salt thrown down by oxalic acid consisted of 
 oxalate of ammonia. The residuum which remained after digestion 
 with absolute alcohol was dissolved in a great measure in boiling 
 spirit of wine, leaving behind a viscid brown substance, in appear- 
 ance and smell completely resembling that which is obtained in the 
 formation of leucine and tyrosine from the decomposition of the 
 proteine principles by acids. The spirituous solution when evapo- 
 rated left behind a syrup, which became converted into a solid- 
 crystalline mass, from the separation of crystals of leucine. 
 
 The urine thus contained the same (or as regards the amorphous 
 matter, perhaps only similar) substances as those which result from 
 the artificial decomposition of the proteine compounds ; whilst the 
 urea, which, under normal circumstances, constitutes the chief pro- 
 duct of the metamorphosis of the tissues, was wholly absent. 
 
 The blood in the heart and in the vense cavse contained a small 
 quantity of leucine, and larger quantities were found in the cerebral 
 substance, the liver and the spleen : these last organs contained a 
 much larger amount than corresponded to what was found in the blood. 
 Not a trace could be detected in the muscular substance of the glutei 
 muscles. The chemical examination of the pancreas met with an 
 accident. Thus the liver and the spleen were the sole organs in 
 which considerable accumulations of these substances had taken 
 place; they are the organs which, together with the lymphatic 
 glands and the pancreas, represent the chief formative masses of the 
 
ILLUSTRATIVE CASES. 209 
 
 body. The presence of a considerable amount of tyrosine in the 
 liver, while in the spleen it could not be detected with positive cer- 
 tainty, favoured the supposition that this substance owed its origin 
 in great part to the destruction of the hepatic parenchyma. 
 
 Observation No. XVI. 
 
 Jaundice in the seventh month of Pregnancy. — Severe pains in the , 
 Head. — Great restlessness. — Abortion. — Vomiting of Mack fluid. — 
 Qbstinate Constipation. — Coma. — Petechia. — Death eight days 
 after the commencement of the Jaundice. — Acute Atrophy of the 
 Liver. — Small Spleen. — Fatty degeneration of the Kidneys. — 
 Abundance of Leucine and Tyrosine in the Urine. — Urea and 
 Leucine in the Blood. 
 
 Kosalie Kienert, aged 35, was admitted on the 24th of Sep- 
 tember, 1857, into All Saints' Hospital, and died there on the 
 28th of the same month. The patient was a servant of robust con- 
 stitution, who had previously been healthy, who, five years before, 
 had undergone a good confinement, and who was now in the 
 seventh month of her second pregnancy. Up to the 20th of 
 September, she had followed her employment as a nursery maid, 
 and had first complained during the last week of a feeling of 
 tightness and pressure in the scrobiculus cordis. Early on the 
 morning of the 20th, when on the point of going to her work, 
 she was seized with a violent rigor ; and at the same time violent 
 pains in the head, loss of appetite, and jaundice of the face made 
 their appearance, for which complaints she first sought medical aid 
 on the 24th. On this day the patient came on foot to the In- 
 stitution, in a violent fever, and scarcely in a condition to drag 
 herself along; she blamed the treatment she had experienced at 
 the hands, of her master as the cause of her illness. 
 
 Her consciousness was unimpaired, but she was very restless, and 
 kept constantly rolling about in bed from side to side ; she suffered 
 from violent pains in the forehead and occiput; the countenance 
 was pale, and of a moderately yellow tinge ; pupils normal ; pulse 120 
 and soft. Vomiting occurred from time to time, by means of which 
 undigested food, such as crude plums, was thrown up. The bowels 
 were confined ; the abdomen was greatly distended by tympanites • 
 
 p 
 
210 ACUTE ATROPHY OF LIVER. 
 
 no hepatic duhiess could be made out ; the urine was brown, and 
 loaded with the colouring-matter of bile. Was ordered muriatic acid. 
 
 The night was spent in loud groans without sleep. 
 
 Early on the 25th, labour-pains came on, and about 1 o'clock, 
 the patient was delivered of a six months' fetus, which showed no 
 traces of jaundice ; during delivery there was a severe rigor and 
 repeated vomiting of a blackish-grey grumous fluid ; the patient 
 complained of constant shivering, groaned much, and from time to 
 time screamed out loudly. 
 
 On the 26th, there had been no sleep during the night; the 
 consciousness was unimpaired; there was frequent vomiting of black 
 fluid; and notwithstanding the administration of compound infu- 
 sion of senna, no evacuation of the bowels had taken place. The 
 hepatic region was tender upon firm pressure ; no dulness could be 
 made out either here or in the splenic region. Pulse small and weak, 
 104 to 108. Inspirations 24. Great apathy. 
 
 Towards evening this apathy increased, until it merged into coma, 
 from which the patient could not be roused. The vomiting of black 
 fluid continued; no stool; lochial discharge scanty. There were 
 petechias upon the skin of the lower extremities; pulse 104, small. 
 The urine, which was drawn off by catheter, was free from albu- 
 men, rich in bile-pigment, and deposited upon standing, a dark 
 reddish-brown sediment. The hepatic dulness was searched for in 
 vain, notwithstanding that the abdomen was soft, collapsed, and 
 painless ; the vomiting of black matter continued during the patient's 
 unconscious condition ; the skin was dry and cool. Towards evening, 
 the respiration became stertorous. At 4 o'clock on the morning of 
 the 28th, death ensued amid symptoms of acute oedema of the 
 lungs. During the last two days of life no internal remedies were 
 administered, as all ingesta were immediately rejected from the 
 stomach. 
 
 Autopsy, 12 hours after death. 
 
 The inner surface of the skull-cap was covered with osteophytes ; 
 and at many places was firmly adherent to the yellow-coloured dura 
 mater. The pia mater and substance of the brain were moderately 
 congested and normal. The mucous membrane of the bronchi was 
 pale and covered with mucus J both lungs were very oedematous, 
 but otherwise normal. The pericardium contained about an ounce 
 
ILLUSTRATIVE CASES. 211 
 
 of yellow serum; numerous ecchjmoses were observed beneath the epi- 
 cardium ; the muscular tissue and the valvular apparatus of the heart 
 were healthy; the cavities of the heart had their lining membrane 
 jaundiced, and contained a considerable quantity of firmly coagu- 
 lated reddish-brown blood. The mucous membrane of the oesohpagus, 
 the epithelium of which was slightly peeled off, was covered with a 
 black pnltaceous material, which was found accumulated in large 
 quantity in the stomach, and extended thence throughout the whole 
 of the small intestine as far as the ileo-caecal valve. Numerous 
 normal blood corpuscles were detected in it by the microscope. The 
 mucous membrane of the stomach was very relaxed, and strewn over 
 with punctiform ecchymoses ; the mucous membrane of the small 
 intestine was pale and anaemic ; solid grey faecal matter was found 
 in the caecum and colon. The mesenteric glands were unaltered. 
 The kidneys were very large and soft ; their cortical substance was 
 coloured greyish-yellow, and their glandular epithelium was in an 
 advanced stage of fatty degeneration. The urinary bladder contained 
 a large quantity of dirty-yellow acid urine free from albumen. 
 Nothing abnormal was found in the genital organs, with the excep- 
 tion of the traces of the abortion. 
 
 The spleen was small, 4 inches long, 2£ broad, and f thick; 
 anaemic, and of normal consistence. Its weight amounted to 0.11 
 kilogr. (4 oz. avoird.) 
 
 The liver was much atrophied, and principally in its thickness ; 
 its right lobe was six inches long, and equally broad; the left, 5| 
 long and 3 \ broad; the thickness of the right lobe amounted to 
 1b inch, of the left to \. The entire weight of the organ, together 
 with the gall-bladder and the trunks of the vessels, was 0.82 kilogr. 
 1.8 lb. avoird.) ; the weight of the body being 44.5 kilogr. (98.104 
 lbs.), made the relative weight of the liver to that of the body as 1 
 to 54.2 ; there was thus a diminution in the weight of the liver by 
 nearly one-half. The consistence of the flattened gland was soft, 
 and at some places almost pultaceous ; its colour was a brownish- 
 yellow ; in the right lobe the branches of the hepatic vein were loaded 
 with blood, which at some places appeared to be extravasated. The 
 outer surface, especially of the left lobe, presented a wrinkled, finely- 
 granular character, owing to the hepatic cells having disappeared at 
 some places, aud the parenchyma having collapsed; the depressed 
 parts corresponded exactly with the circumference of the lobules. The 
 peritoneal covering was at such places opaque and thickened. The 
 
 P2 
 
212 ACUTE ATROPHY OF LIVER. 
 
 hepatic artery appeared large ; but nothing abnormal was observed 
 in the trunk of the portal vein. Injection of the branches of the 
 portal vein could only be made to pass along imperfectly — a remark 
 which was still more applicable to the hepatic artery ; the injected 
 matter penetrated readily into the ramifications of the hepatic vein, 
 but almost everywhere it avoided the tissue of the central part of 
 the lobules, and nowhere reached the capillaries of the portal vein. 
 On making fine sections of the tissue and drying them, its structure 
 could be examined more accurately and traced farther. As far as 
 the periphery of the lobules, the ramifications of the portal vein 
 were completely filled with the injection, but the further passage of 
 this into the capillary network was obstructed ; only at a very few 
 places was this network partially filled. The substance injected into 
 the hepatic vein penetrated as far as the central veins of the lobules, 
 which appeared unusually large, but only entered a short way into 
 the capillaries in the central part6 of the lobules, soon forming diffuse 
 extravasations. A broad rim of oil globules was seen to surround 
 the branches of the portal vein, whilst accumulations of bile-pigment, 
 partly granular and partly diffuse, surrounded the central veins of 
 the lobules. The hepatic cells were in some places still normal, and 
 contained in their interior oil globules or colouring-matter; but, at 
 other places, they were found to have become disintegrated into a 
 finely-granular detritus. Thus the morbid process had not advanced 
 so far as in the last case. The bile ducts were pervious, and con- 
 tained but little secretion. 
 
 The urine, as well as the blood from the right side of the heart 
 and the venae cavse, were subjected to a closer examination. 
 
 The urine, which had been passed twenty-four hours before death, 
 was very acid, and deposited a thick yellowish-brown sediment, con- 
 sisting, in a great measure, of urates, but containing, in addition, 
 large yellow crystalline masses of tyrosine. The urine was further 
 examined according to the method already described. It contained 
 a considerable quantity of urea, and much leucine and tyrosine, 
 together with viscid extractive matter. In this respect, the urine 
 "passed shortly before death differed from that which was collected 
 from the bladder at the autopsy. In the latter there could only be 
 detected an extremely minute trace of urea, and only a few crystals 
 of nitrate of urea could be found, even with the microscope. The 
 residuum, after evaporation of the urine, consisted of globules of 
 leucine,- intermingled with crystalline masses of tyrosine. Both 
 
ILLUSTRATIVE CASES. 2l3 
 
 substances were isolated and purified * so that there could be no 
 doubt as to their identity. . 
 
 The blood also contained much leucine, and, what appeared im- 
 portant, a considerable quantity of urea. The latter was not only 
 obtained as crystals in the form of nitrate and oxalate, but was also 
 separated in a pure state. 
 
 In the case before us, death took place before the cessation of the 
 local functions of the liver, and before the disintegration of the 
 glandular cells was complete, owing to the persistent and profuse 
 haemorrhage from the stomach. Hence it was, that the urine secreted 
 twenty-four hours before death still contained a tolerably large 
 quantity of urea, whilst this had completely disappeared in Observa- 
 tion No. XV., in which the morbid process was more advanced. 
 In other respects, the results of the two observations coincided. 
 The urea which disappeared from the urine, accumulated in 
 the blood; there was no impediment, therefore, to the formation 
 of this substance, but only to its elimination. We see here, that 
 without the existence of albuminuria, and without any remarkable 
 diminution in the quantity of urine, the excretion of urea may be 
 completely arrested. The only cause of this obstruction which could 
 be found on the part of the kidneys was fatty degeneration of the 
 glandular epithelium, the importance of which for the due performance 
 of the renal functions is hereby shown; whether other causes 
 co-operated cannot, in the present state of our knowledge, be ascer- 
 tained. The quantity of urates going along with the absence of urea 
 appeared remarkable. Can it be supposed that the. conditions, neces- 
 sary for the secretion of urates are different from those under which 
 urea is formed ? It is obvious, that the retention in the blood of the 
 constituents of the urine may have favoured the supervention of 
 typhoid symptoms. 
 
 • The detection of leucine in the urine is not unfrequently rendered 
 difficult, from the circumstance that the extractive matters entirely prevent 
 the formation of crystals, and the condensed extracts remain for days of 
 the consistence of syrup. One generally succeeds in removing this im- 
 pediment by digesting the extract for a long time with cold absolute 
 alcohol, which gradually dissolves away the extractive matter : by means 
 of boiling, spirit of wine the leucine can afterwards be obtained in the 
 crystalline form and purified. It is best to remove previously the princi- 
 pal portion of the extractive matter, by means of acetate of lead. 
 
214 ACUTE ATROPHY OF LIVER. 
 
 Observation No. XVII. 
 
 Symptoms of slight Catarrhal Jaundice, lasting fourteen days. On 
 the fifteenth day, sudden maniacal delirium; hemorrhage from the 
 Stomach and Bowels, and Death. 
 
 Atrophy of the Liver ; its secreting cells partly disintegrated, and 
 partly in a state of fatty degeneration. 
 
 Anna Paul, aged 20, a maid-servant, of robust constitution, was 
 admitted on October 17th, 1853. With the exception of slight 
 attacks of cardialgia, she had always before been healthy ; bat for 
 fourteen days she had complained of listlessness, loss of appetite, 
 and tendency to constipation ; along with which symptoms there was 
 slight jaundice of the skin. 
 
 Upon admission, the epigastrium was found distended and painful ; 
 there was no enlargement of the spleen ; the hepatic dulness in the 
 mammary line measured 5 centimetres (2 inches) ; the tongue was 
 dry; bowels constipated for two days. Pulse 104, small and weak; 
 urine abundant, of a yellow colour, but without the reaction of bile- 
 pigment. The patient was insensible, but not delirious. 
 
 She was ordered dilute muriatic acid, and an enema of compound 
 infusion of senna. 
 
 At 7 in the evening, noisy delirium suddenly set in ; the pulse 
 was 140, and small ; extremities cool. About 9 o'clock there was 
 vomiting of black tarry matter ; at 12, there were violent maniacal 
 symptoms, and the pulse was quite imperceptible. Death took 
 place about 5 in the morning. 
 
 Autopsy. 
 
 Brain and lungs normal ; numerous ecchymoses upon the epicar- 
 dium. The heart contained dark fluid blood, with gelatinous fibrin- 
 ous flakes. 
 
 The mucous membrane of the stomach and small intestine was 
 covered with black blood ; the membrane itself was intact. Hard 
 grey faeces were found in the rectum. 
 
 The spleen was slightly enlarged, soft, and congested. 
 
 The liver was small, flattened, and dry; its cut surface presented 
 a uniform ochre-yellow colour; its consistence was at some places 
 
ILLUSTRATIVE CASES. 2l6 
 
 diminished, at other parts normal. The hepatic cells were loaded 
 partly with fat and partly with pigment; in the softer portions of 
 the organ they were entirely absent; here, nothing could be seen 
 but oil globules and brown granules. 
 
 Observation No. XYILT. 
 
 Abdominal Typhus. — Profuse Epidai-is. — Violent Delirium. — Jaun- 
 dice on the fifth day. — Disappearance of the hepatic dulness. — 
 General muscular tremors. — Coma. — Death on the eighth day. 
 
 Small, shrivelled liver, with partially disintegrated cells and empty 
 bile . ducts. — Tumefaction of the Spleen. — Deposits in Peyer's 
 patches, and in the solitary glands of the Ileum. 
 
 Gottlieb Heumann, a clerk, aged 18, came to the Hospital on 
 November 18th, 1851, and died on the 26th. 
 
 This young man, after having felt out of sorts for some days, was 
 seized on the 16th of November with severe rigors and heat of skin, 
 followed by headache, general depression, and bleeding from the 
 nose. He was ordered chlorine. On the 18th, the haemorrhage 
 from the nostrils returned to such an extent that plugging became 
 necessary. Was ordered creosote. So early as the 19th, there was 
 delirium and great restlessness ; the stools were thin and pale. On 
 the 20th, there was protracted delirium, with excitement. The 
 spleen could be distinguished extending" one inch beyond the margin 
 of the ninth rib. Tongue dry; profuse perspiration ; pulse 120. 
 
 On the 21st, slight jaundice made its appearance; the pulse was 
 114, and very weak; the strength was failing; the hepatic dulness 
 in the mammary line was slight, and in the sternal line, absent; 
 two or three thin, pale stools in the day. He was ordered muriatic 
 acid with ether, in decoction of althaea. 
 
 On the 23rd, there was a severe rigor, lasting for two hours; 
 great restlessness, and dyspnoea. 
 
 On the 24th and 25th, there were several attacks of tremors not 
 unlike rigors; respirations 42 ; severe pulmonary catarrh ; extensive 
 rhonchi. Pulse 120, tremulous, and very weak. Stools involun- 
 tary. Was ordered benzoic acid, with camphor. 
 
 On the evening of the 25th', pulse 136; respirations 56; large 
 drops of perspiration; complete loss of consciousness; persistent 
 tremors of the extremities. Death on the 26th. 
 
216 ACUTE ATROPHY OF LIVER. 
 
 Autopsy on the 11 ih. 
 
 The abdominal cavity only could be opened. 
 
 Liver : the left lobe was visibly atrophied, with thin, sharp mar- 
 gins, and great diminution of its thickness ; the margins of the right 
 lobe were likewise very sharp ; the entire organ was soft and shrivelled 
 (welk). The cut surface was pale-brown, completely homogeneous, with 
 no appearance of lobules ; nowhere did any coloured fluid escape from 
 the bile ducts upon pressure ; a small quantity of whitish whey-Jike 
 fluid was found in the gall-bladder, the mucous membrane of which 
 was not at all yellow. The glandular cells were in part disintegrated ; 
 some of them were very pale, and several were filled with fat. 
 
 The spleen was enlarged, very soft and dark. 
 
 The kidneys were of normal size, soft, and anaemic. 
 
 In the small intestine, there were white submucous deposits in 
 Peyer's patches, and the solitary glands, the more extensive the nearer 
 the ileo-csecal valve was approached. There was no abrasion of the sur- 
 face of the mucous membrane ; the mesenteric glands were greatly en- 
 larged, of a bluish -red colour, and partiallyinfiltrated with grey deposit. 
 
 It may be a matter of question whether this case, for the accurate 
 notes of which I am indebted to my friend Ruble, is to be regarded 
 as one of acute atropby of the liver, or as one of severe typhus, 
 complicated with jaundice. The great diminution in the size of the 
 gland, the disintegration of a portion of the hepatic cells, and the 
 disappearance of the bile, have induced me to bring forward the case 
 in this place. It is impossible to draw a sharp definition between 
 the two conditions just mentioned. The diffuse infiltration of the 
 hepatic parenchyma, and the impaired secreting functions of the 
 organ, which, as above observed, occur not unfrequently in severe 
 cases of typhus, are abnormal states, which differ from acute atrophy, 
 with complete arrest of the hepatic functions, more in degree than 
 in nature. In both cases there is an exudation, which deranges the 
 nutrition and the functions of the gland. A case of typhus, in 
 which the atrophy of the liver was even farther advanced, has been 
 described by Buhl (op. eit.). 
 
 IV. ANALYSIS OP THE SYMPTOMS. 
 
 In order to determine with accuracy the symptoms which arise 
 in consequence of acute atrophy of the liver, it appears to me neces- 
 
ANALYSIS OF SYMPTOMS. 217 
 
 sary to make a detailed analysis of the materials hitherto collected 
 The number of reliable observations which I have thought might 
 without hesitation be employed for this purpose, amounts to 31. 
 The description of some of these cases is incomplete, and is, there- 
 fore, not applicable to the determination of every question. 
 
 1. The Premonitory Symptoms. 
 
 These were described in one half of the cases, and usually con- 
 sisted of those derangements which are met with in acute catarrh of 
 the stomach and bowels, occasionally of rheumatic affections; upon 
 these symptoms jaundice supervened, which, in its characters, was in 
 no way distinguishable from simple jaundice until the symptoms of 
 impending danger suddenly broke out. In most cases, the duration 
 of these premonitory symptoms amounted to from three to five days ; 
 but in many cases, to from two to three weeks and upwards. 
 
 2. The Skin. 
 
 This was invariably jaundiced, although the colour seldom attained 
 a high degree of intensity. So far as my owu observations extend, 
 this colour did uot appear at all conspicuous. As a general rule, it 
 commenced in the upper half of the body, on the face and neck ; it 
 extended over the lower extremities less frequently, and was here 
 scarcely observable. Along with the colour, the skin was usually 
 cool, dry, and inactive ; in none of my own cases was any elevation 
 of temperature observed. Alison and Bright likewise make parti- 
 cular mention of this circumstance. It is only at the commencement, 
 during the premonitory febrile stage, and afterwards for a short 
 period in the stage of great nervous excitement, during the restless 
 delirium and convulsions, that the temperature has been observed to 
 be elevated.* 
 
 In the advanced stage of the disease, the cutaneous system not 
 unfrequently participates in the haemorrhages which proceed from 
 various parts of the body, and especially from the mucous mem- 
 
 * Wunderlich (Handb. der Pathol, und Therapie, 2te. Aufl., Bd. IV., S. 
 655) states, that he has observed in several cases of malignant jaundice a 
 sudden rise from the normal temperature up to 34° cent. (99.2° Fahr.) : 
 there is no statement, however, to show what form of malignant jaundice 
 he alluded to. 
 
218 ACUTE ATROPHY OF LIVER. 
 
 branes ; petechia and large ecchymoses, of a reddish-brown or black 
 hue, become developed. These are by no means of constant occur- 
 rence, being wanting in two-thirds of the cases. 
 
 3. The Organs of Ovrculation, 
 
 The heart's action presents great variations in acute atrophy of the 
 liver. If there are premonitory febrile symptoms, the pulse, upon 
 the appearance of the yellow colour, becomes less frequent, and 
 remains in this condition as long as the jaundice retains a simple 
 character. Not until the abnormal nervous symptoms become pro- 
 minent does the rapidity of the pulse begin to increase, and it then 
 rises from 50 or 60 to 90 or 100, or upwards. Remarkable varia- 
 tions in its frequency are at the same time observable; for a brief 
 period it rises to 110, 120, or 130, soon afterwards to fall again to 
 80 or 90. This fluctuation, which is equally observed in reference 
 to the size and hardness of the pulse, may be repeated several 
 times in the course of a few hours. Not until incipient cerebral 
 paralysis supervenes does the increased frequency continue of a 
 uniform character; then it sometimes reaches 140 to 150 beats, 
 whilst its character is small, thready, and intermittent.* 
 
 To these abnormal conditions of the cardiac and vascular func- 
 tions are not unfrequently superadded haemorrhages, which usually 
 take place simultaneously from various parts of the body ; they were 
 observed in one half of the cases. They were met with most 
 frequently from the mucous membrane of the stomach and bowels, 
 in the form of haematemesis and melaena (ten times). Uterine 
 haemorrhages were equally common; they were especially observed 
 in the case of pregnant females, and then most frequently induced 
 abortion. Petechiae, large ecchymoses of the skin, and epistaxis 
 were of less frequent occurrence ; renal haemorrhage was only present 
 in exceptional cases {Buhl). Other haemorrhages were almost 
 always found in the dead body, whieh it was impossible to recognise 
 during life. Among these may be especially mentioned those which 
 took place from the portal system, extravasations between the folds 
 of the mesentery, in the omentum, upon the serous surface of the 
 bowel, haemorrhagic infarctions of the spleen, and likewise, although 
 
 * Even the earlier observers were astonished at this variable condi- 
 tion of the pulse. Vercelloni (Bianchi, loc. cit., II., 794) speaks of it as 
 " pulsus inaequalis turn quoad robur, turn quod numerum vibrationum." 
 
ANALYSIS OF SYMPTOMS. 219 
 
 less frequent, extravasations beneath the pleurse and the pericardium, 
 and upon the mucous membrane of the pharynx and bronchi, 
 hemorrhagic infarctions of the lungs, &c. 
 
 4. The Eespiration. 
 
 The respiration remains unaffected during the first stage of the 
 disease; the mechanism of the respiratory movements is unaltered, and 
 their frequency bears a normal ratio to that of the pulse, or is only 
 slightly at variance with it. It is only in the later stages, when 
 the oscillations in the heart's action, just mentioned, commence, that 
 the respiratory motions, at least in many cases, are wont to be 
 abnormal, and the breathing becomes sighing or stertorous. In such 
 cases, a short inspiration, accompanied by a groaning noise, is fol- 
 lowed by a rapid expiration, and then there is a long pause, similar 
 to what is observed in animals in which the pneumo-gastric nerves 
 have been divided. Structural changes of the air-passages, capable 
 of impairing the functions of the lungs, seldom existed in the cases 
 recorded, and it was only in exceptional instances that there were 
 found hsemorrhagic infarctions and sub-pleural extravasations ac- 
 companying haemorrhages in other parts of the body. 
 
 5. The Organs of Digestion. 
 
 These always undergo important functional changes. The pre- 
 monitory symptoms usually are ushered in by gastric derangements, 
 loss of appetite, oppression in the prcecordium, nausea, furred tongue, 
 constipation, &c. ; when there is no premonitory stage, these sym- 
 ptoms usually make their appearance on the outbreak of the jaun- 
 dice. Among the most important symptoms belonging to this 
 group may be mentioned, in the first place, abdominal pains, which 
 were observed in three-fourths of the cases. They are situated 
 sometimes in the epigastrium ; at other times, and most frequently, 
 in the hypochondria, especially the right, corresponding to the 
 region of the liver. Pressure in this place gives rise to marked in- 
 dication of pain, which is even observable during coma, from the 
 distortion of the countenance. The pains also come on spontane- 
 ously; and the patients complain, especially during the first stage of 
 the malady, of an uneasy sensation in the cardiac region. Although 
 the abdominal walls are very tense and tender, there is usually no 
 fulness present in the hypochondria. 
 
220 ACUTE ATROPHY OF LIVER. 
 
 The results of percussion are of much greater diagnostic import- 
 ance than the pain, which in many cases is completely absent. 
 Percussion shows a rapid diminution in the volume of the liver, 
 commencing with the left lobe and extending towards the right. 
 Usually the hepatic dulness soon disappears entirely, because the 
 organ, constantly becoming softer, owing to the disease of its tissue, 
 collapses, and is pushed towards the vertebral column by the intes- 
 tines distended with gas. In the same proportion as the liver is 
 atrophied the spleen is enlarged, and is the seat of tenderness, on 
 pressure, in the left hypochondrium. It is only in rare cases that the 
 increase in volume of the spleen cannot be made out, owing to the 
 organ being inaccessible to percussion, from old adhesions fixing it 
 in the hollow of the diaphragm, or owing to there being no enlarge- 
 ment at all. The latter may be the case when there is thickening 
 of the splenic capsule, which prevents the organ enlarging, or when 
 there is profuse haemorrhage from the stomach and bowels to such 
 an extent as to drain the portal system. 
 
 Along with these changes in the volume of the liver and spleen, 
 which, with some care, are easily recognised, repeated vomiting is usu- 
 ally observed at an early period. The vomited matters have in most 
 cases contained at first grey mucus, and occasionally bilious matter, 
 but after a time they have consisted of a greyish-brown or black 
 grumous fluid, the colour of which is more or less dark, according 
 to the severity of the gastric haemorrhage. When the haemorrhage 
 is slight, I have noticed, mingled with the mucous fluid, numerous 
 brown flakes, consisting of decomposed blood, which Morgagni ob- 
 served long ago, and designated as a " materien suhobscurus." 
 
 Almost invariably there has been obstinate constipation, which 
 could only be overcome by strong purgatives ; the stools have been 
 dry and clay-coloured; and, at a later period, they have assumed 
 in many cases a dark tarry aspect, in consequence of intestinal 
 haemorrhage. 
 
 6. The Urinary Organs. 
 
 The urine according to my observations, has always been secreted 
 in normal quantity ; but in the more advanced stages of the affec- 
 tion it has been necessary to draw it off by the catheter, for the purpose 
 of examination, otherwise, it has passed off involuntarily. It was 
 always of acid reaction; its specific gravity varied from 1012 to 
 
ANALYSIS OF SYMPTOMS. 221 
 
 1024 ; at first it only indistinctly presented the reaction of bile- 
 pigment, and it was not until a later period that this could be de- 
 tected with certainty. The remarkable changes in the composition 
 of the urine, the appearance in large quantities of leucine, tyrosine 
 and extractive matters of a peculiar nature, together with the gradual 
 disappearance of the urea and phosphate of lime, as was found 
 to be the case in Observations XV. and XVI., are conditions which 
 hitherto have been found in no other disease. These properties 
 of the urine indicate the existence of deeply important, although 
 long unrecognised, abnormal states, of the metamorphosis of matter, 
 and they furnish (provided further observation shall, as I have 
 no doubt, show them to be of constant occurrence), no small 
 insight into the transformations which take place in the albuminous 
 principles, in cases where the functions of the liver are arrested. 
 The peculiarity of the urine of most value in a clinical point of view 
 is the deposit upon exposure to the cold, of a greenish-yellow preci- 
 pitate, which, even with the naked eye, and still more readily upon 
 microscopic examination, can be recognised as differing from all 
 other deposits ; to this may be added, the appearances presented by 
 a drop of the dried urine. (Vide Frontispiece.) Further evidence 
 can only be obtained by careful chemical analysis. 
 
 It ought also to be mentioned, that occasionally small quantities 
 of albumen have been found for a short period in the urine. 
 
 7. The Nervous System. 
 
 Abnormal conditions of the nervous system have been observed 
 in every case as essential, characteristic symptoms ; and they have 
 almost invariably presented the same general characters, although in 
 some cases there have been sundry marked deviations. In most 
 cases we can distinguish two stages, that of excitement, and that 
 of depression, the former of which is characterised by delirium and 
 convulsions, and the latter by a progressively increasing coma, 
 gradually verging into cerebral paralysis. Only in rare cases (in 
 one-sixth of the whole number), was the stage of excitement absent, 
 the patients falling at once into a state of typhoid prostration, which 
 passed into unconsciousness, somnolence, and finally, into coma. 
 
 The nervous derangements are ushered in with severe headache, 
 accompanied by a gloomy, irritable temper and restlessness. These 
 symptoms are soon followed by delirium, which is usually noisy, and 
 
222 ACUTE ATROPHY OF LIVER. 
 
 raging, but occasionally shows itself in the form of quiet, harmless 
 wandering. The patients throw themselves about in a restless manner, 
 moan loudly, and from time to time utter an inarticulate cry ; not 
 unfrequently they fall into maniacal paroxysms.* 
 
 Convulsions accompanied the delirium in ten cases, or in one- 
 third of the total number of observations ; in some instances they 
 extended over the entire muscular system, like those of epilepsy, 
 and not unfrequently commenced like these with a shrill cry; in 
 other cases again/ they consisted of general muscular tremors, 
 resembling a rigor; while, V s %j hi some cases t fle y appeared as 
 partial twitchmgs of the muscles of the face, neck, or extremities, or 
 in the form of hiccup, grating of the teeth, &c. Trismus, and even 
 sometimes tetanic spasms, have been observed in a few cases. 
 
 Towards the termination of the disease, the delirium and convul- 
 sions, as a general rule, have given place to stupor, which in a short 
 time has merged into the deepest coma, from which no shouting 
 nor shaking could rouse the patient. The characters of the pupils 
 have been by no means constant ; in many cases they remained of 
 normal size, and reacted with light, as in my own observations, 
 and in those of Frey, &c. ; in other cases again, they were dilated 
 and immoveable, and in very rare instances, contracted. Yellow 
 vision occurred in exceptional cases only. 
 
 In most cases, the nervous derangements appeared simultaneously 
 with the jaundice ; and they usually attracted the attention of the 
 observer sooner than the slight jaundiced-tint of the conjunctiva, 
 and of the skin surrounding the alae of the nose. Sometimes 
 matters were different, the jaundice lasting 2, 5, 8, 14, 17, or 
 even 21 days, without any impairment of the nervous centres, until 
 suddenly, the scene became transformed, and a train of symptoms 
 betokening danger supervened. 
 
 * This character of the delirium in jaundice appears to have been known 
 to the ancients. Hippocrates (ad Democritum philos. epist.) observes : — 
 " Qui ex pituita insaniunt quieti sunt, qui vero ex bile hi verberant, male- 
 "fici sunt, neque quiescunt." Hippocrates further observes (De morbo 
 
 sacro) : " Qui ex bile insaniunt clamosi, maligni et minime quieti sunt, 
 
 " semper aliquid intempestivum faciunt." Ballonius also (Epidem. ephemer., 
 lib. II., cap. 188) describes the delirium as " vox inarticulata, ejulatus 
 " magnus." 
 
DURATION AND MODE OF TERMINATION. 223 
 
 V. DURATION AND MODE OF TERMINATION. 
 
 The symptoms just described usually run' their course in a few 
 days j in most cases the entire process terminates within the first 
 week, but occasionally the disease is protracted to three or even 
 four weeks. In such cases it is the apparently simple jaundice of 
 the preliminary stage which is protracted. After the commence- 
 ment of the characteristic 'symptoms, the disease almost invariably 
 terminates in five days, and sometimes even in from 12 to 36 
 hours. In 3 of the 31 cases, the date of the commencement 
 was unknown; in the remaining 28 cases, the fatal termination 
 occurred : — 
 
 during the 1st week 13 times. 
 
 2nd „ 6 „ 
 
 » 3rd „ 5 „ 
 
 ,, 4th „ 4 „ 
 
 The termination has almost invariably been fatal; this result has 
 been so constant, that the few observations which have been recorded 
 of a cure having taken place, must be regarded as of a very doubtful 
 character, and the more so, as most of them have occurred at a time 
 when only a few examples of the disease had been collected, and 
 when there was nowhere to be found any accurate account of it to 
 confirm the diagnosis. Griffin* mentions two cases, and Hanlonf 
 one, which terminated favourably ; Budd also makes mention of one 
 case of cure, which took place notwithstanding the previous occur- 
 rence of bloody stools, pains in the hypochondria, hiccup, and coma. 
 In the year 1854, 1 treated successfully a lady, aged 40, for jaundice, 
 associated with symptoms which favoured the supposition that 
 there existed incipient atrophy of the liver ; still I would not venture 
 to assert that this condition was really present. In this case, the 
 jaundice was slight, and was accompanied by delirium and typhoid 
 somnolence, the right hypochondrium was painful; the hepatic 
 dulness was diminished and, in the epigastrium, had completely dis- 
 appeared; the spleen was enlarged. The pulse varied between 88 
 and 104; the bowels were confined and the stools pale; there were 
 repeated attacks of epistaxis, &c. After eight days, these symptoms 
 
 * Dublin Med. Journ., 1834, IV., 12. 
 
 t Graves, Clinical Medicine. 2 ed., 1848, Vol. II., p. 255 
 
224 ACUTE ATROPHY OF LIVER. 
 
 ceased, and the patient slowly recovered. The treatment employed 
 consisted in drastic purgatives and mineral acids. 
 
 When the anatomical lesions, from which this disease is thought 
 to originate, have made considerable progress, and the larger portion 
 of the hepatic cells have become disintegrated, one can understand 
 that a cure can no longer be thought of. 
 
 The prognosis is thus, under all circumstances, in the highest 
 degree unfavourable. 
 
 VI. ANATOMICAL LESIONS. 
 
 The structural changes, which we find on post-mortem exami- 
 nation to account for the derangements of the various functions 
 just described, are very diverse ; the only constant ones are lesions 
 of the liver, next in order to which come those of the spleen. All 
 other pathological states .are inconstant ; they may be absent without 
 the symptoms during life undergoing any important alteration. 
 Hence we regard the liver as the peculiar seat of the disease, from 
 which the derangements in the functions of other organs take their 
 origin. The liver was in all 31 cases considerably atrophied; the 
 diminution in volume was estimated at one-third, one-half, or even 
 two-thirds of the normal size. Accurate measurements and weights 
 were, however, only made in a few instances. Bright saw the weight 
 reduced to 2 pounds, to 23 ounces, and in a third case, to 19 
 ounces : I have myself in two instances, found the liver to weigh 
 only 0.82 kilog. (1 lb. 13 oz. avoird.) the relative weight to that of 
 the entire body being as 1 to 68.5, and as 1 to 54.2, which indi- 
 cated a reduction of more than one-half. 
 
 The size of the organ is diminished in every direction, but 
 especially in its thickness ; the gland is flattened out. The capsule 
 presents an opaque puckered appearance ; the parenchyma is flabby 
 and shrivelled (welh), so that it is unable to bear its own weight, 
 and folds up and collapses in front of the vertebral column. 
 
 The cut surface of the organ presents at those places where th6 
 disease has advanced farthest, and these are usually in the left lobe, 
 an ochre-yellow or rhubarb-like colour ; the blood-vessels are here 
 empty, and in most cases the outline of the lobules is no longer 
 visible. At other places, where the morbid process is at an earlier 
 stage, some of the capillaries are filled with blood, and occasionally 
 there may be seen extravasations or their remains in the form of 
 
ANATOMICAL LESIONS. 225 
 
 crystals of heematoidine. Between the lobules, which are encircled by 
 the congested vessels, and separating them from one another, a dirty 
 greyish-yellow substance is deposited. At a later period the capillary 
 congestion recedes, the size of the lobules diminishes, and their 
 colour becomes yellower, whilst the relative amount of the intervening 
 grey substance gradually increases. After a time, this grey sub- 
 stance disappears at those places where the atrophy of the gland is 
 most apparent, and the organ assumes more and more a uniform 
 yellow tinge, from which the outlines of the lobules by degrees 
 completely disappear. As regards the vascular apparatus of the liver, 
 no important alterations are observed in the trunk and branches of 
 the portal vein; they contain a small quantity of thin blood; in 
 the hepatic veins I have found bundles and masses of tyrosine 
 crystals, along with normal blood corpuscles. Attempts at injection 
 have proved unsuccessful, the size which is injected into the hepatic 
 and portal veins becoming extravasated, without penetrating into the 
 capillaries, apparently because the delicate blood-vessels have lost their 
 support, from the destruction of the secreting cells. In thin sections of 
 the gland, the injection could be distinctly seen to fill only the capil- 
 laries nearest the central vein, and then to escape into the parenchyma. 
 The centre of the lobules appeared of a dirty-yellow colour, and 
 exhibited here and there brownish crystalline masses of leucine ; at 
 their periphery nothing but fine bluish-grey oil globules could be 
 detected. Where the disease had run through its entire course, the 
 hepatic cells were no longer visible ; in place of them were found 
 brown granules, and large particles of colouring-matter, oil globules, 
 and isolated bodies similar to cell nuclei, often accompanied by 
 needles of tyrosine and globules of leucine. It was only where the 
 morbid process had been arrested at an early stage, that there could 
 be seen isolated cells loaded with fat or pigment, and this was espe- 
 cially the case in Jhe rounded margin of the right lobe. In the 
 seventeen most recent observations of acute atrophy of the liver, the 
 disintegration of the hepatic cells was always made out; in the 
 earlier cases the organ was not examined with this object in view. 
 
 The gall-bladder was in most cases empty, containing only 
 a small quantity of grey mucus, or a turbid, pale-yellow, rarely 
 brown or greenish, fluid. The bile ducts exhibited nowhere any 
 impediment to the excretion, and likewise contained no bile; their 
 mucous membrane was in most cases of a grey colour, and their 
 calibre seemed narrowed. 
 
226 ACUTE ATROPHY OF LIVER. 
 
 Along with the atrophy of the liver, the spleen, in most of the 
 cases, was found considerably enlarged and congested; out of 23 
 cases in which this organ was carefully examined, in 19 it was 
 enlarged, in 3 normal, and in 1 small. There are certain causes, 
 such as thickening of the capsule, or profuse haemorrhage from the 
 roots of the portal vein, which may account for the non-appearance 
 of the swelling. In some cases the mesenteric glands were also 
 found to be enlarged.* 
 
 The stomach and intestinal canal present no important altera- 
 tion of structure; the mucous membrane is here and there 
 ecchymosed, but there are no losses of substance nor deposits in 
 the solitary glands, or in Peye/s patches. The intestinal contents 
 consist either of pale, dry faeces, or of black tarry matter, in which 
 the microscope cannot detect any blood corpuscles which have not 
 undergone some change. 
 
 The central organ and the larger trunks of the vascular system 
 present nothing abnormal, with the exception of a jaundiced colour 
 of the lining membrane, and a flabby, shrivelled character of the 
 muscular tissue of the heart. The blood is of various characters; 
 sometimes it is dark-violet and incompletely coagulated, but at 
 other times hard firm coagula of fibrin separate from it; the 
 number of colourless corpuscles is found to be increased in the 
 blood in the right ventricle. The presence of large quantities of 
 leucine and of urea, as in Observation XYL, is a much more re- 
 markable circumstance.! The extravasations of blood in various 
 organs and tissues are also remarkable. These were seen in the 
 larger number of the cases ; they were most frequent in the parts 
 from which the portal vein draws its supplies of blood, from 
 the surface of the mucous membrane of the stomach and bowels, 
 more rarely in the tissue itself of these organs, beneath the serous 
 coat of the intestine, and between the folds of the mesentery and 
 omentum; they were also observed in the retro-peritoneal areolar 
 tissue, and beneath the pleurae and epicardium. The effusions into 
 the serous cavities were often found tinged with blood. More rarely, 
 haemorrhages take place into the parenchyma of the internal organs, 
 such as the lungs, kidneys, &c. 
 
 The kidneys have not received the attention which they de- 
 
 * Buhl; and Observation No. XVIII. 
 
 t Whether there were any other abnormal products present, such as 
 the ammoniacal salts, has unfortunately not been investigated. 
 
theoretical considerations as to its nature. 227 
 
 serve. Besides the deposit of pigment dependent upon the jaundice, 
 I have found the glandular epithelium infiltrated with granules, and 
 in most cases in a state of fatty degeneration, and the tissue itself 
 flabby and shrivelled. The cases occurred for the most part among 
 pregnant females, in whom Spaeth has made the same observation. 
 Whether this abnormal condition is always present remains uncer- 
 tain. The peculiar changes in the urine, the disappearance of the 
 urea from it, and the accumulation of this substance in the blood, 
 and further, the temporary occurrence of albuminuria, point, how- 
 ever, to an important implication of the kidneys. 
 
 The central organs of the nervous system have in most cases pre- 
 sented abnormal conditions. In some cases the cerebral substance 
 has appeared softened ; a hydrocephalic softening has been particu- 
 larly observed in the central parts {Horaczek, Pleischl) ; but it is still 
 doubtful whether this condition is to be regarded, with Lebert, as 
 the result of commencing putrefaction, or as a product of disease ; at 
 all events, this change in the consistence of the brain cannot account 
 for the production of the nervous symptoms, as it is usually absent. 
 The post-mortem examinations which I have myself performed have 
 disclosed nothing abnormal in respect to the consistence of the 
 brain, or to its amount of blood, even when death has been preceded 
 by serious derangements of the nervous system. 
 
 vii. — Nature of the Disease. 
 
 We have now to construct a theory from the facts which have 
 been observed ; we must endeavour to explain the morbid process 
 which takes place in the liver, and to point out the connection in 
 which it stands to the concomitant symptoms. 
 
 Acute atrophy of the liver belongs to those obscure processes, as 
 to the nature of which various opinions may be advanced, without 
 its being possible for any one of them to obtain a general acknow- 
 ledgment. The fact of the disappearance in a few days of one-half 
 or one-third part of the original volume of a large gland abounding 
 in blood, without any alteration in the blood-vessels leading to it, 
 has a complete analogy in no other disease. Hokitansky, who was 
 the first to give an accurate anatomical description of this affection 
 of the liver, regarded the process as one of bilious liquefaction. An 
 excess of the elements of bile, according to him, is formed in the 
 blood of the portal vein, which, becoming separated, and pervading 
 
 q 2 
 
228 ACUTE ATROPHY OF LIVER. 
 
 the entire vascular apparatus of the liver, causes destruction of 
 the glandular substance by liquefaction. Such a mode of origin 
 of the bile in the portal vein is opposed to our previous know- 
 ledge concerning the formation of this secretion, and, moreover, the 
 increased secretion would not account for the destruction of the organ. 
 
 Henoch and Von Dusch likewise refer the destruction of the 
 hepatic cells to the action of the bile. The former assumes the 
 existence of a true polycholia, in consequence of which all the excre- 
 tory ducts, even those- of capillary fineness, become distended with 
 secretion and compress the blood-vessels; hence arises a considerable 
 impairment in the nutrition of the hepatic cells, which ultimately 
 lead to their disintegration by fatty metamorphosis. Yon Dusch 
 is of opinion that the disease proceeds from paralysis of the bile ducts 
 and lymphatic vessels, which gives rise to an infiltration of the organ 
 with bile, and, through this, to a solution of the cells. 
 
 We cannot agree with either of these views, first, because no 
 accumulation of bile can be observed to precede the atrophy; and, 
 secondly, because, even if such were the case, it would not account 
 for the atrophy. Henoch's assumption, that a state of polycholia 
 induces the morbid process, does not harmonize with the symptoms 
 of the preliminary stage, or, when this is wanting, with the com- 
 mencement of the disease itself, inasmuch as the evacuations from 
 the first contain but little bile; moreover, it cannot well be con- 
 ceived, how an abundant formation of bile can distend the ducts as 
 far as their capillary commencements, so long as there is no impedi- 
 ment to its excretion. The paralysis of the bile ducts and lymphatic 
 vessels assumed to exist by Von Dusch, is purely hypothetical, and 
 is not sufficient to account for a stoppage of bile, because the ducts 
 at their commencement contain no muscular fibres, and the absorp- 
 tion of bile takes place more especially by the blood-vessels. 
 But, even admitting that the atrophy was preceded by a stoppage of 
 bile, this would afford no explanation of the rapid disappearance of 
 the parenchyma of the liver, because, in cases where the ductus 
 choledochus is obstructed, the hepatic ducts are not unfrequently 
 filled and distended with bile during many months, and the hepatic 
 cells are saturated with secretion, without any condition resembling 
 acute atrophy resulting.* The experiments, therefore, by which 
 Von Dusch has endeavoured to prove that bile exercises a solvent 
 action over the hepatic cells, appear to be of doubtful value in 
 • See Observations V., VI., and VII. 
 
THEORETICAL CONSIDERATIONS AS TO ITS NATURE. 229 
 
 framing a theory of the disease under consideration; moreover, on 
 repeating these experiments, I have ascertained that the hepatic cells 
 may be immersed in bile for whole days without undergoing solu- 
 tion. 
 
 Buhl regards the disease as analogous in its nature to typhus ; 
 the disintegration of the hepatic cells he attributes to the same 
 cause as the concomitant hemorrhages, namely, to the marked 
 weakening of the heart's action, and to the rapid decrease of the 
 peripheric metamorphosis of matter. The changes which the liver 
 undergoes in typhus, pyaemia, &c, he considers as the commence- 
 ment of acute atrophy. 
 
 In opposition to the theories just mentioned there is another, 
 which attributes acute atrophy of the liver to a diffuse inflammation 
 of the gland. This theory was first enunciated by Bright, who 
 described cases of the disease under the appellation of hepatitis ; in 
 recent times, Engel, Wedl, and Bamberger have subscribed to it, 
 and have explained the destruction of the cells by a fatty degenera- 
 tion arising from an acute exudation-process. 
 
 Although I have some hesitation in identifying the destruction of 
 the hepatic cells with fatty degeneration, — because in the case of 
 other glands, such as the kidneys, fatty degeneration of the epithelium 
 does not produce such a rapid and general destruction of the cells, 
 and especially because, in acute atrophy of the liver, the fat can 
 only be seen deposited in the circumference of the lobules, whilst 
 the destruction of the cells is found to extend as far as the central 
 vein, — still I cannot but adhere to this view in so far that, according to 
 my experience, an exudation-process constitutes the starting-point 
 of the disease. On close examination of a liver which is undergoing 
 acute wasting, portions are found, mostly in the right lobe, in which 
 the morbid process has not run its entire course. In such places, 
 changes of structure may be detected, which appear to prove that 
 the destruction of the glandular elements, and the collapse of the 
 parenchyma, are preceded by hyperemia and exudation. We here 
 observe, not merely a remarkably congested condition of the capil- 
 laries, but, in the circumference of the lobules, broad grey bands, 
 consisting of finely-granular matter with isolated cells undergoing 
 disintegration, whilst the cells nearest to the central vein still con- 
 tinue normal, except that they are infiltrated with bile. At a later 
 period the congestion disappears, the grey exudation matter is 
 gradually removed, and the yellow debris of the secreting tissue 
 
230 ACUTE ATROPHY OF LIVER. 
 
 becomes more closely aggregated ; so that, in addition to the pro- 
 gressive atrophy of the organ, the outlines of the lobules are at last 
 quite obliterated. The destruction of the cells as a result of exuda- 
 tion is partly owing to the fact that this is deposited in a close 
 vascular network, where any effusion soon removes the necessary 
 conditions of nutrition, and partly to the cell-walls being delicate, 
 and the contents of the cells prone to decomposition. 
 
 The bile ducts at their origin are compressed at an early period 
 by the exudation at the periphery of the lobules ; as a conse- 
 quence of this, the secretion formed in the central portion of the 
 lobules stagnates, and passes into the central veins, and so into the 
 general mass of the blood. It is in this way that jaundice comes to 
 make its appearance, while the ochre-yellow colour of the liver and 
 the pale mucous lining of the empty bile ducts owe their origin to 
 the same cause. Against the supposition that an exudation process 
 lies at the foundation of acute atrophy of the liver, it has been 
 urged that no hyperaemic enlargement of the organ can be detected 
 during the progress of the disease. This objection is of small weight, 
 because the liver has rarely been closely examined previous to 
 the appearance of the jaundice, and because no remarkable enlarge- 
 ment of the organ is necessary for the occurrence of diffuse exudation, 
 and the less so, as this does not usually attack the entire gland at 
 one time. 
 
 Another question which we must here endeavour to answer is : — 
 how are the symptoms which accompany the disease connected 
 with the structural changes found in the liver ? 
 
 It has already been shown in what manner the jaundice arises ; it 
 is a more difficult matter to explain the mode of development of the 
 nervous symptoms, the haemorrhages and the tumefaction of the 
 spleen. 
 
 I believe that the abnormal nervous symptoms, of which no ex- 
 planation is furnished by any morbid appearance of either the brain or 
 its membranes,* must be referred to changes in the composition of 
 the blood. I do not refer here to the presence of the constituents of 
 bile, as to the harmlessness of which I have convinced myself by a 
 long series of injection-experiments; but I attribute the cause of 
 the blood-intoxication to the complete arrest of the hepatic functions 
 from the destruction of the secreting cells, and to the derangement 
 
 * Buhl is of opinion, that here, as in typhus, we can always detect an 
 acute atrophy of the brain. 
 
THEORETICAL CONSIDERATIONS AS TO ITS NATURE. 231 
 
 of the renal secretion. The former of these causes includes not only 
 the absorption of bile, and the retention in the blood of the sub- 
 stances intended for the formation of this secretion, but also the 
 cessation of the powerful influence which the liver exerts over the 
 processes of metamorphosis of matter, and the simultaneous passage 
 of the disintegrated glandular substance into the blood. We are 
 not acquainted in its entire extent with the influence exerted by the 
 liver over the metamorphosis of matter ; as yet we only know that 
 the formation of sugar out of albuminous substances is a necessary 
 link in the functional processes of the gland, and we infer from the 
 existence of numerous other substances which have been observed, 
 partly under normal, and partly under pathological conditions, such 
 substances as xanthine, urea, inosite, leucine, tyrosine, cystine, &c, 
 that the organ is intimately related in many ways to the metamor- 
 phosis of matter. The important nature of these relations is shown 
 by the remarkable changes, which the urine — the general recipient 
 of the chief ultimate products of this metamorphosis — undergoes in 
 acute atrophy of the liver. The urea, which is the normal product 
 of the disintegrated albuminous tissues, as we have seen, gradually 
 disappears, and in its place, a large quantity of products which 
 are foreign to healthy urine make their appearance. Its solid con- 
 stituents consist almost exclusively of leucine and tryosine, together 
 with a peculiar extractive matter ; uric acid is present in tolerable 
 quantity. It is doubtful what is the cause of the absence of 
 urea. Is this substance really formed, although not excreted by 
 the kidneys, or is the metamorphosis of tissue so far altered 
 that at last no urea comes to be formed as an ultimate product ? 
 The considerable quantity of urea which is found in the blood, 
 proves that its elimination is really stopped ; still we must not con- 
 clude from this, -that the formation of this product takes places in a 
 normal manner, because we have no idea, not even an approximative 
 one, as regards the amount to which it accumulates in the blood.* 
 
 * It may be mentioned that in yellow fever also a considerable quantity 
 of urea has been detected in the blood. If we assume that the formation 
 of urea ceases, products should arise in its place, similar to those into which 
 the albuminous substances are decomposed under* the action of putrefac- 
 tion, or upon the addition of nitric acid. The urea cannot be entirely re- 
 placed by leucine and tyrosine, because both these are poorer in nitrogen 
 than albumen. It is thus clear, that along with these substances still 
 another must be formed, containing a large proportion of nitrogen. 
 Whether the amorphous matter which is found in large quantity in the 
 
232 ACUTE ATROPHY OF LIVER. 
 
 Thus far it must be regarded as an established fact, that acute 
 atrophy of the liver induces very important abnormal conditions of 
 the metamorphosis of matter, and that during its progress sub- 
 stances circulate in the blood which are not met with in that fluid 
 in a healthy condition. What it is which induces the symptoms of 
 blood-poisoning is uncertain; that it is not leucine or tyrosine is 
 proved, by injections of these substances into the blood of animals 
 producing no derangements of the nervous functions. It is more 
 probable that they are due to a retention of the constituents of the 
 urine ; but this point cannot be determined without further investi- 
 gation. 
 
