I College of 3^i)yiicmns anb ^urgeon£i Hibrarp TRUE SCIENCE IS THE KEY TO WISE PRACTICE A TEEATISE ON DISEASES OF THE LIVER WITH AND WITHOUT JAUNDICE WITH THE SPECIAL APPLICATION OF PHYSIOLOGICAL CHEMISTRY TO THEIR DIAGNOSIS AND TREATMENT BY J)"" GEOEGE HARLEY, F.R.S. l'"ELLOW OP THE ROYAL COLLBGR OF PHYSICIANS ; CORRESPONDDCG MEMBER OP THB ACADEJtY OF SCIEXCES OP BAVARIA, OP THE ACADEMY OP MEDICINE OF MADRID, AND OF SKVERAL COSTTNESTAL irEDICAL SOCIETIES ; FORIIERLY PRESIDENT OP THE PARISIAN MEDICAL SOCIETY; PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL AND PROFESSOR IX UNIVERSTfY COLLEGE, LONDON LONDON J. & A. CHUECHILL 11 NEW BURLINGTON STREET 1883 git ^iTcmoviam. My original Monograph on Jaundice and Diseases of tlie Liver was dedicated in the following words : — 'TO WILLIAM SHARPEY, M.D., LL.D., F.E.S. Proftssor of Anatomy and Physiolojy in University Collese. London, AS A SMALL TOKEX OF A COLLEAGUE'S ESTEEM FOB A PROFOUND THIKKER, A SOUND REASONER, AND A TRUE FRIEND.' As the intervening eighteen years that elapsed between the day when I penned the above dedication, and my colleague's death, only tended still further to cement the bonds of our friendship, I gladly avail myself of this opportunity of re-endorsing the above sentiments, as a posthumous tribute to the memory of one who during a quarter of a century was ever ready to assist me by his advice, and always willing to guide me by his judgment. The intrinsic value of which hnnn it, ia imnossible to over-estimate. CONTENTS. FAGK Dedication v List of Illusteations xv EXPLANATOKY PrELUDE OF THE EeASON WHY THE BoOK IS NOl PRINTED ACCORDING TO ITS AuIHOR's PROPOSED SCHEME OP IMPROVING OUR SYSTEM OF SPELLING, IN WHICH THE IMPOR- TANT Medical and Sanitary aspects of National Spell- ing Reform are pointed oitt 1 Preface explaining the General Plan and Scope of the Treatise 13 CHAPTEE I. Intbodtjctory General Remarks on the Study of Liver Diseases, in which the Value of Physiological Chemistry in the Diagnosis and Treatment of Hepatic Diseases IS pointed out 21 CHAPTEE II. The Chemistry, Physics, and Physiology of the Liver . 37 Its Chemical Composition, 37 — Its Weight at different Periods of Life, 41 — Its Size, 43 — Conditions likely to give rise to Er- roneous Signs of Diminution in the Bulk of the Liver, 48 — Conditions likely to give rise to Erroneous Signs of its Enlarge- ment, 51 — Hepatic Pulsation, 55 — The Liver as a Sugar Manu- facturer, 59 — As a Fat Modifier, 63 — The Caloriiying Hepatic Function, 65— The Biliaiy Function, 67— The Nature of Bile, 68— The Secretion of Bile, 72— Its Arrest, 77— Quantity of vm CONTENTS. PAGE Bile secreted, 70 — Animals Avithoat Gall-bladders, 81 — Quan- titative Constitution of Bile, 82 — Uses of Bile in the Animal Economy, 84 — Chemical Action of Bile, 89 — Bile used as a Condiment, 91 CHAPTER III. Etiology op jAcifDiCE 94 Table showing Conditions under which Jaundice is met with, 96 — Theories of different kinds of Jaundice, 99 — From Suppres- sion, 108 — From Obstruction, 111 — Biliverdin shown to l)e a Blood and not a Liver Product, 119 — Cause of the Yello-miess of the Skin, 121— Dark Urine, 122 CHAPTER lY. GeITEEAL ReMAEKS OS THE SiGNS ASH SYMPTOMS OF HePATTC Disease. . • 126 The Tongue, 127— The Bowels, 127— Coloiu- of the Stools, 128 — FlafulenC}', 129— The Urine, 130— Tlie Pulse, 131— The Bodily Temperature, 131— Blindness,131— Vertigo,132— Head- ache,132 — Hepatic and Shoulder Pain, 132 — Hepatic Neiu-algia, 133— AmenoiThoea, 134 — The Skin, 136— Synopsis of General Signs and Symptoms of Jaimdice, 137 — Cerebral Symptoms, 137 — Dunidian Jaimdice, 141 — Xanthelasma, 142 — Pruritus, 142 — Catamenia, 143 — Epistaxis, 145 — Spurious Jaundice, 146 CHAPTER V. Genekal Remaeks on Teeatment of Hepatic Disease . .149 Hepatic Remedies, 149 — Action of Mercurials, 156 — Alka- lies, 172 — Chloride of Ammonium, 176 — Vegetable Remedies, 177 — Podophyllin, 178 — Taraxacum, 181 — Chiouanthus vir- ginica, 182 — Baptisin, Euouymin, Iridin, Juglandin, Phyto- laccin, and Leptandrin, 183 — Germicides, 183 — Specifics, 185 — Mode of Action of, 188 — Intolerance of remedies, 192 — Vitality of Disease-Germs, 197 — Theory of the so-called Crisis of Disease, 199 — Salicylic Acid, Salicin, and Salicylates, 202 — Benzoic Acid and Benzoates,'207 — Mercury in Combination with Quinine, 211 — Action of Germicides, 213 Mineral Waters in the Treatment of Liver Diseases, 214 — CONTENTS. IX PAGE Modes of Therapeutic Action, 218 — Chemical Constituents of most renowned Mineral Waters, 2-31 — Advantages of Resi- dence at Mineral Springs, 233 Baneful Drugs in Hepatic Disease, 237 Dietetics of Liver Affections, 239 — Injudicious Diet a Cause of Indian Liver Diseases, 241 — Injudicious Drinks, 242^ — Baneful Foods, 245 — Baneful sec, tres sec, and b/-ut Cham- pagnes, 249 — Manufacture of Champagne, 257 — Acquired Depraved Tastes, 259— Arctic Ale, 261 General Remarks on Special Forms of Treatment in Liver Diseases, 263 — Pyrexia, 264 — Vomiting, 265 — Diarrhoea, 266 — Haemorrhage, 266 — Cerebral Symptoms, 266 — Insomnia, 267— Perspiration, 26S— Kidneys, 268— Bowels, 268— Deodo- risers, 269 — Acute Inflammation, 269 — Stimulants, 269 — Tea and Coffee, 270 — Hiccup, its Treatment, 271 CHAPTER VI. Biliousness , 273- Etiology, 274 — Symptoms, 277— Pathology, 281 — Subacute Forms, 283— Mental Effects of, 286— Treatment, 287-289 CHAPTER VII. Intra-uterine, Conge>'ixal, A^^) Herebitary Jaundice . . 295- Chlorosis Neonatorum (Spurious Icterus Neonatorum), 296 — Pathology of Intra-uterine Jaundice, 299 — Cases of, 300 — In- fantile Jaundice, 303 — Treatment, 305 CHAPTER VIII. Jaundice as a Result of Enervation 310 From Mental Emotion, 311— Etiology, 313— Pathology of, 316 CHAPTER IX. Jaundice froji Hepatic Congestion and Inflammation. . 320 Hepatitis, General Signs and Symptoms, 324— Treatment, 325— Peri-hepatitis, 325— Sympathetic Hepatitis, .q97_Tnfpv_ stitial Hepatitis, 329 PAGE 333 X CONTENTS. CHAPTER X. JaTJXDICE CAT7SED BY DiSEASE-GeEMS Etiology, 334— Figures of Different Germs, 335— Theory of their Modes of Action, 336— Epidemic Jaundice of Temperate Zones, 336— Jaundice of Pregnancy, 339— Epidemic Jaundice of Pregnancy, 344 — The Contagious Jaundice of the Tropics (Yellow Fever, so called), 346— Malarial Jaundice, 349— Treatment, 356— Pathology of Malarial Jaundice, 363 Paroxysmal Hepatic Ilsematuria, 370— Etiology of, 377— Peculiarities in Condition of the Urine in cases of, 380 — Treatment, 388 Acute Atrophy of the Liver, 389— Its Similarity to Contagious Jaundice, the so-called Yellow Fever of the Tropics, 391— Symptoms, 394— Treatment, 396— Typical Cases of, 396-404 Etiology of Cerebral Derangement in Febrile Forms of He- patic Disease, 413— Germ Theory, 415— Fermentation Inebria- tion, 419— Diabetic coma, 423— Treatment of Cerebral Symp- toms, 428 Pyrexia, 431 — New views of, 435 — Caused by Germs, 439- 455 — Jaundice from Filaria, 449 — Remedies in Pyrexia, 459 — ■ Subacute Atrophy of the Liver, 460 — Chronic Atrophy (Cir- rhosis, 467; Hobnail Liver, .fee., 477)— Syphilitic Atrophy, 480— With Ascites, 481— Treatment, 486 Pysemic and Septictemic Jaundice, 488 — Treatment, 492 The Fcetor of Disease, 497— New theory of, 500— Germs the immediate Cause of, 505 Jaundice from Obstruction, 515 — Mechanism of, 519 CHAPTER XI. Biliary Conceetions, Geueeal Remaeks on ... . 523 Physical Properties of Biliary Concretions, 524 — Shape, Size, Colour, 626— Specific Gravity, 530 — Spurious Gall-Stones, 534 — How to detect Gall-stones, 535 — The Chemistry of Biliary Concretions, 546 — Composition of Inspissated Bile, 547 — of Gall-stones, 549 — Etiology of Inspissated Bile, 555 — Symptoms of, 556 — Mistaken for Cancer, 564 — Death caused by Inspissated Bile, 671 — Treatment, 572 Gall-stone Affections, 573 — Etiology of, 574 — Periods of Life ga nat HmV>1p tQ^_577r-^limatic Influences, 580 — Modes of Forma- tion, 684— Symptoms, 588— Kinds of Pain, 592— Pain as a CONTENTS. XI PAGE Cause of Deatli, 595 — Dangers of, 596-602— Gall-stones with- out Jaundice, 603 — Pain simulating Peritonitis, 609 — Im- pacted Gall-stones, 613 — Gall-stones inducing Abscesses, 614 — Perforating Gall-stones, 6 15 — Encysted Gall-stones, 621 — Gall- stones in Intestines, 624 — Fatal Effects of Gall-stones, 625 — Inducing Enteritis, 626 — Impacted in Eectiun, 627 — Vomited, 627 — Perforating Abdominal Parietes, 629 — Gall-stones in the Urinary Passages, 633 — Causing Sudden Death by Htemor- rhage, 634 — Spurious Symptoms of Gall-stones, 635 — Treat- ment, 638 — Preventive Treatment, 639 — Dissolution of Gall- stones, 643 — Expidsion of Gall-stones, 654 — Treatment of Head Symptoms, 657 — Of firmly Impacted Gall-stones, 657 — Of Perforating Gall-stones, 667 — with Hsemorrhage, 668 — Choleo-cystotomy advocated, 672 CHAPTER XIL HlJfXS ox THE DrFPEKENTIAL DIAGNOSIS OP CoLICS . . . 678 Renal Colic, 680 — Surgeons' Errors, 685— How to avoid them, 689 CHAPTER Xril. Catarrhal Jaundice 696 Etiology and Pathology, 697 — Treatment, 699 CHAPTER XrV. Jaundice prom Poisons 702 Etiology of, 703— Pathology, 706— Phosphorus Poisoning, 710 CHAPTER XV. Jaundice prom: Permanent Obstruction 713 Different kinds, 714 — Accidentally acquired, 716 — Patho- logy of, 717 CHAPTER XVI. The Chemistry op the Excretions as an Aid to Diagnosis AND Treatment /i-uai^sis uj. j.jAt^o^.^ Diseased Hypertrophied Kidney in a case of Permanent Jaun- XU CONTENTS. PAGB dice, 728 — Colour of the Urine, 720 — Bile-acids iu Urine, 734 — in Blood, 739— Toxic Effects of, 740— Tyrosin Crystals, Figures of, 745-8 — Dicagnostic Value of, 747 — Globules of Leucin, 749 — Pathological Significance of, 751 — Melanin in Urine, 754 — Diagnostic Value of, 757 — Urea and Uric Acid, 761 — Crystals of Uric Acid, 763 — iu Cancer, 764 — Oxalate of Lime, 766 — • Cystin and Ilypoxanthin, 767 — Value of Physiological^Che- mistry illustrated, 769 — Analysis of Urine, 773 — Poisonous Effects of Bile Acids, 777— Sugar in the Urine, 779 — Torulse, 779 — Morbid Anatomical Conditions iu Permanent Jaundice, 784— Altered Liver Cells, 785— Analysis of Bile, 791— Hepatic Albuminuria, 793 — Tube Casts, 798 Table showing the Pathology of Jaundice according to the Author's Views, 801 CHAPTER XVII. Abscesses of the Lr\-ER — Tropical and Tempebate . . . 803 Their Etiology, 803 — Symptomatology, 815 — Diagnostic Table, 819 — Spontaneous Rupture of Abscesses, 823 — Differen- tial Diagnosis of, 825 — Eed Pigment in Abscesses, 832 — Biliary (Joncretions a Cause of Abscess, 834 — Embolism a Cause of Abscess, 838 Traumatic Hepatic Abscesses, 840 Metastatic and Pyoemic Abscesses, 845 — Caused by Pins, 846 — by Bones, 849 — by Disease of the Rectum, 851 — by Gonorrhoea, 852 — by Suppurating Hydatids, 852 — Pathology of Pyaemic Abscesses, 855 — Influence of Dysentery, 858 Treatment of Abscesses, 861 — The Value of Tapping, 865 — Foods and Drinks, 873 CHAPTER XVIII. Cancer of the Liver . 874 Pathology of Hepatic Cancer, 877 — What is a True Cancer ? 881— True Cancer CeUs, 886— Inoculation of Cancer, 887— Of Scirrhus, 883 — Scirrhus (spurious Cancer) Cells, 889 — Etiology of Hepatic Cancer, 892 — Exciting Causes of, 894 — Signs and Symptoms of Cancer, 898 — Negative Signs and ___^il°™lo9l u^^^^S^^ffltS'^ioTicTin'tlie Di^^osis'of Ob- scure Cases, 916 — Errors committed both in Diagnosis and CONTENTS. XUl PAGE Pathology, 919 — Jaundice the Result of Cancer elsewhere than in the Liver, 925 — Cancer causing Occlusion of the Vena Cava, 927 — causingDeath by Haemorrhage, 927 — Treatment of Cancer, 928 CHAPTER XIX. SxPHiLiiic Disease of the Liver 932 Etiology of SyphiUtic Nodules, 933 — Symptoms of, 935 — Treatment of, 936 CHAPTER XX. Hydattb Foems of Hepatic Disease 939 Etiology of Hydatids, 938 — Signs and Symptoms of, 945 — Jaundice from Hydatids, 948 — Jaundice from Suppu- rating Hydatids, 949 — Amount not proportionate to Size of Parasite, 952 — Diseases simulating Hydatids, 955 — Miscalled Cystic Disease, 960— Cancer mistaken for Hydatids, 962 — Hydatids simulating Gall-stones, 963 — Hints to aid in Diffe- rential Diagnosis, 964 — How- to explore a Hydatid, 966 — The Examination of "Withdrawn Fluids, 967 — Heematoidin Ciys- tals, 969 — Hydatids associated with other forms of Diseased Liver, 971 — Implicating Blood-vessels, 972 — Modes of Termina- tion, 976 — Suppurating, 976 — ^Bursting into Digestive Canal, 980 — Bursting into Lungs, 983 — Inducing Secondary Pulmo- nary Disease, 986 — Sudden Death from Hydatids, 986 — Spon- taneous Cure, 988 — Treatment of Hydatids, 989 — How to Tap a Hydatid, 995 Distoma hepaticum (Liver Fluke), 1008 CHAPTER XXI. Cystic Disease of the Liver 1010 CHAPTER XXII. Benign Degenerations of Hepatic Parenchyma . . . 1014 Fatty Liver, its Etiology and Pathology, 1014— Figures showing Different Stages, 1015 — In Phthisical Patients, 1016 — Li Suckling Women, 1010— Symptoms, 1020 — Treatment, 1021 — Amyloid Liver, 1023 — Pathology and Chemistiy of, 1024— Signs and Symptoms, 1027— Treatment, 1029 Fibrous Growtlis, 1030 EmbDlisms, 10.'^2 — Fxtravasations, 1033 xiv CONTENTS. CHAPTER XXIII. PAGE Tkattmatic Affectioxs op the Liver 1035 Wounds, Blows, Bruises, and Squeezes, 1036 Difrestion of the Living Liver, 1040 CHAPTER XXIY. Hepatic Ascites and Dropsy ....... 1044 Sio-ns and Symptoms, 1045 — Hints to aid in Differential Diagnosis, 1047 — Hepatic Ascites in Children, 1049 — Treat- ment, 1053 CHAPTER XXV. Liver Spots : Xanthoma, Xanthelasma, or Vitiligoidea . 1061 Etiology and Pathology, 1062— Treatment, 1066 Chloasma Liver Spots, 1066 CHAPTER XXVI. Affections of the Gall-bladder 106J> Distended Gall-bladder, 1072— by Bile, 1073— by Pus, 1078 — Hydatids in Gall-bladder, 1081 — Gall-bladders containing White Liquids, 1082— Mucus, 1083— Theory of, 1085— White Bile, 1088— Explanation of, 1089— Gall-bladders distended by Biliary Concretions, 1091 Distended Bile-ducts, 1093 Treatment of Distended Gall-bladders and Bile-ducts, 1095 — Sounding for Gall-stones, 1106 — Extraction of Gall-stones, 1107 — Formation of Artificial Biliary Fistulte advocated, 1109— Treatment by Inspissated Bile, 1112— Mode of its Preparation, 1113 Sloughing, Gangrene, and Rupture of the Gall-bladder, 1116 Carbonate of Lime Deposits (misnamed Ossification of the Gall-bladder), 1118 Cancerous and other Growths of the GaU-bladder, 1120 Cancer of the Common Bile-duct, 1123 CHAPTER XXVII. General Hints to aid in the Diagnosis and Prognosis of Diseases op the Liver 1127 INDEX 1163 LIST OF ILLUSTRATIONS. PLATES. I. Chromolithograph of Liver, Gall-bladder, Duodenum, and Pancreas in a case of Occlusion of the Common Bile- duct to face II. Chromolithograph of Diseased Kidney in a case of Permanent Jaundice to face 113 72S WOODCUTS. FIG. 1. Crystals of Glycocholate of Soda 70 2. Globules of Taurocholate of Soda . _ 71 3. Encysted Cretified Trichina 200 4. Strongjlus Filaria undergoing Calcareous Degeneration in the Lung of a Sheep 201 5. Disease-germ Spawn 335 6. Bacilli Disease-germs 335 7. Micrococci .......... 335 8. Bacteria 335 9. Deposit in Urine in cases of Paroxysmal Hepatic Haematuria — Tube Casts, Granular Cells, free Hsematin and Crystals . 380 10. Spirilli 451 11. Sperm Cell containing mature Spermatoza .... 451 12. Section of a Gall-stone showing its Internal Crystalline Struc- ture 530 13. Oat-hair Intestinal Calculus 534 14. Cholesterin Crystals 551 15. Spiculated Balls of Tyrosin 745 16. Stellate Crystals of Pure Tyrosin 748 XVI LIST OF ILLUSTRATIONS. FIG. 17. Globules of Leuciu resembling Microscopic Gall-stones 18. Crystals of Uric Acid 19. Crystals of 0.\alate of Lime 20. Crystals of Cystin . 21. Crystals of Hypoxanthin . 22. Torulse Cerevisife . 23. Altered Liver Cells, Spindle-shaped Cells -24. Renal Tube Casts, Hyaline and Granular 2o, True Cancer Cells .... 26. Scirrhus (spurious Cancer) Cells 27. Hydatid Vesicles — EcMnococci 28. Contents of Hydatids, HooMets, &c. 29. Hjematoidin Crystals •30. Incipient Fatty Degeneration . 31. Well-marked Fatty Degeneration . 32. Very advanced Fatty Degeneration . 33. Liver CelLs of a well-nourished Child 34. Small Sebaceous Gland . 35. Large Sebaceous Gland (Xanthelasma) 36. Pus and Mucus Cells, Cells containing Pigmentarv Matter PAGE 749 763 766 767 767 779 785 798 886 889 942 961 968 1015 1015 1015 1052 1063 1063 1087 PEELUDE. For the sake of my own personal convenience I bad written the ]\1S. of this book according to the first stage of my proposed Progressive Scheme of National SpelUng Reform. That is to say without encumber- ing its words (except personal names) with any re- dundant duplicated consonants. But a friend having pointed out that as all my medical books are exten- sively read by foreigners — indeed- the last one, on the Urine, has not only been translated into French, but also into Italian — the omission of the duplicated con- sonants might add to their difficulty in perusing them, I have relinquished the idea of printing the book according to the proposed new method of im- proving the orthography of our language. I must candidly admit, however, that after having practised this improved method for five years, and tasted the sweets of its advantages, I have not been able to abandon the personal convenience accruing from it without a pang of regret. Although I went fully into the question of National Spelling Reform in an article in the 2 DISEASES OF THE LIVER. 'Medical Times and Gazette ' of January 14, 1882, entitled ' National Spelling Reform in its Relation- ship to the Medical Profession, with a Scheme for its Consideration,' as I am most anxious to induce some of my younger medical brethren who may not only be sufficiently enlightened to appreciate the social value, but also have acumen enough to perceive the important medical bearings, of National Spelling Re- form, to take up the subject, I shall here take the opportunity of saying a few more words upon a matter which I consider the whole medical profession should be alive to. The medical profession being the recog- nised public conservator of our national brain power. For its members as pure sanitarians, quite as much as humanitarians, ought to attach a much greater importance to the Spelling Reform movement than any other individual professional section of the com- munity. In reading what I am now about to say on its strictly medical aspects the reader will perceive why I, as a practising physician, not only entered for a time the lists as a volunteer, but did my best to induce my medical brethren to follow my example. That the mental well-being of millions of children is intimately connected with the question of Spelling Reform, is no mere chimerical assertion. It being well known to everyone who has studied the pernicious effects of the unnecessary mental strain which the inconsistencies of our defective system of orthography PRELUDE ON MEDICAL ASPECTS OF SPELLING REFORM. 3 entails upon every human brain, not in the posses- sion OF AN INNATE SPELLING FACULTr. Eveiyone must have noticed how this is particularly the case with children, whose immature mental faculties are, according to the present system of school education, not alone strained to their utmost, but even far be- yond it. The sad results of which are too well known to every reflecting member of the profession to ne- cessitate my doing more than reminding them that the over-strain of school education often leads to permanent mental weakness, and in some cases to the development of active as well as incurable brain disease. Although the pernicious effects of over mental strain in the acquirement of school education are abundantly apparent, their causes are not so easily recognised. So I purpose briefly to allude to some of them, in order to stir up among general practitioners an interest in the simplification of our system of teaching the young, particularly in so far as concerns orthography. According to Dr. Gladstone, w^ho is no mean authority on the subject, the chief obstacle in the way of primary education is our defective system of spelling. Which, he says, entails of itself no less than two additional, and consequently wasted, years of school study. Before I Y>omt out how this is readily accounted for by the inconsistencies, ay, I B 2 4 DISEASES OF THE LIVER. may even unliesitatino'ly say the downright absurdi- ties, which exist in the orthographical construction of English words, I desire to call special attention to a fact which is neither sufficiently known by schoolmasters and the general public, nor even suffi- ciently appreciated by medical men. Namely, that spelling power is an inborn gift, which cannot be in any case developed, though it can be in all cases in- creased, by cultivation. What I mean by describing the spelling power as an inborn gift, is that the human brain possesses a spelling faculty, exactly as it possesses a calcu- lating faculty, a musical faculty (called in common language a musical ear), the inborn gift of a steady hand or of a correct eye. And, as we all know, when any of these gifts of nature are constitutionally absent, it is absolutely impossible to drum them into a person, however clever he may otherwise be. So I now say, though it is a common, it is an absolutely erroneous notion to imagine that a person, however clever he may be, who is naturally constitutionally devoid of the spelling faculty, can ever, by any amount of cultivation, be made what is commonly called a good speller. No more is this possible than to make a person devoid of a musical ear a good musician. No doubt, by prolonged drumming and (h-udgery, he or she may be taught to play a faultless tune. So, by drumming and drudgery, a person PRELUDE OX -AtEDICAL ASPECTS OF SPELLING EEFORM. 5 may be taught to spell by rote ; but neither the one nor the other will ever be considered a proficient. In case any of my readers may doubt this fact as regards the spelling faculty, I beg to recall to their minds the cases of Sir Walter Scott and the Iron Duke, neither of whom to their dying day could ever trust themselves to write more than a friendly note without the aid of a dictionarjT^. Indeed, so bad a speller was the highly gifted Sir Walter Scott, that the first five lines of his MS. of ' Peveril of the Peak ' contained three misspelt words ; and through- out the body of the MS. — as throughout all his other MSS. — misspellings occurred in superabun- dance. Some amusing anecdotes are told of the late Duke of Wellington's misspellings ; but as most of my readers have no doubt heard of them, I need not take up time by relating any of them. Now, as both of these men were undoubtedly not only possessed of a good education, but of more than ordinary mental abilities, their cases may be uncon- ditionally accepted as fiimishing us with conclusive proof that the spelling faculty is an inherent natural gift. But in case some may require still further evidence of this fact, I may remind them of the start- ling discovery which was made a few years ago — during the temporary existence of spelling bees — when it was found, not once, but often, that the best spellers existed among the semi-educated, and 6 DISEASES OF THE LIVER. the very worst of all among clergymen, lawyers, and doctors. Most of whom, as was seen, though -per- fectly au fait with common words, floundered and fell when asked to spell even what were supposed to be very simple words, merely because they happened not to be in everyday use. The cause of this is very simple. In many cases the orthography of English words is neither in accordance with orthographical general law nor wdth common reason. As every one knows, not a few, but actually hosts, of our English words are neither spelt according to sound nor sense, and, what is still more extraordinary, very many are actually spelt contrary to both. No wonder then that they not only puzzle the educated and re- flecting mind, but are a stumbling-block in the way of the education of the intellectual as well as of the stupid, demanding a fearful amount of mental strain to master their mconsistencies and grapple with their defects. But what is the worst part of all is the fact that the mental strain happens to be required in the early years of life, when the brain is developing and immature, and consequently at the very period when it is least capable of bearing it. Should any reader be happily unconscious of the mental strain our de- fective orthography entails upon the brain, let him inquire of any foreigner what his opinion on the sub- ject is, and he will soon learn the difliculties which even highly educated and powerfully intellected men PRELUDE ON MEDICAL ASPECTS OF SPELLING REFORM. 7 experience in acquiring a knowledge of English spell- ing. He will at the same time probably be quietly told that English spelling is, in the eyes of the edu- cated foreigner, the very essence of sublime absurdity, and have many specimens immediately cited in proof of the statement. As for example, he may be told that we say 'kurnel' and spell it 'colonel.' T\"e write 'bow,' and one time pronounce it as such, as when we speak of the bow of a boat or a salutation, and at another call it 'beau,' as when we allude to an instru- ment either to play a fiddle or to shoot with, not- withstandino; that their orio-in and meanino;, as well as their spelling, is the same. Further, it is not unlikely that the intellectual foreigner may blandly inquire upon what principles of grammar or sense we spell the ough in ' plough,' ' cough,' ' through,' ' enough,' and 'though,' seemg that they are all pronounced dif- ferently. What would the reader's answer be ? I know not. So I would further ask, Why should we go on from day to day, from year to year, with this millstone hanging about our necks ? Or perpetuate the mistake of forcing poor, helpless, and in many cases mentally delicate children into national schools, and insist on their learning absurdities, entailing upon their brains an amount of mental strain in many cases beyond their mental capacity? It is really scandalous that so-called educated men continue to perpetuate tortures on immature intellects 8 DISEASES OF THE LIVER. by forcing them to acquire a knowledge of easily removable orthographical absurdities. The incon- sistency of this mode of procedure, though not self- evident to the ordinary reader, is abundantly clear to the medically educated mind, who knows that it is not tlie ear that hears or the eye that sees, but the brain itself. The organs of hearing and seeing merely performing the respective mechanical parts of the process. Just as a speaking-trumpet or a pair of spectacles do. As the brain has no difficulty in distinguishing between a 'hair' and a 'hare' when presented to it in the same sound, how could it possibly have a difficulty when presented to it in the same spelling ? We know for a fact that it has not. For, as just shown above, we spell four ' bows ' all alike, and yet we instantly, from the context, know which is meant. Why then should we write 'you,' 'yew,' and ' ewe,' to symbolise the same sound, which is only correctly given by the single letter of the alphabet, zi? Or why should we insist upon children spelling the sound oiile as 'isle ' or ' aisle,' entailing a fearful amount of unnecessary perplexing mental drudgery? Is this, I ask, not a system of education alike derogatory to common sense, humanity, and sanitary law ? W^ere it only possible to get people who have paid no special attention to the subject, and, knowing next to nothing, understand still less, of the requirements of written language, to listen to those who have given PRELUDE OX MEDICAL ASPECTS OF SPELLING EEFORM. 9 sufficient time to the mastering of its secrets, there would be but little difficulty in introducing a mode- rate and yet highly satisfactory scheme of spelling reform. Xo one wishes that every scheme of spelling reform, emanatino- from the brains of sano'uine en- thusiasts, should be accepted and acted upon. All that sensible men ask is the removal from the Eng- lish language of the palpable and glaring ortho- graphical inconsistencies which now needlessly infest it, and which are not only a stumbling-block in the way of primary education, but a fruitful source of mental injury ; and it is on the latter ground that medical men, as the recognised sanitary advisers of the general public, ought not only to feel interested in, but assist in the advocacy of, the immediate intro- duction of an improved system of national spelling. Knowing as they all do that the wad of helpless children, quite as much as the cry of their bread- earning parents, is to be reheved from all unnecessary mental strain, both in the acqukement and in the dif- fusion of knowledsce throuofh the intervention of all kinds of mechanical agencies — whether they be pens, types, or telegraphs — and seeing that there is no object to be gained in wasting time, labour, money, and space on written or printed matter, why should we hesitate to improve our spelling, unless it be from the mere pseudo- sentimentality of ' letting things be ' ? On the same principle as the idiot boy refused to 10 DISEASES OF THE LIVER. have the nail which had lamed him removed from the heel of his boot, on account of his having got accustomed to it, and he would miss it if it were withdrawn ! But even this pseudo- sentimental argu- ment is untenable from the fact that language no more than anything else is, or ever was, stationary. Not only the spelling, but the very meaning of our words has changed, and is always changing. Thus, for example, the word ' silly ' no longer means innocent, as it formerly did. Nor does ' candour ' any longer mean whiteness, or 'virtue' bravery, or 'lewd' signify, as it originally did, unlearned. It is quite unnecessary for me to give examples of the strange mutations that have taken place in the course of the last three centuries in our forms of spelling, as every one must be abundantly familiar with them. Nor need I say a single word regarding the objection raised by those unacquainted with scientific etymology, that the re- formation of our spelling would destroy the etymology of words, as every philologist knows that this idea arises simply from a deficiency of etymological knowledge. I ought perhaps, however, to point out a fact of which but few of my readers are probably aware, namely, that the consideration of the desirability of reforming our spelling is not a mere ' whim of the day,' but is a subject which has occupied the attention of many reflecting minds ever since it was PRELUDE ON MEDICAL ASPECTS OF SPELLING EEFOEM. 11 first rocked in its infantile cradle by the learned hands of Dr. Gil — the tutor of Milton — no less than two hundred and fifty-nine years ago. Then it was but a feeble suckling, bound up in swaddling clothes; now it is a full-grown stripling, ready to perform its appropriate part in the affairs of life ; and it only requires countenance and encouragement to become a potent lever in universal social development. It may, indeed, with perfect justice be said, that it will not do for this country to continue much longer to ignore its claims to consideration ; for there is a destiny in language as in everything else, which awaits not the beck and call of frail human mortals. Blind although many may yet be to the fact, it is neverthless a dis- cernible fact, that the time has gone by in the history of civilisation when a nation can comj)lacently fold its hands and say, ' Let things be,' ' What did for our fore- fathers ought equally well to do for us.' Railways, tele- graphs, and telephones have changed, and are changing, the whole relations of civilised society ; and what was sufficient for the wants of our forefathers, two hun- dred or even one hundred years ago, is insufficient for ours now, and will be still less sufficient for the requirements of our successors. Mechanical language — the language which transmits from man to man knowledge by means of pencil, pen, type, or tele- graph — requires simplification, and it is with the view of attaining to this end that I have here ven- 12 DISEASES OF THE LIVER. tured to address my medical brethren on the medical side of the question, as I have done in the ' Medical Times and Gazette ' on its social aspects, and at the same time sketched out a ' Progressive Scheme of National Spelling Reform ' for their consideration. A copy of which I shall be happy to send to any of my readers on application, feeling, as I do, that the social well-being of millions upon millions of the yet unborn must be materially influenced by the apathy or activity with which the question of Spelling Reform is handled in this the last quarter of the nineteenth century. PREFACE. In the year 1863 I published a monograph entitled ' Jaundice : its Pathology and Treatment, with the special Application of Physiological Chemistry to the Detection and Treatment of Diseases of the Liver and Pancreas ; ' and as, during the twenty years which have elapsed smce I wrote it, my experience in the diagnosis and treatment of this particular class of affections has very greatly increased, and, naturally enough, my ideas regarding them have in an almost equal ratio expanded, I am tempted to again lay before my medical brethren the fruits of my further experience. In the hope that the immense advantages which the application of physiological chemistry affords the medical practitioner in the diagnosis and treatment of these diseases may speedily become, not alone more generally known, but at the same time far more generally adopted, than unfortunately they are at present. This new treatise, which I have thought fit to entitle ' Diseases of the Liver, with and without Jaundice, with the special Application of Physiological 14 DISEASES OF THE LIVER. Chemistry to Diagnosis and Treatment,' althoiigli embodying within it the whole substance of my original monograph on Jaundice and Diseases of the Liver, bears no more resemblance to it than a mature adult does to the suckling from which he sprang. For although the scientific principles on which both works are founded are identical, the present is vastly greater than the former, both as regards its scope and materials. Containing as it does in a condensed form a large amount of clinical and scientific data that has never before been collected together by any author into one volume ; while, in a great many instances, it gives a new rendering to old clinical facts by presenting them to the reader in the light of modern pathological science. Moreover (for precisely the same reasons as I gave in the preface to my monograph on Jaundice for excluding from it the consideration of every question not having a direct bearing on the elucidation of the matter in hand), as I still think time is quite of as much value to the professional as it is to the mercantile man, I have endeavoured to condense my materials to the utmost without running the risk of endangering their perspicuity. Added to which, as this treatise has not been penned, either for the use of the tyro or the dilettante in medicine, but for that of my qualified brethren, I shall neither waste time by entering into detailed accounts of the PREFACE. 15 literature, nor give tedious, and probably at the same time profitless, discussions of the theories of the mechanism of jaundice in hepatic derangements, but limit myself entirely to a brief exposition of my own views. Taking care, however, in order that they may carry more weight with them in the eyes of the reader, to illustrate them freely with cases reported by independent observers both at home and abroad. While, in order again that the reader may be able to see for himself at a glance how many of the old- fashioned theories of the pathology of jaundice have been abandoned, as well as how many new ones have been espoused, I have put my views, in accordance with the facts and arguments expressed throughout the body of the volume, as in' my monograph on Jaundice, into a concise and diagrammatic tabular form at p. 801. I may further add that as the object of all theory, and the aim of all science, is to ensure wise practice, I desire to call special attention to that portion of the work devoted to the physiological chemistry of the excretions. Feeling, as I do, that we are entering upon the threshold of an important line of medical inquiry, which, sooner or later, will be followed by valuable practical results. I would also direct the special attention of my readers to the chapter devoted to treatment, as well as that at the end of the book entitled ' Hints on Diagnosis,' being sanguine enough 16 DISEASES OF THE LIVER. to imagine that the adoption of the principles enun- ciated reo-arding the physical and chemical methods of diao-nosinff diseases of the liver, as well as of the modes of action and administration of the remedies usually employed in hepatic affections, may conduce to a more rational and successful method of treating them than has hitherto been employed. I even go so far as to hope that the result of the diagnosis and treatment, as shown in many of the cases cited, will not only justify the adoption of the principles on which they are founded, but also prove a strong in- centive to others to follow the physiological chemical line of investigation I have striven to inculcate. In some portions of the volume the statements may, perhaps, appear to be rather dogmatic ; if so, I may remind the censorious reader that this has arisen from the circumstance of so many old dogmas and deeply rooted prejudices having to be combated. For I am quite as alive as he can possibly be to the fact that what one may regard as scientific truth is in no case incontrovertible certitude, and that the deductions of to-day in an advancing science like that of medi- cine may require material alteration when viewed in the light of the morrow. But I am still equally convinced of the fact, that if men fold their arms, and refrain from acting until every link in the chain of knowledge is made perfect, all progress will be arrested, and the day of certainty still further postponed. PREFACE. 1 7 Too lono' have the members of the so-called practical school of practitioners reversed the natural order of things, and commenced the study of medicine where they ought rather to liave left it off. Too long have they striven, by studying pathology ere they were sufficiently acquainted with physiology, to place the pyramid of medical science on its apex mstead of on its base ; and this is, I believe, the reason why they have remained so long ignorant of the funda- mental doctrine that the same laws which regulate health also regulate disease. Nature does nothing on a small scale, and the more we study her the more we are forced to admire the uniformity and extensive applicability of her laws. If, for example, we pry into the ultimate structure of our bones, we find they receive their nutriment by a system of irrigation carried on through lakes and rivers (lacunse and canaliculi); and if we examine the periosteum surrounding them, the ligaments attaching them, or the muscles cover- ing them, we still find that, notwithstanding their diversity in structure and in use, the one system of irrigation pervades them all. We may even go a step further, and say that the same laws which govern the animal govern also the vegetable kingdom. For. the further science advances, the more apparent does it become, that not only the animal and vegetable, but even the organic and inorganic, form but one c 18 DISEASES OF THE LIVER. world, being but mere modifications in the arrange- ment of the self- same elements, one and all being regulated by the same laws. A knowledge of animal organisation, important though it be, is yet less indispensable to the phy- sician than a knowledge of healthy function, for it is the latter which more especially elucidates the dark problems of life. It is the latter which proves the golden key to the comprehension of disease. Althouo-h not even the most ardent admirers of medicine can say that it as yet merits the name of an exact science, this ought neither to destroy our hopes nor trammel our labours. With the stetho- scope, microscope, test-tube, thermometer, and other physical means of diagnosis, a new era dawned upon our art ; and now the members of the advanced school of thinkers which is rising up, and carrying chemistry into the domains of medicine, are but the pioneers of the revolution which is soon to follow. If we look back to what the exact sciences of to-day were in former times, we shall find they were mucli less perfect then than medicine is now. Astronomy and chemistry a century or two ago were but astrology and alchemy. If, then, we may draw a picture of the future from the progress of the past, we need have no hesitation in saying that chemistry rightly applied, and physiology justly interpreted, will, ere many generations pass away, reveal the deepest secrets of PREFACE. 19 diseased action ; and although scientific medicine will still be, and for ever remain, unable to banish death, it will nevertheless enable the properly trained scien- tific practitioner to follow with unerring certainty the various morbid chano;es occurrino; in the human frame, as well as probably at the same time permit him to mould their course to the advantage of suffer- ing humanity. 25, Haeley Street, W., 1882. o3 21 CHAPTER I. GENERAL REMARK!S OX THE STUDY OF DISEASES OF THE LIVER. The practical experience I have acquired in tlie diagnosis and treatment of diseases of the liver since the publication of my monograph on Jaundice admits of my now asserting, without hesitation, that the old and still prevalent idea that hepatic diseases are, as a class, exceptionally difficult to diagnose, is totally at variance with truth; although I must at the same time admit that the pathology of at least some few of them is not only frequently puzzling, but occasionally obscure. The errors which one every day sees committed in the differential diagnosis of diseases of the liver are not, I believe, due, as is commonly asserted, to the uncertainty of their symptomatology and the inherent difficulties attached to their signs — from the supposed peculiarly obscure nature of the morbid physical conditions themselves — but in a great measure to the defective means adopted by practitioners in attempting to unravel them. 22 DISEASES OF THE LIVER. While the physical means of diagnosmg cardiac, pulmonary, and renal affections have gone on steadily improving during the last quarter of a century, the physical agents now employed by the vast majority of physicians in diagnosing hepatic affections are scarcely, if at all, one whit better than they were half a century ago. And yet, as the sequel will prove, this is not due to an absence of means, but to a disinclination to take the trouble of employing them. At whose door does the blame lie ? To this question I reply, in very many instances, at the door of the teachers of clinical medicine, not one, but many of whom give the students under their charge but little oppor- tunity of becoming practically acquainted with the different forms and phases of the few hepatic cases in the wards of their respective hospitals. Hour after hour of the students' limited, and consequently valuable, time being expended by their teachers in the physical diagnosis and treatment of thoracic affections, to the almost total exclusion of liver derangements ; just as if affections of the liver were things of mere secondary importance to those of the heart and lungs.^ Perhaps the prominence generally ^ However much it may seem to the contrary, I beg to observe that no assertion is made in this book, no matter however bizarre it may at tirst sight appear to the mind of the uninitiated, which I do not believe will bear the strictest investigation. Even this startling accusation of general profes- sional ignorance, which has just been made, I could bring ample printed INTRODUCTION. 23 given by the majority of clinical teachers to thoracic affections may partially arise from the fact that while they themselves excel in physical diagnosis, by means of auscultation and percussion, they are perhaps conscious that the inadequacy of their own physio- logical chemical training renders it almost impossible for them to grapple successfully with some of the complicated cases of hepatic disease. Experience, the most unmerciful of all teachers, having taught them that complicated cases of liver disease cannot be pro- perly mastered without the aid of physiological che- mistry. From the fact that diseases of the liver are not, like those of the heart and lungs^ amenable to direct evidence to support ; as, for example, Professors Parkes and I-ongmore's statements given in the Report on Medical Education of the British Medical Association, dated Jan. 1881, from page 8 of whicli I extract the folio veing : — Professor Longmore, writing in November, 1879, on this subject, observes : ' We see at Netley how little qualified in practical professional matters some of the young men are at starting who have passed the examinations for their licenses to practise, in many instances with much credit. Out of a batch of twelve men, now at Netley, all above the average, not one could make a quantitative analysis of the urine, and only a few had a practical knowledge how to make a qualitative analysis. It is only in a few exceptional instances that I find a young surgeon coming to Netley acquainted with the manipulation of the ophthalmoscope, or knowing how to determine the refractive quality of an eye. As a general rule, it is absolutely necessary prescriptions should be super- vised ; and so on in numerous practical matters.' It is argued that the men who enter at Netley are hardly up to the average standard of practitioners; this is an error, but if true, these gentlemen have all re- ceived diplomas and are legally qualified practitioners, and it is further said — ' We find precisely similar evidence bearing on this subject, repeated over and over again by general practitioners residing in every' part of the United Kingdom.' 24 DISEASES OF THE LIVER. interrogation by means of tlie stethoscope and plexi- meter. Auscultation being in fact of no avail whatever, and percussion yielding nothing more than the meagre information derivable from tlie one solitary factor of bulk. Physiological chemistry, on the other hand — as there will be ample occasion for seeing in the sequel — is the only talisman which can unravel the tangled skein of secrets which involves the vast majority of hepatic disorders. In thus speaking of physiological chemistry, I do not desire it to be for a moment supposed that I imply by that term the mere paltry smattering of physiological chemical knowledge that is picked up by a man of average ability in the lecture-room during an ordinary course of medical study. For, on the contrary, that amount of physiological chemical knowledge will never suffice for the detection and differentiation of hepatic diseases, unless it be sup- plemented with some practical chemical manipula- tive skill. It would be just about as absurd for an ordinarily educated student to think that he is a physiological chemist, as for a retail druggist to imagine himself a scientific chemist because he pos- sesses a spirit-lamp, a test-tube or two, and a set of chemical reagents, no matter however anxious he may be to make the public think so by having the word 'CHEMIST' placarded in large letters over INTRODUCTION. 25 his shop-door.^ Physiological chemistry is a distinct branch of science, which is not to be mastered in either a week, or a month, or a year, and he who desires to profit by its teachings at the bedside of his patient must be content to begin its study at the analytical table of a practical laboratory ; for it is there alone that can be acquired the requisite amount of preliminary information to enable him to turn physiological chemistry to useful account in the sick-chamber. If these, then, are true facts, how is it possible for one to feel in the least degree surprised that the ' In no country of Europe except England, not even in benighted Spain, where barber-surgeons exist until this Aery day, do men who retail medicines style themselves ' chemists.' A chemist is a man who works with chemicals, not a man who sells them. Far less a man who merely sells drugs, many of which are not even so much as in the com- mon sense of the word chemicals at all. An infusion of gentian or a decoction of broom tops, for example, has no more right to the title of a chemical preparation than a cup of tea or a pot of coft'ee. There are in England manufacturing druggists as well as a class of legally qualified druggists — who from having obtained the diploma of the Pharmaceutical Society have a perfect right to call themselves pharmaceutical chemists — but it would be quite as much a solecism, and consequently wrong, for them to drop the first half of their title and simply retain that of chemist above their shop-doors, as it would be for a dental surgeon to drop the word ' dental,' which is equally in the same sense indicative of his special calling, and simply retain that of surgeon on his door-plate. There is in reality the same philological difference between a manufacturing, dispensing, and pharmaceutical chemist, and a ' pure chemist,' as there is between a ' dental surgeon ' and a 'surgeon.' If then the sellers of medicines who do not possess the diploma of the Pharmaceutical Society dislike the name of druggist (about which there is nothing whatever derogatory), let them prefix the word ' dispensing,' which will unmistakably deuote their avocation, and by so doing cease to sail under false colours by putting over their shop-doors the single word chemist. 26 DISEASES OF THE LIVER. present imperfectly chemically educated race of medical students, when transformed into legiti- mately licensed medical practitioners, on encounter- ino' a not self-evident case of diseased liver, at once find their diagnostic powers not only entirely inade- quate for its solution, but at the same time feel themselves to be tossed hither and thither on a most uncomfortable sea of perplexity and danger as regards its treatment ? Ay, still more, it may be equally truthfully said — and that too for a precisely similar set of reasons — that it not unfrequently happens that some of our most talented clinical teachers, as well as the cleverest of our consultants, of justly acknowledged skill in the diagnosis of disease affecting other organs of the body, are com- pletely baffled in their attempts to unravel what they are forced in self-defence to designate ' obscure diseases of the hepatic organ.' Occasionally wander- ing, as will subsequently be shown, so far astray as to diagnose the case as one of cancer of the liver, A •word which has teen ah-eady otbei-wise appropriated in e-verj country of Europe, and carries with it a special and entirely different significa- tion from that of a salesman of medicines in the mind of every well- educated man, be his nationality what it may. Indeed I see no reason why those gentlemen who have not only received a practical chemical edu- cation, but are at the same time Fellows of the Chemical Society, should object to prefix the word Dispensing. Just as many others do Analytical before the word Chemist, in order to indicate their special avocation. For even numbers of gentlemen having a right to the title of sm-geon, from possessing the diploma of Member or even of Fellow of the Royal College of Surgeons, who practise Dentistry as a speciality, always, I believe, employ the distinguishing duplex title of Surgeon-Dentist. INTRODUCTION. 27 when not even a trace of such morbid material exists in the oro-an, or even so much as in the system ; and yet again failing to recognise the presence of a malignant form of this inevitably fatal liver affection until the patient is on the very brink of the grave. Such startling errors in diagnosis are by no means always traceable to the symptoms and signs of organic change having been present in the former and absent in the latter set of cases, but in general, either from the physician having omitted to adopt the proper means for the detection of the morbid condition. Or, if having made use of them, from his failing to recognise the true import of the revelation they have made to liim. From his in- ability to correctly interpret and sufficiently appre- ciate their meanmo-s, even when he has them before his eyes. To the reader not much versed in the history of hepatic cases this may perhaps seem strong, if not even ungenerous, language for me to use. But every consultant who, like myself, has given special atten- tion to the clinical history of liver cases, and con- sequently who is as it were behind the scenes, will, I feel sure, unhesitatingly endorse the remark. I know full well that although I may be the first to put such a statement in type, I am a long way from being the first that has entertained the sentiment. Indeed, should any hypercritical-minded reader feel inclined 28 DISEASES OF THE LIVER. to challenge its truthfulness, let him turn to the report, meagre and imperfect though it be, of the discussion which followed the reading of a paper on Choleocys- totomy in a case of impacted gall-stone, read before the Medico-Chirurgical Society, which appeared in the medical weeklies of November 15, 1879, and after the perusal of the observations therein said to have fallen from the lips of some of the speakers on that occasion, I think he will cease to doubt either the justice or the propriety of the remarks, as well as cease to wonder that the medical ' art ' has been, by cynical critics, stigmatised as an incomprehensible conglomeration of false facts, cemented together by unsupportable theories. Moreover, I will even dare to ask my hypercritical-minded reader if this can be reo-arded as astonishins; when we look around us and see still in vogue, on all sides, the non-philosophi- cal, non-physiological system of treating and speak- ing of mere symptoms, as if they were in reality diseases — that is to say, palpable physical morbid states. Can any one be found bold enough, I will ask, to say that this remark is not specially true as regards liver cases, the therapeutics of which is but little better now than it was a century ago ? For beyond the occasional introduction into prescriptions of one or another of the vegetable hepatic stimulants newly introduced from America, the sum and substance of INTRODUCTION. 29 the vast majority of them neither differ in quality nor quantity from those in general use among English practitioners at the beginning of the present century — a fact not to be wondered at, seeing that many of the men at present occupying the posts of clinical teachers in our metropolitan medical schools lecture to their pupils on what they please to term mere ' Functional Derangements of the Liver,' and teach them to pre- scribe for this so-called species of hepatic disease as if the states of body they described were in themselves morbid physical conditions, instead of being, as they in reality are, mere concomitant symptoms of not unfrequently very widely differing morbid physical conditions of the hepatic organ. Tor just as pain is a symptom common to many diseases, so are jaundice, pipeclay-coloured stools, and saffron-tinted urine, signs common to some diametrically different forms of affections of the liver. Yet, marvellous to relate, this very same class of otherwise enlightened clinical teachers, in spite of their following this pernicious system of teaching students ' how to treat functional hepatic diseases,' would repu- diate with scorn the bare suspicion of being considered capable of prescribing for a mere ' palpitation of the heart,' a ' bronchial expectoration,' or a ' purulent urine,' under the title of functional diseases of the heart, lung, or kidney. Nay. more, one and all of them would naturally 30 DISEASES OF THE LIVER. enough look with supreme contempt upon the mere idea of being thought capable of condescending to treat like a routine empiric what is called a mere symp- tom — such, for example, as a headache or stomach- ache — even if presented to the uninitiated minds of their confiding patients disguised from their cog- nisance in the grandiloquent Greek synonyms of cephalalgia and epigastric neuralgia. Yet, strange to say, this same conscientious class of enlightened practitioners with the most perfect mental equa- nimity, and it may be, even with somewhat of a spice of self-complacency, quietly sit in their study chairs and unblushingiy write out — in true empirical style — prescriptions for mere symptoms in cases of liver disease, just as if they were under the impression that they were prescribing for the case ' rationally ' and to the best interests of the patient. How long, I ask, are we to find diseases of the liver even gravely published by otherwise well-educated medical men as ' cases of functional derangement,' as if they really believed that functional derangement was itself a morbid state, instead of being, as it actually is, a mere symptom of a morbid physical condition of some tangible part or another of the hepatic organ — its secreting cells, its ducts, its parenchyma, its blood-vessels, or its nerves ? Have medical men, as a class, yet to learn that nothing in nature happens without a cause ; that no symp- tom nor sign ever originates spontaneously ; that INTRODUCTION. 31 every change in function, no matter however triflinfj- it may be, is invariably preceded by a change in the material organisation of some part or other of the tissues inducing it ? Although we are not always able to detect it. I have ventilated these oj^inions from having long entertained a strong conviction that the slow, snail- like progress of rational medicine along the road to her legitimate goal — namely, that of becoming an exact science — instead of remaining, as she is now, little better than an empirical art, though practised by educated men, is due far more to the errors com- mitted by its teachers than anything else. For if its teachers fail to impress upon the minds of their pupils the advisability of treating the morbid causes them- selves, rather than the mere symptoms or chain of symptoms they induce, how can we expect to see rational medicine ever rise sphinx-like from out of the ashes and dust of the past ages of empiricism, from whicb she has so long, and as yet unsuccess- fully, struggled to free herself ? I willingly admit that there was a time, and that too not long since, when medical practitioners, in this and all other countries, had a good excuse for pre- scribing for mere symptoms ; but that time vanished when pathological anatomy proved that mere symp- toms were not of themselves morbid states, but merely the result of sometimes widely differing pathological 32 DISEASES OF THE LIVER. conditions. Before morbid anatomy opened the win- dow and admitted the light, all diseases were naturally enough christened after their most prominent symp- toms. Haemorrhages from the lungs, stomach, and bladder were respectively named ha^matemesis, haemo- ptysis, and hajmaturia, from the causes of these various forms of bleeding being as yet unknown. Con- sequently their treatment was of necessity, like their diagnosis, empirical. Now, however, the cause of the haemorrhages being discoverable, and discovered, it is not the act of bleeding, but the cause of the bleeding, which is, and ought to be, prescribed for by the en- lightened practitioner ; and what now holds good for htemorrhages I desire to see hold equally good for jaundice, which, like haemorrhages from the lungs or the stomach, is nothing but a mere sign of a variety of widely differing pathological conditions. To err is human, and no matter however clever and well trained a man may be in medical diagnosis, mistakes he is sure sometimes to make, and that too more especially in hepatic disease. For not even is the highly-trained ' Scientific Physician ' infallible. By this term of ' Scientific Physician,' be it remembered, I do not mean merely members of the promiscuous host of learned and able men who possess in their con- sulting rooms, besides a stethoscope, thermometer, and microscope, a spirit-lamp, a bottle of nitric acid, and a few test-tubes, but quite another class, and that too, INTRODUCTION. 33 alas ! as yet, a very small one — namely, tliose physi- cians who, after having completed the ordinary routine of studies qualifjdng them to become Members of the Royal College of Physicians, have spent two or three years within the precincts of a practical physiological and chemical laboratory. For to such men, and such men alone, can with any degree of justice be applied the title of ' Scientific Physician.' And I say that even such are by no means infallible in the diagnosis of hepatic affections. I must, however, at the same time do them the justice to add, that as there are a variety of different degrees of falhbility, it may not untruthfully be said that for every time the ' scientific physician ' trips and falls, his less educated brother stumbles and falls at least a dozen times. We are still far, very far, from the goal of perfection in scien- tific medicine. For even in highly educated Ger- man}' scientific medicine is but as yet in its infancy ; while in England again it may be said to be still in its long clothes, and what is more, if the illiberal Anti-vivisection Act be not abrogated or allowed to become a dead letter, it is likely to remain so for centuries yet to come. The mysteries of the healing art are far beyond the power of even the best collective human skill, unless it be aided by experimental science. For the clue to the unravelling: of morbid action can only be found through the study of experi- mental physiology. Healthy living nature herself D M DISEASES OF THE LIVER. must be interrogated in order to get at the secrets of morbid living action. Little do the pseudo- sentimental anti- vivisection - ists dream of the incalculable mischief they are doing to humanity by decrying the laudable efforts of en- lightened medical men to advance the progress of the healing art by studying the functions of the frame on animals. Little do they seem to comprehend that the crusade they are so energetically waging against what they please to call vivisection is not one whit less uncalled for or less unreasonable than the same kind of pseudo- sentimental crusade which was waged against the dissection of the dead human body in the cause of humanity by their equally illiberal and un- enlightened predecessors fifty years ago. The present anti-philosophic pseudo- sentimental outcry against vivisection originates in the erroneous idea (partly fostered by a few medical men ignorant of its advan- tages) that while its cruelties are enormous its benefits are nil. But I, who was a vivisector for ten years, and the first officially appointed teacher of practical physiology in a British medical school/ can speak as one having authority on both of these points, and I opine that all the cruelties of the so-called vivi- sectionists, put together, would not amount in a hun- dred years to the cruelties perpetrated under the name of sport during one single shooting and hunting 1 I began the course of Practical Physiology in University College, London, in 1855. INTRODUCTION. OO season. While again the advantages of practical physio- logy to the healing art are simply beyond the powers of human calculation ; though not more apparent to the uninitiated eye than the value of an iron nail is to the equestrian. But as Herbert in his ' Jacula Prudentum ' says, ' For want of a nail, the shoe is lost ; for want of a shoe, the horse is lost ; and for want of a horse, the rider is lost ' — so say I : For want of vivisection, physiology is lost ; for want of physiology, rational medicine is lost ; for want of rational medicine, the patient is lost. Moreover, were it even true (which I emphatically say it is not), as ignorant anti- vivisection sentimen- talists assert, that experimental' physiology has not as yet enabled its cultivators to solve any of the mysteries of disease, it is assuredly true that it has at least already enabled them to avoid many of the errors that were formerly, and are still daily, com- mitted by those who, ignoring its assistance, ti:ust to their own imaginary transcendental ' practical ' acumen. Coupled with the somewhat haphazard sort of assistance derivable from what they please to designate their ' experience.' Which, in the majority of instances, amounts to little better than a routine system, guided by the enlightened ' rale of thumb.' The perusal of the following pages will, I trust, if it does nothing more, at least let one tiny ray of lightpene- trate through the cloud of their scientific darkness. i>2 36 DISEASES or THE LIVER. In order to be able to do this, it will be neces- sary for me to begin by making a few remarks on the functions of the liver, the nature of bile, and the physiology of its secretion, so that all my readers may be able to follow with facility the many scien- tific facts, theories, and arguments which it will be necessary for me to lay before them, in a variety of different forms, and in many different places throughout the work, in support of the new render- ing I give to many of the old data, as well as the fresh colourino- I 2:ive to some of the new. CHAPTER II. THE CHEMISTRY, PI£YSICS, AND PHYSIOLOGY OF THE LIVER. From the fact that in every individual case of hepatic disease the liver, at least in some part of the course of the affection, becomes altered in composition, in specific gravity, in weight, arid in size, it is abso- lutely indispensable for the practitioner to know something about these factors in health, as well as to be acquainted with some of their more salient varia- tions in disease. I shall now consider each of them in brief detail. Chemical Composition of the Liver. There is no single organ in the human body the chemical composition of whose healthy substance varies so much as that of the liver, and this is readily accounted for when the nature of its functions is properly understood. In order to avoid repetition I shall refer the reader to p. 57, where he will find the hepatic functions, which are four in number, treated of in detail. Meanwhile I shall only remark 38 DISEASES OF THE LIVER. that the liver, being an organ of the body intimately connected with the development and nutrition of the tissues, plays a more important part in the animal economy in youth than in age; and hence it gradually diminishes in proportional size and weight as age advances. Moreover, as the important part it plays is in the preparation of the food for assimilation, the contents of its hepatic cells vary from hour to hour, not only according to the state of the digestion, but also according to the quality and quantity of the food taken. Thus, for example, after a fal;ty meal the hepatic cells are loaded with oil-globules ; after a fiirinaceous meal they contain a superabundance of sugar and amylum; while after a meal of purely animal albuminous food they are cram-full of gluco- gen, the animal starchy substance formed by the liver itself out of albuminous and other kinds of non- oleaginous foods. This being the case, it can readily be imagined how it is impossible to state with exacti- tude the chemical composition of a human liver at any fixed period of life, or even at any one particular period of the day. The condition of the organ, liowever, differs so very much in disease, particularly in cases of fatty and amyloid degeneration, that I shall give the analysis of a healthy human liver to serve as a standard of comparison in cases of disease. The analysis of healthy human liver which I have elected to give as the standard of comparison is the CHEMICAL COMPOSITION OF THE LIVER. 39 one whicli was made by Professor Lionel Beale of the liver of a healthy man who was suddenly killed by an accident. It is as follows : — 100 parts of the fresh liver yielded- Water Solids In 100 parts of liver tissue were of — Fatty matters . . 3-82 Albumen Extractive matters Alkaline salts Earthy salts 4-67 5-40 1-17 0-33 Vessels&c.jinsol.invirater 16-03 . 68-58 . 31-42 In 100 parts of dried solids- 12-16 14-86 17-18 3-72 1-05 5101 Dr. Marcet ^ made in another way a comparative analysis of a healthy sheep's liver and a human diseased one. When dried, they yielded the following results : — ■ Healthy sheep's liver Carbon . . 44-00 per cent. Nitrogen . . 9-12 „ Fat . . . 24-90 „ Carbon in fat . 19*00 ,, Lardaceous fatty human liver . 62-99 per cent. . 9-00 „ . 35-30 „ . 27-18 The Specific Gravity of the Human Liver. The very same factors which influence the chemi- cal composition of the liver likewise influence its specific gravity. The specific gravity of the liver increases as age advances, from the fact that the hepatic tissues get denser and denser the older the individual becomes. The specific gravity of the organ is, however, liable to ^ Path, Soc. Trans, vol. xxii, p. 12. 40 DISEASES OF THE LIVER. great fluctuations in disease at all periods of life, in consequence of its depending in a great measure on the amount of the fat-globules stored up in the hepatic cells. This is most markedly shown by com- paring the specific gravity of a piece of normal human liver tissue with a piece taken from a liver in a state of fatty degeneration : — Normal human liver tissue having a specific gravity of 150 = Water 100 Fatty degenerated „ „ „ 1'03 .... There is even found to be a considerable difference in the specific gravity of healthy liver tissues ac- cording as they are taken from lean and fat persons, the specific gravity being on an average as 1"3 against 1"5. The effect of fat in changing the specific gravity of the liver tissue will be readily understood when I say that human livers have been known to float on ordinary drinking water, and on analysis have been found to contain as much as 65 ! per cent, of fatty matter. "Weight of the Human Liver. Not only does the human liver, like all other organs, vary in its absolute weight at different periods of life, but, strange to say, it also varies in its relative weight to that of the whole body at different periods of life. Like foetal organs, though in a much less degree, its relative weight diminishes in proportion to the gross weight of the body in a direct ratio as age NORMAL WEIGHT OF THE LIVER. 41 advances, and the activity of the vital processes diminishes. This is clearly seen in the subjoined table, which ogives the averao:e weio^hts of the human liver and body from birth onwards: — At birth the liver's weight is as 1 to 18 of the whole body lu infancy )) SO „ At puberty }> 30 „ At full growth :> 35 „ In middle life » 40 „ In old age )> 50 „ Thus showing that the child has, in proportion to its bulk, a liver twice and a half larger than the man tottering in decrepitude to the tomb, which fact of itself proves that some one at least of its functions must be of vastly greater importance to animal life in childhood than in old age. What this function of the liver is, which is so much more important in youth than in old age, no one has hitherto even so much as attempted to guess at. Therefore I may perhaps be pardoned if I venture to suggest that it is the saccharine function, which I shall presently have occasion to show is one of the chief the liver performs in the healthy animal econom}''. The reason why I fix the blame upon the hepatic saccharine function as being the cause of the liver's diminution in relative size in old age is based upon the well-known fact that it is in early life, while the tissues are develop- ing and all the vital processes are most active, that most sugar is required. Hence it is that children are 42 DISEASES OF THE LIVER. SO fond of sweets, and that the craving for them steadily diminishes in a greater or lesser degree as age advances and progressing development ceases. However, as I am not going to discuss that point here, I shall now proceed to give a table of liver weights at different ages, which I think will be found to be sufficiently exact to render it of practical service to my younger brethren in the post-mortem room, where I have myself often felt the want of some- thing approaching to a reliable table of comparison. I have drawn the table up from data derived from a variety of sources, and it is as follows : — Weight of Human Liver in proportion to Age and Weight of Body. "^ "^ lbs. _ ^ ozs. Between 1 and 4 weeks of age with a bodily weight of from 7^ it is 6 1 „ 4 months 4 „ 8 >} 8 „12 if 1 „ 2; years 2 „ 4 » 4 „ 8 fj 8 „I6 If 16 „30 }> 30 „60 If 60 „70 ff 70 „80 ff 80 „90 ft 14 7 28 8 34 10 40 12 46 18 56 30 68 40 100 60 150 52 120 46 110 38 100 34 It may be as well for me here to remark that these weights yield no clue to the weight of the liver in disease ; for while an adult liver may be met with weighing as little as 10 ounces, another may be en- countered of the enormous weisfht of 384 ounces DIMENSIONS OF THE LIVER. 43 (24 lbs.!). This last marvellous example occmTed in a case of encephaloid cancer in a man aged 50, which Dr. Gordon has reported in the ' Dublin Quarterly Journal ' for November 1867. The liver had entirely lost its shape, and looked like a great ball, with encephaloid cancerous nodules projecting from all parts of its surface. Taking all in all, the average normal weight of the human liver in proportion to the gross weight of the body is said, according to Quain's ' Anatomy,' to be as 1 to 36; and this I consider to be most probably a correct estimate to go by when, from insufficient data, in doubt as to how to make the pathological calculation. Size of Human Liver. The actual linear dimensions of a normal liver, freshly removed from the body of a well -developed average-sized man, say a sailor of 5 feet 7 inches, are usually 11 inches in its transverse, 65 in its antero-posterior diameter across the broadest part of the organ, and 3 inches at its thickest part from above downwards ; its absolute bulk is about 90 cubic inches, and its averao^e weig-ht 50 ounces. In a healthy female, again — a servant-girl — of 5 feet 4 inches in height, it usually measures 10;^- inches in the transverse, and 6 J in the antero- posterior diameter, and weighs about 45 ounces. 44 DISEASES OF THE LIVEK. As we cannot, however, get at the liver itself, either to measure, weigh, analyse, or take its specific gravity, while the patient is alive — and this is the very time that the physician wants to ascertain these points — the question is, ' How can we by other means obtain the requisite information ? ' Fortu- nately for clinical medicine, the physician has it within his power, under certain circumstances, and with proper precautions, to ascertain with compara- tive exactitude the intrmsic value of the most im- portant (clinically speaking) factor of all, namely, that of size. So I shall now proceed to show how this can be easiest and best accomplished. In consequence of the liver being a large, well- defined, compact, solid body, surrounded by elastic non-solid organs — lungs, stomach, and intestines — by percussion we can obtain a tolerably exact idea not only of its relative position, but of its actual dimensions. When struck, the tissue of the liver yields a heavy, dull sound, whereas all the sur- rounding organs — lungs, stomach, and intestines — give oat, if not a tympanitic, at least a well-defined resonant tone. Consequently, by a process of com- parative percussion, the dull boundaries of the hepa- tic organ are recognisable in the midst of the resonant area formed by the surrounding non- solid organs, and from a combination of the results of numerous physiological and clinical observations made NORMAL SIZE OF THE LIVER. 45 upon subjects with healthy livers, it has been found that, by a system of manual percussion, the exact dimensions, not only of a normal but of a diseased liver, can be thus ascertained with approximate exactitude. It is now a well-determined fact, for example, that the area of hepatic dulness, in healthy well- formed individuals, usually commences at a spot two inches, in a direct line downwards, from the right nipple ; and consequently the main calculations of the perpendicular extent of the anterior dull area of the organ are made in this line. Thus, in de- scribing the normal extent of the anterior hepatic dulness in a person of 5 feet 7 inches in height, the dulness is said to be 4 inches ; which means the dull area which has been ascertained in the direct perpendicular right nipple line, while the patient Avas lying in the dorsal recumbent position. Under the same circumstances again, in a person of 5 feet high, 3^ inches are usually put down as the standard of the absolute dulness ; while in one of 6 feet or more, 4.^ inches are considered to be the full limit of the dull area in the per- pendicular right nipple line. In all persons, be they big or little, the left margin of the dull hepatic area usually terminates at a point situated about l.> inches to the left of the lower margin of the xiphoid cartilage. This measurement is 46 DISEASES OF THE LIVER. oftentimes a very uncertain one, in consequence of the presence of the generally distended and tym- panitic stomach, the resonant tone from which sometimes completely masks the dull sound elicited from the thin left margin of the liver. Fortunately for the purposes of the clinical physician, it happens that in the very set of cases where it is most essential that this boundary should be correctly ascertained, the tissues of the liver are as a rule so hardened, and its edge so thickened and rounded, as well as the organ as a whole so en- larged, that its left margin yields such a distinctly dull sound on percussion as to defy its being masked by the resonant sound yielded by the tym- panitic stomach. The same consolatory remark is, however, not applicable to another set of cases, where it is almost of equal importance to ascertain the exact position of the left margin of the liver, namely, in those of hepatic atrophy. Then it is, indeed, that the stomach interferes most in the establishing with exactitude the left lateral dimensions of the liver ; but fortunately the atrophying process generally proceeds uniformly throughout the whole organ, so that if one of the measurements of the liver has been exactly ascertained in this disease, all the others can be approximately deduced from it by a simple rule-of-three calculation. NORMAL SIZE OF THE LIVER. 47 Thus, supposing, for example, that the exact alo- solute dulness of the atrophied liver in the perpen- dicular right nipple line has been ascertained to be 2.^ inches, the transverse measurement may be ap- proximately ascertained from the relative normal proportions as follows : — 4 : 2-5 : : 11 : x, and the antero-posterior diameter by 4:2-5:: 6'5 : x. Such calculated measurements, however, can only be applied to the very limited number of cases of disease in which a uniform increase or diminution in the size of the liver is known to occur ; they are utterly inapplicable to cases, such as cancer^ abscesses, and hydatids, where no uniformity in the extension of the diseased area is maintained. In such cases, from certain portions of the organ being alone implicated, and the remaining portions being left in an absolutely normal state, it is neces- sary to subject the patient to the fatiguing ordeal of a dorsal, as well as of an axillary, in addition to mere anterior percussion. I must not omit to here call attention to the fact that the dull area ascertained to exist in the hepatic region, through the medium of simple per- cussion, does not in all cases represent the exact dimensions of the liver ; for the liver may occa- 48 DISEASES or THE LIVER. sionally be perfectly normal in cubic capacity, and yet the dull area in the hepatic region be found either to be in excess, or to be less than what it ought to be, had the dull sound elicited represented the boundaries of the organ. The reason of this is easily explained in the following cases : — A. — Conditions likely to give eise to errone- ous SIGNS OF DIMINUTION IN THE BULK OF THE LIVER. The position of a perfectly normal liver in the abdomen of different individuals varies sometimes very considerably, for the following reasons : — 1. The mere difference of sex makes a difference in the position occupied by the liver ; therefore, when arriving at a diagnosis from data obtained from the position and size of the liver in women, it must not be forgotten that the conformation of a woman'.s chest being different from that of a man's, the normal anatomical position of the liver is different in the abdomen of the woman from what it is in the ab- domen of the man, being from one to one and a half inches lower down in the right hypochondriac region, and nearly quite as much below the right nipple, than in a normally formed male subject. I am now speaking from personal observation, and as my ex- perience only extends to civilised women, who distort their chests and abdomens by corsets and straight THE SIZE OF THE LIVER. 49 waistcoats, the above remark has reference to them alone. It matters to us, however, but little what the position of the liver is in uncorseted savage women, for I should think it very unlikely that many of my readers will be called upon to treat liver diseases among them. 2. Some persons have such unusually lax hepa- tic suspensory ligaments, that the liver floats about in the abdominal cavity, and has not inaptly re- ceived the title of ' movable liver,' analogous to ' movable kidney.' And the possibility of a patient possessing one of these ' movable livers ' must not be lost sight of when calculatmg the extent of the dull hepatic area. For if the suspensory ligament chances to be unusually lax the liver sinks down- wards and backwards in the abdominal cavity, when the patient is in the recumbent dorsal position. Occasionally to such an extent as to remove entirely its anterior surface from contact with the abdommal walls, and m consequence thereof a loop of tym- panitic intestine may intervene and completely mask the dull hepatic sound, which would otherwise be elicited by percussion. In a case of ' movable liver ' of this kind, notwithstanding that the liver is of normal dimensions, it may happen, from only a very limited area of incomplete dulness being perceptible, that the case may be readily mistaken by the inexpe- rienced for one of atrophy. In all doubtful cases of E 50 DISEASES OF THE LIVER. ' movable liver ' it is therefore necessary also to per- cuss the organ, while the patient is in the erect position. For although cases of atrophy are not rare, cases of abnormally loose suspensory ligaments are common in delicately formed individuals — both male and female. 3. The position of the liver in the abdomen varies, even in the same individual, at different times of the day, on account of physiological causes. Thus : — a. A full stomach presses the liver downwards and backwards from the abdominal parietes. h. An empty stomach admits of the liver ascend- ing upwards and forwards. ('. Inspiration pushes the liver downwards. d. With expiration the liver rises in the abdo- men. In the upright posture, the anterior margin of the normal liver sinks from one to one and a half inches lower in the abdomen than the position it usually occupies when the individual under examination is lying flat on his back. 4. Another deceptive semblance of atrophied liver arises from an accumulation of gas, either in the stomach, intestines, or peritoneal cavity. This source of error is best avoided by making a com- parative examination of the dull hepatic area while the patient is in a standing position. THE SIZE OF THE LIVER. 51 B. — Causes likely to lead to the idea of the liver's being enlarged when it is not. Tliis mistake may arise from : — 1. An accumulation of hardened fagcal matter in the transverse colon, giving rise to a marked con- tinuous dulness on percussion with that arising from the lower margin of the liver. And from the dulness arising from the fasces in the distended colon being added by mistake to the actual hepatic dulness, the liver may be pronounced to be enlarged ; when, so far from being in an enlarged condition, it is in reality actually smaller than it ought to be. 2. The presence of abdominal tumours impinging on the liver is a frequent source of error. More particularly is this the case in fat females with uterine and ovarian tumours of the right side. Even in males, however, serious errors in diagnosis have thus arisen. An enlarged and displaced spleen — the result of malarial disease — as well as a hydro- nephrosis having been, to my own personal know- ledge, mistaken for, and treated as, cases of enlarged liver, by men of no mean diagnostic power in hepatic diseases. 3. As already said, in calculating the dimensions of the liver in females, when it is suspected to be atrophied, the probable effects of tight lacing must ic 2 52 DISEASES OF THE LIVER. be taken into account. The same remark is equally applicable when hypertrophy of the organ is sus- pected, for the continuous effect of long stays and tight lacing is to induce a marked and permanent displacement of the liver downwards. While at the same time, from the organ being tilted on its axis, its diaphragmatic surface is brought forwards into contact with the anterior abdominal wall, and thus an im- pression of hei^atic enlargement is often given, where no such enlargement exists. On one occasion, to such a marked extent did this occur in a female of sixty years of age — a patient in University College Hos- pital — whose autopsy I made, that the physician in charge, though experienced in he})atic diseases, had diagnosed and treated the case as one of chronic ' idio- pathic enlargement ' of the liver. Which was not in the least to be wondered at, seeing that the lower edge of the right lobe actually reached to the crest of the ilium. At the autopsy a strange state of affairs was discovered. The liver was found to be divided transversely by a deep sulcus, which gave to it, in consequence of the further distortion caused by the lower margin of the tightly laced stays, an hour-glass appearance, as well as communicated to the eye the idea of considerable hepatic enlargement. Whereas when the organ was placed upon the scales it was found to weigh only 40 ounces — that is to say, 5 ounces less than normal. THE SIZE OF THE LIVER. 53 4. In French workmen, as well as in English sailors, who are in the habit of keeping their trousers up by a belt instead of suspenders, it is no uncommon thing to find the liver with a deep farrow running across it, as in the female just alluded to. 5. Just as such errors as these may arise in calculatino; the dimensions of the liver downwards and laterally by percussion, so again mistakes may arise regarding the extent and position of the liver in an upward direction, from coexistent disease in the base of the right lung and pleura. The upper margin of hepatic dulness reaches normally to within two inches of the nipple, and in cases of consolidation of the lower lobe of the right limg — from pneumonia, cancerous infiltration, &c. — as well as when an efi'usion of fluid exists in the pleural cavity, the dul- ness from these causes is sometimes so markedly continuous with that of the liver as to lead to their being confounded together. Thereby giving rise to the supposition that the liver is enlarged and projecting against the diaphragm, pushing it up- wards into the chest, when nothing of the kind has occurred. 6. There is yet another possible source of error, though, from its extreme rarity, an error is unlikely to be committed. But as the mistake is said to have once occurred, and it is quite possible that it may occur again, it is but right that I should call 54 DISEASES OF THE LIVER. attention to it — namely, the possibility of mistaking an anteverted small liver for an enlarged one. Dr. T. D. Griffiths, who related the case where this happened, says that in a man aged 54, ' the liver dulness extended fi'om two fingers^ breadth below the nipple to the crest of the ilium, and partly into the iliac fossa, eight inches in the perpendicidar right nipple line.* Yet at the post-mortem the organ was found to measure only 10 inches transversely, and 8 in the antero- posterior direction, weighing 56 oz. This unusual state of affairs, he says, was due to the ' liver lying on its under surface in the lumbar region. The anterior edge of the right lobe being down in the iliac fossa. The organ appeared as if it had been partly rotated upon its own transverse axis ; or, in other words, anteverted, so as to allow its upper sur- face to be felt through the abdominal wall below the ribs.' 7. It may be as well for me here to remark that on examining the livers of patients labouring under heart disease (especially in cases of well-marked tricuspid insufficiency) by means of palpation, it occasionally happens that a distinct feeling of sys- tolic pulsation is communicated to the hand pressed firmly — though gently — on the right lobe of the liver, which pulsation, it is said, has been mistaken for an aneurism. In the case of exposed liver related at page 1036, as there stated I could feel no pulsation HEPATIC PULSATION. 55 whatever when I applied the palm of my hand to the exposed surface of the patient's liver. Therefore I think that even when a pulsation over the region of the liver is discovered in cases of heart disease, it is much more likely to be communicated to the hand indirectly from the aorta than directly from the hepatic arteries. I think a great deal of needless speculation has been made regarding the pathological nature of the so- called hepatic pulsation. The following remarks on the subject I chanced to fall upon while reading Dr. Milner Fothergill's work on heart disease (p. 85) in connection with insufficiency of the tricuspid valves. He says, ' All the branches of the venae cavse' become distended,' The liver becomes engorged with blood, ' and pulsates with the regurgitating current driven backwards by the hypertrophied right ventricle.' Liver-pulsation from venous engorgement leads to enlargement, and ends in the ' tissue becoming firmer and harder than normal. The liver is easily deranged by an excess of food when so affected, and great care in diet is requisite for the proper performance of its functions. There is serous effusion from the gorged venules into the bile-passages attending it, so that OpjDolzer has given to this condition the term " albumicholie," and he further states that in this condition there is con- gestion of the mucous lining of the bile-ducts with jaundice, and that both these conditions are readily 56 DISEASES OF THE LIVER. affected by a common cold.' I give this quotation simply as it stands in Dr. Fotliergill's book, without making any comment upon it. 8. There is yet another point in connection with hepatic percussion to which I must call special atten- tion, as I am aware from personal experience that it always merits attention ; and that is the possibility, nay even the probability, of mistaking the dull sound yielded on percussing contracted recti muscles for that produced by hepatic tissue. The mere fact of calling attention to the probability of such an error will, I think, of itself be sufficient to prevent the possibility of its occurrence. Lastly, in examinmg the liver, it ought always to be borne in mind that the co-existence of disease in the neighbouring organs may considerably alter its posi- tion, and also that the existence of fluid in the peri- toneal cavity greatly interferes with ascertaining its boundaries by percussion. Armed with a knowledge of these physiological and clmical facts, it is not difficult to ascertain in what respect the dimensions of a diseased differ from those of a healthy liver. By this remark, however, I do not wish it to be supposed that I for one moment mean to assert that an inexperienced hand would be able readily to ascertain, with anything even ap- proaching to exactitude, the correct dimensions of a diseased human liver. For althougfh one accustomed HEPATIC FUNCTIONS. 57 to percuss the organ can do so with facility, a tyi'o in general finds it difficult even to map out the exact boundaries of a healthy liver in a well-nourished individual, even where no pain exists to interfere with the percussing process. The Functions of the Liver, and the Chemistry of its Secretions. As is well known, the liver is not only the largest secreting gland in the human body, but the one to which has been accorded the prominent distinction of being situated in the very centre of the frame, and placed in intimate connection with both the resjDiratory and digestive systems. Being directly connected, on the one hand, with the digestive canal by a special venous system of its own, and indirectly connected on the other with the respiratory organs by the general venous system. Directly receiving from the digestive canal certain portions of the food pabulum, which have there undergone the necessary prepara- tory process of transformation to render them capable of absorption by the numerous portal capillaries — the saccharine and albuminous — and indirectly from the respiratory organs certain other portions of the nutritive elements of the food, which have already undergone in them a still further process of transfor- mation, by having been oxidised in the pulmonary capillaries — the fatty and oleaginous. 58 DISEASES OF THE LIVEE. The essential importance of the liver to animal life is still further demonstrated by the fact that even while the foetus is yet within its mother's womb it is to the liver that is directly returned the blood issuing' from the maternal placenta. The part the liver plays in the animal economy is in fact proportionately greater than that of any other glandular organ in the body, and this can surprise no one who is acquainted with modern physiology. For it is now a well ascer- tamed fact that the secretion of bile is merely one out of four important functions which the liver has to- perform ; to wit : — 1. A suo;ar manufacturino;. 2. A fat modifying. 3. A calorifying, and 4. A bile-forming function. It is not difficult, therefore, to understand what a great amount of disturbance in the performance of the various bodily functions must arise from the liver ceasing to do its proper work, and how essential it must be for the practising physician to understand the normal hepatic functions aright, if he is expected to be able to treat his patients rationally and on scientific prmciples. For just as dirt is nothing more or less than good matter out of place, so disease is merely healthy function out of order. Hence, in order to understand diseased action, it is absolutely essential to understand 1 HEPATIC FUNCTIONS. 59 healthy function. Therefore, before I enter upon the consideration of the liver's disordered action, I shall first speak of each of its normal functions in detail. The Liver as a Sugar Manufacturer. It is now Tvell known to every physiologist that no vertebrated animal — fowl, fish, or mammal — can exist without a certain amount of saccharine matter, which saccharine matter, if not supplied to it along with its food, it must possess the power of itself forming out of some one or other of the elements supplied to it in the shape of alimentary materials ; and thus it is that while the herbivora obtain a great part of their saccharine supply directly from what they live upon, the camivora manufacture the saccharine materials they require for their wants out of the non- saccharine alimentary substances they eat. And it is to the liver, the largest, and, as I have already said, the most important, glandular organ in the body, that has been delegated this sugar-manufacturing f)i"ocess. It is indeed the only organ in the body which enjoys the special power of transforminor albumiaoids into suo:ars, thouo'h others possess the power of transforming amyloids into saccharine matter — to wit, the salivary and pan- creatic glands. Moreover, there are two perfectly distinct kinds of sugar manufactured by the liver : a non-crystal- 60 DISEASES OF THE LIVER. lisable, identical with grape-sugar, and a crystal- lisable, to which chemists have given the name of 'milk-sugar,' from its being normally found in the milk of all animals, be they carnivora or herbivora. Indeed, it is the very fact of the milk of the car- nivora containing sugar, Avhich is the best evidence of all that animals possess within their frames a sugar manufactory ; for the carnivora certainly can- not obtain sugar from without along with their food. Although the mammary glands excrete this crys- tallisable form of sugar, there exists as yet no proof that they manufacture it ; on the contrary, indeed, all the evidence yet adduced tends to show that the liver is the only manufacturer in the body of saccharine matter out of albuminoids. Consequently we must accord to it, at least for the present, the credit of manufacturing the crystallisable animal sugar which the mammary glands of the carnivora, as well as of the herbivora, supply to their offspring in the milk. That healthy human blood, although not always containing sugar, yet always contains glucogen, is easily shown by adding a solution of iodine in iodide of potassium to a drop of blood under the microscope, when the contents of the colourless blood-cor^Duscles immediately assume a brownish-red tint, from their containing glucogen. The question of the saccharme function of the SACCHAEINE FUNCTION OF THE LIVER, 61 liver is a subject to which I have more or less directed my attention since 1853, when I communi- cated to the Soci^te de Biologic of Paris an account of an experimental procedure whereby diabetes can be produced artificially in animals by simply stimu- lating the liver to an excessive production of sugar, by means of ammonia, chloroform, ether, and alco- hol, injected into the portal vein. While again, in 1859, I communicated to the Royal Society another series of experiments founded on a different plan, which I regarded as proving the following eight propositions : — 1. Sugar is a normal constituent of the blood of the general circulation. 2. Portal blood of an animal on mixed diet contains sugar. 3. Portal blood of a fasting animal, as well as of an animal fed solely on flesh, is devoid of sugar. 4. The livers of dogs contain sugar, whether their diet is animal or vegetable. 5. Under favourable circumstances, saccharine matter may be found in the liver of an animal after three entire days of rigid fasting. 6. The sugar found in the bodies of animals fed on mixed food is partly derived directly from the food, partly formed by the liver. 7. The livers of animals restricted to flesh diet possess the power of forming glucogen, which glu- 62 DISEASES OF THE LIVER. cogen is, at least in part, transformed into sugar in the liver — an inference wliich does not exclude the probability of glucogen (like starch in the vegetable organism) being transformed into other materials besides sugar. 8. As sucrar is found in the liver at the moment of death, its presence cannot be ascribed to a post- mortem change, but is to be regarded as the result of a natural physiological condition. These conclusions have been, smce their publica- tion in the ' Proceedings of the Royal Society,' vol. X. p. 289, abundantly borne out by the ex- ■ periments of other observers ; as may be seen, for example, in No. 22, p. 214, of Pfliiger's ' Archives,' where the paper of Seegen and F, Kratschmer ap- pears. I may also mention that since the above series of experhnents were published, Yon Wittich has found that absolutely fresh bile possesses the power of converting boiled starch into sugar. If, for example, from twenty to forty drops of freshly secreted bile be put into a test-tube along with boiled starch, and kept at an ordinary temperature for an hour, when tested with the sulphate of copper solution it gives a distinct saccharine reaction. It is possible, then, that it is the ferment existing m the fresh bile which converts the hepatic glucogen into sugar while it is still within the parenchyma of the liver ; and if such in reality be the case, it is HEPATIC FUNCTIONS. 63 all the more easy for us to understand the rationale of the saccharine function of the human liver. When from any cause the saccharine function of the liver is interrupted, and the transformation of albumen into glucogen, and glucogen into sugar, is interfered with, the hepatic cells get filled with glucogenous albuminoid materials, and the diseased condition of the organ known as ' amyloid ' or ' albu- minoid liver ' is the result. While, on the other hand, when the saccharine function of the liver is abnormally active, and more sugar is formed than the wants of the system demand, the excess is excreted by the kidneys, and the disease which we call * glucosuria,' or diabetes, is established. The diabetes in this case not being due to a diminished bodily saccharine consumption, but (as described in my book on 'Diabetes') to an excessive saccharine formation. There are two kinds of diabetes, which, in consequence of the differences in their pathology, require of course very different kinds of treatment. Fat-modifying Hepatic Function. While the liver not only prepares, but even manu- factures some of the saccharine elements of nutrition, it merely modifies those of the fatty and oleaginous groups ; and even that it cannot do until they have previously undergone a process of oxidation in the lungs. 64 DISEASES OF THE LIVER. The great difference in the power the liver pos- sesses of preparing different kinds of foods for the purposes of assimilation might almost be conjec- tured from a study of the anatomical arrangements made for their reception by the organ. Thus, as I before said, while the saccharine and albuminous portions of the food are directly taken up by the capillaries of the portal vein, and carried at once to the hepatic cells, the fatty and oleaginous elements of the food are absorbed from the intestines by a special system of vessels called lacteals, which merging together form the thoracic duct, and they are carried by it ^J'as^ the liver, and poured into the general venous circulation. At a point from whence they can be at once transported to the pul- monary capillaries and exposed by them in the vesicles of the lungs to the direct oxidising action of the inspired air, before being allowed to come into contact with the hepatic tissues, which are to give the finishing touches to them in their pre- paration for the purposes of assimilation. The precise manner in which the hepatic cells act upon the fatty and oleaginous elements of the food is still a mystery. All we know is that the cells, besides under normal conditions preparing them for the purposes of nutrition under abnormal conditions, possess a remarkable power of extract- ing oil-globules and fat-granules in a free state THE CALOEIFYING HEPATIC FUNCTION. 65 from the blood, and not only storing them up i-n their interior, but transforming them into a beautiful white crystalline substance called cholesterin. AVhich they excrete along with the bile, sometimes in such quantity, too, that it forms itself into hard concre- tions — called gall-stones — either in the bile- ducts themselves or in the gall-bladder. When from some cause or another the fat- modifying function of the liver becomes greatly disordered, the hepatic cells get choke-full of oil globules, and the diseased conditions to which have been given the respective names of ' fatty ' and ' lardaceous ' livers are the result. , Calorifying Hepatic Function. Although the rationale of this function would perhaps be more readily understood if I were to delay its consideration until after I had explained the nature of the biliary function — as the introduc- tion of the few necessary words I have to say upon it after I have described the nature of bile and its mode of secretion would break, in a measure, the consecutive chain in the information to be con- veyed — I prefer taking the consideration of hepatic calorification up here, on the ground of its being the lesser of two evils. Everyone knows that no function in the animal F 66 DISEASES OF THE LIVER. body can be performed without a chemical change of materials. Further, that every chemical change of oro"anic materials is more or less associated with their active oxidation, and yet further, that no form of oxidation whatever can occur without the gene- ration of an amount of heat in direct proportion to the activity and amount of the oxidation. Moreover, from the amount of heat developed being proportionate to the activity and amount of oxi- dation, it follows, as a natural consequence, that the greater the activity of the chemical changes — which, from their occurring in the animal body, we denominate functions — the higher must be the tem- perature of the organ in which they occur. Now after having said that the liver is not only the largest, but, as regards the number of its functions, the most important organ in the whole body, it can astonish no one to hear that it is at the same time normally the warmest gland in the human frame. This is due to no peculiar or specific form of vital action going on in it, but solely and merely the direct consequence of the number and variety of the transforming, modifying, and assimilating chemico- physiological processes which occur in the hepatic cells being attended by the absorption of oxygen and the liberation of heat in a free state. The amount of heat so liberated is indeed actually sufficient to raise the temperature of the organ five degrees higher BILIARY SECRETION. 67 than that of the rest of the body. I have myself found, in experimenting upon the dog, the mercury in a sharp-pointed thermometer, inserted into the hepatic tissue through a small opening made in the abdominal walls, stand at 105° Fahrenheit ; whereas when the end of the instrument was withdrawn from the tissue of the liver, and pushed into the abdominal muscles, the mercury in the space of a few minutes sank down to 100°. It is not to be wondered at, then, that physiologists should re- gard the human liver as p^zr excellence the great calorifying organ of the body. Having given this brief resume of what some of my readers may perhaps regard as the three minor hepatic functions, I have now to take up the con- sideration of what they will in like manner, no doubt, consider the major, and consequently to us, as prac- titioners, the most important, of the hepatic functions, namely — The Biliary Function of the Liver. In order that the reader may all the more readily understand the derangements which arise from a stoppage of the secretion of bile, it will be advisable for me to remind him of the chemical and physical properties of a few of the more important substances which are met with in normal human bile. F 2 68 DISEASES OF THE LIVER. ON THE NATURE OF BILE. In a few words, human bile may be said to be composed of the following substances : — Firstly, biliverdin, a green, nitrogenised, non- crystallisable colouring matter, analogous to the green colouring matter of the leaves and other green parts of plants, and, like it, leaving on incineration — • as I was the first to show (1852) ^ — a distinctly ferruginous ash. This bile- colouring matter appears, like uroh^ematin and all other animal pigments, to be a direct derivation by simple oxidation of the colouring matter of the blood, and not, as some have erroneously supposed (Frerichs), derived from the transformation of the bile acids into pigmentary matter.^ ^ Vide paper by the autbor on the colouring matter of the urine, Tharm. Journ. November, 1852. Also my paper entitled ' Urohsematin, and its Combination with Animal Resin.' Verh. d. Phys.-Med. Gesellschaft zu Wiirzburg, Bd. v. 1854. '^ In a letter which appeared in the British Medical Journal of the 24th April, 1880, Dr. Chas. MacMunn calls attention to the fact that the colouring matter of the urine is partly derived fro^n bile pigment which has undergone the modifying process of oxidation, which fact was already pointed out by me in the above-mentioned papers over a quarter of a century ago. On this subject I received the following letter from Dr. MacMunn dated ' Wolverbampton, Feb. 28, 1881. ' Dear Sir, *I beg to call your attention to a paper of mine in the P)-oc. Boy. Soc. No. 208, 1880, which is the continuation of another publishefl in Proc. Roy. Soc. No. 206, 1880. I would send you repiints of both, but I know you take in the Proceedings. Thus you will see that your own researches on urohsematin, published in 1852, are confirmed by means of 1 COLOUR OF BILE. 69 Fresh and healthy human bile is usually of a brownish-yellow-green colour, varying, however, in depth of hue, very gi'eatly, according not only to its degree of concentration, but to the state of the system, as well as to the kind of food taken. As regards the influence of food upon the colour of bile, if I may be allowed to form an opinion from the effects of different foods on the dog's bile I have experimented upon, I should say that, as a rule, animal food tends to give bile a yellow, and vege- table food a more or less distinctly greenish tint. In some instances even the colour of the food taken is itself communicated to the biliary secretion. Thus it has been noticed that when oxen are fed upon red madder, as they often are in France, the bile taken from the gall-bladders of such of the animals as have freely partaken of the madder has a decidedly red tint. Now this is a point of considerable im- portance in proving that I am right in thinking that the colouring matter of the bile is not formed by the liver, but is directly obtained from the blood ; for, of course, the red bile can only be derived from the madder pigment through the instrumentality of the the spectroscope twenty-eight years after their publication. I have not mentioned this in the paper, but all physiologists will at once recoi'nise the fict. ... So far, I believe it may be taken as established, tliat all these urinary pigments (with one exception) which are discoverable by means of the spectroscope, can be produced from haematin ' C. A. MAcMuNiX; 70 DISEASES OF THE LIVER. blood, which in its turn received it directly from the madder in the intestinal canal. This and the follow- ing substances are subsequently further spoken of in the chapter on the Chemistry of the Excretions. Secondly, two peculiar substances, named respec- tively glycocholic and taurocholic acid — the former yielding, when in combination with soda, a crystal- FlG. 1. Crj-stals of Gl}'cocholate of soda, a beautiful polariscopic object. (■7) Fine neerlle-sbaped ciystals, sej^arated from a rosette-shaped group. (b) Small rosette of crystals, (c) Fan-shaped groups of crystals, which are merely portions of large rosettes that have become broken up. (^d) A fragment of a bundle of needle-shaped crystals. Mag. 90 diam. lisable, the latter a non-crystallisable salt. Tauro- cholic differs still further from glycocholic acid, in containing a large percentage of sulphur, and being, under the influence of hydrochloric acid, convertible THE CONSTITUTEXTS OF BILE. 71 into taurin — a beautiful snow-wliite crystalline sub- stance. The human body has the further power of converting it into cystin, that beautiful yellowish - green sulphur compound which forms certain kinds of Fig. 2. o ° o ° ^ ? ^ O _ o Q o O Taurocholate of soda is found in the form of fatty-looking globules of various sizes. They differ from fat and oil globules, however, in being soluble in water, and insoluble in alcohol and, ether. urinary calculi, which are more common in this country than in any other. Thirdly, cholesterin, a pure white crystalline, fatty matter. Xot, however, peculiar to bile, but found in various tissues and secretions of the body — ■ to wit, brain substance, ovarian fluids, &c., and which in abnormal quantity gives rise to gall-stones, as will be fully explained at page 551, where its chemical and physical characteristics will be found given in detail. Fourthly, a brown resinous substance, resembling, in appearance and consistence, shoemaker's wax, to which I long ago gave the name of ' Hepatic resin ' from not knowing what else to call it. Fifthly, among the constituents of the bile I 72 DISEASES or THE LIVER. must mention sugar, for both in the normal bile of man and of the lower animals, the ox and the dog, I have always detected that substance. On one occasion I even found torulte in the bile within twenty-four hours after its removal from the gall- bladder of a healthy dog, and the torulae were of course the product of the fermentation of the sugar contained in the bile. Sixthly, and lastly, a quantity of inorganic matter, consisting chiefly of soda, potash, and iron. A. The specific gravity of healthy human bile fluctuates, of course, with the percentage of solid matter it contains. From my own observations I consider that healthy human bile has an average specific gravity of 1020, and contains about six per cent, of solid matter, five per cent, of which is organic, and one per cent, inorganic substance. In diseased states the bile may be of so low a specific gravity as 1012, or so high as not to be calculable by a bilometer from its being as thick as tar or treacle. B. The reaction of healthy human bile when fresh is almost always neutral, but on standing it rapidly assumes a strong alkaline reaction, in consequence of an alkaline fermentation taking place in it. THE SECRETION OF BILE. Firstly, let it be remembered that it is an indisputable aphorism in physiology that every glandular secretion may be either temporarily ac- NATURE OF BILE. 73 celerated, retarded, or totally arrested during the life- time of the animal. Secondly, that the acceleration, retardation, or arrest may arise either with or without visible change in the glandular tissue. Thirdly, that all forms of glandular secretion are under the direct and immediate influence of nerve force. With these three preliminary aphorisms I shall begin to prove the first proposition, which seems at first sight to be the most difficult of establishment. Namely, the in- fluence of nerve force over the secretion of bile. Yet in reality this is quite as easy a matter as to prove any of the others, (a) Is my reader not aware of the influence of fear in arresting his own salivary secretion? Perhaps not. So let me put to him a second question : (b) Has he never read or heard of the popular manner of detecting a domestic thief in India? In case he has not, I may as well tell him what every man who has resided in the East Indies knows, namely, that when a household article has mysteriously vanished the servants of the house are all made to stand up in a row, and to each is given a handful of dry rice to chew and swallow, under the popular belief that the guilty man will be unable to swallow the rice. And so he no doubt is, for the simple reason that from the thief's believing in the efiicacy of the ordeal, and being conscious of his guilt, he gets into such a state of fright that an immediate arrest of his salivary secretion takes place, so that after rolling 74 DISEASES OF THE LIVER. about the rice in his dry mouth, and grinding it with his teeth, from not one single drop of saUva being present, either to soften or to lubricate it, he is at length forced to give up the attempt of gulping the dry grain-dust down his parched throat — and as a natural result his guilt is detected. His honest com- panions, on the other hand, from their believing that they have nothing to fear, have plenty of saliva in their mouths, and swallow their handful of dry grain with facility. Further, let me remind the reader that there is a not uncommon disease in this country, tolerably well known to physicians, under the name of ischuria renalis, in which not a single drop of urine is secreted. Not on account of nervousness, but on account of a morbidly congested state of the paren- chyma of the kidneys. Well do I remember m the early part of my consulting career being called to the bedside of an eminent authoress — a patient of Dr. Hastings — who had not passed one single drop of urine for fourteen hours. I immediately catheterised her in order to assure myself that there was actually a total arrest of secretion, and from the bladder I obtained, by means of a flexible male catheter, nothing more than about a drachm of blood-stained mucus. Whereas after applying the requisite treatment for ischuria renalis — hot poultices, &c. — no less than forty ounces of urine were passed within the next thirty- six hours, without the employment of any instrument SECRETION OF BILE. 75 at all. These, then, are two simple and easily under- stood examples of arrested, or as it ought rather to be called suspended, secretion, from glandular organs striking work, from two entirely different causes, one nervousness, one structural change. And if such a state of matters can happen to the sali\ ary and renal glands, how can anyone for a moment doubt that a precisely similar thing may happen to the gland which secretes the bile? There is not so much as a shadow of reason to doubt the possibility of the liver's striking- work, except a want of physiological and pathological knowledge. Which want, if it at all exists in the reader's mind, I shall now attempt still further to supply. At page 310, under the heading ' Jaundice the Result of Enervation,' I cite an example of the in- fluence of fear m arresting the biliary secretion in the dog. I there call attention to the fact that if (as Bernard first observed) a dog with a biliary fistula be caressed, the secretion of bile is actively continued ; while, on the other hand, if the animal be suddenly ill-used, the secretion of bile is instantly arrested; and if he be again caressed, the secretion is re-established, and the bile flows drop by drop from the end of the canula. Here the influence is entirely produced through the intervention of mental emotion on the nerves of the liver, and through them on the secreting cells of the org^an. If sucli efl'ects as are here de- 76 DISEASES OF THE LIVER. scribed occur in the dog, we can surely have little difficulty in understanding how the biliary secretion can be similarly influenced in the highly -developed organisation of the human being. I myself acci- dentally witnessed a still more remarkable example of the effects of nerve influence in arresting the hepatic secretion, not, as in the above case, from mental emotion alone, but from it combined with physical injury. It happened one day that while I was busy in the physiological laboratory at University College collecting bile from the biliary fistula of a bull-terrier dog, just before going in to lecture, the dog, under an uncontrollable murderous impulse, suddenly sprang upon my favourite tame white rat, which was running about the room — ' Eugenie,' an animal of European celebrity, from having been exhibited at several learned societies, both in this country and in France and Germany, as an example of a four-footed beast living without either its supra- renal bodies or spleen, with whom the dog had hitherto lived on teruis of peaceful acquaintanceship, if not of actual friendship. On the rat rushing to me and springing upon my knee for protection, I was just in time to save her from the teeth of the dog by the rapid administration of a smart blow on his head with the end of an ebony ruler which I chanced to have in my hand. The dog stopped, staggered, shook his head, and then slunk quietly away into his ARREST OF THE SECRETION OF BILE. 77 box. I thought 110 more about the. matter, but in a short time afterwards, on detaching the india-rubber bao- from the biliary canula, I was surprised to find that it contained less than half the amount of bile I had expected, and on looking at the end of the canula, I noticed, to my still further surprise, that not a drop of bile was issuing from the end of the canula. Thinking that its canal had got stopped up, I passed a probe into it, and was still more astonished to find that its course was perfectly free, and that yet no bile flowed. After waiting a time, the lecture-bell rang, and I had to proceed to lecture with what little bile I had procured, leavmg the dog behmd in the private room along with Eugenie, who was now securely put back into her cage so as to be safe from his unpleasant attentions. The lecture finished, before preparing to go home I again turned my attention to the dog, who from bearing no malice had greeted my return with a friendly wag of his tail, and to my surprise I found that the secretion was now going on as rapidly as before I had administered the blow to liim. Here then is an admirable example of how physical injury to the brain — most probably coupled with mental emotion — through the instrumentality of the pneumogastric nerve has the power for a time of totally arresting the biliary secretion. These then are pliysiological results explanatory of how the liver may strike work and give rise to a suppression of the 78 DISEASES OF THE LIVER. biliary function. But as in neither of these instances was jaundice a result of the suppression, I shall now turn my attention to pathology, and call it in to my aid in demonstrating conclusively that there does actually exist such a thing as jaundice from suppression of the biliary function. In order to do this satisfactorily I require to prove that where no bile whatever is secreted by the liver, the skin of the patient becomes of as intensely yellow a tint as it does when the whole system is loaded and engorged with an excessive secretion, associated with an arrested elimination of the bile by the natural channels. In fact I must be able to give positive evidence of the actual existence of well-marked jaundice occurring in a case where there is undoubted proof that no bile whatever is secreted. This is clearly and conclusively shown at page 104. To which I beg to refer the reader, in order to save taking up unnecessary space by repe- tition. C. The quantity of bile daily secreted by a healthy human adult has been variously stated in text-books, some giving the daily average amount as low as twenty, others as high as fifty ounces. Judging from the results of my experiments made upon dogs fed on a mixed diet in order to bring them as near as possible under the same dietetic influences as human beino^s, I think that the average amount may be said to be about one-fiftieth of the gross weight of the body. So that a QUANTITY OF BILE SECRETED. 79 person of 100 lbs. weight may be supposed to secrete two pounds of bile daily, one of 150 lbs. weight three pounds, and so on. And I think, in absence of any crucial experimental evidence on the human biliary secretion, we may be content to regard these figures as being sufficiently correct for all clinical j)ur- poses. D. Next, as regards the manner in which bile is secreted. For a long time it was thought, and, indeed, some people think still, that bile exists pre- formed in the blood, and that the liver only excretes it, as the kidneys excrete the urinary ingredients. Another class, running to the opposite extreme, believe that the liver is not merely the excretive, but also the formative organ of the bile. It appears to me, however, that neither of these extreme views is correct, and that the truth lies between the two. It is, in fact, not at all difficult to prove that the liver manufactures certain biliary constituents, and that it merely excretes others from the blood in which they exist pre-formed. Thus, for example, the two substances glycocholic and taurocholic acids are never to be found in quantity either in the blood, tis- sues, or fluids of the healthy organism, with the single exception of those of the liver and gall-bladder; and after extirpation of the liver from an animal neither of these acids is to be found in its body at all. Such a substance as cholesterin, on the other hand, which 80 DISEASES OF THE LIVER. is not peculiar to the liver or its secretion, but is the product of several organs of the body, is always to be detected in the blood, independently of the presence or absence of the liver. While biliverdin again, the colouring matter of the bile, exists in normal blood, and appears to be nothing more or less than a lower oxidation stage of the ferruginous albu- minoid which constitutes hasmatin, the normal colour- ing matter of the blood. That bile pigment exists pre-formed in the blood does not admit of a shadow of doubt ; for, as will be subsequently shown, p. 105, when the biliary secretion is arrested in the human subject, not only does the serum of the blood become deeply tinged yellow on account of the accumulation in it of the bile pigment, but the abdominal serum, the urine, and even, it may be, the milk, all become of a yellow hue, as in a patient suffering from ordinary obstructive jaundice. All these facts when taken together clearly prove that the liver is a formative as well as an excretive organ to some, and merely an excretive organ to others, of the normal biliary constituents. Lastly, the general opinion is that the secretion intermits, and, like the gastric and pancreatic juices, bile is only formed during digestion. Were it so, however, where would be the necessity for a gall- bladder ? Is it not to store up the secretion formed in the intervals of digestion, and to retain it until it SECEETIOX OF BILE. 81 is required ? Xo doubt there are several animals, such as the horse, the deer, the elephant, the rhi- noceros, the dromedary, and the camel, as well as many birds, such as the ostrich, the parrot, and others, which possess no gall-bladders at all. On the other hand, again, some animals, even of the same species, by a freak of nature possess two gall-bladders, while less fortunate members of the same family have to do without any at all. Dr. Crisp, m a paper ' On the Morbid Conditions of the Bile and Gall- Bladder,' published in 1850 in the ' Medical Examiner,' tells us the curious fact that while two of the giraffes that died in the Zoological Gardens were found to have no gall-bladders, a third one," on being examined like his fellows after death, was found to be in posses- sion of two ! In animals which have normally no biliary reser- voir there is a special arrangement of the digestive apparatus, which renders the presence of a gall- bladder unnecessary. In fact, it is easily shown that the biliary secretion in ordinary cases is continuous ; for if in an animal possessing a gall-bladder a biliary fistula be established, and the secretion of bile care- fully watched, it will be found that at no period of the day does it entirely intermit, although it is more active at one time than at another. The minimum of its activity being during sleep — the maximum during G 82 DISEASES OF THE LIVER. active digestion. The absolute quantity of bile secreted in the twenty-four hours is tolerably uniform, being on an average about 50 ounces in a human adult, although the daily amount is slightly influenced by the kind of food.^ The Quantitative Constitution of Bile. The relative proportions of solids to liquids, as well as the relative proportions of the solid constituents to one another, vary considerably, not only in differ- ent individuals, but in the same individual at dif- ferent periods of life, on different kinds of food, and at different stages of the digestion, so that no abso- lutely fixed standard of quantitative constitution of bile can be given. However, an approximative stan- dard can be arrived at, and the two subjoined analyses are those I have elected to go by, as they are not alone the work of different individuals, but while they give the constitution of the bile in healthy persons at almost identically the same period of life, they give it in opposite sexes and of different nationalities. The first analysis was made by myself of the bile taken from the gall-bladder of an exceedingly hand- some and well-nourished servant-girl, aged 20, a resi- dent in London who committed suicide in consequence of finding herself pregnant. The second was made ^ Arnold found that dogs secreted more bile on a bread than on an animal diet. {Zu?- Physiologie der Guile. Mannheim, 1854.) COMPOSITION OF HUMAN BILE. 83 by Frerichs of bile from the gall-bladder of a German, aged 22, who was killed by an accident. Composition of Healthy Human Bile of an En4jlishtcoman aged 20. (George Harley.) Water 920"2 Solids : Pigment . .\ Mucus -Organic substances . 60-3 \ Glycocholic acid TaurochoUc acid Biliary fats Soda Potash Lime Iron . I Inorganic substances . 10-5 70-8 1000-00 Composition of Healthy Human Bile of a Get-man aged 22. (Frerichs.) Water 859-2 SoUds : Glycocholate and Taurocholate of soda . 91 •4\ Bile pigment and mucus Fat Salts . Oholesterin 29-8 9-3 7-7 2-Q 140-8 1000-00 N.B.— Compare these analyses with that of old people's bile given at pages 791-2. Several physiologists have given it as their opinion that bile is not essential to life, from the fact that animals have lived for many months after the artificial establishment of a biliary fistula, throuo-h which the bile was allowed to flow away and be entirely lost to the system. Now, although this latter fact G 2 84 DISEASES OF THE LIVER. is perfectly true, yet it is at the same time evident that the uses of the bile cannot altogether be dispensed with, for animals with a biliary fistula invariably lose flesh, become emaciated, and weak. The hair falls off, the bowels become irregular, while at the same time a great and an almost constant discharge of foul- smelling gases takes place from the intestinal canal. At length, after a shorter or longer period, the animal sinks and dies. The fatal termination can, however, be for a certain time retarded by allowing him an additional quantity of nourishing food. For death from want of bile, as is too often seen in the human subject, is nothing else than death from slow starva- tion, inasmuch as the food is not properly prepared for assimilation without the assistance of bile. The fact just related regarding the beneficial effects of an additional quantity of food in prolonging life should never be lost sight of in the treatment of cases of obstruction of the gall-ducts, for, by attend- ing to this circumstance, it is often in the power of the medical man to keep his patient alive for a con- siderable time longer than would otherwise be the case. It may perhaps not be out of place if I here briefly enumerate the chief uses of bile in the animal economy. In order to live, not only must the individual particles of our frames die, but they must be con- USES OF BILE IX THE ANIMAL ECONOMY. 85 tinually replaced by new materials of a similar kind ; and for the accomplishment of this important end, nature has endowed animals with a digestive ap- paratus in which their food undergoes the various physical and chemical changes necessary to its ab- sorption and assimilation. In the animal laboratory, or digestive apparatus, there are five important agents constantly at work — saliva, gastric juice, bile', pan- creatic fluid, and intestinal secretion, and each of these agents has a special and definite office to per- form in the elaboration of the food.^ At present, however, I limit myself entirely to the consideration of the bile. Bile is the first dio-estive ao-ent with which the food in the shape of chyme comes in contact after leaving the stomach and entermg the intestines, and immediately on the chyme, which is acid, mixing with the alkaline bile, a white flocculent emulsion is formed, which emulsion has been described by many writers as a precipitation of the albuminose (digested albu- men). Careful researches by myself and others have, however, shown that it is not the bile which precipi- tates the albuminose, but the acid of the chyme, which in reality sets free and precipitates certain ingredients of the alkaline bile. In the majority of cases this is ' For an explanation of these offices, see the author's article on ' The Chemistry of Digestion,' in the British and Foreign Quarterly Review, Januaiy, 1860. 86 DISEASES OF THE LIVER. not, however, a true precipitation. For on throwing the milky-looking turbid mixture upon a filter, I found that in the majority of instances almost nothing remained behind, and the filtrate was nearly as white as the original liquid. Further, if the albuminose be separated from the chyme, and the chyme then brought into contact with the bile, the same flocculent-looking milkiness still appears. Nay, more, on adding equal parts of sheep's bile (fresh) to gastric juice drawn from a dog's stomach in full digestion, the apparent flocculent precipitate still appeared, although the acidity of the gastric juice remained unneutralised ; and on throwing the whole on to a filter, I found that the liquid that drained through was as milky and flocculent-looking as the original. Although bile can convert starch into sugar, its chief office in the digestive process is not so much to act on the amylaceous or albuminous portions of our food, as to assist in the absorption of fats. While speaking of the properties of the bile, I may mention that, although bile has no digestive power (properly speaking) over albuminous substances, yet, when injected into the subcutaneous cellular tissue of a healthy animal, I found that it eats its way out through the skin, just as gastric juice or lactic acid does under similar circumstances. Even the muscles with which it comes into contact appear to be eaten, that is to say, digested away. USES OF BILE IX THE ANIMAL ECONOMY. 8^ When fresh bile is mixed with neutral fat, little change is observed, but when brought in contact with the fatty acids, an immediate emulsion takes place. Lenz and Marcet ^ pointed out how the neutral fats of our food are transformed into fotty acids during their sojourn in the stomach: and Bidder and Schmidt- illustrated by experiments on dogs the important part played by the bile in their absorption. A dog, which m its normal condition absorbed on an average seven grams of fat for every two pounds of its weight, ab- sorbed only three grains, or even as little as one grain, after the bile was prevented entering the intestines, in consequence of a ligature being applied to the gall- duct. Further, these last-named observers found that, while the chyle in the thoracic duct of a healthy dog contains thirty-two parts of fat per thousand, that in the thoracic duct of a dog with a ligatured gall-duct contains only two parts per thousand. These facts clearly prove that bile plays an important part in the absorption of the fatty portion of our food. Xext comes the question, ' In what manner does bile aid in the absorption of fatty matter ? ' As everj'one knows, fatb and oils have no tendency to mix with water, and hence diosmose between an aqueous and an oily fluid through a membrane is next to impossible. Matteucci * Vide a ' Discourse on the Chemistry of Digestion,' by Dr. Marcet, Journ. of the Chem. Soc, Oct. 1862. * Die Verdauungssdfte und der Stoffwechsel. Leipzig, 1862. 88 DISEASES OF THE LIVER. lias, however, shown that if an animal membrane be rubbed over on both sides with a weak solution of pot- ash, it allows oil to pass through it. It has also been observed, that when the walls of the intestine are moistened with bile, they allow oil to pass through them, which would not otherwise be the case. To study this property of bile, I performed the following experiments : — Firstly, — A clean piece of duodenum was filled with oil, ligatured at both ends, and suspended in water, holding in solution a small quantity of albu- men. (The albumen was added to the water merely to imitate slightly the albuminous blood.) On examination, twenty-four hours later, no oil was found to have escaped through the intestinal walls. Secondly, — Another portion of intestine had its internal surface moistened with sheep's bile before the introduction of the oil. It was then treated in the same manner as the preceding, and on being examined after the lapse of twenty-four hours, a small quantity of the oil was found to have pene- trated through the intestine. Thirdly, — Into a third portion of intestine were poured equal parts of sheep's bile and chyme — obtained from a dog in full digestion through a fistulous opening into its stomach — after being treated for the same length of time and in pre- cisely the same manner as the others, evident signs THE ACTION OF BILE. 89 of the oily matters of the ch3'nie havmg passed through the walls of the intestine were obtained, for the fatty matters were seen as a scum floating on the surface of the albuminous water. Moreover, the fatty matters were in the form not of pure oil, but of a soapy substance. The bile was thus seen to possess one of the more remarkable properties of the pancreatic juice, namely, the emulsioning of the fats of the food. There is this important difference between the action of these two secretions on fats, however, that while bile merely emulsions and saponifies that portion of our food which enters the duodenum in the form of fatty acids, j)ancreatic juice, on the other hand, possesses the power of emulsioning and saponifying not only the fatty acids, but also the neutral fats ; indeed, its power seems chiefly to be exerted upon the latter. Hence it appears that both secretions are in a measure necessary to the complete digestion and absorption of the oleaginous constituents of our food. A great deal of unnecessary importance has been attached to the fact that a portion of the bile thrown into the intestines during the process of digestion is reabsorbed into the blood along with the food, to be ultimately eliminated by the kidneys as effete matter. Why writers attach so much importance to this fact appears to me a mystery — except it be accounted for 90 DISEASES OF THE LIVER. by the ungenerous supposition that they are ignorant of the equally patent fact that portions of every one of the digestive secretions, saliva, gastric juice, pancreatic juice, and intestinal secretions, are in like manner reabsorbed into the blood along with the food, to be eliminated from it as effete matter by the kidneys. I merely call attention to this circum- stance in passing, lest some of my readers might be surprised if I omitted to allude to it altogether, which I certainly might have done with little dis- advantage to them, as the quantity of bile reabsorbed from the mtestines is a mere bagatelle. From the fact that by far the greatest portion of the bile thrown into the intestines during the digestive process is simply voided as useless material along with the fteces. In proof, however, that a certain amount of bile is taken up by the intestinal absorbents and carried along with the food into the general circu- lation, I may mention that MacMunn has detected, by means of the spectroscope, the effete bile pigment — urobiliverdin — in blood serum, in the same way as he found urohasmatin — the effete pigment of the blood itself. On one occasion, while experimenting with bile in my laboratory at University College, I was sur- prised to hear Minton, the servant who was assisting me, say that while he was travelling with Sir An- drew Smith in South Africa, he had oftentimes seen BILE EMPLOYED AS A CONDIMENT. 91 the CafFres drink bile direct from the gall-bladders of the animals killed by the European party, and that, while passing the gall-bladder round like a loving cup to each other, they would rub their stomachs and say — ' Mooe-ka-kolla,' signifying there- by that it was very good. Since then, I have read, at page 155 of Petherick's ' Egypt, the Soudan, and Central Africa,' that the Arabs and natives of Hasan- yeh, in the Soudan, use bile as a condiment to their food. He says that he has seen them, after killing a sheep and ripping it open, take out the stomach, liver, and lights — after only shaking out the contents of the stomach — cut them into small pieces, and put them into a wooden bowl, then take the gall-bladder, as a substitute for lemon, I suppose, and squeeze out its contents over them, add a copious supply of red pepper, and immediately proceed — while they were yet warm — to eat them ; and that too, apparently, with great relish. It certainly seems at first sight very extraordi- nary that a human being should not only drink, but drink with pleasure, a liquid so bitter and nausea- ting as bile. Perhaps these poor Africans, how- ever, enjoy the sickening-tasted bile for the same reasons as the cattle in their country, at certain periods of the year, go thousands of miles to drink at the brackish salt-springs. There being scarcely any chloride of sodium in the earth in these countries, 92 DISEASES OF THE LIVER. there is insufficient for the animal requirements in the herbage on which they feed, and they are forced thus to supply the deficiency by artificial means. Bile contains a large percentage of soda, and perhaps these two tribes of Africans drink it in order to obtain that substance, just as the cattle drink the brackish water of the salt licks, feeling that it agrees with them, without knowing why. We know that in some parts of Africa the natives will barter a handful of gold-dust for an equal amount of common salt, and this can be for no other reason than that they have a craving for it ; while this fact also well • accounts for the social importance attached by Arabs to the fact of a stranger having partaken of a man's salt ; for as here shown, instead of the giving a man salt being a mere bagatelle, as it would be in this country, it is there tantamount to giving him one of the most valuable things you possess. I One of my patients — Mr. J. De Villiers — who has lived all his life, until the year 1880, in South Africa, tells me that he has seen horses in the Orange Free State actually eat their own and each other's harness, made of native leather — which is tanned by repeated saltings — for no other reason than to obtain the salt from it. This fact, therefore, entirely confirms my views of the reason why the Africans drink and relish bitter gall. He also tells me that the native idea in Caffreland regarding gall BILE DRUNK ON ACCOUNT OF ITS SODA. 93 drinking is that by drinking the bitter gall they pro- tect themselves from the deadly effects of snake-bite and poisoned arrows. Which, of course, is a mere chimerical idea, originatmg in their ignorance of the uses and actions of bile in the animal economy ; but nevertheless one which it may be useful for parents to encouras:e. in order to induce their children to drink of the nauseating stuif, knowing from expe- rience that it will do them good. If the preceding chemical, physical, and physio- logical data are kept clearly in view, I think we are prepared to enter profitably upon the scientific con- sideration of the mechanism, diao^nosis, and treat- ment of diseases of the liver ; and 1 shall commence with the consideration of the — 94 DISEASES OF THE LIVER. CHAPTER III. ETIOLOGY OF JAUNDICE. Before entering upon the consideration of the etiology of jaundice, in case some of my readers may be sur- prised at my giving such prommence to a word which after all is the name of a mere symptom, especially • after having said so much against the pernicious system of raising mere symptoms to the dignity of diseases, I think it necessary for me to repeat what I said in my original monograph on this subject — namely, although I here make use of the word 'jaun- dice ' as if I regarded the pathological condition it indicates as being an actual disease, it is only in its mode of employment and nothing more. For, on the contrary, I look upon jaundice in precisely the same liffht as I reojard the terms ' oxaluria ' and ' albumin- uria,' which are not of themselves diseases, but only the most prominent and the most characteristic symptoms of several widely differing pathological conditions. In like manner the peculiar state of body characterised by yellow skin, saffron-coloured urine, and pipeclay stools, I regard not as itself a disease, but as a mere ETIOLOGY or JAU^'DICE, 95 symptom of several widely differing morbid states. It may be asked, ' Then why do you speak of j aundice as if it were a disease at all ? ' To this I reply, ' Because it is commonly spoken of in books as such, and because, although the condition of the skin called jaundice be merely a manifestation of morbid action, and one too requiring neither skill nor experience to detect, the proper comprehension of its true mecha- nism is of great practical importance to the physician. For without this knowledge it is impossible for him to treat with the slightest chance of success any of the severer forms of hepatic disease giving rise to it. Nay, even his remedies for the symptom jaundice may become dangerous weapons,' if unskilfully ap- plied. In fact, it is almost unnecessary to apologise for speaking of jaundice as if it were a disease per se ; for, notwithstandmg all that has been writ- ten upon the subject, it is universally admitted that hitherto the simplicity of its diagnosis has only been equalled by the obscurity of its pathology and the uncertainty of its treatment ; and no one at all con- versant with the literature of jaundice can be in the least degree surprised at this statement. On the contrary, on glancing at the immense variety of morbid states and known pathological conditions with which it is associated, he cannot fail to perceive its cause as well as to admit its truth. Some of the pathological conditions are closely 96 DISEASES OF THE LIVER. allied ; others are widely separated — so widely, in- deed, that at first sight it is impossible to discover from whence emanates the common symptom. We find jaundice connected with diseases of the liver, of the neighbouring organs, and of the general system — even such as fevers and gout. In some dis- eased conditions, jaundice presents itself when it is least expected. At other times it is absent when, apparently, it ought to be present. On the other hand, again, while there are cases in which jaundice is evidently merely a symptom, there are others in which it seems to be almost in itself the disease. .We have temporary jaundice from transient derange- ments. We have permanent jaundice from stationary causes. There are cases in which the cause of jaun- dice is visible after death to the naked eye. There are others where the minutest search is baffled in ascertaining the cause. That this is no exaggerated view of the case the following table will show : — JAUNDICE IS MET WITH, Firstly, In Diseases affecting the Liver — (a) Cancer. (6) Tubercle, (c) Cirrhosis. i^d) Inflammation. J CAUSES PRODUCIXG JAUNDICE. 97 (e) Atrophy, (/) Amyloid, and (g) Fatty degeneration. Secondly, I?i Diseases of the Bile Ducts — (a) Congenital deficiency. (b) Accidental obstruction. Arising from, gall- stones, hydatids, and fi.'om foreign bodies (such as cherry-stones and entozoa) enter- ing from the intestines. (c) Cicatrised ulcer of the duodenum, occluding the orifice of the bile-duct. ((7) Tumours of the pancreas, interrupting the passage of the bile. Thirdly, Di Affections of other Organs of the Body e.verting an Influence on the Biliary Secretioii — (a) Diseases of the nervous system. {b) Diseases of the lungs. (c) Diseases of the heart. {(l) Imperfect establishment of the extra-uterine circulation. (e) Dyspepsia. (/) Torpidity of the bowels, and consequent ac- cumulation of fa3ces in transverse colon. {g) Pregnancy. (A) Ovarian tumours. Fourthly, In a variety of Zymotic Diseases — (a) Epidemic jaundice. (6) Contagious jaundice (Yellow fevers). H 98 DISEASES OF THE LIVER. (c) Typhus. (rZ) Pyaemia. (e) Ague, Sec. Fifthly, As a Result of the Injurious Efiects of certain Poisons — (a) Snake-bite and fish poisons. (h) Phosphorus. (c) Copper. (c/) Lead. (e) Antimony. (/) Ether. {g) Alcohol. (A) Chloroform, &c. Can it be wondered, then, that a state so easily diagnosed is nevertheless so difficult to comprehend? Notwithstanding the apparent incongruity of the diseases with which the one common symptom of jaundice is associated, I trust in the following pages to be able to reconcile these discrepancies, and prove that the seeming pathological discord is but ' harmony not understood.' All physicians, I think, admit that the peculiar state of the skin to which the name of jaundice has been applied, is essentially due to some derangement of the biliary function, the exact nature of the de- rangement being alone the point of contention. I need not, therefore, waste the time of my readers — who, I presume, are already qualified practitioners — i THE THEORY OF JAUXDICE. , 99 by giving an account of the literature of jaundice. Even while discussing its patholog}^, I shall strictly limit myself to the consideration of the opinions at present held by the more advanced of our modern pathologists. The object of this treatise being merely to give a brief expose of my own views, and to point out how modern physiology and chemistry have not only thrown a new light on the pathology of jaundice as well as all the other morbid states connected with Hver diseases, but have also o-iven a clue to their more successful treatment. Frerichs, Murchison, and Legg, in their elaborate treatises on diseases of the liver/ say that jaundice may result from one of the three following con- ditions : — Firstly, — Obstruction to the escape of bile. Secondly, — Diminished circulation of blood in the liver, and consequent abnormal diffusion. Each of these conditions giving rise to an mcreased imbibi- tion of bile into the blood, and in both cases the liver being more or less directly implicated. Thirdly, — Obstructed metamorphosis, or a di- minished consumption of bile in the blood. From this it is seen, that the pathology of jaun- dice, according to Frerichs, Murchison, and Legg, ^ Frerichs' Clinical Treatises on Diseases of the Liver. New Syden- ham Society's Translation, vol. i. p. 93. Murchison, Lectures on Diseases of the Liver, 2nd ed., London, 1877. "Wickhaiu Legg, On Bile, Jaundice, and Bilious Diseases, London, 1880. B 2 100 DISEASES OF THE LIVER. who strictly adhere to this view, is very different from what was formerly taught. For while they have entirely laid aside the theory of jaundice as a result of suppressed secretion, they have introduced two perfectly new elements — namely, abnormal dif- fusion and diminished consumption. The latter theory being, of course, founded on the supposition that bile, after jDlaying its part in the digestive pro- cess, is reabsorbed into the circulation, again to perform some other function in the animal economy, before its final excretion from the organism as effete matter. The theory of jaundice hitherto most favoured in England, which found such an able exponent in Dr. Budd, and which I have persistently, and not without good cause, I think, advocated for the last twenty years, both by pen and tongue, is, that the disease may arise in two ways — firstly, by a mechanical obstruction to the passage of bile into the intestines, and the consequent reabsorption of the retained bile into the blood ; and secondly, by a suppression of the biliary secretion arising from some morbid condition of the liver itself, whereby the biliary ingredients, from not being eliminated, accumulate in the circu- lation and stain the skin. Now, although I am not prepared to admit the justice of the views held regard- ing the origin and function of bile, on which these opinions were originally based by Dr. Budd, I never- THE THEORY OF JAUNDICE. 101 tlieless believe that in the following pages I shall be able, by the aid of modern medical science, to prove the correctness of Dr. Budd's conclusions themselves, as well as prove that Frerichs's theory is quite in- compatible with the new facts that have been gleaned regarding the etiology of jaundice from modern re- search in the realms of morbid anatomy, as well as in those of experimental physiology. Seeing that three such able practical men as Frerichs, Murchison, and Legg, completely failed to grasp the value of the new data upon which the idea of retaining as correct the old division of jaundice from obstruc- tion and jaundice from suppresS'ion is founded — and which I had, it now seems, vainly flattered myself I had twenty years ago made perfectly plain in my mono- graph on jaundice — no one can be in the least degree surprised that many recent writers on, and reporters of, hepatic cases (among ordinarily educated practi- tioners) should appear to be not only hopelessly m the dark as to the true nature and signification of the two divisions of jaundice, but even somewhat conftised regarding the value of the facts upon which the theory of the two pathological conditions is based. I shall now, therefore, once more endeavour to make the thing intelligible, and perhaps this time I may be successful, and that all the more easily too from my having made the discovery that the weak points in my former argumentation did not actually 102 DISEASES OF THE LIVER. lie in what I said, but in what I left unsaid, unfortu- nately, as it now appears, under the mistaken notion that my readers were perfectly familiar with the phy- siology and rationale of normal glandular secretions, which the subsequent writings of several otherwise able authors on hepatic cases have proved to be an error. For example, in the chapter on jaundice from suppression, at page 244, I find that Dr. Legg, one of my old pupils, is a disbeliever in the doctrine, and actually goes so far as to say that ' the notion of a jaundice from suppression of secretion fell like that of the old and effete theory that bile and all other secretions were formed in the blood.' I think, how- ever, that after he reads and carefully reflects upon the data presently to be adduced, he will find good cause to omit the above passage from the next edition of his work, in which he otherwise displays a deep acquaintance with hepatic literature. What it now therefore behoves me to do is: firstly, to show that the biliary secretion can actually be retarded, and even totally arrested, without alteration of hepatic tissue. Secondly, to prove that when the liver strikes work, and secretes no bile, the animal body becomes jaundiced, as a direct consequence thereof. To do this satisfactorily would at first sight appear to be exceedingly difficult if not even quite impossible. And so, no doubt, it would be had I mere pathological data alone to depend upon ; but i JAUNDICE AS THE RESULT OF SUPPRESSION. 103 with the aid of modern experimental physiology the matter is not only brought within the range of philosophic possibility, but even made comparatively easy of absolute proof. In order to clear up the point satisfactorily I must this time begin by supply- ing the deficiencies in my former argumentation; and I think that by so doing and at the same time not only marshalling my physiological and pathological data in strict logical order, but putting them forward in a graphic and concise manner, it will be next to impossible for any one in the possession of an average amount of physiological and pathological knowledge either to misunderstand them or fail to grasp their clinical as well as their scientific import. This can be done by adducmg a case of jaundice where after death the gall-bladder and bile-ducts have not only been found empty of bile but filled with their own white mucous secretion, and illustrating its pathology by j)lacing it side by side with one of jaundice fi'om ob- struction, where after death the gall-bladder and the bile-ducts have all been found filled with pure bile. Now, in order that my facts should, like Caesar's wife, be beyond the reach of suspicion, I shall require to bring forward a case of jaundice with the biliary passages filled with white mucus and another filled with black bile from among cases published by en- tirely independent observers. I have therefore care- fully gone over the literature of the subject, and, 104 DISEASES OF THE LIVER. most fortunately for the interests of scientific truth, from the midst of our own modern English hterature I can adduce a most typical example of a well- marked case of jaundice from suppression, complicated with stricture of the bile-ducts, which has quite re- cently been reported by a most competent observer. Most luckily, too, it is a case which shows in an extreme degree the effects of an occluded duct, associated with a total arrest of the biliary secretion. The case I allude to was published in the 24th volume of the ' Pathological Society's Transactions' by Dr. Moxon, and I shall now proceed to quote from it all the salient facts necessary to convince even the most sceptical reader, if he be capable of conviction at all, that the theory of jaundice the result of suppression must henceforth and for ever cease to be regarded either as a clinical or a pathological myth of the imagination, by any one at least having the slightest pretence to the possession of a clear judgment, coupled with an average amount of medical knowledge. Dr. Moxon' s case is entitled ' Simple Stricture of the Hepatic Duct, causing Chronic Jaundice and Xanthelasma,' and therefore cannot, from its title at least, be suspected of having been published with the view of taking a part in the discussion in which I am now engaged, or with the object of furnishing a weapon either for attack or for defence in the cause I am about to employ it. Had its reporter intended JAUNDICE ARISING PROM SUPPRESSION. 105 that it should be so employed, I thmk that he would most probably have given to it the title of ' A Case of Jaundice from a Total Suppression of the Biliary Function, accidentally complicated with a Stricture of the Hepatic Duct.' Which title would not only have been equally appropriate, when the case is viewed from another side, but equally true, as will imme- diately appear from the extracts I shall make from it. The patient, a man of 32 years of age, when admitted into Guy's Hospital, was of a dark, dusky- looking, deeply -j aundiced colour, although he stated that in his youth he was both fair and freckled. He had been at sea for eighteen years^ and fourteen years ago had been laid up, while stationed in the Mediter- ranean, with a severe attack of fever, lasting for three months. He never had syphilis, but he used to drink freely — sometimes seven or eight glasses of ' brandy and soda ' in the day. His present illness commenced while at Portsmouth sixteen months before his admission. He then lost his appetite and felt sick. After this condition had lasted about eight months he was attacked with colic in the pit of his stomach, and immediately afterwards he began to be jaundiced. Three months later he had a second and much worse attack of colic, and although he never again had a return of the colic he often had pain in the epigastrium. He was much troubled with itching of the skin when he came to Guy's, which was a month before his 106 DISEASES OF THE LIVER. death. Though suffering but little pain, he had all the other symptoms of obstructive jaundice, and in addition ' xanthelasma was plentifully developed in hands, scrotum, and back.' Two weeks before he died he had frequent hnsmorrhages from nose, bowels, and bladder, which gradually increased in severity, and he died from exhaustion, attended finally with coma. At the post-mortem the liver, though of normal shape, was large and finely lobulated, as if from cirrhosis, and on its surface were ' numerous large dilated tubes full of clear, watery, colourless, slightly mucoid fluid. . . . One ran up in the peritoneum round the gall-bladder; but the gall-bladder itself was flat and empty, having only a little quite colourless mucus in it. The gall-ducts throughout the organ were excessively wide, so that on section of the liver their contents welled up in enormous quantity. It being a white clear fluid was a strong contrast to the serum of the blood, which was golden yellow. This contrast between the contents of the bile-duct and serum of the blood was most remarkable. The gall- ducts had xanthelasmic-looking patches within them — that is to say white opaque patches. The hepatic duct at the point of union of its two divisions was swollen from the presence in it of a firm tough matter, making a little soft knot of the size of an almondj The duct was here bent, and a fine probe would onlj pass with care and some force. The thickening was JAUNDICE ARISING FEOM SUPPEESSION. 107 entirely limited to the duct. The adjacent vein was not affected. The common duct was small and healthy, so was the j)^i^creatic duct. The whole length of the diseased part of the duct was about an inch. The microscope showed only fibrous scar- tissue in the thickening. . . . The stricture, which was situated in the walls of the hepatic duct nearly two inches above its point of junction with the cystic duct, appeared to be composed of simple connective tissue, and resembled the condition seen in an ordinary stricture of the urethra.' Here then we have clearly a case of jaundice, notwithstanding, as is proved by the colourless mucus in the gall-bladder and dis- tended bile-ducts, that the liver's biliary function was not only totally suppressed, but had been so for a considerable time before the death of the patient. As those of my readers who are insufficiently acquainted with the normal physiological functions of the bile-ducts may be at a loss to comprehend how the fact of a white mucous secretion instead of a dark gi'een biliary one being found in all the ducts behind the seat of obstruction in the above case is of itself con- clusive evidence that the jaundice must of necessity have been due to the non- secretion of bile, I shall briefly explain the true nature and the origin in such cases of this white mucous secretion. Bile-ducts are mere passive canals, along which the biliary secretion flows. They take no direct part 108 DISEASES OF THE LIVER. either in the secretion or in the elimination of the bile. Their functions being passive, they have only- physiologic ally to do with their own maintenance and integrity. Every bile-duct has a mucous mem- brane of its own, which secretes a white viscid mucus^ which serves the purpose of lubricating its free surface, and protecting it from the chemical action of the bile flowing along the duct. The secretion of mucus by the mucous membrane of the bile-duct being perfectly independent of, or upon, the biliary function of the liver, goes on in its usual course from day to day, from hour to hour, and from minute to minute^ whether or no bile be flowing along, remaining stag- nant in, or entirely absent from, the duct. The only difl*erence in these tliree sets of cases being — (a) When the bile is flowing along the duct, the excess of mucus is carried away with it. (b) When the bile is stagnant in the duct, the excess of mucous secretion mingles with the bile, imbibes its yellow colour, and remains with it staofnant in the duct. (c) When there is no bile in the duct, the excess of mucus, which is now not bile-stained, accumulates there until there is such an accumulation as necessi- tates its flowing by itself along the duct, and, if the outlet of the duct be not impeded, it finds its way out of the liver along the common bile-duct into the intestines. THEORY OF JAUNDICE FROM SUPPRESSION. 