 As regards the production of the splenic enlargement and the 
 haemorrhages, I believe that the former is to be, accounted for, partly 
 by the altered composition of the blood, and partly by the obstruction 
 of the circulation in the hepatic capillaries, which lose their normal 
 support in consequence of the disappearance of the cells ; the circum- 
 stance of the haemorrhages occurring chiefly in those parts from which 
 the portal vein derives its blood, viz. : from the mucous membrane of 
 the stomach and bowels, and between the folds of the omentum and 
 of the mesentery, is in favour of a mechanical view of the matter. 
 There must, however, be some farther reason to account for those 
 haemorrhages, which occur in other parts, such as the skin, &c. 
 These have been attributed at one time to the debility of the heart's 
 action, the general want of tone in the system, and the defective 
 nutrition of the blood-vessels {Buhl), at another time, to the deficient 
 formation of fibriue (Monneret), and at another, to an over-distended 
 condition of the blood-vessels in consequence of a deficiency in the 
 secretion of bile. There is another explanation which appears to me 
 more probable, namely, an abnormal attraction between the walls of 
 the vessels and the blood which has become altered in its composi- 
 tion, from which arise obstruction and rupture of the capillaries. 
 Bernard* has already endeavoured to show, that the passage of sugar 
 from the liver into the blood prevents the infiltration of the tissues, 
 and promotes the circulation. In the cases before us, it is not only 
 
 urine corresponds to this, has not been ascertained with certainty ; neither 
 has any cause been assigned to prevent the farther transformation 
 of this substance into urea. It is possible that the ferment matter, 
 which experience shows to be contained in the liver, is indispensable to 
 this further metamorphosis ; but the subject can only be cleared up by 
 new observations and direct experiments. 
 
ETIOLOGY. 233 
 
 the formation of sugar which is arrested, but in addition to this, a 
 whole series of substances pass into the blood, which may not be 
 without some influence over the production of the haemorrhages. It 
 is obvious, however, that we do not possess a more complete proof 
 of this theory, than of any of the others. 
 
 VIII. ETIOLOGY. 
 
 We are still without a clear insight into the mode of origin of 
 acute atrophy of the liver ; we can only enumerate in the meantime the 
 circumstances under which the affection makes its appearance, without 
 being able to state the respective share which these causes play 
 in individual cases, or to trace more closely their mode of operation. 
 Unfortunately, however, the same remark applies- to the etiology of 
 most diseases. 
 
 The disease is most frequently observed in the female sex ; of the 
 31 cases, 9 were men and 22 females, so that the number of the 
 latter more than doubled that of the former. Of the 22 females, 
 one-half were attacked during pregnancy ; consequently, more than 
 one-third of all the cases were associated with this condition of the 
 system, a circumstance which points to both of these conditions 
 (sex and pregnancy) as predisposing causes. Nevertheless, acute 
 atrophy of the liver is a rare affection, even in pregnant females ; 
 out of 33,000 cases, Spaeth found this complication present in 
 only two instances. Very frequently during pregnancy, the kidneys 
 and the liver become infiltrated with granular albuminous matter, 
 which gives rise to alterations in the character of their secretions, 
 and to fatty degeneration of the glandular epithelium. Under certain 
 conditions this process advances to diffuse nephritis and hepatitis ; 
 it is generally known how frequently this happens in the case 
 of the kidneys, and also, what are the symptoms which denote 
 the presence of the renal affection; in the liver the process 
 seldom attains such an advanced development, and here destruc- 
 tion of the gland is the result. Acute atrophy of the liver in 
 pregnant females may be recognised by the fact that it is 
 almost invariably accompanied by fatty degeneration of the kid- 
 neys. That it is not mechanical compression, as Scanzoni thinks, 
 to which the cause of atrophy of the liver is to be attributed in 
 pregnant females, is shown by the period at which this affection 
 makes. its. appearance; in most cases, it is from the third to the 
 
234 ACUTE ATROPHY OF LIVER. 
 
 sixth month, sometimes it is the seventh, but it is rarely at a time 
 when the uterus can operate mechanically upon the liver. 
 
 As regards age, the period of life between 20 and 30 seems 
 most predisposed to the disease. Of the 31 cases, there were :— 
 
 6 between 10 and 20 years of age. 
 20 „ 20 „ 30 „ „ 
 3 „ ' 30 „ 40 „ „ 
 2 „ 40 „ 60 „ „ 
 
 Cases of acute atrophy of the liver have also been described in 
 children, but I know of no observation sufficiently detailed to find a 
 place here. 
 
 Of the special injurious agencies, which precede the outbreak of 
 the disease, and- which after its appearance co-operate with its 
 exciting causes, the following are the most conspicuous. 
 
 1. Mental emotions. — In several cases the disease appeared in 
 individuals previously healthy, so immediately after a severe fright, 
 or an outburst of passion, that the influence of mental emotions 
 could scarcely be doubted. The patients became immediately jaun- 
 diced, began to be delirious and died in a few days. Such cases 
 have been described by Vercelloni, Morgagni, BaUonius, and others. 
 
 2. Yenereal excesses, syphilis, the improper use of mercury, 
 drunkenness, and the other morbid influences arising from a disso- 
 lute life, have occasionally preceded the disease : still it is not 
 certain that these morbid influences were connected with the disease 
 as cause and effect, and it is still less possible to prove with certainty 
 the influence of one of them apart from the others. 
 
 3. There would appear to be influences, of the nature of miasmata, 
 confined to certain localities, which contribute to the production of the 
 disease; at all events, we are led to believe in the existence of such influ- 
 ences from the presence of the malignant forms of jaundice, in different 
 members of the same family, or in other individuals living in the same 
 house, examples of which have been recorded by Budd, Griffin, and 
 Hanlon. It still, however, remains a question, whether these cases 
 ought, or ought not, to be regarded as examples of acute atrophy of 
 the liver; sufficient anatomical evidence on the point does not exist. A 
 miasmatic origin of the disease, as under certain circumstances seems 
 at first-sight probable, may indicate rather the existence of one or 
 other of the forms of bilious fever, which supposition is favoured by 
 the frequency with which such cases have terminated favourably. 
 
DIAGNOSIS. 235 
 
 4. Typhus and the allied changes in the composition of the blood. — 
 I have myself seen one case of acute atrophy of the liver proceeding 
 from typhus, and Buhl has observed others, in which the me- 
 senteric glands were enlarged in a similar manner to what they are 
 in this disease. In such cases, there is a greater development of 
 that infiltration of the hepatic parenchyma which we have already 
 found to exist in typhoid jaundice. Usually no other cause can be 
 detected, which can account for the origin of the morbid condition 
 of the liver, and the etiology of the affection must be left for future 
 investigations. 
 
 IX. DIAGNOSIS. 
 
 Acute atrophy of the liver is less easily recognised than it would 
 appear to be. It is very frequently mistaken for other diseases, 
 particularly typhus complicated with jaundice, bilious fevers of 
 various sorts, pyaemia, &c, and such mistakes can only be avoided 
 by a careful weighing of all the symptoms. During the preliminary 
 stage, a diagnosis, as a general rule, is impossible. When haemor- 
 rhages, violent headache, delirium, &c, are associated with jaundice, 
 it then becomes a question whether, independently of the liver, 
 there are local or general derangements present, which can or 
 can not account for these symptoms. Typhus is recognised by 
 the symptoms which mark its progress, the roseolar eruption, the 
 bronchial catarrh, the diarrhoea, and the wandering character of 
 the delirium; bilious fevers as a rule, are characterised by a 
 more or less distinctly remittent type, and by repeated attacks 
 of rigors; pyaemia is distinguished by rigors and by the presence 
 of purulent deposits. Local diseases, such as meningitis, pneumonia, 
 and peritonitis, which, when associated with jaundice and delirium, 
 present a train of symptoms, resembling, as I have myself observed, 
 those of acute atrophy of the liver, can usually be easily recognised 
 by a careful examination of the individual organs. The characters 
 exhibited by the liver itself are of greater importance in diagnosis, 
 not so much the tenderness, which is now and then absent, as the 
 diminution in volume, which advances rapidly, until at last the 
 dulness on percussion completely disappears. The cautions which 
 are to be observed in determining the dulness, have been explained in 
 Chap. III. Of equal diagnostic value are the characters presented 
 by the urine, the deposition of sediments of tyrosine, the crystalline 
 
236 ACUTE ATROPHY OF LIVER.— TREATMENT. 
 
 forms which separate upon evaporation, &e. The importance of 
 the remaining symptoms in diagnosis depends upon the frequency 
 of their occurrence, a point which has already been discussed. 
 Petechise and epistaxis, which in typhus are of frequent occurrence, 
 appear to be of less importance than vomiting of blood, as indica- 
 tions of acute atrophy. 
 
 X. TREATMENT. 
 
 The results of treatment hitherto recorded, are, as has already 
 been stated, of a hopeless nature; hence no approved empirical 
 method exists. English physicians recommend emetics and purga- 
 tives, two classes of remedies, the energetic action of which upon 
 the liver certainly cannot be denied. According to Corrigan, 
 the progress of the disease is arrested by emetics, and accord- 
 ing to Griffin and Hanlon, by drastic purgatives; in the case 
 which I myself saw run a favourable course, purgatives and 
 mineral acids were employed. This experience, small though it be, 
 would be of great value if we could be sure that the observations 
 really referred to cases of acute atrophy of the liver, which unfor- 
 tunately is impossible, considering the uncertain nature of the 
 diagnosis of the incipient stages of the disease. The lack of more 
 direct experience must be supplied by general principles, and by the 
 analogy of allied conditions. 
 
 In the preliminary stage, the same principles of treatment are of 
 service, as in simple catarrhal jaundice; a more direct treatment is 
 not called for, until symptoms denoting serious disease of the hepatic 
 parenchyma manifest themselves. At the commencement, our object 
 should be to remove the congestion and diffuse exudation; afterwards, 
 when the atrophy has extended over most of the gland, no benefit can 
 be expected from treatment. Tor the purpose just mentioned the 
 stronger purgatives are especially recommended, by means of which 
 the congestion of the liver is most effectually relieved, such for 
 instance, as senna, aloes, coloeynth, &c, and they should be adminis- 
 tered in such doses as to bring about profuse evacuations. When 
 there are severe pains in the liver, benefit will be derived from the 
 application of leeches, cupping-glasses, and cold cloths, and in 
 full-blooded individuals from venesection. "When the symptoms of 
 blood-poisoning and haemorrhages make their appearance, the ad- 
 ministration of the mineral acids is indicated, along with which 
 
ACHOLIA FROM OTHER CAUSES. 237 
 
 purgatives may be continued, to keep up the action of the bowels. 
 To check the vomiting we may prescribe ice, the magistery of 
 bismuth,* and small doses of the aqueous extract of nux vomica. 
 Haemorrhages from the stomach and bowels require ice internally 
 and externally, alum, gallic acid and similar astringents. When 
 there are symptoms of nervous depression, we must employ stimu- 
 lants, such as ether, camphor, and musk ; in such cases, however, 
 it is seldom that we can look for any good result. 
 
 In cases where the diagnosis is doubtful, especially where the 
 distinction between acute atrophy and bilious fever remains uncertain, 
 I would recommend large doses of quinine dissolved in acids. 
 
 Besides acute atrophy, there are other morbid processes, which, 
 if they lead to complete disorganisation of the liver, and conse- 
 quently to an arrest of its functions, may give rise to symptoms of 
 blood-poisoning. Symptoms may appear under such circumstances 
 which in most respects range themselves with those just described, 
 but which differ in many points. Here, as in acute atrophy, 
 there may be observed dangerous nervous symptoms, typhoid som- 
 nolence, delirium, coma, and convulsions, accompanied by petechias 
 and ecchymoses of the skin, as well as by haemorrhages from the 
 mucous membrane of the stomach and bowels, and along with these 
 symptoms we may find, in most cases, jaundice of a more or less 
 intense degree; but on the other hand, the jaundice may be com- 
 pletely absent, the abnormal cerebral symptoms may be for the most 
 part less violent, and, moreover, the characters presented by the 
 preliminary stage may be very different from those of acute atrophy, 
 as, for instance, when the disease is preceded for a long time by 
 symptoms of occlusion of the bile ducts, or by those of cirrhosis 
 or fatty degeneration of the organ. 
 
 Among the diseases of the liver, which may give rise to 
 destruction of the glandular epithelium, may be mentioned, in the 
 first place : — 
 
 B. 1. Obstruction to the Flow of Bile resulting from Impermeability 
 of the Ductus Choledochus and B. Hepaticus. 
 
 In some cases, when this condition has lasted for several months, 
 it gives rise to an atrophy of the gland, which in many points 
 
 * Trisnitrate. 
 
238 ACHOLIA 
 
 resembles acute atrophy. The organ diminishes in size and becomes 
 soft and dry, the cells of the parenchyma which are infiltrated with 
 bile become disintegrated into a finely-granular debris, mingled with 
 oil globules and particles of pigment, while at the same time large 
 quantities of leucine and tyrosine may be detected. 
 
 Observation No. XIX. 
 
 Cancerous Deposit in the Duodenum. — Occlusion of the Ductus 
 Choledochus. — Intense Jaundice. — Convulsions. — Coma. — Death. 
 
 Priedr. Bloch, a female, aged 58, who had been suffering for a long 
 time from various diseases in Prankel's Asylum for Old People, was 
 brought to the Jewish Hospital of this place on July 29th, 1853. 
 The patient had her mental powers somewhat impaired, and was of 
 a surly temper, so that it was impossible to ascertain any accurate 
 history as to the mode of origin of her illness. On admission, she 
 presented a series -of symptoms, indicative of intense jaundice as a 
 result of closure of the ductus choledochus. 
 
 The woman was emaciated, and her dry wrinkled skin was 
 coloured at some places brownish-yellow, and at others olive-green; 
 its temperature was low. The tongue was clean, and the appetite 
 unimpaired. The bowels were confined, and the stools consisted of 
 dry, clay-coloured scybala. The urine was brownish-black, and 
 deposited at one time a brick-red, and, at other times, a yellow, 
 sediment of uric acid. The pulse was 50 and weak. The left lobe 
 of the liver extended about 5 centimetres (2 inches) beyond the 
 margin of the false ribs, and reached upwards to a level with the 
 lower margin of the sixth rib ; the right lobe, which was elongated, 
 and drawn downwards by means of a tight-lace constriction, ex- 
 tended 8 centimetres (3.15 inches) beyond the margin of the ribs. 
 Close to the sternum, the hepatic dulness amounted to 9 centimetres 
 (3.54 inches) ; in the mammary line it was 16 cent. (6.3 in.), and in 
 the axillary line, 14 cent. (5.51 in.) The surface of the organ felt 
 smooth; its margins were sharp towards the left side, but on the 
 right side were somewhat rounded. Ten centimetres (4 inches) to 
 the right of the umbilicus, and somewhat deeper, there lay a soft, 
 pear-shaped tumour, the size of a duck's-egg, which was evidently 
 the distended gall-bladder. No tumour capable of compressing the 
 
FROM IMPERMEABILITY OF BILE DUCTS. 239 
 
 ductus choledochus could be made out upon palpation.* No hard- 
 ness could be felt in the region of tbe pylorus and of the head of 
 the pancreas. There never had been any symptoms of colic from 
 gall-stones. 
 
 The patient was treated for a long time with tincture of colocynth, 
 aloes, and such-like remedies, along with warm-baths and easily- 
 digested food, without any marked change in her condition. From 
 time to time she suffered from severe cardialgia, which yielded to 
 the use of the magistery of bismuth (trisnitrate) and belladonna. 
 
 The emaciation gradually increased, the feet became cedematous, 
 the quantity of brownish-black urine was reduced, but remained free 
 from albumen ; the mental powers at the same time became more 
 and more depressed. The patient continued in a state of gloomy 
 silence, answered questions either not at all or incompletely, asked 
 for nothing, complained of nothing, and ate the nourishment offered 
 her with a slight appetite. She was generally asleep; on calling 
 loudly to her, she awoke, opened her dull, lustreless eyes, said she 
 felt well, and immediately went to sleep again. 
 
 Towards the end of October, she had repeated attacks of epistaxis, 
 which were arrested with difficulty.. 
 
 At the end of November, she was suddenly seized with convul- 
 sions ; the attacks lasted from a quarter to half-an-hour, and returned 
 from time to time. The somnolence now passed into deep coma, 
 from which she could no longer be roused. 
 
 The patient now became rapidly collapsed; her skin became 
 shrivelled like that of a mummy, and its temperature sank more and 
 more; the pulse grew smaller, and at last was imperceptible, until 
 death took place on the 23rd of December. 
 
 Unfortunately only a very imperfect post-mortem examination 
 could be made. The liver, stomach, duodenum, and pancreas were 
 the only parts carefully examined. 
 
 The liver was somewhat enlarged, and its right lobe was subdivided 
 by a tight-lace fissure. Its surface was smooth ; its margins were 
 sharp, except those of the right tight-lace lobe, which were rounded. 
 The gall-bladder projected 2J inches beyond the margin of the liver, 
 and contained about 9 ounces of turbid dark-brown bile. The gall 
 ducts, from the ductus choledochus and ductus hepaticus, as far as 
 
 * Firm pressure upon the abdominal walls was made with difficulty, 
 on account of the obstinacy with which the woman kept her muscles in 
 a state of constant contraction. 
 
240 ACHOLIA 
 
 their finest terminal branches, contained a quantity of turbid brown, 
 thin fluid, of which from 18 to 20 ounces could be collected on 
 cutting up the organ. The ducts were all considerably enlarged. 
 The hepatic duct measured 1 inch and 4 lines, and was marked by 
 numerous deep pouch-like depressions, leading into the adjoining 
 branches. The parenchyma of the glands was of a dark-brown colour, 
 soft and easily compressible ; and the outlines of the lobules were 
 indistinct. Upon the cut surface were seen small greyish-white, 
 hard deposits, partly rounded and partly branched, like a tree, which 
 corresponded with the course of the finer twigs of the hepatic 
 vein, and in some places completely filled these twigs. Crystalline 
 deposits of the same substance lay embedded in the walls of the 
 larger branches of the hepatic veins, so firmly, that on scraping 
 with a knife they could only be separated with difficulty. These 
 crystalline masses were made up of an aggregation of fine needles. 
 No abnormal deposits could be detected in the ramifications of 
 the portal vein or of the hepatic artery. The cells of the hepatic 
 parenchyma were in a great measure disintegrated ; on microscopic 
 examination only a few were found to remain intact : in their place 
 were seen fine brown molecules and oil globules, and also numerous 
 bundles of acicular crystals (tyrosine), and globular masses deposited 
 in concentric layers (leucine) .f These deposits were at some places 
 densely aggregated, but at other parts were either very scanty or 
 altogether absent. 
 
 The same crystalline and concretion-like deposits, as were found 
 in the liver, were also present in the turbid bile, along with tables of 
 cholesterine. A large quantity of leucine and tyrosine was obtained 
 from the substance of the liver, the identity of which was proved by 
 Professor Staedeler, on elementary analysis.* In the mother-liquid 
 also, from which these bodies had been separated, a substance was 
 observed, which, upon exposure to the air, assumed an intense blue 
 colour, similar to Chromogen, with which we shall afterwards become 
 acquainted, when considering the transformation of the biliary acid 
 into pigment. The liver did not contain any sugar. 
 
 At the point of entrance of the ductus choledochus into the duo- 
 denum there was a tumour the size of a walnut, with all the 
 characters of villous cancer. By means of this the bile duct was 
 obliterated. The pancreas was flabby and shrivelled; the mucous 
 membrane of the stomach, at some places, was ecchymosed, but 
 
 • See Miiller's Archiv f. Anat, &c, 1854. t See Frontispiece, Fig. 4. 
 
FROM CIRRHOSIS. 241 
 
 ■without any loss of substance. The spleen was somewhat enlarged 
 and anaemic. 
 
 Large quantities of the . brownish-black urine passed by the 
 patient were examined for the presence of the biliary acids, but always 
 with a negative result. It was not examined for leucine and tyrosine. 
 
 The morbid process just described is, on the whole, rare ; in most 
 of the cases where death has followed as a consequence of occlusion 
 of the bile ducts, the hepatio cells, on post-mortem examination, were 
 infiltrated with colouring-matter, but were otherwise unaltered. The 
 manner in which they become disintegrated is still unknown ; this 
 disintegration cannot be attributed with certainty either to the solvent 
 action of the bile, or to the destruction of the branches of the portal 
 vein by the enlarged bile ducts, inasmuch as we often observe the 
 same infiltration of the parenchyma, and enormous enlargement of 
 the ducts, without any such consequences. 
 
 "Whether the derangements of the nervous functions always pre- 
 sent the same characters as in the oase just communicated must be 
 determined by future experience ; this may depend upon the more or 
 less complete disintegration of the hepatic cells, and upon the 
 rapidity with which it takes place. Budd has described a case in 
 which pain in the liver, haematemesis, headache, and other sym- 
 ptoms made their appearance, but where delirium was only present 
 in the night-time during the last week of life.* 
 
 c. Acholiafrom Cirrhosis. 
 
 Cases have repeatedly occurred to me, in which individuals who for 
 a long period have suffered from cirrhosis of the liver, have suddenly 
 presented a series of morbid symptoms which are foreign to that 
 disease. They have become unconscious, and have been afterwards 
 seized with noisy delirium, from which they passed to deep coma, 
 and in this state have died. In one case there were spasmodic 
 contractions of the muscles of the left side of the face. In most 
 cases, slight jaundice made its appearance at the same time, and in 
 one instance there were petechise. Upon post-mortem examination, 
 
 * Budd draws the conclusion from this observation, that the secreting 
 functions of the liver are not indispensable to the continuance of life, and 
 that a patient may live for a lengthened period after the destruction of 
 the hepatic cells ; but we are not entitled to make such an assumption. 
 
 B 
 
242 ACHOLIA. 
 
 not the slightest lesion could be detected in the brain; neither were 
 there indications of any acute disease which could account for the 
 derangement of the cerebral functions. The liver, in all the cases, 
 presented cirrhotic degeneration in a marked degree, and the glandu- 
 lar cells were for the most part loaded with fat ; large quantities of 
 leucine separated from it; the bile ducts contained only a small 
 quantity of pale bile. 
 
 Obseevation No. XX. 
 
 Ascites. — Anasarca. — Diarrhoea. — DeUrium. — Coma. 
 
 Cirrhosis of Liver. — Deposits of Leucine m the hepatic veins. — The 
 central organs of the nervous system normal. 
 
 E. Radesey, a bookbinder, aged 59, came to the Hospital on the 
 4th of December, 1854, with great oedema of the feet, and ascites. 
 The heart and lungs were healthy ; the hepatic dulness could not be 
 distinguished; the size of the spleen could not be determined, owing 
 to its situation being abnormal ; the veins on the right side of the 
 abdomen were greatly enlarged. The appetite was unimpaired ; the 
 stools were thin and pale; the urine scanty, red, and without 
 albumen. The patient confessed that formerly he had been in the 
 habit of drinking much brandy, and could account for his illness in 
 no other way. He was ordered decoction of colocynth. Copious 
 thin evacuations diminished the size of the abdomen, and the patient 
 felt himself better. On the 17th, he suddenly fell into a state of 
 unconsciousness, from which he could not be roused ; the counte- 
 nance became pale and sunk ; the pupils were of normal size, and 
 moveable; the pulse was 70, and full; stools involuntary; no vomit- 
 ing. Was ordered infusion of Arnica flowers, with spirit of nitric 
 ether. 
 
 On the 18th, great restlessness ; inarticulate cries; complete loss 
 of consciousness; pulse 90; respirations 22. About noon, the 
 mouth was observed to be drawn towards the right, as in paralysis 
 of the facial nerve. 
 
 On the 19th, pulse 120 ; deep coma, and stertorous respiration. 
 
 On the 20th, tracheal rales, and death about noon. 
 
 The membranes and substance of the brain were perfectly normal; 
 
FROM CIRRHOSIS. 243 
 
 the lungs, moderately (Edematous. Liver small ; its outer surface, 
 as well as that seen upon section, covered with cirrhotic nodules, 
 separated by grey areolar tissue; the hepatic cells loaded with oil, 
 and in some places with pigment. Granules of a sulphur-yellow 
 colour, and with a diameter measuring up to a quarter of a line, were 
 seen upon the inner surface of the hepatic veins. These were firmly 
 adherent to the wall of the vessel, and were densely aggregated, so 
 as to form a pellicle like that of hoar-frost. They were made up of 
 a collection of globular masses of leucine, along with which were 
 observed paler granules and needles, which were insoluble in alcohol, 
 but were easily dissolved in ammonia. The gall-bladder contained 
 a small quantity of orange-yellow fluid. 
 
 The peritoneum and serous covering of the bowels were covered 
 with black specks. The mucous membrane of the stomach and 
 intestine was pale and cedematous, the mesenteric glands were small; 
 the kidneys and urinary passages were normal. 
 
 Observation No. XXI. 
 
 Ascites. — Diarrhoea. — Unconsciousness. — Coma. 
 
 Cirrhosis of the Liver. — Leucme in the Blood and Urine. — Brain 
 
 Dav. Kliesch, a watchman, aged 53,.stated that he had always led 
 a temperate life, and that up to 1855 he had enjoyed good health. 
 In November, he was seized with diarrhcea, which proved obstinate, 
 and was accompanied by ascites, but not by oedema of the feet. The 
 appetite remained unimpaired, but the vital powers gradually sank. 
 The heart was normal; pulse 90 ; slight bronchial catarrh. Hepatic 
 dulness diminished; spleen considerably enlarged. There were from 
 four to six thin stools in the day, containing little bile ; urine pale 
 and containing no albumen; skin pale; abdominal veins not dis- 
 tended. Was ordered decoction of calumba root with tincture of 
 mix vomica. The appetite continued moderate, and the patient's 
 condition underwent little change, except that the ascites increased. 
 
 On February 4th, he became unconscious ; the features were sunk ; 
 but the pupils remained unchanged. Pulse 86. 
 
 On the 5th, complete coma ; a faint jaundiced tinge of the skin ; 
 several petechiae. Pulse 120. 
 
 r2 
 
244 ACHOLIA FROM 
 
 On the 6th, involuntary evacuations ; pulse 130 ; tracheal rales. 
 Death on the morning of the 8th. 
 
 Autopsy. 
 
 The membranes of the brain were moderately congested; the 
 substance of the brain was unaltered; some of the blood-vessels were 
 atheromatous. The lungs were congested and cedematous. In 
 the heart there was a little loosely coagulated blood, in which 
 could be detected 1.10 per cent, of fat containing cholesterine, and 
 a large quantity of leucine. The lining membrane of the stomach 
 was puffy, and of a livid colour. The mucous membrane of the 
 upper portion of the intestine presented the appearance of recent 
 congestion, that of the lower was of a slaty-grey colour ; in the 
 sigmoid flexure there were a few superficial ulcers, the size of a 
 linseed. The faeces were thin and pale. 
 
 The spleen was enlarged by one-half; its capsule was thick, and 
 its parenchyma of a uniform dark-brown colour. The liver was 
 small ; and its capsule opaque and thickened. Its outer surface, as 
 well as that seen on section, was covered with little nodules; the 
 organ was tenacious (zahe), but flabby and shrivelled. The gall- 
 bladder contained a small quantity of thin pale bile. The hepatic 
 cells contained a large quantity of oil. The uro-poietic system was 
 normal. 
 
 The urine obtained from the dead body had a specific gravity of 
 1011 ; it was acid, and presented the reaction of bile-pigment in a 
 shght degree. It contained traces of albumen, and along with urea, 
 a moderate quantity of leucine. This last was found in larger 
 quantity in the parenchyma of the liver. 
 
 d. Acholiafrom Fatty Degeneration of Liver. 
 
 Only in one case of this form of degeneration have cerebral sym- 
 ptoms been observed. This was a female, in whom the accumulation 
 of fat in the liver became so great, that the secretion of the gland 
 was reduced to a minimum. 
 
FATTY DEGENERATION OF LIVER. 245 
 
 Observation No. XXII. 
 
 Jaundice of fourteen days' duration, — Somnolence. — Vomiting. — 
 Sudden supervention of violent delirium. — Coma. — Death. 
 
 Fatty degeneration of the Liver in its most advanced form. — Enlarge- 
 ment of the Spleen. 
 
 Louise Fischer, a washerwoman, 44 years of age, was admitted in 
 a jaundiced condition, on the 20th of May, 1856. The jaundice had 
 commenced 14 days before, and for 8 days the patient had been 
 obliged to keep her bed. During this time, she had been feverish, 
 and had suffered from profuse mucous diarrhoea ; the urinary secre- 
 tion was scanty. Upon examination, we found the temperature 
 elevated, the pulse 128 and small, no abnormal sound of the heart, 
 and the respiratory organs healthy ; the abdomen was distended from 
 tympanites ; the liver reached as high as the lower margin of the fifth 
 rib, and from this point, in a line with the mamma, extended 17 
 centimetres (6.69 Eng. inches) downwards ; the spleen was likewise 
 considerably enlarged. The stools were frequent, thin, and of a 
 greyish-yellow colour ; mucous vomiting occurred three times in the 
 course of the day. The urine, which had to be drawn off by 
 catheter, was feebly acid, and assumed a greenish colour upon the 
 addition of nitric acid; neither albumen nor the bile acids could 
 be detected in it ; but upon further examination of it, globular masses 
 similar to hypoxanthine, and traces of leucine, were discovered. She 
 was ordered muriatic acid in decoction of mallows. 
 
 Towards evening, the patient, who, even at the time of her admfe . 
 sion, was somewhat unconscious, was suddenly seized with violer 
 delirium; she raged and shouted during the whole night; on th<. 
 following morning collapse set in ; the pulse became thready, and. 
 the extremities cool. 
 
 Death took place at 10 a^m. of the 21st. 
 
 Autopsy, seven hours after death. 
 
 The membranes of the brain were yellow ; the sinuses contained 
 firmly-coagulated blood ; the substance of the brain was moderately 
 congested, and of normal consistence. Both lungs were free from 
 adhesions, congested, and slightly cedematous, posteriorly and in- 
 feriorly. * 
 
246 ACHOLIA FROM FATTY DEGENERATION. 
 
 There was a small quantity of blood in the heart, some of it 
 loosely, and the rest firmly coagulated. 
 
 The mucous membrane of the stomach and intestines was pale; 
 its glands were not enlarged ; there was some thin grey faecal matter 
 m the ileum and colon ; the mucous membrane of the sigmoid flexure 
 was recently injected and puffy. 
 
 The spleen was large; weighed 0.372 kilogr. (13 oz. avoird.) : it 
 was soft and of a reddish-brown colour. 
 
 The liver was considerably enlarged; weighed 3.23 kilogr. (7 lbs. 
 2 oz. avoird.) ; its margins were sharp, and its colour waxy-yellow. 
 Its cut surface appeared remarkably anaemic ; the circumference of 
 the lobules was pale-yellow, their centre was greenish-yellow ; the 
 hepatic cells in the latter situation were loaded with bile-pigment, 
 whilst in the former, they were distended with oil. The portal vein 
 was unobstructed, and the branches of this vessel, as well as those of 
 the hepatic veins, could be readily filled with coloured injection. The 
 gall-bladder contained a small quantity of clear, pale, mucous fluid. 
 The bile ducts were normal, and no obstruction could be detected either 
 in them or in Glisson's capsule, or in the duodenum. The substance 
 of the liver consisted in great part of fat; it contained 78.07 per 
 cent, of fat, and 21.93 p. c. of areolar tissue; along with the fat, 
 were found large quantities of leucine. In the solid residuum of 
 the blood obtained from the right side of the heart, were found 
 1.91 per cent, of fat, and an amorphous yellow-green colouring- 
 matter, together with traces of leucine. 
 
 Other forms of disease might be included with those just described, 
 which terminate in a similar manner, by suspension of the functions 
 of the liver. Thus I have had under my care a lady, aged 53, with a 
 very extensive cancer of the liver, as shown by palpation, who was 
 suddenly seized with delirium, convulsions, and coma; whilst at the 
 same time the skin became slightly jaundiced, and covered with 
 petechias. The stools, which at first were pale, and deficient in bile, 
 assumed a brownish-black colour, in consequence of haemorrhage 
 from the bowels. Death took place in the midst of profuse epistaxis. 
 Unfortunately no post-mortem examination could be made in this 
 case. 
 
 Acholia must always be expected, when the structure of the liver 
 has undergone such extensive changes from acute or chronic diseases, 
 that the function of the organ is necessarily completely arrested. 
 
CHRONIC ATROPHY OF LIVER. 247 
 
 CHAPTEK VI. 
 
 CHRONIC ATROPHY OB THE LIVER. 
 
 I. Causes and Mode of Production. 
 
 The size of the liver in health, is subject to considerable variations, 
 the limits of which we attempted to define in the second chapter. 
 Independently of this, there are numerous pathological derangements 
 of its nutrition which reduce the size of the gland, and give rise 
 to a corresponding diminution of its functional value. These may 
 result from anything which permanently impairs or arrests the cir- 
 culation through the capillary system of the gland.* Hence we 
 observe general or partial wasting of the liver in the course of 
 various structural diseases of the organ, as one of the phenomena, 
 and at the same time as a necessary result of the primary disease ; 
 
 • The liver, like the lungs, possesses a double vascular apparatus, a 
 nutritive and a functional ; the hepatic artery serves the former purpose, 
 the vena porta the latter. Hence impediments to the nutrition of the gland, 
 so far as these are dependent upon the flow of blood, should proceed from 
 the hepatic artery ; this, however, is contrary to experience. A rigid separa- 
 tion of the two functions does not exist in nature; but not, apparently, 
 because the capillaries of the two vascular systems anastomose. Obli- 
 teration of the hepatic artery is not followed by arrest of nutrition 
 (Ledieu, Journ. de Mid. de Bordeaux, Mars, 1856 ; Ginteac, L 'obliteration 
 de la veine porte, Bord., 1856, p. 51). Occlusion of the portal vein is not 
 followed by a cessation of the secretion of the liver (Gintrac ; also my own 
 Observations, Nos. XXIX and XXX). So far as our present experience 
 extends, the portal vein exercises a more powerful influence over the pre- 
 servation of the normal volume of the liver than the hepatic artery, which, 
 for the most part, supplies only the walls of the bile ducts and blood- 
 vessels, and penetrates but a short distance into the interior of the lobules. 
 Diseases of the hepatic artery and its branches, of such a nature as to 
 obstruct the flow of blood, are but little known, and, indeed, have been 
 but little sought for. I have myself frequently observed only one altera- 
 tion in these vessels as of frequent occurrence, viz., an accumulation of 
 black pigment. We have no experience as to the influence of functional 
 derangements of the hepatic plexus of nerves, over the nutrition of the 
 parenchyma of the liver. 
 
248 CHRONIC ATROPHY OF LIVER. 
 
 not unfrequently, however, the wasting is independent of such a 
 cause. "We do not at all refer here to those forms of atrophy 
 which result from the development of new growths in the liver, 
 such as echinococci or cancerous deposits, or which are dependent 
 upon enlargement of the bile ducts, or upon cirrhotic wasting 
 and induration ; neither do we refer to the partial atrophy pro- 
 duced by the cicatrisation of abscesses, or by the obliteration of 
 the larger branches of the portal vein, or lastly, to the atrophy of the 
 liver which follows the enlargement of the hepatic veins in 
 mechanical byperaemia: all these forms can be afterwards dis- 
 cussed more in detail under the head of the respective diseases 
 which give rise to them. We confine ourselves at present to 
 those forms of atrophy which have an independent existence, are 
 accompanied by no other important change of structure, and hence 
 lay claim to a certain degree of individuality. This form of atrophy 
 makes its appearance under very various conditions. 
 
 The first cause which we recognise is the compression of the 
 organ from without, from which results an amount of atrophy cor- 
 responding to the extent and force of the pressure. Bearing upon 
 this there are the familiar effects of tight-lace chest, already men- 
 tioned under the head of ' Diagnosis'. Besides the alteration in the 
 situation of the liver, tight-lacing produces more or less deep 
 depressions on its surface ; and the glandular parenchyma at the 
 parts corresponding to these depressions dwindles into a mere bridge- 
 like process penetrated by the enlarged vessels and bile ducts ; at the 
 same time, the organ in many cases becomes shrivelled and collapsed. 
 The loss of substance which the gland undergoes from this cause 
 is, as a general rule, but very slight ; it is a removal ( Verdrcingung) 
 of the parenchyma, which takes place, rather than an atrophy. 
 
 Occasionally the liver suffers more from compression of its convex 
 surface by extensive pleuritic or pericardial effusions, especially when 
 
 Fig. 24. 
 
 Fie. 24. Secreting cells of a liver, which had undergone chronic 
 atrophy. The cells were much reduced in size, measuring 
 only from ib to ^ of a Paris line. They have also lost their 
 normal granular contents. 
 
CAUSES AND MODE OF PRODUCTION. 
 
 249 
 
 the gland is firmly united to the diaphragm by short adhesions. 
 Under such circumstances, extensive depressions are not unfre- 
 quently produced on the surface of the gland ; the parenchyma at 
 the places corresponding to these depressions assumes a dark-brown 
 colour ; the cells become smaller and lose their granular contents ; 
 whilst at the same time a few brown granules make their appear- 
 ance in their interior. (Fig. 24.) 
 
 A similar result is produced by circumscribed peritoneal exuda- 
 tions, which occasionally leave behind deep depressions on the convex 
 surface of the liver. (Fig. 25.) 
 
 Fig. 25. 
 
 4€Mttlffi 
 
 
 Wj&h 
 
 -;€7* 
 
 Fig. 25. Chronic atrophy of the liver, resulting from the external 
 compression of peritoneal exudations, circumscribed between 
 the concave surface of the diaphragm and the upper surface 
 of the gland. 
 
 Cruveilhier* observed a considerable depression resulting from the 
 compression of an hypertrophied heart, the gland being at the same 
 time firmly adherent to the diaphragm. 
 
 Similar consequences may arise from enlargement of those portions 
 of the intestine which are nearest to the liver, if, from their being 
 distended with gas or fecal matter, they exert a permanent pressure 
 upon the organ. In this way, I have seen an extensive diminution 
 of the liver produced by an enormous enlargement of the curve of 
 the colon. The case was that of a man, aged 36, in whom a cir- 
 cumscribed peritoneal exudation had formed in consequence of a 
 * Anat. pathol. geuer., Tom. III., p. 208. 
 
250 CHRONIC ATROPHY OF LIVER. 
 
 chronic perforating ulcer of the stomach. This gave rise to a constric- 
 tion of the left curve of the colon, and to a stagnation of the gaseous 
 and solid contents of the transverse and ascending colon. By this 
 enlargement of the bowel the liver was pushed towards the ribs, high 
 up into the right hollow of the diaphragm; the left lobe, which was 
 situated nearest to the compressing cause, as also a portion of the 
 right lobe, were atrophied. Budd* describes a partial atrophy of 
 the gland in a preparation preserved in the Museum of King's 
 College, which was obtained from a patient labouring under para- 
 plegia, in whom the large intestines had for a long period been 
 distended. 
 
 Cruveilhier is of opinion, that a diminution of the parenchyma of 
 the liver is produced by the pressure of the fluid of ascites, as also 
 by the adhesions of the organ to neighbouring parts. I have not 
 been able to convince myself of this, even in cases where there has 
 been the most extensive ascites and the most numerous adhesions. I 
 have not unfrequently found the organ small, but often of normal size, 
 or even enlarged. In chronic peritonitis, it is only when the liver has 
 for a long time, been covered with a quantity of purulent exudation, 
 or when the inflammation has extended to the fissure of the liver and 
 Glisson's capsule, that a diminution of the organ has been observed 
 to be of constant occurrence. 
 
 The atrophy which arises in the way just described, as a general 
 rule, remains partial ; its clinical importance is usually small, and 
 depends upon the extent of the atrophy, and upon whether or not 
 the larger bile ducts and blood-vessels have been subjected to the 
 pressure. 
 
 The diminution of the liver, which extends throughout the 
 entire organ, is of much more importance than this atrophy from 
 compression, both as regards its consequences upon the entire 
 organism and its local effects on the portal system. The liver here 
 diminishes in every direction; its weight sinks to one-half the 
 normal weight, or even to less.f The surface of the gland is 
 smooth or slightly granular, or marked by linear wrinkles, and 
 in some cases presents likewise distinct, isolated depressions; the 
 
 * " On Diseases of Liver." 
 
 t In one female, aged 26, the weight was 0.7 kilogr. (1 lb. 8| oz. avoird.) ; 
 in a man, 53 years of age, it was 0.85 kilog. (1 lb. 14 02. avoird.) ; in a 
 woman of 50, it was 0.86 kilogr. (1 lb. 14J oz. av.) ; and in a man aged 59, 
 it was 0.62 kg.. (1 lb. 6 oz. avoird.). 
 
CAUSES AND MODE OF PRODUCTION. 251 
 
 parenchyma is dark reddish-brown, and is sometimes spotted with 
 greenish-brown or yellow deposits of fat. In most cases, no 
 trace of the lobules can be distinguished in the uniformly brown 
 surface; when they are observed, they appear smaller than in the 
 healthy gland.* 
 
 Important alterations may be distinguished in the blood-vessels : 
 the portal vein is usually considerably enlarged as far as its sub- 
 division into capillaries at the periphery of the lobules, at which place 
 the enlargement terminates by a club-shaped extremity. The walls of 
 the enlarged veins are sometimes normal, but at other times they pre- 
 sent a remarkable thickening of the sheath, formed by Glisson's 
 capsule, t This thickening disappears suddenly where the capillary 
 ramifications commence. The capillaries themselves are in a great 
 measure destroyed; they become filled with brown molecules, or 
 they sometimes contain flakes or granules of black pigment ; hence 
 injections of the portal vein usually succeed very imperfectly; it is 
 only here and there that a few isolated capillaries become filled 
 as far as their anastomosis with the roots of the hepatic veins; 
 the latter are usually more easily injected, and the injection runs to 
 a greater distance. The meshes formed by the capillary vessels and 
 by the enveloping areolar tissue are contracted, and at some places 
 completely disappear, so that the walls of the obsolete vessels are 
 in immediate contact with one another. Small atrophied cells are 
 here and there observed in the narrow meshes. 
 
 The hepatic veins in many cases participate in the enlargement of 
 the vena porta, but always in a less degree; their walls for 
 the most part continue thin, and hence their bluish colour forms 
 a marked contrast with the yellowish-red of the walls of the 
 portal vein. The hepatic artery in two cases has appeared somewhat 
 smaller than natural ; Glisson's capsule has frequently been found 
 thickened. The hepatic cells, which at some parts of the organ com- 
 pletely disappear, are distinctly visible at other parts, but are always 
 pale, without any granular contents, with puckered walls and angular 
 outlines; for the most part they are very small; they often contain 
 brown pigment granules, which occasionally fill up completely the 
 cavities of the cells, or little rods of the brown colouring-matter of 
 
 * The thickness of the parenchyma between a central and an inter- 
 lobular vein measures from J to | of a millimetre ; whilst in other cases 
 this space is 1, l\, or 2 millimetres in breadth. 
 
 t In 6 out of 18 cases. 
 
252 CHRONIC ATROPHY OF LIVER. 
 
 bile. In many cases* cells are found filled with oil, sometimes 
 scattered throughout the entire organ, at other times in isolated 
 deposits. In the bile ducts there is only a small quantity of a pale 
 secretion, which frequently contains albumen. 
 
 Together with these changes in the liver, I have repeatedly ob- 
 served enlargements of the veins of the stomach and large intestine, 
 as also subserous ecchymoses and mechanical congestions of the 
 spleen. This last was present in seven out .of eighteen cases. 
 Ulcerative processes in the stomach and intestine were present in 8 
 cases, 3 of which were caused by chronic dysentery ; 2, by simple 
 chronic ulcer of the stomach ; and 3, by cancerous ulceration ; in one 
 case cord-like thickenings in the mesentery, with obliteration of 
 isolated venous branches, could be detected. As consecutive changes, 
 ascites and anasarca were found twelve times, and acute peritonitis 
 twice. 
 
 Observation No. XXIII. 
 
 Chronic Atrophy of the Liver, with considerable enlargement of the 
 branches of the portal vein. — A small ulcer at the pylorus, without 
 any constriction of this opening. Distinctly visible, peristaltic 
 movements of the Stomach. — Death from exhaustion. 
 
 Adam Blaschefsky, a day-labourer, aged 53, was admitted on 
 the 21st of November, 1854. 
 
 The patient was emaciated, but free from oedema and from any ab- 
 normal colouring of the skin ; he had complained for a long time of 
 pains in the epigastrium, and had often brought up the food which he 
 swallowed, without the admixture of any foreign substances. His ap- 
 petite was but slightly impaired ; the stools were regular, of normal 
 consistence, but pale. The thoracic organs were intact, the respira- 
 tion free, the heart's action normal ; pulse 62. The abdomen was col- 
 lapsed, and the abdominal walls when felt, appeared unusually thin. 
 Upon closer examination, the contour of the stomach distended with 
 gas was distinctly visible ; on percussion, the full tympanitic sound of 
 this organ could be distinguished from the more abrupt sound of the 
 adjoining small intestine. Half-an-inch to the right and above the 
 umbilicus, was observed a somewhat prominent tumour, which 
 felt hard and uneven, was tender upon pressure, and could be shifted 
 about. This was of course assumed to be a cancer of the pylorus. 
 • In 5 out of 15 cases. 
 
CAUSES AND MODE OF PRODUCTION. 253 
 
 The hepatic dulness was reduced ; in the median line it amounted to 
 2, in the mammary line to 3, and in the axillary line to 5 centi- 
 metres, (s, Is, and 2 inches.) 
 
 Under the use of tincture of rhubarb and extract of belladonna, 
 the vomiting subsided ; but the emaciation increased with tolerable 
 rapidity, notwithstanding sufficient nourishment and an improved 
 digestion. The tumour at the pylorus changed its position repeat- 
 edly; it was found sometimes to the right, and sometimes to the 
 left, of the umbilicus, and at other times beneath it, right in front 
 of the vertebral column. During the process of digestion, the 
 peristaltic movement of the stomach could be observed most dis- . 
 tinctly. A swelling first formed at the margin of the left ribs, 
 corresponding to the great cul-de-sac of the stomach, which 
 moved slowly towards the pylorus, and from this returned towards 
 the left side. Behind the swelling, there was observed an 
 annular constriction, by means of which it seemed to be pushed 
 forwards. Not unfrequently, a second swelling followed the first, 
 and was separated from it by a constriction; in such cases, the 
 stomach appeared divided into two halves. Each of these move- 
 ments of the stomach lasted from one-half, to an entire, minute, and 
 between them there were intervals of four, or sometimes six minutes. 
 Occasionally the bulging passed beyond the pylorus, which then 
 became more elevated, apparently from the passage of the contents 
 of the stomach into the duodenum. No movement could ever be 
 perceived in the empty stomach. So long as there was any chyme 
 present, the contractions could be produced by giving Hungarian 
 wine, by percussion, and by repeated palpation of the stomach ; they 
 always presented the same characters, except that the interval be- 
 tween two movements was somewhat shorter when they were excited 
 by the causes just mentioned. 
 
 On the 22ntl of December the patient, who felt comparatively 
 well, asked for his discharge ; but so soon as the 27th he returned 
 in a state of great exhaustion. Excesses in diet during the Christ- 
 mas festivities had induced severe catarrh of the, stomach; the 
 tongue was thickly coated ; there was great tenderness of, the epi- 
 gastrium, and no appetite. Vomiting of mucous matter, without any 
 admixture of blood, suddenly supervened ; the bowels were confined. 
 Mild neutral salts and bitter, slightly astringent medicines, along with 
 a suitable diet, failed in checking the catarrh; the patient became 
 rapidly collapsed, and died from exhaustion on the 14th of January. 
 
254 CHRONIC ATROPHY OF LIVER. 
 
 Autopsy on January \hth, 1855. 
 
 The body was greatly emaciated, and weighed 45 kilogrammes 
 (99 lbs. avoir.) 
 
 The brain and its membranes were anaemic, but in other respects 
 normal. The mucous membrane of the bronchi was pale ; the lungs 
 were collapsed and anaemic, except in the dependent portions, where 
 there was a small amount of hypostatic oedema. The heart was 
 small and covered with opaque fibrous spots (Sehnenflecken) ; its 
 valvular apparatus was normal. The mucous membrane of the 
 pharynx and oesophagus was pale ; the abdominal walls were unusually 
 thin." In consequence of the post-mortem rigidity, the stomach lay 
 closely contracted beneath the liver, and did not extend so far down- 
 wards as during life. Immediately beneath the stomach lay the 
 transverse colon, which was tightly contracted ; the small intestines 
 had completely fallen down into the abdominal cavity, so that the 
 abdominal walls were in contact with the spine, and only separated 
 from it by the thin omentum and mesentery. It was owing to this 
 abnormal distribution of the small intestine, and to the unusual 
 laxness of the abominal muscles, that we had been able to observe 
 the movements of the stomach so distinctly during life. 
 
 The spleen was firmly adherent to the hollow of the diaphragm ; 
 its capsule was covered with an extensive white membrane, \\ line 
 in thickness ; the parenchyma was anaemic. 
 
 The lining membrane of the stomach was tumid, of a dark, livid 
 hue, and covered with a layer of mucus. The veins, especially those 
 of the small curvature, were much enlarged and distended, and dark- 
 blue. Just before coming to the pylorus, there was an ulcer half- 
 an-inch long, 3 lines deep, and equally broad, the margins of which 
 were still covered with puckered mucous membrane, and which pre- 
 sented a slightly-elevated edge, formed of cancerous infiltration of 
 the submucous areolar tissue. The muscular tissue throughout the 
 entire stomach, but especially at the pyloric opening, was hyper- 
 trophied. 
 
 The mucous membrane of the small and large intestines was some- 
 what darker than usual, and its veins were enlarged; the faeces were 
 solid and of a yellow colour. 
 
 The uro-poietic system presented nothing abnormal. 
 
 The liver exhibited all the characters of chrome atrophy in a 
 
CAUSES AND MODE OF PRODUCTION. 255 
 
 marked degree. It was small,* flabby, and tenacious (zahe) ; its 
 outer surface was uneven, and covered with flattened prominences 
 about quarter of a line in breadth. Its cut surface discharged an 
 enormous quantity of thin fluid blood from numerous widely-gaping 
 mouths of vessels, which were everywhere visible. The calibre of 
 these vessels was considerably enlarged. The left branch of the portal 
 vein measured nearly 1| Paris inch, and one of its branches, 8 lines. 
 This enlargement extended throughout the entire subdivisions of the 
 portal vein as far as its capillary ramifications, and could also be 
 observed in the hepatic veins, although to a less extent. The 
 tunica adventitia of the portal veins was very considerably thickened ; 
 its ramifications in the substance of the liver were of a reddish- 
 yellow colour, and consequently presented a striking contrast to the 
 thinner bluish-white branches of the hepatic veins. In tracing the 
 ramifications of the portal vein, several of its branches (and at the 
 same time apparently also branches of the hepatic artery and of the 
 hepatic duct,) were found enclosed in a thick common sheath of 
 areolar tissue, which likewise contained a network of elastic fibres, 
 each individual vessel being furnished, in addition, with a tunica 
 adventitia of its own. Interspersed here and there through these 
 sheaths could be seen portions of substance exactly corresponding 
 to the hepatic tissue, which were observed lying between the rami- 
 fications of the portal vein. Hence the approximation of several 
 branches of the portal vein appeared to depend upon the disappear- 
 ance of the intervening portions of hepatic tissue. The thickening 
 of the sheaths of the vessels extended as far as their finer ramifica- 
 tions, and only terminated when these became lost in capillaries. 
 In thin sections (Kg. 26) of the dried hepatic tissue, thick sheaths 
 could be seen everywhere surrounding the apertures of the 
 vessels, some of which were round, and others elongated; these 
 sheaths occasionally enclosed branches of the hepatic artery, and 
 contrasted remarkably with the thin walled branches of the hepatic 
 vein. 
 
 * The weight of the liver amounted to 0.85 kilogr. (1 lb. 14 oz. avoird.), 
 the weight of the body being 45 kilogr. (99 lbs. av.), thus making the rela- 
 tive weight of the two as 1 to 50.3. The weight of the spleen was 0.18 
 kilogr. (6.35 oz. av.), and its comparative weight with that of the liver, 1 to 
 4.7. The left lobe of the liver measured transversely 3 J inches, and from 
 before backwarks 3J ; the right lobe measured 5\ inches transversely, and 
 6 from before backwards ; the maximum thickness of the organ amounted 
 to 2 inches. 
 
256 
 
 CHRONIC ATROPHY OF LIVER. 
 
 The hepatic parenchyma was of a dark reddish-brown colour, and 
 nowhere exhibited a distinct subdivision into lobules. When fine 
 
 Pig. 26. 
 
 Fig. 26. A magnified thin section of a liver, showing the changes 
 in its structure produced by chronic atrophy. The sheaths 
 of the branches of the portal vein (a) are seen to be remark- 
 ably thickened, and form a striking contrast to the thin walla 
 of the hepatic vein (J). At *, hepatic arteries are represented 
 as contained in the sheath of a branch of the portal vein. 
 
 sections of it were submitted to microscopic examination, they 
 exhibited a tolerably distinct and regular network, and also at some 
 places ramifying twigs, where these happened to run in the same 
 plane with one another over a tolerably extensive space. This network 
 was made up of a connected system of small tubes containing small 
 yellow, or yellowish-brown, or occasionally reddish-brown granules. 
 In the spaces included in the meshes of this network (some of which 
 were elongated, others oval, and others rounded), except where the 
 tubes were closely compressed, small pale cells were observed, 
 some of them containing nuclei ; these cells, after repeated washing, 
 could be removed from the fine sections. At first it appeared 
 doubtful in what light this network was to be regarded, whether it 
 was formed by the ramifications of the blood-vessels, . or by the 
 
CAUSES AND MODE OF PRODUCTION. 257 
 
 adherent hepatic cells. Further examination proved that the former 
 supposition, — according to which the network was made up of the 
 capillaries, which were partially destroyed and densely aggregated, 
 owing to the disappearance of the hepatic cells, — was, without 
 doubt, the correct one. This supposition was favoured, in the first 
 place, by the circumstance of cells being found in the meshes, and, 
 secondly, by the attempts at injection, by means of which we suc- 
 ceeded, in some places at least, in throwing the injection both from 
 the portal and the hepatic veins into the granulated network of 
 tubes.* In many parts of the liver the injected substance did not 
 enter at all into the capillary system ; and even water, when injected, 
 could not be forced through it. Moreover, in the apertures of the 
 larger vessels, the lining membrane at some places could be seen 
 coloured by brown granules, in the same way as the network of 
 small tubes. 
 
 The destruction of the hepatic capillaries, which has just been 
 described, as well as the shrivelling, or complete disappearance of 
 the secreting cells, was not uniform throughout the entire organ, 
 but was more advanced at one part than another, as might be shown 
 by the variations in the mode of distribution of the substances injected 
 into the vessels, and still better by an examination of fine sections of 
 the gland. At some places it was scarcely possible to isolate a few 
 stunted cells from the fresh substance of the gland; at other places 
 the cells were more abundant, although for the most part greatly 
 altered in their characters. Most of them were small, pale, and 
 without any granular contents; in only a few could a nucleus be 
 detected ; their walls seemed wrinkled and at some places folded, so 
 that their outlines presented a sacculated, angular appearance. 
 Brown-coloured molecules were accumulated in large quantity in 
 some of the cells, while others were completely filled with brownish- 
 black contents, and here and there throughout the tissue of the liver 
 were seen large granules, and little rods of bile-pigment ; — morbid 
 appearances which proved that the passage of bile into the excretory 
 ducts had been impeded. 
 
 The gall-bladder contained a small quantity of thin, pale-yellow, 
 turbid bile, which, when heated, threw down a coagulnm of albumen. 
 
 * The appearances here described are figured in the Atlas (Plate IV., 
 Fig. 4). The yellow substance injected from the portal vein is seen to 
 penetrate only to a short distance, whereas that injected from the hepatic 
 vein advances much farther into the network. — Transl. 
 
258 CHRONIC ATROPHY OF LIVER. 
 
 •The transudation of this albumen was owing to the increased pressure 
 exerted by the blood, upon the walls of those capillaries of the 
 portal vein, which remained exempt from the process of destruction. 
 
 In this case, the primary cause of the atrophy, of the destruction 
 of the capillaries, and of the disappearance of the secreting cells, 
 depended apparently upon the disease of Glisson's capsule, which, 
 ^proceeding from the ulcerated spot at the pylorus, extended into the 
 fissure of the liver, and along the course of the portal vein as far as 
 its ramifications. The disease attacked the portal vein itself, as proved 
 by the marked structural changes in the walls of that vessel, the 
 brownish spots upon its inner surface, &c. j in the trunk and larger 
 branches, it gave rise to thickening, paralysis of the muscular 
 tissue, and dilatation} but, in the smaller branches and in the capil- 
 laries, to the abnormal conditions just mentioned, obliteration, &c. 
 
 I have frequently observed similar changes arise from a cancer of 
 the stomach, upon which cancerous peritonitis has supervened ; in 
 these cases, Glisson's capsule has been infiltrated with cancer far into 
 the substance of the liver, and the organ itself has been greatly 
 atrophied. 
 
 It is not always, however, that the portal vein in chronic atrophy 
 of the liver becomes enlarged, in the manner above described. I have 
 observed the same appearance in cases where the atrophy of the liver 
 had another origin, directly involving the capillaries, and in which 
 Glisson's capsule was of normal thickness. 
 
 Qbseevation No. XXIV. 
 
 Tertian and Quotidian Intermittent of three months' duration. — 
 Anasarca. — Ascites. — Diarrhea. — Death from Exhaustion. 
 
 Atrophied Pigment-Liver and Pigment- Spleen. 
 
 A boy, 10 years of age, who had been much neglected, and who, 
 for three months had suffered almost uninterruptedly from intermit- 
 tent fever, at first of a tertian, and afterwards of a quotidian type, 
 came to the Hospital at the beginning of May, 1855, with a pale 
 anaemic countenance, and suffering from profuse watery diarrhoea. 
 The spleen was moderately enlarged. No hepatic dulness could be 
 detected in front; in the axillary line it amounted to 2 centimetres 
 (3 inch). The lower part of the abdomen contained a considerable 
 quantity of fluid, but there was scarcely any obvious oedema of the 
 
CAUSES AND MODE OF PEODUCTION. 259 
 
 feet. The evacuations by stool, which occurred six or eight times in 
 the course of the day, were thin, of a pale greyish-yellow, and without 
 any traces either of blood or dysenteric exudations. Pulse 90, and 
 small; no elevation of temperature. Appetite slight. The urine, 
 when treated with heat and nitric acid, exhibited scarcely any 
 turbidity. 
 
 The attempts to check the exhausting evacuations by means of 
 chloride of iron, nux vomica, &c, and to counteract the anaemia by 
 means of a regulated diet, proved fruitless. After three days' stay 
 in the Hospital, the boy died. 
 
 "Autopsy. 
 
 Considerable ascites ; slight anasarca. No important changes in 
 the organs of the cranial or thoracic cavities. The mucous mem- 
 brane of the stomach and intestinal canal pale, at some places 
 cedemaious ; the serous membrane of the small and large intestine 
 exhibited here and there livid spots, — the remains of ecchymoses. 
 
 The kidneys were normal, with the exception of a few isolated 
 pigment-granules in the glomeruli. 
 
 The spleen was large, firm, congested, and densely infiltrated with 
 black pigment. 
 
 The liver was very small and atrophied ; numerous deep depres- 
 sions were seen upon its outer surface. Its parenchyma was con- 
 gested, brownish-black, and of tenacious consistence. Yellow size 
 injected into the portal vein passed along very incompletely ; in thin 
 sections of the injected tissue, the ramifications of the portal vein 
 as far as their entrance into the lobules, could be seen to be much 
 enlarged, and, at some places, unequally so. Black pigment was ob- 
 served in the interior of the capillaries, only a few of which were 
 injected ; a large number of them appeared to be no longer permeable. 
 
 Observation No. XXV. 
 
 Persistent and oft-recurring Quotidian Intermittent. — Hydremia. 
 — Anasarca. — Ascites, — Profuse Diarrhoea. — Death from TSx* 
 
 Atrophy of the Liver. — Blocking-up of the Capillaries with Pigment. 
 
 Mrs. M., aged 26, before she came to the Hospital, on April 27th, 
 1855, had suffered for several months during the winter from inter- 
 
 82 
 
260 CHRONIC ATROPHY OF LIVER. 
 
 mittent fever. This fever continued for a long time after ■ the 
 patient's admission, and did not permanently disappear until after 
 the repeated administration of large doses of quinine. The patient 
 became gradually reduced to an extreme degree of anaemia, 
 to which general anasarca and ascites were superadded, and which 
 rapidly increased to a critical degree, under the additional operation 
 of persistent and profuse diarrhoea (to check which, the vegetable 
 and metallic astringents, particularly the muriate of iron, were 
 employed without effect). Death took place six weeks after admis- 
 sion. Neither albuminuria, nor derangements of the sensorial 
 functions, which before admission had accompanied the intermittent 
 fever, were observed at any time during the patient's stay in 
 the Hospital. 
 
 There was nothing abnormal in the brain; the lungs were anaemic 
 and collapsed; and there was a moderate amount of effusion in the 
 pleural cavities. The heart was normal. The abdominal cavity 
 contained several pounds of clear serous fluid. 
 
 The liver was small;* it weighed 0.7 kilogr. (1 lb. 8| oz. av.), 
 and was thus less than one-half the normal weight; at the same 
 time it appeared shrivelled and tenacious {welk u. zahe), and its 
 parenchyma was congested and dark. Under the microscope, 
 numerous flakes of pigment could be seen in its capillary vessels, 
 some of which were remarkably large. The ramifications of the 
 portal vein were greatly enlarged as far as the periphery of the 
 lobules, but attempts to inject them proved very unsuccessful. A 
 large proportion of the capillaries contained pigment, and were, 
 from this cause, impermeable by the injection. The surrounding 
 hepatic cells were either atrophied or filled with fat ; at some places, 
 lardaceous matter (spechtoffe) was observed. Sugar could not be 
 detected in the liver. 
 
 The spleen was small,t firm, and coloured brownish-black, owing 
 to dense accumulations of pigment; its capsule was thickened. 
 
 The kidneys were' normal, except that isolated pigment granules 
 were seen in the glomeruli. The mucous membrane of the 
 
 * The right lobe was 5 J inches long and 4 broad ; the left, 4 by 3£ ; the 
 thickness amounted to 2 inches. 
 
 t It measured 3 inches in length, 2 1 in breadth, and 1| in thickness. 
 Its weight amounted to 0.14 kilogr. (5 oz. avoird.). 
 
CAUSES AND MODE OF PRODUCTION. 261 
 
 intestine was pale and (Edematous ; in the sigmoid flexure there were 
 a couple of superficial catarrhal ulcerations. 
 
 The origin of the atrophy in this case could not be traced with 
 certainty. The pigment flakes and granules, which not unfrequently 
 are formed in the spleen in the course of severe intermittents, and 
 from this organ are transmitted into the portal vein, partly pass on 
 through the capillary network of this vessel, and, partly owing to 
 their size, remain firmly impacted in it, and give rise to occlusion 
 ending gradually in obliteration. The obstructed flow of blood en- 
 tails an arrest of the secretion, and destruction of the glandular cells. 
 Occasionally it happens that large clots are swept along into the 
 vessels of the liver ; scar-like depressions are then produced at those 
 parts of the surface of the organ to which the obstructed vessels 
 lead. {See Diseases of the Portal Vein.) 
 
 Obsebvation No. XXVI. 
 
 Atrophy of the Liver with Fatty Infiltration. — Dysenteric Cicatrices. 
 — General Dropsy. 
 
 Gottlieb Giinther, aged 34, came to the Hospital on October 
 20th, 1854, on account of catarrh of the stomach and bowels, accom- 
 panied with fever; when convalescent, he was seized in the Hos- 
 pital with a slight attack of dysentery, which at that time was 
 prevalent in the wards. Although the purging was soon checked, 
 still the patient recovered very slowly; he continued anaemic; 
 ascites came on, and anasarca and hydrothorax were superadded.. 
 Along with these symptoms, the urine was free from albumen, 
 the heart normal, and there was no disease in the respiratory organs ; 
 the appetite was tolerably good; the bowels were regular, and the 
 stools were firm, and only abnormal as regards their colour. 
 
 The attempts to counteract the hydrsemia by means of quinine, 
 steel, wine, and an easily-digested animal diet, proved fruitless; the 
 dropsy gradually increased to such a degree, that the respiration was 
 greatly impeded. The administration of colocynth, it is true, led 
 to a diminution of the anasarca, but the patient's state of exhaustion 
 rendered it necessary to abstain from its use ; diuretics took no effect ■ 
 the kidneys secreted only a small quantity of dark urine free from 
 albumen. Intercurrent attacks of pulmonary oedema, which ulti- 
 mately threatened suffocation, were treated with benzoic acid and 
 
262 CHRONIC ATROPHY OF LIVER. 
 
 camphor. In the middle of December, bed-sores appeared ; the ex- 
 haustion now rapidly increased until the 19th, when death ensued 
 after a protracted agony. 
 
 There was nothing abnormal in the cavity of the cranium. Both 
 lungs were oedematous, and there were about four pounds of clear 
 fluid in the pleural cavities ; the heart was normal. The abdominal 
 cavity contained about ten pounds of serum. The stomach was 
 tightly contracted ; its mucous membrane was pale, except at the 
 pylorus, where it was darker ; the lining membrane of the small intes- 
 tine was pale, and at some places oedematous, that of the caecum and 
 of the ascending colon presented similar characters ; in the transverse 
 colon, and extending downwards as far as the rectum, there were 
 found numerous black spots, and superficial ulcerations completely 
 cicatrised. In the meso-colon of the sigmoid flexure, there were 
 observed thick, white, radiating bands, like those of a cicatrix, which 
 compressed a portion of the veins passing through them, and tied 
 down this portion of the bowel in front of the spinal column. The 
 mesenteric glands, the pancreas, and also the kidneys were normal. 
 
 The spleen was somewhat enlarged, anaemic, of a uniform brown 
 colour and firm. 
 
 The outer surface of the liver presented several scar-like depres- 
 sions ; its margins were sharp and furnished with a broad white rim. 
 The size of the organ was very much reduced ; its parenchyma was 
 of a dirty brownish-yellow colour, and abnormally soft. The gall- 
 bladder contained a pale-yellow turbid fluid. 
 
 Observation No. XXYII. 
 
 Chronic Dysentery. — Displacement of the Intestinal Canal. — Atrophy 
 of the Liver. — Death from Exhaustion. 
 
 Gottfr. Dfasner, aged 53, a powerful man for his age, who had 
 been obliged to work in the open air during changeable weather, had 
 been suffering for four weeks from diarrhoea, with copious thin stools 
 of a pale greyish-yellow colour, and from abdominal pains, and 
 tenderness upon pressure, along the course of the descending colon, 
 The tongue was slightly coated; the appetite, diminished; the 
 
CAUSES AND MODE OF PRODUCTION. 263 
 
 respiratory organs, normal ; no cardiac bruit. The size of the liver 
 could not be ascertained ; no dulness could be detected anywhere 
 in the hepatic region. 
 
 An emetic was administered ; and a mixture was ordered containing 
 decoction of calumba and tincture of nux vomica. After a few days, 
 the diarrhoea disappeared; the appetite returned; and the patient 
 was disharged cured on the 14th. 
 
 On the 12th of November, Drasner again presented himself at 
 the Hospital. The diarrhoea had returned soon after his dis- 
 charge, and had lasted for three weeks uninterruptedly and with 
 great severity. The patient appeared pale and emaciated ; the skin 
 was dry and hot; pulse 105 and small; the pains and tenderness in 
 the region of the colon were more severe than formerly; and the 
 stools were of the same thin, greenish-yellow character. Even now 
 no hepatic dulness could be made out, although the abdominal 
 walls were flaccid, and the bowels contained no great accumulation 
 of gas. 
 
 The patient took calumba and opium ; but on the evening of the 
 15th he fell into a state of collapse, and became'unconscious. He 
 died early on the 16th. 
 
 Autopsy. 
 
 The body was emaciated, but free from oedema. There was no- 
 thing remarkably abnormal in the organs contained in the cranial 
 and thoracic cavities. In the abdominal cavity, the first thing that 
 was observed was a remarkable displacement of the intestinal 
 canal. (Fig. 27.) A portion of the ileum, d, was situated 
 where the liver ought to lie, and here it was bounded by the 
 lung, close to the fifth rib; the liver was quite invisible. The 
 first curve of the colon, a, lay in the left hypochondrium. The other 
 portion of the intensely injected small intestine — the jejunum, I, was 
 superimposed over the descending colon and compressed it. The 
 sigmoid flexure, e, lay on the right side, and a long coil of it 
 covered the caecum. The mucous membrane of the stomach, but 
 only that portion near the pylorus, was softened and livid. The lining 
 membrane of the ileum was pale. In the jejunum, the serous coat 
 was intensely injected, and the mucous membrane presented a small 
 ulcer in process of cicatrisation and loaded with pigment. The 
 caecum contained pale clay-coloured feces ; the mucous membrane was 
 
264 CHRONIC ATROPHY OF LIVER. 
 
 here livid, and at the commencement of the colon, it was covered 
 with patches of grey exudation, which, still further on, formed a 
 
 Pie. 27. 
 
 Fig. 27. Arrangement of the abdominal viscera in a case of 
 chronic atrophy of the liver. The liver is completely ob- 
 scured by the superimposed bowels. There is also great 
 displacement of the bowels, as explained in the text. 
 
 uniform layer. In the sigmoid flexure the lining membrane was 
 ieddish-brown, and at some places was infiltrated with exudation ; 
 the rectum was normal. 
 
CAUSES AND MODE OF PRODUCTION. 265 
 
 The spleen was enlarged, of a uniform reddish-brown colour, and 
 firm consistence; it weighed 0.33 kilogr. (llf oz. avoird.).. 
 
 The liver was very small, and weighed 1.13 kilogr. (1 lb. 7| oz. av.) ; 
 its outer surface was smooth, and there was a blank rim (leere Saume) 
 along its sharp margins. The parenchyma was congested, and of a 
 uniform reddish-brown colour, without any indication of lobules ; 
 the branches, as well as the trunk of the portal vein, were enlarged ; 
 but there was no thickening of their sheath. The hepatic cells were 
 small, pale, with sharp, angular outlines, and were destitute of 
 molecular contents ; some of them contained dark-brown granules, 
 which not unfrequently completely filled up the cavity of the cell. 
 Injection penetrated very imperfectly into the vessels. 
 
 Observation No. XXVIII. 
 
 Fibrous thickening of the Mesentery, with firm adhesions of the small 
 Intestine and of the Omentum to the abdominal wall. — Deposit of 
 bluish-black pigment and cicatrizing ulcers in a coil of the small 
 Intestine, three feet long. — Chronic Atrophy of the Diver. — 
 Ascites and General Dropsy. 
 
 Wilhelm Leidling, a baker, aged 36, had suffered for years from 
 a right inguinal hernia, which became strangulated on the 15th of 
 March. To have this reduced, he was brought to the Monastery 
 Hospital of the Brothers of Charity, at Breslau, where, for six weeks 
 after the spontaneous reduction of the rapture, he was treated for 
 diarrhoea, accompanied by great debility and abdominal pains. The 
 diarrhoea, which, so far as could be gathered from report, never was 
 accompanied by bloody stools, remained uncured ; it exhausted the 
 patient more and more, and led to dropsy, so that at the end of six 
 weeks more, viz., on July 1st, 1856, it became necessary to admit 
 the patient into the clinical ward. 
 
 The dropsy had by this time become general; along with great 
 ascites, there was double hydrothorax and extensive anasarca. The 
 heart and lungs were normal; the appetite was slightly impaired, 
 and there were one or two thin, pale-yeEow motions daily; the 
 patient complained of tenderness on pressure, and also of dull pains 
 coming on spontaneously, to the right of the umbilicus. The 
 hepatic dulness in the mammary line amounted to 3 centimetres 
 (Is inch) ; the spleen could not be measured, in consequence of the 
 
266 • CHRONIC ATROPHY OF LIVER. 
 
 anasarca. The urine was scanty, reddish-yellow, and without 
 albumen. The number of white blood corpuscles, in a specimen of 
 blood obtained by the cupping-glass, was not found to be increased, 
 and hence there was no leukcemia present. 
 
 The patient remained in this condition, and no improvement took 
 place, notwithstanding the use of preparations of steel, quinine and 
 other tonics, together with a regulated and easily- digested diet. 
 Although the appetite kept up, and no complications supervened, 
 the evacuations from the bowels continued scanty, and the 
 dropsy gradually increased to an enormous degree, until at last the 
 distended integuments became red and ulcerated; and death took 
 place, after a protracted agony, on July 27th. 
 
 Autopsy. 
 
 The cranial and thoracic organs presented nothing abnormal, with 
 the exception of a general ansemic condition and an abundant 
 effusion of serum into the pleural cavities. There were also many 
 pounds of clear fluid in the abdominal cavity. The mucous mem- 
 brane of the stomach was pale. To the right of the umbilicus there 
 was a fold of small intestine, which, together with the omentum, 
 was connected to the abdominal wall by firm adhesions of long 
 standing. The serous membrane of this portion of the bowel was of 
 a dark bluish-grey colour ; the deposit of pigment commenced by 
 a denned margin two inches above the adhesion, and extended 
 downwards three feet, where it terminated equally abruptly. 
 The coats of this dark portion of the bowel were intimately 
 adherent and thickened; the corresponding portion of mesentery 
 was indurated and fibrous-looking. The mucous membrane 
 presented numerous irregularly-formed cicatrices, surrounded by 
 dark thickened mucous membrane, similar to those which remain 
 after the cure of a severe attack of dysentery. All the remaining 
 portions of the intestinal canal were perfectly normal. The hernial 
 sac was empty. 
 
 The spleen was of its usual size and consistence; its colour was 
 reddish-brown. 
 
 The liver was considerably atrophied; its capsule was grey and 
 wrinkled ; the entire organ was soft and pliable ; its cut surface was 
 homogeneous, of a brown colour, and without any indication of 
 lobules; its consistence was tenacious; the secreting cells were 
 
CAUSES AND MODE OF PRODUCTION. 267 
 
 shrivelled up, small, and filled with brown granules ; the bile was 
 scanty, pale-yellow, and thin, and contained albumen. 
 In the uro-poietic system there was nothing abnormal. 
 
 In the last three cases (and I coidd add others of a similar 
 nature), the atrophy of the liver made its appearance along with 
 chronic exudation-processes, and ulcerations of the small and large 
 intestine. These two affections apparently arose from a common 
 origin ; although it was not altogether clear what was its nature. 
 There was no chronic peritonitis involving Glisson's capsule. It 
 appears to me, that in these cases there is a similar sort of con- 
 nection between the hepatic affection and the intestinal disease as 
 exists- in some of the hepatic abscesses, which in tropical countries 
 are observed to follow an attack of dysentery. The connecting link 
 is the portal vein, which, according to the nature and manner in 
 which its roots participate in the exudation-processes in the tissue'of 
 the intestinal mucous membrane, in one case gives rise to the so- 
 called metastatic abscesses, and in another, produces occlusion of the 
 capillaries, and consequent atrophy of the liver. 
 
 The obliteration of the trunk of the portal vein may be followed by 
 similar consequences to those which proceed from destruction of its 
 capillaries within the liver. When the occlusion of the vascular tube 
 is not the result of an attack of acute phlebitis, which is usually accom- 
 panied by tumefaction of the liver, the formation of abscesses, &c, 
 it gives rise to a uniform atrophy extending throughout the entire 
 organ. Gintrac* has collected a series of observations, both of 
 simple and cirrhotic atrophy of the liver, in which the portal vein was 
 plugged up. He goes a step too far, however, in regarding occlusion 
 of the vein as invariably the primary and exciting cause, and in attri- 
 buting even cirrhosis to the same origin. In cirrhosis and, in all 
 probability, in many cases of chronic atrophy also, the coagulation of the 
 blood in the portal vein is manifestly a secondary lesion, depending 
 upon the impermeability of a large number of the hepatic capillaries. 
 I give here the details of two cases of obliteration of the portal 
 vein, which, even independently of the characters presented by the 
 hepatic parenchyma, have claims to our attention, owing to the 
 nature of their origin and the peculiarity of their symptoms. 
 
 * Observations et recherches sur l'oblitgration de la veine-porte. Bor- 
 deaux, 1856, p. 39. 
 
268 CHRONIC ATROPHY OF LIVER. 
 
 Obseevation No. XXIX. 
 
 Violent Dyspnoea. — Bloody Sputa. — Systolic Bruit in the Pulmonary 
 Artery. — Ascites. — HcemorrAagesfrom the Stomach and Bowels. — 
 Death from Asphyxia.— Occlusion of the Pulmonary Artery by a 
 Thrombus, in consequence of inflammation of the vessel. — Coagulum 
 of blood in the Portal Vein, Mcchymoses of the Peritoneum, as 
 well as of the Mucous Membrane of the Stomach and Bowels. — 
 Atrophy of the Liver. 
 
 Gottfried Schmidt, a joiner, aged 44, was admitted on the 20th 
 of April, 1855. 
 
 The man was of an athletic build of body, and only slightly 
 emaciated, but the colour of the skin was pale and waxy; the feet 
 were slightly cedematousj he complained chiefly of debility and 
 dyspnoea. On examination, the thorax was found to be greatly 
 arched; nothing abnormal could be made out in the lungs, with the 
 exception of rales in the lower lobe on the right side. The heart was 
 broader than in the normal state, and, on auscultation, a widely- 
 extended systolic bruit could be heard loudest on the left side, close 
 to the cartilage of the fifth rib ; there was no exaggeration of the 
 second sound of the pulmonary artery, and no hypertrophy of the left 
 ventricle. Pulse was 70, and small. The digestive functions were but 
 slightly impaired ; the tongue was clean, and the appetite moderate ; 
 the stools were of normal character. The hepatic dulness was 
 reduced, amounting to scarcely two centimetres in the sternal line 
 (I inch); the spleen was somewhat enlarged; and there was a 
 moderate quantity of fluid in the abdominal cavity. The urine was 
 scanty, dark, and free from albumen. 
 
 The disease had been gradually developing itself for a year. 
 About ten months, before, dyspnoea and palpitations had appeared, 
 accompanied by haemoptysis and great debility, without the medical 
 attendant being then able to find any certain proof of the existence of 
 pulmonary tubercles. The pains ceased, but the dyspnoea continued, 
 and the patient's strength did not completely return. The man, 
 however, returned to his work, at which he continued for a long time, 
 until the increasing debility and dyspnoea, and the oedema of the 
 feet, rendered it necessary for him to seek assistance at the Hospital. 
 
 He was ordered lactate of iron, and animal diet. 
 
CAUSES AND MODE OF PRODUCTION. 269 
 
 From the 1st of May the dyspnoea increased in a marked degree; 
 the patient complained of great anxiety, and of a feeling of impending 
 suffocation ; at the same time there was no impediment to taking a long 
 breath, and everywhere throughout the lungs the vesicular murmur 
 of respiration could be distinctly heard. There was frequent vomit- 
 ing of a bitter greenish-yellow fluid; the pulse was 110, and very 
 small ; the extremities were cool ; the countenance was pale, and the 
 features anxious. 
 
 On the 3rd of May, increasing dyspnoea and anxiety; repeated 
 vomiting of a greenish fluid, mingled with black flakes; great 
 tenderness of the abdomen ; thin, reddish-brown, bloody stools ; 
 sudden death at 10 a.m. 
 
 Autopsy, May ith, 24 hours after death. 
 
 Skullcap congested ; sinuses filled with fluid blood, half-an-ounce 
 of serum at the base of the brain ; cerebral membranes moderately 
 congested ; substance of the brain anaemic, of normal consistence. 
 
 The thyroid gland was somewhat enlarged and congested; the 
 bronchial glands were small and melanotic. The mucous membrane 
 of the trachea, and more particularly of the bronchi, was of a dark 
 livid-red colour, and covered with small whitish distended follicles. 
 
 Both lungs were connected to the thoracic walls by somewhat firm 
 bgamentous adhesions ; interiorly they were compressed by a yellow 
 serous effusion in the pleural cavities ; they were tolerably congested ; 
 anteriorly and superiorly, they were dry ; posteriorly and inferiorly, 
 they were cedematous ; they contained a quantity of pigment, without 
 any exudation. The heart was large ; there were numerous 
 ecchymoses beneath the epicardium ; the right ventricle was hyper- 
 trophied and dilated, its valves were slightly opaque, and there was 
 some loose coagulum in the right auricle; the walls of the left 
 ventricle were somewhat thinned, but its valves were normal ; the 
 aorta was of the ordinary width and its coats were sound. 
 
 The pulmonary artery was enlarged, its valves were normal, and 
 the walls of the common trunk were perfectly smooth; near to the 
 place where the main trunk subdivided into the two principal 
 branches, there was a thick, greyish-red, very firm plug, which 
 adhered to the anterior surfaces of the two main branches, but, 
 posteriorly, did not come in contact with the wall of the vessel. 
 The adhesion in front was so firm, that on careful attempts to 
 
270 CHRONIC ATEOPHY OF LIVER. 
 
 detach the plug, the lining membrane of the vessel was torn off. 
 The plug presented all the characters of an old clot gradually 
 becoming organized. The walls of the artery at this place were 
 remarkably diseased. The coats of the vessel were visibly separated 
 from one another; and between the inner and the middle coat 
 was deposited a transparent yellowish-grey, very firm exudation, 
 which at some places was more than a line in thickness; where 
 the clot ceased to be adherent, the coats of the artery again came 
 together. Other plugs were found in the ramifications of the 
 pulmonary artery. Some of these, although evidently of old date, 
 lay loosely upon the walls, and could be easily separated from them ; 
 the wall at these places was smooth, and the artery was of its usual 
 thickness and free from disease. At other places, again, the clots 
 were firmly adherent, and inseparable, and here the arterial walls pre- 
 sented the same changes as have been described in the main branches, 
 although in a less degree. One of the branches was observed to 
 be obliterated; the opening in the vessel could not be found by 
 means of a probe, and the twig was converted into a solid cylinder. 
 
 The endocardium was everywhere smooth; the venre cavse were 
 moderately filled with fluid blood, but nowhere exhibited any coagu- 
 lum or disease of the coats of the vessel; the arteries also were 
 everywhere sound. Thus the coagulum found in the pulmonary 
 artery could have originated in that vessel only. 
 
 The oesophagus was pale. In the stomach there was a greenish 
 fluid, mingled with black flakes ; the mucous membrane presented a 
 considerable number of recent hsemorrhagic erosions, the surface of 
 which was covered with blood, and the margins infiltrated with the 
 same fluid. 
 
 The entire serous membrane of the small intestine and of the 
 mesentery appeared thickly beset with small red ecchymoses. The 
 serum, which was accumulated in large quantity in the abdominal 
 cavity, was reddish-brown and bloody. The mucous membrane of 
 the small intestine, from the duodenum as far as the ileo-colic valve, 
 was of a dirty-red colour, and tumid ; the solitary glands were very 
 prominent ; the contents of the bowel consisted of bloody mucus. 
 In the large intestine, the mucous membrane was only in a moderate 
 degree coloured and turgid. 
 
 As the cause of all these morbid changes in the abdomen, 
 the whole of the blood in the trunk and branches of the portal 
 ^ein, both in the direction of the intestine, spleen, and stomach, 
 
CAUSES AND MODE OF PRODUCTION. 271 
 
 and also in that of the liver, was found firmly coagulated. The 
 coagulum everywhere presented the same characters j it was of a dark 
 reddish-black colour ; completely filled up the tube of the vessel, 
 but only adhered loosely to its lining membrane, which was sound 
 throughout. It followed the ramifications of the portal vein deep 
 into the substance of the liver, where it became looser, and no longer 
 completely filled up the tube of the vessel. 
 
 The liver was small, shrivelled, and collapsed, of flabby con- 
 sistence, and of, a nutmeg-like structure; the cells were loaded 
 with pigment ; the bile was tolerably abundant, and brownish-yellow. 
 There was no sugar present. 
 
 The spleen was large j its veins were completely blocked up ; its 
 parenchyma was dark and congested, and at many places contained 
 deposits of black pigment. Upon closer examination, reddish-yellow, 
 brown, and black pigment in numerous transition forms could 
 be observed. 
 
 The kidneys were anaemic, of normal size and texture ; the bladder 
 and prostate were sound. 
 
 This case was an illustration of the rare circumstance of an 
 inflammation of the pulmonary artery, which, by the deposit of firm 
 coagula, gradually narrowed the tube of the vessel, and at last pro- 
 duced an almost complete occlusion of both its branches. If any 
 conclusions can be drawn from the symptoms, the affection of the, 
 artery commenced so early as ten months before death, at the time 
 when the first indications were observed of a deranged condition of the 
 pulmonary circulation. It was probably at that date that the, firm 
 ligamentous obliterations of several of the branches of the pulmonary 
 artery originated. By the narrowing of this vessel the circulation 
 of the venous blood became more and more impeded, until, some 
 days before death, the blood in the portal vein spontaneously 
 coagulated, so as to produce complete obstruction. The sudden 
 appearance of the abdominal tenderness, the vomiting of black 
 flakes, and the bloody evacuations from the bowels, announced 
 the occurrence of this accident during life. The entirely uniform 
 character of the clot, and the fact that there was no disease 
 of the walls of the portal vein, proved that the thrombus 
 did not proceed from disease of the vessel, but was a secondary 
 result of the closure of the pulmonary artery. The absence of 
 any deranged condition in the nutrition of the lungs, arising from 
 the occlusion of the pulmonary artery, was remarkable, when con- 
 
272 CHRONIC ATROPHY OF LIVER. 
 
 trasted with the changes in the liver, which result from obliteration 
 of the branches of the portal vein. 
 
 Observation No. XXX. 
 
 Ulcer of the Duodenum. — Obliteration of the Portal Vein by com- 
 pression. — Death in consequence of Hemorrhage from the Stomach 
 and Bowels. — Diver and Spleen of normal size. 
 
 A. Petzold, aged 41, a labourer, of robust-build of body, had always 
 been healthy until three years before admission. At this time he 
 suffered for thirteen weeks from dyspeptic symptoms, accompanied 
 by pains in the epigastrium and vomiting of yellow matter. 
 
 These derangements in a great measure ceased, and there 
 only remained tenderness in the region of the stomach, coming 
 on in severe paroxysms from time to time. About eight weeks before 
 he came to the Hospital, he was attacked with pains in the funda- 
 ment, and other symptoms of haemorrhoids. On the 17th of January, 
 1858, the patient, who in the morning had eaten his usual food 
 with relish, vomited, while at work, about half-a-quart of dark blood, 
 and for this reason was obliged to take refuge at the Hospital. The 
 haemorrhage returned twice the same day, but in smaller quantity. 
 On admission, the patient was pale and anaemic, and in a state of 
 exhaustion approaching to syncope ; the extremities were cool and 
 the pulse scarcely perceptible. The thoracic organs were normal. 
 The epigastrium was moderately distended, and there was tenderness 
 upon deep pressure above the umbilicus. No induration, however, 
 could be felt. The liver and spleen, as far as could be ascertained 
 by percussion, appeared to be of normal size. 
 
 He was ordered ice and solution of alum internally ; and cold 
 applications externally. 
 
 On the 19th, the vomiting, which had ceased on the 18th, re- 
 turned twice; there was a tar-like evacuation of the bowels, and 
 the tenderness of the epigastrium had increased. 
 
 Was ordered acetate of lead and opium, to continue the ice and 
 the external applications. 
 
 On the 20th, vomited twice from 4 to 5 ounces of blood. 
 
 On the 21st, the pains had abated, the vomiting had ceased; one 
 bloody stool; syncope; slight delirium; pulse imperceptible ; cold 
 extremities ; was ordered ether and wine. 
 
CAUSES AND MODE OF PRODUCTION. 273 
 
 On the 22nd,, the skin was warmer, and the pulse was again per- 
 ceptible ; one involuntary stool. 
 
 On the 24th, delirium ; the patient attempted to get out of bed ; 
 frequent bloody stools. The collapse increased until death, which 
 took place on the 26th. 
 
 Autopsy, 24 hours after death. 
 
 The membranes of the brain, and the brain itself were moderately 
 congested, and of normal characters ; so likewise the bronchi, lungs 
 and organs of circulation presented no disease, if we except a 
 remarkable degree of anaemia. The stomach contained about two 
 pounds of firmly-coagulated blood ; its mucous membrane was 
 covered with a thick reddish-yellow tenacious mucus ; an inch and 
 a-half from the cardiac orifice, the veins could be observed to be 
 very varicose and enlarged, and filled with firm clots of blood. In 
 other respects, the mucous membrane was pale, of normal thickness, 
 and not ulcerated. In the duodenum, just beyond the pylorus, 
 there was a superficial ulcer, half the size of a silver groschen,* 
 and in the middle of this could be seen an opening as large 
 as a pin's head, leading into a sinus, which extended three 
 quarters of an inch towards the median line. This sinus was 
 found surrounded by a thick layer t of newly-formed areolar tissue, 
 the cicatrising contraction of which had constricted the ductus 
 choledochus, but had left the vena porta entirely exempt. In the 
 interior of the portal vein, and extending into the right and left 
 branches of this vessel, deep into the substance of the liver, 
 was an accurately fitting thrombus, breaking down in its centre 
 into a cheesy-like substance. Behind the stomach, lay a tumour, 
 the size of a walnut, consisting of a fatty, cheesy-looking mass of 
 exudation, enveloped externally by recent areolar tissue. None of 
 the mesenteric glands were enlarged; no haemorrhoids could be 
 observed in the rectum ; but in the mesentery, immediately below 
 the duodenum, could be seen a melanotic patch, several inches 
 in diameter, the remains of an old extravasation of blood. The 
 mucous membrane of the duodenum and jejunum was pale ; that 
 of the ileum was at some places tinged yellow. The csecum, 
 colon, and rectum contained a large quantity of tarry blood, partly 
 
 • A silver groschen-piece measures about | inch in diameter. — Transl. 
 
274 CHRONIC ATROPHY OF LIVER. 
 
 mixed up with solid brown masses of feces. The mucous membrane 
 itself was everywhere pale and free from ulceration. 
 
 The spleen was anaemic and of normal size ; it measured 5 inches 
 in length, 3£ in breadth, and 1J in thickness ; its absolute weight 
 was 0.15 kilogr. (5£ oz. av.) and its relative weight to that of the 
 body, 1 to 208. 
 
 The outer surface of the liver presented numerous white cicatrix- 
 like depressions : its size was not reduced. The right lobe measured 
 transversely, 6 inches, and 7£ inches from behind forwards; the 
 left lobe measured 3-| by 5f inches ; its thickness amounted to %\ 
 inches; its weight was 1.90 kilogr. (4 lbs. 3 oz. av.) and its 
 relative weight to that of the body, was 1 to 27.3. Its tissue was 
 anaemic, and finely granular; the hepatic cells were pale, and had 
 few granular contents ; a few only contained oil globules ; others of 
 them contained molecules of colouring-matter. The bile ducts in 
 the substance of the liver were partially filled with a brown fluid, 
 and a considerable quantity of thick opaque bile was found in the 
 gall-bladder. No sugar was found in the liver. A layer of areolar 
 tissue and fat, - of considerable thickness, enveloped the rami- 
 fications of the portal vein. 
 
 This case is interesting in several points of view. Notwithstanding 
 the complete occlusion of the portal vein, which, judging from the 
 character of the thrombus, must have existed for a long time, 
 there was neither any diminution in the volume of the liver, nor any 
 suspension of its secretion. To what extent this function was impaired 
 it is impossible to determine ; we must not, however, conclude that 
 it was in no way affected, from the fact of the gall-bladder being 
 full, inasmuch as the contents of the gall-bladder had all the 
 characters of a secretion which had been stagnating for a long 
 period, being condensed, and containing deposits of cholesterine and 
 particles of colouring-matter. 
 
 Gintrac* and Ore,t from similar observations, infer that the 
 secretion of the bile is not due to the portal vein, but to the hepatic 
 artery. Such a supposition I hold to be incorrect, and the more so, 
 as there are observations of an opposite nature, in which the hepatic 
 artery was obliterated, and still the bile continued to be secreted 
 (Zedieu). Hence, arguing in this way, one might show that neither 
 the vena porta nor the hepatic artery participated in the secreting 
 functions, or in the nutrition of the liver. The continuance of both 
 * Op. cit., p. 51. t Gaz. des Hopitaux, Sept. 9, 1856. 
 
SYMPTOMS. 275 
 
 processes after obliteration of the trunk of the portal vein, is, in my 
 opinion, dependent upon the intimate anastomosis which subsists 
 between the capillaries of the two systems of vessels, and upon the 
 enlargement which the ramifications of the hepatic artery undergo 
 after destruction of a portion of the portal venous system. One can 
 best convince himself of this by injecting the hepatic artery in a 
 cirrhotic liver, when it will be found, that this vessel presents 
 an unusually abundant and extensive vascular network at those 
 places where the injection has penetrated into some of the capillaries 
 of the portal vein. 
 
 The absence of enlargement of the spleen, notwithstanding the 
 closure of the portal vein, was accounted for by the profuse haemor- 
 rhages from the stomach. 
 
 II. Symptoms. 
 
 The destruction of a large portion of the hepatic parenchyma in 
 consequence of chronic atrophy, necessarily entails a diminution of 
 the functional value of the gland, which reacts upon the system at 
 large, and the more so, as a series of derangements in the digestive 
 organs take place at the same time, owing to the obstruction of the 
 portal circulation. In this way other functional complaints ac- 
 company atrophy of the liver, and make up the clinical features 
 of this disease. The symptoms are developed slowly and in- 
 sidiously. Erst, there are derangements of the gastric and intes- 
 tinal digestion; loss of appetite and a feeling of distention, and 
 tightness at the epigastrium ; tongue sometimes clean, and at other 
 times furred; accumulations of flatus in the intestinal canal; and 
 pale greyish-yellow, or sometimes moderately brown stools. The 
 bowels are irregular ; constipation and diarrhoea alternate ; persistent 
 and profuse diarrhoea is frequently (in 9 out of 18 cases) observed, 
 and soon induces exhaustion; in exceptional cases only are the 
 bowels regular. On examining the hepatic region, the dimensions 
 of the organ are found to be reduced in every direction ; sometimes 
 no dulness can be made out at all ; in most cases, the organ is quite 
 inaccessible to palpation. The spleen is usually unaltered ; in a few 
 cases only (in 7 out of 18 cases) is it enlarged. 
 
 Symptoms of defective sanguification and nutrition supervene 
 sooner or later upon these digestive derangements; the patients 
 exhibit a pale cachectic appearance without any jaundiced tinge,' 
 
 t 2 
 
276 CHRONIC ATROPHY OF LIVER. 
 
 the muscular tissue wastes; and at the same time, as a general rule 
 (in 14 out of 18 cases), accumulations of water take place in the 
 peritoneal sac, which are soon followed by general dropsy. The 
 urine is usually pale and free from bile-pigment ; in a few cases it 
 has presented a peculiar hyacinth-red colour; once only has it 
 been observed to become dirty-green when treated with nitric acid. 
 
 III. Mode of Termination. 
 
 Chronic atrophy of the liver, when it reaches an advanced stage, 
 as a general rule, terminates fatally, from the gradually progress- 
 ing exhaustion, or from general dropsy, or from complications 
 more or less intimately connected with the disease of the liver, such 
 as cancer of the stomach, chronic dysentery, &c. In two cases, 
 death took place by peritonitis, in a third, from delirium tremens, 
 and in a fourth, from profuse bleeding from haemorrhoids. The 
 disease is usually protracted over many months, 
 
 iv. Diagnosis. 
 
 The diagnosis of chronic atrophy of the liver is not unfrequently 
 attended with difficulties, especially when the patient is not 
 seen until the ascites and the oedema of the abdominal walls are 
 so considerable as to render the examination of the abdominal 
 viscera difficult or impossible. We must be mainly guided by the 
 diminution in the size of the liver, by the obstinate gastro-enteric 
 catarrh, the deficiency of bile in the faeces, the ascites, and the 
 cachexia; these symptoms obtain a diagnostic value, when we can 
 exclude all other causes which might account for the ascites or the 
 dyspeptic symptoms. Simple atrophy can only be distinguished from 
 that which arises from cirrhosis, when we can ascertain by means of 
 palpation, whether the surface of the gland is smooth or granular. 
 
 Treatment never holds out much hope of a favourable termination, 
 after the disease is far advanced ; and as this is almost always the 
 case when the diagnosis is clear, the treatment can only be directed 
 against symptoms. First, we should take care that the diet is easy of 
 
TREATMENT. 277 
 
 digestion and nutritious ; then, the secreting function of the mucous 
 membrane of the stomach and bowels should be regulated by bitter, 
 aromatic and slightly astringent remedies, such as infusions of the 
 root of calamus aromaticus, rhubarb, and cloves, tincture of rhubarb, 
 compound tincture of cinchona, and the aqueous extract of nux 
 vomica. When there is profuse diarrhoea, powerful vegetable as- 
 tringents are indicated. 
 
 The anaemia must be combated by mild preparations of steel, such 
 as the carbonate and lactate of iron, or better still by small quantities 
 of the waters of Pyrmont or Spa,* or of similar springs. 
 
 By such treatment we are best enabled to counteract the impending 
 dropsy. After ascites and anasarca make their appearance, we may 
 have recourse to drastic purgatives or powerful diuretics; but the 
 beneficial effects upon the dropsy which may be expected from these 
 remedies, are almost always surpassed by their other injurious 
 consequences. It is best to limit oneself to the use of a diuretic 
 infusion, in combination with some bitter aromatic substance ; and 
 to have recourse to paracentesis, when this becomes necessary from 
 the excessive amount of the ascites. 
 
 * The mineral water of Spa, in Belgium, is a gaseous chalybeate, with 
 a temperature of 50° Fahr. It contains more than three-fourths of its 
 volume of carbonic acid, and rather less than four English grains of solid 
 matter in the imperial pint. These solids are made up of carbonate of 
 iron, carbonate and muriate of soda, lime, and magnesia. 
 
 The waters of Pyrmont are of a similar character. (See note to page 121.) 
 — Transl. 
 
278 THE FATTY LIVER. 
 
 CHAPTER VII. 
 
 THE PATTY LrVEB. 
 
 (Die Fettleher : Hepar adiposum.) 
 
 Deposits of fat in the tissue of the liver are amongst the most fre- 
 quent structural changes observed in the organ. When this deposit 
 attains a high degree, we are wont to regard it as a disease, and 
 to designate it by the name of fatty liver, or fatty degeneration of 
 the liver. 
 
 All attempts to sketch an accurate history of this anatomical 
 lesion from clinical observations, have proved unsuccessful; fatty 
 liver is met with so frequently on opening the dead body, and 
 all clues to diagnosis during life are so inaccessible, that it is 
 impossible to construct a satisfactory symptomatology of the affection. 
 The remark, bearing upon this point, which Louis* made many 
 years ago in his " Eecerches sur la Phthisie," is in many respects 
 still applicable: — "Nous manquons de signes capables de la faire 
 connaitre a une epoque quelconque de sa duree. En vain, j'ai ete 
 au devant des symptomes, qui pourraient lui appartenir, je n'en ai 
 recueilli aucun." 
 
 Such being the case, one can understand how it is that very different 
 views are maintained in reference to the pathological importance of 
 fatty infiltration of the liver, and its relations to other morbid pro- 
 cesses. It has been the custom to regard a liver abounding in fat 
 as diseased, and care has not been taken to define accurately the 
 boundaries within which the normal fatty constituents of this organ 
 may vary without touching upon the confines of disease. Moreover, 
 sufficient attention has not been devoted to the different causes 
 upon which the various forms of fatty liver depend, or to the dis- 
 tinctions which exist between a liver merely abounding in fat and 
 one which has undergone fatty degeneration. 
 
 • Ed. II., p. 129. 
 
OCCURRENCE OF FAT IN HEALTHY LIVER. 279 
 
 I. Pathology of Fatty Liver. 
 
 Before we consider the pathology of fatty liver, it is advisable 
 that we should study more carefully the variations in the fatty 
 contents of this organ compatible with good health, and that we 
 should investigate the conditions upon which an accumulation of 
 this substance in the parenchyma of the liver is found to depend. 
 
 At certain times and under certain conditions, the secreting cells 
 of the liver are so constantly filled with fat, that the idea is forced 
 upon us that some relation must necessarily exist between the 
 presence of the fat and the due performance of the functions of the 
 organ. 
 
 The liver of invertebrate animals, invariably contains fat in 
 abundance, as has already been shown by Schlemm, Karsten, 
 Meckel, Will, Lereboullet, Leydig, and others. Some of the cells 
 are filled with drops of oil, whilst yellow molecules of bile are found 
 in others. Hence, Meckel* believes, that we must distinguish two 
 sorts of cells in the liver, one of which is designed for the separation 
 of bile, the other, for the secretion of fat. This supposition, 
 however, is contradicted by the fact that we can detect transition 
 forms between the cells which contain colouring-matter and those 
 containing fat. 
 
 Among the Vertebrata, it is known that some of the fishes, such 
 as the Plagiostoma, the Chimsera, &c, are remarkable for a live*- 
 abounding in fat. In Raia clavata, Gadus seglefinus, and also in 
 Psyllium canicula, the hepatic cells during the autumn season con- 
 tain such a large quantity of oil globules, that the organ presents a 
 greyish-white colour, and resembles a reservoir of fat more than a 
 gland destined to secrete bile. In Gadus seglefmus, the dried liver 
 contains 92.71 per cent, of fat, and only 7.29 per cent, of insoluble 
 matter. In the foetus, we usually find a large quantity of fine oil 
 globules in the hepatic cells ; these are scattered through the cavity 
 of the cell, and do not become confluent into large drops, as fre- 
 quently happens in the later periods of life. At certain times, the 
 quantity of fat appears to be considerable, whilst at others it is less. 
 E. H. Weber t has made the observation, that in chickens between 
 
 * Miiller's Archiv, 1846, p. 68. 
 
 f Bericht der konigl. sachs. Gesellsch. der Wissensch. mathem. physik. 
 Classe, 1850., S. 15. 
 
280 THE FATTY LIVER. 
 
 the 16th and 19th days of hatching, the yolk was absorbed by the 
 blood-vessels from the yolk sac, and passed into the liver. This organ 
 was then loaded with numerous oil globules, and assumed a yellow 
 colour. Not until the chickens came out of the shell, did the 
 quantity of fat contained in the hepatic cells disappear, and the 
 natural brown colour of the organ become gradually developed. 
 According to the views of Weber and Kolliker,* the absorbed yolk 
 mass serves for the formation of blood corpuscles. Lereboullet,t who 
 observed a large quantity of fat in the hepatic cells of a fetal rabbit, 
 and in those of a mature human fetus, thought that this was a con- 
 dition peculiar to the fetal period of life ; but this is a mistake. I 
 have many times, when an opportunity presented itself, examined the 
 fetal liver of men and animals, and have frequently, although by no 
 means always, detected numerous oil globules in the secreting cells. 
 It would appear, therefore, that the quantity of the fatty constituents 
 of the liver rises and falls with certain stages of development, and 
 possibly also it is influenced occasionally by pathological conditions. 
 
 After birth and in the later periods of life, the fatty contents of 
 the liver are subject to numerous variations, some of the conditions 
 of which are well understood. 
 
 The first agency which exerts a decided influence in this respect, 
 is Diet.J 
 
 Magendie, in his investigations into the relative nutritiveness of 
 the several articles of food, ascertained that by feeding dogs exclu- 
 sively on butter, the liver became very fatty, whilst at the same 
 time the skin assumed an oily character, and volatile fatty acids 
 were secreted by the sebaceous glands. Bidder and Schmidt, and 
 more recently, Laue,§ have published similar observations : so that 
 the fact may be regarded as established. 
 
 I have myself performed a series of experiments on dogs, in order 
 to trace the stages of the process, and particularly with the object 
 of ascertaining the length of time that food differing only from that 
 
 * Gewebelehre, S. 580. 
 
 + Memoire sur la structure in time du foie. Paris, 1 853, page 43. 
 
 t This has in truth been known ever since it has been the custom to 
 fatten geese in order to obtain a fatty liver, an artifice which, as Th. Willis, 
 observes, was known to the ancient Romans : — " Olim apud Romanos 
 ars fuit, anserem ita pascere ut hepar in immensum accrescens totum 
 prseterea corpus praeponderaret." (Pharmac. ration, sive de medic, operat., 
 Sect. II., Cap. II., p. 225.) 
 
 § R. Wagner's Physiol, von Funke, S. 171. 
 
INFLUENCE OF DIET IN PRODUCING IT. 281 
 
 to which the animal has been accustomed, in its being mixed with a 
 quantity of fat, requires to take effect upon the liver.* A small 
 piece of the liver of each animal was first removed through a wound 
 in the abdomen, in order to examine and draw the cells ;t the 
 animals were then made to take, along with the food to which they 
 had previously been accustomed, from one-half to a whole ounce of 
 liver oil in the day, after which the changes which the organ under- 
 went were examined from time to time. The results of these 
 investigations may be thus summed up : — Already, after 24 hours, the 
 cells exhibited an increase of their molecular contents ; after three 
 days, numerous oil globules could be seen ; and after eight days the 
 cavities of the cells appeared completely filled with large and small 
 drops of oil. If we examine the liver of an animal fed in this way, in 
 its entirely fresh state, we find the cells considerably enlarged and 
 distended with fine pulverulent molecules ; not until after some time 
 does the finely-distributed matter collect into globules, leaving the 
 remaining contents of the cells clear and transparent. In the following 
 figures (Kg. 28) are represented the changes which take place in the 
 hepatic cells after three (a), and after eight (b) days' feeding. 
 
 Fig. 28. 
 
 Fig. 28. Secreting cells from the liver of dogs which had been 
 fed upon fat for three (A) and eight (B) days. 1. Their 
 appearance before the commencement of the experiment ; 2. 
 Cells, as they appeared after the animals had been fed with 
 oil, in their fresh state ; 3. The same, after being kept for 
 some time. 
 
 The fatty matter which passes in this way into the parenchyma of 
 the, liver J disappears again after some time, when the food is changed. 
 
 " Rabbits and frogs are unsuited for this purpose. 
 
 t This is necessary, in order to obtaiu a certain starting-point for the 
 experiment, because the liver in animals is npt unfrequently found to be 
 already fatty. 
 
 J The capillaries of the liver allow fat to pass through them with diffi- 
 culty, unless it is in a state of very fine division. When olive oil is 
 
282 THE FATTY LIVER. 
 
 How this is effected is still uncertain. It is probable, that when 
 the accumulation of fat is considerable, one portion returns as such 
 to the blood, whilst another is made use of in the formation of bile. 
 It has been often justly observed, that from the chemical properties 
 of the biliary acids, it is probable that fatty matters take part in 
 their original formation. The histological characters of the liver 
 support such a supposition in so far as the quantity of fat di- 
 minishes simultaneously with the appearance of yellow matter in the 
 hepatic cells ; it is only in exceptional cases that we observe both 
 together.* It can scarcely, however, be doubted, that there are other 
 modes in which the fat is disposed of. The deposit of fat in the 
 liver of the lower animals, and especially in that of fishes, is so 
 abundant, that it cannot be imagined that the substance is entirely 
 consumed in the secretion of bile. In these cases, the gland appears 
 to serve as a depot for fat which afterwards returns as such into the 
 circulation, and is then subservient to some purpose. In support of 
 this view it is worthy of notice, that even fishes which are destitute of 
 fat in other parts, possess a liver, which, is unusually rich in this sub- 
 
 injected into the roots of the portal vein, it is retained in the vessels 
 of the liver, and does not reach the right side of the heart. Under 
 such circumstances, there are found in the liver round cysts the size of a 
 linseed, which are filled with oil, and which are for the most part asso- 
 ciated in groups of from three to seven ; some of the branches of the portal 
 vein are filled with pure oil ; others contain blood as well, and occasionally, 
 also firm coagula. If the animals remain alive for several days after the in- 
 jection, there may be observed scattered through the brown substance of the 
 liver yellow masses containing but little blood, and in which the secreting 
 cells are filled with large and small drops of oil. In one case, in which the 
 animal did not die until after three weeks, the liver was coloured yellow 
 to a. great extent, and penetrated by a beautiful dark-red network of 
 vessels. The hepatic cells were distended with oil globules, and in 
 some places they appeared to be crumbling down into a fatty debris. 
 Besides the more prominent yellow portions, there was the normal reddish- 
 brown hepatic tissue, containing cells free from oil. In one case, signs of 
 slight jaundice made their appearance after the injection. Similar changes 
 could not be brought about by injecting the jugular veins with oil. 
 
 It cannot be determined whether the fat, upon digestion, is carried 
 directly through the portal vein to the liver ; the blood of the portal vain, 
 after feeding on fat, undergoes no change, which would warrant us to 
 answer this question in the affirmative. 
 