109 Now comes the point. What happens when the I)iliary function is totally suj)pressed. and no bile whatever finds its way into the bile-ducts, and the mucus is yet secreted, but remains pent up within the ducts from an impediment in the course of the duct stopping its gettmg out of the liver? Simj)ly this. The mucus gradually accumulates in, and distends, the bile -ducts in precisely the same way as bile does when it is secreted, and its exit is prevented by a similar kind of obstruction. The anatomical conditions of the ducts bemg identical ; their con- tents alone are different. In the one case beiuo^ white mucus, in the other dark green bil.e. Now, after having proved so much, it stiU remains for me, in order to clmch my argument, to adduce a pre- cisely opposite case, and show that in what is called a case of jaundice from obstruction there is not only no white mucus whatever in the biliary passages, as occurs in the jDarallel case from suppression, but that, notwithstanding that all the other signs and symjjtoms of jaundice are identical in the two sets of cases, the bile-passages are, in this instance, entirely filled with pure bile and not with pure mucus as in the other. I shall, I find, be forced to go into this point all the more fully, as even Dr. Moxon m his otherwise admirable report of his case has unfortunately fallen into the error of saying that he thinks his case ' shows that in obstructive [I italicised the word, G. h.] jaundice 110 DISEASES OF THE LIVER. the yellowness [of the skm, g. ii.] is caused b}^ the suppression of the secretion, and not by the reab- sorption of the secreted and pent-up bile; ' for while believing ' that the reabsorption occurs in cases of obstruction, he says he thinks that the reabsorption is only an unimportant accompanying incident of the early stages of the jaundice, and only concerns the bile already in the ducts, whereas the true cause of ob- structive jaundice is suppression of the secretion, not its reabsorption.' Indeed he ' thinks that we may deny that reabsorption of bile is a cause of jaundice.' This is a view that I am sorry to say I cannot endorse, for, as will be shown in the sequel, it is not only contrary to modern physiological data, but at direct variance with well-established pathological facts. While thus dissenting from the views Dr. Moxon has promulgated regarding the pathology of ob- structive jaundice in the latter part of his paper, I must not omit to congratulate him sincerely on the able comments he has made regarding the pathology of his case as a typical example of jaundice from suppression of the biliary function; and I do so, of course, all the more readily from the fact that they perfectly accord in every particular with the views I take of it myself. For example, he calls special attention to what he justly considers the remarkable fact that the contents of the distended bile-ducts * were perfectly clear and colourless,' and that ' there i THEOEY OF JAUNDICE FROM SUPPRESSION. Ill was no bile pigment in them at all,' while on the other hand the serum of the blood was of an ' intense golden yellow.' To this remark he appends the per- tinent question, ' How is it possible that the bile which gave the serum deep jaundice could have been coming all the while from the ducts m which no bile what- ever was present ? ' and moreover wisely adds : ' If we assume that the jamidice was really due to sup- pression of the secretion, then we have a ground for comprehension of the absence of bile from the mucus of the bile-ducts.' In order, then, that there may no longer exist m the mind of a single reader the remotest shadow of a doubt regarding the rationale of a case of jaundice from obstruction, before citmg the other promised crucial example, from an equally in- dependent observer, as a standard of comparison with Dr. Moxon's case, I shall first give an illustrative typical example of jaundice from obstruction in which all the morbid anatomical conditions were carefully and crucially shown, after death, to be directly opposed to those occurring in a case of jaundice the result of suppression. As it is not in the least degree difficult to find cases of this kind of jaundice, although it is very seldom that any single one of them is recorded with sufficient explicitness to be able in itself to answer the purpose of furnishing incontrovertible evidence of the exactitude of the theory on which they are based, I shall quote one from my own practice. Which, 112 DISEASES OF THE LIVER. however, from the f\ict of its not being unusual in any way except as regards the manner in which it was recorded, and from its having been reported in full nineteen years ago — that is to say long before I had any idea of making use of it in this controversy — cannot possibly be suspected of having its details trimmed to suit the theory. While it further possesses the immense advantage of being accompanied by a chromo-lithograph representing the morbid conditions so plainly that it cannot fail to carry along with it conviction to the mind of even the most sceptical and thereby pave the way to the easy comprehension of the parallel case of jaundice from obstruction which I have to place in juxtaposition with that from suppression recorded by Dr. Moxon. Which, like it, I select from cases recorded by independent observers, in order that it may be entirely free from the possibility of exciting in the mind of the most ungenerous reader the barest suspicion of having a theoretical colouring given to its pathological data. The typical illustrative case of jaundice from ob- struction which I now proceed to lay before the reader is one I frequently saw during the lifetime of the patient along with Dr. Prance of Hampstead. When the gentleman, who was aged about 50, was first brought to me, I was told that he had already been the subject of intense jaundice for seve- ral months. At the time I saw him his skin was Plate I. o O O JAUNDICE FROM OBSTRUCTION. ] 13 indeed so intensely discoloured with, bile-pigment that he looked not yellow, but of a dirty yellowish green. His faeces were said to be absolutely devoid of bile, having been for months past of a light pipeclay ■colour, while his urine was of a dark — very dark — saffron hue. In fact, he was a typical case of jaun- dice, from every single pomt of view. At first the liver- dulness had been increased, and then, as in all other cases of jaundice from obstruction, it shrank down until it resumed its normal dimensions. But unfortunately the shrinking process did not stop here ; for, in consequence of the still continuing arrest to the outflow of the bile, the backward pressure on the secreting structure was continued, and as a natural consequence the liver became smaller and smaller until an actual atrophy of the gland was the result. The patient ultimately died, and the condition of things admirably represented by Mr. Ford in the chromolithograph Plate I. was found at the autopsy. 1. The liver was small and deeply stained with bile-pigment, being actually of a blackish-green colour. Not alone from the bile having been long retained in the organ, but from its having permeated every cell, every fibre, and every granule of the tis- sues composing the parenchyma, ducts, and vessels of the liver. 2. Every bile-duct was greatly dilated — not only the cystic, hepatic, and common bile-ducts, but even I 114 DISEASES OF THE LIVER. those in the tissues of the liver themselves, as m shown on a reduced scale in the plate at a. 3. The common bile-duct (d) was distended to eio'ht or ten times its natural size, and the hepatic (b) and cystic (c) ducts were also greatly dilated, though not in like proportion. 4. The gall-bladder was at least fifteen times its natural cubic size {e). 5. All the bile-passages, as well as the gall- bladder, were filled cram-fall with dark, tarry, thick viscid bile. 6. The whole of this mischief was found to be due to a permanent occlusion of the duodenal orifice of the common bile-duct by a cicatrised ulcer (/) preventing the flow of the secreted bile into the in- testines, and the consequent pennmg of it up in the organ itself. 7. The jaundiced condition of the skin, &c., was due not to an arrest of secretion — for, as was shown by the loaded state of the gall-bladder and ducts^ plenty of bile had been secreted — but to a reabsorp- tion of bile from the gall-bladder and bile-ducts by a process of capillary osmosis.^ Here then is what may be considered to be a typical case of jaundice from obstruction, which, I think, will be found to resemble very closely, in all ^ Further scientific details of this important case will be found in the chapter devoted to the ehemistry of the excretions, p. 769. JAUNDICE FROM OBSTRUCTION. 115 its salient points, the crucial case which I am now about to cite from the practice of an independent observer, in order that it may be compared with Dr. Moxon's case of jaundice from suppression. This case of obstruction is one that was reported by Mr. John H. Morgan in vol. xxvii. of the Pathological Society's ' Transactions,' at page 176, under the title of ' Enormous Dilatation of the Bile- ducts from Stricture of the Ductus communis chole- dochus.' It strikingly resembles Dr. Moxon's case in the three following salient particulars. Firstly, the jaundice was intense. Secondly, the ducts were dilated to such an extent that their blind extremities looked like cysts projecting from the surface of the liver. Thirdly, the obstruction was the result of a stricture caused by inflammatory thickening. The difference in the two cases again was — that the ducts, instead of being filled (as in Dr. Moxon's case) by a clear white mucus, were choke-full of dark black inspissated bile. The case is briefly as follows : — The patient, a man aged 52, by occupation a plumber, died intensely jaundiced in St. George's Hospital. He had enjoyed good health until four months before his admission, when, after receiving a prick in the hand, which was followed by an abscess, he was seized with shiverings and diarrhoea, and a day or two later became jaundiced. On admission the skin was bright yellow, irides and conjunctivaB being deeply T 2 116 DISEASES OF THE LIVER. stained. The stools light stone -coloured, and the urine loaded with bile. There was pain at the right side of the ensiform cartilage, but no enlargement of the liver. In a month he began to suffer from such intolerable itching that he scratched his skin till it bled. A couple of weeks later the liver was found to have become enlarged. Both lobes projected so much forwards as to look like two tumours slightly elevated above the surrounding surface of the body. The patient died about ten weeks after his entrance into the hos- pital, and at the post-mortem the following condition of the liver was observed. It ' was greatly enlarged and distended ; its surface smooth and presenting several slight elevations, whose thin and transparent waUs and fluid contents had all the appearance, at first sight, of cysts. These were found especially on the under surface of the left lobe, their sizes varying from an inch and a quarter to a quarter of an inch in circumference. The gall-bladder was very much dis- tended ; it measured from five to six inches, and pro- jected some distance below the edge of the liver ; it contained dark green inspissated bile mixed with mucus and epithelium. A stricture of the common choledic duct existed just below the point of its formation by the union of the cystic and hepatic ducts.' The contraction of lymph arising from the presence of a perforating ulcer of the duodenum (bound down by adhesive bands of lymph to the JAUNDICE FROM OBSTRUCTION. 117 bile-duct) was found to be the cause of the stricture. This obstruction to the outflow of the biliary secre- tion 'had caused the distension of the gall-bladder and its duct, and also those of the liver, which it had distended to such an extent as to cause their extremities to project on the surface as above de- scribed.' Here then is a case of jaundice fi*om obstruction to the outflow of bile, parallel in every respect, as re- gards its morbid anatomy, to that of Dr. Moxon's of jaundice from suppression of the secretion. In the one case the stricture of the duct being the cause of the jaundice, while in the other case the jaundice ivas quite independent of the stricture of the duct, as is proved — and indubitably proved — by the fact that behind the seat of stricture mucus alone, and no bile whatever, was found pent up in the occluded duct. I now leave it for the reader to draw for himself a mental comparison between these typical examples of the two distinct and independent forms of jaundice, and form his own conclusions as to the justice of dividing cases of jaundice into the two great classes of jaundice from suppression and jaundice from ob- struction. To my own mind the thing is as clear as noonday ; for the mere fact of the secretion pent up in the hepatic bile-ducts being dark bile in the one case and pale white mucus in the other sets at once and for ever aside all possibility of reasonable discus- 118 DISEASES OF THE LIVER. sion against the theory of jaundice from suppression, and raises the statement from the humble position of a mere theory — which it must be admitted, scientifically speaking, it has hitherto only occujDied — to the dig- nity of an unassailable and imperishable clinical as well as pathological fact. Deny it who can ! Should, however, any reader be so unfortunate as to have failed to grasp the intrinsic value of the data upon which the theory of jaundice from suppression is founded, which is the most difficult one for the non- scientifically trained mind to understand, I will ask him to turn to page 1083, and carefully read the chapter on gall-bladders distended with mucus, as well as give attention to Wyss and Ritter's observa- tions at pages 708 and 1088 ; and if his eyes are not then opened, I am sorry to say I can do nothing more for him, but leave his case to time and the developmental powers of nature. Only one thing further will I allude to — namely, the fact, which is strongly corroborative of my views, that the serum of the blood in Dr. Moxon's case was — like the skin — deeply stained with yellow pigment, notwithstanding that the liver was secreting no bile, and the urine loaded with dark pigmentary matter, exactly as occurred in my case of jaundice from obstruction, about the pathology of which there can «xist not a shadow of doubt. The condition of the blood in Dr. Moxon's case BILIVERDIN A BLOOD PRODUCT. 119 is a fact which of itself distinctly corroborates my other belief that biliverdin is nothing more or less than oxidised blood haematin, which the liver does not form, but only extracts from the circulation during the passage of the blood through the hepatic capillaries. The natural yellow colour of blood serum being due to the pigment which, when extracted from the circulation by the liver, we call biliverdin, or bile- pigment. When biliverdin is regarded in this light, it greatly simplifies the comprehension of all the various widely differing causes of jaundice. Thus, it shows us that the jaundice of snake poison may be due to the transforming power the venom germs have upon the oxidation of the blood hasmatin. While again as re- gards the cause of the yellow discoloration of the skin in febris icterodes, as well as in fehris icterodes remittens, if we cease to look upon them as peculiar species of malignant fevers, accidentally associated with a jaundiced condition of the skin, and adopt the view, which I espouse, that they are in reality mere disorders of the hepatic organ due to the introduction into the system of toxic agents in the shape of disease- germs, which cause jaundice from suppression, their comprehension becomes simple enough. For, as I shall presently show, not only animal and vegetable, but even mineral poisons, have the power of suspending the secretion of bile and giving rise to jaundice. 120 DISEASES OF THE LIVER. Moreover, the more closely we examine the so-called yellow fevers the more evident does it become that they differ in no respect whatever from the diseases arising in temperate cUmates from the introduction of animal and vegetable disease-germs. Except in so far as the febris icterodes is highly contagious, and that both it and the fehris icterodes remittens only originate in tropical climates. I have still some further observations to make on the mode of the production of the forms of jaundice now under consideration ; but as what I have to say is equally applicable to all the forms of jaundice arising from the introduction into the human system of poisons, no matter whether they be animal, vege- table, or mineral, I shall delay my further remarks on the subject until after I speak of jaundice the result of acute atrophy of the liver, which I regard as being due to the introduction into the system of a toxic agent (page 391), for the rationale of all the poison cases is, in this respect at least, identical. The next point in connection with the etiology of jaundice requiring solution is the question : Why does bile-pigment select the rete mucosum of the skin as the chief seat of its deposition? This is a question which almost every intelligent practitioner, as well as every pathologist, must have put to himself. I question, however, if even so much as one in fifty has ever been able to find a satisfactory answer to his THE CAUSE OF YELLOW SKIN. 121 mental query. Indeed, as far as I am aware, not a single writer on jaundice, either separately or in conjunction with cases of liver disease in general, has ever so much as attempted to explain the etiology of the deposition of bile-pigment in the rete mucosum of the skin, although, no doubt, every one of them must have thought the matter over. I know I have often done so, and as I imagine that I have found a good, if not even the correct, answer to the query, I shall venture to lay it before my readers, and allow them to judge for themselves as to its merits. If they do not consider it satisfactory, and if any one among them thinks he can give a better, I shall be delighted if he will kindly communicate it to me. Having already, I think, made it sufficiently clear that the yellow pigment deposited in the rete mucosum in all cases of jaundice must have originally come from the blood, I have now to show that while, in jaundice the result of suppression, the skin derives it directly and at once from that original source, in jaundice from obstruction the pigment has not only been previously extracted from the blood by the secreting cells of the liver, but, after having been pent up along with the other constituents of the biliary secretion in the hepatic ducts and gall-bladder, again been absorbed back from thence by a process of capillary osmosis into the general cfrculation, before 122 DISEASES OF THE LIVER. being ultimately deposited in the rete mucosum during the attempt made by the skin to eliminate it from the body. The latter part of this last sentence embodies the key to the solution of the question, Why does the skin become yellow? The answer, in my mind, is very simple. The kidneys and the skin are the two great eliminating emunctories of foreign non-volatile matters from the body, both in health and in dis- •ease, acting not only conjointly but vicariously in this respect, and the bile-pigment is ehminated by them. In case some reader may have for the moment forgotten the immense eliminating power of the skin, I may remind him that when in disease the excretory functions of the kidneys are arrested, the sweat and sebaceous glands of the skin immediately vicariously assume their office, and not only eliminate the soluble salts of the urine — such as urea, uric acid, chloride of sodium, and sulphate of potash — but even the in- soluble, such as the oxalate of lime ; and that some- times to such an extent, that the whole surface of the skin, on becoming dry after a profuse sweating, is covered with a rough white crystalline powder of oxalate of lime, just as the ground is with hoar-frost in a sharp cold spring morning.^ ^ See Author's work on the Urine. English, American, French, or Italian editions. ELIMINATION OF BILE-PIGMENT. 123 In health it is the kidneys alone which eliminate all the effete pigments — hasmatin, biliverdin, &c. — in the form of urohtematin (urine pigment) ; but in disease the skin takes a share in this office. Hence, when the blood-serum is loaded, as in jaundice, with pigmentary matter, the skin as well as the kidneys excrete it, and the perspiration, like the urine, becomes so loaded with it that white linen, brought in contact with either the one or the other, becomes dyed of a deep yellow hue. Now having arrived at this point in the argument, we have only to go one step further, and our journey is at an end. Look at Plate II. p. 728. There is shown a kidney which for months has been occupied in eliminating bile-pigment, and, notwithstanding that the so doing is one of its normal functions, it has broken down under the abnormal strain, and as a consequence visible masses of non-excreted bile-pigment are seen scattered all over its external surface. A precisely similar state of matters was observed in its interior. Now what happened in this case with the skin ? It not being the normal function of the skin to eliminate bile or any other animal pigment, but this work having been abnormally forced upon it, and it being compelled to perform it to the best of its ability — which after all it can do but imperfectly — a great part of the insoluble pigmentary matter remained behind in the rete mucosum, thereby giving to 124 DISEASES or THE LIVEK. the skin the yellow hue which we call jaundice. Which is not in the least to be wondered at, seeing that the skin, from possessing no special apparatus for eliminating the bile-pigment, does nothmg more than, as shown in Plate II., the kidneys themselves do when an excess of work is thrown upon them — does the work imperfectly, breaks down, and, instead of passing all the bile-pigment through its cells, allows a quantity of it to remain behind in the rete mucosum, which, by gradually increasing in quantity, causes the skin to assume by degrees a deeper and deeper jaundiced hue, until the patient may at length become of an almost greenish -black tuit. From this theory it is seen that I entirely ignore the idea that the cells of the rete mucosum store up the pigment from any choice of selection of their own, but, on the contrary, as the inevitable conse- quence of a dire necessity. The cuticular cells being,, like the kidney shown in the plate, unable to elimi- nate all the bile-pigmentary matter brought to them by the circulation, become filled with it nolentes volentes, and are thereby made to assume the colour which we- denominate jaundice. It may perhaps be as well for me here to call attention to the fact that the pathological conditions included under the name of jaundice are not peculiar, or limited, to the human being. For, on the con- trary, all animals— fish and fowls as well as qua- JAUNDICE IN QUADRUPEDS. 125 drupeds — are liable to be attacked with precisely the same pathological conditions. I have myself seen jaundice in a domestic fowl, a sheep, and an ox. Indeed, one of my own horses had on one occasion a very smart attack of jaundice. The reason why this condition appears to us to be r.'ire in our domestic animals arises from the fact tbat the ab- normal tint of the skin is hidden from us in conse- quence of the animals possessing a thick covering of feathers or hau', and of the conjunctiva from their eyes showing little or no white. Consfquently, it is only by examining the colour of the longue and inside of the lips of such animals that thf jaundiced condition of their bodies can be detected 'faring life. The effusion of biliary pigment into the buccal mucous membrane of my own horse, which was attacked with jaundice, was most marked, and at once furnished me with the explanation of the fact tlmt patients suffering from jaundice had again and ;)L!ain com- plained to me of having a disagreeable fitter taste of gall in their mouths. 126 DISEASES OF THE LIVER. I CHAPTER IV. SIGNS AND SYMPTOMS OF HEPATIC DISEASE. Although the signs and symptoms will be given fully and in detail when each individual disease of the liver is being specially considered, it will be well for me, in order to make their intrinsic dia- gnostic value more easily understood, to give a brief general view of the more important of them before entering upon the consideration of each disease sepa- rately. So I shall do so now. In case some of my younger readers may marvel at my heading this chapter Signs and Symptoms, I may as well remmd them that a sign is a very different thing from a symptom, and has a totally different diagnostic value. For while a sign is something that the medical practitioner can himself see, feel, or hear, with his own eyes, fingers, or ears, a symptom is something of which the patient is alone physically conscious, and consequently the medical attendant's knowledge of its existence and nature is derived solely from the patient's account SIGNS AND SYMPTOMS. 127 of it. Hence the value of a symptom in a great measure depends upon the mental capacity as well as the veracity of the patient. So that there is an un- mistakable difference to be attached to the intrinsic diagnostic, prognostic, and therapeutic clinical value of signs and symptoms, of each of which I shall now speak separately. The Tongue. — The condition of the tongue is oftentimes very characteristic of liver disease. Every bilious patient, without exception, has a foul tongue. Always white, often furred, frequently yellow, espe- cially at the back, where the yellowness frequently ends in a brownish tint. In abscess of the liver the tongue is said ta be scarlet, or what is commonly called raw-flesh looking, anteriorly, and furred posteriorly. But every case with a raw-flesh looking tongue is not to be diagnosed as one of suppuration of the hepatic tissues ; for raw-flesh looking tongues are not un- frequent in simply inflammatory conditions of the liver. The Taste. — A bitter taste is commonly com- plained of in many forms of liver disease, and this is owing to the fact that in them the blood becomes surcharged with taurocholic acid — the substance which gives to bile its intensely bitter flavour which is brought into contact with the papilhc of the tongue by the buccal capillaries. 128 DISEASES OF THE LIVER. t The Bowels.— The condition of the bowels is variable in liver disease. They are confined or open in exact proportion to the quantity of bile excreted. When, for example, no bile finds its way into the intestinal canal, as in all the various forms- of ob- struction to the outflow of bile from the common bile-duct, constipation is an inevitable consequence. While, on the other hand, when there is an excessive excretion of bile into the intestinal canal, a diarrhoea is the result, from bile possessing among other of its attributes purgative properties— inasmuch as it favours intestinal peristaltic action— which, by older writers, was described, and is still spoken of among the laity, as 'a bilious diarrhcea.' In such cases, however, there appears to be something further wrong than a mere hyperexcretion of ordinary bile ; for the stools are not only dark in colour, but profusely charged with intestinal mucus. Which fact proves either that the biliary secretion must be unusually irritating, or that there exists at the same time an inflammatory condition of the intestinal canal to induce the hyper- secretion of mucus ; an unusually irritating condition of the bile being the most likely cause. a. Pipeclay-coloured stools are due, not to the presence of any new and foreign material, but en- tirely and always to the absence of the normal biliary pigment. Hence they are only present in two sets of cases. Firstly, when there is a suspen- SIGNS AND SYMPTOMS. 129 sion of the biliary secretion. Secondly, when there is an obstruction to the flow of the secreted bile into the intestinal canal. h. Black, tarry, bilious-looking stools may exist when not one drop of bile finds its w^ay into the intestinal canal. Which circumstance has frequently given rise to grave errors in diagnosis. Tarry, bilious -looking stools are, for example, met with when the biliary function is totally suspended, as in some cases of acute atrophy of the liver, as well as in cases of contagious jaimdice — commonly called yellow fever. In both of these sets of cases, the black, tarry, bilious -looking stools are due to the presence of blood in the faecal matter. Hcemorrhage from the bowels not only occurs in many acute forms of liver disease — especially those in which the liver is softened — but also in exactly the opposite condition of things, namely, in chronic diseases where the liver is hardened. As for example in cirrhosis, and all other forms of hepatic disease which impede the portal circulation. A precisely similar cause induces the formation of internal piles, the bleeding from which is often profuse in advanced cases of cirrhosis. Haemorrhage of the bowels is also frequently met with in cases where a gall-stone ulcerates its way into the in- testines, from its opening one or more of the intesti- nal blood-vessels. K i30 DISEASES OF THE LIVER. The presence of black stools, when no bile enters the intestmal canal, may also be due to foods and remedies. Flatulency.— ThQ intestinal flatulency which is not only a common, but oftentimes a most dis- tressing, symptom of liver disease, is readily ac- counted for from bile being an anti-putrefactive in intestinal digestion. When bile is either entirely absent, as it frequently is in certain forms of liver disease, or present in insufficient quantity to admit of the intestinal digestion proceeding in a normal manner, the contents of the intestinal canal undergo putrid fermentation, and large quantities of foul- smelling gases are disengaged, which, not being absorbed into the circulation, to be eliminated by the lungs, are expelled from the intestinal canal, upwards and downwards, to the great inconvenience and discomfort of the patient. The Urine.— The kidneys, from being the chief organs which act vicariously with the liver, have their secretions more or less affected in all the various forms of hepatic disease. In the inflammatory and febrile classes of liver affections, the urine is not only scanty and high- coloured, but loaded with brown, yellow, pink, or vermilion-coloured lithates. In cases of atrophy it contains two abnormal sub- stances, named respectively tyrosin and leucin. ln\ SIGNS AND SYMPTOMS. 131 chronic congestions it contains a superabundance of oxalates as well as urates. In cancer there is usually an excess of uric acid. In all cases of jaundice the urine becomes of a saffron colour, from containing an excess of bile pigment ; while in those cases which result from an obstruction to the outflow of bile into the intestines, bile acids are detectible in it. When sugar appears in the urine during the course of chronic hepatic disease, it is usually the precursor of afatal termination. Urinary calculi — even those consisting of cystia and hypoxanthin — are m a great measure due to disordered hepatic function. The Pulse. — The pulse in all acute forms of liver disease is rajDid. In almost all the sluggish and chronic, normal, or even slower than natural. The Temperature is high in the acute, and low in the chronic, forms of liver disease. Even in the ordi- nary run of minor cases of derangement of the liver's function, patients often complain of feelmg chilly ; and this is easily accounted for on the supposition of the calorifying function of the liver being in general, at the same time as its biliary one, out of order. Blindness. — Defective vision is common in all cases of suppression of the biliary function. The biliary matters circulating in the blood, acting as toxic agents on the nervous system, give rise to disordered vision, musca} volitantes, &c. 132 DISEASES OF THE LIVER. Vertigo. — Vertigo is a symptom familiar to all bilious individuals. I liave seen persons holding on to the furniture of a room while crossing it when labouring under a bilious attack, in order to prevent themselves falling upon the floor. The swimming in the head or giddiness being so great, that they could neither walk straight nor stand steady. Headache. — Headache is a usual accompaniment of liver afi'ections, a ' bilious headache ' being a common occurrence. The pain is usually frontal, and chiefly over the eyes. Sometimes, however, it is not only behind the ears, but actually occipital. Hepatic Pain. — Continuous and acute pain in the region of the liver is common in all the various forms of mflammation, whether it be merely congestive or suppurative. Continuous dull ache is the accompani- ment of all forms of tumour of the liver, except one ; and that is hydatid tumour, which is as a rule painless. Acute paroxysmal pain occurs where there is a gall- stone, inspissated bile, an entozoon, or some other foreign body impacted in one of the bile-ducts. Shoulder Pain. — A great deal was formerly written and said regardmg the diagnostic value of right shoulder pain in cases of hepatic disease. It was learnedly accounted for by the supposed anastomosis of a twig of the supra-clavicular nerve with the right pneumogastric. In the early part of my career, I, like most other people, paid great attention to it, never by I SIGNS AND SYMPTOMS. 133 any chance omitting to ask every patient wlio came to me labouring under liver disease if she or he had or had not shoulder pain ; but the conclusion I have arrived at is, that shoulder pain is an utterly worthless symptom, being frequently absent when it ought, if the theory were correct, to be present, and still oftener present when the liver is not affected at all. Another ' idea ' has been recently started by Dr. Vidal ('Progres Medical,' 1879), and that is, that, in affections of the liver, there is a painful spot at the spinous process of the fourth dorsal vertebra ; that, in perityphlitis, patients have a painful point at the junction of the second and third. dorsal vertebrae on the left side ; and that, in ulcer of the stomach, the patient has commonly a painful spot over the spinous process of the sixth dorsal vertebra. Time will show whether this idea of Dr. Yidal's is anythmg more than ' an idea.' Meanwhile, as I have not yet put it sufficiently to the crucial test of expe- rience, I will say nothing either for or against it, but leave my readers to make what use of the hypo- thesis they please. Hepatic Neuralgia. — It is common to find in the works of non- scientific physicians a condition of liver spoken of under the title of ' Hepatic Neuralgia.' Of course a man who is guilty of describing hepatic pain as a pathological diseased state must necessarily be a believer in ' symptom diseases.' So it naturally 134 DISEASES OF THE LIVER. happens that the man who writes learnedly on the one is invariably found to speak equally learnedly of the other. To my way of thinking, the so-called hepatic neuralgia is nothing more or less than ordi- nary pain, the direct result of hepatitis, cancer, gall- stones, inspissated bile, or some other equally physical disordered condition of the parenchyma of the liver or its ducts. Eepatic Amenorrhoea. — This so-called hepatic symptom, which one occasionally sees spoken of in works on ' Diseases of Women,' appears to me to be little less logical than the hepatic neuralgia treated of in books on diseases of the liver. For after having given considerable attention to the matter, the con- clusion I have arrived at is that the effect of liver disease on menstruation is both doubtful and indirect. For example, we hear people speaking of amenorrhcea as a consequence of fatty liver ; but as amenorrhoea is a common concomitant of many other diseased conditions of the body, I see no reason why a fatty liver should be put specially forward as an exciting cause of amenorrhoea. Is amenorrhoea not common in phthisis ? and phthisis, when treated with cod-liver oil, is often associated (as 1 have shown at page 1017) vrith a fatty condition of the liver. Why then in such cases should not the phthisis itself bear all the blame of the amenorrhoea ? Again, it is not uncommon to hear obstetricians glibly talking of a congested state i SIGNS AND SYMPTOMS. 135 of the liver as being the dwect result of amenorrhoea. Apparently for no other reason than their thinking that as there is no monthly flow of blood from the uterus, and the patient's liver chances to be con- gested, it is not only possibly but probably so. Too much blood being in the body, from none being passed by menstruation, and not being very particular as to which organ it elects to locate itself in, it does so in the liver — probably, one might suppose, from that organ being the most capacious, and at the same time being situated not very far distant from the uterus ! If persons of this pathological turn of mind would only consider for a single nioment the morbid anatomical conditions of the blood-vessels which are essential to the production of a hypersemia, or congestion as it is commonly called, in the liver or any other organ, they would not be quite so ready to give utterance to such theories. For although it is an undeniable fact that fatty liver and amenorrhoea, as well as congested liver and amenorrhoea, do often- times exist simultaneously in the same individual, it by no means follows that they stand in the rela- tion to each other of cause and effect. In fact there are cases which would indicate quite the re- verse state of matters. For profuse menorrhagia occasionally occurs in patients under treatment for ■chronic congestion of the liver. I am glad to see that Dr. Matthews Duncan has apparently eman- 136 DISEASES OF THE LIVER. cipated himself from this erroneous obstetrical theory. For I find that in a lecture of his on hepatic disease in ' Gynaecology ' (published in the ' Medical Times and Gazette ' of January 18, 1879) he refers to the case of a woman, 31 years of age, who was treated in St. Bartholomew's Hospital for menorrhagia the direct result of congestion of the liver, described in the lecture as a case of chronic hepatitis. The Skin. — From the cfrcumstance of the skm, like the kidneys, actmg vicariously with the liver, its functions are always more or less deranged in hepatic disease, and the form of derangement most commonly assumed, as well as the one which is most visible to the eye, is jaundice. However, jaundice is not in- variably present in all liver affections. Indeed, so frequently is it totally absent that I have given this book the title of ' Liver Diseases with and without Jaundice.' As it is, however, much more frequently present than absent, and moreover is never present except when the liver is diseased, it behoves me here to speak of this sign very fully. The peculiar yellow tint of the skin which is so characteristic of certain forms of liver disease received from the French the vernacular name of ' jaunisse,' and was corrupted by bad English pronunciation and still worse English spelling into 'jaundice.' The vernacular English word for the affection is^ * yellows. ' SIGNS AND SYMPTOMS OF JAUNDICE. 137 Although it requires no medical training what- ever to distinguish by the colour of the skin the existence of this morbid state, it will be nevertheless necessary for me to go mmutely into the details of several other signs and symptoms connected there- with, as they are not always at a glance palpable even to the medically trained mmd. They are the following : — A. All forms of jaundice are invariably accom- panied by saffron, greenish, or blackish-coloured urine, which stains the linen from a pale golden yellow to a deep orange tint. B. The stools are usually pipeclay-coloured, constipated, and very foetid. When the stools are dark in a case of jaundice, it arises from blood having escaped into the intestinal canal. C. The perspiration is saffron-coloured, and stains the linen of a rich golden-yellow hue. D. The tongue is foul, and the appetite bad. E. The temperature of the body in cases of jaundice is never increased, except when the disease is associated with pyrexia. In fact it is usually diminished, especially in all the various chronic forms of the disease depending upon obstruction of the common bile-duct. F. The pulse follows the temperature ; being quick when it is high, slow when it is low. G. Occasionally, though exceedingly rarely, a 138 DISEASES OF THE LIVER. •condition of yellow vision is present which has re- ceived the technical name of 'xanthopy' — .xanthos be- ing merely the Greek word for ' yellow ; ' the English word not having been considered by some who bow down and worship grand names good enough for it. Yellow vision, let it be remembered, is a much more common symptom of the toxic effects of santonin on the system than of jaundice ; and as santonin also makes the urhie yellow, care must be taken not to make a mistake, by jumping to a conclusion before thoroughly investigating the case. H. Disordered cerebral symptoms, such as de- lirium, convulsions, and coma, are present in the worst forms of the affection. More especially in ■cases of contagious jaundice and acute yellow atrophy of the liver, as well as in those of sudden suspension of the biliary function from enerva- tion, induced by mental emotion and animal, vege- table, and mineral toxic agents. (See page 413.) I I. Whenever bile ceases to find its way into the intestines, great disorder in the digestion and absoi'ption of the food takes place. Not only does a portion of the fatty foods cease to be emulsioned and absorbed, but a form of putrid fermentation is set up, and a copious disengagement of foul- smelling gases is the result, causing great distress to the patient, fi'om both the faeces and flatus passed having a most noxious odour. SIGNS AND SYMPTOMS OF JAUKDICE. 139 K. The skin does not, immediately after bile ceases to find its way into the intestines, assume a jaundiced tint. Sometimes not even for three, four, or six days. Though generally within seventy hours a distinctly lemon tint begins to be visible. L. The conjunctivae and skin become yellow almost simultaneously, but the conjunctivas usually first. M. The urine becomes safiron-coloured sooner than the skin gets yellow. Usually within thirty- six hours after the flow of bile into the intes- tines has ceased. N. In some very rare cases-^-like the extra- ordinary one related by Bleicher in Schmidt's * Jahrbuch,' p. 48, 1839 — the buccal mucous mem- brane has been noticed to be blue instead of being, as it usually is, yellow. Exactly in the same way as the urine has been observed to be of a similar tint in cases of jaundice, as well as of other diseases. This arises from a mere modification of the degree of oxidation in the animal biliary pig- mentary matter having occurred from some acciden- tal constitutional complication of the system. Bile pigment, like uroha3matin, may be oxidised of a yellow, green, blue, purple, or red colour. N.B. — When the common bile-duct is liofatured in animals, a yellow condition of the buccal mucous membrane begins to make its appearance, as a 140 DISEASES OF THE LIVER. general rule, within seventy-two hours after the operation, but a distinct jaundiced condition is not usually observable before the eighth day after the application of the ligature. The urine and stools show the effects of the ligature much sooner than the buccal mucous membrane. 0. In all cases of jaundice, the bile pigment is found to stain different parts of the body with varying degrees of intensity. The skin of the abdomen is usually the most intensely stained, and next that of the face. Of the internal organs, the liver in jaundice from obstruction is by far the darkest part of the whole body, amounting sometimes even to a greenish-black. All the parts in contact with the gall-bladder and external bile- ducts are also intensely stained. The fat over the whole body is likewise deeply tinted. P. Sometimes jaundice (like sweating) has been found limited to one half of the body. Dr. Frank relates a case of this kind, m the ' Prax. Med. Univ. Prascept.,' 1843, under the title oi Icterus Dimidiatus. Their pathology is, in my mind, perfectly explicable from the cutaneous excretion of the bile pigment being under the influence of the nervous system, just as the perspiration is. Unilateral jaundice, there- fore, is the result of the excretory nerves (not neces- sarily at the same time either the motor or sensory)' of one side of the body being in a state of hemiplegia. SIGNS AND SYMPTOMS OF JAUNDICE. 141 In 1853-4, 1 saw a stran^'e case of • hemi-sweatino; ' in a man in the clinical wards of the Wiirzburg Hos- pital, Avhich at once suggested to my mind the theory of ' hemiplegic paralysis of the excretory nerves ; ' and if that theory were true in the case of the dimidian sweating, I think it may be equally true in that of dimidian jaundice. Q. Besides the urine and sweat, other normal secretions — such, for example, as the saliva, milk, and even the tears — have sometimes been found to be of a yellow hue in cases of marked jaundice. Legg found the serum, both in the chest and body after death, even in cases of slight jaundice, give an intense bile reaction with nitric acid, even when the urine gave scarcely any. Not only have I seen the serum in cases of j aundice with ascites so deeply tinted as to stain linen yellow, but I have seen the serum of blood drawn from jaundiced patients do exactly the same thing, and stain white paper of a deep yellow or saffron hue. Having said that the serum of the blood may be of a deep yellow colour in jaundice from obstruc- tion, I ouofht to remind the reader that it was pointed out at page 111 that the serum of the blood in cases of jaundice from suppression is equally of a deep bilious yellow hue, which of course arises from the simple fact that bile pigment is one of the bihary products not manufactured by the liver, but only 142 DISEASES OF THE LIVER. secreted by it, already formed from the blood. For^ as before said, bile pigment is merely blood haematin in a different stage of oxidation. K. There is an occasional accompaniment of jaun- dice — it cannot be called a sign of the disease — which has received the title of ' xanthoma,' or ' xan- thelasma,' from some, and ' vitiligoidea ' from others ;. which consists of a tumefaction and discoloration of the skin in particular parts of the body, more particularly the eyelids, the scrotum, and the hands^ of which I shall afterwards, at page 1061, more par- ticularly speak. S. Pruritus, shingles, and nettle-rash are not uncommon concomitants of disordered biliary func- tion, and intense itchiness of the skin, without any eruption whatever, is oftentimes the most distress- ing symptom the patient complains of in cases of jaundice. It is usually worst at night, when the patient first goes to bed, and sometimes almost amounts to the ' torment of the damned,' leading patients to lacerate the skin with their nails till it literally streams with blood. So intense is the itchi- ness, that sometimes strong anodynes, both by mouth and by subcutaneous injection, fail to give relief. N.B. — Acid baths increase the irritation, while alkahne baths slightly relieve it. The best treat- ment of all is to give half a teaspoonful of bicar- bonate of soda and from two to ten sfrains of the- SIGNS AND SYMPTOMS OF JAUNDICE. 143^ iodide of potassium in six ounces of water, just before going to bed. This I give on physiological chemical principles, believing, as I do, that the cutaneous irritation is due to the effects of the bile acids — glycocholic and taurocholic acids — circu- lating in the blood, and uTitating the extremities- of the cutaneous nerves. The addition of soda to the blood transformino; these irritating- acids in the body, as it does out of the body, into the com- paratively speaking non-irritating salts, glycocho- late and taurocholate of soda. I am all the more convinced that the cutaneous irritation met with in jaundice is due to the bile acids, from the two following facts. First, it is always most marked in cases of obstruction of the duct, where reabsorption of the secreted bile is the invariable cause of the discoloration of the skin ; and, secondly, of all the biliary substances that I have seen injected under the skin of dogs, the bile acids have always produced the most marked symp- toms of nerve irritation. (See further remarks at p. 739.) T. During an attack of jaundice the catamenia are occasionally observed to be suppressed. And a few cases have even been reported where jaundice instead of menstruation has been observed to occur for three or four days at the monthly period. Which fact led Dr. Hu'schberg to ventilate the hypo- 144 DISEASES OE THE LIVER. thesis that jaundice might in some cases be a mere vicarious form of menstruation. Those of my readers who may feel interested in this bold hypo- thesis will find Dr. Hirschberg's paper in the ' Re- ports of the Berlin Medical Society ' for 1872. All that I shall remark upon the subject is merely that the menstrual function is frequently suppressed in a variety of other diseases as well as in some of those associated with jaundice, and that, bearing on the same subject, it is a matter of common observation that great losses of blood are oftentimes accom- panied with a sallow complexion almost amounting to actual jaundice. Besides which : — U. Cases of actual jaundice following upon haemorrhage have been frequently recorded. Mr. W. Smith of Clifton relates tbe case of a strong and healthy collier, aged 24, who, in killing a duck, thrust the knife into his wrist in the direction of the radial artery. From the profuse and dangerous bleeding which ensued, and other circumstances, the artery was probably wounded. The haemorrhage was ex- cessive. The wound did well, and healed without difficulty. But, about a week after the accident, the pulse assumed a febrile rapidity, the skin became hot, and there were alternate chills and flushings with nausea and anorexia. The patient was jaun- diced, and continued so for about three weeks. The skin and conjunctivae were of a deep yellow hue, the SIGNS AND SYMPTOMS OF JAUNDICE. 145 stools light, and the urine tinted with bile pigment. The bowels were constipated ; but, after the feverish- ness subsided, his general health improved. He got no active medicines, only effervescents, mineral acids, and an occasional dose of castor-oil. He relates another case much resembling this, except that the haemorrhage was venous, instead of arterial. A farmer, aged 56, suffered much from varicose veins. One, over which there had been an ulceration, gave way, and an immense quantity of blood was lost. The condition of this man was like that of the one before described, and the history of the case, to a certain period, the same. Well-marked febrile reaction, with jaundice, set in about the fifth day. He recovered in the same manner as the former case. To these cases he adds one of jaundice in a lady after alarming epistaxis, and another after uterine hoemorrhage. But this last case is of doubtful value, as the patient was not attacked with the jaundice until a month after the delivery, having sufi^ered the previous day from shivering, headache, and symptoms of approaching fever. The yellowness of skin, white stools, and bilious urine, lasted about a week ; the treatment being two grains of calomel and a dose of castor-oil every other morning, with a taraxacum and nitric acid mixture thrice daily. I too have seen very sallow complexions more L 146 DISEASES OF THE LIVER. than once after severe haemorrhage. One very re- cently, where the gentleman died. But the yellow skin was due, not to biliary derangement, but to the mere loss of blood. This patient I saw along with Dr. Foakes and Mr. Parrott, and I do not sup- pose that either of these gentlemen, any more than myself, dreamed of calling the yellow discoloration of the skin jaundice. Such being a brief synopsis of the signs and symptoms of jaundice, I have now to direct attention " to a variety of conditions of the skin which have been, and are again hkely to be, mistaken for it by the uninitiated. They are : — 1. The sallow yellow complexion of chlorotic and other bloodless patients. After having shown that actual jaundice may follow upon profuse haemorrhage, it may be as well for me to remark that loss of blood is always followed by a sallow- ness of the complexion, even when no jaundice exists. 2. The sallow yellow complexion of persons who have lived long in a hot damp climate. 3. The sallow complexion of persons aiFected with the cancerous cachexia. 4. The sallow complexion of acute syphilis. 5. The sallow complexion of mercurialism. 6. Many new-born children have yellow skins, without any other sign or symptom of jaundice. SPURIOUS JAUNDICE. 147 whatever ; and to this condition of spurious infantile jaundice has been given the title of 'jaundice neo- natorum,' the pathology of which will be explained under the heading ' Intra-uterine Jaundice.' 7. A yellowness of the skin, closely resembling jaundice, may be produced by the intentional applica- tion of various colouring matters to the cuticle. But the deception is easily detected by the free application of soap and water, which at once reveals the true nature of the case. 8. Certain medicines have the power of making not only the skin, but also the urine yellow. This is particularly the case with the picrate of potash and santonine ; and this last does so in such a marked manner that a case of this kind was once brought to me by an intelligent medical practitioner as one of jaundice. And it is not surprising that he did so ; for, in spite of my familiarity with cases of the kind, it was not until I had applied the crucial test of adding liquor potassa; to the urine that I felt perfectly certain that it was not a real case of jaundice, complicated with spurious santonine cuta- neous coloration. When caustic potash is added to urine contain- ing any vegetable colouring matter, such as rhubarb, santonine, &c., and the mixture boiled, it becomes red ; whereas this is not the case with bile-pigment ; it then only browns. Besides which, the addition 148 DISEASES OF THE LIVER. of strong nitric acid turns the urine green when it contains bile, while nothins; of the kind occurs with yellow vegetable pigmented urine. N.B. The crucial test for all spurious forms of jaundice is a very simple one — namely, a naked-eye inspection of the faeces. If the stools be pipeclay- coloured, the case may be at once put down as one of jaundice. If, however, the stools are dark- coloured, that circumstance of itself does not nega- tive the idea of jaundice ; for the dark colour of the stools may be due to the presence in them not of bile, but of blood. Or it may be due to medicine — for all metallic remedies whose sulphurets are of a dark colour turn black in cases of true jaundice, from the sulphuretted hydrogen disengaged during the putrid fermentation of the non-bilified food in the intestinal canal combining with the metallic remedies, such as mercury, iron, bismuth, &c., and forming black sulphurets, which, mixing with the pipeclay-coloured faeces of jaundice, give them the appearance of being coloured with bile, and lead to an error in diagnosis. Hence, before concluding in a case of yellow-tinted skin that the hue is not due to jaundice because the faeces are of a dark colour, one must make sure that the dark colour of the stools is not due to the presence either of blood or of black sulphurets, as then, and then only, will the conclu- sion be philosophically justifiable. HEPATIC REMEDIES. 149 CHAPTER Y. TREATMENT OF HEPATIC DISEASES. I HAVE now finished with what may be called the preliminary scientific part of my subject. But before entering upon the purely practical clinical portion of it, which will, of course, include not only the dia- gnosis and pathology, but also the treatment of every form of liver disease, I think it will be well for me, in order to save a great deal of what would otherwise in reality be mere therapeutical repetition, to make a few general remarks on the action and modes of employ- ing what are usually spoken of as 'hepatic remedies,' in the same way as I have already for a similar reason briefly summarised the more important ordinary signs and symptoms of liver disease. For by thus, at once and for all, laying down the general thera- peutical prmciples upon which their employment is founded, I shall not only be enabled to save a considerable amount of space, but at the same tune accomplish what is equally important, namely a considerable economy of the reader's valuable time. 150 DISEASES OF THE LIVER. Wlien speaking of the modes of applying the remedies, unless when otherwise specified, I shall con- sider my remarks to be applicable to every hepatic mor- bid state, no matter whether it be mere local action or general constitutional disturbance. For every change in bodily function is the direct product of some form or another of tissue alteration. To treat hepatic disease rationally, therefore, not only is it requisite that a correct diagnosis be first arrived at — as difi'e- rent forms of hepatic affections of course necessitate different kinds of treatment — but differently consti- tuted and aged patients suffering from similar forms of liver disease not only require in many cases en- tirely different systems of treatment, but the same patients at different times, in different stages of tlie same affection, may even require what might be con- sidered at the first glance to be diametrically opposed forms of therapeutical remedies. The matter before us is consequently not only wide, but difficult, and in order to discuss the subject of the therapeutics of hepatic diseases logically as well as practically, I must be allowed not alone considerable license in the selec- tion of my materials, as well as of my data ; but the privilege of having their therapeutics regarded, not in fragments, but as one great and indivisible whole. For tluis only can the individual value and thera- peutical importance of hepatic remedies be thoroughly understood. This is the main reason (coupled with the HEPATIC REMEDIES. 151 object already alluded to of economising the reader's time and my own space) why, instead of merely con- tenting myself with alluding to the special remedies applicable to particular forms of disease in their respec- tive chapters, I have deemed it necessary to bestow a whole separate chapter to their joint consideration. Believing, as I do, that when once its contents have been mentally digested, and the general principles inculcated impressed upon the mind, the question of appropriate remedies in the special forms of hepatic derangements will be comparatively easily answered. For once the rationale of their therapeutic action is understood, there can exist but very little difficulty in comprehending the reasons for applying the dif- ferent kinds recommended for employment under the various headings of treatment given at the end of each chapter on special classes of disease. I shall only require to mention their names, or at least do very little more than mention their names and doses, when alluding to the propriety of administering them in the treatment of the special case happening at the time to be the one immediately under considera- tion. Fortunately for the sake of poor suffering hu- manity, the day of trusting to the Healing Powers OF Nature in the treatment of disease is rapidly drawing to a close, and will soon become, it is to be hoped, as permanently moribund as the idea of 152 DISEASES OF THE LIVEK. trusting to Nature to set efficiently a broken thigh- bone, or correctly reduce by herself a dislocated shoulder-joint. In such cases we know that the * healing powers of Nature ' invariably make a botch of the case. For while in the one instance she leaves to the patient, as a permanent souvenir of her handi- work, a crooked, in the other she as invariably be- queaths to him a shortened limb as an inheritance. The thoroughly enlightened practitioner of the pre- sent day has now learned from experience, if from nothing else, that contrary to the medical teaching which was so prominent a quarter of a century ago, Nature when left to herself makes nearly as un- satisfactory a physician as she is a bungling surgeon. That ' expectant medicine ' is about as philosophic in its principles and satisfactory in its practice as would be the adoption of an ' expectant form of alimentation.' As God only helps those who help themselves, I consider expectant medicine not only wrong in theory, but pernicious in practice. And this may be said to be in no single instance more true than in the treatment of the class of diseases now under consideration. Not only is ' expectant medicine ' totally inad- missible in the treatment of hepatic affections, but, contrary to what many imagine, even ' routine practice ' is equally reprehensible. In many instances being actually attended with danger. This in a great HEPATIC REMEDIES. 153 measure arises from the as yet imperfectly appreciated circumstances that : — 1st. Scarcely any cases of liver disease — no matter whether they be cases of hydatids or hepa- titis, cancer or gall-stones — ever run an identical course. 2nd. There is not a single form of liver disease — unless it be hepatitis — which, like a small-pox or a fever, will wear out, and cure itself. 3rd. Cases of liver disease, which at first sio-ht appear to possess a perfectly identical pathology and parallel symptoms, and consequently to require simi- lar treatments, are in the majority of instances, on closer inspection, found to pursue entirely different courses, and require different kinds of treatment. One cannot feel surprised at this, seeing what a com- plex organ the liver is, even when physiologically considered. For, as shown on page 58, it has no less than four entirely distinct normal functions to j^er- form, one and all of which are liable to get out of order at different times and in different ways. The reader can scarcely expect me, then, at the present moment and in the present place, to lay down special rules for the treatment of special cases. Indeed all that I shall now either pretend or attempt to do will be to lay before him the ordinary therapeutical knowledge we possess of the so-called hepatic remedies, adding a few hints which, from 154 DISEASES OF THE LIVER. personal experience, I believe, may be turned to nseful account at the bedside. The success of their application will, however, of course greatly depend on the diagnostic skill in the first instance, and the innate therapeutical acumen in the second, of the prescriber. For Though Learning guides us healing herbs to pick, 'Tis Wisdom only makes them cure the sick. Before entering upon the consideration of the employment of individual remedies in the treatment of hepatic diseases, I ought most emphatically to warn the young practitioner against : — 1st. Falling into the error — frequently committed — of imagining that patients labouring under diseases of the liver have a greater tolerance of remedies than those afflicted with more directly exhausting forms of disease : an idea which has, I believe, occasionally led to untoward consequences. 2nd. I would further call his attention to another important point, namely, that in the treatment of no other forms of disease is it of greater importance than in those the result of liver derangements to remember that certain therapeutical agents have a special action not only on one, but on two or more organs or tissues of the body at the same time. Otlierwise, while doing good in one way, he may be actually doing in- jury in another. The twofold action of certain drugs is well illustrated, for example, in belladonna, which HEPATIC REMEDIES. 155 acts specifically both on the pupil and larynx ; in iodide of potassium, which acts equally specifically both on the kidneys and salivary glands ; while mercury, the most common of all hepatic remedies, at one and the same time has a special and triple action of its own on three entirely different organs — to wit, the liver, the intestinal canal, and the salivary glands. 3rd. Let it never be forgotten that all remedies are also poisons, the amount administered alone constituting their right to be designated as the one or as the other. 4th. The treatment of liver diseases naturally divides itself into a general and a special. In the consideration of the former, constitutional symptoms more than local morbid effects ought to occupy chief attention. In the consideration of the latter, the seats or localities of the pathogenic action require special attention. Consequently, in order to be able to treat a patient labouring under hepatic disease rationally, it is quite as necessary for one to ha\e a clear notion of the etiology and natural career of the affection under which his patient labours, as to possess a knowledge of its signs, symptoms, and modes of termination. 156 DISEASES OF THE LTVER. Mercurials. The first remedy to which I must call special atten- tion is the well-known old-fashioned mercurial, which, after having been in general use among all ranks and classes of society for generations, may be still looked upon as the physician's mainstay in the treatment of the majority of liver cases. Every housewife knows that a dose of calomel at bed-time, followed by a black draught in the morning, will suffice, in the vast majority of cases, to cure an attack of biliousness, and that too within twenty-four hours after its administra- tion. At the present moment, however, a change has come over the spirit of the physician's mercurial dream, and the poor old drug has been placed at the bar like a suspected criminal ' on trial,' on account of experimental physiologists having found, that when administered to the canine species, it does not behave itself in what, according to old-fashioned notions, might be called an orthodox manner. As some of my readers may expect me not to pass over in silence the points in dispute, I shall, as briefly and concisely as I can, give my views of the special action of mercury on the human liver. There was a time when mercury was administered in all cases of liver diseases quite irrespective of their cause. Now, however, although men are fortunately TREATMENT BY MERCUKIALS. 157 becoming more careful in the employment of the drug, it is still often misapplied from there being many mistaken notions regarding its therapeutical action. It was at one time thought that mercurials stimulated the liver to secrete bile. But since experimental physiology has shown that they possess no such action on dogs, many have gone to the opposite extreme, and declared that as mercurials do not stimulate the liver to secrete bile in dogs, their benefit in human hepatic disease has been a delusion ; and the dark stools following upon their employment but the result of the sulphuret of mercury formed in the Intestines. The hostile therapeutists stand opposed to each other thus : Those of the practical clinical school declare that mercury is a powerful hepatic biliary stimulant, while those who adopt the views of the experimental physiological school as emphatically declare that mercury has no effect whatever in ex- citing or in increasing the biliary secretion, either in men or in dogs. Now comes the question which side is right and which side is wrong ? Both sides most assuredly cannot be right, though both sides equally certainly may be wrong ! To reconcile not only these two different views, but even the facts upon which each of them is based, on scientific principles, has hitherto been deemed impossible, except upon the supposition that the con- 158 DISEASES OF THE LIVER. stitution of the dog, as regards the action of mercury upon the liver, is entirely different from that of man. Mercury, it was said, might be a powerful hepatic biliary stimulant in the human, and yet perfectly inert in the canine species. This opinion was arrived at by a process of reasoning from analogy. For it is not only a well-known, but a perfectly incontrovert- ible fact that not only one, but many therapeutic and toxic substances act not alone with varying degrees of intensity, but even in a diametrically contrary manner, when administered in precisely the same form and in the same way to different species of animals. I could easily cite a dozen of examples of the actions of different poisons in proof of this statement ; but it is quite unnecessary for me to do more than remind the reader of the well-known and most extraordinary one, that goats eat hemlock with impunity, while sheep instantly succumb to its poisonous action. Nay more, that the milk of the goat fed upon hemlock leaves poisons the adult human being, while the little deli- cate kid not only relishes, but actually thrives upon, its mother's poisoned milk. It is perfectly evident, then, that the contradictory effects of poisonous sub- stances when administered to different species of animals, may, with an apparent good show of reason, be given as the true explanation of the contradictory results obtained from the action of mercurials on human and canine livers. TREATMENT BY MERCURIALS. 159 This explanation does not at all satisfy me, for I have yet to be convinced that mercury does act dif- ferently upon dogs from what it does upon men. My experiments upon the toxic effects of mercury both in suddenly administered large doses, and with insidiously daily administered small doses, varying in duration of time from fourteen to one hundred and twenty days, have led me to the belief that the action of mercury on the liver of the dog is precisely the same as it is upon the liver of the human being. For be the rationale of the action of mercury upon the hepatic organism what it may, I hold it as an undeniable fact, that after the sudden administration of a laro-e dose of mercury to healthy dogs as well as to healthy men, a variable but always considerable increase of bile is detectible in the faeces both by the pigmentary and bile-acid tests. My belief is, that at least one-half, if not three- quarters, of the cause of the dispute regarding the action of mercury on the biliary function arises from the slipshod manner in which the writers engaged in the discussion employ the words ' secretion ' and ' excretion,' often, it appears to me, using the one term, when it is perfectly evident, to the reflecting reader, that they ought to employ the other. I do not imagine that there is a single person who has taken part in the discussion that will seek to deny that, after a smart dose of mercury, not only IGO DISEASES OF THE LIVER. do the human faeces look as if they were loaded with bile ; but that the patient even occasionally complains that the passage of the stool through the anal orifice has produced a feeling of smarting or hot scalding, Avhich smarting can be due to nothing else than the irritation produced by an excess of the bile-acids in the stool. Moreover, I think no one at all versed in the literature of liver diseases will seek to deny that several independent observers are said to have noticed that an increased flow of bile has taken place from accidental human biliary fistulas after the admini- stration of a brisk mercurial cathartic to the patient. Every one, I believe, will, however, at the same time admit that neither an increased elimination of bile by the stool, nor through the fistulous opening directly connecting the gall-bladder with the exterior of the body, is any proof whatever of an increased SEcretion of bile by the liver having taken place ; but is merely positive proof that an increased Excretion of bile has occurred, and that in either case the expelled bile may not have issued, and most probably did not issue directly from the liver at all, but only from the gall-bladder, which had received it from the liver some time previously, and had it stored up in its interior ready for excretion' at any given moment. Not only may bile be secreted in great quantity, and yet not excreted in consequence of the gall- ACTION OF MEKCURIALS. 161 bladder — its reservoir — being sufficiently capacious to retain it ; but a large quantity of bile may be excreted at a time when little or none at all is being secreted ; that excreted being merely the bile that had been secreted some time previously, and been retained stored up in the gall-bladder, as above said, until the proper moment for its excretion arrived. While again, according to my views of the matter, this excretion of the pent-up bile independent of secretion may be entirely due to the brisk action of a mercurial — in the following wise : — Bile is only expelled from the gall-bladder as a result of the mechanical effect of its contraction. Its muscular contraction is called into play by reflex nervous action. And, in the normal state at least, this is brought about by the periodic stimulus given to the peristaltic action of the duodenum during the passage through it of the irritating acid chyme — from the stomach. The stimulating efl:ects of the acid chyme on the muscular coat of the intestines being communicated by reflex action, back along the common bile-duct from its duodenal orifice, to the muscular coat of the gall-bladder, which in its turn is thereby excited to contraction, and expels the neces- sar}'- amount of bile into the intestines to play its physiological chemical rule in the digestive process ; by which mechanical contraction of the gall-bladder, moreover, its contents — bile — if not expelled, under M 162 DISEASES OP THE LIVER. the normal circumstances, along the common bile- duct into the duodenum, may be under the abnormal circumstances expelled through a fistulous opening in the abdominal walls directly to the exterior of the body, and give rise to the condition that has been de- scribed as above by different observers. In oppo- sition to the latter part of this theory, again, we have the, at first sight, apparently irreconcilable statement of experimental physiologists that mercurials have no effect whatever on the quantity of bile eliminated through a biliary fistula in a dog. How is this ? To me it appears to be not another example of scientific discord, but simply of scientific 'harmony not understood.' And now for the explanation. What is it that the experimental physiologists tell us ? Merely this — that when a dose of calomel is given to a dog with a gall-bladder fistula, after the common bile-duct has been secured by a ligature, in order to prevent any bile escaping unnoticed into the intestines, no visible increase takes place in the quan- tity of bile flowing from the orifice of the fistula. Now, this is of course a perfectly conclusive statement. But of what ? Certainly not that the administration of a dose of calomel does not produce bilious stools, either in a dog or in a man, but merely that a dose of calomel does not increase the ^^cretion of bile by the liver. Which is quite another thing. The emptying of a distended gall-bladder of its bile being a thing ACTION OF MERCURIALS. 16e3 M'hich a dose of calomel can do. The stiraulatino- of a o healthy liver to .9^crete bile being a thing which a dose of calomel cannot do. Some clear-headed reader may feel inclined to put to me the question, ' But how, then, do you reconcile the negative statement of the physiologists with the positive one of the practical physicians who say that a dose of calomel increases the flow of bile from the fistulous opening of their patient's gall- bladder ? ' Easily enough. An experimental phy- siologist's biliary fistula is in most instances a very different thing in its anatomical relations from the vast majority of biliary fistulas which origmate as the result of disease in the human beino-. As I well know fi'om practical experience, having made many of them, the fistula in the dog generally opens directly into the free top end of the gall-bladder, and the gall-bladder, not having any longer its natu- ral contents allowed to accumulate in it, very soon dwindles (in function at least) into a mere bile tube. So that it ceases to be any longer a reservoir of bile, fi'om which a dose of calomel, by causing it to con- tract, can suddenly expel its accumulated contents, and that too for the simplestreasonof all, namely that it contains nothing to expel. In the human being, on the other hand, the fistulous orifice in the gall- bladder is mvich more often in its side than anywhere else, and in the cul-de-sac formed by the opposite V 2 164 DISEASES OF THE LIVER. side of the gall-bladder, together with the pendulous globular end of the viscus, bile may not alone daily and hourly collect, but most probably does accumulate there in considerable quantity, so that when a dose of calomel is given to this sort of biliary -fistulous patient, the dilapidated organ contracts and suddenly expels the collected bile it chances to contain in its interior at the time, just as a healthy gall-bladder would do under similar circumstances. The bile that comes away through the fistulous opening in the dilapidated gall- bladder not being secreted at the time of its expul- sion, but merely g^'creted from its reservoir by the stimulating efi'ects communicated to the gall-bladder from the duodenum excited into brisk peristaltic action by the mercurial purgative administered to the patient. Perhaps not more than one patient in ten may have this peculiar form of gall-bladder fistula (asso- ciated with a cul-de-sac admitting of the accumulation of bile in its interior), and consequently the effects of a dose of calomel on the other nine would be fol- lowed by the same negative results as in the dog with the artificial biliary fistula. This is the only way in which I can reconcile the discordant statements of men on either side, whose experimental powers, as *vell as veracity, are unimpeachable, and I think it is not alone the most generous, but at the same time the most philosophic way of meeting the difficulty. ACTION OF MEECUEIALS. 165 Having said this much regarding the dispute, I may now venture to give my ideas regarding the mode of the immediate action of mercury when it is given in a purgative dose to a bilious patient. As every medical practitioner well knows, when he administers a sufficiently large dose of a cathartic mercurial to a bilious individual, a large, black, tarry stool comes away. Look again at the effect of calomel on the stools of a child at the breast. Normally the stools are of a pale straw colour ; but give a dose of a mercurial, and immediately they become of a distinctly bilious green hue. The bile being in many instances in sufficient quantity and sufficiently concentrated to scald the anus during its exit. It is not, however, the bile which has just been secreted that then alone comes away, but the accumulation of thickened tarry bile, which has been, perhaps for days or weeks, stored up in the gall-bladder, that the mercurial has all of a sudden expelled from the viscus. The sudden expulsion of the accumulated bile from the gall- bladder being due to the stimulating effect of the mercurial on the peristaltic action of the duodenum. Its irritative or, physiologically speaking, stimulative effects on which being communicated, by reflex ner- vous action, along the bile-duct to the gall-bladder, and thereby exciting to immediate contraction its mus- cular coat. By which contraction the biliary contents 166 DISEASES OF THE LIVER. of the viscus are suddenly expelled into the intestines, and give origin to the tarry bilious stools. While giving this as ray theor}^ of the immediate effects of mercury on a bilious patient, it is by no means all that I have to say upon the rationale of the curative effects of mercury in hepatic diseases. An equally important and more intricate one has now to be considered, namely, its beneficial action in all the various forms of cons^estion of the liver, and conse- quently, of course, in all cases of jaundice the result of hepatic congestion. While admitting that there is sufficient evidence derivable from physiological sources to prove that mercury has no power to stimulate the normal liver to secrete bile, I shall now endeavour to prove that I am justified in holding and in promulgating the theory that in certain cases of diseased liver, where the biliary secretion is retarded, or even arrested, in consequence of a congested condition of the tissues of the liver, mercury has a powerful, though only an indirect, effect in restoring the biliary secretion. Not alone in the human, but equally so in the canine, bovine, and equine species. And this it does, I believe, by means of its antiphlogistic action upon the hepatic capillaries ; by subduing, if not indirectly actually removing, the congested condition of the blood-vessels, it relieves the secreting structures from the mechanical pressure arising from the congestion ACTION OF MERCURIALS. 167 of the blood-vessels, which prevents the hepatic cells from secreting bile. If this view of the action of mercurials, when administered in cases of congestion of the liver, be equally tenable with the theory of the immediate power they have in mechanically empyting an overloaded gall-bladder in a bilious patient (coupled also, perhaps, with their antiphlogistic action on the conofested condition of the liver with which an attack of biliousness is usually associated), we have at least advanced two steps in the right direction towards arriving at correct notions regarding the action of mercurials in the treatment of liver diseases, and I think are thereby prepared to go yet another step, and attempt the solution of the problem of the bene- ficial action of mercury in the various other forms of liver disease beyond those merely included in the generic terms of biliousness and congested hver. The further beneficial effect of mercurials, in man}^ other forms of hepatic derangement, appears to me to consist in a great measure in the powerful effect repeated doses — even Bmall doses — of mercury have upon the blood, particularly on its red cor- puscles. A large dose of mercury, by inducing liquid stools, not only reduces to a certain extent the total volume of blood in the circulation, but it at the same time impoverishes the blood by its disintegi'ating power on tbe cell-walls of the red 168 DISEASES OF THE LIVER. corpuscles, and thereby allowing tlieir nutritive contents to escape. Small doses again — not large enough to produce purging — though they may not directly reduce the total volume of the blood, still nevertheless act by impoverishing it. For no matter however small a quantity of mercury finds its way into the circulation, I believe from the results fur- nished to me by my experiments on the action of mercury on animals, that a directly proportional im- poverishment of the blood invariably takes place. Sir Thomas Watson has poetically said that mercury can blanch the cheek of the rose to the whiteness of the lily, and nothing, I believe, is more true. For in experimenting on animals, I have found the prolonged use of mercury reduce the red blood- corpuscles in a marked manner. Reckoning by the eye when they are viewed through the micro- scope, I should be inclined to say, at least one-: fourth. From this it is easy to understand how mercury acts in inflammatory affections ; and as in the majority of cases of jaundice from suppression, the stoppage of the biliary secretion is due to active congestion of the liver, mercury proves beneficial in such cases, not by directly stimulating the sup- pressed biliary secretion, but by simply removing the obstacle to its re- establishment ; namely, the liepatic congestion in the two ways just indicated. As a good illustration of the correctness of ACTION OF MERCURIALS. 169 this theory regarding the action of mercurials in cases of jaundice arising from hepatic congestion, I shall quote the following case, which appeared in the Hospital Reports of the ' Lancet ' of the 7th December, 1861. The case is headed, ' Intense Congestion of the Liver, simulating an Abdominal Tumour : ' — Alex. E , aged forty-eight, was admitted into St. Bartholomew's Hospital, under the care of Dr. Farre, on the 17th October, 1861. The patient had, it appeared, been suffering from jaundice during six weeks. He stated that the tumour in the epigastrium began at the same time as the yello>\mess of the skin. On examination, a prominent swelling was noticed in the epigastric region, possessing an indistinct feeling of fluctuation, but it was found to be con- tinuous with the liver. The motions were not bilious, but were of a pipeclay colour, and the urine looked like pure bile. Three grains of blue pill and two of Barbadoes aloes were ordered every night. By the 2oth the hepatic tumour was less, and the icterus was disappearing. On November 4th the urine was clearer and full of lithates. The con- junctivae were now the only parts observed to be of a yellow colour. November 11. — Although the pills had been continued up to this date, the mouth was not sore. The urine and stools were natural, and the patient 170 DISEASES OF THE LIVER. , was convalescent. A few days afterwards he left the hospital. The result, as the reporter stated, clearly proved not only that the swelling Avas from a highly congested liver, but also that the jaundice depended on this state. In this case it is evident that the primary bene- ficial action of the mercury was to reduce the con- gested state of the hepatic organ, and no one, I think, would venture to say that this was accom- plished by any power that the mercury possessed of exciting by means of stimulation the liver to secrete bile. If, then, the above views of the therapeutical action of mercurials be correct, it is easy to under- stand how, while in cases of jaundice from hepatic congestion it is beneficial, in those again from a per- manent obstruction of the common bile-duct in any part of its course, the administration of mercury or any other lowering medicine must prove detrimental by hastening the fatal termination. Like most other men actively engaged in prac- tice, I have three favourite grades of mercurials, of gradually decreasing strength, suitable for patients of different ages, sexes, and constitutions. At the head of the list stands our old and vene- rable friend Calomel, in his from three to six grain doses. Next in order of sequence comes Blue Pill, which again in its turn is followed by the less se- verely acting Grey Powder. One and all of these to ACTION OF MERCURIALS. 171 be given at bed-time ; but not to be followed in the morning by a purgative — as was the almost habitual practice some years ago — unless the boYrels will not act within twelve hours without one. Severe pur- gation I have over and over again found to be not only uncalled for, but even detrimental, in all except fat, fleshy, plethoric patients, who appear to require reducing. All that is required of the mercurial — unless we desire to salivate — being to cause one free and copious action of the bowels. Not half-a-dozen, as was formerly considered to be requisite. Conse- quently, before telling a patient to take opening medicine in the morning after a nocturnal dose of mercurial, 1 always enquire if the bowels are easily moved, and unless they are not I prescribe none — except he be at the same time a person of the above- described constitutional type. Should I consider a matinal purgative desirable, then I usually select the one the patient is most accustomed to, regulating- its strength according to circumstances, but in all cases giving strict injunctions not to take the purga- tive along with the mercurial at night. For I have the idea that no matter in what form the mercury be given, it always acts best upon the biliary function of the liver, through its direct action upon the blood, when administered alone. If, however, prescribing for a trifling bilious attack, I pay no attention to this rule, and may advise a five-grain 172 DISEASES OF THE LIVER. pill of equal parts of ext. colocynth and blue pill to be taken at bed-time ; but whenever I desire to act on the biliary function of the liver thoroughly, I give the mercurial alone, following it up with the purgative, when necessary, eight or ten hours later, with the view of simply increasing the peristaltic action of the duodenum and by reflex action stimu- lating the gall-bladder to contract more powerfully and the better be able to expel its bilious contents. Moreover, for a precisely similar reason — namely, non-interference with the cholao-oo-ic action of the mercury — it is that I prefer giving it on an empty stomach. For if the stomach is loaded with food when the drug is taken, or if food is introduced into the stomach after the mercury has been administered, and before it has had time to produce its therapeutical action through the blood on the liver, not one half of its beneficial effects are, I believe, obtained. Alkalies in Hepatic Disease. | Although mercury has not, there are some sub- stances which have, the power of directly exciting the flow of bile. Just as there are substances which directly excite the flow of saliva. Among these the mineral acids and soluble alkalies hold the first rank. It may seem strange that acids and alkalies should be here placed in juxtaposition ; but the reason of this arrangement will immediately appear. I ACTION OF ALKALIES. 173 According to a physiological law, acid substances have the power of exciting alkaline secretions, and alkaline substances of stimulating acid secretions. Bile being an alkaline secretion, we can therefore have no difficulty in understanding how the mineral acids act in cases of jaundice from suppression in- duced by enervation. They simply stimulate the secretion of bile. Bernard proved this by direct experiment, for he found that acetic acid applied to the duodenal orifice of the bile-duct caused an instan- taneous expulsion of bile from the gall-bladder. It is not so easy, however, to comprehend the action of alkalies in similar cases.. My explanation of their action is as follows : — When taken after food on a full, and when taken before food on an empty, stomach, the action of an alkali is entirely different. After food, and during digestion, the stomach contains a quantity of acid gastric juice, and an alkali taken then only neutralises the acid of the gastric juice. On the other hand, when an alkaline substance is introduced into an empty stomach, it acts according to the general law of exciting an acid secretion : and consequently'- an immediate flow of acid gastric juice takes place. And I believe it is the excess of this acid gastric juice, which, on reaching the duodenum, not only stimulates the secretion of the bile by the hepatic cells, but also excites the excretion from the gall- 174 DISEASES OF THE LIVER. J bladder of the alkaline bile. Just as the mineral acids do under similar circumstances. One remark further is, however, necessary. The quantity of alkali employed for the purpose of stimulating the secretion, or of excitmg the excretion of the already secreted bile, must be small, for if much be used, the greater part of the acid of the gastric juice will be rendered useless, in consequence of its being neu- tralised by the alkali as fast as it is secreted. More- over it may be laid down as a general rule, that Avhen we desire to increase the flow of bile by means of a mineral acid, the acid must be given after food. When, on the other hand, an alkali is selected for that purpose, the alkali must be administered before food. For obvious reasons, both alkalies and acids are counter-indicated in cases of jaundice resulting from active congestion of the liver ; and it is equally evident that they can be of no direct service in jaundice arising from occlusion of the bile-duct, where our object should rather be to diminish than to increase the secretion of bile. I believe that all tlie contradictory results which have been recorded by experimentalists, regarding the effects of carbonate of soda on the excretion of bile by dogs, are entirely due to sufficient attention not having been paid to these important physio- logical facts. For example. Dr. Fraser, in an article ACTION OF ALKALIES. 175 in the ' Edinburgh Medical Journal' for April 1871, tells us that larg-e doses of carbonate of soda de- creased both the jiuids and solids of the bile, when administered to dogs with biliary fistula?. And no wonder that they did. For had he given tlie animals a large dose of kitchen salt, I have little doubt he would have found a precisely similar result, and that, too, for a precisely similar reason. Namely, that the salt would diminish the quantity of liquid in the blood-vessels — from a palpable cause, as would be manifested by the thirst it would create — and there would be less for the hepatic secreting cells to obtain for their requirements, and hence a diminution in the amount of bile issuing from the orifices of the biliary fistulae. It is not with either Dr. Eraser's, Nassi's, or Rohrig's facts ' on this supposed action of carbonate of soda on the biliary secretion of dogs ' that I find fault, but it is with the modes of theorising adopted by one and all of these gentlemen that I disagree. Professor Rutherford's results are even opposed to theirs ; for he found that carbonate of soda in similar cases slightly increased the biliary secretion ( ' British Medical Journal,' 1879, p. 105). Alkalies, or at least some alkalies, possess certain other properties besides those to which allusion has just been made, which may be usefully turned to account in the treatment of jaundice from gall-stone 176 DISEASES OF THE LIVER. obstructions. To this yjroperty of alkalies I shall specially allude under the head of the treatment of gall-stones. Chloride of Ammonium. To the peculiar action of chloride of ammonium I must here direct special attention, as by some of our best writers on the tropical forms of hepatic disease it is said to be quite equal to mercury in its beneficial effects, without possessing any of the deleterious qualities of the m'neral. Chloride of ammonium is most suitable in cases of hepatic con- gestion, which it speedily relieves when administered in full doses — from twenty to thirty grains — three or four times a day. The pain rapidly disappears, and the size of the liver diminishes within forty-eight hours after beginning the administration of the remedy. As far as I am aware, we are indebted to Dr. William Stewart for first having called the atten- tion of home practitioners to the valuable therapeutic properties of the chloride of ammonium in hepatic congestions. Following his advice, I very frequently prescribe it in the doses he recommended, as above given, and with, in general, marked bi^neficial results. It often speedily relieves the ])ain, stimulates the appetite, and increases the flow of urine ; but how it acts in this way on the liver, in reducing the con- gested state of the organ (which of course is the HEPATIC REMEDIES. 177 cause of the pain), I know not, for in no sense of the word can it be called an antiphlog-istic. On the contrary, it seems rather to be a stimulant of both the nervous and circulating systems, for which reason I suppose it is that Dr. Stewart considers that a dry and hot skin counter-indicates its admini- stration. Vegetable Remedies in Hepatic Disease. To persons much in the habit of prescribing for liver affections it is well known that a great number of new hepatic remedies have been recently intro- duced into Europe from America — to wit, podophyl- lin, and a number of other vegetable drugs which I shall prevsently allude to. But I must remind m}^ readers that even before this we had no lack of either vegetable or mineral substances in our pharmacopoeia of considerable repute in precisely the same class of affections, among the most noted of which I may mention taraxacum, aloes, colocynth, croton oil, rhubarb, colchicum, scammony, senna, ipecacuanha, and jalap. At the same time it literally abounds in mineral ones, besides mere mercurials, among the best known and most valued of which are the sul- nhates of soda and magnesia, the bicarbonates of soda and potash. While, again, among the semi- organic and semi-inorganic may be named the chlo- N 178 DISEASES OF THE LIVER. ride of ammonium, the benzoates of soda and potash, and the salicylate of soda. One and all of which remedies are more or less powerful stimulants of the biliary secretion. The action of some of them, how- ever, is not only peculiar, but special. I shall now therefore speak of their therapeutical actions some- what in detail, and, to begin with, I shall direct attention to the vegetable drug which is thought by many to possess equally beneficial curative powers with mercury, especially in all cases of torpid liver, and of jaundice the result of a suppression of the biliary secretion. I allude to podophyllin, or, as it is vernacularly called by our American cousins, May- apple. This remedy was first introduced to the profession nearly a quarter of a century ago, by an American physician who believed it to possess, as he said, both the alterative and purgative properties of mercury. As an alterative, he recommended the resin to be given in doses varying from one-eighth to one-fourth of a grain, three times a day ; as a purgative, from one-fourth to one grain, as a single dose. I have given this remedy a tolerably fair trial, and although it seems to me to be very useful as a purgative in hepatic disease, and to increase the flow of bile, I have found it open to two objections : firstly, its action is not always certain ; and, secondly, in deli- cate females it gives rise to a good deal of griping. PODOPHYLLIN AS A REMEDY. 179 This latter objection can, however, to a certain ex- tent, be counteracted, by combining the remedy with hyoscyaraus. On the Avhole, I prefer mercurials to podophyllin resin, and only administer the latter in slight cases of jaundice, or in those where mercurials are counter-indicated. For example, in cases of feeble liver, where there is an insufficient secretion of l^ile fi-om want of ner- vous power, podophyllin is decidedly of service, for in such cases mercury is of course counter-indicated. Moreover, podophyllin can be advantageously com- bined with vegetable tonics, and, when given along with gentian or strychnine, forms an admirable he- patic stimulant in some of the cases usually denomi- nated ' torpid liver.' Dr. Dobell says that the best way by far of ad- ministering podophyllin is to dissolve it in spirits of wine in the proportion of gr. j. to the ounce, and combine it with essence of ginger in the proportion of 3Jss. to an ounce ; a teaspoonful of this given in a wineglassful of water every night, or every second or third nio-ht, Avill secure all the advantao:es of podophyllin without any chance of incurring those disadvantages which so often result when it is given in pills (' British Medical Journal,' May 24, 1879). I cannot refrain from here making a few remarks on what I consider the injudicious employment of podopliyllin, notwithstanding that I shall have again 180 DISEASES OF THE LIVER. to refer to it when on the subject of the treatment of gall-stones. Like every new remedy, podophyllin and its eleven sister American new hepatic stimulants have to run the risk of falling into disfavour in con- sequence of their too ardent admirers blindly pre- scribing them in all cases of hepatic disease, in many of which they must of necessity prove unsuitable, if not even detrimental. In cases of jaundice, for example, they must of necessity, at one and the same time, he the bane and the antidote. The bane in all cases of jaundice from obstruction. The antidote only in some cases of jaundice from suppression. In all hepatic diseases, independent of a diminu- tion in the secretion of bile, not alone one, but all hepatic stimulants do absolutely no good, and even sometimes do actual harm by adding to the mis- chief already accniing from an excess in the system of secreted and unused bile. So long as the bile they excite can be poured into the intestines — even should they excite too great a secretion — they can do no harm, but so soon as they excite a secretion of bile which cannot find its way into the intestines, m consequence of some cause of occlusion or other existing in the common duct, then one and every hepatic stimulant does harm ; for every particle of bile secreted, and not excreted, but adds to the stock pent up in the gall-bladder and hepatic ducts, which gradually becomes more and more concentrated in its TAEAXACUM AS A EE:MEDY. 181 consistence, from the fact that there is a constant ab- sorption of the aqueous particles of the bile, by means of a process of capillary osmosis, going on during the whole time it is shut up in its reservoir and ducts. When the liver during the intervals of digestion secretes merely sufficient bile to meet the require- ments of the succeeding meal, by the end of the digestive process the gall-bladder has entirely emptied itself, and is again quite ready to receive a fresh supply. AVhereas, when the liver secretes more bile than it can get rid of, the excess remains in the gall- bladder and ducts, and by its presence there leads, sooner or later, to the entne disorsfanisation of the secreting tissue of the liver, in consequence of the deleterious backward pressure exerted by the pent- up secretion on the hepatic cells. Taraxacum has been widely used in hepatic disease associated with jaundice, and is, I think justly, believed to be particularly well adapted to the treatment of cases arising from congestion. As in such cases I generally combine it with more potent drugs, my experience with this remedy when ad- ministered by itself has been too limited to admit of my offering an opinion of its value in an uncombmed state. I may, however, with perfect propriety, I think, speak most favourably of it when combined along with an alkali, such as soda or potash. My favourite prescription when I use taraxacum is 182 DISEASES OF THE LIVER. R Succi taraxaci 5xvj Sodae bicarb. . - Siij. So(?3e sulpbatis 5vj. Inf. calumba3 ad . Jvj. M. Sig. : Sliake well, and take a tablespoonful in six ounces of water three times a day. Dr. Washington again, who practises in Georgia, thinks that Old-man's -beard (^Chionanthus virginica) should be placed in the foremost rank as a curative aofent in all the various forais of liver disease inci- dental to malarial poisoning. According to him it not only stimulates the liver to secrete bile, but im- proves the digestive and assimilative functions, and thereby acts as a general tonic, and proves exceed- ingly useful in the dropsical concomitants of malarial jaundice, either in their acute or in their chronic forms. His mode of administering it is to give a teaspoonful of a strong aqueous extract three or four times a day ; and he says this will succeed in some of the more obstinate forms of intermittent malarial fever poisoning, when quinine has failed. In addition to these vegetable hepatic stimulants, the profession has recently been strongly invited by adv^ertising druggists to patronise other six newly proposed remedies for liver diseases, of varying degrees of activity, all said to be of undoubted value when given in the following doses : — AMERICAN REMEDIES. 183 Baptisin (wild indigo), gr. ij., gr. iv. ; Euonymin (wahoo), gr. j., gr. ij. ; Iridin (blue flag), gr. ij. ; Jug- landin (butternut), gr. ij. ; Phytolaccin (poke-root), gr. I, gr. j. ; and Leptandrin, gr. ij. One and all of these preparations are kept, made up in the foregoing mentioned doses, by druggists, in the elegant form of pearl-coated pills. Some of the fore -mentioned so-called hepatic stimulants possess a double salutary action in cases of biliousness, in not only stimulating the secretion, but also the excretion of bile by the intestines ; while others again limit their beneficial effects en- tirely to stimulating the secreting hepatic cells. Thus, while taraxacum, ipecacuanha, colchicum, lep- tandrm, and benzoate of soda merely act upon the liver, aloes, colocynth, calomel, podophyllin, jalap, sahcylate of soda, sulphate of potash, and sulphate of soda not only stimulate the secretion of bile, but by their purgative action excite its expulsion fi'om the intestines, and thus exert a double beneficial influence on bilious patients. Germicides. The new word ' Germicides ' may perhaps to some seem peculiar, especially in connection with diseases of the liver. But it will appear nothuig extra- ordinary to the reflecting medical man who has been keeping himself au coiirant with the discoveries that 18-i DISEASES OF THE LIVER. have recently been made regarding the important part played by disease-germs in all hepatic affec- tions of a malarial and epidemic character. For in the mighty revolution which the study of germ pathogenic action is rapidly producing in our ideas of the etiology and pathology of all kinds of epide- mics, as well as of many forms of sporadic jaundice, he must have perceived it is but the forerunner of an equally great change taking place in our systems of treatment. Here, as everywhere else, it may be said that rational medicine brooks neither curb nor restraint. Her movements always are, as they ought to be, quite as untrammelled as those of the course of a bird in the air or a fish in the sea. And now that the marvellous success of antiseptic surgery has given a clue to some at least of the lines along which she may advantageously proceed, it is impossible to pre- dict how soon or how effectively the medical thera- peutics of liver disease will profit by the example set by her twin sister surgery. The end and the aim of therapeutics is, and ought to be, the discovery of specifics. Specifics, not in the narrow sense of mere panaceas, but in the broad one of true curative agents. And most fortunately for us, of all the various forms of human disease set forth in our compendious nosology, it is those which have already been, and are still about to be, philo- GERMICIDES AS HErATIC EE:\IEDIES. 185 gophically enrolled under the heading of ' Parasitical Affections ' — in which category of course all germ diseases must logically come — which offer us the fairest chance for the discovery of their specifics. Already we possess a number of specifics more or less infallible, and nearly every one of them is a parasiticide. I am now speaking solely of internal remedies, leaving altogether aside the numerous ex- ternal applications with which are successfully de- stroyed the many vegetable and animal parasites affecting the skin and its appendages. Limiting myself to the consideration of those alone which make the mternal tissues, cavities, and organs of the body their habitats, I may tabulate our at present known more or less infallible specifics as : — Oil of male fern in tapeworm. Quinine in ague. Acid perchloride of iron in erysipelas. Santonine in ascarides. Mercury in syphilis. Salicylic acid in sibbens. Chaulmoogra oil in leprosy. Salicylate of quinine in typhoid. Cod -liver oil in scrofula. Belladonna in asthma. Conia in nerve-spasm. Salicylate of soda in rheumatic fever. Opium in lead-colic. 186 DISEASES OF THE LIVER. One and all of these, though not infallible — for nothing in this world is infallible — when judiciously employed in appropriate cases, are, in the true sense of the word, specifics. That is to say, they possess a special and peculiarly curative power in the various forms of disease above mentioned, ameliorating the sufferings of all, and tending to prolong the lives of most of the patients labouring under them. To this list, I anticipate, will soon be added many more, from a new era having dawned on therapeu- tical studies. For, while hitherto the action of reme- dies in the cure of disease has been entirely limited to the observation of their physiological effects on the healthy frames of the lower animals, or their therapeutical effects on the diseased constitution of man. Now that we have learned that many forms of human diseases are due to the action of the microscopic organisms included in the generic term disease-germs, an entirely new field of enquiry has opened out to us. All that we want is to discover agents which, while they prove fatal to germ exis- tence, will be harmless to the germ's host to whom they are administered. Seeing, then, that the primary part in the therapeutical enquiry is simply to ascer- tain how disease-germs can be most readily killed, all the preliminary observations may be conducted in the chemical laboratory, or even in the study ; all the implements that are requisite for the re- GERMICIDES AS HEPATIC REMEDIES. 187 search being a good microscope, a few flasks con- taining animal fluids or tissue infusions, and one or two simple chemical reagents. I have been thus working in my consulting room for months, and nobody has ever noticed anything particular going on, except when I called their attention to my work. After these remarks it will, I think, surprise no one, if I add that the 'great secret ' in the treatment of all hepatic germ-diseases is precisely the same as it is in that of the various kinds of what have hitherto been looked upon as specially parasitical forms of hepatic afl*ections ; namely, the slaughter of the off'ending parasite. Kill or submit to be killed being seemingly an inevitable law of animal exis- tence, for life appears to be but little else than one long fight between the destroyer and his victim. The wellbeing of one individual dependmg in a great measure upon his powers and his opportunities of killing and consuming another. Indeed, it may truthfully be said, that the maintenance of life, even in the vegetable, as well as in the animal world, consists in an uninterrupted succession of correlated consonance and disconsonance. For man destroys the sheep which consume the grass, that grew and developed out of the elements wliich constituted his ancestors' frames. It is not however always, as in this case, the stronger that destroys and consumes the weaker. In the group of diseases with which we 188 DISEASES OF THE LIVER. are at present dealing, it is actually the reverse. For it is tiny and apparently individually weak disease- germs which destroy and consume the stronger, the human being, their involuntary host. And it is a crusade against their lives I am now about to preach. For although to live and let live is a motto as philosophic in its conception as it is humane in its precept, self-preservation being the first law of nature, we, as the healers of disease, must put it entu'ely out of sight, and do our utmost to destroy disease-germs in every shape and character. For if they are let alone, they will most assuredly have no compunction in destroying us. It must no doubt be supposed that every living thing in nature was created some Avise end to fill ; but what the wise end in the creation of disease-germs can possibly have been, it completely beats me to discover. For while I fail to see that they do any thmg or any creature any good, I am painfully conscious that a vast amount of bodily and mental human suffering must be laid to their charge. For they not only engender painful and exhausting diseases of a tran- sient character, and sometimes give rise to what are called tertiary and quaternary signs and symptoms of disease which neither time nor treatment can re- move, but often hurl the victims of their onslaught with scant warning into an unwished-for tomb. There is one great and important fact that I 1 GEEMICIDES AS HEPATIC REMEDIES. 189 desire the reader to bear steadily in mind while perusing what I have to say regarding the treat- ment of hepatic germ diseases. Which is that in- finitesimally minute though disease-germs be, they must be looked upon in the light of as true corporeal entities as we are ourselves. For germs, like men, are born, grow up to sexual maturity, perform for a definite and allotted time the functions for which they were created, decay, die, and disappear. And just as human life may last but a few brief moments, or continue a hundred or more years, so perhaps may the life of a disease-germ be as brief or as extended. While, by a similar process of reasoning from ana- logy, we may further pliilosophically conclude that while we have the power to curtail, though not to extend, the allotted span of human life, so in like manner we possess the power of artificially curtail- ing the existence of germs. Our object being to discover the safest and the simplest means of killing and exterminating disease- germs from the tissues and fluids of the human body, and thereby mitigating, if we cannot entirely put a stop to, the effects of their ravages, in the shape of local lesions as well as constitutional effects. The salient points requiring attention are, how we can with the least detriment to their host counteract — 1. The development of colonies of germs in the tissues or vessels of the human body. 190 DISEASES OF THE LIVER. 2. The blood fermentation induced by the general contamination and sj^read of germs throughout the system. 3. The fever resulting from the growth and de- velopment of the disease-germs. 4. The cerebral and other nerve symptoms arising from the circulation in the blood of toxic products engendered by the fermentation of the fluid and solid constituents of the body through germ growth and development. 5. The consequent exhaustion of the patient's vital powers. It is easy enough to kill germs, but unfortunately not so easy to kill them quickly and effectually, without at the same time doing injury to their host. The reason of this is very simple. Disease-germs have a marvellous power of reducing human vitality. A few days, ay, even a few hours, will sometimes suffice for them to destroy life. It often happens in the course of hepatic germ diseases that death occurs quite suddenly and with scarcely any warning, making it appear as if a mere trifle were sometimes sufficient to totally extinguish the flickering flame of life. Which fiict of itself makes it all the more necessary for the practitioner to exercise the greatest care in the selection of remedies in treating germ diseases. A drug which might at least be taken with perfect impunity, if not even with actual ad- GERMICIDES AS HEPATIC REMEDIES. 191 vantage, in some cases of jaundice, may be attended with fatal consequences if administered to a patient labouring under the exhausting effects of disease- germs. In fact I am not quite certain that some of the cases of supposed unaccountably sudden death might not with some show of reason be attributed to the injudicious administration of an mappropriate remedy. Just as is known to have occurred in cases of typhoid fever. When the life of the patient has hung upon such a slender thread that a single small dose of iodide of potassium has sufficed to bring on immediate and fatal collapse. In my own experi- ence this has occurred. The case was that of a widow lady aged about 70, living at East Sheen, whom I saw in consultation with Dr. Hassall and Mr. Cresswell. Of all medicinal substances, germicides require the most judicious handling. In proof of the truth of this statement I need only refer the doubting reader to the cases which have been published, where rapidly fatal symptoms have followed upon the mere dressing of wounds by their solutions. Many of which are already on record ; but I will only cite two, and select them from a foreign source, as recorded in the ' British Medical Journal,' 1881. It says that two cases of poisoning by carbolic acid are reported in abstract in the ' Nordiskt Medi- cinskt Arkiv.' One of them, by Dr. J. A. Malmgren, 192 DISEASES OF THE LIVER. is that of a child aged 5;^ months, who had an erup- tion, followed by an nicer, in his groin, which was ordered to be dressed with carbolised oil (8 per cent,). The next day he had vomiting, which was repeated during the night. The urine was ' very dark and foul,' and the child was very sleepy. The carbolised oil was removed on the third day ; the child slept almost constantly ; the pupils were somewhat con- tracted. On the fourth day the somnolence ceased, the vomiting was less frequent, and the urine had become much clearer. The child recovered ; but the urine retained a dark colour for a fortnight. In the second case, related by Dr. Nordenstrom, a child one year old had a large fluctuating swelling in the left parotid and submaxillary regions ; it was opened, and pus discharged. The part was dressed with cotton-wool saturated with carbolised oil (1 in 10). About an hour after the application of the dressing, the child had vomiting, which continued through the following day. The urine was of >' dark green colour. On the third day, the conditio was about the same, and the breathing was impeded i A mixture of equal parts of camphorated oil andl olive oil was now substituted for the carbolised oil ; but the child died the next morning. j As cases of this sort, though only occasionally reported in the public prints, are most probably not uncommon, and it would be well if we could under I^JTOLERANCE OF REMEDIES. 193 stand their proximate cause, so that we might be able to guard against such untoward accidents, I shall here venture to throw out a few hints. Which may perhaps suggest to the mind of some reflecting reader a theory, which will tend to solve the pro- blem of the exceptional intolerance to particular forms of remedies that certain states of the system occa- sionally manifest. And, to begin with, I may state that the theory which I have myself formed is that the suddenly fatal results are due to the nervous system of the patients having been, previously to the administration of the fatal drug, so greatly exhausted from the debilitating effects of non -nutrition (from the constituents of the blood, on account of the germs' presence, not being properly prepared for tlie ])urposes of assimilation), as to be unable to stand any further depressing influence. This theory I found on the following demonstrable data. 1 . Magendie long ago showed that by extracting lood from a healthy animal it was rendered fear- ■ dly susceptible to the toxic effects of poisons. He ound, for example, that a quarter of the usual fatal lose of almost any mineral poison killed an animal sooner than when the fall dose was taken, if not bled before it was administered. 2. That blood, even though abundant, when cir- culating with its ingredients unfitted for the purposes f "f tissue assimilation and nutrition, is not one whit o i 194 DISEASES OF THE LIVEK. better than no blood at all, i,s provetl by the fact that if a sparrow has its toes slightly pinched after twenty-four hours' starvation, it instantly expires from the depressing effects on its already debilitated nervous system of even that moderate amount of pain. 3. It is my belief that germs, by disorganising the blood — as I showed in my experiments recorded m the ' Lancet ' of 1881 — reduce it to a nonentity, in ' as far as nutrition is concerned, and consequently the animal with bad blood in its vessels from the effects of disease-germs is no better off than if it had lost a proportional amount of good blood, and is conse- quently, like the bled dog and the starved spar- . row, rendered incapable of resisting the toxic effects of even small doses of poison. All remedies, be it remembered, are, at the same time, poisons. Their amount alone constituting their right to the respec- tive titles of remedy or j^oison. This then is, I be- | lieve, the philosophic explanation of the intolerance of active remedies occasionally manifested in cases of jxerm disease. I now come to the consideration of the destruc- tion of disease-germs within the human body by means of germicides. That this has been success- fully accomplished by numbers of us, there can be no doubt, as will be seen in the cases reported further on. Meanwhile I will only here allude to GERMICIDES. 195 the cases recorded by Dr. C. Gr. Rotlie (' Deutsche Medicinische Wochenschrift,' 1880, Xos. 11 and 12), and Mr. C. E. SheUy ('British Medical Journal,' April 9, 1881), of enteric fever treated by the ad- ministration of carbolic acid and tincture of iodine in frequently repeated doses until apyrexia was pro- duced ; and thereafter, at longer intervals, for two or three weeks. The advantages claimed are rapid and permanent subsidence of the high temperature, and of the vascular excitement (the pulse usually falling before the temperature, and often remaining subnormal in frequency for weeks, but not becoming irregular or intermittent) ; early subsidence of the gastric symptoms (by the beginning of the second week at latest) ; after which uninterrupted conva- lescence following. In a short series of cases of enteric fever which came under Mr. Shelly' s observation a few months since. Dr. Rotlie's treatment, slightly modified, was put in practice, with results which were not less gratifying. The subjects were young people, their ages ranging from sixteen to twenty-seven years ; as none of the cases — with one exception, in which the morning temperature, during the first three days on which it was observed, fluctuated between 10-1 "7° and 105'2"F. — were of more than medium severity at the outset, the patients would probably have re- covered under any form of rational treatment, com- 2 196 DISEASES OF THE LIVER. bined with good and careful nursing. But Mr. Shelly was struck by the early and rapid fall of temperature, the retardation and steadying of the pulse, the quick- ness with which the motions lessened in number and improved in quality, the cleaning of the tongue, the absence of sordes, the early removal of the abdominal pain and tenderness, the refreshing sleep, the com- paratively slight emaciation, and the remarkable unanimity with which all the patients agreed in ex- pressing themselves as feeling quite comfortable after the first few doses of the remedjr. No increase of temperature was observed to attend the eruptions of the five successive crops of spots which appeared in the most severe case. No complications occurred in any of the cases treated. So that his idea is that the carbolic acid acted as a parasiticide, and, by killing the fever germs, stopped the manifestation of their pathological effects. Surgeon Worgan, in his report of the health of the 3rd Regiment of Native Indian Infantry for 1879, says that he gave an ounce of water containing 10 minims ( ? g.h.) of crystalline carl^olic acid as often as six times a day with satisfactory results. Salicin he also tried, but he thought that although it reduced the temperature, it had no effect in checking the attacks of the intermittent fever. Probably from the fact soon to be alluded to, namely, that these different antiseptics exert different toxic effects in different i VITALITY OF DISEASE-GERMS. 197 animal fluids, and it is probable that the same prin- ciples which control their actions out of the body control them also within the body. The vitality of disease-germs is very various. Some species seem to be short others long hved. Some resist the action of powerful destroying che- mical agents. Others succumb to trifling causes. SyphiHtic and malarial disease-germs appear to be the most endurable of all. For once a human con- stitution has become thoroughly mipregnated with either of these species, it may 2;iot be able to free itself from them for years — ten, twenty, ay thirty, or even more — after their primary symptoms have manifested themselves. As regards syphilis, this fact is familiar to all ; but as it may not be equally so as regards malarial disease, I may mention that on one occasion I had a patient suffering from he- patic malarial ha3maturia, fifteen years after he left the West Indies (see page 371), where he origi- nally contracted the disease. While I once saw, along with Dr. Phillips, an old Indian officer twenty years after his return from Bengal. Where he had suffered from repeated attacks of jungle fever and dysentery. Who had still an enlarged liver, and was actually seized with a shivering fit while we stood by his bedside. This fit, he insisted, 7nust be due to a fresh infection of malaria, as he had not had an attack for several years. A fresh infection, however, was, in 198 DISEASES OF THE LIVEK. my opinion, out of tlie question, as he was then living in a healthy part of the Marylebone Road, where ague is unknown — and had been nowhere where it was likely or even possible for him to have contracted the disease, since he returned from Bengal twenty years before. Now, although this permanency, as it were, of disease-germ existence holds true in the case of syphilis and malarial affections, it is certainly, fortu- nately for mankind, the exception, and not the rule. .For death being the inevitable end of life, all germs die, and with their death their effects usually cease. In the exceptional cases just alluded to, the per- manency of the effects is probably due to the foct that, while in those cases the individual disease- germs perish, the whole species flourishes. Just as colonies of human beings do in suitable localities. The vast majority of germ diseases, however, may be said naturally to come speedily to an end. Either from the germs' pathogenic action extinguishing the life of their host, or from the food requisite for their sustenance (contained in his body) becoming ex- hausted, and they themselves bemg exterminated by starvation, ere they have time to produce their host's vital exhaustion. In the cases where the patients recover, it may well be asked, wliat becomes of the myriads of germs which impregnated their tissues and fluids, and pro- ELIMINATION OF DISEASE- GEEMS. 199 ducecl the disease ? I suppose that they are elimi- minated by the various emunctories. For as I showed in the experiments I related in the ' Lancet ' of June and July 1881, the fungi and fungi species of germs, which 1 injected into dogs' veins, were all got rid of in the short space of forty-four hours. Though in that brief time they had suc- ceeded in destroying the life of the animal. As it is not, however, necessary that the host should die in order that they may be got rid of, and all germ diseases possess more or less of a distinct crisis, I imasfine that it is the death and sudden elimination of the dead disease-germs which induce the chain of signs and symptoms usually called the ' crisis.' This being a new idea of the nature and cause of the so-called crisis of disease, I have deemed it advisable to give my views of the matter in the chapter specially devoted to the ' Foetor of Disease ' (page 497). Where it is attempted to be shown that the odoriferous perspiration, as well as foetid urine and stools, which are so characteristic of the crisis of disease, are most probably due to the elimi- nation of dead or living strongly smelling disease- germs. Were it in our power to imitate all of Nature's methods of destroying germs, we would certainly adoj^t the system of their artificial calcification ; for that appears to be one of Nature's means of effecting a 200 DISEASES OF THE LIVEK. spontaneous cure of parasites both large and small. Thus it happens that when a hepatic hydatid, a liver fluke, a filaria, or trichina dies, and it cannot be elimi- nated, it shrivels up and becomes transformed into a calcareous inert mass. Chiefly consisting of the carbonates and phos- Encystedcretified Trichina. , n -,• ^ phates 01 Imie and magnesia. And just as these large forms of parasites do, so like- wise do the minute forms of parasites which we call germs. We know this to be the case at least with both tuberculous and cancerous germs. The subjomed woodcut, again, well illustrates the commencing stage of this process of parasite creti- fication, as it is seen in the so-called tubercular cal- xiification in the lungs of sheep. This brino;s me to the consideration of what are germicides ? The most potent germicides with which I am at present acquainted belong to three distinct thera- peutical and chemical groups, and, strange to say, they are all, directly or indirectly, derivatives of the vegetable kingdom. Being of the cinchona, the car- bolic acid, and the creosotic varieties. They may be tabulated as quinine, creosote, thymol, eucalyptus oil and gum, carbolic, benzoic, and salicylic acids. I may add to these almost all vegetable gum resins (espe- cially of the empyreumatic pine group), pitch, tur- GERMICIDES. 201 pentine, camphor, and sucli like. All of wbich have long been looked upon as disinfectants — destroyers of the contamnm Yi\iim. But neither sahcin nor Fig. 4. Strongylus Filaria undergoing Calcareous Degeneration in the Lung of a Sheep. benzoin are germicides in any sense of the word, for they do not kill germs at all until they are decom- posed. Thougli they are constantly being prescribed for that purpose. 202 DISEASES OF THE LlVEIi. The therapeutical blunders that one occasionally sees committed, by otherwise Avell-educated men, in consequence of tlieir defective knowledge of physio- logical chemistry, are not all unimportant. A simila- rity in name and source fostering the idea of an identical therapeutical action. Thus it appears from cases reported in the jour- nals within the last couple of years or so that a considerable number of therapeutical errors have been committed from salicylic acid, salicin, and salicylate of soda having been imagined by several to be not only almost identical in therapeutical action, but j)rescribable in similar doses. While in reality they are not. Indeed are very far from it, so I shall devote a short chapter to their consideration. Salicylic Acid, Salicin, and Salicylate of Soda. To begin with, I may at once state that salicylic acid is as different from salicin and salicylate of soda, as sulphuric acid is from sulphur and sulphate of soda, and ouglit equally carefully to be differentiated in prescribing. For salicylic acid is, like sulphuric acid, a potent poison, and consequently ought only to be administered in very small doses. Whereas the salicylate of soda may not only be given in large doses with impunity, but with advantage. Mr. Watts Parkinson, in the ' l^ritish Medical Jour- SALICYLIC ACID AS A KEMEDY. 203 nal ' of May 7, 1881, while speaking of its beneficial eiFects in acute rheumatism, says that in the cases in which he administered it, he found that althouo;h chloral and bromides moderated the delirium, and pro- cured some little sleep, yet the temperature continued to rise, and the delirium and restlessness went on until salicylate of soda was given. Then there was a daily declme of about a degree in tlie temperature, and a corresponding improvement in the other symptoms. One gentleman took over a thousand grains of salicy- late of soda in six days without any toxic symptoms; and again took, after three days' interval, over seven hundred grains in six days. In proof of what I say regarding the necessity of not confounding the therapeutical actions of such nearly allied substances as salicylic acid, salicin, and salicylate of soda, I may mention that I have found by a series of carefully conducted experiments upon their respective behaviour towards disease-germs, cultivated in various orcfanic solutions of animal and vegetable matter, that while salicylic acid acts almost invariably as a powerful germ poison, neither salicin nor salicylate of soda, so long as they remain unde- composed, have any such effect. Moreover, che- mistry has shown that, instead of being a germicide, salicin is in reality a germ food. Being actually under certain circumstances, like fibrin and sugar, a fermentable substance. Splitting up, under the 204 DISEASES OF THE LIVER. influence of .sulphuric acid, as well as of the electric current, into, among other things, glucose. More- over, not only is salicin isomorphic with benzoin, but benzoic acid, as well as carbolic acid, can be prepared from it. The three acids, carbolic, salicylic, and benzoic, are all indeed transmutable into each other, and so easily is this transmutation accomplished, that at the present moment the salicylic acid of com- merce, instead of being (as it ought to be) the natural product of the oil of winter green, is in reality arti- ficially manufactured out of carbolic acid. Besides which, I may mention that it can be equally readily prepared in fine needle-shaped crystals from the benzoate of copper (Amer. Chem. Jour., vol. ii. p. 338, 1881). When salicin is taken into the stomach, it is decomposed in the system, and salicylic acid is one of the products. This can easily be proved by testing the patient's urine with tincture of iron, which gives a fine purple coloration with salicylic acid, but not with salicin.^ ^ In testing the urine witli percbloride of iron for salicylic acid, it must be done carefully ; otherwise the white, cloudy, dirty milky-lookiug mixture that forms will completely obscure the purple reaction. If the iron solution be poured down the side of the test-tube, and the tube be not shaken, then the reaction will immediately be visible enough ; but aa it will most probably vanish at once on agitating the test-tube, my advice is to put the test-tube, standing directly on its end, aside for a few minutes, when the white coagulum will subside and the beautifully transparent purple liquid appear on the top of the coagulum. This milky com- pound, which I have found forms in all normal human urine on the ad- GERMICIDES. 205 On the other hand, salicylic acid is a powerful germicide. But only upon those of the animal class. Such as Brownian granules, vibrios, and spu'illi. It has no deleterious effect whatever, I find, on bac- teria and micrococci. For I have again and again taken two bottles of tlie same saccharine urine, and while to one I have done nothing, and to the other added a pinch of pure powdered salicylic acid, sliaken the bottles well, and then placed them side by side under precisely the same circumstances, in a day or two I have found both equally crowded with torulae germs. Showing clearly that the deleterious properties of salicylic acid do not act perniciously on the vegetable torula cerevisin?. On the other hand, ajrain, benzoic acid kills tliese veo-etable fferms. Neither the salicylates of quinine nor soda appear to me to have any deleterious effect on germs what- ever, and Miiller has made a precisely similar remark regarding the non- antiseptic effects of the benzoate of soda. Quinine, in the form of the sulphate, readily kills vegetable germs. So does carbolic acid. But carbolic acid, like salicylic, appears to be most deadly to animal germs. I find, however, the effects dition of perchloride of iron, is not due to the presence of either ordinary albumen nor mucus. Although I have often seen it, I have never taken the trouble to analyse it, on account of time being to me now-a-days a rather valuable commodity. Were I less occupied, I should investigate the point at once. 206 DISEASES OF THE LIVEK. of these germicides are, to some extent, inflaenced by the nature of the fluids in which the germs are cultivated. Milk, blood, and urine, all modify more or less their toxic actions o.n the germs cultivated in them. The salicylate of soda has recently become a fashionable remedy in hej^atic aifections as well as in acute rheumatism ; but like all other fashionable remedies, I fear it is doomed soon to be discarded. Not however from any want of intrmsic therapeu- tical merits of its own, but from the injudicious em- ployment of it by its too ardent admirers. Already it has been given so injudiciously, and in such large doses, as to have brought on delirium in some cases, and a comatose drowsiness in others. It is very easy to detect that an excessive quan- tity of the drug is being or has been given by the appearance of it in quantity in the urine. After large doses have been taken for three or four days consecutively, salicylic acid may be detected in the urine, sometimes as long as seventy hours after its discontinuance. The proper dose of the salicylate of soda in hepatic cases is from fifteen to twenty grains three times a day, and the moment head symptoms manifest themselves, it ought to be instantly dis- continued. I GEKMICIDES AS REMEDIES. 207 Benzoic Acid and Benzoates. There is another remedy to which I desire at this place to call special attention, as it is applicable to the treatment of any form of biliousness and jaun- dice whenever the staining of the skm produced by the bile-pigment is wished to be got rid of. The remedy to which I allude is benzoic acid and its salts. Benzoic acid was first recommended as a remedy in the treatment of jaundice a quarter of a century ago by a German physician, the name_ of whom I have forgotten ; but led by his suggestions I have been in the habit of largely employing it, not, however, as he su<»:2:ested, for the cure of the disease erivino- origin to the yellow discoloration of the skin, but simply for the removal of the discoloration itself. Having discovered that benzoic acid, especially when in combination with alkalies, in the form, for example, of benzoate of soda, ammonia, or potash, in from ten to twenty grain doses, has a marked effect in causing the reabsorption of biliary pigments ft-om the skin. In fact it acts, as a lady on one occasion graphically described it, by saying that the remedy ' bleached ' her. which was a much more philosoi)liic term than what I had applied to it, namely, the title of a whitewash ; for in reality it acts as a bleaching agent by extracting the pigment, not as a whitewash by simply hiding it from view. 208 DISEASES OF THE LIVER. Dr. Green (one of my former pupils), who has been resident for several years in Bengal, tells me that, following my suggestion, he often uses the benzoic acid either in six-grain doses in the form of pill three times a day, or in the form of an alkaline mixture (as I usually recommend), and finds it exceedingly useful in clearing away the jaundiced tint of the slvin, after the excitmg cause of the discoloration has been removed. To one case in particular he called my attention, namely, that of a man attacked with jaundice follow- ing upon delirium tremens, who, he said, after taking the benzoic acid for eight days, was of a perfectly natural colour, and it would have required an expe- rienced eye to detect even the then slight remaining yellow tinge of the conjunctivce. The following case may be cited as a tolerably good example of the value of benzoic acid in cases of jaundice from enervation : — William M , aged eleven years, labouring under an acute attack of severe jaundice, came under my care at University College Hospital on February 2. The patient aiipeared to be a moderately de- veloped and very intelligent boy. The jaundiced condition of the skin, his mother said, was first noticed on January 30, only two days before he came to the hospital. Although the boy had been for some length of I BENZOIC ACID. 209 time subject to bilious headaches and vomiting, he had never before (though frequently very sallow) been attacked with marked jaundice. On the present occa- sion he also complained of headache, but it was un- accompanied either by sickness or vomiting. On exammation the liver was found normal in size, and not in the least tender on pressure. The bowels were moderately open, and the stools not jDipeclay-coloured. The urine was, however, of a deep orange tint, and the skin of a dark yellow hue. There was an abun- dance of bile-pigment, but not a trace of bile-acids in the urine. As the jaundice appeared to be the result of enervation, brought on by over mental exertion, the boy was ordered to be kept from school, and not allowed to read any books (his mother said he was always reading). At the same time three grains of benzoic acid were ordered to be taken thrice a day. February 9. — The skin was now very much paler, the yellow colour bemg nearly gone. The conjunctiva.* were still yellow, although less so than at last visit. The urine remained unchanged in colour. He was ordered to continue the medicine. February 16. — The skin was now perfectly nor- mal in colour ; if anything perhaps a shade whiter than natural. Conjunctiva) no longer yellow. Dis- missed cured. 210 DISEASES or THE LIVER. In this case no medicine whatever, except the ben- zoic acid, was given. As far as my experience goes, benzoic acid appears to be most useful in bleaching the skin in jaundice arising from enervation or from active congestion ; but it is of little or no service until the acute symp- toms have disappeared. I am still rather doubtful regarding the mode in which it acts, although it is clear that it hastens the reabsorption from the tissues, and elimination from the body, of the bile-pigment. It thus appears to play the part of a bleaching agent : as my lady patient graphically said, the medicine had bleached her. On one occasion I tried benzoic acid during an attack of jaundice following upon an attack of ague ; but it proved of no service. Indeed, quinine, combined with mercurials, seemed in that case to be the only remedy. When a large dose of benzoic acid is given, hippuric acid appears in the urine. And, as we know, hippuric acid is not a normal constituent of human urine in any quantity whatever, but onl}^ normally met with in the urine of herbivora such as oxen, horses, and sheep. The benzoate of ammonia — an officinal prepara- tion — being very soluble in water (1 in 5) may 1)e employed instead of benzoic acid. In general I administer the benzoate of ammonia in from fifteen to twenty-five grain doses three times a day in the form of mixture. But sometimes, from 1 QUIXIXE AND MERCURY AS GERMICIDES. 211 wisliino; to combine the benzoic acid with a strono-er alkali, I order two drachms of benzoic acid to be dis- solved by boiling in one ounce of liquor potassa3 or liquor soda3, and then made into a six-ounce mixture, a tablespoonful of which to be taken as a dose three times a day, in a quarter of a tumbler of water. Sometimes again, in order to obtain a clear mixture with less trouble to the dispenser, as benzoic acid is only very slightly soluble in cold water (1 in 300), and exceedingly soluble in alcohol (1 in 4), I add a little aromatic tincture of cardamoms to the mixture, which has the double advantage of makmg it agree- able to the palate as well as pleasant to the eye. Mercury and Quinine in Hepatic Diseases. Both of these substances, separately and com- bined, have powerful effects in affections of the liver. For while quinine is of itself a powerful vegetable and consequently malarial germicide, mercury, be- sides its specific cholagogic functions, is a syj^hilitic disease germicide. Quinine, in combination with mercury, is given with the most marked advantage in cases of malarial hepatitis,^ and still more so in those rare cases of paroxysmal hepatic hiematuria referred to at page 374. Grace Calvert has published * It acts, I believe, by killing the germs. Just in the same ^\■ay as it cures an influenza cold in the head when suufled up the nose. ]?y killing the disease-germs. p 2 212 DISEASES OF THE LIVEE. a most interesting series of experiments which he made in order to ascertain the respective powers of different substances to prevent the development of germ life. A few of the more important of his results I herewith subjoin. Prussic acid, carbolic acid, and cresylic acid pre- vented fungi developing in a solution of albumen. Quinine, pepper, and caustic lime did the same thing. Chloride of zinc and sulpho-carbolate of zinc, while they exerted no influence on the vegetable fungi species of germs, effectually prevented the develop- ment of animal organisms such as vibrios. While, strange to say, the only two substances that he experimented upon, that were found to be inimical to both animal and vegetable germs, were quinine and carbolic acid. The former, the well-known agent in curing malarial disease. The latter, the great antiseptic agent of modern surgery. In another series of experiments made with gela- tin, he found that while with arsenious acid animal germs appeared within two days, no vegetable organisms appeared at all. With protosulphate of iron, again, neither animal nor vegetable micro- organisms appeared. He also found that cresylic acid was the most potent agent in destroying vibrio life. While next to it in order of potency stood carbolic acid, sulphate of quinine, chloride of zinc, sulphuric acid, picric acid, sulpho-carbolate of zinc, THERAPEUTICS OF GERMICIDES. 213 chloride of ammonium, sulphm-ic acid, and prussic acid. Common salt, chloride of calcium, chlorate of potash, sulphite and bisulphite of lime, phosphate of lime, hyposulphite of soda, turpentme and pepper had no deleterious action on the animal germs. While, on the other hand, lime, charcoal, permanga- nate of potash, the phosphate of soda and ammonia actually favoured the production of vibrio germs, and thereby promoted putrefaction (Pharm. Journ., 15tli June, 1872). In addition to these interesting facts, Grace Calvert showed (Pharm. Journ., 15th June, 1872) that decomposmg white of egg develops no living germ organisms when exposed under nitrogen, hydrogen, or carbonic acid gases, while it does so freely, under precisely the same conditions, when exposed to oxygen or ordmary atmospheric air. Moreover he adds to this observation the interest- ing fact that the animal organisms produced under the putrefactive process — which, as I showed, is simply a process of fermentation — when kept in closed tubes exhale sufficient carbonic acid not only to stop their own development, but to asphyxiate themselves, just as a mouse or a man would do if shut up for a sufficient length of time in a closed space with only a limited supply of oxygen. Pasteur tells us that the germs of chicken cholera 214 DISEASES OE THE LIVER. disease are killed by dilute sulphuric acid. While I have noticed the marvellous toxic effects produced upon gonorrhoea! pus-germs and spermatozoa by- dilute acetic acid. It kills them at once. Mineral Waters in Hepatic Diseases. I must not leave the consideration of reme- dies in the treatment of liver diseases without directing special attention to the valuable curative therapeutical powers possessed by certain natural mineral waters in the treatment of non-organic diseases of the hepatic organ. To wit, our own well- known mineral springs, such as those of the Bridge of Allan, which is a saline aperient, containmg 90 grs. of salts to the pint, chiefly magnesian. Cheltenham, which is also a saline aperient, and near it Kings wood, which contains nearly 56 grains of sulphate of soda and magnesia to the pint. Lea- mington with its 104 grains of chlorides and sul- phates, and lastly the Victoria mineral spring (Stratford, Essex) with its 81 grains of salts (chiefly , sulphate of soda) to the pint. On the continent of Europe there are nme mineral springs, much stronger in their hepatic therapeutical action than any of our British ones, which have acquired a very high repute among our continental brethren for the treatment of almost all kinds of liver diseases. In alphabetical order they are the seven I GERMAN JIINERAL SPRINGS. 215 Bads, as they are called in Germany, of Aachen (Aix-la-Chapelle), Carlsbad, Ems, Friedrichshall, Kissingen, Marienbad, and Pullna ; and the two eaiLi\ as they are named in France, of Vals and Vichy. I will say nothing more special about any of our British mineral waters, as they are, no doubt, well known to all my readers ; but as those of the conti- nent are probably not so well known to them, I shall call attention to their more prominent features, alike as regards position, altitude, and special che- mical constituents. Aachen (Aix-la-Chapelle) is a town of 80,000 inhabitants in Khenish Prussia. Situated at the height of 450 feet above the sea level, in a volcanic district, at the ends of the Eifel and Ardennes moun- tains. It possesses a pleasantly cool atmosphere. Which, even in the hot months of July and August, never exceeds a mean of 63° F. The chief mgTedient of its waters is chloride of sodium (common salt). The next in relative pro- portion is carbonate of soda (washing soda), of which ingredient it contains about a fourth of the chloride, and lastly sulphate of soda (Glauber's salts). Which is, in its turn, in about half the proportion of that of the carbonate. It is thus seen that the mineral base in all these cases is sodium. Carlsbad, which is situated in the Bohemian 216 DISEASES OF THE LIVEE. Switzerland, as the district is called in Germany, enjoys the delightfully cool altitude of 1,200 feet above the sea level. So that its atmosphere is, com- paratively speaking, cool even in the hottest months of the year, at a time when the lowlands of Germany are parched and scorched by the broiling sun. The chief and most active chemical mgredient in its waters is the sulphate of soda, which it contains in exactly the same proportion as Aix does of com- mon salt. While, again, having only half the quantity of common salt, it has double the quantity of alka- line carbonates, and an equal amount of sulphate of potash, as the waters of Aix-la-Chapelle have of sul- phate of soda. Next m alphabetical order comes Ems. It has a much lower altitude, being only 291 feet above the sea level, and possesses a soft and balmy atmo- sphere. Ems is a town on the river Lahn. Not very far from its confluence with the Rhine. The chief ingredient of its water is also soda ; but this time it is the bicarbonate which is most abundant. Exactly doubling its chloride (common salt). While the bicarbonates of lime and magnesia stand in lieu ' of the sulphate of soda. Which latter substance only exists m the water in mfinitesimal propor- tion. Friedrichshall, situated in a valley in Saxe-Mei- ningen (near Coburg), has a water exceedingly rich GEKMAN MINEEAL SPRINGS. 217 in both the sulphate of soda and the sulphate of magnesia ; contains also a large quantity of sulphate of Hme ; besides an enormous amount of common salt. Hence it is an exceedingly active alkahne pur- gative water. Kissingen has an altitude of 800 feet, and a mild dry atmosphere. Its waters contam twice as much common salt as Aix-la-Chapelle, while it replaces the carbonate of soda by about an equal proportion of Epsom salts. Marienbad m Bohemia, again, _ stands at an alti- tude of 1,900 feet above the level of the sea, and consequently enjoys the coolest and purest atmo- sphere of them aU. Its waters contain abundance of sulphate of soda, and about equal quantities of bakmg soda and common salt. The last of the Grerman mmeral springs to which I have to allude is that of Pullna, m Bohemia, which is a strongly bitter saline purgative. Containing three tunes more of the aperient sulphates than any of the other strongly laxative waters. Although its chief base is sodium, it contains neither the chlo- ride nor the carbonate of that metal. Consequently differs very materially in its therapeutical effects from all the other six waters alluded to. Presently I shall give a comparative table of the chief con- stituents of these different springs, in order that the reader may see at a glance how their actions on \ 218 DISEASES OE THE LIVER. the liver must vary. But before doing so I shall make a fe^v remarks on the two French mineral waters of A'als and Vichy. Vals is a town in the province of Ardeche, south of Lyons, highly celebrated for its alkaline springs. The chief chemical constituent being bicarbonate of soda, of which it contains the large quantity of over 30 grains to 16 ounces of water. In addition to this it contains a small quantity of sulphate of soda and chloride of sodium. The next French •alkalme ean. of great repute is Vichy, which is charmingly situated in the centre of France, not very far from Vals, at an altitude of 787 feet above the sea level. Like Vals, it owes the celebrity of its waters to the (still larger) quantity of the bicar- bonate of soda (baking soda) they contain. Although the reader can for himself readily understand, from the constituents of each of these waters, what their therapeutical effects on the human system ought to be, I shall nevertheless point out, somewhat in detail, the comparative therapeutical actions of each of these nine continental natural mineral waters, so that he may the more easily comprehend their mode of action in the general treatment of NON-organic diseases of the liver. I shall not go into the question of the general action of mineral waters upon the human constitution, but merely direct attention, in a philosophic as well I THEEAPEUTICAL ACTIOX OF MINERAL WATERS. 219 as a scientfic medical spirit, to the probable mode by -svliich their physiological action on the liver, stomach, and kidneys has a curative effect m hepatic diseases. Alkaline carbonates, chlorides, and sulphates have all respectively specific effects on the biliary, urinaiy, gastric, and intestinal secretions. An alkaline car- bonate, for example, increases the flow of bile, neutral- ises the gastric juice, and renders the urine alkaline. A chloride acts chiefly in increasing the organic and inorganic substances eliminated by the kidneys, while all sulphates act more or less powerfully on the bowels, and increase not only the number of stools, but the actual total amount of fieces excreted in a given time. The actions of the nine contmental waters on the human system may be gleaned therefore by merely glancing at the comparative table I have drawn out. From it will be learned not only the different ways in which the various waters ought to act, but likewise the varying degrees of intensity with which they will act on liver, stomach, intestines, and kidneys. For, as will be seen by the table at page 231, the waters of Ems are saline as well as alkaline. Those of Yals and A'^ichy are alkaline without being saline. Those of Pullna and Friedrich shall are not only saline but pur- gative. While Carlsbad and ]\larienbad again are not alone purgative and saline, but at the same time alkaline. Those of Kissingen, on the other hand, are 220 DISEASES OF THE LIVER. strongly saline, and only .slightly purgative ; while Aix-la-Chapelle's are not alone slightly alkaline and purgative, but at the same time markedly saline. The manner in which these various chemical properties manifest themselves therapeutically upon the system is interesting. 1. As regards the purgative action of mineral waters. The degree of intensity of course varies with the amount of sulphates they contain. 2. All of them augment, in greater or lesser pro- portion, the quantity of solids passed from the bowels during twenty-four hours. And the reason of this is very simple. By the purgative effects of the waters the peristaltic action of the intestines is increased, and the food is hurried through and out of the digestive canal before all its nutritive materials have had time to be absorbed from it by the lacteals, and hence more feculent matter is excreted by the bowels than would have been the case had the digestive materials sojourned longer in the intestinal canal, and gone to nourish the body. 3. The saline constituents of the waters by in- creasing the thirst increase the quantity of liquids in- gested, and the more ingested the more solids they dissolve, and as the greater part of the fluid that is drunk is eliminated by the kidneys the urinary secre- tion both in fluids and solids is proportionally aug- mented. :modes of action of mineral waters. 221 4. Althouorh the first effects of alkaline and saline mineral waters are to increase the organic solids passed during the twenty-four hours by the urine, this soon ceases to be the case in those of the waters possessed of purgative properties. In a few days after the con- tinued use of Pullna, Friedrichshall, and Marienbad water, for example, the total amount of organic solids eliminated by the kidneys in twenty-four hours is actually diminished. And tliis is due to the fact that the nutritive materials are liurried through the intes- tines, and consequently, from less getting absorbed into the circulation, there is a smaller excess in the blood to be excreted alono- with the urine : while ao-ain, the temporaiy increase at first is no doubt owing to the elimination of the excess of oro-anic nutritive materials which had accumulated in the circulation before the employment of the mineral waters began. 5. The free use of mineral waters, especially those of the non-purgative class, largely augments the quan- tity of inorganic solids excreted during the twenty- four hours by the kidneys. The augmentation of sulphates, chlorides, pliosphates, &c., being in a direct ratio to the relative proportion of these chemical com- pounds contained in each ounce of the water im])ibed . 6 . All alkaline mineral waters render the urine alka- line; with varying degrees of ra]:)idity, in direct propor- tion to the amount of alkaline carbonates they contain. From those chemical, pliysiological, and tlicra- 222 DISEASES OF THE LIVErv. peutical data, it will be apparent to every enlightened reader that it is impossible to doubt even for a single moment, far less to deny, the beneficial powers of alkaline, saline, and purgative mineral waters in the treatment of certain non- organic diseases of the liver. I mean by non-organic those diseases that are un- accompanied by permanent structural change. Such, for example, as simple hepatic congestions, acute and chronic inflammations. Not such diseases as can- cerous tumours, hobnail liver, hydatid cysts, or fibrous deposits. And I think all will agree with me that it is a pity that every spring of the year England should be flooded by hosts of puffing pamphlets ex- tolling to the skies the curative powers of certain continental mineral springs in almost every species of liver disease, when it is evident, from the chemical constitution of the waters so lauded, that such a state- ment must be untrue. It is indeed to be regretted, if from no otlier than the mere fact that every ordinarily educated man sees for himself, by the analysis of the waters usually appended to the touting pamphlet, that they contain no extraordinary or uncommon in- gredient whatever. Dr. John Macpherson, in his notes of visits to foreign watering-places, which were published in the 'Lancet' of April 1872, makes some most judicious remarks bearing on this point which I cannot do better than quote here. He says : — MODES OF ACTION OF MINEEAL WATERS. 223 * I had occasion to make the acquaintance of many of the bath doctors, and was much struck with their general intelligence, and pleased with the freeness with which they discussed the operation of their own waters. Few of them, however, appeared to me to take extended views of the subject of balneology ; they knew a little of other baths employed for the same complaints as their own ones, and knew some- thing of the baths which they could recommend after their own as after- cures, but their knowledge did not seem to extend much further, nor did they seem to take much interest in the subject in its general rela- tions. One very general subject of complaint among them was, the unperfect selection of cases sent to them for treatment. I thouo-ht at first that this mioht refer only to cases coming from England ; but they told me that their own practising physicians and pro- fessors constantly sent them the most unsuitable cases. ' Then, when such cases came to them, the difficulty arose, how they were to act : were they at once to declare to the patients that their doctors had made a mistake in sending them there, or might they not discover that, in some respects at least, their own baths might be found useful ? Most mineral waters, if they do not happen to be very powerful ones, are applicable to so many different and varied conditions that they easily supply an excuse to a medical man 224 DISEASES OF THE LIVEE. for makino: a short trial at least of his own waters on patients who have been sent to him. In suchi cases they usually endeavour to make up by some more purely medical treatment, or by the use of waters from other sources, for the shortcomings in their own spring in the treatment of a case for which it is not specially adapted. ... It was freely admitted to me at various baths by the doctors themselves, or proved to me con- vincingly by tbe doctors of other baths, that in many cases patients believed themselves to be cured by par- ticular mineral waters, whereas a great portion of the cure depended on the exhibition of medicines. This was more particularly the case with regard to syphilis. Many a patient cured at a sulphur bath in reality owes his cure to mercury, especially in the form of in- unction. Again, iodine is used freely in cases oi syphilis and of scrofula ; and I doubt whether there are any so-called iodine waters the operation of which is not, in certain cases, increased by the artificia' addition of that substance.' This multiplicity of so-called ' Kurs ' is a verj humblmg fact, and one sufficient of itself, it might b* supposed, to put an end to all the injudicious laudatioi contained in the majority of the pamphlets, in someo which we are unblushingly told, in quasi-professionr lano'uaoe too, of the transcendental healins; virtues c the waters in almost every imaginable complaint- from a simple stomach-ache to an incurable form < BKNEFITS OF MINERAL WATERS. 225 disease. From two mineral -spring pamphlets now on the table before me I extract the followinor liver affections mentioned in the list of diseases said to be within the curative scope of the waters recommended: — Hepatitis, acute and chronic ; retention of bile ; gall- stones ; enlargements of the liver, and suppurating abs- cesses. Then follow some more liver diseases with the following high-sounding titles : — Stasis of the circula- tion ; hyperplasia of the connective tissue ; and hepatal- gia. Added to which there is a whole host of stomachal and renal diseases appended. Just as if the \raters were an infallible cure for almost every complaint which human flesh is heir to ; and not only are all sufferers invited to come and partake of their healino- virtues, but all are equally promised a cure. Even those whose sojourn at the springs may have apparently not at first been attended with the promised results have the cheering; assurance friven to them that althousfh the benefits derivable fi-om a course of the waters are not immediately apparent they need not despair, as they are nevertheless sure — quite sure — to supervene within six weeks, or at most a couple of months, after the patient's return home. By this wise means none are allowed to leave the springs in a desponding state of mind, but on the contrary all are made to return home — not only if they have as yet received no benefit, but even rather the reverse — in the buoyant hope til at ' the good time is coming.' One would almost Q 226 DISEASES OF THE LIVER. fancy that the curative properties of some springs far exceeded, in the eyes of their partisans, those recorded fin the 4th verse of the 5th chapter of St. John) of the pool of Bethesda, where it was only the first who stepped into the water after it was moved by the hand of the angel that received the promise of cure. For, in the monographs alluded to, all are promised a cure, without even havino; to undero-o the fatisfuin"" ordeal of wearisome waitmg and anxious watching for the advent of any miraculous moving of the waters. When looked at philosophically, it is easily understood fi'om whence the mineral springs on the continent of Europe have derived their great reputation. It is mainly, I believe, from the fact that the localities in w^hich they are situated supply the great and import- ant want of easily accessible pleasant holiday resorts which the vast majority of our inland- dwelling continental brethren suffer from. From any part of England a two hours' inexpensive railway journey transports an inland- dwelling inhabitant to some one or other of our charming, invigorating, health -■ restoring seaside watering-places. But, alas ! for the ' inland-dwelling inhabitant of the Continent there is no such near-at-hand seaside refug'e. For him to o-et to the seacoast requires not only long fatiguing hours of journey, but also a long purse to pay for it. So in the majority of instances he contents himself with the next best thing to a dip in the saline restless BENEFITS OF AVATERIXG -PLACES. 