 • Lereboullet even observes (op. cit., p. 86) : — " Les cellules graisseuses 
 "ne me paraissent etre que transitoires ; je crois qu'elles se transforment 
 "elles-memes en cellules biliares par depot de granules biliares et par 
 "disparition de la graisse, qu'elles renfermaient." 
 
INFLUENCE OF DIET IN PRODUCING IT. 283 
 
 stance, and farther, that according to Leydig, in Palndina vivipara, 
 before the commencement of its winter sleep, the liver is rich in fat, 
 and assumes a white hue, whilst at other times it is brown. 
 
 It is not merely food unusually rich in fat that gives rise to these 
 deposits in the liver, but, under certain circumstances, every kind of 
 food, when in too great quantity, has the same effect, even when it is 
 free from fat, and only contains a large quantity of the carbo-hydro- 
 gens. Here, however, the deposit does not make its appearance 
 in the liver until the other organs and tissues, such as the cellu- 
 lar tissue, are loaded with fat, nor until the serum of the blood 
 begins to be milky. Lereboullet * observed, that on feeding geese 
 with maize, the relative weight of the liver in proportion to that of 
 the entire body was at the commencement reduced; whilst the 
 cellular tissue first became loaded with fat; not until sometime 
 afterwards did the liver increase disproportionately and become infil- 
 trated with fatty matter ; at the same time, the secretion of bile 
 diminished, and the serum of the blood became turbid. In this 
 case, the fat was not conveyed directly to the liver, and its deposit 
 in this organ did not commence until the composition of the blood, 
 and the nutrition were essentially modified in consequence of an im- 
 proper diet.f 
 
 Prom what has just been stated, it will be understood how a fatty 
 liver is not unfrequently found in individuals who have died suddenly 
 in the bloom of good health. J It is then merely a transitory 
 phenomenon, and does not of itself constitute any disease. By 
 a persistence, however, in improper food, the deposit increases more 
 and more, and gradually exceeds the boundaries of health. In such 
 cases there are usually other agencies at work, which aggravate the 
 
 * Op. tit., p. 96. 
 
 t Claude Bernard (Lefims de phys. expkrim., 1855, p. 149) is of opinion 
 that the sugar which passes from the digestive organs to the liver, is here 
 converted into fat. The milky matter found in a decoction of the liver, and 
 upon the appearance of which, after the use of a diet containing sugar, 
 Bernard mainly relied in making this statement, is poor in fat, and is, 
 moreover, found also in animals which have been restricted for a long 
 time to animal food, and occasionally also in the foetal liver. 
 
 J I have found the liver very fatty in a railroad official who was killed 
 at his employment ; also in a mason who met with his death from a violent 
 fall ; and likewise repeatedly in individuals who have died after a few 
 days' illness, during the eruptive stage of the acute exanthemata, scarlet 
 fever, and measles. 
 
284 THE FATTY LIVER 
 
 bad effects of diet. First amongst these, is a diminished activity 
 of the metamorphosis of matter, such as is found in individuals 
 who avoid all bodily and mental exertions ; secondly, there is a de- 
 fective action of the liver, from which results an incomplete appli- 
 cation to the formation of bile of the fat brought to this organ ; and 
 lastly, there are constitutional influences of an unknown nature. 
 
 There are some individuals in whom the metamorphosis appears to 
 take place slower than in others ; in such persons there is wont to be 
 a predominant tendency to the deposit of fat in the various' organs 
 and tissues, whilst the secretion of bile, so far as this can be ascer- 
 tained, is scanty. This is the case even in animals; and in the 
 experiments of feeding above described, differences were observed in 
 respect to the rapidity with which fat was deposited in the secreting 
 cells, which were of a purely individual nature. These discrepancies 
 apparently depended upon dissimilarities in the development and 
 functional activity of the several organs, which are concerned 
 in the absorption and metamorphosis of the elements of food. 
 Such constitutional peculiarities are hereditary ; and this partly ex- 
 plains why it is that a train of abdominal derangements, haemorrhoids, 
 excessive embonpoint, &c, are hereditary in certain families, and how 
 successive generations come to be visitors at Kissingen, Marienbad 
 and Karlsbad. Even as regards the mere digestion of fat, important 
 differences exist. There are individuals who can only tolerate very 
 small quantities of fat, without the functions of the stomach becom- 
 ing deranged, whilst there are others who consume a large amount 
 without any ill effects, and still continue lean; and again, there are 
 others in whom the use of large quantities of fat is followed by a 
 corresponding increase in bulk. 
 
 Along with individual idiosyncrasies, there are agencies of a more 
 general nature which favour the deposit of fat, and with the mode of 
 operation of which we are as yet only partially acquainted; such are, 
 the middle period of life, the female sex, and a temperate, humid, 
 marshy climate.* 
 
 The modes of origin of fatty liver hitherto discussed may, for the 
 most part, be reduced to external agencies ; in other cases, this con- 
 dition exists in connexion with internal pathological processes, some 
 of which at least do not at all directly implicate the liver. Of these 
 morbid processes we are particularly familiar with the frequent con- 
 currence of fatty liver with pulmonary tubercle, and other wasting 
 * See Frout : On Stomach and Renal Diseases, 5th Ed., p. 255. 
 
FROM PULMONARY TUBERCLE, &c. 285 
 
 diseases, as also with the drunkard's dyscrasia ; both, of these morbid 
 conditions, however different they may be in other respects, agree in 
 this, that the blood is usually characterised by the presence of a large 
 quantity of fat, and that a milky turbid serum separates from it. 
 This, indeed, is the cause of the change which the hepatic tissue under- 
 goes in these affections. The production of fatty liver in the course 
 of pulmonary tubercle has been attempted to be explained in various 
 ways ; most writers lean to the view which attributes the production 
 of the carbo-hydrogens and fat to obstructed respiration, and to the 
 defective oxydation of the blood resulting from this. Without en- 
 tirely denying the influence of respiration, — as has often been done, 
 on the ground that in other derangements of the respiratory function, 
 snch as emphysema, fatty liver does not make its appearance, and 
 that it is met with in cases where there is tubercular deposit in other 
 parts of the body, such as the bones (fiolntanghy), — I beheve myself, 
 that the cause of this form of fatty liver must be sought for in those 
 changes in the composition of the blood, which take place during the 
 process of wasting. The blood becomes loaded with fat, which is 
 taken up during the advancing emaciation, in order to be employed 
 for supplying the demands of the metamorphosis of matter in the 
 system.* The accumulation of fat in the liver is usually more re- 
 markable in pulmonary tubercle than in other wasting diseases, in 
 which the respiration is unaffected, merely because the impaired ab- 
 sorption of carbonic acid entails a more tedious metamorphosis. In 
 women, in whom the adipose tissue is wont to be more developed than 
 in men, the absorption of fat is greater; fatty liver is, therefore, 
 more common, and more marked in tubercular females than in males. 
 
 The condition of the digestive system exercises a farther influence; 
 the more this is impaired, and the more the secretion of bile becomes 
 from this cause diminished, so much the less of the fat which has 
 been removed from the body is employed in the formation of bile, 
 and so much the more of it accumulates in the liver. 
 
 In other wasting diseases, fatty liver occurs certainly less fre- 
 quently than in pulmonary tubercle, but still oftener than is usually 
 believed. Bright mentions cases in which it appeared in the course 
 
 * This view was expressed years ago by Larrey, who appealed to 
 the injurious method then prevalent in France, of promoting the for- 
 mation of a fatty liver in geese. The animals were shut up in close, hot 
 cages, without food of any sort whatever, whereupon they became ill and 
 remarkably emaciated, whilst the liver became enlarged and fatty. 
 
286 THE FATTY LIVER. 
 
 of chronic dysentery and along with cancer; Budd records other 
 instances of fatty liver accompanying cancerous ulcers, and I have 
 myself observed the most advanced grade of the disease going along 
 with compression of the spinal cord, in a case where great exhaus- 
 tion was induced by a sloughing bed-sore. (For further examples, 
 see the Table showing the different diseases in which this affection is 
 met with.) 
 
 Accumulation in the blood of fat proceeding from another source, 
 is the cause of the fatty liver of drunkards. To what extent the 
 direct influence exerted upon the liver by the alcohol entering the 
 blood, can contribute to the development of the affection in question 
 will have to be discussed in the chapter on cirrhosis. 
 
 Prom what has already been stated, the general conclusion may 
 be drawn, that in every instance in which the blood becomes loaded 
 with fat, either as a consequence of improper diet, or owing to 
 abnormal conditions of the metamorphosis of matter, infiltration 
 of the liver with fat may be developed, either in a transient 
 or permanent form. There are two sets of glands, particularly, 
 which become implicated by this altered composition of the blood, 
 viz. : — the liver and the sebaceous glands of the skin. A greasy, or 
 velvety character of the cutis is thus a frequent accompaniment of 
 fatty liver, and may, under certain circumstances, be of service in 
 diagnosis. 
 
 Besides these general influences which act through the medium 
 of the blood, there are other derangements of a local nature, con- 
 fined to the liver itself, which may tend to fatty degeneration. 
 That such agencies really exist, is shown by the partial develop- 
 ment of this affection in isolated masses scattered through the 
 liver, while the remaining portions are comparatively sound. Limited 
 local deposits of this nature are found in atrophied livers and in 
 cirrhosis, where not unfrequently a portion of the lobules, or even 
 the half of an individual lobule, is in a state of fatty degene- 
 ration, while the remaining portion or half remains exempt j they 
 are further found in lardaceous {spechig) infiltration of the liver, and 
 lastly, in the circumference of cancerous nodules, cicatrices, and 
 inflammatory deposits, &c. Moreover, pale, irregular spots, from 
 a to 2 inches in diameter, are not unfrequently observed over the 
 outer surface of the gland, which, in other respects, is normal; 
 these penetrate several lines into the substance of the parenchyma, 
 and then terminate by a defined border. Such places sometimes 
 
STRUCTURAL CHARACTERS. 287 
 
 contain pale, perfectly normal, hepatic cells, but frequently also cells 
 filled with fat. The causes which occasion such local changes, 
 can only be partially investigated with any degree of certainty. In 
 most of the cases, the fundamental causes are abnormal conditions 
 of nutrition, such as are perceived in consequence of hypersemias 
 arising from an alteration in the character of the fluid pervading 
 the tissues, which are often found in the kidneys, the pulmonary 
 epithelium, the muscles, &c. In this way we must explain the 
 fatty degeneration of the hepatic cells, which takes place in the 
 neighbourhood of inflammatory deposits, cicatrices, and pathological 
 new-growths, and, to some extent, also in cirrhosis. A similar expla- 
 nation may be given of- the formation of fat throughout the entire 
 organ in the cells undergoing disintegration in acute atrophy, and 
 also of the fatty degeneration, which occasionally takes place in 
 the later stages of the so-called lardaceous or waxy infiltration (der 
 qpeckigen Infiltration). 
 
 The deposit of fat in the liver which originates in this way, is 
 essentially different in its consequences from the first-described form. 
 In that, the fat was simply deposited in the cells, which were not 
 altered in their other characters; but, on the other hand, in the 
 instances last enumerated, the cells which are infiltrated with an 
 abnormally concentrated plasma, and of which the nutrition is par- 
 tially impaired, cease entirely to perform their functions. We distin- 
 guish this form of fatty degeneration from the former, which we may 
 designate fatty infiltration. In many cases, however, where the 
 deposit of fat is partial, its mode of origin cannot be traced in the 
 manner just mentioned ; the same remark is applicable to the deposits 
 of fat, which one often finds in atrophied livers, where some of the 
 cells are collapsed and shrivelled, whilst others are filled with fat, and 
 to the deposits which are found scattered through comparatively 
 sound livers, &c. In such instances, deranged nutrition may 
 be at one time to blame, and at another time an impaired condition 
 of the secreting function; and it is not impossible that other 
 influences of an unknown nature may also operate. 
 
 ii. Structural characters of Fatty Liver. 
 
 So far as my experience extends, the deposit of fat in the liver is 
 always limited to the secreting cells; I have never been able to 
 discover deposits of fat in the intercellular spaces of the parenchyma 
 
288 THE FATTY LIVER. 
 
 even in the most advanced stages of the affection.* Appearances 
 are not unfrequently in favour of a deposition in the intercellular 
 spaces, inasmuch as in preparing objects for microscopic examination 
 a number of cells become destroyed, and their fatty contents escape, 
 and thus appear to lie external to the cells. Where, however, the 
 elementary structures are isolated with care, we find the fat everywhere 
 enclosed in cells; these cells are sometimes distended to such a 
 degree that their external membrane only becomes visible after the 
 removal of the fat by the addition of oil of turpentine. In fine 
 sections of the liver made after the organ has been injected and 
 dried, we can see the cells loaded with fat, in the spaces corre- 
 sponding to the meshes of the blood-vessels ; these cells can be freed 
 from their contents by treatment with ether. By boding the sections 
 with ether, we easily succeed in removing the cells ; and then the 
 vessels with their sheaths of areolar tissue alone remain. It is 
 our conviction, that an interlobular fatty liver does not exist, and 
 indeed it would be difficult to reconcile the existence of such a 
 lesion with the anatomical distribution of the elementary tissues of 
 the hepatic parenchyma. 
 
 The fat is at first deposited in the form of fine small drops in the 
 interior of the cells, usually close to the nucleus, but also at other 
 parts of the cavity of the cell. These little drops then increase in 
 
 Fig. 29. 
 
 Fig. 29. Hepatic cells, loaded with oil globules, in many of which 
 a nucleus is distinctly visible. 
 
 number and size, they approach nearer to one another, the granular 
 and brown molecular contents diminish, and the nucleus is obscured. 
 
 * J. Vogel (Icon. Histol., Taf. XIX. and XX.), and, more recently, 
 Wedl (Grundxiige der pathol. Histolog. Wien, 1854, S. 192; transl. by the 
 Syd. Soc, 1855, p. 162) maintain that they have observed such a deposition 
 of fat. The latter distinguishes two forms of fatty liver ; in the one, which 
 he calls the lobular fatty liver, the oil globules lie scattered every where 
 through the dirty-yellow substance of the liver ; hi the second form, or 
 the interlobular, they lie in the interstices of the lobules. 
 
STRUCTURAL CHARACTERS. 289 
 
 In most cases, the nucleus comes into view on removal of the fat by. 
 means of oil of turpentine ; it does not usually disappear until the ac- 
 cumulation of fat has become far advanced, and not always even then.* 
 
 The little drops of oil afterwards run together, into two, three, or 
 four large drops ; and these also, in the further progress of the disease, 
 xrften become united into one single drop, almost entirely filling up 
 the cavity of the cell. The granular cell contents, with the small 
 oil globules, are then seen to be pressed to one side, and to surround 
 the margin of the large drop of oil lite a fringe. 
 
 The fat itself in general appears fluid; we rarely see solid 
 granules or drusic masses of crystalline needles of margarine, such as 
 were figured by J. Vogel and Lereboullet. 
 
 The accumulation of fat usually causes the cells to enlarge ; in 
 cases where the deposit is partial, the cells containing oil, have a 
 larger diameter than other cells from the same liver which contain 
 none ; this, however, is by no means always the case. Very small 
 cells containing fat are sometimes found, particularly in atrophy of 
 the liver, and frequently even when the accumulation of fat is con- 
 siderable, we are unable to detect changes of any sort in the size of 
 the cells, f 
 
 In most cases, when the disease is in an advanced s£age, the form 
 of the cells becomes altered; their angular outlines disappear, and 
 their form becomes more rounded; when the accumulation of oily 
 matter is considerable, the outer surface of the cell assumes an 
 uneven character from the projecting oil globules. The wall of 
 the cell cannot then always be detected; it does not become dis- 
 tinct until the fat has been removed by means of ether or oil of 
 turpentine ; previous to this, it is often impossible to distinguish the 
 cells with their contents from aggregations of globules of oil. In 
 proportion to the increase of the fatty matter, the remaining con- 
 tents of the cells recede; the fine granular contents diminish, as 
 also the albuminous substance, which is rendered turbid by alcohol, 
 
 * Lereboullet believes lie has ascertained that the nucleus perishes 
 when the deposit of fat reaches an advanced stage. My own experience 
 is at variance with this. Many cells, containing a large quantity of fat, 
 possess a distinct nucleus. (Fig. 29.) 
 
 f The cells of a fatty liver measured 0.036 to 0.025 or 0.022 of a line ; 
 those of a healthy liver, taken from an individual of the same age, mea- 
 sured 0.030 to 0.022, and another, 0.015 to 0.017 of a line. These numbers 
 indicate a considerable increase of size in the fatty cells. 
 
 TJ 
 
290 
 
 THE FATTY LIVER. 
 
 and especially the brown or yellow granules and globules, which are 
 the product of the secreting function. No trace of these substances 
 is usually to be found in the cells which are loaded with fat, whilst 
 they are accumulated in considerable quantity in those which con- 
 tain no fat. It is only in exceptional cases that we find fat and 
 pigmentary substances associated. This usually only occurs to any 
 extent, when the deposit of fat has affected all the cells, as far as the 
 
 centre of the lobules. 
 
 Fig. 30. 
 
 Fig. 30. Represents a magnified thin section of a fatty liver in a 
 moderate degree of advancement. The cells containing oil 
 are seen to be distributed, for the most part, at the periphery 
 of the lobules, in the vicinity of the branches of the portal 
 vein (pale). As the disease advances, they penetrate farther 
 into the substance of the lobules, towards the central veins 
 (dark). A transverse section of one lobule shows that it con- 
 tains two central veins. The cells containing pigment are 
 situated mostly towards the centre of the lobules, as seen at 
 upper part of cut. Copied from Atlas, Plate VI., Fig. 2. 
 
STRUCTURAL CHARACTERS. 291 
 
 The alteration which has just been described in the hepatic cells 
 almost always commences at the periphery of the lobules, in the 
 region of the interlobular vessels pertaining to the portal vein,* and 
 advances step by step towards the centre of the lobules, which is 
 supplied by the hepatic veins. (Fig. 30). We can distinguish 
 three stages in the development of fatty liver. In the first stage, 
 the cells in the neighbourhood of the ramifications of the portal 
 vein become fatty, and this abnormal appearance gradually disappears 
 towards their centre, the cells being here partly normal in their 
 characters, but for the most part loaded with pigment. 
 
 In the second stage, the deposit of fat advances more than half- 
 way to the centre* of the lobules, and it is only in the immediate 
 neighbourhood of the central veins that we can detect cells still 
 containing pigment and free from oil. 
 
 In the third stage, the change extends as far as the central vein.f 
 
 Some authors, and particularly Wedl, speak of a softening of the 
 fatty liver: a condition in which free fat, molecular masses, and 
 nuclei, are all that remain visible of the hepatic cells, the walls of 
 which must, therefore, have become destroyed. Without wishing to 
 call in question the possibility of such a destruction of the secreting 
 cells, I must observe, that I have never met with this appearance 
 myself in simple fatty liver ; on carefully treating the, tissue with oil 
 of turpentine, I have invariably detected the walls of the cells still 
 intact. Such a destruction I have only observed at places, where 
 new areolar tissue has been developed in the parenchyma of the 
 liver, in consequence of exudation-processes. In such places we 
 see infiltrated here and there, through the elementary structures of 
 the new tissue, rounded groups of oil globules, and of brown 
 
 * Exceptions to this are rare ; in a few cases only I have observed the 
 reverse hold good, the cells at the circumference, next to the portal vein, 
 being free from fat, and those in the neighbourhood of the hepatic veins, 
 infiltrated. In one of these cases there existed a passive congestion of the 
 blood in the roots of the hepatic vein, in consequence of mitral incompe- 
 tence ; another case was an example of hypertrophied fatty liver. 
 
 t If we wish to obtain a distinct view of this distribution of the fat, we 
 must inject differently-coloured substances into the portal and hepatic 
 veins, and then cut up the liver into small pieces, and carefully dry it ; 
 fine sections of this, made with a razor, may then be examined under the 
 microscope, either at once, or better, after the fat has been removed by 
 boiling with ether. In the latter case, the fatty cells are removed, and 
 the areolar tissue, containing the blood-vessels, only remains. 
 
 u2 
 
292 THE FATTY LIVER. 
 
 granules, which are the debris of former cells. Here, however, and 
 in all cases where exudation-processes constitute the causes of fatty 
 degeneration, the mode of deposition of fat in the cells, as well as 
 the other characters of these cells, is entirely different from what we 
 find in the ordinary fatty liver of persons labouring under tubercle, 
 and in that of drunkards. In the latter cases, the fat is deposited 
 in the interior of the cells directly from the blood ; in the former, the 
 tissue first becomes infiltrated with abnormally concentrated plasma, 
 in consequence of which the endosmotic properties of the cells are 
 altered, and their nutrition is impaired. Under such circumstances 
 the cells are seen in the first place to become filled with a granular 
 albuminous precipitate, obscuring the nucleus, which only becomes 
 visible on the addition of acetic acid ; it is not until afterwards that 
 oil globules make their appearance in large number, but even then 
 they are seldom remarkable for their size. This fatty degeneration 
 of the liver, which we beheve to differ from fatty infiltration, is 
 usually limited in its extent to the circumference of inflammatory 
 deposits, recent exudations, cicatrices, &c. ; it is found extending 
 over the entire organ, apparently as a terminal stage of infiltration of 
 colloid matter, in the so-called lardaceous or waxy liver (SpecMe&er). 
 We have repeatedly met with individuals presenting lardaceous 
 spleen, and in some cases also, lardaceous liver, in whom the liver, 
 which at first had been large and tense, became in the course of 
 treatment smaller, softer, and more shrivelled {welker). The 
 hepatic cells were found filled with oil globules and granules, but 
 contained no' substance yielding, with iodine and sulphuric acid, 
 the characteristic reaction of colloid matter, which, however, could 
 be detected in the spleen and kidneys. 
 
 This degeneration is far more injurious to the functions of the 
 organ than infiltration.* 
 
 in. Quantity of Fat. 
 
 The quantity of fat which is deposited in an advanced stage of 
 fatty liver may be considerable. In one case I found 78.07 per 
 cent, of fat in the substance of the liver after this had been freed of 
 its water ; — the quantity of fat, therefore, amounted to nearly four 
 times that of the remaining portions of the tissue ; — in its fresh 
 state, this same liver contained 43.84 per cent, of fat, 43.84 of 
 
 * See below : Obs. XXXI. 
 
GENERAL ANATOMICAL CHARACTERS. 293 
 
 water, and 12.32 of areolar tissue, cells, and blood-vessels. In 
 another case, the quantity of fat amounted to 76.6 per cent. The 
 quantity of water contained in the hepatic tissue is considerably 
 diminished; it falls from 76 per cent, to 50 or even to 43.84. 
 
 Along with the fat, which consists of oleine and margarine in 
 varying proportions, with traces of cholesterine, sugar has been found 
 in most cases. Where the deposit of fat has attained an advanced 
 stage, we have also succeeded in finding large quantities of leucine 
 and tyrosine. In some cases, moreover, there is a peculiar yolk- 
 yellow substance, which differs essentially in its characters from bile- 
 pigment. It is worthy of notice, that the decoction of the liver is 
 always found poorer in free acid than in the normal state. Cystine 
 has been sought for, but in vain. 
 
 iv. The General Anatomy of Fatty Liver. 
 
 It is not always possible to arrive at a positive opinion as regards 
 the fatty contents of the liver, by means of simple inspection. 
 Moderate, or even advanced degrees of this abnormal condition do 
 not always alter the colour and consistence of the organ in such a 
 manner, that they can be distinguished with certainty from other 
 changes in the gland, and especially from anaemia ; there is a pale 
 and soft bver, which in its characters so closely resembles the fatty 
 liver, that it is liable to be mistaken for it, and yet which contains 
 no fat. 
 
 A perfectly certain decision in this matter can only be arrived at 
 by means of the microscope. I do not regard the coating on the 
 blade of the knife which remains after making a section of the 
 organ, and upon which anatomists lay great stress, as a criterion 
 to be relied upon, because this coating is also observed in the 
 case of soft livers containing but little fat, when the cells are only 
 loosened in their adhesions to one another, and contain a quantity 
 of granular matter. 
 
 It is true, that forms of fatty bver are met with, which with some 
 experience can be immediately recognised as such ; such for example, 
 as the large flattened, dull-yellow liver, with rounded margins, and 
 a smooth,* tense peritoneal covering, which on section is found to 
 
 • The outer surface occasionally appears to be slightly granular, from 
 the peripheral portions of the lobules which contain fat becoming more 
 
294 THE FATTY LIVER. 
 
 contain but little blood, and to present a colour similar to that of 
 autumn foliage {Rokitansky). These characters, however, cannot 
 constitute a rule for our guidance, inasmuch as there are so many 
 exceptions to them. 
 
 The size and weight of fatty liver are liable to great variations ; 
 they may exceed, correspond to, or be less than, the normal size and 
 weight. When the results of numerous weights and measurements 
 are taken together, the weight and volume are on the whole increased. 
 Out of 34 cases of fatty liver in adults, the average weight was found 
 to be 1.6 kilgr. (3 lbs. 8^ oz. avoird.) in males, and 1.5 kilgr. 
 (3 lbs. 5 oz.) in females.* 
 
 The ratio of the weight of the liver to that of the entire body was 
 as 1 to 28 in males, and as 1 to 25 in females.f 
 
 The average measurements were as follows : — 
 
 In males, right lobe 5.3 inches; left lobe 3.4 in. transversely. 
 „ „ 7.7 „ ; „ 5.6 „ longitudinally. 
 
 Thickness, 2.1 inches. 
 
 In females, right lobe 5.8 inches ; left lobe 3.3 in. transversely. 
 „ „ 6.6 „ ; „ 5.6 „ longitudinally. 
 
 Thickness, 2.3 inches (Paris inches). 
 
 The weight of the spleen in these cases amounted in men to 0.23 
 kilogr. (8.1129 oz. avoird.) ; and in women to 0.24 (8.465 oz. 
 avoird.) ; and the relative weight of the organ to that of the entire 
 body was as 1 to 202, and as 1 to 156. 
 
 The relative weight of the spleen to that of the liver, was as 1 
 to 6.90 in males, and as 1 to 6.25 in females. 
 
 prominent than the central portions. For the relation of this form to 
 granular liver, see chapter on " Cirrhosis." 
 
 * Cases, however, have been met with in which fatty liver has attained 
 a great weight ; thus, in a female aged 40, it was found to weigh 3.4 kilogr. 
 (7 lbs. 8 oz. av.), and its relative weight to that of the whole body was as 
 1 to 20. 
 
 + Lereboullet has attempted to determine the changes in the relative 
 weight of the liver to that of the entire body which the organ undergoes 
 in geese, from being made fatty. Before the commencement of the feeding 
 on maize, it was as 1 to 26.5; after nine days' feeding, it was as 
 1 to 30; after fourteen days, as 1 to IS; and after twenty-eight days, as 
 1 to 12.8. Thus the consequences of excessive feeding manifest them- 
 selves during the first nine days, in an increase of the weight of the body ; 
 but after this the increase of weight is mainly in the liver. 
 
GENERAL ANATOMICAL CHARACTERS. 295 
 
 .Besides the hypertrophied fatty livers, we also meet with others, 
 which are atrophied, their size and weight being less than that of the 
 normal state, although the amount of fat which they contain is 
 considerable. Such atrophied forms are by no means rare. 
 
 The form of fatty liver is in many cases peculiar; the organ 
 increases mainly in breadth, is flattened out, diminishes in thickness,* 
 and has its margins rounded. But to these characters there are also 
 numerous exceptions ; even when the deposit of fat is considerable, 
 the margins of the organ may be sharp, and its measurements in 
 every direction may remain normal. 
 
 The colour in general becomes paler, and the more so, in propor- 
 tion to the abundance of fat, and the extent to which the normal 
 contents of the hepatic cells and the capillary injection are reduced. 
 A considerable amount of fatty deposit may take place without the 
 colour being essentially changed. In most cases, the parenchyma 
 of the liver assumes a reticulated appearance; we find a reddish- 
 brown and a pale-yellow substance alternating with one another; 
 the latter usually forms rings surrounding little rounded islets of the 
 former substance ; or the brownish substance presents longitudinal or 
 sometimes leaf-like figures, bounded by a pale margin.f Which of 
 these appearances presents itself depends upon the direction in which 
 the lobules are divided, the latter occurring when the section falls 
 parallel to the branches of the hepatic veins, but the former, when 
 the central veins are divided transversely. The pale parts almost 
 always correspond to the periphery of the lobules, the region of the 
 portal vein, in which the fat is usually first deposited, while the dark 
 parts correspond to the hepatic veins around which the cells are wont 
 
 • This is shown by the mean measurements above given. 
 
 t The nutmeg-like appearance which the liver assumes under such cir- 
 cumstances becomes the more marked, the greater the deposit of pigment 
 in the cells around the central veins and the larger the quantity of blood 
 contained in these veins. 
 
 The same alternation of colours is observed in consequence of obstruc- 
 tion of bile, where the deposit of pigment in the cells always takes place 
 first around the central veins of the lobules. 
 
 It is also observed, with somewhat different shades, to be produced by 
 irregularities in the distribution of blood, and by congested states of the 
 roots of the hepatic veins, which are of such frequent occurrence. Hence 
 the nutmeg-like appearance of the cut surface can only be employed for 
 the diagnosis of fatty liver with great caution ; we have to distinguish 
 between a fatty, a pigmentary, and a hyper«mic nutmeg liver. 
 
296 THE FATTY LIVEE. 
 
 to continue rich in pigment, and the capillaries, filled with blood.* 
 The area on section of the individual lobules is enlarged. In the most 
 advanced stages of fatty deposit the liver is pale-yellow, and only small 
 intensely-yellow dots or streaks stand out of a nniformly-coloured 
 ground; these are the pigment cells in the neighbourhood of the 
 central veins. In such cases the finer vessels on the surface of the 
 organ are completely deprived of their blood ; but ramifications of 
 enlarged vessels are seen in the serous covering, the same as in 
 cirrhosis. Sometimes we see larger yellow islets scattered through 
 the parenchyma, corresponding to places where there has been a 
 particularly great obstruction to the bile. 
 
 When the deposit of fat does not take plaee in a uniform manner, 
 it may assume the form of streaks more than an inch in length, or 
 of pale insular masses of a greater or less size, occasionally not 
 exceeding in diameter that of a bean or pea. These patches are 
 more frequently observed upon the surface (from which they pene- 
 trate only a few lines into the parenchyma), than deep in the interior 
 of the organ. 
 
 The consistence of the Hver is wont to diminish in proportion to 
 the increase in the deposit of fat ; it becomes flabby, abnormally soft 
 and easily broken up, and, like oedematous areolar tissue, retains 
 impressions made upon it for a long time. 
 
 The waxy liver {Wachsleber) formerly described by Home, con- 
 stitutes an apparent exception to the characters just described, being 
 remarkable for its great hardness and firmness. This form of disease 
 usually belongs to the so-called colloid or lardaceous degeneration 
 of the gland; but there are cases in which the cause of the abnor- 
 mality must be attributed to the deposition of fat of a firm 
 character.t When we compare the ethereal extracts of different 
 fatty livers with one another, no small differences may be observed 
 in respect to the consistence of the fat. No quantitative analysis, 
 however, of the amount of margarine has yet been made. 
 
 Lastly, we would mention one other peculiar form of fatty deposit 
 of rare occurrence, viz.: — that which has its seat principally in 
 
 * It is much more difficult than is usually believed to distinguish be- 
 tween the central and peripheral portions of the lobules, inasmuch as very 
 different appearances are produced, according to the direction in which 
 the section of the blood-vessels passes. The matter is only to be decided 
 by injecting different coloured substances into the blood-vessels. 
 
 t Laennec, Traite de V auscultation, Tom. VI., p. 36. 
 
FREQUENCY WITH WHICH IT OCCURS. 297 
 
 Glisson's capsule, and following the course of this and the blood- 
 vessels penetrates deeply into the substance of the liver. I have 
 seen this abnormal condition developed in a high degree in one 
 individual, who died from obliteration of the portal vein. In this 
 case, the trunk of the portal vein, before its entrance into the liver, 
 was closed up by the compression of collections of pus in the 
 surrounding areolar tissue. . No fat was observed to be deposited in 
 the secreting cells. 
 
 v. Frequency with which Fatty Liver occurs. 
 
 It will be seen from the previous remarks on the causes of fatty 
 liver, that higher or lower grades of this alteration of structure are 
 not unfrequently met with. In order to obtain accurate and reliable 
 data as to the frequency of occurrence of fatty liver, this gland has 
 been for a long period examined for fat at the autopsies in All 
 Saints' Hospital, and always with the microscope; sufficient in- 
 formation on the point cannot be derived from simple inspection. 
 The results of 466 examinations of this nature are collected in the 
 annexed Table. 
 
 Considering the powerful influence exercised by the habit of 
 living, it should be mentioned, that these cases strictly refer only to 
 Breslau, and to the class of the community who are wont to seek 
 refuge in public hospitals ; in connection with which we must observe, 
 that hepatic affections generally are of frequent occurrence both here 
 and in the neighbouring Sclavonian provinces. The frequency of fatty 
 liver in other countries can only be determined by direct examination. 
 So far as I can trust my memory, I have seen this affection less 
 frequently in Gottingen than in Holstein and Silesia; it has also 
 appeared to be more frequent in summer than in winter.* 
 
 * As regards the different grades mentioned in the Table, I understand 
 by fatty liver of the highest grade (I.) those forms in which the deposit 
 extends through all the hepatic cells as far as the centres of the lobules. 
 Under the second heading, I reckon those in which the cells are found 
 copiously infiltrated, at least halfway, to the centre of the lobules. It is 
 obvious, however, that we cannot define these different grades with great 
 precision. 
 
298 
 
 THE FATTY LIVER. 
 
 Tabular View of the Occurrence op Fatty Deposit in the Liver, in 
 different diseases, determined by microscopic examination. 
 
 
 i. 
 Fatty 
 
 XI. 
 
 in. 
 
 LV. 
 
 
 
 Proportion h 'tween 
 
 
 Liver o 
 
 f Cells 
 
 Quantity 
 
 Cells 
 
 
 Total. 
 
 the number of the 
 
 
 the 
 
 rich l 
 
 a of Fat 
 
 free from 
 
 
 
 Cases i. and u. and the 
 
 
 highes 
 
 Fat. 
 
 small. 
 
 Fat. 
 
 
 
 total number. 
 
 
 grade. 
 
 
 
 
 
 
 : 
 
 
 u 
 
 
 i 
 
 i 
 
 
 
 i 
 
 
 
 i 
 
 
 
 
 
 
 
 1 
 
 
 . s 
 
 . § 
 
 
 
 i 
 
 
 
 s 
 
 
 
 
 
 
 Diseases. 
 
 O 
 
 d 
 
 ji 
 
 i ■S s. 
 
 i 3 
 
 8 £ 
 
 H o 
 
 1 o- 
 
 1 
 
 1 
 
 d 
 
 8 
 
 S 
 
 •a 
 1 
 
 o 
 
 o 
 d 
 
 •a 
 
 i 
 a 
 
 § 
 
 
 
 
 
 R 
 
 a £ 
 
 ; & a 
 
 fc. S3 
 
 a 
 
 & 
 
 fe 
 
 a 
 
 f* 
 
 fc 
 
 a 
 
 t, 
 
 t-H 
 
 
 &< 
 
 1. Tubercular Affec- 
 
 
 
 
 
 
 
 
 
 tions 
 
 17 
 
 9 
 
 B 62 33 
 
 29 34 
 
 25 
 
 9 
 
 4 
 
 3 
 
 l 
 
 117 
 
 70 
 
 47 
 
 1 : 1.48 
 
 1:1.66 
 
 1: 1.27 
 
 2. Pulmonary Em- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 physema - 
 
 
 
 
 - 6 2 
 
 4 5 
 
 3 
 
 2 
 
 2 
 
 1 
 
 l 
 
 13 
 
 6 
 
 7 
 
 1:2.16 
 
 1:3.00 
 
 1:1.75 
 
 3. Pneumonia 
 
 
 
 
 - 8 3 
 
 5 20 
 
 12 
 
 8 
 
 14 
 
 10 
 
 4 
 
 42 
 
 25 
 
 17 
 
 1:5.25 
 
 1 : 8.33 
 
 1 : 3.40 
 
 4. Pleurisy - 
 
 1 
 
 1- 
 
 _ 
 
 — 4 
 
 2 
 
 2 
 
 1 
 
 1 
 
 
 
 6 
 
 4 
 
 2 
 
 1 : 6.00 
 
 1 : 4.00 
 
 
 
 5. Heart Disease 
 
 — 
 
 
 
 - 10 2 
 
 8 16 
 
 10 
 
 6 
 
 9 
 
 5 
 
 4 
 
 35 
 
 17 
 
 18 
 
 1 : 3.50 
 
 1:8.50 
 
 1 : 2.25 
 
 6. Bright's Disease 
 
 1 
 
 1- 
 
 - 8 6 
 
 2 7 
 
 5 
 
 2 
 
 3 
 
 3 
 
 
 
 19 
 
 15 
 
 4 
 
 1:2.11 
 
 1:2.14 
 
 1:2.00 
 
 7. Typhus 
 
 1 
 
 1- 
 
 - 6 3 
 
 3 21 
 
 12 
 
 9 
 
 16 
 
 13 
 
 3 
 
 44 
 
 29 
 
 15 
 
 1 : 6.28 
 
 1 : 7.25 
 
 1 : 5.00 
 
 8. Pyaemia - 
 
 3 
 
 2 
 
 1 3 2 
 
 1 5 
 
 5 
 
 — 
 
 2 
 
 — 
 
 2 
 
 13 
 
 9 
 
 4 
 
 1 : 2.16 
 
 1 : 2.25 
 
 1 : 2.00 
 
 9. Variola 
 
 1 
 
 — 
 
 1 7 4 
 
 3 14 
 
 10 
 
 4 
 
 7 
 
 5 
 
 2 
 
 29 
 
 19 
 
 10 
 
 1 : 3.62 
 
 1 : 4.75 
 
 1 : 2.50 
 
 10. Intermittent Fever 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 and its Sequelae 
 
 — 
 
 
 
 - 6 4 
 
 2 3 
 
 3 
 
 
 
 3 
 
 
 
 3 
 
 12 
 
 7 
 
 5 
 
 1 : 2.00 
 
 1 : 1.75 
 
 1 : 2.50 
 
 11. Diabetes - 
 
 
 
 
 - 1 
 
 1 
 
 
 
 4 
 
 3 
 
 1 
 
 5 
 
 4 
 
 1 
 
 
 
 
 
 
 
 12. Anaemia and In- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 anition from Hae- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 morrhage, Ulcer 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 of the Stomach, 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Stricture of the 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (Esophagus, &c. 
 
 — 
 
 
 
 - 5 3 
 
 2 3 
 
 
 
 3 
 
 2 
 
 2 
 
 
 
 10 
 
 5 
 
 5 
 
 1 : 2.00 
 
 1 : 1.66 
 
 1:2.50 
 
 13. Senile Marasmus, 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Apoplexy 
 
 1 
 
 1- 
 
 8 1 
 
 7 8 
 
 3 
 
 5 
 
 2 
 
 1 
 
 1 
 
 19 
 
 6 
 
 13 
 
 1:2.11 
 
 1 : 3.00 
 
 1 : 1.85 
 
 14. Cancer 
 
 — 
 
 
 
 2 1 
 
 1 11 
 
 4 
 
 7 
 
 8 
 
 2 
 
 6 
 
 21 
 
 7 
 
 14 
 
 1:10.50 
 
 1:7.00 
 
 1:14.00 
 
 15. Delirium tremens 
 
 — 
 
 
 
 7 5 
 
 2 5 
 
 4 
 
 1 
 
 2 
 
 2 
 
 
 
 14 
 
 11 
 
 3 
 
 1 : 2.00 
 
 1:2.20 
 
 1:1.50 
 
 16. Constitutional Sy- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 phlis 
 17. Chronic Atrophy 
 
 
 
 6 3 
 
 3 2 
 
 2 
 
 
 
 
 
 8 
 
 5 
 
 3 
 
 1 : 1.33 
 
 1 : 1.66 
 
 1:1.00 
 
 
 
 
 
 
 
 
 of Liver - 
 
 1 
 
 1- 
 
 2 1 
 
 1 2 
 
 2 
 
 
 2 
 
 1 
 
 1 
 
 7 
 
 5 
 
 2 
 
 1 : 2.33 
 
 1:2.50 
 
 1:2.00 
 
 18. Lardaceous Liver 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 in the stage of 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Colloid infiltra- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 tion - 
 
 
 
 3 2 
 
 1 — 
 
 
 
 
 1 
 
 1 
 
 
 4 
 
 3 
 
 1 
 
 1 : 1.33 
 
 1 : 1.33 
 
 1:1.00 
 
 19. Cirrhosis of Liver 
 
 2 
 
 1 1 
 
 7 4 
 
 3 4 
 
 3 
 
 1 
 
 — 
 
 
 
 13 
 
 8 
 
 5 
 
 1 : 1.44 
 
 1 : 1.60 
 
 1 : 1.25 
 
 20. Obstruction of Bile 
 
 
 
 1 — 
 
 1 4 
 
 2 
 
 2 
 
 4 
 
 3 
 
 1 
 
 9 
 
 5 
 
 4 
 
 1 : 9.00 
 
 
 
 1:4.00 
 
 21. Cancer of the Liver 
 
 
 
 — — 
 
 - 6 
 
 3 
 
 3 
 
 3 
 
 2 
 
 1 
 
 9 
 
 5 
 
 4 
 
 
 
 
 
 
 
 22. Individuals who 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 have died sud- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 denly without pre- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 vious disease 
 
 
 
 
 2 1 
 
 1 4 
 
 3 
 
 1 
 
 2 
 
 1 
 
 1 
 
 8 
 
 5 
 
 3 
 
 1:4.00 
 
 1:6.00 
 
 1:3.00 
 
 23. New-born Infants 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 and Children dur- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ing the first weeks 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 of life 
 
 
 
 5 3 
 164 83 8 
 
 2 3 
 
 1 182 
 
 1 
 115 
 
 2 
 37 
 
 1 
 92 
 
 1 
 
 60 
 
 32 
 
 9 
 
 5 
 
 4 
 
 1 : 1.80 
 
 1 : 1.66 
 
 1:2.00 
 
 Total - 
 
 28 
 
 1711 
 
 466 
 
 275 
 
 191 
 
 1 : 3.02 
 
 1:3.57 
 
 1:225 
 
FREQUENCY WITH WHICH IT OCCURS. 299 
 
 It appears, then, from this Table, that out of 466 bodies, fatty 
 liver attained its highest grade in 28, or in 1 out of 16.6 cases ; 
 and that the hepatic cells were found rich in oil in 164 cases, or in 
 about one-third.* Females are more frequently affected than males 
 with this morbid change in the parenchyma of the liver, the proportion 
 in the latter sex being as 1 to 3.5, and in the former as 1 to 2.2. 
 In healthy individuals, who have died suddenly from accident, the 
 proportion was 1 to 4 : in men, 1 to 5, and in women, 1 to 3. 
 Under certain physiological conditions, there is an increased ten- 
 dency to the deposit of fat in the liver, as in newly-born infants and 
 in children, during the first few weeks of life, where the proportion 
 was 1 to 1.18. In infants who continue taking the breast until 
 death, the hepatic cells are usually rich in fat, as they likewise are in 
 sucking animals.t In pregnant and* puerperal females also we 
 very frequently find fatty deposits in the liver. 
 
 Among the pathological conditions which influence the develop- 
 ment of fatty liver, tubercle of the lungs stands first ; of 117 cases 
 of this affection, in 17 there was the highest grade of infiltration, 
 and in 62 the hepatic cells contained much oil. The proportion 
 was as 1 to 1.48: in males, as 1 to 1.66, and in females, as 
 1 to.1.27. 
 
 Next in order comes the drunkard's dyscrasia. Of 13 individuals 
 who died of delirium tremens, in 6 the liver was very fatty, in 3 
 the organ contained little fat, and in 2, none at all ; lastly, 2 died 
 of cirrhosis of the liver. 
 
 • Constitutional syphilis was in 8 cases always accompanied by a 
 more or less fatty liver ; three times the infiltration attained a high 
 degree, and twice lardaceous matter (Speckstoffe) could be detected. 
 
 When we compare other pulmonary diseases with tubercle, the 
 ratio is found to be entirely different; in pnemonia it was as 1:52; 
 in pleurisy, 1:6; in emphysema of the lungs, 1:2.1. But of 35 
 observations of heart disease, the frequency of fatty liver was as 
 1 to 3.5. Patty liver made its appearance more frequently 
 with Blight's disease (1:2.1) and with intermittent fever and its 
 
 • This proportion must, as a general rule, be somewhat too great, 
 because, of the 466 cases, 117 were tubercular subjects, who are remark- 
 able for the frequency with which fatty liver is met with in them. 
 
 t This circumstance has been already noted by Gluge (Atlas der path. 
 Anat, Lief. 1) ; and more recently by Kolliker (Verhandl. der pkysik. med. 
 Gesellscliafi in Wiirzhurg, Bd. VII., Heft 2). 
 
300 THE FATTY LIVER. 
 
 seqeulse (1:2). It was an equally frequent accompaniment of senile 
 marasmus, and of inanition from haemorrhage, diseases of the 
 stomach, &c. 
 
 The comparative frequency of fatty liver in the cancerous ca- 
 chexia (1:10.5) was remarkably small, when contrasted with that 
 observed in tubercle (1:1.4). 
 
 Patty liver of the highest grade was repeatedly observed in acute 
 diseases of a general nature, such as typhus, variola, and pyaemia; 
 of three cases of erysipelas ambulans, this condition of the liver was 
 met with in all. 
 
 Among the local diseases of the liver, cirrhosis and the lardaceous 
 liver (Speckleber) are remarkable for the amount of fat which they 
 contain. The smallest quantity of fat in the liver occurred in dia- 
 betes mellitus. In several cases of stricture of the oesophagus, 
 leading to prolonged abstinence, every trace of fat had disappeared; 
 this was also the case in an individual who had been bedridden 
 for years on account of hemiplegia; — a prdof that bodily rest does 
 not alone suffice for the production of fatty liver. 
 
 When we compare these results with the observations of Louis and 
 others, we find that there are important discrepancies. Louis found, 
 out of 230 individuals who died of acute and chronic diseases, 
 excepting pulmonary tubercle, that fatty hver only existed in 9, and 
 of these 9 there were 7 of a tubercular diathesis; whilst out of 
 120 persons who had died of phthisis, 40 had fatty liver. Home, 
 in Edinburgh, observed fatty liver 15 times out of 65 phthisical 
 persons, and these 15 were exclusively females. I believe, myself, 
 that these remarkable discrepancies must mainly depend upon the 
 fact that, without the assistance of the microscope, it is impossible 
 to form a correct opinion as to the amount of fatty matter contained 
 in the liver ; moreover, a certain amount of influence must be exerted 
 by the different modes of living, as also by the nature of the treat- 
 ment to which the patient has been subjected, as for example, 
 whether cod-liver oil has been used or not. 
 
 vi. Pathological Importance of Fatty Liver. 
 
 Various opinions have been entertained as to the nature of fatty 
 liver, and as to its effects upon the entire organism, according to 
 the manner in which it has been supposed to originate. Most, 
 observers have classified this structural change with those derange- 
 
PATHOLOGICAL IMPORTANCE. 301 
 
 ments of nutrition which are wont to be included under the name 
 of atrophy. Andral,* Thomson, Barlow,t Cruveilhier,J Wedl, 
 Henoch, and others, are all influenced by this view of the matter 
 in their opinions concerning fatty liver, although they differ as re- 
 gards the more remote causes of the atrophy. Henoch § speaks 
 of the deposit of fat in the hepatic cells as a degeneration of the 
 epithelium and other elementary tissues, which takes place in conse- 
 quence of congestion and exudation. Lereboullet || blames a defec- 
 tive organic combustion as the cause of the impaired nutrition of 
 the hepatic cells. 
 
 There are unquestionably forms in which the fatty degeneration 
 must be regarded as resulting from a deranged nutrition of the 
 secreting cells. The appearance of the fat is here preceded by an 
 infiltration of the cells with an abnormal plasma, or by some other 
 derangement of their nutrition, which gives rise to a retrograde 
 development, and to the transformation of the cell contents into 
 fat. When this process has terminated, the cells almost always 
 lose their secreting functions. But in by far the larger number of 
 cases of fatty liver, this explaaation is inapplicable. The fat is 
 taken up as such into the cells from without; this imbibition is 
 intimately associated with the functional activity of these structures ; 
 it rises and falls according to the nature of the food, the quantity 
 of fat contained in the blood, the more or less active nature of 
 the secretion of the gland, &c. The liver serves here as a temporary 
 reservoir for the surplus fat which has been absorbed ; functional 
 derangements do not ensue until the overloading of the cells with 
 fat, by compressing their other contents, and by impeding the cir- 
 culation in the portal vein, begins to affect the metamorphosis 
 of matter in the cells and to interfere with the secreting function 
 of the gland. All these injurious results disappear as soon as 
 
 * Clinique Medicale, Tom. II., p. 240. 
 
 t On Fatty Degeneration, 1853, p. 9 : — " This organ degenerates from 
 general atrophy." 
 
 J Anat. Path. Qinir., Tom. III., p. 292. Paris, 1856. " La metamorphose 
 " adipeu3e du foie n'est done autre chose qu'une atrophie adipeuse, bien 
 " qu'elle s'accompagne constamment d'une augmentation de volume de cet 
 " organe." 
 
 § Klinik der Unterleibskrantcheiten, Bd. I., S. 122. 
 
 || Op. cit., p. 112. "Le developpement de la graisse dans ces cellules 
 " parait 6troitement li6 a un ralentissement dans le travail nutritif, et a 
 " la combustion organique, qui est la premiSre condition de ce travail." 
 
302 THE FATTY LIVER. 
 
 the chief portion of the fat deposited is reabsorbed. It is impossible 
 to define accurately this physiological change in the structure of the 
 liver from one which would amount to disease. 
 
 vn. Effects of the deposited fat upon the function of the Liver, and 
 upon the entire System. — Symptoms of Fatty Liver. . , 
 
 The conditions of the system under which fatty liver is met with, 
 and the relations of fat to the due performance of the functions of the 
 liver, show that moderate accumulations of this substance may exist 
 without giving rise to pathological derangements. "We should rather 
 regard as a sign of disease, a complete absence of oil globules in the 
 hepatic cells, such as is particularly the case in diabetes mellitus. 
 The deposits arising from the absorption of food, come and go, ac- 
 cording to the nature of the food, and the consequent amount of fat 
 contained in the blood. They only attain a high grade, when they 
 have been brought on by a long continuance of improper habits 
 of life. 
 
 The forms of fatty liver which dapend upon consumptive diseases, 
 the drunkard's dyscrasia, and other more radical changes in the 
 composition of the blood, or which originate from local changes in 
 the parenchyma of the liver, impairing the nutrition or the functions of 
 the cells, are more persistent in their duration. These forms, there- 
 fore, more frequently arrive at such a high grade as to impair the 
 functions of the organ. 
 
 Considerable accumulations of fat in the hepatic cells derange 
 the functions of the liver in many ways ; but it is only in rare cases 
 that they suspend it entirely, or impair it to such an extent, that 
 the entire system suffers. 
 
 In the first place, they act mechanically by impeding the flow of 
 blood through the portal vein, and the excretion of the bile. 
 
 Owing to the cells becoming distended with fat, the vascular 
 meshes in which they lie become enlarged, and the calibre of the 
 capillaries is in a corresponding degree narrowed. Hence, as a 
 rule, the advanced stage of fatty liver is found to present an anaemic 
 aspect.* The circulation, however, is never impeded to any remark- 
 
 * Even the sections of the larger vessels, seen upon a cut surface, not 
 unfrequently, as Cruveilhier has already observed, present an angular in 
 place of a rounded outline, in consequence of the unequal lateral compres- 
 sion of the swollen glandular tissue. 
 
SYMPTOMS. 303 
 
 able extent, inasmuch as the soft fluid fat appears to yield before the 
 pressure of the blood ; the vessels in a fatty liver are usually injected 
 with ease. The obstruction to the circulation of blood is very 
 seldom so great as to give rise to dropsical effusions of any amount; 
 it is, however, sufficient to produce chronic congestion of the gastro- 
 intestinal mucous membrane, which, from slight causes, may become 
 exaggerated into catarrhs, derangements of digestion, diarrhcea, and 
 haemorrhoids. The enlarged vessels which are frequently seen 
 running through the serous coat in a similar manner as in cirrhosis, 
 prove that the flow of blood may become obstructed in fatty 
 liver of a high grade. Enlargements of the spleen, however, are 
 rare; this organ remains of its medium size, and is smaller on an 
 average than in the case of the lardaceous liver and in cirrhosis. 
 (See Table IV., page 26.) 
 
 Besides the impeded circulation of blood, we constantly observe, 
 that the excretion of bile -becomes obstructed. The hepatic cells 
 in the vicinity of the central veins are always loaded with pigment, 
 they contain a large number of yellow granules, and not unfrequently 
 are infiltrated with a brownish or yellowish homogeneous matter. 
 The same cause which compresses the capillaries also impedes the 
 entrance of the bile into the commencement of the excretory ducts 
 at the periphery of the lobules.* This derangement also seldom 
 exceeds a certain point ; it never reaches such a degree as to give 
 rise to an intensely jaundiced hue of the skin. 
 
 In simple fatty infiltration of the gland, it is rare for the functions 
 of the liver — in so far as these influence the metamorphosis of matter, 
 and manifest themselves in the secretion of bile, and in the compo- 
 sition of the blood — to be deranged to any great extent, although 
 there are anomalous cases which must not mislead us. Symptoms 
 of advanced anaemia or hydraemia, such as are observed in lardaceous 
 degeneration and in cirrhosis of the liver, are here only met with in 
 exceptional cases; we must not, however, overlook the fact that 
 pasty-looking individuals afflicted with fatty liver, bear losses of 
 blood and other debilitating agencies badly. 
 
 * Occasionally the larger ducts also appear to be compressed. Under 
 such circumstances, I have repeatedly observed, in advanced stages of 
 fatty liver, sacculated enlargements of the ducts filled with thickened bile. 
 In one case, numerous crystals of hsematoidine developed themselves in 
 the decomposed bile contained in such a sac. Cruveilhier describes a 
 similar enlargement of the ducts in a fatty liver (Anat. Pathol. Genir., 
 Tom. III., p. 230). 
 