227 sea. Which is, a dip in the saline placid inland bath. The people on the Continent who cannot afford to go to the seaboard and enjoy the delights and benefits of the ' Wellenschlag,' as they graphically term the 'blows of the waves ' of the briny deep, betake themselves with their families during thesummermonthstosome one of the many mineral- water localities ; and just as our people talk of it requiring so many dips in the sea to ' set them up,' they talk of their ' Kur ' as consisting of so many tumblerfuls, or so many ' Bads.' The continental can no more than -the British Pater- and Materfamilias exist without annual refreshing summer holidays, and, Avhile the one set betake them- selves to inland mineral springs, the other set, for precisely similar reasons, wend their way to the sea- coast. If Great Britain had not a so easily come-at- able seaboard, we should hear quite as much of Bath, Cheltenham, Harrogate, and the Bridge of Allan as of Carlsbad, Kissingen, Vals, and Yichy. For there, parent and child would be able to enjoy the hygienic curative influences of change of climate, change of scene, change of food, and change of mode of life, which a residence at any and every natural mineral spring furnishes. No matter what the chemical ingredients of its or their waters are. Should any one doubt this, let me remind him of what Christopher Anstey wrote about the watering-place of Bath in the last century. Which is a clever fragment of social 42 228 DISEASES OF THE LIVER. satire on mineral watering-places in general, as it points out in graphic poetry the known attractions which all natural mineral springs possess in a greater or less degree to the desponding invalid: — Of all the gay pbces the world can afford, By gentle and simple for pastime adored, Fine balls and fine concerts, fine buildings and springs, Fine walks and fine views, and a thousand fine things, Not to mention the sweet situation and air, What place, my dear mother, with Bath can compare? Dr. Macpherson, in his ' Notes ' already referred to, remarks that ' there is now scarcely a considerable village in any tolerable picturesque part of the country, however deficient it may be in mineral waters, that has not its cold and vapour baths, its pine extract, its baths of herbs, and its electrical baths. Most of the new baths now alluded to with tdhles dliote, are in fact lodging-houses in which you need not undergo | treatment unless you like. A good table is what patients look for in such places, and a good table will confirm the reputation of an establishment more than the most scientific treatment ; but it is in this matter of diet that such institutions are apt to be defective. I Was repeatedly warned in this sense against becoming an inmate of one of them. I observed generally very few changes from former years as to diet. The table is excellent in most of the larger ones, but there are many crowded baths, as Schwalbach, in which it has not reached the proper standard. English patients i BENEFITS OF HEALTH-RESORTS. 229 still complain of the want of tables cTIwte at Carlsbad, and in Austrian baths, where the physicians endea- vour to control the diet of their patients more rigidly than they do in the baths nearer the Rhine.' In my opinion, however, this is one of the greatest of their ad- vantages, for a restricted diet, as shown in the text, is absolutely indispensable in the treatment of many liver diseases. I may add that Kurhiiuser, Badanstalten, Trinkhallen, and Trinkquellen, for the cure of every imaginable disease, curable or incurable, by every imaginable aj^pliance, sw^arm throughout the whole of Germany. Not alone are there natural alkaline, saline, iodine, sulphurous and ferruginous baths and drinking fountains ; but there are sand baths at Xorderney, mud baths at Driburg, peat-earth baths at Franzen- bad, peat-water ones at Untersberg, tar-water ones in the Schwarzwald ; grape Kurs at Diirkheim, whey Kurs at Gleisweiler. Besides which there are places for beer Kurs, extract of pine Kurs, juices of herbs Kurs, breathing the air of cowhouse Kurs, condensed air Kurs, pulverised water Kurs, galvanic and electrical bath Kurs, birch-leaf packing Kurs, and so on ad infinitum. In order to show that I am not overstating the case, I subjoin verbatim (with the exception of omitting the prices) a list of the modes of cure held out to the visitors by one of the French establish- * a 3 230 DISEASES OF THE LIVER. ments, in which it will be seen that no less than thirty-eight different forms are enumerated. Douches locales a vapeur „ „ „ aromatique „ „ sulfureuses Bain de vapeur „ „ aromatique „ electrique ou galvanique Sudation „ medicameuteuse Maillots, etc. Piscine Maillots a domicile Inhalations d'air comprim^ pour la gorge et la poitrine Inhalations medicamenteuses sui- vant les substances Pulv(5risations Bain simple „ d'eau de mer „ „ de barege „ „ m^dicamenteux (suivant les substances) „ de siege ,, aA'ec douches ascendantes „ terebenthine ,, a la seve 6ther(5e de pin mari- time „ tonique et vivifiant, suivant la formule du docteur P. A. Desjardin „ a Viocle naissant, suivant la formule du docteur J. Ber- nard „ a I'extrait d'eucalyptus „ d'algues avec frictions „ d'amidon „ de carbonate „ de g6latine Douches simples „ ecossaises, etc. „ locales simples Seance d'electricite dynamique „ electro-magn^tique Massage oriental ,, simple Friction simple avec gant au savon statique ou I shall now subjoin my promised comparative analytical table of the active therapeutical ingredients in the waters of the eight most celebrated of the before- mentioned continental mineral springs in the treatment of liver diseases. It has been drawn up from a variety of analyses published by different chemists, and the calculations are made in grains of the substances contained in every sixteen fluid ounces of the waters. CONSTITUENTS OF MINERAL WATERS. 231 Comparative Chemical Analytical Table of Alkaline, Saline, and Aperient Mineial Waters of the most celebrated Continental Springs. i CJ ^ 'v "3 <^. "O J S. C3 •a _o .O d 6 PuUna .2 d «>1 .2 1 "a > Carbonate of Soda . 90 — „ Lime . 2-0 0-77 10-3 1-4 — — — — ,, Magnesia . 0-3 6-40 11 40 — — — — Bicarbonate of Soda — — — 13-9 15-0 30-9 37.5 „ Potash . — — — — _ — 2-6 2-8 „ Lime — — — — _ 6 1-7 3-5 31 „ Magnesia — — — — 5-3 1-5 4-3 3-5 Chloride of Sodium 8-7 — 61-1 20-2 150 7-7 3-9 4-3 „ Magnesia — 16-66 30-2 — — — — — Sulphate of Soda . 200 123-80 455 91 38-7 1-4 2.9 3-2 „ Potash. 20 4-80 1-5 11 0-5 0-3 — — „ Magnesia — 9808 39o — — — — — Be it remembered that this list includes only a mere fractional part of the continental mineral springs possessing almost identical chemical compositions and properties, and the above have been selected merely as types of each class of the alkaline, saline, and aperient waters. This table of the active ingredients of the eight natural mineral waters of the highest repute in the treatment of liver diseases shows that there is nothing extraordinary, or even peculiar, either about their constituents, or in their proportions, or even as regards their forms of combination. Indeed, on the contrary, these analyses prove that there is neither rule nor order either in the kind of the 232 DISEASES OF THE LIVER. ingredieDts themselves, in their proportion, or in their modes of arrangement, and that, so far from the constituents of natural mineral waters being in the slightest degree peculiar, they are on the contrary precisely such as are to be met with not only in every British druggist's shop, bat almost in every English housekeeper's room. To wit, common salt, washing soda, baking soda, together with Epsom and Glauber's salts. Moreover, they show how very different must be the actions of different mineral waters in the same class of disease, and how necessary it is, in prescribing any individual one of them to a suffering patient, to consider the different therapeutical effects of their ingredients as carefully as it is to consider the action of any and every single drug which enters into the composition of a prescription. Nay more, the analyses of these eight celebrated waters still further reveal the important fact that, so far from there being anything specifically curative in any of their con- stituents beyond the reach of the at home practising physician, he has it readily within his power not only to give every one of their therapeutical ingredients, active or other, in precisely the same form and in the identical proportional combination in which they occur in the natural mineral waters ; but he possesses the yet more important power of being able to alter them at will. To suit the exigencies of any given case, he can not only add to the one and diminish the propor- I BENEFITS OF HEALTH-EESORTS. '266 tions of the others, but he can altogether omit anyone or more of the ingredients just as he chooses. In fact he can not only manufacture a facsimile of the water of any given mineral spring out of the medicinal bottles in his own surgery, by simply mixing their contents in proper proportions with a sufficient quantity of hard spring drinking water, but he can manufacture any new form or combination of the ingredients of natural mineral waters to suit the special conditions not only of the disease, but of the patient's age, sex, habits, and constitution. The only thing which he cannot do, a most important one, is — he cannot combine with his artificial waters the advantages the patient derives from a sojourn at the springs themselves. The immense advantages deriv- able in the treatment of disease from change of air, change of scene, change of mode of life, coupled with the restorative effects of quietude and freedom from life's cares, are the great factors the at home practising phj'-sician has it not in his power to give alonjr with the chemical inscredients of the waters of the natural mineral sprmgs, unless he sends his f)atient away from home. Again, however, the doctor at the baths themselves labours under equally important disadvantages in treating his patients with natural mineral water. For he is powerless either to modify the relative proportions of its ingredients, or to alter its composition to suit the changing phases of the 234 DISEASES OF THE LIVER. disease and bodily condition of his patients. All he can do, and that is but little, is to diminish or increase the daily consumption of the water as a whole, or to refrain from its administration altogether. An over- whelming disadvantage insuperably connected with the treating of any serious form of disease by natural mineral water. In fact, of the two evils connected with the treatment of disease by artificial and natural waters, the former mentioned is, I believe, much the less of the two. For the advantages derivable from the judiciously concocted prescription of the at home practising physician can always be readily supple- mented by a change of air, scene, and mode of life, coupled with quietude both bodily and mental, by merel}^ sending the patient a few miles away from his home and its associations. Whereas in no case whatever can the natural mineral water prescribing doctor change the constituents of his prescription to suit the peculiarities of the case. From these remarks it will be perceived that I look upon mineral waters as powerful chemical com- pounds, and that in the treatment of serious liver diseases not only must the spring be selected with discrimination, but its waters employed with care. And that whenever it is possible the patient, while tak- ing the water which has been selected as the most suit- able in the treatment of his special case, should reside at the spring itself. While on the other hand, when it is BENEFITS OF MINERAL WATERS. 235 impossible for the patient to avail himself of the ad- vantages of a temporary sojourn at the appropriate watermg-place, I think that it is better, in the majority of instances, to concoct for him a prescrijotion contain- ing only such of the constituents of the natural mmeral water as are directly suitable for the particular form of liver affection under which he labours than to prescribe for him an inappropriate water. Seeing that we are aware that every particle of mineral matter introduced mto the system unsuited to its require- ments acts the part of a detrimental foreign sub- stance. In my opinion, natural mineral waters are simply ready-to-hand made prescriptions, and consequently, like all prescriptions, resemble sharp instruments which may be equally emploj^ed in doing good or evil, according to the abilities or the inclinations of their employers. Hence I say that a natural mineral water is no more to be administered thoughtlessly than a dose of black draught or a compound colo- cynth pill. There is an old poetical adage which tells us that ' fools rush in where angels fear to tread.' Which, in plainer and more homely lan- guage, simply means that rashness is the usual ac- companiment of inexperience. Just as self-opinion is the equally invariable twin-sister of ignorance. To prescribe for symptoms in cases of severe hepatic disease will, no doubt, after what was said at the 236 DISEASES OF THE LIVER. beginning of this chapter, be considered to be repre- hensible enough, while haphazard prescribing in doubtful cases will with equal justice be regarded as nothing short of criminal imprudence. For no man has any right to trifle with another man's health, far less with another man's life, by ingenuously adopting the seductive course — on account of its supposed simplicity — of giving a mineral water, under the con- soling: reflection that ' if it does no o:ood it cannot possibly do any harm.' While in any case it may pro- bably have the advantage of making the patient and his friends believe that the nature and the treatment of the case is thoroughly understood by the dishonest prescriber. In plain language, the man who in such a case prescribes it as a placebo is a quack of the deepest dye. For under the shield of his diploma he commits a practical fraud — and it may too be a dangerous fraud, from its lulling in the mind of both the patient and his friends all suspicion of danger and efl'ectively preventing them from seeking the benefit of further advice, until, when in the end it is sought for, it may come too late not only to retard the course of the disease, but even to save the life of the patient ; for, as was said before, hepatic diseases do not, like fevers, as a rule run either a definite or a salutary course. All honourable men will, I am sure, agree with me when I say that it is the bounden duty of every practitioner of medicine — no matter whether he stand at the very BANEFUL DRUGS. 237 top or the very bottom of the professional tree — when he fails to grasp the true nature of a serious case of disease, at once to ask for a consultation with the most able man he can get. For no matter what his own personal mental calibre may be, or what the extent of his professional experience is, the solution of every doubtful case of disease is invariably simplified by the application of two heads (when they are of the right sort) instead of one. Baneful Drugs in Hepatic Disease. While one and all of the foregoing remedies are more or less powerful stimulators of the hepatic biliary secretion, there are a few drugs in our pharmacopoeia which have a diametrically opposite effect ; and there- fore I must allude to the most prominent of them, in order to prevent' their employment in cases of torpid liver, at least when there is no absolute necessity for using them on account of the existence of more urgent symptoms of another kind. The most power- ful stopper of the biliary secretion is the acetate of lead ; but opiates, contrary to what is in general believed, act in a precisely similar way on the liver as they do on the kidneys, and greatly retard its bihary^ secretions. Every one must have occasionally noticed how bilious a patient often looks after he has had for the first time an opiate sleeping draught administered 238 DISEASES OF THE LIVER. to him. I well remember after having given a lady lead and opium pills for diarrhoea that she accused me of havmg made her skin the tint of ' wash leather,' and certainly she did not do so without good cause, as even I was shocked at her sallow appearance, which was so strikingly different from her usually clear white complexion. Either opium or acetate of lead, if given at all to patients labouring under the depressing and enfeebling effects of biliousness, must be given, when possible, in conjunction either with a vegetable or a mineral hepatic stimulant, which in the majority of cases will be found to readily prevent any deleterious action on the biliary function. Iron is admissible only in exceptional cases ; for in almost any form it is a substance which acts banefully in most hepatic cases. In fact a few doses of iron will oftentimes cause the secreting cells of the liver in a biliously predisposed indi\ddual to strike work, and a severe attack of biliousness, even amount- ing in some instances to actual slight jaundice, may be the immediate result. So often indeed have I found iron do harm in hepatic cases that I now never by any chance prescribe it where there is disease of the liver, except in the few rare cases of idiopathic dropsy accompanied with liver derangement, which I shall subsequently take occasion to allude to. No one has as yet been able to explain the per- nicious action of iron in liver cases ; all we know about DIETETICS OF LIVER DISEASE. 239 it is that it has the effect of diminisliing the normal transformation of insoluble uric acid into soluble urea by the liver, and that the set of cases in which it apparently acts most detrimentally are those in which the hepatic capillary circulation is most disturbed. To wit, all kinds of congestive and inflammatory affections of the liver. This is not surprising, seeing that iron is seldom or never useful in inflammatory diseases affecting other organs of the body. It is specially objectionable, however, in those of the liver. Even quinine combined with iron ought, according to my experience, seldom or never to be administered in any case of hepatic disease ; but of course there are exceptions here, as there are to every rule. Certainly in none of a congestive, and still less in any of an inflammatory character. For the combina- tion of these remedies, just like iron alone, diminishes the power of the liver to transform uric acid into urea, and hence in many cases they only aggravate the constitutional disturbance. Dietetics of Hepatic Disease. I have now to consider the action of food and drink in the treatment of hepatic disease, and I think, if the reader has paid attention to what has been said, in the physiological chapter, regarding the active part the liver takes in the elaboration and transformation of fatty and starchy foods, he will 240 DISEASES OF THE LIVER. I have little difficulty in perceiving the important part food and drink must play either as banes or antidotes in many of the affections to which the organ is liable. Should the reader not have already given attention to the chapter specially devoted to the consideration of the saccharine, fat-modifying, and calorifying func- tions of the liver, I think it will be well for him to peruse it (p. 57) before reading what I am now about to say regarding the action of foods and drinks in hepatic cases. Or he will possibly not only fail to appreciate the intrinsic value of the facts brought forward, but even fail to follow the line of argument pursued. Indeed, I believe that the remarks on the action of foods and drinks in liver cases would even be more easily understood if they were delayed until after the subjects of torpid liver and biliousness were con- sidered ; but for the sake ,of avoiding a great deal of repetition I prefer giving them here. For the general principles I am about to enunciate are not alone applicable to cases of biliousness, but to all cases of deranged liver function, be their cause wtat it may. We saw at page 58 that, besides having a biliary function, the liver has also normally a saccharine and a fat-modifying function to perform. So that it may easily be inferred what an important influence an excessive ingestion of either of these kinds of food must have upon the organ when it is in a state of I CAUSES OF INDIAN LIVER-DISEASES. 241 disease. As elsewhere pointed out, even healthy- livers become diseased when an excessive quantity of starchy and fatty foods are given to animals (page 578), and further the fatty and amyloid degenerations thereby engendered are greatly accelerated by heat and want of exercise (page 1014). It can surprise no one, then, when I say that one of the most fruitful causes of biliousness, in adults as well as in children, is the habitual indulgence in rich fatty, saccharine, and starchy foods. A person predis- posed to be bilious will sometim'es suffer from an attack immediately after one single rich fatty meal. Especially during the hot months of the year, when sufficient bodily exercise is not taken to ' burn off ' the excess of hydrocarbons contained in them. For in hot weather, from the body being abundantly supplied with external heat, the animal tempera- ture does not require to be kept up by an excessive internal oxidation of hydrocarbons, as is requisite in the cold months of the year when the animal heat is alone maintained by internal oxidation. Hence in summer, from there being less call for pulmonary and bodily activity, the excess of hydrocarbons admitted into the circulation in the shape of food is, as a natural consequence, not consumed, but simply re- mains behind in the hepatic cells. Until the se- creting cells of the organ become so cram-full of them as to be forced to strike work, and what is 242 DISEASES OF THE LIVER. called in milder cases an attack of biliousness is the result. Not only foods, but drinks, produce the same result. A bottle of heavy stout has often been known, in hot weather, to produce an attack of biliousness in a predisposed individual. Unfortunately, however, it is not alone mere temporary attacks of biliousness that follow upon an over-indulgence in rich foods and drinks. Their continuous use — especially in hot climates — is a fruitful source of congestion, inflammation, and sup- puration of the hepatic tissues. At one time nearly one half of the liver cases coming home to this country from India were directly traceable to an habitual over-indulgence in rich foods and strong drinks coupled with an indo- lent mode of existence. Fortunately for the livers of Europeans inhabiting the tropics, the fashion of drinkino- strong bitter ' Indian ale ' at all hours of the day has given place to the less dangerous habit of consuming light French clarets. While at the same time luxurious sofas and wicker lounges have been in a measure abandoned for lawn tennis and foot- ball. And as a natural result not only are much fewer ' Indian liver ' cases now met with in London, but the cases that are met with are, in general, of a much milder type than they were between twenty and thirty years ago. Another reason for tliis INDIAN LIVER CASES. 243 change, however, may be that since the communica- tion with India has become so much easier men run home oftener, and when they get ill, as a rule they return home earlier, and thus greatly diminish the dangers of Indian service. I am sorry, however, to be forced to add — from my own personal observation — that Indian liver cases are still much more common than they ought to be, or would be, I imagine, if more attention were paid to food, drink, and exercise. For careful enquiries among the Indian liver patients who come to me have led me to the conclusion that, notwithstanding the improvement that has taken place in the habits of Europeans resident in the tropics, there is still room for more. As one and all confess that there is still prevalent an habitual over- indulgence in rich, highly seasoned, stimulating food, both by men and women, while resident in climates so hot as to render it impossible for them to take sufficient bodily exercise to use up all the hydro- carbons admitted into the circulation. In fact I be- lieve that it is not so much the heat of the climate as the over-feeding, coupled with the inactive mode of life followed by the majority of English residents in India, which is the fans et origo of the greatest number of the hepatic cases there met with. In this country again, I regret to say that many of the liver cases, especially those met with among women, are due in a great measure to the pernicious b2 244 DISEASES OF THE LIVER. and alas ! nowadays but too common practice of flying to sleeping draughts and soothing mixtures on every trifling occasion. For nothing in the world so effectively and promptly impedes the per- formance of the hepatic function as narcotics, be they opiates or chlorals. A couple of grains of opium will bring on an attack of biliousness more speedily in most persons than anything else; while its pro- longed use will lead to active, as well as passive, congestion of the liver. Even in many cases iron cannot be long given as a tonic without disordering the functions of the liver. As is well known to all men in active practice, many patients cannot live at the seaside for beyond a fortnight or three weeks without suff'ering either from mere biliousness or from active congestion of the liver. The stimulating efl'ects of the bracing sea air in general get all the blame of these bilious attacks ; but I have strong suspicions that the biliousness is not directly due to the sea air at all, but to an increased appetite, givmg rise to an indulgence in a quantity — and quality, it may also be — of food to which the person is unaccustomed when at home. The hver has consequently more work suddenly thrown upon it than it is capable of j^erforming, and, as a natural consequence, breaks down and strikes .work. In fact, it acts like a wise horse when over- loaded — simply stands still until part of its burden FOODS CAUSING BILIOUSNESS. 245 is removed. This is not only figuratively but literally the case, as I have frequently proved by effectually curing my bilious patients with a day or two's starvation diet. The two species of food which are in general found to be the most detrimental in the vast majority of hepatic cases are the saccharine -formuig and the fatty. Starchy puddings and fat bacon cause more gall-stones in this country, I believe, than all other kinds of food put together, and yet, as far as I am aware, no writer has ever before called attention to this fact. As I go fully into this point in the chapter on the etiology of biliary concretions, 1 shall say nothing more about it now, but refer the reader to page 580, where he will find that the effects of climate are also considered in connection with the for- mation of the pathological fatty product cholesterin. In the treatment of all hepatic cases I attach much importance to diet — and no wonder, seeing that the liver has a sugar-manufacturing, a fat-modify- ing, and a bile-forming process daily and hourly to perform, and when either one or other of these functions is out of order, the kind of food upon which the fimction sj)ecially acts cannot be given to the patient in excess, or even m ordinary quantity, with impunity. For, as is well known, every organ acts better upon little than upon much, at all times and under all circumstances. 246 DISEASES OF THE LIVER. Moreover, it is a peculiar fact that bilious patients are more frequently found to be the subjects of dietetic idiosyncrasies than others. A food that will be palatable to one is in many mstances found to be obnoxious to another, without the slightest apparent reason. In illustration of this I will cite a few most telling examples. Thus, many bilious persons cannot touch either milk or eggs without being made ill. Others can indulge freely in milk, and not in eggs. While again to some the white of the egg is an agreeable food, and yet the yolk is but little better than an emetic. Even as regards tea and coffee, bilious people show equally strange idiosyncrasies. Some can drink both with pleasure and impunity. Others again find tea alone palatable, coffee acting on them not only as an emetic, but as a purgative. To me the most extraordinary thing of all is that I have a lady patient — for whom I have occasionally prescribed during the last twenty years — and she has told me not merely once, but many times, that a single cup of coffee, with or without milk, induces in her a diarrhoea withm an hour after partaking of it, while chocolate has a diametrically opposite effect. So much so indeed that a cup of chocolate instantly stops the diarrhoea occasioned by the coffee. This has always been, and still is, to me a dietetic puzzle. This same lady, who is now forty-five years of age, I FOODS CAUSING BILIOUSNESS. 247 married, and the mother of five healthy children, is an inveterate tea-drinker. I say inveterate, for she will drink tea when she has the chance at any hour of the day or night. She begins with an early cup of tea before she rises. She drinks tea at breakfast. She has tea in the afternoon. She takes it again after dinner, and it is no uncommon thing for her to drink another cup about twelve o'clock at night before retiring to rest, with apparently nothing but a beneficial efi'ect. How then, I ask, is it that a small quantity of cafi'ein upsets h,er system, when a large quantity of them — a substance almost identical in chemical composition and physiological properties — does her good ? I know not, except it be owing to the difference in the aromatic ingredients in the two beverages. Just in the same way that brandy, whisky, gin, and rum produce — as was shown by the late Dr. Edward Smith — diff*erent physiological and pathological effects ; notwithstanding that the supposed most active base of them all is precisely the same — namely, alcohol. The difference in their mode of action, as Dr. Smith suggested, is probably due to the aromatic principles they respectively con- tain ; and the same idea is the one I entertain with regard to the difference in the action of chocolate, tea, and coffee on the human system. With shell-fish foods equally anomalous effects are met with in bilious people. One can, in modera- 248 DISEASES OF THE LIVER. tion, partake of all kinds. Another can only eat one or two kinds. Some will sicken at the mere flavour of a lobster, or at the sight of a raw oyster ; while the same individual will consume (what we call) an indigestible crab with perfect comfort and relish. In fact the same peculiarity of constitution which pro- duces a tendency to disordered hepatic functions gives rise, I believe, to the most anomalous dietetic idiosyncrasies. So that one has to be more than usually particular in prescribing any one particular form of diet to a bilious patient. But, as a guide to the reader, I may say that, as a general rule, the following principles may always be acted upon, at least until the special peculiarities of the invalid have been ascertained. J Firstly. All fatty matters are to be reduced to a minimum, and butter and bacon totally avoided in the vast majority of hepatic diseases. Secondly. All salted and spiced foods are to be shunned. Such as corned beef, ham, sausages, bloaters, Finnan haddocks, and all other kinds of salted fish. Thirdly. All river fish are to be eschewed. Salmon, trout, and eels more especially. On the other hand, white sea fish in the shape of cod, sole, turbot, whiting, smelts, and dabs, may be taken with impunity ; but mackerel, pilchards, fresh herrings, and sprats, ought not, as a general rule, to be partaken of. Fourthly. Pastry — whether as pie or tart crust — DIETETICS OF HEPATIC CASES. 249 dumplings, plum-puddings, and all heavy starchy and sweet dishes, are to be avoided. Whereas plain arrow- root, sago, taf)ioca, and such like light and pure farinaceous dishes, may be moderately indulged in. Fifthly. The lean of mutton and beef is a better animal food, because more nourishing and digestible, than poultry or game. Pork, lamb, and veal, being less nutritious, are to be avoided. Sixthly. Beers and porters, port, madeira, and sherry, are more likely to do harm than weak gin, whisky, or brandy, and claret, ■ hock, or cham- pagne. All stimulants should be given in small quantities, diluted with sparkling alkaline natural or artificial mineral waters. Iced in summer, but not in winter. As champagne plays a not unimportant part in the treatment of all the more exhausting forms of liver disease, I shall take the present opportunity of venti- lating my views on this universally appreciated vinous beverage. For I wish to change, if possible, the present pernicious English habit of drinking sour wine disguised under the name of champagne sec, under the mistaken notion that it is good and whole- some wine which has become naturally dry with age. While in reality it is no such thing, but tastes dry, simply because it is sour. I say sour, for the various degrees of dry, very dry, and extra dry (sec, tres sec, et brut) champagne are simply wines of different de- 250 DISEASES or THE LIVER. grees of acidity — sourness. If any reader doubts this, let him for himself make the experiment of dipping a piece of blue litmus test-paper into his fine ( ?) dry wine, and (if not already aware of the fact, which in all probability he is not, or he would not have a single drop of the liquid within his doors) I promise that he will open his eyes wide with astonishment at the tint the paper will assume. Vinegar, pure strong wine-vinegar, will not bestow upon it a brighter red tint — and why ? Simply because the flavour which he ignorantly imagines is due to ' drjoiess ' is, on the contrary, due to the presence of acid. And the secret is simply this. ' Dryness,' as it is absurdly called, is the product of age. It is in fact due to the slow transformation of the sugar in the bottled wine into alcohol — as takes place in the twenty, thirty, and forty year old port. But it does not pay the wine merchant to keep his champagne until its saccharine matter has been transformed by fermentation in the bottle into alcohol and the sweetness of the wine has consequently disapjjeared. So he adopts the speedier course of getting rid of the sweet flavour of the wine by setting up the quick acetous instead of the slow alcoholic fermentation. Which has the efi'ect of de- stroying all the saccharine matter contained in the bottled wine in a few months. Or he adopts another equally efi^ectual course, of adding less than four in- stead of, as he ought, eight per cent, of syrup to the DEY CHAMPAGNES ? 251 wine at the time of cUgorgement. In fact there are many ways, well known to the trade, of ' spoiling' champagne to suit the ignorant depraved taste of the English consumer. I say English, for no other nation has as yet been found foolish enough to swallow sour wine under the delusion that it is drinking good sound dry wine from finding the words sec, tres sec, or hrut on the labels of the bottles. Of course some of my readers will think this very strong language ; but let me tell them that not a syl- lable of it is too strong, and if any one doubts the truth of what I say, and thinks he knows a deal more about the matter than I do, let him take the trouble to make enquiries of a champagne wine merchant — not an ordmary English wine merchant, for most probably he will be as ignorant of the whole matter as the reader is himself, but a French wholesale cham- pagne wine dealer — and he will soon discover that every word I have said is not only perfectly true, but not even exaggerated. The following anecdote will show the ideas of a Continental champagne dealer regarding the Enghshman's knowledge of good champagne. All my champagne I import myself, and, as my personal friends know, it is Al . The gentleman, whom I in general deal with, comes to England occasionally, and on one occasion when he called upon me and got an order, I observed that, in booking it, he wrote after the name of the wine the word Continental, 252 DISEASES OF THE LIVER. and not only so, but carefully underlined it. On seeing him do this with an au' of the most perfect sang-froid^ I exclaimed in a voice of surprise, ' Why have you written the word " Continental" after the champagne ? Is all your champagne not Continental ? ' To this he immediately replied, and that too with an air of sweet innocence — ' Oh ! no. We never now send any Continental wine to England.' ' What on earth do you send then ? ' exclaimed I in breathless astonishment. He smiled, and answered^ — ' Spoilt English champagne.' Being more bewildered still, I slowly repeated his words, ' Spoilt — English — cham- pagne ! What do you mean ? ' ' Oh ! Doctor Harley^ don't yon know that all the dry champagne is spe- cially prepared for the English market ? We can't sell a single drop of it on the Continent ; for no- body will drink such stuff. It's quite sour.' Seeing my consternation, I presume, he quickly added — ' W"e never send it to you. Your champagne is what we drink ourselves. It's true champagne — none of the tres sec stuff.' ' But,' said I, ' all good champagne is slightly acid on account of the carbonic acid it contains.' ' Yes. That is perfectly true ; but it's not sour, which so-called dry champagne is. You're a chemist. The first time you have the chance, dip a piece of blue litmus paper into the two wines, and you will soon see the difference. While the Continental one wiU yield a faint pink, the Eng- I SOUR champagnes! 253 lish one — that is, the sour, which you call dry wine — will immediately turn the paper crimson, just as sulphuric acid would.' Here was a piece of impor- tant information for me, and now I shall proceed to give a little further information, which may perhaps prove almost equally interesting to the reader. The very next day I was called by Dr. Macaldin to see an old rich bachelor, suffering from a violent bilious attack, accompanied not only by vomiting, but by diarrhoea. On finding that it was brought on by his having made a hearty dinner of a poimd of salmon steak and a bottle of champagne, without partaking of anythmg else, and my wine merchant's information regarding ' spoilt English champagne ' running in my head, I mildly asked if the cham- pagne partaken of was sec champagne. The prompt reply was ' Oh ! yes — the very best tres sec that can be bought. It could do me no harm.' ' I am not so sure of that,' said I. ' Perhaps the wine is sour.' * Sour ! ' said he. ' I never drink common 40.'ESS. 277 biliary secretion, is in general only met witliin adults, more especially tliose who have been for some years resident in hot climates. Moreover I think it may be safely said that, as a rule, the severity as well as the frequency of all kinds of bilious attacks, in predisposed individuals, gradually diminishes after puberty ; that the first two forms are rarely if ever met with in persons over forty years of age ; and that the acute form is decidedly most common among children and young women, especially among bru- nettes at the period of puberty, who in general speak of these attacks as ' sick headaches.' So much for the excitinor causes of biliousness in the predisposed. I say predisposed, for unless a predisposition, either hereditary or acquired, actually exists, neither over-feeding, deficient exercise, hot weather, nor habitual constipation, are of themselves sufficiently powerful exciting agents to induce a bilious attack. I now come to the symptoms. Sympto:hs presented by the three forms of bilious- ness differ considerably from each other. In the acute form alone there is either bilious vomiting or diarrhoea. In the subacute, headache is usually the most prominent symptom. While the chronic attack is chiefly characterised by the sallowness of the com- plexion and the ' good-for-nothingness ' of the patient's feelings. The attack of the first usually terminates within 278 DISEASES OF THE LIVER. forty-eight hours. Of the second, within four days. While that of the last may extend over months. The other respects in which the three forms oi bilious attacks differ will be pointed out when eacl is being separately considered ; but in the meantime I shall give a general summary of the symptoms which are popularly supposed to characterise an at- tack, which everyone imagines he can easily diagnose from his personal familiarity with it, in consequence of scarcely a single dark-complexioned person in this country, in childhood and early youth, ever escaping a hot summer without suffering from at least one more or less severe bilious attack. The general symptoms are usually ushered in either by bilious vomiting or a frontal headache. The form of headache is in general very significant, as it is usually situated immediately above the eyes, the upper half of the balls of which are painful on pressure. Sometimes the headache is more or less parietal, and occasionally, though more rarely still, occipital. Where there is no marked headache, drowsiness is a frequent accompaniment of a bilious attack* While, on the other hand, a condition of sleepless- ness is almost as common when the headache is severe. A bilious headache is frequently associated with in- tolerance of light, in some instances almost amounting SYMPTOMS or BILIOUSNESS. 279 to photophobia. In most cases, too, there is dimness of vision, ahnost amounting to a partial bhndness ; for the sufferer may be unable to read ordinary type at the usual distance, on account of the words running, as it were, into each other. What are technically called muscse volitantes — black, fly-like specks before the eyes — are common. Giddiness and great lassitude are likewise symp- toms often complained of; with loss of appetite, and a bad taste in the mouth. At the same time the skin assumes a decidedly sallow tint, varying in intensity from a mere sallowness up to a yellowness sufficiently pronow e to merit the title of 'a slight jaundice.' The subacute and chronic forms of biliousness are indeed, when their pathology is properly con- sidered, nothing more or less than forms of jaundice from suppression, merely differing from true jaundice as regards degree, and only escaping the title of jaundice from the skin not assuming a sufficiently intense yellow hue. Such being a brief summary of the general symp- toms of biliousness, I now turn to the special charac- teristic of each of the three forms of the disease. As regards the first, or, as I call it, the acute, form of biliousness, which arises from a hyper- secre- tion of bile, which is common anions; children and young women, it may, as rule, be easily traced to 280 DISEASES OF THE LIVER. I some error in diet in a predisposed subject — some- times both slight and temporary. A surfeit of plum- pudding is, as everyone knows, a fruitful source of biliousness among children at Christmas time. And it may occur in the adult from an equally transient cause. In a woman from eating a cheese-cake, or in a man it may (as ha^Dpened in the case of the old rich bachelor I saw in consultation along with Dr. Macal- din) be traced, as said at page 253, to an injudicious dinner, which, in the case referred to, consisted of a pound of salmon steak and a bottle of champagne. This form of acute bilious attack is sudden in its onset, rapid in its course, and temporary in its duration. The principal and most characteristic of its symptoms being bilious vomiting, with or without diarrhoea. There is but little sallowness of the com- plexion, no light-coloured stools, and although the urine is usually scanty and high-coloured it contains — at first at least — no abnormal quantity of bile- pigment. The tongue is foul, but the pulse is little affected. Sometimes even slower than natural, from considerable nervous prostration accompanying the attack. In acute biliousness, headache is not a promi- nent symptom, except in the case of weakly-nerved people ; nor, indeed, are any other cerebral symp- toms, as a rule, present except the depression just alluded to. Indeed, I have more than once been PATHOLOGY OF BILIOUSNESS. 281 told that even the headache was nothing until after the sickness commenced. Which fact leads me to suppose that the headache in these cases is occasion ally- not due to bile-poisoning at all, but merely to the pain caused by an mcreased flow of blood to a hyper- sensitive brain substance during the violent and repeated efforts of vomiting ; and that may probably account for the fact that young ladies have christened these forms of attack ' sick headaches.' Very often, indeed, sudden sickness seems to usher in the attack. For the patient, after feeling a little out of sorts, perhaps for a few hours only, all at once complains of being dreadfully sick, rushes to a basin, and almost immediately empties the stomach. Then, after repeated retchings, brings up a quantity of pure yellow -greenish, sometimes even bluish, bile, recog- nisable both by its taste to the patient, and by its look to the doctor. If the latter has any doubt about the nature of the coloured liquid, he can always easily satisfy himself on this point by adding to the vomited matter a few drops of strong nitric acid, when the intense play of colours produced by it on the bile-pigment will at once yield evidence of its presence. The Pathology of acute biliousness appears to me, on physiological data, simple enough. As 1 said in my definition of this form of the disease, the 8}'mptoms are due to a hyper- secretion of bile. The 282 DISEASES OF THE LIVER. mechanism of which is, I believe, as follows : — A tem- porary hepatic capillary congestion is suddenly in- duced in a person predisposed to it by an injudicious meal of indigestible food and drink. Or by a mere over-indulgence, during hot weather, in a single rich stimulating fatty or saccharine dish at a time when insufficient bodily exercise is taken to burn oiF the excess of hydrocarbons in the blood, as explained at p. 65. The introduction into the portal circulation of the elements of food abnormal either in quantity or quality induces congestion of the hepatic capillaries in precisely the same way — although, of course, in a less exao-aerated form — as occurs when stimulatino^ substances, such as ammonia, alcohol, ether, and chloro- form, are artificially introduced into the portal vein.^ In consequence of this temporary capillary con- gestion more blood than normal is carried to the he- patic secreting cells, and as a natural consequence theu' action is accelerated, and, their function being to secrete bile, an excessive secretion of bile is the result. More bile being secreted than the system re- quires, the gall-bladder gets over-filled with it, and at length, probably owing to some merely trifling cause, suddenly expels its surcharged contents into the duodenum, and the duodenum, rebelling against the ^ See author's experiments on tbe production of diabetes artificially in animals by introducing stimulants into the portal circulation, already referred to at page 61. SUBaCUTL BlLIorSNESS. 283 mtrusion of such a large amount of irritating bile, makes violent peristaltic efforts to expel it. This excessive peristaltic action is communicated to the stomach ; the patient feels sick, is attacked with violent retchings, and after repeated straining efforts succeeds in vomiting up probably nearly the whole of the bile which was thrown into the duodenum. If not, the remainder soon finds its way into the ileum, and, by there exerting its normal physiological purgative effect, brings on a bilious diarrhoea. This acute form of bilious attack may here end, and oftentimes does here end, almost as suddenly as it commenced, without any treatment whatever being necessary. From Nature herself having got rid of the whole of the offending bile that was thrown into the duodenum, the symptoms its presence there in- duced speedily disappear, and in a couple of days or so the patient is himself again. Not so, however, with the subacute bilious attack, depending on the diminished secretion of bile, which I have now to consider. In the first place, the imme- diate or proximate exciting cause of Subacute Biliousness is not one or two accidental indiscretions in diet, but a continued habitual indulgence in richly oleaginous and saccharine foods. Coupled, it may probably be, with an excessive consumption of fer- mented liquors. Every patient liable to subacute biliousness, however, is not to be put down either as 284 DISEASES OF THE LIVER. a glutton or a drunkard. For an hereditarily or consti- tutionally predisposed individual, in hot weather, and from taking little exercise, Avill often be attacked with the subacute form of biliousness, though exceedingly moderate both in food and in drink. And to me the explanation of this is simple on the supposition that the subacute form of biliousness is the direct effect of a subacute form of chronic hepatic capillary conges- tion (see p. 100). In fact being merely a minor form of jaundice from suppression, though, strange to say, it springs from the identical same pathological cause as that which produces the previously considered acute form of biliousness — biliary hyper- secretion. This reads very like a paradox, and as such it might be regarded. Yet though seemingly an absurd pro- position, it is nevertheless a true pathological fact, easily enough understood when the explanation of it is given. Its explanation is : — The first stage of hepatic capillary congestion leading to a hyper-secretion of bile, by being pro- longed in its action, inevitably leads to a second stage of Diminished Biliary Secretion. Which is brought about thus : — The hepatic capillaries not only being themselv'BS eno-oro-ed, but the bile-ducts after a time becoming also cram-full of secreted but not excreted bile, combine together to exert a sufficient amount of backward pressure on the secreting hepatic cells to effectually prevent them performing their work pro- EFFECTS OF BILIOUSNESS. 285 perly. Hence the normal bile ceases to be secreted in its usual quantity. The colouring matter and other biliary ingredients which the liver removes from the blood remain behind in the circulation, and, gTadually accumulatmg there, give rise to the chain of symptoms usually included in the generic name of a bilious attack. To wit, a sallow complexion — from the serum of the blood becommg overloaded with the non- ehminated bile-pigment, and exuding into and staining the pigmentary layer of the cuticular rete mucosum — headache, giddiness, disordered vision, sickness, and prostration. This latter series of symp- toms, ao'ain, are the result of the toxic action of the biliary substances circulating in the blood on the nervous system. In fact this second form of bilious- ness is nothino; more or less than a slight or in- cipient stage of jaundice. Which it only escapes from being called in consequence of the amount of bile-pigment effused into the skin not being sufficient TO stain it distinctly yellow, nor the suppression of the biliary function being sufficiently complete to en- tirely exclude bile from the stools and cause them to I ssume a distinct pipeclay colour. There is clearly, however, a sufficiency of the elements of the bile re- tained in the blood to produce slight symptoms of bile-poisoning. Kot the serious ones of delirium, con- vulsions, or coma, but the minor ones of giddiness, con- fusion of ideas — or perhaps it would be better to say 286 DISEASES OF THE LIVER. M loss of clear-headedness — dimness of vision, and in- tolerance to light, sound, or contradiction. It is no nncomiuon thing, we know, to hear it said of an angry man that ' his bile is up.' And it is almost equally common to hear that a person takes a jaundiced vieAV of things. In fact, popular ideas, I think, are much oftener correct ideas than most people suppose= When I was a boy, hypochondriacism was a favourite word in everybody's mouth to define what Webster in his popular dictionary calls dys- peptic melanchol}''. Now, if we look at the etymo- logy of the word, it at once leads us to the liver — the organ occupying the hypochondriac region. The mind and the liver are marvellously connected. Who amongst us does not know that a dose of blue pill will dispel an attack of the ' blues ' ? How depression of spirits, irritability of temper, and peevishness vanish after a good clearing out of the bowels by a dose of calomel ? How the discontented melancholic man is at once himself again, a pleasure to his friends and a comfort to himself, after a copious bilious motion ? Do not our ' alienists ' give the name of melancholia to a form of mono- mania frequently associated with derangement of the hepatic functions ? So that in very many instances the way to cure the mind is to treat the body. As soon as the liver's functions return to their normal state, groundless fears, melancholy forebodings, ima- SPECIAL THERAPEUTICS. 287 ginary anxieties, one by one dwindle into shadows, become fainter and fainter, and finally entirely dis- appear. Fortunately we have it m our power to make a rapid and safe cure of these cases, and this, I think, must be self-evident after what has been said re- garding the pathology of subacute biliousness. Nor can it fail to be readily understood how a smart dose of a mercurial should be the sheet-anchor of our treatment. In fact, a single dose of calomel, say from three to five grains, given to an adult on the verge of a subacute bilious attack will dispel it as if by magic, and, even after it has commenced, will cure it, in the majority of instances, within twenty- four hours after the time of administration. Podophyllin, and all the other forms of hepatic stimulating purgatives, act well enough in slight cases ; but mercury, either in the form of calomel, blue pill, or grey powder, is the king of remedies when once a subacute bilious attack has fairly set in. With or without a purgative superadded, ac- cording to the necessities of the case. (For the rationale of its action, see the article on Mercury in the chapter on the General Therapeutics of Hepatic Disease, p. 15G.) I now come to the special consideration of the third or chronic form of biliousness, the one arisini? from a sluggish or torpid condition of tlie liver. 288 DISEASES OF THE LIVER. This condition, as was before said, is most com- monly met with in adults who for a time have been resident in hot climates, where the causes pro- ducing a state of chronic congestion of the hepatic capillaries may be said to be in the ascendant (see page 241). The secretion of bile, like the majority of other glandular secretions, not only varies nor- mally in quantity and quality at different periods of the day, but is also liable to special variations according to the quantities and qualities of the food taken, even by the most healthy, as well as accord- ino- to the stao:e of diii'e.stion. Besides these normal variations in the rapidity of the biliary secretion depending upon physiological causes, there are other abnormal fluctuations in the total amount of bile secreted within a given time, due to purely pathological causes. At page 73, I not only pointed out the effect of nerve influence in diminishing and even entirely arresting the biliary secretion, but also gave a striking example of the effect of inflammation in totally arresting glandular secretion. It is easy, therefore, to understand how a chronic state of hepatic capillary congestion may give rise to an equally chronic condition of diminished biliary secretion. For, as already shown, while the primary effect of moderate capillary congestion is to accelerate, the secondary effect is to diminish glandular sacretion. No organ whatever, indeed, with its capillaries in a TREATMENT OF BILIOUSNESS. 289 chronically congested state, ever pours out its secre- tion in normal quantity or of normal quality, and the liver is no exception to the rule. Hence a slug- gish or torpid liver induces an attack of biliousness — or sub -jaundice as it might be called — from a chronic partial suppression of the biliary function. The symptoms of which are precisely the same as those arising from the second or subacute form. Only diifermg from them in their being of a more thoroughly chronic character. Treatment. The acute bilious vomiting and diarrhoea! forms of attack usually cure themselves. For the sub- acute form, a smart mercurial purgative is all that is in general required ; but the third or chronic form of biliousness is much less under the control of remedies. A sino-le smart dose of a mercurial will not cure it. o The chronic congested condition of the capillaries is gradually to be attacked, and here it is not mercury but alkahes — especially alkaline purgatives, such as sulphate of soda and potash — which prove of the most marked service. If the patient chances to have been for some time resident in a hot climate, he must be carefully questioned with the view of ascertaining if the congested state of the liver has been induced by malaria, as will be subsequently shown at ])age 365 ; for if it has, his cure is not likely to be effected u 290 DISEASES OF THE LIVER. without the administration of quinine, or a decoction of Chionanthus virginica (see page 182). The course of procedure which I find in ordinary cases success- ful is as follows : — First, to give a single smart mercurial purgative. To a strong adult, probably a powder consisting of : — R Calomelanos . . . gr. iij. Pulv. Rhei . . • gi"- iv. Magnesias . . . gr. xij. M. Hora somni sum. After the free action of this mercurial alkaline purgative, in order to stimulate the secreting func- tion of the liver, and retain the bile in as fluid a state, by getting into it as much taurocholate and glycocho- late of soda, as possible, I prescribe half an ounce of the following mixture to be taken, in the intervals of the meals, three times a day in half a tumbler of water. R Succi Taraxaci . . .3 xv. SodsB Sulphatis . . • 3 "vj. Soda3 Bicarbonatis . . 3 ij. Inf. Calumbae ad . . | vj. M. Telling the patient to shake the bottle well before measuring out his doses. Once the attack has been subdued, the next ques- tion is ' How can its recurrence be prevented ? ' For just as a horse that has once stumbled and fallen is TREATMENT OF BILIOUSNESS. 291 apt to come down again, so a patient predisposed to biliary derangement, if great care be not taken to prevent it, is almost sure, sooner or later, to be seized with another attack. Fortunately for tlie reputation of our art, the doctor's advice can here be of great service ; for although he cannot eradicate the tendency, he can ward off, and oftentimes even totally prevent, the attacks, by prophylactic treat- ment, therapeutic and dietetic. If the reader has paid due attention to what was said in the chapter devoted to the consideration of the functions of the liver, and will take the trouble of carefully balancing it in his mind along with what was said reo-ardins^ the etioloo^v of biliousness, it will be self-evident to him that the prophylactic treatment must be directed solely to removing the cause ; for, ar, everyone knows, no effect is producible without a pre- existing;' cause. The regulation of the patient's food, drink, and exercise, is therefore the first — I might almost say the chief — thing requiring to be considered ; for with a well-regulated diet and regime attacks of bilious- ness might be reduced to things almost unkno'>vn. It is not only the quality but the quantity of the food that has to be regulated. For an excess of the most wholesome of foods acts in persons predis- posed to biliousness as an exciting cause. Therefore it is good policy never to allow the patient at any V 2 292 DISEASES OF THE LIVER. time to eat more than the wants of his system demand. If he be corpulent, even put him on short commons. Stop his beer, and reduce his wine to a couple of glasses of hock or claret a day. If he be thin or only moderately stout, only stop all salted I foods, ham, bacon, hung beef, bloaters. Finnan had- | docks, &c. Order him to take nothing but fresh foods. Not too fatty, and rather underdone. To avoid shellfish and pastry. To make his chief meal in the middle of the day. To take as much walking exercise as he possibly can without actually fiitiguing himself, and to go to bed early. For further dietetic details see page 239. In some persons with a more than usual tendency to bilious- ness, traceable to sluggish biliary secretion, besides chronic hepatic capillary congestion there sometimes exists also defective nerve action. The secretory nerve twigs appear as if they had literally as well as figuratively gone to sleep, and I believe it is by waking them up, as it were, with small doses of mix vomica, that homoeopathic practitioners have obtained the credit of being able to cure bad bilious attacks. Certainly, for some years past, I have taken a leaf out of their book, and treated many cases of torpid liver with strychnia with marked benefit. The rationale of the action of the strychnia in these cases appears to me to be precisely the same that it is i TREATMENT OF BILIOUSNESS. 29o in mild cases of paralysis, where it evidently calls nerve action into play, as is visibly seen by the paralysed muscles twitching under its influence. When given in torpid liver from defective nerve in- fluence, the stimulating effect of the strychnia upon the nerves is, I think, rendered equally patent to our minds, though not to our eyes, by the increa.-e of the biliary secretion. Moreover, as a sluofSfish state of the bowels is a usual concomitant of a sluggish biliary secretion, I usually combine the strychnia with belladonna, which has a specific action on the intestines, and produces easy motions without purging the patient. In order to gain a still further advantage, I give, as a rule, the stryclmia and belladonna in combination with taraxa- cum, generally in the form of a dinner pill to be taken at the commencement of the meal ; and as I should like others to try my plan, its formula is as follows : — - 5^ Strychnife Acetatis . . . gr. j. Ext. Belladonnas . . . ot. vi. Aloes SocotriniG . . • gi*- ^i^^- Ext. Taraxaci . . . 5 ij. M. Divide in pil. xxxyj. ; obduce argento et siojna. Sumat unam diebus sino;ulis. From what has now been said it is evident that all the three forms of biliousness are greatly under 294 DISEASES OF THE LIVER. the control of medicine, diet, and regime. With care- ful prophylactic treatment, biliousness might be made a thing unknown. For even after the premonitory symptoms of an acute or subacute attack have manifested themselves, it is almost invariably possible to nip it in the bud by a single brisk mercurial alkaline cathartic dose of medicine. And, as pre- vention is invariably better than cure, the opportunity of arresting an attack ought never to be allowed to slip. I have now only further to add that the foregoing prescriptions ought to be regarded in the light of . mere samples ; for, as I said before, I do not pretend to be able to lay down definite lines of treatment in individual cases. For, in prescribing, constitutions, as well as idiosyncrasies, require to be considered quite as much as the special disease under consideration. Consequently it is general prmciples which I can alone indicate, and merely as such are my remarks to be considered. \ 295 CHAPTER YIL INTRA-UTERINE, CONGENITAL, AND HEREDITARY J A UNDICE. Not only are infants, from tlie very moment of their birth, liable like adults to be attacked with a variety of forms of jaundice, the direct result of different kinds of liver derangement, but, while yet even within their mother's womb, they may suffer from the same affection, and in identically the same forms. Namely, jaundice from suppression and jaundice from obstruction. This fact can surprise no one who is aware that the secretion of bile, like the secretion of urine, begins long before birth — begins, indeed, so soon as the secreting cells of tlie foetal liver are formed ^ — and hence it is that children have again and again been born labouring under an attack of well-marked jaundice. Although both malarial and idiopathic hepatitis are frequent causes of intra-uterine jaundice, the most common cause of all is ' In proof of this statement that the hiliary function begins as soon as the hepatic tissue is formed, I may cite the observation of Zweifel who found not only bile pigment, but bile acids in the contents of the intestines of a three months foetus. {Centralblatt , No. 69. 1874.) 296 DISEASES OF THE LIVER. congenital malformation, and imperfection of the bile- ducts. Having early in my professional career, even before I graduated — while acting as house surgeon to the Edinburgh Royal Maternity Hospital — met with an exceedingly well-marked case of this kind, I have ever since given considerable attention to the literature of all the various forms of infantile jaundice ; and I deem the subject of sufficient importance to go pretty fully into it. To begin with, I shall consider the spurious form of jaundice which, from ignorance of its true pa- thology, received the incorrect title of ' Icterus Neo- natorum.' While, strange to say, in the morbid state to which this learnedly sounding name is given, there does not exist one single sign or symptom of jaundice whatever, except it be the slightly yellowish tint of the skin. No high- or saffron-coloured urine is present. No pipeclay-coloured stools. Nothing whatever that can be traced to a derangement of the biliary function, any more than can be the equally sallow complexion of the cuticle met with in cases of chlorosis, syphilis, or other forms of blood-poisoning. Indeed, be the cause or causes of the so-called icterus neonatorum what they may, among the chief of them must at least be reckoned a defective oxygenation of the red h^ematin of the blood, just as occurs in the true chlorosis of the male as well as female human adult. In icterus neonatorum the skin is never yellow at the moment CHLOROSIS NEONATORUM. 297 of birtli as in true jaundice. On the contrary, it is of the rosy tmt pecuhar to the new-born babe, and it is not until twenty-four, often indeed not until seventy, hours after birth that it assumes a yellow tint. The rosy hue first changes to a dirty white, then to a dull pale yellow. Exactly like that of the skin in cases of true chlorosis in the adult. At the same time be it observed that the health of the child is not impaired beyond what it was before the yellowness appeared. This form of affection — which, on account of its patholog}^, I shall henceforth name Chlorosis Neo- natorum — is only seen in weakly children chiefly, among the immature, and is, I believe, as before said, entirely due to the imperfect oxidation of the blood from the defective respiratory powers of the child, associated, it may be, with a vitiated atmosphere. Which still further tends to increase the imperfect oxidation of the hagmatin. Especially when it is combined with the depressing influeaces of external cold on the low vital powers of an immature or weakly infant. This idea of its etiology is very strongly sup- ported by the fact that in maternity hospitals, where attention is paid both to ventilation and temperature, chlorosis neonatorum is an exceedingly rare disease. While, on the other hand, in institutions in wliich sanitary arrangements are defective, as in many — I 298 DISEASES OF THE LIVER. might even say, from personal observation, in most — ■ of the Continental lying-in charities, this so-called icterus neonatorum is of frequent occurrence. It is easily differentiated from true congenital jaundice by the fact that although the skin of the child is yellow, neither are the conjunctivas of a yellow hue, nor the urine of a saffron tint, nor the stools of a pipeclay colour. Facts quite sufficient of themselves to upset the idea that chlorosis neonatorum is due to a de- rangement of the hepatic biliary functions, either in the form of a suppression to its secretion or an ob- struction to its excretion. An easy, and at the same time a crucial, way of making a differential diagnosis between cases of chlo- rosis neonatorum and congenital jaundice, is simply to gird u]3 the child's loms with a clean piece of white linen, and watch the effect the urine has upon it. If the child's urine stains the linen of a yellow tint, the case is one of true jaundice ; if, on the con- trary, it merely gives it the ordinary urine stain, the case is as decidedly simply one of chlorosis neo- natorum. Of intra-uterine and consequently congenital jaundice there are almost as many varieties as in the adult, for the simple reason that almost all of the same causes which produce jaundice in the adult are equally potent enough to produce it in the foetus. Indeed, there are even extra causes for its production I INTRA-UTERINE JAUNDICE. 299 in the unborn babe — congenital anatomical malforma- tion from defective development, one of the common- est forms of which is the entire absence or im- perviousness of the common bile duct. As the ex- ample of this kind which fell under my notice while I was actmg as house surg*eon to the Edinburgh Royal Maternity Hospital is well worth putting on record, I shall give it briefly. A married woman, already the mother of several children, was safely and easily delivered of a male child, whose skin at the moment of its birth was of a well-marked jaundiced tint. Immediately on escaping from the maternal passages, the moment it began to cry, and before it was even separated from the placenta, it passed in a full stream a quantity of dark saiFron-coloured urine, which stamed the bed- sheets of a bright lemon -yellow hue. The urine had a strong odour, as I know, for I smelt some that went upon my hands. The child seemed quite healthy, though not robust. It weighed 7 lbs. It took the breast, and nothing was thought the least remarkable about it, except that it had a yellow skin. It was however found dead by its mother's side on the fourth morning after its birth. Although the mother, from beino- a married woman, was not sus- pected of foul play, I considered it my duty to make a j)ost-mortem examination, in order, if possible, to discover the cause of the child's death. At the 300 DISEASES OF THE LIVER. necropsy the gall-bladder was found distended to tKe size of a small hen's egg. The hepatic tissue was stained green, but not deeply. The contents of the intestines were of a pale creamy hue. The urine was dark in colour. Indeed, there was present every pathological sign usually met with in cases of jaun- dice from obstruction. A carefal search was made for the cause of the disease, and ^it was soon dis- covered that the common bile-duct was impervious ; in fact, its lower part looked like a mere cord of solid fibrous tissue ; whereas both the hepatic and cystic ducts were enlarged, and full of fluid bile, just like that in the distended gall-bladder. As many forms of liver disease, and consequently jaundice, are frequently hereditary, it will astonish no one when I say that a jaundiced mother may give birth to a jaundiced child. Dr. Moxon met with a remarkable example of this kind. The case was that of a man, aged 30, who said he was born yellow, and had remained yellow ever since. His brother was also born jaundiced, and they were both supposed to inherit the disease from their mother, who had jaundice and died jaundiced at the age of 54. Dr. Moxon's patient, with the exception of the jaundice, was otherwise in good health. Not only his skin, but his conjunctivre were yellow. His urine contained bile-pigment, and de- posited lithates. He felt giddy when looking up, as J HEREDITARY JAUNDICE. 301 many bilious patients do. His liver, Dr. Murcliison (to whom Dr. Moxon showed the case) says at p. 426 of the second edition of his book on diseases of the liver, was enlarged ; but as the measurement given is 4^ inches in the r. n. 1., it ought not, properly speaking, to be called an enlarged liver ; for many perfectly healtliy men have livers of that size. Both brothers had several children, all of whom are reported to have ' become deeply jaundiced two days after birth, the colour of eyes, body, and whole frame being of a deep yellow hue, but disappearing after about a month.' So long ago as in 1752, Mr. Benj. Cooke reported a case of jaundice in a newborn child, in the ' Philo- sophical Transactions' (p. 207), which he thought was directly transmitted to it by the male parent through the spermatozoa. The case is so curious that I shall give it in extenso in the author's own words. ' A man of about 22 years married a healthy woman much of the same age. Soon afterwards he went to America, and at the end of seven j^ears re- turned, cachectic, anasarcous, and deeply tinged with the jaundice endemical in hot latitudes. In a few months after his return his wife became pregnant (with her first child), of which she was delivered in due time. The child was born with a jaundice upon it, and died about six months after, under ascitical 302 DISEASES OF THE LIVER, and icterical symptoms, of which the mother had not the least impression. Soon after this (and before the husband, though much better, was quite cured) she became again with child, and after about three months' pregnancy turned yellow, and was the whole time of her going with child, and some months after her delivery, deeply affected with jaundice. Bat the child was born quite fair, white, and healtliy, without anything of that distemper on it ; and is still livino- and the last born.' These last cases of true intra-uterine jaundice ought perhaps, in the present state of our knowledge, to be regarded as cases of jaundice from suppression, due to some as yet unknown hereditary cause. More easily understood, but still almost equally curious, is the fact quoted by West in his ' Diseases of Infancy,' that a lady lost three children (out of five) in succession from most intense jaundice ; and, although in one instance alone was it accurately ascertained to be due to defective biliary ducts, it is highly probable that, in obedience to the laws of hereditary malformations, the same cause existed in the other two. Dr. West also says that he saw another woman's child die of jaundice from imper- vious biliary ducts, who had already lost three infants from the same cause. While, strange to say, as illustrating still more strongly the influence of the hereditary transmission of liver disease with jaundice. i INFANTILE JAUNDICE. 303 her sister's only child died under exactly similar circumstances. A great number of writers on infantile diseases liave stated that haemorrhage from the navel is almost an invariable accompaniment of infantile jaundice, and most assuredly it would appear not to be rare ; for a German physician of the name of Grandidier, published in 1871 a monograph on the subject, in which he makes reference to eighty cases that he found recorded in various journals. It would appear, therefore, to be an undeniable fact that there actually exists some sort of close con- nection between the occurrence of .umbilical haemor- rhage and infantile jaundice. This connection, how- ever, is perhaps due, as I believe, to the simple fact that infontile jaundice usually occurs in immature and defectively developed children. The umbilical tissues and organs of whom, even when not actually malformed, are at least more feeble than they ought to be. Not only in cases of jaundice from obstruc- tion, arising from imperfectly developed bile-ducts, but likewise in the cases that I call infantile chlorosis, which, as already said, only occurs in children of an abnormally weak state of body. A condition of course very likely to conduce to the accidental occur- rence of umbilical haemorrhao:e while the lio;atured end of the umbilical cord is sloughing away. Which is said to be the exact period of the occurrence of 304 DISEASES OF TPIE LIVER. infantile umbilical ha3mori*liao:e. The slouo:hino: of the end of the cord — barrino; the htemorrhao-e — beinsr in itself, of course, a perfectly normal process. With all due deference to Dr. West, 1 therefore beg to differ from him in toto when he says at page 622 of his sixth edition, ' The bleeding is dependent on a con- genital malformation of the hepatic ducts.' For I believe — and I think with good reason, too — that the umbilical haemorrhage in cases of congenital malfor- mation of the bile-ducts is not due to any deficiency in their organisation, but to a similar species of de- fective organisation existing in the umbilical blood- vessels and navel themselves. In a word, to general deficient developmental power in the constitution of the infant, giving rise at one and the same time to an arrest of development in the hepatic ducts, as well as to an arrest of development in the vessels of the umbilical cord. All these parts are so intimately connected together in foetal life, by means of the ductus venosus and umbilical vein, that we can readily understand how a deficiency in the ducts ma}'' also be associated with a defective development in the coats of the umbilical vessels. Sufficient, at least, to admit of haemorrhage occurring from them before their divided ends have become perfectly closed up. This theory or view of the matter is strongly supported by the fact that in most of the cases of umbilical haemorrhage in which the ana- I TREATMENT OF CONGENITAL JAUNDICE. 305 tomical conditions have been carefully recorded al- lusion is made to the divided ends of the foetal vessels having been found imperfectly healed up. While, had they been normal, they ought to have been healed at least by the end of the fourth or fifth day after birth. Cases of intra-uterine jaundice from obstruction to the flow of bile mto the intestines will have asrain to be referred to further on, while speaking of the various kinds of obstructive jaundice. Treatment. I must begin my remarks on the treatment of congenital jaundice by sajring a few words regarding the treatment of the spurious kind, which, in order to make its title accord with its pathology, I have changed the name of to ' chlorosis neonatorum.' From having said that it is a morbid state met with in immature and weakly children, it can be readily imderstood why not medicine but good mother's milk, external heat, and plenty of fresh dry warm air must be the essentials of treatment. When I have said this, I have said all that is necessary to be said upon the subject. So now I turn to the con- sideration of the treatment of true congenital jaun- dice. For the one form of which we can do much ; for the other, nothing at all. The treatment of congenital jaundice from sup- 306 DISEASES OF THE LIVEK. pression of the biliary function is in most cases a very simple affair. A single dose of a mercurial being, in general, sufficient to dispel it. But here I have an important word of advice to give, and that is, to advise my readers not to follow the plan recom- mended in books of giving either the grey powder or the calomel to the baby -, on the contrary, give the medicine to its wet-nurse — whoever she may be — for a dose of mercurial given to the woman who suckles is sure to affect the child who sucks her. Ay, and that, too, much more naturally and satisfactorily than if the medicine be poured down the infant's own throat. There is no fear of the mercurial doing the mother harm, even if it be given within seventy- two hours after the confinement, as I well know from personal experience, or I should not thus un- hesitatingly recommend it. I need say little about treatment in cases of jaun- dice from a congenital deficiency of the bile-ducts, for, of course, they must inevitably, sooner or later, end fatally. One might expect even, after what was said in the physiological chapter on how very essential to life is the presence of bile in the digestive process, that it w^ould be almost an impossibility for a child to survive beyond a few days, or at the very utmost beyond a few weeks, with an entire absence of any canal by which the bile could obtain access to the duodenum. JAUNDICE FROM SUPPRESSION. 307 Yet, strange to say, Dr. Xunneley has put on record the extraordmary case of a boy who was born jaundiced in consequence of a malformation of tlie bile-duct preventing bile from reaching the intestines, and actually lived for nearly seven months. At the time of his death he was deeply j aundiced and ema- ciated. Emaciated, naturally enough, he would be, from no bile having reached the chyme to prepare and fit it for the process of intestinal absorption and assimilation. Even in the apparently most hopeless cases, as it is just possible that an error may be made in the diagnosis — for infantile affections of this kind are not easily differentiated — it is always advisable in the first instance to try the effect of a mercurial, given, as above said, through the instrumentality of the wet- nurse. I now come to the special consideration of the hepatic diseases which give rise to Jaundice, the Result of Suppression of the Biliary Secretion. Pathologically considered, they divide themselves into three perfectly distinct classes : — A. Those arising from Enervation. B. ,, ,, ,, Disordered Hepatic Circu- lation. C. „ „ ,, Absence of Secreting Sub- stance. I 2 308 DISEASES OF THE LIVER. Althouofh there can be no misunderstandino; the meaning of the term ' Jaundice from Suppression,' there may, nevertheless, be some difS.culty in compre- hending how the skin becomes yellow, and the urine high-coloured, when the secretion of bile is arrested, by those of my readers who have not paid attention to what was said regarding the physiology of the biliary secretion (p. 100); it may therefore be as well for me to remind them that while the liver's function is to manufacture certain biliary constituents out of the elements of the blood, its duty is merely to ex- tract therefrom certain others which exist therein pre- formed. Hence it is perfectly evident that when the secretion of bile is arrested, those substances alone which the liver itself manufactures are wanting. While those again which it merely extracts preformed from the blood remain behind and accumulate in the circulation. Just in the same way as urea accumulates in the circulation when the urinary secretion is in a like manner arrested. Hence, when the biliary secretion is arrested, bili- verdin — which is one of the substances which exist in the blood, and which the liver only extracts from it in a preformed state — accumulates there until the serum gets completely saturated with it, and assumes a dark saffron tint. The skin and kidneys, from their assuming vica- riously the function of the liver and eliminating the JAUNDICE FROM SUPPRESSION. 309 biliverdin, have their secretions impregnated with it — the sweat becomes yellow, and the urine of a saffron hue. At the same time the cells of the cuticular rete mucosum being unable to eliminate all the pigment brought to them for excretion become filled with it, and the discoloration of the skin, which is termed jaundice, is the direct consequence thereof. The order of occurrence of these changes is that, on the second day of arrested biliary secretion, the urine becomes high-coloured ; a day or two later the skin and the sweat begin to assume a yellow tint. While in severe cases, within a week or two, the milk, the tears, and the sputa, as well as the serum in the thoracic and abdominal cavities, become of a more or less decided yellow hue. From this it is seen that I regard the production of the yellow skin and high-coloured urine of jaundice as being simply due to the non-excretion by the liver of biliverdin from the blood, quite independent of the presence or absence of the other constituents of the bile. The effects produced by which will be referred to elsewhere. Meanwhile I shall now proceed to con- sider separately the further pathology of the three subdivisions of jaundice arising from suppression, as given above. 310 DISEASES OF THE LIVER. CHAPTER YIII. JAUNDICE AS A RESULT OF ENERVATION. It is now a well-establislied physiological fact that all secretions are under the direct influence of the nervous system. Stimulate a nerve supplying a gland, and its secretion is accelerated. Stop nervous action by dividing the nerve, and secretion is instan- taneously arrested. Again, just in the same way as volition can produce or suspend muscular movement, mental influence can hasten or retard glandular secre- tion. As an illustration of this fact, I need only call to mind the influence the mere sight of savoury food has in exciting in a hungry man the salivar}^ secretion, and the eff'ect of bad news in arresting it. Exactly the same influence as is here alluded to is exerted by the mind over the biliary function. If, for example, as Bernard first observed, a dog with a biliary fistula is caressed, the secretion of bile is actively continued ; if, on the other hand, the animal is suddenly ill-used, the secretion of bile is instantly arrested. While if he is again caressed, the secre- JAUNDICE FROM ENERVATION. 311 tion is re-established, and tlie bile flows drop by drop from the end of the canula.^ Here the influence on the biliary secretion is entirely produced through the intervention of the nervous system ; and if such efi'ects as are here described occur in the dog, we can surely have little difiiculty in understanding how the biliary secretion may equally be influenced in the highly- developed organisation of the human being. Indeed, every one must have felt how quickly sad tidings received during a meal not only destroy the appetite and retard digestion, but occasionally alter the comjjlexion. This efi'ect, that all of us must have experienced in a slight degree in our own persons, several may have observed to a greater extent in the j)ersons of others, even to the produc- tion of well-marked jaundice. At this very time (this was written in 1861) I have under my care a young married lady, who during the last two j^ears has twice suff'ered from an attack of jaundice mduced by witnessing her child in convulsions, and this I regard as an example of jaundice from enervation. In the ' Dictionnaire des Sciences Medicales,' 1818, p. 420, two very remarkable examples of sudden jaun- dice arising from mental shock are recorded. The first is that of a young soldier who, on being pre- vented from wreaking his vengeance upon a man who ' Look at what has been said regarding the nervous influence on the biliary secretion at p. 102 under the heading ' Etiology of Jaundice.' 312 DISEASES OF THE LIVER. had insulted him in public, suddenly became jaun- diced, and in a few hours afterwards died in delirium and convulsions. While the second is that of a young priest who became jaundiced, and immediately died, after having been frightened by a mad dog. In the ' British Medical Journal,' again, of November 19, 1870, the following interesting case of jaundice pro- duced by mental anxiety is recorded by Mr. Churton of Erith. I give it in his own words : — ' In October 1868, 1 attended a married lady, aged 30, for jaundice following mental and physical fatigue. The ordinary remedies were used. The nitro -muriatic acid was of the most service ; but the discoloration persisted for some weeks. Six months after this, she had several visitors staying in the house, and, having little inclination for society, was somewhat disturbed by attending to them, and by the addition to the ordinary cares of her household. In the midst of this anxiety, one of her children, subject to asthma, had a severe attack one evening, and was in considerable distress all night. Next morning, at five o'clock, I found her sitting up in bed, rocking to and fro, and complaining of acute pain in the hepatic and gastric regions. Pulse 72 ; temperature 98*4 degrees. She showed slight but unmistakable symptoms of hysteria — quiverrug eyelids, &c. Ten grains of the bromide of potassium were given, therefore, every four hours. The first dose cured her of all pain at once. On the fol- JAUNDICE FKOM ENERVATION. 313 lowing day, however, I found her completely jaun- diced, and the urine of a dark brandy colour. The bromide was continued, but less frequently ; and an aperient pill (podophyllin with colocynth and hen- bane) was given. On the next day, the jaundice was less intense ; and three grains of the bromide with infusion of calumba were given three times daily. Two days afterwards the yellowness had entirely gone, and the urine was of a natural colour.' Jaundice arising from enervation may be regarded as the most typical form of jaundice from suppression. For there is no organic change in the hepatic tissue. No premonitory obstruction to the natural flow of bile, either into the intestines or the gall-bladder. There is, indeed, no visible cause for the jaundice whatever. The Kver simply appears to be ' on strike.' It ceases, and that too occasionally at a moment's notice, to do its accustomed work. Bile is no longer secreted or excreted. Jaundice is in- stantly developed. The conjunctivae and skin become yellow, the stools pipeclay-coloured, and the urine of a saffron hue. Cerebral symptoms supervene ; con- vulsions, delirium, and coma follow. While death frequently ends the scene. All this takes place, and yet not a particle of lesion, not a sign of the cause, is detectible in the body after death. If not the rationale of the jaundice, at least the cause of the fatal issue, is left entirely to hypothesis. We see from the jaun- 314 DISEASES OF THE LIVER. dice that tlie colouring matter of the bile has accumu- lated in the circulation. We guess from the nervous symptoms that bile has poisoned the blood. We imagine that this has been the direct effect of enerva- tion. But further all is doubt and obscurity. Seeing that the skin became yellow and death ensued within the course of a few minutes after the application of the supposed exciting cause. Time, seemingly, havintr been an element omitted from the calculation. For the patient was well at one moment, jaundiced in the next, and dead in the succeeding. The effect appeared, as it were, to trip up the heels of the cause. I may mention that in the 'Annuaire de Therapeu- tique,' 1846, is reported a case of jaundice from great JOY in a man — a sex not usually supposed to be very emotional — and although doubting the accuracy of the theory, I willingly admit the possibility of the fact, from knowing as I do that, even in matters medical, extremes meet. No more strikmg example of which can I give than by referring to the fact that extreme cold is as conducive to hydrophobia in dogs as ex- treme heat. Kane havino- durino: his Arctic travels lost sixty dogs from this cause alone. It is just possible, then, that intense joy may act like intense fright in producing jaundice. The extreme rapidity with which the skin assumes a yellow tint in cases of sudden jaundice has been JAUNDICE FROM ENERVATION. 315 hitherto considered to be an unaccountable mystery. To me it appears nothing so very extraordinary, when the physiology of the biliary secretion is properly understood. For, as the colour of the skin depends entirely upon the effusion of the yellow pigment which exists preformed in the blood, it is easy to understand, when, in consequence of great nervous shock, the elimination of the pigment by the excret- ing cells of the liver is suddenly arrested, it at once and instantaneously begins to be vicariously elimi- nated from the blood by the skin, the rete mucosum of which immediately, in consequence thereof, assumes a yellow hue. Moreover, as an aid to the more easily compre- hending how enervation may produce jaundice, I may remind the reader that the to us invisible effect of nerve paralj^sis on the capillaries of the liver is no doubt analogous to, if not even precisely the same as, the, to us, visible action of the paralysis of the nervous system uj)on the capillaries of the skin of the face and ears of the rabbit, which follows an arti- ficial mechanical interruption to the function of the eighth pan' of nerves : as occurs when their nerve- cord is divided in the animal's neck by a scalpel or a pair of scissors. No sooner is the division made than the capillaries of the same side of the face and head become visibly congested and enlarged. This effect is markedly apparent in the ear if the animal 316 DISEASES OF THE LIVER. { selected for experiment be an albino rabbit. Not only is there congestion, but actual turgescence and increased temperature, of the whole side of the face and head, just as if a pathological and not a mere physiological inflammation had been induced. If this, then, is the visible effect of interrupted nerve action in the eighth pair of cerebral nerves following upon their paralysis by artificial section, surely it requires no great stretch of the imaginative faculties to enable us to believe that it is not only possible, but even highly probable, that a corresponding effect is pro- duced on the invisible capillaries of the brain. Fol- lowing up this line of argument still further, can we not see in it an explanation of how the enervation of the liver is attended with such an amount of capillary congestion as is sufficient to induce jaundice from suppression ? Nay more, may we not go so far (although the ground is no longer so firm under us) as to believe that the enervation which induces jaundice is at the same time potent enough to act in a similar paralysing manner on the nerves of the cerebral capillaries, and thereby, on the congestive hypothesis, furnish us with a clue to the well-recognised and ofttimes observed fact that one of the most charac- teristic concomitants of jaundice the result of ener- vation, whether from nervous shock or the introduc- tion of toxic agents into the system, is its invariable, or at least almost invariable, association with cerebral J PATHOLOGY OF ENERVATION. 317 disturbance ? Cerebral congestion being the most potent of all pathological causes of mental disturb- ance. I am perfectly aware that this theory of mine is not unlikely to be gamsayed, for the fons et origo of cerebral symptoms in cases of jaundice is still a matter of virulent dispute among hepatic pathologists. One set b8lie\dng that they are in all cases due to the accumulation in the blood of those substances which are normally extracted preformed or eliminated from it by the liver, to be manufactured into biliary in- gredients. Another set, ignoring this bile-poisoning theory altogether, assert that the derangement in the cerebral functions is merely due to the imperfect elabo- ration and elimination of the effete matters of the tissues — such, for example, as the urea, the uric acid, the uro-hoematin, and other normal urinary products — which it is the duty of the kidneys and not of the liver to eliminate. They say, too, that in by far the majority even of cases of contagious jaundice, which are always attended by marked cerebral disorder, the elimination of urea is invariably found to be dimin- ished, and moreover that in these cases Dr. Blair has detected such an excess of carbonate of ammonia both in the expired air and blood of patients, as to lead him to the belief that ammonagmia (from the decomposition of urea in the circulation) may be at least one, if not the sole, cause of the cerebral symp- toms. 318 DISEASES OF THE LIVER. This last class of theorists, however, only strike at one half of the question. They strike at the cerebral symptoms ; but they leave the jaundice, with which they are associated, untouched. And as it is often the case that truth is found in the centre of two or three differing sets of conflicting opinions, probably the truth might be here found by combining into one great whole the separate theories advanced on either side. At the same time, it must be in the meanwhile admitted that the rapidity with which not only cerebral symptoms, but an actual jaundiced condition of the skin, supervene upon sudden mental emotion, is of itself a sufficient reason for adopting, for the present at least, my theory of the congestive action of enervation on the hepatic and cerebral capillaries in preference to any of the others. Mental emotion, especially of a sudden and dis- agreeable kind, is not only capable of producing jaundice from arresting the biliary secretion, but may actually cause very serious hepatic structural change. Such, for example, as occurs when acute atrophy of the parenchyma of the liver follows intense fright. Mental emotion, I believe, may even so stimulate the peristaltic action of the gall-bladder, that it may suddenly contract with sufficient force to cause the immediate extrusion of a gall-stone from it, and at once give rise to an attack of acute biliary colic, i PATHOLOGY OF JAUNDICE FROM EXERVATION. 319 from the stone being suddenly thrust into the cystic duct. To be followed in a few days afterwards by a true jaundice, from the stone descending into and obstructing the common bile-duct. Moreover, it has been repeatedly hinted at by writers on hepatic disease that primary cancer of the liver, in the predisposed, may have been the direct result of prolonged mental worry or protracted grief. One of the reasons, no doubt, why jaundice does not more frequently follow upon unusual mental emotion, is simply that a certain amount of pig- ment is required in order to produce a visible ting- ing of the body, and it seldom , happens that the emotional effect on the biliary secretion is sufficiently great or permanent to permit of the requisite amount of pigment accumulating in the blood. The rea- son, too, why mental emotion is more apt to cause jaundice immediately after a meal is, as will after- wards be better understood, that the congested state of the liver at that time favours the stoppage of the secretion. A blow on the head, which is now and then observed to be suddenly followed by jaundice, acts, I believe, in the same way as fright, namely, by paralysing the nerve force required for the continuance of the biliary secretion. Just as happened in the case of the dog with the biliary fistula, which I struck on the head, related at page 76. 320 DISEASES OF THE LIVER. CHAPTER IX. JAUNDICE FROM ACTIVE HEPATIC CONGESTION. As this is one of the commonest causes of jaun-" dice from suppression, and many different varieties of active hepatic congestion have been described by- home and foreio^n medical authors, in order to make myself easily understood I shall require to say a few words on each of the different forms separately, paying greater or less attention to them in exact proportion to their clinical importance. In all cases where the congestion of the liver exists to a sufficient extent to produce jaundice, the organ is found to be appreciably enlarged ; and the first variety of the congestion I shall consider is that named Hepatitis. The most striking sign of hepatitis is jaundice ; and the mechanism of jaundice arising from either the acute or clironic forms of hepatitis, as well as from all the other varieties of active congrestion i HEPATITIS. 321 of the liver, is readily explained on physiological grounds. Which are : — A congested condition of any gland, whether amounting to actual inflammation or not, is un- favourable to secretion. We know, for example, that congestion of the kidney is accompanied by a suppression of the urinary secretion, and that the secretion is gradually re-established, pari passu, as the conofested condition of the oro-an diminishes. The suppression of the renal secretion is no doubt due to the engorged capillaries pressing upon the secreting structure and ramifications of the urine tubes, and thereby annullmg their functions. A similar explanation is equally applicable to the biliary secretion ; and just as it happens in the case of the kidney, that it is exceedingly rare for a total suppression of its functions to take place, so with the liver it seldom happens that the congestion is sufficiently universal to induce complete arrest of the biliary secretion. We find, therefore, that although there may be sufficient to induce a yellow- ness of the skin and high-coloured urine, pipeclay stools are frequently absent in such cases. Sufficient bile to tinge the fteces still being secreted by a portion of the liver, and finding its way naturally into the intestines, prevents the stools from becommg pipeclay-coloured. Undoubtedly it must have occurred to many of Y 322 DISEASES OF THE LIVER. my readers, that jaundice is even frequently absent in severe cases of acute inflammation of the liver — even those running on to suppuration — and that, consequently, the foregoing theory of the pathology of such cases is insufficient. At one time I was puzzled to explain this apparent anomaly, but on subsequent investigation the true cause became ap- parent, and instead of the above facts detracting from, they only tended to strengthen the theory. For when we closely examine even severe cases of acute hepatitis without jaundice, we invariably find they are those in which only a portion of the liver is affected. It matters not whether it be one lobe or two, the surface or the centre of the organ : the disease is invariably found to be circumscribed, and enough hepatic tissue left in a sufficiently normal condition to prevent the constituents of the bile accumulating in the blood and producing jaundice. This may, and often does, occur, even when the disease has run on to suppuration. The abscess, or abscesses, being limited entirely to one portion of the liver. The most typical example of jaundice as the result of active congestion is to be found in those cases where it supervenes on an attack of subacute hepatitis, such as is met with in hot climates, where indolent habits and high living favour portal con- gestion. It is occasionally also met with in England, i HEPATITIS. 323 however, and is then generally associated with con- siderable gastric derangement. I had occasion to witness a good example of this form of subacute active hepatic congestion in the person of a French gentleman, who was brought to me some days after his arrival in England, on account of his skin having assumed a most intense yellow hue. It appeared that he had come to Eng- land on a visit to friends, and, rather enjoying the novelty of an English table, indulged too freely in a quantity and quality of food and drink to which he had hitherto been a stranger. The consequence was, that within three or four days after his arrival, he began to suffer from dyspeptic symptoms and hepatic tenderness. His skin at the same time assumed a dusky hue, which soon merged into a decided yellow- ness. These symptoms were accompanied by saffron- coloured urine and pipeclay stools. On the urine being tested it gave a distinct bile-pigment, but no bile-acid reaction — a point which, I shall afterwards have occasion to show, is of great diagnostic value in obscure cases of jaundice. This gentleman, under the influence of low diet, blue pill, and benzoic acid, perfectly recovered his normal complexion in the short space of a week. The symptoms of all the varieties of hepatic con- gestion being in their main features the same, and only differmg slightly from one another in individual y2 324 DISEASES OF THE LIVER. cases, I shall give them here, once for all, in a well- marked form, and then I shall only require to call attention to the characteristic peculiarities they ex- hibit in the special variet}^ happening at the time to be under consideration. General Symptoms of Hepatitis. 1. A sense of fulness and discomfort in the hepatic region, in some cases amounting to actual pain. 2. Tenderness on percussion, and acute pain on firm pressure. 3. More or less increase of dulness in the perpendicular right nipple line. Instead of the dull extent bemg the normal four^ it may be as much as six, eight, or even, in rare cases, ten inches. 4. Yellow, hot, and dry skin, with pyrexia. 5. Yellow conjunctivas, foul tongue, and rapid pulse. 6. Urine scanty, saiFron-coloured, and, on cooling, turbid, with a great deposit of lithates — ochre, pink, or red coloured — sometimes albuminous, but always (except when kidney disease also exists) of a specific gravity of over 1015. 7. Light- or pipeclay-coloured stools. If these symptoms are present, there need be no hesitation felt in diagnosing the case as one of jaun- dice from suppression in consequence of active con- gestion of the liver. INFLAMMATION OF THE LIVER. 325 General Treatment. The first thing in a case of acute hepatic conges- tion is to enjoin strict rest. The second is to put the patient on low diet. The third to freely clenr out the bowels. The fourth to relieve the slight dis- comfort by the application of hot, thick, and large linseed poultices. The fifth, if there be signs of acute inflammation, to apply a fi'eezing mixture of ice and salt or leeches or even cupping-glasses over the painful hepatic region. It is sometimes surpris- ing how speedy and complete is the relief afforded by free local depletion. As may be judged of from my remarks on general therapeutics, podophyllin and the whole of the other forms of hepatic pur- gative stimulants, without one solitary exception, are totally inadmissible in all cases of active hepatic congestion. Mercury is here, as in many other instances of hepatic disease, our sheet-anchor, both in the shape of a purgative and an antiphlogistic, for the reasons already fully given in the chapter specially devoted to its consideration, and to which, in order to save repetition, I beg to refer the reader (page 157). Peri-hepatitis. Peri-hepatitis is the name applied to those cases where not the parenchyma, but the capsule surround- ing the parenchyma alone, is inflamed. That the capsule of the liver is often inflamed by itself, the 326' DISEASES OF THE LIVER. parenchyma remauiing unaffected, I much doubt. But that both are at one and the same tune inflamed is, I believe, a matter of frequent occurrence, and one readily knows when this is the case by the friction sound distinctly audible when the stethoscope is applied in the right hypochondriac region. The Mction sound is produced during the act of inspira- tion by the rubbing of the inflamed serous covering of the upper convex surface of the liver on the sym- pathetically aifected lining serous membrane of the under concave surface of the diaphragm. In these cases, the application of the stethoscope in this region reveals a friction sound just as readily and quite as audibly as in acute pleuritis. If an hepatic friction sound exists without jaundice, or even without so much as a sallowness of the skin, then the case may be safely diagnosed as one of peri- hepatitis ; but if the friction sound is associated with a yellow discoloration of the skin, it shows that the parenchyma as well as the capsule of the liver is affected, and that the case is consequently not one of peri-hepatitis pure and simple, but one of general hepatitis, with the inflammation extending to the capsule of the organ. Sympathetic Hepatitis. Sympathetic inflammation of the liver associated with distinct jaundice has been known to supervene SYMPATHETIC HEPATITIS. 327 upon an attack of pneumonia of the base of the right lung. The pathology of this condition is simple, for there cannot be any doubt that it is due not to the transposition of morbid matters, but to a sympathetic inflammatory action being excited in the liver, or per- haps it would be more correct to say extended to the liver through the diaphragm from the inflamed lung by the pneumogastric and sympathetic systems of nerves. The extension of this inflammatory action, or even its supervention in the liver by sympathy from the inflamed lung, is rendered all the more comprehen- sible from the known anatomical fact that both the liver and the right lung are freely supplied by branches of the same pneumogastric nerve, and, as we well know from our experience with eyes, that direct nerve communication favours sympathetic inflamma- tory action. I may mention that in the ' British Medical Jour- nal ' of 1868, Dr. Cheadle relates a strange case of a girl aged six, who, while she was labouring under jaundice, was seized with pneumonia of the upper left lobe. When immediately the jaundice disappeared, and as speedily returned after the inflammation of the lung subsided, and remained for some weeks afterwards. The connection between general pulmonary disease and jaundice has not yet been properly accounted for J nor will it be so until the subject has been more 328 DISEASES OF THE LIVER. fully investigated than it has hitherto been. We have too many theories and too few facts in hand at present to admit of ray generalising on the subject. But in connection with this matter I would call attention to a fact very little known, though it was pointed out by Alexander Shaw in the numbers of the ' Medical Times ' of loth July and 30th September 1842, which is that the portal circulation is greatly influenced by the respiratory movements. The mere expansion and contraction of the thoracic walls being sufficient of itself to propel the blood through the portal vessels, by as it were a suction force. This being the case, it is very easy to understand how in cases of pneumonia, when the movements of the chest are greatly impeded, a stagnation of the portal blood may occur in the liver and induce sufficient hepatic engorgement to produce jaundice. This observation of Shaw's explains, too, the beneficial effects of violent exercise, which increases the respiratory functions, in cases of torpid liver. Not only does thoracic but abdominal inflam- mation sympathetically affect the liver. Thus M. Hervieux has shown that an attack of jaundice may supervene in cases of peritonitis following upon delivery. He published, in 1867, a brochure entitled ' Ictere puerperal,' which he commences by relating the case of a woman, aged thirty-four, who six days after delivery (while suffering from acute peritonitis) SYMPATHETIC HEPATITIS. 329 was seized with an attack of well-marked jaundice, and died two days afterwards. At the post-mortem the liver was found stained yellow, soft, fatty, and the cells granularly degenerated, as in acute atrophy, but not to such a marked extent, nor was the volume of the liver diminished. Even the kidneys, as well as the liver, were stained yellow by the bile-pigment. This case I specially refer to, as it is the most typical oue he cites of jaundice sympathetically induced by ab- dominal inflammation, and from its beinof the one upon which his observations chiefly hinge. Interstitial Hepatitis. This supposed special form of inflammation of the liver is said to merit the name of interstitial in consequence of ' an inflammatory hypertrophic con- dition of the interlobular cellular tissue beinsr the principal structural change observable in the tissues of the liver.' But as the interstitial tissue — that is to say, the connective tissue — of every inflamed glan- dular organ presents a precisely identical state of things, and ordinary hepatitis itself ofl'ers no excep- tion to the rule, the mere finding an excess of white blood-corpuscles in the inflamed connective tissue (which said excess of white blood-cells, we are told, is the sole diagnostic characteristic of interstitial hepatitis) appears to me scarcely a sufficient patlio- logical reason for dubbing even this, mpposed to he, 330 DISEASES OF THE LIVER. special inflammatory condition interstitial hepatitis : especially seeing not only that the difference in its histological conditions from those of ordinary hepa- titis is at most merely a difference of degree, but that the functional biliary derangements it produces are perfectly identical with those produced by ordi- nary hepatitis — namely, jaundice from suppression. Dr. Borelli,^ however, actually goes so far as to say that he can distinguish the one form of hepatitis from the other, even during the lifetime of the patient, by the peculiar circumstance that in intersti- tial hepatitis the dulness increases upwards, towards the nipple, instead of — as in ordinary hepatitis — downwards, into the abdomen. A peculiarity which he attributes to the non-resistance of the diaphragm, from the interstitial inflammation of the liver ex- tending itself to it and weakening its powers of re- sistance. I give this idea of Dr. Borelli's without comment, for the simple reason that I fail to grasp it, and consequently will leave my readers to accept or reject it as they think fit. These are the four forms of hepatitis which have been specially named from their supposed patho- logical characters. The varieties next to be considered are those that have derived their titles from the most prominent factors in their symptomatology. In one respect all the members of this latter ^ Wurzburg. Arch. Med.-Phys. Gesellschaft, Bd. viii. IXFLAMilATION OF THE LIVER. 331 group closely resemble each other. Namely, in that they are all more or less directly traceable to the introduction into the body of a toxic agent, animal, veo-etable, or mineral — to wit, of true fermentative li\'ing animal micrococci and bacteria ; of living vegetable miasmatic and malarial germs ; the poison of snake-bite, of fish, and of fungi, as well as of dead mineral poisons, such as phosphorus, lead, and antimony. Before proceeding to consider each of these exciters of active congestion of the liver in detail, I beg to call the reader's special attention to the fact that good reasons will presently be given for believing that all the various and, at first sight, apparently different varieties of liver affection, arising fi'om the direct introduction into the human system of toxic agents — so widely differing from each other as pyogenic, epizootic, miasmatic, and mineral — have an identical structural pathology, and that, too, even when they assume the apparently distinct forms of either endemic and sporadic, or epidemic and con- tagious diseases. It seems as if Nature acted here, as she does everywhere else, on one great and uni- form plan. This is rendered all the more evident when we compare together cases so apparently widely differing from each other as the sporadic acute atrophy of the liver of temperate zones with the contagious epidemic jaundice (yellow fever) of the 332 DISEASES OF THE LIVER. tropics, which, at first sight, appear as different as midnight from noonday, and yet, on nearer inspec- tion, are found to resemble each other so closely as to force upon us the conviction that they are in reality mere varieties of precisely the same morbid state, only differing from each other as regards 1 degree of contagiousness ; which probably, again, is solely regulated by the temperature of the locality in which the disease occurs. Acute atrophy, though generally sporadic, sometimes assumes the form of a miniature contagious epidemic. Contagious jaun- | dice (yellow fever), on the other hand, although it ' generally sweeps in great epidemic waves over the districts it infests, sometimes appears in the form of mere isolated and but slightly contagious cases. 333 CHAPTER X. JAUNDICE, THE RESULT OF HEPATIC DISEASE, CAUSED BY DISEASE-GERMS. Although it has long been known that certain forms of large parasites produce hepatic disease — to wit, hydatids, flukes, and round worms — it will no doubt surprise some of my readers to learn that the minute parasites which are denominated germs are sometimes also the producers of serious and even fatal forms of hepatic complaints. Dr. Evans, as I elsewhere (p. 4-19) show, found that an epidemic of jaundice among horses was the direct result of the presence of minute filaria in their blood-vessels ; and now I am about to add another interesting fact to the etiology of hepatic derangements by pointing out that minute microscopic organisms, both of an animal and vegetable type, are the cause of various forms of pyrexial hepatic diseases. There are several apparently widely different forms of hepatic disease which I believe to be direct!}'' traceable to the introduction into the circulation of epizootic (animal) and miasmatic (vegetable) germs ; and being now at the chapters specially devoted to 334 DISEASES OF THE LIVER. the contagious and epidemic forms of liver derano-e- ments, I shall take occasion, as I proceed, to call special attention to a point in their etiology and pathology hitherto unnoticed. Namely, the impor- tant part germs not only play in the production of many hepatic diseases, but in the production of the pyrexia and brain symptoms accompanying the multitudinous forms of tropical as well as temperate hepatic derangements. Not only associated with specific, typhus, scarlet, and malarial fevers, but with acute atrophy, septicaemia, pyaemic and metastatic, abscesses, &c. I believe that tropical contagious jaundice — the so-called yellow fever — the temperate zone acute atrophy of the liver, pya3mic hepatitis, &;c,, are one and all of them due to epizootic disease - germs of the bacilli type. A full account of whose nature I gave in the ' Lancet ' of June and July 1881. While all the various forms of malarial hepatitis and jaundice are equally, I believe, due to the pre- sence in the body of disease -germs of a vegetable type. Either in the form of micrococci or bacteria. When the etiology of many hepatic diseases is so regarded, the difficulties hitherto encountered in find- ing a logical explanation, not only for the occurrence of isolated sporadic cases, but of the waves of hepatic epidemics which ever and anon sweep over the surface of the globe in different forms at various times, ceases to be an inscrutable pathological problem. DISEASE-GERMS. 33o AVhile the albuminoid fermentative germ theory moreover, with its known development of multitudi- nous animal and vegetable microscopic organisms, not only satisfactorily explains the cause of an incubation Fig. 5. Fig. 6. f.'.- '-..'> ^ •• f •■' f.. Disease-germ spawn. Bacilli disease -germs. period, but likewise in an equally satisfactory manner the intermittent character of all epidemics of hepatic disease. As I fully explained all this in the ' Medi- cal Times and Gazette ' of November and December, 1881, I need not do more here than say that in the Fig. 7. Fig. 8. / I hi, jO«, . /ti li Ji 1/ \ »° 0°' Micrococci. Bacteria. first place the germs admitted into the circulation always requu'e a certain time to develop and multiply before they can produce sufficient toxic effects to admit of our applying to them the name of disease, and that we all know, although the period of incuba- 336 DISEASES or the liver. tion is, as a general rule, well defined in each par- ticular form of disease, it is nevertheless liable to great variations. Ay, I believe to far greater varia- tions than is in general supposed. For example, it will probably startle some of my readers who do not accept the theory of contagious hepatic disease- germs, and even some of those who do, who are not, however, well versed in the life-history and mode of action of disease-germs, to learn that those pro- ducmg malarial hepatitis often lie dormant in the patient's body for one or two years before producing any visible signs. As my papers in the ' Medical Times and Gazette ' give a full explanation of this, at first sight, strange anomaly in the history of disease, in order to save space by not repeating the data I have collected, I beg to refer my readers to the series of papers above alluded to, both in the ' Lancet ' and ' Medical Times ' of 1881, and at once proceed to the consideration of The Epidemic Jaundice of Temperate Zones. It is seldom that jaundice attacks persons in an i epidemic form in temperate zones, but it does so ' occasionally, and that too in almost all parts of the : world, Europe, Asia, and America. For the last hundred years and more, epidemics of jaundice have been at various times recorded, and recently in the j ' Recueil de Memoires de Medecine Militaire,' vol. iii. EPIDEMIC JAUNDICE. 337 p. 374, M. Martin gave an account of an epidemic of jaundice which he had the opportunity of observing among the artillerymen and engineers of the French army stationed at Pavia during the last Italian war. The epidemic commenced during the great heats of August, and terminated in the end of October. There occurred 71 cases in an effective of 1,022 men. The causes which he considered gave rise to the conges- tion of the liver were the unusual heat, the fatiofue of long marches, the indulgence in alcoholic drinks, and the marsh miasmata prevalent in the district. Great increase in the size of the liver was ob- served in most of the cases, and of the spleen in many ; all complained of pain in the epigastrium and in the hypochondria. In fact, the onset of this last was the first symptom of the approaching jaundice. None of the cases proved fatal. Professor San-Galli informed M. Martin that a similar kind of epidemic prevailed among the inhabitants of the town of Pavia itself at precisely the same time. M. Martin's theory of the cause of the epidemic among the soldiers requires revision before being implicitly accepted. For if a similar epidemic occurred in the town, the inhabitaats of which were not subjected to the same influences, coupled with facts which I shall pre- sently adduce to show that heat is by no means an essential factor in the production of epidemic jaundice, M. Martin's theory falls to tlie ground. z 338 DISEASES OF THE LIVER. In order to prove that heat is by no means an essential to epidemic jaundice, I may refer : First, to the history of an epidemic of jaundice of six months' duration, which occurred near Offenbach in the winter of 1874-5, recorded by Dr. Klingelhoeffer in the * Berliner Klinische Wochenschrift ' of February, 1876, in which he states that both sexes were equally affected, though none under twenty years of age, and that the jaundice appeared to him to be due to catarrh of the bile-ducts. Secondly, to what is further stated in the ' Lan- cet ' of February 21, 1863, under the head of the ' Health of Rotherham,' that ' in last November scarcely had a fatal epidemic of fever subsided ere another, less fatal, but as widely spread, took its place. Several persons were attacked with jaundice, and now not less than 150 persons are suffering from it. None of those who were attacked by the late fever are suffering from the present epidemic' Thirdly, in the cold months of January and February, 1869, an epidemic of jaundice occurred in Dublin, and was brought under the notice of the Dublin Medical Society by Dr. Haydon in a paper which he entitled ' An Epidemic of Jaundice,' &c. We thus see that heat, though it may be, and most probably is, a favouring cause, is by no means an essential factor in the production of epidemic EPIDEMIC JAUNDICE. 339 jaundice. As bearing also on the etiology of the disease, I may, Fourthly, further state that M. Corville has given an account of an epidemic of jaundice among the in- mates of a prison, which occurred during the summer of 1859, in which eleven persons died out of a total of forty -seven that were attacked ; which gives the high rate of mortality of 23 per cent., and makes it, in this respect, approach the epidemic jaundice of the tropics. (' Arch, de Med.,' 1864.) Fifthly. Before leaving the subject of epidemic jaundice in temperate zones, I have again, as I did twenty years ago, to call special attention to the fact that jaundice may, and does occasionally, occur in an epidemic form among pregnant women. But as attacks of jaundice sometimes come on in pregnant women without assuming an epidemic form, I shall briefly allude to them first. Jaundice of Pregnancy. It has been long noticed that sporadic cases of jaundice are now and again met with where the pregnant condition of the uterus appears to be the sole exciting cause of the attack. For example. Dr. Gooch in his work on diseases of women (Sydenham Society's edition, p. 56) relates the case of a lady who became jaundiced after three consecu- tive confinements. Her case is peculiar, for her first z 2 340 DISEASES OF THE LIVER. attack of jaundice might be attributed to sudden nerve-shock, caused by a house taking fire close to hers. The shock was sufficient to induce a tempo- rary attack of mania, and might therefore be supposed to have been sufficiently severe to produce jaundice in the manner described at page 310. But fifteen months afterwards she was again confined, and eight days later temporary jaundice showed itself, but nnassociated with cerebral symptoms. While she again became jaundiced before her third confinement. It was completely cured before delivery by the ad- ministration of purgatives. This may be considered as a good example of jaundice occurring as the result of pregnancy. It thus seems as if the mere normal function of gestation in the human female predisposes to attacks of jaundice much in the same way as it predisposes to attacks of x\siatic cholera. Indeed, in more ways than one, the peculiar condition of system to which the pregnant state gives rise in the human female seems to render the body specially liable to hepatic derangements of a very grave character. For ex- ample, it is now a well-recognised fact that the fatal disease known under the name of acute atrophy of the liver not only more frequently attacks women in the early months of pregnancy — at which time their nervous systems are more prone to both mental and physical impressions than at any other I JAUNDICE OF PREGXANCY. 341 — but is also more frequently followed by fatal con- sequences than when it attacks non-pregnant indi- viduals. I need not at present dilate further on this point, as I shall again have occasion to refer to it in the chapter specially devoted to the considera- tion of acute atrophy. Meanwhile, I need only further remark that it is not only acute atrophy, but also other conditions of liver, oivino; rise to ordinary jaundice, which are common in the early months of pregnancy. So that it may be unhesi- tatingly said that there is an undeniable intimate connection between affections of the liver and the condition of the system resulting . from pregnancy ; the only question being, how is this connection to be explained ? Is it due to du'ect nerve influence — like sympathetic hepatitis — or does it depend on some other cause ? In a letter from Mr. J. J. Frederick Barnes, which appeared in the ' British Medical Journal ' of January 24, 1880, it is suggested that the jaundice of pregnancy is due to ' the vital force of the economy as a whole not having sufficient potentiality for the due performance of the animal functions under the access of fresh conditions caused by the pregnant state. The liver, owing to its proximity to the disturbing factors, suffering local congestions and other abnor- mal interferences with its functions, is the organ most likely to yield to the pressure put upon it. We thus 342 DISEASES OF THE LIVER. have a previously bad state of health rendered worse by the disturbance of function of the hepatic ma- chinery and the consequent imperfect performance of the digestive process, ending in impaired nutrition and a condition of aneemio-chlorosis.' Some others again have gone even so far as to suggest that normal pregnancy is associated with abnormal parenchymatous glandular degeneration. Such an idea, however, is contrary to all the laws of nature. To suppose that a normal gives rise to an abnonnal process in a healthy frame, would be simply a solecism in the interpretation of organic structural as well as functional law. An idea only tenable by a mind totally unversed in scientific medical philosophy. The etiology of the connection between pregnancy and liver disease appears to me much more likely to be found in the peculiar condition of blood and nervous system to which the foetal development and the rapid evolutionary changes in the utei*us give rise during pregnancy. More especially in the earlier months, when, as is well known, there exists extreme irritability of the nervous system, associated with a supersensibility to mental and physical impressions. At the same time, I must here call attention to the important fact, that not only may a jaundiced woman become pregnant, but a pregnant woman become jaundiced quite independent of the existence of any apparent direct connection between the hepatic JAUNDICE OF PREGNANCY. 343 organ and the foBtal development and uterine evolu- tionary changes taking place during the pregnant state. Just as a man may happen to have a broken leg and a black eye at one and the same time, mth- out there being any direct connecting link between their exciting causes. It is, therefore, necessary for the young practitioner to guard carefully against con- founding together a case of jaundice occurring during pregnancy with one of jaundice occurring as the re- sult of pregnancy. The being able to make a diffe- rential diagnosis of these two kinds of cases is highly important ; for while in the one case it is the jaun- dice alone to which particular attention requires to be paid, m the other it is the condition of the uterus which demands special care ; for abortion, miscarriage, or pre- mature labour is the usual sequel of the latter class of cases. This is, unfortunately, about all that can be said on the matter, for we have no proof whatever that the pregnant uterus per se acts prejudicially on the liver's functions either mechanically or physio- logically. For the enlarged uterus cannot possibly be said to exert a deleterious pressure on the liver, either as a whole or partially. Otherwise every, or nearly every, pregnant woman's liver would get out of order in the last few weeks before dehvery. Besides which, every enormous fibrous tumour of the uterus, as well as every large ovarian cyst, would be associated with hepatic derangements. Whereas, so 344 DISEASES OF THE LIVER. far from this being the rule, it is in reality the excep- tion. That there are still believers in the theory that the pressure of the pregnant uterus may induce jaundice, is not to be wondered at, when men like Dr. Litten believe in the pressure of a movable kid- ney being capable of doing so. He reports in the ' Charite-Annalen,' Band v., 1880, the history of the case of a woman thirty- seven years old, in whom he believes that repeated attacks of intense icterus were produced by the pressure on the gall-duct of a mov- able kidney. I shall now proceed to give an example of The Epidemic Jaundice of Pregnancy, before I attempt to explain its pathology, or sum up my views on the rationale of the epidemic jaundice of temperate zones. That jaundice may occur in an epidemic form among pregnant women was conclusively shown by Dr. Saint- Vel, who relates that 'in 1858 the island of Martinique was, without appreciable cause, visited by an epidemic of jaundice, remarkable for its severity in pregnant women. It broke out at St. Pierre towards the middle of April, attained its maximum height in June and July, and terminated towards the end of the year. All races were attacked ; the patients were mostly adults ; no liver complication JAUNDICE OF PREGNANCY. 345 could be detected ; nor could any resemblance be traced between the disease and yellow fever. It was fatal to females only, especially during pregnancy. Of thirty pregnant women who were attacked at St. Pierre, ten only arrived at the full period of pregnancy without presenting any other symptoms than those of ordinary jaundice. The other twenty all had abortion or premature labour a fortnight or three weeks after the commencement of the attack, and died in a state of coma, which appeared a few hours before or after the expulsion of the foetus. The females who died were from the fourth to the eighth month advanced in pregnancy. In some cases, sUght delirium preceded the coma, which was never interrupted, but became more and more profound up to the time of death. Its longest duration, which was only in two cases, was twenty-four and thirty-six hours. It was not preceded by any notable modification of the general sensibility, or of the respfration or circu- lation. Haemorrhage was absent, except in one case, where a female had it before delivery. When death was delayed till three or four days after delivery, the lochia were healthy. Almost all the children were still-born ; some lived a few hours ; one alone sur- vived. None of the infants had the icteric colour ; nor was there any other sign of jaundice whatever in the ten children born at the full term.' The foregoing translation, which is from the 346 DISEASES OF THE LIVER. ' Gazette des Hopitaiix,' November 20, 1862, ap- peared in the ' British Medical Journal ' of Febru- ary 7, 1863, p. 141. Notwithstanding that the epidemics of jaundice which occur in temperate climates are not limited to the hot months of the year alone, nor usually present contagious symptoms, nor are as a rule very fatal, yet, as they are occasionally associated with hsemorrhages from both stomach and bowels, are occasionally con- tagious, and have sometimes a high mortality ( = 23 per cent.), I have no hesitation in placing them in the same category as the contagious epidemic jaundice of the tropics, which 1 am now about to describe, and of which I regard them as being only a less virulent form, m consequence most probably of milder climatic causes. The value of this theory will become more apparent after the chajDters on con- tagious jaundice and acute atrophy of the liver have been perused. The Epidemic and highly Contagious Jaundice of the Tropics. There are two perfectly distinct forms of tropical jaundice, which have been described in books as yellow fevers. They are ui general spoken of as : — A. Febris Icterodes = Specific Yellow Fever. B. Febris Icterodes Remittens = Malarial Yellow Fever. The difference between these two forms of disease CONTAGIOUS JAUNDICE. 347 is, that while the first is a form of epidemic jaundice accompanied by continued fever, the result of epi- zootic disease-germs, and propagable by contagion both in temperate and tropical regions, though only producible de novo in the latter, and only occurs once during the lifetime of a patient, the second is a form of non-contagious epidemic jaundice associated with fever of a distinctly remitting type, the result of mias- matic disease-germs, transportable by a patient into temperate zones, but not producible there, and liable to recur several times in the same individual. These two forms of epidemic jaundice possess the following points of similarity : — 1. They both originate in tropical countries only. 2. They are both capable of being transported by infected individuals into temperate zones. 3. The liver is the glandular organ mainly at fault. 4. The kidneys are sympathetically more or less affected. 5. Black vomit and tarry stools are their usual accompaniments. 6. Their febrile symptoms are moreover said to be so very much alike that when a sporadic case of either occurs within the geographical range in which both forms of the disease are known to be indigenous, it is said to be not only difficult, but frequently impossible, to distinguish which form of the affection 348 DISEASES OF THE LIVER. the patient is labouring under. A fact which appears all the more extraordinary when it is known that these two forms of jaundice, though possessing such well-marked common febrile symptoms, have dia- metrically opposite exciting causes, namely : — The first, or Febris Icterodes, is essentially due to the introduction into the system of a highly con- tagious epizootic germ poison. The second, or Febris Icterodes Remittens, is, on the other hand, as palpably due to the introduction into the system of a non-contagious malarial germ poison. Lastly, I may observe that these two pathologically distinct diseases were christened yellow fevers at a time long before their pathology was known, and derived the name solely from their possessing the common signs of yellow skin and febrile disturbance. With these preliminary remarks I shall now proceed to show, by the aid of modern research, that the so-called yellow fevers of the tropics are nothing more or less than ordinary cases of jaundice from hepatic disease of a more than usually severe type, and that we possess in England their exact counter- parts, in at least a sporadic, if not even in a merely milder epidemic form, on account of a high temperature being one of the essentials in their production. I expect even to be able to show this so clearly that after I have fully explained the whole facts of this 1 CONTAGIOUS JAUNDICE. 349 case, I believe that if the symptoms of either form of the affection were presented to the reader, disasso- ciated from the words tropical and yellow fever, and he were required to give an opinion regarding the nature of the case, he would spontaneously and unhesitatingly put it down as one of jaundice from liver disease, without the idea of its being one of tropical yellow fever having ever so much as crossed his brain. So I have very little doubt that after he carefully peruses all the facts I am about to lay before him regardmg the pathology as well as the symptomatology of the so-called tropical yellow fevers, he will coincide with me in saying that the name of yellow fever ought to be expunged from our nosology, as bemg both cKnically and pathologically an incorrect definition of the morbid condition the name is intended to convey, and that the word Jaundice should be substituted. For, as will imme- diately be shown, the titles which both clinically and pathologically correctly define these diseases are : — A. Contagious Jaundice = Febris Icterodes. B. Malarial Jaundice = Febris Icterodes Remittens. The following are my reasons for abandoning the misleading titles of specific and malarial yellow fevers. a. The so-called specific yellow fever not only resembles, in so far as yellowness of the skin and conjunctiviB is concerned, one and all of the ordinary forms of jaundice from suppression, but is likewise 350 DISEASES OF THE LIVER. analoofous to them in the liver beino; enlaro;ed and tender. h. The pyrexia, delirium, and suppression of the urine, which are spoken of as being characteristic signs of specific yellow fever, are not uncommonly met with in bad cases of jaundice occurring in tem- perate zones. c. Both in some severe cases of acute atrophy, snake-bite, and emotional jaundice, the signs and symptoms are occasionally as sudden in their onset, as brief in their course, and as rapidly fatal in their termination as even the most virulent cases of yellow fever. d. In acute atrophy, in virulent snake-bite, and in emotional jaundice of temperate climates, hsemor- rhage into the stomach and bowels is a common symptom, producing the appearance of the black vomit and the tarry dejections of tropical yellow fever. e. In acute atrophy, exactly as in yellow fever, the skin so completely assumes the functions of the kidneys as to cause the sweat to acquire a distinctly urinous odour. /. The only point of dissimilarity observable in severe cases of acute atrophy and the so-called specific yellow fever is that while the one occurs sporadically in temperate climates, the other occurs epidemically in the tropics. g. Specific yellow fever, or, as I prefer to call it, YELLOW FEVER ? 351 contagious jaundice, resembles very closely the jaun- dice associated with the typhus and scarlet fevers of temperate zones, in so far as they are all distinctly due to the introduction of specific forms of septi- caemic germ poison. The germs of which, when once introduced, grow, spread, and propagate themselves in the human body. h. So-called specific yellow fever closely resembles in all its essential symptoms the severe febrile forms of jaundice, even of the remittent and intermittent types, which occur in certain parts of Africa and Asia, where true yellow fever is supposed to be totally unknown. The only difi^erence between the two sets of cases being that the one is highly contagious and the other is not. i. In order still further to substantiate my view that specific yellow fever is nothing more or less than a mere form of ^rwe jaundice, arising from a dis- ordered condition of the liver consequent upon the accidental introduction into the circulation of an epizootic germ, I shall here cite a case of supposed yellow fever which was reported in the ' Lancet ' of July 22, I860, by Surgeon Gabriel of the Royal Navy, in which the disease was associated not only with hepatitis, but with psoas abscess. The patient, a sailor, aged 23, came under his treatment at Nassau, N. P., on December 7, 1863, suftering with the symptoms of acute hepatitis. 352 DISEASES OF THE LIVER. ' Under the usual treatment for that affection the symptoms were successfully combated. On the third day the patient no longer experienced pain, became cheerful, and could lie in any posture without incon- venience. On the fourth day the belly was observed to be somewhat distended, and the patient complained of the presence of flatus. No pain was experienced over the abdomen under ordinary palpation, and only a sense of uneasiness under firm pressure. Pulse 100, weak. In the morning (the sixth day of illness) a severe pain occurred in the abdomen, and the patient looked much distressed, and groaned. Hot water was procured and the belly well fomented, while a dose of brandy and morphia was administered warm. The patient's countenance suddenly assumed a col- lapsed expression ; at the same moment a coffee- ground-like vomit escaped from his mouth, and he expired. ' On examining the body seven hours after death, there was a lemon-yellow tinge over the surface generally and the conjunctivae. (The clearness of the skin and conjunctivse from yellowness previous to death had been particularly noted.) On opening the abdomen, the peritoneum was seen to be marked here and there with patches brightly injected, indicative of recent morbid action. Within the peritoneum puru- lent fluid was found in profuse quantity. ' On reaching the right iliac region the source of CONTAGIOUS JAUNDICE. 353 the pus was at once revealed : the great psoas muscle was represented by a band of white fibrous matter so soft and yielding that the fingers could be gently passed through its substance. The iliacus was in a similarly degenerated condition ; and in the course of the vessels a cavity extended into the thigh for six inches. The lumbar and a few dorsal vertebra? were cursorily examined (thermometer 87°), but no disease was detected in them. ' On examining the stomach, it was found filled with black vomit. Yellow fever formed an element in this disease, and a cause is not wantmg to account for it. A merchant steamer was lying ahead, in which sixteen cases of fever had occurred, of which nine had died with black vomit. ' Previous to his fatal attack, the patient had been a month under treatment for a hypertrophied con- dition of the tissues of the thiffh and iliac reo^ion : the flexure of the groin was obliterated, and the part be- tween the thigh upwards to the abdomen was almost of uniform level. The patient complained only of the difficulty he experienced in the progression of the ex- tremity.' j. Again, as regards the pathological conditions of the hepatic organ in the so-called yellow fever, I may mention that Drs. Leggatt and Greenfield have, in the eleventh volume of the Clinical Society's ' Transac- tions,' reported a fatal case of the disease in a military A A 354 DISEASES OF THE LIVER. man, aged 52, who died in England (in whom the period of incubation appeared to have been twenty- five days). In which the liver was carefully ex- amined microscopically, and is said to have presented the following appearances. The outline of the lobules was normal. Under a low power, they were found to be in many places sepa- rated by exudation. Each lobule showed at parts bright yellow staining. In some at the centre. In others at the periphery. Under a high power, the exudation in the portal spaces was found to consist of leucocytes. Some of the bile-ducts were filled with swollen epithelium. Some of the liver cells retained their normal shape and arrangement. But they were very granular and pigmented. In many places, only a confused mass of cell-fragments mingled with nuclei were to be seen. The number of the nuclei appeared to be increased. The changes seemed to be the result of simple inflammatory interstitial exuda- tion (which was most marked at the periphery of the lobules), and consisted of swelling of the cells, multi- plication of the nuclei, fatty and pigmentary degenera- tion with disintegration of the cell-walls — 'in fact a true parenchymatous and interstitial hepatitis.' This description reads exactly like one of the histological condition of the liver in cases of acute atrophy. ( See pages 404-409). k. I have yet to call attention to another condition I CONTAGIOUS JAUNDICE. 355 of the liver which tends to throw light upon the true nature of the so-called yellow fever. It has received the somewhat extraordinary title of Emphysema he- patis, and is described by Dr. Meigs of Pennsylvania as a complication of the indigenous enteric fever of liis district. The case is published in the ' Philadel- ])liia Medical Times.' The patient was a sailor, twenty-five years of age, who exhibited well-marked symptoms of enteric fever, which terminated fatally after profuse hasmorrhage from the bowels. At the autopsy, made eleven hours and a half after death, the upper part of the body was found swollen from sub- cutaneous emphysema — a condition' that had not been observed before death. The liver was enlarged, and its tissue everywhere cribriform, crepitant, and spongy. Pieces cut off from it floated in water. The weather was not very hot, and no general decomposition of the tissues was present. Louis, in his work on Ty- phoid Fever, states that he has never seen this con- dition in fever, but remarks that he has met with it three times in patients dying of other acute diseases. While again, Frerichs alludes to emphysema he- patis as a local process of disintegration originating in some of those complicated metamorphoses which occur in the liver from the presence of large quantities of hydrocarbons. A A 2 356 DISEASES OF THE LIVER. Treatment of Contagious Jaundice. Even the very forms of treatment recommended for specific yellow fever by our greatest authorities on the subject add support to the view of its being a mere contagious form of jaundice, and, like all other forms of jaundice, originating in a derangement of the biliary function depending upon physical changes in the secreting cells 6f the liver. For example, Dr. Blair, the well-known writer on this subject, speaks of ' aborting the attack ' — that is to say, in more poetic language, ' nipping the disease in the bud ' — by giving a scruple of calomel and a scruple of quinine for a dose, and following this up with a drastic purgative, consisting of two ounces of the sulphate, along with two drachms of the carbonate of magnesia, in peppermint water. This indeed looks like heroic treatment, and I presume is more likely intended for negroes than for white men. I, for one, should certainly object to be personally subjected to it. More especially when he adds that it is some- times expedient to repeat the dose four times in the twenty-four hours in order that the desired effect may be attained. I merely mention this form of treatment recommended for the so-called yellow fever in order to show how closely it resembles the old- fashioned system of treating j aundice in this country, where yellow fever is said to be unknown. Were I asked to give an opinion regarding the propriety of CONTAGIOUS JAUNDICE. 357 employing Dr. Blair's heroic doses, I think I should mildly remark that I would divide each of his doses into four, and give one of them, at least as a commence- ment, not oftener than every six hours. Beyond that, I think I should, with my present knowledge, hesitate to go. Dr. Blair makes another and much more pleasant (suggestion, and that is, to give the patient gum water to drink (two ounces of gum-arabic in six ounces of water), in order to quench the great thirst usually complained of, until he tires of it, and then weak arrow- root or other demulcent. He further recommends enveloping the patient in a cold wet blanket. Which has the double advantage of aiding in allaying the thirst and reducing the temperature. The tenderness of the liver, which is due to hepatitis, is to be at the same time relieved by hot poultices. When, however, there is, as frequently happens, a distinctly active mflammation of the liver, other remedies must be employed, such as leeching or cup- ping over the tender and painful part. Blistering in these cases must be avoided, for, as was said before, the kidneys are often sympathetically affected with a tendency to urinary suppression, and if they should happen to be so in the case under treatment, the application of a blister to the liver is almost certain to be followed by an attack of strangury which will not improbably turn out to be a grave complication in the treatment of the case. 358 DISEASES OF THE LIVER. Since, as I previously pointed out at page 207, benzoate of soda has a marked effect in removing the jaundiced tint of the skin, and Drs. Klebs, Lehnebach, and Letzerich have found it act ahnost as a specific in puerperal fever, I would strongly recommend a fair trial to be given to it in cases of contagious jaun- dice. And, as an inducement to do so, I may mention that after two out of six cases of puerperal fever (a primipara and a pluripara) had died in a few days, in spite of the energetic use of quinine and wine, in whom the temperature exceeded 109° Fahr., Dr. Lehnebach was led to trj^, in the remaining four cases, benzoate of soda, as recommended by Klebs and Letzerich. The result was so remarkable that he believes that, if his experience be confirmed by that of others, benzoate of soda will be as much a specific in puerperal fever as salicylic acid is in acute rheumatism. Benzoic acid, like salicylic and carbolic acids, is a true germicide, and consequently, if my theory of animal germs being the cause of contagious jaundice be correct, it is easy to understand how benzoate of soda acts. Either benzoate of potash or of ammonia, I should imagline, would act about as well as that of soda. And when the temperature is high, the addition of the salicylate of quinine or quinine itself might be of service. The latter in about ten -grain doses. In 1854, great excitement existed at Havannah in consequence of a Dr. Humboldt asserting that he TREATMENT OF CONTAGIOUS JAUNDICE. 359 had found in the venom of a snake (the species not mentioned) a certain prophylactic against yellow fever. So much was it believed in that the Spanish Govern- ment gave orders that it should be practised among its troops. In consequence of which order the whole of them were inoculated with the snake venom ; and ]\Ianzini, who published in 1858 a small book on the subject entitled ' Histoire de 1' Inoculation Preserva- tive de la Fievre Jaune,' states that, as far as his ex- perience went, it seemed in 2,461 cases to be attended by beneficial results. While Dr. Humboldt himself asserts that during the nine previous years he had inoculated 1,438 persons, only seven of whom were attacked with yellow fever, and out of the seven only two died. Whether this be true or false, the attempt to find a prophylactic for such a scourge as yellow fever (contagious jaundice) is both highly creditable to its author, and suggestive to his reader. And if the disease be due to the presence of animal germs, it is quite possible that snake poison might act beneficially by killing the germs. Just in the same way as salicylic, benzoic, and carbolic acids do. It has even been stated that the hypodermic injection of germicides has been found to be useful. And I see no reason to doubt that, if they could be introduced in sufficient quantity into the circulation without en- dangering the life of the patient, the attack of the disease might be aborted. 360 DISEASES OF THE LIVER. In any case, I should strongly recommend the trial of germicides administered by the mouth. After thoroughly clearing out the stomach by the prelimi- nary administration of an emetic, immediately followed, if it were deemed necessary, by a rapidly acting pur- gative, such as sulphate of soda combined with a little aromatic tincture. (Avoid the use of mercury at first. For it is too weakening in such cases, as there is always more or less tendency to haemorrhage from the intestinal canal, either in the shape of coffee- ground vomiting or tarry dejections — the colour of both of which is due to the presence of effused and disorganised blood, and nothing else.) As soon as the stomach and bowels have been unloaded, then give a full dose of the germicide along with quinine. Further, avoid iron in these cases, as it only ag- gravates the disordered state of the liver, which is in reality the organ which bears almost the whole brunt of the disease. For it seems as if the germs concen- trated their attacks upon it. At first making it con- gested and tender. Then soft and small as in acute atrophy. Which I shall presently show is a mere sporadic and mitigated form of contagious jaundice (yellow fever). As regards the head and general nerve symptoms in these cases — delirium and convulsions — they are in general best subdued by the fi'ee administration of the chloride of ammonium, the bromide of ammonium, TREATMENT OF CONTAGIOUS JAUNDICE. 361 the acetate of ammonia, and the carbonate of ammonia, either given separately, or combined in pairs dissolved in camphor mixture. Morphia has been recommended ; but owing to the supposed inaction of the kidneys, and its tendency to produce suppression both of the renal and of the biliary function, it must be employed with great caution, and even then only in very exceptional cases. Light and non-stimulating foods are to be given every two hours, along with good sound light claret in ounce doses, if the condition of the patient demands stimulation. For further hints on treatment, consult the chapter specially set apart to its general consideration (p. 149). I cannot quit the subject of contagious jaundice — the so-called specific yellow fever — without repeating what an intelligent layman, a patient of mine, once said to me about it. The gentleman, Mr. J. E. Nay- lor, bank manager of Buenos Ayres, one day, while speaking of liver disease, said to me, ' Well, do you know, I think yellow fever has more to do with the liver than anything else, for you can cure it if you only get rid of all the bile.' Then he went on to say that he was in Buenos Ayres in 1871, when 25,000 persons died of the disease. The greatest number in one day being 1,250. He said the epidemic began by a solitary case coming into the town from Paraguay, 362 DISEASES OF THE LIVER. and the disease spread and was kept up spreading by the bad drainage more than by the effects of mere contagion ; for, as he remarked, it did not attack people living beyond a mile of the town, and not even a single grave-digger, who lived in the country, five miles from the town, took it ; though they used to sit and smoke their pipes on coffins so badly made that the effluvium from the decomposing corpses in them was disgusting. The first symptoms of the disease, he said, were headache, pain in the back of the neck and down the spine, and the way to stop the' disease was immediately to give a sudorific and a large dose of castor oil, and • keep the bowels continually going and quite empty by repeated doses of the oil, which he said brought away enormous quantities of black tai^-y stools, and the marvel to him was where all the ' tarry stuff ' came from, as the small quantities of food the patients took would not account for it. Purge, purge, purge, was, he thought, the thing to cure. The ' tarry stuff,' as he called it, was, as I before pointed out, not bilious, but bloody stools. Blood during its passage through the intestines is always turned black, and is con- stantly being mistaken even by medical men for bilious matter ; not alone in cases of contagious jaundice of the tropics, but in those of acute atrophy of temperate zones. ' Suppression of the urine,' he said, ' we regarded as a most dangerous sign. It TREATMENT OF YELLOW FEVER ? 363 always began early in the disease in all the fatal cases, and until the urine again began to flow we never thought the patient safe. As soon as the urine made its appearance, however, the patients were sure to get well.' Having, as I think, shown good grounds for ex- punging from our nosology the name of ' Specific Yellow Fever,' I shall now proceed to show that the title of malarial yellow fever ought for similar reasons to be abandoned ; for, as will be presently seen, it is nothing beyond a severe form of ordinary Malarial Jaundice. , Febris Icterodes Remittens is generally described in text-books as follows : — A malarial form of yellow fever originating in tropical countries, though capable of being transported into temperate zones, but in- capable of being propagated by contagion. Oftentimes recurring in the same patient, and its course being marked by distinct remissions and exacerbations. Resembling specific yellow fever (contagious jaundice) in its most characteristic symptoms. Namely, a jaundiced condition of the skin associated with black vomit — haemorrhao;e from the stomach. DifFerino* from it again in the stools being rarely tarry — h^emorrhagic — or the urine suppressed, and, although headache is a constant symptom, delirium or convulsions being but rarely met with. 364 DISEASES OF THE LIVER. The malarial jaundice, no matter whether the malarial attack have been of the intermittent, re- mittent, or relapsing type, is invariably associated with a greater or lesser enlargement of the liver. There is usually, however, less sensation of fulness or pain complained of, and the hepatic region bears both percussion and firm pressure much better than in the majority of other cases of jaundice from active hepatic congestion. In fact, the symptoms and signs are all less marked. The skin is less yellow and hot. The febricula is less. The pulse is less quick — not usually above 90. The stools, though pale in colour, are not in general what are termed pipeclay- coloured, and the urine, though scanty and dark, is seldom of a yellowish black or deep saffron hue. Generally, though not always, however, it deposits urates on standing. In some cases again, as I shall presently show, the urinary sym])toms are among the most striking features of the malarial jaundice, and so important that I shall devote a few pages to their separate con- sideration (page 370). Chronic Malarial Liver Disease. This title includes within its capacious boundaries all the various forms of yellow discoloration of the skin arising from the different and peculiar conditions of the liver induced by one severe chronic or many slight acute attacks of malarial fever. Either with or MALARIAL JAUNDICE. 365 without distinctly intermittent aguish symptoms, in which the liver either partially or entirely for a time, at least in so far as its biliary secretion is concerned, strikes work. In the majority of such cases there is an appreciable chronic enlargement of the hepatic organ, and consequently, when there is distinct jaun- dice along with the other signs and symptoms, little hesitation can be felt in putting the case down as one of jaundice from suppression — in consequence of malarial hepatitis. Every now and again, however, one comes across cases where there is malarial jaun- dice, and yet no very distinct evidence of enlargement of the liver, nor any very great diminution of the quantity of bile in the stools, although the patient's skin and urine are both distinctly impregnated with bile-pigment. Under these circumstances, only a partial suppression of the biliary secretion can be said to have occurred. Nevertheless the case may be a very dangerous one, for the constitutional disturbance may be very great. So great, indeed, as to induce a speedy fatal termination. More than once have I seen this happen in cases where the usual medical attend- ant, as well as myself, has been for a time at least thrown off guard. A s an example of the truth of this remark, I shall briefly cite a case which I saw along with Dr. Duke of Sydenham, who, at the time, furnished me with the following brief history of the case, when neither he 366 DISEASES OF THE LIVEE. nor I had the slightest intention of putting it into print ; and consequently, though imperfect, it is none the less valuable as a clinical history of the case. ' Captain P. D., Royal Navy, aged 46. Left the navy five years ago. Just before leaving the navy, he was on the Mediterranean station three years, during which time he had a great many attacks of fever. After leaving the navy in 1873, he went to Sierra Leone, where he stopped three months, during w^hich time he was three times down with fever and ague — something of the same type as he had in the Mediterranean. He reached home in March 1875, much reduced by fever, which he first got in China in 1857. He went down to Norfolk, and gradually improved, and became quite strong. He came up to London, early in 1876, in good health, and during the rest of the year he was well. In 1876 he went before a Naval Medical Board, and was pronounced sound in health. At this time he was living at Penge. During 1876 saw a doctor, occasionally, for gout. In October 1876 came to Sydenham, and was then in good health. Walked, at Easter time, thirty miles on two consecutive days. Early in 1878 I first saw Captain D., professionally, with an attack of jaundice, which was not preceded by pain, and, at that time, no fever. He felt very weak at this time, and had a good deal of mental anxiety. After being under my treatment two months, and the . MALAKIAL JAU>'DICE. 367 jaundice not going, Captain D. consulted Sir J. Fer- guson, who told him that his liver was enlarged, and that the medicines he was taking were suitable, but that he might expect to be jaundiced two or three times before he got well. A month after this, Sir J. Ferguson saw him again, and said the liver was now normal, that it was inclined to be hard, and he would alter the prescription, so as to prevent its getting too small. In July of this year he was at Plymouth for a fortnio;ht, when he had a slio-ht attack of ao-ue, which he has had more or less ever since. The first severe attack of an aguish character took place about six months ago (Nov. 29, 1878).' . Many persons would have considered this patient to be in no great danger. Yet, from my knowing the insidious history of these cases, a somewhat dubious prognosis was arrived at, which the sequel, unfortunately, but too well verified ; for the poor patient died, under the care of Mr. Douglas Duke, at Hastings, where we sent him to winter, within four months from the date of our consultation. The fatal termination being hastened by haemorrhage from the bowels — a not uncommon occurrence when the liver becomes atrophied after prolonged malarial en- largement. Malarial hepatitis, both in its acute, subacute, and chronic forms, frequently ends by inducing suppura- tion of the tissues of the liver. I believe I have 368 DISEASES OF THE LIVER. seen cases where hepatic abscesses have formed twenty years after the patients have returned to England invalided on account of jungle or other malarious fevers. In fact, the poison of the worst forms of malaria seems to saturate the tissues and adhere to the constitution with as much tenacity as the poison of syphilis. For there is no period of an individual's life, after he has had a bad attack of malaria, at which he may be said to have completely got over it. While in the act of revising this (Sep- tember 23, 1879), I have a marked example of the kind in my mind's eye. For, two days ago, I was summoned to meet Mr. R. Phillips, of Leinster Square, in consultation regarding the case of a gentleman, aged 70, an old Indian who had returned to England nearly twenty years ago after having been saturated with jungle-fever and other malarial poisons, from the effects of which he is still suffering. On my arrival at the house, I found him in a dis- tinctly marked aguish rigor ; and on making a physical examination of his liver I found it greatly enlarged, both perpendicularly and laterally. The dulness in the perpendicular nipple line was over six inches, and Mr. Phillips informed me that it was then small in proportion to what it had been four weeks previously, when, he said, it had reached below the umbilicus. In this case, the history, a$ well as the physical sigTi of intense pain on pressure J CHRONIC MALARIAL JAUNDICE. 