304 THE FATTY LIVER. 
 
 Out of a large number of instances in which the parenchyma of 
 the liver was examined for sugar, this substance was found in most 
 cases, even when the deposit of fat was very considerable; occa- 
 sionally it was absent, as happens even in the case of the healthy 
 gland, whenever death has been preceded by a disease which entails 
 prolonged abstinence. Thus the accumulation of fat in the liver 
 does not arrest those processes which give rise to the formation of 
 sugar. There can be no doubt, however, that the metamorphoses of 
 matter which take place in the interior of the cells, are altered and 
 impaired by the presence of fat in place of the other contents of 
 these cells. This opinion is favoured by the feebly acid character 
 of a decoction of the liver, and by the presence of abundance of 
 leucine. Additional evidence as to the modifications of the meta- 
 morphosis of matter resulting from fatty liver may be expected from 
 further examinations. 
 
 It is a difficult matter during life, to judge of the quantity of bile 
 secreted. The colour of the faeces furnishes only an uncertain indi- 
 cation of the quantity of this secretion which is formed within a fixed 
 period of time. The colour may be but slightly altered, even in 
 cases where there is a very remarkable diminution, or a complete 
 cessation of the secretion. In the slighter deviations from the normal 
 amount of bile, there is no corresponding alteration in the colour of 
 the faeces, and the less so, as the latter is influenced not merely by the 
 quantity of bile, but also by the activity of the intestinal absorption, 
 and by the length of time that the bile is retained in the intestinal 
 canal. When we consider the small. quantity of yellow matter which 
 is contained in the hepatic cells (which is the more remarkable, the 
 greater the deposit of fat), and when we further consider the above- 
 mentioned alterations in the chemical characters of the gland, as also 
 the experiments of Bidder and Schmidt, who found that the infiltration 
 of the hepatic parenchyma with fat, consequent upon feeding animals 
 with fatty food, reduced the secretion of bile to the same condition 
 as in starving animals, we are justified in assuming a diminution of 
 the secretion as a result of fatty liver. The post-mortem appearances 
 also, which are found in cases -of very advanced fatty degeneration, 
 coincide with such an opinion. In two cases of this nature, I have 
 found the bile ducts empty, and covered with a greyish-yellow 
 mucus ; the faecal matter in the small and large intestine was ash- 
 coloured. A complete cessation of the secretion, however, is rare.* 
 • The statements of Lereboullet (op. cit., p. 100), who observed the 
 
SYMPTOMS. 305 
 
 I have not been able to detect any important changes in the quality 
 of the bile secreted in a fatty liver. It only presents those variations 
 of colour and consistence which are dependent upon a greater or 
 less degree of concentration, a shorter or longer retardation in the 
 gall-bladder, and the secreting activity of the mucous lining of the 
 bile ducts. It may be pale and thin, or at another time dark, thick 
 and viscid. Albumen, which was found by Thenard in five out of 
 six cases, I have never met with ; neither have I ever observed the 
 large quantity of oil mentioned by Lereboullet. 
 
 Addison* has remarked, that the bile is characterised by a peculiar 
 odour, which is developed upon the addition of acids. This, he says, 
 is perhaps the most disagreeable and intolerable odour which is 
 ever emitted by animal matter and can be compared to no other. 
 I have never myself been able to perceive any increase of that 
 peculiar odour, reminding one of fsecal matter, which is exhibited by 
 thickened bile. The opinion, therefore, which seemed to me a 
 probable one, that under such circumstances, a stinking fluid fatty 
 acid might be present in the bile, is not confirmed.t 
 
 characters of the bile in geese, which had been fed with the object of pro- 
 ducing fatty livers, have an important bearing upon this matter. After 
 nine days' feeding, the gall-bladder was distended with green bile, con- 
 taining a moderate quantity of oil globules. After 28 days, however, it 
 was small and puckered, and contained a. very small quantity of olea- 
 ginous bile, in which flakes of mucus and numerous oil globules could be 
 detected. 
 
 * Guy's Hosp. Reports, I., p. 478. 
 
 t I have repeatedly determined the amount of oil which is contained in 
 the secretion of the gland, when its tissue is infiltrated to a great degree. 
 The ethereal extract of the dried bile in no case exceeded 0.50 per cent., 
 usually it amounted to from 0.33 to 0.38 per cent., the solid residuum 
 being from 13.1 to 33.6 per cent, of the entire quantity of bile. The bile was 
 of acid reaction, and contained an oily fat along with cholesterine. In 
 many cases, the ethereal extract presented a pale, blood-red colour, and, 
 upon evaporation, left behind a peculiar crystalline colouring-matter. 
 This, consisted of reddish-yellow lancet-shaped leaflets, which were 
 partly isolated and partly united in arborescent groups. Along with 
 these, an amorphous pigment, presenting, upon exposure to the air, the 
 play of colours characteristic of chromogen, was not unfrequently present. 
 I have not yet succeeded in collecting a quantity of the crystals sufficient 
 for analysis. (These have since been ascertained by Valentin to be 
 crystals of haematine, and not at all peculiar to the bile of fatty liver. 
 See Preface. — Transl.) Moreover, they are by no means peculiar to the 
 bile of fatty liver ; they have not unfrequently been absent in it, and 
 
 X 
 
306 THE FATTY LIVER. 
 
 Tin. Diagnosis. 
 
 From what has been above stated, it will h6 understood, that the 
 symptoms which accompany fatty liver, and which in practice must 
 furnish the data necessary for diagnosis, are usually of a very uncer- 
 tain character, and from the nature of the subject must still remain 
 so. The slighter forms of the disease, which can scarcely be 
 regarded as of a pathological nature, give rise to no remarkable 
 derangements; in the more advanced grades .of the affection, the 
 symptoms are of such a nature that they can only, under favour- 
 able circumstances, be appealed to with confidence. The first 
 which is of service, in a diagnostic point of view, is the alteration 
 in size and form which the liver is wont to undergo when the 
 accumulation of fat is considerable. The diameter of the gland from 
 behind forwards increases, and at the same time the organ becomes 
 flabby and shrivelled (welk), bends upon itself and sinks down- 
 wards: — two conditions which equally contribute to increase the 
 extent of the dull percussion sound, and to remove the anterior 
 margin to a greater or less depth below the margin of the false ribs. 
 Owing to this sinking of the anterior margin, a fatty liver upon 
 examination appears to be larger than it really is. When the ab- 
 dominal parietes are soft, and not too thick to permit of palpation 
 being practised with effect, we can feel the rounded margin of the 
 liver, and also make out its soft consistence. The positive value of 
 these signs is not slight, but their absence is altogether without 
 importance, inasmuch as these changes in the size and form of the 
 gland are by no means constant. A second indication for the 
 diagnosis of fatty bver is furnished by the derangements which arise 
 from the interruption of the circulation through the portal vein. 
 The complex train of symptoms so frequently described by the older 
 authors, under the title of ' abdominal plethora/ and which occur in 
 incipient cirrhosis, and in other mechanical obstructions to the flow 
 of blood through the portal vein, are met with here in a more or 
 less marked form: — such symptoms, for example, as an impaired 
 gastric and intestinal digestion, associated with the development of 
 
 have been observed under other conditions, as, for instance, in cholera. 
 The colouring-matter of the bile of fatty liver, in other respects, presents 
 the usual characters. In one case, hydrochloric acid produced the same 
 play of colours as nitric acid. 
 
DIAGNOSIS. 307 
 
 gases, distention and tenderness of the epigastric region, irregular, 
 and usually constipated bowels, a hypochondriacal frame of mind, 
 haemorrhoids, &c. The faeces are at one time dark, at another, pale 
 and clay-coloured ; occasionally we observe in cases of fatty liver 
 an undue tendency to diarrhoea, — a circumstance which was noted 
 years ago by Schonlein. I have had repeated opportunities of examin- 
 ing the bodies of individuals, who during life have had a pasty com- 
 plexion, who had been wont to suffer from profuse diarrhoea from 
 trifling causes, and in whom death has taken place suddenly from 
 apoplexy, or, in one case, from acute pulmonary oedema, and have 
 found nothing abnormal in the abdomen, with the exception of a 
 fatty liver in an advanced stage. Similar observations have been 
 repeatedly made at the posi-mortem examinations in hospital practice. 
 In the same way, we frequently find fatty liver in overfed children, 
 who die from exhaustion after profuse pale diarrhoea.* 
 
 The skin has been found by Addison altered in such a manner, 
 that were the change constant, it would be of great value in dia- 
 gnosis. It was pale, anaemic, semitransparent, and waxy, and at the 
 same time soft and smooth to the feel, like satin. The paleness was 
 at one time devoid of colour, and at another dirty-yellow ; it was most 
 distinctly marked in the skin of the face, but was also present in other 
 localities. Such changes of the skin are not unfrequently observed 
 in females labouring under tubercle (I have frequently seen them 
 myself), where of course fatty liver was present, as it usually is in 
 pulmonary phthisis ; but I am unable to state whether the liver is the 
 cause of the change, or the hectic fever with its profuse sweating ; 
 at all events, fatty liver of an advanced grade is met with, without 
 the skin presenting this character. In drunkards with fatty liver, the 
 skin has not unfrequently a greasy, fatty feel ; owing to the abun- 
 dance of fat contained in the blood, the cutaneous secretion becomes 
 loaded with fatty matter, in a similar manner to what takes place 
 from the continued use of large doses of cod-liver oil (where the 
 odour of the cod oil is transmitted through the skin by fatty acids in 
 a fluid state), and to what was observed in dogs fed by Magendie 
 upon butter. 
 
 A due regard to the recognised causes of fatty liver is of greater 
 importance in diagnosis. Where an enlargement of the liver is de- 
 
 • Legendre also has observed diarrhoea in children, in connection with 
 fatty liver ; and Bright hasconnected both diarrhoea and amenorrhoea 
 with it. x 2 
 
308 THE FATTY LIVER. 
 
 tected in persons labouring under tubercle, in drunkards, or in 
 individuals of a torpid luxurious habit of life, and when this is 
 associated with the consequences which are known to result from 
 obstructed circulation in the portal vein, then the individual sym- 
 ptoms acquire a greater weight than under other circumstances wfluld 
 belong to them. 
 
 Cases, however, are met with, where the derangements to which 
 fatty liver gives rise, are of a much more marked character; the 
 secretion of bile becomes more and more diminished, extreme anaemia 
 comes on, until at length death supervenes under symptoms of 
 increasing exhaustion, or of complete acholia. This train of symptoms 
 is very seldom observed, and only in the excessive grades of fatty 
 infiltration (See Observation No. XXII., p. 245) ; it occurs more 
 frequently with the fatty degeneration of the gland, which takes 
 place after the parenchyma becomes infiltrated with colloid and 
 other exudations, sometimes along with lardaceous spleen, and at 
 other times independently of this. The organ, which at first is 
 enlarged, is gradually reduced to even below its normal size; its outer 
 surface continues smooth, or becomes slightly granular, the bilious 
 colour of the stools becomes paler, and the appearance of the patient 
 assumes more and more the characters of general cachexia. Under 
 such circumstances, the liver is found to be of normal size, or some- 
 what smaller, its cells are filled with fat or albuminous granules, the 
 parenchymals sometimes traversed by bands of newly-formed areolar 
 tissue, and the bile ducts contain but little secretion. Frequently, 
 but by no means always, the parenchyma of the spleen, or kidneys, 
 or sometimes of both organs, are infiltrated with lardaceous matter, 
 not a trace of which can be found in the liver. 
 
 "When other important organs, such as the spleen, lymphatic 
 glands, and kidneys, are found diseased as well as the liver, it is a 
 difficult matter to determine the share which the liver takes in the 
 generation of the symptoms of general derangement, the cachexia, 
 hydrfemia, &c. In many cases, however, the kidneys and lymphatic 
 glands are free from disease, and the spleen is only changed to such 
 a slight extent, that the symptoms must be mainly attributed to the 
 fatty degeneration of the liver. 
 
 The diagnosis of fatty degeneration during life is often attended with 
 great difficulties, especially when one has not the opportunity of 
 tracing the entire development of the process. The following sym- 
 ptoms are often of great service for this purpose : — the diminution 
 
DIAGNOSIS. 309 
 
 in volume of a primarily enlarged liver, along with increasing 
 cachexia, a smooth surface of the gland, the co-existence of chronic 
 enlargement of the spleen, the decrease of the biliary secretion, and 
 the presence of those predisposing causes which experience shows to 
 give rise to the colloid and lardaceous infiltration of the gland, 
 such as intermittent fever, constitutional syphilis, diseases of the 
 bones, &c. 
 
 I shall only record here one instance of this nature, but, for 
 additional illustrations, I refer to the chapter on Lardaceous Liver 
 (SpecMeber). 
 
 Observation No. XXXI. 
 
 Persistent Intermittent Fever. — AneemiaandHydrtsemia. — Fxhamting 
 Diarrhea, with but little Bile in, the Stools. — Death under Cerebral 
 Symptoms. — Fatty Degeneration of the Liver. — Small Lardaceous 
 Spleen. — A limited Cancerous Ulcer in the Ceecum. 
 
 J. Pallifka, aged 31, during July and August 1853, was treated 
 in the Clinique for anaemia without benefit. He was a large, broad- 
 shouldered man, of a pale, waxy countenance, and complained of 
 remarkable weakness, accompanied by wandering pains and deranged 
 digestion. At the origin of the aorta, there was heard a systolic 
 bruit, which was propagated into the carotids ; lungs healthy ; spleen 
 and liver of normal size; the tongue slightly coated; the bowels 
 were moved two or three times in the day, and the stools were of a 
 pale colour; urine had a specific gravity of 1012, and was free from 
 albumen. Under the use of the preparations of steel, the ethereal 
 tincture of the muriate of iron, the lactate of iron, &c, the appetite 
 increased; but the paleness, the feeling of weakness, and the other 
 symptoms of anaemia, remained unchanged, notwithstanding a full 
 diet. The patient left the Hospital, and did not return until 
 the 16th of February, 1854. The anaemia had now increased to 
 hydraemia ; anasarca and ascites had supervened ; there were from six 
 to ten thin pale stools daily ; a tender induration, which, however, 
 was not very accurately circumscribed, could be felt upon palpation 
 in the caecal region; urine 1007, pale and without albumen; blood 
 drawn off by a cupping-glass showed no increase of the white 
 corpuscles. Vegetable and mineral astringents, nux vomica, &c, 
 
310 THE FATTY LIVER. 
 
 were administered in vain to check the diarrhoea. On the evening 
 of the 25th, loss of consciousness set in suddenly, the speech 
 became stammering, the features distorted, and the eyes fixed 
 and staring; pupils dilated; pulse slow and thready; the respiration 
 slow and feeble. On the 26th he died. 
 
 Autopsy. 
 
 The contents of the cranial cavity presented nothing abnormal. 
 The bronchi were empty, and the lungs very cedematous ; the heart 
 appeared unchanged in its muscular tissue and valvular apparatus. 
 About four pounds of clear serum were found in the abdominal 
 cavity. The mucous membrane of the stomach and of the small 
 intestine, as far as the ileo-csecal valve, was pale. The caecum over 
 its greater extent was firmly adherent to the fossa iliaca, and its 
 mucous membrane was partially converted into an ulcerated sur- 
 face of a dirty-grey ragged character; the walls of the caecum 
 presented a pulpy infiltration about five lines in thickness. The 
 lower portion of the intestinal canal, as also the retro-peritoneal 
 glands remained intact. 
 
 The spleen was slightly enlarged, five inches long, and three in 
 breadth; its consistence was firm, and its cut surface glistening. 
 
 The liver was of normal size; its surface was smooth, audits margins 
 sharp ; the secreting cells had an irregular outline, and most of them 
 contained no nucleus, but were filled with fine granules and drops 
 of oil, and some of them also with brown pigment. The gall-bladder 
 contained a small quantity of yellow mucus, and in the gall ducts 
 within the liver were aggregated masses of cylindrical epithelium 
 of a grey colour. The liver contained no sugar, but large quantities 
 of leucine and tyrosine. 
 
 The patient attributed his illness to an obstinate intermittent fever, 
 from which he had suffered during three months, 2J years before 
 his death. The altered conditions of the spleen and liver, which 
 must be regarded as constituting the starting-point of the anaemia, 
 apparently dated from that period. The spleen, which was scarcely 
 enlarged, was in a state of lardaceous degeneration, and the liver 
 was affected with fatty degeneration, such as we find as a final result 
 of infiltration of the parenchyma with albuminous matter, in con- 
 sequence of malarious poison, constitutional syphilis, &c, which 
 may or may not be accompanied by lardaceous degeneration of the 
 
TREATMENT. 311 
 
 spleen, kidneys, and lymphatic glands. The functions of the liver 
 under these circumstances were in a great measure destroyed, and 
 the results, which the suspension of these functions entails upon 
 the entire system, ensued. 
 
 The limited cancerous deposit in the caecum, which did not make 
 its appearance until the symptoms of anaemia had already existed for 
 two years, might have contributed to expedite the death from exhaus- 
 tion, but could not be regarded as the cause of the poverty of blood. 
 
 In the present state of our knowledge, the diagnosis of fatty 
 infiltration, like that of fatty degeneration, is in many cases uncertain. 
 The disadvantage arising from this, however, in medical practice, so 
 far as it concerns the former condition or the simple fatty liver, is 
 not very important, inasmuch as the affection very seldom comes 
 under treatment. The slighter forms exist without causing any im- 
 portant derangement of the general system ; the more advanced forms, 
 such as react injuriously upon the system, are often associated with 
 other dangerous morbid conditions, as for instance, pulmonary 
 tubercle, which make the treatment of the hepatic affection a very 
 secondary matter. The cases, in which the liver affection exists per 
 se, are usually the result of improper living, hereditary predisposition, 
 &c.; they may be recognised with some degree of certainty from the 
 etiological agencies which give rise to them, in connection with the 
 diagnostic measures already described, either directly, or by way of 
 exclusion. 
 
 ix. Treatment. 
 
 The treatment of fatty liver, which has for its object the diminu- 
 tion of the fatty contents of the liver, may be regarded in several 
 points of view. First comes the regulation of the diet: fat and 
 amylaceous articles of diet, as well as spirituous liquids of every sort 
 should be avoided; fruits are beneficial, as well as those vegetables 
 which are rich in pectine,* and in compounds of the alkalies with 
 the vegetable acids, and also the lean flesh of young animals; 
 active exercise in the open air is to be enjoined, and in short, a 
 mode of life which shall have the effect of hastening the metamor- 
 phosis of matter. Those medicinal agents are best suited for the 
 diminution and removal of the fat deposited in the hepatic par- 
 
 * These are carrots, turnip3, and some pulpy fruits, such as apples, pears, 
 red currants, &c. — Transl. 
 
312 THE FATTY LIVER. 
 
 enchyma, from which, so far as our present experience in this 
 matter extends, we may expect an increase in the secretion of bile.* 
 In the choice of medicines, we must attend carefully to the condition 
 of the digestive organs, and must avoid everything, by the persistent 
 use of which the functions of these organs might be deranged. 
 
 In the slighter forms of the affection, it is sufficient, along with a 
 regulated mode of life, to administer the bitter vegetable substances 
 abounding in alkalies, such as the extract. saponar.,t the extract 
 card, benz.jj extract of taraxacum, extract of chelidonium,§ &c, 
 either alone or in combination with alkaline carbonates, or the com- 
 pounds of the alkalies with vegetable acids ; we may also recommend 
 rhubarb, or aloes, when there is great torpidity of the bowels. 
 
 In the more advanced forms, it is usually necessary to have re- 
 course to the waters of Karlsbad, Marienbad, Homburg, or 
 Kissingen, || of which that should be selected which is most suited 
 to the individual case, to the general symptoms, and to the degree 
 of derangement of the functions of the gastric and intestinal mucous 
 membrane. When there is a marked tendency to diarrhoea, it is 
 best to avoid all the springs just mentioned, and to employ in their 
 place the springs of Eger^T or Ems.** In anaemic individuals, the 
 easily-absorbed preparations of steel, such as the lactate and car- 
 bonate of iron, or, better still, small quantities of the waters of Spa, 
 or Schwalbach,tt are not unfrequently necessary. When there, is 
 persistent exhausting diarrhoea, we must have recourse to the vege- 
 table and mineral astringents. 
 
 * Few of the observations bearing on this point, which we possess, can 
 be depended upon. It is only in recent times, that the experiments which 
 have been made upon animals by means of biliary fistulas, have furnished 
 some reliable data. The information, however, which has been derived 
 from this source, is still far from sufficient to meet the demands of 
 treatment. 
 
 t Prepared from the root of the Saponaria officinalis, or soapwort. — 
 Transl. 
 
 J Extract prepared from the leaves of the Cardwus benedietus, a species 
 of thistle. — Transl. 
 
 § Chelidonium majus, or celandine. — Transl. 
 
 II See note, page 125. 
 
 f The Springs of Eger, in Bohemia, are saline chalybeates, and contain 
 a considerable amount of free carbonic acid. The solid constituents con- 
 sist of the sulphate and carbonate of soda, chloride of sodium, and car- 
 bonate of iron. — Transl. 
 
 ** See note, page 125. ft See note, page 121. 
 
TREATMENT. 313 
 
 The treatment of fatty degeneration of the liver is mainly pre- 
 ventive and symptomatic; the object here is to avert as soon as 
 possible the circumstances which may lead to the liver becoming 
 infiltrated with albuminous matter, and to remove this substance 
 before the nutrition of the cells becomes impaired. Constitutional 
 syphiHs, rickets, and otber diseases of the bones, the marsh poison, 
 &c, are to be combated by an appropriate treatment ; the infiltration 
 of the liver is to be removed by means of iodide of, potassium, iodide 
 of iron, the alkalies, and the waters of Karlsbad and other similar 
 springs. It is seldom that we succeed in accomplishing this 
 last indication. I nave seen tbe volume of the liver reduced by 
 such means, but at the same time the symptoms of degeneration 
 often supervened in a threatening manner. "When this is the case, 
 the prognosis is unfavourable, and deobstruent medicines are then 
 prejudicial; the treatment must now be confined to the use of 
 the weaker preparations of steel, a bland nutritious diet, and tbose 
 remedies which are best adapted to regulate the digestion of the 
 stomach and bowels, such as bitter vegetable substances, &c. 
 
314 THE PIGMENT-LIVER. 
 
 CHAPTER VIII. 
 
 THE PIGMENT-LIVER. MELAN.EMIC LIVER. ALTERATIONS IN THE 
 
 LIVER RESULTING FROM INTERMITTENT FEVERS. 
 
 i. Historical Account. 
 
 There is an old tradition, that black substances are formed in the 
 spleen and in the blood of the portal vein, and may give rise to 
 disease ; the so-called black bile constituted an important element of 
 the earliest theories of humoral pathology. Galen thought that this 
 substance accumulated in the spleen, as a product of the formation 
 of bile, and that from that locality it gave rise to obstructions of 
 the vessels, enlargements (Anschvppungen) of the abdominal viscera, 
 and dangerous nervous symptoms. This theory, with a few inter- 
 missions ( Van Helmont, Sylvius), and with some slight modifications, 
 continued to be resorted to for the explanation of abdominal affec- 
 tions generally, and of diseases of the portal system in particular. 
 The mode of origin, and the pathological importance of atra-biliary 
 matter, we find discussed in detail by Boerhaave* and Yan Swieten.f 
 These observers were of opinion, that owing to morbid influences of 
 a varied nature, the fluid elements of the blood were diminished, and 
 the solid constituents condensed into a black, fatty, earthy sub- 
 stance.} This substance, it was believed, in virtue of its peculiar 
 nature, accumulated in the portal vein, stagnated here for a long 
 period, assumed acrid and corrosive characters, deranged the func- 
 tions of the abdominal viscera, and ultimately was converted into 
 black bile. || This black bile was then set in motion by certain 
 exciting causes, and, penetrating into the liver, the heart, the 
 lungs, and the brain, produced most serious derangements every- 
 where : — at one time fever, when the substance had become 
 putrid; at another time, when it led to mechanical obstruction of 
 
 * Aphorismi de cognosc. et curand. morb. 
 
 t Comment, ad Boerhaav. aphorism. Tom. III., p. 461, et seq. 
 
 X § 1092. II § 1098, 1102. 
 
HISTORICAL ACCOUNT. 315 
 
 the cerebral vessels, dangerous symptoms of another character, such 
 as convulsions, paralysis, delirium, &c* 
 
 The theories in question received a considerable expansion from 
 Kampf,t who added to the atra-biliary matters a series of other 
 substances, which he regarded as proceeding from the blood- 
 plasma. 
 
 It was not until the end of last century that Beil, who in this, as 
 in so many other questions, anticipated the age in which he lived, 
 showed how the doctrine of black bile was opposed to physio- 
 logical observations.^ After him, Heusinger § attributed the morbid 
 condition under consideration to a deposit of black pigment, and, 
 along with Puchelt, accounted for it by an exaggerated venous 
 condition of the blood. The majority of physicians, however, con- 
 tinued, as before, to believe in the dreaded pathogenetic potency of 
 the black bile. The marsh fevers of the tropics, and the diseases 
 which in 1826 devastated the littoral districts of the northwest of 
 Germany and the Netherlands, were regarded as atra-biliary fevers. 
 Even in the year 1829, Vogel described the atra bills after the 
 fashion of the ancients in the Berlin Encyclopaedia. 
 
 Scientific medicine had scarcely removed this traditional remnant 
 of a Hippocratic humoral pathology, when it became necessary, from 
 an unprejudiced observation of facts, to relapse into the old doctrine. 
 Diseases became known in which black matter produced by decom- 
 position of the blood, became developed in the spleen, which black 
 matter passed into the portal vein, and at one time obstructed the 
 hepatic vessels, at another, passed through these, and, entering the 
 general circulation, filled up the capillaries of the brain and other 
 organs, — morbid processes, in fact, which gave rise to symptoms 
 similar to those which were described by the ancients. 
 
 It is only in the most recent times that accurate observations 
 have been made of this lesion, although isolated instances are found 
 recorded by the older physicians. Long ago, Lancisi || found the 
 liver of an individual who had died of bilious fever, of a blackish 
 tinge; and Stoll^ described a dark pigmentary deposit in the brain 
 and liver of a female who had succumbed after several attacks of 
 
 • § 1104. t Op. ant. cit. p. 14. 
 
 X Reil. Memorab. clinic, med. pract., Fasc. III., p. 54. 
 § TJntersuchungen iiber anomale Koklen-und Pigmentbildung im men- 
 schlichen Korper. Eisenach, 1823. 
 
 || De noxiis pallidum effluviis. 1 Ratio medendi, Tom. I., p. 196. 
 
316 THE PIGMENT-LIVER. 
 
 fever. The statements made by Bailly* in his " Pathological Ana- 
 tomy of Intermittent Fever," are more copious and to the point : — 
 " Le foie tout entier etait noiratre, semblait compose" de sang noir," 
 &c. — " la couleur du cerveau beaucoup plus foncee." Simultaneously, 
 Billard described the same change in the brains of three patients who 
 died of acute cerebral disease ;t and observations of a similar nature 
 are found in Montfaucon's " Histoire medicate des marais" (pp. 
 306-322). 
 
 Black pigmentary deposits were repeatedly observed in the spleen, 
 liver, and brain, during the fever epidemic which, in 1826, raged 
 along the coast of the North Sea. J 
 
 Richard Bright, in his "Reports of Medical Cases," published in 
 London in 1831 (Plates XVII., XIX., and Chap. CI.), gives a 
 masterly representation of a brain, the cortical substance of which 
 was of a dark colour, like black-lead.§ This was taken from a man 
 who died of cerebral paralysis, after an attack of fever. Physicians, 
 who have had an opportunity of observing intermittent and remittent 
 fevers in hot climates, have frequently described a black tinging of 
 the spleen and liver; particularly Annesley,|| Haspel,^[ Stewardson,** 
 and others. 
 
 All these observations remained without further results, because the 
 mode of origin and distribution of the pigment were not accurately 
 traced. Not until the year 1837 did Meckel tt ascertain that the 
 dark colour of the organs depended upon an accumulation of pig- 
 ment in the blood ; two years later, Virchow found numerous pig- 
 ment cells in the blood and in the enlarged spleen of a man who 
 became dropsical after a persistent intermittent fever. JJ Heschl §§ 
 and Planer || || have recorded numerous observations of a similar 
 nature. 
 
 * Traitfi anat. patholog. des fi&vres intermittentes. Paris, 1825, p. 181, 
 &c. t ArcHv gener., 1825. 
 
 % Popken, Historia epidem. malignse Jeverse observ. Bremae, 1827. 
 Fricke, Bericht iiber seine Reise nach Holland im Jahre, 1826. 
 
 § " It was almost of the colour of black-lead." 
 
 || Op. cit., vol. II., p. 482 : — " Liver of very dark colour.'' 
 
 H Maladies de l'Algerie, I., 335 ; II., 318. 
 
 ** The American Journal, April, 1841, p. 42. 
 
 tt Zeitschr. fur Psychiatrie von Damerow, 1847; also, Deutsche 
 Klinik, 1850. 
 
 tt His "Archiv fur Patholog. Anatomie," 1849 and 1853. 
 
 §§ Zeitschrift der Gesellschaft de Aerzte in Wien. 1850. 
 
 Illl The same for 1854. 
 
ANATOMICAL DESCRIPTION. 317 
 
 n. Anatomical Description of Pigment-Liver, and of the co-existing 
 conditions of the Spleen, Brain, Kidneys, 8fc. 
 
 In individuals who die from the effects of marsh poison, under 
 symptoms of severe intermittent, remittent, or continued fevers, we 
 frequently find peculiar changes of the liver associated with functional 
 derangements of the organ, and of the parts pertaining to the portal 
 system. The liver presents a steel-grey, or blackish, or not unfre- 
 quently a chocolate colour ; brown insulated figures are observed 
 upon a dark ground. This change of colour is produced by pigment- 
 matter which is accumulated in the vascular apparatus of the gland. 
 In fine sections of the hardened tissue, accumulations of pigment may 
 be observed in the capillary network of the portal and hepatic veins, 
 as also in the larger branches of these vessels : these deposits are 
 either uniformly distributed, or limited, for the most part, to certain 
 regions. Sometimes the brownish-coloured lobules appear surrounded 
 by black margins, owing to the interlobular veins being filled with 
 coloured particles (Kg. 31); in general, however, the pigment- 
 matter is more uniformly distributed, extending from the circumfer- 
 ence of the lobules halfway to their centre, or penetrating as far as 
 the commencements of the hepatic veins, or, still farther, into the 
 vena cava. 
 
 In most cases, the arterial system is implicated as well as the 
 venous, the branches of the hepatic artery containing large quantities 
 of black colouring-matter.* The hepatic cells remain exempt; in 
 no case have I observed any deposit of pigment in them, such as is 
 described by Virchow.f They are either normal in their characters, 
 or filled with brown bile; they are often infiltrated with oil, and 
 occasionally, but only after a long continuance of the disease, they 
 contain colloid or lardaceous matter. In the acute cases, the size of 
 the entire organ appears either normal or enlarged; the gland is 
 swollen from congestion, and here and there, also, it is infiltrated and 
 softened by extravasations of blood ; at a later period, it diminishes 
 
 * Not only in malarious fevers, but very frequently, also under other cir- 
 cumstances, as in cirrhosis, cancer, and echinococci of the liver, the 
 hepatic artery contains black pigment, apparently owing to interruptions 
 in the capillary circulation of this vessel. 
 
 t After extravasations of blood into the hepatic parenchyma, red, 
 brown, and black deposits of pigment in the cells are not unfrequently 
 observed; in one case of cirrhosis I met with extensive masses of this 
 nature. 
 
318 
 
 THE PIGMENT-LIVER. 
 
 in volume, and there frequently ensues a true atrophy, provided that 
 the gland does not become infiltrated with colloid matter, — an occur- 
 rence which I have only met with in rare instances. 
 
 Fig. 31. 
 
 Fig. 31. -Fine section of a pigment-liver, previously dried and 
 treated with a solution of potash ; magnified 90 diameters. 
 The pigment is seen to be deposited, for the most part, in the 
 interlobular veins, forming a black zone surrounding each 
 lobule, and to have penetrated but very slightly into the 
 interior of the lobules. In most cases, the pigment is dis- 
 tributed more uniformly than is here represented. 
 Copied from Atlas, Plate IX., Fig. 4. 
 
 Along with these abnormal conditions of the liver, we constantly find 
 similar appearances in the spleen. This organ is likewise dark-brown, 
 or sometimes bluish-black ; at one time it presents a uniform colour, 
 and at another, is speckled ; in its parenchyma large quantities of 
 the same pigment can be detected as is present in the liver. At 
 the same time, the size and consistence of the organ become altered; 
 in the acute cases of the disease, it is usually soft, congested, and 
 considerably enlarged ; in the less severe cases, there is usually only 
 a slight alteration in the volume of the organ, unless, as seldom 
 
ANATOMICAL DESCRIPTION. 319 
 
 happens, it undergoes lardaceons degeneration; in this case, its 
 volume and consistence are considerably increased. Analogous 
 changes are observed in the lymphatic glands. 
 
 The liver and the spleen are the parts in which the black pigment 
 is most constantly observed under the circumstances just mentioned. 
 Yery frequently, however, there are other organs implicated as well, 
 the pigment, when it passes in large quantity into the circulation, 
 being carried to them by the current of the blood. 
 
 A large quantity has usually been found in the capillaries of the 
 lungs ; in old individuals, however, in whom pigmentary deposits of 
 another nature take place in these organs, it is difficult to distinguish 
 between the two. 
 
 This tinging with pigment is much moTe easily detected in the 
 brain, in which considerable collections are sometimes recognised 
 by the dark-colouring of the cortical substance. This assumes 
 a chocolate or black-lead-like hue, whilst the white matter remains 
 unchanged; it is only when the pigmentary deposit is excessive, 
 that we see the white matter present a grey appearance, and the 
 fine vessels in it resembling brown streaks. Under such circum- 
 stances, microscopic examination has shown the capillaries to 
 be filled with black granules and scales (Schollen), which at one 
 time are uniformly distributed, but at another are aggregated in 
 groups. Frequently we observe along with the pigment scales a pale 
 hyaline coagulum, which when viewed with a light of a strongly 
 refracting power, may be seen to fill up the calibre of individual 
 capillaries. 
 
 The kidneys frequently participate in the pigmentary deposit 
 to a remarkable extent. "When this is the case, grey spots make 
 their appearance in the cortical substance ; and in a few cases, we 
 may observe dark lines in the pyramids following the course of the 
 blood-vessels and uriniferous tubes. Under the microscope we can 
 detect the pigment-matter in the capillaries ofiiie cortical substance, 
 and particularly in the Malpighian bodies ; now and then we find 
 isolated little fragments in the uriniferous tubes. 
 
 The remaining organs and tissues, such as the external integument, 
 the mucous membranes, the muscular tissue, &c, by no means re- 
 main exempt, as may at once be seen by a simple inspection of their 
 grey tint ; but the accumulation is seldom so considerable in these 
 parts as in the organs previously mentioned, and it appears to be of 
 subordinate importance, owing to the comparatively slight physiolo- 
 
320 THE PIGMENT-LIVER. 
 
 gical value of these structures. In the typical forms of the disease 
 we find, as a general rule, pigment deposited everywhere where the 
 blood penetrates, and independently of the abdominal glandular 
 organs, we find it in greatest abundance in those parts of the body 
 where the capillaries are most narrow, and consequently where the 
 pigment flakes are most easily arrested. 
 
 The pigment which is found in the organs and tissues, is brought 
 to them by the blood;* it exists in abundance in this fluid, and 
 particularly in that portion of it contained in the portal vein, 
 where we can most easily study its properties, colour, and chemi- 
 cal relations. The usual form in which the pigment makes its 
 appearance is that of small, rounded, or angular granules, which at 
 one time are sharply defined, and at another are surrounded by a 
 brownish or pale margin. These granules are occasionally isolated, 
 but most frequently several of them are connected together in 
 groups, by a pale substance soluble in acetic acid and in caustic 
 alkalies. In form they are rounded or elongated, sausage-shaped or 
 irregularly branched. They have no defined membranous outline; 
 the hyaline connecting-substance which presents the characters of 
 fibrinous matter, forms sometimes a broad, and sometimes a narrow 
 rim, without any sharply-defined outline. 
 
 True pigment cells are observed along with the granules and 
 granular masses, though in somewhat smaller quantity. These partly 
 resemble in form and size the colourless corpuscles of the blood, 
 and partly consist of larger spindle-, or club-shaped cells with 
 rounded nuclei, and sharply-defined walls, like the cells which 
 we are wont to find, along with free granules, in the spleen. These 
 cells contain a greater or smaller number of black granules. Planer 
 was unable to convince himself of the presence of these pigment 
 cells, which Virchow had previously described; I have seldom 
 failed to find them in the blood of the portal vein ; in most cases it 
 is easy to avoid confounding these cells with the granular masses, 
 which are bound together by fibrinous material. (Fig. 32.) 
 
 Besides the forms just described, larger fragments of pigment are 
 observed, which, for the most part, have an irregular form, and upon 
 pressure, look as if they had been broken off from still larger masses. 
 Sometimes these fragments appear to be cylindrical, and are bounded 
 laterally by two straight parallel lines, whilst their extremities are 
 
 • In the capillaries of the hepatic artery, and occasionally also in those 
 of the portal vein, the pigment appears to lie in the walls of the vessel. 
 
ANATOMICAL DESCRIPTION. 321 
 
 irregularly broken off; so that they remind one of the appearance of 
 the smaller vessels, of which they appear to be casts. Their size is 
 not unfrequently considerable ; I have seen some which were to of a 
 line in breadth, and A of a line in length. They are usually sur- 
 rounded by a rim of pale transparent substance of greater or less 
 breadth; sometimes this rim is only visible on one side. (Fig. 32.) 
 
 Fig. 32. 
 
 
 
 Fig. 32. Pigment-matter from the portal veins. 
 
 a, From the trunk of the vessel. The epithelium of the lining 
 membrane containing black pigment, and some of the cells with 
 a distinct rounded or spindle-shaped nucleus ; the younger 
 cells were coloured reddish-brown ; normal blood corpuscles. 
 
 b, Cylindrical scales. (Schotten) containing pigment. 
 
 c, Fragments of black pigment, enveloped in a hyaline sub- 
 stance, from the splenic vein. 
 
 a', From the splenic vein. 
 
 Copied from Atlas, Plate IX., Fig. 2. 
 
 The colour of the pigment is, for the most part, deep black, 
 more rarely it is brown or ochre-coloured, and least frequently 
 of all, reddish-yellow. These different colours represent the various 
 stages in the transformation of the red pigment of the blood into 
 melanotic matter. The gradually advancing metamorphosis, how- 
 ever, manifests itself not merely in the colour, but also in its rela- 
 tions to re-agents. The resistance offered by the different sorts of 
 pigment to the action of acids and caustic alkalies is very variable. 
 The more recent products are rendered pale, and lose their colour with 
 greater or less rapidity ; those, on the other hand, of an earlier date, 
 resist the action of these agents for a long time ; I have not un- 
 frequently permitted the latter to be acted on for days by caustic 
 soda, without their colour being destroyed. 
 
322 THE PIGMENT-LIVER. 
 
 Along with this pigment, coagula of a hyaline character, and free 
 from colouring-matter, are found in the blood. These resemble in 
 their form the last described variety of pigment flakes ; from the fact 
 of their being colourless, they are easily overlooked. Nothing unusual 
 can be detected in the blood corpuscles ; sometimes the number of 
 the white corpuscles appears to be increased, — a fact long ago ob- 
 served by Meckel, but by no means of universal occurrence ; in the 
 majority of cases, and especially in those of an acute nature, nothing 
 abnormal can be made out with regard to the corpuscles. 
 
 Such are the post-mortem appearances found "in melansemic indi- 
 viduals. The first question which now forces itself upon us, is : — 
 "Whence, and in what way does this pigment originate ? — and the 
 second : — What are its results upon the functions and textures of 
 the individual organs ? 
 
 in. Place and Mode of Origin of Pigment. 
 
 This question has been answered by most observers, to the 
 effect that the spleen constitutes the seat of formation of the mela- 
 notic matter. There are many grounds for such an opinion, but no 
 proofs exist which can claim this function for the spleen exclusively. 
 Experience shows that the transformation of the red matter of the 
 blood into black pigment may take place everywhere thoughout the 
 vascular system, and also external to it. Although the spleen, 
 from the nature of its structure and circulation appears pre- 
 eminently adapted for such a purpose, we must keep in view, a priori, 
 the possibility of the same blood metamorphoses taking place in 
 other parts of the body, and we cannot arrive at the conclusion that 
 these changes are exclusively confined to the spleen, until observa- 
 tion lends no support to the participation of other parts of the 
 vascular system. 
 
 There can be no doubt, however, that the largest portion of the 
 pigment is formed in the spleen, that it passes from this oTgan into 
 the portal vein, and that part of it remains impacted in the capil- 
 laries of the liver, while the rest passes through these capillaries, and 
 is carried into the general circulation. 
 
 There are many facts which may be appealed to in favour of such 
 an hypothesis. It is known, that in the spleen of men and animals, 
 and particularly in the spleen of the naked amphibia, cell-like struc- 
 tures are met with, even in the healthy state, which contain blood 
 corpuscles or pigment molecules. It is true, that similar formations 
 
ORIGIN OF PIGMENT. 323 
 
 are occasionally found in other parts of the body, as in extravasations 
 of blood in the brain, but nowhere so generally as in the spleen. Id 
 melaneemia, the accumulation of pigment is not so constant in any 
 organ as in the spleen ; — this is a rule almost without exception. 
 Next to the spleen, as regards the frequency and intensity of the 
 deposit of pigment, comes the liver, and after this the remaining 
 organs, the lungs, the brain, the kidneys, &c. Cases are not nnfre- 
 quent, where only the spleen contains a quantity of pigment, and 
 others, in which the spleen and liver alone are infiltrated with dark 
 colouring-matter, whilst the other organs preserve their normal hue ; 
 but I have never observed an accumulation of pigment in the blood 
 of the heart, in the capillaries of the brain, kidneys, &c, without 
 the large glandular organs of the abdomen being implicated. 
 Another argument, in favour of the origin of the pigment of me- 
 lanaemic patients in the spleen, is the form in whieh the black 
 pigment is found in the blood. In portions of blood-clot, I have 
 observed the pigment contained in the same elementary structures 
 as are present in the splenic pulp, colourless blood-corpuscles, 
 with a simple or divided nucleus, and spindle- and club-shaped 
 epithelium cells "from the cavernous sinus of the spleen. The sup- 
 position that other organs are implicated in the formation of pigment, 
 rarely finds any support from examination. The epithelium of the 
 endocardium, and of the lining membrane of the vessels in different 
 regions of the body, does not present any unusual appearance ; the 
 accumulation of pigment in the liver, the brain, the kidneys, &c, is 
 always limited to the finest capillaries; extensive deposits which 
 might cause the blood to become overloaded with pigment are no- 
 where to be found. Only in one case have T been able to ascertain 
 with certainty, that the formation of the black pigment is not 
 exclusively confined to the spleen, but occurs also in the liver. In 
 an individual who died of exhaustion, after a protracted quartan 
 fever, complicated with albuminuria, the enlarged and lardaceous 
 spleen was completely free from pigment, whilst considerable quan- 
 tities were accumulated in the liver. Not only did this pigment fill 
 the finer capillaries of the portal and hepatic veins, but it also 
 extended into the larger branches of the portal veins; these were 
 blocked up at many places with black, friable coagnla, and might be 
 easily traced with a pocket lens, or with the naked eye. Besides the 
 liver, the parenchyma of the kidneys contained much pigment, whilst 
 that of the brain remained free. 
 
 y2 
 
324 THE PIGMENT-LIVER. 
 
 Hence, it would seem that the usual source of the formation of 
 pigment is the spleen, and that, along with it, but only in excep- 
 tional cases, other organs, and particularly the liver, participate. 
 
 It is a more difficult matter to reply to the other question, which 
 has reference to the manner in which this formation of pigment 
 takes place. We shall not solve this problem until we possess 
 a more intimate knowledge of the minute structure of the splenic 
 pulp than we do at present. If we assume, what in the present 
 state of the question appears the more probable view, that the 
 capillaries of the splenic artery pour their blood into a system 
 of large sinuses, whence it passes into the efferent veins, the fol- 
 lowing explanation of the production of the pigment might be 
 offered. Even in the normal state, the blood which has flowed rapidly 
 through the narrow capillaries, would pass more slowly through the 
 ample channel of the venous sinuses, and not unfrequently would 
 stagnate in some places, so that conglomerate masses of blood cor- 
 puscles would be formed, which gradually might be transformed into 
 pigment. In the intense congestions which experience shows to 
 attack the spleen as a consequence of intermittent fever, these 
 stagnations are very great, and would lead to considerable accumu- 
 lation of pigment. According to this view, the pigment would 
 arise from the stagnation of the blood in the venous sinuses of 
 the spleen j the club- and spindle-shaped pigment cells are the 
 epithelium of the lining membrane of the sinuses infiltrated with the 
 decomposed red matter of the blood, the globular pigment cells are 
 colourless blood corpuscles, infiltrated with molecules of colouring- 
 matter, and the pigment scales (Sc/wllen) are the broken-up fragments 
 of the coagulum. Why the formation of pigment is either absent or 
 less marked* in many other congestions of the spleen, in typhus, 
 pyaemia, and simple intermittent fever, why it is, that the metamor- 
 phosis of the blood-pigment into melanotic matter, apparently takes 
 place much more rapidly here than at other places, are questions to 
 ■which at present we cannot give a satisfactory reply. The acid 
 character of the splenic pulp, however, must exercise an important 
 influence over the metamorphosis of the blood-pigment. 
 
 Another point of importance for the clinical elucidation of the con- 
 sequences of this morbid process, would be the tracing of the chemical 
 products of metamorphosis which are formed by the destruction of 
 the blood corpuscles, the morphological residue of which presents 
 * See Observations No. XIII. and XVI. 
 
COMPLICATIONS. 325 
 
 itself in the form of pigment. It is scarcely to be imagined, that 
 amid so great a destruction of the elements of blood, products of 
 metamorphosis should not be formed, concerning which the micro- 
 scope can furnish no information. These are carried along with the 
 pigment into the circulation, and will be taken into consideration in 
 explaining the nervous symptoms, which we know to accompany 
 malignant intermittent fever.* 
 
 iv. The Results produced by the formation of Pigment upon the 
 Structure and Functions of the various organs. 
 
 The effects upon the system of the morbid process taking place in 
 the splenic parenchyma which has just been described, are of a 
 complicated nature, and can only be understood by a close inves- 
 tigation of the individual agents which are concerned in them. 
 
 The destruction of large numbers of the blood corpuscles con- 
 tributes, in the first place, to the production of a state of the blood 
 like that of chlorosis, which usually soon makes its appearance in 
 the course of intermittent fevers. This effect upon the general mass 
 of the blood is aggravated by the interruption of the important 
 blood-forming function of the spleen which takes place at the same 
 time. It is a difficult matter to determine to what extent each of 
 these agencies is calculated to act ; the loss of blood corpuscles, how- 
 ever, must be proportioned to their destruction, and consequently to 
 the quantity of pigment which has been formed.t An increase of 
 
 * Boerhaave and Van Swieten (loc. cit., III., p. 496) long ago assumed 
 the existence of a putrefaction of the atra-biliary matter, and attributed 
 the symptoms which were induced by this, partly to the pollution of the 
 blood by the products of putrefaction, and partly to the mechanical 
 obstruction of the capillaries by the black masses. It is obvious that the 
 detection of these products was not to be thought of in the condition of 
 chemical science at that time. Even at the present day, the same difficulty 
 presents itself in explaining the problem before us, because the intermediate 
 substances which arise from the decomposition of the albuminous prin- 
 ciples have no characteristic properties, and cannot be detected until the 
 decomposition has arrived at certain ultimate products. Such being the 
 case, negative results cannot decide the question. 
 
 We have repeatedly examined the spleen of melanaemic patients, and 
 have found numerous products of metamorphosis which are developed in 
 large quantities in this organ, but have failed to detect any character- 
 istic new substance foreign to the organ. 
 
 t The loss in this way may be very considerable. Occasionally the 
 
326 THE PIGMENT-LIVER. 
 
 the colourless corpuscles,, as a consequence of the disease of the 
 spleen, is not observed : in most cases the examination of the blood 
 has shown no remarkable deviation in this respect. 
 
 The pigment originating in the spleen, passes first with the 
 blood of the portal vein into the liver. It is here that the first func- 
 tional derangements are observed. One portion of the pigment passes 
 through the capillaries unarrested and enters the general circulation; 
 the larger particles remain impacted in the capillaries of the portal 
 vein, and obstruct the circulation of the blood through these vessels. 
 The accumulation of pigment is sometimes seen to take place 
 chiefly at the periphery of the lobules in the interlobular veins ; but 
 at other times it extends throughout the entire capillary vascular 
 system, and penetrates into the interior of the lobules as far as the 
 central veins. The derangements of the circulation and their con- 
 sequences vary according to the quantity of the large pigment scales 
 and cells. 
 
 These derangements manifest themselves first in an abnormal 
 secretion of the liver. The bile is usually secreted in large quantity, 
 and we have repeatedly found in it considerable quantities of albu- 
 men; leucine can always be detected in the hepatic parenchyma; 
 its saccharine constituents, however, are unchanged. 
 
 Extensive capillary stagnation gives rise to obstruction of the 
 circulation of the blood in the roots of the portal vein, which mani- 
 fests itself in various ways according to its intensity. Sometimes 
 we see exhausting haemorrhages from the gastro-intestinal mucous 
 membrane coming on in an intermittent manner, or more frequently, 
 profuse diarrhoeas, occasionally associated with vomiting, &c. ; acute 
 serous effusions into the peritoneal sac, together with bloody suffusions 
 of the serous membrane, constitute another result ; while at a later 
 period, chronic atrophy of the liver, with its train of consequences, 
 may make its appearance. 
 
 The next organ, in point of frequency to the liver, which under- 
 goes important organic and functional derangements, is the brain. 
 Numerous particles of pigment, which have passed unarrested through 
 the vessels of the liver and of the lungs, accumulate in the narrow capil- 
 laries of this organ, and particularly in those of the cortical substance. 
 Even by simple inspection of the shade of colour, we can form an 
 
 organ, which is almost black from the accumulation of blood, is con- 
 siderably enlarged, diminished in its consistence, and, at some parts, 
 infiltrated with extravasations of blood. 
 
COMPLICATIONS. 327 
 
 approximative notion of the quantity of colouring-matter which has 
 been deposited, and of the extent of the vascular obstruction. We 
 must not, however, rely entirely upon inspection, for slight accumula- - 
 tions of pigment in the capillaries easily escape notice, particularly 
 when viewed by an unpractised eye, and can only be distinguished 
 with the assistance of the microscope. In addition to the above, it is 
 not at all uncommon for the vessels to become obstructed by a colour- 
 less fibrinous-like coagulum, which of course does not affect the shade 
 of colour. The mechanical interruption to the circulation which is 
 produced in this way, not unfrequently gives rise to rupture of the 
 small vessels, and the formation of numerous capillary apoplexies. 
 Meckel long ago made observations of this nature ; Planer described 
 eight cases in which small extravasations were scattered through the 
 grey and white substance of the brain. These numerous haemor- 
 rhages have not come under my own observation ; but in two cases 
 I have observed extravasation into the meninges. 
 
 It has not been proved by direct examinations whether, besides 
 haemorrhages, other organic lesions of the brain, such as atrophy from 
 interrupted supply of plasma, result from occlusion of the capillaries. 
 
 I have seen pigment brains of old date without any remarkable 
 diminution of the cortical substance. Other functional derangements, 
 indicative of material changes in the cortical substance of the brain, 
 have only occurred to me in three cases; these cases, however, I 
 only saw in a cursory manner during a journey in Poland.* 
 
 * One of these was a lady in her fortieth year, who, after an attack of 
 quotidian fever, accompanied by somnolence, suffered from protracted 
 loss of memory. The functions of vegetative life resumed their nor- 
 mal condition, and there were no derangements of motion or sensa- 
 tion present. The headache and giddiness gradually diminished after 
 the removal of the intermittent fever by means of quinine ; but the weak- 
 ness of memory and the inability to find suitable words for objects and 
 ideas were still on the increase two months after the cessation of the 
 ague. 
 
 Another case was that of a girl, aged 9, living in the same district, 
 where, according to the evidence of the medical men, intermittent fever, 
 terminating fatally, was at the time very prevalent. This girl, whose 
 mental powers had previously been normal, had undergone several attacks 
 of tertian fever. After a protracted use of preparations of bark, she 
 recovered in her bodily symptoms ; but her mental faculties gave way, 
 and a state of complete idiocy, accompanied by a ravenous appetite, 
 supervened. 
 
 In these two cases, it is uncertain whether atrophy of the brain had 
 
328 THE PIGMENT-LIVER. 
 
 Along with the structural changes of the brain which have just 
 been described, remarkable aberrations of the functions of the organ 
 are usually observed during life. 
 
 These derangements vary in their nature ; sometimes they inter- 
 mit, and cease with each paroxysm of fever, but more frequently 
 they are protracted into the period of the intermission, or are 
 continuous. Even in the last case, however, there are usually 
 unmistakable indications of more or less distinct remissions. 
 
 The nature of the cerebral disturbances manifests itself in very 
 various ways ; in the slighter cases, they assume the form of headache 
 and giddiness; in the more severe, that of delirium, but more 
 usually of coma, and not unfrequently, there are disturbances of 
 mobility, convulsions, or paralysis. The most constant symptom is 
 dull pain in the head extending over the entire vertex, and almost 
 always associated with attacks of giddiness. This pain was observed 
 in every case in which the loss of consciousness had not arrested 
 all power to communicate subjective sensations; occasionally, the 
 pain was so severe as to cause the patients to utter loud cries; 
 The headache was frequently accompanied by derangements of 
 the senses, noises in the ears, deafness, black vision, and dimness 
 of sight, and occasionally by nausea, a tendency to vomit and 
 vomiting. 
 
 Delirium is less frequent; sometimes it is quiet, like that usually met 
 with in typhus ; but at other times it is violent, and associated with 
 great excitement and restlessness, so that it is necessary to fasten the 
 patient in bed. By degrees the excitement passes into somnolence 
 and deep coma, which is the most usual form of cerebral disturbance.' 
 In several cases giddiness, without any headache, has existed for a 
 long period after the removal of the fever, and this has even been of 
 such intensity that the patients have fallen down suddenly while 
 walking, while at the same time, the anaemia has not been so 
 
 resulted from occlusion of the capillaries, or whether it had been induced 
 by the extensive capillary apoplexies consequent upon this occlusion, or 
 whether the intermittent fever was complicated with other accidental 
 changes in the brain. 
 
 It is worthy of notice, that Sydenham (Opera med. Genev., 1736, Tom. I., 
 Sect. 1, Cap. V., p. 60) long ago made mention of. mental derangements; 
 which remained after attacks of intermittent fever, and which, under the 
 employment of depleting treatment, soon passed into a state of imbecility. 
 He was surprised that no one had made mention of an occurrence which 
 he himself had so frequently met with. 
 
COMPLICATIONS. f 329 
 
 great as to account for the occurrence. (Febris vertiginosa Pae- 
 einotti.) 
 
 The slight forms of somnolence from which the patient can be 
 roused by loud calling, so as to give rational answers, in most cases 
 after a short time lapse into deep stupor. This stupor sometimes 
 ceases during the intermission, to return with the next paroxsym. 
 
 Abnormal conditions of mobility, convulsions and paralyses are 
 much less frequent than derangements of the mental faculties. I 
 have met with convulsions in eight cases ; at one time they appeared 
 as slight spasmodic movements of individual muscles of the trunk 
 and extremities, at another time as rapid, rotating, or tossing move- 
 ments of the extremities and head, and, again, as general convul- 
 sions, similar to those of epilepsy, which usually lasted from five to ten 
 minutes, and returned after a shorter or longer interval. Paralysis 
 was only present as an exception. It attacked at one time the 
 muscles concerned in articulation or swallowing, and at another, 
 the extremities ; in the latter case, the paralysis was either double ; 
 or confined to one side. In one case I have seen the paralysis make 
 its appearance suddenly, and here capillary haemorrhage was found ; 
 in another case, however, in which there was simply an accumulation 
 of pigment, the development of the paralysis was gradual. 
 
 That the deposit of pigment in the substance of the brain and the 
 abnormal cerebral symptoms are connected with one another as 
 cause and effect, is a probable supposition, which acquires the more 
 weight from the fact, that in general there is an unmistakable cor- 
 respondence between the intensity of the two. Hence, the earlier 
 observers, and especially Planer, had no hesitation in attributing the 
 cerebral symptoms to the occlusion of the capillaries with pigment. 
 
 I cannot give my unconditional support to this view, however 
 plausible it may at first sight appear, because a close analysis of the 
 observations, and a careful comparison of the anatomical lesions with 
 the symptoms present during life, render the connection between the 
 two, as cause and effect, in many cases, at least, doubtful. Extensive 
 interruptions to the circulation, with capillary apoplexies of the cor- 
 tical substance of the brain, indicating rupture of the vessels and 
 capillary haemorrhage, constitute unquestionably a sufficient anato- 
 mical basis for the explanation of the cerebral symptoms, but obstruc- 
 tion to the circulation of the blood is by no means always present, even 
 when the colour is dark. The greater part of the pigment passes 
 freely through the capillaries, and may be found in. large quantities 
 
330 *. THE PIGMENT-LIVER. 
 
 in the veins. The dark contents of the capillaries are nowhere so dis- 
 tinctly marked as in the white ground of the substance of the brain; 
 hence they always appear more remarkable in this place than in other 
 organs, of which the parenchyma is naturally darker. Even when the 
 circulation of the blood does become arrested here and there, this 
 is not to be regarded as a sufficient cause of functional disturbances, 
 because the numerous branches of the vascular network permit of 
 collateral currents. 
 
 On comparing the post-mortem appearances with the symptoms 
 during life, we find, on the one hand cases where, in spite of the 
 dark colouring of the brain, no cerebral disturbances have been 
 present, and on the other hand, cerebral disturbances without any 
 deposit of pigment. The last statement I have found to hold good 
 six times, out of 28 cases of Intermittens cephalAca. The older 
 observers, such as Lancisi, Senac, Bailly, and also Maillot and 
 Haspel, have made similar observations. We cannot, therefore, 
 doubt, that the cerebral disturbances of intermittent fever above 
 described, may occur without melansemia, and that, consequently, 
 there must be other causes, which can give rise to them. Hitherto, 
 we have been unable to detect these causes. The fact of the morbid 
 symptoms intermitting appears to argue in favour of their being 
 periodically generated in the system, and again disappearing. I 
 have already called attention to the circumstance, that in melanse- 
 mia, the extensive decomposition of the blood pours periodically 
 into the circulation, not merely the debris of the morphological 
 disintegration of this fluid, but also the products of its chemical 
 metamorphosis, which elude microscopic examination. A closer 
 study of these metamorphoses may bring us nearer to the source of 
 the cerebral symptoms. 
 
 The third organ in which we observe abnormal conditions of 
 structure and functions in melansemia, is the kidneys. The larger 
 pigment cells and scales which enter these organs along with the 
 arterial blood, not unfrequently become impacted in the capillary 
 coils of the Malpighian bodies, and by altering the pressure of the 
 blood, give rise to derangements in the secretion of urine, which 
 exercise a powerful influence over the further progress of the disease. 
 Albuminuria makes its appearance to an extent which varies with 
 the quantity of pigment found in the kidneys. In the cases where 
 the fever has presented a distinctly intermittent type, and where, as 
 in quartan fever, the intermissions have been of considerable duration, 
 
COMPLICATIONS. 331 
 
 we have observed during each paroxysm a great increase of the albu- 
 minous contents of the urine, and during the intermissions a marked 
 diminution, or a complete disappearance of them. 
 
 The albuminuria is frequently simple, and then the process may last 
 a long time without leading to intimate structural changes in the 
 kidneys. But in other cases, fibrinous matter passes off in the urine 
 along with the albumen; I have repeatedly observed fibrinous casts, 
 including pigment masses and granules of the same nature as those 
 found in the blood; I have, moreover, met with cases in which 
 bloody urine was excreted. Complete suppression of the urinary 
 secretion is of frequent occurrence. In cases where the secretion of 
 albumen and fibrinous matter has lasted for a long time along with in- 
 termittent fever, or after its cessation, and ultimately has led to a fatal 
 termination from exhaustion, alterations of comparative insignificance 
 have been found in the kidneys. Numerous flat, scarred depressions 
 have been observed on the outer surface of the organ, but no 
 distinct granulations. In some cases there has been lardaceous 
 degeneration. 
 
 With the exception of the liver, the brain, and the kidneys, in no 
 other organ or tissue can any remarkable change of structure, or 
 derangement of function, be observed. It is true that we can detect 
 pigment throughout the entire capillary vascular system, so far as 
 this is filled with blood, but accumulations of this pigment, and 
 occlusion of the capillary vessels, are only wont to take place to any 
 extent where the smallnesss of the capillaries, or the peculiar nature 
 of their distribution, impedes the free motion of the pigment scales. 
 The supposed production of dyspnoea and oedema of the lungs, from 
 -occlusion of the pulmonary capillaries, is not supported by actual 
 results, at least, in the cases which have come under my own 
 observation. I do not believe that the inflammatory swellings which 
 I have observed in isolated cases, such as limited deposits in the 
 parotid and in the muscular tissue of the heart, are the result of 
 extensive occlusion of the vessels. Close examination of the deposits 
 in the muscular tissue of the heart discloses no remarkable accumu- 
 lations of pigment. 
 
 The peculiar colour of the skin which is produced by the quantity 
 of pigment in the blood contained in the vessels of the cutis, is of 
 importance in diagnosis. In the slighter grades of melansemia it 
 is ash-coloured ; in the more intense forms it is dirty greyish-brown, 
 and sometimes deep yellow-brown. In most cases, a few drops of 
 
332 THE PIGMENT-LIVER 
 
 blood, obtained by scarification of the skin, suffices to show numerous 
 particles of pigment, under the microscope. 
 
 v. Pigment- Liver an accompaniment of Malarious Fevers. 
 
 The derangements just described are ushered in and accompanied 
 by a fever, which may assume very various forms and types. 
 
 In most of the cases the fever is an intermittent, and usually 
 a quotidian or double tertian, — more rarely a simple tertian, and 
 least frequently a quartan. The fever does not, as a rule, make its 
 appearance in the regular form with distinctly-marked stages, but the 
 intermission is usually incomplete ; in most cases, the elevation of 
 temperature and the increased frequency of pulse do not disappear 
 completely, although the repeated attacks of rigors with subsequent 
 aggravation of the symptoms indicate the true type of the fever. 
 After two or three incomplete intermissions, followed by a paroxysm, 
 the fever in most cases becomes continued;, patients have been 
 repeatedly brought to the Hospital in this condition as cases of 
 typhus. As a general rule, the intermittent type of fever is less 
 marked, the more prominent are the local, and particularly the 
 cerebral, derangements. 
 
 The pulse varies very greatly in frequency. In the most severe 
 forms it does not usually exceed 80 or 90, which is an important 
 circumstance for distinguishing the affection from typhus ; in a few 
 cases only has the pulse reached 120 or 140. Sometimes the 
 the pulse abates in frequency upon the supervention of nervous 
 symptoms. 
 
 The three stages of the intermittent are seldom very distinctly, 
 marked ; the rigor stage is often entirely absent, and distinct critical 
 discharges by the skin and urine do not usually occur. Twice I 
 have met with paroxysms of unusual duration (48 and 60 hours). 
 The severe symptoms which usually accompany this form of inter- 
 mittent, as a rule, make their appearance along with the fever. 
 Sometimes severe brain symptoms, which speedily prove fatal, are 
 developed after only a few hours of vague indisposition, without any 
 distinct febrile symptoms manifesting themselves. 
 
 In other cases, a simple intermittent fever has existed for weeks 
 or months, when suddenly a severe fit comes on, which often termi- 
 nates fatally in an instant. This last form has occurred frequently 
 in relapses of apparently simple tertian or quartan fever. 
 
IN MALARIOUS FEVERS. 333 
 
 The cases vary in their progress : there are some which prove fatal 
 in a few hours or days, whilst others are protracted over months ; 
 the cases with head-symptoms are almost always acute, the remainder 
 are as frequently chronic. Out of 51 cases which I have observed, 
 there were 24 acute and 27 chronic. 
 
 Such are the most important derangements which are observed in 
 the disease under consideration. They seldom all exist together ; in 
 most cases one or other of them occupies a prominent place, while 
 the remainder are either absent or developed in a milder form. In this 
 way. there arise varieties of disease which exhibit a wide difference 
 in their progress and results. Four forms may be distinguished : — 
 
 i. Cases with predominant brain-symptoms. 
 
 ii. Cases in which the kidneys are pre-eminently implicated. 
 
 in. Cases with predominant derangements of the gastrointes- 
 tinal tract, and of the appertaining glands, but particularly of the 
 liver. 
 
 iv. In a fourth group, we may include those forms in which the 
 local derangements are not very conspicuous, and do not influence 
 essentially the further progress of the disease, but where the aneemia 
 and hydrsemia, resulting from affection of the spleen, constitute the 
 most important morbid conditions. The pigment contained in the 
 blood is here of subordinate importance, inasmuch as its quantity and 
 characters do not give rise to extensive lesions of the capillary cir- 
 culation ; it is productive of no injurious consequences, provided we 
 succeed in checking the ansemia. 
 
 In order to give some idea of the frequency of the individual 
 derangements, and of their fundamental anatomical lesions, I may 
 annex a short analysis of 51 cases observed here in Breslau. The 
 results are, of course, only of value as regards the epidemic of this 
 place, and must by no means be generalized indiscriminately. 
 
 Of the 51 cases, 38 terminated fatally, and 13 in recovery.* 
 Severe brain-symptoms, such as delirium, convulsions, coma, &c. 
 occurred 28 times out of the 51 cases ; in 7 of these cases, there 
 was no deposit of pigment in the brain; in 2 cases there was 
 haemorrhage in the cerebral membranes along with the pigment ■ and 
 there was 1 case of cysticercus cerebri. 
 
 * Of the cases which ran a favourable course, only those are here in- 
 cluded in which pigment could be detected in the blood. These fi<nires 
 do not express the ratio of mortality, because the examination of the 
 blood was often omitted, where no severe symptoms called for it. 
 
334 THE PIGMENT-LIVER. 
 
 Out of the 51 observations, albuminuria was found in 20 cases, 
 in 2 of which there was hBematuria, and in 5, suppression of urine ; 
 albuminuria occurred without any pigment in 4 cases, whereof 2 
 were instances of lardaceous degeneration of the kidneys ; in 5 cases 
 pigment could be detected where there had been no albumen in the 
 urine, but the quantity was scanty. 
 
 In 17 of the 51 observations, there was profuse diarrhoea, and 
 5 of these were cases of dysentery ; profuse intestinal haemorrhage 
 was seen three times. Jaundice was present in 11 cases, but was 
 always slight ; bile-pigment also was observed in the serous effusions 
 of the pleural cavities, without any distinct colouring of the skin 
 and urine. 
 
 Iu all the cases which terminated fatally, the liver contained a 
 quantity of pigment; in 10 it appeared enlarged and congested, 
 and in 8 atrophied; in 9 cases the cells contained much oil; lar- 
 daceous matter could be detected in 3 cases, but only in small 
 quantity. 
 
 Except in one case, pigment was always found in the spleen; three 
 times this organ was lardaceous; and in 30 cases its volume ex- 
 ceeded the usual limits. 
 
 In a treatise upon affections of the liver, the cases which come 
 under the first and second groups of melansemia require only a pass- 
 ing consideration. I annex a few examples, in order to show 
 that the liver is involved at the same time as other parts ; and those 
 cases only will be given in detail where the disease of the liver, and 
 the disturbances resulting therefrom, were conspicuous. 
 
 I. CASES WITH CEREBRAL DISTURBANCE. 
 
 Observation No. XXXII. 
 
 Tertian Intermittent Fever of three months' duration, ultimately with 
 Coma during the fit. — Pneumonia, passing on to Consolidation. — 
 Sudden Death. 
 
 Pigment-Spleen and-Liver. — Consolidation of the Lungs. — The Brain 
 free from, Pigment. 
 
 W. Klein, aged 65, locksmith, was admitted in an unconscious 
 condition on the 7th of January, 1855. He had been suffering for 
 
ILLUSTRATIVE CASES. 335 
 
 three months from tertian fever, which latterly had taken on an 
 irregular type, and, during the fits, was attended by loss of conscious- 
 ness. On the 8th, he regained the use of his mental faculties. On 
 examination, the spleen was found to be considerably enlarged; on 
 fne left side of the thorax there was dulness and bronchial breath- 
 ing, extending from the middle of the scapula as far as the base ; 
 there was no expectoration. Pulse 96. The patient stated that 
 during a frost, eight days before, he had felt a shooting-pain in the 
 left side, and had expectorated saffron-coloured sputa. 
 
 The next attack of fever was cut short by bark, in combination 
 with sal-ammoniac. 
 
 The bronchial breathing and dulness continued unchanged, and 
 were accompanied by a slight expectoration of grey mucus. The 
 pulse varied in frequency between 80 and 90; the appetite was 
 normal, the bowels regular, and the sleep quiet ; neither albuminuria 
 nor oedema was present. There was considerable anaemia. 
 
 He was ordered the ammoniated sesquichloride of iron. 
 
 On the morning of the 21st, the patient ate his breakfast ; and 
 while sitting upon a stool, in order to have his bed made, he became 
 unconscious, and died. 
 
 Autopsy, 24 hours after death. 
 
 Neither the membranes nor the substance of the brain contained 
 much blood ; there was nothing abnormal either in the colour or the 
 consistence of the brain. No pigment was found in the capillaries 
 of the cortical substance. 
 
 The mucous membrane of the bronchi was pale ; the right lung 
 was dry, bloodless, and emphysematous; the left was very firmly 
 adherent to the costal wall ; it was diminished in size ; its tissue was 
 firm, and not friable ; its cut surface was very slightly granular, and 
 of a uniform pale-brown colour ; the bronchia] tubes were somewhat 
 enlarged, and their lining membrane reddened; the upper lobe con- 
 tained but little blood. 
 
 The heart contained loosely-coagulated dark blood. 
 
 The mucous membrane of the stomach and intestinal canal was 
 pale. 
 
 The spleen was enlarged by about one-third, and slightly wrinkled • 
 its parenchyma was flabby, tenacious (zahe), and of a bluish-black 
 colour. 
 
336 THE PIGMENT-LIVER, 
 
 The liver was of normal size, its colour was blackish-brown. Its 
 consistence was normal. 
 
 The bile was thick and yellow. 
 
 The cortical portion of the kidneys was atrophied. 
 
 The bladder and prostate were normal. 
 
 Observation No. XXXIII. 
 
 Febrile Gastric Catarrh. — Vertigo. — Convulsions — Coma. — Return 
 of Consciousness. — Parotid Swelling. — Albuminuria. — Death from, 
 Exhaustion. 
 
 Melanamia. — Accumulation of Pigment in the Spleen, Liver, the 
 Grey Matter of the Brain, and the Kidneys. 
 
 Eosine Hornig, the wife of a day-labourer, aged 61, came to the 
 Hospital on the 22nd of August, 1854, after having suffered for four 
 days from loss of appetite, headache, and giddiness. On examina- 
 tion, there was found to be consolidation of the apices of both 
 lungs ; the tongue was coated grey ; there was slight distention of 
 the epigastrium, and moderate enlargement of the spleen. The 
 pulse varied between 80 and 90 ; there had been no rigors. 
 
 On the 24th, the patient became restless, complained of severe 
 headache, and was, when in this state, suddenly seized with general 
 convulsions, which, with short intervals, continued for about two 
 hours, and was followed by complete loss of consciousness. On the 
 £5th, the consciousness had not returned. Pulse 84. The urine 
 drawn off with the catheter, contained a considerable quantity of 
 albumen, but no fibrinous coagula ; involuntary stools ; great rest- 
 lessness ; much sighing and groaning, so that it became necessary 
 ia remove the patient to a separate ward. 
 
 Here, as we were told, she was tolerably quiet ; her con- 
 sciousness gradually returned, but her memory continued bad, 
 and she only gave slow and unsatisfactory answers. A few 
 days after, an inflammatory exudation made its appearance at 
 the angle of the lower jaw, in the areolar tissue surrounding the 
 parotid. By poulticing, this became soft, burst and discharged a 
 large quantity of putrid pus. The patient then became more and 
 
ILLUSTRATIVE CASES. 337 
 
 more collapsed, and died from exhaustion, without any return of the 
 convulsions, or loss of consciousness. 
 
 Autopsy, Sept. 11th, 20 hours after death. 
 
 The bones of the cranium and the membranes of- the brain were 
 congested ; the cortical portion of the brain appeared of a choco- 
 late colour, and formed a marked contrast to the white substance ; 
 this last was of proper consistence and contained the normal amount 
 of blood. The microscope showed that there was a large quantity 
 of pigment included in the capillary vessels. 
 
 Grey tubercular matter was infiltrated through the apices of both 
 lungs; lower down, their parenchyma was moderately congested, 
 but free from deposit. 
 
 The blood in the heart was coagulated, and of a dark colour. 
 Numerous pigment cells and scales could be detected in it. 
 
 The spleen was enlarged by one-half, and was pulpy, soft, and of 
 a dirty greyish-brown colour ; numerous brown and black pigment 
 cells and granules, like those in the blood, were found in this organ. 
 
 The liver had sharp margins and a smooth surface; its parens 
 chyma was of normal consistence and of a greyish-brown colour; 
 some of its secreting cells contained much oil. The bile was pale 
 and contained no albumen. In the stomach there was the cicatrix 
 of a deep ulcer ; its mucous membrane was pale ; as was also the 
 mucous membrane of the small and large intestines. 
 
 The kidneys were apparently normal ; but, on closer examination, 
 a tolerably large quantity of pigment was found in the glomeruli, and 
 uriniferous tubes. 
 
 Obseetation No. XXXIY. 
 
 Quotidian Fever. — Enlargement of the Spleen. — Coma. — Death. — 
 Melanamia. — Accumulation of Pigment in the Spleen, Liver, 
 Kidneys, and cortical portion of the Brain. 
 
 Elizabeth Ermler, a tailor's widow, aged 45, came to the Hospital 
 on the 13th September, 1854. For a week before, she had had daily 
 attacks of fever; but previous to this, she had enjoyed perfect 
 health. Her statements, however, seemed scarcely deserving of. 
 credit, owing to loss of memory and deafness, which had lasted 
 
338 THE PIGMENT-LIVER. 
 
 for eight days. She could not say whether the fever had been 
 ushered in by a rigor-stage. The respiratory and circulating organs 
 were normal ; the pulse was 90, small, and soft ; tongue dry ; abdo- 
 men soft and flat; no diarrhoea. The spleen extended about an 
 inch beyond the false ribs; no roseolar eruption. The colour of 
 the skin was pale greyish-yellow, but this tinge was not very 
 striking ; the temperature was elevated. 
 
 She was ordered muriatic acid with bark. 
 
 The state of unconsciousness rapidly increased into complete 
 coma. The countenance became pale, and the pupils small. The 
 temperature continued high; and the pulse varied from 90 to 100. 
 The urine, which came away involuntarily, was not examined. Death 
 took place on Sept. 18. 
 
 Autopsy, 20 hours after death. 
 
 The membranes of the brain were tolerably congested, and the 
 sinuses contained small colourless coagula. The cortical substance 
 of the brain was of a leaden hue, and there was a considerable 
 quantity of pigment granules and scales in its capillaries ; the white 
 substance of the brain was of normal consistence. A small quantity 
 of serum was contained in the sac of the arachnoid. 
 
 The mucous membrane of the air-passages was pale; dark obso- 
 lete tissue was found at the apices of both lungs, accompanied on the 
 right side by enlargements of some of the bronchi, which contained 
 a calcareous pulp ; posteriorly and inferiorly, there was oedema. 
 
 The heart contained a small quantity of loosely coagulated blood, 
 in which numerous pigment particles could be detected. 
 
 The spleen was enlarged by about one-third ; it was flabby, and 
 its surface was wrinkled; its tissue was soft and of a greyish- 
 brown colour. 
 
 There was a tight-lace mark upon both lobes of the liver; the 
 surface of the organ was smooth, its parenchyma friable and choco- 
 late-coloured ; from the lower surface of the left lobe there projected 
 the sac of an echinococcus undergoing disintegration. The hepatic 
 cells were loaded with brown pigment, and contained but little oil. 
 
 The mucous membrane of the stomach was tumid, and of a livid 
 hue ; in the small and large intestine it presented, at some places, a 
 slaty-grey colour. 
 
 The kidneys were apparently normal, and the glomeruli loaded 
 
ILLUSTRATIVE CASES. 339 
 
 with pigment. A small quantity of slightly albuminous urine was 
 found in the urinary bladder. The genital organs presented nothing 
 abnormal. 
 
 Observation No. XXXV. 
 
 Fever of an undecided type. — Delirium. — Coma. — Vomiting. — Death 
 on the fifteenth day. — No albuminuria. 
 
 Pigment in the Blood, the Cortical portion of the Brain, the Liver, 
 Kidneys and Spleen. — Spleen slightly enlarged. 
 
 Bertha Meissner, aged 38, sempstress, was admitted in an un- 
 conscious condition on September 11th, 1854. She had been ill 
 for fourteen days; and after suffering from delirium and great 
 restlessness, she had since the beginning of the last week com- 
 pletely lost her consciousness. The patient was of a pale, dirty- 
 yellow colour; her head and extremities were cool; her eyes were 
 coated over with mucus ; the pupils were of medium size, and acted 
 somewhat slowly. The pulse was 84 and small ; no enlargement of 
 the spleen could be made out. The abdomen was tender; thin, 
 deep-brown stools were passed involuntarily. The urine was free 
 from albumen. 
 
 Notwithstanding the employment of stimulants, the patient be- 
 came very rapidly collapsed; and 14 hours after her admission she 
 was a corpse. I did not observe any attack of rigors, nor were 
 any noticed by the relatives. 
 
 Autopsy, 15 hours after death. 
 
 The inner surface of the skullcap was covered by a thin layer of 
 bony growths ; the dura mater was at some places firmly adherent ; 
 the pia mater was anaemic ; there was a small quantity of clear serum 
 effused beneath the arachnoid. The cortical substance of the brain 
 was of a dark ash-grey colour ; its capillaries were filled with pigment 
 granules. The white substance of the brain was anaemic and of 
 normal consistence ; the lateral ventricles were of the usual size. 
 
 The air-passages and the lungs presented little that was abnormal; 
 the posterior and inferior portions of the lungs were hypostatic and 
 oedematous ; the deposit of pigment in them was considerable. 
 
 z2 
 
340 THE PIGMENT-LIVER. 
 
 The heart, as well as the large vessels, was normal. The blood, 
 both in the right and left ventricles, was rich in pigment. 
 
 The stomach had a somewhat thickened, slaty-grey mucous 
 membrane, presenting a few ecchymoses upon the prominent folds. 
 The mesenteric glands and the intestinal canal were healthy. 
 
 The spleen was slightly enlarged; it lay very far back; its paren- 
 chyma was very soft, and dirty greyish-brown; brown and black 
 pigment in the form of scales and cells could be detected in it in 
 abundance. 
 
 The liver was of normal size; its surface was smooth and its 
 edges sharp ; its parenchyma was soft and of a dirty greyish-brown 
 colour ; the secreting cells appeared pale ; the capillaries were filled 
 with pigment. The gall-bladder contained a quantity of thin, 
 mucous, pale bile. 
 
 The surface of the kidneys was smooth; their parenchyma was 
 shrivelled and anaemic; the glomeruli contained pigment scales. 
 The urinary bladder was quite empty. 
 
 The uterus was that of a virgin ; and there were small corpora 
 lutea in both ovaries. 
 
 Obseevation No. XXXVI. 
 
 Intermittent Fever with Convulsions and loss of Consciousness. — Type 
 irregular. — No rigor stage. — Recovery by treatment with lark. 
 
 Carl Grand, aged 28, was admitted on the 27th of October, 1854. 
 His illness commenced fourteen days before, and was characterised 
 by persistent headache, accompanied by noises in the ears, nausea, 
 and great weakness and delirium; there was no evidence, however, 
 of jrigor, or of any of the other symptoms of intermittent fever. On 
 the 27th of October, soon after admission, the patient was seized 
 with an attack of convulsions, accompanied by loss of consciousness, 
 which lasted about half-an-hour and returned once more during the 
 night. On the morning of the 28th, a considerable enlargement of 
 the spleen was detected; pulse 78; great headache, but conscious- 
 ness clear ; the skin secreting actively ; the urine throwing down a 
 slight deposit, but containing no albumen ; stools normal. 
 
 The increased frequency of the pulse and elevation of the tem- 
 perature appeared 'at irregular intervals, at one time daily, and at 
 another time every second day, and were accompanied by giddiness 
 
ILLUSTRATIVE CASES. 341 
 
 and severe headaches, passing into delirium; these symptoms gradu- 
 ally subsided with sweating. They were never ushered in by a 
 rigor. During the intermissions, the patient's condition was but 
 little deranged. On the 8th of November, he was ordered 3 grains of 
 quinine every two hours; under the use of this, the headache, giddi- 
 ness, and excitement of the vascular system ceased ; but on the 16th 
 they returned in a severe and regular tertian form, though still 
 without any rigor stage. Bark was administered for a long time ; 
 and under its use the symptoms gradually disappeared. 
 
 These attacks left the patient in a very low state, and he required 
 a regulated chalybeate treatment, before he could be dismissed from 
 the Hospital cured, and free from any enlargement of the spleen. 
 
 Observation No. XXXVII. 
 
 Intermittent Fever of an, irregular type. — Two paroxysms of 48 
 hours' duration. — Furious Delirium (hiring the paroxysms. — 
 Cure. 
 
 Heinr. K. Gurtler, aged 39, a year before had suffered from 
 intermittent fever for several weeks, and at the end of July was 
 seized with violent pains in the region of the spleen, accompanied 
 by moderate enlargement of the organ. Along with this there was 
 bronchial catarrh, without any fever. He was treated at the Poly- 
 clinique with muriate of ammonia, and afterwards with senega. 
 
 At noon on June 29th, a moderately severe rigor came on, last- 
 ing about an hour, and followed by heat of skin, violent headache 
 and furious delirium. Towards evening, the patient became com- 
 pletely unconscious ; pulse 130 ; the skin dropping with perspira- 
 tion. Not until noon of July 1st, did the sweating and frequency 
 of pulse abate, and the consciousness return. In the evening, the 
 patient was free from fever. 
 
 He was ordered three grains of sulphate of quinine every two 
 hours. 
 
 On the afternoon of the 5th, the temperature became elevated ; 
 pulse 92 and bisferiem; tongue dry; severe headache. This condi- 
 tion lasted until the 7th, when profuse sweating and sudamina 
 made their appearance, the pulse falling to 70. 
 
 By the continued use of quinine the patient rapidly recovered, and 
 on the 16th was able to leave the Hospital. 
 
342 THE PIGMENT-LIVER. 
 
 Observation No. XXXVIII. 
 
 Quotidian Intermittent with severe Vertigo. — Febris vertiginosa of 
 Paccinotti. — Cure by Quinine. 
 
 Carl Forster, aged 30, since the middle of September, had suffered 
 from a quotidian intermittent, associated with severe vertigo. The 
 patient could scarcely advance two steps without staggering; on 
 attempting to walk across the room, he fell repeatedly, and was 
 obliged to be led. The colour of his skin was greyish-brown, like 
 that of a mulatto ; the spleen was enlarged ; there was no albumen in. 
 the urine. The pulse became more frequent; neither headache, 
 rigors, nor any of the other symptoms of fever were present; the 
 appetite was unimpaired, and the stools normal. 
 
 The patient having been treated before admission into Hospital, 
 by cupping and purgatives, without any benefit, recourse was now had 
 to quinine, whereupon the giddiness rapidly diminished, and ere 
 long entirely ceased. 
 
 In a few days, the patient was able to be discharged from the 
 Hospital, there being no anaemia to necessitate a longer treatment. 
 
 II. CASES WITH PREDOMINANT AFFECTION OE THE KIDNEYS. 
 
 Observation No. XXXIX. 
 
 Quotidian Intermittent of four weeks' duration ; Diarrhoea; Albu- 
 minuria and Hematuria j Sudden Stupor ; Convulsions ; Death. 
 
 Accumulation of Pigment in the Spleen, Liver, Kidneys, and Brain. 
 
 C. Bunschke, aged 50, came to the Clinique on the 3rd August, 
 1854.. For four weeks he had suffered from a quotidian fever, which 
 had latterly become complicated with diarrhoea. His complexion 
 was of an extremely pale greyish-yellow hue ; there was no oedema, 
 however, anywhere. The spleen extended an inch beyond the margin 
 of the false ribs ; the abdomen was soft and painless, and there was 
 no ascites ; the liver was of normal size ; there was nothing abnor- 
 mal in the respiratory organs or in the heart. 
 
 The urine was deep reddish-brown, and coagulated upon boiling, 
 
ILLUSTRATIVE CASES. 343 
 
 or on the addition of nitric acid. The pulse was 80.; and there 
 was much complaint of headache. 
 
 Was ordered quinine with opium. 
 
 On the 4th of August, the patient stated that he had an attack 
 of rigors during the night; but the nurse had not observed it. 
 The pulse was unchanged, 80, small and weak. The headache was 
 considerably increased. One formed stool. 
 
 Ordered quinine with elix. acid. Hall.* 
 
 In the night, sudden restlessness and loud groaning. Professor 
 Eiihle, who was summoned to the patient, found him in a state of 
 deep coma, with irregular, interrupted respirations, and a small fre- 
 quent pulse ; the pupils were not enlarged ; the temperature of the 
 head was increased. 
 
 At 7 in the morning, he expired ; death being preceded by slight 
 convulsions. 
 
 Autopsy, 14 hours after death. 
 
 Thepia mater congested; the dura mater thickened and adherent 
 to the inner surface of the skullcap. 
 
 After removing the meninges, the grey substance of the brain ap- 
 peared of a dark chocolate colour, and was defined by a sharp line 
 from the central white matter. This copious deposit of pigment 
 was very marked in the corpus striatum and cerebellum, and also in 
 the pons Varolii. The white substance was intersected by fine 
 blackish lines ; besides this, the brain presented nothing abnormal 
 in consistence, or in any other respect. 
 
 The air-passages pale; the lungs congested and cedematous. 
 
 In the heart there was a moderate quantity of loosely coagulated 
 dark blood, with much pigment in various forms. 
 
 Spleen large, soft, and darkly speckled. 
 
 The liver normal in size; surface smooth; margins sharp; its 
 parenchyma loaded with greyish-brown pigment ; the bile pale and 
 copious. 
 
 The mucous membrane of the stomach was of a slaty-grey colour ; 
 the Uhing membrane of the intestine was perfectly normal. The 
 pancreas contained a larger quantity of pigment than is usual in 
 
 * Elixir acidum Halleri, or Mistura acida sulphurica, is composed of con- 
 centrated sulphuric acid (1 part), and rectified spirit of wine (3 parts). Its 
 specific gravity varies from 1005 to 1010. Dose 5 to 20 minims^TRANSt. 
 
344 THE PIGMENT-LIVER. 
 
 such cases. The kidneys were lobulated, and, on section, presented 
 a homogeneous, brown, glistening surface. There were numerous 
 pigment cells and scales in the glomeruli of the Malpighian capsules. 
 The bladder contained a large quantity of bloody urine, and its 
 walls were hypertrophied. There was a slight stricture of the urethra 
 in front of the bulb. 
 
 Obsbevation No. XL. 
 
 Continued Fever, with symptoms like those of Typhus. — Coma. — Albu- 
 minous and bloody urine containing clots loaded with black pigment. 
 — Right Pneumonia. — Abortion. — Death on the sixteenth day. 
 
 Spleen and Liver soft and loaded with pigment. — Occlusion of the 
 tubuli uriniferi by pigment. 
 
 Eosalie Hellmann, aged 28, was admitted on August 25th, 1854, 
 after having been treated for fourteen days, by a physician out- 
 side the Hospital, for a disease which was considered to be typhus. 
 The woman was perfectly unconscious; her yellowish-grey skin 
 was covered with perspiration ; pulse 120, small and weak; respira- 
 tion frequent, irregular, and stertorous. The thorax was of normal 
 resonance in front, at some places slightly tympanitic; there was 
 dulness at the lower and back part of the right side. Here bronchial 
 breathing was audible ; loud rales were to be heard in front ; heart's 
 sounds normal. The patient was in the eighth month of pregnancy. 
 
 At 10 in the evening, labour-pains came on, and about 2 in the 
 morning a living child was born. The patient's general state did 
 not improve. The dyspnoea and frequency of the pulse increased; 
 the pulse rose to 136. The skin was warm and trickling with 
 perspiration. The urine drawn off by catheter was bloody, and con- 
 tained a quantity of albumen and fibrinous coagula. Death took 
 place at 1 p.m. 
 
 Autopsy, 16 hours after death. 
 
 The membranes and substance of the brain were somewhat con- 
 gested; the consistence and colour of the latter were normal. The 
 mucous membrane of the air-passages was injected and covered with 
 frothy mucus. The upper lobes of both lungs were congested and 
 
ILLUSTRATIVE CASES. 345 
 
 (Edematous ; the lower portion of the right lung contained no air, 
 was friable and greyish-yellow, and exuded a purulent fluid upon 
 pressure. The margin of the lower lobe of the left lung was col- 
 lapsed. The heart was flabby and shrivelled; its valves were normal; 
 the blood in the auricles was loosely coagulated, and contained much 
 pigment. 
 
 The spleen was considerably enlarged, pultaceous and chocolate- 
 coloured. The blood of the splenic vein contained much pigment. 
 
 The liver was dark-brown, without any distinct indication of 
 lobules ; its cut surface was smooth, its margins sharp, and its con- 
 sistence friable. The cells of the organ were very pale; the bile 
 was dark, thick, and viscid. 
 
 The mucous membrane of the stomach was relaxed and injected, 
 and covered here and there with ecchymoses. The mesenteric glands 
 were small, and contained no deposit; the mucous membrane of 
 the small intestine was pale, without any abnormal development of 
 its glandular apparatus ; the large intestine was intensely injected. 
 
 The kidneys were of normal size ; their outer surface was smooth, 
 and they contained a moderate amount of blood. The glomeruli 
 of the Malpighian capsules contained numerous brown and black 
 pigment scales. 
 
 In the urinary bladder was a small quantity of bloody urine, 
 containing small, pale, cylindrical clots infiltrated with pigment 
 
 Obseevation No. XLI. 
 
 Quartan Intermittent Fever. — Intermittent Albuminuria. — Anasarca. 
 — Dysentery. — Rapid cure by means of Quinine and Iron. 
 
 Heuriette Schadek, aged 27, wife of a day-labourer, six months' 
 gone with child, came to the Hospital on the 8th of November, 
 suffering from a quartan fever of six weeks' duration. There was 
 much oedema of the upper and lower extremities, and also of the face ; 
 the urine was scanty and contained a quantity of albumen, and a 
 number of fibrinous coagula, in some of which black pigment was 
 observed. The spleen extended 4 centimetres (1| inch) beyond the 
 margin of the false ribs. The thoracic viscera were normal. It was 
 stated, that the anasarca had made its appearance soon after the 
 commencement of the fever. 
 
 The quantity of albumen contained in the urine diminished 
 
346 THE PIGMENT-LIVER. 
 
 considerably on the 9th; and on the 10th it almost completely 
 disappeared. 
 
 On the 11th a severe paroxysm set in, whereupon the albumi- 
 nuria returned with renewed severity. 
 
 On the 13th there were frequent mucous stools mixed with blood, 
 and accompanied by tenesmus. The fever was cut short by quinine; 
 enemata of tannine and opium were administered to counteract the 
 dysentery. 
 
 On the 18th the dysentery ceased, and the albuminuria disappeared. 
 
 On the 19th recourse was had to the lactate of iron; the quantity 
 of urine became remarkably increased, and the oedema disappeared ; 
 so that on the 8th of December the patient was able to be discharged 
 from the Hospital cured. 
 
 III. CASES WITH PREDOMINANT IMPLICATION OP THE LIVER AND 
 GASTBO-INTESTINAL CANAL. 
 
 The implication of the liver is distinguished in many cases by a 
 tenderness upon pressure over the right hypochondrium, as well as by 
 an increase in the volume of the gland. These signs, however, may 
 be absent even when the terminal ramifications of the portal vein are 
 filled with pigment. "We frequently observe a slight jaundiced tint of 
 the skin and conjunctiva, together with brown bile, or allied colouring- 
 matters in the urine ; but these symptoms are not constant. 
 
 When the passage of the blood of the portal vein .through the 
 liver is interrupted td a great extent, we soon perceive the conse- 
 quences of obstructive congestion upon the gastro-intestinal mucous 
 membrane and the peritoneum ; haemorrhages take place, or increased 
 secretion from the bowels, profuse diarrhoea, and sometimes also 
 acute ascites supervene. 
 
 Intestinal haemorrhages I have observed on three occasions ; the 
 bleedings were intermittent and came on each time with the paroxysm 
 of the fever; they were not affected by any treatment directed 
 against the haemorrhage, but yielded to large doses of quinine. 
 
 The first case of this nature which I met with, terminated fatally; 
 because, from the continued character of the fever, the disease was 
 supposed to be typhus. The case was that of a young man, aged 
 20, in whom severe intestinal haemorrhage took place after he had 
 been suffering for fourteen days from what his medical attendants 
 called a slight attack of typhus. The patient, when I saw him, 
 
ILLUSTRATIVE CASES. 347 
 
 had passed several pounds of dark blood, and was much ex- 
 hausted. His skin was greyish-yellow ; pulse 110, scarcely 
 perceptible. There were, first, three attacks of haemorrhage, each 
 relapse being preceded by an interval of two days ; the attacks took 
 place amidst great excitement of the vascular system, and were 
 apparently arrested by styptics, such as alum, and the muriate of 
 iron. The fourth attack, which also came on after an interval of two 
 days, proved fatal. 
 
 Soon after this, I saw another patient at the same place, in whose 
 case, likewise, the diagnosis of mild typhus had been made, from the 
 fact that, after four attacks of a quotidian fever, the intermission 
 had become indistinct ; in this case also there was profuse intestinal 
 haemorrhage, which was subject to daily exacerbations, coming on 
 always about the same hour. Styptics were tried in vain. Under 
 the use of quinine, with elix. acid. Hall.,* the haemorrhage ceased, 
 and the patient became convalescent. ■ 
 
 In a third patient with quartan fever, the intestinal haemorrhage 
 came on every three days, and was accompanied each time by 
 haematuria; here, also, quinine sufficed to effect its removal. 
 
 Many cases of a similar nature occurred about the same time ; I 
 only mention those which I was able to observe most carefully. 
 I have frequently found, upon post-mortem examination, dark 
 suffusions upon the serous covering of the bowels and in the 
 mesentery, resulting from the obstructions to the circulation. It 
 could not be ascertained whether or not these cases were accom- 
 panied by intestinal haemorrhage during life. 
 
 In other cases, where the obstruction to the circulation in the 
 portal vein appeared to be less intense, there were profuse secretions 
 from the intestinal mucous membrane, and rapid effusions of 
 serum into the abdominal cavity. Diarrhoea occurred chiefly in 
 individuals who were employed in the waterworks during the inun- 
 dation of 1854; not unfrequently it passed into dysentery. I am, 
 however, unable to state whether in these cases the interruption to 
 the portal circulation was the only cause, or whether there were any 
 additional causes in operation. Spontaneous catarrh of the bowels, 
 unaccompanied by intermittent fever, was at the time rarely met with. 
 
 In cases where the effects of the accumulation of pigment in the 
 portal vein were less marked during the persistence of the inter- 
 mittent fever, more remote consequences might be observed at a 
 * See note, p. 343. 
 
348 THE PIGMENT-LIVER. 
 
 later period. After the obliteration of a portion of the capillaries, 
 the cells of the parenchyma in their neighbourhood disappeared, 
 and there arose a chronic atrophy of the liver, such as has been de- 
 scribed in Chap. "VI., Observations XXIV. and XXY., pp. 258-9* 
 
 Obseevation No. XLIL 
 
 Persistent and oft-recurring Intermittent Fever, ultimately of a 
 quartan type; Albuminuria of a high grade; fibrinous casts, with 
 pigment in urine. — (Edema. — Rapidly '-supervening ascites. — Tap- 
 ping after the inefficacious employment of steel and purgatives. — 
 Return of the Fever. — Paroxysm of two days' duration. — Death 
 from exhaustion. 
 
 Pigment in the Spleen. — Occlusion of the hepatic capillaries. — 
 Atrophy of the Liver. — Accumulation of Pigment in the Kidneys. 
 — Consecutive Pneumonia. 
 
 Doroth. Schirmer, aged 38, a labourer's wife, was in the clinical 
 ward from the 17th May to the 31st July. She had suffered re- 
 peatedly from intermittent fever of various types, and, during the 
 last winter, from an almost uninterrupted quartan fever. At the 
 time of her admission, the form of the fever was double quartan. 
 ]?or fourteen days, the patient had observed oedema of the feet, and 
 a remarkable diminution in the secretion of urine ; the urine was 
 turbid, greyish-yellow, and contained an enormous number of 
 fibrinous casts, which were partly covered by black pigment granules 
 and cells. By boiling, the urine was converted into a solid coagu- 
 lum. The region of the kidneys was tender upon pressure. The 
 spleen extended about 4 centimetres (If inch) beyond the margin of 
 the false ribs. The blood drawn off by means of a cupping-glass 
 (care being taken to avoid the admixture of any foreign matter), 
 contained brownish and black pigment masses, in the form of scales 
 (Schollen) and cells. 
 
 After taking a drachm of quinine, the attacks of fever ceased. 
 The characters of the urine, however, did not alter, and it continued 
 scanty; there was repeated vomiting of greenish mucous fluid, 
 
 * Haspel (Mdlai. de VAlgirie, T. I., p. 335) appears to have previously 
 observed a case of this nature in an individual who had suffered from 
 obstinate diarrhoea, with ascites, after an attack of tertian fever, and whom 
 it had been necessary to tap repeatedly ; he found the liver small, not 
 easily lacerable, and blackish internally. 
 
ILLUSTRATIVE CASES. 349 
 
 without any headache or darkening of the countenance. Was 
 ordered lemon-juice. The quantity of urine diminished somewhat, 
 the vomiting ceased, and the appetite improved. Was ordered lactate 
 of iron. The cedema of the feet diminished; but ascites became 
 rapidly developed to such a degree as to interfere with respiration. 
 Colocynth, gamboge, and similar purgatives were of little avail against 
 the dropsy; the energetic employment of these remedies only gave 
 rise to derangements of digestion, vomiting, &c, so that it did not 
 appear advisable ]p persist in them. 
 
 On the 10th of July, twelve pounds of clear serum were drawn off 
 by tapping. The volume of the liver, which could now be deter- 
 mined with greater accuracy, was slightly diminished. 
 
 On the afternoon of July 12th, there was an attack of fever, — 
 rigors, heat, and sweating; the fever did not return on the 13th. 
 
 On the night of the 14th, after the usual interval, notwith- 
 standing the employment of quinine, the paroxysm again made its 
 appearance; the pulse continued very frequent, rose to 140, and 
 was scarcely perceptible, without our being able to detect any 
 cerebral disturbance, dyspnoea, or physical changes in the heart 
 or pericardium. The pulse continued frequent from the evening 
 of the 14th to the morning of the 17th, when it suddenly sank 
 to 88. No fresh attack of fever took place; the pulse remained 
 to the last varying between 80 and 90 ; but the ascites rapidly in- 
 creased, and the oedema of the feet spread to a remarkable extent. 
 The patient became rapidly prostrated ; and, after a protracted agony, 
 death took place on the 31st, without any cerebral symptoms. 
 
 Autopsy, August 1st, 12 hours after death. 
 
 No remarkable alteration was observed in the skullcap, meninges, 
 or substance of the brain, either in their amount of blood, colour, or 
 consistence. The mucous membrane of the air-passages was pale ; 
 the left lung was oedematous superiorly; inferiorly, it was infil- 
 trated, but only to a slight extent, with soft exudation; the 
 pleura, at this place, was covered with a thin layer of grey flaky 
 exudation. The right lung was hypostatic posteriorly, and emphy- 
 sematous along its anterior margin. The pericardium contained 
 about three ounces of clear serum; the muscular tissue and valvular 
 apparatus of the heart were normal. The blood in the right auricle 
 was firmly coagulated. 
 
350 THE PIGMENT-LIVER. 
 
 The oesophagus was pale. The mucous membrane of the stomach 
 was ecchymosed at some places, and, around the pylorus, was of a 
 slaty-grey hue. The lining-membrane of the bowel was pale 
 superiorly, and, in the large intestine, was cedematous, and at some 
 places the larger vessels were injected. The faeces were yellow. 
 The pancreas and mesenteric glands were normal. 
 
 The spleen was not enlarged, but flabby and shrivelled ; its cap- 
 sule was thickened; and its parenchyma was tenacious (zahe), and 
 of a bluish-grey colour. „ r 
 
 The left lobe of the liver had a broad atrophied rim ; white traces 
 of obliterated vessels could be seen in its serous covering. The 
 parenchyma had a smooth surface on section, was somewhat friable, 
 and of a greyish-brown colour. The entire volume of the organ was 
 diminished. The gall-bladder was found to be adherent to the 
 stomach and colon, and was greatly distended with a green, mucous, 
 somewhat albuminous bile. 
 
 On microscopic examination, the usual forms of black pigment 
 could be detected in the spleen, in the blood of the portal vein, and 
 in the capillaries of the liver. 
 
 The kidneys were of normal size ; their surface was smooth ; their 
 capsule firmly adherent ; and their cortical substance greyish-yellow, 
 soft, and friable. The microscope showed the existence of pigment 
 in the glomeruli, as also in the vessels of the cortical substance, and 
 occasionally, also, in the interior of the uriniferous tubes. 
 
 The mucous membrane of the bladder was ecchymosed; the urine 
 was scanty and albuminous. 
 
 The genital organs were not altered to any great extent ; there 
 was a cyst the size of a hazel-nut in the right ovary. 
 
 Obsebvation No. XLIII. 
 
 Intermittent Fever of a Tertian and Quotidian Type, lasting for seven 
 weeks. — Intestinal Catarrh. — Hydremia. — Anasarca. — Improve- 
 ment under preparations of steel. — Relapse. — Rapid increase of 
 the Dropsy. — Unconsciousness. — Death. 
 
 Pigment in the Spleen and Liver, without any implication of the 
 Brain or Kidneys. 
 
 , Franz Rrocker, aged 45, a worker on the roads, came to the 
 Hospital on the 1st of November, 1854. Tor seven weeks, he had 
 
ILLUSTRATIVE CASES. 351 
 
 suffered from an intermittent fever, at one time of a tertian, and at 
 another, of a quotidian type; and, four weeks before, anasarca had 
 made its appearance. The spleen was found to be considerably 
 enlarged, extending about three inches beyond the margin of the 
 false ribs; the heart and lungs were normal; there was no albumen 
 in the urine ; the bowels were relaxed and the motions thin. 
 
 After the arrest of the fever by means of quinine, the patient's 
 condition improved ; under the use of nutritious diet, wine, and the 
 preparations of iron, the anasarca receded and the diarrhoea abated 
 until the 8th of November, when the temperature became elevated, 
 the pulse rose to from 96 to 100, and dyspnoea, with sibilus and 
 rhonchus in the air-passages, and acute headache, made their ap- 
 pearance. At the same time, a copious effusion of fluid was detected 
 in the abdominal cavity, and, soon afterwards, in the pleural sacs 
 likewise. Although this change in the patient's condition did not in 
 any way resemble a fever paroxysm, yet considering the uncertain 
 character presented by the malignant forms of fever, recourse was 
 had to quinine. The patient, however, rapidly collapsed ; his colour 
 became earthy; somnolence set in, and on the 14th, he died. 
 
 Autopsy, 24 hours after death. 
 
 The body was greatly swollen from dropsy. The meninges and 
 substance of the brain contained the normal amount of blood. 
 There was no alteration in the colour or consistence of the brain, 
 and no pigment in the capillaries of the cortical substance. 
 
 The mucous membrane of the air -passages was slightly reddened, 
 and covered with grey mucus. Several pounds of serum were found 
 in each pleural cavity. The lungs were ansemic, and of a dirty-grey 
 colour, with emphysematous margins superiorly; inferiorly, they 
 were compressed and non-crepitant. 
 
 The pericardium contained a pound of clear serum ; in the heart, 
 there was loosely coagulated blood, in which pigment was found in 
 tolerable quantity. The muscular tissue and valvular apparatus of 
 the heart were normal. 
 
 The peritoneal sac contained many pounds of clear serum. The 
 stomach and intestinal canal were pale, but in other respects healthy. 
 
 The spleen was very large; its capsule was tensely distended; its 
 parenchyma was soft and of a dark greyish-brown colour. 
 
 The liver was shrivelled up at its margins ; the serous membrane 
 
352 THE PIGMENT-LIVER. 
 
 along the anterior rim of the left, as well as of the right, lobe, was 
 opaque from recent exudation, and covered with pale-red newly- 
 formed vessels. The hepatic tissue was of a dark greyish-brown 
 colour, and of soft consistence. Here, as well as in the spleen, there 
 were large masses of pigment. 
 
 Bile, thin, pale, and albuminous. 
 
 Kidneys anaemic. 
 
 Urinary bladder and prostate normal. 
 
 Observation No. XLTV. 
 
 Slight Dysentery. — Albuminuria. — Death from exhaustion. — No 
 cerebral disturbance. 
 
 Accumulation of Pigment m the Spleen, Liver, Drain, Kidneys, and 
 
 Pancreas. 
 
 Josepha "Weiss, aged 54, wife of a day-labourer, came into the 
 Hospital, on August 29th, 1854. 
 
 This woman was in a very low state, emaciated and anaemic ; and 
 for three weeks, had been suffering from diarrhoea, accompanied by 
 the passage of bloody mucus and great tenesmus. She referred 
 this diarrhoea to a cold ; she had not noticed any attacks of inter- 
 mittent fever. On admission, the sphincter ani was so relaxed, 
 that bloody mucous stools constantly flowed away from it ; the uri- 
 nary bladder was paralysed; the dark urine drawn off by catheter 
 contained a large quantity of albumen. 
 
 A transient improvement was obtained under the use of a suitable 
 nutritious diet, wine, and enemata of decoction of calumba and 
 tannine. Soon, however, the dysenteric affection increased. The 
 exhaustion made rapid progress; the patient became more and 
 more indifferent, slept much, but always gave perfectly intelli- 
 gible answers. After a protracted agony, death took place on the 
 9th of September. 
 
 Autopsy, 26 hours after death. 
 
 The meninges were moderately congested ; there was slight oedema 
 of the arachnoid. The cortical substance of the brain was of a slaty- 
 grey colour, and sharply defined from the anaemic white matter. 
 
ILLUSTRATIVE CASES. 353 
 
 The consistence was normal. The capillaries of the cortical sub- 
 stance were filled with granules and scales of pigment. 
 
 The lungs were dry and anaemic. There was much pigment in 
 the blood contained in the heart. 
 
 The spleen was enlarged by about one-third, of a pulpy consistence, 
 and dirty-grey colour, and loaded with black and brown pigment. 
 
 The liver was of normal size, soft, and chocolate-coloured, and its 
 secreting cells were pale. The bile was scanty and dark, and con- 
 tained no albumen. The capillaries of the liver were filled with pig- 
 ment at the circumference of the lobules, and to a less extent near 
 their centre. The mucous membrane of the stomach was of a slaty- 
 grey hue; the lining membrane of the small intestine was pale. The 
 mucous membrane of the large intestine, from the ileo-colic valve as 
 far as the sphincter ani, was covered with a grey puriform fluid ; at 
 many places it was abraded and marked by haemorrhagic effusions, 
 but it was free from any great amount of exudation, or from losses 
 of substance of a deeper nature. 
 
 The pancreas was deeply tinged with pigment. The kidneys 
 were anaemic and shrivelled (welk) ; the glomeruli, as well as the 
 uriniferous tubes, contained a moderate amount of pigment. 
 
 There was much turbid urine in the urinary bladder, which, upon 
 boiling, deposited albumen, but contained no casts of tubes. The 
 genital organs were normal. 
 
 Observation No. XLV. 
 
 Abdominal Typhus. — Repeatedly recurrent Intermittent Fever. — 
 Dysentery. — Exhaustion. — Death. 
 
 Spleen and Liver loaded with pigment. — The latter organ atrophied. 
 — Dysenteric ulcerations of the large Intestine. 
 