369 over a circumscribed space at the centre of the lower margin of the liver, with a corresponding feeling of fulness, led to the diagnosis of a small chronic abscess ; and this, too, notwithstanding that the patient had been away from India, and out of all malarial miasma, for a period of nearly twenty years. The history of the case precluding the probability of the suppurative hepatitis having originated earher than a few months before I saw him. Moreover, I ascertained from Mr. Phillips that this gentleman had, while m India, suffered not only from jungle- fever and true aguish attacks, but from dysentery in all its worst forms. I have not yet done with the malarial kinds of hepatic disease ; for malaria, both of an aguish and a febrile variety, has much more to do with all the various forms of tropical liver congestion than the mere factor of heat. I question, indeed, if mere heat, per se, gives origin to hepatic congestions, for hundreds of English men and women residing m intensely hot but otherwise salubrious places are known not to be troubled with liver affections in a greater ratio than their compatriots dwelling in temperate zones. Moreover, the fact of ipecacuanha and quinine being the sheet-anchors in the treatment of tropical hepatic congestions likewise goes to the support of the theory that it is miasma, not heat, which is their exciting cause. B B 370 DISEASES OF THE LIVER. Malarial poisons not only produce hepatic, but even also renal congestions ; and tlie two in con- junction produce an as yet mysterious chain of cha- racteristic, though anomalous, symptoms, which I first brought under the notice of the profession in my monograph on jaundice published twenty years ago, and subsequently, in a more developed form, in a paper read on May 9, I860, before the Medical and Chirurgical Society, and published in the forty-eighth volume of its ' Transactions,' under the title of ' Inter- mittent Hcematuria,' but which, now that I know a great deal more of the matter, I believe I ought rather to have called Paroxysmal Congestive Hepatic Haematuria. The most remarkable features of this afi'ection consist in the strange fact that although the abnor- mal urine passed by the patient durmg the attacks contains the whole of the ingredients of the red blood-corpuscles, scarcely a single entire blood-cell is to be detected in it by the microscope. Their debris being at the same time visible in every direc- tion. Although, as I have already shown, and shall still further show, the urine is nearly always more or less abnormal in all cases of hepatic disease, in no single form of liver, or any other disease, indeed, is it so curiously abnormal as it is in this paroxysmal congestive hepatic haematuria. More- PAROXYSMAL HEPATIC HiEMATURIA. 371 over, in this remarkable affection, though highly albuminous, the urine possesses the notable charac- teristic of combining a high specific gravity with a great coagulability. While in renal albuminuria the specific gravity is always under 1010, in this form of hepatic albuminuria it is almost mvariably over 1015. No more correct idea can be given of one of the special features in this peculiar hepato-renal affection, than by quoting the reply of one of the patients suffering from it, when asked what was the matter with him. His answer was given to me in these words — ' I can't tell you ; but each time I get cold hands or cold feet I pass bloody urine, while my urine is at other times perfectly healthy.' In the other case, which I am about also to relate, the urinary symptom was not traceable so much to the effects of cold as to malarial poisoning ; and as it was the one which first fell under my observation, I shall cite it first. Dr. , a member of our own profession, after several years' residence in one of the West Indian Islands, was, in consequence of repeated attacks of intermittent fever, forced to give up practice and return to England, where for the first two years he was still liable to occasional outbursts of his old enemy. On one occasion, while consulting me re- garding his case, he mentioned what he considered B B 2 372 DISEASES OF THE LIVER. to be a very peculiar symptom, namely, that he occasionally suddenly passed five or six ounces of urine of a dark red or chocolate colour, a symptom which would recur once in twenty-four hours during two or three days, and then as suddenly disappear. Never having before met with such a case, I requested him to send to me, on the next occasion, a specimen of the fluid. In the succeedmg November (1861) I received from this gentleman three samples of urine — one passed at 8 a.m., which was clear, pale, of a specific gravity of 1025, of an acid reaction, de- positing no lithates, and containing no albumen, being, in fact, normal in every respect. Another quantity, passed at 2 p.m. of the same day, of a dark chocolate-brown colour, opaque, turbid, having a specific gravity of 1032, of an acid reaction, de- positing lithates, containing a large quantity of albumen, some sugar, and a large excess of urea (3'6 per cent.). The deposit from this specimen of urine, when examined with the microscope, was found to contain nucleated epithelium (fig. 9, p. 380), some granular cells, and a large quantity of free o-ranules of ' a brownish-red ha3matin colour, scattered among which were a considerable number of renal tube-casts. The tube-casts presented one or two remarkable peculiarities, namely, that the majority of them were short and broad, and filled chokefull with brown pigment, as represented in I PAEOXYSMAL HEPATIC HEMATURIA. 373 the woodcut. Besides these, there were a small number of fine, long, pale tube-casts, with only a few granules of dark pigment distributed in them ; these looked not at all unlike the renal tubes emptied of their epithelium obtained by scraping a section of fresh kidney. No blood-corpuscles were to be found in this specimen of urine. The third sample of urine sent by the gentleman in question was passed in the evening of the same day, and presented a striking contrast to that just described. It was normal in colour, contained no albumen, deposited a small quantity of ordinary coloured lithates, among which were neither tube-casts nor granular cells. The specific gravity of the liquid was 1021. Its reaction was acid, and its percentage of urea exactly half (namely, 1*8 per cent.) of that of the preceding specimen. These three different conditions of the urine were certainly very peculiar ; for had the morning's specimen alone been brought under the notice of the physician, he could never have dreamt of the existence of any urinary affection. On the other hand, if the single specimen of urine passed four hours later had been submitted to his inspection, he must have come at once to the conclusion that there existed very grave organic changes in the renal organs. Whereas neither the one nor the other of these opinions, as I shall presently show, could possibly be correct. Oti DISEASES OF THE LIVER. The gentleman alluded to, at the time when he passed these urines, was labouring under hepatic de- rangement ; being, in fact, slightly jaundiced, as a result, most probably, of the malarial poison, from the effects of which, as before said, he had not yet entirely recovered. The varymg conditions of the three urines clearly pointed to intense congestion of the chylopoietic viscera of a transient and periodic character. Suiting the practice to the theory, mercurials, and afterwards quinine, were taken by this gentleman, in order to remove the congestion of the chylopoietic viscera, and check the periodicity of the disease. The results were most favourable, for, although twenty-one years have passed away since then, he has never had a recurrence of these munary symjDtoms, and is now alive, well, and in active practice in Devonshire. I shall now proceed to call attention to the second case, w^hich is equally traceable to malarial liver disease, notwithstandino- that the man was never out of England. On December 16, 186J:, M. X., a dark, sallow- corn {)lexioned, careworn-looking man, was sent to me by my colleague. Professor Fox, in consequence of his case presenting unusual characters. The history of the patient is briefly as follows : — He is a blacksmith by trade, thirty-two years of age, and unmarried. Until two years ago, he considered I PAROXYSMAL HEPATIC HEMATURIA. 375 himself perfectly healthy, having always been able to do forge work without either difficulty or incon- venience, having, in fact, been a strong man. Two years ago, he, for the first time, observed that he occasionally passed urine as dark as brown old ale, while that voided at the preceding and suc- ceeding micturitions possessed the normal colour and transparency. Twelve months later — a year before 1 saw him — the urine for the first time assumed the colour of blood — a symptom which greatly alarmed him, as it recurred about three times a week durino- the whole of that winter, except during a fortnight in Januar}', while working in the open air, when it became still more frequent, occurring about once every day. Sometimes the attack of bloody urine lasted over two micturitions, amounting to a period of from four to five hours. In the spring of that year, as the warm weather advanced, the attacks gradually be- came less frequent, until from the month of ^iay to September they entirely ceased. In September, however, they reappeared at intervals of about every ten days, the intervals gradually diminishing, until a fortnight before he came under my care, when be passed bloody urine every other day ; and for the last five days he had passed it every day at irregular hours varying between 10 a.m. and 6 p.m. The quantity usually emitted was about six ounces. The 376 DISEASES OF THE LIVER. patient further stated that smce the commencement of his illness, with the exception of the summer interval, he was constantly under treatment for bloody urine at different London hospitals without receiving the slio-htest benefit. On his first visit to me, the man brought with him two bottles containing the urine that he passed at 9 a.m. and at 2 p.m. on the previous day. The former sample was clear, transparent, straw-coloured, and normal-looking ; the latter, a dark purple blood- coloured fluid. On carefully cross-questioning the patient as to the origin of these liquids, he stated that the dark urine was usually passed about an hour after his feeling cold ; that the urine did not invariably become clear at the next micturition ; and that occasionally it did not resume its perfectly natural colour until he had emptied his bladder three times. He stated, moreover, that he then felt cold, and that even during the time he was kept in the waiting-room he had passed four ounces perfectly similar to the bloody-looking fluid which he had brought with him. He was accordingly requested to go behind the screen and make some more, which he immediately did, and produced about two ounces of a liquid of a dark purple-red colour. As he com- plained of feeling intensely cold, notwithstanding that he was sitting in front of a large fire, the tempe- rature of the palms of his hands was taken, and PAKOXYSMAL HEPATIC HEMATURIA. 377 found to be only 60* Fahr., while the temperature of my own hand was 95 '4° Fahr. The temperature of the patient's axilla was also carefully taken, with as little disturbance to his dress as was possible, and, in spite of his being well clad with warm clothing, it Avas ascertained to be only 96*1° Fahr., a result which entirety confirmed his statement regarding his sensations of cold. He moreover added that he was a Londoner, and had never, as far as he knew, suffered from ague ; the most that could be ascer- tained on this point being that on some occasions he had felt so cold as to shiver during the night, which shivering was not, however, followed by a true hot stage. As before mentioned, the man was dark com- plexioned, and had a sallow look. Which sallow- ness appeared to be due to disturbance of the hepatic functions. He admitted that he was a very bilious subject, but denied having ever had any hepatic affection beyond what might be included in the term functional derangement, and this had never at any time amounted to actual jaundice. It will be observed that this and the preceding case present many features in common, the only apparent difference being that while the first could be distinctly traced to tropical malarial poison, the second appears to be simply the result of the direct effects of cold and damp acting upon a predisposed '378 DISEASES OF THE LIVER. constitution. Such, at least, was the theory I formed of the disease at the time, and, accordingly, the line of treatment recommended in ordinary hsematuria was abandoned, and the plan of treating it as the result of malaria adopted, as in the first case. A course of treatment which proved most beneficial, for before twenty-four hours had elapsed the disease received a check, and by the end of forty-eight hours it may be said to have completely disappeared, for from that time he never had a single recurrence of his urinary symptoms. The patient was a regular attendant at the hospital during the whole winter months, coming once a week, no matter how cold or wet the day was, up to the time the warm weather set in, when, by permission, he ceased his visits. The amelioration of the condition of the patient in this case can scarcely, I think, be attributed to anything else than the effect of the treatment, as the diet and other conditions under which he was placed remained entirel}'" unchanged. We cannot even suppose that the weather had anything to do with it, for the temperature of the atmosphere in the last two weeks of December, throughout January, February, and the beginning of March, was often lower than in any of the preceding months of the winter. The patient was at no time taken into the hospital, but made to come, as already said, once a week, no matter whether the day was wet or dry, PAROXYSMAL HEPATIC H^MATUEIA. 379 cold or warm. Moreover, until the very clay on which the treatment was commenced, the patient's condition had been gradually becoming worse and worse, while, as just said, within twenty-four hours after it was begun, the disease had evidently received a check, and within forty-eight, the urinary symp- toms had entirely disappeared. At page 756, vol. i. (3rd edition), of Sir T. Wat- son's ' Lectures,' it is mentioned that when qumine, given alone, fails to cure an ague, a few grains of calomel, followed up with quinine, will often entirely check the disease — a fact which rather goes to sup- port the view that even the second case might be due to a form of malaria] poisoning. These remarks might be allowed to end here ; but as I consider that the pathology of such cases as have just been described is of great clinical value in connection with hepatic disease of a malarial cha- racter, I shall say a few words more regarding the condition of the urine, as by so doing it will not only be seen on what grounds I founded my diagnosis, but I may perhaps aid the labours of some future inquirer, who may have the good fortune to throw more light upon the nature of these cases than the data I have at present at command enable nie to do. The man was ordered to preserve all the urine he passed during the forty -eight hours after I first 380 DISEASES OF THE LIVER. saw him, and to put what was passed at each mictu- rition into separate bottles. On examination, it was found that the specimen passed at 8.30 a.m. was normal in colour, devoid of any sediment, six and a half ounces in quantity, acid in reaction, and of a specific gravity of 1010 ; it contained 1*75 per cent, of urea, traces of sugar, but no albumen. That passed at 2 p.m. was dark red, almost black- looking, six ounces in quantity, acid in reaction, of a Fig. 9. 1. Granular tube-casts. 4. Free h^matin. 2. Large granular cells. 6. Oxa'ate-of-lime cr^'stals. 3. Mucus-corpuscles. 6. Amorphous urates. specific gravity of 1017, and, on standing, deposited a copious precipitate of dark -coloured urate of soda, leaving the supernatant liquid quite clear, and of 8 fine rich port-wine colour. This urine contained 2*5 per cent, of urea, was highly coagulable by heal and nitric acid, and gave evidences of traces of sugar On examining the deposit from it under the micro- scope, although scarcely a single blood- corpuscle wa^ II PAROXYSMAL HEPATIC H^MATUEIA. 381 to be foimd, it contained a great abundance of granu- lar tube-casts (fig. 9, l), large granular cells (2), free granular rnatter of a h^ematin colour (4), and among the urates a few octahedral crystals of oxalate of lime (5). It will be seen that this urine presents a striking resemblance, both in its chemical and micro- scopical character, to that of Dr. , being of high specific gravity, coagulable by heat and nitric acid ; containing a large excess of urea, abundance of granular tube-casts, and scarcely any blood- corpuscles. For all practical purposes one may say that there were no blood-corpuscles in the urme, for out of sixteen of the gentlemen attending my practical class only two found any, and even then there were only one or two in the field of the micro- scope ; while, had the case been one of ordinary ha^maturia, the absence of blood-corpuscles would have been the exception, not the rule. I was particularly struck with the resemblance this urine bore to the urine I have occasionally seen dogs pass after I had injected either bile or bile- acids in toxic doses under the skin of their backs. Their urine not only occasionally presented exactly the same colour, but contained lots of granular tube- casts, and still further closely resembled this human urine in being coagulable by heat and nitric acid. All this leads me to the conclusion that the condition of the urine in cases of paroxysmal hepatic idbu- 382 DISEASES OF THE LIVER. minuria is in greatest part due to disorder of the biliary secretion brought about by the direct result of malaria acting upon the liver. The urine passed at 6.30 p.m. was five and a half ounces in quantity, slightly smoky in colour, with a moderate deposit of pale urate of soda, a specific gravity of 1016, and acid reaction ; it contained 2 per cent, of urea, and was slightly coagulable by heat and nitric acid. The deposit, when examined by the microscope, was found to contain only a few granu- lar tube-casts, one unusually long one, with some granules in it ; a few mucus-cells, no crystals of oxalate of lime, no blood-corpuscles, and only small collections of pigment scattered among the amor- phous urate of soda. The urine passed at 9 p.m. was about six ounces in quantity, perfectly normal in colour, without any sediment ; had a specific gravity of 1016 ; acid re- action ; contained I'SJ: per cent, of urea, and not a trace of albumen. The urines passed on the following day were all normal in colour except one, namely, that passed at 10 a.m., which was of a slight brownish-red tint ; it deposited a copious sediment, coagulated freely on the application of heat and nitric acid, and contained 2*05 per cent, of urea. In the sediment of this urine were found a number of granular tube- casts, but nothing like the quantity in that of the well-marked j PAROXYSMAL HErATIC HEMATURIA. d8o specimen. This specimen presented, in fact, the last appearance of the disease, for from then until he left the urine never again became either albuminous or of a dark colour, and only tmce, on the 12th and 20th of January, did it deposit any precipitate. On the first occasion the natient suspected a re- currence of his old disease, a suspicion which, fortu- nately for him, was not verified, for, on testing the urine, it was found to become perfectly transparent on the application of heat, and to be entirely devoid of albumen or tube-casts, the turbidity being simply due to the presence of urate of soda. The second specimen was exactly similar. There are one or two points regarding the con- dition of these various urines requiring special notice. 1 . The presence of the granular tube-casts clearly points to congestion of the renal organs, but their appearing and disappearing in the course of a few hours at the same time proves that it was not an ordinary case of renal congestion. 2. The almost total absence of blood -corpuscles, notwithstanding the hsemorrhagic appearance of the urine, stamps the case as being entirely different from ordinary haematuria, and shows its resemblance, in this particular, to that variety of non-intermittent i urohfematuria in which the contents of the blood- corpuscles alone pass into the urine. 384 DISEASES OF THE LIVER. ( 3. It cannot be regarded as a sample of simple intermitting albuminuria ; for although the protein substance coagulable by heat and nitric acid has been hitherto spoken of as albumen, it differed very materially from the albumen of blood -serum in its ready solubility m an excess of acid. In making the analysis it was found necessary to be exceedingly careful with regard to the amount of nitric or acetic acid employed, for after the coagulable point was arrived at the addition of a single drop more of either of these acids instantly redissolved the coagu- lum, and set the colouring matter free, a circum- stance which, taken in conjunction with the uniform diffusion of the pigment and the coagulable matter in the liquid, leads to the conclusion that it was not simply the albumen of the blood- serum, but the haemato-giobin itself, which was excreted by the kidneys. 4. The case was not one of urohtematuria, such as I have elsewhere described,^ for two reasons- first, on account of the urine being coagulable by heat and nitric acid ; and, secondly, from the fact of the addition of acids diminishing instead of in- creasing the dark tint of the urine. 5. The bilious appearance of the patients in both cases would lead to the belief that the attacks were ^ Lectures on the Urine, and Diseases of the Urinary Orgawt^ ChurcbiU & Co. PAROXYSMAL HEPATIC HEMATURIA. 385 connected with the disturbance of the hepatic function, which, in one case at least, was distinctly traceable to malarial poisoning. 6. As the bile- acids have a powerful disinte- gratmg effect on the cell-walls of the red blood-cor- puscles, it has once or twice crossed my mind that this peculiar condition of the urine in paroxysmal hepatic haematuria may possibly be due to an ab- normal quantity of bile-acids in the circulation. Although this is only a passing idea, it may never- theless be w^ell worthy the consideration of future observers who may have the opportunity of studying cases of this kind, and hence my reason for here directing attention to it. 7. The copious deposition of urates, as well as the excessive elimination of urea, which takes place during the attack, points to considerable general constitutional disturbance. Lastly, the transitory condition of the urinary symptoms shows that, whatever might be the nature of the disease, the exciting cause could not be in constant operation, unless we admit that it required distinct periods of incubation as in ague, which we know is liable to assume an almost endless variety of forms. In conclusion, I have only to remark that it is of great clinical importance to be able to make a correct differential diagnosis between cases like the present and those of ordinary hagmaturia, for without c c 386 DISEASES or the liver. it, it will be utterly impossible to treat them with any chance of success. The last-quoted case is, indeed, a striking illustration of the truth of this remark ; for, notwithstanding the patient having been at different London hospitals, under the care of men of high professional standing, he failed to obtain relief, in consequence of the orthodox line of treat- ment laid down for ordinary htematuria having been adopted, and, as has been said, was at once cured when the case was treated as one resulting from the combined effects of hepatic and renal malarial dis- turbance. Since these cases were first published I have had at least a dozen of a jDrecisely similar cha- racter under treatment, all of which made speedy recoveries. I cannot refrain from here remarkmg that since I first called attention to this peculiar affection in 1863, a whole host of cases have been reported by writers both at home and abroad — but principally at home — and that the majority of them have not only manufactured new names for the disease, according to their own theories regarding its pathology, but that some of them have not had even the common politeness to mention so much as my name in con- nection with it, although they have reiterated almost jj my very words regarding the peculiar characters of its urine, by which they would lead — no doubt un- intentionally — the uninitiated to suppose that they PAROXYSMAL HEPATIC HiEMATUEIA. 387 had discovered them all for themselves. Dr. Jones of Louisiana has called attention to the fact that in his district there is a very marked acute form of this hepato -renal malarial affection, which, he says, is characterised by well-marked jaundice as well as haematuria. • In some cases immense quantities of green biliary fluid, or liquid tinged with bile, are vomited, and the patients die in a state of collapse, with blue-mottled, purplish extremities, and sunken, pinched features. As a general rule, suppression of the functions of the kidneys is a fatal sign, and, as in yellow fever, is sometimes attended with convulsions, coma, and delirium. And whilst some of the symptoms — as the nausea, incessant vomiting (in extreme cases black vomit), deep jaundice, and the impeded capil- lary circulation — resemble those of yellow fever, yet there are marked diflferences between this disease and yellow fever. ' The pathological changes observed after death are characteristic of paroxysmal malarial fever, and not of yellow fever — viz., enlarged slate- and bronze- coloured liver, loaded with dark pigment gi*anules, deposited in greatest numbers in the portal capillary network ; gall-bladder distended with thick, ropy bile, presenting, when seen en masse, a greenish - black colour, and in thin layers a deep yellow. As much as 1,000 grains of bile of high specific c c 2 388 DISEASES OF THE LIVER. general rule, contained in the gravity has been obtained from the gall -bladder J whilst in yellow fever not more than 120 grains of bile are, as a gall-bladder,' This form of jaundice, he says, prevails only ii certain years, and appears to be dependent to a large extent upon the degree of heat and moisture, as well as upon the amount of organic matter in the soil. Treatment. As regards the treatment of cases of malarial hepatitis and jaundice, whether in a smart acute or a severely chronic form, the free use of mercurials] m combination with quinine, salicine, or ipecacuanha is almost invariably absolutely essential in order tc effect a complete cure. But, sad' to say, even undel the most favourable conditions, both of hygiene anc treatment, many of the cases that have been Ipn^ subjected to some of the worst forms of malarial influence succumb, from the constitution having be-] come, as it were, thoroughly and irretrievably underj mined by the poison. After the preceding descriptions of the etiolosfj symptoms, and pathological appearances, in the twc kinds of the so-called yellow fevers, I think I nee( offer no further apology for recommending the toil abolition of the name of ' yellow fevers,' and substi- tuting, as I have done, that of ' contagious and mala- PAROXYSMAL HEPATIC HJEMATURIA. 389 rial jaundice.' For I presume that even the most nonchalant of my readers must have observed for themselves that not only are the so-called yellow fevers nothing but different forms of jaundice, but that, though allied to each other in some of their symptoms, theh' pathology — at least in so far as regards their origin and cause — must be looked upon as being entirely different. In so much as the one — specific yellow fever — as is proved by its con- tagious character, is due to the introduction into the system of a peculiar and special epizootic poison. Which not only germinates and multiplies within the animal organism, but, like smallpox or scarlatinal poisons, can be communicated from an infected to a healthy individual. Whereas the other form of so- called yellow fever — fehris icterodes remittens — malarial jaundice, is, in its turn, as palpably due to the intro- duction into the system of a malarial or paludal miasmatic poison. Which can only be obtained by the human body directly from the atmosphere of the districts in which it is indigenous, and therefore cannot be propagated by contagion from one human being to another. Acute Atrophy of the Liver. Acute, or, as it is sometimes called, yellow atrophy of the liver — in consequence of the yellow appearance of the hepatic tissue — though a disease of temperate 390 DISEASES OF THE LIVER. zones, I unhesitatingly assert is a mere sporadic form of the contagious jaundice of the tropics. At this conclusion I have arrived — 1. On account of their symptoms as well as their signs being the same. m 2. The post-ynortem appearances in both being identical. 3. On account of the similarity existing between them in point of fatality. 4. Because, as is now known, acute atrophy of the liver may, even in temperate zones, manifest a contagious character. Before more fully alluding to the points of iden- tity in these two forms of disease, I shall go fully into the signs and symptoms of acute atrophy ; for the account I shall give of its clinical history will very materially facilitate the understanding my exposition of the identity of these two forms of disease, whose pathology has so long been a stum- bling-block to practical medicine. For on account of the one being only indigenous and epidemic in certain tropical regions, and the other sporadic and never assuming a true epidemic form in temperate climates, it was thought that the pathology of the diseases must of necessity be different. I shall im- mediately show, however, that acute atrophy of the liver is often as sudden in its onset, as rapid in its course, and as fatal in its termination, as the most ACUTE ATROPHY. 391 virulent form of contagions janndice. Added to which, that it manifests the same kind of cerebral symptoms, as well as identically the same kind of black vomit and tarry dejections (haemorrhage from the digestive canal — stomach, and intestines). While similar kinds of urinary derangements are likewise its invariable accompaniments. Like all forms of virulent disease — cholera, plague, malignant typhus, &c, — acute atrophy of the liver, contrary to what was until within the last few years supposed, attacks persons of either sex and at all ages. But it shows a predilection for females between the ages of fourteen and twenty-three, as well as for the puerperal state, especially the first four months of pregnancy. In this respect, again, it closely re- sembles Asiatic cholera and plague, which have a striking predilection for pregnant women. This proneness of acute atrophy of the liver to attack pregnant women must not be allowed to lead one into the error of confounding the j aundice which it gives rise to with what is called the 'jaundice of pregnancy ' — either epidemic or sporadic — which has an entirely different pathology, and is fortunately of a much milder nature. So much so, indeed, that Gooch, in his treatise on the diseases of women (p. 56, Sydenham Society's edition), is able to relate a case in which it recurred in the same patient during three successive pregnancies. Whereas a 392 DISEASES OF THE LIVER. pregnant woman, once the victim of an attack of jaundice the result of acute atrophy, is not likely to live to have another. But even when she has sur- mounted the disease, I know of no case on record where it has attacked her a second time. In this respect it resembles all other epizootic germ diseases in showing but little tendency to recurrence. Predisposition is, in this as in all other cases of germ disease, necessary for its appearance. The urine becomes scanty, and of a bright saffron colour — quite different from the brown ale tint of ordinary jaundice urine. The stools become loose. The dejections are black and tarry, leading to the idea that they are loaded with bile. While the dark colour, on the contrary, is due to the presence of blood. In those cases where no haemorrhage has taken place, the stools are of a pale colour. Sometimes, indeed, the patient passes no stool at all for several hours. A few hours later, extravasations of blood take place under the skin ; while hasmorrhages from the bowels, nose, and vagma, are frequently observed to occur. Lastly, delirium or coma generally closes the scene, within a couple of days, or at most a week, after the commencement of the violent symptoms. Frerichs, who has well described these cases, even says that ' in the severest forms the disease may run its course and end fatally within twenty-four hours * Clinical Treatises on Diseases of the Liver vol. i. p. 197. ' 1 ACUTE OR YELLOW ATROPHY. 393 As regards the morbid anatomy, little need be here said, as it may all be embodied by simply comparing it to what I have pointed out as occurring in the worst forms of contagious tropical jaundice. For it is invariably found that the liver is not only softened, but completely degenerated. Sometimes almost re- duced to a yellow pulpy mass, and not one half of its normal weight. So that, like tropical jaundice, it is well described as one of the most formidable of human diseases, seeing that all these changes may occur in the brief space of a few hours. In 1868, Dr. Grainger Stewart called attention to the fact that acute atrophy of the * kidneys may not only be associated with, but precede, acute atrophy of the liver.^ It is generally asserted — and I repeat the state- ment, though I do not believe it — that mental depres- sion is its almost invariable exciting cause. It may 1)6 a predisposing, but that it is an exciting cause I am inclined to doubt. In the two typical cases I am about to relate, the depression of spirits was mani- festly the result, not the cause, of the attack. So I am inclined to think that the same is the case in the majority of others where marked depression of spirits is observed. It appears to me to be much more probable that the exciting cause is in all cases the direct accidental admission into the system of epizootic ^ On BrigMs Disease, p. 159. 394 DISEASES OF THE LIVER. disease-srerms. To which it has in some few instances been clearly traced. Symptoms. The symptoms in an ordinary case of acute atrophy of the liver may be said to begin with a feeling of restless uneasiness accompanied with a gTadually deepening yellow tinging of the skin, fol- lowed by headache, gastric derangement — vomiting — and pyrexia. In a few hours all these symptoms be- come alarmingl}' exaggerated. Bloody, bilious-look- ing vomiting sets in. The tongue becomes brown and dry. Shooting pains are complained of through- out the body. The patient assumes a depressed, typhoid look. The pupils become dilated. The mind wanders ; delirium supervenes, coma follows, and the patient sinks and dies without a single break having occurred in the rapid downward progress of the disease. The speedy diminution of the hepatic dulness in the perpendicular nipple line is the most characteristic, as well as the most curious, physical feature in the case. From four, or four and a half inches in extent, the livar dulness may in the course of twenty-four hours diminish to two inches, to one inch, or even less. While before another twenty-four hours have passed away, its boundaries may be actually inappreciable on even the most careful per- cussion. While, after death, instead of the organ ACUTE OR YELLOW ATEOPHY. 395 weighing about fifty ounces, as it ought to do, it may weigh but little more than twenty or even fifteen ounces, and present no appearance of a liver at all, but merely look a soft, pulpy, structureless yellow mass. Another marked and curious feature of this incomprehensible form of disease — which so closely resembles in many respects the contagious jaundice of the tropics — is, that although there are marked jaundice and deep saffron -coloured urine, the stools, as m contagious jaundice, occasionally present all the appearances of bile about them — when none is actually present — from their containing blood, from the very beginning to the very end of the attack. Treatment. As can easily be imagined, in rapid cases of acute atrophy of the liver, one can often do very little in the wa}^ of treatment. For, treat them as one may, the majority of the rapid cases prove fatal. So the only advice that can be given with advantage is to say : Direct all your energies to thwart what appears to be the immediate cause of impending death. If there be violent vomiting or diarrhoea, try to stop it. If there be obstinate constipation, give an active alkaline purgative. If there be acute delirium, give antimony, and apply ice to the head. If there be haemorrhage from mouth, nose, stomach, bowels. 396 DISEASES OF THE LIVER. or vagina, try to arrest it by the most appro- priate ordinary means. If there be (as sometimes happens) a diminished secretion of urine, give non- stimulating diuretics. If there be hepatic pain, apply hot fomentations ; and, above all things, support the strength of the patient by nourishing, non- stimulating, fluid diet. Avoid all lowering remedies. At one time it was generally believed that all cases of acute atrophy of the liver were necessarily fatal. Fortunately this is not the case, for in some the violent symptoms gradually disappear, and, as in contagious jaundice (yellow fever), recovery takes place after free evacuation of the bowels. I shall now relate two cases as an encouragement to others never to despair of a patient's recovery, even in very bad cases. For I believe, so long as life exists, there may yet be hope. I also select them as being examples of the disease occurring not only in the opposite sexes, but at totally diffe- rent periods of life. The first I shall relate is that of a gentleman aged 58 (brought to me by Mr. Roberts — formerly of St. Asaph, now of Den- bio-h), in whose case I took more than ordinary interest, from his being the son-in-law of one of our former presidents of the College of Physicians. He besran to feel ill a fortnio-ht before I saw him, with loss of appetite, sickness, vomiting, and sallow- 1 ACUTE OR YELLOW ATROPHY, 397 ness of the skin, but no pain. On June 9, 1869, when I first saw him, within a few hours after his arrival in London, his appearance made a profound impression on my mind. He had become dangerously- exhausted in the train on his way up to town, and had I been asked what I thought of his chances of recovery, I should have estimated the value of his life at not more than a few hours' purchase. He was deeply jaundiced. He had a typhoid, dark- furred tongue. The skin was burning hot, though moist and clammy to the touch. The pulse rapid, thready, weak, and intermitting. The expression dull and heavy. The intelligence sluggish, and his manner restless and fidgety. He complained of in- tense headache and general malaise, but no hepatic pain whatever, not even on firm pressure. On per- cussion, the hepatic dulness in the perpendicular nipple line was exceedingly difficult to ascertain in consequence of its small extent, coupled with the thickness of the abdominal parietes — for the patient was rather stout ; but in the nipple line it was cer- tainly not more than one inch in extent. While in the axillary line the perpendicular dulness was jlestimated at only one and a quarter inches. The urine [(was so loaded with bile as to be almost black. There l;was haemorrhagic vomiting and bloody stools, but I no distinct diarrhoea. The case was at once seen to be one of acute or yellow atrophy ; and a more 398 DISEASES OF THE LIVER. unfavourable one in appearance could scarcely be imagined. Yet, strange to say, tlie bad symptoms all yielded to treatment with marvellous rapidity : and the patient, to the astonishment of both Mr. Roberts and myself, got speedily well ; and what is still more surprising is, that his health has been satisfactory ever since. I have had occasion to examine the size of the liver of this gentleman several times during the last ten years (as he usually presents himself for inspection when ho visits London), and from within about the first eio'hteen or twenty months after the attack until now the liver dulness in the perpendicular nipple line has never been less than four and a half inches. After the attack the liver slowly but gradually in- creased in size. It was three inches within ten months after the attack, and I think had reached its normal dimensions in about fifteen months from the time he was first seen by me in London. Although my memory is a good one, in order tc make perfectly sure that the above statements re- o-ardinff the case were correct, I wrote to Mr. Roberts, and the following is his reply, dated Denbigh, Sep- tember 23, 1879 :— ' R. A. A , Esq., aged 58, was suddenly attacked with jaundice, and without any visibk premonitory signs other than a general feeling oi languor during the previous fortnight. Among the ACUTE OR YELLOW ATROPHY. 399 first immediate symptoms were restlessness and fear- ful headache. He was easily agitated, and his limbs became more or less tremulous. The pulse was ab- normally quick ; the tongue coated, and of a typhoid character. Another symptom was vomiting ; and on the mornmg of the third day the vomit was like coffee-grounds. [From blood acted on by gastric juice. — G. H.] The diminution in the hepatic dulness was very sudden and marked, and he complained of shght pain on pressure in the hepatic region. The urine passed was of normal quantity, but of the saf- fi'on colour peculiar to jaundice ; it had an acid re- action. The bowels were confined, and the fasces totally devoid of biliary matter, being of a doughy white clay colour. At my earnest request, on the fourth day, I got him up to London to consult you, with what result you can best describe. That was ten years ago ; and now to all appearance he may live other ten years. I may add that on the whole j Mr. A 's health has been very satisfactory ever j since.' , The treatment I adopted in this case was very ! simj^le. Hot bath, hot fomentations to the liver, grey powder, rhubarb and magnesia. Along with a I carefully regulated diet. j The other case, as I before said, I shall cite not I only from among the opposite sex, but also at the ' opposite extreme of life, and in a state of pregnancy. 400 DISEASES OF THE LIVER. It has an additional importance attached to it from the fact of the disease having attacked tlie patient almost as soon as she was capable of be- coming pregnant. The patient was a mere child in appearance, who at the early age of fourteen years and nine months was already three months advanced in pregnancy. She was admitted into University College Hos- pital, under my care, on July 30, 1864, and gave the following history as abbreviated from the case- book. Eliza N. Has always been subject to ' bilious attacks ' and ' fainting fits.' The latter usually coming on in the morning, when getting up. She states that she has had all the diseases of childhood, as well as smallpox and typhus fever. Has not menstruated for three months. On examinino; the skin of the chest in order to judge of the depth of the jaundiced tint, I was forcibly struck with the unusually dark colour of the nipples and their surrounding areolae, which was all the more remarkable on account of the smallness of the mammaB. A patch of a dark chocolate tint of exactly the size of a half-crown in diameter, with unusually large papillae upon it, surrounded each nipple, and this, fi'om the fact of the girl's hair being fair, notwithstanding her child- ish appearance, and her age being only fourteen years I and nine months, raised in my mind the suspicion that ACUTE OR YELLOW ATROPHY. 401 she might be pregnant, and the jaundice be in some way or other traceable to the pregnancy. For the depressed and anxious look of the patient, coupled with the comparatively slight tint of the jaundice, had already raised the suspicion that the case was not one of ordinary jaundice. Although the abdomen was not perceptibly en- larged to the naked eye, when the hand was placed in the umbilical region, immediately a well-defined moveable tumour was found, pear-shaped and some- what bio:2:er than a foetal head. On auscultation a foetal heart was distinctly heard beating 160 per minute, and in the left iliac region a placental murmur. She had had no mornino; sickness. On being closely questioned, patient acknowledged the possibility of her being pregnant, and said she thought that she might have become so on May 13, and that it was impossible to have been sooner, as she had just recovered from an attack of small-pox which had con- fined her to bed for three weeks. So, if her version were true, she was only two months and three weeks pregnant. The case-book further says : — Present attack : came on three weeks ago, with pain over her eyebrows. She at the same time noticed that her eyes became yellow. The night before she had a sharp pain coming on suddenly, and continuing the whole of that night in hepatic region ; has slight pain there now on pressure. No pain elsewhere. D D 402 DISEASES OF THE LIVER. States that everything she takes makes her sick: Bowels during the last three weeks have been much relaxed, and stools very light-coloured. Skin is of a slightly greenish lemon yellow ; the conjunctivae of a more marked jaundice tinge. Complains of pain in the epigastric region after eating, increased on firm pressure. Unusually marked tj^m- panites in hepatic region. Hepatic dulness in a line perpendicular to nipple, is very difficult to make out, but may be put down at only an inch in depth, commencing at one inch below the nipple. Urine high-coloured and stains the linen of an ochre colour. On August 10 the jaundiced tint of the skin had much decreased. While the hepatic dulness had in- creased to an inch and a half in depth. The stools were darker in colour, and the urine much paler. One thing about it was, however, peculiar — namely, that although the patient was taking three-grain doses of benzoic acid three times a day, not a trace of hip- puric acid could be detected in the urine. On the 24th the patient was so much better as to be dis- missed. Through the kindness of Dr. Wilks I had the opportunity of examining the liver, and analysing the urine, in a typical fatal case of acute atrophy, which he reported in the Pathological Society's ' Transac- tions,' vol. xiii. p. 107. The brief history of the ci ACUTE OR YELLOW ATROPHY. 403 is as follows : — E. K., aged seventeen, a married woman, in the third month of pregnancy, was seized with a bilious attack, and jaundice, after having a violent quarrel with her husband, who accused her of infidelity. The patient was first under the care of Mr. Bisshopp, of South Lambeth, who found her sufi'ering from jaundice, accompanied by some febrile symptoms, and vomiting. In two days she became delirious, had violent screaming, and convulsive fits, which were rapidly followed by ' unconsciousness. Next day the patient was seen by Dr. Wilks ; she was then quite insensible, with slight stertorous breathing, and foam on the lips. The pupils were moderately dilated, and sensible to light. The pulsp 120. The hepatic dulness reduced to a narrow band over the lower ribs. No urine had passed for twenty- four hours ; a catheter was therefore introduced, and twelve ounces of clear bilious-lookino; fluid were drawn off. This urine I had the opportunity of ana- lysing a few days afterwards. It was then of a yellow- ochre colour, and contained a considerable deposit. The analysis of this urine is given in detail at page 746, where I call special attention to the diagnostic value of ty rosin and leucin, two chemical products which are never absent from tlie urine in cases of acute atrophy of the liver. During the night before her death the patient aborted, and lost a considerable quantity of blood by 404 DISEASES OF THE LIVER. the vao-ina. The whole duration of the disease was merely six days, and the more urgent symptoms only manifested themselves two days before the fatal termi- nation. After death the liver was found to be very small in size, not exceeding, as was supposed, 1^ pound in weight. It was deeply stained yellow, and its cells were found to be small and broken up ; not an entire cell could be detected by either Dr. Wilks or myself — nothing, indeed, but a quantity of debris of hepatic tissue, and fat. The gall-bladder was contracted, and contained only a little mucus ; the urinary bladder was empty. In a case of acute atrophy of the liver, which was brought to the London Hospital, and placed under the care of Dr. Head, although the patient was a woman aged twenty-eight and of average size, the liver at the necropsy was found so small as, in the words of the reporter, ' not to have been seen on cutting through and folding back the abdominal walls ; until, on draw- ing down the coils of intestine, it was observed shrunken, as it were, and lying up under the ribs against the diaphragm. When removed, it was seen to be smaller and much thinner than natural. It was very flaccid, and folded by its own iveight over the hand. It weighed 1 lb. 15 oz. Its surface was smooth, and of a pale reddish-yellow colour. On section, its substance for the most part had a Turkey- ACUTE OR YELLOW ATROPHY. ^ 405 rhubarb -like yellow appearance ; almost all signs of lobular structure were lost. Here and there, however, were portions that seemed more healthy ; m such parts the intralobular veins were distinct ; and here also there were some minute blood-extravasations. The gall-bladder was almost empty. The microscopic examination of the liver showed there was recognis- able lobular arrangement ; and, although the minute biliary ducts seemed smaller than natural, yet their outline was distinct, but the liver cells were greatly altered, broken down, and almost completely disinte- grated, and in their place there was a larger quantity of granular debris. There were many granules, which permitted light to pass readily through their centre ; so-called fat-granules ; also some yellow seemingly bile-pigment. The fibrous matrix of the liver was very distinct. The capsule was for the most part normal ; but from its mider surface a number of cor- puscles were seen extending into the liver- substance, looking as if some new growth were going on at the time of death. The foetus, weighing 5 lbs. 14 oz., showed no signs of hepatic derangement. (' British Medical Journal,' July 25, 1874.) In a case reported in the ' British Medical Journal,' 1871, p. 367, by Dr. Clements, the liver of a girl aged seventeen, who died of acute atrophy, weighed only thirteen ounces. It is not in every case of acute atrophy of the liver 406 DISEASES OF THE LIVER. that the tissue of the organ is found soft and friable ; for in a case on which I was required to make a report for the Pathological Society in 1864 along with Dr. Murchison, the organ which was removed by Dr. Robinson from a soldier in the Scots Fusilier Guards, aged 20, though of a deep yellow colour, was found to be quite dense in structure. The organ, instead of weighing 4 lbs. as it ought to have done in a man of his size and age, weighed only 2.^ lbs. Yet. notwithstanding its dense structure, scarcely a single entire hepatic cell was to be found in it. Only granular matter and oil-globules. In the kidneys were found crystals of tyrosin ; but none were noticed by either of us in the liver. The crystals found in the kidneys were spiculated balls and stellate needle-shaped groups. The clinical history of this man's case was somewhat peculiar. He was being treated in hospital by Dr. Robinson for soft chancre on the prepuce, when he was noticed to be slightly jaundiced ; but his general health seemed to be un- affected. When on the morning of the second day after his admission (having taken a mercurial aperient the night before) he was found in a comatose state by the hospital-sergeant. The man was passing his urine involuntarily, and it was the fact of his comrade in the next bed noticing the urine trickling through the bed-clothes on to the floor that first called atten- tion to the poor man's comatose condition. When 1 ACUTE OR YELLOW ATROPHY. -107 visited shortly afterwards by Dr. Robinson, his pupils were found dilated and insensible to light. His skin cold. His respiration laboured. His pulse weak and slow. Nothing else was noticed until later in the day when he moved restlessly about in bed. Al- though the urine flowed freely, the bowels were not moved. He became gradually more and more j^ro- strate, and died on the following day. Exactlj^- thirty- two hours after he was found in the comatose state by the hospital- sergeant. In the ' Lancet ' of May 14, 1881, a fatal case of acute atrophy (under the care of Dr. Ralfe) is recorded in which no pain or tenderness of the liver was com- plained of until shortly before death. The chief symptoms being jaundice, nausea, and drowsiness, ending in coma. The patient was a man aged eigh- teen. His liver after death weighed only 2 lbs. 2 oz. ' Its substance was friable and rotten,' and on section presented a greenish-yellow hue. The gall-bladder was empty and shrunken. Dr. Ralfe thought the disease was ' excited by an indiscretion in diet.' Twenty years ago when I published my ])ook on the dift'erent forms of jaundice, neither I nor anyone else had the slightest idea that acute atrophy of the liver was a disease that ever attacked either infants or aged people. Lebert in his whole sixty-three collected cases gave only two under ten years of age. Since then, 408 DISEASES OF THE LIVER. however, our knowledge of the clinical history of the disease has greatly extended in consequence of several examples having been met with in infants. It is true that Politzer (' Jahrbuch fiir Kinderheilkunde,' 1860) had related the case of a new-born babe which was on the fourth day after birth seized with j aundice and black vomit, in which the liver became very small, and which terminated fatally on the fifteenth day of the attack ; but until more cases of the same kind were reported by other observers little or no attention was given to Politzer' s case. Now, how- ever, I have it in my power to cite many examples of acute atrophy of the liver in young children, and the one which I shall select as the most noteworthy is a typical case which was recorded by Dr. Hilton Fagge in vol. xx. of the Pathological Society's ' Transactions,' p. 212. The case is briefly as fol- lows : A little boy aged two and a half years was brought to the out-patient department on two suc- cessive weeks with what appeared to be ordinary jaundice, and had a mixture of taraxacum and nitric acid prescribed for him. The day after his last visit a double dose was twice given to him by mis- take, and shortly after\>^ards, as the father described it, he went 'raving mad.' The child soon became unconscious, and died two days after the onset of the serious symptoms. On post-mortem examination, ' the liver was found to be in a well-marked state of ACUTE OR YELLOW ATROPHY. 409 yellow atrophy, the cells being destroyed. There were also some balls of tyrosin in the substance of the organ.' Dr. Fagge adds that there was a rash on this child's skin, and that he had before noticed a similar condition in another somewhat similar case. In both instances he observed that the liver on section presented a ' pellucid nucleated matter,' and that he believes that ' the destruction of the hepatic cells is preceded by the formation of a fibrillated substance diffused through the organ.' I think it may be safely said that the chief feature in the anatomical condition of the liver in cases of acute atrophy is dissolution of organic structure. First, a rapid disintegration of the liver cells. Secondly, an almost equally rapid disintegration of tlieir sur- rounding connective tissue. And thirdly, a disinte- gration of the coats of the ducts and blood-vessels themselves. At the same time that the liver is atro- phied the spleen is in general tumefied. The name ' yellow ' atrophy was given to this acute form of liver disease, from the tissues of the organ after death being stained by the bile pigment of a distinct lemon or orange yellow hue. Quite a different tint from that met with in cases of jaundice from obstruction, when the liver is in general of a greenish -black colour. In acute atrophy, from the tinging of the liver being due to precisely the same pathological cause as the tinging of the blood serum 410 DISEASES OF THE LIVER. and skin, the hepatic tissue is not deeper coloured than the rete niucosum. Having thus fully described the nature of the acute atrophy of the liver which occurs sporadically in temperate zones, I shall now proceed to fulfil my promise of pointing out more fully how closely it re- sembles the contagious jaundice of the tropics both as regards its etiology and pathology. Indeed the only pomt of difference existing be- tween contagious jaundice of the tropics and acute atrophy of the liver of temperate zones is that, while the former almost invariably assumes an epidemic, the latter almost equally mvariably occurs only in an isolated and sudden sporadic form. This distinction between these two differently named diseases is, how- ever, one of no pathological importance whatever. For it may be thought and said to be merely due to the climatic differences existing in the localities of their occurrence. Which seems indeed to be proved by the facts : — 1st. That even the most virulent forms of conta- gious jaundice not only rapidly die out, but entirely cease to be contagious or infectious, when imported, as they occasionally are in ships, into temperate zones. 2nd. Occasionally, even sporadic cases of con- tagious jaundice occur within the climatic area of the epidemic form of the disease. I ACUTE OR YELLOW ATROPHY. 411 3rd. Acute atrophy of the liver sometimes as- sumes a contagious form even in this country. For, 88 Graves in his clinical lectures relates, two members of the same family were attacked by the disease about the same time. And the reason why it did not become epidemic was no doubt simply due to the absence of those climatic influences which favour its spread. 4th. Both diseases are attended with a marked heemorrhagic diathesis. Blood being extra vasated into the stomach, giving rise to black vomit, and into the bowels, giving rise to black tarry -looking evacua- tions. oth. Both are attended with febrile symptoms and cerebral disturbance. 6th. Both are essentially blood diseases, in the true sense of the word. That is to say, both are the result of an organised disease-germ fructifying in the system. Xo matter what its mode of introduction into the organism may have been. By direct con- tagion or otherwise. 7th. Bacilli (by observers, before the different forms of disease-germs were properly differentiated, spoken of as Bacteria : see my papers in the ' Lancet ' of June and July, 1881) have been abundantly found, both in the tissues of the liver and in the blood, in all the fatal cases in which they have been looked for. 8th. Neither in the case of acute atrophy nor in 412 DISEASES OF THE LIVER. that of tropical contagious jaundice is the liver, though the most prominently, the only organ at fault. Its softened condition being merely one of the local mani- festations of the disease-germs' action. Exactly in the same way as the sore throat in scarlet fever, the pustular eruption in small-pox, and the enlarge- ment of the spleen (ague cake) in paludal inter- mittent fever, are all merely jDortions of the general diseased action. 9th. The post-mortem appearances of the liver are in both identical. Although jaundice the result of acute atrophy of the liver might in all cases be thought to be a typical example of jaundice arismg from a complete suppres- sion of the biliary function — the diminution in secret- ing substance naturally inducing a diminution in secreting power — it is not so, because, although less bile than usual is secreted, there is nevertheless sometimes nothing like an entire suppression of the biliary function. Which circumstance most pro- bably arises from the fact that, although by far the greater part of the biliary secreting cells are dis- organised, there still remains a sufficiency of them to carry on to some extent the secretion of bile. Dr. Hilton Fagge has, I think very judiciously, suggested that, as the whole of the liver is not attacked uniformly, some parts being much sooner affected with the dis- ease than others, the secretion of bile may go on in ACUTE OR YELLOW ATEOPHY. 413 the parts less affected, while it is completely stopped in the others, and hence the stools may in some instances actually contain bile. ('Guy's Hospital Reports,' p. 159, 1875.) The presence, too, of violent cerebral symptoms of bile-poisoning leads to the same conclusion. The cerebral symptoms which supervene in bad cases of jaundice are all in general said to be due to what is called Bilcemia. Xamely, to the toxic effects produced upon the nervous system by taurocholic and glyco- cholic acids, or rather, I should say, their compounds, circulating in the blood, and giving rise to convul- sions, delirium, and coma. As this, I believe, is by no means the case in the class of cases now under con- sideration, and the whole subject of cerebral dis- turbance in cases of liver disease requires revision, I shall here introduce a separate chapter upon the matter. The Etiology of Cerebral Derangements in Febrile Forms of Hepatic Disease. At one time it puzzled me, as it must have done everyone else who has cast a thought on the sub- ject, why — if the theory of bile-poisoning being the cause of the cerebral symptoms in cases of jaundice be correct — it so frequently happens that while cere- bral and other nerve symptoms sometimes supervene in a few days, or even hours, after the commence- 414 DISEASES OF THE LIVEK. ment of the attack, in certain other cases of jaundice from obstruction, where not only the blood, but every tissue in the body — judging from the prolonged du- ration of the attack and the depth of the discolora- tion of the skin and urine — must have been saturated with the constituents of the bile for many weeks, not a vestige of nerve derangement is perceptible. Beyond the mere symptoms of prostration and cerebral ex- haustion, which are common to all cases of disease associated with malnutrition of the nervous system. A knowledge of these facts drove me to search for some other assignable cause of the presence of head symptoms in certain cases of acute jaundice, and it was a long time before I could satisfactorily to myself account for them. Now, however, I think that I have obtained a scientific and logical solution to the pro- blem. Which is this. In all cases of jaundice where cerebral symptoms rapidly supervene, the fons et origo of the morbid state inducing it may be said to be germs. Thus the cerebral syniptoms supervene very rapidly in acute atrophy of the liver, in contagious jaundice (yellow fever), and tolerably speedily in severe cases of malarial and paludal jaundice. All of which, as I have already I think conclusively shown, are due to pathogenic germs. Now, if this part of my proposition be granted, the subsequent details connected with it are simple enough of com- prehension. Even although, at first sight, from their CEREBRAL DERANGEMENTS. 415 very novelty, they may appear improbable. They are as follows : — All physiologists are agreed that cerebral symp- toms and spinal nerve disorders, drowsiness, delu'ium, coma, convulsions, and paralysis of a particularly well-marked character, follow the artificial introduc- tion into the healthy animal body of both physiological and pathological forms of toxic germs. The only point of difference among them really is as to the proximate cause of the nerve disoi'der. Some think it due to the non-elimination of excrementitious sub- stances from the blood, and consequent poisoning of the nerve tissue with biliary matters, urea, uric acid, and other such like effete products. While again, the most recently broached theory is that of M. Pasteur, who, from observing the drowsy condition of the fowls into whom he had injected chicken -cholera germs, has been led to believe that, during the hfe of the parasitical germs in the birds' bodies, a species of narcotic is formed in their blood which produces the somnolent symptoms ; yet be it observed, he at the same time attributes their death to a combination of other causes. To wit, pericarditis, serous extravasa- tions, and asphyxia (' Chemical News,' January 7, 1881). Mark the last assigned cause. For what I am about to say has an important bearing on as- phyxiation. With Pasteur's narcotic theory 1 have no sym- 416 DISEASES or THE LIVER. pathy whatever. For after having given considerable attention to the spontaneous production of toxic sub- stances in dead animals — from my having in the year 1857 thought I had discovered that hydrocyanic acid spontaneously formed in dog's intestines after death — I fancy I can give a much more philosophic theory of the drowsiness his fowls presented, as well as of the exactly analogous comatose symptoms manifested by my dog killed b}^ snake-poison/ and the cerebral symptoms met with in human germ disease, than to imagine that germs manufacture a narcotic in the circulation. I shall relate a personal reminiscence which tends to throw considerable light upon the subject. Everything is said to be fair in love and war, and I think my readers will therefore not feel shocked if I add to my list of arguments in favour of the germ fermentation theory an account of a practical joke which was played upon me during the time I studied in Grermany. Everyone knows that when a sufficiency of alcohol in any form what- ever enters the stomach it affects the brain. At first it stimulates, and makes lively. Next it acts like a hypnotic, and makes drowsy. While, finally, it nar- cotises, and makes insensible. The alcohol contained in wine is, or at least ought to be, the direct product of the fermentation of the sugar of the ripe grape. During the early stages of vinous fermentation the ' Royal Society's Transaciions, 1864. I ETIOLOGY OF CEREBEAL DERANGEMENTS. 417 fermenting liquid — ' must,' as it is called — is crowded with actively developing living organisms. The un- wary drink this sour- sweet fermentmg liquid, loaded with life, without the remotest suspicion of its pos- sessing inebriating properties. Without dreaming that while they might drink a whole bottle of the wine made from it without a feeling of cerebral dis- comfort, a tumbler of this fermenting ' must ' may prove a disagreeable narcotic. This I learned by a personal experience made in the following wise. While working in Kolliker's private laboratory at Wiirzburg in 1853, my companions were among the Privatdocenten — all of whom who are yet alive being now distinguished professors at different German universities — and it was our usual habit to take a long walk into the country after our day's work was done, and before commencing our evening's studies. On one occasion we reached a little hillside village Wirthshaus just as its occupants were busily attending to the fermentino^ wine ; and while we were standins: looking at them, one of my companions — now Pro- fessor Friedreich of Heidelberg — handed to me a lecher of must, freshly drawn from the fermenting cask, saying, ' Taste that, Harley, and see how good it is.' It being as agreeable as it was novel to my palate, I drank it all. He then took the goblet, refilled it, and laughingly handed it back to me, saying, ' You have nothing so good as that in E E 418 DISEASES OF THE LIVER. England — take some more.' But, from the smile on his face and his taking none himself, suspecting that there was possibly some trick or another being played upon me, I did little more than taste the second tumblerful ; and lucky it was that I did so, as it afterwards turned out. For notwithstanding that there could have been scarcely any alcohol m the must — from the fermenting process having not yet been nearly completed — we had shortly after- wards scarcely begun the descent of the hill, when ] began to feel giddy, my ideas to become confused and my gait unsteady. In fact, I was in a state not of alcoholic intoxication, but of ' fermentatior inebriation.' Exactly in the condition of the dof into whose blood the puff-adder virus had entered and the fowls into whose circulation M. Pasteui put chicken- cholera germs. The state I call ' fer- mentation inebriation.' Fortunately, in my case the effects were of short duration ; but it was { warning to me never again to give my companion ^ the chance of repeating on me a germ-fermentatior experiment. I totally disagree with Pasteur when he sayt that the chicken cholera-germs he introduced intc the fowls formed a narcotic in the blood, if by th( term narcotic he means some alkaloid or another For such a proposition is not only undemonstrable but, as I shall now proceed to show, wholly unne I ETIOLOGY OF CEREBRAL SYMPTOMS. 419 cessary. I believe germs produce the cerebral symp- toms he describes exactly in the same way as any gas, fluid, or substance which narcotises by virtue of preventing the brain -substance from being supplied with a sufficiency of properly oxygenated pabulum. In a word, by diminishing tissue oxidation. This is a theory easily understood when it is recollected that if, from any cause whatever, a sufficient amount of oxygen is prevented from obtaining access to the brain, first drowsiness, and then insensibility, is the immediate result. This is most easily demonstrated by making animals breathe harmless nitrogen gas — air simply deprived of its oxygen. Not alone insensibility, but profound coma and death, soon follow upon an absence of oxygen in the blood. While convulsions, terminating in paralysis, are well known to be the efl'ects of a prolonged diminished supply of oxygen to the spinal cord. It is to be remembered that marked dyspnoea is a sign in many germ diseases ; and not only is it common in miliary fever, scurvy, and purpura, but it likewise existed in a very striking degree in Pas- teur's fowls inoculated with chicken -cholera germs, as well as in my dogs poisoned with snake-venom germs. The explanation of this is, to my mind, very simple, on the ground that the presence of disease- germs in the circulation interferes with the due and £ £ 2 420 DISEASES OF THE LIVER. necessary oxidation of the normal nutritive materials of the blood. For example, so far back as in the year 1856, I pointed out in papers entitled the ' Physiological Action of Strychnine ' and the ' Direct Action of Strychnine on the Spinal Cord ' (' Lancet,' June 7 and 14, and July 12, 1856), the rationale of the convulsive and comatose symptoms arising from toxic agents which destroy the power of the blood- corpuscles to take up the necessary quantity of oxygen for their wants. As I then pointed out, whenever the oxidised materials required as nourish- ment by the nervous system are either deficient in quantity or impaired in quality, disordered function of the nerves is the immediate result. We have a most striking example of the former condition in cases of hteraorrhage, where an insufficient supply of the oxidised substances is not unfrequently followed by convulsions ; while the latter is exemplified in cases where oxygen is prevented from entering the blood, and consequently the organic substances fail to be- come oxidised and fitted for their peculiar office. Lastly, nerve-disorder occurs when even both the oxygen and the organic substances are present, but where the oxidising process is either partially o^ totally arrested by the presence of a foreign sul stance possessing the pro])erty of hindering the coni stituents of the blood from combining with oxygen] Derangement in the functions performed by the mole ETIOLOGY OF CEREBRAL DISTURBANCE. 421 cules of the nervous system occurs just as surely in the latter set of cases as when either the oxygen alone, as in the second, or both the oxygen and the oxidisable materials, as in the first instance, are wanting. Germs act in the third of the ways cited — that is to say, they have no immediate effect upon the nervous system themselves, but only act indii-ectly through the power they possess of using up the oxygen which ought to go to oxidise the constituents of the blood, and thereby fit them' for the purposes of nerve nutrition. This mode of action is readily accounted for by the fact that all germs have a very active respiratory function — absorbing oxygen and exhaling carbonic acid exactly as other animals and vegetables do — and in direct proportion to their respiratory activity is their deleterious action on the constituents of the blood, and through it on the nervous system of their host. For the more oxygen the germs consume, the less is there left to enter into combination with, and oxidise the host's tissues, and keep them up to the proper working standard. As the just appreciation of this novel theory requires not only physiological knowledge, but an intimate ac- quaintance with the life-history and physiologico- chemical actions of disease-germs, and I cannot afford space to go into more details, I beg those of my readers who are not well versed in the matter, before reading further, to peruse the chapters on the Pyrexia 422 DISEASES OF THE LIVER. and Foetors of Disease. For, as I explained in the Preface, as I have no space to waste in unnecessary repetitions, many of my data and arguments must be considered not in fragments, but as one great and indivisible whole. Many poisons, I doubt not, exert their influence on the nervous system in an equally indirect manner ; for I have found that hydrocyanic acid, chloroform, nicotine, alcohol, ether, morphine, and several other narcotics, have the power of de- stroying the property possessed by the organic con- stituents of the blood of absorbing oxygen and ex- haling carbonic acid. And as strychnine, which is a markedly convulsion- producing poison, has this power, as I showed in the papers above referred to, I believe its physiological action on the nervous sys- tem is due to its preventing, like germs — though by another process — the nerve-tissue of the whole cere- bro-spinal system receiving properly oxidised pabulum for its nourishment, and, as a natural consequence, its functions are thrown into disorder, and delirium and convulsions occur ; just as they do when it receives an insufficient supply of blood pabulum — as happens in cases of haemorrhage. In cases of fevers, again, there are additional causes of nerve disorder. Among the most promi- nent of which is increased temperature. No one doubts the power of heat in producing nervous dis- turbance, since all know the rationale of sunstroke j ETIOLOGY OF CEREBRAL DISTURBANCE. 423 and it is consequently easy to understand how the heat developed in the body by the germs' fermenta- tion must act prejudicially upon the nerve-tissues, already weakened from being supplied by pabulum not properly prepared for then- wants. The lassitude, nervous prostration, and want of mental as well as bodily power, which are so charac- teristic of all germ diseases, ought to be attributed to the above causes. For as soon as the crisis of the disease is passed and the germs are eliminated, all the visible signs of vital exhaustion rapidly dis- appear ; thereby showing that they only depended on the existence of temporary causes such as I have shown in the manner above described would be pro- duced by germs. Before quitting the question of the etiology of germ-action in producing nerve disorder, I must add a few words on the rationale of the cause of the sudden production of nerve symptoms and rapidly fatal ending in certain cases of diabetes wliich appear to be so absolutely unaccountable as well as so startling to the uninitiated, from the patients being often apparently in their ordinary state of health one day and yet dead the next, as the consideration of them throws some light on the etiology of the cerebral disturbance met with in certain cases of liver disease. In the ' British Medical Journal ' of November 1, 1879, it is stated that Dr. Jules 424 DISEASES OF THE LIVER. Cyr, in the December and January numbers of the ' Archives Generales de Medecine ' for 1877-8, details thirty-two cases of sudden death in diabetes, collected from various sources. He considers that there are at least five different conditions to which these may be ascribed : 1. The formation of acetone in the blood under conditions nearly unknown — ace- tonsemia ; 2. The accumulation of excessive quantities of sugar in the blood — hyperglycsemia ; 3. The re- tention of urinary solids or water in the blood — uraemia, dropsy of the ventricles ; 4. Atrophy of the cardiac muscles ; 5. Cerebral anaemia. Of the thirty-two cases, twenty-one are stated to have died comatose ; in a few the mode of death is not stated ; in others there is no mention of coma ; but this large proportion shows the relative frequency of this mode of death. Dr. Balthazar Foster has in the same journal, of January 19, 1878, urged the proba- bility of acetonaemia being the cause of death in a large number of diabetic cases. This theory he sup- ports by quoting three cases from his own practice ; in the first no smell of acetone was noticed in the breath, but the blood of the patient, examined after death, was of a peculiar pale colour and creamy con- sistence ; under the microscope, the blood -corpuscles were broken down into a granular material, which he subsequently found could be artificially imitated by treating blood with acetone. In the other two cases ETIOLOGY OF CEREBRAL DERANGEMENTS. 425 there was a strong odour of acetone in the breath of the patients. Dr. Foster alludes to the objection which has been made that, in many cases, no odour of acetone is perceptible, and replies that a tempera- ture of 100° Fahr. is necessary to volatilise acetone. Kussmaul (' Deutsches Archiv fiir klinische Medicin,' 14 Bd., 1874) has gone very fully into this ques- tion of aceton^emia, and from his experiments con- cludes that it is not possible to believe in a theory of acute intoxication from acetone, but that chronic poisoning by this substance may so affect the nervous system as to render it liable to take on an acute form, just as chronic alcoholism may suddenly ex- plode in delirium tremens. As the onset of the dangerous and fatal symptoms in these cases of diabetes always occurs suddenly, and when, as far as one can see, the pathological conditions existing in the patient are not in the least different from what they have been for months or it may even be for years previously, it is clearly evident that some change has suddenly been brought about in the patient's body by the introduction of an entirely new element. That new element is, to my way of thinking, the accidental and sudden introduction into the system of ferment-germs. The blood of the diabetic patient is full of sugar. The temperature of his body is exactly the one of all others the most favourable for the fermentation 426 DISEASES OF THE LIVER. process ; so that nothing further is wanting to in- duce a fatal fermentation of the blood than the presence in it of ferment-germs. They at length, I believe, from some cause or other, find accidental admission, and instantly, as a natural consequence, fermentation begins ; and in a few hours, or it may even be minutes, the blood's constituents have under- gone a sufficient amount of morphological and chemi- cal transformation to induce all the usually described chain of nervous symptoms which culminate in the sudden death of the victim. Why, it may be asked, if this theory be cor- rect, did the ferment-germs which entered my stomach along with the must I drank, and which must have got into my blood, or otherwise they could not have produced the chain of effects which I have described under the title of ' fermentation inebriation,' pass so soon away, and not only not kill, but even leave in me no bad after-results ? This question, I think, is very easily philosophi- cally answered. Had I been a diabetic patient, and my blood loaded with sugar, the must-germs would in all probability, having found suitable pabulum, have increased and multiplied, and thereby set up an amount of fermentation changes in my blood sufficient in all probability to have killed me ; but I was not a diabetic patient, and my blood was not loaded with sugar. Consequently, as the germs ETIOLOGY OF CEREBRAL SYMPTOMS. 427 found but little food for their growth and multiplica- tion within my circulation, they could neither set up within it a rapid and, to me, fatal fermentation, nor could they themselves live there. From there being no suitable pabulum for them to live upon, they were simply starved to death ; and, as a conse- quence, the slight disturbance they were at first able to create soon entirely ceased, and their involuntary host speedily felt no farther effects from their tempo- rary sojourn in his system. I am not quite sure if delirium tremens — the re- sult of alcoholism — may not be a condition of system due to the action of germs. Germs, as we know, are essential to the production of all fermented in- toxicating liquids, and the peculiar odour of the perspiration in delirium tremens points to germs having something to do with the symptoms. It is usually described as being of a saccharo-alcoholic description. Not unlike that arising from fermenting must. Again, I attribute the local gangrenes and slough- ings, which occasionally take place in typhoid cases and diabetic patients, to the germs producing them being of the species that thrives locally. Some germs, we know, have a tendency to produce only local effects, and others, again, general. In the way typhus-fever germs always produce a general disease, while vaccine germs give rise usually to a merely local affection. 428 DISEASES OF THE LIVER. The kind of germ in the two sets of cases determinins: CD O the nature of the result. The delirium which is such a prominent concomi- tant of contagious jaundice, and atrophy of the liver, and other forms of acute and febrile hepatic disease, is, I believe, as in diabetes, due to the presence of fermentation -germs in the patient's blood. Whereas the cerebral symptoms which accompany the chronic forms of jaundice from obstruction and suppressed secretion are due to the condition called bilasmia, as above interpreted. Treatment in Cerebral Cases. It is well to remember that in cases of hepatic disease, with delirium and other forms of head symptoms, associated with marked pyrexia, there are other ways and means of reducing the circulation, the temperature, and the head symptoms, than by the admmistration of quinine and other forms of germicides spoken of in the general chapter upon remedies — to wit, the administration of aconite or digitalis. Or, if these are considered inadmissible, the direct application of cold to the head m the shape of an ice-bag or cold-water head -irrigator. In most cases, James's Powder, as well as the liquor ammonise acetatis, is useful in subduing vio- lent delirium. When suddenly called to the bedside of a delirious TREATMENT OF CEREBRAL SYMPTOMS. 429 patient labouring under jaundice, the pathology of which is obscure, it is always well to bear m mind before prescribing that dark stools are not, per se, proof of the presence of bile in them ; for, as already- shown, the black bilious-looking colour of the mo- tions may be due, not alone to the presence of blood in them, as happens both in cases of contagious jaundice and acute atrophy, but to the medicines the patient has been taking. That delirium in the case of contagious jaundice is accompanied with intense febrile symptoms, and in the case of acute atrophy by greatly diminished dull hepatic area. When, again, the delirium is the result of pyiemic jaundice, it differs from that occurring in both of the preceding cases, not alone in ha^^ing been slow and gradual in its advent, but in having been usually preceded by distinct symptoms of hepatic mflamma- tion. Be the cause of the delirium, however, what it may, it invariably indicates the existence of danger to life, from the circumstance that it is due to blood- poisoning. In the case of acute atrophy and pyaemia from a form of albuminoid putrescent fermentation. In contagious jaundice, and in malignant jungle-fevers, from a malarial or paludal vegetable germ-growth. Consequently, in all cases of delirium occurring in the course of hepatic disease, it is good policy to favour, in every possible way, the elimination of the poisoning materials from the blood, and this 430 DISEASES OF THE LIVER. is best done by increasing the action of the skin as well as of the kidneys. Brisk cutaneous friction, a hot-air, a steam, or a hot- water bath, ought there- fore to be had recourse to, according to the consti- tution and strength of the patient, at the same time that diuretics, such as squills, digitalis, broom-tops, or sweet spirits of nitre, are administered by the mouth. In some cases the stools are loose, but not always, and in the latter case their free action should always be encouraged by the administration of vegetable purgatives, such as castor-oil, colocynth, or rhubarb, when mercurials are contra-indicated. As the lungs greatly assist the skin and kidneys in eliminating biliary products, and thus mitigate cerebral symptoms, the free access of dry fresh air is an adjunct of great therapeutical value in all cases where there are signs of blood-poisoning. As I have thus far digressed from the immediate consideration of atrophy of the liver, I must not let the opportunity slip of saying something on the pyrexia of hepatic affections. For I am of opinion that it is quite as great a clinical pathological puzzle as the rationale of cerebral disturbance, if not even a still greater. From the causes of pyrexia as a whole not only being but imperfectly interpreted, but ac- tually, I believe, entirely misunderstood. I shall therefore here bestow another entire chapter on its' consideration. And shall treat the question on the ETIOLOGY OF PYREXIA. 431 same broad basis as I have done cerebral derange- ments, so as to make my remarks applicable to all kinds of pyrexia in general, fevers, &c. The Etiology of Pyrexia. The etiology of the abnormal temperature met with in a variety of different diseased states of the human system is a subject which has puzzled the philosophic physician ever since clinical thermometri- cal studies began. From the ever recurring question being ' Why does the temperature of the human body fluctuate so greatly in disease without any apparent assignable cause, when it remains so stationary during health in spite of many well-marked assignable reasons ? ' Scientists as well as able philosophic phy- sicians have at various times and in different ways tried to explain the reason why the temperature of the healthy human body is at the North Pole, with an external and breathing temperature of 46° Fahr. below the freezing point, exactly the same, to within a few tenths of a degree, as it is at the tropical equator with an external temperature of 136°. Giving thus a range of difference of 150 degrees. This to the reflecting mind is an astounding fact. When it is remembered that the temperature of the diseased human body often varies as much as 10° in the space of a few hours, not alone while the external tempera- 432 DISEASES OF THE LIVER. tui'e remains stationary, but even when it is reduced to more than a half of the temperature of the body itself. In perfect health the temperature of the human body is subject to periodic fluctuations, and these physiological diurnal fluctuations of temperature were ascertained by Dr. AYilliam Ogle (St. George's Hos- pital Report, 1866) to be at their minimum at 6 a.m., and maximum between 2 and 4 p.m. The diff'erence ranging in diff*erent persons from a half to a whole degree. These physiological and pathological facts, even when regarded by themselves, convincingly show that the biological laws regulating the temperature of the human body in health are entirely set at naught in disease. So that we cannot apply to them for a satisfactory answer to the question of ' What is the cause of abnormally high temperatures ? ' but seek for its explanation not alone outside the pale of healthy action, but probably even beyond the confines of the human body itself. Indeed, I thmk I may as well here at once further state that it is my opinion that the reason why the causes of the high temperatures in disease have not as yet been satisfactorily explained arises in great measure from two circumstances. 1st. That all abnormal high temperatures have been placed in the same category, and consequently ETIOLOGY OF PYEEXIA. 433 been attempted to be explained by one and the same theory. 2nd. From cases of pyrexia having been supposed to originate in, and be due to, abnormal nerve action. Pyrexia, for example, as defined by Aitken in his able work on the ' Science and Practice of Medicine,' is : ' A comj)lex morbid state wliich ac- coQipanies many diseases as part of their phemomena more or less constantly and regularly, but variously modified by the specific nature of the diseases which it accompanies. It essentially consists in elevation of temperatiu^e, which inust arise from an increased tissue change, and have its immediate cause in alterations of the nervous system.^ (The italics are mine.) This de- finition is founded upon the published views of Parkes, an English physician ; Virchow, a German pathologist ; and Bernard, a French jDhysiologist whose opinions upon the etiology of pyrexia are those which within recent years have been received with most general favour all over the Avorld. These writers having at- tributed the increase of bodily temperature in all cases of disease, even in fevers — that is to say germ diseases — to increased blood and tissue metamorphosis. In- duced by an abnormal action of the nervous system. Founding this opinion on the well-known fact that section of the eighth pair of cerebral nerves in the neck of a rabbit not only produces an increased flow of blood to that side of the face and head, but an F F 434 DISEASES OF THE LIVEK. increase of temperature. This nerve theory beinp^ further supported by the fact, that so soon as the nerve influence is artificially restored by galvanising the upper end of the divided nerve, the turgescence of the vessels diminishes, and the temperature of the parts supplied by them falls. Now I may add that, on these experimental phy- siological facts, the generally accepted nerve inducing blood and tissue metamorphosis theory of high tern-- perature in certain (though not in all) forms of disease may be scientifically accounted for. On the supposi- tion that, on account of the centripetal nerve lesion, the inhibitory action of the nervi vasorum is lost. In consequence thereof, the vessels lose their tonicity, and allow the blood to rush through them in mcreased volume, and probably at the same time also with in- creased speed, from the heart's action being likewise accelerated. Assuming then that this theory is physiologically and pathologically correct, it gives a satisfactory ex- planation to all the cases of elevation of temperature arising from nerve irritation and nerve lesion, such as those reported by Dr. Good ridge, where, in a case of softening of the pons Varolii, the thermometer indi- cated a temperature of 103°. In Dr. Little's case of C]prebro-spinal meningitis, where it stood at 106°, and in Mr. Teale's case of concussion of the brain with spinal injury where it rose to 108° Fahr. As is seen, I am not quoting the extremely high readings ETIOLOGY OF PYREXIA. 435 of the thermometer which occurred in those cases, ].eing in Mr. Teale's 122°, and in Dr. Little's 133°/ MS they are now regarded by many as fictitious, and it is not with the etiology of fictitious but of real high temperatures I am now dealing. So I leave the exceptionally high thermometrical readings of the above-cited cases aside, and merely cite such as may be accepted by us as real. Now I come to an important point — which is, that, while I believe the nerve inhibitory theory yields a satisfactory solution to the probable cause of the bodily temperature being increased in all cases of idiopathic as well as traumatic nerve de- rangements, I consider that it is not only totally inadequate, but totally inapplicable, as a rational explanation of the cause of the increase of bodily temperature occurring in any of the other kinds of diseases in which it is usually met witli — to wit, those grouped together under the name of true pyrexial or febrile diseases. Which all belong to the germ class of infectious, contagious, and inocu- lable affections. I will even go so far as to say that the nerve theory of high temperatures when applied to any single one of them is radically wrong, and even, at the risk of startling some of my readers, add tliat the increase of bodily temperature in such cases has ' See Medical Times and Gazette, November 5. 1881. F F 2 436 DISEASES OF THE LIVER. possibly — ay, even probably — primarily nothing to do with the patient's nervous system whatever. Nay, even more, I am actually prepared to assert, as well as to prove, that the heat of the body in pyrexial diseases of the infectious, contagious, and inoculable class, has primarily nothing whatever to do with the patient's own body, but entirely origi- nates in, and is dependent upon, the activity in the development of parasitic germ life. This may appear to be an astounding proposi- tion, but I venture to say it is only astounding because it is new ; certainly not because it is untrue, as the sequel will show. In my mind, the nerve and tissue metamorphosis theory of high temperature received its death-blow when, on proceeding to make the necropsy of a well-developed plump young woman of 20 years of age, who died on the night of her admission into University College Hospital of acute pericarditis supervening in scarlet fever with cerebral symptoms, I found the tissues of the body quite warm. Not- withstanding that the body had lain for several hours in the cold post-mortem room. I was told that she had died during the night, and, as is well known, the term ' during the night,' in hospital par- lance, is in general intended to mean between theJ hours of 11 P.M. and 4 a.m. So that this woman hadj probably been dead not less than ten, and not more] ETIOLOGY OF PYREXIA. 437 than fifteen hours, as I made the post-mortem at the usual hour of two o'clock. Well knowing that the human body cools rapidly after death — sometimes, indeed, the extremities and exposed parts becoming stone cold even before the vital spark has fled — I was surprised to find this woman's body quite warm, that the chest steamed when opened like that of a newly-killed ox, and that the heart felt hot to the touch. jFrom my not then perceiving the great clinical importance of finding that a dead human body in certain forms of disease might retain an abnormally high temperature, and having no clinical thermometer at hand, I neglected to send for one. Yet I think from my familiarity with manual temperature-taking, that in this case it was certainly not less than 100° — probably even as much as 102° — notwithstanding that she had lain several hours dead in a cold room. Which fact is of course of immense importance when taken into consideration with the high temperature theory of the present day. For seeing that life was extinct, and consequently the circulation not only completely arrested, but all nerve force totally annulled, how could it be possible that the temperature of this woman's body could be maintained on the nerve influence and tissue metamorphosis theory ? Simply impossible. And many and many a time since my eyes were opened to the importance of this fact, 488 DISEASES OF THE LIVER. have I reflected on this, to me, extraordmary ob- servation, and long and patiently have I waited in the hope of meeting with a similar case which I might be able to thoroughly investigate. Fortunately at last my wishes have been fulfilled. Not, hoAvever, by my meeting with a similar case, but by what is equally good, if not even better — findmg one ready to hand by Professor Wunderlich. Which has not only the advantage of being reported by a trustworthy and perfectly independent observer, but likewise that of not having attracted his atten- tion to it in the important way it has mine. Professor Wunderlich gives to his case the title of ' rheumatic tetanus,' and he says that after the patient's death the temperature did not alone not begin to diminish, but actually went on increasing until within an hour after death, when it was found to have risen from 112-5° to 113-8°. That is to say, 1*3° Fahr. ; and, further, the temperature of this corpse did not fall even so much as to the normal standard until thirteen and a half hours after death. Here then is proof positive that nerve influence is not the sole cause of the temperature of the body bemg increased in all forms of disease, as stated by Bernard, Parkes, Ludwig, Yirchow, and a host of subsequent writers. For in one of the above-cited cases we see that not alone was the high tempera- ture of the body maintained, but actually increase( ETIOLOGY OF PYREXIA. 439 after death. When not only the circulation of the blood had completely ceased, but all nerve influence had been likewise totally extinguished. The factor of death thus gives the coup de grace to the commonly accepted theory of the probable cause of abnormally high temperatures in certain forms of disease being due to a hyper blood and tissue metamorphosis, induced through the inter- mediary action of a living nervous system. Having thus demolished the nerve theory of pyi'exia in cases of germ disease, and shown that it is only applicable to the local and general increase of bodily temperatures arising m a limited number of cases as the direct result of nerve irritation or lesion, I shall now attempt to establish another theory of abnormal temperature, on a soundly scientific and demonstrable basis, and one, too, which shall be applicable to all the forms of pyrexia met with in infectious, contagious, and inoculable diseases. In order to save time, I shall begin by at once stating that I believe that in as far as the etiology of the increase of bodily temperature in germ diseases is concerned, the nerves, blood, and tissues of the human body merely play the part of passive agents. The abnormal heat of the body being produced by, and totally depending upon, the development, growth, and multiplication of the germs engaged in producing the disease. The pyrexia being in 440 DISEASES OF THE LIVER. fact the outcome of the germ's life itself, and the rise in the temperature of their host's body nothing else than the chemico-physical effects of the heat developed by the germ's respiratory activity. Animal heat being, as we know, one of the products of tissue oxidation. These remarks may probably appear to some of my readers as absurd ; but like many other state-, ments the apparent absurdity only exists in their novelty, as I shall now proceed to show. But in order satisfactorily and conclusively to prove the justness of the ideas I am endeavouring to pro- mulgate I must request my readers to allow me to address them for a few minutes not as physicians and surgeons, but purely as physiologists. For in the present, as in many other cases, my pathological theory is entirely dependent for its logical explana- tion on the twin sister science of physiology. A thing not to be wondered at, seeing that both patho- logy and physiology are the offspring of one common parent — biological science. I will not, therefore, offer any further apology for putting practical medi- cine entirely aside for a few minutes, and turning the train of thought into a purely physiological chemical groove in which I expect to meet with a talisman by whose aid I may perhaps be enabled to unlock the door to the etiology of the high temperatures met with in cases of infectious, contagious, and inoculable diseases. ETIOLOGY or PYREXIA. 441 Of course I may take it for granted that my readers are all conversant with the comparatively speaking new doctrine that fermentation, whether occurring without or within the animal body, is simply the direct effect of living organisms, generically named germs, on organic matter ; and that the fer- mentative action is not in any way dependent upon the chemical constitution of the germs themselves, but upon their attribute of life, and life alone. And farther, that as disease is simply the outcome of mis- placed healthy action, in a precisely similar manner it is the life and the life-manifestations of disease- germs which alone possess the power of producing what are named pyrexial diseases. These points being admitted, I have further to call attention to the fact that when I speak, as I shall presently have to do, of the respiratory function of germs, I mean respiration in its broad and philosophic sense. Not the merely limited physical process of the inhala- tion and exhalation of gases by special organs, but the chemical combination of oxygen and the exhala- tion of carbonic acid gas by the solid constituents of all animal fluids, as well as of all animal tissues. Which function is the inherent attribute and in- separable concomitant of all active animated existence. Be it remembered that what we call active, stands in contradistinction to what we name passive life in a direct and progressive ratio to the chemico-physio- 442 DISEASES OF THE LIVER. logical activity of the indispensable function of respi- ration. From the fact that ' life,' animal or vegetable, in a strictly philosophic sense is merely the collective visible functional manifestations of organised tissue and fluid oxidations. The more rapidly tissues and fluids are oxidised, the more active are the functional manifestations which we collectively denominate ' life,' and as a certain proportion of heat is set free from every molecule of material oxidised — whether it be in the muscle, in the bone, in the brain, or in the blood of hio;her, or in the homoo:eneous tissues of lower animal and vegetable species — it follows as a natural corollary that the quicker the development and multiplication of germs, just as of other animals* and plants, the greater must of necessity be the ab- solute oxidation, and consequent amount of heat evolved by them. Thus it is that the parasitic germs themselves, by virtue of their own vital activity, develop, among other things, heat, at the expense of their host's component parts, and, as a natural sequence, raise the temperature of its body. No matter whether it be, as in the case we are now considering, a living human body, or a dead inanimate object. For pre- cisely the same thing occurs when the germ's host happens to be a milk-can or a soup-tureen. M This apparently strange assertion is as compreP hensible, when scientifically viewed, as is the heating I ETIOLOGY OF PYREXIA. 443 of a pot of water by a coal fire ; and I shall now endeavour to substantiate it, as far as it is possible to do so, by a legitimate process of reasoning from demonstrable analogy. Which, although it may be regarded as a roundabout way of proving a fact, is hv no means an unsatisfactory manner of establishing a scientific principle. For be it remembered that pre- sumptive is invariably of equal value to direct scien- tific evidence, when it rests upon a demonstrable l)asis. As it is generally admitted that in establishing the validity of an argument one single incontro- A'ei'tible demonstrable fact is of more mtrinsic value tlian tens of thousands of assailable statements, I shall, for the sake of brevity, content myself with adducino; one crucial illustration of the correctness of my views. Takino' for granted that it is now admitted that Licrm fermentation is the chief factor in the produc- tion of pyrexial diseases, I may at once proceed to say that few persons have the faintest idea of the enormous amount of heat developed by germs during their active fermentative life, and therefore I expect that it will not a little astonish some of my readers to be informed that the amount of heat developed and evolved by germs during the fermentation of certain organic substances amounts to no less than 65° Fahr. ! This I can prove by referring to the 444 DISEASES OF THE LIVER. results of the experiments recorded by a professional chemist. Professor Atkinson in his paper — which, fortu- nately for my argument, has nothing whatever to do with medicine — on the fermentation of rice in the formation of the Japanese diastase, ' koji,' by the spores of the Eurotium oryzece^ tells us that when the temperature of the external air was 41*5°, that of the fermenting mass itself was 106 "6° Fahr. ; and that the heat set free and evolved from it during the process of fermentation was actually sufficient to raise the temperature of the chamber in which the operation was conducted to double that of the ex- ternal air — namely, from 41 "5° to 83° Fahr. If such then occurs in a cold dead fermenting vat, how can we be surprised that an analogous kind of fermentation taking place in a living human body should suffice to raise its temperature a few paltry degrees beyond the normal range, when it is re- membered that the human living body, so long as it contains the requisite materials for the germs to live and develop upon, plays nothing more than precisely the same part as a dead containing-vessel, such as a vat or anything else, does ? The tempera- ^ Atkinson says that the change taking place in the rice during the process of the fermentation of koji — which is a powerful ferment, used 'by ' the natives to raise their bread, make soy sauce, and sak6 liqueur — is the ' conversion of the insoluble albuminoids of the rice into soluble. During i which oxygen is absorbed, and carbonic acid freely exhaled. {Proc. Moi/A Soc. No. 213, p. 299.) i II ETIOLOGY OF PYREXIA. 445 ture of the human body, like that of the vat, being only maintained above the normal standard so long as it contains germ-pabulum. This is all the more readily understood when viewed in connection with what I said regarding the immensely rapid develop- ment of putrefactive germs in the human body after death, at page 598 of the ' Medical Times and Gazette,' November 19, 1881, where I related three cases of rapid putrefaction, in one of which, the development of the germs and the activity of their respiration was actually made visible to the eye by the evolution of gas. Which of course, as germs breathe, is an in- separable concomitant of their active existence. There is yet another important point in con- nection with the fermentation of koji, which is of great interest to us as practical physicians, as it may probably furnish us — though it is not yet explicable — with a clue to the cause of the chilliness, often amountmg to rigors, experienced by patients at the onset of such germ diseases as malarial jaundice, smallpox, typhoid, typhus, relapsing fever, &c., which has so long baffled all human ingenuity to fathom. For Atkinson says that on the second day after the raw rice has been mixed with the germ-spores, and before active life in the koji has actually begun, its temperature, from some unknown cause or other, is suddenl}^ reduced half a degree lower than that of the surrounding atmosphere ; which, from its having 446 DISEASES or the liver. been said to be 41*5°, gives the koji one of only 41° Fabr. This is certainly, to say even the least of it, a curious fact, and undoubtedly, to us, exceed- ingly interesting from a clinical point of view ; for h- its ultimate explanation what it may, it is the un- doubted typical analogue of the chill patients expe- rience at the onset of germ diseases. I have yet to call attention to another equally remarkable circumstance in connection with the ier- mentation of koji — namely, that just as the tempe- rature of the human body labouring under germ diseases varies at different times of the day, in pre- cisely like manner does the temperature in a vat ol k6ji vary during the fermentation process. This fact can surprise no one who is conversant with natural periodic biological law. For he must at the sain time know that while no effect in animal or vege- table nature, no matter how trivial it may be, ever occurs without a cause, every similarly chemicall and morphologically constituted organic and or- ganised, simple or compound, substance or organ — vegetable or animal, whether livins; or dead — when placed under the same conditions, invariably dis- plays the same properties. So that there is nothini: surprismg in the fact that the same periodic changc^ should equally take place in a living human body and in a dead wooden vat — changes denominated vital inj_ the one case, and chemico-physical in the otheri ETIOLOGY OF PYEEXIA. 447 when the one instead of the other happens, by a mere alteration of circumstances, for the time being to be the germ's host. Moreover, I explain the diurnal variations which I am about to show take place in the fermenting vat according- to the g^reat and universal law of periodicity of function in every animated thing, be it a plant or an animal — a law very little attended to, and still less understood. For the microscopic objects which we denominate germs, and which are now regarded by the advanced school of pathologists as the immediate cause of all pj^exial diseases, minute though they be, nevertheless, I believe, possess the same physical and chemical attributes in proportion to their size and constitution as man himself, who is thought to stand at the pinnacle of animated nature. And just as every function of the human body is essentially more or less regu- larly periodic, so, in like manner, is every germ- ftinction. Plence the similarity in the fluctuations of temperature in diseased man and in the ferment- ing-vat, when he or it happens to be the germ's host. As I deem this fact to be one of very great import- ance in studying the etiology of human abnormal high temperatures, I subjoin a table of the diurnal fluctuations in the temperature of fermenting koji, which I liave drawn out from the observations re- corded in Professor Atkinson's purely chemical paper. 448 DISEASES OF THE LIVER. Date Hour Outside temperature Temperature of Chamber Temperature of Kdji Degrees Fahr. Degrees Fahr. Degrees Fahr. Dec. 5 (8 a.m. )2 P.M. 40-7 — 104-8 49 5 83-0 91-8 . 6 \S A.M. a P.M. 41-5 830 106-6 50-0 82-5 1041 „ 7 (9 A.M. )2P.M. 38-5 82-5 104-2 51-0 82-0 93-6 „ 8 8 A.M. 37-5 82-5 100-0 As is seen, the last column reads exactly like the temperature table of a case of pyrexial human disease. So like, indeed, is it to one that were it placed in a clinical report, without any notice being made of its origin, the reader would almost for a certainty imagine it was a record of the human bodily temperature fluctuations. These remarks will be all the better appreciated ^ if the reader will kindly refer to what I said in \ Chapter II. on the Periodicity of Disease in the 'Medical Times and Gazette' of November 1881. Where I called attention to the interesting fact that I not only is every function of animated existence } more or less distinctly periodic, but that every movement hi nature likewise obeys one great and fundamental periodic law. Even the migrations of the ova of the Filaria sanguinis hominis show the same periodic law, for they are found to abound in the patient's blood between the hours of 9 p.m. and fi A.M., and are totally absent from it between 9 a.m. and 7 p.m. And the temperature of the body is in JAUNDICE CAUSED BY FILARIA. 449 cases of filarial mio-rations found to be hio-hest at the hours when they are most numerous in the circulation. Although it has been long known that various species of filaria produce a variety of diseases, it was only last year that we became aware that a small microscopic species could induce jaundice, by the dis- covery of Dr. Evans that the disease among horses called 'surra,' which prevails in the Derajat, west of the Indus, is due to filaria. Dr. Evans describes the disease in the following terms : ' A specific, parasiti- cal, non-inflammatory, enzootic blood-disease, charac- terised by fever with jaundice ; petechite of mucous membranes, especially of the eye and vagina ; dropsy ; albumen sometimes in the urme ; great prostration of strength, rapid wasting, and with a specific para- site in the blood during life ; but no characteristic structural organic lesions are found after death. It may be transmitted by the subcutaneous injection of blood, and by drinking freely blood containing the parasites alive, but is not contagious or infectious in the ordinary way. The average duration of the disease is probably not less than two months, but reliable statistics are wanting upon that pomt.' The parasite is described as having a round body tapering in front to a sort of a head, and ending behind in a tail, about three or four times the diameter of a white G G 450 DISEASES OF THE LIVEK. corpuscle in length, and one-eighth to one-tenth in breadth. He asks whether the disease has been known to exist in any other part of India ; and, if so, whether the localities were marshy and the water unwholesome, and whether the animals had been par- ticularly exposed to the sun or to fatigue before they showed symptoms of the disease. On reading the above description of the filaria, I was forcibly reminded of a specimen of jaundice urine from an old Indian officer I once examined, in which were found a few exceedingly minute worms, which I exhibited to my histology class at University College under the title of Filaria injinitesima. First, because, though of minute size, they still exactly resembled in shape and form an ordinary round filarial nematoid worm — such, for example, as the strongylus, represented in fig. 4, which is taken from my ' His- tological Demonstrations ' ^ — and secondly, though a real worm, from its being in many cases not bigger than an ordinary human spermatozoon. The form and appearance of which it so closely resembles that if two headless spermatozoa were united together by their necks, and their tapering tails left free, they would conjointly be a good portrait of ^Filaria injini- tesima, which they resemble equally well in pellucidity and shape. In case some of my readers may be led from the ' Longman & Co., 2nd edition, p. 247. JAUNDICE CAUSED BY FILAEIA. 451 above description to imagine that these worms may- be a form of spirilli, I may as well mention that I have never seen them put on a corkscrew-like ap- pearance, never go beyond forming the single anterior and posterior undulating S- shaped curve of the true nematoid worm. Whereas fig. 10 shows that spirilli are characterised by many twistings. On examining these small worms, I could not help feeling that, morphologically speaking, they stand at one end of a type of parasites, while spirilli stand Fig. 10. Fig. 11. Spirilli. Sperm-cell containing mature spermatozoa, from common house-sparrow. at the other, and that the intermediate species of animated creation might be said to be a spermato- zoon. As in the spermatozoon of the common house- sparrow we possess a united type of both. For while at its one end it presents the form of the spirilli disease-germ, at the other it is a true repre- sentative of the Filaria injinitesima, as may be seen in the annexed woodcut (fig. 11), taken from my ' Hi.stological Demonstrations,' showing a parent sperm-cell full of spermatozoa. G G 2 452 DISEASES OF THE LIVER. There is yet another point of analogy in the chnical history of febrile diseases the result of para- sites and ordinary fermentation, which I desire to call special attention to, and that is, the definite periods of their course. Every pyrexial germ-disease which does not end fatally, if left to itself, runs a definite course, and terminates, of its own accord, in a certain number of hours or days. In precisely like manner does every known species of fermentation, whether it be that of dough, sauce, soup, beer, or wine and I believe from a precisely similar cause : namely, the life's career of the germs being in all cases definite. And just as external physical circum- stances, as well as internal constitutional causes, hasten or retard the progress of pyrexial disease, so in like manner do they hasten or retard the various forms of fermentation. This opinion is not a mere hypothesis. It is a legitimate scientific theory, for it is demonstrable, and it requires neither any great stretch of imagination to understand that when normal ferment-germs have ceased to live, they cease to be able to produce fermentation — in a lump of dough, in a barrel of beer, or in a vat of wine — nor any violent effort to comprehend that with their life's career fermentation ceases in the human bod] and when fermentation ceases the disease it gave rig to is at an end. Finally, now comes the question : Does the gen PYREXIA ARISING FROM GERMS. 453 theory of pyrexia explain what the nerve theory fails to do : namely, the cause of the high bodily tempe- rature being in certain cases maintained after death ? Most decidedly it does : and how, I shall now pro- ceed to show. The mere fact of the pyrexia! temperature of the tissues of the human body being maintained for many hours after the death of the patient shows that the heat-producing agents act independently of the life of the patient. For otherwise it would be impossible for their thermometric effects to continue so long in operation after all the human vital actions had ceased. The fact is easily accounted for in the following wise. As will have been noticed, accoi'ding to the views I take of the causes of high temperatures in germ diseases, the germs, and the germs only, are the real heat-producing agents. The heat they evolve and communicate to their host's body being the direct product of their vital activity, and quite independent of the life, death, or even the nature of their host. So long as the host contains the pabulum neces- sary for their growth and multiplication, it matters not one whit to them whether it be a living animated being, or a dead inanimate inorganic thing, in which they carry on their operations, from their life's activity not depending upon the nature of their host, but of their host's contents. For as germs are mere parasites, they are perfectly independent 454 DISEASES OF THE LIVEK. beings, in as far as the nature or functions of their host are concerned, so long as its nature and functions are not incompatible with their existence. Conse- quently germs can live, grow, multiply, and evolve heat, even better in a dead than in a living human body, for the very simple reason that, while the former is merely the passive receptacle of their pa- bulum, the latter is in addition an active ao-ent in their destruction and elimination — as I pointed out in the ' Medical Times and Gazette ' — and the only reason that I can see for the pyrexial heat of the body not being usually maintained after death ■ is because the pabulum has, in the majority of cases, become exhausted ere the host dies, and with the extinction of the host's, that is to say, the patient's, life, ceases the generation of a fresh supply. In those exceptional cases again where the ab- normal temperature is maintained for several hours after the patient's death, as in Wunderlich's and my case, I imagine that there existed in the patient's system a superabundant supply at the moment of death, and so long as the supply lasted the germs went on growing and multiplying and evolving heat, just as they did while the host was alive, and the amount of heat they evolved was sufficient, like that evolved from the koji, to maintain the dead host at a high temperature. A similar amount of heat being contributed b}?- the germs to the dead as to the living PYREXIA CAUSED BY GERMS. 455 tissues of the body, equally independently and in pre- cisely the same manner as the heat was contributed to the chamber in which the fermentation of the koji was conducted. Thus then, in conclusion, I think I may venture to say that the fact of the temperature of the human body after death having been maintained in the cases cited, has, by a logical and philosophic process of reasoning from analogy, yielded a probable clue to the abnormally high temperatures met with in dis- eases of the infectious, contagious, and inoculable class. Having now shown that there are at least two distinct causes at work in the human body pro- ducing abnormally high temperature, I may mention that the reason why in all pyrexial diseases the bodily temperature does not reach the same point is readily explained by the fact that all diseases are not the product of the same germs, and different kinds of germs produce different amounts of heat. For ex- ample, the fermentation of horse-dung is due to one species of germ, that of the koji to another, and while both develop a sufficient amount of heat to elevate the temperature of the chamber in which the fer- mentation is conducted, the amount of heat they respectively develop is vastly different. Indeed some germs in fermenting develop scarcely any heat at all in comparison with the extraordinary 65° Fahr. evolved by the koji. We all know, however, that in 456 DISEASES OF THE LIVER. the fermentation of horse-manure there is sufficient heat developed to raise the temperature of a conser- vatory several degrees above that of the external atmosphere. Before concluding my remarks on pyrexia I have to call attention to a well-marked third cause, which is not, however, an independent one, but the result of a hybrid between the other two. I allude to the elevation of temperature which, during the first two or three days, follows upon severe injuries and surgical operations with lesions of external tissue continuity. All operations are, as is known, followed by an elevation of bodily temperature. For even the element of pain itself is sufficient, in cases where there are no signs nor symptoms of shock-collapse, to slightly raise the temperature. Whereas after all severe injuries and operations, especially on the abdominal organs, accompanied by a solution of external tissue ' continuity, an elevation of temperature of from 3° to 10° may occur. Ay, it even occasionally happens that in some patients the thermometer will indicate an increase of 2, 4, 6, or even 8 degrees in as many I hours. Now according to my ideas this elevation of. temperature is due not solely to nerve influence, but to the action of germs also. And my reason for saying i so is, that when operations are performed according | to the antiseptic system of surgery introduced HYBEID FORM OF PYREXIA. 457 Lister, the elevation of temperature is almost in- variably found to be much slighter than when no germicide is employed. Of course, while the anti- septic destroys the germs, and thereby prevents their adding to the bodily temperature, it has no effect upon the abnormal heat resulting from the nerve influence. Hence it cannot be expected that anti- septics, as some of their too sanguine votaries have asserted, ought to prevent the appearance of all pyrexial signs after operations. In fact it has been over and over again shown that in consequence, I suppose, of some human constitutions being peculiarly susceptible to its irritating toxic effects, the deadly germicide — the nervous-irritant poison carbolic acid — instead of invariably diminishing, actually in exceptional cases increases, the temperature of the patient's bod}" ; not, however, from fjiiling to kill the germs, but from adding its nerve -irritating effects to those of the operation. Which fact is another good example of how necessary it is, in attempting the in- terpretation of abnormal biological phenomena, never in any case to restrict our lines of reasoning to purely practical medical facts and observations. For if we do we assuredly fall into errors, just as I observe Dr. Bantock has done (in his otherwise able paper in the last volume (Ixiv) of the ' Medico- Chirurgical Trans- actions ' ) when he comments unfavourably on the Lis- terian method, citing a clamp and a drainage case of 458 DISEASES OF THE LIVER. ovariotomy, in both of which the temperature only rose to 103 '6°, while in four others performed under the influence of the carbolic acid spray it rose con- siderably higher — in one case which he cites actually to 107*2° Fahr. At the same time, however, he admits that on an average the Listerian method has at least the advantage of diminishing post -operative abnormal temperatures by four-tenths of a degree, as calculated on fifty-five cases, the average highest temperature being 100*3°, the lowest 99"9°. As is here seen, this beneficial effect of germicides after operations is but another link in my chain of reasoning regarding the important part played by germs in the production in the majority of cases of abnormally high temperature. When the etiology of pyrexia is thus interpreted, it is easy to see how quinine and other germicides produce their effects in lowering the temperature of the body. They, simply by killing the germs, put a stop to the fermentative process upon which the rise of the bodily temperature of the patient depends. The action of aconite and digitalis, neither of which is known to be germicidal, is not so readily explained. They act, I believe, through their direct influence upon the circulation. Lowering the heart's action by diminishing its power, through the depressing eftect they have on the nervous system, and by diminish- ing circulation they diminish tissue metamorphosis, and, as is well known, heat as well as functional I ACTION OF EEMEDIES IN PYREXIA. 459 activity is one of the direct products of tissue oxida- tion. Cold again, I think, acts in a threefold manner : a. Like diofitalis and aconite it diminishes tissue metamorphosis by its depressing action on the nervous .system, and thus reduces the bodily temperature. h. It diminishes the oxidation of organic sub- stances by its direct cooling action retarding chemi- cal affinity. c. It is a true germicide. For cold kills germs just as it kills other animals and plants. The chief action of germs, as we see, is fer- mentative, and we all know that every species of fermentation is hastened by moderate heat, and re- tarded by moderate cold. While extreme heat as well as extreme cold annihilates the process altogether. Cold, then, judiciously employed, ought to be a most powerful adjunct in the treatment of hepatic germ disease, and so it is, as we shall subsequently see. This of course is an entirely new \iew of the modus operandi of cold in the treatment of hepatic and other forms of pyrexial diseases ; but although this is the first time I have put these ideas on paper, they have for many years past occupied my attention, and the more consideration I bestow upon them, the stronger is the hold they take of me. 460 DISEASES OF THE LIVEE. Subacute Atrophy of the Liver (Rokitanskys Red Atrophy). The true pathology of this condition of hver — a1 least as a separate form of disease — is as yet unknown All that I can say on the subject is that in 1854 while a student at Vienna, I saw that Rokitansk\ gave the name of red atrophy to all cases of atrophies liver, the substance of which was more than usuall} red, from a hyperaemia of the hepatic capillarie; induced apparently by the outward flow of bloo( from the portal veins being obstructed. The liver: in persons so affected, and who, he said, had ii general been the subjects of repeated attacks o remittent or intermittent fevers, were occasionally reduced to half their normal bulk. I w^as then, as . am still, very much inclined to doubt the propriety of grivino; to this state of liver the honour of bein« considered as a separate form of disease ; for to m( it appeared, and still appears, merely to occupy th< debatable ground between the acute and chroni< forms of hepatic atrophy, just at the very spot when it is exceedingly difficult to say where the one fom of the disease ends and the other begins. In fact . look upon Eokitansky's so-called red atrophy ai merely a less advanced stage, or a less pronouncec form of virulent acute atrophy. For they diffe in no way whatever from each other clinically ex cept in so far as red atrophy runs a slower an( SUBACUTE ATROPHY. 461 consequently a less severe course. Red atrophy lasting from six days to even six weeks, whereas acute or yellow atrophy may terminate fatally in six hours or at the longest within six days. Being thus less virulent, red atrophy is naturally enough less frequently fatal, and after death the liver presents only in a modified degree the pathological appearances of acute atrophy. Being red or yellowish-red and firmisli, instead of a saffron hue. and pultaceous. As these are my own and as yet unsupported opinions, I shall not in order to prove them select an illustrative case of the disease from among those I have myself seen, and consequently might be sus- pected of havmg a personal interest in recording with partiality, but I shall take one from a totally independent observer, and he too one who, from the very title he gave to his case, had evidently him- self some doubts as to which category of atrophies of the liver it properly belonged to. The case has likewise the additional advantage of being so fully as well as ably reported, that it admits at least of a decided if not even a correct conclusion being' drawn from it. If I had adopted my old teacher Rokitansky's views, I should unhesitatingly have called it a case of red atrophy ; but as they are different from his, I think its reporter, Dr. Mac- naughten Jones, has with great propriety cautiously and somewhat doubtingly entitled it ' A Case pre- 462 DISEASES OF THE LIVER. senting the Symptoms of Acute Yellow Atrophy ol the Liver,' and given at the end of his paper the following nine reasons for so doing. 1. The sudden accession of the attack ; 2. Th( slight constitutional disturbance at its commence- ment ; 3. The cephalalgia ; 4. The obstinate bowe] and intolerant stomach ; 5. The peculiar head- symptoms, and their rapid and intense occurrence, and, as regards physical signs, 6. The diminished dulness over the liver ; 7. The tenderness also, though not excessive, yet well marked ; 8. The stools being most peculiar in occurring when they did, and being of a htemorrhagic nature ; 9. The pulse, except on a few occasions, was from 75 to 80 per minute. The following is an abstract of the history of the case as given by Dr. Macnaughten Jones in the ' British Med"cal Journal ' May 4, 1872. ' The patient, a married woman aged 20, in the seventh month of her pregnancy, had her attention suddenly drawn to the jaundiced tint of her skin on October 18. She had been lately greatly depressed about her husband's health, having had a shock from seeing him spit up blood. When Dr. Jones saw her, she had intense pain in the head ; her pulse was normal. She was sitting up, and had been attending in her place of business that day up to the time when he was called. He ordered her to go to bed ; the next SUBACUTE ATROPHY. 463 morning he found the pulse natural, no heat of skin, an icteric tint marked over the body, and intense depression of spirits. On examining the liver it appeared smaller than usual. The bowels were costive, and she felt sick. A powder containing ten grains of nitrate of potash, three grains of James's powder, and three grains of grey powder, was ad- ministered at bedtime. In the middle of the night, labour came rapidly on, and she was delivered of a dead male child after a few labour pains. The next morning she had no pain or tenderness anywhere ; the stomach was settled ; the mind more cheerful ; the pulse perfectly natural. The icterus, however, was rather increased than diminished. The stools passed up to this time were perfectly colourless, and the urine was thick and portery. A peculiar heavy odour was exhaled from the surface of her body ; but there was almost unusual clearness over the region of the liver, and an impossibility of feeling the margin of the gland. The bowels not being moved on this day, an enema of oil and yolk of egg and gruel in the evening brought away two copious watery dis- charges. ' October 21st. She was greatly jaundiced. Her mind was wandering ; she did not recognise her friends, and was delirious at times, muttering on religious subjects, fancying that a person beside her was Jesus Christ. She had had one small stool, 464 DISEASES OF THE LIVER. nearly white. The urine was scanty, thick, deep- coloured ; pulse 115. There was a heavy smell from the body. She lay sunk in the bed, with her eyes closed ; and was difficult to rouse. There was no pain or tenderness anywhere. The lochia were not suppressed, and of fair colour. She had not the least tympanites. There was unusual clearness still over the hypochondriac region. She took this day the same nutriment ; and a teaspoonful of brandy in milk and wine was added alternately every hour. A saline purgative was given ; and, as it did not act, the enema was repeated with assafoetida at night. Mustard stupes and large linseed cataplasm were alternately applied over the abdomen. ' On the 23rd she was still drowsy, but not so wandering as on the previous day. She had draught of infusion of roses and sulphate of magnesia with spirit of chloroform, which operated. There was no change in the stools and urine. At night she took two pills containing eight grains of compoimd rhubarb pill, five grains of calomel, and two graine of extract of hyoscyamus. She had two stools in the nio'ht of the same character as before. ' On the 24th there was no sickness of stomach ; she was more conscious ; the pulse had fallen to 80. She spoke rationally. ' On the 25 th she was much improved ; the ictei tint was less ; the urine of better colour. There )80. I tern SUBACUTE ATROPHY. 465 slight secretion of milk. The head symptoms were entirely gone. The saline aperient draught was re- peated. This brought down frequent copious stools of a watery consistence and of a dark hasmorrhagic nature. The lochia had passed in quantity again ; and though there was great weakness and prostration, her general symptoms were much improved.' From the 26th onwards, the stools and urine improved. Her strength gradually returned, and Dr. Jones ceased to attend her on November 25. When seen on February 24, she was in perfect health, and expressed herself ' never better in her life.' This case I regard as a very good example of what Rokitansky called red atrophy of the liver, and I think was, as is seen, with perfect justice entitled by Dr. Macnaughten Jones ' A Case presenting the Symptoms of Acute Yellow Atrophy of the Liver,' the red, I believe, as already said, being nothing more or less than a mild form of the yellow atrophy of the organ, both as regards its clinical history and its pathology ; and being such demands nothing- more or less than a modification of its treatment. In order to show how easy it is to give diseases wrong names, I quote the following case of subacute atrophy (red atrophy so called) of the liver, which appeared in the ' British Medical Journal ' of November 6, 1880, under the misleading title of li II X 466 DISEASES OF THE LIVEK. Acute Atrophy of the Liver. — Mr. Cullingworth narrates the history of the case in a married lady, aged 28, which terminated fatally at the end of four weeks, as follows. The patient, who was nursing her first child, had an attack of jaundice, which, for the first three weeks, appeared to be of the mildest character and simply catarrhal. Severe symptoms suddenly supervened, ending in delirium, coma, and death. The temperature did not rise until the last twenty-four hours ; an hour before death it was 105** Fahr. The jaundice became intense, and haemor- rhage occurred. After death, the liver was found atrophied and softened, for the most part reddish in colour, with large irregularly distributed patches of orange-yellow. The weight of the organ was 677 grammes (about 1\ lbs.). Haemorrhagic spots were found over the heart, the mesentery, and the large and small intestines. Microscopic examination showed destructive chano;es to have advanced further in the red portions of the liver than in the yellow ; in the former the liver-cells had entirely disappeared. Professor Arthur Gamgee had made a chemical examination of the liver, and of the whole of the urine passed during the last thirty-six hours of life. The amount of urea found in the urine was consider- able ; and, while abundance of leucin and tyrosin was found in the liver, the urine contamed no trace of either of these substances. CHRONIC ATROPHY — CIRRHOSIS. 467 Two facts in the history of this case incontrover- tibly show that it more properly belongs to the sub- acute than to the acute form of atrophy of the liver. Though it is one of those transition cases which pos- sess some of the characteristics of both. 1st. The red- dish colour of the tissues. 2nd. The duration of the disease, namely four weeks. The third and last variety of atrophy of the liver was formerly called contracted or' cnrhosed, but is now more appropriately known under the title of Chronic Atrophy of the Liver. This condition of the hepatic organ is, and I think most unnecessarily, very imperfectly under- stood by the great majority of practitioners. The misunderstandino' arisino;, in o-reat measure, from the number of different names that have been given by pathologists to the multitudinous mere varieties of one and identically the same disease. I shall now endeavour to unravel the tangled path ologico- clinical skein, and place the subject, as far as I am able, in a clear light. Chronic atrophy of the liver has been named 'cirrhosed,' 'nutmeg,' hobnail,' 'contracted,' and * dram-drinker's ' liver, according to its supposed ex- citing causes and pathological ajipearances. It has been most injudiciously called ' cirrhosed,' from the simple fact that neither the Latin word 468 DISEASES OF THE LIVER. cirrus, a curl or lock of hair, nor the Greek word kirrhos, signifying tawny, in the slightest degree de- fines the pathological condition of the liver which each of them is supposed to denote. Again, the term ' hobnailed ' liver is applicable to only one special form of atrophy. While that of ' dram- drinker's ' liver is still less appropriate ; for, as I shall presently show, the most typical pathological forms of the so-called dram-drinker's liver are not only to be met with in the temperate adult's, but are even to be found in the milk- and water-imbibing babe's liver. A chronically atrophied liver — that is to say one that has been hitherto described under the name of a ' contracted ' or ' cirrhosed ' liver — may indeed be, I believe, pre-natal ; for as atrophy of the liver is, sooner or later, the inevitable sequel of obstruction of the common bile-duct, and an imperforate duct is oftentimes a congenital abnormality, I see no reason whatever to doubt the possibility of the existence of an atrophied liver m a new-born child. I know, indeed, for a fact, from my knowledge of the litera- ture of infantile hepatic diseases, that children at the breast — from a week or two old and upwards — who have succumbed to jaundice the result of a con- genital deficiency of the common bile or hepatic duct, have had livers not only atrophied, but truly cirrhotic in the widest sense of the word. In so fa CHEONIC ATROPHY. 469 at least as the whole secreting substance of the orga]i has been found interspersed with, and enclosed within, dense bands of hypertrophied and hardened fibrous tissue. While, curiously enough, in many of the well-marked cases the spleen has been found to be considerably hypertrophied, just as if it had been attempting in some way or another to do vicariously, in addition to its own normal work, the work of the liver. In precisely the same way as the spleen is sometimes found enlarged in cases of acute atrophy of the liver. In fact, a more or less distinctly atrophied condition of the liver may be said to follow upon all the various forms of chronic hepa- titis, be the exciting cause of the inflammatory en- largement what it may. The signs and symptoms which are in general indicative of a chronically atrophying liver are :— Sallowness of countenance ; yellowishness of the conjunctiva ; disordered digestion ; loss of appetite ; furred tongue ; flatulence ; irregular stools ; dark urine ; depressed spirits ; diminished mental power, and general inability to exertion of any kind what- ever. The liver itself is uncomfortable, but not painful ; and smart percussion adds but little to the discomfort. The dull perpendicular area is reduced ■pari passu with the advance of the atrophying pro- cess, until it may be less . than two inches in extent. 470 DISEASES OF THE LIVER. Intense jaundice is seldom or never seen in cases of chronic atrophy, except in those where it follows upon occlusion of the common bile-duct, in which case the discoloration may indeed be intense, some- times amountmg to an actual dark yellowish-green hue. There is also almost invariably a gradual de- crease of the jaundice as the chronic atrophy of the liver advances, even in spite of there being persistent occlusion of the common bile-duct, as, for example, by a large gall-stone. This fact is well illustrated in the case of a woman aged 60, recorded in vol. xv. of the Pathological Society's ' Transactions ' by Mr. Wale Hicks, in which it is stated that the jaundice decreased, ' until at last the skin was free from any icteroid tinge.' Ascites is a common accompaniment of cases of chronically contracting liver, and it is easily ex- plained by the gradually atrophying glandular tissue contracting round the large portal vem and vena cava inferior, and compressing them to such an ex- tent as to impede the outward and upward flow of the abdominal venous blood. Along with the ascites there is marked dilatation of the external abdommal veins. When the ascites is considerable, it, in its turn, impedes the flow of blood through the iliac vems, and thus produces oedema of the lower extremities. In the earlier stages of the contraction of th( CHRONIC ATROPHY. 471 liver tissue, ascites is absent ; but in the later, never. Haemorrhage from the bowels is nothing un- usual in chronically atrophied livers. At the Medical Society of Dublin (1881) Dr. Quinlan exhibited the Uver of a patient who died in St. Vincent's Hospi- tah The patient was a light-weight steeplechase- rider, aged 44. He was of most temperate habits. About two years previously he got a very severe fall, which was followed by an attack of what Dr. Quinlan inferred to be mfiammation of the liver. He died from intestinal hemorrhage. On examma- tion of his body, a ' hobnailed ' liver was found. Its weight was only 2 lbs. 2 ozs. There were no signs of syi^hilis, cardiac disease, or albuminuria ; but the patient had been very deeply jaundiced. In December 1881, 1 was summoned to Grantham, to meet Dr. Paterson in consultation on a suspected case of this kind, occurring in a young lady of 14 ; but after careful examination we came to the conclu- sion that the haemorrhage did not come from the diseased liver, but from a gall-stone ulcerating its way into the intestmes. She was treated accordingly, and the haemorrhage did not recur, as it would have been sure to do had it been the result of hepatic atrophy. The form of passive haemorrhage associated with an atrophied liver is, as a rule, best treated with repeated doses of a mixture like the one of which the formula is given at ]). 266. 472 DISEASES OF THE LIVER. The sequel of this case may be judged of by the following quotation from a letter I received from Dr. Paterson on January 25, 1882, in which he says : — ' I thought you would like to hear how Miss progresses, and I think I can give you a pretty good account of her. She has apparently quite regained her strength, and appears quite well, with the excep- tion of a quick pulse, and that, I believe, she always has. She has regained her flesh. Appetite good, sleep natural, bowels regular, and stools of proper colour.' The most common cause of atrophied liver, whether in the child or in the adult, is obstruction to the flow of bile into the intestines, from a more or less permanent occlusion of the ductus communis choledochus. And what is equally noteworthy is the fact that one and all of the various forms of chronic atrophy (which I shall presently describe) are invariably preceded by a proportionate stage of hepatic inflammatory or congestive enlargement of the organ. The stage of enlargement may be long, or it may be short ; but, in every case of chronic hepatic atrophy, it must have had a preceding exist- ence. The brevity of the stage of enlargement in some cases may be conjectured from the fact that Dr. Legg found the livers of animals in a markedly atrophied (which he calls cirrhotic) condition four< CHEONIC ATROPHY. 473 teen days after he had applied a ligature to their common bile- ducts. ^ Were this merely a pathological instead of a clinical treatise on diseases of the liver, I should devote considerable space to the microscopic appear- ances found in all cases of chronic atrophy ; but being as it is a practical treatise, I must refer those of my readers "who take any special interest in this subject to an admirable paper on the ' Histology of the so-called Nutmeg Liver,' by Dr. Wickham Legg, in vol. Ivii. of the ' Medico- Chiruroical Transactions,' where they will find the gist of the matter clearly and fully put forward ; likewise to a good account of the literature (as well as to the morbid anatomy) of what is called hypertrophic cirrhosis of the liver, which has been given by Dr. Robert Saundby in vol. XXX. of the ' Pathology Society's Transactions.' To this paper I would also refer the reader who is specially mterested in the subject of the multipli- cation of biliary canaliculi in hypertrophic cirrhosis of the liver, as it will not do for me to go into the matter here, seeing that it has nothing to do either with the diagnosis or treatment of such cases. I shall now proceed to point out the pathological varieties of chronic atrophy of the liver, in so far at least as a knowledge of them is of importance to us from a clinical point of view. And to begin with, I ^ iS^ Bartholomeiv's Hospital Reports, 1873. 474 DISEASES OF THE LIVER. must of course take the form which, as has just been said, is most common. Namely, the one met with in this and m all temperate climates, where, as a direct consequence of the atrophying process beinu universal in extent and uniform in degree, the organ, though it may become exceedingly small and dense, yet retains its relative proportions. Cases of this kind frequently follow upon the congestive form of hepa- titis induced by a permanent impediment existing to the flow of bile through the common bile-duct into the duodenum-. Such, for example, as occurs when the intestinal orifice of the bile-duct is sealed up by a cicatrised ulcer. The continued backward pressure of the accumulated and long pent-up bile causing sucli an amount of disturbance in the capillary circulation as is sufficient to mduce a degeneration and ultimate shrinking of all the hepatic tissues, and. from the fact of the pressure being exerted universally and equally upon the intercellular tissues and the secreting cells, the atrophying process is so nearly uniform that there is a shruiking of the whole tissues of the organ, and no hobnailed appearance is perceptible m uncomplicated cases. As I give a most typical example of this patho- logical condition of uncomplicated true chronic atrophy when specially speaking of the value of physiological chemistry in connection with the diagnosis and treatment of obscure hepatic dis- I CHRONIC ATROPHY. 475 ease, I shall not introduce it here, but merely refer the reader to page 719. I may here add that as in acute and subacute, so also in chronic atrophy of the liver both tyrosin and leucin are detected in the urine in the last stages of the disease. A fact well worthy of the attention of the clinical physician in the study of obscure hepatic cases. In cases where a syphilitic taint is associated with the chronic he- patic atrophying process the contraction of the tissues sometimes occurs irregularly. In consequence of the erratic deposition in diiferent parts of the organ of the syphilitic materials, either of the so-called ; gummatous or of the fibroid forms. While again, I in cases of perihepatitis, where only limited portions ! of the liver have suffered from inflammation, they i alone are the parts that undergo the atrophying pro- I cess, and consequently at the j^osf-mortem examina- ! tion the organ presents a peculiarly irregular shape, on account of its tissues being more atrophied in I one direction than in another. In all cases of chronic hepatic atrophy, however, be the cause what it may, the fibrous capsule of the liver is in general not only found thickened, but at the same time firmly adherent to the hepatic tissue. I nmst now return for a moment or two to the dram- drinker's liver, for there actually exists a peculiar pathological condition of the liver which may be said to be the especial possession of the habitual tippler 476 DISEASES OF THE LIVER. of ardent spirits, which hence obtained the expressive, though only vernacular, name of dram-drinker's liver. More especially in those cases where the tipple in- dulged in has been Jamaica rum, and particularly so when it has been taken in a hot climate, the condition of liver has an exceptional right to be christened, after its most characteristic appearance, 'hobnail,' as it decidedly looks as if it were all studded over with hobnails. This nodulated so-called ' hob- nail' appearance of the external free surface of the liver is due, not to a series of local and limited por- tions of the organ becoming atrophied, as in the cases of perihepatitis just alluded to, but to a definite and distinct irregularity occurring in the shrinking of the different tissues of which the oro-an as a whole is composed. The fibrous parts, or more correctly, his- tologically speaking, the intercellular (now hyper- trophied) connective tissue, shrinking not only more rapidly, but more completely, than the secreting hepatic cells, small lobuli are thereby formed in consequence of the puckering in, as it were, of their surroundino; connective tissue, and cause the surface of the organ to assume a distinctly nodulated appear- 1 ance. Not at all unlike the surface of an old- fashioned church oak door thickly studded over with globular-topped hobnails. A wax model of a mag- nificent specimen of this kind of liver exists in University College Anatomical Museum. CHEOXIC ATROPHY. 477 That this morbid anatomical appearance should come about after a preceding inflammatory enlargement of the organ is easy enough to understand, when it is remembered that during the inflammatory stage the connective tissue becomes greatly hypertrophied, and, by the pressure it then exerts on the secreting cells, interferes not only with its own but at the same time with their proper nourishment, and thereby induces degeneration of tissue. So that •ultimately both the size and numerical proportion of the secreting cells to their surrounding, now dense areolar tissue, are so much altered that the normal smooth uniform appearance of the surface of the organ is entirely lost, and in its place is substituted the abnormal condition to which has been applied the term hobnail liver. But that neither hobnail liver nor any otlier form of shrunken, cirrhosed, or atrophied liver, is always due to dram-drinking, may be inferred from the fact that even ty|)ical examples of this peculiar pathologi- cal condition are occasionally, as I previously said, though very rarely, met with in children. One of the very best examples of a hobnail liver occurring in a child, that I am acquainted with, is described by Dr. Wilks. It occurred in a boy aged 11, who had been an out-patient at St. Bartholomew's Hospital in 1862. The boy's necropsy was carefully made by Dr. Wilks, and he describes the condition of the liver as follows : — 478 DISEASES OF THE LIVER. ' The organ appeared to be of the usual size, but its surface was studded with nodules about the size of peas, which at first sight appeared like little tumour^ growing on the organ. On section the same appearance was found throughout the liver. On closer examina- tion the disease was seen to be cirrhosis.' ^ The boy was the son of an itinerant chair-maker, and was said to have occasionally participated in the gin and water which his father indulged in ; but that is not sufficient evidence to make it appear at all probable that he was a confirmed youthful tippler. In fact, general atrophy of the liver may occur at any period of life when there exists an impediment to the free exit of bile from the secreting hepatic cells. Dr. Quain exhibited in 1854 to the Pathological Society a specimen of lobulated liver taken from a boy 3 years and 10 months old, which looked like a lobulated kidney. The whole organ, with the gall- bladder attached, weighed only 13 ounces. Its capsule was opaque and thickened, and the sides of the lobules were adherent to each other by old inflammatory adhesions. In the bottom of each fissure between the lobules was a branch of the portal vein. The child died with the symptoms of general anasarca, fi'om the combined action of renal and hepatic disease. The two kidneys weighed together 6 ounces. Their tubules were fuU of casts of oily epithelium. The_ ^ Pathological Society s Transactions, vol. xiv. p. 176. CHRONIC ATHOPHY. 479 urine had been albuminous. There was no jaun- dice. A still more curious example of chronic atrophy of the liver occurred in a girl aged 13, who died in University College Hospital in 1856. For the organ looked much more like a brain than a liver, not only in colour but in the way it was convoluted and lobu- lated, while, strange to say, it was actually divided by one great fissure into two slightly unequal hemi- spheres. The girl died within twenty-four hours after her admission into the hospital, and, from her being too ill to give a history of herself, little is known of the case ; but Dr. Hillier, who made the necropsy along with me, from finding the stomach full of black and clotted blood, coupled with the peculiar condition of the liver (which weighed 26 ounces), entered it in the hospital books as one of ' cirrhosis of the liver, accompanied with profuse haemorrhage into the stomach and intestines.' To show that an atrophied liver is not in the least degree uncommon in youth, not only without there having been an habitual indulgence in ardent spirits, but even without any other distinctly assignable cause, I may mention that Sappey has described a number of cases to which he gave the special title of 'congenital cirrhosis of the liver.' Moreover, Dr. Moxon has recorded an extreme case of the kind which occurred in a young and temperate man of 20 480 DISEASES OF THE LIVER. years of age.' In this case the spleen was greatly enlarged, and a cluster of veins {cajmt Medusce) de- veloped near the nmbilicus. From the veins bleedino occurred on one occasion, and fatal hsematemesis was the final symptom. The spleen weighed 36 ounces. A large vein ran from the right branch of the vena porta' alons: the lio-amentum teres towards the umbilicus, probably the permanently patent umbilical vem. The case was thought by Dr. Moxon to be one of con- genital cirrhosis followed by perihepatitis. There is yet another form of chronic atrophy of the liver, which by several writers has had the special term of syphilitic prefixed to it ; but some people are so ver}^ fond of making subdivisions of all varieties of morbid conditions now-a-days, that I think it is scarcely worth while to do more than call attention to the name. For just as it is fashionable for us to difi'erentiate during life cases of gouty bones, gouty brains, gouty stomachs, and gouty everythings, so it is thought by some to be equally correct to apply the terms syphilitic cirrhosis and syphilitic cancer even to simple cases of cirrhosis and of cancer in whicli the morbid taint of the sj^philitic poison chances to be accidentally present. There is, however, no doubt a form of disease of the liver which well merits the cognomen of syphilitic, as it possesses special and well-defined features of its own, and I shall give special consideration to it at the proper time ; but SYPHILITIC ATROPHY. 481 at present I dismiss tlie syphilitic cirrhosis as a mere variety of a pathological condition unworthy of special consideration in a practical clinical treatise such as this pretends to be. Havino; thus run throuo-h the most salient cha- racters of the various forms of chronic hepatic atrophy which have been separately described by different writers both at home and abroad, I shall now give an illustration of what may be called the ordinary form of the disease met with in this country. The case I shall select for my illustration is one which I several times saw in consultation along with Dr. Ban- nister of Addison Terrace. It is such a typical ex- ample of the commonest form of chronic atrophy, both as regards clinical history and mode of fatal ter- mination, that I shall relate it somewhat fully. On September 28, 1879, I was called to meet Dr. Bannister at the patient's house at Shepherd's Bush, and there I saw a stockbroker of 38 years of age, who had been for several months previously under Dr. Bannister's care. Tlie history given to me was, that, notwithstanding his having been what is usually denominated a free liver and hard drinker for many years, he had enjoyed, comparatively speak- .ing, good health until the summer of 1878, when he was attacked with jaundice from acute hepatitis. After the mflammation of the liver subsided, the organ speedily returned to its natural size. It did I J 482 DISEASES OF THE LIVER. not, however, long stop there, but went on gradu- ally diminishing, and the jaundiced tint, though much faded from what it was at first, never entirely dis- appeared. In the next July, 1879, he had a second attack of hepatitis, and rapidly became of a deep jaundiced colour. The liver, though painful on this occasion, never perceptibly increased in size — at least if it did it was only to a small extent. The hepatitis of this second attack soon yielded to remedies, but the jaundiced hue of the skin remained persistent. A week or two before I was called in, the hepatic dulness began to decrease in extent, and concomitantly with the diminution in the size of the liver, ascites set in. When I first saw the patient — which was about four months after the commencement of the second attack of hepatitis — the liver had already become so shrunken that its perpendicular nipple- line dulness was barely two inches. The abdomen was at the same time enormously distended with fluid, and the superficial veins all over it greatly dilated. Thus clearly indicating that the ascending vena cava was already severely constricted by the contracted liver. The patient's legs were at the same time oedematous, and the prepuce and scrotum simi- larly affected. The conjunctivaa were greenish -yellow, and the skm of a deep greenish-yellow jaundiced hue. The pulse was 120 and feeble. The bowels opei (three or four times a day). The urine scanty and ATROPHY WITH ASCITES. 48d deeply bile- coloured, with a copious red brick-dust urate-looking deposit. He had been slightly delirious during the night preceding the day on which I first saw him, and consequently the case was regarded as a very unfavourable one. He was ordered to be tapped, and to have ten gi'ains of James's and five of Dover's powder given to him at bedtime. Three days later I again saw him. Dr. Bannister had tapped him two days previously, and had drawn off no less than 28^ pints ( 3^ gallons) of a rich saffron- coloured serum, so impregnated with bile pigment as to stain his hands of a bright orange-yellow tint. After the fluid was evacuated the patient rapidly rallied and greatly improved. His pulse became stronger and less rapid, though it remained still close upon 100. The urine contmued to be very scanty, only ten ounces in the twenty-four hours, and loaded with bile and brick-red lithates. The abdomen in forty-eight hours had refilled itself very nearly to the same extent as it was before. As the kidneys were acting badly, a mixture of squills, digitalis, nitrate of potash, in a decoction of l)room tops, was prescribed, and he was ordered again to be tapped, and this time a drainage-tube to be inserted. At this second tapping (made six days after the fonner, and with a fine drainage trocar), 2^ gallons came away in the first twenty-four hours, Ij gallon in the second, and ^ gallon in the third. Unfortu- T I 2 484 DISEASES OF THE LIVER. nately the trocar got accidentally stopped up, and had to be withdrawn, and when I again saw him, thirty-six hours afterwards (on October 7), the abdo- men was about half as much filled as it was when I saw him on the first occasion. Fortunately the kidneys were now acting much better. Instead of passing only ten, he was now passing about thirty ounces of urine in the twenty-four hours. The urme was still, however, very dark in colour and loaded with lithates of a strikingly deep red hue. When they were separated by filtration, washed with distilled water, and dried, they looked exactly like red-lead powder. From the 8th of the month the quantity of urine passed each day was carefully noted, and it was found that On the 8tli was passed 30 ounces. 9th „ 271 10th 27J 11th 30 12th 34 13th 34| 14th 40 The abdomen having again become entirelj filled up with fluid, the drainage-tube was reinsertec on the 12th, but on the left instead of on the righ^ side of the abdomen, as the patient said he preferrec to lie on the latter side. In twenty-four hours nc ATROPHY WITH ASCITES. 485 less than other 460 ounces (eleven quaits and one pint, or nearly three gallons) of peritoneal secretion had again flowed away. It then suddenly ceased to flow, and on the three succeeding days none what- ever came away. While on the fourth day it began to flow again, and before it again entirely ceased between one and two quarts came away. No sooner did the flow cease than the urine again became very scanty. So much so indeed, that on the day preceding the patient's death, which occurred on October 18, that is to say three weeks after I first saw him, only four ounces of urine were passed. During the last few days of his life he was more or less delirious, no doubt from urajmic poisoning in consequence of the kidneys having struck work, and about twelve hours before his death he gradually sank into a comatose stupor. Here it is seen that in this patient the enormous amount of twelve gallons of ascitic fluid was secreted by the peritoneal cavity in thirteen days, giving on an average close upon a gallon a day, all of which fluid was withdrawn by tapping within the same length of time. The marvel is how the serous peritoneal membrane could secrete it so rapidly from the blood, neither food nor drink having been taken in sufficient quantity to supply that amount of fluid. There is but one way to account for it, namely, that this large amount of fluid was extracted by the lungs in the 486 DISEASES OF THE LIVER. shape of gasiform moisture from tlie inspired air, added to which the aqueous vapour normally gene- rated in the tissues of the body during the process of the transformation and assimilation of the hydro- carbons supplied by the food was taken up by the peritoneum instead of extracted from the blood by the kidneys. Unfortunately no necropsy of this interesting case w^as obtamable. Treatment. — In the treatment of all cases m which an atrophying liver is diagnosed, it is not so much the morbid condition of the organ itself as the original exciting cause of the pathological state which is to be attacked, and only the most prominent of the symptoms it induces treated. Whereas, again, when the organ is already decidedly atrophied before the patient comes under the practitioner's care, no matter whether the contracted state of the liver be the result of dram -drinking, malarial hepatitis, ob- struction to the outward flow of bile into the intes- tines by a gallstone impacted in the common bile- duct, or any other cause, regulated diet and regimen are the chief means which the enlightened practi- tioner adopts to retard the progress of the disease and prolong the life of his patient. To aid in that object, the following suggestions, both as regards food and medicine, may be found not unacceptable. A. 1st. Give a due proportion of animal and TEEATMENT OF ATROPHY. 487 vegetable food. The former always fresh, and rather underdone. The latter especially of the starchy variety and thoroughly cooked. A good combination is milk and eggs along with tapioca, com flour, ground rice, sago, or arrowroot, in the shape of puddings. 2nd. Moderate and slow exercise in the open air ; sleeping in a high altitude, and, when the weather permits of it, with the bedroom wuidow open. 3rd. The careful avoidance of xiold baths, or any other sudden change of temperature which will give a shock to the system, is also a point of vital importance. 4th. Xight and mommg brisk cutaneous frictions with hair flesh-brushes. B. While as regards medicines — 1st. Stomachic tonics and vegetable purgatives are to be used accord- ing to circumstances. Mineral acids and ferruginous salts I have ceased to employ, never having seen the slightest benefit follow their administration ; while, on the other hand, the constipating effects they invariably produce upon the bowels always require to be counteracted by other medicines, otherwise hepatic congestion is greatly favoured. 2nd. Symptoms of ascites and oedema are to be counteracted in the usual way — relieved by tapping, if necessary. One of the best forms of diuretic I have found in these cases has been a combination of dioi- talis, squills, nitrate of potash, and sweet spirits of nitre m an mfusion of broom tops, and a dose of 488 DISEASES OF THE LIVER. it given every six hours. For further remarks see chapter on Ascites, at page 1044. 3rd. In cases with a syphilitic history, I add to the above 5 grains or so of iodide of potassium per dose. Small doses of iodide of potassium — that is to say, anything under 1^ grain — I find most decidedly objectionable in bringing on much too rapidly the disagreeable weakening symptoms of iodism — to wit, deafaess, runnhig at the nose, pimples on the face and back, &c. &c. Pyaemic and Septicsemic Forms of Jaundice. As ichor^emia, or the purulent diathesis, may be said to be the pathological synonym of pyaemia (for they equally belong to the same morbid state of system as is included under the general term of Metastatic Dyscrasice), and pyogenic or putrid fevers may be equally regarded as the pathological syn- onyms of septicgemia, in the remarks I am now about to make on pyaemic and septicaemic jaundice I in- clude in them the morbid states usually signified by the other names above mentioned. Only making the broad pathological distinction, which I believe (notwithstanding what has been afiirmed to the con- trary) is a correct one, that while the formation of multiple abscesses is the rule in the pyaemic, it is the exception in the septicaemic group of these morbid PYiE.AIIC AND SEPTICEMIC JAUNDICE. 489 states. My object in considering them together is to save space ; and there is no harm in doing so, seeing that they all belong, as regards their etiology, to the same class, which happens too to be identically the same as that to which belong the contagious jaundice of the tropics and the jaundice of sporadic acute atrophy of the liver in temperate zones. The speak- ing of them conjointly is, moreover, all the more per- missible from the fact that it matters not one iota, from a pathological point of view, whether the disease- germ spawn of the specific form of the jaundice has been introduced fi'om without, as in the contagious jaundice of the tropics, or been generated within or upon some merely local part of the affected in- dividual himself, as in pyaemia, by a morbid retro- grade metamorphosis of decomposing tissues or se- cretions. For in all these cases the course of the specific pya^mic and septiccemic disease-germs during their career in the human body, in so far as their mode of action in ^^I'oducing the jaundice is con- cerned, is identical — the only difference being as regards their origin and primary modes of attack. It has long been noticed that many of the other- wise common forms of both pya?mia and septicaemia are very frequently associated with a more or less well-marked yellow condition of the skin. In many cases the skin is sufficiently deeply tinted to merit being called jaundiced, while in others again it presents 490 DISEASES OF THE LIVER. more the characteristics of a chlorotic sallowness than of a true yellow hue. Moreover, in both sets of cases it not unfrequently happens that neither is the urine loaded with bile nor are the stools of a decidedly pipe- clay colour ; while in others again, not only are the stools of a pipeclay colour, but the urine, besides be- ing loaded with bile-jDigment, is distinctly albuminous. Just as occasionally happens in cases where a jaun- diced condition of the skin is associated with fevers, such as those of a typhus, typhoid, relapsing, and scarlet fever type ; which pyasmic jaundice in the majority of cases still further resembles, from its being also associated with grave constitutional symptoms of a more or less febrile, typhoid, and hectic character ; the skin being hot and dry, occasionally with pete- chise upon it ; the tongue brown, dry, and crusted ; the breath offensive ; the lips covered with sordes. In the worst forms the urine is suppressed, the stools h^emorrhagic, the brain function greatly disturbed, and in general convulsions or coma close the scene, just as in contagious jaundice and acute yellow atrophy of the liver. Septica3mic jaundice may be equally appropriately said to be the counterpart of pya3mic jaundice. For not only are its etiology and its symptoms, but even its chemistry, the same. Bemg, in my opinion, due to albuminoid fermentation, caused by the multitudinous development of protoplasmic animal organisms, be PYEMIC AND SEPTICEMIC JAUNDICE. 491 their kind or name what it may. For although OUT present knowledge is insufficient to determine, ither in pyaemia or septica3mia, their true nature, or indeed so much as the exact class in animated crea- tion to which the ferment- organisms producing these different diseases properly belong, or even whether the deleterious action of the disease-germs on the human being is due to a chemical or to a morpho- logical form of poisoning, I think we at least now know that the process by which they both act is as truly a fermentative one as is that of the saccharine fermentation produced by the multitudinous develop- ment of the spores of the torula or yeast plant in the barrel of beer or hoo'shead of wine. I even venture to opine that if this theory be extended into the domain of all forms of disease associated with increased tem- perature — be they fevers or be they mflammations — a clue to their true pathology is not unlikely soon to be found. I make this statement with all the more confidence, seeing that the analogous one (I made in a paper read before the Physico- Medical Society of Wlirzburg,^ and which obtained for me the honour of its corresponding membership) that not only are the organic constituents of the animal and vegetable kingdoms identical as regards the chemical constitu- tion of their oleaginous and albuminous principles, as ' ' Ueber Urobaematin und seine Verbindung mit animaliscbem Ilarze.' Ver/iandl. dei- p/ii/s.-i7ied, Gesellschaft zii Wiirzburg, Bd. v. 1854. 492 DISEASES OF THE LIVER. had been previously well known, but even as regards their pigmentary constituents, has been completely confirmed by the subsequent researches of numerous observers. These remarks lead me to make one other observa- tion on JAUNDICE AS A COMPLICATION OF OTHER FORMS OF GERM DISEASES, from its being a common though erroneous notion that the jaundice in the case of fevers is a mere accidental independent concomitant of the pyrexial state, and not, as it really is, part and parcel of the disease itself, quite as much as is the rash of scarlet fever or the pustules in small-pox. True jaundice, besides being almost an essential in all germ diseases of an epizootic as well as of a vegetable malarial type, both of the intermittent and remittent varieties, is not unfrequently met with in cases of typhus, typhoid, plague, and relapsing fever, or, as it is vernacularly called, famine fever. The reason of this is not far to seek, when we recall to mind the great tendency all disease-germs have to attack glan- dular organs in general, and the liver in particular. Treatment. The presence of jaundice in cases of pyaemis septictemia, or any case of fever or blood poisoning whatever, is always to be regarded as a most forj midable complication. For experience has taugl us that it not only necessitates a sj)ecial line TREATMENT OF PYEMIC JAUNDICE. 493 treatment of its own, but seriously embarrasses the treatment of the disease with which it is associated. And frequently, in spite of the greatest care, even when jaundice is present only in a slight form, the patient shps through the practitioner's fingers almost before he has become conscious of the serious nature of the case. This is not in the least surprising, seeing that before jaundice makes its appearance in those cases, the constitution of the patient has, in general, been so thoroughly undermined, as it were, by the primary disease, that therapeutical substances, the ordinary action of which would be beneficial, seem to be transformed into banes instead of anti- dotes, in consequence of the vital powers of the patient being so low that a triflmg over-action of the remedy is sometimes sufficient to extinguish the flickering flame of life. Were proof wanting of the pertinence of this statement, it is abundantly furnished to us by the efl'ects of the ordinary cholagogue cathar- tics. For while they may in most cases of non-germ jaundice be administered with advantage, and in all cases, it may be said, with perfect impunity, their employment is sometimes here followed by disastrous results. This arises from the fact of the vital stamina of the patients being so low in some of these cases that they sink under the exhausting efl'ects of an excessive biliary secretion, when it is coupled with active purgation. Great care, as well as judgment, is 494 DISEASES OF THE LIVER. therefore necessary in the selection of the choLagogue cathartic by whose action the stomach and bowels are intended to be cleared out ; for although it may be requisite to encourage, it is at the same time essential to control, the biliary secretion. For an ex- cessive action in some of these cases is quite as detri- mental to the welfare of the patient as a complete stoppage. Caution is therefore necessary in order to avoid the risk of lettmg the patient fall between thesp two stools. If a mercurial be deemed necessary, a probably it may be, unless the patient's vital powers seem good it must be given in the form of mild grey powder. But no matter what the cholagogue cathartic employed may be, no sooner has the ali- mentary canal been unloaded than it is advisable to administer germicides of a tonic character. And the best of these are quinine and its congeners. While, if the patient is considered sufficiently strong, sali- cylic, benzoic, and carbolic acid may be substituted. Always bearing in mind that in the complicated forms of disease no'^v^ under consideration a remedy which may be given, even in a considerable quan- tity, in an uncomplicated case of such a disease is not only not always tolerated in similar doses, but may in small doses be found to be unsuitable or even detrimental. For general rules of treatment, see the chapter specially devoted to remedies and their modes of administration. TEEATMENT OF PYEMIC JAUNDICE. 495 Cases of jaundice associated with septicaemia and pyaemia, in as far as the constitutional symptoms are concerned, are to be treated perfectly alike as regards the administration of quinine and salicylic, benzoic, or carbolic acids, which may be regarded as sheet-anchors. While the local signs and symptoms of each are to be subdued by its own appropriate remedies. For example, head symptoms, with an ice-cap, which has the double advantage of diminishing cerebral symptoms and reducing the whole bodily tempera- ture by cooling down the blood as it circulates in the head beneath it. To tender parts and suppura- tions apply warm soothing applications, with poul- tices. Attend carefully to the action of both bowels and kidneys ; and see that the patient has plenty of fresh air, and good, easily digested food, in small quantities at a time, but often. Agreeable com- panionship, and a cleanly kept sick-chamber, devoid of noise or much light. When the septica3mia is the result of a dissection -wound, or occurs in a puer- peral, erysipelatous, or peritonitis case, promptitude in treatment is the element of success. For the whole course of even a fatal attack may be of but a few hours' duration. Early and deep incisions through the swollen parts, even before the appear- ance of suppuration, ought to be had recourse to. Leeching and hot fomentations, quinine and mineral acids. 496 DISEASES OF THE LIVER. Whenever purpuric (haemorrhagic) blotches ap- pear on the skin in a case of jaundice the result of germ disease, the attack is to be regarded as a grave one. No matter whether the jaundice be associated with typhus, typhoid, scarlet fever, or anythmg else. If the purpura be associated with much foetor of the perspiration, the sufferer seldom recovers. Even although he gets apparently convalescent for a time, the chances are that, sooner or later, a relapse or sudden prostration will supervene, and a fatal ter- mination is then much more likely than a recovery to be the result. Violent sickness and diarrhoea are also most un- favourable signs in the course of jaundice the result of germ disease ; almost as bad as that of severe and acute delirium. As in the whole group of cases of hepatic germ diseases, both of the animal epizootic and the vege- table miasmatic malarial types, which we have just had under consideration, there is almost invari- ably, at some period or another of their course, a strong offensive odour emitted from the patient's excretions, not only from those of the bowels, but from those of the skin, kidneys, and lungs, and the significance of the effluvia met with in disease general is but little appreciated and still less undei stood, I think it may be just as well for me here devote a special chapter to its consideration, making THE FCETOE OF DISEASE. 497 my remarks on the etiology and pathology^ of the smells emitted in hepatic diseases equally applicable to the foetors of disease in general, in the same broad way as I treated the subjects of delirium and pyrexia. The Foetor of Disease. All of my readers who have seen much practice must have been struck with the peculiarly sickening odour of the breath in cases of purulent phthisis and gangrene of the lung. They must likewise have noticed the offensive odour of the sweat in very many forms of disease, and also the peculiar stench of the stools and urine, not only in ordinary cases of jaun- dice, but more especially in those associated with pyaemic and septicjBmic forms of blood-poisoning. In fact, in all cases where a deranged liver is the accom- paniment of any form whatever of pythogenic affec- tion. The very word 'pythogenic,' indeed, of itself signifies ' born of putrescence; ' and, unless they possess particularly obtuse olfactory nerves, they may have occasionally felt called upon to exert a strong effort of moral control to prevent themselves beating a precipitate retreat from the obnoxious stench of sick-rooms where patients' erysipelatous sores have a.ssumed a oanorenous character. With these in- troductory remarks, I shall now proceed to show K K 498 DISEASES OF THE LIVER. that the fcetor of certain forms of disease almost deserves to be ranked amono-st the so-called sisms of morbid action. My reason for saying so is that the effluvia emanating from the breath, the sweat, the eruptions, the urine, and the faeces are not only sui generis, but, in many cases, quite peculiar to and characteristic of the particular disease under which the patient labours. For example, the odour of the sweat in contagious jaundice, in the jaundice of acute atrophy of the liver, in malarial hepatitis, as well as in all the various forms of the jaundice complicated with pyaemia and septicsamia, is peculiar. Just as in typhus, typhoid, puerperal, and rheumatic fevers, it may almost be said to be of itself typical of the diseased state under which the patient labours. Everyone knows the sour odour of the perspiration in cases of rheumatic fever, the sweet vinous odour of it in delirium tremens ; and I think that no one who has ever stood by the bedside of a case of acute glanders in the human subject will fail to remember the peculiar smell which proceeded from the patient's body, if he happened to be, as is more than likely, perspiring profusely. While the odour of the sweat in cases of hectic and pyaemia, though a less formi-j dable nasal offender, must have equally succeeded] in making an indelible impression upon his memory,] Some describe the smell from pyjemic cases asj resembling that of new-made hay, and that proceed- THE rCETOR OF DISEASE. 499 ing from septica^mic patients like that of putrefying albumen. ^Yhile others again have spoken of both as reminding them of different degrees of the mitigated stench of an old cesspool. This diversity of definition is not to be wondered at, seeing that every one of these odours is exceedingly difficult to describe in words, notwithstanding that they are quite characteristic and peculiar, and make such a deep impression on the mind that they are almost certain to be recog- nised again even on the very threshold of the sick- chamber. So difficult is it found to be to reduce to words some of the sensations produced by the smells emanating from the diseased human body, that the common and well-known odour of relapsing fever has been described by one author as a ' compound non- descript semi-foetid mawkish smell.' No single word being capable of symbolising the idea desired to be conveyed to the mind of the reader. The odours proceeding from sloughing cancers, phageda3nic erysipelas, necrosed bones, and gangrenous tissues, which are reckoned by hospital nurses as olfactory abominations, are quite characteristic of each form of affecti(m alluded to. Indeed, so much atten- tion do nurses give to some of these noxious odours that it has been said, and I believe too not without good reason, that some of the nurses in small-pox hospitals can calculate with very considerable exacti- tude the virulence of an attack, both as regards its £ £ 2 500 DISEASES OF THE LIVER. danger to the lives of the patients and the risk of infection to the persons coming into contact with them, from the intensity of the smell alone. This is most probably true, seeing that the intensity of the stench is in direct proportion to the number, size, and condition of the suppuratmg pustules, coupled, as I shall presently attempt to prove, with the fact that the odour is in no case the direct product of the patient's tissues, but only of the disease-organisms infesting them. No wonder then that the fatality of the disease may be computed by the intensity of its odour. Typhus fever is equally thought by many hospital physicians to be most powerfully infectious when the pungent odour from the skin is strongest, which is from the end of the first week of the attack until a day or two after the crisis occurs and conva- lescence sets in. The foetor of hospital gangrene is almost equally prognostic as in small-pox and typhus. For not only the gravity of the condition of the individual patient, but his power of spreading the disease, may be reckoned by the intensity of the stench proceeding! from his body. The effluvium from the mouth and nostrils of patients labouring under degenerative diseases of the respiratory passages, such as gangren and acute tubercular softening of the pulmonar tissue, as also from malignant sore throat, syphiliti and scarlatmal ulcerated throats, diphtheria, &c., is, I i THE FCETOR OF DISEASE. 501 need only remind the reader, quite peculiar to each of these dilFerent forms of disease. In cases of local gangrenes occurring in the course of germ diseases, such as typhus, small-pox, &c., the perspiration has a most peculiar sort of cadaveric odour, quite different from that of the mortifying part itself, but nearly as oifensive, except when it is the lung which is mortifying, in which case the stench of the breath far exceeds that of the perspiration. That the odours of all diseases do not communicate infection, notwithstanding that they may be peculiarly offensive and strong, was proved to me by one of my patients — an intelligent banker from Buenos Ayres. Who told me that during a fearful epidemic of yellow fever (contagious jaundice) which occurred while he was living there, he knew for a fact that not one of the men living at the cemetery — three miles distant from the town — and who were daily and almost hourly engaged in burying the dead, took the disease, although they were being continually ex- posed to the noxious smells proceedmg from tlie corpses in the badly made coffins, which allowed the offensive effluvia to escape from them through their ill-constructed joints. My patient even said he had Inmself seen these men deliberately sitting on the coffins smoking their pipes, although the odour was so strong and offensive that it made him feel quite sick to be within a few yards of them. This fact seems to 502 DISEASES OF THE LIVER. show, first, that all disease odours arenotmfectious, and, secondly, that yellow fever, though, as is well known, it is infectious as well as contagious, is nevertheless not communicable through the mucous membrane of the air-passages, however readily it may be so through that of the digestive canal. While, thirdly, it further shows that, although in many cases the intensity of the bad smell from germs is an index of theii* viru- lence, it is not by means of the odoriferous principles of the germs alone that infection is communicated. To make this perfectly intelligible to my readers, after having so distinctly shown that the intensity of the stench is in many cases of germ disease an index of vi- rulence, I shall relate the case of a medical friend, phy- sician to one of our south coast hospitals, who, on calhng one day upon me at University College, no sooner entered my private laboratory than he beat a sudden retreat, exclaiming ' Oh ! you have prussic acid! I can't stand it. The smell makes me so ill.' To me the odour was imperceptible. It proceeded from a stoppered bottle in one of the cupboards. The servant was ordered to remove the offending bottle into another room, and my susceptible friend entered.j He then told me some curious details about the effects the odour of prussic acid had upon him, whichJ interested me exceedingly. I told him to -come bad and see me on the following day, and I would sho^ him something worth seeing, at the same time pro- THE FCETOR OF DISEASE. 503 mising that nothing containing prussic acid should be in the room. That afternoon I provided myself with six ounces of myrbane — a liquid which has precisely the same odour as prussic acid, but which hke genuine mara- schuio, though smelling like prussic acid, contains none — and placed it out of sight in the same cup- board in which the prussic acid bottle had been. On the following day my friend returned ; but no sooner had he crossed the threshold of my room than he rushed from it. As soon as he got outside of the door, and into the current of fresh air from the stair- case, he stopped and began upbraiding me with having deceived him. I only laughed, and was just upon the point of telling him that his prussic acid theory was a mere 'figment of imagination,' when he spontaneously exclaimed, ' How funny ! I don't feel ill to-day, and I am sure your room is as full of prussic acid as it was yesterday.' Here was a valuable piece of information. For it conclusively proved to me that the toxic properties of prussic acid did not exist in its odoriferous principles, but was only associated with them. To make a long story short, it ended in my friend — who, I think I may as well state, as there is no reason that I can see for his objecting to my giving his name, was Dr. Magrath, physician to the Teignmouth Hospital — putting his nose to the bottle without suffering the 50-1 -DISEASES OF THE LIVER. slightest unpleasant sensation, while he could not tolerate my bringmg the prussic acid bottle within yards of his olfactory organs. These cases, then, show how the toxic effects of living germs and dead poisons, though associated witli, do not necessarily exist in, the odoriferous prmciples of the deleterious agents. This leads me to express an opinion regarding the origin and nature of the foetor of disease, and I shall cut the matter short by at once saying that I do not think it proceeds from the tissues of the human body themselves, but wholly and directly from the disease-germs infestmg it. In the same way, I believe that the odours as well as the colours of decaying animal and vegetable matter result from the emanations from and hues of putrefactive germs and nothing else. Indeed I believe that the foetor of disease no more owes its origin to the human body itself than the fragrance of ' pot pourri ' owes its to the vase. The human body, like the vase, being the mere container of the source of the odour. And this belief I found on the folio wino; facts. a A. Everything which destroys disease-germs or any other kinds of germs destroys the odours with which they are directly associated. Thus it is that not alone are sulphurous and carbolic acids, solutions of the sulphate and chloride of zinc and iron, &c., powerful deodorisers, but likewise powerful disinfec- I THE FCETOE OF DISEASE. 505 tants, from their destroying (I believe) the smell by killino; the o-erms from which it emanates. Just as the odour of a flower vanishes (in great measure) when it ceases to live. B. All ferment germs emit a peculiar odour during their active life as ferments. No matter whether they exert it in a cesspool, a dung-heap, a vat of wine, a barrel of beer, a lump of dough, a soup tureen, or a human stomach. C. Most ferment and disease germs are highly odoriferous. Those producing the disease called wheat-bunt (the Tilletia caries) have so strong an odour that it is vernacularly called ' stinking smut,' and while sulphuric acid at once destroys its smell it at the same time destroys the germs' vitality. D. The amount of odour evolved, as gauged by the olfactory nerves, may be said in every case to be proportionate to the quantity as well as the vital activity of the germs. Grace Calvert pointed out in the case of decomposing albumen (' Pharmaceutical Journal,' June 15, 1872) that the smell was in direct proportion to the development of germs. He says that in the case of albuminoid fermentation, the greater the number of vibrios produced, the stronger is the smell emitted from the decomposing matter. E. In my papers on germs published in the 'Lancet' (June and July, 1881), I pointed out the fact which I had observed, that the dead bodies of 506 DISEASES OF THE LIVER. the dogs into whose vems I had injected the spores of a strongly smelling green fungus, had a strange foetid odour, which, although not at all unlike the odour of putridity, could not possibly be due to any ordinary form of putrefaction, as they emitted it immediately after death, consequently long before any natural form of tissue decomposition could have time to manifest itself to the nasal organs. It was in fact, I believe, due to the ante-mortuary kind of fermentative pu- trefaction which disease-germs set up in the living tissues and blood of animals impregnated with them. In support of the correctness of this idea I may men- tion that in the case of the keeper of the snakes at the Zoological Gardens, killed in nmety minutes by the cobra's bite, his blood is described as having been found, after death, fluid, dark, and alkaline, and to have emitted a sickly ' sour ' smell. In this case a smelling substance must have been manufactured in the man's body, as I have never been able to detect any sour smell proceeding from snake's venom, not- withstanding my familiarity with it. In other cases again, however, the germs which are introduced are odoriferous, as in the case of the dog just alluded to. F. Different kinds of germs, like different kinds of flowers, possess not only different odours, but differ- ent colours ; and as nobody will deny that the green, yellow, brown, red, and black specks on cheese, stale bread, &c., owe their colours to fungi and fungi- THE FCETOR OF DISEASE. 507 germ spores, I think I may venture to say that the green of the sarcina vomit, the black hue of mortifi- Ication, and the greenish hue of human tissue decom- positions are equally due to the colour of the germs present in each of these sets of cases. And further that the different odours emitted by patients labour- ino; under different forms of disease are in like manner due to the differences in the species of the jgerms giving rise to them. Some have odours which jwe call sweet, others odours which we call nasty. The {majority are certainly of the latter class, which is not to be wondered at, as the majority of disease-germs are fungi, and the whole fungus tribe ma}^ be said to possess more or less disagreeable odours. All toad- stools have a more or less offensive smell, and I am not quite sure that if mushrooms were poisonous fungi, we should not even designate their odour as disagreeable. For agreeable and disagreeable odours are, like flavours, merely relative conventional terms for different kinds of mental impressions, what is regarded as an agreeable odour by one set of men being oftentimes designated as a disgusting stink by another. I need not, however, say anything more on this point, as I scarcely think any of my readers are at all likely to consider the eflluvium from either the nose, mouth, skin, urine, or faeces of patients labouring under germ diseases peculiarly agi'eeable to their olfactory nerves. 508 DISEASES OF THE LIVER. It is thus then that I account not only for the existence of a special foetor in a large class of diseases, but for there being a peculiar and specially character- istic form of odour emanating from patients labour- ing under different forms of disease. After having said this much, I must specially guard myself against being supposed to imagine that all the odours emanating from a human being either in health or disease are due to the presence of germs, for such an idea would be absurd. Many of the odours in disease, and almost all of them in health, are due to the presence of fragrant or stinking organic, though not organised, animal ' immediate principles.' The sweat, for example, often contains not only sebacic and butyric, but formic and valerianic acids. While in all cases of urinary suppression it is loaded with the ordinary urinary excrementitious matters, urea, uric acid, oxalate of lime, &c. &c., and acquires therefrom a distinctly urinous odour. Besides which many of the excretions eliminate in a state of almost chemical entirety the odoriferous constituents of the food. Even the breathing a putrid atmosphere from diseased bodies communicates to the excretions, both cutaneous, urinary, and faecal, a disease-germ odour. This need not surprise us. however, when we re- member that the urine and perspiration partake of the respired odours of vegetable matters very quickly, 1 THE FCETOR OF DISEASE. 509 iand that it is a well-known fact that some students ■;are seized with sickness and diarrhoea from working long in badly ventilated dissecting-rooms. There is an interesting fact recorded by Dr. Stork which I ought not to omit mentioning, j Namely, that he noticed that if he wore black iclothes while dissecting typhus corpses, they always I acquired sooner, and retained longer, the odour I emitted from the bodies than light-coloured ones. I From the preceding remarks it is seen that all the odours met with in disease are not to be supposed to arise solely from disease-germs. But as additional evidence that I am correct in attributing the peculiar odours emitted from the bodies of patients labouring under germ diseases to the germs themselves, I would call particular attention to the fact that in all cases, without, I may venture to say, a single exception, there is a marked increase of the specific form of smell at the crisis, that is, at the time the germs are being eliminated en masse. It is likewise observed that at what is called the crisis of a disease there is an unmistakable sudden outburst of activity in several of the secreting organs, the respective functions of which have, up to that time, been more or less in abeyance. For example, there are often sudden and profuse sweating, diuresis, and purging, just as if the great emunctories of the 510 DISEASES OF THE LIVER. body were no longer held in bondage, and, by the sudden removal of some pernicious controlling cause or another, were once more in a position to perform their normal function of eliminating noxious and effete matters from the system. This may be re- garded as a highly probable idea, as it is invariably noticed that these sudden discharges from the skin, kidneys, and intestines are immediately followed by a decrease in the pulse and a fall of the temperature, coincident with a general improvement in the con- dition of the patient. The pyrexial and cerebral symptoms disappear, the appetite returns, the patient feels better, and convalescence all at once sets in. One of the most striking features in the case often being the sudden offensiveness of all the excretions, most notably of the perspiration. The ' sweating crisis ' was formerly a common expression in medical books, and no doubt it was an appropriate one. For we all know that sudden profuse perspiration is one of the most remarkable features in many forms of disease, particularly in ague and hectic, and is almost instantly followed by an amelio- ration in the symptoms. The perspiration smelling strongly. No doubt this arises from an elimination of the offending disease-germs having been effected by the sweating process. On more than one occa- sion I have particularly noticed that at the crisis of measles — that is to say, at the disappearance of I I THE rCETOR OF DISEASE. 511 the eruption — there is not only occasionally a diar- rhoea, but a distinct sweating stage, and that the per- spiration is of a peculiar and sour smell. In fact most disease-germs, like almost every species of fer- ment germ, have a peculiarly sour odour. It is not alone the odour emitted by the sweat, how- ever, that is stronger at that time, for the bad smells of the breath, the urine, and the fasces seem to be equally augmented. I was particularly struck with this in the case of a medical man, aged 45, whose case is sufficiently interesting to merit my giving a brief account of its most salient features, ^v^hich are the following : — On the third day after having breathed for a few minutes the disgusting effluvium from a freshly opened ancient cesspool, his friends noticed that his complexion was of a strange greenish-yellow hue, while he at the same time complained of feeling listless and uncomfortable. Shortly afterwards he was all at once seized with a violent rigor, which, after lasting for some time, left him so completely prostrated that he went to bed. On the following day he was in a state of high fever, and Dr. William Aitken diagnosed the case as one of acute blood poisoning from the cesspool gases. The case rapidly assumed a serious aspect, and from finding him one night, at half past eleven, in a state bordering on delirium, with a pulse of 124 and a temperature of 512 DISEASES OF THE LIVER. 105", Dr. Aitken not only regarded his case as hope- less, but left him in the expectation that he would die ere the morning. At twelve o'clock, however — that is to say, within half an hour after this — his skin suddenly burst into a profuse perspiration, which lasted for at least four hours, his night shirt and sheets being drenched with the sweat. Xext morning the delirium was gone, the restlessness had ceased, the pulse had fallen to 108, his temperature to 101*7°, and, though fearfully weak and exhausted, he expressed himself as bemg comfortable. Then it was that I noticed the peculiarly strong increase in the foetid odour of both perspiration and urine. On the mornmg following what we considered had been the sweating crisis, not only his perspiration, but his urine, literally stank. The urine at the same time was very high-coloured and loaded with a darkish - coloured lithate of soda deposit. Which fact, however, I chiefly attributed to its being concentrated, from hnving been passed in very small quantity on account of the profuse perspiration which had occurred during the night. He soon got well. It has been noted by several observers that a peculiarly foetid diarrhoea follows the crisis in cases of recovery from septicasmia. While I and others have been particularly struck with the stench of the first stools passed by patients after the crisis in erysipelas, puerperal, typhoid, typhus, and other THE FCETOR OF DISEASE. 513 fevers. It is simply abominable, and even the smell of the urine is sickening to those who, like myself, possess acute olfactory nerves. It may not be out of place for me here to mention that Gaspard and Cruveilhier long ago published the fact that they had noticed that the dogs which re- covered after having putrid pus injected into their veins invariably passed terribly offensive black stools, as if the putrid poisonous matter was being eliminated by the bowels. I thmk that I have now advanced sufficient data to justify my asserting that the foe tor met with in all cases of germ diseases — contagious jaundice, epidemic jaundice, acute atrophy of the liver, erysipelas, gan- _grene, phtliisis, small-pox, malignant sore throat, &c. — is : — 1st. Not the direct product of the patient's dis- eased tissues and fluids, but the normal odour of the germs themselves infesting the patient's body and producing the disease under which he labours. 2nd. That the differences in the morbid odours of the breath, sweat, urine, and fasces m germ diseases are not dependent upon any differences in the com- position of the patient's tissues and fluids, but entirely upon the differences in the species of the germs in- festing them. 3rd. That the increase of the stench — which usually occurs immediately after the crisis — is directly L L 514 DISEASES OF THE LIVER. due to the increased elimination of the odoriferous germs. Lastly. Just as my former colleague, Professor Williamson, one day told me, when I complained of the stink in his laboratory at University College, that he never objected to any smell which he was able to define by a chemical formula, so have I ceased to murmur against the stench of the sick- chambers of patients labourmg under germ disease, since I dis- covered that it is not due to diseased filth — matter out of place — but to the normal odour of the healthy developing pathogenic germs which the patient's excretions are most laudably doing their best to get out of their involuntary suffering host's — the patient's — body. And further, that it is my, as it is every other practitioner's duty, not alone to avoid thwartmg their endeavours, but to aid by every possible means in our power this eliminating process, even though by so doing we may in some instances necessarily increase instead of diminish — at least for a time — the intensity of the offending smell. The next group of liver diseases about to be con- sidered is an important one, as it includes all the incurable as well as remediable forms of hepatic affections which possess the power of inducing II THE FCETOK OF DISEASE. 515 Jaundice from Obstruction. Examples of jaundice from obstruction are not only frequently met with, but are due to a multitude of widely -differing morbid anatomical conditions. In some cases the diseased state giving rise to it originates in the hepatic tissue itself ; as, for instance, when can- cerous tumours press upon and obstruct the ducts, or inspissated bile blocks up their canals. In many the obstructing cause originates in the gall-bladder, as when gall-stones induce it. In other cases it is the common bile-duct alone which is at fault ; while in yet others the source of the mischief lies beyond both the liver and its apj^endages. As, for example, when a duodenal ulcer's cicatrix, or the pressure of a tumour of the head of the pancreas, occludes the mtestinal orifice of the bile-duct. But what has been hitherto considered the strangest part of all is, that while in the majority of cases the gall-bladder is found enonnously enlarged and distended with bile, in others it is met with not only empty but shrivelled up. This being the case, one cannot feel surprised that no single form of affection in the whole range of medical nosology has proved so puzzling m its minute details as the pathology of jaundice from obstruction. And yet notwithstanding all the erroneous sugges- tions regarding it which have so long appeared in our printed books, when the reflected light of modem physiological and pathological science is focussed upon 516 DISEASES OF THE LIVEE. it, it appears to be almost as simple of comprehension as A B C. I shall now endeavour to show that this is really the case. But as the unravelling of the more compli- cated parts of the mechanism of the different varieties of jaundice as the result of obstruction, in order to be clearly understood, requires not only the adjunct of attention and reflection on the part of the reader, but a categorical as well as a lucid exposition by the writer, I shall begin by offering a few general remarks, equally applicable to the merely transient and the most permanent forms of jaundice from obstruction, which may serve as a sort of preliminary clue to the solution of the mystery in which it has been hitherto imagined to be involved. And in order to make the remarks terse as well as lucid, I shall tabulate them in the form of hepatic pathological axioms, which, even should they prove devoid of any other merit, will at least possess the salient advantage of enal:>]ing me to put forward my views on the mat- ter in a few plain words, and thereby considerably simplify the comprehension of this hitherto considered most abstruse part of the study of the pathology of complicated hepatic disease. The axioms regarding the mechanism of jaundice from obstruction which I desire to put forward are : — 1st. That jaundice never arises from the congenital absence, or from tlie accidental destruction, of a human gall-bladder, for the simple reason that a bile reservoir JAUNDICE EROM OBSTRUCTION. 517 is in no case absolutely essential to animal life. For just as in the horse, the deer, the rat, and other animals that possess no gall-bladders, the biliary function is perfectly well carried on, so also it may be in the human subject, labouring under a congenital or an accidental deficiency of the gall-bladder. In such cases, if, as in the animals above referred to, the hepatic ducts are pervious, the secreted bile finds no difficulty in reaching the intestines. In the ' Edin- burgh Medical Journal' (May 1861, p. 1045), Dr. Alexander Simpson reports a case of this kind occur- rmg in a child, who died when only a few weeks old, in whom there was no trace of the existence of a gall- bladder. On laying open the duodenum, the orifice of the bile-duct was seen in its ordinary situation, and a drop of pale bile was expressed fi:'om it. On tracing the duct back into the liver, it was found to pass up undivided into the horizontal fissure, where it at once divided and sent branches into the hepatic tissue of the right and left lobes. 2nd. Jaundice is an inevitable concomitant of complete occlusion of a normally formed common bile- duct in any part of its course from its beginning to its end. 3rd. Jaundice may, and frequently does, arise fi'om occlusion of the hepatic duct itself. 4th. Jaundice cannot possibly, in any case what- ever, arise from an obstruction of the cystic duct, be 518 DISEASES OF THE LIVER. the obstruction ever so complete or ever so perma- nent. oth. Death never did, nor ever can, arise from occlusion of the cystic duct per se ; for just as a gall-bladder is not a necessity to human life, neither is the presence of a cystic duct m the least degree essential. 6th. When the common bile-duct is obstructed, the gall-bladder and bile-ducts, if normally formed, are mvariably found after death distended with dark, thick, tarry bile. 7th. Whereas, when the hepatic duct is obstructed, the gall-bladder after death is always found to be EMPTY, and frequently even shrivelled up. 8th. While, when the cystic duct is obstructed, the gall-bladder after death is found neither empty nor distended with bile, but filled with a lohite glairy secre- tion possessing no analogy whatever to bile, either in appearance, physical properties, or chemical com- position, being in fact nothing more or less than the pent-up normal mucous secretion of the mucous mem- brane of the gall-bladder. For the logical explanation of the mechanism of this condition, which has hitherto led the uninitiated to imagine that the function of the gall-bladder had in such cases undergone a marvellous change, see my remarks at p. 1083, where I consider the diseases special to the gall-bladder. JAUNDICE FROM OBSTRUCTION. 519 9 th. In explanation of the mechanism of the mode of emptying and shi'i veiling up of the gall- bladder, when the hepatic (instead of the cystic) duct is obstructed, I may mention that even in many cases, where the patient has succumbed from the direct effects of the jaundiced condition itself, the gall-bladder has been found after death not only to contain not a trace of bile, but to be perfectly empty and shrivelled up to the size of a writing quill. This at first sight strange phenomenon I account for in the following wise. While no bile can find its way through the obstructed hepatic duct into the gall-bladder to fill it, all the gall-bladder's own normally secreted mucus (fi'om the cystic and common ducts being still pervious) readily finds its way out of it into the intestines, and conse- quently no accumulation of pent-up glairy white mucus takes place in the organ, as occurs when the cystic duct is obstructed. While again from the gall-bladder's natural function of becoming distended and acting as a reser> voir for the excess of bile secreted during the inter- vals of digestion, being in abeyance, the organ is never called upon to dilate at all, and as a natural consequence, from the want of use, it gets smaller and smaller, until it at length dwindles down to the -diameter of a mere tube. When the common bile-duct is obstructed, not 520 DISEASES OF THE LIVEE. only is there in general severe jaundice, but also a gall-bladder distended with bile — concentrated bile from the fact that although the bile is prevented from finding its way out of the gall-bladder into the intestines, its secretion still goes on, and more and more of it is forced into the gall-bladder, until the viscus gets enormously distended and can dilate no more — then, from a process of capillary osmosi> being set up, the aqueous and more soluble parts ol the bile are absorbed by the fine capillaries of the walls of the viscus, and gradually and slowly its contents become more and more concentrated, till at length, if the patient only survives long enough, the gall-bladder is found after death to be choke- full of a thick, viscid, black, tarry-looking bile. This is the true and simple explanation of the hitherto sup- posed to be obscure facts, that a gall-bladder may be found in one case of jaundice as big as a child's head, and full of bile. In another, empty and shrivelled up to the size of a writing quill. "While in a third case it may be found fully distended, and yet con- taining no bile whatever, but, in its place, a glairy white mucous secretion, about the supposed obscure pathology of which one occasionally sees such round- about theories ventilated in medical journals. For further details on these points see the chap- ters specially devoted to diseases of the gall-bladder. 11th. In no case of jaundice resultmg from an JAUNDICE FROM OBSTEUCTION. 521 obstruction to the outflow of the bile is the obstruc- tion ever found either in the secreting cells of the liver itself or in the gall-bladder, but only in the bile- ducts — either before or after their exit from the hepatic tissue. 12th. In jaundice from obstruction, by far the most frequent seats of the obstructions met with are in the ductus communis choledochus. 13th. All cases of jaundice arising from an im- pediment to the flow of bile along the ducts of the liver originate in one of the following three perfectly distinct pathological conditions : — a. It may arise from an accidental obstruction in the course of the ducts, as from gall-stones, hydatids, or other foreign bodies. b. From a congenital deficiency of the bile- ducts. c. From closure of the outlet of the common duct. For example, from the cicatrisation of a duodenal ulceration, from the pressure of hepatic tumours, of the distended transverse colon, from organic disease of the head of the pancreas, or other growths of the neighbouring organs. 14th. The main feature in the pathology of jaun- dice from obstruction lies in the fact, that although no impediment whatever exists (at least in the first instance) to the normal secretion of the bile by the hepatic cells, yet, from the natural passage of the 522 DISEASES OF THE LIVEK. secretion into the intestines being arrested, it gradually accumulates behind the point of obstruc- tion. Is' re-absorbed by a process of capillary os- mosis into the general circulation. The serum of the blood becomes surcharged with the bile-pigment, allowing it to transude through the coats of the cutaneous capillaries into the rete mucosum of the cutis vera and stain it yellow, thereby producing the tint of the skin which we designate jaundice. 15th. While at the same time, from no bile finding its way by the natural channel into the intestines, the faeces are of a pipeclay colour instead of being stained of the usual brownish tint by the bile-pigment. I 523 CHAPTER XI. BILIAMY CONCRETIONS. Introduction and General Remarks on Inspissated Bile and Calculi. Jaundice arising from a stoppage to the flow of bile through the gall-ducts by a solid biliary sub- stance of some kind or another is, in my opinion, a very much more common occurrence in this country than appears to be generally imagined. And this, I believe, arises from the fact that the clinical history, pathological significance, and chemical constitution of all kinds of solid biliary substances are not only very imperfectly understood, but their symptoma- tology as given in books is in many respects actu- ally erroneous. For example, not only do we find solid biliary substances like gall-stones and inspis- sated bile lumped together as if they were one and the same pathological product, but there is abundant evidence in both our home and foreign medical jour- nals to show that many writers on hepatic affections are but very imperfectly informed regarding the man- ner in which either of these substances produces jaun- dice, and are unaware that inspissated bile as well as a 524 DISEASES OF THE LIVER. gall-stone is capable of producing fatal occlusion not only of the bile-ducts, but of the intestines, abscess of the liver, and even malignant disease of both the liver and gall-bladder. I shall, therefore, endeavour to throw all the light of modern science that I pos- sibly can on this as yet but very imperfectly appre- ciated subject. In order to be able to do this suc- cessfully, it will be necessaiy to begin at the very foundation, and clearly demonstrate what is the real difference between the chemical composition and physical properties of the various forms of biliary concretions. For it appears to me that much of the ambiguity springs from the confused notions that still exist regarding the true nature of the solid biliary substances which obstruct the flow of bile through the gall- ducts into the intestines. Physical Properties of Biliary Concretions. Concretions of inspissated bile and true gall- stones appear to be lumped together in the minds of most persons as if they were merely different shaped and sized, identically constituted substances, merely called by different names. Hence, in the conversa- tions and writings of medical men, one not only occasionally, but frequently, finds these two terms employed synonymously. A gross and, in a clinical as well as a pathological point of view, most important error. For while the one is the dii'ect result of a BILIARY CONCRETIONS. 525 truly abnormal pathological formative process, iii as far as quantity is concerned, the other is merely due to the relative proportions of the solid and aqueous ingredients of the otherwise normally secreted bile having become accidentally disturbed from extraneous causes. In fact, the two kinds of solid substances which I designate as inspissated bile and biliary cal- culi, bear no resemblance to each other whatever, either in chemical composition, physical properties, or pathological origin. Except in so far as they are both products of the biliary secretion. In order to avoid the risk of being considered either unjust or guilty of exaggeration, I shall quote a reported case which abundantly proves that even amono^ the most enlightened of our medical brethren, some speak of all biliary concretions as if they had not only a common origin, but a similar chemical composition. For example. Dr. Quain has published the case of a Greenwich pensioner, aged 91, from whose gall-bladder, after death, he says he removed ' 735 stones,' while, from the description given of the substances removed, it is clearly seen that they were not ' stones,' but merely hard masses of mspissated normal bile. For they are described as being friable, of a dark greenish colour, and pos- sessing rough irregular surfaces. A combination of properties which, even without any chemical analysis, stamps them in the mind of the initiated as not being 526 DISEASES OF THE LIVER. gall-stones at all, but merely agglutinated masses of inspissated bile, consequently not pathologically speaking morbid products, in the true sense of the word. Only agglutinations of normally secreted physiological materials. I have cited this case in order to show how, if an otherwise medically-learned writer, such as Dr. Quain, falls into an error as regards the nature of biliary concretions, we cannot be surprised at the undeniable fact that our whole British and foreign medical literature teems with precisely similar mis- takes. As it is quite as much in the interests of clinical medicine as of pathological science that such errors should be as speedily as possible consigned to oblivion, I shall now proceed to explain what is the difference between a gall-stone and a concretion of inspissated bile. A gall-stone may be as big as a goose's egg, or so small as to be invisible to the naked eye. Not- withstanding which it invariably possesses a definite composition if not even also a definite structure. Whereas concretions of inspissated bile are never large, and, no matter what their size, shape, or posi- tion may be, are invariably mere heterogeneous struc- tureless aggregations of ordinary biliary materials » Again, while the external surface of a gall-stone may be rough, raammillated, or even spiculated like a hedge-, BILIARY CONCRETIONS. 527 liog, or as smooth and polished as the surface of a mirror, it never presents the rough irregular jagged in- descrihable formation of surface invariably presented by merely agglutinated bile. Every gall-stone has a describable form. No matter whether it be globular, oval, elongated, cylindrical, and truncated ; of a tri- angular, hexagonal, or polygonal shape ; or even of the extraordinary form of branched coral (a repre- sentation of a specimen of which is given in Plate Y. of Cruveilhier's ' Pathological Anatomy'). When dry a gall-stone is hard and unyielding to the pressure of the finger and thumb, even when it is of a steatomatous nature. Whereas, when dry, a concretion of inspissated bile is brittle, and crumbles into gritty dust under the pressure of the fingers. I must here further allude to a very peculiar and rare form of steatomatous gall-stone, or its future description might lead to misconception, from the fact that the term ' stone ' is usually associated in the inind with the property of hardness ; and although not generally known, there are such things as per- fectly soft biliary concretions. At least when first passed and warm, they are both soft and pultaceous — so soft that they can be kneaded into any shape by the fingers, like a piece of putty — and, even when old and dry, are no harder than a piece of stearin, and consequently can easily be scratched with the nail or cut with a knife, just as a stearin candle 528 DISEASES OF THE LIVER. can, and that, too, for precisely similar reasons. Namely, that they are of a fatty nature. Indeed, I believe them to be nothing else than masses of cholesterin in its preliminary stage of crystalHne formation. Biliary products of this kind are rare ; but, as will be subsequently seen, both I and others have met with them assuming the appearance of dirty- white barleycorns, orange-pips, grapes, and pigeons' eggs, leading even the most experienced to commit awkward mistakes. As regards colour again, while masses of inspis- sated bile, be their size or shape what it will, are invariably dark in colour, generally blackish-green, though occasionally brownish-red, gall-stones, on the other hand, are of a great variety of colours, sometimes as white as newly fallen snow, some- times as black as ink. They may be yellow like bees- wax, green, brown, or even red. In my collection I have an extraordinary coloured one, which I took from the gall-bladder of a woman who died in 1862 with bronzed skin. It is of the size of a small hazel- nut, and has a brown outside shell-like crust, with a blue slate-coloured kernel-like ulterior. Specimens of this kind, I fancy, must be rare. For I have never seen another like it, notwithstanding that I have seen most of the biliary concretions in nearly all of the great pathological museums of Europe. Some gall-stones are entirely comjjosed of pure BILIAEY CONCRETIONS. 529 white crystalline cholesterin. I possess one the size of a pigeon's egg of this kind. It is slightly nodu- lated externally, crystalline internally, and of an alabaster colour. A more curious fact still is that some gall-stones actually resemble (not only in form and size, but in general appearance) ' pearls of the purest water.' I have in my collection six beautiful white small pearl- like gall-stones, which were found in the gall-bladder of a Danish ox. So like are they to pearls of the purest water, that they would deceive the eye of even an experienced judge, if he were not allowed to handle them. I have also a beautiful specimen of a brownish-red, distinctly stratified biliary calculus, taken from the gall-bladder of a Danish woman. Both the pearls and the red calculus were presented to me by Professor Panum on my visit to Copen- hagen in 1874. Being duplicates of specimens existing in his museum. There are several beautiful differently coloured and shaped specimens of gall-stones in the Museum of the Royal College of Surgeons. Some of them hke yellow beeswax. Some like tailor's white chalk. Some pinkish in colour. Some perfectly globular in shape. Some columnar. Some truncated cylinders. One specimen of the latter shape, over an inch in length and three-quarters of an inch in diameter, has a small globular stone set into one of its ends ; the two to- il M 530 DISEASES OF THE LIVER, gether forming a good specimen of a ball-and-socket joint. On section, or better still on fracture, gall- stones present either a crystalline, a homogeneous, or a stratified appearance, whereas concretions of inspis- sated bile are always totally structureless. Sometimes, though very rarely, gall-stones have foreim materials as nuclei — a blood - Fig. 12. " _ clot, a shrivelled-up entozoon, or, it may be even, a fragment of inspis- sated bile. While, as far as I am Section of gall-stone awarc, coucrctions of inspissated bile showinsr internal crys- i • talline structure. HCVCr pOSSCSS nUClci. Specific Gravity of Biliary Concretions. All biliary calculi — true gall-stones — very greatly diminish in weight after being exposed for a few days to the air, from their sometimes containing, when freshly passed, as much as 50 per cent, of hydroscopic water. It would therefore, I think, be decidedly to the interests of medical statistics if gentlemen would refrain from recording the weights of calculi before they are dried. For when newly passed and moist, their weight is of no clinical importance whatever, since it is often quite as much due to the quantity of water they accidentally contain as to the solid substances of which they are composed. This remark is not uncalled for, seeing that a great deal of nonsense has been written regarding the specific gravity of freshly passed gall- BILIAKY CONCKETIONS. 531 stones, which nonsense has given rise to an important error in the mode of procedm'e recommended for their detection. I made some particular experiments on this subject, which were as follows : — On putting thirty gall-stones taken promiscuously from my collection, and therefore representing all kinds of comparative shapes and sizes, and which, from their having been put up as dry specimens, had be- come air- dried, into a vase of distilled water, I found that about one half floated and the other half sank to the bottom of the jar. On putting seven freshly passed stones — that is to say, stones which had been passed within forty-eight hours — into the same jar of distilled water, six sank to the bottom, and only one, a small one, the size of a pea, with a whitish, smooth, soapy feeling and tailor's -chalk-like surface, floated. Having thus satisfied myself that while the vast majority of freshly passed stones are heavier, only one-half of dried stones are lighter than water, I proceeded to take the specific gravity of those that were heavier than water, and I found that it varied very greatly, from 1000-1 to 1025. The heaviest stone being of the last-mentioned specific gravit}^. It had a slightly nodulated mulberry-looking surface, was of the colour of a dirty- white piece of alabaster, and the size and shape of a wood pigeon's egg. On making a section of it three-quarters through with a saw, and then splitting the remaining uncut portion, M M 2 532 DISEASES OF THE LIVER. in order to show its appearance both on section and fracture, I found it consisted entirely of beautifully white, almost chemically pure, large crystals of cholesterin, densely packed together ; the crystalline appearance being in this, as in all other cases, best seen on the fractured surface. From this series of carefully conducted observations it may now, I think, be confidently affirmed that, contrary to previous teachings, almost all gall-stones, when fresh, are heavier than water, varying in specific gravity from 1000' 1 to 1025, but when air- dried many of them, by losing moisture, become lighter even than distilled water, and hence float upon it. Those that float on water are in general found on section to have a hollow centre, from their unsolidified substance while drying shrinkinof from the centre towards the hard external shell, just as many a molten mass of silica, by hardening on its surface during the cooling process more quickly than in its interior, presents on section a hollow centre. Concretions of inspissated bile, on the other hand, no matter how dry they become, are never hollow in the centre, but uniformly heteroge- neous throughout, and always heavier than water. I may here incidentally allude to a fact of some importance, as it may save others from falling into error regarding the exact nature of calculi passed from the human bowels, which is, that while I was busy in 1859, preparing a series of intestinal con- SPECIFIC GEAVITY OF GALL-STONES. 533 cretions for exhibition along with their analyses at the Pathological Society (see vol. xi. p. 86 of the ' Transactions '), Professor Sharpey, who always took oreat interest m pathological as well as physiological analyses, while sitting talking to me in my laboratory at University College, all at once exclaimed, ' Oh ! I have a much rounder gall-stone than any of these passed by the rectum. I shall let you see it.' Going immediately to his private room on the same landing, the door of which was nearly opposite mine, he returned with a perfectly globular concretion in his hand ; it measured exactly one inch and a quarter in diameter, and had a hard smooth exterior of a dark greenish-black colour, just like a dark gall-stone. Being in the act of preparing to wash my hands when he gave it to me, I popped it into the clean water in the basin, when to my surprise it floated like a cork, being far more buoyant than any gall-stone under similar circumstances would have been. Never be- fore havino- seen a ffall- stone either so lio-ht or so beautifully globular, I turned io Professor Sharpey, and said, ' Well, if that is really a gall-stone, it is a curiosity. Will you let me cut it ? For I don't think it is a biliary calculus at all.' ' Oh yes,' replied Professor Sharpey, ' you may do what you like with it, for it is of no use to me.' In a few minutes it was divided in two, and the felt-like appearance it pre- sented on section told me at once that it was not a 534 DISEASES OF THE LIVER. gall-stone at all ! but an intestinal oat-hair concre- tion, exactly the same, except in colour (being some- what darker), as some I had just been examining from Mr. Liston's collection in the college museum. When teased out with needles, the dense felt-like substance of these calculi is found to consist of the hairs of oat-seeds, mixed with intestinal mucus and inorganic salts ; their ashes being composed of lime and magnesia, with a little soda. Those in Liston's collection are about an inch in diameter, and twenty in number ; they were all passed at different times by a patient whose chief food had for many years con- sisted of oatmeal porridge. The subjoined woodcut, taken from the Morbid Anatomy part of my ' Histological Demonstrations,'^ Fig. 13. Oat-hair Intestinal Calculus. represents the matters composing these calculi when examined under the microscope. ' 2nd Edition, p. 192. Longman & Co. J BILIARY CALCULI. 535 How to detect Biliary Concretions voided by Stool. Very great difificulty is experienced not alone in the detection of small masses of inspissated bile, but even of large gall-stones that have been passed along with the faeces. This in great measm'e arises from the false advice given for their detection in books. All of which say that biliary concretions are to be detected by adding water to the stools, and that if gall-stones are present they will be found floating on the surface. A more ridiculous piece of advice it is scarcely possible to conceive ; for, as already shown, the vast majority of freshly passed gall-stones are heavier than water, and even some of the air-dried ones may have a specific gravity actually reaching to 1025. So that in almost no case w^hatever, when freshly passed, could they be found floating on water. I have never yet been able to detect a gall-stone in this way. The plan I recommend is, to mix the stool freely with water, and either decant the super- I natant fluid, and then add fresh portions of water till the w^hole of the soluble matter is removed, or better still to strain the mixture through a hair- sieve. I The gall-stone in either case remains behind, and can be readily detected. Moreover, it is ahvays necessary to explain to the searcher that gall-stones may be as small as pins' heads, or as large as hen's eggs. As black as the 536 DISEASES OF THE LIVER. faeces themselves, or as pale and white as frosted silver or snow. As irregular in shape as a triangle, or^s round as a marble. As smooth and as white as polished ivory, or as rough and as dark as a mulberry. On one occasion I got from a lady's maid a gall- stone the size of a very large field pea, which she actually found the first time she strained the stool through a sieve, although she had been fruitlessly searching for gall-stones for months on the old plan of adding water to the stool, in the expectation oi finding the gall-stones floating on the surface. How many gall-stones this maid had missed before she adopted my plan of search, I know not ; but thirteen were found in the stools within two months after its adoption. Twelve of which specimens I exhibited tc the Pathological Society. Not one, but a dozen, nay, even a whole hundrec gall-stones, as large as ordinary garden peas, havi been found in one single motion of the bowelS' While, in a remarkable case which occurred whiL the patient was taking the waters of Carlsbad nearly three hundred, varying from the size of i millet-seed to that of a pea^ are said to have bed discharged with one action of the bowels. In i case of this kind I should suppose that the stone did not come through the channel of the comm^ duct from the gall-bladder, but were all at o: am DETECTION OF GALL-STONES. 537 passed into the intestines through a direct ulcerated opening between the gall-bladder and intestines. In looking for gall-stones in the stools, great care must be taken not to confound the seeds of fruits passed by the bowels with gall-stones, and vice versa. A mistake which often happens. As was the case with a specimen I exhibited in connection with a series of gall-stones to the Pathological Society, which had not only deceived the patient, but actually deceived many of the medical gentlemen who saw it at the meeting. Until I demonstrated its true nature by cutting it in halves. An exactly opposite kind of mistake is equally liable to be made. Xamely, that of mistaking true biliary concretions for seeds. In proof of how exceedingly easily this is done, and in order to show how very difficult it is some- times to avoid making mistakes of this kind, and missing gall-stones even when they are actually be- fore our eyes, I shall relate what happened to myself. When, notwithstanding my twenty years' experience of gall-stones of all shapes, colours, sizes, and con- sistency, I fell into the error of taking two steatoma- tous biliary concretions for lemon- seeds ! As a warning to others, I think I had better tell the tale in full. It happened thus : — In September 1881, Mr. John Gay, surgeon to the Great Northern Hospital, sent me a lady. Who had been for some time under the care of a clever 538 DISEASES OF THE LIVER. general practitioner, aided in consultation by one of our leading London (titled) consultants, without (as she expressed it) their doing her any good. What their treatment may have been I know not ; but I assuredly know that their diagnosis was correct. For a clearer case of gall-stones it has scarcely ever been my lot to see. There was paroxysmal pain and tenderness over the liver, bilious urine, pipeclay- coloured stools, sickness, and jaundice. Lasting for a few days. Followed by a total subsidence of all signs and symptoms, and, after ten days or so of re- pose, bursting out again afresh. Again to subside, and reappear after a longer or shorter interval. On no occasion — at least while I saw her — was the in- terval sufficiently long to admit of the patient's being said to be convalescent. My opinion was that she had a lot of small gall-stones, or a quantity of in- spissated bile, in her gall-bladder. Which came away in small quantities at a time, temporarily blocked up the common bile-duct, and was then voided by stool. But against this supposition stood the salient fact that the stools were carefully searched for the offending substances, without avail. The longer I live, however, and the more experienced I become with the difficulties besetting the path of gall-stone stool detection, less and less importance do I attach to the negative data of ' not finding a stone,' and I think the reader, after perusing what DETECTION OF GALL-STONES. 539 I am now about to say, will feel strongly inclined to endorse this opinion. The lady above alluded to was under my care from September 1 till Decem- ber 17, that is to say, fifteen weeks. During which period she had four separate attacks, and, as I saw her many times, I had ample opportunities afforded me of modifying, correcting, or entirely changing my opinion of the nature of her case, had new facts and signs presented themselves. But the more I saw of her, the more convinced was I that the dia- gnosis of repeated discharges of small biliary concre- tions being the cause of her jaundice was essentially correct, and fortunately for my own personal infor- mation, during the few last times I saw her, from the appearing of ' pure bile ' in the vomit crucial evidence was at length afforded not only of the exactitude of the diagnosis, but of the success of the treatment. At the termination of one of her attacks I had the benefit of Sir William Gull's opinion, and on another occasion when she had sio;ns of ileo-c£ecal valve irritation, no doubt from what is a common occurrence, the lodgment of a concretion in the valve — which the patient, however, thought was a return of an inflammation of her uterine appendages, from which she had at one time suffered — I had the additional advantage of her former surgical attendant, Mr. Spencer Wells's, advice. Both of these gentle- men, I need scarcely say, came to the same conclusion 540 DISEASES OF THE LIVER. regarding the nature of the case as I had done. In fact, no other opinion could under the circumstance^ possibly be arrived at ; yet, as there was never n gall-stone found, the patient was not only dissatisfie< with the treatment, but an unbeliever in the diagnosis. Now conies the episode of my being completely deceived by mistaking two biliary steatomatous con- cretions for the seeds of a lemon. At the termination of the second last of the attacks for which I attended her, and while the stools were yet of a creamy hue. and consequently without any distinct evidence qi bile in them, I saw two pale turtle-dove coloured oblong masses in the soft fteces ; they looked exactl; like lemon seeds, and knowing that she was then ii the daily habit of drinking the juice of squeezes lemons, and receiving no contradiction from the professional nurse, who was holding the chamber- pot in her hand, I concluded that a couple of lemon- pips had been accidentally thrown into the utensil. and so I thought nothing more about them. What, however, was my dismay when at my next visit 1 learned that no lemon- seeds could by any possibilit} have got into the pot ! From the juice only of the lemon, carefully freed from seeds and pulp, being ever brought into the sick-chamber. Now to me all was clear ; the supposed seeds were oblong soft' steatomatous concretions, moulded into the shape oi lemon-seeds during their passage through the bile- DETECTION OF GALL-STONES. 541 ducts ; their appearance, size, and soft nature com- pletely accounting for the pain being so slight, as well as for their having hitherto invariably escaped detection. Consequently I gave orders that whenever any more of these seed-looking substances appeared, they should be kept for me to examine. An order which was disregarded. For on the next occasion of their appearance, the patient examined them herself ; tested their nature by squeezing them, and, from finduig them soft and pultaceous, her medically untutored mind ' knew that they had nothing what- ever to do with the jaundice ' — at least so she positively affirmed — and, without more ado, she con- signed them to the w.c. Of course I knew that she was mistaken about the nature of the soft substances ; but how to convince her of that fact was the difficulty. For I had on more than one occasion observed, while endeavouring to explain to her the nature of her case, she appeared to be one of those persons who, while sceptical of the diagnostic knowledge of the doctor, entertain an implicit belief in the infallibility of their own notions of the etiology of their symptoms. I Consequently, after unsuccessfully trying the effect of a little mild reasoning as to the steatomatous nature of the bile substances she had passed, I thought it better to leave her in the happy delusion of the I correctness of her opinion. In fact, no good could possibly have arisen from my contradicting her. As 542 DISEASES OF THE LIVER. it did not matter what her peculiar views on the subject were, as time would of itself prove her to be in the wronof. Which idea was much sooner verified than I expected. By her vomiting a very few day> afterwards a large quantity of pure bile, thus affording positive proof that the obstructing biliary concretion> had actually been passed, and that the bile-ducts between the gall-bladder and the duodenum were once more perfectly free. For otherwise pure bile could not have found its way into, and been vomited from, the stomach ; at least not unless there had previously been bile-duct or gall-bladder perforation, to induce an opening into the stomach througli which the bile could have directly passed from the gall-bladder in spite of the obstruction. After this evacuation of bile I saw nothing more of the case, so I cannot say whether or no all the biliary concre- tions that were origmally in the gall-bladder had then been got rid of. One thing, however, I do know, and that is that owing to the treatment by biliary solvents, administered to her in the shape of soda and taraxacum and alkaline salicylates, she was, when I last saw her, on the high road to complete re- covery. After what has just been said the reader will not be surprised to learn that ' sad experience,' the most infallible of all guides to human success, may be said to whisper to us that the only possible way to avoid I DETECTION OF GALL-STONES. 543 failures in searching the excretions for voided biliary concretions of all kinds is to pick out from them everything, though it be as small as a pin's head or as big as a hen's egg, which differs in appearance from the general mass. No matter what its colour, form, or consistence may be. For biliary concretions may, as we have seen, vary from the whiteness of newly-fallen snow to the blackness of ink ; be round as a ball, oblong like an orange-pip, or as flat as a small fragment of note-paper. Even inspissated bile is sometimes passed by stool as tiny dark thin scales, the true nature of which is only discoverable on their being treated with strong sulphuric acid, which instantly turns them of a bright crimson hue. While again, as regards consistence, the concretions may be as hard as stones, or as soft as newly melted wax. My advice is therefore to pick out everything that at all difl^ers in appearance from the general constitu- tion of the stool. Wash, dry, and test it, physically, chemically, and microscopically, if need be ; for then, and then alone, is it possible to avoid mistakes. But even in that case a ne2:ative result is not neces- sarily to be considered proof positive that no biliary concretion has been passed by stool ; far less is it a proof that an offending concretion has not escaped from the hepatic appendages into the intestines. My reason for so saying simply arises from my knowledge of the fact that a gall-stone, after being 544 DISEASES OF THE LIVER. passed out of the bile-ducts, may quietly remain in the intestines for days, weeks, months, or even years, and ultimately pass out along with the faeces when not expected, and consequently at a time when it is not being looked for. As a curious example of this, I may mention that a gentleman, some time after having ceased to have symptoms of gall-stone, and when he had come to the belief that the diagnosis of his case had been wrong, as no biliary concretions were found in his stools, heard, while he was sitting on the closet, something hard fall into the pan. On looking at it, he saw a dirty-white-looking thing' among the faeces as big, he said, as a pigeon's egg : but never dreaming that a gall-stone could be any- thing like that, he drew up the plug, let it slip away, and thought nothing more about it, until I began one day explaining to him the many curious appearances gall-stones assume. When, from my description, he at once knew that the egg-shaped dirty- white-looking mass which he had voided was the gall-stone hv had so long fruitlessly searched for. A still stranger anecdote is the following. Last year a lady whom I was attending for gall-stones one day showed me a substance (as big as half a walnut when cut transversely), of a polished whit)''-yellow look, with irregular facets upon it. Which she said was kept in her family as an heir- loom. It being supposed to be a piece of the back- J DETECTION OF GALL-STONES. 545 bone( !) of an aunt of hers. Which she had passed at stool. The history of it was this. Long after the patient had ceased to have hepatic symptoms, one day she passed by stool a hard substance which hurt her considerably, and, on looking at what had come away, she saw, as she thought, a lump of bone in the faeces. She took it out. Washed it, showed it to her famity, who unitedly diagnosed it as ' a piece of her backbone ' which had come away, and hence- forth carefully preserved it as a family heirloom. I saw that it was merely a cholesterin concretion, and had the cruelty to dispel the interesting family delusion. I might cite many cases of a somewhat similar character to the above ; but I think that these two examples are sufficient to show how even patients who have been in the habit of searching for gall-stones in their stools may make mistakes when they are actually passed, merely from their coming away not only at a period when they are not being looked for, but at a time long after all the symptoms of the biliary derangement have vanished. Which fact is of course not in the least surprising, when it is ! known that gall-stones, after being passed into the I intestines, may not only quietly remain there for years before being voided by stool ; but may, as will be subsequently shown, never be voided at all, and their existence only be discovered at the post-mortem. N N 546 DISEASES OF THE LIVER. Prognosis of the Number of Gall-stones in any given Case. In the earlier part of my career as a teacher at University College Hospital, I taught, as I had mysell been taught, that the number of facets found on any voided gall-stone was a trustworthy indication ol the probable number of stones in the patient. While if there were no facets upon the stone found in th( stools, it would in all probability be the case of a solitary calculus, and the patient might be safely con2:ratulated that he would have no more attacks, Within the last few years I have learned that this i^ utterly false ; for although the presence of two, three, four, or more facets tells plainly that other stones have been formed in the body along with the one that ha^ been voided, the absence of facets is no proof what- ever that the stone has been a solitary one. Three stones are now in my possession, as big as small hazel-nuts, and, although four such came awa\ within a few days of one another, not one has ;i vestige of a facet upon it. The details of this cas( will be given under the heading of gall-stones beinf; mistaken for cancer. The Chemistry of Biliary Concretions. It will now be shown how the different kinds <> biliary concretions, which I respectively designate in spissated bile and gall-stones, bear quite as little con- II COMPOSITION OF BILIARY CONCEETIONS. 547 stitutional similarity to each other m a chemical as in a physical point of view. For while those of the gall- stone class are found to consist chiefly of cholesterin, with mere traces of bile-pigment, concre- tions of mspissated bile are composed of biliverdin j and other organic and inorganic bile products, with scarcely any cholesterin entering into their composi- tion. Gall-stones again are not even so much as formed in the same way as concretions of inspissated bile, for like urinary calculi they are formed by gradually repeated I depositions of pathological products, in so far as quantity is concerned ; whereas, as will be immediately shown, concretions of inspissated bile are mere I heterogeneous agglutinated masses of normal biliary j soHds, resulting from a deficiency of their normal I aqueous solvent. Hence, as will presently be seen, gall-stones, that is to say true biliary calculi, and I concretions of inspissated bile possess but one feature in common — namely, being the direct products of the biliary secretion. Chemical Composition of Inspissated Bile. The following is the result of an analysis which I made of 120 grains of hard, irregularly shaped green masses of inspissated bile of the average size of small barleycorns, taken promiscuously from my collection : — N N 2 548 DISEASES OF THE LIVER. Water 5-4 Solids 94-6 The solids consisted per cent, of • Bile pigment . . . . . 84*2 Cholesterin . . . . . 0'6 Inorganic salts (iron, potash, and soda) 15*2 On comparing the above analysis of inspissated biliary concretions with the analysis of specimens of healthy bile taken from human gall-bladders given at p. 83, it is seen that they actually consist of nothing beyond the normal solids of the biliary secretion, being in fact merely normal bile dej^rived of its aqueous elements. Chemical Composition of Gall-stones. On chemical analysis I found that twelve air- dried gall-stones, taken promiscuously from my collection, and of an average weight of 31 grains each, yielded Water ..... . 4-2 Solids ..... . 95-8 100-0 The solids consisted per cent, of Cholesterin .... . 98-25 Pigment and mucus . 0-50 Inorganic salts . 1-25 COMPOSITION OF GALL-STONES. 549 In 1856 I exhibited to the Pathological Society a gall-stone which had ulcerated its way out of the gall-bladder, and become lodged in an artificially formed cul-de-sac of the intestine.^ The mass con- sisted of three jointed pieces of nearly equal size, collectively being of a pear shape, as if they were a cast of the gall-bladder, and weighing 450 grains. On analysis I found that they consisted of "Water . 2-543 Solids . 97-451 100-000 The solids consisted of Cholesterin . . 90-346 Mucus . 2-218 Colouring matter and biliary resin . . 4-242 Inorganic salts . . 0-661 The difference in the proportion of the ingre- dients in the small and in the large calculi is perhaps not altoo-ether due to an orio-inal difference in com- position, but partly to the fact that while the above analysed small calculi came direct from the gall- l>ladder, the big one had sojourned, and been sub- jected to the chemical action of the digestive juices for many years perhaps, in the intestinal canal. ^ This case is fully report ed in the Pathological Society's Transactiom, Tol. viii. p. 235. 550 DISEASES OF THE LIVER. In 1858 Dr. Gibb brought to the physiological laboratory at University College a curious specimen of a calculus Trhich he found encysted in the gall- bladder of a man aged over 70. The patient had been a hard drinker, and his liver was both chroni- cally atrophied and nodulated. The gall-bladder, which was quite embedded in the hepatic tissue, con- tained four calculi. Three were free, and a fourth, the largest, weighing 6G grains, was encysted close to the ofall-bladder orifice of the duct. Which it com- pletely plugged up. Not a single drop of bile. Dr. Gibb said, was found in the gall-bladder. On chemi- cal examination it was found that all the stones con- sisted of more or less pure cholesterin. The purest of the four being the one which weighed 66 grains. It had the further peculiarity of its external surface consisting of a loose foliaceous layer of crystals. Which, when exammed under the microscope, looked so like crystals of sulphate of soda, that I mistook them for such, until strong sulphuric acid revealed that they were cholesterin, by producing with them the beautiful play of colours, presently to be alluded to, characteristic of that substance. Before proceeding further with the subject oi biliary concretions, I will redeem the j)romise made in the physiological chapter of saying a few words more on the nature and chemical properties of choles- terin. J COMPOSITION OF GALL-STONES. 001 Cliolesteriii, although a biliary product, appears to be a normal constituent of healthy human blood, from which it can readily be extracted by treating dried serum either with boiling alcohol or ether. From the extract made with the former, the choles- terin crystallises in the flat rhombic plates shown in fig. 14. From the latter in fine needle-shaped crys- FiG. u. Cholesterin crystals in the form of fine transparent four-sided plates of various sizes and shapes. The crystals are freely soluble in hot alcohol, from which they are re-deposited on cooling. tals. Pure cholesterin is insoluble in water, dilute acids, and alkaline solutions. With strong sulphuric acid it gives a beautiful play of prismatic colours, which are best seen when the reagent is applied to it on a clean white porcelain capsule. When a solution of iodme is added after applying the strong sulphuric acid, a still more beautiful play of blue, green, yellow, and red colours is obtained. 552 DISEASES or the liver. Cholesterin occasionally appears in the urine in some hepatic diseases where a large quantity is being formed, and, for some as yet unknown reason, crystals of it are frequently to be met with in serous exuda- tions. Such as pleuritic, peritoneal, ovarian, and hydrocele fluids. The foregoing details are not to be regarded in the light of merely curious physical and chemical data, but as important pathological facts. Which every practitioner ought to be fully acquainted with, and bear in mind when he is called upon to treat a doubtful case of gall-stone, or a suspicious one of inspissated bile. For, as I have just shown, while in the former case he has an actual chemical vice in the system to correct by his therapeutic agents, in the latter case he has only to attempt to retain the normal bile in its usual state of aqueous fluidity. Two entirely difi'erent matters, requiring the aid of difi'e- rent therapeutical agents. For, although what is called a gall-stone may occasionally, but only rarely, contain a large amount of biliary pigment mixed up with cholesterin, that which is properly known under the title of inspissated bile never con- tains a sufiicient amount of cholesterin in it to be recognisable, except by chemical analysis. Such being the physical and chemical difl'erences existing between the two great classes of biliary concretions — inspissated bile and gall-stones — in COMPOSITION or BILIARY CONCRETIONS. 553 future when I speak of concretions of inspissated bile, I wish it to be distinctly understood that I never, by any chance whatever, mean a gall-stone, no matter however small in size it may be, but solely and simply an irregular structureless agglu- tination or concretion of concentrated, thickened, hardened bile. Of variable size, shape, and colour, but of only slight!}'' variable composition. While on the other hand, when 1 speak of a gall-stone or a biliary calculus, I always mean a true stratified or crystallme stone. Always containing a maximum of cholesterin, and a minimum of bile-pigment. Vary- ing, it may be, in size from a naked-eye invisible point to that of a goose's egg or bigger, and in colour from a pure pearly or snowy whiteness to a light or dark brownish red or black hue. According to the greater or less admixture of colouring matter it accidentally contains. It is necessary for me here to call atention to a fact of some clinical importance. Namely, that gall- > tones and inspissated biliary concretions may co- exist not only in the same patient, but in precisely I lie same locality at one and the same time. This I iiave several times noticed ; but a much more striking; case than any I have met with is one recorded by Mr. Wale Hicks of a woman aged 60, who died from atrophy of the liver induced by obstruction of the common bile-duct by a large gall-stone. The descrip- 554 DISEASES OF THE LIVER. tion given is, that ' the gall-bladder was small, and contained a little thin bile ; the cystic duct and part of the common bile-duct were occupied by a large gall-stone, which also projected mto the gall-bladder. The hepatic duct and its branches were very much enlarged, and filled with dark green masses of nearly solid inspissated bile.' Inspissated Biliary Affections. One occasionally hears medical men speaking in an offhand manner of cases of jaundice that they imagine they have met with as the result of a blocking up of some one or other of the bile-ducts by concretions of inspissated bile, as if they were thmgs of almost everyday occurrence. AVhereas from over twenty years' personal experience I know that while cases of jaundice from impacted gall-stones are exceedingly common, those from inspissated bile are exceedingly rare. Consequently I opine that inspissated bile is a much-maligned substance, being frequently blamed for mischief it never produces by a class who talk as if many hepatic affections, both with and without the concomitant of jaundice, arose from it. While others again, running to the opposite extreme, not only ignore the existence of inspissated bile as a pathological pro- duct of any importance whatever, but occasionally go so far astra}- as to confound its signs and symptoms with those arising from malignant disease. An error INSPISSATED BILE. 000 which, as will be presently shown, has not always only been revealed at the po.st-mortem examination, but even, in some cases, durmg the actual lifetime of the patient by its being voided by the stools, and the morbid supposed cancerous symptoms immediately vanishing, it may be never to return. Etiology of Inspissated Bile. Before a concretion of inspissated bile can form, either in a gall-bladder or in a bile-duct, there must have existed a preliminary, though it may have been a merely temporary transitional stage of thickening of the bile. Which stage I shall now allude to, and no better published example of it can I find than that given by Dr. Hunter in his book on ' Diseases of the Army in Jamaica,' in which he describes a tj^pical case. Which is briefly as follows : — ' A few daj^s before the death of a patient from pulmonarj^ consumption jaundice came on, and at the autopsy there were found signs of superficial inflammation all over the liver, the lower surface being bound to the stomach by adhesions. The gall- bladder was full of bile. The common duct was filled with a thick ropy black molasses -like bile coagulum. So firmly implanted in the duct was this thickened bile that pressure on the gall-bladder failed either to dislodge it, or to force a single drop of the thin bile contained in the gall-bladder past the coagulum into 556 DISEASES OF THE LIVER. the duodenum. It was even not until after the intro- duction of a blowpipe into the duct, and by consider- able force, that air could be driven along it into the gall-bladder. The duct was subsequently laid open from the gall-bladder to the duodenum, and not a trace of any other obstructing cause beyond the thick ropy tarry bile coagulum could be found.' This is such an excellent example of the ante- cedent and transitional stage between healthy fluid and the formation of hard concretions of inspissated bile from a mere deficiency of water, that I need adduce no further examples of it. Symptoms of Inspissated Bile. The symptoms which characterise an obstructive attack of hardened inspissated bile are in general, like those of gall-stones, sudden in their onset and painful in their duration. They usually begin during the period of fasting, and are therefore most common between ten at night and ten in the morning. Some- times they are little more than a dull aching feeling in the right hypochondrium. At others they amount to acute paroxysmal colic, sometimes increased by direct pressure, yet frequently relieved by soft manual frictions. When the attacks are moderate there is neither jaundice nor vomiting ; when they are severe there are usually both. The attacks generally last from INSPISSATED BILE. 557 twelve hours to twelve days. Then in general subside as suddenly as they came on. As a rule, the patients are what may be called bilious subjects. Many of them come of a bilious family ; and usually they can recall to mind a previous attack during which they were either actually jaundiced or very nearly so. If the attack be not sufficiently severe to produce discolora- tion of the skin, it seldom gives rise to much gastric derangement, nothing perhaps beyond a little flatu- lency and constipation. Now as regards the pathology of this state of things, the explanation is very simple. A viscid state of the bile gives rise to the formation of small concretions of hardened biliary matter ; these plug up and irritate the small ducts sufficiently to produce pain. If only a few of the small ducts are plugged up, there is not a sufficient amount of biliary disturbance to produce jaundice. If, on the other hand, the con- cretions are sufficiently large or numerous to block up some of the large bile-ducts, especially the hepatic or the common bile-duct, jaundice is the inevitable consequence. When small concretions cause pain, they only do so as long as they remain in the smaller ducts. For as soon as they reach the larger ducts, which they are not big enough to plug up and irritate, all pain instantly ceases, and the patient feels sud- denly as well as ever he was. If the fragments of the liardened bile, so soon as they reach the larger duct, 558 DISEASES OF THE LIVER. are floated away, as they frequently are, into the in- testines, they mix with, and are expelled along with, the feces, their symptoms vanish entirely, and nothing more is ever heard or seen of them. This, however, only happens under exceptionally favourable circum- stances. For sometimes the patient is not only a victim to paroxysms of pain at irregular recurring intervals from a succession of concretions forming in the ducts ; but occasionally the concretions become so large that they block up the ducts permanently, and either a fatal jaundice or the formation of fatal abscesses in the parenchyma of the liver behind the seat of the obstruction is the result. As a striking illustration of the theory that jaun- dice may arise from inspissated bile blocking up the ' small ducts ' of the liver, and not only give rise to all the symptoms of gall-stone, but even end fatally, I shall cite the case related by Dr. Grainger Stewart at p. 627, vol. xviii. of the 'Edinburgh Monthly Medical Journal.' The case was that of a man aged 24, who died jaundiced with symptoms of impacted gall-stone, and at whose necropsy it was found that the right lobe of the liver was enlarged, the left atrophied, and throughout the whole organ were numerous abscesses, var3dng from the size of a pea to that of a walnut, while the ramifications of the bile-ducts in the sub- stance of the liver itself were so dilated that many of them admitted the point of the finger. Most of them i INSPISSATED BILE. 559 contained ' partiall}' inspissated bile and a finely granular blackish material ; but some contained pus in addition, others almost pure pus.' When this history is scientifically interpreted, as there was no impacted gall-stone found, and the gall-bladder and cystic duct were of normal size, while the ductus communis choledochus was also perfectly normal, it is impossible to doubt the fact that the enormous dilata- tion of the ducts, as well as the jaundice and the death of the patient, were entirely due to the ob- struction caused to the flow of bile through the small ducts by their being blocked up with inspis- sated bile. To Dr. Handfield Jones we are indebted for the pubhcation of a case ('Pathological Transactions,' vol. V. page 150) of 'universal jaundice,' where on post-mortem examination the cause was found to be the plugging up of the outlet of the common bile- duct by a quantity of fine ' sandy matter ' consisting entirely of bile-pigment. The presence of inspissated bile in the ducts has even proved fatal to infants. A well-marked case of this kind is reported in the ' Northern Journal,' under the head of fatal jaundice in a new-born child. Where on post-mortem examination the cause of death was found to be occlusion of the common gall-duct by ' an indurated cord-shaped plug' of inspissated bile.^ > Nm'them Journal of Medicine, vol. i. p. 240. 560 DISEASES OF THE LIVER. Occasionally, inspissated bile blocks up and irritates the small bile tubes in the parenchyma of the liver, producmg no symptoms whatever beyond pain. These cases are exceedingly difficult of diagnosis, from its being only by adopting a system of eliminating the diseases which cannot exist, and by a process of scientific reasoning from analogy, that one can by any possibility arrive at a correct diagnosis. As a good illustration of this, I may relate the result of a consultation which I had with Dr. F. Weber in February 1880. The patient was a leading London banker, of about 60 years of age, of whom I received from Dr. Weber the following history. For two years past he had been at irregular intervals, of from one to two months' duration, seized with severe, sudden, spasmodic attacks of pain in the right hypochondrium, which, after lasting from twelve hours to a day or two, as suddenly ceased as they began ; the patient feeling instantly as if quite well. The pain Dr. Weber said he could compare to nothing else than ' tic,' and morphia was the only thing that relieved it. During the time of the attacks all the bodily functions seemed perfectly normal. For al- though the patient was the subject of an habitually weak digestion, he had neither vomiting nor sickness, constipated nor loose bowels. The urine was natural in every respect, and there was neither jaundice nor sallowness of the complexion. In former years he INSPISSATED BILE. 561 had suffered from oxaluria ; but that had passed away, and there was no reason whatever to suspect the existence of a renal calculus. In fact, as Dr. Weber said, if it were not for the ' unaccountable symptoms of the paroxysmal abdominal tic,' the gentleman ailed nothmg. My familiarity with the oftentimes anomalous and puzzling symptoms arismg from biliary concre- tions led me to suggest the possibility of inspissated bile being the cause of the paroxysmal pain. So the patient was without more ado brought into the room, and I proceeded to examine him. He was an average-sized man, of spare build, and, though not robust, had a healthy look. The account he gave of himself tallied in every particular with the history Dr. Weber had given. The seat of pain was directly to the right of the navel, and occupied an area bounded above by a line drawn transversely parallel to the lower margin of the xiphoid cartilage, and below by another across the abdomen at the level of the umbilicus. On percussion the liver was found to be perfectly natural as regards size, and not the least tender on firm pressure. He at the time of examina- tion was quite free from all pain, but he assured me that even when he had an attack, rubbing the painful part gave relief As nothing tangible could be discovered in the abdomen to account for the paroxysms of pain coming on at irregular intervals, I felt more convinced than ever that the case was one 562 DISEASES OF THE LIVER. of inspissated bile. So I cross-questioned the patient very minutely as to his previous personal and family history, and learned that he was not only a member of ' a liver family,' but that he had once had an attack of jaundice — though it was forty and more years ago. In fact, when he was only a boy of twelve years of age. Here now was a direct clue to the cause of the paroxysmal pain, and my next question was ' At what time do the attacks usually come on ? ' The reply was, ' Before breakfast.' This was another small, though not unimportant, link in the diagnostic chain. Fasting, as I before said, being the usual time when the spasms from inspissated bile come on. This history was sufficient for me. No Ion O'er had I the slightest doubt as to the nature of the case, and on communicating to Dr. Weber my ideas of its rationale, he at once put the not uncalled^ for question, ' But how can such small particles of in- spissated bile, by plugging up the small ducts of a I non- sensitive organ like the liver, cause such severe pain, while they yet produce no jaundice ? ' To this I replied that although the liver was a non- sensitive organ, the bile-ducts when irritated by the presence of foreign bodies — as, for instance, when a gall-stone blocks up one of them — give rise not only to pain, but to most excruciating agony, which ceases as suddenly as it begins, so soon as the offending foreign body finds its way into the intestines. The relative amount of pain caused by small fragments of inspis- PAIN FROM INSPISSATED BILE. 563 sated bile blocking up the smaller being proportionally the same as that produced by large calculi blocking up the bigger ducts. The amount of pain induced in any case being directly proportionate to the bulk of the foreign body in comparison with the calibre of the duct in which it happens to be impacted. I further pointed out how the absence of jaundice in many of the cases of inspissated bile is readily ex- plicable, not alone on account of merely one, or at most only a few, of the small ducts being blocked up, but on account of the free anastomosis of the ducts with each other preventing in general any local accu- mulations of bile sufficiently large to produce jaundice, as well as from the fact of the hepatic and common ducts remaming pervious. Whereas the sudden dis- appearance of the symptoms, and the patient's im- mediately afterwards feeling perfectly well, were equally readily accounted for by comparing the case with one of paroxysmal pain from gall-stones, to the suddenness of the disappearance of which it offers a most striking analogy, both as regards cause and effect. Dr. Weber having expressed himself as satis- fied with these pathological explanations, the case was prescribed for on rational, in contradistinction to empirical principles. That is to say, the caicse of the disease, not its symptoms, was attacked ; soda and taraxacum were accordingly given, in order to induce a larger secretion and flow of thin fluid, instead of a 2 564 DISEASES OF THE LIVER. small one of thick viscid bile. The result of the treatment may be j udged of by the following extract from a letter regarding another matter which I re- ceived from the patient's wife on September 6, 1880. In it she says : — ' My husband remained quite well until three weeks ago [that is to say, six months from the time I saw him : G. h.], when he had a return of the pain. Five weeks after leaving off the medicine.' The Symptoms produced by Inspissated Bile are oftentimes mistaken for those of Cancer. At first sight one would think it almost impossible for a well-educated medical man to mistake the symp- toms produced by such an apparently insignificant thing as inspissated bile for those caused by such a grave morbid product as cancer. Nevertheless, not only is such often the case, but the reason of it is very simple. Both seldom produce much jaundice, diffuse hepatic pain, or considerable constitutional disturbance. I shall cite two typical illustrative cases of this kind, and the first I shall select is a fatal one, about which I was consulted by letter in 1864 by Mr. Cripps, of Cirencester. The case was diagnosed as one of jaundice arising from cancer of the liver, and treated accordingly; but at the '^mst-mortcm the jaundice was discovered to have been merely due to the presence and accumulation of inspissated bile in the ducts. Mr. Cripps kindly sent INSPISSATED BILE MISTAKEN FOR CANCER. 565 me the gall-bladder, with the ducts attached to it, for examination, and I found impacted in the common duct a quantity of hard granular-looking black par- ticles of inspissated bile. While the gall-bladder itself contained only one globular mass, the largest of all, it being almost of the size of a small pea. Which on examination was found to be merely made up of a number of small granular particles, similar to those in the common duct, feebly agglutinated together, but forming a mass too large and too firm to pass through the vesical orifice of the cystic duct, as the loose particles had no doubt done. These specimens of inspissated bile, when taken collectively, I consider form one of the most instructive in my collection, from their showing what a very trifling quantity of misplaced biliary matter may cause the death of a patient ; for even when the whole were put together they did not weigh twenty grains. I shall now relate the history of a most instructive, and certainly to me one of the most interesting hepatic cases I ever met with. The case is that of a Northum- berland squire whom I saw in May 1877, along with the present President of the Royal College of Phy- sicians. He was sent up to London to consult us conjointl}^ by Dr. William Murray, physician to the Newcastle Infirmary ; and as the case was not only a puzzling one, but presented many interesting pecu- liarities, I shall give it somewhat fully. 566 DISEASES OF THE LTVEK. The patient, a strongly built tall man of 59 years of age, from labouring, like some others, under the erroneous belief that he would get more information out of his two consultants if he saw them separately, came to me and got my opinion, without even so much as alluding to Sir William Jenner's name. Then he went by himself to Sir William Jenner, and got" his opinion, but did not tell him either what my opinion was, or even so much as that he had ever heard of my existence. Now after having done so, however, to his great annoyance he found himself in an awkward position. For the two consultants had expressed entirely different opinions, both of the nature of his case and its treatment. In fact, not only did the opinions he got disagree in mere details, but they were absolutely opposed to each other in every single particular. For while Sir William Jenner had told him that his case was one of organic enlargement of the liver, and given him at the same time to under- stand that, being such, it was incurable — thereby confirming the opinion of one of the medical men he had previously consulted in the North — I had told him his disease was merely a slight, temporary, and curable one. That all the bad symptoms, even that of a state of collapse from which he said he had suffered, were entirely due to the accidental blocking up of the hepatic ducts by inspissated bile. What was he now to do ? Return home with these con- I INSPISSATED BILE MISTAKEN FOR CANCER. 567 tradictory diagnoses ? Try a third doctor ? Or what ? He knew he had disobeyed Dr. ]\[urray's instruc- tions ; for he had not even so much as delivered to either Sir William Jenner or myself the letters of introduction he had with him. After some little, no doubt unpleasant, reflection, he made up his mind to call on one of us, make a clean breast of his folly, and ask what he had better do under the circumstances. On the following day he called and communicated to me his dilemma. So I at once wrote to Sir William Jenner and asked for a consultation. Well knowing, as I told the patient, that if he had described his case to Sir William Jenner in the same way as he had done to me, there could not have been any material difference in our opinions. For equally trained minds must of necessity draw the same conclusions from the same data, when placed before them in the same light. The consultation was held, and the chief facts elicited were : — That the patient complamed of a dull aching- pain and a distinct tenderness on pressure over the whole of the hepatic region. The dull area of which was considerably increased. There was no nodulation to be detected. The patient had an unhealthy sallow look, but no true jaundiced or cachectic tint. The conjunctivas were more of a pale dirty green than of a yellow hue. He looked depressed and anxious, but not particularly ill. He said that he had most 568 DISEASES or the livee. discomfort and pain at the pit of the stomach, and, when asked to point to the spot, he placed his finger on the end of the xiphoid cartilage. He said his hepatic symptoms had begun six months before (in December 1876), when he was seized with a strange feeling of malaise, sickness, pain in the stomach with tenderness on pressure, accompanied by fruitless efforts at vomiting. Thinking that it was a severe attack of indigestion, he put on a poultice, and took a dose of castor-oil. The result was magical. In a few hours he felt perfectly well. The whole attack did not last, he said, above six hours. He remained well for fourteen days, when again suddenly the same symptoms reappeared. The same line of treat- ment, however, had no effect whatever. Rapidly he grew worse, until he became so bad that he fell into a state of complete collapse. In which state he re- mained for twelve hours. There was no jaundice. By the end of four days he quite recovered, and re- mained perfectly well for four months. When he was again seized while asleep in bed. At twelve o'clock at night he suddenly awoke with pain at the stomach and intense sickness, so intense that he vomited freely, though only once. For a couple of hours after vomit- ing he felt as if a cord was bound disagreeably tight round his waist. Exactly on a level with the xiphoid cartilage. At the same time there was a general un- easiness and great tenderness over the whole of the INSPISSATED BILE MISTAKEN FOR CANCER. 569 hepatic reo^ion. This last attack happened just three -^veeks before he came up to London. During the three weeks which intervened he had felt very poorly and good for nothing. The feeling of the cord, the uneasiness, and the tenderness in the liver had been continuous. With more or less slight daily exacerbations. After talking the case carefully over together, and discussing the pros and cons of every one of the anomalous symptoms, as well as taking into con- sideration the fact that there was but a slight and incomplete obstruction to the flow of bile into the duodenum, there being no distinct jaundice, Sir AYilliam yielded so far to my view of the case that he allowed me to prescribe for the patient. I strongly suspect, however, that he doubted my diagnosis. For before leaving he somewhat sig- nificantly remarked that if my prognosis of what he termed ' the minute pathological diagnosis ' should chance to be confirmed by the recovery of the patient, the diagnosis itself never possibly could. Strange to say, however, by one of those unforeseen lucky turns in the wheel of fortune, not only has the prognosis been verified by the patient's complete recovery, but the diagnosis itself was confirmed, even to its minutest details, within four days after the consultation, in the following most unexpected wise. Believing, as I before said, that all the symptoms 570 DISEASES or THE LIVER. arose from inspissated bile blocking up the ducts, I prescribed for the patient a strong alkaline cholagogic cathartic mixture, with the view of flushing them with liquid bile, and thereby washing out of them the in- spissated hardened masses of the secretion. What was the result? I shall leave the subjoined letter, which I received from the patient himself on the morn- ing of the fourth day after the consultation, to say. I give it verbatim^ simply omitting names and the last paragraph, which has no reference to the point under consideration. ' On my way to Newcastle on Saturday I had two premonitory attacks — the first from 8 to 9,30, and the last from 12.30 to 2.30. ' I slept in Newcastle, and had another and very severe attack, commencing at 8 and continuing until 7. The pain and sickness were dreadful. After the violence of the attack had abated I had a motion, in which were found the substances I now forward for your examination, and shall be glad to know if, in your opinion, they are what are called gall-stones. ' I had an excellent night's rest, sleeping from II till 6.30 ; and to-day, notwithstanding the blue pill I took last night, feel myself perfectly well.' On readinof this letter I felt doubtful as to what the hard masses might possibly turn out to be. For I could not for a moment imagine that the ' minute pathological diagnosis,' about which I had been twit- II INSPISSATED BILE MISTAKEN FOR CANCER. 571 ted, was so soon to be verified. However, on applying to one of the masses the proper chemical tests, it instantly yielded a result which incontestably proved it to be a mass of inspissated bile. Having satisfied myself that the small dark masses forwarded were undoubtedly inspissated bile, I wrote in reply that he might tell the doctor that he could easily convince himself that the diagnosis had been confirmed by simply pouring a few drops of strong sulphuric acid over one of the masses placed on a white plate, when the acid would at once turn the green biliverdin into a magnificent scarlet colour, thereby proving conclusively that the mass was com- posed of inspissated bile. Fortunately the treatment of the case has proved, as successful as the diagnosis was correct ; for although six years have elapsed since it was begun, the patient is not only still alive, but in the enjoyment of robust health. Never once having had a return of the attack. Death may occur from Inspissated Bile blocking up the Intestinal Canal, after having safely escaped from the gall-bladder, by direct ulceration of its coats ; and that, too, when neither doctor nor patient has even so much as sus- pected its existence. A most instructive case of this kind was brought by Dr. Pye Smith before the Pathological Society in 1854. The case was that of a woman aged 69, who, after a fortnight of slight pain 572 DISEASES OF THE LIVEE. in the right hypochondrium, began to feel sick and vomit bile. A few days later she brought up about a gallon and a quarter of bilious fluid, after which the bowels became constipated. On the fifth day the vomited matters, though less in quantity, had a most offensive smell, and therefore an intestinal obstruction was suspected. She died on the sixth day. On the post-mortem, examination the jejunum was found com- pletely obstructed by a solid oblong mass four and a half inches long, two and a quarter inches in circum- ference, consisting of hardened inspissated bile of a dark colour and pungent odour. ' On raising the liver, its under surface was found occupied by firm fibrinous adhesions surrounding Glisson's capsule, in the midst of and protected by which was an ulcerated communication from the almost absorbed gall-bladder into the duodenum, half an inch below the opening of the common bile-duct. It is inferred that through this the above-described large mass of inspissated bile had passed.' (Pathological Society's ' Transactions,' vol. V. p. 163.) Treatment of Inspissated Bile. The treatment of the active symptoms which arise from a blocking up of the bile-ducts by concretions o\ inspissated bile is in general simple enough, and may be summed up in a few words. During the attack apply hot poultices to the seat of pain. Give the patient a hot bath. Administer II GALL-STOXES. 573 an anod3'ne along with belladonna, to dilate the ducts, and follow it up with a smart purgative. Prophylactic Treatment. — In order to prevent the formation of concretions of inspissated bile, it is necessary to administer to the patient every now and asfain those chemical substances which are most effective in keeping the bile fluid. Soda given in the shape of bicarbonate or sulphate is transformed in the system mto the glycocholate and taurocholate of soda, the two active and normal biliary solvents, and so long as they exist in the bile m sufficient quantity there is no chance of a concretion of inspissated bile forming. This theory having a clinical as well as an experimental basis to rest upon, my usual plan of preventive treatment is either to give one or two drachms of sulphate of soda in a bitter infusion every morning before breakfast, or from twenty to thirty grains of bicarbonate of soda along with a drachm of taraxacum juice in a bitter infusion every night at bedtime at regulated mtervals, for a month or so, according to the constitution of the patient and the severity of the symptoms. Further details of treatment will be gleaned from the special chapter on treatment, and what has yet to be said on the preventive treatment of gall-stones. Gall-stone Affections. ; The clinical history of biliary calculi forms, as a whole, one of the most interesting as well as important 574 DISEASES OF THE LIVEK, chapters of hepatic affections. For not only, as before said, are gall- stones the commonest of all the causes which produce jaundice, in this country at least, but their symptoms are frequently mistaken for those arising from entirely different forms of disease — renal calculi, cancer of the liver, &c. Thereby not- only leading to an erroneous prognosis, but even to fatal errors in treatment. Added to which few are aware of the great number and variety of collateral fatal forms of disease to which gall-stones give rise. For example, they occasionally, as will be presently shown, induce abscess as well as cancer of the liver, perforation of the stomach and intestines, enteritis and peritonitis, hcemorrhages, &c. It will therefore be necessary for me to treat the subject of gall-stone affections very fully, and the more so as I have a great many new facts to adduce. The Etiology of Gall-stones. Of the etiology of gall-stones it may be truly said that as yet little definite is known. But as we are already in possession of some very important data connected with their clinical history and chemi- cal composition, I think I am in a position to adduce some more facts m connection with their pathological formation beyond what I have already given while treating of biliary concretions in the aggregate. Gall- stones, and indeed biliary concretions of all kinds, are, like urinary calculi, very frequently hereditary. I ETIOLOGY OF GALL-STONES. 5<0 Not once, but several times, I have had more than one member of a family under my care, suffering from either concretions of inspissated bile or actual gall-stones. While writing this (1879) I have a lady aged 42, and her son aged 18, under treatment for gall-stones, and the mother of this lady was at one time similarly affected. So here is an example of the hereditary descent of the disease in at least three generations. As there are several cases already re- corded, where gall-stones have appeared in two suc- cessive generations, I may pass on to the next point, namely, that Prout, Budd, Trousseau, and many j others, have called special attention to the frequency I with which biliary and urinary calculi are found in i the same individuals, especially in those of a gouty ; constitution. Scudamore in 1823, and several other older writers, have even described a condition of chronically congested liver in gouty patients, to . which they accorded the special name of ' gouty he- patitis.' ] Gall-stones are much more frequently met with among women than among men. The proportion generally given being as three to two ; but if I may form an opinion of the proportion occurring in Britain from observations made in my own and my friends' practices, I should say that as many as about two women are affected with the complamt to every one man. This I attribute to their usually more obese 576 DISEASES OF THE LIVER. habit of body, from natural constitution as well as from their less active modes of life. The fact that ffall- stones are more common amono- women than men is, however, rather extraordinary, seeing that they are oftentimes associated with the gouty diathesis, it being a well-known fact that gout is a much more common complaint among the male than among the female sex. A striking examj^le of this exists in my own family, where, notwithstandmg that for four consecutive generations gout has af- fected almost every male, not a single female member of the family is known to have suffered from it, although even their male descendants have had that disease, and in some instances in a severe form. Gall-stones may occur at any period of life be- tween the cradle and the coffin. Indeed at the post- mortem of a child not a month old, was found a gall-stone. And what is more curious still is the I fact that gall-stones may actually form in a child's body while it is yet in its mother's womb. This we know to be the fact from Bouisson having found three gall-stones in the gall-bladder of a newly born infant with an impervious common bile-duct. This can astonish no one, however, who has paid attention to what I previously said about the secretion of bile beginning as soon as the foetal liver is formed, which is about the end of the third month of intra-uterine life, as from that moment onwards the formation of gall-stones becomes of course possible. ETIOLOGY OF GALL-STONES. 577 Gall-stones occur in varying proportions at dif- ferent periods of life. From a comparison of the sta- tistics which have been given by different European writers, I think it may be said that in every 1,000 cases 750 occur in persons of over 40 years of age. 200 „ „ between 30 and 40 40 „ „ „ 20 and 30 10 only ,, under 20 This fact as regards age strongly supports my theory that the kind of food used, as well as the bodily activity, has greatly to do with the formation of gall- stones in predisposed constitutions. For while in early life, when the vital processes are in greatest activity, the hydrocarbons of our food — the elements out of which gall-stones are formed — are rapidly and com- pletely consumed, in later life, when the vital pro- cesses are less active, only a portion of them is used up by the frame, and the excess, which is neither eliminated from nor consumed by the body, is gene- rally deposited and stored up in and around its organs and tissues as fat. While in the predisposed a portion of the fat forming principles of the food is transformed by tha liver into the crystalline fat called cholesterin, and is deposited in an insoluble condition from the bile in the shape of ijall- stones. In connection with the important part played by the p p 578 DISEASES OE THE LIVER. ' hydrocarbon elements of food in the formation of gall-stones, I may here mention that, by a strange coincidence, two gentlemen who came to me on the ! same day labouring under gall-stones, confessed that ' they were exceedingly fond of, and in the daily j habit of eating, salt bacon. While the one said he had constantly had it for breakfast during the pre- vious nineteen months, the other declared he had scarcely for a single day breakfasted without par- taking of it for very nearly as many years. The accidental circumstance of these two gall-stone sufferers having made to me the confession of their j fat-bacon proclivities, on one and the same day, natu- rally produced a profound impression on my mind — so profound indeed, that ever since I always ask gall- stone patients if they are addicted to bacon-eating, and it is really surprising how many of them say that they are not alone fond of bacon, but of all other kinds of fatty, oleaginous, and starchy foods. Be it remembered that a purely starchy or saccharine diet is nearly as favourable to fatty formations and cholesterin deposits as a diet of strictly oleaginous ; materials, from starch being converted into sugar, and ' sugar into fat, in the animal economy. Consequently all ' animals freely supplied with starch or sugar become fat, and seeing that cholesterin, which is the main ingredient of gall-stones, is a true crystalline fatty substance, it is easy to understand how a copious J GALL-STONES. 579 supply of farinaceous foods, in the predisposed, tends to the development of biliary concretions. This is not a mere theory, but a demonstrable fact ; for Dr. Crisp has ascertained that sheep fed and fattened with sugar, as well as stall-fed oxen, who consume a large proportion of starchy foods, are particularly hable to gall-stones. From among the facts I gleaned while on a tour in Russia in 1874, I may mention that I noticed, in the Museums of both Moscow and St. Petersburo;, that not alone were gall-stones exceedingly numerous, but many of the specimens were likewise of very large size. Indeed, the largest gall-stone I have ever seen is one in the Pathological Museum of the Civil Hos - pital at Moscow. It is nearly as large as a goose's egg. The cause of the Russian gall-stones being of such unusually large dimensions is probably partly due to the habit of the natives of consumino^- larjje quantities of oleaginous foods. Xot butter ; for that is not only an unheard-of luxury among the people, but actually an unknown product of the dairy. The Russian peasantry not even so much as knowing how to make it ; fat and suet being used in its place. There may, however, exist another cause, one origina- ting in the medical profession itself. For throughout the whole of Russia, except in the large towns, it is at a very low ebb, and the absence of proper treatment in liver disorders no doubt favours the p p 2 580 DISEASES OF THE LIVER. formation of gall-stones. While the same absence of treatment, later on, favours their attaining to a large size. From gall-stones being relatively more common in cold than in warm latitudes, and bilious disorders thought to be more general at the fall and the sprmg of the leaf, a cold and damp atmosphere has been supposed to favour their development. After havmg given considerable attention to this point I have, however, arrived at the conclusion that it is neither the cold nor the damp of the northern latitudes which directly interferes with the biliary functions, but the kind of food which the damp cold necessitates. It is a thoroughly understood axiom in experimental physiology that, in order to sustain the weight of the animal body at a low temperature, more oleaginous and fat-producing foods are required than are necessary for the purpose in a warm atmosphere. We all know that while Englishmen hving in the cold climate of the Arctic regions tolerate, if they do not even actually enjoy, a meal of oily blubber, they instinctively turn from such food with disgust when living at the equator. And, as before said, fatty and fat-ffeneratinor foods are conducive to the formation of gall-stones, from the mere fact, if from none other, that cholesterin, their chief component, is a crystalline fat. This theory, that it is the food more than the cold which accounts for the frequency of gall-stones among the natives of the northern hemisphere, is GALL-STONES. 581 further borne out by the observation that in Korway (which is certainly both as damp and as cold as, if not indeed much colder than, the southern parts of Finland, Sweden, and Denmark) I found proportionally fewer gall-stones in the museums of Christiania and Bergen than in those of Helsingfors, Stockholm, Gothenburg, and Copenhagen. Which I account for by the fact of the inhabitants of Southern Norway employing more of a fishy and less of a fatty kind of food. I may further mention, as an additional fact in favour of my theory regarding the etiology of gall-stones, that lardaceous livers some- times contain a large amount of cholesterin. So much so that, by the spontaneous evaporation of an ethereal extract of the hepatic tissue, crystals of it are deposited in abundance. As having an important bearing on their etiology, I may here further remark that I was particularly struck with the fact that the majority of the gall-stones I saw in Russia and Finland were white. A precisely similar circumstance, though in a less striking degree, I had previously noticed in connection with those exhibited in the museums of Sweden. Where gall-stones seem to be almost as plentiful as in Russia. While in the Pathological Museum of Christiania, I particularly noticed that instead of the general colour of the stones being- white, as in Russia, Sweden, and Finland, it was decidedly the reverse. Indeed, I saw among the DISEASES OF THE LIVER. Norwegian gall-stones four perfectly black nut- sized ones, said to have been removed from one and the same human gall-bladder, and a tumbler full of equally black small (pea-sized) ones, which were said in like manner to have been all removed from another gall-bladder at the post-mortem examination of a patient who was not until then known or even sus- pected to have gall-stones. The mere fact of the colour of the gall-stones in Norway being different from those of Russia is of itself evidence that while in the latter country the fatty elements greatly predomi- nated, in the former the pigmentary entered largely into their constitution. As is the case with inspissated biliary concretions, whose etiology is quite different. I may further incidentally remark, in connection with what 1 have already said regarding the constitutional tendency to form urinary and biliary calculi co-exist- ing, that in Norway urinary calculi seemed to be almost as rare as gall-stones (probably from the purity of the drinking water), while both forms of calculi appeared to be about equally abundant in Russia. It is worthy of remark, in connection with the etiology- of gall-stones, that any derangement of the biliary function likely to induce the introduction of the bile acids into the general circulation may possibly favour their formation. For Feltz and Ritter observed that' crystals of cholesterin (the substance of which the- vast majority of gall-stones are composed) appear in I GALL-STONES. 583 the serum of the blood of animals into whose circu- lation bile acids have been artificially introduced (' Comptes Rendus,' April 12, 1875). The number of gall-stones which may form in the body is unlimited. Moro-ao-ni tells us of 3,645 ha vino; been found in one gall-bladder, and Dr. Otto put up a specimen of a gall-bladder that contained no less than 7,802 ! Of course, the more numerous they are, cceteris paribus^ the smaller is their relative size. Just as it occasionally happens that two or more urinary calculi, after attainmg a considerable size, become glued together, and surrounded by a common covering of a different kiud of urinary deposit from that of which the calculi themselves are composed, so I noticed in the Anatomical Museum of the University of Moscow that there was a rare and beautiful speci- men, in which two gall-stones — each of an inch in length and about three-quarters of an inch in breadth, of a pale white colour, and possessing dark gTeenish- black nuclei of inspissated bile — were enveloped in a compact common capsule of white cholesterin. The extreme measurements of the capsule, judging by my eye, which in such cases is usually to be depended upon, being two inches and a quarter in length, and one inch and an eighth in breadth. On one occasion a medical 2:entleman brouo-ht to the Physiological Laboratory of University College a gall-bladder containing besides bile a large number 584 DISEASES OF THE LIVER. of dark round hard granules. The largest of which was not much bigger than a pin's head, and looked like what sportsmen call sparrow-hail or dust-shot. While the smallest of them were invisible to the naked eye. When a drop of the bile was placed in the field of the microscope, even the smallest of the granules were at once recognised to be perfect little miniature globular gall-stones. Not particles of in- spissated bile, but true calculi — I dare say there were many thousands of them in the bladder. I thought at first, as they were hard globular bodies, they were concretions of carbonate of lime, merely stained black by bile -pigment ; but as they did not effervesce on the application of strong nitric acid, or leave any residue on being calcined, theu* organic nature was rendered undeniable. While their fatty constitution was at the same time demonstrated by their flame. Gall-stones, like mere concretions of inspissated bile, form not only in the gall-bladder, but in the biliary ducts. Even in the small ones in the tissue of the liver itself. As is proved by the fact that small gall-stones have, not only once, but again and again, been accidentally found ojipost-rr).ortem examina- tion, by giving a gritty sensation to the knife when making sections of the hepatic tissue.^ Small though these intra-parenchymatous gall-stones occasionally ^ I must here allude to a strange and rare form of calcareous deposit in the liver substance, which might, from the gritty sensation it gives to the tnife on a section being made, lead the unwary to imagine that the II GALL-gTOXES. 585 are, they sometimes produce many of the symptoms of biliary concretions impacted in the large ducts. Namely, pain, tenderness of the liver on pressure, vomiting, and constipation. Without, however, jaun- dice. For that only occurs when the hepatic or com- mon duct gets stopped up by them. Sometimes, though more rarely, one stone alone forms in a radicle of the hepatic duct, and, remaining there until it is of sufficient size to completely block it up, not only causes great dilatation of the distal end of the duct, but, by its irritative effects on the surrounding liver substance, induces suppuration. A case of this kind is reported by Dr. Thomas Cole in the ' British Medical Journal,' February 28, 1880. A labourer, aged 24, was admitted into the Royal United Hospital, Bath, on November 18, and died on December 19. He was taken with jaundice a year before, having been suddenly seized with pain and vomiting, lasting for three weeks. In August vomit- ing and pain came on again, and the jaundice returned. The pain left him in about five Aveeks, but the skin remained jaundiced. His legs were oedematous, case was one of intra-hepatic biliary concretions, and thereby lead to erroneous pathological deductions. The case I shall relate is one the specimens from which Dr. Bristowe exliibited at the Patho- logical Society in 1856. It was the liver of a boy, £et. 16, who died from scarlatinal dropsy, of the natural size, but studded throughout its sub- stance with hard gritty deposits of a beef-coloured earthy material. The earthy formation, which was chiefly found in small irregular-shaped groups in the left lobe of the organ, seemed to be seated in the secreting cells. 586 DISEASES or the liver. bowels loose, motions clay-coloured, and the hepatic dulness extended to the umbilicus. The urine was high-coloured and of specific gravity 1019. Decem- ber 16, severe pain came in the abdomen, and tem- perature rose to 101*6° F. During the night he had a rigor lasting an hour and a half, and the tempera- ture reached 101:° F., and he gradually sank from the combined effects of peritonitis and h^ematemesis. At the post-mortem, the gall-bladder contained two drachms of thick bile. The liver was congested and bile- stained ; in the centre was a cyst, containing half a pint of clear bilious fluid, and a large number of small dark gall-stones. The floor of this cavity was very much thickened ; and there was a layer of tough lymph, like chamois-leather, adherent to it. This was encrusted by a mass of biliary concretions as big as a small Brazil nut. The hepatic duct was normal. After these remarks it is advisable for me to state that the vast majority of gall-stones are formed in the gall-bladder, their formation being due to the deposition of the less soluble normal or abnormal parts of the bile. Either as a consequence of these ingredients being present in excess, or in consequence of the solvent, whose duty it is to retain them in solution, being in reduced and insufficient quantity. The formation of gall-stones seems to follow exactly the same law as the formation of stone in the bladder. The only difference being, that while in the one case GALL-STONES. 587 urinary salts are the ingredients which go to form the vesical calculus (many of which salts, uric acid, cystin, xanthin, and oxalic acid, being actually formed in the liver, while the kidnej^s only excrete them), cholesterin, and other biliary products, are the ingre- dients which go to form the hepatic concretions. As still further bearing upon the etiology of gall- stones, I may mention that, although they are liable to form in almost every constitution, and it is gene- rally considered that they are most frequently met with m gouty persons, they are nevertheless very frequently met with in individuals of the tubercular and cancerous diathesis, either hereditary or acquired. It may therefore be said that certam individuals are born with a constitutional tendency to form gall- stones, just as others are born with a constitutional tendency to form urinary calculi. And such being the case, the inborn vice in the system must be kept in check or be eradicated before the formation of gall- stones can be effectually prevented. Before quitting the etiology of gall-stones I would call the special attention of the reader to an important fact which the perusal of the preceding sixteen para- graphs may possibly have suggested to his mind. Namely, that the vice in the system leading to the production of gall-stones might not unphilosophically be said perhaps to lie simply in one of the two proxi- mate elementary factors : — 588 DISEASES OF THE LIVER. (a) An excessive production of the substances composing them. (^) Their normal biliary solvents — glycocholate and taurocholate of soda habitually present in the bile —being in deficient quantity. Symptoms and Signs of Gall-stones. The most characteristic symptom of gall-stones is PAIN, the most visible sign jaundice. Both of these factors are apparently so easily recognisable that it might be thought that in a diagnostic point of view very little would be required to be said about either the one or the other of them. The sequel will, how- ever, abundantly show that such an idea is a gross error. For not only has an immense deal been writ- ten about them by a variety of different authors, but it will be found that I shall now add a great deal of important new material to what has already appeared in home and foreign publications. To begin with, I have to state that the symptoms and signs of gall-stones lodged in the human body are simply nil until they create local disturbance, either by impeding the outflow of bile, or by exciting inflammatory action in the tissues with which they are in contact. For example, gall-stones, large or small, located in the gall-bladder, produce, as a rule, no discomfort and no symptoms whatever. While a gall-stone, no matter what its size may be, occluding I SYMPTOMS OF GALL-STONES. 589 the common bile-duct, gives rise to a distinct and well-marked train of constitutional symptoms and local signs. As soon as a gall-stone becomes impacted in a bile-duct, slight shiverings, occasionally amounting to actual rigors, followed by feverishness and ab- dominal pain, set in. At the same time there is stomachal and intestinal flatulency, great nervous de- pression and mental irritability, loss of appetite, and general malaise. Itching of the skin is one of the most intolerable symptoms of impacted gall-stone. The itching is generally worst on the arms and legs. The fingers and toes are not exempt from it. It is occasionally so severe — especially m women — that they scratch themselves until their flesh bleeds. In general the itching only attacks them in bed, but in bad cases it may come on paroxysmally during the day. It is not pathognomonic of impacted gall-stone ; for it equally occurs, though generally in a less degree, in jaundice arising from any other form of obstruction. From which fact it is my belief that the itching is due to the irritative effects upon the periphery of the cutaneous nerves of the bile acids circulating in the blood. The pain produced by a gall-stone is in general of a spasmodic or paroxysmal character, and is usually situated in the right hypochondrium, about midwa}' 590 DISEASES OE THE LIVER. between the xiphoid cartiLage and the navel. It is almost invariably aggravated on pressure — even slighl pressure — though relieved by gentle rubbing from right to left. It is in general also associated with nausea and retching, with or without vomiting. The intensity of the pain not only varies greatly in different cases, but at different times in the same case. It may be a mere paroxysmal twinge, or it may be the most excruciating agony, driving the- strongest minded man to shed tears like a child, yell like a madman, contort his body like a fool, or lie rolling sprawling and shrieking upon the floor in the throes of despair. This is no imaginary or highly coloured picture. It is exactly what I have myself witnessed, not merely on one but on different occa- sions. Indeed, to my personal knowledge, so great was the agony that a strong-minded legal gentleman on one occasion experienced, that he was barely pre- vented from committing suicide by cutting his throat during the intensity of one of the paroxysms. Little do mothers imagine (or doctors either) that the agonising and apparently unaccountable screams of children in the cradle are occasionally due to the presence of gall-stones. For the sake of those not well versed in their symptomatology, I may mention that in the ' British Medical Journal ' of April 22, 1882, Mr. Dunbar Walker relates the case of a healthy- looking child, who on one occasion, when three I SYMPTOMS OF GALL-STONES. 591 months old, cried incessantly for six hours, on whose diaper were afterwards found three small ovoid biliary concretions of a green colour. The largest weighed two grains. Had these stones escaped notice, as they might readily have done, the cause of the child's agony would never have been ascertained. The pain arising from the passage of a stone through the bile-duct depends much more on the hardness and shape than on the actual bulk of the concretion. A small hard angular stone producing excruciating agony ; a large oval soft one only a fractional part of the pain produced by its hard angular brother. The sudden total cessation of pain during an attack of hepatic colic usually arises from the gall- stone having abruptly passed from a smaller into a larger duct, or into the intestines. When, for ex- ample, a small stone passes suddenly through the orifice of either the hepatic or the cystic duct into the larger common bile-duct (see Plate L, page 113), where there is plenty of room for it to move freely about without pressing on the walls of the duct, the excruciating pain instantly ceases. So also when it passes out of the common duct into the intestines. Prolonged paroxysmal pain may exist without jaun- dice ; for it is only when the gall-stone becomes impacted in the hepatic or in the common bile-duct, that sooner or later there are superadded to the pain 592 DISEASES OF THE LIVER. a distinctly yellow or jaundiced tint of the skin and conjunctivte, high-coloured urine, and pipeclay- coloured stools. The sudden disappearance of all the signs and symptoms of gall-stones, when none is discovered to have passed in the stools, is m general attributed to the gall-stone, after having occluded the duct, slipping back into the gall-bladder. This of course originates in the erroneous idea that gall-stones can ascend bile-ducts, which is an impossibility from the ducts possessing valves. Paroxysmal Pain. As it is quite possible that the question of how the pain of an impacted gall-stone is paroxysmal may suggest itself to the mind of some readers, I may explain it by mentioning that all the gall-ducts, and more especially the large ones, are, like the arteries, supplied, though in a lesser degree, with contractile muscular fibres, no doubt in order that they may assist by rhythmical contractions the flow of the bile ; and that they exert this contractile power in a precisely similar way, in order to favour the passage of gall-stones along their canals, seems highly probable. The bile- ducts, besides being supplied by con- tractile muscular fibres, are also freely supplied with nerves of both the sensory and motor varieties, and THE PAIN OF GALL-STONES. 5 S3 althongli the passage of normal fluid bile along tlie ducts causes no objective sensations, it is a very dif- ferent thing when either inspissated bile or gall-stones attempt to make their way through the same channels. And still more so when either a mass of inspissated bile or a gall-stone becomes impacted in the canal, and by the abnormal pressure which it there exerts inflames the lining mucous membrane, and thereby renders its nerves acutely sensitive. Exactly in the same way as the nerves in bone become acutely sen- sitive to all kinds of physical impressions the moment the osseous tissue surrounding them becomes inflamed. In consequence of the nerves of the bile-ducts being thus rendered acutely sensitive to the presence of the abnormal substance, they, by a process of reflex action, stimulate the muscular coat of the ducts to make violent efl'orts to expel the intruder. And as j^eriods of exhaustion and consequently of compulsory repose always follow periods of super-eftort, again in their turn to be superseded by one of renewed activity, the pain induced by gall-stones assumes a distmctly spas- modic or paroxysmal character. I must not quit the subject of the characteristics of gall-stone pain without calling attention to the fact that it is not always paroxysmal in its character. ' >n the contrary, it may be continuous, and is in- variably so when the gall-stones are not trying to escape from the body by forcing their way along the Q Q 594 DISEASES OF THE LIVER. natural channels, but by making an artificial channel for themselves by directly ulcerating their way into the stomach, intestines, peritoneal cavity ; or out of the body even more directly still through an opening in the abdominal parietes. Amount of Pain no reliable Criterion of either the Size or the Number of Gall-stones. It is a very prevalent notion that the larger and more numerous the gall-stones are, the greater must necessarily be both the amount of the pain and the intensity of the jaundice. Neither supposition is, however, correct. As regards the jaundice, it does not depend so much upon the actual size or number as upon the position and shape of the stones. For example, a circular gall-stone, not bigger than a pea, effectively blocking up the common bile-duct, will sometimes produce a fatal jaundice, while a stone as big as a goose's egg, lodged m the gall-bladder, often causes no symptoms whatever. Again, there might be but one single small gall-stone in the whole body, and yet it might cause intense jaundice and speedy death. While 100 or 10,000 much larger ones might be lodged in the body for five or for fifty years, and cause no disturbance whatever. It is upon the posi- tion of the stones then, and neither upon their size nor their number, that the amount of pain and jaun dice depends. I PAIN FROM GALL-STONES. 595 From the intensity of the pain, taken in conjunc- tion with the de^^th of the jaundice, it is in general possible to guess the form and size of the stone. Although this is a rule liable, as will be presently shown, to many exceptions. Yet a small stone or a soft steatomatous concretion very seldom gives rise to pain and jaundice anything approaching in severity to that springing from a large stone, or even to that caused by a hard, rugged concretion of inspissated bile. The danger to life arising from gall-stones may in some cases likewise be conjectured from the in- tensity of the agony, associated with the depth of the jaundice, though even here again there are many ex- ceptions to the rule. For sometimes but little pain is complained of, and there is no jaundice whatever, when a gall-stone is doing deadly mischief by perforating its way out of the biliary appendages. Pain as a Cause of Death in Gall-stones. The jiain caused by a gall-stone may be so intense as of itself to produce a fatal collapse. The symp- toms preceding death being cold sweats, slow feeble pulse, extreme exhaustion, and coma. Even with but few of these symptoms manifested, sudden death may be caused by the presence of a gall-stone. One of the most telling cases with which I am acquainted is that reported by Mr. Arthur Sargent, of the Bombay Army, in the ' British Medical ft Q 2 596 DISEASES OF THE LIVER. Journal' of June 7, 1879, in which a woman sud- denly died after being ill for less than half an hour. The body was thin and ill -nourished. Nothing abnor- mal exhibited itself, but a lump two inches long in the umbilical region, and a stone completely filling up the small intestine, which was tightly stretched over it. The lump was found to be the gall-bladder, pear-shaped, about an inch and three-quarters long, and three-quarters of an inch thick, completely ad- herent to the duodenum. It showed a longitudinal fissure, through which the gall-stone had ulcerated. The intestine above and below the gall-stone was perfectly natural. The Dangers of Gall-stones are not always proportionate to the Amount of Pain. It is a mistaken though very prevalent idea that you may guess the probable amount of danger to life by the severity of the pain j^roduced by a gall- stone. It would indeed be fortunate in a prognostic point of view were this in reality the case. But, alas ! I know it is otherwise, and, what is still worse, that the gradual subsidence of acute agony is in some cases but the forerunner of a fatal result. And a knowledge of this fact is oftentimes a most disagree- able one. For what can be more distressing than tb have to warn a patient and his friends of approaching danger when the lull in the storm has given them buoyant hopes of a speedy recovery ? THE DANGERS OF GALL-STONES. 597 The explanation of this is very easy. And to make it plain I shall suppose an imaginary typical case. A patient has a gall-stone for several days or weeks, firmly impacted either in the cystic or in the common duct, and while in the former case he has had most excruciating agony, without jaundice^ and in the latter equally intense pain with jaundice, he all at once expresses himself as feeling comfortable. For after having suffered the torments of the damned, he feels nothing beyond a slight ache in what was formerly the acutely tender spot, and even moderate pressure no longer augments it much. The natural idea of himself and friends is that he is doino- well, and will soon be himself again. On the con- trary, he is doing very badly, for the stone has only made room for itself by ulcerating a hole in the walls of the duct, and once the ulcerative process has begun no one knows how the case will end. If adhesion takes place between the walls of the duct and intes- tines, or the stomach, or the abdominal walls, good and well — for there is a chance that the stone will find for itself a safe exit. But still there remain dangers. For in the first place it may,. during its course, lay open a blood- vessel and fatal haemorrhage occur. Or the stone may, after finding its way safely into the intestines, from being too large to pass through them, produce a fatal, obstruction. Or the 598 DISEASES OF THE LIVER. stone may perforate its way directly into the perito- neum and induce a fatal peritonitis. So that the learned practitioner looks with horror on the gradual subsidence of pain in all cases of hitherto manifested acute agony from gall-stones. On the other hand a sudden subsidence of pain he hails with joy ; for that is not in general indicative of ulceration, but of the exit of the stone out of the duct by the natural pas- safi^e into the intestines. "O" Diagnostic Value of the Position of the Pain. As a gall-stone proceeds from the gall-bladder downwards along the duct into the intestine, the seat of greatest pain changes more and more from the neighbourhood of the xiphoid cartilage, first down- wards and outwards to three and a half inches to the right of the cartilage, then downwards and in- wards towards the neighbourhood of the navel. The angle of union of these two oblique lines indicates the point of union of the cystic and common ducts. The position of the greatest intensity of the pain on pressure indicates the exact position of the impacted calculus. As before said, the often alluded to shoulder pain I have long since ceased to regard as a point of importance in the diagnosis of gall-stones or any other hepatic aifection. While the dorsal pain I regard as even less valuable. For dorsal pain is much more common in renal, stomachical, and duodenal, DANGERS OF GALL-STONES. 599 than in hepatic disease. Although it has occasionally happened that in cases of impacted gall-stone the chief pain complained of has been in the back. Dangers of Gall-stones not necessarily in Proportion to their Size. The dangers arising from gall-stones are not, as is generally supposed, in direct proportion to the size of the calculus. A small stone may find its way into the peritoneal cavity, and induce fatal collapse or peritonitis, while a very large one may ulcerate its way into the intestines, there become sacculated, and give rise to no farther symptoms, not even so much as discomfort during a long period of life, and its actual existence be at last only made known by the autopsy after death. I may call attention to a case of fatal obstruction of the common duct by a large calculus, after many weeks of suffering, related by Dr. Thomas Coles in his paper already cited: — 'The patient, aged 3-i and very delicate, had had a great many attacks, and had passed some very large stones. Every time she became pregnant, calculi were expelled. Her last attack came on when she was five months pregnant. Pain and vomitmg were incessant, the jaundice intense, and rigors and sweats most prostrating. Hypodermic injection of morphia, thrice daily, was the only means of relief. At last a stone escaped, another took the place of the one released, and the 600 DISEASES OF THE LIVER. poor creature slowly sank, worn out by suffering and exhausted by innutrition, although nourishing enemata had been freely resorted to. At the post-moriem examination, a cone-shaped stone was found wedged in the duct, just under its narrowed ending in the duodenum.' Gall-stones of larc^e size have been found in the stools when not expected. A case presumably of this kind was brought before the Pathological Society on the 6th January, 1880, by Dr. Ord. The stone was sent to him for exhibition by Dr. C. Roberts. It had been passed by a lady shortly after her con- finement. There had been only two symptoms asso- ciated with its passage : excessive pain in the back, and constant diarrhoea of a pale yellow colour. The stone measured one inch and five-eighths by one inch and one-eighth, and weighed five drachms. The concretion was composed of cholesterin mixed with bile-pigment. Another lady, aged 56, after seven days' sickness, pain, and constipation, voided a pyriform- shaped cholesterin calculus which in a dry state weiged 400 grains and measured two and a quarter inches in length, and one and one-tenth in diameter. In reporting this case (Pathological Society's ' Transac- tions,' vol. xix.p. 254), Dr. Hilton Fagge mentions that there exists a calculus weighing 462 grains, said to have been passed by a middle-aged lady (along with the faeces), who afterwards enjoyed good health. As there is DANGERS OF GALL-STONES. 601 no notice of a preceding attack of jaundice having j occun*ed, the stone most probably did not pass I through the common duct, but ulcerated its way from the gall-bladder directly into the intestine. While house physician in the Royal Infirmary, Edinburgh, a rapidly fatal case of jaundice from impacted gall-stone came under my notice. It occurred in a woman, aged 36, who died in Professor Bennett's clinical ward, in the middle of December 1851, and at whose sectio cadaveris a pale yellow gall-stone, about the size of a boy's marble, was found iirmly impacted close to the duodenal orifice of the bile-duct. The liver was of the normal size, of an intensely green colour, and everywhere throughout its substance the ramifications of the bile-ducts were enormously dilated into elongated cavities big enough to admit the point of the finger, and filled with dark, thick bile. Professor Bennett thought that the patient died fi'om the toxic effects of the absorbed bile, from her symptoms having been vomiting and prostration, feeble and rapid pulse, dry brown tongue, and low muttering delirium ; followed by coma and death. There was no remission or intermission of the symp- toms in this case. The gall-stone^ after having be- come impacted in the common duct, there steadily remained, producing most intense agony, as well as the above-named symptoms of bile poisoning. From my present knowledge of the effects of reabsorbed 602 DISEASES OF THE LIVER. bile, I should say that Dr. Bennett was wrong in attributing the rapidity of this patient's death to bile poisoning ; for when the orifice of the common bile- duct is completely occluded by a cicatrised ulcer, and the bile is absorbed into the blood (^and there is little or noiJain), the patient generally lives for at least eighteen months. So I attribute the death of this patient, which occurred in six weeks after the jaun- dice had set in, more to the intense pain than to the blood-poisoning. Danger of G-all-stones not proportionate to the Intensity of the Jaundice they induce. From the mere intensity or persistence of jaundice per se, no trustworthy prognosis can be arrived at. For death may occur in a few hours in a slight case, and recovery actually take place in another after jaundice has existed even for two or three years in an intense form. I shall presently relate a case of gradual recovery from impacted gall-stone, in a lady aged 44, who has been intensely jaundiced for more than six years. It may be said, however, that, as a rule, a case of jaundice from complete obstruction to the flow of bile into the intestines usually ends fatally within three years from its commencement. Although under judicious treatment, in the majority of cases, the life of the patient may easily be prolonged for from four to six years. In those cases where patients DANGERS OF GALL STONES. 