 B. Hahn, a female, aged 59, passed through a slight attack of 
 typhus in September, after which, she was seized with an oft-re- 
 curring intermittent fever. In the course of this, and without any 
 other apparent cause, the digestion being tolerably good, and 
 there being no diarrhoea or albuminuria, great anaemia came on 
 within a short space of time : the skin assumed an eminently white 
 appearance, and became dry and desquamating ; extensive anasarca 
 set in. 
 
 In November, several paroxysms of a quartan type occurred, which 
 
 AA 
 
354 THE PIGMENT-LIVER. 
 
 were soon removed by means of quinine, but which left behind 
 a diarrhoea > gradually assuming all the characters of dysentery. 
 Muriate of iron, nitrate of silver, with opium and other remedies, 
 were employed to check this, without effect; the oedema rapidly 
 increased ; the patient passed into a state of collapse, and died 
 from exhaustion on December 9th, death not being preceded by 
 any loss of consciousness. 
 
 Autopsy, 12 hours after death. 
 
 The brain and its membranes, as well as the organs of respiration 
 and of circulation, did not exhibit any important change, with the 
 exception of paleness and an appearance of anaemia. 
 
 The spleen was of the normal size ; its tissue was greyish-brown, 
 and of moderate consistence. Its capsule was much wrinkled. 
 
 The bver was small; its outer surface was smooth, and its margins 
 sharp ; its parenchyma was moderately consistent and bluish-brown. 
 The lobules were surrounded by dark rings. There was a small 
 quantity of dark bile in the gall-bladder. The stomach and pancreas 
 were normal. 
 
 The sigmoid flexure was drawn towards the right, and fixed there 
 by bands of false membrane. The serous membrane of the rectum 
 was opaque ; its mucous membrane was very tumid, and covered with 
 thick greenish-yellow masses of exudation; scattered over it were 
 numerous patches of ulceration. These morbid changes extended, 
 with a gradually diminishing intensity, as far as the ileo-colic valve. 
 The mucous membrane of the ileum was pale, and presented some 
 grey typhus cicatrices. 
 
 The kidneys were rather small, at some places granular, but 
 otherwise normal. 
 
 The right ovary contained a simple cyst, the size of one's fist. 
 
 VI. 
 
 Considering the great frequency of intermittent fevers, the cases 
 in which there is a marked development of pigment are compara- 
 tively rare ; hence, in such cases other agencies, of which we possess 
 no accurate information, must co-operate with the usual causes of 
 intermittent fever. In the present defective state of our knowledge 
 as to the nature of infectious diseases (Infectionskrankheiten), it 
 
DIAGNOSIS.— PROGNOSIS. 355 
 
 cannot be determined whether a particular quality, or an unusual 
 intensity of miasm is necessary for this purpose. The epidemic, to 
 which the cases that I have described, belonged, made its appearance 
 after an inundation in Silesia, resulting from an overflow of the 
 Oder, in 1854. Since then, cases of this nature have very seldom 
 been met with there, although the ordinary forms of intermittent 
 fever are never absent. 
 
 vii. Diagnosis. 
 
 A perfectly accurate diagnosis can only be made by direct exami- 
 nation of the blood : a few drops carefully collected, so as to avoid 
 contamination with any foreign matter, are sufficient to determine the 
 presence or absence of large quantities of pigment. To the practised 
 eye, the peculiar grey, ash-coloured, or greyish-yellow colour of the 
 skin furnishes an obvious means of diagnosis. The supervention of 
 severe cerebral symptoms with the co-existence of albuminuria or 
 hsematuria, or rapid collapse, is less to be depended on. More 
 reliance is to be placed upon the occurrence of such cases in an 
 epidemic form; this must especially guide us, when severe brain 
 symptoms, intestinal haemorrhages, suppression of urine, &c, are 
 suddenly developed in the course of a fever of an indistinct 
 type, without any other cause sufficient to account for these de- 
 rangements. The periodic increase of such symptoms, the compara- 
 tively slow pulse, the increased volume of the spleen and liver, the 
 colour of the skin, &c, may supply further data for diagnosis. In 
 some cases, the favourable effects of quinine may of themselves con- 
 firm the diagnosis. 
 
 vin. The Prognosis. 
 
 The prognosis always remains a matter of doubt. The mere ces- 
 sation of the fever does not entitle us to give a favourable prognosis, 
 because sudden and unexpected relapses, speedily terminating in 
 death, not unfrequently supervene. The cachexia and anaemia, re- 
 sulting from the changes which the spleen and liver usually undergo, 
 are ominous symptoms. The albuminuria, when it comes on periodi- 
 cally, and has not lasted a long time, yields readily to quinine ; when 
 of longer duration, it is often treated without any benefit. Coma 
 and convulsions are in general of bad omen; yet such cases are not 
 unfrequently cured by appropriate and well-timed remedies. 
 
 A A2 
 
356 THE PIGMENT-LIVER. 
 
 ix. Treatment. 
 
 The cure of the intermittent fever is the first thing to be done, 
 and the necessity for this is the more urgent, the more severe the 
 symptoms are during the paroxysm ; every fresh paroxysm endangers 
 life or increases the sum-total of the derangements which threaten 
 to put an end to it. In such cases, so soon as we are sure of our 
 diagnosis, large doses of quinine are sufficient, and the remedy is 
 best given diluted with acids, in which form it is most easily and 
 rapidly absorbed. The presence of counter indications must not be 
 allowed to occasion delay, unless they are of a very important nature, 
 such as great congestion of the brain. 
 
 In the slighter forms, with predominant abdominal derangements, 
 great gastro- enteric catarrh, jaundice, congestive swelling of the 
 liver, &c, it is judicious treatment to counteract these disturbances 
 by suitable remedies, before having recourse to the quinine. This 
 medicine must not be discontinued too early, because relapses are 
 very apt to occur, and are particularly dangerous. 
 
 After the removal of the fever, the second indication is the treat- 
 ment of the remaining local derangements of the spleen, liver, kid- 
 neys, brain, &c. Simple enlargements of the spleen usually yield to 
 the use of quinine, and the easily absorbed preparations of steel, such 
 as the hydrochlorate, the lactate, or the citrate of iron. It is a more 
 difficult matter to effect the removal of the colloid infiltration of 
 the organ, which is met with every now and then ; for this purpose 
 we must have recourse to the preparations of iodine, particularly 
 the iodide of iron, and the mineral waters containing iodine and 
 bromine, which are to be employed with more or less caution, ac- 
 cording to the condition of the blood. 
 
 The congestion of the liver usually disappears spontaneously after 
 the cessation of the fever, or even before this ; when it remains 
 stationary for a long period, we may employ rhubarb, the extractum 
 saponarise,* with the neutral salts, the ammoniated sesquichloride of 
 iron, with extract of aloes. The same treatment is applicable in cases 
 of enlargement of the liver, dependent upon biliary obstruction 
 arising from catarrh of the duodenum and hepatic ducts. 
 
 A much greater danger, as regards the progress of convalescence, 
 consists in the derangements of the nutrition of the liver, which are 
 * See note, page 312. 
 
TREATMENT. 357 
 
 apt to result from the capillaries of the organ becoming loaded with 
 pigment, and from the antecedent congestion conjoined with the 
 alteration in the composition of the blood, produced by the marsh 
 poison. What we have most to dread, is a gradually progressing 
 atrophy of the gland, resulting from the destruction of numerous 
 capillaries, the consequences of which we have already become 
 acquainted with in Chapter VI. I know of no treatment, by means 
 of which such atropby can be averted. We have already considered 
 how the consequences of this atrophy, the gastric catarrh, the ex- 
 hausting diarrhoea and the ascites are to be treated. The intermit- 
 tent haemorrhages and the acute ascites which succeed extensive 
 obstruction of the capillaries, are best met by a speedy arrest of the 
 intermittent fever; not until after this, can we have recourse to as- 
 tringents and styptics. 
 
 The fatty and the colloid infiltrations of the liver, which occur in 
 other cases, are to be treated according to the general principles 
 laid down in subsequent chapters. 
 
 The third organ to be considered in the treatment is the kidneys ; 
 they become diseased, in such a manner as to excite apprehension, 
 sometimes at an early date, at other times, not until a later period. 
 Albuminuria and haematuria, which accompany the fever paroxysm, 
 and remit and intermit along with it, yield best to quinine, and dis- 
 appear for the most part, so soon as the fever ceases. When the 
 abnormal condition of the secretion continues after the cessation of 
 the fever, tonic and astringent remedies are suitable, such as the 
 extract of cinchona, dissolved in some aromatic water, tannic or 
 gallic acid, the preparations of iron, &c. A similar treatment, alter- 
 nated with derivation to the skin and bowels, by means of warm 
 baths on the one hand, and purgatives on the other (these last, 
 however, only to be employed when the mucous membrane of the 
 bowel is unaffected), is adapted to chronic albuminuria and the 
 dropsy, which, in most cases, are developed, as the consequence 
 of the cachexia remaining after the fever. The result in these cases 
 depends chiefly on whether the affections of the spleen and kidneys 
 are accompanied by still more important lesions of the liver, and 
 of the mucous membrane of the stomach and bowels. When these 
 parts are involved, it is seldom that we succeed in arresting the dropsy. 
 When there is obstinate albuminuria, and at the same time a solid 
 enlargement of the spleen, we have reason to believe that there 
 is colloid infiltration of the kidneys, and we must employ the 
 
358 THE PIGMENT-LIVER. 
 
 iodide of iron, so long as the condition of the digestive organs and 
 the hydrsemia will tolerate it ; this is one of the most dangerous 
 forms of the affection. 
 
 Cerebral disturbances during the febrile attack, demand a special 
 treatment, when there is great plethora, or when there is a threaten- 
 ing of cerebral paralysis ; in the former case, abstractions of blood, 
 with cold applications, are to be employed; in the latter, diffu- 
 sible stimulants, ether, musk, ammonia, &c. "We must not, under 
 these circumstances, neglect the use of quinine. Headache, giddi- 
 ness, and other derangements, which remain after the removal 
 of the intermittent fever, yield best to the protracted use of this 
 alkaloid. 
 
 The altered composition of the blood, the anaemia and the 
 hydraemia, in almost all cases, necessitate a tonic after-treatment, 
 consisting in an easily digested animal diet along with steel. The 
 effects of this mode of treatment soon become apparent, when there 
 are no important local affections in the liver, bowels, or kidneys, 
 to interfere with assimilation, or to keep up abnormal secretions. 
 When this is the case, all our endeavours to effect an improve- 
 ment often prove fruitless. 
 
HYPEREMIA OF LIVER. 359 
 
 CHAPTEE IX. 
 
 HYPEMMIA OF THE LIVER, AND ITS CONSEQUENCES. 
 
 The liver, in virtue of its structure and the arrangement of its 
 vessels, is more subject than any other organ to abnormal distributions 
 of its blood. The current of blood, which under the pressure of 
 the heart flows but slowly through the enormous and much ramified 
 vascular network of this gland, — seeing that this pressure has already 
 had to overcome one set of capillaries in the roots of the portal vein, — 
 is acted on by agencies of a peculiar nature, as a result of which its 
 rapidity and tension are liable to many variations. 
 
 Besides the heart's action, the organs in which the roots of the 
 portal vein originate, influence the circulation in the liver. During 
 digestion, when the abundant secretion of the mucous membrane 
 of the stomach and bowels causes an active flow of blood to these 
 parts, and when, at the same time, large quantities of fluid are ab- 
 sorbed, the blood flows more actively through the portal vein to the 
 liver than is the case at other times.* Similar consequences may 
 result from the irregular contractions of the splenic vessels, which 
 are amply provided with muscular fibres. 
 
 The hepatic circulation is still more affected by the action of the 
 diaphragm and abdominal muscles, by means of which the abdominal 
 cavity is narrowed, the portal vein compressed, and its contents 
 carried towards the constantly open vessels of the liver.f The 
 
 * According to CI. Bernard, in order to protect the liver from too great 
 a pressure of blood during the period of digestion, special communications 
 exist between the portal vein and vena cava, which carry the blood directly 
 into the vena cava, without passing through the portal capillaries. 
 
 t The earlier physicians had peculiar notions as to the circulation of 
 blood in the portal vein, upon which they grounded their theories of 
 obstructions and enlargements (Anschoppungen) of the liver. Boerhaave 
 believed that the blood in the portal vein circulated independently of the 
 heart. " Sanguis venae portarum amittit omnem a corde acceptum impe- 
 tum (Praleet. academ. Ed. Haller, vol. III., p. 115). The blood, he 
 thought, was propelled through the liver by means of the muscular 
 
360 HYPEREMIA OF LIVER 
 
 contractions of the muscular tissue of the stomach, and intestines 
 produce a like effect upon the delicate roots of this vein, although in 
 a more limited degree. 
 
 A third important agency affecting the circulation of the liver, 
 is the varying opposition made to the escape of blood by the 
 hepatic veins. This diminishes during each inspiration, and in- 
 creases with the expiration. During the inspiration, the blood is 
 drawn towards the heart from the open hepatic vessels, whilst at the 
 same time the portal vein and the liver are compressed by the de- 
 scent of the diaphragm, and their vascular contents propelled further 
 towards the heart. This movement is favoured by the contraction 
 of the greatly developed muscular tissue of the hepatic veins. 
 
 Besides these influences, which for the most part are due to the 
 position of the liver and its vessels, and which are very variable in 
 the extent of their operation, the hepatic circulation is influenced by 
 other agencies, which are less accurately known. Among these may 
 be mentioned the contractility of the walls of the vena porta, as well 
 as of those of the hepatic vein and artery, which appears to be chiefly 
 dependent upon innervation, and which, in rare cases, is liable to 
 modifications from an altered state of their nutrition. When 
 treating of chronic atrophy of the liver, we ascertained that dila- 
 tations of the portal vein may result from interruptions to the nutri- 
 tion of the vascular walls ; other forms of derangement arising 
 from a similar cause will afterwards be brought forward. We know 
 little that is positive as to the influence exerted by the nerves over 
 the circulation of blood in the various divisions of the portal vein, 
 and in the hepatic artery. According to the experiments and 
 observations of CI. Bernard, injuries of certain localities of the 
 medulla oblongata [Diabetic puncture), electric irritation of the 
 proximal extremity of the divided vagus nerve, contusions of the head, 
 poisoning with curari, &c, may give rise to hyperaemic swelling of 
 the liver ; I have myself observed a remarkable degree of congestion 
 of this organ after division of the splanchnic nerves, and removal of 
 
 tissue, with which the portal vein is furnished in the capsule of Glisson 
 {ibid. p. 115 to 118), as well as by the respiratory movements of the 
 diaphragm and abdominal muscles (ibid. p. 183). Stahl likewise denied 
 the influence of the heart, and thought that the blood of the portal vein 
 was propelled by the respiratory movements, and by a peculiar tonic 
 motive power, having its seat in the spleen, intestines, mesentery, &c. 
 Even at the present day, these views are brought to bear upon the 
 doctrine of abdominal plethora. 
 
FROM OBSTRUCTED CIRCULATION. 361 
 
 the greater part of the cceliac ganglion. As might have been expected, 
 the circulation of the blood in this organ is modified to a greater 
 extent than we are aware of, by nervous influences. These still re- 
 quire investigation, because we are by no means entitled, without 
 further investigations, to apply to the portal vein the results of experi- 
 ments which have been made on other portions of the vascular system.* 
 From what has just been said, it will be understood, that in a 
 system of vessels, subject to such manifold modifying agencies, 
 various derangements may occur, the causes of which are at one time 
 obvious, but at another time less intelligible. We confine ourselves in 
 t the first place to the simpler forms, the etiology of which is more 
 easily investigated, and shall afterwards pass on to the consideration 
 of the more complicated varieties. 
 
 a. Hyperemia of the Liver , arising from obstruction to the circulation 
 of the Blood. (Stauungshyperamie.) 
 
 I. Pathology. 
 
 In valvular diseases of the heart, and especially in such as give 
 rise to accumulations of blood in the venae cava? at an early period, 
 such as constriction of the left auriculo-ventricular opening, in- 
 competence of the mitral, and still more of the tricuspid valves, 
 and further in affections of the lungs, which greatly impede the 
 circulation through the pulmonary artery, such as emphysema, ex- 
 tensive induration or atalectasis, in constriction of the thoracic 
 cavity from angular curvature, in great pleuritic effusions, &c, 
 hyperemias of the liver are met with as a general rule. Under such 
 circumstances, a powerful agency in the circulation of the blood in 
 the liver, viz. : the suction power exercised during inspiration, is 
 either more or less powerful than it ought to be ; either the blood in 
 the vena cava and hepatic veins is subjected to a higher degree of 
 pressure, which interferes with the evacuation of the capillaries of 
 
 * Kolliker and Virchow observed in the body of an executed criminal, 
 that no contraction resulted from galvanic irritation of the trunk of the 
 portal vein, and only a slight contraction in the superior mesenteric vein. 
 Iii experiments made by myself and Reichert on living dogs, a distinct, 
 although slight, contraction was observed to take place in the splenic and 
 mesenteric veins ; in the trunk of the portal vein this was indistinct; no 
 contraction could be observed in the hepatic veins and vena cava inferior, in 
 which, from their very muscular character, the effects might have been 
 expected to have been more remarkable. 
 
362 HYPEREMIA OF LIVER 
 
 the portal vein, or the current of blood regurgitates with each 
 systole of the heart into the hepatic veins, as may be made the 
 subject of direct observation in the case of the veins of the neck. 
 
 When this is the case, the branches of the hepatic vein in the liver 
 continue permanently distended, and gradually enlarge, while their 
 walls become hypertrophied ; the stagnation is propagated to the 
 portal vein, and to the organs in which this vessel takes its origin ; 
 and there results a series of derangements in the functions and nutri- 
 tion of the liver and of the organs comprised in the portal system. 
 
 The liver enlarges in every direction without any important 
 alteration in its form; its capsule becomes tightly distended, and the 
 consistence of its parenchyma firmer.* On section, the organ pre- 
 sents a nutmeg- like appearance, which can also be seen through the 
 capsule, and which varies in character according to the degree of the 
 congestion. Usually there may be seen rounded, simple, or branched, 
 dark brownish-red patches, surrounded by portions of tissue of a 
 pale-brown colour. The dark spots correspond to the situations of 
 the hepatic veins, and their form depends upon the direction in 
 which the section of the vessel passes.f The light-coloured portions 
 of the parenchyma exhibit upon closer inspection, pale delicate rami- 
 fications corresponding to branches of the portal vein. 
 
 When the congestion attains a more advanced stage, the dark 
 parts become incorporated together, and enclose in an annular 
 manner portions of the pale tissue which corresponds to the branches 
 of the portal vein ; the forms of these pale parts then appear to be, for 
 the most part, rounded or oval, sometimes they are elongated, or 
 divided in a dichotomous manner, and more rarely they resemble a leaf. 
 
 In the highest grade of hepatic hypereemia, the organ exhibits 
 over extensive portions a uniformly dark-red colour, in the midst of 
 which the reddish-black outlines of the greatly distended branches 
 of the hepatic vein can be made out.f 
 
 * Here and there, the parenchyma is doughy and osdematous, serum 
 can be squeezed out of it, and it retains impressions made upon it with 
 the finger. 
 
 t Even in the normal state, the blood is retained here in considerable 
 quantity, and indications of such a nutmeg-appearance are not of very 
 great importance, especially in cases where death has proceeded from 
 disease of the lungs. For other causes of this appearance of the liver, 
 see page 295, note f. 
 
 X Kiernan (Transactions of the Royal Society for 1833) has correctly 
 described this variation in the degree of hyperaemia of the liver, but the 
 
FROM OBSTRUCTED CIRCULATION. 363 
 
 The obstruction in the hepatic veins necessarily interferes with the 
 circulation of the blood throughout the entire capillary system of the 
 liver, and through this, reacts upon the portal vein, as far as its 
 primary roots. The secretion of the liver does not appear to suffer 
 any important change : I have not been able to convince myself that 
 it is either increased or diminished ; in a few cases, the bile contains 
 albumen. The mucous membrane of the bile ducts are often seen to 
 become swollen, and to throw out an increased secretion, and in this 
 way the ducts themselves may become partially obstructed, and 
 occasionally, also, a stoppage to the flow of bile, with slight jaundice 
 may be observed. The nutrition of the hepatic cells remains 
 at first unaffected, but after a time, we observe in those which are 
 situated nearest the commencements of the hepatic veins, an 
 abundant deposit of fat, such as in other cases is only met with in 
 the cells next the branches of the portal vein. 
 
 From the persistence of this obstruction to the circulation of the 
 blood, there is gradually developed a peculiar atrophy of the hepatic 
 parenchyma, which formerly was frequently confounded with cir- 
 rhosis. The gland which hitherto has been swollen from the quantity 
 of blood which it has contained, begins to diminish in size, and at 
 the same time its surface, and afterwards its parenchyma, acquire a 
 finely-granular structure. The granulations arise from the circum- 
 stance that the central veins of the lobules, and the capillaries 
 opening into them, or in other words, the roots of the hepatic veins 
 become enlarged under the powerful pressure of the obstructed blood, 
 and thus lead to a disappearance of the hepatic cells enclosed in their 
 meshes. The cells situated in the middle of the lobules become 
 atrophied, and in their place appears a soft vascular tissue, consisting 
 of enlarged capillaries and newly-formed areolar tissue, whilst the 
 cells in the periphery of the lobules nearest the branches of the 
 portal vein remain unaffected* The farther this atrophy extends, 
 
 numerous delineations of these varieties given by him are far from 
 natural. 
 
 * These appearances can be traced best in the injected liver. A mag- 
 nified representation of such an injected liver is given in the Atlas (PI. 
 XII., Fig. 4) ; different coloured injections had first been thrown into the' 
 hepatic and portal veins. The central veins are seen to be surrounded by 
 capillaries considerably larger than those met with under normal circum- 
 stances ; the meshes containing the cells are greatly narrowed, so that 
 at some places they are found to be smaller than the surrounding 
 vascular tubes. As we approach the portal veins, the capillaries 
 
364 HYPEREMIA OF LIVER 
 
 the more does the entire volume of the liver diminish, and the more 
 distinct do the granulations become. 
 
 Through the hepatic veins the obstruction is propagated to the 
 portal vein, and to the structures in which the roots of this last 
 vessel take their origin. The vessels of the mucous membrane of the 
 stomach and intestine, of the spleen, pancreas, &c, become distended 
 with venous blood; and, as a consequence of this, their nutrition 
 and secreting powers are deranged. These results manifest them- 
 selves first and most distinctly in the mucous membrane of the 
 stomach and bowels ; this assumes a more or less dark-red colour, 
 its tissue becomes softened, infiltrated with serous fluid, and con- 
 sequently swollen ; while not unfrequently, extravasations of blood 
 take place, which give rise sometimes to a deposit of black pigment, 
 and sometimes to erosions and ulcerations. The secretion is usually 
 increased in quantity and altered in quality, being thinner and more 
 watery, or it often continues scanty. At the same time, watery effu- 
 sions take place from the serous surfaces of the abdominal cavity. 
 The spleen increases in volume, but only for a time, and never to a 
 remarkable degree ; at a later period, it becomes more solid and firm, 
 and is reduced to its normal dimensions.* In many cases, we find 
 old extravasations of blood between the folds of the mesentery, the 
 mesenteric glands of a livid tinge, with congestive swelling and 
 serous infiltration of the pancreas. In consequence of the increased 
 pressure on the part of the blood of the portal vein, the absorption 
 of the liquefied ingesta, so essential for nutrition, is greatly impeded. 
 
 It is worthy of notice, that, although the pressure must be uni- 
 formly distributed from the trunk of the portal vein over its radical 
 branches, still the results of the obstruction are by no means uniform 
 in the various parts from which these branches come. Of the gastro- 
 intestinal mucous membrane, it is only some portions which are 
 always seriously diseased, whilst the remainder appear but little 
 changed. Disease of the mucous membrane of the stomach is the 
 
 become smaller, while the meshes are larger, and contain cells of normal 
 character. 
 
 * In thirteen cases of organic disease of the heart, in males, the average 
 weight of the spleen was 0.23 kilogrammes (8.1 oz. avoird.); its relative 
 weight to that of the body was as 1 to 276 ; of nine cases, in females, the 
 absolute weight was 0.17 kilogr. (6 oz. avoird.), and the relative weight as 
 1 to 282 ; in thirteen cases, of females, in which there was also extensive 
 dropsy, the absolute weight was 0.14 kilogr. (5 oz. avoird.), and the rela- 
 tive as 1 to 464. See pages 24 and 25. 
 
FROM OBSTRUCTED CIRCULATION. 365 
 
 most constant, and the most marked ; out of 20 eases, this mem- 
 brane was of a dark-red colour in 12, and in 7 it was covered with 
 ecchymoses and erosions ; in 4 cases only was the membrane relaxed 
 and of a pale colour. The small intestine is quite different from the 
 stomach in this respect ; as a general rule, the lining membrane of 
 this portion of bowel is pale and scarcely altered ; in 5 out of 20 
 cases, only, was the ileum moderately congested, and never to such a 
 degree as the stomach. The large intestine, and particularly the 
 caecum and sigmoid flexure, have been observed to be congested 
 somewhat oftener, or in 7 out of 20 cases ; this congestion has 
 at one time been uniformly distributed over the greater extent 
 of the mucous membrane ; at other times, it has been limited more 
 to the folds of the bowel, and to the circumference of the solitary 
 glands ; in no case did its intensity equal that of the injection of 
 the stomach. 
 
 These inequalities in the distribution of the congestion appear to 
 be dependent upon the differences presented by the individual por- 
 tions of the intestinal canal, as regards their vascularity, and the 
 size and position of their vessels ; besides these causes, there are 
 other circumstances, which in many cases must co-operate, such 
 as the irritation of ingesta or medicines, and also the variations in 
 the degree of post-mortem congestion, produced by the accumulation 
 of gas in isolated portions of the bowel. 
 
 Independently of the portal system, we find the derangements 
 just described almost always accompanied by albuminuria, which 
 sometimes is persistent, and at other times is only observed from time 
 to time. This morbid condition is of importance as regards the 
 affection of the liver, inasmuch, as all the derangements referrible to 
 the portal vein, including the affection of the liver itself, are less 
 prominently developed, the greater the loss of albumen by the urine, 
 and the more marked the anemic condition, which is gradually in- 
 duced by this drain upon the system, as well as by the interference 
 with digestion and intestinal absorption. 
 
 ii. Symptoms. 
 
 The several stages in the development of obstructive hyperemia of 
 the liver, may usually be traced with ease at the bedside of the patient. 
 The enlargement of the gland first makes itself known by a feeling 
 of tightness and heaviness in the right hypochondrium, usually as- 
 
366 HYPEREMIA. OF LIVER 
 
 sociated with more or less severe symptoms of gastric catarrh, and 
 not unfrequently with slight jaundice. Percussion and palpation 
 at once indicate an increase in the volume of the organ, the extent 
 of which varies with the degree of obstruction to the circulation ; 
 during an attack of violent dyspnoea and cyanosis, the dulness soon 
 increases to the extent of several centimetres. The surface of the 
 organ at first feels smooth and tense ; at a later period, it is uneven 
 and granular. After a long continuance of the disease, the volume 
 of the organ gradually diminishes; and this diminution is more 
 rapid, the more complete is the obstruction to the circulation, 
 and the earlier the date at which a marked degree of anaemia shows 
 itself. 
 
 Besides the local changes in the liver itself, we observe the effects 
 of the obstruction to the portal circulation, manifesting themselves 
 chiefly by derangements* of digestion, pains and tension in the 
 epigastrium, nausea, &c, and occasionally, also, by enlargement 
 of the hsemorrhoidal veins. The bowels, as a rule, are confined; 
 in rare cases, a transient diarrhoea makes its appearance (only in 
 4 out of 20 cases). The scanty, highly-coloured urine, almost 
 always contains small quantities of albumen, and sometimes also 
 of bile-pigment ; the latter of these complications is in most cases 
 only temporary, and is associated with a slight jaundiced tinge of 
 the conjunctiva and skin. 
 
 These derangements of the abdominal organs are accompanied by 
 the symptoms of the cardiac or pulmonary disease, which constitutes 
 the primary cause of the obstruction to the circulation, and which, 
 sooner or later, leads to death from pulmonary oedema, apoplexy, 
 general dropsy, &c. 
 
 m. Treatment. 
 
 In the treatment of the hepatic affection under consideration, we 
 must keep in view, that it constitutes only a link in the long 
 series of pathological processes, which are originated and kept up by 
 one common cause, and that it depends upon the nature of this 
 cause, whether the results produced are temporary or permanent. 
 
 * Not unfrequently we find, upon post-mortem examination, all the signs 
 of chronic catarrh of the stomach, tumefaction, lividity, a thick layer of 
 mucus, &c, in cases where no indications of any derangement of diges- 
 tion had existed during life. 
 
FROM OBSTRUCTED CIRCULATION. 3S7 
 
 In most cases, palliative treatment is all that is possible, inas- 
 much as the fundamental organic lesions cannot be removed. 
 The main point to be attended to is to reduce the congestion 
 of the portal system, and to moderate the injurious consequences 
 which this produces upon digestion and nutrition. A careful 
 fulfilment of these indications contributes greatly to the relief 
 of the complaints which are necessarily associated with cardiac 
 diseases, and to ward off the dangers to which they give rise. Con- 
 siderable swelling of the liver, accompanied by pain in the right 
 hypochondrium, is most easily reduced by mild saline purgatives, 
 the action of which may be kept up for a longer period by infusion 
 of rhubarb; at the same time, we may apply cupping-glasses oyer 
 the hepatic region, and leeches to the anus. Where the obstruction 
 to the circulation is not of too threatening a character, we may 
 often succeed in procuring permanent relief by the careful employ- 
 ment of the Eagoczy Spring of Kissingen, or of the Mill Springs of 
 Karlsbad. I have had under my care a patient suffering from con- 
 striction of the left auriculo-ventricular opening, who for four years 
 contrived to pass a tolerable winter by using the cooler springs of 
 Karlsbad; and I have repeatedly obtained similar results by the 
 careful employment of the waters of Marienbad and Kissingen,* In 
 cases where the disease of the valves or of the muscular tissue of the 
 heart is far advanced, the mineral waters can no longer be borne. 
 
 On the appearance of dropsy we must avoid saline medicines, and 
 substitute for them the bitter vegetable substances, such as rhubarb, 
 aloes, and similar preparations, to which must be added, in the event 
 of tympanites, aromatics, sethereal oils, and small quantities of ether. 
 When there is great tenderness of the stomach, we must apply a 
 few leeches, or confine ourselves to the employment of the watery 
 tincture of rhubarb with cherry-laurel water, extract of belladonna 
 and similar remedies. Gastric haemorrhage, which, however, is 
 seldom profuse, and also ulceration of the stomach, call for the 
 employment of ice and astringents. 
 
 We must beware of inflicting a lasting injury upon the digestive 
 organs, by persisting in the use of digitalis. 
 
 * See note, pages 58 and 125. 
 
368 HYPEREMIA OF LIVER 
 
 Observation No. XL VI. 
 
 Constriction of ike left auriculo-ventricular opening of the Heart. — 
 Incompetence of the tricuspid valves. — Marked venous pulse. — 
 Haemoptysis. — Albuminuria. — Obstructive hyperemia of the 
 Liver, Stomach, and large intestine. 
 
 Carl Scholz, a journeyman baker, aged 38, was admitted into 
 Hospital on December 19th, 1854, and died on the 19th February, 
 1855. Five years before, the patient had suffered from an attack of 
 acute articular rheumatism, which had been followed by cardiac 
 palpitations, dyspnoea, and bloody expectoration. 
 
 On admission, there was marked dyspnoea, extensive rales, and 
 finely-frothy sputa tinged with blood. The impulse of the heart was 
 felt at its normal site, and over the apex there could be heard 
 a systolic and diastolic murmur ; the systolic sound was heard 
 still louder over the ensiform process of the sternum ; both disap- 
 peared in an upward direction ; the second sound of the pulmonary 
 artery was unusually loud. The cardiac dulness was increased 
 in width. The countenance, and particularly the lips, were of a 
 cyanotic hue. The. veins in the neck were greatly distended, and 
 exhibited systolic pulsation in a marked degree. The pulse in the 
 radial artery was 80 and small. The liver extended about \\ inch 
 beyond the margin of the ribs, the hepatic dulness in the mammary 
 line amounting to 11 centimetres (4j inches); its surface felt uneven 
 and communicated a sensation of pulsation to the hand placed 
 over it. The tongue was clean; the appetite slightly impaired; 
 and the bowels confined^ The urine was scanty, dark, and slightly 
 albuminous. 
 
 Was ordered infusion of digitalis with 2 grains of extract of aloes, 
 daily. 
 
 The dyspnoea and abdominal tension were relieved, but only for a 
 time. (Edema of the feet and ascites gradually became developed, 
 and there were repeated attacks of hsemorrhagic oedema of the lungs 
 (blutiges Lungenmdem), which had to be removed by digitalis and 
 benzoic acid. Up to the beginning of February, the patient con- 
 tinued tolerably comfortable, his appetite kept up, and his sleep was 
 but httle disturbed ; but from this date, without any alteration in the 
 auscultatory signs above described, the dyspcena, cyanosis, and dropsy 
 
FROM OBSTRUCTED CIRCULATION. 369 
 
 daily increased, and were accompanied by complete prostration of the 
 digestive powers, until on the 19th the patient had an attack of 
 asphyxia, which terminated in death. * 
 
 ',17 hours after 
 
 The cerebral membranes were congested and thickened; the sub- 
 stance of the brain was normal. In the neck was observed a 
 remarkable enlargement of the internal jugular vein, which pre- 
 sented a bulbous projection above the clavicle, the size of a walnut ; 
 the external jugular vein was likewise enlarged. 
 
 The mucous membrane of the air-passages was congested, and at 
 some places suffused with blood ; both lungs were crepitant through- 
 out, much congested, but not eedematous. The pericardium was- 
 opaque, white and thickened ; over the right ventricle, which at its 
 base measured %\ inches in breadth, was a large fibrous spot [Sehnen- 
 fiech); the tricuspid valve was thickened and opaque, its margins 
 were rounded; the chordae tendinese, as well as the flaps of the 
 valves, were adherent to one another; in consequence of this the auri- 
 culo-ventricular opening was much enlarged, and its valvular apparatus - 
 incompetent. The endocardium of the enlarged auricle had an opaque 
 white appearance, the foramen ovale was one line in diameter: the 
 valves of the pulmonary artery were normal. The walls of the left 
 ventricle were unaltered; the bicuspid (mitral) valve was con- 
 nected to a rigid ring, and at its base were rough calcareous 
 deposits'; the coronary veins were much enlarged; the aorta was 
 normal. 
 
 The mucous membrane of the stomach was intensely congested, 
 bluish-black, and at some places covered with grey flakes; the lining 
 membrane of the jejunum and ileum was pale ; the csecum and 
 colon were at some places congested and ecchymosed. The mesen- 
 teric glands and veins were unaltered. 
 
 The spleen was of normal size ; its capsule was thickened ; and its 
 parenchyma reddish-brown, firm, and congested. 
 
 The liver was large, its capsule opaque, and its surface unevenly 
 granular; its parenchyma was very congested; its colour appeared 
 at some places of a uniform dark-red, with black specks corre- 
 sponding to the hepatic veins ; here and there spots could be dis- 
 tinguished, partly white and partly of a greenish-yellow colour, 
 surrounded by dark congested spaces. The vena cava descended 
 
 BB 
 
370 HYPEREMIA OF LIVER 
 
 and the hepatic veins were enormously enlarged, and their walls were 
 thickened. This enlarged condition extended, as was shown by 
 injection, as far as the capillaries of the lobules; the hepatic cells 
 were partly atrophied, and partly filled with oil globules; in the 
 greenish-yellow spaces the cells were loaded with bile-pigment. The 
 gall-bladder contained a scanty, thick, dark secretion. 
 
 The cortical substance of the kidneys presented a few isolated 
 superficial scars. 
 
 Observation No. XLVII. 
 
 Constriction of the Left Auriculo-ventricular opening. — Repeated 
 Attacks of oedema of the Lungs. — Albuminuria. — Congestion of the 
 Liver from Obstructed Circulation. — Hemorrhagic erosions of the 
 Stomach.— ^-Intestinal mucous membrane, pale and tumid. 
 
 "Veronica Graser, a joiner's wife, aged 29, was admitted on October 
 31st, 1854, and died on the 6th of December following. She had 
 already, three years before, been treated in the Hospital for cedema of 
 the lungs, which became developed soon after delivery, in consequence 
 of constriction of the left auriculo-ventricular opening of the heart. 
 Even then the same physical signs could be made out, as on the 
 patient's last admission. A diastolic murmur, associated with fre- 
 miessment, could be heard loudest over the apex of the heart, which 
 was felt to beat at its normal place; this was accompanied by a 
 remarkable exaggeration of the second sound to the left of the 
 sternum in the second intercostal space; the cardiac dulness was 
 increased in its transverse diameter, and extended beyond the right 
 margin of the sternum. The pulse was 90, small and irregular. 
 There was very extensive bronchial catarrh, a moderate amount of 
 effusion in the right pleural sac and in the abdominal cavity, and 
 oedema of the feet. The renal secretion was scanty; and there was a 
 small quantity of albumen in the urine. The liver extended about 
 2^ inches beyond the margin of the ribs; its dulness in the mammary 
 line amounted to 14 centimetres (5£ inches) ; the surface of the 
 gland was smooth, its margin sharp, and its consistence firm. There 
 was no appetite, although the tongue was clean; the bowels were 
 somewhat confined, and the stools of a dark-brown colour. 
 
 "Was ordered infusion of digitalis leaves with tincture of rhubarb 
 and acetate of potash. 
 
FROM OBSTRUCTED CIRCULATION. 371 
 
 The respiration became freer, and there was an increased secre- 
 tion from the kidneys and the bowels; the oedema of the feet 
 disappeared; the hepatic dulness diminished by abont 31 centi- 
 metres (1.378 inch). 
 
 Up to the 18th of November, the patient contmned to improve 
 under the nse of a weak infnsion of rhubarb; the digestive powers 
 rallied; the bowels were moved regularly; and the dyspnoea was less 
 violent. On the 18th, the pulse became very irregular ; the dyspnoea 
 again increased; there were finely-frothy sputa; the volume of the 
 liver attained its former size. Under the use of the ethereal tinc- 
 ture of digitalis, the rhythm of the heart's action certainly improved; 
 but the nausea, which soon supervened, and the complete loss of 
 appetite, rendered it necessary to exchange this preparation for 
 mild bitter remedies. The urine was always scanty, and its albu- 
 minous contents inconsiderable; the ascites and oedema of the 
 feet rapidly increased. 
 
 On the 5th of December, there was repeated vomiting, great 
 debility, imperceptible pulse, and oedema of the lungs. Death on 
 December 6th. 
 
 Autopsy, 25 hows aftef death. 
 
 The brain and cerebral membranes anaemic, but otherwise normal. 
 In the right pleural sac were found abont three pounds of clear 
 serum ; the surface of the left lung was everywhere firmly adherent. 
 The mucous membrane of the air-passages was of a bright- 
 red colour, and covered with small ecchymoses. The parenchyma 
 of the lungs was bark-brown, oedematous, and somewhat firm in 
 consistence; the lower lobe of the right lung was compressed; in 
 the middle lobe was found a haemorrhagic infarction the size of a 
 walnut. 
 
 There were about seven ounces of serous fluid in the pericardium ; 
 the heart was considerably enlarged transversely ; its right ventricle 
 was dilated and hypertrophied, the hypertrophy being particularly 
 marked in the conns arteriosus; the valves were normal; the left auricle 
 was enlarged, and its muscular tissue thickened ; the left auriculo- 
 ventricular opening appeared narrowed to an oval slit, scarcely 
 admitting the point of the forefinger; the margins of the valves, and 
 a portion of the chordae tendineae adhered to a smooth thick ring. 
 The muscular tissue of the left ventricle, and also the aorta, were 
 normal. 
 
 BB 2 
 
372 HYPEREMIA OF LIVER. 
 
 There were about seven pounds of fluid in the abdominal cavity. 
 The mucous membrane of the stomach, which was covered by a 
 tenacious blackish substance, presented hemorrhagic erosions, which 
 were-most numerous in the neighbourhood of the pylorus; its tissue 
 was everywhere tumid and congested. The mucous membrane of 
 the intestine, however, was throughout pale and relaxed. 
 
 The spleen was of normal size, dark-brown, and firm. 
 
 The liver was enlarged, its surface was slightly granular, and its 
 margins sharp.* The gall-bladder contained a considerable quantity 
 of thin bile, in which albumen was detected. 
 
 The left kidney was of normal size ; small depressed scars were 
 observed upon its surface, and its parenchyma was somewhat firmer 
 than usual. The right kidney was much contracted; its surface 
 was scarred and furrowed ; its cortical substance had disappeared ; a 
 yellow infarctus the size of a sechser (or of a threepenny-piece) was 
 observed upon its convex edge. 
 
 No important pathological change was found in the urinary 
 bladder or genital organs. 
 
 In addition to the morbid conditions of the heart and lungs, 
 which, from the fact, that the entire mass of the blood must pass 
 through these organs, pre-eminently give rise to obstructions in 
 this portion of the venous circulation, we observe, although with 
 comparatively less frequency, mechanical congestions of the liver, 
 produced by constrictions of the vena cava inferior above the opening 
 of the hepatic veins, as also by constrictions of the hepatic veins them- 
 selves at their entrance into the vena cava. Watsont has described 
 an instance of hypersemic swelling of the liver, extending as low 
 down as the crest of the ilium, which was caused by the lateral pres- 
 sure upon the vena cava of an aortic aneurism. After the bursting 
 of the aneurism, the pressure upon the vena cava ceased, the stag- 
 nating blood flowed on, and the organ had returned to nearly 
 its normal size before the post-mortem examination was made, 
 I have myself observed slight obstructions result from the com- 
 pression of the vena cava by retro-peritoneal cancerous tumours. I 
 have also seen a constriction of the hepatic veins caused by valvular 
 projections into the interior of this vessel in a case of cirrhosis of the 
 
 * The changes in the parenchyma are represented in Plate XII., Figs. 
 1 and 4 of the Atlas. 
 
 t Principles and Pract. of Physic, 3rd Ed., Vol. I., p. 22. 
 
ATONIC HYPEREMIAS AND CONGESTIONS. 373 
 
 liver; in this case, the obstruction had given rise to numerous apo- 
 plectic patches in the parenchyma of the liver. 
 
 However obvious the effects of the obstruction may be, it is 
 seldom that we can arrive at a perfect knowledge of derangements 
 of this nature during the life of the patient. This remark applies 
 also to the partial mechanical hyperaemias, which are developed as 
 a result of deep fissures in the liver from tight-lacing; and to 
 the swellings of one lobe caused by induration of the other, or 
 by obliteration of one of the branches of the portal vein, whereof 
 I have before me several observations. 
 
 b. Congestions and Atonic Hgpenmias of the TAver. 
 
 We include under these designations the hyperaemias of the liver 
 which are developed independently of any obstruction to the circu- 
 lation of the blood. They are partly of an active character, and 
 produced by exciting causes acting upon the parenchyma of the 
 liver ; but, on the other hand, they are partly of a passive nature, 
 being occasioned by an atony of the vessels, or by a debilitated 
 action of the heart,* and in this case, they are mostly of long dura- 
 tion. It is impossible, however, to draw a strict line of demarcation 
 between these two forms, inasmuch, as we meet with undoubted 
 examples of a transition from the one to the other, and because we 
 cannot always ascertain with sufiicient accuracy the mechanism 
 of the affection in individual' cases. It is equally impossible to 
 determine to what extent the capillaries of the hepatic artery are 
 implicated along with those of the portal vein; it can scarcely be 
 doubted, that differences exist in this respect, when we consider the 
 varying character of the influence which hyperaemias exercise over 
 nutrition.f 
 
 * The simplest forms of passive accumulation of blood in the liver 
 which I have observed, have been in old decrepit individuals with extreme 
 prostration of the heart's action, and in whom the abdominal muscles, 
 from being greatly relaxed, no longer possess the property of assisting 
 the portal circulation. It was under such circumstances that Virchow 
 correctly pointed out that the veins of the mesentery, spleen, and 
 stomach, are distended with dark blood. (Virchow '* Archives, Vol. V., 
 p. 289.) The portal system is particularly liable to suffer from such 
 derangements, owing to its double capillary circulation, and to the com- 
 paratively scanty muscular tissue and feeble contractility of its vascular 
 walls. 
 
 t Hyperemia of the liver from abuse of spirits soon leads to cirrhotic 
 
374 HYPEREMIA OF LIVER 
 
 Congestions of the liver constitute the starting-point of almost 
 all the structural diseases of the organ. They also induce and 
 accompany the formation of pseudo-plasmata. An accurate know- 
 ledge, and a careful attention to these conditions are particularly 
 important in medical practice, inasmuch as at this stage of the 
 disease such results may be hoped for from treatment, as at a later 
 period it is usually vain to expect. 
 
 a. Congestions proceeding from the processes of Digestion. 
 
 Even in health, the quantity of blood contained in the liver is 
 liable to constant fluctuations, arising from the process of digestion. 
 The increased flow of blood to the mucous membrane of the stomach 
 and the active intestinal absorption, — both of which circumstances are 
 necessary accompaniments of this function, — increase the pressure 
 of blood towards the liver, and give rise to a temporary swelling of the 
 gland, which is compensated for by the augmentation of its secre- 
 tion and by an increased consumption of plasma in the cells of 
 its parenchyma. This hyperemia not unfrequently exceeds the 
 boundaries of health, as when acrid, irritating matters, such as 
 alcohol, pepper, mustard, strong coffee, &c, are taken in too large 
 quantity. The action of spirits in this way is the one of which we 
 know most. These liquids, if taken very frequently, give rise at 
 last to palpable changes of structure. In our climate, they gradu- 
 ally lead to cirrhotic degeneration ; but in hot countries, according 
 to the experience of Annesley,* Twining,t Cambay,J and others, 
 they contribute greatly to the development of suppurative hepatitis. 
 
 The other irritating substances just mentioned, are less apt than 
 spirits to be followed by injurious consequences, inasmuch as the 
 ingestion of an excess of any of them is usually only a matter of 
 occasional occurrence. Their action manifests itself chiefly by a 
 feeling of tightness and fulness in the right hypochondrium, accom- 
 panied by a distinct enlargement of the gland, which can be made 
 
 degeneration of the gland, whilst other forms of congestion may last for a 
 long period without producing any such results. Moreover, the circula- 
 tion in the hepatic artery often appears to become deranged, and black 
 pigment is very frequently found deposited in the finer twigs of this 
 vessel. 
 
 * Annesley, Diseases of India. London, 1828. Vol. I., p. 488. 
 
 t Twining, Diseases of Bengal, Vol. I., p. 247. 
 
 % Cambay, De la Dyssenterie ties pays chattels, p. 217. 
 
DEPENDENT UPON DIGESTION. 375 
 
 out by means of the pleximeter, and by pains which are wont to 
 eomeon soon after meals, and which, as a general rule, cease after a 
 short time. These results are chiefly observed during the warm seasons 
 of the year, and in individuals who have already suffered from some 
 affection of the liver, or in whom that organ is unusually irritable. 
 
 Beau* has, by a series of observations endeavoured to prove, 
 that severe neuralgic pains in the liver can be produced by the same 
 exciting causes as those just mentioned,— an attempt, which, in my 
 opinion, can lead to no certain results, when we consider the difficulty 
 of excluding the co-operation of gall-stones. We shall return here- 
 after to this matter in treating of Cobca hepatis. 
 
 The question has frequently been discussed in what way acrid 
 ingesta come to act upon the parenchyma of the liver. Broussais 
 is of opinion that the irritation of the intestinal mucous membrane 
 is transmitted along the bile ducts to the parenchyma of the liver • 
 others have assumed the existence of an irritation sympathetic with 
 that of the bowel; whilst Beau first of all pointed out the direct 
 action of irritating substances by their absorption into the portal 
 blood.f It is impossible to arrive at an accurate discrimination 
 between these different modes of action; substances which, like 
 alcohol, are readily taken up into the blood which is about to pass 
 through the liver, produce their effects principally by way of absorp- 
 tion; other substances, again, which are less easily absorbed, 
 transmit their effects from the mucous membrane along the nerves ; 
 a direct transmission of the irritation along the bile ducts, such as 
 was assumed by Broussais, occurs much more rarely, and is attended 
 in most cases by other consequences, involving the excretory ducts 
 more than the glandular substance itself, as, for instance, catarrh of 
 the bile ducts, obstruction of the secretion, &c. 
 
 The form of hyperemia just alluded to, usually passes off without 
 being productive of any great mischief; it is only from its recurring 
 repeatedly, or from its co-existence with other irritating causes, that 
 it leads to more serious disease ; even then the affection is most fre- 
 quently of a chronic nature. 
 
 This last condition of chronic congestion is particularly observed in 
 
 * Archives general, de Med. April, 1851. 
 
 t Afterwards, in treating of diseases of the portal vein, we shall consider 
 a fourth modification of the mode of transmission of pathological pro- 
 cesses from the intestine to the liver, namely, that through the veins, 
 which was particularly pointed out by Ribes (Andral, op. tit., p. 290). 
 
376 HYPEREMIA OF LIVER. 
 
 individuals who devote themselves too freely to the pleasures of the 
 table, and who make use of a succulent stimulating diet, notwithstand- 
 ing their sedentary mode of life, their great muscular inactivity, and 
 comparatively imperfect respiration. In such cases, the absorption of 
 nutritive material exceeds the waste, and, sooner or later, but usually 
 in the middle period of life, the muscles become flabby, and other 
 affections show themselves in patients with a hereditary predispo- 
 sition, while even at an earlier period there arises a disproportion 
 between the power of the heart and the quantity of blood, owing 
 to which that part of the vascular apparatus where the greatest 
 obstacle has to be. overcome, becomes over- distended with blood. 
 This is usually the portal system, which is the more readily 
 congested from the fact, that under the circumstances just men- 
 tioned the irritation of the intestinal mucous membrane, resulting 
 from errors in diet, as also the copious intestinal absorption, 
 contribute to the interruption of the circulation. In this way, one 
 often sees chronic gastro-intestinal catarrh commencing with irregu- 
 lar, and, for the most part, retarded defsecation, and accompanied 
 by swelling of the hemorrhoidal veins, tympanites, and pains in the 
 hypochondrium. To these symptoms there is frequently super- 
 added a habitual hypersemia of the liver, which from time to time 
 increases and mates itself known through painful distention of the 
 right hypochondrium, a jaundiced tinge of the conjunctiva, &c* This 
 condition may exist for a long time without inducing more serious 
 lesions of this gland, such as fatty infiltration of the cells and catarrh 
 of the bile ducts. In most eases, we may succeed without any 
 difficulty in moderating or removing the hypersemia of the liver by 
 means of a carefully regulated diet, by avoiding all indigestible, 
 fatty, and over-nutritious articles of diet, by increasing the waste of 
 material by means of active exercise in the open air, riding, &c, as 
 well as by the use of bitter laxative medicines, the solvent extracts 
 with salines, rhubarb, aloes, and similar substances, by the applica- 
 tion of leeches to the anus, and still better, by regulating the intes- 
 tinal secretions by the use of the Springs of Kissingen, Homburg, 
 Marienbad, and Karlsbad t ; but if the condition is one of very old- 
 
 * Every extensive development of gas in the intestinal tube, by press- 
 ing the blood from the roots of the portal vein towards the trunk of that 
 vessel and the liver, may induce transient hypersemia of this organ ; great 
 accumulations of fascal matter may give rise to similar results. 
 
 •(■. See page 125, note. — Transl. 
 
TRAUMATIC HYPEREMIA. 37Z 
 
 standing, it is seldom that the improvement is permanent. It would 
 appear that the nutrition of the muscular tissue of the intestinal 
 canal, and probably also of the lining membrane of the portal veins 
 becomes at an early period impaired, and as a result of this, there is 
 induced a predisposition to relapses, and the patient's complaints are 
 protracted. Accurate examinations of the anatomical characters of 
 the tissues just mentioned are necessary, in order to confirm and 
 explain those circumstances which hitherto have been made the sub- 
 ject of theoretical speculation. Along with the mechanical de- 
 rangements which have been pointed out, we usually find abnormal 
 conditions of the metamorphosis of matter, which were formerly 
 attributed to arthritis, to the formation of urinary gravel, &c. Our 
 knowledge of these conditions deserves to be placed upon a firmer 
 footing than it is at present ; we shall afterwards see how far the 
 tissue of the liver may be implicated in their development. 
 
 This is not the place to discuss in detail the various morbid processes 
 which medical men have included under the name of abdominal 
 plethora; when the liver is implicated, which, however, is by no 
 means the general rule, there is in most cases nothing more than 
 hypersemia, or fatty degeneration {see Chapter on Fatty Degenera- 
 tion, page 306) ; more serious lesions, such as cirrhosis, induration, or 
 lardaceous degeneration are rarely present. The mutual relations 
 which exist between these affections and the condition of the intes- 
 tinal mucous membrane, will be understood from what has been 
 already stated. 
 
 b. Traumatic Hyperemia. 
 
 Contusion of the hepatic region is not unfrequently observed to 
 give rise to accumulations of blood in the liver, entailing a consider- 
 able amount of swelling of the organ. Piorry has described a case 
 of this nature resulting from the blow of a spent pistol-ball ; the 
 remarkable increase in the volume of the gland, which was ac- 
 companied by dyspnoea and fever, disappeared after a copious 
 venesection, so soon as the following day. I have myself met with 
 a similar enlargement of the liver in a railway-labourer, the right 
 side of whose chest had been crushed by a waggon. The, recovery 
 in this instance was more tedious ; the patient continued jaundiced 
 for three weeks, at the end of which time he was dismissed from 
 the Hospital cured. In many cases, the effects of the contusion are 
 restricted to the part ; the hypersemia may then pass readily into 
 
378 HYPEREMIA OF LIVER 
 
 inflammation, which may lead insensibly to the formation of abscess. 
 Most of the hepatic abscesses which occur in our own climate, have 
 this traumatic origin. R. Bright has published some cases, which ap- 
 pear to prove that the hyperaemia resulting from external violence may 
 pass into a chronic form of inflammation, ending in induration. 
 
 c. Hyperemias dependent upon the influence of a high temperature 
 and miasmatic effluvia. 
 