603 live longer than that, it is generally found that although there has been a permanent obstruction in ' the duct, there have been slight intermissions of the jaundice, from the stone occasionally changing its position, and allowing bile to find its way past it into the intestines. Gall-stones even of large size may exist without producing Jaundice. By far the majority of medical men with whom I come into professional contact possess, I find, the fixed idea that in all cases of firmly impacted gall- stones, jaundice must occur. At least in one stage of the disease. Such a belief is, as I shall presently show, founded upon the old crude and imperfect data our predecessors possessed of the clinical history of gall-stones. And as this mistake has on more than one occasion, I have found, given rise not only to an erroneous diagnosis, but to defective treatment, I must call the special attention of my readers, in con- nection with the general clinical history of gall-stones, to the fact that it is absolutely essential, when at- tempting to make a diagnosis in any doubtful case, to remember that patients may not alone have gall- I stones, but be afi'ected with their severest and most i dangerous symptoms, without the skin showing the slightest trace of jaundice. In some cases the gall-stone, or stones — for there 604 DISEASES OF THE LIVER. may be many, even hundreds or thousands — remain in the gall-bLadder during the whole life of the indi- vidual, without giving rise to any disagreeable results, either as regards pain or jaundice. In other cases the gall-stones — and this usually happens when they are small — get into the cystic duct, becoming lodged, there ; and although the patient may suffer intense pain in such a case, there is no jaundice. For it is not until the stones have passed down from the gall- bladder into the common bile-duct that jaundice can be induced by them. An illustrative example of this) I shall give presently. Meanwhile I may here only further remark that so long as a stone remains in the cystic duct, although it completely block it up, and effectually prevent the bile either entering into or escaping from the gall-bladder, yet, as in this situa-- tion it offers no obstacle to the direct flow of the. biliary secretion from the liver into the intestines, there cannot be retention and consequent reabsorp- tion of bile. In fact, the presence of the stone in this position, in as far as the biliary function is con- cerned, only reduces the patient to the state of a person in whom the gall-bladder is accidentally absent ; or to that of a horse, or other animal, in which the absence of the gall-bladder is a normal condition, and in whom the biliary functions are per- formed without either hitch or hmdrance. This is readily understood when it is remembered that the GALL-STONES WITHOUT JAUNDICE. 605 gall-bladder is a mere passive receptacle or reservoir for the excess of bile secreted during the intervals of digestion, and is not in the remotest degree, as I pre- viously pointed out, an essential organ in the animal economy. So long, therefore, as a gall-stone, by blocking up the cystic duct, only prevents the bile from getting into or out of the gall-bladder, there is not only no jaundice, but no saffron -coloured urine or pipeclay stools. And it is only the presence of hepatic colic, associated with sickness and the clinical history of the case, which leads to the recognition of the symptoms being due to gall-stone impacted in the cystic duct. I may as well, however, also here call attention to the fact that the cystic duct may, and has in some few cases, become permanently occluded by a deposit of carbonate of lime, and the cause of the occlusion been accidentally mistaken for a gall- stone. A case of this kind where the o-all-bladder was also filled by the lime deposit, associated with cirrhosis of the liver and hypertrophied spleen, is recorded in the Pathological Society's ' Transactions ' of 1856, p. 238. Intra-hepatic gall-stones, be their size what it may, are, as a rule, unattended with jaundice, and only with subacute pain. The symptoms they give rise to, when they are either large or numerous, are a feel- ing of dull weight or discomfort, with sudden and sharp stitches of hepatic colic, accompanied with nausea and retching. 606 DISEASES OF THE LIVER. Intense Pain from Gall-stones may occur without Jaundice. From the fact that jaundice is usually supposed to be an inseparable concomitant of gall-stones, when it is absent the pain arising from them is fre- quently attributed to a great variety of other causes. To wit, gastralgia, intestinal colic, peritonitis, per- foration of the stomach or bowels, renal calculi, &c. &c. Sometimes the pain produced by a gall-stone, though exceedingly acute, is of very short duration, from the stone quickly gettuig out of a small into a larger duct, where it not only causes no pain, but gives rise to no obstruction ; and from the fact of its not having remained long enough in the small duct to cause jaundice, and not obstructing the larger duct at all, we have the unusual phenomenon of an acute brief gall-stone colic, without the patient ever show- ing a trace of jaundice. This arises from the fact that a jaundiced tint of the skin never appears in less than sixty or seventy hours after complete occlusion of the hepatic or com- mon bile-duct has taken place. Though high-coloured urine and pipeclay-coloured stools may appear several hours earlier. This piece of information is of great importance in a diagnostic point of view. Again and again have I known the pain produced by gall-stones (in con- GALL-STONES WITHOUT JAUNDICE. 607 sequence of the absence of janndice) put down as cramp of the stomach, or, more learnedly, as gastric neuralgia. The sudden advent and occasionally equally sudden cessation of the pain favouring this idea. Ay, what is more, the excruciating agony has been mistaken for perforation of the stomach. A case of this kind I shall now relate. But before doing so, as but little attention has hitherto been paid to the pathology of gall-stone pain, or hepatic colic as it is m general called, without jaundice, I shall explain its pathology, which to my mind is very simple. Although I must confess it has not always been so. It is, according to my present ideas, this : — Gall-stones always produce more or less pain, be their situation what it may, when they press against living tissues, be they the walls of bile-ducts, intes- tines, or anything else. Gall-stones never produce jaundice except when they impede the flow of bile into the intestines through its natural channels. A glance at Plate I. will make this clear. By showing that, by the arrangement of the ducts, a gall-stone can in two situations only possibly intercept the flow of bile into the intestines. First : — If it blocks up the hepatic duct (^), it will not only prevent the secreted bile getting into the intestines, but into the gall- bladder. Second : — If it blocks up the common bile- 608 DISEASES OF THE LIVEK. duct (d), it then not only prevents the secreted bile flowing directly from the liver into the intestines, but it equally prevents the stored- up bile finding its way from the gall-bladder into the intestines. A stone lodged in the cystic duct (c), on the other hand, can by no possibility produce jaundice. This, then, is the true explanation of why gall-stone colic may exist without jaundice. A most impressive case of this kind fell under' my notice while I was acting as house physician in the Koyal Infirmary, Edinburgh. It has so many important bearings connected with it, seeing that it was mistaken for a case of perforation of the stomachj that I shall relate it in full. And I do so all the more readily, as I am strongly of opmion that had this very case not fallen under my notice, and made such an impression on my mind as to specially direct my attention to gall-stones in the early part of my professional career, it is highly probable that this book would never have emanated from my pen. Trifles are said to mould the careers of men, and I see no reason to doubt that what I witnessed in the case I am now about to relate is the chief cause of my having made liver diseases a special study. I will tell the story exactly as it happened, and leave the reader to think what he pleases about it. I happened after the hour of visit to be passings through one of Dr. 's wards on my way to thes GALL-STOXE COLIC SBITLATIXG PERITONITIS. 609 fever ward on the same floor, when my attention was drawn to the agonised expression on the face of one of the patients to whose abdomen a nurse was doing something. The man's face was the picture of extreme ao-ony. His eyes were starting from their sockets. Drops of perspiration stood on his forehead. Drops of sweat trickled down his cheeks. His hands clutched the bed-clothes. He literally writhed in torture. A more horrid example of human suffering than what he presented when I approached his bedside it is im- possible to imagine. I found the nurse preparing his abdomen in order to apply leeches, and I saw it was not her rough scrubbing that produced his pain. For the pain was apparently increased when she discon- tinued it. On asking what was the matter, the nurse replied, 'It's a case of perforation, and I am going to put on twenty -four leeches.' ' AVho ordered the leeches ? ' asked I. ' Dr. .' ' Did he examine the 3ase ? ' ' Yes, and he says it's acute peritonitis from perforation of the stomach.' ' I don't believe it,' said I, ' for if it was peritonitis the man could never bear ^"our rough handling. Let me examine him.' I put my hand gently on his abdomen. I rubbed it from side to side. I then pressed it down between aavel and stomach, and, instead of increasing the pam, :he gentle though firm pressure seemed not only to be borne with impunity, but to give relief. I at once turned to the man, and asked, ' Had you ever an R R 610 DISEASES OF THE LIVER. attack like this before ? ' No reply did he, however, vouchsafe. He was in too great pain to pay the slightest attention to me. I repeated the questior more emphatically. Still getting no reply, I repeated it loudly. Still not the slightest attention was paid to my question. The man was in fearful agony, ] knew ; but, being determined to get an answer to mj question before I would allow the nurse to apply thf leeches, as it appeared to me to be a simple case ol mtestinal colic, certainly not peritonitis, and having already had nearly two years' hospital resident prac- tice, I thought I knew something about the diagnosis of acute peritonitis, of which I had seen many ex- amples. I gave the man a good shake, and asked hin: to answer my question with a simple yes or no, as that was all I wanted. He now answered in the affirmative, and, that being enough for my purpose I ordered the leeches to be put away, a large dose oj morphia to be given at once, and the abdomen to b( fomented with hot water ; then turpentine stupes tc be applied. I returned to his bedside in about an hour, and found the treatment had acted like magic, For now the man's expression was no longer one de- noting extreme agony. His forehead, though still moist with perspiration, had no sweat drops trickling from it. His teeth no longer bit the bed-clothes. His hands lay in calm repose, crossed upon his breast, and being able to reply freely to my questions he in- GALL- STONE COLIC SIMULATING PERITONITIS. 611 formed me that he had once before had a similar attack. Added to which I gleaned from him the aU-important fact that the previous attack had been followed by jaundice. This piece of information at once told me that though my treatment was apparently correct, my diagnosis was probably wrong. For now the case was much more likely to be one of gall-stone than intestinal colic. The only thing that puzzled me was that he had not only no jaundice, but not even so much as a tinging of the skin. I ascertained also that I his stools were dark-coloured, and the urine of a per- ' fectly normal hue. If I was puzzled then, I was a thousand times more puzzled a week afterwards by finding him as yellow as a guinea, in spite of his I having had no return of the excruciating pain. Pian he certainly had, but nothing to speak of in com- j parison with what he had when I first saw him. Yet I he had jaundice, pipeclay- coloured stools, and bilious urine, all apparently from gall-stones. I The cause of the absence of jaundice in the first i instance, in spite of the excruciating pain, coupled ' with the slightness of the pain and presence of jaun- dice in the second, was to me a perfect mystery. And for many long years it remained so. For I could find j no one who coidd explain it, and it was not until some ! years after I had made the pathology of gall-stone affections a special study that I discovered the true mechanism of this apparently anomalous phenomenon. R K 2 612 DISEASES OF THE LIVER. Which, instead of now appearmg to me a pathological puzzle, is easily explicable in the following wise. The man had a stone which suddenly escaped from his gall-bladder into the cystic duct, and, being too large to pass easily through it, caused the agony I described ; but, as at the same time the bile secreted by the liver continued to find its way down the hepatic duct (Plate I. , h), and through the common duct (c?) into the intestines, there was no jaundice. The morphia I gave him, and the hot fomentations, not only relieved the pain, but helped to dilate the cystic duct and allow the stone to pass into the larger common bile-duct, and from the size of the stone not being great (although it was big enough to block up the duct and induce jaundice by obstruction) it did not again induce excruciating agony like what it did while it was within the much smaller cystic duct. This case requires no further comments to be made upon it by me. For the reflecting reader must have already taken in all its important differential diagnos- tic bearings with reference to the question of gall- stone colic in contradistinction to the pain of peri- tonitis following upon perforation of the stomach, for which it had been mistaken. Chiefly, I presume, from the intensity of the pain, associated with the absence of jaundice. Now, although it is not at all probable that mistakes of this kind can often occur, yet, as there are other forms of colic with which gall- IMPACTED GALL-STONES WITH JAUNDICE. 613 stone pain is very frequently confounded, so as to lead to grave errors in treatment, I consider the subject of sufficient importance to induce me to de- vote further on a special chapter to it, under the title of the differential diagnosis of colics. Gall-stones may be impacted in the Common Bile-duct without Jaundice. I have next to call attention to what at first sight appears to be a strange fact. Namely, that a gall- stone may be firmly impacted in the common bile- duct, and yet totally fail to induce jaundice, and that, too, not so much on account of the size as on. account of the peculiar shape of the stone. As a specimen now lying on the table before me testifies. This stone was passed by a lady (aged 34, the wife of the editor of one of our daily newspapers), after a period of excruciating agony, accompanied, however, with but a very trifling discoloration of the skin. The peculiar form of the concretion, though it is the size of a ! hazel-nut, amply accounts both for the agony and the I absence of jaundice. Paradoxical though this state- ment at first sight appears to be, it is readily ex- I plicable by the fact that the stone is not only tri- I angular, but almost equilaterally triangular. It I possesses five sharp projecting points, which accounts I for it sticking so fast in the duct, as well as producing BO much pain, notwithstanding that it allowed the 614 DISEASES OF THE LIVER. bile to ooze past it into the intestines, and thus set ; all the rules of positional diagnosis at defiance. Here, • then, is a case illustrating how a gall-stone may be impacted in the common bile-duct, and yet there may exist neither the jaundiced skin, pipeclay -coloured i stools, nor saiFron-tinted urine so characteristic of ; ordinary cases of stone impacted in this duct. Had I been prepared with this knowledge beforehand, the i exact position of the stone in the duct (although not ; preventing the passage of the bile mto the intestines) I might have been correctly surmised from marking ; the exact spot of the greatest intensity of pain pro- ■; duced by careful local manual pressure. Gall-stones as an exciting Cause of Abscess and Cancer of the Liver. Gall-stones, like inspissated bile, occasionally / induce hepatic abscesses as well as even cancer of the !> liver, but in order to avoid repetition I shall defer the consideration of that branch of their pathology until I come to the special chapters on abscess and cancer of the liver. Meanwhile I shall describe another new phase of the pathological effects produced by gall-stones. Namely, those they induce while at- temptmg to ulcerate their way directly from the biliary appendages, as well as those they give rise to in the regions into which they migrate. I PERFOEATIXG GALL-STOXES. 615 Gall-stones passing by Ulceration into the Intestines. Symptoms of Perforating Gall-stones. When gall-stones ulcerate their way from the gall-bladder into the bowels, there are no well-marked characteristic symptoms. But the practitioner ought to be alive to the fact that when, after hepatic symp- toms have existed for a time, there is a considerable increase of the dull aching pain complained of in the region of the gall-bladder upon the application of pressure, and blood appears in the stools, the case is almost for a certainty one of perforating gall-stone. I shall relate a case showins;, meaofre thouo-h these data be, how valuable they are ; for, as will be seen, I was able, by pajdng careful attention to them (four- teen years before the autopsy revealed the truth of my statement), to correctly diagnose a case of the kind where another consultant, vastly my superior in experience, totally failed. As no doubt the reader will be glad to learn how I came to form a correct diagnosis when another more experienced, placed under precisely similar circumstances, failed, I may as well at once tell him that my tahsman is very simple. Namely, that whenever bloody or grumous stools appear in the course of a case with obscure gall-stone symptoms, even without a single gall- stone sign having so much as manifested itself (ac- cording to my opinion), the case may be unhesita- tingly regarded as one of perforating gaU-stone. At 616 DISEASES OF THE LIVER. the same time I must remark tliat the absence of bloody or grumous stools under precisely similar conditions in no wise of itself negatives the idea of in- testinal perforation. For perforation sometimes takes place without any signs of haemorrhage appearing. As the following case related to me by Dr. Leared shows. A woman was suddenly seized with pain in the abdomen and sickness, both of which lasted but a very short time, when thirty hours afterwards, to her surprise, she found a stone as big as a pigeon's egg in her fasces. On examination it was found to consist of almost pure cholesterin. I shall now adduce two typical cases (one which ended fatally, the other which got well) occurring in women, both of which respectively, though in totally different ways, present all the most salient features usually met with in such cases. The first 1 shall select from Dr. Peacock's, the second from my own practice. Dr. Peacock's case was that of a woman aged 27, who was only seriously ill during four days. The abdomen became tense and tympanitic on the third. Collapse supervened on the fourth, and in a few hours afterwards she died. At the post-mortem the gall- bladder was found adherent to the curvature of the duodenum, and an aperture big enough to admit the forefinger existed between the fundus of the gall- bladder and the intestine. In which was found a biliary PERFORATING GALL-STOXES. 617 calculus too large to pass through the duodenum. A somewhat smaller calculus, however, must have done so, as it was found in the ileum. The opening from the gall-bladder mto the intestine had been unattended with any great disturbance of health, and it was only when the stone blocked up the intestine, four days before the death of the patient, that really serious symptoms began. The case I saw possesses several important features, from the fact of its not only affording a typical illustration of the difficulties sometimes en- countered in diagnosis, and how the effects of a perforating gall-stone may be mistaken for those of a cancer, but how, in spite of the patient getting well, the diagnosis may be confirmed even to its minutest details by a post-mortem made fourteen years after- wards. The history of the case is briefly this. On March 22, 1864, just as I was starting to the country for an Easter week's holiday, I was asked to see a dangerous case along with Mr. Pearse. The patient was the wife of a celebrated ecclesiastic. She had been previously seen by my colleague Professor Walshe, who confirmed the diagnosis of her ordinary medical attendant. Which was that it was a case of maliof- nant disease of the liver. She was so ill that the night before I was summoned to her bedside she had bid adieu to her relatives, and assuredly a less hopeful -looking case than what she appeared to be 618 DISEASES OF THE LIVER. when I entered the room it is scarcely possible to imagine. For the poor woman was haggard, blood- less, and worn to skm and bone. Too weak to raise herself in bed. With a voice so feeble as to be scarcely audible. She was jaundiced. The stools were pipeclay-coloured, with the exception of once or twice when they were mixed with blood. Pulse 120, and feeble. The tongue very foul, and breath smell- ing disagreeably. I examined, or should rather say that I tried to examine, the liver by percussion, but she was so weak, and it was so painful, that I had to desist after a very imperfect examination of it. So I listened to the history of the case, and examined the urine. Which was literally black, thick, and muddy, containing both albumen and blood-corpuscles. Although it contained a copious deposit of urates, the actual amount of uric acid was supposed to be diminished (I say supposed, because a correct quantitative analysis could not be made from the patient being too weak to admit of its being all collected). The stools contained grumous blood. The liver, as far as could be made out, appeared to be greatly enlarged and tender to pressure. The most tender spot, however, was, I imagined, at the point where the bile-duct would open into the duodenum. When the abdomen was pressed at this particular spot, intense pain was the result. That fact, coupled with the other conditions PERFORATING GALL-STONES. 619 above given, led me to diagnose the case as one of gall-stone ulcerating its way into the duodenum. On explaining to Mr. Pearse the reasons which led me to take this view of the case, and particularly when I said I thought the patient would get well, he sug- gested that I should tell this to the reverend doctor himself, adding, ' You know he is learned in science as well as in theology, so you may unhesitatingly speak to him not only fully, but quite openly.' This I accordingly did, and it was arranged that, if I did not hear to the contrary, I should call that day week, and see the patient on my way home from the railway station. Mr. Pearse accordingly altered the treat- ment ; for, as he justly remarked, as the patient was evidently dying, there could be no possible harm in treating her for gaU- stone, and giving her even the faintest chance of recovery. Hot fomentations were consequently had recourse to, an alkaline mineral purgative mixture given, and nourishing stimulating foods prescribed. An immediate change for the better was observable. Rapidly the patient rallied. In a week she was able to sit up in bed. In a month she was on the sofa, and within three months more she was walking about apparently quite well. And for fourteen years afterwards well she may be said to have remained, till at length another gall- stone again ruptured the bile-duct, and in a few brief hours terminated her existence bv h^emorrhaoe and 620 DISEASES OF THE LIVER. fatal collapse. The account of her death and post- mortem I received from her husband m a letter dated May 9, 1878. Which I shall here give exactly as it stands. With the exception of omitting some family details. For, although written by a clergyman, it is sufficiently pathologically explicit for what it is desired to prove. ' As you took a great interest in the ailment of Mrs. , I think perhaps you would like to know the revelation of the post-mortem. We had three medi- cal men at the examination, and I apprehend their judgment is conclusive. They found three large gall-stones in the bile-duct. The largest was the size and shape of a knuckle-bone, the two above it not so large. They were not of a crystal character, but a hard concreted gum, as hard as rock ; they had so distended the walls of the duct that they had burst it, and the gall had made its way out of the chink into the bowels. One other consequence of this enormous distension was the adhesion of part of the bowels to the duct, but the immediate cause of death was the rupture of the duct. Mrs. had been ailing since last November, but was considered con- valescent. She had been out in the village and garden the day before, and on the very night of her decease we had friends to spend the evening with us. Mrs. was with them till about nine o'clock, and then told me she did not feel well, and that she ENCYSTED GALL-STONES. 621 should go and lie down. About four hours after she died in a tranquil sleep.' Nothing could be more conclusive than this re- port. For it proves in eveiy individual particular the exactitude of the diagnosis made nearly fifteen years before. As some of my readers may like to hear what were the chief signs and symptoms in the case which led me to diagnose perforating gall-stone, I may say that what I most relied upon as being indi- cative of a gall-stone ulcerating its way directly from the common bile-duct into the intestines were (a) the indefinable soreness in the right hypochon- drium ; (b) acute pain on pressure over the tender spot ; (c) presence of jaundice ; (d) bloody stools ; and (e) febrile symptoms, with great prostration of strength, almost amounting to collapse. Gall-«tones that have ulcerated their way into the Intestines .may become encysted there. A case of gall-stone encysted in the intestinal canal and producing no irritation whatever fell under my notice in 1856, and I reported it, under the heading of hepatic intestinal calculus, in the eighth volume of the Pathological Society's 'Transactions,' p. 235. The following is an abstract of its history. The body of a man aged 87, who died in the St. Pancras Work- house, was being dissected at University College, when Mr. Jakins, one of my then students, found a large 622 DISEASES OF THE LIVER. hard oblong mass, measuring three mches in length, and three and three-quarters in circumference, lying in an artificially formed cul-de-sac in the right side of the duodenum about equidistant from the pylorus and the entrance of the bile-duct into the intestine. The outer wall of the cul-de-sac was firmly adherent to the gall-bladder by old-standing adhesions. The gall-bladder itself was small and contracted, and the common duct abnormally dilated. All these facts when taken together left no doubt that the stone had ulcerated its way from the gall-bladder mto the intes- tine, and thereafter become encysted. The stone, or it might rather be called stones, weighing (when dried) four hundred and fifty grains, consisted of three distinct portions, articulated and afffflutinated to2:ether. And as on the middle one were two distinct large lateral facets, it must have been originally composed of five pieces. Judging from the size of the facets, it must have weighed not less than two thirds more than it now did, thereby makinof the enormous total of seven hundred and fifty grains. On analysis it yielded Cholesterin . . . 90-346 Mucus .... 2-218 Pigment and resin . . 4*242 Inorganic salts . . . 0-661 From this analysis it appears that it was a biliai ENCYSTED GALL-STONES. 623 calculus, although one containing not only less than the average amount of cholesterin, but less than the average amount of inorganic salts. It was no doubt fortunate for the patient that the stone remained lodged in the cul-de-sac, for had it attempted to de- scend through the intestine, from its large size it would undoubtedly have completely blocked up the canal, and produced fatal ileus. The appearance of the exterior of the calculus, as well as those of the old adhesions by which it was surrounded, rendered it probable that it had been lodged where it was found for many years. On making inquiiy at the workhouse, nothing could be ascertained of the man's cHnical history, except that during the five years he had been an inmate of the institution he had never had jaundice, or been known to complain of any hepatic derangement. A number of biliary calculi which had escaped from the gall-bladder by ulceration of its coats were found by Dr. Sidney Coupland, at the autopsy of the patient, encysted in peritoneal adhesions close to the pylorus. The case was that of a man aged 40, who died at the Middlesex Hospital under Mr. Hulke's care, from the effects of a tumour growing from the base of the skull. Nothing was known of his liver history, so that there is nothing to add to the fact that gall-stones may become encysted even in the peritoneal cavity itself. 624 DISEASES OF THE LIVER. In the Museum of St. Thomas's Hospital there Is a preparation with two calculi lodged in an ulcer at the fundus of the gall-bladder, and seventy-five more are said to have been found embedded beneath the abdominal muscles outside of it. The Danger arising from Gall-stones continues after their Entrance into the Intestines. That the dangers attendant upon gall-stones do not necessarily cease after they have reached the intestinal canal in perfect safety is a point never to be lost sight of. For not only may they become im- pacted in some part or other of the intestines, and give rise to distressing symptoms, but their impac- tion may, and frequently does, lead to fatal results. Many cases of this kind have been reported both in home and foreign journals. Many years ago Dr. Vanderbyl exhibited to the Pathological Society the parts in a case of this kind, where the patient died from ileus caused by a gall-stone. Mr. Le Gros Clark has put on record, in the 55th volume of the ' Medico -Chirurgical Transactions,' a fatal case of impaction of gall-stones in the ileum in a lady aged 58, who never had jaundice, but eight months previous to her death was seized with pain in the right hypochondriac region ( where a hard tumour could be felt), bilious vomiting, and griping pams in the bowelsj The fatal attack began with obstinate constipatioi and in a few days she was attacked with severe abj FATAL EFFECTS OF GALL-STONES. 625 ■dominal pain, chiefly in the region of the ileo-cffical Talve, where a hard tumour was felt, and with bilious vomiting which shortly afterwards became stercora- -ceous. She died in eight weeks from the commence- ment of this attack without ever having once had a proper motion. The post-mortem examination revealed two large gall-stones blocking up the ileum close to its valve. Each stone measured about four inches in circum- ference, and one in length. Together they weighed nearly 600 grains. As there was no previous jaun- dice, these stones must have ulcerated their way from the gall-bladder into the intestines, yet no adhesion or cicatrix was anywhere found. Another interesting fatal case is recorded by Mr. Lammiman ('British Medical Journal' of May 20, 1876), as follows :— A woman, aged 54, complained of constipation and some abdominal pain. An ordinary purgative was prescribed ; next morning, there having been no relief, another aperient was given. Early on the third day, abdominal pain increased by pressure, and )ther signs of inflammation, supervened ; vomiting of I stercoraceous character came on, when she began to >ink, and died. The inspection showed the ordinary ;onditions of difl'use peritonitis, with trifling eff*usion. The ductus communis choledochus and gall-bladder -ould not be found, but in their place was a dense s s 626 DISEASES OF THE LIVER. cicatrix connecting tlieir normal site with the duode- num, while in the lower part of the ileum was tightly impacted a biliary calculus, two inches long, one inch and a quarter in diameter, three inches and a half at its greatest girth. It weighed four drachms. In another fatal case reported by Dr. Baly, the stone, though measuring only one inch in length, had a circumference of 3| inches. Gall-stones may induce Enteritis. It is no uncommon thing for gall-stones, eveD when small, to become lodged in the ileo-c^cal valve and. produce great irritation, but as it is rather an unusual thing for them to induce a fatal result, I shall relate a cas'L of this kind of which the history was given tc me by Mr. Ward. The patient (a lady, aged aboui 40), in whose caecum after death from an acut( attack of enteritis a number of large gall-stone: were found, had for some years previously sufferec from vomiting, diarrhoea, and great abdominal pair Previously to this she had been habitually very con stipated. Just before her death the stools were lik peasoup, both in colour and consistence, with no^ and agaui scybalous masses in them, which Mr. War thought might in reality have been gall-stones, seein that a great many were found in the caecum aft( the patient's death. I DANGERS OF GALL-STOXES. 627 Gall-stones impacted in the Rectum. Enormously large gall-stones sometimes find their ^viiJ quite safely through the intestmes, and yet be- come lodged in the rectum. Dr. H. F. Walker (referred to by Dr. Flint at p. 460 of his ' Practice of Medicine ') removed from a patient's rectum a gall- stone which measured three and a half inches in its longest and one and a quarter mches in its shortest diameter. In this case the patient had previously suffered from symptoms of peritonitis, which were probably caused by the stone ulcerating its way from the gall-bladder into the intestines. Most likely into the colon. For I hardly think so big a stone could have passed though the small intestine of the patient, seeing it stuck in his rectum, the calibre of which would of course be considerably greater than that of the small intestines. Gall-stones may be vomited. Gall-stones are sometimes expelled by vomiting, probably in consequence of their finding their way from the duodenum into the stomach, by the same retrograde peristaltic action of the bowel as leads to bilious and stercoraceous vomiting. Or the gall-stone may ulcerate its way directly from the gall-blad- der (by adhesive inflammation and ulceration) into the stomach, and produce so much irritation in its 8 8 2 ^28 DISEASES OF THE LIVER. transit as to lead to the death of the patient. For- tunately, however, this is not always the ease, and the stone occasionally passes direct from the gall- bladder into the stomach by ulceration with so little disturbance that its existence is not even so much as suspected until it is expelled by the mouth. A remarkable case of vomited gall-stone I was requested to report upon to the Pathological Society (vol. xii. p. 129). It occurred in the practice oi Mr. Jeaffreson. A lady aged 94, after only two days' illness (consisting of pain in the stomach, accompanied with vomiting), ejected a hard dark oval mass, measuring an inch in length and half an inch in diameter, and weighing sixty-five grains. Which on chemical examination I found yielded over ninety per cent, of pure cholesterin. The concretion was therefore a genuine gall-stone. So little disturb- ance to the patient's health either preceded, accom- panied, or followed the passage of the stone from the gall-bladder into the stomach, that beyond the two days' illness she never made any complaint which could be attributed to the presence of the stone. No sooner was it ejected from the stomach than the pain and vomiting ceased ; and although six months had elapsed since this occurred, before it was sent to mc for examination, she had remained during the whole of that time in the enjoyment of perfect health. So that we are compelled to suppose that if the stone. PERFORATING GALL-STONES. 62^ did not reach the intestines before it arrived in the stomach, the opening through which it passed from the gall-bladder into the stomach must have rapidly healed up. It is of course almost out of the question to imagine that such a large mass could have passed through the pylorus into the stomach from the duo- denum by a reversed peristaltic action of the bowel with so little pain, for apparently it was too large to pass easily through the pyloric sphincter. While it would be equally contrary to probability to imagine that it could pass through the narrow orifice of the bile- duct into the duodenum without causing jaundice as well as paroxysmal and excruciating agony. Indeed, the only comparatively painless way it could get from the gall-bladder into the stomach was by direct ulceration. Hence I adopt that theory in preference to any other. Gall-stones may perforate the Abdominal Parietes. It is no imcommon thing for gall-stones to ulcerate theu' way out of the body through the abdominal parietes. Even in very aged people this may hap- pen. For example, a bishop at the age of 90 passed three gall-stones by his umbilicus, the largest of which weighed 180 grains. A woman aged 60, who had twenty-two years before suffered from jaundice, passed, after great pain, by an ulcerated opening close to the navel, a biliary calculus an inch and a half in length 630 DISEASES OF THE LIVER. by three-quarters of an iudi in diameter. The open- ing rapidly closed, and the woman got quite well. The case occurred in 1852 at St. Thomas's Hospital, under the care of Mr. Simon. Dr. J. W. Ogle in 185-1 reported the case of a man at the age of 57, who passed about thirty gall- stones of the size of small nuts through an ulcerated openmg in the umbilicus, and who, after their dis- charge, got quite well, and subsequently (ten years later) died of phthisis. At the post-mortem one small biliary calculus was found embedded in the diaphrag- matic surface of the right lobe of the liver. The omentum was adherent to the umbilicus, and in it could be made out the boundaries of an abscess which had evidently originally implicated the gall-bladder, as it contamed a quantity of dark-coloured liquid in which were found a number of agglomerated biliary concretions composed of mucus and inspissated bile, altogether making a mass of about the size of a hen's Another case of an analogous kind is recorded by Dr. Robertson in the Pathological Society's ' Trans- actions,' vol. V. page 158, in which a man aged 67 passed about tliirty gall-stones the size of nuts. During the time the fistula at the umbilicus re- mained open, the discharge of yellow matter from it was so excessive that it brought him to the very point of death. It ultimately healed up, and the maa PERFORATING GALL-STONES. 631 lived for three years afterwards. At tlie post-mortem one small irregular biliary calculus was found em- bedded in the diaphragmatic surface of the right lobe •of the liver, but none elsewhere. The gall-bladder was shrunken, but contamed a small quantity of bile. That even attacks of gall-stones or colic without jaundice may be followed by the establishment of a biliary fistula is well shown by the case of a lady, -aged 40, who was under the care of Mr. Curling. For many years she had been subject to paroxysmal pain in the hepatic region accompanied with vomitmg, but never any jaundice, when suddenly a swelling was noticed immediately below the margin and about the middle of the right ribs. It gradually increased ^in size and dimmished in hardness. At length fluc- tuation made its appearance, and it was lanced, when several ounces of viscid yellow but not bilious - looking fluid came away. Within a month of the •date of the evacuation a biliary calculus not bigger than a hempseed came through the fistulous opening, and three months later four slightly larger ones were also discharged, which was immediately followed by a diminution of the pain. Two days afterwards, how- ever, the pain returned in an agonising form, especially in the back, with violent sickness, and all at once an un- expected discharge of pure dark-green bile took place, and contmued at the rate of from one to two ounces in the hour— being most after meals— for nearly two 632 DISEASES OF THE LIVER. montlis, when, after the expulsion of another equally small biliary concretion, the wound closed. Dr. Murchi^ son (Pathological Society's ' Transactions,' vol. xxii, page 153) gives the rationale of the case as follows : — {a) A concretion which had been formed in thsr gall-bladder entered the cystic duct, causing paroxysms- of pain and vomiting, but no jaundice, as the common duct remained free. {h) The cystic duct being blocked up by the con- cretion, no more bile could obtain access to the gall- bladder. The bile already retained there became absorbed and replaced by a viscid opaque fluid. The gall-bladder became distended and formed the tumour midway between the margin of the ribs and umbilicus, in the perpendicular right nipple line, which was opened, and its contents evacuated along with five biliary concretions. (c) A fresh attack of biliary colic followed. The concretion already spoken of as blocking up the cystic duct became dislodged, passed down into and ob- structed the common bile-duct. The bile could then no longer pass along it into the intestine, therefore passed by the now free cystic duct into the gall- bladder, and from thence discharged itself through the fistulous opening in the abdominal parietes. {d) With another attack of biliary colic the stone was again dislodged, and passed through the common bile-duct into the intestines. The duct thus being PEEFORATING GALL-STONES. 633^. once more free, the secreted bile passed along it into the duodenum and not into the gall-bladder, and, there being no frirther necessity for the fistulous opening between the gall-bladder and abdominal parietes, it healed up and the patient got well. Gall-stones may ulcerate their way into the Urinary Organs. Biliary concretions have been known to ulcerate their way into the pelvis of the kidney and even into the urinary bladder. Giiterbock describes in ' Yirchow's Archiv,' vol. Ixvi., a biliary concretion which had ulcerated its way into the urinary bladder, and was removed by lithotrity from a woman aged 50, who had observed no other symptoms than those produced by the pre- sence of the calculus. An examination showed the concretion to consist of cholesterin, with small quan- tities of urea, phosphate of lime, and bile-pigment. The urine had contained bile-pigment. The con- cretion removed weighed in all 200 grains. The author refers to two recorded cases of gall-stone in the urinary bladder. In one, there was found an obhterated communication between the gall-bladder and urinary bladder through the urachus, in which there had been a temporary discharge of biliary colouring matter with the urine. Bniary calculi, after finding their way by ulcera- tion into the pelvis of the kidney, have passed down 634 DISEASES OF THE LIVER. along the ureter with all the symptoms of ordinary renal colic, become for a time lodged in the urinary bladder, and been ultimately voided along with the ^rine, and their true nature and clinical history only been revealed by their chemical analysis. A still more remarkable case is related in the 'Gazette des Hopitaux,' Paris, October 8, 1846, where two gall-stones were removed from the pubes of a female, which had passed down along the recti muscles and become encysted in the subcutaneous tissue a little above the clitoris. Gall-stones may cause Death by Haemorrhage. Gall-stones sometimes cause death by ulcerating their way into a blood-vessel. This is well shown in a case (reported by Dr. Bristowe at page 285 of the ninth volume of the Pathological Society's ' Trans- actions ') of a woman aged 32, in whom after death it was found that the common duct was not only •obstructed and dilated by a gall-stone, but suppuration had occurred, and a communication been established between the bile-duct and the portal vein, through which bile had flowed and minoied with the blood. She had suffered from intense jaundice, with all the symptoms of obstruction to the flow of bile into the intestines, and in addition presented just before her death the unusual spectacle of spitting up pus stained with bile. This was partially accounted for by the H-a:MORRHAGE FROM GALL-STONES. 635 discovery in the liver of cavities filled with bile-stained purulent fluid, which communicated with the lung through the medium of the vena cava. Fatal haemorrhage may even arise from a rupture of the gall-bladder taking place on account of occlusion of the common bile-duct by an impacted gall-stone. Dr. Leared recorded a case of this kind which oc- Ammonii Chloridi . , gr. xx. Pulv. Antimonialis . . gr. iij. Aq. Sambuci . . . 5 ss. M, Large doses of liquor ammonias acetatis are like- wise exceedino-lv useful in cases of delirium from biliousness. The stage in a gall-stone's career which, on account of the signs and symptoms, is not alone the most alarming to the patient and his friends, but also the one which usually causes thp gTeatest amount of anxiety to the medical attendant, is when it is impacted in the common bile-duct. For one can never feel quite certain what ultimate course the stone will take, and consequently whether or not the case may come unexpectedly to a fatal termination. Treatment of Firmly Impacted Gall-stones. When a gall-stone has become firmly impacted in the common bile-duct, the majority of practitioners u u 6'58 DISEASES OF THE LIVER. regard the case as a hopeless one, and usually reckon the patient's life by months. Fortunately I believe that I am in a position to state positively that almost no case of impacted gall-stone is hopeless, for my own experience tells me quite the reverse. I have known, and at this very moment know^ patients who have had gall-stones firmly impacted in their ducts for years, not only without dying, but ultimately re- covering. And their treatment has not been difficult, seeing that it essentially consisted in only two par- ticulars — dilating the duct by belladonna, and re- ducing the size of the stone by appropriate solvents. As an encouragement to my readers I shall relate three cases which have more than usual interest at- tached to them. The first is one I saw along with Surgeon- General Dr. George Smith, I. M.S., and which I will give in his own words. 'A. B., born in India in 1855. In June 1877, had an attack of hepatitis. Health was quite restored after the attack. Took much exercise, and seemed to be in perfect health. In July 1879, jaundice appeared with white stools, deep-coloured urine. Later in the year appeared the biliary acids and leucin. Left India in 1880, and passed five weeks on the Continent without advantage. Suffered from recurrent con- gestion and enlargement of liver, with severe pain. During these attacks the liver enlarged up and down and increased in thickness. At such times the skin I IMPACTED GALL-STONES. 659 discoloration increased ; there was general hepatic pain, headache, and pain in the eyes ; urine dark and stools dirty white. At times the intervals between these attacks were prolonged, and a fair approach to health was for a time made. She always suffered from general pruritus and sleeplessness. In July 1880 she was attacked with fever, pain over the right kidney and loins, and in the pit of the stomach. This pam became so severe that during a whole night she was kept under the influence of chloroform. She vomited a brio-ht o-reen fluid mixed with food. Had abdominal pain most pronounced over the caput coli. Temp. 100° Fahr. The attack was a severe one. Symptoms gradually subsided. Condition very unsatisfactory. On August 7 passed a naturally coloured evacuation, but this change for the better lasted only five days ; then white stools reappeared, with hepatic uneasiness. And so the case Imgered on, the liver often quiescent, at times passing bile m small quantity, at other times the motions were colourless. In July 1881, her condition was con- sidered critical. Her pulse was 112, weak and small. The temperature 100°, and not only was there pronounced jaundice, but her legs began to swell, and assumed a state resembling phlegmasia dolens ; and the cramps in the legs became so severe as to require the continued use of chloroform. Dr. George Harley's opinion was now obtained, and he at V V 2 660 DISEASES OF THE LIVER. once diagnosed the case as one of impacted gall-stone and prescribed for her accordingly. There was pain over the popliteal, and pain with distinct hardness over the femoral veins. The strength became im- paired, the skin discoloration increased, and the temperature over 100°, being higher in the evening. Pulse small, weak, and 112. On July 24 a free passage of bile ended the attack. No calculus was detected, nor did pain in the liver accompany or im- mediately precede the appearance of bile. For eleven nights good sleep was obtained without narcotics. In August there was a slight relapse with fever. Pulse 110, temp. 103°, liver enlarged and tender. Com- plained of weakness. State unsatisfactory ; skin very dark ; pruritus nearly constant ; insomnia the rule ; heart weak. In September the liver became enlarged and tender, with slight fever. Bile frequently ap- peared after mild hepatic pills. On December 4 bile appeared m the stools, then disappeared to re- appear in quantity on December 15, since which date its outflow has been natural and unimpeded. The liver is now (February 27, 1882) normal in size and free from uneasiness ; the skin is clearing, the urine is free from biliary discoloration ; pruritus has disappeared, so have headaches ; the strength has returned ; appetite and digestion good, and the patient is putting on flesh ra2)idly. She pronounces herself to be quite well. Appetite is good and spirits excel- IMPACTED GALL-STONES. 661 lent. Is able to take long walks without any feeling of distress. Her secretions are all normal. The change from valetudinarianism to health took place on November 15, and from that date there has been a rapid restoration to normal health and strength.' The next case I shall relate is that of a certain Lady N , who, though not yet cured, is certainly on the high road to cure, for she walked into my study this morning — February 23, 1882 — as briskly as if she ailed nothing. This patient's case is well known to several members of the profession both in this country and abroad, from one of our London phy- sicians, who has great faith in the efficacy of mineral waters, having two years before I saw her sent her to both Carlsbad and Vichy, in the hope that their waters would rid her of her impacted gall-stones. When first summoned to the bedside of this patient, which was on February 27, 1878, she was suffering from a violent paroxysm of gall-stone colic. Her stools were pipeclay- coloured, her urine as dark as porter, and the colour of her skin an incongruously combined mixture of black, green, and yellow. In- deed, such was her strange complexion, that, as she subsequently told me, she could never go for a drive in the open carriage without a thick veil, as people stared at her so ; and when she walked in the streets the children would turn round and call out to each other to look at the ' funny woman.' 662 DISEASES or the liver. As it is over four years since I first saw her, and she had been ill with the same symptoms and signs for two years previously to that, the gall-stone must have now been firmly impacted in the common bile- duct for at least six years, notwithstanding which she is not only still alive, but in good health, and is even now passing small quantities of bile by stool, while the urine is at the same time only of a dark straw colour, and her complexion whitish-yellow. So well indeed is she that she was able to dance at a ball a few niofhts a^o, to the amazement of all who knew how ill she had previously been, and how nearly she had approached the brink of the grave. She has been treated by duct-dilators and biliary solvents at diff'erent times and in different ways. Alkaline carbonates have been freely used, as well as the iodide of potassium and bromide of ammonium, with occasional mercurials. Great benefit was derived from benzoates, chiefly given in the following manner, which is a favourite formula of mine : — :^ Acidi Benzoici . 5 ij. Potassae Causticse . 3 ss. {yel Liq. P. 5 ss.) Aqu« Destil. . . 5 vj. M. Dissolved with heat, and a tablespoonful taken in water thrice a day. The next case is related chiefly for the benefit I I IMPACTED GALL-STOXES. 663 of the reader who, bemg but little versed in the clinical history of gall-stones, may perchance doubt not only the diagnosis but the benefits of the treat- ment in the foregoing cases, from the fact of no stones having even so much as been suspected of having been voided by the patients. Kegarding the nature of the case now to be recorded, there cannot possibly exist a shadow of doubt, for not only one, but actually four stones were picked out of the fa?ces within the brief space of a month after the treatment began. The case has another advantage, for it had originally been mistaken for one of cancer, and, had a change of treatment not been promptly adopted after the error in diagnosis was discovered, would in all probability have termmated fatally — ^like most other cases of a similar kind. When I come to the chapter on cancer of the liver, I shall take occasion to point out the landmarks on which I rely in making a dif- ferential diasfnosis in these cases. Meanwhile I shall give a bare statement of facts. The case was that of a lady of some sixty summers who was sent from Devonshire, shortly after she had been seen in consultation (along with her usual medi- cal attendant, Mr. Edwards) by Dr. Budd of the Exeter Hospital, who diagnosed the case as one of cancer of the liver. On her arrival in town I was asked to 2:0 at once to the hotel and see her. I found her much exhausted, from the effects no doubt 664 DISEASES OF THE LIVEE. of the long railway journey. Her skin was not deeply jaundiced, having more of a greenish livid than of a yellow colour, not at all unlike what one sees when slight jaundice accompanies the cancerous^ cachexia. The tongue was foul, the pulse rapid, the skin hot. The liver moderately enlarged. Tender on pressure, smooth, and hard to the touch. The stools were pipeclay-coloured. The urine scanty, very dark in tint, and with a copious deposit of lithates. On careful palpation I detected a distended gall-bladder, which was acutely painful on pressure. She said she had never passed gall-stones. Nor had she at that time suffered from what could be put down as hepatic colic, though she admitted having occasionally suf- fered from stoDiach-ache. I at once diagnosed the case as one of gall-stone impacted in the common bile-duct, and proceeded to treat it accordingly. To make a long story short, I may skip over details until that day three weeks, when a gall-stone the size of a femall hazel-nut was put into my hands. Two days later another, the size of a field bean, and four days subsequently a third, the size of a small hazel-nut, all three more or less circular, without a single facet on any of them. All of an exceedmgly dark and rather roughish exterior, with a pale fawn- coloured crystalline interior. After the passage of the stones the patient got rapidly well, and I very soon had the pleasure of sending her back to Devon- IMPACTED GALL-STONES. 665 shire, cured of her ' cancer.' The day before she left, her maid made a voluntary confession, in somewhat the following words : — ' I got tired of searching the dirty stools for the stones, and I was just makmg up my mind to do so no more, when (five days before I gave you the first stone) I found in the middle of the stool what I thought was a boy's marble, so I picked it out and washed it. Then, seeing it was not a marble, I wiped it quite dry, and, in order to find out what it was, I tried to cut it in halves with a pair of scissors, when to my surprise it broke into a lot of shiny-looking pieces. I then thought it must be a gall-stone. And as I was afraid you would be angry at my breaking- it, I made up my mind to say nothing about it and threw all the little bits mto the fire, where they blazed away like wax. Although I said nothing about it to anyone, I now looked far more carefully in every stool, and on the fifth day I found the one I gave first to you. So mistress, I know, has at least passed four of them.' There is an important moral to be drawn from this anecdote. For supposing this maid had pos- sessed a less inquiring mind, or no scissors had been at hand, the true nature of the marble would never have been discovered by her, and not only would it most probably have been consigned to the w.c, but no more stools would have been searched for gall- 666 DISEASES OF THE LIVEK. stones, and her mistress and I should have been con- fidently informed that no stone had ever passed. And, although the patient got well under the treatment, I should most probably never have had the credit of having either made a correct diagnosis, or been successful in getting rid of the gall-stones, I think the reader will cease, after reflecting on this case, to feel the slightest surprise at my having said that the longer I live the less importance do I attach to the non-discovery of gall-stones in patients' stools, and that too even after there is distinct symptomatic evidence of their being passed into the intestines. The above case is an exceptionally favourable example of the benefits of energetic gall-stone treat- ment. It and the one I recorded at page 650, in which thirteen stones were passed, are two of the speediest cases of cure I ever had, and that is saying a great deal, seeing the immense number I have had to do with. Now the sequel of the above case has yet to be told. The lady is still alive at the age of 74, has grown stout, and is, as far as the hepatic symptoms are concerned, comparatively speaking, well. She however sufi*ers from other thins^s — but neither from cancer nor gall-stones. PERFORATING GALL-STONES. 667 Treatment of Gall-stones seeking an Exit by Perforation of Tissues. When we have reason to suspect that a gall-stone is workmg its way out of the gall-bladder or out of a bile-duct by ulceration, all our efforts must be directed to aiding that process, both by accelerating it and by mitigating its serious consequences. Strict rest is to be enjoined, hot fomentations are to be assiduously applied to the tender locality. The strength of the patient is to be carefully supported by a judicious selection of easily digested non-stimu- lating animal foods, in the shape of nourishing soups and drinks. No solids, sweets, or fatty foods are admissible. In cases where the o-all- stone or stones have caused rupture of the gall-bladder or bile-duct, or where the ulceration has opened a blood-vessel or into the peritoneal cavity, all that can be recommended to be done is simply to use the best means which suggest themselves, under the circumstances, to ward off the cause of death. I cannot particularise any special line of treatment to be adopted in the manifold possible forms of comphcation which may arise m the erratic course of a gall-stone, but merely recommend the practitioner to remember that in all bad cases in a multitude of counsellors there is wisdom — provided the counsellors are of the right sort — and it is always good policy to have some one else to share the responsibility 668 DISEASES OF THE LIVER. when a suddenly fatal and unexpected termination may possibly occur. However, I think I may venture to give here at least one valuable piece of special advice in the Treatment of Perforation with Hsemorrhage. Which is, immediately on blood appearing in the vomit, the stools, or the urine, or even when invisible internal hsemorrhage is, on account of the symptoms, suspected to have occurred, no matter into what cavity or tissue, to apply ice over the supposed seat of the rupture. I may as well incidentally remark that often the worst cases are those where no blood appears externally. And even in them a freez- ing mixture of ice and salt, if speedily had recourse to, is most useful. It being the most powerful of all styptics. Don't make the mistake, however, of putting the freezing mixture into a waterproof bag, and then applying its dry external surface to the patient's skin. For as waterproof cloth is a bad conductor of cold, it is absolutely essential to tvet the surface of the hag which is to go next the patient's skin. The cold cannot be too intense. For in order to cope successfully with an internal hasmorrhage through the instrumentality of the external appli- cation, it is essential that it should be sufficient to freeze the external parts. A little blistering of the cuticle does no harm, as it produces no more dis- HiEMORKHAGE IN GALL-STONES. 669 agreeable effects than a case of cantharides blistering, and heals just as readily. The giving the patient lumps of ice to suck is an unimportant adjunct. For unless he swallows the fragments whole, the ice becomes warm water before it reaches the stomach. The next thing is to administer a potent astringent. Of these our Pharmacopceia possesses a superabund- ance. Lead and opium, gallic and sulphuric acids, krameria and kino, &c., &c. But there is a formula which has proved so successful in my hands that I have given it at page 266, in the hope that, either as it stands or with some modification, it may be found equally useful by others. A dose being given as frequently as the urgency of the symptoms demands. When there is fear of collapse, balsamic astringents ouo-ht to be given. Turpentine, though not one of the nicest, is one of the best. In almost hopeless cases yet another plan may be tried, and that is the newly proposed one of injecting freshly-drawn warm blood into the peritoneal cavity. It is said not only to produce no disturbance, but soon to disappear by absorption. Treatment of Gall-stones impacted in the Intestines. It will, I think, be readily admitted that in the preceding pages it has been clearly shown not only that the evil results of a gall-stone do not always cease when it has reached the intestines, but that even 670 DISEASES OF THE LIVER. death itself has again and again resulted from the impaction of a gall-stone in the intestinal canal. When we have any suspicion that the stone is large, our treatment must be carefully contiuued until its extrusion by the mouth or rectum has been accom- phshed. The removal by operation of a gall-stone from the ileum in a case of acute intestinal obstruction is recorded by Mr. Bryant in vol. xii. of the Clinical Society's ' Transactions.' The patient, a married woman aged 50, had never had any illness of any kind until the commencement of this attack. AVhicli began by her waking at night with severe abdominal pain and sickness. The vomiting being greenish led to the belief that it was simply a bilious attack. On the following day the vomited matters became faecal, and the abdominal pain excruciating, especially to- wards the left of the umbilicus. The countenance was anxious, and the pulse feeble. As death seemei 1 imminent on the third day of the symptoms of strangulation, the abdomen was opened from the um- bilicus four inches downwards, and a hard ovoid body was detected in the lower part of the ileum, about a foot above the ileo-caecal valve. The intestine beino- distended above, and collapsed below the seat of the obstruction. An incision was made into the gut, and a gall-stone measuring If inch in length, 1-| in diameter, and 3^ in circumference, weighing 238 grains, was extracted, and the wound immediately i FATAL ILEUS FROM GALL-STONES. 671 afterwards stitched up with carbolised catgut. The patient never rallied, but died in eight hours. At the autopsy the wound in the mtestine through which the calculus had been extracted was found well sealed up with new material. There was some blood- stamed serum m the abdominal cavity, but no fascal matter. The gall-bladder was absent and replaced by a thickened pouch, about the size of a walnut, and firmly adherent to the hepatic flexure of the duo- denum, in which was a sUght annular constriction at a point where it communicated by a small opening with the gall-bladder. The reason why she had never been jaundiced was, of course, that the stone had ulcerated its way directly from the gall-bladder into the duodenum, and never had the chance of blocking up the common bile-duct. I may allude to another case in which Mr. Hugh R. Ker removed by abdominal section a gall-stone, as large as a pigeon's egg, from a patient suffering from intestinal obstruction of thu'ty-six hours' dura- tion. The stone was situated immediately above the ileo-caecal valve. The wound was carefully brought together by a catgut suture. Death took place four days after the operation, but no post-mortem examina- tion was allowed. 672 DISEASES OF THE LIVER. Artificial Removal of Gall-stones from the Hepatic Appendages. There is a certain class of cases where I would follow the advice of a celebrated French surgeon of the last century and unhesitatingiy recommend the removal of gall-stones — when dangerously impacted in the common bile-duct — by the surgeon's knife. Although I shall have a good deal to say on this subject when I come to the consideration of diseases of the gall-bladder, I may here mention that I do not consider the removal of gall-stones from the living human body, though a bold, a hazardous operation. Indeed, I hAve but little doubt it will sooner or later come to be an operation frequently practised. For once the existence of the offending foreign body has been accurately ascertained, I see no reason why it should not be removed. In my opinion, judging from my experience in operations on the gall-bladders of animals, the operation of choleo- cystotomy is not even at the present moment one whit more dangerous than that of lithotomy, and ought, if proper precau- tions are taken, to be mfinitely less so. I think, from the fact that not only the presence of gall-stones, but even their exact situation, when once they have be- come firmly impacted in a duct, is in general easily ascertained, that no hesitation need be felt in suitable cases early to call in the assistance of a surgeon. In order to show that there are good grounds for CHOLEO-CYSTOTOMY EECOIklMENDED. 673 recommending the removal of gall-stones in suitable •cases by making an artificial opening into the common bile-duct when they are givmg rise to •dangerous symptoms, I may refer to cases where it has been successful when done accidentally, as well as when done intentionally. One day in speaking to Sir James Paget regarding the possibility of successfully establishing a biliary fistula in the human subject m cases of permanent obstruction to the entrance of bile into the duo- denum, he related to me a case where he had seen a gall-stone extrude itself spontaneously fi-om the gall- bladder through an mflammatory opening in the right hypochondriac region of a patient while he was being examined in his own study ; and as I naturally enough manifested great interest in the case, he kindly sent the patient to me a few days afterwards. The patient, a clergyman of over eighty years of age, when I examined him, had two fistulous openmgs in the ab- dominal walls just over the fundus of the gall-bladder. One of these was closed up, but from the other exuded a small quantity of bilious-looking pus. There was distinct tenderness on pressure over the seat of both of the fistulas, and notwithstanding that the first fistula had formed nearly three years previously and discharged ever since, the gentleman, considering his great age, appeared to be in the enjoyment of excellent health. The history of the case as given to X X 674 DISEASES OF THE LIVER. me by the patient himself, in a letter dated 4th. December, 1879, is the following : — ' The first detection of a formation on the right, side was on March 15, 1877, closely succeeding a. lengthened and severe illness from congested lungs. I had eminent physicians, who failed to find the enlargement, so I suppose it did not exist. From May 20 I was in Scotland walking as well as any of my age, and feeling no inconvenience and no pain. About the second week after my return from Scotland, it felt as if matter were forming, and on October 11 it came to a head and broke, discharging two gall- stones, about the size of a small pea, in the presence of Sir James Paget. No matter has ever passed. Nine or ten stones and crumbs of stone have come away. Their passage caused very little pain. The first orifice, after three or four months, healed, and a second opened. I do not think they have ever dis- charged together. The discharge never ceased.' In the 'Lancet' of January 5, 1878, Mr. Cookson relates the case of a gentleman aged 65 who passed a number of calculi through a fistulous 02:)ening in the abdominal parietes. The history is briefly as follows : — He complained of nausea and vomiting, with gi-eat pain at the junction of the right hypochondriac and epigastric regions, where there was a visible enlargement. For two years previously he had felt pain in this situation when leaning forward or against CHOLEO-CYSTOTOMY RECOMMENDED. 675 anytliing. Over a spot which he said he could cover with his thumb, situated immediately below the ribs, and about three or four inches to the right of the median line. At length an abscess formed, and burst about an inch above and a little to the right of the umbilicus. It discharged a quantity of foetid matter along witli i from twenty to thirty gall-stones. Which were almost ! colourless, friable, and soluble in ether, varying from I the size of a pin's head to that of a field pea. The I largest weighed sixty grains. For several days two or three calculi came away daily. The discharge, which was at first thick and purulent, in a few days became thin and serous, but contained no bile. After this the patient's health rapidly improved. The nausea and vomiting ceased, and the pain and tender- ness disappeared. Eight days later about a dozen more calculi were extracted by means of a probe, and the swelling and induration which up to this time had existed around the umbilicus now rapidly sub- sided. On the following day some more small calculi were discharged, and among them a large triangular one which passed with difiiculty through the opening, which was of the diameter of a writing-quill. A probe was passed into it, and its depth was found to be four inches. For the first time the discharge was noticed to contain bile, and on pressure being applied over the liver two or three drachms of it flowed out 1x2 676 DISEASES OE THE LIVER. This is about the usual mode by which gall-stones make for themselves a direct exit through the abdominal walls ; but in further illustration I may briefly refer to the case published by Mr. Booth in the 'Lancet' of March 11, 1882. He says that his patient, a lady aged 77, after liaving suffered from occasional attacks of biliary colic for ten years, had a painful swelling in the right side, which became red and burst, discharging a 3^ellowish fluid. After remaining open for six months she observed ' a hard black point protrudmg from the orifice,' which hurt her on being touched. She dislodged it with a hair-pin, and found it to be a black pea- sized body. On the following day, two other similar concretions came away. Several more were afterwards extruded, and the colicky attacks ceased. For reports of other cases see page 629, and for further remarks on operative interference see what is said on the establishment of artificial biliary fistulas in the chapter on gall-bladder diseases. In parting from a patient who either has had a gall- stone, or is known to be predisposed to become the victim of one, it is always well to tell him not only to be careful about his diet and drink, but even about liis mode of life. Of course he ought to be told to avoid fatty and rich saccharine foods, and all kinds of salted provisions, as well as every species of fer- mented drinks ; but in addition he ought to be told to CHOLEO-CYSTOTOMY. 677 eat fresh lean meat and cooked vegetables ; to smoke little ; take plenty of muscular exercise ; live as much as is possible in the open air ; go to bed early and rise early, and never at any one time eat more than the wants of his system demand. In fact he GUirht to follow the advice of the Cid, which was ' not live to eat, but eat to live ; ' for the pleasures of life greatly depend upon the ' liver,' as a superabun- dance of rich foods always, sooner or later, puts its functions out of order. After havino' said so much on the treatment of gall-stone affections, it may perhaps be as well for me to remind the reader that success in practice in most instances depends less upon an intimacy with therapeutical formuljB than on a thorough acquamtance with the pathology and clinical history of the special case being prescribed for. Much on the same prmci- ple as the possession of a box of the finest paints does not of itself suffice to enable an artist to paint fine pictures. For, as the celebrated pamter, Opie, told the young artist, who asked him what he mixed his colours with that enabled him to paint such beautiful pictures, that it was with Brains, in like manner the medical tyro may be told that m order to make therapeutical substances cure gall-stone diseases, they must, like the artist's colours, be compounded with ' brains.' 678 DISEASES OF THE LIVER. CHAPTER XII. HINTS ON THE DIFFERENTIAL DIAGNOSIS OF HEPATIC FROM OTHER KINDS OF COLIC. From its having been shown that gall-stone pain often exists without jaundice, it is easy to imagine how it may be confounded with other kinds of colic. The generic term of colic has been applied to every form of obscure pain occurring in the abdomen be- tween the xiphoid cartilage and the umbilicus. The pain may have for its cause a gall-stone, a renal calculus, acute gastritis, enteritis, intestinal worms, invagination, strangulation, chronic copper and lead poisoning, ovaritis, or the inflammation of any other of the organs in that neighbourhood. Still all these forms of pain are included under the head of ' colic' For no other reason, that I can see, than that the word ' colic ' is derived from the Greek koiha, signifying the belly, and pain in the abdomen is, m homely lan- guage, a ' belly-ache.' But alas ! this name, like the equally significant one of headache, is a term some- times unwittingly applied to obscure and dangerous diseases. So that it is equally essential to the safety THE DIFFERENTIATION OF COLICS. 679 of the patient and the reputation of the medical adviser, that the various kinds of colic should be correctly differentiated. As I have already related a case showing how a hos- pital physician fell into the error of mistaking a case of acute gall-stone colic for a peritonitis supervening upon supposed perforation of the stomach, it may be as well for me to remark that mistakes of this kind are rare, and that it is the renal variety of colics alone which in general puzzle the practitioner. Indeed, the TrT NrinOTT / Taurin, C2H,NS03, or J XFT I Amido-ethene-sulphouic acid, CoH^<\o() tt Cystin, CgH^NSO^, or C,H3(SH)(NH2)OOOH. /Hippuric acid, C9II9NO3, or J . . . " /NUC^H.O iBenzamid acetic acid, 0H2\/-iqqtt Oxalic acid, C.^U.fl^, or C^O^Vqjj ^JJ Q. It will be observed that three of the above sub- stances are sulphur compounds. To the liver, there- fore, we must look as the source of the sulphur- containing urinary calculi, whose origin was so long a puzzle to urologists. I CHEMISTRY IN AX OBSCURE CASE. 769 The experiments of Salomon (' ZeitscJirift fiir Phys. Chem.' 1877-8, p. 90) and Chittenden (' Jour. of Phys.' 1879-80, p. 28) show that, besides uric acid and urea, hypoxanthin, another substance which forms urinary calculi, is a decomposition product of blood-fibrin. Blood-fibrin, after being in simple contact with boiling water for from twelve to twenty-four hours, yields appreciable quantities of hypoxanthin, and when blood-fibrin is acted upon by pancreatic juice, it is not only changed into hypoxanthin, but into leucin and tyrosin as well. The value of the preceding remarks regarding the amount of urea, uric acid, &c., daily eliminated, will be best appreciated by giving a short account of a case of obscure disease where a correct diagnosis and prognosis could not have been arrived at without the application of the chemical knowledge referred to. I shall, therefore, relate briefly the history of a typical case, the diagnosis of which was solely arrived at by chemical means, for the very good reason that none other were of any avail in unravelling its puzzling symptoms. The case was that of a gentleman, aged 50, who had been a remarkably healthy man until within eighteen months of his death, when for the first time he noticed that his skin was gradually assuming a more and more jaundiced tint, without, as bethought, any assignable cause. The stools were pipeclay- 3d 770 DISEASES OF THE LIVER. coloured, and the urine loaded with bile-pigment. Soon after he noticed the discoloration of the skin he began to lose flesh. The liver became enlarged, and somewhat tender to the touch ; the gall-bladder being at the same time so distended that it could be seen, as well as felt, projecting from under the false ribs. As the case resisted the usual remedies, the patient was recommended to try change of air. Dur- ing his absence from town, he suddenly passed a large quantity of yellow matter by stool (supposed by him to be bile), and immediately afterwards the swelling in the abdomen disappeared. On the patient's return to town, the gall-bladder could no longer be felt, and it was naturally supposed that it had emjDtied itself on the occasion referred to. As, notwithstand- ing this, the jaundice continued, and the health and strength gradually declined. Dr. Prance, of Hamp- stead, under whose care the patient was, sought the assistance of a physician of distinguished reputation in these affections. At this period, however, the en- tire absence of physical signs beyond the clay- coloured stools, and those directly referable to the jaundice, rendered it impossible for Dr. Prance, or the consultant who then saw him, to form any very decided opinion regarding the nature of the case. At the time now alluded to, the liver, from hav- ing been at first enlarged, had resumed its normal size, and the only points ascertainable on physical CHEMISTRY IX AX OBSCURE CASE. i 71 examination were a slight tenderness of the organ on firm pressure, and a somewhat doubtful fulness in the pancreatic region. (See p. 114.) These signs, associated as they were with gra- dually increasing emaciation and debility, led to the suspicion of malignant disease, either in the course of the bile-ducts, or at the head of the pan- creas. About this time it was discovered that the patient occasionally passed a considerable amount of a fatty-looking matter by stool — not mixed with the motions, but separate, though lying upon them. After the passage of this matter, there in general appeared to be a slight improvement in the patient's condition. The substance in question, on cooling, solidified into a firm pale-brown matter, resembling Old Brown Windsor soap, and not at all unlike a solid mixture of chyme with some of the biliary pro- ducts. This led to the idea that it might partly be composed of the fats of the bile and chyme. So on one occasion a portion of it was forwarded to me for analysis, and on subjecting it to chemical examina- tion I at once discovered that it was modified fish-oil, the olein of which had entirely disappeared. In fact, on further analysis and enquiry regarding what the patient was taking, it turned out to be nothing but the sparingly soluble fatty acids of cod-liver oil, which had been modified during the process of diges- tion in the stomach, and from which all the olein 3 D 2 772 DISEASES OF THE LIVER. liquid principles had been absorbed. This was con- sidered an important discovery, as it not only nega- tived the idea of the bile still reaching the intestines, but also proved that the fancreas^ as well as the liver^ was affected. Having thus learned that the pan- creatic juice, as well as the bile, failed to reach the intestines, an effort was at once made to counteract the pernicious effect on the system caused by the absence of the former secretion, by giving 1^ grains of pure solid pancreatin in the form of pill three times a day. During the period that the patient was taking this medicine, the quantity of fat passed by stool was supposed to diminish. No decided im- provement in the patient's condition, however, took place, and on November 2 the gentleman was brought to me by his medical attendant, in order that I might personally examine him, which I had not as yet done. At this time the patient was much in the state already described, and I noted his condition to be as follows : — Skin of a black jaundiced tint (dark green). Eyes deeply stained. Lips angemic. Considerable emaciation and debility. Extreme languor. Appe- tite good. Tongue and pulse not remarkable. Slight pain on pressure over the gall-bladder. Indistinct fulness in pancreatic region, and to the left of middle line. The hepatic dulness was perfectly natural ; there was no tenderness to speak of, and no distinct history of gall-stones, while the only evidence of A CHEMISTEY IN AN OBSCURE CASE. 773 tumour was the doubtful sense of fulness on palpation in the pancreatic region. The digestive and other functions of the body, except those already mentioned, seemed unimpaired, and yet the patient's strength daily declined. As physical as well as symptomatica! diagnosis proved inadequate to unravel the mystery of this obscure case, and as chemistry had already, in as far as it had been tried, been of advantage, it was resolved to subject the excretions to a rigid chemical examination. The patient was accordingly desired to collect all the urine he passed during twenty-four hours, and while I analysed it. Dr. Prance daily ex- amined the stools with the naked eye, in order to ascertain their probable composition — especially as regarded the amount of fatty and albuminous matters contained in them. The urine yielded on analysis the following result : — TwEXTT-FOrR PIOURS' UrISE. Quantity (55 oz.) 1705 cc. Reaction Acid Specific gravity 1018 Colour .... Greenish-yellow Urea .... 27'28 gi'ammes Uric acid (crystals larg-e, and of a dark-green colour) . 0-511 „ Bile acids Abundant Bile pifrment ^ Abundant Albumen None Sugar .... None * Nitric acid at first turned the urine green, but on the application of peat it became red, and, after prolonged boiling, of a pale straw colour. Hydrochloric acid changed the colour of the urine immediately to a deep olive-green tint. 774 DISEASES OF THE LIVER. The facts elicited were interpreted as follows : — • 1st, — The quantity of urea, which might be said to be normal, was considered a favourable sign. 2nd, — The quantity of uric acid being below the average was likewise regarded as favourable, tending as it did to negative the idea of cancerous disease of the liver. Uric acid being said to be in cases of cancer of the liver usually increased, a fact about the value of which I have, however, still some slight doubt. 3rdly, and lastly — The presence of the biliary acids, as well as the bile-pigment, in the urine, showed that bile, though still being secreted, was not being excreted, but retained and re-absorbed. This fact at once led to the diagnosis that the case was one of jaundice from obstruction. Here, then, was another important step gained. The next point was, if possible, to ascertain the cause of the obstruction. Taking into account the absence of any history of gall-stones, together with the fact of the sudden disappearance of the enlarged gall-bladder, my first idea was that it might be a case of hydatids blocking up the common bile-duct, and that on the occasion when the sudden discharge of bile took place the cyst had ruptured, and discharged itself through the intestines, and at the same time allowed the gall-bladder to empty itself. On talking the case over with Dr. Prance, however, that idea I CHEMISTRY IN AN OBSCURE CASE. 775 was abandoned, and we were forced to content our- selves with the simple conclusion that the case was one of jaundice from obstruction of the common bile- duct, complicated with occlusion of the pancreatic duct, which fact had been previously ascertained by the discovery of the fatty acids in the faeces, and was subsequently verified by the result of the autopsy. About this time the patient took three grains of benzoic acid, in the form of pill thrice a day, and, it was thought, with the advantage of slightly diminishing the jaundiced state of the skin. But no permanent benefit was obtained, and after a time this remedial agent had to be discontinued, in consequence of its having induced slight dyspepsia. In the letter I re- ceived informing me of this fact, it was also noted that there was much less both of the oily matter and albumen in the stools. There was, at the same time, a considerable deposit of urates in the urine. The specific gravity continued to be about 1018. The quantity in twenty-four hours about forty ounces. On November 29, the patient was again brought to me, and we made a careful examination of the size, shape, and exact position of the hepatic organ. Its perpendicular measurements were found to be 5 inches in the right axillary line, 4 inches in a line drawn perpendicularly to the nipple, and 2f inches midway between nipple and sternum. Beyond the centre of the sternum the liver did not reach. Hence it was 77fi DISEASES OF THE LIVER. concluded that the liver was somewhat atrophied ; for the patient was fully six feet high. On this occasion it was observed that the patient's memory was not so good as formerly, and that there was also a certain amount of mental as well as bodily languor. His hearing was likewise sluggish, words having occasionally to be repeated before they made an impression on the cerebral organ. This, no doubt, arose from the poisonous effects of the bile circulating in his blood. (See p. 739.) It may here be mentioned that six grains of pure glycocholate of soda killed a small dog, into whose femoral vein I injected it, in the course of two hours. In experimenting on animals, I have made the curious observation, that although bile has the pro- perty of retarding or arresting putrefaction, both in the intestinal canal and out of the body, yet, when injected into the subcutaneous cellular tissue of a healthy animal, it causes the surrounding tissues to decompose and become foetid, and an artificial disease to be set up, whose most peculiar feature is the engendering of a rapid putrefaction of the whole body after death. (See p. 741.) In cases of jaundice from suppression we do not often meet with those extreme symptoms of cerebral disturbance which are so common in cases of jaun- dice from obstruction. I believe the reason of this difference in the two forms of jaundice arises froi CHEMISTRY IN AN OBSCURE CASE. 777 the circumstance that the really most virulently poisonous parts of the bile are the biliary acids, and that they, like urea, are powerful narcotic poisons. The results of my experiments on artificial jaundice led me to this conclusion. The views I published in 1863 regarding the poisonous effects of the bile acids upon the nervous system have since then been fully borne out by the results of the experiments of Feltz and Ritter, pub- lished in Robin's ' Journal de I'Anatomie et Phy- siologic' for 1875. They found that when the bile acids obtained from ox bile were injected into the veins of dogs they acted as violent cerebral poisons. The blood-corpuscles were destroyed, and their con- tents eliminated with the urine, as well as the bile acids themselves. Haemorrhages from the mucous membranes also occurred. The injection of choles- terin produced no such efi'ects, while that of bile- pigment produced only a lowering of the temperature, obstinate constipation, and an increased flow of urine, but no cerebral symptoms. The injection of fresh bile itself into the veins was followed by its raj^id elimination by the kidneys, salivary glands, and intes- tines. After large doses, vomiting, bilious diarrhcea, and bloody urine supervened, while in still larger doses it produced tetanic convulsions, coma, and death. A series of effects exactly the same as those arising in cases of jaundice of varying severity. (See p. 7-12.) 778 DISEASES OF THE LIVER. As neither the symptoms nor the physical signs threw any hght whatever on this highly interesting- case, it was determined once more to interrogate nature by again bringing chemistry and the micro- scope to bear upon it, with the view, if possible, of still further extending the information these methods of investigation had already yielded. Accordingly, a specimen of the urine was again obtained for analysis, and it yielded the following results : — Twenty-four Hoijes' Ubine. Quantity (43 oz.) . . 1333 cc. Specific gravity . 1016 Reaction . Acid Urea . 23-994 grammes Uric acid . 0-266 Bile pigment . Abundant Bile acids . Only in small quantity Sugar . . A little Solids (total) 41-989 Organic matter . 31-992 Inorganic ,, . 9-997 A marked change is here seen to have occurred in the constitution of the renal secretion. For, first, the quantity of urea has notably diminished, from 27*28 to 23*99 grammes, in other words from 423*84 to 370 grains. The amount of uric acid has also fallen from 0*511 to 0*266 gramme, or, in other words, from 8 to 4 grains. At the same time the biliary acids have considerably decreased, while the quantity of bile-pigment remains almost the same. These changes are also seen to be accompanied by another, CHEMISTRY IN AN OBSCURE CASE. 779 which I at once regarded as a most unfavourable sio'n — namely, the appearance of sugar in the urine. Sugar in the Urine. Although the quantity of sugar was as yet small, and it was associated with a diminution in the bile acids, it nevertheless made me look forward with gloomy forebodings, for, as far as my experience goes, the appearance of saccharine matter in the urine, in the course of a chronic and exhausting disease, is generally the forerunner of a fatal termination. Although present in only small quantity, it was nevertheless sufficiently abundant to spontaneously Fig. 22. 9 ® Torulae Cerevisije from Saccharine Urine. ferment, and after standing forty-eight hours, abun- dance of torula spores were found in it when a drop of the deposit which had formed in the urine glass LJ was examined with the microscope. This case, I am sorry to say, proved no exception to the rule that the appearance of even a trifling 780 DISEASES OF THE LIVER. glycosuria of a permanent character during the course of severe chronic disease is a sign of bad omen. In connection with this subject I may mention that Dr.LeggC St. Bartholomew's Hospital Reports,' 1873) says that he found that after he had imitated the ef- fects of jaundice from obstruction by placing a ligature on the bile-duct, glucogen disappeared from the healthy liver of the animal operated upon ; and to this he adds the still more unaccountable observation, that irritation of the fourth cerebral ventricle (which under ordinary circumstances would have caused glycosuria) failed to produce any such effect. Theorising on these ob- servations, he says he thinks that in cases of jaundice from obstruction, sugar ought not to he found in the urine. Such a theory is in direct opposition to my own experiences in the human subject, as well as to those of Golowinin dogs (' Arch. Path. Anat. ' 1871, p. 428). To return to our patient. There was, indeed, but one consolatory fact in the last analysis, and that was the diminution of the uric acid, which, as I before remarked, tended, it was thought, to negative the idea of malignant disease of the liver ; and this was a great source of satisfaction to the patient and his friends, who had been alarmed by the opinion expressed by the first consultant. Eight days later (November 12) a qualitative am quantitative analysis of the urine was again madeJ with the following result : — CHEMISTRY IN AX OBSCURE CASE. 781 Twenty-four Houes' Urine. Quantity (33 oz.) Reaction . 102.:icc, . Acid Specific gravity Urea Uric acid . 1017 . 15-345 grammes ? Bile acids . None Bile pifrment . Sugar . Leucin and tyrosin Solids (tote Organic matter Inorganic ,, . Abundant . Increased jIn distmct, though i [ small quantity' only il) . 23-420 . 17-698 . 5-728 Here is now to be observed tbe rapid downward progress of the case. Stomachal digestion, as indi- cated by the amount of urea, is much impaired. The general health, as indicated by the sugar, is sadly affected, and, to crown all, tyrosin and leucin, the decided indicators of atrophy of the liver, have made their appearance. On precipitatmg the urine with the acetate of lead, filtering, and freeing the clear liquid from the excess of that reagent by means of sulphuretted hydrogen, and again filtering, in the liquid, after evaporation, was found a deposit of small crystals of tyrosin, while floating in and on its sur- face were round balls of leucin. This discovery of tyrosin and leucin in the urine was a most important one, from the fact that until it "^'as made on this occasion no one knew that these substances were to be met with in any form of liver atropliy except one, 782 DISEASES OF THE LIVER. namely, acute or yellow atrophy. So I naturally enough saw that my findmg both tyrosin and leucin in this case had a wide pathological significance, as it suggested not only that Frerichs's ideas of their pathology would possibly require considerable modi- fication, but that we should most probably meet with them under still more decidedly different patho- loo:ical conditions. An idea which has since been verified. So unfavourable was the result of this analysis considered, that Dr. Prance felt himself bound to fulfil a promise he had made to the family some time previously to warn them of approaching danger so soon as we had no longer hope of the patient's recovery. Some time afterwards, in the be2:innino; of December, we again saw the patient together, and made a physical examination of the liver, the result of which only confirmed our suspicions. The organ was already decidedly smaller. The epigastric tender- ness increased. The jaundiced tint deeper. Petechial i spots had now appeared on the trunk and arms. The f lower extremities were cedematous, and the abdomen two-thirds filled with fluid. On December 31 I received a sample of urine, and a note saying that the patient had slightly rallied. But on examining the urine, it was found to have a neutral reaction — it had previously been I CHEMISTRY IX AN OBSCUKE CASE. 783 acid — to be of a specific gravity of 1019, and, on standing, to deposit a copious sediment of lithates, coloured intensely yellow, not pink, with the bile- pigment. The sugar had increased. A few days later, and just before his death, the patient had the benefit of another physician's opinion. Dr. Bence Jones being asked to meet us in consulta- tion. Although his opinion entirely difi*ered from the foregoing, it was, nevertheless, equally unfavour- able, for he considered the case to be one of malig- nant disease of the liver, as it had been originally diagnosed. The gentleman, having noticed that his symptoms excited considerable interest and some difference of opinion among his medical attendants, directed that his body should be examined after death ; and as this wish was seconded by his wife, a lady of superior mind and accomplishments, a post-mortem exami- nation was accordingly made, with the following results. Morbid Anatomical Conditions in a case of Slow Obstructive Jaundice. First, — The orifice of the common bile-duct was completely obliterated (Plate I.,/, p.ll3),and the duct itself immensely distended with dark thick tarry bile, which on microscopic examination was found loaded with beautiful crystals of cholesterin, as represented 784 DISEASES OF THE LIVER. at fig. 14, p. 551. I have occasionally, though rarely, found crystals of pure cholesterin m the urine of hepatic cases, and although this at first surprised me, on account of cholesterin being insoluble in water, it does so no longer, seeing that crystals of it are met with in such a variety of circumstances, and in so many different situations. To wit, hepatic hydatid fluids, ovarian fluids, cystic fluids, pleuritic fluids, abscesses, tumours of the brain, as well as in atheromatous, fibrinous, and epithelial growths in various parts of the body. Secondly, — Both hepatic and cystic ducts were proportionally dilated, and equally full of the same tarry thick bile. Thirdly, — The liver was small in size, excessively dense, even hard to the touch, and very heavy. Externally, it had a dark green olive hue, and on section presented a most curious appearance. The cut surface of the section was of an almost uniform yellowish-green colour, and studded over with ex- y cavations (Plate I., b), from which thick tarry bile slowly streamed in all directions. The apparent excavations were nothing more or less than im- mensely distended ducts. On looking into the ducts it was observed that they presented all the appear- ance of possessing valves, and I satisfied myself that they actually did. On microscopical examination ^ the hepatic cells were found smaller than normal, as MORBID ANATOMICAL CONDITIONS. "785 if partially atrophied. The nuclei were unusually well marked, in consequence of fat-granules being almost entirely absent. (Fig. 23, a.) In the field of the microscope were a number of caudate or spindle- FiG. 23. a, Altered Hepatic Cells, b, Spindle-shaped Connective-tissue Cells. shaped cells (fig. 23, h) from the epithelial lining of the ducts. In the hepatic tissue were found some beautiful stellate crystals, as well as a number of separate needles of tyrosin. A few small crystals of cystin were also seen. While on the anatomical conditions in cases of per- manent obstruction to the outlet of the common bile- duct, I may as well here refer in general terms to |what is frequently observed to be the condition of the liver in cases of death arising fi'om long-impacted gall-stones, as they not only difi^er from the foregoing, but are in many respects even more characteristic of the effects of the backward pressure of the pent-up bile, and their perusal will perhaps give the reader a clearer idea of its true pathology. I may remind 3 E 786 DISEASES OF THE LIVER. him that the condition met with entirely depends on the duration of the obstruction ; for while it is enlarged, engorged with blood, and reddish yellow in the first, it is in the last stage small, shrunken, even atrophied sometimes to little more than one-third its natural dimensions, and of a deep black-green colour. The hepatic ducts again, while only visible in the first, are large dilated tubes in the last stage, sometimes with bulging extremities ; resembling cysts, as big as walnuts, full of thickened tarry-looking bile. Again, while the secreting cells seem to be in- creased both in size and in number in the first, they appear to be decreased in both respects in the last stage, and thus give rise to the appearance of the connective tissue being absolutely as well as relatively increased in quantity. Relatively increased I admit it must be ; but absolutely increased I am inclined from the results of my own observation to deny. Perhaps it may be so in some cases, but assuredly it is not so in all. Except at least in those where there is a marked hardened as well as a simply atrophied condition of the organ. Fourthly, — Thepatient's gall-bladder was enlarged to the size of a swan's egg, and choke-full of thick tarry viscid bile. Fifthly, — In the abdomen was a considerable quantity of dark yellow straw-coloured serum, which on the addition of strong sulphuric acid became of MOEBID ANATOMICAL CONDITIONS. 787 a fine emerald- green colonr, in consequence of tlie presence of bile -pigment. Traces of sugar were also present in this effused liquid. The serum had only collected in the latter weeks of the patient's life, and after a decided shrinkmg of the liver was observed to have begun. The gall-bladder, duodenum, abdo- minal parietes, and in fact all the abdominal viscera, were more or less intensely stained — some almost blackened — by the osmosed bile. Sixthly, — The pancreatic duct, as had been sus- pected from the result of the chemical examination of the fasces, was found to be as completely occluded at its outlet as the common bile-duct. Moreover, it was found so distended by the pent-up pancreatic secretion, as when empty readily to admit the little finger. Seventhly, — The kidneys were enlarged, pale, and fatty, as is represented in the chromolithograph, Plate II. p. 728. While all over the surface of the section, as well as immediately under the capsules, which were very loosely attached, were small abscesses. The surface was also studded with numerous dark bile-pigment pomts, and probably the abscesses were i the result of the blocking up of the capillary vessels { by the pigment deposit, as previously alluded to at ;•: page 733. Eighthly, — The head of the pancreas Avas con- : siderably enlarged, and on cutting into it, a quantity 3 E 2 788 DISEASES OF THE LIVER. of pus oozed out from an abscess in its interior. The abscess was fonnd to communicate with a large cicatrised ulcer in the duodenum, which in cica- trisine' had occluded both the orifice of the bile and pancreatic duct, and thus produced all the described signs and symptoms. (Plate L, /.) On micro- scopical examination, the tumour of the pancreas was found to consist of an hypertrophy of the normal gland tissue, being, in fact, a chronic inflammatory tumour of the gland substance. In no portion of the body was so much as a trace of cancer detected, nor any enlargement of the mesenteric or other glands, even to justify the remotest suspicion of the case being one of malignant disease. So the opinion arrived at regarding the pathology of this case is, that the disease originated in an inflammatory afl'ection of the pancreas ending in an abscess which opened into the intestines by ulceration, and during the progress of the cica- trisation of the ulcer, the openings of the bile and pancreatic ducts became blocked up. The interrup- tion to the excretion of the bile giving rise to the jaundice, and at the same time inducing engorgement and enlargement of the liver. The inflammatory affec- tion of the pancreas with its abscess, by pushing the enlarged liver forwards, admitted of the distended gall-bladder being readily seen, and felt through the abdominal parietes. At length the abscess burst, MORBID EFFECTS OF OBSTRUCTION. 789 and suddenly emptied itself into the duodenum ; the yellow fluid discharged from the intestmes being not pure bile, as the patient had supposed, but pus mixed with bile. Xo sooner had the abscess emptied itself, and the liver returned to its natural position, than the emptied gall-bladder suddenly ceased to be seen or felt. The ulcer in the duodenum appeared to be the spot at which the matter was discharged — in fact the mouth of the abscess. Once the occlusion of the orifice of the common bile-duct was complete, the slow and gradual atrophy of the liver would, arise from the continued pressure of the distended bile-ducts mterrupting the hepatic circulation. Lastly, there being no bile or pancreatic juice admitted into the intestines, the greater part of the food taken passed out of the body unabsorbed, and the patient, though possessing an excellent appetite, and taking plenty of food, actually died of slow starvation. The presence of bile acids in the urine in the earlier, and their disappearance from it in the later stages of the disease, are easily accounted for, on the natural hypothesis that as long as the hepatic cells were able to perform their functions they manufactured the acids ;. but as soon as their functions, in consequence of their compression, became abolished, the bile acids ceased, to be formed, and consequently none were found in: the urine. While it was quite another thing with, the bile-pigment ; for from its being formed in the- 790 DISEASES OF THE LIVER. circulation, and only excreted by the liver, its manu- facture went on unimpeded, and hence there was always abundance of it in the urine up till the time of the patient's death. Having before explained the mechanism of the two forms of jaundice — that arising from suppres- sion, and that induced by obstruction — it only re- mains for me here to remind my readers that there is frequently, as was no doubt in this case, a distinct progressive combination of these two conditions. For jaundice from obstruction cannot in any case long exist without becoming complicated with jaun- dice from suppression. The continued pressure exerted on the hepatic parenchyma by the over- distended bile-tubes sooner or later impedes the cir- culation in the organ, to an extent sufficient to induce an impairment, if not an almost total arrest, of the biliary secretion. Hence, as has just been said, is explained why, in the last stage of jaundice from obstruction, the biliary acids gradually diminish, and at last finally disappear from the urine. Fortunately, nevertheless, we have it still in our power to distin- guish, in the lifetime of the patient, between the two forms of disease. Thus, whereas, in jaundice arising from simple suppression, there is only an absence of the bile acids, in jaundice from obstruction, compH- cated with suppression, the absence of the bile acids is usually .associated with the presence of tyrosin and I MORBID EFFECTS OF OBSTRUCTION. 791 leucin. For before complete suppression occurs as a result of obstruction, the hepatic tissue has ah'eady had its nutrition so impaired as to admit of the abnormal formation of these foreign substances by the Kver itself. Lastly, the history of the case will of itself always be an additional important guide. My object in giving such prominence to this in- teresting case is to show clearly how valuable an adjunct physiological chemistry is to the other methods of diagnosis in obscure diseases of the abdominal organs, and to encourage others to follow in the same path. It must be remembered that the foregoing was no mere dead-house diagnosis, but that every fact here stated was discovered and recorded before the patient's death, so that the evidence it fur- nishes of the value of physiological chemistry in the diagnosis of obscure hepatic disease is undeniable. Analysis of the Bile taken from the Gall-Bladder. The bile taken from the gall-bladder was found on analysis to contain in one thousand parts : — Water 694-45 Q ,.^ (Organic 288-99 ) „^- -. Solids ^ ■ Tonn • ' ^^^'^^ (Inorganic lOoG j lOOU-00 Thereby showing a vast difference between it and normal bile — so great, indeed, that I obtained a speci- 792 DISEASES OF THE LIVER. men of what was considered to be normal bile from the gall-bladder of a woman aged 61 (the person nearest in age to the patient from whose body I could at the time obtain a specimen). It had a specific gravity of 1020, and contained in one thousand parts : — Water 933-27 Solids ]0^-g^°i« 56-73 I ^ _ gg.yg (Inorganic lO'OO j 1000-00 The difference in composition of the solids of these two biles is very striking. The one contains more than four times as much solid matter as the other ; and when the relative amounts of organic and in- organic substances are compared, the curious fact is observed, that the difference in the amount of solids in the two cases is almost entirely due to the change in quantity of organic matter. The inorganic salts have not even so much as doubled themselves in the abnormal bile, while the organic have increased five- fold. Soda is the chief inorganic substance found in bile, and occurs in it in the form of glycocholate and taurocholate of soda, both of which substances are re- absorbed from the distended ducts and o-all-bladder into the circulation, from whence they are eliminated with the urine. This fact is no doubt the cause of the inorganic salts being in such small quantity in the abnormal bile of jaundice from obstruction, as is ex- HEPATIC ALBUMINURIA. 793 ceedingly well shown in this case, a more typical than which in every single particular it has never been my lot to meet with. Hepatic Albuminuria. Before quitting the subject of the chemistry of the excretions, it may be as well for me to say a few words re2;ardino; a form of albuminuria which is a frequent concomitant of hepatic disease, and to call special attention to a simple means of differentiating renal from hepatic albuminuria, which will no doubt be found by the reader useful at the bedside. I know it has on more than one occasion enabled me to make a correct diagnosis where other phj^sicians of justly acknowledo-ed diamostic skill have fallen into error. Probably it may surprise even some accomplished urologists to be informed that the index alluded to is the very simple one of ' urinary specific gravity.' Strange to say, by paying special attention to that single factor alone, the practitioner may not only be enabled to arrive at a correct differential diagnosis, but, what is of even more importance in a professional point of view, probably be prevented from committing the unfortunate blunder of confounding the effect with the cause of the disease, and treating a healthy kidney instead of a diseased liver. As nothing is so impressive as personal narrative, I shall briefly relate a case which fully illustrates all 794 DISEASES OF THE LIVER. I have to say on the matter, even to its minutest details. A gentleman from Teignmouth, under the care oi the late Dr. Murchison in 1874 for albuminuria, in- stead of improving rapidly got worse, so Dr. Murchi- son called and asked me to see the patient along with him. It being, he thought, a very bad case of renal disease. The patient's history was briefly as follows : — He was a gentleman aged about 73, who had resided for thirty years or more in Australia, and always enjoyed good health until within the previous eighteen months. When, while living at Teignmouth, his health began to give way. The first thing he noticed wrong bemg that his feet swelled and his strength declined. After talking over the symptoms presented by the case, it was arranged that we should meet at the patient's house the same afternoon. On arrivino^ there I found the patient very ill in bed, but complaining more of prostration, with loss of appetite and sleep, than any- thing else. Before making a physical examination, Dr. Murchison called my attention to the urine, which he tested with heat and nitric acid, and showed me that it was loaded with albumen. In the urine standing in a glass upon the table was a urinometer, and glancing at it I observed that it indicated a specific gravity of 1022, and moreover that, though clear, the urine had a dark amber colour. This made me put the question, ' Is this an average specimen of HErATIC ALBUMINURIA. 795 the twenty-four hours' urine, or is it only the result of one micturition ? ' On learning that it was a sample taken from a mixture of the whole twenty- i four hours' urine, I at once said, ' This is not a case of kidney disease ! If, as you say, there is nothing wrong I with the man's heart, it is probably his liver that is I wrong.' Dr. Murchison, looking at me with an air I of surprise, said, ' What makes you think that ? ' I • replied, ' The specific gravity,' and, seeing that he did not grasp the import of the remark, I added, ' Let us examine the patient's liver.' We at once pro- ceeded to the bed-room and did so, and soon dis- covered that the liver was slightly enlarged, o| inches in the perpendicular nipple line, and tender on firm pressure, especially in the region of the gall-bladder. On being carefully questioned, the patient told us that for a long time past he had felt a dull undefined feel- ing of uneasiness with a sense of fulness in the right hypochondriac region. Adding that, from always having been accustomed to lie on that side, he had, for the sake of comfort, to turn shortly after getting into bed, and sleep on the left side. There was no jaundice, but the condition of the urine, coupled with the history of the case, led me to the diagnosis of ! scirrhus of the liver. I said scirrhus, for there was no distinct cancerous cachexia, or I should have said encephaloid. As soon as Dr. Murchison heard my I theory of the case, together with my explanation of 796 DISEASES OF THE LIVER. the cause of the albuminuria, he at once consented to alter his treatment from that of kidney to that ol liver disease, and requested me to prescribe for the patient in my own fashion. I accordingly did so, and gave him a cholagogue cathartic to unload the liver. The effect of which was marvellous. In three days the patient was able to get out of bed, and although to expect a cure was of course out of the question, the functional derangement of the kidne3^s so greatly improved, that the poor patient, as I was afterwards informed, for I did not see him again, began to think he was getting well. The liver disease, however, steadily increased, and within two weeks before his death (which occurred about ten weeks after I saw him) Dr. Murchison discovered a hard mass in the neighbourhood of the longitudinal fissure. Which, as he said, confirmed his suspicion that the view I had taken of the case two months previously was the correct one. Now, although the disease of the liver was too far advanced, at the time of our consultation, to admit of much amelioration by the change of treatment from the healthy kidney to the organ that was actually diseased, it nevertheless had the advantage of quickly relieving all the most distx*essmg symptoms, and at the same time, I have little doubt, enabling Dr. Murchison to keep the patient alive for as many weeks as he would probably have done for days, HEPATIC ALBUMINURIA. 797 had there not been a prom^^t change in the treat- ment. It may be as well for the benefit of others for me to mention that one, and that too perhaps the chief, reason wliy Dr. Murchison was so completely mis- led by the condition of the urine in this case was, as he himself said, on account of his finding granu- lar renal tube casts in the urine, and being unaware that tube casts are quite common even in genuine cases of hepatic albuminuria. Indeed I may mention that granular renal tube casts are not only present (as I have already shown at p. 380) in hepatic ha3ma- turia, but even in many cases of simply hepatic albuminuria, where there is scarcely more than a trace of albumen to be detected by heat and nitric acid. I have met with both hyaline and granular tube casts (fig. 24). Nothnagel (' Deutsches Arcliiv flu- Klin. Med.' Oct. 1873) thinks that renal tube casts always exist in the urine of jaundice when the bile acids are eliminated b}^ the kidneys. Though the majority of the tube casts are of a j granular and sometimes of a hyaline character, they i often contain small yellow glistening granules in I their interior, and are accompanied by true ej^ithelial : renal casts, which are also occasionally stained yellow by the bile-pigment. This is no more than ought to be expected, seeing that the renal cells in the tubuli uriniferi have the elimination of the bile- 798 DISEASES OF THE LIVER. pigment tlirust upon them in every case of jaundice. No matter whether it be one arising from suppression or from obstruction. But tube casts are no doubt Fig. 24. 1, Hyaline ; 2 and 3, Granular Renal Tube Casts. most common in the obstructive forms of jaundice ; that is to say in those cases where bile acids appear in the urine, as Nothnagel observed, but probably not for the precise reasons he gives. Dr. George Johnson, in his ' Lectures on Bright's Disease,' gives it also as his opinion that desquamated epithelium tube casts appear in the urine in cases of obstructive jaundice from the excess of biliary matter eliminated by the kidneys being so irritative to them as to engender a mild form of nephritis. An idea which I think is a highly probable one. For, as is shown by the lithographed kidney in Plate II. at page 728, the I HEPATIC ALBUMINUKIA. 799 continual elimination of bile products along Avith the urine gives rise not only to an inflamed, but even sometimes to a suppurative condition of the organ. Having thus shown how all-important is the factor of urinary specific gravity in making a differential diagnosis between cases of renal and hepatic albu- minuria with and without jaundice, I shall close my remarks on the chemistry of the excretions, and proceed to the second department of diseases of the liver. Namely, the consideration of those not necessarily associated with jaundice. But before doing so, as I think that I have not only redeemed the promise I made, in the Introduction, of addu- cing evidence to show how valuable an adjunct physiological chemistry is in the diagnosis and treat- ment of obscure diseases of the liver, but also given a clear, I hope, though succinct account of all the hepatic affections with which jaundice is of necessity associated, it may be well for me now to place before the reader my views of the pathology of jaundice in a talmlar form. With but very trifling alterations the table I am about to give is the identical one I pub- lished in my work on Jaundice twenty years ago ; and as Dr. Murchison did me the honour to reproduce it in his book on 'Diseases of the Liver,' published in 1 1874, almost verbatim, though setting it up in para- i graphs, instead of, as I did, in a tabular form, witli- 1 out mentioning my name in connection with it, I am reluctantly compelled, in mere self-defence, for fear of 800 DISEASES OF THE LIVEPw being suspected of plagiarism by those wlio never saw my original monograph on ' Jaundice '—a book which has for many long years been out of print — to draw attention to the fact that my synoptical patho- logical table of jaundice was published eleven years before it was reproduced by Dr. Murchison. Per- haps, and not at all unlikely, some of my reader.^, not versed in the pathological history of jaundice, may regard this as quite an uncalled-for piece of re- clamation, from their being ignorant of the fact that at the time I drew up the table the whole sub- ject of the pathology of jaundice was nothing more than an unintelligible chaotic mass of theoretical pathological confusion. So that, although the syn- optical table may now appear very simple on paper, it was in reality the product of long and deep clinical and pathological study. And just as it is said that Columbus was nearly as proud of having been the first to perform the feat of making an egg stand upon its end (which seems such a trifling matter when we know how to do it), as he was to be considered the discoverer of America, I think that I, in my gmall way, may be pardoned for feeling anxious to have the correct parentage assigned to my own mental off- spring. It being a well-known fact that literary men are, as a rule, as reluctant to lose the credit of the product of their brains as mechanicians are to lose the produce of their hands. PATHOLOGY OF JAUNDICE. 801 Tabular View of the Pathology of Jaundice, according to the Author's Views. r Fright Anxiety Enervation . . . . ^ Sudden J03' j Over Mental Exertion (_ Concussion of Brain ' Hepatitis from Direct Vio- lence Indigestion Ague Typhus r Active -^ J-^P^i^ bcarlatma Pyaemia Yellow Fever Poison, such as that of Snakes, Phosphorus, Cop- per, &c, / Heart-Disease Pneumonia I. Passive J Pleurisy Imperfect Respiration in the Newborn From Suppression Jaundice Congestion of Liver ' Absence of Secreting Substance ' Congenital Deficiency of Ducts Accidental Obstruction in Course of Duct From Obstruction -1 Closure of Duct 3f f Cancer Cirrhosis J Fatty Degeneration J Amyloid do. [^^-P'^>'{chronic Small Ducts (V) Hepatic Duct Common Duct ' Inspissated Bile Gall-stones Hydatids, and other Forms i of Entozoa I Foreign Bodies from In- L testines ■ Stricture Catarrh Pressure of Pregnant Uterus Tumours of the Liver and Gall-bladder, Stomach, Ovaries, and Intestines Impacted Faces in Trans- verse Colon Organic Disease of Pan- creas, or of neighbouring Glandular or other Or- gans Abscess in Head of Pancreas Cicatrised Ulcer of Duode- num 802 DISEASES OF THE LIVER. The annexed table has the advantage of placing before the reader all the causes of jaundice, as dealt with in the text, in so sharply defined a manner as to render its teachmgs devoid of all possible traces of ambiguity, so that it requires from me no explanatory remarks for its easy comprehension by any one who has carefully perused the preceding chapters. We now come to the consideration of a class of Diseases of the Liver not necessarily associated with Jaundice. This is a much wider and more important branch •of our subject than is commonly supposed. For under the above heading are not alone included a great variety of widely differing pathological condi- tions of the hepatic tissues ; but at the same time ■embraced within this heading's area are several of the most formidable as well as a few of the most benign of liver affections. It includes, for example, abscess, cancer, hydatids, cysts, sy[3hilitic, fibroid, fatty, amy- loid, and several other less common forms of hepatic tissue degeneration and adventitious tissue growths. Each one of the above-named forms of hepatic disease will now be separately considered. 803 CHAPTER XVII. ABSCESS OF THE LITER. On clinical grounds the subject of hepatic abscess requires to be subdivided into three distinct parts, and each considered separately, notwithstanding that their symptomatology, as well as their pathology, is nearly identical. The subdivisions I make are : — 1. Idiopathic Hepatic Abscesses (Of tropical and of temperate zones). 2. Traumatic „ „ 3. Metastatic „ „ (Includiug the pvsemic variety). Suppuration of the liver may occur from a great variety of exciting causes, in any country or climate, as well as at any period of life, between early infancy and advanced as^e. The Etiology of Hepatic Abscesses. Until a few years ago it was, indeed I might almost say that it still is, a prevalent notion that all idiopathic abscesses of the liver are, par exccUoice, indigenous fonns of tropical disease, and that rarely, if ever, is an idiopathic hepatic abscess to be met 3 F 2 804 DISEASES OF THE LIVER. with in temperate climates, except among persons who have previously resided in the tropics. This was the notion I imbibed from my teachers as well as from my text-books, and as a natural consequence it was the one with which I started on my medical career, and one too from which, I candidly admit, I found it hard to emancipate myself. So that I am not in the smallest degree surprised at finding the majority of medical men, with whom I come in con- tact about liver cases, still entertain the idea that abscess of the liver is par excellence, I might even say, a purely tropical disease. Education and experience have taught me not alone to regard this opinion as an erroneous one, but likewise to regard the very name of ' idiopathic/ when applied to any form whatever of abscess of the liver, as being a most objectionable distinguishing title, from the simple fact that it conveys to the mind a false idea of the etiology of the suppuration. The term ' idiopathic,' being supposed to denote that the disease to which it is prefixed arises without any known exciting cause, is quite inapplicable to suppu- ration of the liver ; for, as I shall presently, I hope, be in a position to show, every form of hepatic abscess is invariably preceded by a recognisable ex- citing cause. The cause being, in most cases, not only apparent to the medical attendant (who knows how to discern it) during the lifetime of the patient, I IDIOPATHIC ABSCESSES. 805 but demonstrable and tangible at the autopsy. Hence the prefix of ' idiopathic ' to an abscess of the liver is, logically speaking, a misnomer. Unfortunately, however, as a distinguishing title is required for the purpose of lucid exposition, and the term 'idio- pathic abscess ' is already in general use, I feel that it will be better for me to continue its employment than to fabricate a new name ; for of different names for the same diseases we have already, alas ! a super- abundance. It is, however, the name only, and nothing more, that I shall retain, for I shall do my very utmost to assist in demolishing what I consider is both a false and a pernicious clinical theory regard- ing its nature, namely, the belief that an abscess en- gendered in the liver of a European residing in a tropical country differs in any way whatever from a similar kind of abscess occurring in the liver of an inhabitant of a temperate zone. At the very outset, therefore, I shall advance the proposition that all the varied forms of hepatic abscesses, and most assuredly they are many, have an absolutely identical pathology, no matter in what part of the globe they occur, and that for all clinical purposes they may be both logi- cally and scientifically embodied in two classes — primary and secondary hepatic abscesses : — 1st, Abscesses essentially primarily local, includ- ing the two forms of idiopathic and traumatic. 2nd, Abscesses essentially secondary, including 806 DISEASES OF THE LIVER. the two forms respective!}'' named metastatic and py^emic. For clinical purposes it matters not one iota how or in what order these classes of hepatic abscess are considered ; for every abscess of the liver is nothing but an abscess, whether it be idiopathic, traumatic, metastatic, or pyremic, in so far as its morbid anatomy is concerned. So I shall first give the general symptoms of hepatic abscesses, and then allude to the defining characteristics of each kind separately. To begin with, I must state most emphatically that no form of abscess whatever is necessarily asso- ciated with jaundice, and that when jaundice accom- panies suppuration of the liver it is the direct result of hepatitis, or of some accidental form of occlusion of the hepatic or common bile-ducts, either produced by the presence of the abscess itself, or by the co- existence of other disease. In the next place I think I may equally emphatically state, although it is directly contrary to accepted notions, that no tropical abscess of the liver ever originates spontaneously, but on the contrary, like the hepatic abscesses of temperate zones (when carefully investigated), is found to be the mere sequel or concomitant of some other form of disease in the liver or some other organ of the body. That is to say, of hepatitis, either of the malarial or idiopathic varieties, impacted I SO-CALLED TROPICAL ABSCESSES. 807 inspissated bile or gall-stones, dysenteric or any other form of intestinal suppurations, or even suppu- rations in parts of the body distant from and uncon- nected with the liver. All of these exciting causes will be considered in their appropriate places. Mean- while I may remark that the exciting cause of idiopathic, or so-called tropical, hepatic abscess has long been, and still is, a fearful pathological bone of contention, not so much, however, among scientific pathologists as among clinical physicians ; and although to give the j^^^os and cons of both sides (or I should rather say of all sides, for there are several) of the question would be a most profitless waste of time and energy, I must not entirely slip over the subject, for it has important diagnostic and thera- peutical bearings, which merit special attention. I will therefore proceed to say a few more words on the subject, in so far as it concerns practice. At the outset I may remark that if, to begin with, we accept it as a pathological aphorism that of the multitudinous and varied exciting causes, hepa- titis is the most common producer of hepatic abscess, it is easy to understand why an abscess of the liver is more frequently met with among Europeans resi- dent in the tropics than in the same class of indi- viduals residing at home, without fostering the idea that its pathology has anything peculiar or specific about it, at least sufiiciently so to render it desirable 808 DISEASES OF THE LIVER. to distLDguish it by a special name from abscesses of the liver encountered in temperate zones. To the honour of Dr. George Budd be it said, he was the first to call attention to the fallacy of imagining that abscesses of the liver differ from each other accord- ing to climate. He clearly showed that, both as re- gards its clinical history and pathology, an abscess of the liver is exactly the same in a temperate as in a tropical climate, and that the tropical and the tempe- rate abscesses differ in no respect whatever, except as regards their relative frequency. In fact, I go so far as to believe that idiopathic abscess of the liver is limited to no terrestrial zone whatever, being equally indigenous in all latitudes, and that its pathology is exactly the same at the torrid equator as at the frigid North Pole. Having said thus much on the world- wide indigenous distribution of hepatic abscesses, I wil- lingly admit that they are much more common among natives of temperate climates living in the tropics than elsewhere. But this again, I believe, does not arise so much from the hot temperature of the climate as from the mode of life pursued by Europeans while living in tropical countries. I arrive at this conclu- sion chiefly from the fact that the natives of hot climates, whose mode of life is entirely different from that of the Europeans living amongst them, are not one whit more liable to be affected with abscesses of the liver than Englishmen residing in Great Britain. SO-CALLED TROPICAL ABSCESSES. 809 Moreover, the twenty years' experience I have had in the treatment of cases of abscess that have originated in patients while living in the East, as well as of cases of precisel}' the same nature which have occurred in Englishmen who have never put their feet beyond the confines of the British shores, enables me to say emphatically that the chief exciting causes of hepatic abscesses are gluttony and intem- perance, which, in proportion to the habits of life, are far more common in Europeans living in the tropics than in the same class of individuals resident in tempe- rate zones, as I have already pointed out at page 242. It is to be remembered that the words 'intem- perance ' and ' gluttony ' are here employed as rela- tive terms, ruled and modified by collateral circum- stances, as will presently be explained. Meanwhile, as bearmg forcibly on this question, I may cite a case which goes far to prove that an idiopathic abscess of the liver may occur from what might be thought to be very insufficient causes, even in a temperate zone. The case I allude to is one entitled ' Lobular Hepatitis terminating in Extensive Suppuration,' and is recorded in the ' Pathological Transactions ' (vol. iv. p. 171) as occurring in a woman 20 years of age, who died four months after its onset, and who had never been out of England, in whom the only exciting cause seemed to be the living in a close hot room in a damp situation. 810 DISEASES OF THE LIVEK. In case the reader may think that this is not a sufficiently telling example of so-called tropical disease originating in a temperate zone, I shall present him with another more striking example in the shape of an hepatic abscess associated, as in India, with a true dysentery. And it is all the more remarkable, seeing that not only both affections occurred at the same time in the same patient, living in a temperate zone, but that the patient was a mere child. The case was brought before the Pathological Society on January 18, 1881. It is briefly as follows : — ' Dr. Xorman Moore showed a specimen of abscess of the liver following dysentery in a child aged 3^, who was admitted into St. Bartholomew's Hospital suffering from diarrhoea and pains in the abdomen, accompanied by high temperature. Post mortem., the whole large intestine, including the rectum, showed extensive patches of ulceration. In the right lobe of the liver was an abscess as large as an orange, which had pene- trated the diaphragm, and opened into the right lung. There was a second abscess in the left lobe. The child had never been out of London.' In citing these cases I do not desire it for a single moment to be supposed that I ignore the fact that by far the majority of idiopathic hepatic abscesses met with in England occur in individuals who have during some period of their lives been resi- dent in tropical climates. For my own experience,^ IDIOPATHIC ABSCESSES. 811 as well as information obtained from a variety of other sources, has satisfied me that idiopathic hepatic abscess is by no means a very common indigenous disease in England. Indeed, the records of the 'post- mortems performed in our public hospitals in a mea- sure prove this. For example, in the statistics given by Dr. Norman Moore of the results of the autopsies made at St. I^artholomew's Hospital, it is stated that out of a total of 2,464 examinations, there were only twenty cases of abscess of the liver. That is to say, less than 1 per cent. An mteresting fact, too, is that the situation of the abscesses in these indigenous cases is almost identical with what it is in the case of Europeans resident in the tropics. Eleven abscesses having been found in the right, one in the left, and nine in both right and left lobes of the liver. Although statistics of this kind cannot be gain- sayed — as far as they go — I dare not venture to say that they correctly represent the relative proportion of hepatic abscesses occurring in England. For my own experience tells me that, at least among the better classes, abscesses of the liver are far more common than here represented. Of which class, of course, hospital statistics take no cognisance, and con- sequently their data cannot be regarded as furnish- ing reliable statistics of the relative proportion of abscesses of the liver to other forms of fatal disease occurring among all classes of the community. I 812 DISEASES OF THE LIVER. am no less conscious, however, that generalisations founded upon data furnished by private practice would be equally misleading. More especially in cases like my own, where, from the simple fact of my havmg made the subject of liver diseases a spe- cial study, hosts of cases are drifted, as it were, into my net, which under other circumstances I should never so much as even hear of Consequently the numbers I come into personal contact with in no way represent the relative frequency of cases of hepatic abscess occurring among the general popu- lation. But even when all this is taken into account I still opine that indigenous abscess of the liver is a far more common disease than our hospital statistics would lead us to imagine ; and the reason of this is, I think, not far to seek, seeing that not only the modes of life pursued by the upper and lower classes in England are entirely different, but their forms of diet are even more different still. And, as I shall now proceed to show, these are the two most essential elements everywhere at work — in temperate as well as tropical climates — as the exciting causes of abscess of the liver. To begin with, I may allude to the not unim- portant fact in connection with the solution of the question, that not only in the tropics, but every- where else, it is found that hepatic abscesses are much more common among men than among women ; I ETIOLOGY OF SO-CALLED TROPICAL ABSCESSES. 813 and the reason of this, I believe, is easily explained when we consider the marked difference in their modes of eating and drinking. More especially in the tropics, where the whole of their surroundings may be regarded as abnormal. Consequently, when the functions of the liver (pointed out in the physio- logical chapter, page 65, more especially that which I have spoken of under the head of the calorifying one) are taken into consideration, one cannot feel in the slightest degree surprised that the liver should be not only the first organ of the body to rebel, but the first to give way and entirely break down under the pressure of adverse circumstances. (a) An increase of external temperature arrests, to a certain extent, the normal hepatic calorifying process ; for while external cold increases, external heat proportionally diminishes it. (b) The climatic- ally enforced indolent habits of its proprietors in the tropics, in comparison with their accustomed muscu- lar activity at home, reduces still further the neces- sity for the exercise of the liver's normal functions. (c) Notwithstanding that its calorifying functions are reduced, the organ is still supplied, as a rule, with the same amount of highly heat-making nutri- tive foods and drinks. That is to say, foods and drinks rich in hydrocarbons. While again, partly from the increase of external temperature, and partly from the enforced indolent habits of its proprietors. 814 DISEASES OF THE LIVER. the hepatic cells not being called upon to consume the hydrocarbons in the normal manner, and yet being forced to get rid of them, have a great amount not only of unaccustomed, but detrimental, labour thrown upon them, in consequence of which they strike work, and at length completely break down. First, the hepatic tissues become congested; secondly, they become inflamed ; and thirdly, they suppurate. This theory is strongly supported by the well- known fact that the natives of the tropics, who, rela- tively to their surroundings, live quite as regularly and judiciously as the majority of the natives of tem- perate zones in their own countries do, manifest no greater tendency to hepatic abscesses while living in their tropical homes than the inhabitants of tempe- rate zones do while living in their cooler climates. It appears to me, then, to be quite as ridiculous to speak of the pathology of a tropical hepatic abscess as a thing specially tropical, as it would be to speak cf a tropical sunstroke as being something specifically different in its pathology from a case of sunstroke occurring in Hyde Park. Or even a case of frost-bite occurring in Camden Town (as it did a few years ago) as being different in its morbid anatomical re- lations from a similar case of frost-bite occurring in Iceland. In fact I believe that an abscess of the liver, exactly like a sunstroke, is precisely the same SYMPTOMATOLOGY OF HEPATIC ABSCESS. 815 in every respect when it occurs in temperate Eng- land as in tropical India, except as regards its rela- tive frequency. I shall now, therefore, proceed to consider the symptomatology of hepatic abscesses collectively. General Symptoms common to all Forms of Hepatic Abscesses. It may be as well for me, before entering upon the consideration of the symptoms, to remind the reader that the diagnosis of hepatic abscess in the majority of cases is no easy matter, and the reason of this is not far to seek. For, in the first place, there is no well-defined class of symj^toms which distinctly point out the affection ; in the second, the signs of suppuration of the tissues of the liver are exceedingly indefinite ; while, in the third place, the clinical history of hepatic abscesses is in the majority of instances obscure. What adds most to the difficulties of the dia- gnosis is the fact that pain, so usually characteristic of suppurations occurring elsewhere, is a symptom of no pathognomonic importance whatever in a case of abscess of the liver, from the fact that not only may there be great pain with only slight hepatic inflammation, but scarcely any pain with consider- able suppuration. While again, the amount of pain induced by an abscess of the liver depends mucli 816 DISEASES OF THE LIVER. more on the seat than on the extent of the suppu- ration, a small superficial abscess being invariably more painful than a large deep-seated one. Moreover, additional difficulty is thrown in the way of diagnosis by the fact that the abscess is in general so circumscribed that there is not sufficient hepatic tissue affected to give rise to anything ap- proaching to a suppression of the biliary function ; so that there is often neither a yeUow skin, pipe- clay-coloured stools, nor saffron- tinted. urine to assist us. In fact, beyond a mere icteric tint of the com- plexion and conjunctivae, with febrile symptoms and hepatic malaise, there may be no physical signs to guide one to the liver ; for in many cases there is not even the slightest enlargement of the organ detectible. I may further mention that the rigidity of the right rectus muscle (which has been vaunted as a pathognomonic sign), though exceedingly useful when it is present, is unfortunately when absent of no negative importance whatever. The justness of the preceding remarks is amply verified by the well-known fact that it is no un- common thing even in the tropics to find an abscess in the liver of Europeans who have died from the effects of some non-hepatic form of disease, during whose lifetime the existence of suppuration of the liver was never so much as suspected. To SIGNS OF HEPATIC SUPPUEATION. 817 these cases has been given the name of ' Latent Hepatic Abscesses,' from, its being supposed that (as pus once formed in the liver is never absorbed?) they may have existed for years, having probably origi- nated at a time when, from the mildness of the symptoms, only hepatitis had been suspected. With these general remarks I shall now point out the special signs and symptoms which are usu- ally considered as evidence of suppuration in the liver. After the ordinary signs and symptoms of hepa- titis have been present for some days, the patient suddenly complains of chilliness, rapidly developing into a distinct rigor, which in its turn is speedily followed by an aggravation of all the local signs and general symptoms of hepatitis. The occurrence of the rigor in the course of a hepatitis, though the most reliable sign to go upon, is not, however, an infallible one, from the simple fact that rigors occur in other forms of painful liver disease. Gall- stones, inspissated bile, and entozoa impacted in the ducts, for example, cause rigors, and that, too, unfortunately, occasionally without inducing jaun- dice. However, when rigors occur in the course of hepatitis without much pain, and they are im- mediately followed by an increase of constitutional disturbance, the pulse becoming more frequent and hard, the skin hotter and drier, the tongue more 3 G 818 DISEASES OE THE LIVER. foul, the appetite entirely lost, and great thirst complained of, the uneasiness in the region of the liver being at the same time increased, the tender- ness on firm pressure becoming more acute, deep inspiration, sneezing, or coughing causing sharp pain, and lying on the right side being almost next to impossible, suppuration may be diagnosed. Occasionally, though not often, suppuration of the liver is accompanied by both vomiting and purging ; but neither of these can be regarded as a diagnostic sign. Sometimes the formation of puru- lent matter is exceedingly insidious in its course, and the signs and symptoms of its occurrence are so slightly marked as to altogether escape the notice of the medical attendant. This is more particularly the case when the suppuration follows in the wake of some well-marked form of chronic hepatic disease, such as impacted inspissated bile, gall-stones, or any of the other liver derangements which induce some one of the multitudinous forms of jaundice. In those cases even where there are but slight hepa- tic pain, little malaise, and only trifling febricula, the supervention of rigors (without any other ap- parent assignable cause) ought always to raise the suspicion of the occurrence of suppuration. I must here call particular attention to what is designated the red raw-flesh looking tongue, which some writers have gone so far as to say is a patho- SIGNS OF HEPATIC SUPPURATION. 819 gnomonic sign of abscess of the liver. This is un- doubtedly a mistake ; for not only is a raw-flesh looking tongue to be met with in other forms of hepatic disease besides suppuration, even in hepatic diabetes for example, but it is not unfrequently met with in severe forms of gastric derangement quite unconnected with liver disease. As an addition to our slender means of diagnosis I may mention that in a clinical lecture, published by Deputy Surgeon- General Dr. Furnell (' Indian Med. Gazette,' January 1881), on Abscess of the Liver, he says that he believes that the thermometer fur- nishes the only reliable guide to diagnosis. But un- fortunately the evidence he adduces in support of this opinion can scarcely be said to bear it out ; for all that it in reality proves is that the variations of the temperature in cases of abscess of the liver resemble those usually met with in cases of chronic phthisis. My own observations lead me to put down the average temperature at between 102° and 105° Fahr. Seeing that the diagnosis of hepatic abscess is so perplexing, it may perhaps be as well for me to tabulate the signs and symptoms upon which I myself put most reliance when investigating a doubtful case. They are the following : — 1. The fact of the rigors occurring without any other assignable cause, and being unassociated with paroxysmal pain. For if the pain is paroxysmal it 3 G 2 820 DISEASES OF THE LIVER. indicates that the rigors are due to impacted biliary concretions, entozoa, or some other obstructive cause. 2. The co-existence of fever with hectic exacerba- tions, assuming more of a typhoid than of an aguish character. 3. Intense prostration of strength, associated with gastric derangement. 4. The antecedent existence of some one or other of the many possible exciting causes of hepatic abs- cess, such as dysentery, biliary concretions, intestinal ulcers, suppurating wounds, either external or inter- nal, even a gonorrhoea, or having swallowed a fish- bone or a pin (see illustrative cases further on). 5. Abscess of the hver is often associated with one or more abscesses in other organs of the body. Even an abscess in the brain, as well as in the spleen, having been found in the same patient associated with an abscess of the liver (vide a case reported by Dr. Moxon in the Pathological Society's ' Transac- tions,' 1868). 6. An abscess may even exist in a cirrhosed liver, and that, too, along with well-marked jaundice. The abscess in such a case is usually of small size, not bigger than a walnut, or at most an orange, and is in general the result of metastasis. 7. When there is enlargement of the liver, it ceases to be uniform so soon as sufficient matter has formed to cause a bulging of its tissues ; and when the abscess SIGNS OF HEPATIC ABSCESS. 821 is situated at its lower surfiice, or when it projects from under the false ribs, it can usually be detected with the fingers as a tense, smooth, tender globular tumour, with a feeling of more or less distinct fluctua- tion about it. 8. When the abscess is small, and even, I may- say, when tolerably large, if seated within the margin of the ribs, palpation furnishes no signs whatever of its existence. For even on the application of firm pressure no pain, beyond perhaps a feeling of diffused uneasiness, is complained of. 9. When the peri-hepatitis which accompanies an abscess of the liver is acute, and aggravated during deep inspiration, it is apt to be mistaken for pleurisy, and all the more likely so in inexperienced hands, when, on the application of the stethoscope, an he- patic finction sound is audible, which is of general occurrence in such cases. 10. A superficial suppurating hydatid is not un- likely to be taken for a case of idiopathic abscess ; but when this mistake occurs it is of no moment, for the suppurating hydatid assumes, at least for the time being, aU the characteristics and effects of an ordinary hepatic abscess, and therefore demands the same line of treatment. A precisely similar remark may be made regarding a suppurating gall-bladder, which has more than once been mistaken for an hepatic abscess bulging downwards from the liver. 822 DISEASES OF THE LIVER. 11. The more superficial an hepatic abscess is, the more decided and acute is the pain which it causes. Hence, whenever a change in the character of the pain takes place in the course of a correctly diagnosed abscess — the dull subacute suddenly changing to a sharp acute pain — it may be regarded as a trust- worthy indication that the matter is pointing at some part or another towards the surface of the liver, and consequently be looked upon as a favourable symptom. For in any case it at least renders it highly probable that the exact situation of the pointing part will sooner or later become manifest, and thereby the operation of tapping be made comparatively easy and danfjerless. 12. Occasionally the diagnosis of hepatic abscess is simple in consequence of the formation of pus rapidly supervening upon the rigors, the collection almost at once pointing at the lower edge of the false ribs, and making its presence visibly apparent to the eye. Under these circumstances the sooner surgical aid is had recourse to, in the majority of instances, the better are the chances of the patient's recovery. 13. Abscesses of the liver often burst sponta- neously, evacuating themselves sometimes into the pleural cavity, sometimes into the pericardium, some- times into the peritoneum, sometimes into the intes- tines, sometimes into the pelvis of the kidney, and] sometimes, though rarely, externally. The rupturoj SPONTANEOUS EUPTUEING OF ABSCESSES. 823 of the abscess into the intestinal canal is its most favourable mode of bursting, yet it seems to be at the same time almost the rarest course it pursues ; for on combining the statistics of Waring and Morehead on hepatic abscesses of the tropics, I find that out of a grand total of 424 patients only twelve cases are mentioned in which the abscess burst into the diges- tive canal. 14. It is well to bear in mind that an abscess may burst into a blood-vessel and prove suddenly fatal. Also that an aneurism of the hepatic artery has been found occupying the cavity of an hepatic abscess. While a still more extraordinary case has been re- corded by Dr. Pearson Irving, where an hepatic abscess perforated its way into the stomach, and carried along with it an aneurism of the hepatic artery. (' Path. Soc. Trans.' vol. xxix. p. 128.) 15. When the abscess bursts into the pericardium, it is, as might be expected, rapidly fatal. A typical ease of this kind occurred in a man aged 29, who died in the City of London Hospital for Diseases of the Chest, under Dr. Bentley's care. At the autopsy the pericardium was found to be enormously dis- tended, containing no less than half a gallon of sero- purulent fluid, and communicating with a very large abscess in the left lobe of the liver. The liver itself extending to the umbilicus. 16. Occasionally, though very rarely, an hepatic 824 DISEASES or the l:ver. abscess bursts at different times in two totally diffe- rent directions. I sball presently relate a case of this kind which fell under my own observation, where the abscess burst first into the intestines, and the opening healed up, and some months afterwards burst into the lung and rapidly killed the patient by suffocation. 17. The last, though certainly not the least im- portant, adjunct which we have at our disposal in settling the question of the presence or absence of pus' in a doubtful case, is the exploring needle. An in- strument, in my opinion, far too little used as an aid to diagnosis in liver cases, from the mistaken notion that its employment maybe attended with disagreeable consequences. For it is a strange fact that a diseased liver may be punctured in more than half a dozen places, not only without detriment, but with actual benefit. In proof that this is no exaggerated state- ment, I have simply to refer to the letter published in the Lancet of August 8, 1863, by Deputy Inspector- General Dr. J. C. Cameron, in which it is recorded that an enlarged liver resumed its natural size after having been freely punctured in the vain search for an abscess, not a drop of purulent matter having been anywhere found. Before I proceed to cite cases illustrative of the value and importance of the preceding remarks, I shall add a few words on DIFFERENTIAL DIAGNOSIS OF ABSCESSES. 825 The Diflferential Diagnosis of Hepatic Abscesses. As regards the distinguishing features of the different kinds of abscess of the liver, it is to be specially noted that while the idiopathic and traumatic forms of suppuration are usually single, circumscribed, and of large size, those of metastatic and py^emic origin are in general not only of small size, but multiple in number. An idiopathic hepatic abscess is usually deep-seated in the tissues of the right lobe of the liver, though occasionally it is superficial, in which case it is in general situated in the diaphrag- matic surface of the organ. Having said that the idiopathic and traumatic abscesses are usually of large size, and the metastatic and pyaemic forms only of small dimensions, I may as well add that while the latter rarely exceed the size of an orange, those of the former variety are sometimes capacious enough to contain more than a gallon of purulent matter. Indeed cases have been met with where the whole of the liver has been transformed into a single great suppurating mass, its capsule merely acting the part of a containing sac to the purulent contents. A curious case is related by Flint, in his ' Practice of Medicine,' where, in spite of the whole of the right lobe being transformed into a purulent sac, from which after death no less than two and a quarter gallons of 826 DISEASES OF THE LIVER. pus were removed by Dr. Rothrop, the left lobe con- tained no purulent matter whatever. All idiopathic abscesses, even those of true tropi- cal orio'in, are not laro-e. Some have been found not bigger than a walnut, and, unless they have been superficial and pouited externally, their existence has only been discovered after death. Indeed the only symptoms of small and deep-seated abscesses may be an mdefinite liver pain, slight febricula, and a trifling chill or rigor or two. The following are illustrative cases, and to begin with I shall cite a most remarkable one both as re- gards its duration and clinical history, as it is not only an excellent example of an idiopathic abscess in a London resident, but shows that the matter may be spontaneously discharged in two different ways at different times. First, by bursting in the most salutary way into the intestinal canal, and the open- ing healing up, and months afterwards bursting into the lung and proving rapidly fatal. The case is briefly as follows : — A City merchant, of middle age, when first brought to me by his medical attendant (Mr. Cresswell), com- plained of hepatic paui, feverishness, biliousness, and sickness. The symptoms being so decided, and there beino^ no distinct evidence of enlargement of the liver, the case was diagnosed as one of hepatitia tending to suppuration, and was prescribed for ac<^ CASES OF HEPATIC ABSCESS. 827 cordingiy. After a few weeks' energetic treatment the patient got well, and I saw nothing more of him for about two years, when he returned to me with a note from Mr. Cresswell asking me to examine, prescribe, and report. This second attack was dia- gnosed as one of subacute hepatitis, and prescribed for accordingly. Hot fomentations, local blisters, and mild mercurials. He again got apparently quite ! well, and I heard nothing further of the case for I nearly two years, that is to say four years after the j suspicion of suppuration had arisen. He was now in London, having taken lodgings by Mr. Cress- well's advice, in order to be under my immediate care. On examination the liver was found to be ; excessively tender to pressure. Percussion he could I scarcely bear ; but by careful manipulation the organ j was ascertained to have a dull area of six inches in i the perpendicular line, and to extend beyond the left margin of the xiphoid cartilage. The skin was sal- 'low, hot and dry, with an afternoon temperature of 102 "6° Fahr. The tongue intensely furred. The urine scanty, high-coloured, and turbid with urates. He had night hectic, and complained of having for -I veral days (ten or more) had occasional shiverings. This train of signs and symptoms, with the history subsided, and after a fourth spontaneous, though les?^ copious, evacuation of the abscess (which occurred within the next few days), the improvement in the condition of the patient was rapid — so rapid that within a month he was able to leave town, compara- tively speaking, quite convalescent. The next time I saw this patient was about seven months later, along with Dr. Macleod at Ben Rhydding in Yorkshu'e, whither he had gone for change of air. On examining the liver I found that it had again increased in size, and to the naked eye there was a marked fulness in the right h3rpochondriac region, with an mdefinite obscure sense of elasticity over the liver immediately underneath the margin of the false ribs, occupying an indistinct area of about three or four inches in lateral as well as perpendicular diameter. Beyond which, and tenderness on pressure, there were no other signs of a purulent collection in the tissue of the liver. The tongue was moderately clean. The temperature of the skin almost if not quite normal. Appetite natural. Bowels regular, and the pulse I CASES OF HEPATIC ABSCESS. 831 ranging, I was told, from 88 to 94. The condition was now diagnosed as one of chronic hepatic abscess. So I advised artificial evacuation, but neither Dr. Macleod nor the patient seconding the proposition, on account, as they said, of there being no urgent symp- toms, a strong iodine liniment and warm fomenta- tions were ordered to be applied over the supposed seat of the abscess, in the hope of getting it to point externally. At the same time, to prevent further suppuration and to favour absorption — if that were possible — a mixture containing quinine and iodide of potassium was to be given thrice a day, and the patient's strength to be supported by plenty of nourishing non- stimulating food. Fresh air and carriaofe exercise were also recommended. Some months afterwards I was again summoned to the gentleman's bedside, and I now found a sad change had taken place for the worse. The local >ymptoms, though but slightly exaggerated, had induced grave constitutional disturbance. Fever had been succeeded by marked hectic, hectic by pyremia, the pyaemia being associated with considerable de- rangement of the cerebral functions, rapidly runnincr on to delirium. As the patient was then residing in the Bloomsbury district, I put him under the imme- diate care of Mr. William Gill, a gentleman in whose professional skill I had entire confidence, and who, from the proximity of his residence, could not only 832 DISEASES OF THE LIVER. easily see him frequently, but, on an emergency, almost at a moment's notice. The condition of the patient daily became worse. Until at length the abscess suddenly burst, and poured its contents into the right lung. And the poor patient, not possessing enough physical strength to enable him to expel sufficiently rapidly the purulent discharge from the bronchi by coughing, died as- phyxiated in the course of a few minutes. This was a most instructive case to me. Not only from my having it under observation for more than five years, but on account of its having presented at various times so many different phases in its clmical history. Not the least among its peculiarities may be reckoned the long period — nearly six years — of the hepatic abscess's existence. The friends were sufficiently enlightened and liberal to offer me the privilege of making a post- mortem ; but unfortunately I was too much pro- fessionally occupied at the time to be able to avail myself of it, and, Mr. Gill not caring to make the autopsy without my presence, the opportunity was let slip. A circumstance which I have since deeply re- gretted for many reasons, but for one in particular* Namely, that I had observed that the night-dress and bed-sheets, on the morning of the patient's death, were deeply stained of a bright vermilion colour, from something that came away along with RED PIGMENT IN HEPATIC ABSCESSES. 