 In hot climates, and particularly in those marshy districts 
 which exhale deleterious substances, hyperaemias of the liver, and the 
 injurious consequences resulting therefrom, are among the ordi- 
 nary forms of disease. In addition to the high temperature, the 
 miasmatic infection of the blood contributes very powerfully to their 
 development; but it is a difficult matter to determine the share 
 which is taken by each of these two agents. There are facts which 
 would seem to show that the influence of heat has been over- 
 estimated, owing to the idea, that in a high temperature the liver acts 
 vicariously with the lungs. Haspel states, that in the year 1846, 
 when the temperature in Oran was unusually high, so that the 
 marshes were dried up and the sources of malaria destroyed, hepatic 
 affections, in place of being more prevalent, completely ceased. In 
 India, the prevalence of hepatic diseases depends less upon the tem- 
 perature of the stations, than upon their situation in the neighbour- 
 hood of stagnant water and marshes. Hepatic affections usually 
 attain their greatest frequency in autumn, when the temperature is 
 beginning to fall. In the cold foggy climate of Holland, Pringle 
 found conditions of the liver precisely similar to those met with 
 in the. tropics. Malaria must, therefore, be regarded as the principal 
 exciting cause of hyperaemia of the liver, although the co-operation 
 of a high temperature cannot be doubted. 
 
 The hyperaemia of the liver, which is wont to be developed in 
 warm climates, usually attains a remarkable intensity, and, not 
 unfrequently, in a short time induces serious structural changes. 
 The gland is distended with dark blood ; the gall ducts and bladder 
 are filled with secretion, and in this condition haemorrhages and 
 sub-peritoneal effusions take place in the liver, which may end 
 in softening of the parenchyma; in other cases, limited inflam- 
 matory deposits are formed, which, after a shorter or longer period, 
 terminate in abscess; or derangements of nutrition arise, which 
 
FROM HIGH TEMPERATURE AND MIASMATA. 379 
 
 give rise to hypertrophy or fatty degeneration, or, on the other 
 hand, to induration, or, less frequently, to cirrhotic degeneration 
 with shrinking of the parenchyma.* 
 
 The hepatic hyperemias of the tropics are often uncomplicated, 
 but more frequently they make their appearance along with dysen- 
 tery, or in conjunction with malarious fevers of an intermittent, re- 
 mittent, or continuous type. In the latter case, hypersemic swellings 
 of the spleen, and often of the kidneys also, co-exist with the hepatic 
 affection, and in this way the various complications originate, the 
 pathology and symptoms of which we have already briefly alluded to. 
 
 Simple hypersemia is either acute or chronic in its progress ; the 
 derangements to which it gives rise are more marked in the former 
 ease than in the latter. Chronic hypersemia is usually developed so 
 slowly and insidiously that its existence is frequently not recognised 
 until serious structural changes in the hepatic tissue, such as 
 abscesses, induration, &c, take place, and remove all hopes of a 
 favourable result from treatment. 
 
 The acute form of hypersemia is characterised by more or less 
 painful distention of the right hypochondrium, accompanied by 
 dyspnoea, and often, also, by tension of the splenic region, and pains 
 stretching towards the right shoulder and lumbar region. Along 
 with these symptoms, the tongue is either clean or sometimes coated 
 grey, amd there is headache, nausea, and vomiting of mucous or 
 green bilious matter : the bowels are irregular ; in some cases they 
 are constipated, but more frequently there is diarrhoea, with yellow, 
 bilious, or sometimes even bloody stools : at the same time, there is 
 great depression of spirits and rapid loss of strength, in most cases, 
 without any increased frequency of pulse or elevation of temperature. 
 After some days or weeks the symptoms quite disappear, or slight 
 derangements remain, obvious only to an attentive observer, and 
 denoting the transition of the acute into the chronic form. 
 
 Although the unpleasant sensations in the right hypochondrium 
 may abate or disappear, the hepatic dulness still remains extensive ; 
 the appetite only partially returns, some articles of diet, particularly 
 animal food, excite loathing, and the tendency to diarrhoea continues. 
 These symptoms are subject to exacerbations from time to time ; the 
 hepatic tumour increases, and the gastric and intestinal derange- 
 
 * The deposits of pigment and their consequences, which one meets 
 with under such circumstances, have already been treated of in Chap. 
 VIII. 
 
380 HYPEREMIA OF LIVER 
 
 ments become more marked. Amidst alternations in the severity of 
 these symptoms, the patients emaciate more and more, and become 
 sad and desponding ; their skin assumes a pale cachectic appearance, 
 or sometimes there is jaundice ; and dropsical effusions are poured 
 out into the abdominal cavity, and into the subcutaneous areolar 
 tissue. Towards the termination of the disease, there are frequently 
 developed exhausting catarrh of the intestines, dysenteric affections, 
 and intermittents of an irregular type, accompanied by suppuration 
 of the parotid, &c. ; or symptoms of suppurative fever, indicating the 
 formation of abscess in the liver, may show themselves. 
 
 These symptoms of the final stage of chronic hypersemia are 
 mainly dependent upon the nature of the structural changes which 
 the organ undergoes during the progress of the affection, and vary 
 in accordance with the varying character of these changes. Upon 
 post-mortem examination, the liver is sometimes found to be con- 
 gested and softened, at other times it is pale and jaundiced or fatty, 
 or it may be indurated and cirrhotic, or lastly, it may be pene- 
 trated by abscesses. The study of the clinical history of these 
 pathological changes will explain the varieties in the symptoms 
 induced by chronic hypersemia of the liver. 
 
 In temperate climates, the affection usually runs a milder course, 
 the symptoms are less prominently marked, and the modes of ter- 
 mination are different. Hypersemia of the liver may exist here for a 
 long period, before it gives rise to derangements of nutrition of any 
 consequence ; abscesses are scarcely ever met with. What we most 
 frequently observe is an increase in the volume of the liver, caused 
 by fatty deposit, or by an infiltration of the parenchyma with an 
 albuminous substance, which gradually passes into colloid degenera- 
 tion ; in rare cases the liver becomes cirrhosed. Acute hyperemia 
 of the liver is especially observed during the hot summer months ; 
 chronic hypersemia, with its sequelse, is not usually developed until 
 autumn. 
 
 The first object, in the treatment of the acute form, is to remove 
 everything which can act by stimulating the action of the liver. The 
 diet is to be restricted to mild demulcent or somewhat acid vegetable 
 substances ; animal food, fat, strong spices, and alcoholic drinks are 
 to be avoided. The reduction of the excess of blood in the portal 
 system and in the liver, is best effected by the application of leeches 
 to the anus, tepid baths, and cooling saline purgatives, such as 
 tamarind pulp, purified tartar, and sulphate of soda. If spontaneous 
 
FROM HIGH TEMPERATURE AND MIASMATA. 381 
 
 diarrhoea sets in, it must not be checked too early; when it is neces- 
 sary to interfere, it is best to make use of ipecacuanha, either in small 
 divided doses, or as an emetic. The general compression to which 
 the liver is subjected during the act of vomiting, has a great effect 
 upon the circulation of blood through the organ. The mineral 
 acids may also be prescribed. 
 
 When the affection is of a chronic or passive character, change of 
 air is advisable, taking care to avoid all marshy districts. In such cases, 
 in order to promote intestinal absorption, small doses of rhubarb, 
 aloes, colocynth, &c, in combination with the sesqui-chloride of 
 iron, and the bitter solvent extracts (page 123), will be found most 
 serviceable. An emetic may also be tried here with the object of 
 assisting, mechanically, the circulation of the blood in the hepatic 
 capillaries. A too strict diet is not adapted to this form of the 
 affection: easily digested nutritious food is necessary in order to 
 improve the condition of the blood and correct the atony of the 
 vascular apparatus; in more advanced cases, preparations of steel 
 are usually employed for the same purpose. Where circumstances 
 permit, a resort to Kissingen, Homburg, or Marienbad* is advisable. 
 Pringle, Lind, Portal, and Haspel have advised the application to 
 the hepatic region of blisters, setons, and moxas, and that they 
 should be kept open for a long period. Calomel and mercurial 
 ointment have been frequently recommended, but must be resorted to 
 with caution when a cachectic condition threatens to become de- 
 veloped. In cases where the hepatic affection is accompanied by 
 irregular forms of intermittent fever, quinine must not be employed 
 too hastily; this febrifuge is usually of little service until the 
 hyperaemia of the liver has been subdued by other means.f When 
 there is reason to apprehend from the symptoms, that an abscess is 
 forming, or that lardaceous degeneration, or cirrhosis, is being 
 developed, the treatment appropriate to each of these conditions 
 must be adopted. 
 
 Closely allied to the chronic hepatic hyperaemia of malarious re- 
 gions, is the congestion of the liver which is observed in scurvy, and 
 in similar conditions of the system, along with swelling of the 
 spleen. Baillouf and Portal§ long, ago described cases of extreme 
 
 * See note, page 125.— Transl. 
 
 t See Andral, op. cit., p. 31 ; and also Portal. 
 
 t Ballonii, Opera, Tom. III., p. 30. 
 
 § Portal, op. cit., p. 377. 
 
382 HYPEREMIA. OF LIVER. 
 
 distention of the hepatic vessels with dark blood, occurring in 
 scorbutic subjects, and giving rise to softening of the glandular 
 tissue. Andral* never failed to find this condition under such cir- 
 cumstances. According to my own observation, this morbid change 
 in the dead bodies of scorbutic patients has not been of such con- 
 stant occurrence ; I have repeatedly found the organ soft, infiltrated 
 with fat, and anaemic. Portal has recorded cases in which he ob- 
 tained favourable therapeutic results from the employment of anti- 
 scorbutic remedies combined with mild laxatives. 
 
 d. Hyperemia of the Liver, from the Suppression of habitual 
 Hemorrhages. 
 
 During the climacteric period of life, the cessation of the cata- 
 menia is not unfrequently observed to be accompanied by tumefac- 
 tion of the liver, which disappears with each recurrence, after a long 
 interval, of the uterine haemorrhage ; and in this way, the swelling 
 may return repeatedly. Like consequences are often noticed in the 
 earlier periods of life from sudden suppression of the menses ; Por- 
 tal, and more recently, Henoch,t have published cases of this 
 nature. The cessation of haemorrhoidal discharges of blood, which 
 have become habitual, may be followed by similar results. . It has 
 been ascertained, however, that this effect is by no means constant ; 
 in many cases, the liver remains quite unaffected ; hence, other 
 causes must co-operate in producing these congestions. So far as 
 my knowledge extends, this form of hyperaemia of the liver has 
 not been observed to give rise to any serious derangement in the 
 nutrition of the liver; it is obvious, however, that pre-existing 
 diseases of the liver may be aggravated and hastened in their pro- 
 gress by it, and hence, in treatment, care should be taken to repro- 
 duce at an early period the original haemorrhages, or to obtain some 
 compensation for them. 
 
 There can be no question that there are other causes of hyperaemia 
 of the liver, besides those already mentioned, with which we are either 
 imperfectly, or not at all, acquainted, and that, therefore, it must very 
 frequently happen that the cause of such an affection must remain 
 doubtful. Hence, the forms of hyperaemia hitherto considered 
 are not all, but merely the most important. There are three 
 
 * Ahdral, Clinique Midicale, T. II., p. 244. 
 t Henoch, op. cit., p. 85. 
 
HEPATIC HEMORRHAGE, APOPLEXY, &c. 383 
 
 agencies in particular, which may serve for the farther elucida- 
 tion of these affections. First, there is the influence of the nerves, 
 which has been in some measure experimentally proved by Claude 
 Bernard and others, although it has not been studied by any 
 means sufficiently, in order to be made use of in clinical investi- 
 gations. That this influence may operate powerfully under certain 
 circumstances, is apparent from the cases of diffuse inflammation 
 and acute atrophy of the Ever, which are developed immediately 
 after mental emotions.* A second agency, although one that is 
 but imperfectly understood, is the composition of the blood, the 
 importance of which, in malarious infection, in scurvy, &c, has 
 already been pointed out, but which probably assists in many other 
 cases, in producing hepatic hypersemia. Thirdly and lastly, the 
 altered nutrition of the walls of the hepatic vessels, which hitherto 
 has attracted but little attention, promises to explain many points, 
 not only in the chronic forms of hypersemia of the liver, which are 
 for the most part dependent upon atony of the blood-vessels, but 
 also in the partial congestions and apoplexies of the organ. These 
 causes of hypersemia must be reserved for further investigation. 
 
 As an appendix to the hyperemias, we shall consider as briefly 
 as possible : — 
 
 Hcemorrhage from the Liver. — Apoplexy and Hemorrhagic Sofbenmg 
 of the Liver. 
 
 These affections are in general of rare occurrence, and are for the 
 most part the result of intense congestions, which are induced by 
 miasmatic infection of the blood. Hence, they are particularly 
 observed as a complication of the malarious fevers of the tropics, 
 and occasionally, also, of the malignant intermittent fevers of colder 
 climates. The extravasated blood is sometimes accumulated in 
 isolated masses, or circumscribed beneath the serous covering of the 
 gland, whereas, at other times, the parenchyma is more uniformly 
 infiltrated with blood, and converted into a dark, abnormally soft, 
 and at some places, pultaceous mass, in which the remains of the 
 normal tissue can only be sparingly recognised. The gall-bladder 
 usually contains a dark, thick secretion.f This condition is accom- 
 
 * See above, page 234. 
 
 t It has not yet been determined with sufficient accuracy to what ex- 
 tent the extravasated blood enters the hepatic ducts and is conveyed, by 
 
384 HYPEREMIA OF LIVER. 
 
 panied during life by the symptoms of malignant marsh fever, by 
 pains in the right hypochondrium, and almost always by jaundice 
 and bilious vomiting ; the co-existence of haemorrhages from other 
 parts of the body is not uncommon. Annesley, Haspel, and others 
 record many examples of this nature, 
 
 Similar morbid changes in the liver have occasionally been ob- 
 served in scurvy and allied affections. Extravasations of blood in 
 the hepatic tissue, or beneath its capsule, are also, frequently caused 
 by external violence, and occasionally by obstructive hypersemia ; 
 they are particularly observed in new-born children after tedious 
 deliveries, and in conjunction with atalectasis of the lungs.* 
 
 There are some very remarkable cases of haemorrhage of the liver, 
 where, without any pre-existing complaints, the bleedings have come 
 on suddenly, and in a short space of time have terminated in death. 
 Andralf records instances of this nature, which do not admit of any 
 certain explanation. One case was that of the Superintendent of the 
 Mint at Paris, who, on awaking in the morning, complained of slight 
 uneasiness, and expressed a desire to remain in bed. Some hours 
 after, he was found dead. On post-mortem examination, the organs of 
 the head and chest appeared perfectly normal ; the abdominal cavity 
 contained a large quantity of partially coagulated blood. In -the 
 middle of the convex surface of the right lobe of the liver, an opening 
 was visible, the size of the point of the finger ; this led into a cavity, 
 the size of a hen's-egg, filled with blood, at the bottom of which 
 was detected the ruptured wall of a large branch of the portal vein ; 
 in other respects, the liver was healthy. Andral unfortunately 
 makes no mention of the condition of the coats of the vena porta. 
 In another case, described by Honore, the liver contained several 
 cavities filled with blood ; no search for a ruptured vessel was made. 
 Louis J found in the liver a cavity the size of a nut, filled with 
 
 them to the gall-bladder and intestine, or whether it does so at all. 
 Saunders believed that he had found blood in the bile in several cases ; 
 this secretion was almost black, coagulated, and deposited, upon the addi- 
 tion of water, a sediment consisting of red corpuscles. 
 
 * In a stillborn child, with hernia umbilicalis congenita, I have found 
 upon the convex surface of the left lobe of the liver a sub-peritoneal ex- 
 travasation of blood, 1 J inch in diameter, and at the same time smaller 
 extravasations in the substance of the gland. See further, F. Weber, 
 Beitrage %ur patholog. Anat. der Neugeborenen, Bd. III., S. 56. 
 
 t Andral, Clinique Medicale, T. II., p. 247. 
 
 I Louis, Recherch. anatomico-patholog., 1826, p. 381. 
 
HEPATIC HAEMORRHAGE. 385 
 
 coagula of blood arranged in concentric laminae. It is probable, that 
 these haemorrhages depend upon local diseases of the vascular coats, 
 which have not yet been sufficiently examined. In the Second Volume 
 of this wort, I shall communicate a case of fatty degeneration of the 
 coats of the portal vein, which occasioned rupture of this vessel 
 before its entrance into the liver, and, as a consequence of this, fatal 
 haemorrhage. The coats of this vein may be subject to similar 
 derangements of nutrition in the interior of the liver. 
 
 One additional case of haemorrhage from the liver may be here 
 mentioned in detail. 
 
 Observation No. XLTIII. 
 
 Tedious Delivery. — Symptoms of Peritonitis. — Jaundice. — Vomiting 
 of black flakes. — Delirium. — Death. 
 
 Purulent effusion in the peritoneal cavity. — Hemorrhagic softening 
 of the Liver. — Extravasation of blood beneath the capsule. 
 
 Caroline Herbst, aged 38, on January 10th, 1856, was confined for 
 the twelfth time; labour was tedious. The very day after, vomiting 
 and diarrhoea, with suppression of the lochial discharge, made their 
 appearance. 
 
 On the patient's admission into Hospital on the 18th, the abdo- 
 men was found remarkably distended and tympanitic ; dulness upon 
 percussion could be made out in the iliac regions ; there was a slight 
 amount of pain; the uterus extended a hand's-breadth above the 
 symphysis of the pubes ; the liver and spleen were of normal dimen- 
 sions; the stools were brown, hard, and scybalous. The organs of 
 the chest were normal j pulse 110 and small. Was ordered tama- 
 rinds with sulphate of soda and warm cataplasms. 
 
 On the 19th, the bloody discharge from the genital organs re- 
 turned ; meanwhile, the right hypochondrium had become painful ; 
 the pulse had risen to 120, and there was slight diminution of the 
 tympanites; the conjunctiva and the countenance had assumed a 
 jaundiced hue. The bowels had not been moved. Continuation of 
 the same remedies, and an enema. 
 
 On the 20th, the jaundice was very intense, and was accom- 
 panied by typhoid somnolence, great prostration, and repeated 
 vomiting of brown flaky masses. The urine drawn off by catheter 
 abounded in bile-pigment, was acid, and free from albumen, and had 
 
 CO 
 
386 HYPEREMIA OF LIVER. 
 
 a specific gravity of 1014. Was ordered phosphoric acid and ana- 
 leptics. The tympanites and somnolence increased, and death ensued 
 on the following morning. 
 
 Autopsy, 17 hours after death. 
 
 The body was of a dark-yellow colour; there were a few patches 
 of putrefaction. There were no important morbid changes in the 
 organs of the head or thorax; the heart contained dark, firmly 
 coagulated blood. A considerable quantity of purulent fluid dis- 
 tinctly tinged with bile was effused into the peritoneal sac; the 
 peritoneum was opaque and injected. 
 
 A greyish-yellow fluid, mingled with black flakes, was found in the 
 stomach; the mucous membrane was pale, and free from ulcera- 
 tion; the intestinal canal contained at its upper part, thin and 
 yellow, and at its lower, firm and brown, fsecal matter ; the mucous 
 membrane was normal. 
 
 The spleen was unaltered in size and consistence ; it weighed 0.17 
 kilogr. (6 oz. avoird.). The kidneys were of a jaundiced tint, but in 
 other respects normal. 
 
 The uterus extended about three inches" above the symphysis 
 pubis, and its inner surface was covered with a reddish-brown fluidj 
 but presented no morbid change of any consequence ; the veins and 
 lymphatics were empty ; the left ovary contained a cyst the size of a 
 walnut, filled with a clear fluid ; the vagina was of a livid hue, without 
 any exudation. 
 
 The liver appeared enlarged, it weighed 2.3 kilogr. (5 lbs \\ oz, 
 avoird.); its form was not much altered; its consistence was soft 
 and flabby, and some parts of the right lobe and lobulus quadratus 
 felt pultaceous. Beneath the serous covering, numerous extrava- 
 sations of blood were observed, varying in size from that of a 
 groschen (6£ Eng. lines, or rather less than a sixpence), to that of a 
 thaler (1£ inch, somewhat larger than a half-crown) ; a flabby, 
 bladder-like elevation of the capsule, filled with bloody fluid, and 
 more than an inch and a-half in diameter, was situated at the outer 
 margin of the right lobe. Numerous large and small extravasations 
 of blood were found in the parenchyma of the gland ; the glandular 
 tissue was at some places reddish-yellow or yellow, and exhibited 
 distinctly the outlines of the lobules ; at other places, it was of a 
 dirty reddish-brown colour. A large quantity of bloody serous fluid 
 
HEPATIC HEMORRHAGE. 387 
 
 exuded from the cut surface, especially from the deeply injected portal 
 margins of the lobules. The hepatic cells in the centre of the lobules 
 were normal ; at the periphery they were mingled with a quantity of 
 debris and free nuclei ; many of them contained oil globules ; there 
 was very little bile-pigment, either in a granular, or in a diffused 
 form. 
 
 The bile ducts contained a little pale-yellow mucus j and the 
 gall-bladder, a small quantity of thick, greenish-yellow hile;, free 
 from albumen. The branches of the portal vein, which were traced 
 as far as was practicable, were of normal character, and the fluid 
 blood contained in them presented nothing unusual under the 
 microscope. 
 
 This case, so far as regards the lesion of the hepatic tissue, was 
 allied to the changes which the liver is wont to undergo in the fevers 
 of tropical climates and in scurvy. No cause, however, of this 
 nature could be made out, while the idea of a putrid infection 
 of the blood was countenanced by neither the symptoms nor the 
 anatomical lesions. The intense hypereemia of the liver could not be 
 attributed to the suppression of the lochia, because the jaundice did 
 not make its appearance until this discharge had returned. It 
 would seem that the same condition was present in this case, 
 as, in a milder form, not unfrequently induces diffuse hepa- 
 titis and acute atrophy of the liver in pregnant females. The 
 incipient disintegration of the hepatic cells at the margin of the 
 lobules, the deposit of fat in these cells, and the infiltration with 
 fluid exudation, are circumstances which render this view of the 
 case more probable than any other. 
 
 cc2 
 
APPENDIX 
 
 OF OBSERVATIONS AND EXPERIMENTS IN SUPPORT OP THE 
 STATEMENTS MADE IN THIS WORK. 
 
 I. Observations of Disease. 
 
 No. I. (Page "55.) Tertiary syphilis — Tumour of the liver, which 
 ascended as high as the second rib, and consisted of echinococci, 
 together with lardaceous infiltration — Bulging and fluctua- 
 tion of the intercostal spaces — Displacement of the heart — 
 Immobility of the tumour upon deep inspiration — Diagnostic 
 value of exploration by a trocar. 
 
 No. IT. {Page 65.) Cancer of the small omentum — Compression of 
 the portal vein and atrophy of the liver — Ecchymoses in the 
 serous coat of the intestines and in the parietal peritoneum. 
 
 No. III. (Page 73.) Cancer of the right kidney — Displacement of 
 the liver upwards and to the left. 
 
 No. IV. (Page 104.) Pneumonia duplex — Icterus — Bilious stools 
 
 v. . . — Green expectoration, continuing for ten days after the cessa- 
 tion of the pneumonia, and for eight days after the disappearance 
 of the jaundice from the skin. 
 
 No. V. (Page 132.) Dyspepsia — Symptoms of chronic simple ulcer 
 of the stomach — Jaundice — Distention of the gall-bladder — 
 Pleurisy on the right side — Dropsy — Petechise — Death. 
 
 Cancer of the duodenum and dilatation of the bile ducts — 
 Simple ulcer of the stomach — Exudation in the right 
 pleural cavity. 
 
 No. VI. (Page 137.) Cancerous deposit in the head of the pancreas 
 and in the duodenum — Occlusion and widening of the bile 
 ducts and of the pancreatic duct — Distention of the bile ducts, 
 with mucus and bile — Dysentery — Diminished secretion of 
 urine — Infiltration of the kidneys with solid deposits of bile- 
 pigment — Death from exhaustion. 
 
OBSERVATIONS OF DISEASE. 389 
 
 No. VII. {Page 145.) Cancerous deposit in the head of the pancreas 
 — Occlusion of the ductus choledochus and of the pancreatic 
 duct — Enlargement of the pancreatic duct and of the bile 
 ducts — Jaundice — Intestinal haemorrhage — Diabetes, jnellitus 
 — Dysentery — Death from exhaustion. 
 No. VIII. {Page 151.) Closure of the ductus choledochus by newly- 
 formed areolar tissue, the result of Peri-hepatitis — Jaundice 
 and enlargement of the bile ducts — Dropsy — Secondary pneu- 
 monia — Death. 
 No. IX. {Page 162.) Contusion of the pelvic bones — Kigors — 
 Somnolence — Jaundice — Albuminuria — Death. 
 Phlebitis of the pelvic veins — Metastatic deposits in the 
 lungs — Soft anaemic liver. 
 No. X. {Page 164.) Acute articular rheumatism — Endocarditis — 
 Repeated rigors — Painful enlargement of the spleen — Jaundice 
 — Albuminuria and haematuria — Petechias — Convulsions — 
 Coma, and death. 
 
 Recent deposits upon the mitral valve — Splenic infarctions — 
 Elabby anaemic liver — Ecchymoses upon the mucous mem- 
 brane of the intestines, bronchi, &c. 
 No. XI. {Page 168.) Exanthematic typhus — Jaundice — Albumi- 
 nuria — Haemorrhage from the bowela — Ecchymoses of the skin 
 — Parotitis — Death on the twelfth day. 
 
 Small spleen — Anaemic liver — Normal hepatic cells — Un- 
 obstructed bile ducts^-No disease of the intestine, nor of 
 the mesenteric glands. 
 No. XII. {Page 170.) Petechial typhus — Jaundice-^Albuminuria 
 Suppression of urine — Right pneumonia — Dysentery — Death 
 on the seventh day. 
 
 Lardaceous spleen of old date — Anaemia of the liver^— Exu- 
 dation into the right lung — Dysentery — Recent exudation 
 in the kidneys. 
 No. XIII. {Page 172.) Abdominal typhus — a severe rigor during 
 convalescence — Eresh enlargement of the spleen — Great tender-, 
 ness in the region of the liver, and afterwards of. the entire 
 abdomen — Jaundice — Dyspnoea — Somnolence — Death. 
 
 Cicatrizing typhus ulcers in 'the ileum — Recent enlargement 
 of the spleen — Round softened masses, of a brown colour, 
 and about an inch in diameter, in the liver-^-Bile ducts 
 unobstructed— ^-Peritonitis . 
 
390 APPENDIX. 
 
 No. XIV. (Page 199.) Repeated attacks of lumbago in the seventh 
 month of pregnancy — Gastric catarrh — Icterus — Delirium — 
 Convulsions — Coma — Death under symptoms of blood-poison- 
 ing. 
 
 Acute atrophy of the liver — Complete disintegration of the 
 hepatic cells — Crystalline deposits in the tissue of the 
 liver and in the blood of the hepatic veins — Enlargement 
 of spleen — Abortion. 
 No. XV. (Page 202.) Symptoms of gastric catarrh and jaundice in 
 the seventh month of pregnancy — Delirium — Convulsions and 
 Coma — Abortion — Death on the seventh day of the disease. 
 Acute atrophy of the liver — Haemorrhage from the intestinal 
 canal, and from the mucous membrane of the bronchi — 
 Peculiar composition of the urine. 
 No. XVI. (Page 209.) Jaundice in the seventh month of pregnancy 
 — Severe pains in the head — Great restlessness — Abortion — 
 Vomiting of black fluid — Obstinate constipation — Coma — Pete- 
 chias — Death, eight days after the commencement of the jaundice. 
 Acute atrophy of the liver — Small spleen — Patty degenera- 
 tion of the kidneys — Abundance of leucine and tyrosine 
 in the urine — Urea and leucine in the blood. 
 No. XVII. (Page 214.) Symptoms of slight catarrhal jaundice, 
 lasting fourteen days — On the fifteenth day sudden maniacal de- 
 lirium ; haemorrhage from the stomach and bowels ; and death. 
 Atrophy of the liver ; its secreting cells partly disintegrated 
 and partly in a state of fatty degeneration. 
 No. XVIII. (Page 215.) Abdominal typhus — Profuse epistaxis— 
 Violent delirium — Jaundice on the fifth day — Disappearance of 
 the hepatic dulness — General muscular .tremors — Coma-r-Death 
 on the eighth day. 
 
 Small, shrivelled Hver, with partially disintegrated cells and 
 empty bile ducts — Tumefaction of the spleen — Deposits in 
 Peyer/s patches, and in the solitary glands of the ileum. 
 No. XIX. (Page 238.) Cancerous deposit in the duodenum — Occlu- 
 sion of the ductus choledochus — Intense jaundice — Convulsions 
 — Coma — Death. 
 No. XX. (Page 242.) Ascites — Anasarca — Diarrhoea — Delirium — 
 Coma. 
 
 Cirrhosis of liver — Deposits of leucine in the hepatic veins 
 — The central organs of the nervous system normal. 
 
OBSERVATIONS OF DISEASE. 391 
 
 No. XXI. {Page 243.) Ascites — Diarrhoea — Unconsciousness — 
 Coma. 
 
 Cirrhosis of the liver — Leucine in the blood and urine — Brain 
 normal. 
 No. XXII. {Page 245.) Jaundice of fourteen days' duration— Som- 
 nolence — Vomiting — Sudden supervention of violent delirium 
 - — Coma — Death. 
 
 Patty degeneration of the liver in its most advanced form — 
 Enlargement of the spleen. 
 No. XXIII. {Page 252.) Chronic atrophy of the liver with con- 
 siderable enlargement of the branches of the portal vein — A 
 small ulcer at the pylorus, without any constriction — Distinct ' 
 peristaltic movements of the stomach — Death from exhaustion. 
 No. XXIV. {Page 258.) Tertian and quotidian intermittent of 
 three months' duration — Anasarca — Ascites — Diarrhoea — Death 
 from exhaustion. 
 
 Atrophied pigment-liver and pigment-spleen. 
 No. XXV. {Page 259.) Persistent and oft-recurring quotidian in- 
 termittent — Hydrsemia — Anasarca — Ascites — Profuse diarrhoea 
 — Death from exhaustion. 
 Atrophy of the liver — Blocking -np of the capillaries by 
 pigment. 
 No. XXVT. {Page 261.) Atrophy of the liver with fatty infiltra- 
 
 tration- — Dysenteric cicatrices — General dropsy. 
 No. XXVII. {Page 262.) Chronic dysentery — Displacement of the 
 intestinal canal — Atrophy of the liver — Death from exhaustion. 
 No. XX V 111. {Page 265.) Pibrous thickening of the mesentery, 
 with firm adhesions of the small intestine and of the omentum 
 — ta the abdominal wall. Deposit of bluish-black pigment 
 and cicatrizing ulcers- in a coil of the small intestine, three 
 feet long — Chronic atrophy of the liver— Ascites and general 
 dropsy. 
 No. XXIX. {Page 268.) Violent dyspnoea— Bloody sputa— Systo- 
 lic bruit over the pulmonary artery — Haemorrhage from the 
 stomach and bowels — Death from asphyxia. 
 
 Occlusion of the pulmonary artery by a thrombus, in conse- 
 quence of inflammation of the vessel — Coagulum of blood 
 in the portal vein — Ecchymoses of the peritoneum, as 
 well as of the mucous membrane of the stomach and 
 bowels — Atrophy of the liver. 
 
392 APPENDIX. 
 
 No. XXX". {Page 272.) Ulcer of the duodenum— Obliteration of por- 
 tal vein by compression — Death in consequence of haemorrhage 
 from the stomach and bowels — Liver and spleen of normal size. 
 No. XXXI. {Page 309.) Persistent intermittent . fever — Ansemia 
 and hydrsemia — Exhausting diarrhoea, with but little bile in the 
 stools — Death under cerebral symptoms. 
 Fatty degeneration of the liver — Small lardaceous spleen: 
 — A limited cancerous ulcer in the caecum. 
 No. XXXII. {Page 334.) Tertian intermittent fever of three 
 months' duration, ultimately with coma during the fits — : 
 Pneumonia passing on to consolidation — Sudden death. 
 Pigment-spleen and -liver — Induration of the lungs — The 
 brain free from pigment. 
 No. XXXIII. {Page 336.) Eebrile gastric catarrh. —Vertigo — 
 Convulsions — Coma — Return of consciousness — Parotid swell- 
 ing — Albuminuria — Death from exhaustion. 
 
 Melanaemia — Accumulation of pigment in the spleen, liver, 
 the grey matter of the brain and the kidneys. 
 No. XXXIV. {Page 337.) Quotidian fever— Enlargement of tha 
 Spleen — Coma — Death. 
 
 Melanasmia — Accumulation of pigment in the spleen, liver, 
 kidneys, and cortical portion of the brain. 
 No. XXXV. {Page 339.) Eever of an undecided type — Delirium — 
 Coma — Vomiting — Death on the fifteenth day. No albumin- 
 uria. 
 Pigment in the blood, the cortical portion of the brain, the 
 liver, kidneys, and spleen — Spleen slightly enlarged. 
 No. XXXVI. {Page 840.) Intermittent fever with convulsions 
 and loss of consciousness — Type irregular — No rigor stage — 
 Recovery under treatment with bark. 
 No. XXXVII. {Page 341.) Intermittent fever of an irregular type — 
 Two paroxysms of forty-eight hours' duration — Eurious deli- 
 . rium during the paroxysms — Cure. 
 No. XXXVIII. {Page 342.) Quotidian intermittent, with severe 
 
 vertigo— Febris vertiginosa of Paccinotti — Cure by quinine. 
 No. XXXIX. {Page 342.) Quotidian intermittent of four weeks' 
 duration — Diarrhoea — Albuminuria and haematuria — Sudden 
 Stupor — Convulsions — Death. 
 
 Accumulation of pigment in the spleen, liver, kidneys, and 
 brain. . . 
 
OBSERVATIONS OF DISEASE. 393 
 
 No. XL'. {Page 344.) Continued fever with symptoms like those of 
 typhus f— Coma — Albuminous and bloody urine, containing 
 dots loaded with black pigment — Eight pneumonia — Abortion 
 —Death on the sixteenth day. 
 
 Spleen and liver soft and loaded with pigment — Occlusion of 
 the tubuli uriniferi by pigment. 
 No. XLI. {Page 345.) Quotidian intermittent fever — Intermittent 
 albuminuria — Anasarca — Dysentery — Rapid cure by means of 
 quinine and iron. 
 No. XLII. {Page 348.) Persistent and oft-recurring intermittent 
 fever, ultimately of a quartan type — Copious albuminuria — 
 Kbrinons casts containing pigment in urine — (Edema — Rapidly 
 supervening ascites — Tapping after the inefficacious employment 
 - of steel and purgatives — Return of the fever — Paroxysm of two 
 days' duration — Death from exhaustion. 
 
 Pigment in the spleen — Occlusion of the hepatic capillaries — 
 Atrophy of the liver — Accumulation of pigment in the 
 kidneys — Consecutive pneumonia. 
 No. XLTII. {PageShQ.) Intermittentfeverofa tertian and quotidian 
 type, lasting for seven weeks — Intestinal catarrh — Hydremia — 
 Anasarca — Improvement under preparations of steel — Relapse 
 — Rapid increase of the dropsy — Unconsciousness — Death. 
 Pigment in the spleen and liver, without any implication of 
 the brain or kidneys. 
 No. XLIV. {Page 352.) Slight dysentery — Albuminuria — Death 
 from exhaustion — No cerebral disturbance. 
 
 Accumulation of pigment in the spleen, liver, brain, kidneys, 
 and pancreas. 
 No. XLY. (Page 353.) Abdominal typhus — Repeatedly recurrent 
 intermittent fever — Dysentery — Exhaustion — Death. 
 
 Spleen and liver loaded with pigment — Liver atrophied — 
 Dysenteric ulceration of the large intestines. 
 No. XLYI. {Page 368.) Constriction of the left auriculo-ventricular 
 opening of the heart — Incompetence of the tricuspid valves — - 
 Marked venous pulse — Haemoptysis — Albuminuria — Obstruc- 
 tive hypersemia of the liver, stomach, and large intestine. 
 No. XLVII. {Page 370.) Constriction of the left auriculo-ventri- 
 cular opening of the heart — Repeated attacks of oedema of the 
 lungs— -Albuminuria — Congestion of the river- from obstructed 
 circulation — Hsemorrhagic erosions of the stomach — Intestinal 
 mucous membrane pale and tumid. 
 
394 APPENDIX. 
 
 No. XL VIII. {Page 385.) Tedious delivery— Symptoms of perito- 
 nitis — Jaundice — Vomiting of black flakes — Delirium — Death. 
 Purulent effusion in the peritoneal cavity — Hemorrhagic 
 softening of the liver, and extravasation of blood beneath 
 the capsule. 
 
 n. EXPERIMENTS IN SUPPORT OF THE THEORX OP ICTERUS, 
 ADVOCATED IN THIS WORK. 
 
 Injection of pure bile into the blood of living animals. 
 
 In order to ascertain the effects upon the various functions resulting 
 from the absorption of a large quantity of bile into the blood, but par- 
 ticularly with the object of tracing what becomes of the bile in the 
 blood,— whether it is transformed, or is excreted as bile, and, if trans- 
 formed, what may be the nature of the changes it undergoes, — a series 
 of experiments were undertaken, the results of which are here given. 
 Fresh ox-bile, — from which the mucus had been removed by means of 
 alcohol, and the whole of the colouring-matter, by animal charcoal, — 
 was employed for injection. Two or three, and in some cases,, four 
 or five, grammes* of dried bile were dissolved in from thirty to forty- 
 five grammes of distilled water, and filtered; the colourless or pale- 
 yellow fluid was then carefully injected into the jugular veins, or more 
 rarely, into the veins of the thigh, a quantity of blood corresponding 
 to that of the injected fluid, having previously been drawn off. by the 
 opening in the vein, so as to prevent the vascular system being 
 over-distended. In some cases, the inspissated bile of the Prussian 
 Pharmacopoeia was employed in place of fresh bile. Dogs were the! 
 animals on which the experiments were always performed ; in most 
 instances, they had been previously etherised to a slight degree; 
 but by the time of the injection the action of the ether had 
 ceased, and could no longer mask any derangements of the nervous, 
 system, which might make their appearance. After the injection, 
 the animals were placed in a box constructed for the collection of 
 the urine, and carefully watched. In most cases, however, the urine 
 was poured directly into the utensil by compressing the bladder, so 
 that the possibility of the admixture of any foreign matter was com- 
 pletely excluded. Some of the animals died under symptoms of 
 • 1 gramme = 15.4325 troy grains- 
 
EXPERIMENTAL ENQUIRIES. 395 
 
 violent dyspnoea (obstruction of the capillaries of the lungs), owing 
 to the entrance of air into the lungs or to the too great consistence 
 of the injected fluid; in other cases the urine passed into the box, 
 was soiled; twenty-nine of the experiments succeeded in such a way 
 that their results could be made use of.* 
 
 1. Effects of Bile introduced into the Blood upon the Junctions of the 
 Nervous System. 
 
 In no case did any remarkable derangements of the nervous func- 
 tions follow the injection. As soon as the bile entered the blood, 
 the animals usually appeared, by licking with the tongue, to expe- 
 rience a change of taste ; but in no case were stupor, convulsions, 
 retardation of the pulse, &c, observable ; vomiting alone occurred 
 Tepeatedly (perhaps in one-fourth of the experiments), and particu- 
 larly in those cases where the inspissated ox-bile was employed; in 
 some of. these cases, also, the experiment was followed by some drowsi- 
 ness. A short time after the injection, so little that was unusual 
 could be observed in the behaviour of the animals, that in one 
 the operation was performed four times in different veins, without 
 being productive of any lasting injury. 
 
 2. Changes in the urine^r-Appearance of bile-pigment, S/'c. 
 
 The character of the urine which was voided after the injection 
 varied; sometimes it contained a larger or smaller quantity of 
 colouring-matter, and at other times it contained none ; the former 
 was the case in 19, and the latter in 10, of the 29 experiments. 
 
 The urine containing colouring-matter was always passed in small 
 quantity; it was of a greenish-brown colour, became turbid upon 
 cooling, and then appeared green, rapidly depositing flakes, which, 
 under the microscope, presented a finely granular appearance. When 
 collected upon a filter, this deposit formed a dark, grass-green layer, 
 which dried readily, and which, when recently dried, exhibited the 
 characteristic properties of the colouring-matter of bile, becoming 
 decomposed by the action of impure nitric acid, or by a mixture of 
 
 * I omit here the experiments which I performed seven years ago at 
 Gottingen and Kiel with filtered ox-gall ; inasmuch as the changes in the 
 urinary secretion were not investigated, and, consequently, they are of but 
 limited value. 
 
396 . . APPENDIX. 
 
 sulphuric and nitric acids, with a lively play of colours of green, 
 blue, violet, and red. The flakes which were suspended in the urine 
 presented unmistakably the same play of colours, although in a 
 fainter degree. The reaction of the urine was, in most cases, neutral 
 or alkaline, the removal of the flakes of colouring-matter was 
 speedily followed by an abundant deposit of triple phosphates ; the 
 specific gravity of the urine varied from 1012 to 1019. In 17 
 of the 19 cases the urine was albuminous, and after the separation 
 by filtration of the green flakes, its colour was blood-red, apparently 
 owing to dissolved blood-pigment; no blood corpuscles could be 
 detected in the sediment. In two cases mere traces only of albumen 
 could be found, along with an abundance of colouring-matter. This 
 altered urine was voided from four to twenty hours after the injec- 
 tion ; in one case, in which there was obstinate retention of urine for 
 forty-eight hours, the colouring-matter was very distinct; but in 
 most cases the urine, excreted from twenty-four to forty-eight 
 hours after the injection, had regained its normal characters. 
 
 3. Chemical examination of the urine, passed within 24 hours of 
 the injection of bile. 
 
 a. Examination of the urine which contained colouring-matter. 
 
 In five of the nineteen cases, the urine was freed by filtration from 
 the pigment flakes, evaporated to dryness, and the residue extracted by 
 means of ether, and afterwards by alcohol. In no case, did. the 
 ethereal extract contain an amount of colouring-matter deserving of 
 mention, but only traces of a yellow fat. The alcoholic extract was 
 coloured brown, and did not usually exhibit the reaction of bile- 
 pigment ; in one case only, where the animal had died of dyspnoea 
 some hours after the injection, did the greenish-brown colouring- 
 matter obtained by means of alcohol, and which upon evaporation 
 separated in the form of flakes, present the properties of bile-pigment. 
 This alcoholic extract, when reduced to the consistence of syrup, 
 exhibited the coloured rings characteristic of the chromogenic 
 ingredients of bile; and green, blue, violet, and red rings, were 
 observed to be formed upon the vessel by the action of atmospheric 
 air during evaporation. 
 
 . Ppttenkofer's test with sugar and sulphuric acid failed to detect 
 any of the biliary acids. 
 
EXPERIMENTAL ENQUIRIES. 397 
 
 In four of the five eases, the alcoholic extract contained leucine in 
 considerable quantity. 
 
 In three cases crystals were obtained, which, from their characters, 
 must be assumed to have been taurine, but their quantity was too 
 small to admit of their being further examined. 
 
 In five cases the urine filtered from the flakes was treated with 
 neutral and basic acetate of lead; the precipitate was dried, digested 
 with alcohol and boiled. The alcoholic solution, which only took up 
 small quantities of the compound of lead, was freed frbm lead by 
 means of solution of sulphuretted hydrogen and concentrated. There 
 remained a substance like myeline, and likewise leucine in the form 
 of globules, composed of concentric layers, or of drusic masses made 
 up of acicular crystals, together with isolated crystals of urea. The 
 urea as well as the leucine appeared to be left, owing to the imper- 
 fect washing-out of the lead-compound. The mass was repeatedly 
 re-crystallized, but no crystalline forms, corresponding to those of the 
 acids of the bile, ever made their appearance, nor did Pettenkofer's 
 test in any case yield a distinctly positive result. 
 
 - In order to prove the certainty with which the biliary acids could be 
 detected in the urine by treatment with lead, a small quantity of ox- 
 bile freed from colouring-matter, was dissolved in healthy urine; 
 the greater portion of it could be obtained again by precipitation 
 with lead ; and the alcoholic extract of this precipitate, when freed 
 from lead, presented distinctly the characteristic reaction with Pet- 
 tenkofer's test. "We may therefore conclude, that in the above 
 experiments the biliary acids were not excreted in an unchanged 
 condition in the urine. 
 
 5. Examination of the urine, which was passed free from colouring- 
 matter after the injection of bile into the blood. 
 
 Of the ten cases in which the urine was passed clear and pale, 
 there was -invariably a remarkable increase of the secretion ; the 
 quantity voided in twenty-four hours not unfrequently amounted to 
 about 1000 cubic centimetres (35 fluid ounces). This urine was 
 carefully examined in eight cases. The specific gravity varied from 
 1008 to 1012 : on the addition of nitric acid, the pale-yellow colour 
 was not changed in any way, so as to remind one of bile-pigment ; 
 no albumen was precipitated. In order to isolate any biliary acids 
 which might have passed oyer, unchanged, the secretion voided 
 
398 APPENDIX. 
 
 within the first twenty-four hours was precipitated by neutral and 
 basic acetate of lead; the precipitate was collected and dried, and 
 digested and boiled in alcohol ; and then the filtrate was freed from 
 lead by means of solution of sulphuretted hydrogen, and condensed. 
 The quantity of the compound of lead, soluble in alcohol, appeared 
 to vary according to the longer or shorter time that the precipitate 
 had been washed with distilled water; in the former case, the quantity 
 was small, in the latter it was large. The residuum remaining after 
 the removal of the lead, and the evaporation of the spirit of wine, 
 exhibited in five cases very beautiful crystals of leucine, and twice, 
 where the washing had been only superficial, urea also ; the so-called 
 myeline, was usually seen to accompany these substances. When 
 treated with sugar and sulphuric acid, in two cases only did the 
 residuum yield the red colour indicative of traces of the acid of 
 bile; in the other cases, there was a negative result. In one instance 
 the colourless spirituous solution, after being freed from lead, ex- 
 hibited, shortly before complete desiccation over the water-bath, the 
 colour of the chromogen of bile ; in this instance, too large a quantity 
 of free sulphuric acid was not present ; at least leucine was found 
 undecomposed in the residuum. 
 
 In one other case, where the urine, which was free from both 
 colouring-matter and albumen, was at once condensed, flakes of a 
 green colouring-matter were formed during evaporation, which with 
 nitric acid presented the same reaction as was observed in the 
 spontaneous precipitate of the first nineteen cases. This appearance 
 was not produced in two experiments which were subsequently made 
 in the same way. 
 
 In many of the cases the urine was precipitated by lead, and after 
 the removal of the excess of this metal, evaporated. Isolated globules 
 of leucine could usually be found in the residue, which was loaded 
 with urea, but sometimes they were searched for in vain in the mass 
 of other crystals. 
 
 The following propositions result from the preceding series of 
 experiments : — 
 
 1. The injection of large quantities of bile into the blood of living 
 animals is followed by no important derangement in the vital 
 functions. 
 
 2. After the injection into the blood-vessels of large quan- 
 tities of bile deprived of its colouring-matter, pigment is in most 
 cases excreted, along with the urine, which exhibits .most of the 
 
EXPERIMENTAL ENQUIRIES. 399 
 
 characteristic properties of bile-pigment.* This colouring-matter 
 closely corresponds in its behaviour with the products, which may 
 be formed artificially by the action of sulphuric acid upon the acids 
 of the bile. 
 
 3. In rare cases, in place of the colouring-matter, we find chro- 
 mogen substances, which are not transformed into colouring-matter 
 until the evaporation of the urine upon exposure to the air. 
 
 .4. Unchanged biliary acids are not found along with the colouring- 
 matter, but leucine is usually present.t Taurine and glycine cannot 
 be detected with certainty. 
 
 5. The injection of bile is, in some cases, not followed either by 
 the excretion of colouring-matter with the urine, or by the appear- 
 ance of large quantities of unchanged bile. 
 
 The causes of this anomaly are unknown ; the failure in the 
 appearance of the pigment is accompanied by a profuse secretion of 
 urine, whilst its presence is almost always associated with albu- 
 minuria, and often also with haeinaturia. The appearance of the 
 colouring-matter appears to be favoured by whatever interferes with 
 the respiration, at all events, it was particularly abundant in one 
 animal, which died asphyxiated some hours after the injection, as 
 also in two other animals, which had oil introduced into their air- 
 passages with the object of obstructing their breathing. 
 
 The theory of that form of jaundice, which occurs without any 
 structural lesion of the liver or bile ducts, which has been already 
 discussed (page 89), mainly rests upon these observations. It is 
 obvious, that defects still remain to be filled up, before this view can 
 be regarded as firmly established. The only point proved with cer- 
 tainty, is the possibility of the transformation of the biliary acids into 
 colouring-matter, and the dependence of this transformation upon 
 
 * The insolubility of the pigment constitutes an apparent difference. 
 The colouring-matter, however, of the urine of jaundiced patients fre- 
 quently exhibits the same character ; in many cases, it can be completely 
 separated from the fluid by filtration. 
 
 t Experiments, with the object of detecting leucine in decomposing 
 bile, have failed for the most part in summer; but a large quantity of 
 leucine, along with crystals of taurine, have been obtained from human 
 bile which has been for a week in a freezing state during winter. The 
 quantity of leucine which is obtained through precipitation of the biliary 
 acids by the neutral and basic acetate of lead, appears much too consider- 
 able to be probably induced by the decomposition of the mucus of the 
 bladder. 
 
400 APPENDIX. 
 
 certain conditions, which appear to consist principally in the func- 
 tional activity of the respiratory organs and kidneys. When these 
 conditions are more accurately determined, the individual causes of 
 the metamorphosis of bile in the blood, and the connection of the 
 various pigments with one another, must be better understood than 
 hitherto has been the case. 
 
 in. Experiments on the rapidity of the absorption of bile after 
 ligature of the ductus choledochus. See page 94. 
 
 rv. Experiments on the influence of a fatty diet on the generation 
 of fatty liver. See page 281. 
 
 v. Experiments on the injection of oil into the portal vein. See 
 page 282, note. 
 
LIST OF WOODCUTS. 
 
 Fig. Page 
 
 1. Liver of an abnormal, quadrangular form : upper surface . 40 
 
 2. The lower surface of a liver presenting an abnormally rounded out- 
 
 line, so that when in situ the left lobe scarcely reached to the 
 median line. The right margin is abnormally fissured . 40 
 
 3. Liver with an abnormally prolonged left lobe and a tight-lace 
 
 depression . . . . . .41 
 
 4. Adhesion of the extremity of the left lobe of the liver to the 
 
 spleen ; a section has been made through the line of junction of 
 the two organs . . . . .41 
 
 5. Cirrhosis of the liver, with remarkable atrophy of the left lobe . 42 
 
 6. Abscission of the right lobe of the liver with thickening of the 
 
 capsule, the result of tight-lacing . . .43 
 
 7. Abscission of both the right and left lobes of the liver, with en- 
 
 largement of the bile ducts and veins, below the tight-lace 
 fissure . . . . . .44 
 
 8. Abscission of the right and left lobes of the liver ; a section is 
 
 made, showing enlarged vessels in the tight-lace constriction . 44 
 
 9. Dislocation of the liver towards the median line; a depressed 
 
 furrow on the upper part of the right lobe ; apparent enlarge- 
 ment of the organ . . . . .46 
 
 10. Represents the situation of the parts in a case of acute atrophy 
 
 of the liver. The organ has become folded upon itself, and col- 
 lapsed towards the spine, the space corresponding to it being 
 occupied by folds of intestine . . . .49 
 
 11. Dislocation of the liver, downwards, resulting from exudation 
 
 into the right pleural cavity . . . .51 
 
 12. Dislocation of the liver towards the right side, resulting from 
 
 effusion into the left pleural cavity . . .52 
 
 13. Dislocation of the liver, especially of the left lobe, downwards, 
 
 resulting from a remarkable effusion into the pericardium . 53 
 
 14. The appearance presented during life by a patient affected with 
 
 echinococci of the liver. Simulated effusion into the right 
 pleural cavity . . . . .57 
 
 15. Arrangement of the viscera found after death in the individual 
 
 represented in Fig. 14 . . . . .60 
 
 16. Cancer of the great omentum, forming a mass which filled the 
 
 entire abdominal cavity . . . .67 
 
402 LIST OF WOODCUTS. 
 
 Pig. Page 
 
 17. Represents a case in which the right lobe of the liver was found 
 
 overlapped by the first curve of the colon . . .70 
 
 18. Represents a case in which the entire liver was covered by the 
 
 colon . , . . . .71 
 
 19. Enlargement of the bile ducts, and of the pancreatic duct in 
 
 consequence of a cancerous tumour in the head of the pan- 
 creas ...... 115 
 
 20. A thin section of the liver represented in Fig. 19, showing the 
 
 thickened walls of the bile ducts, and the hepatic veins sur- 
 rounded by cells loaded with bile pigment . . .116 
 
 21. An ulcerated cancerous deposit in the duodenum, obstructing 
 
 the bile ducts, and involving the head of the pancreas . 135 
 
 22. Represents an enormous enlargment of the bile ducts, resulting 
 
 from cancerous deposit in the head of the pancreas . . 1 40 
 
 23. Cancer of the head of the pancreas, penetrating in the form of a 
 
 pendulous tumour, into the interior of the duodenum, and pro- 
 ducing occlusion, and consequent dilatation of the pancreatic 
 and bile ducts ..... 143 
 
 24. Secreting cells of a liver which had undergone chronic atrophy . 248 
 
 25. Chronic atrophy of liver resulting from the external compression 
 
 of peritoneal exudations, circumscribed between the concave 
 surface of the diaphragm and the upper surface of the gland . 249 
 
 26. A magnified thin section of a liver, showing the changes in its 
 
 structure produced by chronic atrophy . . .256 
 
 27. Arrangement of the abdominal viscera in a case of chronic atrophy 
 
 of the liver . . . . . .264 
 
 28. Secreting cells from livers of dogs which had been fed with 
 
 fat . . . . . . .281 
 
 29. Hepatic cells loaded with oil globules, and with their nucleus still 
 
 visible . . . ., . .288 
 
 30. Represents a magnified thin section of a fatty liver in a moder- 
 
 ately advanced stage, showing that the cells containing oil are 
 distributed, for the most part at the periphery of the lobules 
 in the vicinity of the branches of the portal vein . . 290 
 
 31. Fine section of a pigment-liver, previously dried and treated 
 
 with a solution of potash. Magnified 90 diameters . 318 
 
 32. Figment-matter from the portal veins, in a case of pigment- 
 
 liver . . . • • -321