833 an involuntary motion passed during the act of dying. At first I thought that it might be Condy's fluid, or some logwood, or other red -co loured disinfectant or medicine ; but, as my enquiries failed to elicit the sHo'htest clue to the oriodn of this colourino; matter, I am forced to the conclusion that it was some highly oxidised animal pigment, which had been expelled along with the faeces during the agony of death. This peculiar staining of the night-dress and bed- sheets has now to me a very special interest from the fact of Mr. Thomas Pick having communicated a case to the Pathological Society in 1869, where in the in- terior of an enormous hydatid of the liver (from which before death thirty- one pints of a dark greenish al- buminous fluid, containing quantities of cholesterin, but no echinococci) were found a number of masses of the size of horse-beans, consisting of a ' material exactly resembling vermilion' ! Which, upon micro- scopic examination, were discovered to consist of rhomboidal crystals of hcematoidin (Fig. 29). Pro- r, bably an autopsy in my case might have thrown some light upon the source of the red colouring matters which are every now and again observed to pass away by the stools in cases of hepatic abscess, and which (as in a case presently to be referred to) ! have been described as bearing a close resemblance to ' red-currant jell}^' They are not uncommon in hydatids. i 3h 834 DISEASES OF THE LIVER. Biliary Concretions as a Cause of Hepatic Abscess. I shall now cite a few cases in proof of the state- ment that biliary concretions, both inspissated bile and gall-stones, induce abscesses of the liver. The first case I shall refer to is one reported in the fifth volume of the Pathological Society's ' Transactions,' p. 161, by Dr. J. W. Ogle. The patient, a man of middle age, died immediately after entering St. George's Hospital. The skin was jaundiced. An abscess was found in the right lobe of the liver, full of dark ofiensive fluid in which were a number of variously sized polygon -shaped biliary concretions, asffflutinated toorether with mucus. The mass, which was the size of a small hen's egg, was supposed, from its shape, to have been originally in the gall-bladder, not a trace of which, however, remained. Dr. Ogle's theory was that ulceration of the gall-bladder had set up inflammation, which had spread to the neigh- bouring surface of the liver and ended in the for- mation of an abscess, into which the gall-bladder, with its contents, ultimately merged. A case of abscess in the left lobe of the liver induced by a gall-stone impacted in the common bile-duct m a woman aged 23, who died in St. Bartholomew's Hospital, will be found in the twenty-fifth volume of the Pathological Society's ' Transactions,' p. 133. The following case of abscess induced by galli i BILIARY CONCRETIONS INDUCING HEPATIC ABSCESS. 835 stones is one which came under my notice in 1868. It was that of a barrister who, after having been for a few years in the East Indies, returned home suffer- ing from liver disease. He was 44 years of age, and said he had been attacked with excruciating pain in the liver while in India. Which was diagnosed by his medical attendant as the effects of entozoa. On carefully examining his liver, I found it enlarged and tender on pressure, more especially in the region of the gall-bladder. On getting him to describe to me minutely his symptoms, I perceived that the pain had been caused by gall-stones and not entozoa, and that he had had an attack of acute hepatitis consequent thereon. After a few months' sojourn in England, the question of the propriety of his returning to his Indian practice arose, and I, knowing well the con- stitution of the man I had to deal with (he being a friend of several years' standmg), at once told him that to think of returning to India under the circum- stances would be an act of madness. For most as- suredly before he was many months back in a hot climate he would have another, and most probably a much more severe, attack of acute hepatitis. From which he would either die there, or merely return home to die, as a liver in the condition his then was could not possibly stand the mode of life in a tropical climate with impunity. He then asked me why I took such an unfavourable view of his case, seeina* 3 H 2 836 DISEASES OF THE LIVEE. that he had no urgent symptoms. This led me to review to him his clinical history, and I particularly dwelt on the fact that, although he had no pain now, and even but very little discomfort, his liver was nevertheless not only congested, but chronically en- laro'ed. That there was a distinct fulness and ten- derness in the region of the gall-bladder, which I believed was due to the presence of one or more gall- stones. Adding, moreover, that he knew as well as I did that he had a marked constitutional tendency to biliary derangements, although not cognisant of the fact that it took the form of biliary concretions. When all these facts were taken together, in conjunc- tion with his already generally enfeebled state of body, my experience of the effects of a life in tropical climates in similar cases was such as led me to the belief that his return to India would not only be fol- lowed by another attack of acute inflammation of the liver, but most probably a severe one, which in all likelihood would run on to suppuration, and, if it did so, would most certainly kill him. On my putting' the matter thus clearly and emphatically before him, he at once said : ' I believe you are right. I won't go back to India.' But alas ! poor man, he had a wife who, I suppose, found an Indian life better suited to her tastes than an English one. At any rate she I apparently had made up her mind that back to India they should go. Consequently I received a visit from! GALL-STONES A CAUSE OF ABSCESS. 837 her, the object of which was — I won't say to make me change my mind, but I will say — to cliange the wording of my opinion. All that she wanted, she said, was for me merely to give my consent that her husband should be allowed to go back to India for a month or two on trial. Not finding me so amenable to persuasion as she had anticipated, however, and being not only determined to get her own way, but, what was more, to shelter herself from the censure of her husband's friends under the cloak of a ' doctor's opinion,' she took him back to an eminent consultant who had seen him on one or two occasions after his return fi:-om India. What took place at that interview I know not. All I know is that she assured me that he had said that ' there was not the slightest danger in her husband's returning to India.' The fatal step was soon taken. Back to India he went, and no sooner was he there than he had a severe attack of hepatitis which made him return almost im- mediately to England. But alas ! too late. For suppuration of the liver had already set in, exactly as had been prophesied ; and the accompanying ex- tract fi:om a letter written to me by Mr. Sibley, who attended hun in his last illness, tells the sad end of one who, had he but had a little more control over his own actions, would, in all probability, be at this moment still alive and well. Mr. Sibley says in his letter : ' When T commenced to attend him, his S3n[np- 838 DISEASES OF THE LIVEE. toms were urgent. There was a considerable amount of fever, at uncertain times. The abscess wa& opened by Mr. De Morgan, and, as a large quantity of pus was found, an ordinary drainage-tube was left in. He seemingly did well for several days ; but symptoms of exhaustion set in, and he died on the fourteenth day after the opening of the abscess.' Let this sad history be a warning to the reader never, under any circumstances whatever, to advise a patient with gall-stones, or who has had even a single attack of acute hepatitis, if he has a consti- tutional tendency to biliary derangements, to reside in a tropical climate. For, even under the most favourable circumstances, the probabilities are that not only will his hepatic functions rapidly get out of order, but in all likelihood he will contract some fatal form of liver disease. It is always best to err on the safe side ; and even when there are strong pe- cuniary inducements for disregarding the above advice, the patient should be made thoroughly to understand the risk he runs, and the responsibility be thrown entirely on his own shoulders. Abscess of the Liver from Embolism. The following case of hepatic abscess, supposed to be the result of embolism, was brought before the Pathological Society (February 1881) by Dr. Andrew Clark. EMBOLISM A CAUSE OF HEPATIC ABSCESS. 839 The patient, aged 40, never suffered from any illness until June 1880. About that time, after leaving Calcutta, he began to feel ill, to lose flesh, and was feverish at times. He landed at IS^atal, and there was told that he had an enlarged liver. Not improving, he pursued his journey to England, and soon after his arrival was admitted into the London Hospital. When first seen, there were no physical signs of disease in any organ, beyond that the liver appeared to be smaller than natural ; there were no tender spots ; he occasionally suffered from night sweats. An aspirating needle was introduced from rio'ht to left tlirous-h the oro;an ; after some httle difficulty, about ten ounces of reddish-yellow matter were drawn off. For about a week after, physical exammation revealed that the liver reached upward in front as high as the nipple, and a little higher behind ; over the liver a dry friction-rub was heard ; and the rio-ht lung- was consolidated as hio^h as the middle of the scapula. The patient died a few days later ; a short time before his death, he coughed up some pellets of the colour of the matter drawn oft' at the aspiration ; elastic tissue from the lung was found in these pellets, and also evidence of bile-pigment. Post raovtem, an oval abscess was found in the middle and back part of the liver, reaching as high as the level of the root of the lung ; in the liver-tissue around it were numerous 840 DISEASES OF THE LIVER. smaller abscesses. The large intestine showed nu- merous ulcers, extending from the caput ca3ci to the hepatic flexure. Dr. Clark thought the origin of the abscess was probably embolic. I myself regard it as being due to the presence of the in- testmal ulcerations. I, however, record it as a case of abscess from embolism, in order that further in- vestigation may be excited by its narration. As I have more to say regarding the causes of so-called idiopathic abscesses, which, as I said before, in no way difi^er in their pathology from many of those which are denominated metastatic abscesses, I shall, in order to prevent repetition, delay their further consideration until I come to the exposition of the metastatic variety. Traumatic Hepatic Abscess. Abscesses of the liver as the result of external violence are exceedingly rare, and when they do occur are in general the result of a blow or of a squeeze. Traumatic suppuration of the liver may occur at any age. It has been frequently met with in children. A case of this kind in a little girl, aged 9, came under the care of Mr. Obre. She fell down- stairs, and hurt her side, and three or four months afterwards there was noticed a distinct intercostal bulging at the seat of the injury, which proved to TRAUMATIC HEPATIC ABSCESSES. 841 1)6 an abscess. For on an exploring needle being inserted at the junction of the epigastric and hypo- chondriac regions, about a pint of pus was evacu- ated. A second evacuation was made a few days later, but the child sank and died. At the i^ost- niortem a large hepatic abscess was found in the riofht lobe, containino; about a Dint and a half of greenish-brown thick pus. The gall-bladder was contracted and healthy. The hepatic tissue round the abscess presented an milamed, deep red hue, and was hardened, as is usually the case in uiflamed hepatic tissues. No ulceration of the intestines was anywhere to be seen ; so the abscess was put down as the direct result of the injury which the child had met with four months before. Sometimes, indeed, even a succession of abscesses form in the liver after severe mechanical injury. A very curious case of this kind, where an abscess of the liver, which burst into the peritoneal cavity fourteen days after the receipt of the mjury, was followed by the formation of a second abscess (a little away from the first), which in its turn burst, eleven days later, into the intestines, occurred in a member of our own profession, aged 69, who was thrown from and injured by the upsetting of his vehicle. It is recorded in the fourth volume of the Clinical Society's ' Transactions,' by Dr. John Harley. The case is peculiarly interesting, so I shall quote it 842 DISEASES OE THE LIVER. at some lenofth, as not the least remarkable feature in it is the fact that recovery took place after the second abscess had continued to discharge itself more or less interruptedly during three months. The salient points in the history of the case are that althoug'h the erentleman was able to ride home on horseback immediately after the receipt of the injury (which he at first merely spoke of as a bruise in the epigastrium), on the seventh day he was suddenly seized with a deep-seated pain in the upper part of the right side of the abdomen, accompanied with vomiting. In a few days more there was an elevation of the right rectus muscle, where the finger could detect a solid deep-seated tumour, con- tinuous above with the liver. It was exquisitely tender to the touch, and painful on coughing. The pulse was 80 ; the tongue clean and moist. There was no thirst. The urine was high-coloured ; the bowels regular. On the fourteenth day, when turn ing in bed, he was suddenly seized with agonising pain in the epigastrium, and became bathed in a cold sweat. The abdomen was tense, and every- where tender to the touch ; but ' the special pain, dulness, and tumidity on the right side had dis- appeared.' ' The symptoms indicated, and subse- quent examination proved, that the tumour had ruptured and its contents been diffused.' Dover's powder was given, and a tranquil though sleepless TRAUMATIC HEPATIC ABSCESSES. 843 night was obtained. On the foil owing day the pulse was 120. No tumour could now be seen or felt. The urine was scanty, of an orange tint, and deposited lithates. He perspired freely. He lay easiest on his back, with thighs outspread and legs flexed. At night, again a sudden change occurred. After turning in bed, he became faint, and bathed in cold perspiration — pulse 160 — and was in a state of collapse, which lasted for three hours. He then slowly rallied, but remained prostrate up till the twentieth day, when there began to be a decided improvement in his condition — pulse 96, regular and good. On the twenty- second day he was at- tacked with pleurisy of the left lower lobe. On this day he passed a motion containing a mass of ' clear red mucus, exactly like red -currant jelly.' On the twenty-fifth day the pleurisy was gone, but to the left of the umbilicus there was a pamful tender fulness, and again another mass of ' tawny red jelly-like mucus ' was passed, which was soon fol- lowed by an offensive motion — 'blood-stained mucus, strings of coloilrless mucus, and black specks of altered blood.' The swelling now seemed to subside, with a gurgling sound on gentle pressure, and a ' large fluid, almost involuntary, evacuation imme- diately followed, with much flatus, causing a scalding sensation.' ' It was pus.' The whole motion amounted to about twelve ounces in quantity. 844 DISEASES OF THE LIVER. Two hours afterwards there was no tenderness of the abdomen left. Pulse 96. Tongue moist, and like a piece of raw meat. After the next day ' no pus was discharged, but there was a constant oozing of clear watery fluid, faintly tinged with blood.' On the forty-second day three motions, partly of healthy fa3cal matter and partly of offensive purulent matter, were passed with relief. From the forty-ninth until the fifty-first day, ' large quantities of healthy pus were passed, both alone and with the faeces/ On the fifty-fourth day, the jelly-like mucus reappeared. The bowels acted naturally. On the fifty-fifth jaun- dice appeared, accompanied with great abdommal dis- tension and pam. At noon he began to get relief by the discharge of offensive purulent fluid from the bowels, and it continued to run away involuntarily during the rest of the day. He passed in all about a quart ; it was partly ochre- colom*ed, and partly pure greenish-yellow pus.' On the fifty-sixth day the jaundice disappeared. He was free from pain, and the stools were natural, but with a little pus. On the 112th day the pus finally disappeared. He was by that time able to walk in his garden, and he soon afterwards regamed his weight and usual healthy appearance. Nothing is said in the report regarding the pro- bable cause of the temporary attack of jaundice, which lasted only a single day ; and as there is METASTATIC ABSCESSES. 845 nothing" in the clinical history of the case which offers any direct clue to its solution, I merely call attention to the fact, in order that in future cases some note may be taken of what might be regarded as a peculiar phenomenon by some, but which I think was due to the accidental presence of a biliary con- cretion. Metastatic and Pyaemic Abscesses of the Liver. Under this headino; is included a lono; and varied series of pathological affections, which, though at first sight apparently incongruous, prove on close exami- nation to be not only nearly allied, but actually iden- tically produced forms of suppuration. Having, as I think, already successfiiUy undermined the hitherto supposed right of any form of liver abscess whatever to the specific title of ' Tro^^ical,' I shall now in like manner attempt to prove that the metastatic hepatic abscess which follows as a sequela to tropical dysen- tery, in spite of all that has been written to the con- trary, is not due to any specific dysenteric poison whatever, but simply and solely to the absorption of pus into the blood from the purulent ulcers in the intestines, just as occurs in the course of the ordinary metastatic and pj^icmic abscesses met with in England as sequelae to intestinal, urethral, and other suppura- tions. In order to demolish the, as I believe, false pathological doctrine regarding the specific connec- 846 DISEASES OF THE LIVER. tion between tropical dysentery and hepatic abscesses, I shall cite a few crucial cases, the careful considera- tion of which will, I think, of itself be sufficient to scatter to the winds this ' specific ' theory which has long obstructed the path of clinical truth. The first case I shall quote is one brimful of important and incontrovertible data. It fell under my notice when house physician in charge of the fever wards of the Edinburgh Royal Infirmary in 1851, and is briefly as follows. Pins a Cause of Hepatic Abscesses. A well-built and well-nourished lad of 19 years of age was sent into the male fever ward by the admitting physician under the impression that he was suffering from typhus fever, and I, not being then as au fait at liver cases as I am now, ignorantly treated the case as if it were one of typhus fever with anomalous symptoms. The anomality of the symp- toms consisting in the fact that the disease had apparently flown to the liver instead of to the brain. The lad was very ill, his pulse rapid, his skin hot, his tongue foul and tremulous. The liver, though not enlarged, was excessively tender on percussion. There was neither jaundice nor bilious urine, and the stools were of the normal colour. A few days after his admission he was seized with pulmonary symptoms — thought to be pneumonia — rapidly got into a hec- PINS A CAUSE OF HEPATIC ABSCESSES. 847 tic, and then into a low typhoid state, and died nine days after coming into the hospital. A post-mortem examination was made, and an unsuspected abscess, the size of a swan's egg, was found embedded in the substance of the right lobe of the liver. Besides two smaller ones, the larger of them about the size of a walnut, were found in the middle lobe of the right lung. On examining the intestines a drop or two of pus was found in the peritoneum, on the outside, and at the very apex, of the appendix vermiformis ; and its cause was soon discovered to be the presence of a thick brass pin, about an inch and a quarter in length, with its head somewhat green and eroded, pointing downwards, and projecting half through the caudal extremity of the appendix vermiformis. Here then is an excellent example showing how an abscess of the liver may occur in an otherwise healthy consti- tution, through the medium of metastasis, from a drop of purulent matter. Dr. Payne has recorded a very similar case, where a pin lodged in the vermiform appendix became surrounded by a concretion of ftecal matter about an inch long, which led to the formation of four hepatic abscesses, one of which was large enough to contain ' many ounces of greenish pus.' The patient, a woman aged 37, gave no account of ever having swallowed the pin, and the only clinical history of the case obtainable was that, three weeks before her 848 DISEASES OF THE LIVER. death, slie was seized with severe pain in her right side, which was more or less continuous, and accom- panied with slight tenderness of the abdomen. The bowels were regular, pulse 110, respu-ations 36, and temperature 104*o°. Four days before her death, she fell into a state of stupor, and a gangrenous patch appeared upon the sacrum the day before she died. At the autopsy it was observed that although the coats of the vermiform appendix were thickened, they showed no signs of inflammation. Yet ' the hepatic abscesses were precisely such as would be called py?emic,' although ' no seat of primary suppuration was discoverable.' (Pathological Society's ' Transac- tions,' vol. xxi. p. 232.) The following is another case of abscess of the liver from perforation of the appendix vermiformis and caecum by a pin, recorded b}?- T. Whipham,M.B., in the twelfth volume of the Clinical Society's ' Transactions.' It occurred in a lad 18 years of age, who had suffered from severe pain in the right side, extending to the flank ; vomited, and been purged during six days at the rate of fourteen motions a day. The right inguinal region was so tender that it was impossible to examine it properly. At the autopsy the liver weighed six pounds. Beneath its under surface was a large abscess containing ' red- brown pus.' A limited abscess was found in the right iliac region, and its purulent contents were FOREIGN SUBSTANCES CAUSING ABSCESS. 849 mixed with faeces, wMch had found their way thither from the caecum. A pin one and a half inches long was found in the cavity of the abscess. In none of the above cases was anything known of how the pins found entrance into the body. Fish-bones inducing Hepatic Abscesses. In the same way as abscesses of the liver may arise from the irritation caused by pins in the digestive canal, they may follow upon that result- ing from the presence of fish-bones. The ' British Medical Journal ' of February 26, 1881, says that two cases following: the swallowino- of fish-bones are recorded in the last number of the ' Nordiskt Mediciniskt Arkiv.' The first case was reported by Dr. Carl Wettergren. The subject, a man aged 41, in September 1875, swallowed a 1.^ inch long bone of a bream ; at the time, it produced much pain, which soon passed off. In October he had an attack of suppurative perityphlitis, and another in the autumn of 1876. After his recovery from this, he had pain in the course of the transverse colon. On July 29, 1877, he had a severe rigor, followed by deep collapse. He died in October. At the necropsy, the upper third of the vermiform appendix was found to be quite obliterated, while its lower two-thirds were distended into a cyst. There was no trace of perforation. Adhesions were found to 3i 850 DISEASES OF THE LIVER. exist between the upper part of the duodenum, the transverse colon, the sigmoid flexure, and the portal reo;ion of the liver. The left lobe of the liver con- tained several abscesses of various ages ; and in one of them, lying close to the suspensory ligament, a fish-bone was found. Dr. Wettergren assumed that it entered the vermiform appendix, then passed be- tween the laminae of the lesser mesentery, and reached the retro-peritoneal connective tissue, in which it caused inflammation and suppuration. The second case is related by Dr. E. Winge. The subject died after pain in the right hypochondrium, with swelling and tenderness of the liver. At the necropsy, on the upper surface of the liver, and in the organ, numerous small yellowish -white branched bodies were seen ; pus escaped from them on pressure. There were also numerous small abscesses in the peritoneal and mucous membranes of the gall-bladder. A de- colorised thrombus, as thick as a thumb, was found in the main trunk of the portal vein ; a fish-bone projected half an inch into the lumen of the vessel ; and, on tracing its course, the other end was found in the jejunum. A somewhat similar case of this kind, where the presence of a fish-bone in the portal vein produced abscess of the liver, is given by Flint in the fourth edition of his ' Practice of Medicine,' p. 556. A ABSCESS FROM STEICTURE OF THE EECTUM. 851 A Stricture of the Rectum may cause an Abscess of the Liver. Any form of suppurative intestinal disease seems capable of producing hepatic abscesses of a meta- static or pya3mic character. Dr. Wilks exhibited specimens at the Pathological Society, where an abs- cess, or, I should rather say, a diffused purulent infiltration of the liver, and a gall-bladder filled T^ith purulent bile, were distinctly traceable to the suppu- ration arising from an ulcerating stricture of the rectum, consisting of dense fibrous tissue, situated about four inches from the anus of a man aged 37. The case is reported in the eleventh volume of the Society's ' Transactions,' and the liver is described as having been found in a state of ' diffused suppura- tion,' without any separate distinct abscesses in it ; but of a uniform condition of purulent infiltration. The gall-bladder was filled with ' a curdy yellow bile.' With the exception of the suppurated liver and the ulcerated and constricted rectum, all the oro-ans of the body were healthy. Suppurating ulcers of com- mon typhoid fever, contrary to what has usually been stated, occasionally give rise to hepatic abs- cesses. A good example of this kind, where one of the abscesses in the liver contained thirty-seven ounces of pus, was met with in a man aged 40, who died in Guy's Hospital in 1870. 3 I 2 852 DISEASES OF THE LIVER. Tuberculous ulcerations of the intestines, on the other hand, as far as I am aware, have never been found to give rise to hepatic abscesses. So that one might almost be inclined to say that there must be something peculiar in the forms of intestinal suppu- rating ulcerations which give rise to hepatic abscesses. But I very strongly suspect that ere long hepatic abscesses will be met with traceable to pus effused in tuberculous intestinal ulceration, although hitherto none have been recorded. Gronorrhcea as a cause of Hepatic Abscess. That an ordinary gonorrhoea may induce suppura- tion of the liver, has been proved by a case that was published by Dr. Bristowe. It occurred in a shoe- maker, aged 50, who died in St. Thomas's Hospital in 1853. He was admitted labouring under ' suppu- ration of the vesiculae seminales and prostate,' and on post-mortem examination it was found to have iiiduced multiple secondary abscesses in the liver, the lungs, and the kidneys. Suppurating Hydatids of the Liver give rise to Secondary Hepatic Abscesses. A case of this kind died in the London Fever Hospital in 1866. The patient, a man aged 35, stated that he had never had a single day's illness until five weeks before his admission, when he was suddenly seized with a pain in the liver, began to HYDATIDS INDUCING ABSCESSES. 853 feel sick and to lose his appetite. In three weeks' time he became deeply jaundiced. The stools were loose and pipeclay-coloured, and the urine like old ale. His tongue (on admission) was very red, and the hepatic dulness in the perpendicular right nipple line was eight inches. A distmct, smooth, painless, fluctuatmg tumour was to be felt, but no hydatid fremitus could be detected in it. A fortnight after admission the patient was seized with rigors, which recurred at uTegular intervals for eighteen days, when he sank and died. On post-mortem examina- tion a collapsed suppurating hydatid cyst, as big as a child's head, was found in the right lobe, near the posterior margin of its under- surface. Xo other hydatids were found in the liver, but the entire organ was studded over with small abscesses, vary- ing in size from that of a pea to that of a chestnut. The cause of the jaundice was thought to be the compression of the common bile-duct by the hyda- tid. Two or three other hydatids, smaller than an orange, were found in the renal region, attached to the peritoneum. In the hepatic hydatid was a quantity of bilious-looking pu&, in which floated a number of secondary vesicles. There were no ulcera- tions of the bowels, or other suppurating sores, de- tected in the body. Dr. Murchison, under whose care the patient was, attributed the abscesses of the liver to the result of metastasis from the suppurating 854 DISEASES OF THE LIVER. hydatid. A fortniglit before the patient's death, about six ounces of thin opaque bilious fluid, getting purulent towards the end, were drawn off from the tumour by a small trocar and canula, and at the post-mortem, although no sign whatever of inflamma- tory action marked the course of the trocar, it was seen to have passed through at least an inch and a half of healthy hepatic tissue before it had arrived at the cyst. A consolatory therapeutical observation greatly in favour of hepatic tapping. (Pathological Society's ' Transactions,' vol. xviii. p. 123.) As suppurating hydatids have induced not only hepatic abscesses but fatal pyaemia, whenever such an unfortunate occurrence as suppuration of an hepatic hydatid is suspected to have taken place, it ought immediately to be punctured with a small exploring trocar, the contents of the cyst emptied, and, when practicable, the cyst itself washed out by the re- peated injection of an antiseptic solution. Some- times suppurating hydatids give rise to what have been described as gangrenous abscesses of the liver, from their contents being excessively foetid and the surrounding tissues both friable and decomposed. A case of this kind will be found in the Patholo^ gical Society's ' Transactions,' voL xviii. p. 145. METASTATIC AND PYEMIC ABSCESSES. 855 What is the Difference between a Metastatic and a Pysemic Hepatic Abscess? The only difference between an ordinary meta- static and a so-called pytemic liepatic abscess that I know of exists in nothing, unless it be in the re- lative severity of their signs and symptoms. The pyaemic form usually being the worst, from its oc- curring in more enfeebled constitutions, and, as a natural consequence, being in general attended with more marked hectic and other febrile symptoms. The most typical case of what might be called pyasmic hepatic abscess that I ever came across, occurred in a middle-aged gentleman whom I saw at Teignmouth, in 1868, in consultation with Dr. Magrath. The most remarkable feature in the case being the severity of the nocturnal exacerbation of hectic, associated with profuse offensive perspira- tion. There was no jaundice, indeed no icteric tint whatever ; which, if it had been present, could not possibly have escaped notice, as the patient was a very decided blond. The liver was enlarged, and exceedingly tender upon firm pressure, more especially exactly over and all round the neighbourhood of the gall-bladder. The case slowly terminated fatally, and at the au- topsy a number of small abscesses were found in the liver, and an agglutinated mass of firm tissue occupied the position of the common bile-duct, which 856 DISEASES OF THE LIVER, was in a suppurative condition, in consequence, as was supposed, of the previous irritative effects of an impacted gall-stone, which had ulcerated its way into, and escaped unnoticed by, the intestines. A« the rationale of pus-action in the production ■of secondary abscesses of the liver is as yet un- known, I may here with advantage cite a few pas- sages from a paper by Mr. "Watson Cheyne on a ^ New Method of arresting a Gonorrhoea' ('British Medical Journal,' July 24, 1880), For having shown that gonorrhoeal pus may induce a hepatic abscess, Hs remarks may probably throw eome light on the possible mode of pus metastatic miction. Mr. Cheyne says that ' the extreme contagious- ness of gonorrhoea, the existence of a distinct period of incul»ation, and the steady spread of the inflam- mation from a given spot, all point strongly to a parasitic origin. Acting on this idea, he made, in the spring of 1879, a number of inoculations of gonorrhoeal pus, under certain precautions, into flasks containing infusion of meat or infusion of cucumber. In these flasks micrococci grew in large ■numbers^ and also sometimes bacteria, showing that these organisms were present in the gonorrhoeal pus.' Circumstances prevented him from pursuing the sub- ject further at that time. In the meantime. Dr. Neisser published an elaborate research on this sub- ject, in which he showed the presence of enormous ETIOLOGY OF TROPICAL ABSCESSES. 857 numbers of micrococci in gonorrhoeal pus, and in the pus from contagious ophthalmia. In erysipelas, it has been demonstrated that the skin at the margin of the inflammatory redness is full of micrococci. Koch found, in erysipelas in rabbits, that bacilli were present throughout the inflamed part, and co-extensive with the inflamma- tion. The same writer obtained a progressive gan- grene of the tissues in mice by the injection of putrid blood, and he demonstrated conclusively that the gangrene is due to an organism which he calls a streptococcus, which is present in large numbers around the limits of the gangrenous part. From researches like these, one is led to the conclusion that the production of multiple secondary abscesses may be due to the propagation and spread of living animal or vegetable organisms, and not actually to the pus-corpuscles themselves ; and it is this belief, as well as that all the various forms of contagious and epidemic jaundice are the direct re- sult of disease-germs, which induced me to say so much on germicides in the chapter specially devoted to treatment. Figures of the germs are given at p. 335. Are so-called Tropical Abscesses of the Liver specially due to Dysentery? This question has long been, and still is, a bone of contention. Some regarding dysentery and abscess as cause and effect ; others saying that they are 858 DISEASES OF THE LIVER. frequently associated together, simply because they both have similar exciting causes. I think, after careful perusal of the preceding cases the reader will have little difficulty in deciding which side is most likely to be in the right. For if such trivial amounts of pus in the digestive and urethral canals as have been here indicated are of themselves sufficient to induce a series of secondary abscesses in the liver, pleura, lungs, and iliac regions, in what might be otherwise supposed to be perfectly healthy constitu- tions, in youthful inhabitants of temperate climates, unaccustomed to an excessive indulgence in either rich foods or stimulating drinks, how can one pos- sibly be surprised, or regard it as in the least degree extraordinary, that an equally trifling amount of purulent matter in the intestinal canal in cases of dysenteric ulcerations, &c., should in like manner be sufficient to induce the formation of an abscess in the liver of an Anglo-Indian, with a constitution under- mined by malaria, and a liver upset by over eating and drinking, while living in an abnormally high atmospheric temperature favouring all forms of hepatic congestions and inflammations ? Dr. Finlay- son, in the ' Glasgow Medical Journal ' of February 1873, gives it as his behef that, instead of hepatic abscess being the result of dysentery, the disease of the liver is in reality the cause of the dysentery ; but unfortunately he has adduced no telling facts in support of this bold theory. ETIOLOGY OF TROPICAL ABSCESSES. 859 In a letter to the 'Lancet' of May 14, 1881, Sir Joseph Fayrer also adds the weight of his opinion to the side of those who believe that statistics do not support the theory that tropical abscesses of the liver are due to dysentery. The statistics he draws this conclusion from being those of Moore in the ' Annals of Military Surgery,' where it is stated that twelve observers in the aggregate report 1,532 cases of dysentery in which onlj^- 295 were followed by hepatic abscess, thus giving only 18 per cent. ! and as Moore justly remarks, ' if the theory were sound, how could it possibly happen that 77 per cent, of the cases of dysentery occurred without hepatic disease ? ' As it would be wrong of me to ignore the views of those who hold opposite opinions, and yet, from my not believing in them, it would be almost equally wrong for me to take up space by detailing them, I beg to refer those of my readers who take special interest in the question to the admirable report on the subject furnished to the Pathological Society in 1858 by Dr. Bristowe (vol. ix. pp. 241-269), on the connec- tion between intestinal ulcerations and hepatic abs- cess. The conclusion he arrived at being that abscess of the liver cannot be regarded as a conse- quence of intestinal ulceration ; nor dysentery be regarded as the result of hepatic disease, but that a general common cause may excite in one man abscess of the liver, in another dysentery, and in a third a 860 DISEASES OF THE LIVER. combination of the two. Althougli I am adverse to ttie first of these three theories, I am quite in accord ' with the last two. I would further recommend the perusal of Dr. Bristowe's paper on the modes in which hepatic abscesses may be formed, at pp. 273- 294 of the same volume of the Society's ' Transac- tions.' Both communications are pregnant with closely reasoned data. Before leavmg the important subject of abscess of the liver, it may, perhaps, be as well for me to state the general conclusions I have arrived at after having given considerable attention to all sides of the ques- tion. They are these : — The abscesses which occur in the livers of Europeans living in the tropics (as a sequel to dysentery or to anything else) have pre- cisely the same pathology as abscesses of the liver occurring in persons resident in temperate zones. And they only differ in being more common and at the same time, perhaps as a general rule, more sevei-e in patients who have resided in hot cli- mates. These differences, I believe, are not, how- ever, due to anything whatever specific about the abscess itself, but arise wholly and solely from the habits of the patients while resident in the tropics, together with their surroundings, favouring not alone the production of the severer forms of hepatic con- gestions and inflammations, but likewise hepatic tissue suppurations. Further, I have been equally- TREATMENT OF HEPATIC ABSCESSES. 861 led to the conclusion that the so-called idiopathic abscess of the liver is in the majority of cases ac- tually nothing more or less than a form of meta- static abscess, the fons et origo of which has eluded detection. The exciting cause perhaps ha\ing been a dysenteric or other form of intestinal suppura- tion, of a malarial or other origin. For be it re- membered that an enlarged liver and spleen, with a tendency to suppuration, are the very commonest of all the sequelae of malarial poisoning. So common indeed is the disorder of the spleen that one of its forms has been named ague-cake. Treatment of Hepatic Abscesses. The treatment of an hepatic abscess, whether it be of the idiopathic, traumatic, metastatic, or py^emic varieties, in so far as the local suppuration is con- cerned, is always the same. But the constitutional treatment varies according to the cause of the suppu- ration. Unfortunately we can, at best, do but little more than alleviate the sufferings of the patient ; for when once a collection of matter has formed in the liver, the pathological conditions upon which it de- pends are, as a general rule, beyond the physician's control. However, notwithstanding that a cure, or even a recovery, may in the majority of cases be un- attainable, we must in no case fold our hands in complacent idleness, but be * up and doing.' For 862 DISEASES OF THE LIVER. even in the very worst of cases, as long as the thread of life remains unbroken there is always hope, and we always have it within our power not only to soothe the patient's passage to the tomb, but very considerably delay the fatal issue. In a wide subject like that of hepatic abscess, which embraces so many and so varied phases, it is impossible to give a succinct resume of all the different plans of treatment. So all I shall attempt to do is briefly to portray the lines along which I myself usually travel. The fact of course of my following these lines being the best proof I can offer of my possessing confidence in them ; and it is at least a cheering thing to be able to say that a disease which, when fully developed, is fatal, can, in the majority of cases, be completely aborted if diagnosed correctly and treated energetically in its incipient stages. The chief lines of procedure I venture to recom- mend in this formidable form of hepatic disease are : — 1st. If called to the case early — that is to say, when suppuration is threatened, but before pus has actually formed — try to arrest the onward progress of the disease by leeching, cupping, and the application of a freezing mixture of pounded ice and salt over the most pronounced seat of pain. Not only is the freezing process to be continued until the subjacent parts are frozen quite hard, but until actual blistering I TREATMENT OF HEPATIC ABSCESSES. 863 of the skin subsequently takes place. As then, and then only, is the cold communicated to the deep tissues of the liver sufficiently intense to abort in the majority of instances the suppurating process. 2nd. In this, the incipient stage of the disease, avoid the application of hot fomentations and poul- tices, as they only favour instead of retarding the formation of pus. 3rd. Administer a brisk mercurial purgative. Enjoin strict resi; of body and mind. Put the patient on low diet, and keep the room well ventilated and of a temperature of not more than 60° Fahr. 4th. Prescribe germicides in the form of sahcylic, carbolic, or mineral acids, and quinine, and carefully eschew the administration of alkalies, in any form whatever, as they favour instead of preventing germ development, as well as suppuration. 5th. If the case be not seen until matter has actually formed, the chances of cure are but small, for we as yet know no therapeutical agent which has the power of inducing pus absorption. All we can do is to try the effects of the application of iodine liniment, mustard poultices, or blistering, in the, I fear futile, hope not only of arresting the further progress of suppuration, but of favouring the reabsorption of the already effused pus. 6th. Artificial evacuation is, I believe, the only way of getting pus out of a human liver. 864 DISEASES OF THE LIVER. Tth. Believing, as I do, that evacuation of the con- tents of the abscess is the only possible way. of getting rid of the pus, I shall go into this mode of treatment fully. In the first place I may as well observe that to evacuate the contents of an hepatic abscess is not always an easy matter, from the simple fact that, even after the existence of pus has been correctly dia- gnosed, its exact seat may still remain a mystery. Luckily for us, we not only possess a knowledge of the use of the exploring needle, but are at the same time in possession of the invaluable fact that an exploring needle may be thrust, not alone once, twice, or thrice, but even half a dozen times, within as many minutes, deep into the substance of the human liver with perfect impunity. Dr. J. C. Cameron has the merit of having pointed out (in the ' Lancet ' of June 6 and 13, and of August 8, 1863) that 'the liver may be punctured deeply with an ordinary trocar without any evil consequences ; the greatest incon- venience witnessed after many such operations being slight local irritation, requiring a few leeches over the wound — and that but very rarely.' He adds that ' in cases where the abscess sought had been missed, and the patient died subsequently of hectic and ex- haustion, it was extremely difficult to trace the marks of the trocar in the liver, there being no signs of peri- toneal irritation or effusion of any kind.' From this THE TAPPING OF HEPATIC ABSCESSES. 865 it is seen that when the abscess is not encountered in the first exploratory attempt, the repetition of it half a dozen times is perfectly safe, unless under excep- tionally unfavourable circumstances. When the case appears to be a very doubtful one, and there is a strong suspicion that more than two exploratory punctures may be required, it is well to use an anassthetic, and the safest that has as yet been devised is the one recommended by the Chloro- form Committee of the Royal Medical and Chirur- gical Society (at my suggestion). It is composed of alcohol one part, chloroform two parts, and ether three parts. A formula easily impressed upon the mind by making the quantities of its ingredients rhyme with their initial letters. Thus the initials of alcohol, chloroform, and ether, rhyme as ACE = 1 2 3 And be it remembered, this is not only a perfectly safe, but at the same time an effective anaesthetic to administer on a pocket-handkerchief. The next point is the selection of the spot for the first puncture. This ought to be the highest part of the bulging. No matter whether it be in the epigastric, lateral, or dorsal region. When there is a bulging in any of these situations, no difficulty can be felt about the matter. Sometimes when the abscess is near to the edge of the right lobe, merely an indistinct oblitera- 3 K 866 DISEASES OF THE LIVER. | tion of the intercostal spaces is discernible. Fortu- nately, however, this is the spot where least risk is encountered. So that a long fine trocar may be thrust in at this point fearlessly. When the in- distinct bulging, on the other hand, is in front, and in the neighbourhood of the gall-bladder, one naturally feels a little more anxious as to the result, in case the gall-bladder instead of an abscess should be punc- tured. But even little risk attends that accident ; for, as will be seen in the chapter on gall-bladder diseases, an escape of bile into the abdominal cavity gives rise to no serious consequences whatever. (Page 1101.) The following successful case of evacuating an abscess of the liver is recorded by Mr. Arthur Wear : — In August 1879, a milliner, aged 45, complained of feeling ill. On September 20, the temperature was 102'4°, and pulse 108. On the 21st, she had a rigor, and complained of a sense of great constriction around the diaphragm, which caused severe dyspnoea. A tumour was bulging out, and fluctuation could be distinctly felt through the abdominal wall. On the 22nd, Mr. Wear and Dr. Wicks, using the hand- spray, made a preliminary incision through the skin with a bistoury, and plunged a trocar and canula into the most prominent part of the swelling. About thirty ounces of pus mixed with bile passed through the canula, and the patient expressed herself as greatly I THE TAPPING OF HEPATIC ABSCESSES. 867 relieved. The temperature fell to 99*2° by the even- ing, and her pulse to 8-i ; she was almost free from pain, but still the tumour did not entirely disappear. On the 23rd, the temperature rose, and, on the 25th, stood at 103*-i°. She had a rigor. On the 26th, by means of Potain's aspu'ator, six ounces of pus and bile, which had reaccumulated, were removed. For many days the temperature remained about 102°, and, on October 5, it rose to 103'4° ; but it gradually fell. By the end of November she was mending rapidly, all traces of the swelling having entirely disap- peared. It must not be supposed, however, that all cases are as successful as this. Sometimes death follows the operation, even when it is skilfully performed. This is usually owing to the operation having been deferred until the patient has become weak and ca- chectic. In exhausted, weak, and cachectic patients, the aspirator ought to be used instead of a free trocar, from its being less likely to excite the trifling amount of constitutional disturbance which sometimes follows the evacuation of purulent matter from an hepatic suppuration in badly constitutioned individuals. Some go so far, in employing the exploring needle, as even to attach it to the aspirator. In no case would I recommend the adoption of the proposal of Begin and Recamier to attempt open- 3x2 868 DISEASES OF THE LIVER. ing an hepatic abscess with a scalpel ; nor do I advise the use of a large trocar. Not even when the abscess has pointed. For the same advantages may be gained with a small trocar (just of sufficient' diameter to allow pus flocculi to escape), and that too mth less danger and inconvenience. As I am writing for the sake of poor patients quite as much as for the advantage of my medical brethren, I may here briefly cite a case illustrative of the danger of opening an abscess of the liver by means of a scalpel, even as a mere auxiliary to the aspirator. The case I refer to is one recorded by Dr. Neil Macleod, of Shanghai, in the ' British Medical Journar of November 27, 1880, under the title of ' Hepatic Abscess opened antiseptically.' A man aged 39, who had been a free 'liver, had taken little or no exercise for some years. In July 1879, had a severe attack of diarrhoea ; in the end of August, an acute attack of dysentery. In November, temperature varied from 97*8° to 103*8°. The pulse varied from 80 to 104. He had night-sweats. There was no rigor or shivering at any time. On Novem- ber 11, abscess of the liver was suspected, from the increased liver-dulness, fever, sweats, tenderness and pain on the right side. Slight bulging was seen over the lower ribs in the mid -axillary line and behind it ; and in this region there were flatteninff of the intercostal spaces, and a tender spot. I OPENING OF HEPATIC ABSCESSES. 869 November 14, Dr. Macleod, with antiseptic precau- tions, passed the largest-sized Matthieu's aspirator- needle between the seventh and eighth ribs in the medio- axillary line, at the tender spot. At a depth of little more than an iQch, yellow pus flowed through the tube. Aspiration was immediately stopped ; and, the canula being left in situ as a guide, he made an incision on each side of it, and cut down until pus began to well up by the side of the canula. Having removed the latter and enlarged the opening with a probe-pointed bistoury, fully a pmt of thick yellow odourless pus flowed from it, with the aid of pressure on the epigastrium. A drainage-tube, with a calibre of half an inch, was introduced. From December 1 to December 20, he had two severe rigors, with an interval of a week between, each followed by a change from liver-coloured discharge to a fresh yellow pus, lasting for two or three days, and then becoming once more dark-coloured, remaining aseptic throughout. Strength began to fail, and the appetite was lost ; and, finally, severe diarrhoea set in. Death occurred on the 20th. Post mortem^ the back part of the right lobe, op- posite the wound, was occupied by a cavity nearly twice the size of a hen's egg, having prolongations backwards and inwards ; one nearly two inches long, admitting the finger. I may now mention that after pus has been with- drawn from an hepatic abscess (when no drainage-tube 870 DISEASES OF THE LIVER. has been considered necessary), a hypnotic dose of bromide of ammonium or chloral ought to be admi- nistered to the patient, and he ought to be kept quiet, and be told to lie on the side of the puncture, as pus often discharges itself by driblets through the wound for days afterwards. The dangers attached to hepatic abscess do not always terminate even when they have been success- ftdly opened. Flint ^ alludes to a case where, after an abscess pointed externally and was opened, it subse- quently perforated into the stomach, and the patient died from inanition. A slow recovery is always to be looked for, even after a most successful evacuation of matter from the liver. Four, eight, or even twelve weeks often elaps- ing before the patient can leave his bed and move about his room. This arises from the fact that the functions of the liver are in these cases always slow in resuming" their normal course. It being merely the traumatic and, strictly speak- ing, idiopathic forms of hepatic abscess that can be regarded in the light of local affections (assuredly not those generally spoken of as metastatic or pygemic, which are undoubtedly due to the impregnation of the constitution with purulent poison), it is the arti- ficial evacuation of them alone that can be expected to be attended with salutary results. And I thin^ ^ Practice of Medicine, 4th ed. p. 561. OPENING OF HEPATIC ABSCESSES. 871 in all suitable cases operative procedure ought early to be had recourse to. For, even as a mere pallia- tive, when the evacuation is made early, its benefits are by no means to be despised. By the term ' early,' I mean before the constitution of the patient is broken down by the exhausting effects of the suppu- ration. The reason why the artificial evacuation of pyaemic abscesses is attended with no benefit springs from the fact of the constitutional purulent impreg- nation not being done away with by the withdrawal of matter from one of its mere local foci. When to attempt the artificial evacuation of an abscess of the liver is deemed un advisable, either on account of its true seat bemg unrecognisable, or on account of its nature or the condition of the patient being unfavourable, all our efforts should be directed to induce it to point and discharge itself, either externally, or, what is even quite as good, into the digestive canal. To materially influence its course is unfortunately impossible, but to encourage and hasten it along its own elected route is abun- dantly within our power. For just as the matura- tion and pointing of abscesses in other parts of the body may be materially assisted by artificial means, so in like manner can the maturation and pointing of an hepatic abscess be either hastened by judicious, or retarded by injudicious, means. Among the former 872 DISEASES OF THE LIVER. may be reckoned the continuous application of heat and moisture. Hot linseed poultices, hot water fomentations, hot turpentine stupes, all of them being applied as hot as ever the patient can tolerate them, and directly over the seat of pain, are the most successful local means of coaxmg an abscess to point and burst. But as to do so takes time, and every day the suppuration lasts the patient's strength diminishes, and with it his chances of recovery fade, we must associate the local with an energetic con- stitutional line of treatment. Which is to soothe and strengthen him, by giving him amusement with- out excitement, and nutrition without stimulation. The ventilation and temperature of the room in the early stage of suppuration I have already spoken of Now I have to pomt out that a slightly higher temperature is requisite when the object in view is to favour the progress of an abscess of the liver to- wards bursting. Then it is that a room temperature of from 65° to 70° Fahr. is not too much. But the true index to temperature are the feelings of the patient. Sleep must be encouraged by hypnotics, chloral, bromide of ammonium, and such like. Not, however, by opiates. The diet should be milk and eggs, animal and vegetable soups, and no solids, except white fish, such as whiting, haddock, sole, turbot, cod, &c. No mackerel, eels, or salmon, lobsters or crabs. Nothing TREATMEXT OF HEPATIC ABSCESSES. 873 indeed that will in the least degree tax the digestive powers. As regards drinks, no stimulants whatever in the shape of brandies or whiskies, unless their employ- ment be distinctly indicated. No port wines or so- called dry sherries. No heavy mdigestible malt liquors. But in their place light nutritious feebly alcohoHc drinks. Good sound claret, hock, tarragona, or moselle. Effervescing drinks in moderation. That is to say in small quantities at a time — a small wine- glassful may be given frequently. Of sparkling drinks there are a great variety, and they may be selected according to the palate of the patient, so long as none of them are of the acid character sold under the name of tres-sec and brut champagne, the true nature of which I gave my ideas of in the chap- ter specially devoted to dietetics. Sparkling Devon- shire cider (not sweet) ui eluded. I prefer really good (not sour) French champagnes to sparkling hocks, moselles, burgundies, &c. &c. With this general exposition of the principles of treatment, I conclude my somewhat long chapter on abscess of the liver, and pass on to one of almost greater im- portance and equally interesting. 874 DISEASES OF THE LIVER. CHAPTER XYIII. CANCER OF THE LIVER. No single word in medical nosology conveys to a patient such a chill of horror as that of cancer, when it is attached to the diagnosis of his case. Consequently it is a word which a medical practi- tioner ought never to let fall from his lips in a sick room in connection with a liver case, except under very exceptional circumstances, and not even then unless he has indisputable data to rely upon. For, as will be presently seen, the diagnosis of hepatic cancer, even in experienced hands, is often a very difficult task, from the recognition of its existence depending nearly as much on the appreciation of negative, as on the recognition of positive, signs and symptoms. I therefore advise my younger brethren not only never to give a decided opinion that any given case is one of cancer of the liver without having the strongest reasons for so doing, but, even when they have, to break the subject to the patient's friends rather than to the patient himself. MALIGNANT DISEASE OF THE LIVER. 875 I am led to be thus emphatic from knowing not alone that there is scarcely a single form of hepatic disease — I might even say of any disease — which is so puzzling for a young practitioner to diagnose cor- rectly as a case of malignant disease of the liver, but that of all forms of affection that human flesh is heir to, there is not one about which if he should un- fortunately make a mistake, his professional reputation is more likely to suffer. This arises from the fact that almost every old woman imagines that ' a cancer * is a disease easily recognised, and that therefore it ought to be about as plain to the eye of a doctor as a dropped stitch in knitting would be to hers. Con- sequently, should the poor doctor err, he is almost certain to have his blunder most uncharitably criti- cised. Here then is a dilemma ; for while on the one hand I tell him not to communicate his suspicions of the case being one of cancer, I nevertheless warn him that if he fails to communicate his knowledge of the existence of that particular form of disease, his repu- tation is likely to suffer. Fortunately there is an easy way out of the difliculty. Be silent until sure. No sooner feel sure than gently moot your suspicions, not to the patient, but to the patient's friends. Then all will be well. The sequel will, I think, readily explain why, in spite of cancer of the liver being by no means a rare disease, its diagnosis baffles one more than the dia- 876 DISEASES OF THE LIVEK. gnosis of almost any other form of hepatic affection whatever. For in studying what is now about to be said on the subject, it will become painfully appa- rent that while most of the positive diagnostic signs testifying to its presence are common to other forms of liver disease, almost all the negative symptoms in general relied upon as being indicative of its absence may with equal propriety be negatively apjDlied to a host of other hepatic affections. Added to which the signs and symptoms of cancer of the liver hitherto given in text books (as will be seen on comparing them Avith those presently to be put forward) are not only in the majority of cases defective, but in several instances actually erroneous. Consequently they are more or less misleading guides to the diagnosis of any beyond the plainest of cases. Such being my belief, I will enter more fully than I should other- wise do both into the pathology and etiology of hepatic cancer, in the hope that a knowledge of these branches of the subject will facilitate both the dia- gnosis and treatment of the disease. While, further, I shall tabulate a few hints which I trust may be useful to the beginner in the differentiation of ob- scure cases, which I know by personal experience will occasionally tax his energies as well as his abilities to the utmost. HEPATIC CANCEE. 877 Pathology of Hepatic Cancer. It is in general asserted, not only in text-books but in special treatises on diseases of the liver, that the hepatic organ is liable to be attacked with the fol- lowing six forms of cancer only : encephaloid, mela- noma, fungus hcematodes, epithelioma, sarcoma, and scirrhus. On going carefully through the recent British and foreign literature of liver diseases, I have found, however, that every known form of so-called cancerous diseases attacks the human liver. Even the rarest of all the specially named forms of cancer, namely, the colloid variety, which has again and again been said never to attack the human liver, I have met with in at least three reliable well-re- corded cases. One is that of a preparation in Guy's Hospital Museum. Another is a case which Dr. Vanderbyl exhibited to the Pathological Society in 1858. Which specimen greatly impressed me, as it was taken from a woman aged 64, who, notwith- standing that her liver was extremely diseased, had shown neither symptoms of jaundice nor anasarca. And yet the transverse fissure was completely filled with colloid growths, while the external surface of the Hver as well as of the gall-bladder was studded over with colloid tumours, varying from half an inch to an inch in diameter. As I shall afterwards attempt to prove that the 878 DISEASES OF THE LIVER. irritative effects of gall-stones are among the excit- ing causes of cancer of the liver, I may incidentally add that forty small gall-stones were found in this patient's gall-bladder, which led Dr. Vanderbyl to the not improbable supposition that the irritation caused by their presence m a measure accounted for the peritoneal covering of the gall-bladder having become so prominently affected with the morbid deposits. In this case, however, the presence of the stones could scarcely be suspected of having in- duced the cancerous disease, as the deposits, both in the gall-bladder and in the liver itself, appeared to be secondary to other similar growths existing in the omentum and ovaries. The third case is also one in which the hepatic colloid appeared to have extended as a secondary formation from the intestinal tract. The case is reported by Mr. George Lawson in the thirteenth volume of the Clinical Society's ' Transactions.' The liver is described as having been ' enormously en- larged, especially the right lobe, and almost wholly converted into a mass of colloid, Avhich projected from its surface in the form of large irregular tumours. On section, but little hepatic tissue re- mamed.' Yet, notwithstanding this, and the fact that the diseased growths were secondary to a simi- lar morbid degeneration in the sigmoid flexure, and that even the pelvic glands were affected, the left lobe HEPATIC CANCEK. 879 of the liver, in spite of being enlarged, was free from disease. (The immunity of the left lobe of the liver, not alone from cancer, but from abscess, as well as from hydatids, is a pathological phenomenon to me quite inexplicable. No doubt an anatomical or physiological cause for its immunity must exist, but what it actually is I know not.) The patient in this case was only 23 years of age, and had had gastro-enterotomy performed on him nine months previous to his death for an in- testinal obstruction (supposed to have been caused by a twisting of the bowel) in the neighbourhood of the caecum. The cancer probably owed its origin to the irritative effects of the previous bowel mis- chief. While asserting that the human Hver is liable to be attacked with every known variety of can- cerous disease, I cannot refrain from entering a pro- test against the slipshod manner in which tumours of the liver and its appendages are often described as cancerous when not a trace of malignancy exists about them. Everyone conversant with the modern literature of liver diseases will, I am sure, bear me out in the opinion that the common generic title of ' cancer ' is oftentimes most erroneously and misleadingly employed in the morbid anatomical descriptions given of liver cases. Every tumour, tissue-thickening, growth, or degeneration of the 880 DISEASES OF THE LIVER. liver whose histology is not self-evident, is dubbed a ' cancer.' Again and again have medical men sent to the physiological laboratory at University College specimens of what they were pleased to denominate ' cancer,' which on investigation proved to be no- thing more than inflammatory thickenings of the capsule, neck of the gall-bladder, or of the ducts, following upon inflammatory ulcerative action caused by the presence or passage of gall-stones. In fact, not only general practitioners, but men with some pretence to a special pathological knowledge, apply the name of ' cancer ' to all species of doubt- ful growths. Even those which produce no cancerous cachexia or infiltration of the neighbouring tissues, and consequently are not constitutional, but merely local diseases. There is, perhaps, some excuse for many of these mistakes, from the fact that at the present moment there are no forms of hepatic structural tissue change about which there exist such confused notions as those thought to merit the name of ' cancer.' Every- one knows, for example, that the generic title of ' cancer ' is given not only to a wide, but also to an absolutely incongruous, variety of new tissue- growths and degenerations, some of which possess not a vestige of similarity to one another, either visually, microscopically, chemically, or clinically. Some being of slow development, solid in structure, MALIGNANT DISEASE. 881 as hard as a cricket-ball, and giving rise to no constitutional signs. Others are of rapid growth, soft, juicy, and inducing a well-marked constitutional cachexia. How, then, let me ask, can the generic title of ' cancer ' be legitimately applied in a clinical any more than a pathological sense to such widely differing morbid structures ? Another and most fruitful cause of error in the nomenclature of hepatic tumours and tissue de- generations in the non-pathologically trained mind, orio'inates in the fallacious belief that all forms of new growth or tissue degeneration, which inevitably lead to a fatal termination, ' must be a cancer.' After havinof said this, I think it incumbent on me to try and answer the question — What is a Cancer of the Liver ? It may perhaps be as well for me to take the reader at once mto confidence, and show him the true colours under which I sail. They are these : — It is my opinion that the name of ' cancer,' not only as regards the liver, but equally as regards ever}^ other organ of the body, ought only to be given to those forms of new tissue formation which are clearly of a constitutional in contradistinction to a merely local origin, as testified by their tendency to affect the glands, infiltrate the neighbouring tissues, and produce the so-called cancerous cachexia. Thus 3 L 882 DISEASES OF THE LIVEE. a cancerous tumour of the liver, to my way of think- ing, is an abnormal constitutional growth, totally distinct and entirely different in its pathological characters, as well as in its clinical signification, from a merely, though, it may be, necessarily, fatal form of liver tumour. For plenty of perfectly be- nisrn forms of growth affectino; the human liver are, on account either of their size or position, of ne- cessity fatal. None of these, however, give rise to what is called a cancerous cachexia, and to the form of tumour alone which possesses this power would I, under any circumstances whatever, give the title of ' cancer.' As I entertain very decided views on this subject, and as I believe that cancer — that is to say, true malionant disease of the liver — differs in no sinoie particular from malignant disease in any other organ of the body, except in so far as the histological ele- ments of the normal tissues it attacks slightly modify its naked-eye and microscopical characters, I shall here reiterate some of the views I have so freely expressed in the morbid anatomy part of ni}^ ' His- tological Demonstrations,' ^ specially devoted to the consideration of the microscopical characters of va- rious morbid growths ; for I believe the universal adoption of the doctrines there propounded would not only advance the progress of pathological ana- ^ Second edition, p. 180. Longman & Co., London. WHAT IS A CANCER ? 883 tomy, but greatly facilitate the correct interpreta- tion of many at present seemingly obscure clinical data in connection with a variety of so-called can- cerous diseases. Moreover, I believe that it will not only tend greatly to assist the reader to follow the lines of argument I shall pursue in giving the etiology of hepatic cancer, but also enable him all the more readily to understand the clinical histories of the cases I shall cite, and the therapeutical bearings of my subsequent remarks, if he attends to the pre- sent exposition of my views on the nature of hepatic cancer. So he need not regard their perusal as an unnecessary waste of time. They are : — 1. In diseased livers neither are new histolog-ical elements created, nor are new functions developed ; but existing tissues are only modified or misplaced, and their normally existing functions disordered. 2. All liver, like other tumours, grow in the direction of the least resistance. Where there is entire freedom from pressure, the form of the tumour is globular, as is the case when it grows outwards from the liver into the peritoneal cavity. 3. All liver tumours are liable to alteration of texture in the course of their growth. A fibrous tumour may become softened, cystic, cancerous, or calcified, a hard and benign scirrhus may either be- come fattily degenerated, or gradually transformed into a soft true encephaloid cancer. 3 L 2 884 DISEASES OF THE LIVER. I have on several occasions, while examining cases of malignant disease of the liver, been struck with the very marked tendency encephaloid tumours have to become softened in their centres into a white opaque creamy liquid, making the tumour assume an al- most cystic character. Sometimes the interior of the cyst appears to be divided into sections by fibrous partitions, giving to the tumour a multilocular ap- pearance. When several growths existed in the same liver, they would, according to their degrees of ad- vancement m the degenerating process, show the dif- ferent stages of the gradually softening disorganisa- tion 2:oino: on in their interiors. 4. Benign liver tumours show no tendency to infiltrate the neighbouring tissues or to affect glands. 5. In true scirrhus, which is a benign form of growth, there is no affection of the glands, no infil- tration of the tissues, and no ' cancerous cachexia.' 6. All kinds of morbid growths of the liver have a tendency to run into each other. The charac- teristic features of each becoming gradually less and less distmct, until ultimately the benign appear to be almost identical in character with the malignant. 7. Malignant liver tumours affect glands, infil- trate the neighbouring tissues, and induce a ' cancerous cachexia.' 8. The accession of malignancy in the course of CHAEACTERISTICS OF A CANCER. 885 any case of hepatic disease can be recognised by the supervention of the ' cancerous cachexia.' 9. When examined after death, there ou2:ht to be no difficulty (although I regret to say there very often is) experienced in recognising hepatic cancer, from the simple fact that all truly malignant forms of growth present the following well-marked naked-eye and microscopical characteristics. First as regards the microscopic elements. At one time there was a universal implicit belief in the existence of an essentially characteristic form of cancer-cell, the presence of which in any tissue or fluid of the body was thought to be indubitable evi- dence of the existence of malignant disease. Then came a time when this supposed fiction was totally abandoned. The advancing wheel of pathological knowledge has, however, again revolved. A fresh epicycle in morbid histological thought has been reached, and I am now, as I have no doubt many others are, fully prepared to affirm that the existence of a veritable specific form of cancer-cell is not a con- ceit of the imagination, but it is as easily and infallibly recognisable by the eye of the initiated as. the different individual members of a flock of sheep are to the eye of their shepherd, though at the same moment they may be totally undistinguishable to the eye of an outsider. The subjoined figure, copied from the mor- bid anatomy part of my ' Histological Demonstra- 886 DISEASES OF THE LIVER. tions,'^ shows exactly the kinds of cells upon which im- plicit reliance may be placed in diagnosing a malignant tumour. There are many benign cells bearing a re- semblance to those here depicted ; but there is not a single cell to be met with, either in the diseased or in the healthy human body, identical with these, except Fig. 25. Iv ^m^^ r Encephaloid Cancer-cells. With Brownian Granules. in connection with cancer — that is to say, as I define it, a true cachexial constitutional form of disease. Mark these words ; for they must not be misin- terpreted. They have no reference whatever to any of the other, erroneously, so-called ' cancer cells.' They have nothing to do with the constantly misin- terpreted pathological elements met with in growths called scirrhus. Which, in my opinion, has no more right to be designated ' a cancer ' than either an adenoma or a fatty tumour has. This idea can be ' 2nd ed. p. 224. IXOCULABILITY OF CANCER. 887 proved to be a legitimate one ; alike experimentally, histologically, and clinically. Thus, for example, inoculated encephaloid cells or juice beget cancer. While inoculated scirrhus cells or scirrhus exudation (there is no scirrhus, juice proper) beget — Nothing. Lansrenbeck and Lebert found cancerous tumours form in animals inoculated with cancer cells and cancer juice. A fact not in the least difficult to understand, for recent cases have been reported as having occurred which illustrate in a remarkable de- gree how cancer germs may be transmitted even, in some as yet unknown way, from one organ to another not only having no dnect connection with each other, but possessing no similarity either in their structure or functions. Secondary cancerous deposit afFectmg the entire pulmonary tissue havmg been traced to primary encephaloid in the spleen. In the same way encephaloid growths upon the lip and in the mammary gland develop the disease in distant lymphatic glands. The mere contact of a cancerous growth of one organ wdth the surface of another is, in some instances, sufficient to propagate the disease. For we some- times meet with encephaloid of the liver inducing en- cephaloid in that portion of the mesentery with which the organ is in intimate contact. Thereby showing that when the constitution is saturated with the can- cerous cachexia, the transudation of morbid fluids into a healthy structure in mere contact with a diseased DISEASES OF THE LIVER. one is sufficient of itself to induce the development of malignant growths. Numerous other instances of encephaloid cancer spreading by mere contact (from the stomach to the liver, and vice ver>ia^ for example) could be adduced. But who can point to a single case where a scirrhous tumour has ever propagated its species either by contact or any other means whatever ? When Mr. Z. Lawrence was preparing for the press his book on cancer, I performed a number of experiments for him on the inoculability of cancer, among which was the following crucial one with scirrhus. The result of which completely negatives the idea of scirrhus being: a malisriant disease. The experiment was planned with the object of testing the possibility of communicating scirrhous dis- ease from one living mammary gland to another by keeping a freshly made surface, two inches in dia- meter, of a living scirrhous tumour in close contact with an equally freshly made surface of a healthy living mammary gland of an animal of the same species. Although this was done for thirty minutes, and at the end of that time the two mammary glands were found to be in a measure glued together by the exudation from their cut surfaces, not a vestige of the disease was communicated from the scirrhous tumour of the diseased to the healthy mamma of the other dog. At least during the year the animal was kept under observation. I may further mention that I EXPERIMENTS WITH SCIREHUS. 889 have repeatedly injected scrapings from scirrhous tumours freshly removed from the human subject into the veins, as Tvell as under the skin, of healthy dogs, without on one single occasion having so much as seen more than a trivial temporary inconveni- ence arise from the inoculation. Most assuredly not so much as a vestige of scirrhus or any other form of tumour was ever discoverable in the bodies of Elements of Scirrhus from a Human Mammary Gland. any of the animals experimented upon. Which were killed, and carefully examined at varying periods from one to eight months after the inoculation had been made. As regards the histological elements of scirrhus, again, they bear not the remotest resemblance in any respect whatever to those of true cancer, as before depicted (fig. 25). For they are spindle-shaped fibre cells, with no large nuclei or Brownian granules. The 890 DISEASES OF THE LIVER. accompanying fig, 26, which is also from the morbid histological part of m)^ ' Demonstrations,' shows roughly, though exceedingly well, the elements met with in an ordinary scirrhous tumour. In deciding upon what tumours of the liver ought, and upon what ought not, to he considered malignant, it may be convenient to recollect the fol- lowing characters, which, when coexistent, at once decide the growth to be malignant in its nature. a. The tumour has a milky juice, which, under the microscope, is found to be full of variously shaped large granular nucleated cells (fig. 25). h. The growth has no well-defined outline, but gradually shades away into the surrounding tissues. c. It is generally soft and pulpy. Mottled red and white. d. The neighbouring lymphatic glands are cer- tain to be affected if the disease has existed for any length of time. e. The disease is associated with the ' cancerous cachexia.' Finally, — The disease to which I opine ought to be restricted the name of cancer is a constitutional and not a merely local affection. Its local manifesta- tion in any one part or in any series of parts of the body being exactly analogous to the local manifes- tations of small-pox, glanders, contagious jaundice, or any other form of germ diseases, of which I regard CHARACTERS OF CANCEROUS GROWTHS. 891 cancer as being one. Consequently, as the vice is in the patient's system, the removal of the merely local manifestation of a true cancer by the surgeon's knife or by the empiric's caustic is an uncalled-for piece of cruelty. Just as much as would be the ex- cision of a malignant pustule. The operation, instead of retarding, invariably (in consequence of its weaken- ing effects on the patient's constitution) hastens, the fatal end. For no matter however skilfully the local manifestation may be extracted, its removal can never eradicate the vice from the system. Hence it is that a local manifestation of true cancer always recurs either in the same or in some other part of the patient's body ; not once merely, but again and again after each successive operation for its artificial removal. Which fact of itself is proof positive that cancer is a constitutional and not a merely local disease, as some would have us imagine. While studying the subject of cancer of the liver, it is essential to remember that strange forms of tissue metamorphosis may occur in the organ. For example, a simple inflammatorj^ tissue degeneration may change into a hard scirrhous tumour. Which in its turn may gradually become metamorphosed into a soft juicy encephaloid. There are but few excep- tions to this general law of developmental change. But fortunately one does exist, and that is, that en- cephaloid parasitic germs sometimes die, and, like the 892 DISEASES or the liver. larger forms of parasites (triclima, hydatids, &c.), spontaneously undergo calcareous cretification. As tlie history of a nation repeats itself, so do tlie doctrines of its people, and it will be noticed that my saying a cancer is a germ disease is tantamount to saying that it is a parasitical form of disease. And in so saying I but resuscitate the old doctrine that a cancer is an animal ! I think that I showed in my series of papers on germs, in the ' Lancet ' (June and July 1881), that Brownian granules (the form of germs so constantly present in all varieties of encepha- loid and melanotic cancers) have a much stronger claim to the title of animal than of vegetable germs. Hospital dead-house statistics show that the liver comes next to the uterus as regards its proneness to be affected with those forms of tissue degeneration which have hitherto been grouped together under the common name of cancer. Etiology of Hepatic Cancer. This is a most important subject both in a diai gnostic and therapeutical point of view, for a know- ledge of the exciting causes, as will presently b seen, materially facilitates not only the diagnosis, but even the treatment of obscure cases. The most common of all exciting causes of he- patic cancer is hereditary predisposition. And, in order to raise the suspicion of the existence of this important i ETIOLOGY OF HEPATIC CANCER. 893 diagnostic factor, it is not at all necessary to be able to discover that a parent or grandparent, a sister or a brother, an uncle or an aunt, have suffered from the same form of disease. All that is requisite to furnish legitimate grounds for the suspicion is that some blood relation, no matter how distant, cousin or half cousm, has been affected with some form or another of malignant disease in any part of the body — the brain or the stomach, the uterus or the ovaries, the testicles or the mammce, or even in the limbs. For it matters not one whit where the cancer has been located. The mere fact of its having existed being of itself sufficient to raise the suspicion of hereditary taint. For the locality in which the visible manifestation of the constitutional disease appears is in many instances the result of mere accident. For example, a blow on the breast may induce a cancer to form in that locality in one, while a blow on the liver will induce an hepatic cancer in another member of the same family. Moreover, it is well to bear in mind that a cance- rous inheritance may descend through several genera- tions, even though missing more than one in direct succession. It is a noteworthy fact, too, that cancer appears to be common in tuberculous families. Frequently tuberculous parents give birth to cancerous children, and m connection with this point, after what was 894 DISEASES OF THE LIVER. said regarding the prevalence of Brownian granules in enceplialoid and melanotic cancers, I may mention that not only I, but several other microscopists, have noticed how exceedingly common not only Brownian granules, but the next stage of their higher develop- ment — namely vibrios — are in the sputa of advanced phthisis. In persons constitutionally predisposed to cancer, a mere trifle seems in some instances to be suffi- cient to call it into existence in the liver. Xot once, but on several occasions, patients have attributed the presence of the cancerous growth in their liver to an antecedent injury to the organ. Indeed, the more attention I give to this point, the more impressed do I become with the belief that mere mechanical injury to, or irritation of, either the nerves or tissues of the liver is a far more frequent exciting cause of its mahgnant degeneration than the majority of phy- sicians imagine. I suppose that all or nearly all surgeons are now ao'reed that direct injury to female mammae is a common cause of cancer of the breast. So I shall now do my best to make physicians equally alive to what I believe to be a fact, namely, that injury to, or irritation of, the liver is often followed by malignant disease in that organ. I shall cite cases in support of this opinion. And, to begin with, I quote what I reo-ard as a typical example. It is recorded by EXCITING CAUSES OF CANCER. 895 Dr. Pye Smith in the thirty-first vohime of the Pathological Society's ' Transactions.' It is there stated that a healthy countr}^ boy, aged about 12 years, three months after having had a fall on his side noticed a swelling, which gradually in- creased and gave pain. It was accompanied with fever and occasional coffee-coloured urine. He died in fifteen months after he first sought advice ; that is to say, about sixteen or seventeen months after receipt of the injury. At the autopsy, although the boy was only twelve years of age, his liver weighed two hundred ounces. The cancer consisted of ' circumscribed masses of soft yellow material,' and was limited to the right lobe. Having already referred to a case where cancer of the liver followed upon the irritation caused in the digestive canal by the performance of gastro-entero- tomy, and to another where it was associated with the presence of gall-stones, I will ask the reader to peruse the chapter on cancer of the gall-bladder, as he will there find other illustrative cases, among which is an interesting one wliere the presence of gall-stones appears to have been the direct exciting cause of can- cer both in the liver and in its bile-ducts. While, from the history of the following case, it even appears as if a mere hepatitis were sufficient to excite the development of cancer of the liver in a predisposed constitution. For among four cases of primary cancer 896 DISEASES OF THE LIVER. of the liver, occurring in natives of India, related by Dr. Ewart in the ' British Medical Journal ' of September 18, 1880, there is one strongly sugges- tive of this opinion. It is as follows : — - A Hindoo woman, aged 45, whilst in the enjoy- ment of good health, was seized with hepatitis, and suddenly became jaundiced, with porter-coloured urine, white evacuations, and itchiness of the skin. Jaundice was so extremely developed that a yellow tinging was observed in the tears, as well as in the mucous lining of the mouth, fauces, and in the nails of the fingers and toes. There was yellow vision. The liver reached to the iliac crest below, and to the nipple above. There was no pain or tenderness. Purpuric spots ap^^eared on the face, hands, arms, and trunk ; the kidneys gradually struck work ; coma came on ; and, after remaining in a state of in- sensibility for two days, she died. On post-mortem examination, the liver weighed one hundred and thirty ounces. It was nodulated from cancerous growths. The glands around the common duct were enlarged from cancerous growth, causing the complete obliteration of it and of the cystic duct. The gall-bladder contained a small quantity of pale-coloured fluid. Some of the bile-^ ducts were enormously dilated, and distended witl bile. The left lobe was free from cancerous materialj Every other organ was healthy. In connection with the excitins: causes of cancer] EXCITING CAUSES OF CANCER. 897 I may mention that it is my opinion that cancer- germs, like other disease-germs (as I showed in the series of papers I published in the ' Medical Times and Gazette ' in November and December 1881, on the action of germs in the production of human diseases), may lie latent or dormant in the system for years, and yet at length be called into sudden developmental activity by some trifling local irritation or constitu- tional disturbance. I have now to call attention to another important fact in connection with the etiology of hepatic cancer. Which is, that while the liver may be the seat of soft ■encephaloid, some other organ of the body may at the same moment be affected with what is called a hard cancer. And what is more curious still is the possi- bility of the soft cancer owing its origin to the irri- tative effects of the pre-existing hard growth. A case of this kind came under the notice of Mr. Nunneley in 1858. The patient, an elderly maiden-lady, had first a painful scirrhus of the right breast, and then in a year later began to complain of acute pain in the region of the liver. She died within the second year, apparently from exhaustion, and at the post-mortem, the liver was found three times its natural size, and infiltrated throughout with me- dullary fungoid matter. The latter soft form of dis- ease, though apparently not only supervening on, but depending upon the pre-existence of, the hard tumour, 3 M 898 DISEASES or the liver. yet far outstripping it in rapidity of growth. It has long been known that two allied forms of cancer- might even exist in the liver at one and the same time ; for cases had again and again been met with where a melanotic degeneration was associated with an encephaloid cancer. This pathological fact, how- ever, is not, and cannot be, regarded as anything extraordinary. Seeing that a melanotic degeneration is often a mere sub-form of pigmentation of an en- cephaloid tumour, Nunneley's case was, as seen, quite different from this, and is exceedingly valuable in teaching us the important clinical lesson, never to imagine, because we have a hard scirrhous growth in a visible organ, that its secondary form of growth attacking the invisible liver must necessarily possess the selfsame morphological elements and pathological characters. Signs and Symptoms of Cancer of the Liver. Before detailing the symptoms usually given in text-books, I wish to call special attention to four essential factors in connection with the diagnosis of malio-nant disease of the liver which we are not nearly, I consider, sufficiently alive to. Namely : — 1. That trvie malignant disease of the liver may, and actually does, occur at any period of life between the cradle and the coffin. In proof of this I may refer to the caye recorded SIGNS AND SYMPTOMS OF CANCER. 899 by Dr. Grouse (' Philadelphia Medical and Surgical Reports,' 1874) of a child who was found to have encephaloid disease of the liver when it was less than five months old. The tumour was nodulated, increased rapidly, and gave rise to the cancerous cachexia. The infant died when it was about a year old, and at the necropsy the liver was found softened, and is said to have actually weighed between fifteen and twenty pounds ! and to have nearly filled the whole abdominal cavity. A microscopical examination of its tissue proved the disease to be encephaloid. Two aunts of this child had died, it was said, of scirrhus ; but both its parents were quite healthy. Cases of this kind in infants are exceptional. In- deed, it might almost be given as an aphorism that malignant disease of the liver increases in relative frequency in direct proportion as age advances. 2. In the vast majority of cases cancer begins in, and is entirely limited to, the right lobe of the liver. 3. In all cases of malignant disease of the liver, at any rate towards their latter stages, there is present more or less of a well-marked cancerous cachexia. 4. Not alone is jaundice by no means a necessary concomitant of hepatic cancer, but it is in reality seldom associated with it. For by a calculation I have made of reported cases it seems that no less than ninety-four out of every hundred are unaccompanied 3 If 2 900 DISEASES OF THE LIVER. by a distinctly icteric tint. In not more than about six per cent., therefore, of cases of hepatic cancer is jaundice encountered. This statement may appear to be startling intelligence to some, but it is never- theless quite true, as can be shown by reference to hospital dead-house statistics. Thus, for example, those of the Middlesex Hospital, which were pub-, lished by Dr. Vanderbyl in the ninth volume of the Pathological Society's ' Transactions ' (p. 234), show only two cases of jaundice in a total of twenty-nine of hepatic cancer. The reason of this rarity of jaundice in cases of cancer of liver is readily explained when it is re- collected that, as I previously showed, jaundice can only occur from a blocking- up of the hepatic or common bile-ducts, or from a total arrest of secretion; and cancer seldom either completely occludes the ducts or destroys all the bile-secreting structures. The first symptom, and one upon which great stress is usually laid in text-books, is that of pain in the right hypochondriac region, and no doubt it is a constant one ; but pain is so common an accompani- ment of hepatic disease, that it is necessary for me to say something more about it than is generally said in books. To begin with, I may state that it is to be differentiated from the pain produced by gall-stones, for which it is often mistaken, and vice versd, by its being neither acute nor paroxysmal, in general being I SIGNS AND SYMPTOMS OF CANCER. 901 described by the patient as of a dull aching character. Firm pressure always increases it, and sometimes causes it to assume an acute and stinging character at the part immediately beneath the seat of pressure. In hepatitis (for which the pain of cancer is apt to be mistaken), the pain is not only more acute, but at the same time it is invariably accompanied by febrile symptoms. The only other form of pain with which that arismg from cancer is likely to be con- founded is that associated with abscess ; but here again the difficulty in differentiation is but slight, when it is remembered that rigors and hectic are the almost invariable accompaniments of suppuration of the liver. The next sign of hepatic cancer upon which em- phasis is usually put is enlargement of the aiFected organ, or part of the affected organ. For the whole liver is seldom implicated, from the simple fact that the patient usually succumbs before the disease has spread itself over the whole organ — though there are even exceptions to this rule. The sign of hepatic enlargement, though of some value in the majority of cases, is unfortunately not to be depended upon, from the fact, as I shall now proceed to show, that even fatal forms of hepatic cancer may be present, and yet the liver, instead of being above, be actually below the normal dimen- sions. 902 DISEASES OF THE LIVER. My former colleague, Professor Charles Hare, had a case where the whole cancerous liver weighed only- twenty ounces ! And Dr. Fagge has recorded another, which he named primary contracting scirrhus of the liver, weighing thirty- six ounces and a half. It came from a man aged 52 who had ordinary ascites. On post-mortem, examination was found a granular cir- rhotic-looking liver. Some of the lobules contained cheesy-looking matter and were friable. There was a thrombus in the portal vein. ( See rem arks at p. 1 030. ) At the February (1881) meeting of the Birming- ham Branch of the British Medical Association, Dr. Mouillot showed a liver in which cirrhosis and scirrhus were both present ; and the appearances suggested that the scirrhus had supervened upon an already cirrhosed liver. In contradistinction to these exceptional cases of small liver I shall now cite the startling one already alluded to as having been recorded by Dr. Gordon, where the liver, instead of weighing from forty-five to fifty ounces,, as it ought, if healthy, to have done, weighed no less than 380 ounces. The case is recorded in the ' Dublin Quarterly Journal ' of November, 1867. It was one of encephaloid disease in a man aged 50, who never suff'ered from jaundice, and in whom the organ was supposed to have in a single month attained the enormous weight of twenty-four pounds. RAPID GROWTH OF HEPATIC CANCER. [)()6 According to Dr. Gordon's measurements, the man's liver increased from about six pounds in weight on January 1, to twenty-four pounds on the 31st — the day he died. That is to say, it increased at the rate of nearly ten ounces daily. For Dr. Gordon says that on January 1, 'as far as could be judged from external measurement, it was about one-fourth of the dimensions it subsequently attained.' At the post-mortem ' the enlarged liver seemed to occupy the entire abdominal cavity.' The only symptoms at first noticed were pain and rapid emaciation. But within a few days of his death he became anasarcous. The urine was scanty, with a copious deposit of Hthates. Two days previous to the patient's death the abdominal pain became so intense that the .patient fell into a state of collapse, from which he never rallied ; and this was found after death to have arisen from a perpendicular rent having taken place in the peritoneal covering of the right lobe, of about '"three inches in extent, from which a quantity of blood had escaped. The liver had lost all its normal ' shape, and looked like a great ball thickly studded -over with cerebriform tumours, numbers of which were also in the lumbar glands, as well as in the peritoneal and pleural cavities. This is an exceedingly and exceptionally rapidly i^owing case of hepatic cancer ; but it is by no J means the only example with which I am acquainted. u 904 DISEASES OF THE LIVER. for several cases of very rapidly developing encepha- loid of the liver are on record. When I say ' rapidly developing,' I mean, the illness from its beginning t the fatal termination not having exceeded a period of six months. Even some of the cases have been subjects under 25 years of age. It may be said that, as a rule to which there are but few exceptions, cancerous growths in the liver are insidious in their onset, and slow in their progress — . which is fortunate for the practitioner in a diagnostic point of view, as it enables him, in diagnosing cancer of the liver, to eliminate from his calculation the acute congestive forms of hepatic enlargement, all of which, malarial and other, as a general rule, are sudden in their onset and rapid in their progress. As reg:ards the averao;e amount of enlaro-ement of the cancerous liver, I think it may be said not to be great. For on looking over the weights given of diflPerent livers, I find that the whole organ, cancerous mass and all, is in general stated to have ranged between sixty and ninety ounces. The next valuable diagnostic sign of the existence of hepatic cancer usually given in books is nodula- tion of the abdominal surface of the liver. I believe that far too much importance is attached to this sign, from the fact that not only is it sometimes absent, even in the encephaloid as well as in the colloid varieties of the disease, but it occasionally happens i SIGNS AND SYMPTOMS OF CANCER. 905 that a distinct nodulation is perceptible when no form of cancer is present. As, for example, occurs in certam cases of superficial multiple abscesses and hydatids, which render the differential diagnosis all the more embarrassing, on account of their often being not only of exactly the same size — as big as chest- nuts or orang-es — but communicatino- to the hand the same sort of indistinct feeling of fluctuation. Fortu- nately in these cases we have a differentiating guide in the presence or absence of the cancerous cachexia. For, as far as I have been able to make out, when cancerous nodules are perceptible, the system is al- ways so impregnated with the morbific agent as to give evidence of its presence in the complexion. Here, too, the existence or absence of jaundice is a sign of no avail. For it is as fi'equently absent in cases of hydatids and suppurative disease as it is in those of cancer. The sign to which I attach the greatest impor- tance in a suspicious case is the existence even of a very slight cancerous cachexia. For it, I believe, is pathognomonic. So that whenever T detect its pre- sence, especially if it is associated with a cancerous family history, I put down the enlargement of the liver, in absence of other evidence to the contrary, as due to malignant disease. Besides the above-mentioned physical signs, there are also a variety of constitutional symptoms which 906 DISEASES OF THE LIVER. may be regarded as aids to the arriving at a correct diagnosis. For example, in malignant cases there is in general some derangement of the digestive and assimilative functions, furred tongue, torpid bowels, flatulence, and nausea. Or the digestive derangement may assume somewhat of the opposite form, and diarrhoea, and even vomiting, be prominent symp- toms, leading to the suspicion that the cancer is seated in the stomach instead of in the liver. A circumstance easily accounted for, from the fact that the liver and stomach are such highly sjnnpathetic organs that cancer of the one is often accompanied with cancer of the other. In fact it is generally believed that hepatic is very often secondary to sto- machical cancer. Some say that it is so in at least a third of the cases met with. In the next place, as may be judged of by what was previously said regarding the influence of age on the relative frequency of malignant disease of the liver, the time of life at which the patient has arrived fur- nishes a not unimportant factor in the diagnosis. For cancer of the liver is, comparatively speaking, rare 'before the age of 25, and is most common between the ages of 40 and 60. Even infancy, however, as was be- fore said, does not preclude the possibility of the case being one of soft cancer. In addition to Dr. Grouse's case of encephaloid which began when the child was /Oiily five months old, I may allude to the one Dr. liVest has recorded at page 732 of the sixth edition of EAELY DEVELOPMENT OF HEPATIC CANCER. 907 his book ' On the Diseases of Infancy.' The patient was a boy only eight months old when he began to lose flesh, and within a month afterwards his mother noticed solid masses in his abdomen. He became exceedingly sallow, and sufi'ered from diar- rhoea, which, accompanied as it was with severe paiu, killed him at the age of twelve months. The tumour felt in the abdomen, which was larger on the left than on the right side, turned out to be the almost healthy left lobe pushed out of its place by the en- larged and diseased right lobe, part of which was converted into a soft white brainlike matter, mter- mingled with which were portions of a firmer, highly vascular, fibro-cellular substance. A few deposits of medullary cancer also existed in the right lung. As a further aid to diagnosis I may specially men- tion the fact that whenever cancerous disease of the liver is sufficiently advanced even to make its presence suspected, it usually runs a rapid course. I am not alluding to the hard forms of so-called cancer, which are invariably of slow growth, but only to what I have said I consider deserving of the title of true malignant disease. Namely, soft growths. Negative Signs and Symptoms of Hepatic Cancer. a. Jaundice is rare, even a slight icteric tint seldom being seen in more than one out of every seventeen cases of the disease. h. All signs and S3miptoms of pyrexia are, in cases 908 DISEASES OF THE LIVER. of non-complicated cancer of the liver, totally absents It may be indeed confidently affirmed that fever is never present unless in connection with some form or another of mdependent disease, as, for example, when inflammatory action occurs as an accidental compli- cation to the malignant disease. c. Acute pam is seldom or never present. d. The superficial veins of the abdomen are seldom enlarged, as it rarely happens that the can- cerous growths implicate either the vena cava or the main trunk of the portal vem. e. Ascites is, for similar reasons, also uncommon, except in the very last stage of the disease, when the general debility of the absorbents becomes manifest in this way. Some of the difficulties encountered in the dia- gnosis of hepatic cancer having been already made apparent, both in a case of inspissated bile, and in one of gall-stone, in the respective chapters on these sub- jects, it only remains for me now to adduce a typical example illustrative of the forms of difficulty which now and again beset the path of its diagnosis, in order that it may serve as a danger-signal. For- tunately I have ready at hand a most remarkable as well as a most instructive case. For its history at one and the same time embodies in itself the most salient points of embarrassment as well as of their solution. DIAGNOSIS OF AN OBSCURE CASE. 909 The case I refer to is that of a gentleman who was connected with one of our large metropolitan public institutions, which presented nearly all the difficulties in the way of diagnosis it is possible to imagine. So very anomalous indeed were its signs and symptoms that one of our most accomplished hospital physicians diagnosed it for, and treated it as, a case of malignant disease, when not a trace of cancer, as subsequent events proved, was present in his system. I first saw the patient on March 3, 1869, at which time, in spite of his being strong enough to come by himself to consult me, he had all the appearance of a man tottering on the verge of the grave. The account he gave of himself was that for several months previously his health had gradu- ally failed him. The first prominent symptoms that attracted his attention having been a feeling of dis- comfort, scarcely amounting to actual pain, in the right hypochondriac region, accompanied with a general feeling of malaise and loss of strength, which soon increased to such an extent that he could not exert himself either bodily or mentally. These symp- toms were associated with a marked sallowness of the complexion, which rapidly merged into a decided jaundice. It was then noticed that his stools were of a pipeclay colour, and the urine of a very dark tint. As he not only felt but looked very ill, and was likewise losing flesh, his medical attendant took a 910 DISEASES OF THE LIVER. gloomy view of his case, and called in Dr. (now Sir) George Burrows, who, after a very careful examina- tion, pronounced the case to be one of malignant disease of the liver, which would inevitably end fatally, and that too, as the disease appeared to be progressing rapidly, at no very distant date. Seeing that this weighty opinion exactly coincided with that of the other medical men he had previously consulted, the patient was advised to give up all further attempts at performing his public duties. A piece of advice which, from its being in accord not only with his own feelings but with the opinion of his family, was at once acted upon, and resigning his appointment he retired to a pleasantly situated country house, there to await, as he said, his summons to eternity. Some weeks afterwards he was led by the earnest solici- tations of Mr. E. Jacob, surgeon to the Birkenhead Hospital, to come and consult me. This being the brief history of the case up to the time I first saw him, I shall now relate its subsequent history from personal observation. When he entered my study, he looked like a man, as I before said, on the brink of the grave. He was thin, haggard, and sallow. His liver was enlarged, measuring in the perpen- dicular nipple line over six inches. It was tender, but not acutely painful on pressure, except at one point, and that was directly over the gall-bladder. He complained of all the before -mentioned symptoms DIAGNOSIS IN AN OBSCURE CASE. 911 in a more or less marked manner. He had no pruritus as in gall-stone, and no cancerous cachexia as in malignant disease, nor febrile symptoms enough to justify the enlargement being diagnosed as one of an inflammatory kind. While, on the other hand, the pain negatived the idea of hydatids, or amyloid or fatty degeneration, being the cause of the increased size of the organ. To add still further to the difficulties in the way of diagnosis, the enlargement of the liver seemed to be general, which is seldom the case either in cancer, abscess, or hydatid disease, in all of which it is usually the right lobe of the organ alone that i& afl'ected. It did not look exactly like a case of impacted biliary concretion or calculus, (a) On accoimt of there being but little acute pain, and (b) its advent having been gradual, (c) There being no itching of the skin. (d) There being intense pro- stration, and (e) increasing loss of flesh. A case presenting such a combination of anomalous signs and symptoms I had never up to that time seen. So I felt sorely puzzled to say what it really was. The patient, being a man of mental acquirements, had given no ambiguous answers to my questions. On the contrary, he had given me the history of his case, and explained its symptoms; , with unusual lucidity, as well as detailed the opinions of the difl'erent medical men he had consulted with a minuteness that tsur- 912 DISEASES OF THE LIVER. prised me. From their all being of the opinion that it was an example of rapidly advancing malignant disease, and the absence of a cancerous cachexia making me doubt the correctness of that diagnosis, I hesitated in givmg an opinion before I had analysed the urine. After summing up in my mind the respective values of all the negative as well as the positive signs and symptoms, I came, by a process of elimination, to the conclusion that the case could only be one of three things : — Either an anomalous case of cancer, an anomalous one of gall-stone, or an anomalous one of chronic hepatic congestion, I therefore told the patient that, although not prepared to say what the case really was, I felt almost cer- tain that it was not one of malignant disease, and that I beheved a properly conducted chemical analysis of his urine would in all probability reveal its true nature. For, as I explained to him, if the urine was found to contain bile-acids it would show that the jaundice was due to obstruction of the bile-ducts, and thereby prove the case not to be one of chronic congestion, but one either of cancer or gall-stones. While, ao-ain, the amount of uric acid eliminated in the twenty-four hours would probably in its turn decide between cancer and biliary concretion. The course for me to pursue was therefore plain enough — subject the urine to a careful chemical analysis, and, diagnose according to its teachings. CHEMISTRY APPLIED TO AN OBSCURE CASE. 913 It was soon arranged that he should send me samples of his urine, with the estimated quantity he passed in the twenty-four hours, and come and see me again that day week, when I. hoped to be in a position to give him a definite answer. The urine arrived in due course, and was taken to University College for analysis. The analysis was made, and two most important facts were ascertained. First, it contained bile-acids, which, while it nega- tived the idea of chronic hepatitis, left it an open question whether the obstruction of the bile-duct was due to the presence of a cancer or a biliary concretion. Secondly, it contained little more than half the calcu- lated normal amount of uric acid, which in its turn, while it almost negatived the idea of cancer, strongly favoured the idea of impacted biliary concretion. Acting then upon the principle that out of a multi- tude of conflicting data it is wise policy to accept the theory, however weak it may be, least open to objection, I consequently accepted that of impacted biliary concretion, attributmg all the anomalous signs and symptoms presented by the case to the inconsis- tencies of the erratic course either of a fragment of inspissated bile or a true gall-stone. Being armed with the above additional piece of chemical knowledge, I was now prepared to put some more specifically defining questions to the patient, Avith the view of eliciting, if possible, some clue to ai> 3 N 914 DISEASES OF THE LIVER. antecedent bilious Mstoiy. They were put, and, the replies to them being all in the affirmative, I unhesi- tatingly told him that he laboured under no form of fatal disease whatever, but, on the contrary, one that was, barring accidents, perfectly curable. To my amazement he received this piece of information witli anything but thankfulness, plainly telling me that he thought it was very wrong of me to attempt to raise . futile hopes in the bosom of a man at his time of life, t who had learned to look with calm resignation on a speedily approaching end, and it would be cruel of me if I attempted to excite in the minds of his wife and children anticipations which he instinctively felt could never be realised. Naturally enough this made me feel the gravity of the position I had assumed ; but knowino; that I had not assumed it without due consideration, I simply replied : ' It is not I that say what is the matter with you ; it is science, and science is never wrong. Although I, as its inter- preter, may be wrong, I have only said what believe to be the truth, and I leave you to act upon it] or not, just as you please.' A little more conversa- tion, and it was arranged that, before my opinion was made known to the family, Mr. Jacob should be consulted. He was at once telegraphed for, and I had an interview with him the next day. After hearmg the view I took of the case, and having ex- plained to him the data upon which the opinion of CHEMISTRY APPLIED TO AN OBSCURE CASE. 915 its being one of impacted biliary concretion was based, Mr. Jacob, of bis own accord, said he would advise the patient to place himself at once unconditionally in my hands, and he hoped that the result would prove the accuracy of the diagnosis. From that day the pa- tient put himself unreservedly under my care. The fons et origo of his malady was attacked : the obstruc- tion in the common bile-duct was attempted to be removed, and with what success the sequel shows. Within six months from that day he was, compara- tively speaking, well. Never since has he had a relapse, and now, after thiii;een years have passed away, and he is seventy -four years of age, he is still in the full enjoyment of excellent health and spirits. I last saw him on July 10, 1880, when, being up in London, he paid me a friendly visit, and he then told me that he never had been in better health in his life and most assuredly his looks appeared to confirm thf^ assertion. For he looked both hale and hearty, and, as I said to him, hkely enough to live for twenty years to come. Here, then, is another admirable living example of the benefits which accrue from the introduction of pure science into the practical domain of clinical medicine. Seeing that the diagnosis of hepatic cancer is so difiicult, I shall now put into a synoptical form a few additional hints, which, when taken in conjunc- tion with what has already been said regarding its 3 « 2 916 DISEASES OF THE LIVER. symptomatology, may materially facilitate its de- tection. Additional Hints to aid the Diagnosis of Hepatic Cancer. 1. As fully three-fourths of the cases of true hepatic cancer are the secondary result of a precisely similar pathological condition pre-existing in another part of the body — the stomach, the intestines, the mammary gland, the uterus, &c. — a knowledge of the nature of the morbid product co-existing in the other organs of the body will, as a rule, suffice to reveal the true nature of the disease affectmg the liver. The one often being the mere prototype of the other. Be it colloid, scirrhus, melanoma, epithelioma, or what else it may. At the same time it must be remembered that, in accordance with the law of transmutability, cancers of different kinds may actually exist in the same patient at the same time. 2. When the nature of the co-existing morbid growth cannot be correctly determined, the existence of a well-marked cancerous cachexia, with enlargement of the abdominal, inguinal, axillary, or cervical glands, may be taken as evidence of the morbid hepatic deposit being encephaloid. 3. The palpable existence of nodules on the pa- rietal surface of the liver favours the idea of the case being one of encephaloid disease. Though colloid is also occasionally nodulated. DIFFERENTIAL DIAGNOSIS OF CANCERS. 917 4. If the disease progresses rapidly, the case may, almost for a certainty, be put down as one of en- cephaloid. For that is the form of hepatic cancer which is by far the most rapidly fatal. 5. If the so-called cancerous tumour is of slow growth, non-nodulated, hard, and resisting on pres- sure, and but slightly painful, it is most likely a non- malignant form of growth. 6. Primary hepatic cancer is frequently a true encephaloid. 7. AVhen a pulpy, non-fluctuating tumour pro- jecting from the surface of the liver can be distinctly felt, and other sjrmptoms and signs of cancer are present, but without a cancerous cachexia, the case is most likely to be one of fungus haematodes. 8. When in doubt, to diag-nose the case as one of encephaloid disease is wise policy. For as that form of cancer is by far the most common one affecting the liver, that opinion is the most likely to prove correct. 9. The enlargements and other derangements of the liver arising from multilocular hydatids, as well as from fatty and waxy disease of the hepatic tissue, have often been confounded with cases of cancer ; but if the before-mentioned signs and symptoms are care- fully considered, and if it is at the same time borne in mind that hydatid, fatty, and waxy enlargements are invariably painless, there is but little likelihood of even the novice confounding these affections. 918 DISEASES OF THE LIVER. 10. While studying the diagnosis of a suspected case of hepatic cancer, it ought never to be forgotten that frequently the disease has been preceded, if not even, as I suspect it often is, mduced, by the irritative effects of gall-stones, a blow, or chronic hepatitis. Hence the pre-existence of temporary jaundice with biliary colic can only be relied on as neo'ativino; the existence of cancer when there is a total absence of all cancerous cachexia. 11. In cases of cancer following upon chronically impacted gall-stones, the liver, though at first en- larged, becomes, in the long run, atrophied, and jaun- dice is in general a well-marked sign. 12. In cases in which cancer supervenes on an atrophied liver, the jaundiced condition of the skin ma}^ be well marked ; but I have never as yet met with one single case of hepatic cancer in which there has been severe jaundice associated with acute pa- roxysmal pain. I desire particular attention to be paid to this remark, as on more than one occasion I have seen not only an erroneous diagnosis result from a want of this knowledge, but, what may appear perhaps to be more extraordinary still, a false view to have been taken even of the pathological conditions met with at the autopsy. So important do I consider this point, both from a clinical and pathological point of view, that I shall here introduce the details of a tjrpical case of the kind, which shows how the inflam- ERRORS IN DIAGNOSIS AND PATHOLOGY. 919 matory agglutinated parts round the healed perfora- tion caused by a gall-stone may be taken for and described as a ' scirrhus ' by the gentlemen making the autopsy of the patient. The case I shall relate is that of a patient aged 50, a poet of local reputation, as well as the holder of a public appointment in one of our great pro- vincial towns, who, when I first saw him, was m- tensely jaundiced. The stools were pipeclay-coloured, the urine being at the same time loaded with bile. He told me that he suffered from acute pain, was sick, and had occasional rigors. With such character- istic signs and symptoms, I, of course, with scarcely more than a moment's thought, diagnosed the case as one of jaundice from obstruction of the common bile- duct by impacted gall-stone. I treated the case as such, and the patient slowly and gradually improved. The acute pain entirely disappeared, and the skin got less and less of a jaundiced tint. At length I lost sight of the patient altogether, and the first thino- I further learned of the case was fi'om reading a long and complimentary obituary notice of the patient in the papers sent to me by his widow. This led to a correspondence with her, and my being informed that ' cancer ' was the cause of death. To which I replied that as there had been a post-mortem, and I doubted the probability of cancer being the cause of the death, I should feel obliged if she would 920 DISEASES OF THE LIVER. forward to the medical man who made the post- mortem the letter which I enclosed. In which I stated my diagnosis to have been jaundice from obstruction to the common bile-duct from gall-stone. Knowing, of course, that it was quite possible that since I had seen the patient an important change might have taken place in his condition, and that it was within the range of probabilities that the impacted gall-stone which was the cause of all his symptoms and signs at the time he was under my care might have induced the development of cancer, I put emphasis in my letter to the medical attendant on the fact of my doubting that cancer was the imme- diate cause of the patient's death. This I did from my knowing that : — (^a) There had been, up till the time at least when I last saw him, not a trace of a cancerous cachexia. (^) The history of impacted gall-stone being exceptionally definite. (c) The existence of well-marked jaundice. Which facts, taken in conjunction with my being aware that all sorts of growths and tissue degenerations which lead i to fatal results are often erroneously spoken of asj ' cancerous,' when not a vestige of malignancy exists I in them, made me be thus particular. My letter j brought forth the following reply from Mr. W. O.j Jones, of Bowden, dated May 11, 1881: — ' After you last saw Mr. he gradually im- proved. The jaundice entirely disappeared. The liver | ERROKS IN DIAGNOSIS AND PATHOLOGY. 921 diminished in size until it could only just be felt about an inch below the ribs. The gall-bladder, which had been so markedly prominent, became imper- ceptible to the touch, and his healthy colour returned. He went to his business as usual, gained flesh rapidly, and his appetite and digestion were excellent. This happy condition of affairs lasted about seven months. At the end of February the old symptoms returned somewhat suddenly, though without any severe pain. He had occasional shivering and vomiting, great pro- stration, deep jaundice, no bile in the excreta from the bowels, urine very high-coloured, containing large quantity of bile. My diagnosis was, as in the previous attack, impacted gall-stone. For the first three weeks bile appeared in the faeces about half-a- dozen times ; since then there was never any trace of it visible. The liver enlarged untU it reached within a finger's breadth of the umbilicus. The gall-bladder became as prominent and hard as in the previous attack. There was never — although often searched for — any hard nodule felt in the liver. He gradually Bank and died on April 26. I made a post-mortem examination on the following day, but only opened the abdomen. The gall-bladder and ducts were very much distended and adherent to surroundinsf struc- tures ; the coats of the gall-bladder were a good deal thickened and of a dull white colour. The duct was twisted upon itself. On opening the gall-bladder, 922 DISEASES OF THE LIVER. a quantity of thin pale purulent fluid escaped. I passed my finger into the duct, and was surprised not to find any calculus. There was a contraction about half an inch from its opening into the duodenum, hard and gristly, and about half an inch in thickness, and completely closing the duct. I think there is no doubt that this was scirrhus, though I never saw a case of scir- rhus of the ductus communis before. On the surface of the fiver about a dozen small nodules like small marbles were seen, and one large one, as large as a small Tan- gerine orange ; this was covered by the ribs. On section of these, they presented the appearance of medullary cancer. The liver was nutmeggy throughout, and all the bile had degenerated into thin purulent fluic similar to what the gall-bladder contained. I shoulc very much like to know your opinion of the course oi the disease. Surely a case of cancer could not have lasted all these years, and apparently become cured for a time. Is it possible a large gall-stone could^ have passed without giving rise to the usual agonising pain ? Is it probable or possible that the thickening (scirrhus) was originally simply inflammatory thick- ening due to pressure of gall-stone (or even ulcera- tion), that during the seven months of comparative health this went on contracting, that it became cancerous, and that the liver became secondarily afi'ected ? ' As is here seen, the details of the autopsy givei INTLAMIVIATOKY THICKENINGS NOT CANCER. 923 by Mr. Jones make the pathology of the case as clear as noonday. (a) The cause of the patient's death was the per- manent occlusion of the common bile-duct. (b) The occlusion was the result of the inflam- mation which had been set up by the gall-stone which had perforated its way into and escaped unobserved by the intestines. The agglutinated mass not being a scirrhous growth, but the hard contracted and cica- trised tissues at and around what had been the seat of the gall-stone's perforation. (See pp. 625 and 855.) (c) The small projections on the surface of the liver, thought to be medullary nodules, were (in all probability) the ends of dilated bile-ducts. As is frequently known to be the case in cases of permanent jaundice from stricture of the common bile-duct, as I have already explained at p. 786. (d) Two things excluded the probability of can- cer having been the cause of the jaundice. 1st, the presence of rigors and acute pain, and 2nd, its dis- appearing for no less than seven months, and then reappearing and continuing up till the patient's death. This is not the history of a case of jaundice from cancer at all, but one of perforating gall-stone and subsequent permanent occlusion of the duct after the passage of the stone. (See pp. 112 and 769.) (e) The morbid anatomical conditions of gall- 924 DISEASES OF THE LIVER. bladder, twisted duct, and agglutinations, together with the described contraction about half an inch from the duodenal orifice of the bile-duct, all plainly indicate the course taken, as well as the subsequent effects induced, by a gall-stone that had ulcerated its way into the intestines. Further : — i (/) It was during the time that the ulcerated opening into the intestines remained pervious (that is to say immediately after the passing of the stone) that the patient's health improved, and the jaundiced tint of the skin disappeared, again to reappear on the complete cicatrisation of the ulcerated opening which killed the patient. Just in the same way as happened in the case the parts of which are repre- sented in Plate I., p. 113. Lastly, I think that I may venture to say from the result of experience that the signs and symptoms most often mistaken for cancer of the liver are those arising from chronically impacted biliary concretions. \ For even some of our most distinguished hospital physicians, to my personal knowledge, have fallen into this error. Which is not at all surprising, seeing that in both sets of affections there may be the com- mon symptoms of pain, vomiting, jaundice, prostra- tion, and emaciation. In some instances, indeed, the only way I know of distinguishing between the two classes of affections is to bear in mind that in the case of biliary concretions all the most marked signs and DIFFERENTIAL DIAGNOSIS OF CANCER. 925 symptoms are produced rapidly, whereas in cases of cancer they are, comparatively speakmg, of slow de- velopment. For example, in cases of impacted biliary concretions — inspissated bile, or gall-stones — a. The discoloration of the skin in most cases begins within seventy hours after the onset of the pain. h. Pipeclay- coloured stools and dark urine are equally rapid in appearing. c. The pain is not only acute, but accompanied, in the majority of instances, with rigors as well as vomiting. d. The vomiting in cases of gall-stone seldom occurs without being associated with paroxysmal pain. Whereas in cases of cancer the pain is seldom or never paroxysmal. e. The history of previous attacks of biliary colic, associated with clay-coloured stools and jaundice, taken in connection with a total absence of cancerous cachexia or enlargement of the glands, may, in the ma,jority of instances, be regarded as conclusive evidence against the case being one of cancer. Jaundice the Result of Cancerous Disease elsewhere than in the Liver. The most frequent cause of jaundice in cases of hepatic cancer is said to be the du*ect result of the pressure of the cancerous mass upon the bile-ducts 926 DISEASES OF THE LIVER. blocking up their canals. I must, however, call atten- tion to the fact that it is no uncommon thing for an occlusion of the common bile-duct to occur, not only from mere cancerous infiltration of its walls, but also from growths in their parietes, and that in both sets of cases a well-marked jaundice is produced. Likewise that cancer of the pyloric orifice of the stomach has been known to produce jaundice by ob- struction in consequence of its extending to the walls of the common bile-duct, and thickening them to a sufficient extent to entirely occlude the passage of the bile. But even when the walls of the duct have not been attacked by the malignant deposit, jaundice has also been known to occur from the pressure exerted upon the orifice of the duct by a pyloric or a surroundino* mass of duodenal cancer. Pressure on the duct from a malignant growth in the lesser omentum, without the liver itself or its appendages having been afi'ected by the disease, has also caused jaundice. Dr. Bristowe has recorded^ the case of a man aged 68, who suffered from jaundice, in whom the liver was small and the seat of scirrhous infiltration, and whose capsule of Glisson contained a few peritoneal cancerous nodules. The cause of the jaundice, however, was a scirrhous tumour of the lesser omentum, involving and constricting the walls of the common bile-duct. ^ Patholoyical Society's Transactions, vol. xi. p. 127. VENOUS OCCLUSION FROM HEPATIC CANCER. 927 Cancer of the Liver may cause complete Occlusion of the Vena Cava Inferior. A case of this kind is recorded by Dr. Little in the Dublin Pathological Society's ' Transactions,' 1878. The patient, a man 26 years of age, was only ill three months, and at the post-mortem the liver was found gTeatly enlarged, with deposits in it of spherical masses of primary cancer, which had caused such complete obstruction to the vena cava as to make the vena azygos assume the dimensions of the vena cava. There was a complete system of com- munication between epigastric, anterior intercostal, and internal mammary veins on the one hand, and iliac and thoracic veins on the other. Though the urine looked bilious, there was no distinct jaundice, and no ascites appeared until just at the last. The external veins of the trunk were distended and varicose, not only in front, but on the side of the body. In a case of Cancer of the Liver, Death may occur from Haemorrhage. A case of death from hcemorrhage from a medullary cancer of the liver occurred in Middlesex Hospital in 1861. The patient, a man aged 50, under the care of Dr. Goodfellow, suffering from jaundice, was suddenly attacked with great prostration, urgent vomiting, distended abdomen, rapid pulse, great pain 928 DISEASES OF THE LIVER. and tenderness in tlie region of the liver. The next day he vomited a quantity of dark bloody-looking fluid. This was soon afterwards followed by collapse, which m a few hours ended in death. At the post-mortem examination about six quarts of red bloody serum were found in the peritoneal cavity. While on the upper surface of the right lobe of the liver, and in contact with the diaphragm, was a coagulum weighing five ounces. Besides which the intestines were ' bathed with bloody fluid.' The liver weighed seventy-two ounces. The left lobe was atrophied to the appearance of a mere appendage of the right, not exceeding 1^ inches in diameter transversely, and had a cirrhosed granulated-looking surface. The surface of the right lobe was studded over with prominent nodules, varying from the size of a pea to that of a cherry. The larger of the nodules were elastic, and the haemorrhage was ascertained to have come from the bursting of one of them. In the interior of the liver were a number of cherry- sized cavities, filled with soft yellow cancer. The haemorrhage was supposed to have begun three days before the patient's death. Treatment of Hepatic Cancer. Alas ! for the credit of medical science, no cure has as yet been discovered for cancer. The physician's skill is unable to cope with it, for his pharmacopoeia 1 TREATMENT OF CANCER. 929 contains no antidote. The surgeon cannot conquer it, as his knife fails to reach constitutional disease. To alleviate its discomforts, to retard its inevitably fatal progress, is therefore all that is within human power. Consequently, when once the case has been clearly diagnosed as one of cancer, all our efforts must be directed to foster the patient's vital powers, to increase his strength, and to relieve his sufferings. In this respect we have much ^\4thin our scope, and fortunately for the credit of our profession we can even do more. For although we cannot eradicate the disease when once it has permeated the system, we have it in our power in many instances, even in the hereditarily predisposed, to ward off its attack. Things which of themselves may be regarded in the light of no small mercies, when it is considered that the babe in the cradle and the dotard on the verge of the tomb are alike liable to become the victims of the formid- able affection we denominate cancer. The lines of action which I recommend are as follows : — Having either detected the presence, or suspected the tendency to the development, of an hepatic cancer in a patient, an attempt ought to be at once made to stop the development of the local manifestation or control the growth of the disease. First, by improving the patient's constitution, and then maintaining it at as high a standard as is pos- sible. How can this best be done ? By diet by 3o 930 DISEASES OF THE LIVER. regimen, and by the avoidance of everything which tends to exhaust the vital powers or impede the proper performance of the animal functions. In order to do this successfully the patient's food must be of a mixed character. Flesh and fish, but neither salted nor high -seasoned. No frizzled bacon or salted haddock. No curries, sausages, or spiced meats. Let the flesh be that of mature animals, not of babes and sucklings, which is both indigestible and non-nutritious. Let the fish be sea-fish, but neither salmon nor mackerel, crabs nor lobsters. Allow a free supply of fresh vegetables and fruits, both cooked and uncooked. Let the vegetables be potatoes, cabbage, cauliflower, carrots, turnips, celery, lettuces, and watercress. Neither peas nor beans, for both are heating. No pastry, but milk and egg farinaceous puddings of all kinds. Corn-flour, rice, sago, arrowroot, tapioca, and such like. If stimulants are required, let them be those which possess nutritive qualities. Such as wines and beers. Not brandies or whiskies, which stimulate much, while they nourish little. Keep the skin clean, and in good acting condition, by a nocturnal and matu- tinal ' dry-bath,' in the shape of hair gloves, or skin scrubbing-brushes. Give plenty of opportunity for sleep, that is to say ten hours of bed. Avoid gynn- nastics and all possibilit}'- of receiving physical in- jury ; for nothing is so conducive, as already shown, to TREATMENT OF MALIGNANT DISEASE. 931 the local formation of a cancer in the predisposed as a blow or a bruise, from the fact that all local irrita- tions lead to tissue degeneration in predisposed con- stitutions, liegulate the outdoor exercise according to the powers of the patient, by telling him or her to walk as much as he or she conveniently can with- out being fatigued. The moment that fatigue has been experienced it is a sign that too much has been done, and consequently harm instead of good. The sensation of fatigue being nature's cry for rest. By a judicious and timely administration of remedies, relieve pain, promote sleep, and regulate the bowels. Prevention being always better than cure, the action of stomach, liver, and kidneys must be attended to with special care. Digestion favoured by stomachics, the biliary function by cholagogues, the action of the kidneys by diuretics. See that there are no deposits in the urine ; if there are, stop those of the acid variety by alkalies ; those of the alkaline and the earth}^ varieties by acids, on prin- ciples dictated by a mixture of scientific knowledge and common sense. Lastly, and not least, attention should be paid to keeping the patient cheerful, by diminishing as much as possible the cares of life. In fact, I generally embody my advice in the three following golden rules : — Take amusement, without excitement ; exercise, without fatigue ; and nutrition, without stimulation. 3 o 2 932 DISEASES OF THE LIVER. CHAPTER XIX. SYPHILITIC DISEASE OF THE LIVER. Syphilitic disease' usually attacks the liver in the form of well-defined, circumscribed nodules. The deposits vary in size, from small microscopic objects up to the dimensions of an orange, and present different naked-eye appearances according to their states of maturity. On section, a small pea-sized one has a distinctly reddish-white colour, while one, varying from the size of a cherry to that of a walnut, looks like a dirty yellowish-white mass, of moderately solid consistence. While, again, one as big as an orange has a decidedly yellow, cheesy, somewhat softened appearance. All appear to the naked eye to be surrounded i by a semi-translucent capsule, which, on close in- spection, however, is seen to be merely the differently] coloured outer margin of the mass, gradually shading away into the surrounding healthy liver tissue. So the nodules cannot be enucleated. When examined with the microscope, scrapings, as well as sections, are seen to be composed of a fine fibrous matrix, in I SYPHILITIC HEPATIC DISEASE. 933 •which are embedded fatty granular cells and albu- minoid matter, very like what one sees in true tubercle. Among the debris cholesterin crystals are occasionally visible. When the liver is injected, and the syphilitic nodules, after being hardened in absolute alcohol, examined under a microscope, they are found to be freely supplied with blood-vessels. SyphUitic present marked anatomical differences from cancerous liver nodules. For example, they never project from the surface of the liver, but, on the contrary, are always imbedded in its sub- stance, and, in consequence of the shrinkmg of the hepatic tissue, the portion of the liver over them is indented or even depressed. The large nodules show a great tendency to soften, but instead of softening into a creamy fluid, like medullary cancer, their softening resembles a purulent degeneration. Etiology of Syphilitic Nodules. a. They are almost always multiple. h. When small, they may occur in great numbers. So many as fifty, and even a hundred, having been met with in one liver. c. They are merely local manifestations of con- stitutional disease-germ impregnation. d. They are a tertiary form of syphilitic disease, and are associated with the special form of cachexia — the so-called syphilitic cachexia. 934 DISEASES OF THE LIVER. P. They may occur at any age. The mfant, as well as the adult, being liable to be affected with them. /. They may be hereditary as well as acquired. g. They frequently co-exist with similar growths in other parts of the body. h. Dr. Wilks (who has given special attention to these forms of liver deposits) justly, I think, com- pares them to the peculiar fibrous forms of deposit met with in the tongue, intestinal canal, brain, muscles, and testes of patients labouring under ter- tiary syphilitic disease. i. Syphilitic nodules are not unfrequently asso- ciated with tubercular deposits in the lungs, espe- cially those of the miliary variety. j. Moreover, we find that syphilitic nodules are also occasionally associated with amyloid degenera- tions. Not alone in the liver itself, but in other and distant organs of the body. h. Not only may syphilitic disease of the liver be met with at all ages between the cradle and the coffin, but it may even have an intra-uterine origin. For a child came under Mr. Canton's care at the Charing Cross Hospital, which was scarcely seven: weeks old when it died, and although the mother, a prostitute, aged 18, stated that she had never suffered from syphilis, the child had such distinctly copper-coloured syphilitic lepra spots over its body SYPHILITIC HEPATIC DISEASE. 935 as to leave no doubt in the mind of Mr. Canton that it was the subject of inherited syphihs. More- over, on the post-mortem examination, no organic disease whatever was found in the body, except a number of fawn-coloured, putty-like deposits, vary- ing in size from that of a pin's head to that of a pea, scattered irregularly throughout the liver. An excellent chromolithograph of their appearance is given in plate iv. vol. xiii. of the Pathological Society's ' Transactions.' Symptoms of Syphilitic Liver. Syphilitic disease of the liver only produces jaundice when it attacks the neighbourhood of the hepatic and common bile -ducts, and either implicates or compresses them to a sufficient extent to occlude their channels. Many continental physicians are, however, of opinion that the syphilitic taint itself is sufficient to induce jaundice, an opinion which I am not at all inclined to endorse ; for although syphilitic patients are, as a rule, sallow, few, if any, of those I have ever met with could be said to be actually jaundiced. Moreover, if jaundice is a concomitant of syphilis (although no doubt it may be the direct result of the syphilitic poison), I am certainly more inclined to look uj^on it as the product of the mercury which has been ffiven as a remedv for the disease. Mercury being one of the mineral poisons (as pointed 936 DISEASES OF THE LIVER. out in the special chapter upon the subject, p. 702) which produce jaundice. Syphilitic livers are seldom, if ever, appreciably increased in size. Hence we have not so much as that physical sign to aid us in their diagnosis. However, the absence of this sign does not much matter ; for whenever an ill-conditioned, anaimic, dark, bilious, sallow-complexioned, cachectic- looking syphilitic -tainted individual complains of hepatic discomfort, with disordered biliary symptoms, for which no direct cause can be assigned, the case is in all probability one of tertiary syphilitic disease of the liver. And this supposition may be considered j almost a certainty when tertiary syphilitic deposits are detectible in any other part of the body — as, for example, in the tongue or testes. Treatment of Syphilitic Liver Disease. The first step in the treatment of syj)hilitic disease of the liver is to improve the general health, and support the vital powers by administering every two hours small quantities of the most nourishing, non- stimulating kinds of food. Especially in the form of milk and egg farinaceous puddings, of which for- tunately we have a large supply to select from, and can vary them from hour to hour. For example, there are arrowroot, tapioca, sago, semolina, corn flour, revalenta arabica, rice, oatmeal, and a host of others well known to every housewife, who in this I TREATMENT OF SYPHILITIC LIVEE. 937 instance must act as the handmaiden of the doctor. Besides these farinaceous foods, animal and vegetable broths are to be freely administered, ox-tail and hare soups, rabbit, chicken, and neck -of- mutton broths. All kinds of white fish may also be given in modera- tion. But neither eels, salmon, nor mackerel, which of our native kinds of fish are the most liable to disorder the digestive and hepatic functions. More- over, all foods that have undergone the process of salting, as well as all tinned foods, are to be eschewed as being only moderately nutritious, while they are at the same time less easy of digestion. No beer or wine is, as a rule, to be given ; but of course where in any exceptional case either or both seem desirable, they are not to be forbidden. Then as regards pharmacopoeial remedies, we have in the an ti- syphilitic category a whole host to select fii'om. Mercurials, however, must in the majority of cases be left aside, and iodides and bromides employed in their stead. And as regards them, I may remark that I prefer, in the case of hepatic syphilitic disease, to give the patient ammonium iodides and bromides instead of potassium ones, on account of theu' being less lowering and more hypnotic. Lastly, careful attention to ordinary sanitary laws is indispensable, cleanliness being in this case an invaluable aid to treatment. Early to bed and early to rise is to be strictly enjoined. 938 DISEASES OF THE LIVER. Benign Forms of Hepatic Disease. The so-called benign forms of hepatic disease are not to be regarded as benign in the sense that ' they do not kill ; ' for, on the contrary, some of them at least are inevitably fatal affections. Their so-called benignness consists in the fact that they are not painful affections, and give rise to very little consti- tutional disturbance. Under the heading of benign affections of the liver regarded in this sense may be included hydatids, fatty, amyloid, and fibrous degene- rations, simple cysts, emboli, and blood extravasa- tions. Even a so-called fibrous degeneration, which, in contradistinction to forms of disease productive of grave constitutional symptoms, might be regarded as the type of a benign liver affection, is yet wholly beyond the powers of the liealing art. For though producing but little discomfort to the patient, it slowly marches on to a fatal termination, with as steady and as relentless a pace as the most rapid form of cancerous degeneration. None of these so-called benign forms of hepatic disease is necessa- rily associated with jaundice. Rarely indeed does the skin present more than a sallow appearance, while saffron- coloured urine is not often met with, and pipeclay stools rarely or never seen. 1 939 CHAPTER XX. HYDATID DISEASE OF THE LIVER. This disease resembles, in its medical history, cancer of the liver in four respects. Firstly in being not quite so uncommon a complaint in this country as the general run of medical men who have not made liver affections a special study, appear to imagine. Secondly, from its being one of those hepatic affections Tvith which jaundice is by no means necessarily, or even so much as usually associated. Thirdly, in generally attacking the right lobe of the liver alone. Lastly, in occurring at all ages. Etiology of Hepatic Hydatids. Although all my readers are of course perfectly aware that a hydatid of the liver is an animal para- site, possibly some of them may not be equally aware of the fact that the parasite is nothing more or less than an early and transitional stage m the life's history and strangely varied developmental career of a dog's tapeworm. A species of entozoon 940 DISEASES OF THE LIVER. also found in the intestines of the fox and the wolf. So it may well be asked, ' How does this parasite get from these animals into the human liver ? ' I reply, easily enough, and most probably in the following wise. A dog infested by a tapeworm passes thou- sands, nay, probably millions, of the parasite's eggs along with its faeces. The fa3ces becoming dry crumble into dust, to which dust the eggs of the tapeworm tenaciously adhere, the first gust of wind whisks them into the air, and they get blown about here and there and everywhere. At last some of them land in a fruit or vegetable garden, where they attach themselves to any ripe or unrij^e fruits and vegetables which happen to be m their way. Such as strawberries, gooseberries, apples, pears, lettuces, radishes, celery, watercresses, and all the other kinds of garden produce which are daily sold in our markets and hawked about in our streets, and which men, women, and children, rich and poor alike, often eat in an unwashed state, swallowing at the same tune all the worm-eggs which happen to adhere to them. A number, however, are not required to pro- duce a hydatid in the human liver. A single one is sufficient for that purpose — ay, even to generate a thousand hydatids. For so soon as it finds a suitable habitat in the human body, it hatches, develops, and multiplies with rapidity. No wonder then that hydatid disease is so common amongst us. The I ETIOLOGY OF HEPATIC HYDATIDS. 941 marvel to me is that it is not more common still. I may begin my description of the disease by making a few remarks upon the nature and life's history of the parasite which gives rise to it, the scientific name for which is Echinococcus hominis. An entozoon which differs considerably in its mode of action upon the human body from many other forms of entozoa. For in the first place it cannot develop and arrive at maturity in the body of the individual ia which it is born. It cannot so much even as advance beyond the embryo stage until it has changed not only its habitat but its host. Then, and then only, does it attain to maturity, and become capable of propagat- ing its kind by the production of eggs. Which, as I have just said, after being expelled from the intes- tiaes of their primary host, are subsequently conveyed by various means into another organism, where they develop into the larval form, and after a time become hydatids. In their turn agaia to change their host, in some cases returning even into the species of animal from which the eggs originally came, and then become mature animals — tapeworms. This pro- cess of change is characterised by the term ' alternate generation,' and in describing it authors make use of the terms Strohila. to signify the entire worm, sexually mature ; Proglottis^ the mature segment or joint ; Scole.v, the liydatid or larval form, which includes 942 DISEASES OF THE LIVER. the tapeworm head ; and Pro-'^cohw, the embryo con- tained in the ovum.^ The subjoined woodcut conveys some idea of the fonn and development of the scolices within the parent cyst as they are met with in the human liver. The echinococcus cysts, which are developed from the six -hooked embryo of the mature Tsenia, occur in Fig. 27. Echinococcus hominis (from Wilson). A, B. Grouped and single Echino- cocci, attached by peduncles to the inner membrane of the cyst, -f C. An expanded (a. The peduncle), and D, a contracted Echinococcus E. A shrivelled animal. various organs besides the liver. Even the lungs, kidneys, bladder, bones, neck, and several other parts of the human body are infested with them. In a case in University College Hospital, the fluid taken from an apparently serous cyst in a woman's neck, I found, on microscopic examination, contained a number of echinococci, thus proving the tumour to ' See Dr. Oobbold's excellent work on Entozoa, published by Messrs. Churchill. I ETIOLOGY or HEPATIC HYDATIDS. 943 be an animal parasitic hydatid instead of an ordinary serous sac for which it had been mistaken and treated. Hydatids are sometimes voided entire from the kidneys along with the urine. ^ Echinococcus cysts are often found in the liver of the horse and ox. Sometimes too in such numbers that scarcely any of the gland structure remains. When a man, a sheep, or any other animal swal- lows the ova, their shells are dissolved by the digestive juices, and the tiny coiled-up six-hooked embryos escape. They then bore their way through the coats of the digestive canal, and getting into tiie blood-vessels are floated alono; with the circulating blood to the liver, or some other equally appropriate organ, in which they find a house, or habitat, as it is in scientific language called. No sooner have they found an appropriate resting-place wherein to take up their abode than they at once settle themselves down, as it were, and immediately begin to grow, and very soon develop into what is known to us under the name of hydatids. Even within three months or so from their settling down in their new homes, heads, with booklets upon them, begin to make their appear- ance, and at the same time daughter, and shortly afterwards grand -daughter, vesicles are formed within the parent hydatid by a process of endogenous de- velopment. ^ Medical Times and Gazeffe, March 25, 1865. 944 DISEASES OF THE LIVER. From the foregoing brief sketch of the para- site's life's history in so far as it relates to the human liver, it will be readily perceived how easy it is for a person to become the victim of hydatid diseases by swallowing along with his food a pro- scolex from a dog's tapeworm. It being almost certain sooner or later to develop itself into a hydatid. Curiously enough, it appears that the right lobe of the liver is of all places in the human body the one the parasite is most prone to select for its habitat during the cystic stage of its development. Sometimes hydatids, developed in the hepatic organ, multiply, and spread themselves over the whole abdominal cavity, attaching themselves to the peritoneum, and penetrating into its substructures, be they intestinal, diaphragmatic, splenic, or renal. In f such cases the parasites may not only be numbered by dozens, or even hundreds, but by thousands. Dr. Gibb recorded a remarkable case of an enor- mous tumour of multiple hydatids ' springing from the anterior of the left lobe of the liver ... in- vading every part of the abdominal cavity, becoming incorporated with the neighbouring structures, and especially with the entire peritoneal surface, pene- trating it in front, at the sides, and upwards, the hy- datids being attached to the muscular structure of the diaphragm and the abdominal muscles.' . . . ' There were probably some thousands of the animals,' and I I HEPATIC HYDATIDS. 945 they destroyed life by arresting (by their compres- sion) its most ordinary functions.' The patient was a lad 16 years of age. (Pathological Society's ' Trans- actions,' vol. xvi. p. 159.) In examining patients suffering from hepatic hydatids, I have been particularly struck with the fact that in general they trace back the origin of their disease to the reception of a local injury — a blow or a squeeze on or in the neighbourhood of the liver. Of course this cannot possibly be the origi- nating cause of the animal hydatid, but is merely the reason of their attention having been called to its existence. The injury to the liver, or it may be perhaps to the parasite itself, producing sufficient inflammatory action and consequent local discomfort to call the patient's attention to it. Signs and Symptoms of Hepatic Hydatids. The chief points to be borne in mind in ascertain- ing the presence or absence of a hydatid of the liver in any suspicious case are the following : — Hydatid disease may occur in children from two years of age and upwards. I may even say that, like many other diseases of the liver, it may have an intra-uterine origin. For Cruveilhier says an infant, only a few days old, was brought to him with a well- developed hydatid of the liver, wliich must have had an intra-uterine origin of some standing, as the cyst, 3p 946 DISEASES OF THE LIVER. he tells us, burst spontaneously into the intestines as early as the twelfth day after the child's birth. The parasite, from some as yet inexplicable cause, in nine out of every ten instances locates itself in the right lobe of the liver. The growth of the parasite is so msidious and slow, that it seldom attracts the pa- tient's attention until it begins to cause discomfort from the pressure it exercises by its mere bulk on the neighbourmg organs. And even then it is, as a rule, regarded, from the inconvenience it causes being but trifling, as a mere harmless swelling. By the time the medical attendant is consulted, the cyst has usually attained a sufficient size to appear as a visible projection from beneath the false ribs. 1 once made the post-mortem of a man^ied woman, in University College Hospital, of 30 years of age, who, as far as I am aware, had never had an hepatic symptom in her whole life, and yet in the right lobe of her liver I found a hydatid cyst as big as a new-born child's head. ■ The tumour is usually perfectly painless, even on the application of firm manual pressure. But there are exceptions to this rule not generally recognised in books, to which it behoves me to call special atten- tion, m order to prevent the possibility of the practi- tioner committing a grave error in diagnosis. Some hepatic hydatid cysts have been brought under the notice of the medical attendant solely on account of their being painful. The most important case of this SYMPTOMS OF HEPATIC HYDATIDS. 947 kind, in a clinical point of view, with which I am acquainted, is one that was published by Dr. Risel in the ' Deutsche Zeitschrift,' Xo. 45, 1874, from which, on its being opened by a direct incision, nearly seventy ounces of offensively smelling, bile-tinged, purulent fluid was withdrawn. The pain in such cases is not due to the pressure of the hydatid itself, but to its being inflamed, and all its surroundings symj^athising with the inflamed con- dition of the cyst. Had the hydatid in Dr. Risel' s case been in a normal healthy state, I do not believe it would under any circumstances have been sensitive to pressure. In making a diflerential diagnosis in an obscure case of hydatid disease, it will be well, there- fore, to take into consideration the possibility of its being (under certain unusual abnormal conditions) tender to pressure. A hydatid tumour may be either soft, and give rise to a distinct feeling of fluctuation, or as hard and as resistmg as a stone. In order to save repetition I may refer the reader to a most remarkable example of this kind related at page 991, which I saw in consultation with Dr. Macaldin. If the hydatid be in close proximity to the ab- dominal walls, and the patient not corpulent, when the left hand is laid flat and firmly on the tumour, and smartly tapped upon by the knuckles of the right (the hands being tlius made to act the part of a pleximeter and hammer), a peculiarly tremulous 3 p 2 948 DISEASES OE THE LIVER. vibratory thrill — called the hydatid fremitus — is felt by the palm of the left hand, as it lies flatly and firmly pressed against the abdominal wall over the cyst. I am sorry to say, however, that this, which is otherwise a crucial and consequently a most important diagnostic sign, is far more frequently conspicuous by its ab- sence than by its presence. After having made this remark I rejoice at being able to add that, fortunately alike for patient and practitioner, the existence, in any given case, of a combination of any three of the above-named signs is in by far the majority of instances quite sufficient to lead to a correct diagnosis, if they are at the same time associated with an entire absence of distressing constitutional symptoms, and this, too, even when jaundice is present, as well as when it is absent. ' Unfortunately, however, as we shall presently see, all cases of hydatid disease of the liver are not equally easy of diagnosis. Some indeed baffle the skill of men of undoubted talent, and their consideration will specially engage attention a little further on. Mean- while we shall consider the subject of Jaundice from Hydatid Disease. Jaundice from hydatid disease is far from common, about ninety per cent, of the cases being without it. When it does occur it is caused either by the external pressure of a cyst obstructing the outflow of bile into I JAUNDICE IN HEPATIC HYDATIDS. 949 the intestines from the common bile-duct, or what is more often the case — though still rare — from the hepatic duct being plugged up by hydatids. This occurs, I have little doubt, much oftener than is imagined, from the fact that when the hydatids are discharged into the intestines the jaundice disappears, the patient gets well, and no opportunity is afforded of ascertaining the cause of the jaundice or verifying the diagnosis, even when correctly made. It is only in rare cases, when the cysts are detected m the stool or the obstruction is permanent, and the patient succumbs, that we can positively ascribe the cause of the jaundice to the blocking up of the common bile- duct by hydatids. Jaundice from the bursting of a hydatid cyst into the bile-duct is, I believe, b}^ no means an uncommon occurrence. For several cases have been reported, both in this country and abroad, where hydatids, or portions of hydatids, have been discharged with, and discovered in, the patient's stools, and their discharge having been followed by a sudden cessation of the jaundice and biliarj' colic with which it was accom- panied, has made the cases look like those of jaundice from gall-stones. Some of these cases unfortunately prove fatal, like one I shall presently relate that I saw along with Dr. Nuttall. (See page 981.) 950 DISEASES OF THE LIVER. Jaundice from Suppurating Hydatids. An unusual case of jaundice from a suppurating hydatid, where bile flowed out along with the pus on its being tapped, occurred under the care of Dr. Ramskill at the London Hospital in August 1873. The case was that of a Londoner who had during five years been subject to what he called ' ague.' He had usually had two attacks every year, each con- tinuing about a fortnight, which always commenced with cold sweating, on alternate mornings, between eleven and twelve o'clock. He had been jaundiced about a month. About the same time that he noticed the change in his colour, he found a lump growing in his right side, which gave him no pain. There was a tumour coming down from under the right ribs, and extending below the umbilicus, and a little to the left of the median line. During respira- tion it protruded, but did not descend. The mass was soft, very elastic, and indistinctly fluctuating. The patient was very prostrate ; his voice was re- duced to a whisper ; he seemed to be unable to move ; his temperature was 103 ; pulse, 120 ; and respira- tions, 36. The tumour was punctured, the pneumatic aspi- rator being used. Owing, however, to the canula becoming almost immediately plugged, only a few drops of thick off'ensive greenish fluid were evacu- JAUNDICE IN SUPPURATING HYDATIDS. 951 ated ; this, upon microscopic examination, showed a quantity of broken-up membrane, but no booklets. A free opening was made with a scalpel through the abdominal Tvall about two inches above and one inch to the right of the umbilicus, and the depth of the wound was cautiously increased, until the whole of the blade of the scalpel had disappeared in the wound, when a free flow of purulent matter took place, to the extent of fully sixty ounces. A drainage-tube was left in the wound, from which a discharge, which often appeared to be only bile, continued for some time. The patient expressed his sense of great relief soon after the operation. About a fortnight after- wards, the wound threatened to heal ; a tent was, therefore, put in, and on examining it, a probe passed in to the depth of fully six inches. The discharge continued, to the extent of about two ounces daily of creamy-looking pus mixed with blood. Three months after his admission his colour was natural ; he had gained considerably m weight ; the discharge had ceased, and the wound apparently closed, and the patient expressed himself as being ' very well.' This is a case well worthy of being put on permanent record as an encouragement to operate even in appa- rently very bad cases. Dr. Wilks has recorded ^ tlie case of a man aged 50, who died from an attack of jaundice, in whom ^ Pathological Societi/s Transactions, vol. xi. p. 128, 952 DISEASES OF THE LIVER. was found, at the post-mortem, a large suppurating' hydatid cyst of the liver, which had opened into an hepatic duct. The Amount of Jaundice is not in proportion to the Size of the Hydatids. That even very small hydatid cysts occasionally give rise to intense jaundice, is proved by the case related by the late Dr. Murchison, who had under his care, in the spring of 1869, a man, aged 34, with two small fluctuating and distinct tumours in the right hypochondrium. From the first five, and from the second seven, ounces of characteristic hydatid fluid were let out ; and although the cysts were small, yet the man was deeply jaundiced, evidently from pres- sure upon the bile-duct. After tapping, the jaundiced tint of the skin disappeared, thereby confirming the correctness of the diagnosis, that it had been the result of the pressure of the distended cyst on the* external wall of the bile-duct. A somewhat anomalous case of supposed ' com- pound suppurating hydatid of the liver ' is reported by Dr. Cockle and Mr. Rose in the ' Lancet ' of July 8, 1882. It is briefly as follows : — A man aged 37, who had sufl'ered from lumbago and loss of] appetite for some time, eventual^ observed that hisi feet and ankles were swollen at night, and, having caught cold, had shiverings, recurring at irregular intervals, with severe cough and difficulty of breath' HEPATIC HYDATIDS WITHOUT JAUNDICE. 953 ing. He had also pain in the stomach, and the area of hepatic dulness extended from the fourth rib in the right mammaiy line to two inches below the umbilicus. There was no jaundice. On December 2 there was a visible prominence over the middle of the enlargement. It was tense, elastic, with obscure hydatid fremitus on percussion, and a distinct feeling of fluctuation. Upon firm pressure over the pro- minence the fluid in the swellino- seemed to be dis- placed, reappearing slowly with a rebound as the pressure was gradually relaxed. These signs led to the diagnosis of a compound suppurating hydatid cyst of the liver. Mr. Rose opened the cyst by incision, on Decem- ber 6, under the antiseptic spray. An incision one inch and a half in length was made just internal to the cartilage of the ninth rib ; a large amount of pus and about five hundred hydatids escaped. They varied in size from an ordinary pea to two inches in diameter. A laro;e-sized caoutchouc drainao;e-tube was inserted. On several occasions durmg the progress of the treatment discharge of bile took place through the tul^e, and several of the cyst membranes were stained with bile. In many of the secondary cysts minute buds studded the germinal membrane. Such of the undamaged cysts as were microscopically examined contained booklets. Some cysts were passed iniptured and decomposing. A stercoraceous odour, tolerably 954 DISEASES OF THE LIVER. persistent, was more or less detectible in the dis- charge through the tube, yet at no period did there exist the slightest ground for supposing that any communication with the bowel existed. By May 2, the patient was in excellent health, and able to resume his duty as a constable. The reason why jaundice is nearly, though not quite, as rare in cases of hepatic hydatid disease as it is in cancer, is that it can only arise in those excep- tional cases where the parasite, like the cancer, by its position causes an actual mechanical obstruction to the outflow of bile through the common bile-duct, either by exerting pressure upon it directly from without, or from hydatid vesicles gaining access to its interior, and plugging it up. Diseases which simulate Hydatids of the Liver. As there are several forms of disease which closely simulate the physical signs of hepatic hyda- tids, before leaving the symptomatology it will be well for me to specially allude to them. These diseases are : — A dilated stomach, a distended gall-bladder, a hydronephrosis, an ovarian tumour, pregnancy, a phantom tumour, encephaloid disease of the liver, an abscess, impacted biliary concretions, and cystic disease. HYDATID RESEMBLING DILATED STOMACH. 955 An Hepatic Hydatid may simulate a Dilated Stomach. The best example I can cite of an hepatic hydatid Toeing mistaken for a dilated stomach is a case I saw along with Mr. Beale of Paddington, in 1865. The patient was a lady aged 27, who had been married three years, but never been pregnant, and never ailed anything until eleven months before I saw her, when she began to feel distension and gastric discomfort after eating. Oftentimes to such an ex- tent that she had to loosen her stays. At the same time she noticed that her skin was assuming a more and more dusky hue. Two months before our consultation, she for the first time observed that her stomach projected visibly ft'om beneath the breast-bone, and that it was impossible for her any longer to wear her ordinary stays. She then called in Mr. Beale, who brought her to me, under the impression, in consequence of her gastric symptoms, that she was suffering from a dilated stomach. On examining her very carefully, I found that there was a distinct fulness and bulging of the abdominal parietes just below and more particularly to the right of the xiphoid cartilage, and that, instead of her measuring round the waist 20 inches, as she said she had done a few months before, her girth was 27 inches. The liver dulness in the perpendicular nipple line was ascertained to be 5i inches. Her skin, though very 956 DISEASES OF THE LIVER. sallow, was not sufficiently so to merit the title of being jaundiced. The stools were light, though not pipeclay-coloured, and the urme a dark brown sherry- wine colour, and contaming a copious sediment of urates. On manipulating the swelling carefully and percussmg it, I detected a vibratory fremitus, which sign instantly settled the diagnosis. The swelling was not a dilated stomach, but an hepatic hydatid. Tapping was proposed, but the patient would not submit to it. The case, I was told, ultimately ended in a spontaneous cure. Liver Hydatids mistaken for Ovarian Cysts, &c. That an hepatic parasite may be fatally mistaken for an ovarian tumour, and operated upon as such, is well shown in a case recorded by Dr. Ward Cousins. A woman aged 27, who, on admission into the Portsmouth Hospital, complained of shortness of breath, though her lungs and heart were quite healthy, when examined in the erect posture had the appearance of being at the full term of pregnancy. The outline of the tumour was somewhat irregular, the right side, especially above the umbilicus, being more prominent than the left. Entire dulness was elicited over the whole abdomen, except just below the margin of the ribs. Fluctuation was coincident with the dulness, and could be detected in all directions. Dr. Cousins diagnosed ovarian tumour, probably unilocular. HYDATIDS MISTAKEN FOR OVARIAN TUMOURS. 957 On January 7, 1874, he performed ovariotomy. An incision was commenced two inches below the umbilicus, and continued downwards for five inches in the median line. Slight retching occurred, which projected the tumour against the wound, and it ap- peared to move freely under the peritoneum ; but, when this was divided, the cyst was found every- where adherent by long bands to the parietes. The tumour was then tapped, and two gallons and a half of clear yellowish limpid fluid were withdrawn ; the final portion which escaped was slightly opaque. The adhesions, which were almost universal over the front of the cyst, were readily broken down with the hand, and the mass detached from the pelvic brim. There was scarcely any hajmorrhage during the operation. The wound was closed in the ordinary way. The patient never rallied from the shock of the operation. Obstinate vomiting supervened, and she died in thirty- six hours. Mistakes of this kind, although not often publicly recorded, are by no means uncommon. I shall, there- fore, cite another equally important one that was published by Mr. Thomas Smith in the ' British Medical Journal,' February 1, 1868, where a hydatid of the liver, from which bile escaped during the opera- tion, was attempted to be removed under the impres- sion that it was an ovarian tumour. Mr. Smith says : — ' A widow aged 39, who eight years before had 958 DISEASES OF THE LIVER. her last child, and immediately afterwards noticed a small firm swelling just above the left groin. This increased in size without causing pain until a year ago. Since then she suffered at times severely. The swelling increased quickly in size. On June 4, 1867, the abdomen was symmetrically distended. Fluctuation was verj^ perceptible over the whole surface, which was dull to percussion ; the only resonant parts of the abdomen being the flanks, the epigastrium, and the hypochondria. There were in the abdominal walls one or two hard knots, which seemed to be unconnected with the tumour. The uterus was pushed very low down in the pelvis ; its fundus was plainly to be felt, and could be moved from side to side freely with the finger. From the history of the case, and physical ex> amination, little doubt existed that she was suffering from an ovarian cyst, probably unilocular. On July 11, the operation of ovariotomy was undertaken. An incision about three inches in length was made in the linea alba. On dissecting through the abdominal wall, a granular and adherent membrane, distended with fluid, was reached. This was opened with a minute puncture ; and, as fluid resembling that found in ovarian disease escaped, the separation of the cyst from the abdominal wall was attempted. This sepa- ration had been accomplished to some extent, when suddenly the cyst-wall gave way at the point of 1 HYDATID MISTAKEN FOR OVARIAN DISEASE. 959 puncture, and a hydatid escaped. The nature of the disease being now evident, the opening was enlarged, and an immense quantity of hydatids were discharged. They were of all sizes, from the size of a marble to that of a .cocoa-nut. In all, eight pints of fluid escaped, and seven pints of hydatid cysts. The cavity having been emptied, the cyst-walls were drawn out and attached by silver sutures to the mar- gins of the external wound. The subsequent progress of the case was thoroughly satisfactory. The cyst was syringed twice daily with a weak solution of iodine (two drachms of the com- pound tmcture to a pint of water). Occasionally collapsed hydatids escaped after syringing. At no time was there any disagreeable odour from the wound. The fluid that escaped was tinged by bile. On September 10, the patient left in good health, with the wound soundly healed. This case serves to illustrate the uncertainty of the diagnosis of abdominal tumours. Though the cyst must have been of hepatic origm, yet its con- nections, so far as could be ascertained, before, during, and after the operation, were chiefly among the lower part of the abdominal and pelvic regions. Nor is it peculiarly unique that a liver hydatid should present in the pelvis. •960 DISEASES OF THE LIVEli. Hydatids simulating Pregnancy. In the ' Medical Times and Gazette ' of August 1864 is a case related by Dr. Sadler where Csesarean section was undertaken at the full period of gestation. The tumour, which had been thought to be a preg- I nant uterus, was found at the post-mortem examina- tion to be a calcified hydatid of the liver. The stethoscope is the instrument which ought in these cases to be relied upon in making a differential diagnosis. For with a sharp ear the foetal heart in a not very fat patient is detectible at the third month. I have, while house surgeon to the Eoyal Maternity, Edinburgh, occasionally even heard it as early as ten weeks after the termination of the menstruation. Hydatids simulating Cystic Disease of the Liver. In addition to ovarian there is another form of cystic disease which is not unfrequently mistaken for hydatids, and that too even after the death of the patient and the autopsy has revealed — or I should perhaps rather say might have been expected to reveal — the true state of matters. I allude to a form of afi'ection which has received the title of ' Cystic Disease of the Liver.' So many are the errors com- mitted in these cases that I shall subsequently devote a few special paragraphs to their consideration. Mean- while I may mention that an exceedingly interesting case of hydatid disease was published under the above ■ HYDATIDS SIMULATING CYSTIC DISEASE. 961 title in the Pathological Society's ' Transactions ' of 1857, p. 245, by Mr. Jabez Hogg, which has so many interesting features connected with it that I shall not only briefly quote it, but at the same time introduce its instructive illustrative woodcut (fig. 28). The patient, a man aged 45, from being jaundiced, imd at the same time suffering from acute hepatic colic, with pipeclay-coloured stools and saffron-tinted Fig. 28. ■a, Cyst with echinoccocns within it. b, Hooklets of the entozoon. c. Crys- tals of cholesterin in plates. The true nature of the needle-shaped crystals is uncertain. They were all distributed irregularly through the hydatid fluid, d, Cylindrical epithelium, some enclosed in a struc- tureless membrane, e, Puro-mucous corpuscles from outside of the cyst-wall. Mag. 200 diameters. urine, was naturally enough supposed to be labouring under the effects of an impacted gall-stone. After a time his S3nnptoms assumed an ahirming character. He had rigors, the lower extremities became (Edematous from the feet to the loins. The superficial abdominal veins became enlarged, and he died suffering from distressing dyspnoea. On post- mortem examination the abdomen was found to con- 3q 962 DISEASES OF THE LIVER. tain about a gallon of deep yellow-coloured serum.. The liver was enormously enlarged, occupying the whole epigastric and right hypochondriac regions. It weighed eight and a half pounds. The right lobe contamed a large hydatid filled with a gelatin-^ ous pale amber- coloured, thick, purulent, gruel-like, offensive- smellmg fluid, which, when examined with the microscope, showed the elements represented in fig. 28. It may be added, as points of further interest, that the hydatid had, by its external pressure on the bile- duct, completely obliterated its canal ; that the left lobe of the liver was (most probably also on account of the pressure exercised upon its vessels and paren- chyma) reduced to a softened mass, and its ducts charged with inspissated bile, while the gall-bladder contained four gall-stones. Hydatid Disease may be mistaken for Cancer of the Liver. In consequence of hydatids sometimes appearing on the free anterior surface of the liver in a multiple form, and not exceeding the size of a small orange, they have been by the unwary mistaken for, and treated as, encephaloid tumours. This is readily accounted for by the fact that the feeling they give rise to through the abdominal parietes is identical with that communicated to the hand by cancerous nodules. While in addition they still further simulate cancer in HYDATIDS MISTAKEN FOR CANCER. 963 being usually situated in the right lobe, of slow gi'owth, and the discomfort caused by their presence, amounting occasionally to distinct pain. These cases are, however, with proper care usually easily differen- tiated, from the fact of the most prominent differential characteristic features between these two forms of liver disease being : — a. The total absence of constitutional symptoms in hydatid disease. h. An entu'e absence of a cancerous cachexia. c. The nodules usually not being painful on pressure. The Jaundice arising from Hydatids may closely simulate that from G-all-stones. In the Pathological Society's ' Transactions ' (vol. xxvi. p. 127), Dr. Cayley records the case of a labourer, aged 36, who was occasionally seized with violent pain and vomiting, followed by jaun- dice, which would last a few days and then pass off. Twelve of these attacks occurred in a year, and at the last a number of hydatid vesicles the size of peas and beans were found in the stools. After which he got quite well. (See also case at p. 981.) When a hydatid bursts into the common bile-duct, the pain produced by the cyst vesicles is so similar to that arising from an impacted gall-stone as to be in general mistaken for it, and it is only when the M (J L> 964 DISEASES OF THE LIVER. vesicles, or portions of them, begin to pass by the stools that the true nature of the attack is revealed. For the blocking up of the duct by the hydatid gives rise to jaundice, pipeclay- coloured stools, and high- coloured urine, pain, itchiness of the skin, &c., ex- actly in the same manner as a gall-stone or a mass of inspissated bile. Hints on the Differential Diagnosis of Hepatic Hydatid Disease. , a. Jaundice will most likely be associated with a distended gall-bladder. h. Pain and febrile disturbance always attend the presence of an abscess, and the swelling is usually acutely tender on pressure, which is never the case in a non-inflamed hydatid. c. The mobility of an ovarian tumour, together with its history and the result of a vaginal examina- tion, usually suffices to distinguish it from a liver hydatid. The hepatic hydatid has its dull area dis- tinctly continuous with that of the liver, while the ovarian tumour very seldom has. An ovarian tumour is more or less mobile under a uterine sound exami- nation, while a hver hydatid never is. d. In the case of a dilated stomach there is usu- ally a specific history of gastric derangement, which is seldom the case in hepatic hydatid. e. In the case of hydronephrosis there is almost HINTS ON DIFFERENTIAL DIAGNOSIS. 965 sure to be a distinct history of a urinary derange- ment having existed for some length of time. /. A phantom abdominal tumour vanishes at once when the patient is placed under the influence of an anaesthetic, to return immediately he or she becomes agam conscious. g. As, notwithstanding all these apparently so easily recognised diagnostic beacons and readily applied differentiating tests, there yet oftentimes lurk beneath the surface of the seemingly most simple cases conditions, ignorance of which has led even experienced men into grave errors in the differential diagnosis of hepatic hydatids, I shall now direct attention to what I look upon as being my best friend in doubtful cases. Namely, the exploring needle, an instrument far too much neglected by physicians, as I have already observed, under the mistaken idea that its em- ployment is not altogether free from risk. I have never once seen the exploring needle do harm, although I have used it under circumstances which, were I to relate some of them, would make those unaccustomed to its use open their eyes wide with astonishment. I say, and say advisedly, that, when judiciously em- ployed, the exploring needle is harmless, and in the case of a hydatid its employment will not only be the certain means of making an accurate diagnosis^ but probably at the same time (if the fluid be allowed to drain away) effect a permanent cure of the dis- 966 DISEASES OF THE LIVEK. ease without the necessity of any further treatment whatever. Ein23hatically, therefore, do I recom- mend the employment of the exploring needle in every case of doubt, no matter whether the tumour be seemingly distinctly attached to the liver or not. For, as I shall immediately show, an examination of the fluid withdrawn when it contains fluid, or of the tissue brought away when it is solid, will, if pro- perly performed, never fail to reveal the true nature of the suspected tumour. After making these remarks I think it my duty to point out How to Explore a Hydatid. I may remind the reader of what I said in the chapter on abscesses ; namely, that a human liver may be penetrated by an exploring needle in all directions without danger. But as there is a right and a wrong way of doing everything, even the very simplest act, it is well for me to give a few hints as to the best way of doing it. Begin by marking out with ink the exact absolute dull area, after which select the most prominent part of it for the first puncture. After having lubricated the needle with carbolised oil, push it in rapidly and with some force from three to six inches into the tumour. Withdraw the trocar and allow the canula to remain quietly in its position for at least thirty HOW TO EXPLOKE A HYDATID. 967 •seconds, in order to give fluid, if it chance to be thick, time to escape. If nothing comes away, then slowly and gradually withdraw it, pausing at every half- inch of its withdi-awal, in the hope that (should the cyst be a small one and the exploring needle have entirely transfixed it) the end of the canula during the time of its withdrawal may get within the confines of the sac, and its fluid contents thereupon escape. Should the first puncture be attended with nega- tive results, let the operation be repeated at places about two inches apart as often as is thought neces- sary. The Examination of Withdrawn Fluids. Having been fortunate enough to withdraw fluid, the next thing is to be able to recognise its true nature. If it be pure pus or bile, there can be no dif- ficulty about the matter ; but if the fluid be from a hydatid, an ovarian cyst, a hydronephrosis, or the peritoneal cavity, a chemical as well as a microscopi- cal examination of it may be necessary before its real nature can be ascertained. Each of these fluids possesses well-marked distinguishing characteristics. For example, the fluid from a hydatid is a pale, slightly opalescent, limpid, alkaline liquid, of a specific gravity of between 1007 and 1014, loaded with chloride of sodium, but containing neither urea 968 DISEASES OF THE LIVER. nor albumen — at least the presence of albumen is the exception, not the rule. When examined micro- scopically it is found to contain, though not always,, hooklets and shreds of echinococci, together with plates of cholesterin, as represented in fig. 28. Besides these elements there are sometimes, as Dr. Bristowe found, a number of deeply red-coloured rhomboidal plates of cholesterin floatmg among the colourless ones. Some of the cholesterin crystals Fig. 29. Hffimatoidin Crystals. were, in Dr. Bristowe' s case, studded over with ruby- red haematoidin crystals. The case was that of a middle-aged man who died of phthisis (Path. Trans, vol. iv. p. 166). Free htematoidin crystals are by no means uncommon products of hydatid fluid, even when there exists no other evidence of blood extra- vasation having occurred. They are identical with those found in old blood clots, though generally bigger (fig. 29). EXAMINATION OF DOUBTFUL FLUIDS. 96^ Ovarian fluid, being albuminous, is consequently,, like ascitic fluid, coagulable by boiling. It contains no urea, nor any great amount of clilorides, thus difi^ering from urine and hydatid fluid. Ovarian fluid is always of a specific gravity of more than 1011. It is viscid and glutinous to the finger touch. It may even be grumous. It sometimes contains cholesterin crystals, but never booklets. Ascitic fluid is of a pale amber colour, or, if tinged with bile, of a saff'ron hue. It is highly albummous,. and has a specific gravity of over 1012. It contains neither urea nor any excess of chlorides. Hydronephrosis fluid is merely concentrated urine, and consequently gives all the ordinary reac- tions of urine in a marked form. Sometimes it is albuminous. If the distended gall-bladder has been punctured, then it is either bile or white mucous secretion which comes from it. If the tumour be an ordinary abscess or a sup- purating hydatid, pus is the fluid obtamed. It must not be forgotten that any one of the six fluids brought away during the exploration may chance to be puriform, m consequence of suppura- tion accidentally existing in the sac from which it came. But j^ure pus only comes from an abscess ; pure bile from a gall-bladder ; pure viscid and albu- minous fluid from an ovarian tumour ; limpid non- ^70 DISEASES OF THE LIVER. albuminous fluid from a hydatid ; clear albuminous liquid from ascites ; urea in hydronephrosis ; chlo- rides in hydatid as well as in hydronephrosis ; choles- terin both in hydatid and ovarian, and booklets only in hydatid liquids. Finally, let it be borne in mind that the fluid coming directly from a true hepatic hydatid — living or dead — does not necessarily contain either booklets or shreds of the entozoon. So that one must be on his guard not to be led into an error in diagnosis from not finding morphological evidence of an ento- zoon in the withdrawn fluid. In 1868 I read a report of a case of this kind by Mr. Fearn which is worthy of quotation. ' A man was admitted into the Derby Infirmary for a tumour J connected with the liver, and on December 8 Mr. Fearn passed a smaU trocar into it and evacuated eighty-five ounces of fluid, of the appearance of pure water. Its specific gravity was 1012 ; it contained no albumen, no sugar ; and nothing was detected in it under the microscope. On the 24th of the same month the patient was discharged, greatly relieved. In the following March forty ounces of turbid whey-like fluid were evacuated, and the cyst then injected with diluted tincture of iodine, which caused some pain and smarting. Altogether, one hundred and twenty-five ounces of fluid were removed, of ivhich the first eighty-five were as limpid as water, EXAMINATION OF DOUBTFUL FLUIDS. 971 and contained no echinococci. After fifteen months the patient had perfectly recovered.' Supposing no fluid, except a few drops of blood, st -mortem, the liver has presented a nodulated appearance, some- what like what is seen in cases of cancer and cirrhosis. (See p. 480). 3 TJ 2 1028 DISEASES OF THE LIVER. of the liver, and sallow bilious look, there is in most instances a concomitant amyloid enlargement of the spleen, and also disorder of the urinary secretion from the kidneys themselves partaking of the disease. For be it remembered, amyloid is a constitutional much more than a local affection. The urine is in general loaded with urate deposits, is usually very scanty, dark -coloured, and of high specific gravity. Yet it may contain albumen, and that too in a quantity which to the uninitiated might appear as being quite out of proportion to its specific gravity. (Seechapteron Hepatic Albuminuria, p. 793.) And what may appear to him still more surprising is the occasional absence of renal tube casts from this form of albuminous urine. In addition to these physical signs of disease, there are in general symptoms of impairment of the mental powers, disordered digestion, lassitude, and general malaise. In fact, the patient often describes his symptoms correctly, as well as graphically, in feeling himself, as he says, ' good-for-nothing.' Treatment of Amyloid Liver. Amyloid disease of the liver ought to be treated on purely scientific principles, for, as far as I have been able to ascertain, no form of empmcal treat- ment whatever, except it be that of the administration of large doses of chloride of ammonium, has ever been 4 TREATMENT OF AMYLOID DISEASE. 102^ found to be of the slightest service. And assuredly the rationale of the action of the chloride of ammonium in these cases I have never as yet been able to under- stand, although so many persons have said that they have found it useful that I suppose its action is un- deniable. In fact, I have myself found it act well when given in from 60 to 100 grains a day for several days running. However, I have never trusted to its action alone, but invariably treated the patient at the same time upon what I regarded as strictly scientific principles by doing my best to combat the supposed cause of the disease, be it scrofula, tuberculosis, syphihs, or what it might. Added to which, as amyloid disease has the same rationale as fatty de- generation of the liver, the amyloid substance being nothino; more or less than the transition staere in the physiological transformation of starch into sugar, and sugar mto fat, the same dietetic rules are to be enforced on patients suffering from amyloid disease as I said were necessary for patients labouring under fatty degeneration. So, in order to avoid unnecessary repetition, I refer the reader to them. Moreover, as the victims of amyloid degeneration are, in the majority of instances, the scrofulous and tubercu- lous waifs of poor ill-fed and ill-clad humanity, it is evident that good clothing and warm dwellings are quite as essential to then* cure as suitable food and medicine. 1030 DISEASES OF THE LIVEK. ribrous Growths, Embolisms, and Blood Extravasations. This is a part of hepatic pathology requiring, I think, complete revision. I do not believe in the occurrence of a true fibrous hepatic tumour, for the simple reason that fibrous growths never develop in cellular structures, and the liver is essentially a cellu- lar organ. The so-called hepatic fibrous growths are, I beheve, and I shall now endeavour to show, nothmg more or less than the remnants of old blood coagula. The nearest approach to a true fibrous growth which I can find among the many recorded cases is one described by Dr. Wilks. It was found in the liver of a sailor aged 34, who died apparently from an attack of peritonitis following upon a second tap- ping for ascites ; and Dr. Wilks found the hepatic veins and the vena cava obstructed by a mass of tough yellow dry fibrous tissue, occupying a large portion of the posterior of the right lobe of the liver, sur- rounding and compressing the hepatic veins at their junction with the cava, and diminishing their calibre. The liver itself was extremely congested from the interruption of its outward circulation. In some parts actual extravasations of blood had occurred, which I regard as a pomt of great pathological im- portance when considered in comiection with what I have to say on hepatic fibrous tumours. The cause of the fibrous deposit was not ascertained. There FIBROUS TUMOURS. 1031 was no history of S3rpliilis, but there were scars in the groins as from old buboes, and also an excavation in the penis, near the fr^enum, which might well be re- garded as proof positive that he had at some time or other suffered from the disease. But whether the fibrous mass was the result of an old effusion of blood or of true inflammatory lymph, or a spon- taneous growth, could not be decided. (Pathological Society's ' Transactions,' vol. xiii. p. 122.) In order to show that many, if not even all the liepatic fibrous tumours met with at autopsies of patients, are the result of blood extravasations either from undoubted embolisms or other forms of directly effused blood, I cite the following cases observed and reported by different gentlemen. In 1869 Dr. John Murray published the case of a woman, aged 24, whose liver, though pale in colour, had numerous diffused patches of extravasated blood scattered throughout its whole parenchjrmatous struc- ture, as well as here and there under ' its peritoneal covering.' Nevertheless the tissues of the organ are said to have been found, when examined microscopi- cally, perfectly normal ; and consequently had the fibrous masses not been recognised as blood extrava- sations, they might readily enough have been put down as fibrous growths surrounded by normal tissue. Dr. Murray further remarks that the only other morbid condition met with besides the extravasation 1032 DISEASES OF THE LIVEE. was the existence of several small biliary calculi in the gall-bladder ; but these of course could not pos- sibly have had anything to do with the blood extra- vasations in the liver, which indeed were proved to be the direct result of a general constitutional haemor- rhagic diathesis. For there were precisely similar kinds of blood extravasations in the ovaries, in the uterus, and in the left ventricle of the heart itself. In 1869 Dr. Payne reported the case of a cab- driver, aged 39, m whom the left-lobe branch of the portal vein was filled by a firm adherent thrombus. The trunk of the vein at its point of entrance into the liver was completely occupied by a dark red, ap- parently recent centrally soft coagulum, with a dis- coloured outer older surroundmg part, adherent to the walls of the vessel. Both the splenic and mesen- teric veins contained coasjula, and as there was also hasmorrhagic infarctus of the lungs, the case was looked upon as one of general thrombosis, though the cause of this condition was not ascertained The man had had endocarditis, but it had completely passed away before the time of his death, and the only cardiac sign that remained was an extremely weak and rapid pulse — 180 per minute. He had, he said, suffered from palpitation of the heart for twenty years. (Path. Soc. 'Trans.' vol. xxi. p. 228.) I have not the slightest doubt that this was a case of embolism, fi'om knowing that cases of embolic blood extravasations are occasionally, indeed not so FIBROUS TUMOURS. 103S very imfrequently, met with throughout the hver substance. I recollect well seemg the liver of a woman in the jjost-mortem theatre at Vienna, when I was studying there, in which were a number of dark red cherry and chestnut sized masses scattered throughout both lobes of the liver, the nature of which was at first thought to be pecuHar, until on closer inspection they turned out to be merely solid blood coagula, which had apparently escaped from minute lesions in the twigs of the portal veins. In 1863 Dr. Murchison exhibited to the Patho- logical Society a liver taken fi'om the body of a woman aged 29, who died at the end of the fifth week of enteric fever. The greater part of the organ appeared perfectly healthy, but on the upper surface of the right lobe was a white circular patch about the size of a florin, beneath which was an oj^aque yellow- ish mass bigger than a pigeon's ^g^^^ with well- defined margins, enabling the mass to be enucleated by the fingers with little difliculty. The mass when examined microscopically, though slightly softer and more friable than normal liver tissue, was found to consist of the same kmd of hepatic secreting cells, loaded mth oil-globules and fine granular matter. Dr. Murchison thought it a case of embolism, from the mass closely resembling, he thought, similar masses met with in the spleen and kidneys in cases ascribed to embolism. (Vol. xv. p. 132.) I may now sum up by saying that the more I 1034 DISEASES OF THE LIVER. look at the subject of liver fibrous growths, the more convinced I become that the vast majority, if not even all of them, are not, properly speaking, fibrous degenerations at all, but merely the post-products of old blood coagula. There is indeed good reason for my taking this unusual view of the pathological and histological nature of the majority of the hitherto described hepatic fibrous growths. Which is that abnormal fibrous tumours only grow in fibro-muscu- lar organs — such, for example, as the unimpregnated uterus — and, the liver being, with the single excep- tion of the brain, the least fibrous organ in the whole body, it in like manner ought to be, with the single exception of the brain, the last organ of the body to have fibrous tumours developed within its substance. To the above- described forms of hepatic tissue degeneration I might add a number of others : to wit, the so-called adenoid, tuberculous, lymphadeno- matous, &c. &c. But as not a single one of them possesses either characteristic signs or symptoms by which their presence might even be so much as sus- pected during the patient's lifetime, it would be a mere waste of space to say anything whatever re- garding them in a clinical treatise like this. And as there are no known sjmiptoms or signs by which either these or hepatic blood extravasations can be diagnosed, I naturally enough refrain from offering any suggestions regarding their treatment. 1035 CHAPTER XXIII. TRAUMATIC AFFECTIONS OF THE LIVER. As general practitioners are frequently, and phy- sicians occasionally, called to the bedsides of patients suffering from the effects of mechanical injuries to the hepatic organ, though this is a medical and not a surgical treatise, I must call attention to one or two facts connected with the prognosis of such cases, which cannot fail to interest them ; and to begin with I shall offer the following piece of politic advice to the young practitioner, who perhaps at the very outset of his career may be called to the bed- side of a patient the victim of severe mechanical hepatic mjmy — which is : Never give a hasty opinion of the probable result of the accident ; because, while severe and fatal mischief may have happened to the liver, and yet the integuments be scarcely so much as bruised, the organ may be severely bruised, lacerated, or punctured, and yet the patient make a good and quick recoveiy. I shall give examples to prove the truth of this assertion. In the first place 1036 DISEASES OF THE LIVER. I may mention that it has been recorded by military and naval surgeons, not once or twice, but a dozen of times, that a rapidly fatal injury has been caused to the liver by a solid cannon-ball, or a mass of shell, without the abdominal parietes being so much as penetrated. The only visible external evidence of injury havmg been ecchymosis of the integument, and yet the liver was ruptured. But what is more extraordinary still is that there may be actually fatal laceration of the liver, and yet no outward sign of injury whatever visible, as occurred in the case recorded by Mr. Partridge in the Pathological Society's ' Transactions,' vol. xi. p. 127, where a cart- wheel produced this kind of lesion in a lad aged 13. On the other hand, agam, it has happened that the whole of the hepatic abdommal parietes have been completely shorn away by direct violence, and the anterior surface of the liver exposed, without a trace of injury on the organ bemg visible. As these cases are, comparatively speaking, exceedingly rare, I shall cite one which I saw several years ago, at Shaldon, along with Mr. Thomas Brookes. The patient, a man of 34 years of age, strongly built and perfectly healthy, had the anterior hepatic portion of his abdommal parietes completely shot away by a blank cartridge from a cannon fired ofi^ within a yard or two of him. The cartridge sliced away, as it were, the whole thickness of the abdomi- TRAUMATIC LESIONS. 1037 nal parietes, and left not only the liver completely exposed, but at the same time perfectly intact. I saw the patient within six hours after the receipt of the injury, and he was then in a state of collapse, and consequently could feel nothing. So I took the opportunity of examining the exposed surface of the liver very carefully. It had the normal bluish- purple tint of a newly killed animal's liver. Its serous covering was moist, glistening, and felt warm to the touch ; and from its having been affirmed that the human liver has been known to manifest pulsa- tion, as spoken of at page 54, I did my best to discern any by throwing the light directly upon it, as well as by viewing it from every side and in every direc- tion ; but not a trace of pulsation could I detect. I next pressed my fingers gently but firmly against every part of the liver's exposed surface, but still failed to feel even the faintest evidence of pulsation. This non-success was not due to an absence of cardiac pulsation, for the radial pulse could be distinctly felt. The patient never rallied. His state of stupor became more and more profound, until he expired in about thirty hours after the receipt of the injury. The human liver has even been forced throuo-h the diaphragm, and partially lodged in the riglit pleural cavity. A case of this kind is reported in the Pathological Society's ' Transactions,' vol. xvii. p. 164. A man, aged 55, was brought to the Royal Free 1038 DISEASES OF THE LIVER. Hospital so extremely prostrated that he could give no account of himself. His skin was sweating pro- fusely. His pulse 108. His tongue dry and brown. With dulness and friction sounds over the lower two- thirds of the right lung. He died in seven days, and at the post-mortem it was found that the whole of the right lobe of the liver along with the gall-bladder protruded into the right pleural cavity through a six-inch- sized opening in the diaphragm. Yet there were neither signs of peritonitis in, nor of ecchymosis of, the abdominal walls. Unfortunately nothing was ascertained regarding the manner in which this extraordinary hernia was produced ; but no doubt it was the result of direct violence, and had probably existed some time, as there was a well-marked con- striction of the liver at the point where the edges of the diaphragm were in contact with it. It is well to know that even very severe injuries of the liver are not necessarily fatal, at least not im- mediately so. For example, punctured wounds in the liver, unless a blood-vessel has happened to be injured, are even, as a rule, unattended with serious disturbance. Bayonet wounds on the battle-field have frequently not so much as made the wounded soldier, on account of the injury, fall out of the ranks until after the fight was finished. This re- mark can surprise no one after what I said on the complete immunity from danger following repeated TRAUMATIC LESIONS. 1039 puncturing of the hepatic tissue by exploring needles and trocars. Leaden bullets have penetrated into, and been deeply lodged in, the substance of the human liver, and the patient yet lived for months afterwards. In illustration of the truth of this remark I may cite (from the ' British Medical Journal ' of January 10, 1880) a case recorded by Mr. Bernays of a pistol bullet having been lodged three-quarters of an inch deep in the substance of the liver of a child for two months before it died. The first notes of the case were published in the ' Journal ' of December 6^ 1879. After the child had been considered practi- cally well, with the exception of weakness, she died two months after the accident. At the post- mortem the bullet was found in the liver, but not at the spot where it pierced the skin. It had glided over the smooth surface of the liver to the right side, where it appeared to have struck a rib, rebounded, and entered the liver to the deptli of about three- quarters of an mch. There were about three ounces of old blood-clot. The small cavity where the ball lay was lined with organised lymph. The functions of the liver were well performed to the last. All the other organs were healthy. Mr. Bernays says that the child did not die from the presence of the ball in the liver, but simply from exhaustion through not being able to take sufficient nourishment. 1040 DISEASES OF THE LIVER. Even an extensive rupture of the liver may unite, and that, too, rapidly. As was shown by the post-mortem of a man aged 38, who died in St. George's Hospital, from fracture of the seventh cervical vertebra, three weeks after having fallen from a height upon a log of wood. For a rupture of the convex surface of the right lobe of the liver, five inches in extent, was found ' perfectly united, with the exception of at some few points, where the peri- toneal coat still remained broken.' ^ The rupture in this case did not appear to have extended very deeply ; but from the fact of its being so completely healed, it was impossible to conjecture what its origi- nal depth actually was. This case proves that even very severe lacerations of the liver are not to be looked upon as necessarily hopeless. It is a noteworthy fact that the posterior part of the right lobe is the most general seat of rupture m cases of laceration fi'om a blow or a violent compres- sion of the hepatic organ. The Digestion of the Living Liver. It was at one time, and that too even until within my own medical day, thought that as the stomach during life was never known to be digested by its own peculiar secretion, all living animal tissues pos- sessed a specific immunity fi'om the solvent action of gastric juice. Experimental physiology upset this ^ Holmes's System of Surgery, vol. ii. p. 648. DIGESTION OF THE LIVING LIVER, 1041 theory twenty years ago, by showing that the tail of n living rat, introduced into a dog's stomach through a fistula, and kept there for half an hour or more, was digested. Exactly in the same way, too, as if it had been detached from the living animal, and introduced as a piece of mere dead tissue into the stomach. No sooner was this important discovery made than all sorts of wild theories were promulgated with regard to the possible cause of the non-digestion of the healthy living stomach by its own gastric juice. Having at one time paid a great deal of attention to the physiology of digestion, and not being a man •constitutionally prone to be carried away by theory, I resolved to make for myself some crucial experi- ments on the action, or rather, I should say, non- action, of the gastric juice on its own secreting mem- brane. The most telling of which experiments was the scraping away of the epithelial covering of a part •of the mucous membrane of the living stomach of a dog, through an artificial fistulous opening, and watching the result — which was, that the portion of the stomach denuded of its epithelial lining (from its thereby ceasing to be protected by a continually re- placed layer of alkalme mucous secretion) fell a prey to the solvent action of the gastric juice, and was digested, just as a piece of dead stomach would have been under similar circumstances. The conclusion forced upon me from the result of 3x 1042 DISEASES OF THE LIVEK. this and other somewhat similar experiments — which I need not here waste time by referring to, as they were published m the ' British and Foreign Medico- Chirurgical Quarterly Review ' of January 1860 — was that the stomach is protected from the solvent action of its own acid gastric juice by a continually replaced layer of mucus, which is perpetually being secreted by its epithelial lining during the digestive process. From this the reader will easily understand how gastric juice can digest a living liver, and not be sur- prised to learn that Dr. Mackenzie found a hole of about three inches in depth in the liver of a patient from whose stomach a quantity of gastric juice had accidentally escaped and come in contact with the hepatic tissue. As Dr. Mackenzie's case is, I believe, the first of the kind that has ever been recorded, and possesses several interesting pathological bear- ings, I shall quote it almost in extenso from his paper in the ' British Medical Journal,' May 8, 1880, which is entitled ' Case of Ulcer of the Stomach penetrating into the Liver.' The patient was a man ' aged 56, ill- nourished and rather emaciated in appearance. His skin was dry ; pulse 60 ; tongue covered with whitish fur. Appetite small ; bowels sluggish ; abdomen dis- tended. He complained of pain in the right hypochon- driac and epigastric regions, increased by pressure and followed by sickness. Had been subject to " sick attacks " for years. He was treated with nitro- murintic acid, smnll doses of ipecacuanha wine, and DIGESTION OF A LIVING LIVER. 1043 opium pill to give sleep. He improved so much that he was able to go out and superintend a small farm. On April 10 an indigestible supper reproduced the old symptoms, but in an aggravated form. The treatment was continued with varying success up to the middle of July, when he died unexpectedly. ' Post-mortem eight hours after death. — A distended stomach concealed all the other viscera ; the walls were so thin that the scratch of a finger-nail instantly ruptured them, disclosing the contents to be a coffee- ground like fluid, in quantity about two and a half pints. On raising the stomach, it was found to be attached to the left lobe of the liver, and a lar^e ragged ulcer, opening direct into the liver, was found near the pyloric end. The cavity in the liver con- tained the same grumous fluid as the stomach, the edges of the ulcer being firmly agglutinated round the orifice, forming a continuous structure. The cavity in the liver, had no wall, but was a " burrow " caused by the action of the contents of the stomach.' The ulcer of the stomach had evidently tried to close itself up by attaching itself to the liver. This efi^ort of nature at repair must have occurred some time before the patient's death, as the edges of the ulcer were firmly adherent to the structure of the liver, and the gastric juice on coming in contact with the exposed inner portion of the hepatic tissue had digested it as if it were a dead organ. 3x2 1044 DISEASES OF THE LIVEK. CHAPTER XXIV. HEPATIC ASCITES. Ascites, like jaundice, though a frequent, is by no means a constant associate of hepatic disease. Etiology. The term ascites simply means a collection of fluid in the peritoneal cavity, the mechanism of its pathology being in all cases of hepatic disease in- variably the same. No matter whether the liver affection inducing it be a benign growth or a malig- nant cancer, the fluid is simply blood serum, and the cause of the serum's exuding from the capillaries into, and collecting in, the peritoneal cavity, is a mechanical obstruction to the normal upward flow of the ab- dominal blood through the inferior vena cava. The blood being pent up in the abdominal veins, its most fluid part, the serum, exudes through the thin coats of their capillaries by a process of osmosis, collects and becomes pent up in the shut serous sac formed by the peritoneum. HEPATIC ASCITES. 1045 Ascitic fluid thus regarded is seen to be nothing more or less than intre blood-serum in an abnormal situation. Its specific gravity, like serum withdrawn directly from blood itself, is consequently 1012. Signs and Symptoms of Hepatic Ascites. In all cases, no matter however severe may be the form of the hepatic disease, the effused liquid is at first limited to the abdominal cavity, and then pre- sents us with what may be called a case of ascites pure and simple. Should, however, the obstruction to the upward flow of the abdominal blood be pro- longed as well as severe, the eff'used serum goes on increasing (after the peritoneal sac is quite full) and diffuses itself in the subcutaneous cellular tissue of the lower limbs, thereby producing what is technically known as dropsy. When the effusion in the lower extremities is very great, the exudation extends to the external genitals, and produces oedema of the prepuce and scrotum in men, and of the labia majora in women. In the case of men with phimosis, some- times giving to the penis a most extraordinary con- torted sausage-like appearance. Difficulty of breathing, with palpitation, may occur in a severe case of hepatic ascites, the cause being merely that the pent-up abdominal fluid pushes the diaphragm upwards to such an extent as to inter- fere with the free action of the lungs and heart. 1046 DISEASES OF THE LIVER. Whenever the exudation extends to the tissues above the diaphragm — that is to say, whenever there exists osdema of the thorax, arms, or face, or an effusion into the pleurae or pericardium — the case is not one of uncomplicated hepatic disease, but one in which the kidneys, heart, or lungs are likewise disordered. In the later stages of ascites from hepatic disease, it almost invariably happens that the kidneys sym- pathise with the liver affection, and their function also gets out of order ; but that solely arises from the circumstance that the kidneys, as previously pointed out, are the organs to which are vicariously assigned some of the functions of the liver. Hence it is that when the liver functions have been long in abeyance, the kidneys gradually get out of gear, and ultimately break down from the prolonged excess of work they have to perform in daily elimiuating a heterogeneous mass of abnormal hepatic materials. This state of things is not to be confounded with a case of concomitant though entirely independent renal complication, or it will give rise to grave errors in the line of treatment, by leading the practitioner to treat the effect instead of the cause — the kidney instead of the liver — and thereby only aggravate instead of, as he intended, ameliorate the patient's sufferings. I put great emphasis on this point, from well knowing that physicians of undoubted and well- merited reputation occasionally fall into this error, to THE DIFFERENTIAL DIAGNOSIS OF DROPSIES. 1047 the great disadvantage of their patients, as I have shown happened in the case referred to at page 794. As yet I have been speaking merely of cases of hepatic ascites of easy diagnosis ; but, alas I all are not equally easy. Ascites may exist from liver dis- ease, and yet its cause be exceedingly obscure. In- deed, it is sometimes almost impossible for even one well versed in liver cases to decide on the spur of the moment (as it occasionally happens a man in con- sulting practice is expected to do) whether the accumulation of fluid in the abdomen is due to liver, kidney, or heart aiFection. Consequently I shall here call attention to a few data which have more than once done me good service in doubtful cases ; for if they have helped me to arrive at a correct diagnosis, they will, no doubt, under similar circumstances, prove useful to others. When called in consultation to the bedside of a patient with a defective clinical history, who is too ill to admit of being subjected to the ordeal of a critical physical examination, a careful consideration of the following facts is invariably of service. Hints to aid in the Differential Diagnosis of Dropsies. a. Neither in renal nor cardiac, but in hepatic ascites alone, are the superficial abdominal veins dilated. b. In uncomplicated hepatic cases there is no cedema whatever above the patient's waist. 1048 DISEASES OF THE LIVER. c. Albumen may be present in the urine in cases of hepatic, as well as of renal and cardiac disease. d. If an average specimen of the twenty-four hours' urine be albuminous, it is never, in an uncom- plicated case of hepatic disease, of a lower specific gravity than 1010, and very rarely even below 1016. The reason why, although the urine is equally albuminous, it is not of such low specific gravity in hepatic and cardiac as m renal cases, is simply, I be- lieve, from the fact of the kidney structures beings sound, thfiy are able to eliminate the urea and other normal urinary solids. The albumen passing through them solely as an excrementitious substance, fi'om its not being properly metamorphosed by the liver- (as explained in the physiological chapter) and thereby fitted for tissue assimilation. Consequently it is eliminated as a foreign material, and not on ac- count of the kidneys being diseased. e. Even the mere colour of the urine is a valu- able diagnostic sign, from the fact that in hepatic and cardiac disease it is never of a lighter shade than normal. In general much darker. While it is usually very pale or smoke-coloured in renal cases. So that even its naked-eye appearance may be re- garded as a guide of some importance in making a differential diagnosis. I take no notice here of the differential diagnostic THE DIFFERENTIAL DIAGNOSIS OF DROPSIES. 1049 help afforded by the employment of the microscope, being now speaking merely of a rough and ready way of arri\TLng, at the bedside of a patient, at a correct diagnosis in doubtful cases. If time and opportunity permit, as a matter of course the micro- scope should be called to aid, as well as chemical reagents, and they will either negative or confirm the idea of the case being one of hepatic origin. /. When, in addition to the urinary indications above alluded to, there is present the additional fact that no dropsical symptoms exist above the patient's waist, the suspicion of the case having a cardiac origin is at once negatived. Hepatic Ascites in Children. Although it is not a common thing to meet with cases of ascites as the result of liver disease in chil- dren, such cases are by no means so exceedingly rare as the majority of persons suppose, from the simple fact, I believe, that the ascites of liver disease in infancy is usually mistaken for that of renal disease, in consequence of the urine in the majority of in- stances being albuminous. In 1871-2 I was asked by Mr. Wakefield to see a case of kidney disease. The patient, an mtelhgent boy of about 9 years of age, had been born at a hilly and healthy station in the Madras Presidency, where his father's regiment was stationed, but he had been 1050 DISEASES OF THE LIVER. in England for three years, and his disease only began about ten months before I saw him. The chief signs were albuminous urine, associated with an enor- mously distended ascitic abdomen. The navel, from having been originally somewhat imperfectly closed, presented a strange appearance, from the fact of its having its loose cutaneous covering distended with fluid, which projected it for over two inches, and made it look exactly like a Cambridge sausage. The liver itself was greatly enlarged, nearly half filling the abdominal cavity. The mere look of the urine, but particularly its specific gravity (as I related in the case of suspected kidney disease at page 794), at once showed me that we had a case of hepatic and not one of renal ascites and albumi- nuria to deal with. Knowing from this that the tissues of the kidneys were not disorganised, I recom- mended the administration of a powerful diuretic mixture, consisting of squills, digitalis, iodide of potassium, nitrate of potash, and infusion of broom- tops. This for a short time had the desired effect, and greatly diminished the ascites j but in little more than a fortnight it was as bad as ever. In order to relieve the discomfort the child endured fi'om the great accumulation of fluid in the perito- neal cavity, I proposed tapping as a palliative. The mother, however, would not agree to it, so still stronger doses of the diuretic were had recourse ASCITES IN CHILDKEN. 1051 to, coupled with an iodine embrocation over the abdomen. I saw the child once again. He was then greatly improved in every way, and the fond mother thought her boy was in a fair way to re- covery ; but, alas ! I knew too well that it was but a temporary lull in the storm, that the hepatic disease was incurable, and that, ere a few weeks had glided by, her beloved child would inevitably have passed life's Rubicon. As, however, no good could arise from undeceiving her, 1 left her in the sweet delu- sion. The child steadily improved for a few weeks more ; then suddenly a change for the worse took place ; the ascites increased, and the boy died. As Mr. Wakefield, though he loyally followed my advice, still adhered to his original opinion that the albuminuria and dropsy were due to renal disease, and not, as I had diagnosed, the result of a hardened and congested liver, arising from long-standing chronic subacute inflammation, it was arranged that we should have a 2^ost-m.ortem examination, to which the mother readily assented. So I got Dr. Nunneley, my former class assistant, to make it for me along with Mr. Wakefield. The result was exceedmgly mterest- ing. For while it confirmed the diagnosis of the case being hepatic to the letter, it revealed the impor- tant fact that had the boy been tapped, and tapped frequently, it is not in the least degree improbable that he might have survived for years. For, strange to 1052 DISEASES OF THE LIVER. say, the liver tissue was but slightly diseased, being- merely a little fatty, though greatly congested. So congested, indeed, that when cut into, Dr. Nunneley told me, the blood literally gushed from its section. The specimen of liver that he brought away and gave me for examination presented a condition of affairs I had never in my life before seen. The whole tissues of the organ — lobular and interlobular — ^were literally gorged with blood. While the hepatic Fig. 33. Human Liver-cells containing oil-globules from a well-nourished child. cells contained no more oil-o;lobules in them than are- often to be met with in well-nourished children. From these facts I think it is highly probable that had the constant backward pressure exerted by the presence of such a large quantity of ascitic fluid, pent up in the peritoneal cavity, but been by re- peated tappings removed from the hepatic blood- vessels, the organ might have regained, perhaps, sufficient vigour to have gradually recovered from its hyper- congested condition. Whereas, left as it was- I ASCITES IN CHILDREN. 1053 to its own devices, the congested liver primarily caused the ascites, and the ascites in its turn reacted in keeping up a condition of hepatic hyper-congestion. The post-mortem, therefore, taught me the impor- tant lesson, never again to allow myself to be over- ruled, by either parent or practitioner, until they have had the value of tapping, in such a case as the above, placed before them in the clearest and strongest pos- sible light ; for had I known then what I know now, I think I should have been able to win over to my views both Mr. Wakefield and the boy's mother, and thereby perhaps have been able to keep the poor little fellow alive for many months, if not even for several years. I cannot quit the subject of hepatic ascites with- out sajring a few words in favour of the old-fashioned and nowadays much-neglected drug, elaterium. Al- though it acts but little on the kidneys, it has a powerful effect in getting rid of ascitic fluid, in con- sequence of its producing copious watery evacuations. It is best given in the form of pill, and if it be fresh and of good quality, it is seldom or never necessary to give more than one-eighth of a grain in order to produce profuse aqueous stools. Its only disadvan- tages are its depressing effects ; but these are easily combated by a few doses of carbonate of ammonia dissolved in sweet spirits of nitre. In cases where the oedema of the Hmbs or exter- 1054 DISEASES OF THE LIVER. nal genitals is extreme, I generally order small trocars to be introduced into, and kept for fifteen or twenty minutes in, the cellular tissue of the parts. Puncturing with needles is seldom sufficient, and if care be used to employ clean trocars moistened with carbolised oil, there is not the slio;htest dano;er of the operation being followed by the disagreeable conse- quences which one occasionally hears spoken of. At least, all I can say is, that in my experience I have never on one single occasion known any untoward result to accrue from it. Even when I have en- trusted the operation to men who have told me of their having previously been unfortimate in such modes of treatment. Of course, when I have been told this, I have been particularly careful to impress upon their minds the necessity of employing perfectly clean instruments, and before employing them to dip their points in carbolised oil. Dr. Southey has invented what is called a capil- lary drainage trocar, over the bulbous extremity of which a fine india-rubber tube may be drawn, and the canula retained in the limb for many hours by means of a thread and a piece of adhesive plaster. Instead of using trocars I often simply employ the points of my hypodermic syringe, and the relief obtained from their employment is sometimes quite surprising. As an illustration of this fact I may mention that on one occasion Dr. Silver took me to TREATMENT OF DROPSY BY TAPPING. 1055 see a member of our own profession, who was in a dying state at the Euston Hotel. The gentleman was not only ascitic, but fearfully oedematous all over the body, from heart disease. I lent Dr. Silver the two nozzles of my syringe, and with these were drawn away in the course of the next eight hours several quarts of fluid, which at once relieved all the most distressing symptoms, and was, I believe, the means of keeping the patient alive for many months. I have already said so much about ascites in the chapter upon chronic atrophy of the liver, and given so good an example of the value of tapping in the case I saw along with Dr. Bannister (p. 481), when more than twelve gallons of ascitic fluid were with- drawn from the patient in thirteen days, that I need not further dilate upon the subject here ; but simply content myself with asking my readers to re- peruse the chapter in question, and in addition cite a case which well illustrates the value of the repeated tappings which I have advocated in distressing cases arising from incurable disease of the liver. The case, which is ably related by Dr. George Johnson in the ' British Medical Journal,' August 7, 1880, is as follows : — A woman aged 36, on her admission into King's College Hospital, was jaundiced, and her urine deeply bile-tinged. The liver dulness extended from the fifth rib to two inches below the costal margui. 1056 DISEASES OF THE LIVER. On September 27, 344 ounces of bile-tinged liquid were removed by tapping, with great relief from pain and distension. The fluid re-accumulated, and caused great pain and distress. On October 28 again was removed 284 ounces of fluid. After this, the urine became lighter- coloured, and the skin less jaundiced ; but the abdomen again enlarged ; on November 26, 271 ounces were removed, and the skin and con- junctivae nearly regained their normal colour. She recovered appetite and strength, and was discharged January 10, 1880. Readmitted on June 21. The skin and eyes were deeply j aundiced ; the urine contamed bile ; the abdomen measured forty-four inches and a half at the navel. She had pain and dyspnoea from abdomi- nal distension. On the 24th, 303 ounces of liquid were withdrawn, after which the liver was felt with its thin edge two inches and a half below the ribs. Great relief was afforded by the tappmg ; but, four days after the operation, she had a rigor. Tempera- ture 102"3° ; abdomen tender, and again becoming distended. There was occasional vomiting ; the pulse became rapid and feeble, the tongue dry ; and she died on July 4, ten days after the last tapping. The necropsy revealed the case to be one of stricture of the common bile-duct. The liver was olive-green and somewhat enlarged. The gall-blad- der distended by dark bile to the size of a turkey's TEEATMENT OF DROPSY BY TAPPING. 1057 'egg. The cystic and hepatic ducts much dilated. The common duct, just below the junction of the cystic and hepatic ducts, was obstructed by a fibrous thickening of its coats. Very firm pressure on the distended gall-bladder caused only a slight oozing of bile through the common duct into the duodenum. As Dr. Johnson remarks, the main phenomena were deep jaundice, followed by great ascites ; the disappearance of both the jaundice and the ascites after the third tapping ; the reappearance of jaundice and ascites after an interval of about five months. The last tapping, when her strength had been much impaired, was followed by fatal peritonitis. The previous three tappings not only afforded great relief, but unquestionably prolonged her life in comfort for several months. Dr. Johnson thinks that the pathology of the case was that the dilated ducts compressed the portal veins within the liver, thus obstructmg the whole jDortal circulation, and causing the ascites. The temporary passing away of the jaundice and ascites after the third tapping being explained by supposing that, in addition to a permanent constriction of the duct by inflammatory exudation, there was a con- gested and swollen condition of the lining membrane, which, after removal of the dropsical pressure by tapping, subsided. Be that as it may, as he says, the satisfactory 3 Y 1058 DISEASES OF THE LIVER. result is an encouragement to repeat the operation of tapping when other means have failed to remove the dropsy. It may perhaps be just as well for me to call attention to the fact that tapping of the abdominal cavity ought never to be spoken of to the patient or his friends as being a trifling operation ; for notwith- standing the facility with which the operation is performed, and the rarity of any disagreeable conse- quences following upon it, fatal peritonitis is occa- sionally the unfortunate sequel to the operation. On February 14, 1880, Dr. C. J. Mxon presented to the Dublin Pathological Society specimens from the body of a man aged 45, who died after the operation of simple tapping for an ascites consequent on cir- rhosis of the liver. Paracentesis was performed, and several quarts of fluid were withdrawn from the abdominal cavity. In a few days a difl'use erysi- pelatous blush appeared round the site of punc- ture, general peritonitis supervened, and the patient speedily sank. At the necropsy an abscess was found lying between the peritoneum and the abdomi- nal wall. Perihepatitis was present. The left lobe of the liver was very large, and the seat of cirrhosis. The spleen was cirrhosed to some extent. I think I ought here to allude to a very simple and readily prepared form of drainage-tube, the in- vention of Mr. H. J. Roper. The mode of making TREATMENT OF DROPSY BY TAPPING. 1059' it he describes as follows : ' A piece of ordinary india- rubber drainage-tube is slit up at one end ; then turned up, like a coat-sleeve, for a short distance beyond the slit, and passed into the wound by an oiled probe, placed in the axil of one of the branches thus formed. This, I submit, is more efficient — inasmuch as an open canal is, perforce, maintained for drainage ; and simpler — inasmuch as both drain- age-tube and probe are always to hand.' In no case is to be neglected the judicious ad- ministration of tonics, even with or without the additional advantages which are derived from the re- moval of the pressure of the fluid by tapping. The plan usually adopted of relying on diuretics and pur- gatives alone is, I believe, to be deprecated ; for as a rule it is not the removal of the already secreted fluid which one has to combat, but its re- secretion, and that lies beyond the scope and influence of diure- tics, tappings, or purgatives, and only within the province of tonics. I cannot refrain from calling my readers' atten- tion to an admirable paper from the pen of Dr. Bristowe in the second volume of the Clinical Society's ' Transactions ' on the subject of treating ordinary cases of liver ascites by tonics, for its peru- sal will amply repay the trouble of referring to it. Drs. Thompson and R. Liveing relate cases in the third volume of the Clinical Society's ' Transactions,' 3 Y 2 1060 DISEASES OF THE LIVER. which go far to show that copaiba is also a valuable diuretic in cases of ascites. Dr. Thompson success- fully combined it with quinine and iron in the case of a man aged 60, suffering from emaciation, anorexia, and thirst, with great abdominal distension from fluid from liver disease. In this case the liver was irregular, knobby, and evidently contracted. A more utterly hopeless case. Dr. Thompson said, could scarcely be, ' and yet the man recovered under the use of the copaiba, quiuine, and iron.' A diminution of the abdomen and an augmentation of the urine went on concurrently and commensurately ; and this. Dr. Thompson thinks, was mainly due to the copaiba, which acted as a steady diuretic. Although I have not tried it, I may mention that an infusion of the plant called milkweed (Asclepias syriaca) is said by Dr. Spurway to possess specific powers in dispelling dropsical effusions. 1061 CHAPTER XXV. LIVER SPOTS. In bygone days, and still among a few practitioners of the old school, one hears a good deal said about the diagnostic value of what are called liver spots — which are brown or yellow cutaneous patches, sup- posed to be the special result of hepatic disease. As modern pathologists have described two entirely distinct kinds of liver spot, and at the same time attached to them not only a different pathology, but a different clinical significance, I shall consider each separately, and give my views of their intrinsic value and import. Xanthoma, Xanthelasma, or Vitiligoidea. While on the subject of the signs and sym23toms of jaundice, a passing reference was made to the con- dition of skin which has received the above titles. Not, however, because it is a specific sign of hepatic disease, but because it is an occasional concomitant of some of the severer and prolonged forms of jaundice. 1062 DISEASES OF THE LIVEE. Before going into the pathology of the condition Tfhich has received the above titles, I may remark that when they are translated into plain English they simply mean yellow, or ' yolklike -yellow ' patches ; which, like many other trivial morbid states, acquire a dignified importance in the eyes of some from the circumstance of their possessing high-sounding names. Etiology and Pathology of Xanthelasma. The condition described under this title is a more •or less white, creamy, dove- coloured, or dark yellow state of cuticle, about the eyes, nose, hands, feet, and scrotum — wherever, indeed, sebaceous glands are large and abundant. The peculiar condition of skin so named has been supposed to be due to a special and inscrutable manifestation of a peculiar and as yet not understood form of hepatic disease. Instead of which, it is my belief that there is nothing what- ever inscrutable about it, it being merely the acci- dental concomitant and natural sequence of a pro- longed attack of jaundice — six months or more — in persons with a constitutional tendency to large sebaceous glands and local subcuticular tissue de- rangements, originating in the following wise. All persons have sebaceous glands about the nose, eyes, hands, feet, and genital organs, which are usually more or less filled with their own normal viscid fatty sebaceous secretion, as shown in the sub- joined woodcuts : — XANTHELASMA. 1063 Fig. 35. In many persons the glands empty themselves of their secretion with difficulty, in consequence of its being abnormally tenacious ; fig. 34. and as a natural consequence the sacs of the glands become distended, and, from bulging beyond the level of the epider- mis, give to the skin the appear- ^ X^'^^^ZSed^S ance of being mammillated or its natural secretion, «, J, c. tuberculated — the appearance described as being cha- racteristic of most cases of xanthelasma, barring the yellowness due to the presence of jaundice. Sebaceous glands distended with their own normal secretion may be found on the genital organs of most persons, especially on the penis. Many youths have the sebaceous glands on their faces not only choke-full of secre- tion, but with an accumulation of dirt in their orifices, caus- ing their faces to look as if they were speckled all over with black points ; which black points have received the name of comedones. Like all other morbid anatomical formations, enlarged sebaceous glands are •often hereditary. A large racemose Sebaceous Gland filled with secretion (a). Mucous lining mem- brane (i). Root branches (c and d). Hair follicle (*). Hair (/). 1064 DISEASES OF THE LIVER. These preliminary remarks, I think, have paved the way for the acceptance of my theory regarding the origin and cause of the cuticular condition learnedly called xanthelasma. When a so-called xanthomatous portion of the skin is examined under the microscope, nothing whatever peculiar is found in it except an hypertrophy of its connective tissue, enlarged sebaceous glands, and an abnormally yellow- stained sebaceous secretion and cutis vera. In many instances the bile-pigment not only stains the contents of the sebaceous follicles and sweat glands, but actually tints their very walls. Occasionally, too, yellow crystals — erroneously de- scribed as tyrosin — are seen in the xanthomatous patches. The crystals are nothing extraordinary, nor can their presence or colour surprise anyone who has had much experience in the examination of healthy sebaceous follicles or even ordinary fat-cells» The fat-cells of mutton, for example — especially during the cold winter months — have often beautiful stellate crystals of margarin in their interiors. And as all crystals take up the colouring matters with which they chance to be surrounded, those in xan- thelasma are, like the sebaceous secretion itself, deeply stained yellow by the bile-pigment. Hence there is absolutely nothing at all extraordinary about the so- called xanthomatous portions of the skin, its glands, or their crystals. For just as the urine and the sweat XANTHOMATOUS LIVER SPOTS. 1065 are stained yellow with bile-pigment in cases of jaun- dice, SO in like manner is the secretion of the sebaceous glands. And the reason why the sebaceous secretion is more deeply stained than the sweat is simply that it does not, like the sweat, flow away as soon as it is formed, but remains pent up in the follicles ; and the longer it remams there the deeper and deeper is the colour it assumes by fresh additions of bile-pig- ment. Hence the longer the attack of the jaundice is, the darker are the xanthomatous patches. As tending in the same line of argument, I may mention that Dr. Unna has attempted to prove that the so-called comedones, or plugged-up sebaceous follicles, do not always owe their dark colour to the existence in theu' mouths of extraneous dirt, but to true pigment. Which he says is not only sometimes brown, as well as black, but even occasionally blue, giving the reaction of ultramarine.^ In corroboration of my view of the pathology of xanthelasma, it may be mentioned that those parts of the body most commonly affected with it are those where, under normal circumstances, the sebaceous glands are found both largest and most prominent — to wit, the face, the penis, and the scrotum. Cases of xanthelasma palpebrarum have been described by Grafe and Samisch in the ' Handbuch der Augenheilkunde,' vol. iv. part 2 ; while they have 1 Virch. Archiv, 1880-1. 1066 DISEASES OF THE LIVER. l)een equally ably treated by Mr. Jonathan Hutchinson in the fifty-fourth volume of the ' Medico- Chirurgical Transactions.' I must mention, however, that my views of the pathology of xanthelasma as above given and the views of these gentlemen are totally different. Treatment. The treatment may be summed up in a few words. Daily brisk cutaneous frictions with a hard rough towel, after the parts have been washed with an aqueous alkaline lotion, such as a table- spoonful of carbonate of soda to a pint of water. And if that be not sufficient, a piece of bent iron, such as a watch- spring, may be applied as a scraper to the affected parts, and the sebaceous follicles emptied of their yellow secretion in that way. The biggest and most prominent of them, again, may be emptied by pressing them between the finger-nails, just as young ladies remove black sebaceous spots from their faces. Chloasma Liver Spots. This is a rare form of dark discoloration of the skin, only met with in chronic and severe cases of liver disease. So rare, indeed, is the affection, and so few persons have ever seen it, that not only ordinary practitioners, but dermatologists, have confounded it with an entirely different form of cutaneous disease, namely, pityriasis versicolor ; the dark colour of the s kin in which is not due, as in true chloasma, to the CHLOASMA LIVER SPOTS. 1067 presence of pigment in the rete mucosum, but to that of a coloured vegetable microsporon parasite attaching itself to the epidermis. From this it is seen that chloasma and pityriasis, though described in manuals as identical diseases, are nevertheless not fio, for they possess an entirely different pathology. Indeed, their only point of similarity consists in the fact of their inducing a darkening of the skin. The colorations of pityriasis may occur on all parts of the body in patients without a trace of liver disturbance, while those of true chloasma generally appear in patches on the anterior part of the trunk, most frequently in the hepatic region. And under no circumstances whatever are they met with unless there exists at the same time a marked derangement of the bihary function. The nearest approach to chloasma in naked-eye appearances, as well as in histological characters, is bronzed skin ; and the only mark of distinction, as far as I know, between the true liver spot and bronzed skin, is that bronzed skin pre- sents, as a rule, a much browner colour than chloasma, and is not necessarily associated with hepatic derange- ment. As liver spots have neither a diagnostic nor any other form of hepatic clinical importance, I shall dis- miss the subject by merely further remarking that so little is known about their true nature that at a meet- ing of the Pathological Society in 1881, in the dis- 1068 DISEASES OF THE LIVER. cussion wliich followed the exhibition, by Dr. Cavafy,. of a patient suffering from what lie described as ex- tensive chloasma, one of the speakers, who has given considerable attention to skin diseases, took it for a case of leucoderma (vitiligo) modified by jaundice^ — which is not in the least surprising, seeing that, as before said, few persons have ever seen a case of true chlo- asma. Though I have seen abundance of spurious chloasma cases, I never to my knowledge came across but one genuine one. The patient was a middle-aged man, who died in University College Hospital with a long-standing jaundice. He had two irregular- shaped almost greenish-black patches on the abdomen.. One extended on the right side from near the margm of the xiphoid cartilage to about an inch below the umbilicus ; the other, more to the left of the abdomen, was of about the size of the palm of the hand. When examined under the microscope (after the patient's death), the cells of the rete mucosum were found to be full of dark pigment, exactly as seen in cases of bronzed skin (see my ' Histological Demon- strations,' page 200, where a woodcut of these ap- pearances is given) and in the skin of negroes. So the conclusion I arrived at was, that in cases of chloasma the cells of the rete mucosum in certain parts of the body have a greater tendency to get filled with bile-pigment than in others, from a de- ficiency of their vicarious pigmentary eliminating power, which I have spoken of elsewhere (p. 122). 1069 CHAPTER XXYI. AFFECTIONS OF THE GALL-BLADDER AND COMMON BILE-DUCT, The human gall-bladder is subject to several impor- tant diseases, which, for the sake of brevity, may be summarily divided into three distinct classes ; though every individual member will require to be separately considered. The first class is that where the gall- bladder's function is annihilated, either from the org-an itself being altogether absent, atrophied, or shrivelled up, so that its cavity, and its functions as a recep- tacle of bile, are obliterated. The second class is that in which it is found distended either with green or white bile, mucus, pus, biliary concretions, or cal- careous matter. The tliird is where the gall-bladder is the seat of adventitious growths, either benign or malignant. Each of these causes of gall-bladder dis- tension I shall now speak of separately. With the appearance and size of a normal human gall-bladder the reader is of course perfectly familiar. Some are not perhaps, however, aware, that while in a normal state its cavity can seldom contain more 1070 DISEASES OF THE LIVEK. than two or three ounces of bile, when in a diseased condition it has been known to contain no less than 260 ounces = a gallon and a half (!) of fluid. Absence or Atrophy of the G-all-bladder. This, the first class of gall-bladder diseases, need not detain us for more than a minute. For from this being a purely clinical treatise, and the symp- toms of an absent or an atrophied gall-bladder, even with a total annihilation of its functions, being simply NIL, nothing further need be said on the pathology — either of its congenital absence, or of its acciden- tal atrophy and abolition of function — than has al- ready been said in the chapters on physiology, and the efi"ects produced upon it by occlusion of the cystic and hepatic ducts; for what has already been said is amply sufficient for all practical clinical purposes. So I refer the reader back to the chapters on physio- logy, and gall-stones in the cystic duct. Only here reminding him that there are not only one, but many species of animals, such as those I have already referred to (pp. 81 and 517), which have no gall- bladders, and that even human beings have been born without a trace of a reservoir of any kind what- ever for the bile, and notwithstanding the deficiency have developed and lived till adult life. The absence of a gall-bladder has often been noticed in children, who have died within the first six months of birth, DISEASES OF THE GALL-BLADDEE. 1071 and that oftentimes, too, without their having mani- fested the slightest biliary derangement of any kind whatever. Even in adults complete atrophy and obliteration of its cavity have been met with. Mr. Wood, in 1859, showed, at the Pathological Society, a small nodular-lookmg mass, not bigger than a large pea, which he described as being the only remains of a human gall-bladder. It contained a minute cavity, communicating with the bile-ducts, which were found to be dilated to double their normal size, and filled with viscid bile. The exhibitor thought the atrophy of the gall-bladder was most probably due to a pre- vious attack of inflammation of the orgfan. Gall-bladders distended by Liquids. This, the second class of disease — that in which the viscus becomes distended and enlarged — is one which is marked by varied and very special symp- toms, and consequently it is one of so much impor- tance to the practitioner, that I require to particu- larise the various morbid conditions which give rise to tliis phenomenon. All forms of accumulation of lluid in the gall-bladder have long been, and still are, erroneously included under the generic term of ' dropsy,' Hydrops vesicae fellece, and a more inappro- priate term could scarcely be given ; for none of them has any characters in common with what the 1072 DISEASES OF THE LIVER. word ' dropsy ' really implies, namely a collection of a watery-like secretion. For not a single secretion ever met with in the gall-bladder can properly be said to be ' watery -looking.' Neither bile, mucus, nor pus having any resemblance whatever to water, ex- cept that of being in the possession of the property of fluidity. The sooner, therefore, the term ' dropsy of the gall-bladder ' is banished from medical books, the better it will be for the credit of the intelligence of the profession. I for one shall certainly put the term ' dropsy of the gall-bladder ' on one side, and describe the diseases usually included under that name each as it ought to be in its own true patholo- gical garb. Signs and Symptoms of Distended Gall-bladder. The signs and symptoms of a distended gall- bladder are in general plain enough to interpret. In the first place there is more or less fulness, or even a distinct globular tumour, not only palpable to the touch but visible to the eye, in the normal situation of the gall-bladder ;^ and when the tumour is asso- ^ As it has happened that when, after havmg made a careful examina- tion of the abdomen of a patient, I have said the gall-bladder is distended with probably so and so many ounces of bile, my co-consultant has re- garded me with an air of significant incredulity, not only from his being unable to guess at the probable quantity of fluid contained in the dis- tended gall-bladder, but from his inability to recognise the presence of any gall-bladder at all, I have given him a hint which may possibly be equally useful to the reader who is desirous of knowing not only how to DISTENDED GALL-BLADDERS. 1073 ciated with jaundice, whicli is, however, not always the case, pipeclay- coloured stools and high saffron- coloured urine, together with the presence of bile- acids in the secretion, the case may at once be put down as one of distended gall-bladder by pent-up biliary secretion, in consequence of an obstruction in the course of the common bile-duct. In none of the other cases of gall-bladders distended with liquid is jaundice at all likely to be present, or, I should rather say, necessarily present ; for of course it may be an accidental concomitant of any one of them, in the same way as it might be the accidental concomitant of a broken leg or a stone in the urinary bladder. Gall-bladders distended with Bile. When a distended o-all-bladder has been diasrnosed and the patient is jaimdiced, it may, in the absence of any reasons to the contrary, be suspected to be filled with ordinary bile, and to be due to the pre- ■detect, but how to be able to estimate the size of a patient's gall-bladder through the abdominal parietes. It is, to commence by acqiui-ing the ne- cessary tactus eruditus on his own urinary bladder, in the following wise. Before getting out of bed in the morning, and while lying on his back with his bladder full, gently but firmly rulj the hand over the supra- pubic region, and a globular tumour will be felt. Then completely empty the bladder, and repeat the rubbing process, noting the difference. Let him do this two or three mornings running until he is quite au fait with the manual sensation of a distended urinary bladder. Next let liim pro- ceed to educate himself to detect the quantity of its contents by feeling the organ before and after emptying it of measui-ed quantities of urine, and he "vvnll soon learn how to be able to tell not only when a gall-bladder is dis- tended, but what is, within certain Umits, the probable quantity of its contents. 3 z 1074 DISEASES OF THE LIVER. sence of an obstruction to the flow of bile into the intestines through the ductus communis choledochus. But after making this statement I must call attention to the fact that neither is the existence of jaundice nor of a distended gall-bladder an absolutely necessary- consequence of occlusion of the outlet of the common bile-duct, for the very simple reason that the duct may be completely occluded, and yet the bile find its way into the intestinal canal through an ulcerated or other opening at some point above the seat of the obstruction, and thereby nullify the effects of what, under ordinary circumstances, would produce both a distended gall-bladder and jaundice. Such cases are of course exceptional. For in the majority of in- stances of obstruction to the normal flow of bile through the common bile-duct into the intestines — no matter whether its cause be a cicatrised duodenal ulcer, the pressure of a cancerous or other form of growth, or an impacted gall-stone — the occlusion of the duct is in general followed by distension of the gall-bladder, and its natural concomitant jaundice. Indeed it is only, I believe, in the very exceptional cases in which a gall-stone ulcerates its way into the intestines from a point above the seat of obstruction in the duct that there is associated with it neither a distended gall-bladder nor jaundice. When the obstructing cause is of a jDermanent nature — such, for example, as was the case in the DISTENDED GALL-BLADDERS. 1075 patient with the cicatrised duodenal ulcer, whose biliary organs are delineated in Plate I. p. 113 — -jaun- dice is invariably present ; and, as was said, his gall- bladder was at one time (until it suddenly emptied itself) so enormously enlarged as not only to have been felt, but seen, projecting as a globular tumour, through the abdommal walls. As it is a true saying that forewarned is forearmed, I think it well to guard the reader against the possibility of mistaking an en- larged gall-bladder for a kidney; for Dr. Austin Flint, in his ' Practice of Medicine,' relates a curious case in which not only he, but several others of the physi- cians to the Bellevue Hospital, took a distended gall- bladder for a floating kidney. In order to avoid yet another form of mistake, it must be carefully borne in mind that prolonged occlusion of the common bile- duct may give rise to such enormous distension of the gall-bladder as to cause it to sunulate an ovarian tumour. The enlarged organ not only extending to near, but even beyond, the crest of the ilium, and, but for the co-existence of jaundice and other signs of biliary derangement, being almost of necessity liable to be mistaken for an ovarian or other abdomi- nal tumour, entirely unconnected with the liver. It was formerly thought that when gall-bladders were so distended as to contain a couple of quarts of bile, and reach down into the pelvis, they were very extraordinary ; but since the publication of Mr. 3 z 2 1076 DISEASES OP THE LIVER. Gibson's case in vol. xi. of ' Edinburgh. Medical Essays,' where 160 ounces, that is to say exactly a gallon, of bile was removed from the gall-bladder, and Dr. Barlow's case of a man aged 54, in whose gall-bladder thirteen pints, or 260 ounces, nearly a gallon and three quarters, of bile were found accumu- lated twelve days after the occlusion of the common duct caused by a gall-stone ("^ Medico -Chirurgical Transactions,' vol. xxvii.), little is thought of a gall-bladder containing a quart or two of bile. When the gall-bladder has been long distended with pent-up bile, the fluid portions of the secretion are gradually (more rapidly than the solid) re-absorbed into the general circulation, and the remaining bile, as a natural consequence, becomes thicker and thicker, until it yields on analysis quite a different propor- tionate result from the normal secretion, as is shown by the subjoined analysis of the bile removed from the case of occlusion of the common bile-duct of which the lithograph Plate I. is given at page 113. The contents of the gall-bladder in this case were found on analysis to consist in one thousand parts of Water 694-45 Solids 305-55 1000-00 Pigment . . \ Bile acids . . I Organic matter 288-99 Oholesterin . j Soda • •) Potash . I Inorganic salts 16-56 Iron . . .1 ' ALTERED BILE IN DISTENDED GALL-BLADDERS. 1077 Whereas the specimen of normal bile ah'eady spoken of (p. 792), taken from the gall-bladder of the woman of about similar age, and analysed at the same time, was of a specific gTavity of 1020, and contained in one thousand parts — Water SoUds Pigment Bile acids Cholesterin Sugar Soda Potasli Iron 933-27 6673 1000-00 L Organic matter 56*73 I Inorganic salts 10-00 The one specimen of bile is thus seen to contain more than four times as much solid matter as the other • and when the relative amoimts of organic and inorganic substances are compared, as was before said, the curious fact is observed, that the difference in the amount of solids in the two cases is almost entirely due to the change in the quantity of organic matter. The inoro-anic salts havins; not even so much as doubled themselves. AVhence is this ? Soda, the chief inorganic substance found in bile, we have already shown (p. 70), occurs in the forms of glycocholate and taurocholate of soda ; substances which, as before remarked, are re- absorbed from the distended ducts and gall-bladder into the circulation, from whence they are bemg constantly eliminated with the urine, which is, no doubt, one of the causes 1078 DISEASES OF THE LIVER. of the inorganic salts being proportionally in such small quantity in the abnormal bile accumulated in the gall-bladder in cases of obstruction to its exit from the viscus. As I propose going fully into the subject of the treatment of distended gall-bladders, in order to avoid repetition I shall delay my remarks upon those distended with bile until I have completely finished with all the other forms of gall-bladder distension. Gall-bladders distended with Pus. Grall-bladders distended with purulent matter are not only not uncommon, but at the same time they fortunately present certain symptoms which may, and often do, lead to their correct diagnosis. A suppuration of the lining membrane of the gall-bladder is sometimes the result of the presence of gall-stones ; but unless there is at the same time an occlusion of the cystic duct, the suppuration pro- duces no recognisable symptoms during the lifetime of the patient. From the fact of the purulent matter draining away into the intestines by the ordinary biliary channels, and passing out of the body along with the faeces unnoticed, the existence of gall-bladder suppuration is not even so much as suspected, and remains undiscovered until the post-m.ortem examina- tion reveals it. In the American ' Journal of Medi- cal Science,' of January 1857, Dr. Pepper relates a GALL-BLADDERS DISTENDED WITH PUS. 1079 case where lie found the cystic duct ^occluded by a false membrane, and m the gall-bladder was no less than half a gallon of purulent fluid tinged with bile. Mr. Greorge Brown has recorded in the ' British Medical Journal,' 1878, p. 916, the case of a woman who, after suff'ering from an enlarged gall-bladder for* a year with gradually increasmg urgent symptoms, had six ounces of pus drawn off from it by an aspi- rator, without apparently diminishing the size of the tumour. And as the symptoms continued urgent it was twelve days later cut down upon, but unsuccess- fully, for the gall-bladder failed to be reached. How- ever, after an attack of violent retching, a pint of yellowish fluid escaped from the wound, which was followed not only by a diminution of the tumour, but by the complete recovery of the patient. The microscopic appearances of pus are shown in fig. 36 (page 1087). When on the subject of the treatment of gall- stones, I referred to a case in which an abscess of the gall-bladder was connected with the presence in it of gall-stones. The surgical history of this case, as recorded by Mr. Bryant in the twelfth volume of the Clinical Society's ' Transactions,' is that the patient, a woman aged 53, had enjoyed good health until within five years, when she noticed a small painless swelling on a level with and to the right of her navel. It gradually increased until in two years it 1080 DISEASES OF THE LIVEE. attained the size of a hen's egg, when it was opened by a surgeon and some matter evacuated. The open- ing never closed, purulent matter continuing to be discharged durmg three years. A second swelling formed a little below and to the right of the other, which was also opened, and pus escaped and a sinus- formed. It was laid open, but did not heal up, and in a short time bile began to be daily discharged. On the sinus being probed for two inches upwards, a gall-stone was felt ; so the sinus was carefully enlarged and the stone removed by means of forceps and a lithotomy scoop. The stone measured one and a quarter inches in length, and three-quarters of an inch in diameter. No untoward symptoms followed its removal ; although about half an ounce of bile escaped daily from the wound, the patient's health steadily improved. Six weeks after the operation a Sayres plaster of Paris splint was applied to keep at rest the abdominal muscles, and withm a couple of months the wound closed. Krumptmann relates (' Centralblatt,' March 14, 1873) that on making an incision into a tumour of the size of a pigeon's egg, two inches below the mar- gin of the right ribs, and two and a half inches from the median line, in a jaundiced man aged 64, who complained of subacute inflammation of the liver, nearly a gallon of pus poured out from it. A fistula established itself, and from seven to eight ounces of HYDATIDS OF THE GALL-BLADDEE. 1081 pure bile were daily discharged from it. This went on for a whole year, when the fistulous opening be- came blocked up by a gall-stone. It was dilated, and in the course of four days twenty-two calculi came away. The patient lived for eight years, enjoying, comparatively speaking, good health, notwithstanding the daily loss to his system of eight ounces of bile. He ultimately died at the age of 74, of inflammation of the lungs. The stools, during the eight years the fistula lasted, were of a grepsh-white colour, thereby proving the absence of bile from the intestinal canal, and forcing upon us the belief that the process of chemical mtestinal chylification must have beem carried on solely by the pancreatic and intestinal juices themselves. The treatment for all cases in which a gall-bladder is distended with pent-up pus is simply evacuation by means of a trocar, and subsequent washing out of the viscus by a stream of carbolised or aceticised tepid water passed into it through the canula, and a general attention to the patient's health. The carbolised water should be of the strength of 1 of carbolic acid to 100 of water, and of the aceticised of a table-spoonfiil of vinegar to the half-pint. Suppurating Hydatids of the Gall-bladder. Hydatids have not only gi'own, but suppurated and died, in the gall-bladder. Indeed gall-bladder 1082 DISEASES OF THE LIVER. hydatids may frequently end in so complete a suppu- ration, tliat even at the autopsy the debris of the cyst escapes notice, and the case is, in error, put down as being one of abscess of the gall-bladder. Hydatids sometimes distend the gall-bladder to a very great size. An example of a large suppurating gall-bladder hydatid is reported by Dr. Coley in vol. i. of the Pathological Society's ' Transactions,' p. 272. The case was that of a man aged 40, in whom a tumour, extending below the umbilicus, existed for ten or twelve years. It was hard, tender, and extended downwards to the pubes. It fluctu- ated. On the seventh day after being first seen it burst and discharged itself at the navel, the dis- charge consisting of pus, bile, and flakes of lymph. Hectic supervened, the patient died, and as at the post-mortem the liver was found perfectly healthy, Dr. Coley put the case down as one of suppurating hyda- tid of the gall-bladder. The spleen also contained hydatids. Gall-bladders distended with White Liquids. That a gall-bladder should be found containing a white liquid instead of a dark green one, has been looked upon and spoken of as a marvellous pheno- menon. But, like several of the other generally con- sidered inscrutable hepatic anomalies, I think I shall be able to show that there is in reality nothing ex- WHITE LIQUIDS IN THE GALL-BLADDER. 1083 traordinary in the fact of white liquids being found, under certain pathological conditions, in the human gall-bladder. For when the light of modern science is focussed upon their pathology they assume a readily comprehensible and simple form. To begin with, I may mention that I believe that there are two entirely distinct forms of white liquids to be met with. One bemg a secretion from the gall- bladder itself, the other a secretion furnished to it by the liver. The former, which is by far the most common kmd met with, I believe, is simply a true mucous secretion, the latter and rarer form an ab- normal species of white bile. White Mucus distending the Gall-bladder. It has frequently been observed at necropsies, both of jaundiced and non -jaundiced patients, that the gall-bladder has been found full of, and sometimes even distended with, a glairy dirty- white liquid in cases where there has existed an occlusion in the course of the cystic duct, so complete as equally to prevent the admission of bile into, and the exit of any other liquid whatever from, the gall-bladder. The second class of cases again, though due to a much rarer form of disease (one in which there is no occlusion of the cystic or any of the other ducts), has not been considered to be in the least degree more remarkable than the former. From both having 1084 DISEASES OF THE LIVEE. been erroneously thought to be the direct result of one and the same incomprehensible change having taken place in the function (!) of the gall-bladder. While in reality, as I shall now show, there is nothing whatever amiss with the functions of the Sfall-bladder in either one or the other case, and the presence of the white liquid in the first set of cases is due to nothing whatever beyond a purely normal physiological process (in so far as the gall- bladder itself is concerned) occurring under abnor- mal anatomical conditions existing in its cystic duct. While in the second class of cases, I believe I shall be equally able satisfactorily to prove that the pre- sence of the white liquid in the gall-bladder is not due to any abnormality in the anatomical conditions either of the gall-bladder itself or the cystic duct, but to a natural physiological, in the general circu- lation, having been transformed into an unnatural pathological process. According to these views, I think that the true rationale of the presence of the white fluid in the gall-bladder in the first set of cases — that is to say, in those where there is present an occlusion of the cystic duct — is readily explained on the following physiological principles. Firstly, be it remembered, the gall-bladder does not form, but only stores up, bile. Secondly, it possesses a mucous lining membrane whose duty it is to keep its interior continually lubri- WHITE LIQUIDS IN THE GALL-BLADDER. 1085 cated with mucous secretion, in order to prevent the stored-up bile acting uj)on its lining membrane. Such being the normal state of matters, what hap- pens when, from some abnormal cause or another, no bile whatever reaches the gall-bladder ? Simply this : — Should the gall-bladder chance to be full of dark bile at the moment when the occlusion of the cystic duct takes place, it is obvious that this highly- coloured biliary secretion must have been got rid of ere the viscus became filled with a white liquid ; and as the occlusion of the cystic duct efi*eetuaUy pre- vented the gall-bladder emptying itself of the dark green bile by the usual channel into the intestines, it got rid of it in some other manner — namely, by osmosis, through the instrumentality of the capillaries ramifying in its coats. The bile having been simply osmosed into the general circulation, and thence elimi- nated by the kidneys and skin. Should it, however chance that the patient died at the precise moment the gall-bladder had got rid of all its biliary contents, then the peculiar phenomenon of an occluded cystic duct and an empty gall-bladder would be found at the 2:>ost-mortem. Supposing, however, that the patient lived somewhat longer, a still further change would then be brought about in the contents of the gall- bladder. From being empty, it would gradually again become filled, but this time not by bile — for 1086 DISEASES OF THE LIVER. none could possibly find its way into it through the occluded cystic duct — but filled by its own normally secreted mucus. For, fi'om its mucous membrane being in a healthy state, the mucus would be daily and hourly secreted, just as if there was no obstruc- tion in the cystic duct preventing the entrance of bile into the gall-bladder ; and, as this secreted mu- cus could not get out of the gall-bladder, any more than bile could get in, the secretion would go on gradually accumulating within the viscus, until at length it distended it. And if the patient hap- pened to die at tliis stage, the still more unusual phenomenon of a gall-bladder full of white mucus, instead of dark bile, would, as a natural result, be met with at the autopsy. In proof of the correctness of this explanation of the pathology of at least one of the kinds of white liquids occasionally met with in human gall-bladders, I may briefly quote the report of the post-mortem of a woman aged 43, pubhshed by Dr. Duckworth in vol. xvii. of the Pathological So- ciety's ' Transactions.' It is there stated that the gall-bladder was found enlarged and full of a trans- parent thick yellowish mucus, with abundant flaky masses of columnar epithelium and plates of choles- terin suspended in it. The commencement of the cystic duct was firmly plugged up by a gall-stone the size of a musket-ball, the common bile-duct being quite free. There was a distinct history of GALL-BLADDERS DISTENDED BY JIUCUS. 1087 tlie occasional passage of gall-stones accompanied with jaundice. This case so clearly and so com- pletely confirms the above views regarding the way in which gall-bladders get filled with white mucus, that it requires no comments to be made upon it by me. Thus far, then, we have a truly scientific ex- planation of the strange phenomenon of a human gall-bladder being filled with at least one of the forms of white liquid instead of dark green bile. I'us and Mucus Cells. — A. Pus cells before and after treatment with acetic acid. B. Ordinary mucus cells : a. After treatment with acetic acid. c. Mucus cells loaded with pigmentary matter. The scientific explanation here given, it will be observed, is exactly the same in its major details as that already offered respecting the ratioivde of 1088 DISEASES OF THE LIVER. cases in which the hepatic bile-ducts are found distended with white liquid in cases of jaundice from suppression, as detailed at page 107. In the .cases of the gall-bladders containmg white mucus, however, there is, as a general rule, no jaundice whatever, in consequence of there being usually no impediment to the secreted bile flowing directly along the hepa- tic and common bile ducts into the mtestines. As has already been explained in the chapter on oc- clusion of the cystic duct by biliary concretions at page 604. White Bile. It was mentioned in the chapter on fatty degene- ration of the liver, that there are good grounds for believing that under certain pathological conditions the formation of green bile-pigment does not take place ; for it has been asserted that at autopsies gall- bladders have been met with containing a white fluid which resembled bile in aU its chemical properties, except one. Namely, the total absence of biliverdin. A specimen of this kind of colourless biliary fluid, which was taken from the human gall-bladder and examined by Ritter (Comptes Rendus, vol. Ixxiv.), contained cholesterin, bile acids, mineral salts, fats, and other biliary organic matters, with the single exception that it contained no biliverdin. To aU intents and purposes, therefore, the fluid was true WHITE BILE. 1089 l^ile, minus pigment. Had Ritter's remarks stopped here, I should have completely agreed with him ; but he has unfortunately supplemented his descrip- tion of the white biliary liquid with the remark that in such cases there is not only usually present jaun- dice, but a fatty condition of the liver. This asser- tion, I think, is not merely a theory, but an erroneous theory ; and I believe I can give both a reasonable and a scientific explanation why white bile was found in his non-jaundiced patient's gall-bladder, without regarding the circumstance, as he did, as very ex- traordinary. Indeed, I shall be able, I think, to show that, contrary to what he imagines, the very fact of the absence of jaundice in such cases is an essential factor to the easy comprehension of the rationale of the presence of white bile in a patient's gall-bladder. My theory, indeed, not only logically explains the presence of the white bile, but the absence of the jaundice, in all such cases, and con- sequently shows that Ritter's own case was no ex- ception to the rule. And, further, it shows that when jaundice is associated with white liquids, either in the gall-bladder or bile-ducts, the fluid is then not ' white bile ' at all, but merely the more common form of white liquid, which I have already described as simply gall-bladder and bile-duct normal mucous secretion. White bile, on the contrary, being, as I shall now show, a pathological and not a physio- 4 A 1090 DISEASES OF THE LIVER. logical product, from its being* the result of an arrest of the nonnal oxygenation, and consequent transfor- mation of blood h^ematin into biliverdin in the gene- ral circulation. In consequence thereof, from the liver finding no green biliverdin to excrete and pigmentise its secretion with, and the skin none to deposit in its rete mucosum and produce jaundice with, there exists the double phenomenon of white bile and no jaun- dice. The liver's function itself, in fact, not being disordered at all ; but, just as the children of Israel failed to make proper bricks from not being fur- nished with straw, in like manner the liver fails to secrete properly coloured bile, from not being fur- nished by the circulation with the necessary pigment for its coloration. As Ritter points out, the white. BILE is true bile in every sense of the word, except that it is not pigmented. While the absence of jaun- dice again, which he considered so peculiar, I equally attribute to the absence of bile-colouring matter from the circulation. There being no biliverdin to stain the skin, as a natural consequence there can be no jaundice and no saffron- coloured urine, though there may be, at the same time, from the same cause, most probably colourless stools. Thus, then, I think, I have now given two logical scientific theories capable of rending asunder the veil of mystery which has hitherto enshrouded the origin of the white liquids met with m the human gall-bladder. Those who BILIARY CONCRETIONS IN THE GALL-BLADDER. 1091 have still doubts of the correctness of the above ex- planation regarding the absence of colour from the bile, had better carefully peruse what I have said regarding the formation of biliverdin at pages GH and 119. And as there are as yet no known signs or symptoms by which the existence of white liquids in the gall-bladder can even so much as be suspected during life, I may be excused for declining to offer any hypothetical suggestions regarding their treatment. Gall-bladders distended with Biliary Concretions. Gall-bladders may be distended with gall-stones. The stones found in a distended gall-bladder may be not only of all shapes and sizes, but even of different colours and composition. Thereby proving that they have been formed at different times, and under different pathological circumstances. A gall-bladder may even be completely fiUed by one large stone. Which may be as big as a goose's egg ; and in that case the hard lump can be felt through the abdominal parietes. An excellent spe- cimen, showing how a single gall-stone may com- pletely fill up a gall-bladder (where the stone measures 1| by IJ inches in diameter), is among the wet pathological preparations in the museum of the Royal College of Surgeons. Gall-bladders, though they may be chokefull of calculi, are very seldom, however, found much en- 4 A 2 1092 DISEASES OF THE LIVER. larged. For tlie simple reason tliat as soon as the viscus becomes filled with the calculus or concre- tions, from there being no more room left for bile to lodge within it, the calculus or concretions, from failing to be supplied with fresh materials for their aggrandisement, cease to grow bigger. This is, how- ever, not always the case, for it sometimes, though but rarely, happens in the case of gall-bladders, as it does with the pelvis of the kidney, that a conical- shaped stone forms at the gall-bladder orifice of the cystic duct, and acts like a valve, more freely ad- mittmg of the entrance than of the exit of bile. Just as I showed had occurred in the specimen I exhibited to the Pathological Society (' Transactions,' vol. xv. p. 147), where fifty-nine calculi were found in the pelvis of one kidney ; from its having a conical- shaped stone actmg as a valve at the mouth of the ureter. Not only may gall-bladders distended with stones be felt through the abdominal walls, but it has been affirmed by more than one accustomed to manipulate liver cases, that they have detected the actual pre- sence of numerous gall-stones in a distended gall- bladder, by their giving origin to a distinct crackling sound, not alone audible by the stethoscope, but re- cognisable through the sensation of sound given by them to the finger-tips. Be that as it may, there may be said to be but little difficulty in diagnosing the DISTENDED BILE-DUCTS. 1093 presence of calculi of any great size or number in a gall-bladder, from the simple fact that firm pressure over the organ, in such cases, is always attended with considerable pain ; and when there are no signs to otherwise account for the pain, and there is reason to suspect the existence of gall-stones, the distension and hardness of the viscus may, with a tolerable chance of exactitude, be put down as a case of en- largement of the gall-bladder caused by the presence in its interior of gall-stones. Distended Bile-ducts. Not alone gall-bladders, but even the bile-ducts become enormously distended with pent-up bile. In the first volume of the ' DubliQ Hospital Re- ports,' Dr. Todd gives the case of a girl, aged 14, who, from an occlusion of the duodenal orifice of the bile-duct, on account of a scirrhous tumour of the pancreas, had the bile-duct so dilated that it reached down into the pelvis. A distended gall-bladder greatly complicates the diagnosis in cases of suspected distended common bile-ducts ; for they may occur together, or the bile- duct may be even enormously distended and the gall-bladder quite empty. The latter state of things occurs when there exists an obstruction in the cystic duct itself, as well as an occlusion of the common bile-duct, preventing the secreted bile from finding 1094 DISEASES OF THE LIVER. its way into the gall-bladder. In which case the pent-up bile only accumulates in the common and hepatic ducts, and not in the gall-bladder at all. A case of this kind was reported by Dr. Halliday Douglas in the ' Edmburgh Monthly Medical Jour- nal ' of February 1852. The case was that of a maid-servant, aged 17, whose common bile-duct was so distended with bile, that, although she had thirty ounces withdrawn from it by tappmg a month before her death, it was found at the post-mortem to contain nearly a gallon of bile. Her clinical history was peculiar, for the complaint was thought to have begun three years before her death, that is to say, when she was only fourteen. Her symptoms were pain in the right side, recurring again and again with paroxysmal aggravations and rigors until within three months of her death, when it began to be almost incessant, and the jaundice became much more decided. An acutely tender tumour was felt and seen in the seat of the gall-bladder, and dulness extended five inches in the perpendicular line. Her agony was sometunes intense. The pulse was in general 100. The tongue dry and brown. The bowels constipated, but the faeces dark- coloured. She had profuse perspirations. As the tumour fluc- tuated, it was tapped with a hydrocele trocar, and thirty ounces of liquid drawn off. This gave im- mediate relief. She gradually, however, got more TREATMENT OF DISTENDED GALL-BLADDERS. 1095 and more emaciated, and died somewhat suddenly about a month after the tapping. At the post-mortem examination a large fluctuating sac was found, occu- pying the whole right side of the abdominal cavity, and closely adherent to the lower surface of the liver. It contained within a few ounces of a gallon of yel- low syrupy offensive fluid, in wliich were crystals of cholesterin in abundance. In the hepatic extremity of the sac were the orifices of the hepatic and cystic ducts, dilated so as to admit the finger. The gall- bladder was undilated. In fact, the whole sac con- sisted of a dilatation of the common bile-duct, and nothing else. The non-dilated condition of the gall-bladder, in this case, Dr. Halliday Douglas attributed to the possession by the cystic duct of a valvular orifice. Treatment of Gall-bladders and Bile-ducts distended by Biliary Concretions, Bile, Pus, and other Liquids. The treatment of distended gall-bladders and bile-ducts is a point of far greater importance than at first sight appears, from death being the almost inevitable result when they are left unattended to. It is not, however, the mere factor of the disten- sion of the biliary appendages, which, per se, causes the death of the patient, but, as will be imme- diately shown, the combined result of three totally •distinct pathological factors, one and all of which 1096 DISEASES OF THE LIVER. may be said to be a proximate cause of death.. Being a zealous advocate of the adoption of the operative plan of procedure in cases of distended gall-bladder and bile-ducts suggested by Petit nearly a hundred and fifty years ago — not alone, however, on new grounds, but with additional facts in its sup- port — I beg leave to remind my reader that in look- ing upon it with a critical, or, it may even be, with a somewhat cynical eye, it will be well for him to- remember that the majority of cases of jaundice from obstruction are much less under the power of remedial agents than those arising from suppres- sion, in consequence of our having three distinct conditions to combat. Firstly, — The derangements originating in the absence of bile from the digestive canal. Secondly, — The morbid effects arising fi'omt its accumulation in the ducts, and consequent inter- ruption to the hepatic functions. Thirdly, — The general poisonous action on the system of the re- absorbed bile. As regards the first of these effects — namely, the derangements arising from an absence of bile from the digestive canal — it may be said that if these were the only difiiculties with which we had to- contend in cases of jaundice from obstruction, they could easily be overcome. For, in the first place, the- mere absence of bile is not attended with any imme- diate dansjer. A circumstance which has led to the- TREATMENT OF DISTENDED GALL-BLADDERS. 1097" common belief that the presence of bile is not abso- lutely essential to life. Experiments on dogs with biliary fistulas, like those before referred to, as well as cases of disease in the human subject, have proved that life may be sustained, under certain conditions, for a very long period, without bile reaching the intestines. Indeed, the only immediate bad effects which appear to result from its absence are costive bowels, great flatulence, and extremely offensive stools. While again the indirect bad results — . namely, loss of flesh, &c. — as has been proved by experiments on animals, can be counteracted by giving an additional amount of food ; and the direct results of constipation, flatulence and foetor, may be easily overcome by appropriate remedies. The secondary morbid effects — namely, those arising from the accumulation of bile in the ducts — are unfortunately not so easily under control. Could we remove the cause of obstruction, these would, of course, immediately cease. This, however, is seldom in our power, except in the case of gall- stones, the expulsion of which, as I have already shown, we can aid in various ways. When the occlusion of the common bile-duct is caused by an organic tumour, no treatment of ours can be expected to remove the obstacle, and sooner or later the patient is carried to an untimely grave. Our efforts at relief in such a case ought therefore 1098 DISEASES OF THE LIVER. to be directed into another channel ; and here, in order to give the sufferer at least some chance of recovery, even although it be little better than a forlorn hope, I cannot refrain from recommending, in cases of permanent occlusion of the duct in which there is great distension of the gall-bladder, the esta- blishment of an artificial biliary fistula. Dogs, as is well known, live perfectly well for years after the artificial establishment of a biliary fistula in them ; and human beings (as I have already shown at page 673, and will yet further show) in whom a fistulous opening into the gall-bladder has spon- taneously or accidentally been established, have also been known to live an equal, indeed a much longer, period of time. For example, at page 273 of the first volume of the Pathological Society's ' Trans- actions/ Mr. Obre relates the case of an exceedingly corpulent lady, aged 75, who about six years before her death observed a globular swelling, of the size of an orange, at the junction of the right hypo- chondrium and epigastrium, which, after remaining dormant for a time, suddenly became painful and elastic. It was punctured with a knife, and pus and bile flowed fi-om it, and continued to do so, more or less, through a fistulous opening which established itself, until the time of her death five years after- wards. The fluid which flowed away during the five years she lived after the opening was made, TREATMENT OF DISTENDED GALL-BLADDERS. 1099 ivas clear, thin, and of a deep yellow colour. The patient's health remained good, with the exception of being dyspeptic. The bowels were irregular, and the stools pale ; though sometimes they were dark in colour and loaded with bile, showing that there was an occasional communication between the bile- ducts and intestines. At the 2^ost-mortem examination the gall-bladder was found thickened, and firmly contracted round a gall-stone weighing ninety-four grains. The bile- ducts were all pervious, and the tissues of the liver quite healthy, in spite of the biliary fistula having existed for five years. A case was reported by Dr. Moxon, in 1866, where a woman, aged 50, after a bilious attack com- plamed of pam and swelling a little below and to the right of the umbilicus, which gradually became as large as a cricket-ball, and ultimately burst, and discharged a sero -purulent fluid through a small •opening. After continuing to discharge for a month, pure pus began to come away, and shortly after- wards four gall-stones of about the size of small marbles were found on the poultices. They passed without any pain ; were flattened on their sides from -apposition, and consisted of cholesterin. The open- ing did not close up after their discharge, but another fitone, and a quantity of Mable material, supposed to lie dried bile, came away. After which the opening 1100 DISEASES OF THE LIVER. healed up ; which was not until nine months from the time it formed. A case of human biliary fistula which discharged eighteen ounces of bile during ten days and then healed up, is reported in the ' Berliner Klinische Wochenschrift ' for April 7, 1873, by Dr. J. Hertz.^ A sempstress, aged 28, enjoyed comparatively good health until she had an attack of enteric fever, a month after which she was seized with severe ab- dominal pain, soon followed by a swelling the size- of a hen's egg, near to and to the left of the navel,, which disappeared of its own accord in a few days.. Eight months later it reappeared as a sharply defined painless tumour, with a constricted neck. Its lowest portion being about three inches broad. Two months later it fluctuated, and the skin over it was red and tender, like a pointing abscess. An incision was made into it, and about two ounces of a white slimy fluid escaped — not pus. Ten days later a gall-stone was spontaneously discharged ; and during the next eight days thirteen more, varying from the size of a pea to that of a small hazel-nut. Four days later a stream of bile suddenly burst from the wound, and continued to flow from it, at the rate of eighteen ounces a day, for ten consecutive days. From this time all traces of bile disappeared from the stools,, and, although she had a good appetite, she com- plained of weakness ; so an attempt was made to- TREATMENT OE DISTENDED GALL-BLADDERS. 1101 close the fistula by ligaturing its orifice, treating it like a hare-lip. Six days elapsed after its closure before bile reajDpeared in the faeces. The patient then regained her strength, and within a month Ts^as able to resume work. It must be remembered, however, that the mere tapping of the gall-bladder would, in a case of gall- stone impacted in the common duct, or indeed in any case whatever of occlusion of the common duct, be of no permanent advantage, whereas the extraction of the gall-stone or the establishment of an artificial biliary fistula would be of the greatest service in pro- longing the life of the patient. For what in reality is wanted in a case of enlarged gall-bladder, or ducts distended with pent-up bile on account of a per- manent obstruction to its normal mode of exit into the duodenum, is not only to get rid of the accumu- lated bile, but also of the pernicious results on the hepatic tissue itself of its accumulation. For as soon as these pernicious results are got rid of, the normal biliary secreting function of the liver naturally enough re-establishes itself. In addition to what I have already said — in tlie chapter in which I recommended the artificial removal of gall-stones from the hepatic appendages (page 672) and the above facts — as incentives to the production of artificial biliary fistula? in appropriate cases, as well as the removal of impacted gall-stones by the 1102 DISEASES OF THE LIVEK. surgeon's knife, I may mention that not only one^ but several successful cases of emptying the human gall-bladder by operation have been recorded. One was brought before the Royal Medical and Chirurgical Society, in November 1879, by Mr. Lawson Tait, under the title of ' Choleocystotomy performed for Distended Gall-bladder due to the Impaction of a Gall-stone.' The woman had spasmodic pains in the right side, aggravated by walking and lifting slight weights ; presented a cachectic appearance, suffered from head- ache, sickness, and obstinate constipation. The seat of pain was over the right kidney, where there was a heart-shaped tumour, firm and elastic without fluctua- tion, tender to the touch, and movable to each side. On August 23, the abdomen was opened in the middle line to the extent of four inches. The tumour was found to be a distended gall-bladder containing a white starchy-looking fluid and two large gall-stones, one lying loose, and the other impacted in the entrance of the duct. The latter was removed. It weighed 6*11 grammes (94'3 grains). The wound in the gall- bladder was stitched to the upper end of the wound in the abdominal walls by continuous sutures ; the aperture into the bladder was left open, and the rest of the abdominal opening was closed in the usual way. The operation was performed antiseptically, under ether. The patient rallied completely in a few TREATMENT OF DISTENDED GALL-BLADDERS. llOii hours, and the dressmgs of the wound were found stained with healthy bile. The flow of bile from the wound continued till September 3. The wound was completely healed on September 9. On the 30th, she went home quite restored to health. Still further to encourage surgeons to take opera- tive proceedings in cases of dangerously impacted gall-stones, I may mention that Mr. Bryant com- municated a case to the Clinical Society in 1879, in which a biliary calculus was successfully removed from the gall-bladder of a woman aged 53, who was a patient in Guy's Hospital under his care in the preceding 3^ear with two discharging sinuses of three years' standing, following an abscess, which had been previously forming for two. At first the sinus was laid open, and pus alone escaped ; but subsequently, as bile flowed in quantities from the wound, an ex- ploratory operation was performed, and, at a depth of two inches, a biliary calculus, one inch long, taken out of the gall-bladder. Everything went on well after the operation ; and although bile continued to escape from the wound for about two weeks, the parts quite healed, and in about four months the patient left the hospital cured. This case shows that nature might be copied, and gall-stones removed from the gall-bladder through the abdominal walls ; and indicates that, under cer- tain circumstances, the operation is justifiable when 1104 DISEASES OF THE LIVER. the sinuses by their presence are setting up inflam- matory and sujDpurative changes about the gall- bladder, without any obstruction to the bile- ducts, as well as in the more serious class of cases in which i:he cystic or common bile-duct is obstructed, and dropsy of the gall-bladder, with jaundice, complicates the case. Dr. J. M. Sims, a still bolder and generally suc- cessful operator, cut down upon the enlarged gall- bladder of a lady aged 45, and extracted therefrom no less than sixty small gall-stones, and nearly thirty ounces of fluid which was not bile, but mucus. The operation seems to have been a very tedious one, as it is reported to have lasted one hour and sixteen minutes. Chiefly on account, it is said, of the difli- culty experienced in securing the coats of the gall- bladder to the sides of the incision, and closing up the wound. It was performed under the antiseptic method, and although the lady lived only eight days, the immediate benefits of the operation were consider- able, as it relieved the pain, nausea, vomiting, as well as the itching, and at the same time produced natural stools. The 2Wst-mortem showed that there was no peritonitis, and that the gall-bladder, which was al- ready firmly adherent to the abdominal walls, still contained sixteen sacculated gall-stones.^ The cause of death Dr. Sims considered to have been the ab- 1 Brit. Med. Jour. 1878, p. 811. EXTRACTION OF BILIARY CALCULI. 1105 sorption of poisonous biliary salts. A doubtful theory, for biliary salts are absorbed in every case of biliary obstruction, and do not cause death m eight days or even in ei2:hteen months. The question of the removal of gall-stones by operative procedure was exhaustively treated in the ^ Memoires de Chirurgie ' in the year 1700. In a case there discussed, the stone was withdrawn by the for- ceps, and the author drew an analogy between it and the operation of lithotomy. I verily believe that the day is not far distant when the removal of impacted gall-stones from the common bile-duct by the surgeon's knife will not only be a frequent, but as successful an operation as that of the removal of a calculus from the urinary bladder. For just as the presence of urinary calculi can be in- dubitably ascertained by sounding, so also may the existence of gall-stones be equally indubitably de- monstrated. Dr. Whittaker, in a paper in the ' New York Medical Record ' (1882), advocates the employ- ment of a long hypodermic needle, as a means of de- termining the presence of gall-stones and their situa- tion. He relates a case of occlusion of the bile-duct, in which the diagnosis lay between gall-stones and cancer, in which he used the needle repeatedly with- out any bad effect, and at length, at the depth of ' four and three-fourths inches,' struck a stone. No incon- venience followed. He then operated, and although 4 B 1106 DISEASES OF THE LIVER. the case ended fatally, tliat is no reason why the attempt should not be made again. As regards the sounding for gall-stones, I may remark that as I have not only repeatedly inserted darning-needles into the hearts of dogs and rabbits (while studying the rhythm of their pulsations), but kept them there for ten or fifteen minutes at a time without apparently inconveniencing the animal, far less producing disagreeable after-effects, I see no reason whatever to anticipate the slightest danger supervening in probing for gall-stones. And, although I have never as yet done so myself, from my extensive experience in the use of long needles in dogs, &c., I have no doubt the best way to be successful in the search for gall-stones by sounding would be to employ a six inches long fine sharp-pointed steel wire, of not more than the diameter of a darning-needle, fixed in a handle in order to communicate the more readily the sensation of hardness to the hand. Moreover it may be here added that the escape of a small quantity of bile into the peritoneal cavity is attended by merely imaginary dangers. I say this from the fact that bile has again and again been known to escape into the peritoneum after the accidental rupture of the gall-bladder, and not lead to the death of the patient, nor even to so much as peritonitis. In the fourth volume of the ' Medico- Chirurgical Transactions,' a case is actually recorded where thirteen pints (!) of SOUNDING FOR GALL-STONES. 1107 bile were removed by tapping from the abdomen of a boy whose gall-bladder had been ruptured three weeks previously. He was tapped twice, and after forty-eight pints, in all, of bilious -looking fluid had been withdrawn, he got well. As, from the histories of the cases previously cited, it is clearly seen that there would be no very great risks run in establishing a biliary fistula in the human subject, I shall now point out what I con- sider would be its advantages. By the artificial establishment of a biliary fistula the human being would be placed as nearly as pos- sible in the same condition as the animal in which the operation has been performed for physiological purposes, and, we might reasonably hope, with an equally favourable result, at least in as far as the biliary functions are concerned. In the first place, we should have removed all the derangements result- ing from the interruption to the flow of bile, and consequent upon the distension of the ducts. In the second place, we should have obviated the danger arising from the poisonous efi'ects of the re-absorbed bile, which are of no trifling nature ; and, lastly, we should only require to combat the evils arising from the absence of the biliary secretion in the digestive process, which, as was before said, can to a certain extent be overcome by giving an additional quantity of food, and paying attention to the bowels. In these 4 B 2 1108 DISEASES OF THE LIVER. remarks I have omitted taking into consideration the effects that might arise from a tumour, or other obstructing cause to the biliary secretion, for these would in no way be directly influenced by the mere establishment of the biliary fistula. As might natu- rally be expected, the patient would, like animals with artificial biliary fistul?e, lose flesh, become ema- ciated and weak, his hair have a tendency to fall off^, his bowels to become irregular, and a great and an almost constant discharge of foul -smelling gases take place from the intestinal canal. At length, after a shorter or longer period, he would sink and die, unless the fatal termination were retarded by giving him pig's bile in capsules, and at the same time allow- ing him an additional quantity of nourishing food. For death from want of bile is nothing else than death from slow starvation. The fact regarding the bene- ficial efi'ects of an additional quantity of food in pro- longing life should never be lost sight of in the treatment of any case of obstruction of the gall-ducts ; for, by attending to this circumstance alone, it is often m the power of the medical man to keep his patient alive for a considerable length of time. Such then being the case, if a suflicient artificial supply of bile be at the same time given I can see no reason whatever for the patient not surviving for a long period of time. The artificial establishment of a biliary fistula in HUMAN BILIARY FISTULA. 1109 the human subject is therefore not such a Utopian idea as might at first be imagined. Distended gall- bladders having been several times tapped, as we see with success, both in this and other countries, the permanent establishment of a fistula, if done in the manner I shall immediately point out, would even, in my opinion, not be a more hazardous operation than simple tapping. Biliary fistulte in dogs are generally made in a single operation, by cutting through the abdominal parietes, seizing the gall-bladder, stitching it to the lips of the wound, and inserting a canula. But here there is always some danger of the wound not healing by the first intention, and of the passage of bile into the abdominal cavity . In the case of the human subject I should therefore recommend the inducing of an adhesion of the gall-bladder to the abdominal parietes by means of an escharotic, before making the opening ; in which case I can scarcely imagine that the operation would prove one either of the slightest difficulty or danger. But even supposing that it were not entirely free from either, it is stiU surely wiser to give the patient at least the chance of having his life prolonged, than to permit an inevitably fatal affection to run an uninterrupted course, which we know can, at best, be calculated by months only ? In my humble opinion, until the troubles of life be- come permanently greater to an individual than its pleasures, it is more philosophic for him to try and 1110 DISEASES OF THE LIVER. bear ' the ills he has, than fly to others that he knows not of.' From all that has been said it will appear that I do not regard the establishment of a biliary fistula in a human being as a formidable operation, and that, when once it has been successfully established, the benefits it would bestow upon the patient would be very considerable. For, in the first place, it would not put him in one whit worse a condition than a quadruped which has been in a similar way operated upon for experimental purposes ; and the only bad symptoms, as we know, which are likely to arise from it are simply those resulting from the non- admittance of bile into the intestines. Which fact cannot, of course, be used as an argument against the operation, seeing that it is in those very cases where the disease itself has precluded the entrance of bile into the intestines, that the performance of the opera- tion is advocated. So that if the artificial fistula does not diminish the whole of the evils, it will at least in no case increase even a single one of them. The triumph of operative surgery would of course be to establish an artificial fistula between the gall-- bladder and the duodenum. For then not alone would the evils resultmg fi'om the pent-up bile be removed, but those arising from the non- admittance of bile into the intestines likewise be at the same time overcome. I am not quite sure if, in these ARTIFICIAL HUMAN BILIARY FISTULA. 1111 days of antiseptic surgery, this operation is not prac- ticable ; for I can see no reason why the adjacent surfaces of the gall-bladder and duodenum should not be eroded by potassa fusa and speedily stitched together. Adhesions would rapidly form (see case re- ported at page 671, where eight hours sufSiced to seal up the opening), and a permanent duodenal fistula be thereby established. My almost invariable com- plete success in all forms of abdominal operations on animals (gastric fistula, &;c., &c.) have led me to the conclusion that the danger in the human subject arises almost solely fi:om the operation being delayed until the patient's constitution is so broken down by the disease, that, when in the end it is under- taken, the poor sufierer has not strength left in him to bear it. Whereas, had he been operated upon before his constitution became broken down, the operation might, perhaps, have been as success- ful as if it had been performed on a healthy dog. The difference in the amoimt of danger between operations on healthy dogs and unhealthy men not being so much due to organic constitutional pecu- liarities, as to the differences in their vital powers, from the one being in robust health, and the other in an advanced state of disease, when operated upon. So, in advocating the artificial establishment of a biliary fistula, or the extraction of an impacted gall-stone from the common bile-duct, in a human 1112 DISEASES OF THE LIVER. being, my advice is — operate early, instead of waiting until the patient has no vital stamina left in him. In those cases of jaundice from permanent ob- struction where it is considered unad vis able to adopt the plan of operating above suggested, we ought in our general treatment carefully to avoid the common error of administering foods likely to produce an increased secretion of bile. For the sufferings of the patient are not so much due to a deficient secretion, as to the want of biliary excretion. Our whole energies should therefore be directed to sustaining the strength of the patient, and mitigating, if possible, the patholo- gical effects of the absence of bile from the intestines. This, I believe, we can best do by artificially supply- ing the place of the absent bile in the digestive pro- cess. Not, however, in the way usually recommendedy of giving inspissated, ox or sheep^s, bile along with the food; a method of treatment which originated ere- modern physiology rent the veil of therapeutical em- piricism. For, in the first place, all the bile pre- pared according to the methods indicated in the pharmacopoeias, has its most essential properties destroyed during the process of preparation. In the second place, the only bile which closely ap- proaches in its composition that of man, is that of the omnivorous domestic pig, whose food not only, but even whose digestive process, closely resembles that of the human being. And, in the third place^ TREATMENT BY PIG's BILE. 1113 we have hitherto been mstructed to admmister it at the very time which modern research has proved to be the most unsuitable that could possibly be devised. In administering bile immediately after food, as is usually done, we most effectually pro- duce the contrary result to what is intended. For when bile mingles with gastric juice, it destroys its digestive power. So that, by giving the bile imme- diately, or soon after a meal, we really diminish instead of increase the power of the digestive func- tions. My experiments, both chemical and physio- logical, led me to propose, twenty years ago, not only another method of preparing bile for medicinal purposes, but also to suggest an entirely new mode of administering it. As regards the method of preparation. Nothing can be more simple, and at the same time more effectual. Fresh bile, taken directly from the gall- bladder of the newly-killed pig, is filtered, through very porous filter-paper, to free it from mucus ; it is then as rapidly as possible evaporated to dryness at a temperature not exceeding 160° Fahr. The bile, as soon as dried, is ready for use. Simple as this operation appears in theory, there are two practical difficulties connected with it : — 1st, Bile filters very slowly, and consequently little must be put into the filter at a time. 2nd, Bile is rather hygroscopic, and consequently, m order to get it dried quickly, it is 1114 DISEASES OF THE LIVEK. necessary to spread it over a large surface. If the bile has been well prepared, that is to say, thoroughly freed by filtration from its ferment mucus, and well dried, it will keep in stoppered bottles for many months, and in gelatin capsules for many years, without losing any of its active properties. I have at this moment in my possession some that were so prepared twenty- one years ago, and they are still, to all appearance, in a perfectly good condition. Having stated that bile as at present employed more frequently does harm than good, by retarding instead of hastening the digestive process, I have now to point out the manner in which it may be given with advantage. If bile be administered, as I propose, at the end of stomachal digestion, it will, as in the healthy organ- ism, act on the chyme at the proper moment, and thereby render it fit for absorption. In order still further to ensure the action of the bile being delayed until the food is in a condition favourable to its action, that is to say, until it is ready to pass from the stomach into the duodenum, I had the bile, as above prepared, put into gelatm capsules, which are not readily acted on by the gastric juice. While in the stomach, the capsules, however, swell up from the size of a pea to that of a small gooseberry, and at the same time become so soft that they readily burst in passing through the constricted pylorus into the duodenum, TEEATMENT BY PIG's BILE, 1115 and thereby allow the bile to escape, and come in con- tact with the food at the precise moment its action becomes requisite in the digestive process.-^ Each capsule should contain five grains of the prepared bile. Five grains being equal to about a hun- dred grains of liquid bile fi'esh from the gall-bladder. Two capsules therefore represent two hundred grains of pure bile, a quantity which, though perhaps less than the healthy organism consumes during each digestion, would in most cases be sufficient for the wants of the system. If, however, a larger amount be considered necessary, there is no reason why three or more capsules should not be given. By the administration of prepared bile in the manner here described, the physician is enabled to imitate nature, and supply an important element to the system ; which, although incapable of curing the disease, can nevertheless aid in warding off for a time the fatal tennination. ^ Prepared "bile, made up into an ordinary pill, dissolves in gastric juice in a quarter of an hour. "V\Tien the pill is silvered it is dissolved in half an hour, and when gilded, in forty minutes. Whereas, in experi- ments made many years ago on the same specimen of gastric juice, the gelatin capsules prepared for me by Savory & Moore, although swollen to more than three times their original size, were nevertheless intact at the end of an hour and a half. They readily broke on being gently squeezed between the finger and thumb ; it is not therefore probable that they would pass through the pylorus •without giving way, and allow- ing their contents to escape. Capsules of pig's bile prepared as above may be had at the wholesale druggists', Burgoyne, Burbidges, & Co., 16 Coleman Street, E.G. 1116 DISEASES OF THE LIVEE. Sloughing, Gangrene, and Rupture of the Gall-bladder. These conditions must be regarded as exceedingly- rare, for one seldom reads in medical periodicals of their occurrence. Some cases of the kind I will^ however, mention, each with special characters of its own, so as to present the reader with different types of these pathological conditions. Gall-bladders have not only sloughed, but become gangrenous and ruptured, from the effects of gall- stones. At least, such was supposed to have been the cause of death by htemorrhage in a patient seen by Dr. Leared, who in 1859 exhibited the parts at the Pathological Society. The case was that of a man, aged 22, who, after suffering for a few days from agonising pain in the region of the gall-bladder and navel, suddenly fell into a state of collapse, and died within a few hours. On post-mortem examination the gall-bladder was found not only to be ruptured, but in a gangrenous sloughing condition, the rupture being caused. Dr. Leared thought, by over- distension, the only thing found to account for which was a small pea-sized calculus blocking up the duodenal orifice of the common bile-duct. The man was ill only a fort- night, and his symptoms commenced with paroxysmal pains — like gall-stone colic — in the right hypochon- driac region, with tenderness on pressure over the EUPTURE OF THE GALL-BLADDER. 1117 gall-lDladder. These symptoms were associated with slight jaundice. As I, however, told Dr. Leared at the time, I had grave doubts of the correctness of his theory that the gangi-enous condition and rupture of the gall-bladder was the result of its over-distension. The argument I advanced against the theory was that gall-bladders distended with pent-up bile to twenty times greater size neither become gangrenous nor rupture. Therefore I thought that some other cause induced the sloughing of the gall-bladder. There can, at the same time, be no doubt whatever that a rupture of the gall-bladder may arise from its over- distension in cases where there exists ulceration or other thinning and weakening disease of its coats, induced by the presence of gall-stones, &c. But when this kind of rupture, in contradistinction to an ordinary perforation, occurs, it is usually rapidly followed by symptoms of acute peritonitis. For further information on this subject see what I have said regarding the rupture of the common bile-duct in the chapter devoted to gall-stones, page 629. Rupture of the gall-bladder has occurred during protracted labour ; and undoubtedly, when such an untoward accident occurs, it must be attributed more to a diseased state of the gall-bladder itself than to the mere severity of the labour. As I know nothing of such cases personally, and none of them lias been reported sufficiently fully or lucidly to enable me to 1118 DISEASES OF THE LIVER. draw any conclusions as to their morbid anatomy, I decline to say anything more on the subject. Carbonate of Lime Deposits— erroneously called Ossifica- tion—of the Gall-bladder. The name of ossification of the gall-bladder has been, I believe, erroneously given to cases where an extensive deposit of amorphous carbonate of lime has taken place within the viscus, without a trace of true ossification having been detected, or even ever ex- isted. Gall-bladders have not only been found lined with, but entirely filled up by, a deposit of carbonate of lime, exactly like what is sometimes met with in the cystic duct. Dr. Murchison recorded a case of this kind, where at the post-mortem no bile whatever was found in the gall-bladder. It was collapsed, and had its mucous membrane encrusted with a layer of white carbonate of lime, which effervesced strongly on the addition of nitric acid. The specimen was taken from the body of a woman aged 37, who died from cirrhosis of the liver, coupled with hypertrophied spleen and leukaemia. The gall-bladder end of the cystic duct was completely blocked up by the cal- careous matter, (Pathological Society's ' Transac- tions,' vol. vii. p. 240.) In 1850, Dr. Ogier Ward showed at the Patho- logical Society a portion of a gall-bladder (having small calcareous plates embedded in it), which was dis- CRETIFICATION OF THE GALL-BLADDER. 1119 charged through a fistulous opening in the right iliac region of an unmarried lady aged 48. The history of the case was somewhat j^eculiar. She had suffered from purulent expectoration and signs of a cavity in the left lung for twenty years, and about eight years previous to the portion of the gall-bladder being dis- charged, she was attacked with diarrhoea, vomiting, and fainting, when a tumour was for the first time discovered in the right side, apparently unconnected with the liver, as it was more in the centre of the ab- domen, and had a marked sulcus between it and the liver. In a twelvemonth's time it had descended into the right iliac fossa, and there it pointed and burst midway between the pubes and spine of the ilium. From it came a purulent hydatid discharge mixed up with whole hydatid cysts varying from the size of a pea to that of a turkey's egg. Some singly, some in clusters, and striated externally. In five weeks the liydatids ceased to be discharged, and the pus became less offensive. The fistula, however, did not heal up until it had been open for four months. When sud- denly, after a bilious attack, the discharge ceased, and the wound closed. The right side of the abdomen at the same time becoming tense and tender, and the patient suffering from rigors. Four days later, the orifice reopened, and a quantity of pure bile, at the rate of about a pint a day, discharged itself for nine days, when a slough of a portion of the coats of 1120 DISEASES OF THE LIVER. the gall-bladder came away. The bile continued to pass, in gradually diminishing quantity, until, by the end of seven months from the first bursting open of the fistula, only about a drachm of bile was dis- charged in the twenty-four hours. This was at the time the specimen was shown to the Society, and when the patient was still only in a very moderate state of health. Although gall-bladders that are found completely filled with a deposit of lime are, I may say invariably, described as being cases of ossification, yet, when the deposit is chemically and microscopically examined, it is found neither m its composition nor its histology to bear any resemblance whatever to true ossification, no matter however hard and bone-like it may be. For it consists not only chiefly of carbonates instead of phosphates, but is structureless, being a mere hete- rogeneous mass. This pathological condition of gall- bladder is unfortunately one of those which furnish no specific signs or symptoms during the lifetime of the patient ; so at present it is to us of no clinical im- portance whatever. For some further information on the subject of calcareous deposits, see pages 584 and 605. Cancerous and other Growths of the Gall-bladder. Like the liver itself, the gall-bladder is liable to become afi^ected with both malignant and benign TUMOURS OF THE GALL-BLADDER. 1121 forms of tissue degeneration, and the exciting cause appears in many cases to be, as in the case of the hver, the irritative effects of gall-stones. Gall-stones apparently, indeed, not only give rise to serious organic changes in the walls of the viscus, such as inflam- matory thickenings and hypertrophies ; but to the formation of new growths in the shape of benign scirrhous and malignant encephaloid tumours. (See chapter on Cancer.) In most books these tissue changes in the coats of the gall-bladder are said to be merely secondary to liver-tissue degenerations ; but this, like many of the other old-fashioned notions which have been passed down from sire to scion, is only another of the errone- ous notions arising from generalising upon imperfect data. For not only does recent pathology prove that most of the gall-bladder tissue changes occur inde- pendently of liver diseases ; but that they are them- selves actually in many instances the exciting cause of secondary degenerations in the liver itself. In support of this opinion I quote the following series of cases illustrative of its correctness from cUfferent points of view. The first case is one reported by Dr. Markham of a woman aged 28, who died in St. Mary's Hospital. The patient was intensely jaundiced, and her chief symptoms were pain and vomiting, coming on about a quarter of an hour after taking food. Slie died 4 c 1122 DISEASES OF THE LIVER. apparently from exhaustion arising from the com- bined effects of inanition and pam. The urine was deeply bilious, while the stools never contained a trace of bile. The only physical sign detected was the existence of a hard swelling at the pyloric end of the stomach, which led to the erroneous diagnosis of pyloric disease. At the post-mortem examination, the gall-bladder was found to be completely converted into a hard solid mass of scirrhus, which, Dr. Markham thought, had commenced in the coats of the viscus itself. It had thrown out at one or two points several processes into the liver tissue. The centre of the mass con- tained a number of gall-stones, which naturally originated the belief that the irritation caused by their presence excited the disease. A case of cancer affecting the gall-bladder, where the presence of gall-stones also appears to have been the probable exciting cause, is related by Dr. Sidney Coupland in the thirty-first volume of the Patho- logical Society's ' Transactions,' as occurring in a woman aged 56. The tumour could be readily felt as a swelling just below the false ribs, and was asso- ciated with sharp pain in the right hypochondriac region. At the jwst-mortem no trace of a gall- bladder could be found, but occupying its place was an ovoidal epithelial cancerous mass, the size of a cocoa-nut ; in the substance of which were found numerous small orange- coloured calculi of the CANCER OF THE GALL-BLADDER. 1123 size of split-peas. And it appears highly probable that it was the irritative effects of these calculi in a predisposed constitution which called the cancer of the gall-bladder into existence. In support of this theory I may cite another case of supposed primary cancer of the gall-bladder associated with gall-stones. It is related m the same volume of the Pathological Society's ' Transactions ' as the preceding, by Dr. Norman Moore. It occurred in a woman aged 59, and was felt as a hard tumour near the liver, and at the post-mortem the gall-bladder was found in- filtrated and surrounded by a mass of medullary cancer, while its ulterior contained four large and several small gall-stones, which Dr. Moore, I think judiciously, remarks might be regarded as the exciting cause of the cancer. Cancer of the Common Bile-duct. Cancerous tumours of the common bile-duct are by no means rare, but they are seldom or never dia- gnosed during the lifetime of the patient, from the simple fact that their signs and symptoms possess nothing characteristic about them. I may mention that the jaundice produced by cancer of the bile- duct is as intense and as permanent as it can pos- sibly be, and that it invariably produces all the worst collateral symptoms which the most inveterate impacted gall-stones can produce. An excellent illus- 4 c 2 1124 DISEASES OF THE LIVER. tration of tlie truth of this remark is afforded by a case which Dr. Vanderbyl published in the ninth volume of the Pathological Society's ' Transactions,' page 230. The case was that of a man, aged 36, who had been in good health up till within about six months of his death, when he was suddenly seized with vomiting and purging, and in a week or two after- wards became jaundiced, the stools piped ny-coloured, and the urine loaded with bile. The liver being both enlarged and tender to pressure. After a month or two the liver got smaller in size, and the gall-bladder became perceptible to the touch. The jaundice got more and more intense. The patient became delirious, emaciated, with cedematous lower limbs, sank, and died. At the ijost-mortem the Hver weighed sixty ounces. The gall-bladder measured, from entrance of duct to fundus, seven and a half inches, and contained fifteen ounces of a pale liquid, like barley-water, of a specific gravity of 1010, and alkaline reaction. All the biliary ducts, even those in the substance of the liver, were dilated by a similar kind of liquid. An obstruction was found at the duodenal orifice of the common bile- duct, caused by a medullary growth in its interior. In concluding this chapter, my treatise on affec- tions of the biliary organs might not inappropriately be brought to a close ; but, as a notorious punster, IS LIFE WOKTH LIVING FOR? 1125 on being asked if life was worth living for, wittily answered — ' All depends upon the liver ' — and every physiologist knows that this jocular reply embodies a great and philosophical truism. Not only from the fact that the functions of all animal organs are correlated inter se, and reciprocally dependent for their individual healthy activity one upon another, but from the equally important fact that from the functions of the liver being fourfold (see page 58), its normal action is ij^so facto one of the most es- sential factors of healthy life, it may be well for me to add a supplementary chapter of hints on differen- tial diagnosis, which will not onty most probably be very acceptable to those who, from being actively engaged in practice, have but little time to devote to study, or even to keep themselves att courant with the rapid advance of medical literature, but besides may suffice to refresh the minds of those who have perused the book, with the facts that have been taught and exemplified m the text, showing that not alone the kidneys, the spleen, and the skin, but even the lungs, to a certain extent act vicariously with the liver. And, what is more, that the biliary function cannot get out of order without the whole nervous S37stem becoming seriously de- ranged. The brain itself even becoming diseased. For not only do headaches and deliriums result, but even hallucmations arc engendered, and actual in- 1126 DISEASES OF THE LIVER. sanity sometimes follows in the wake of hepatic de- rangements. Indeed, the very name ' melancholia ' is a compound of the two Greek words, ' black ' and ' bile,' and, as every one knows, the sallow, bilious look of the melancholic monomaniac is something more than a mere proverbial phrase. Indeed, it is well known that not alone have threatened attacks of simple melancholia, but even of desponding religious mania, been occasionally staved off, if not actually cured, by a judicious and timely restoration of the normal functions of the liver. It wiU, I think, be scarcely necessary for me to waste space by recapitulating all that has been said in different parts of the text regardmg the reciprocal action of the liver and other organs ; for every wary practitioner is supposed to have his eyes open to all forms of vicarious hepatic function, and never to fail, during the course of diseases affecting the general sys- tem, to keep careful watch upon the supervention of liver derangements. From it being a generally recog- nised fact that there is not a single febrile or non- febrile constitutional disease — not even gout, syphilis, or diabetes excepted — which does not demand, as an essential preliminary to convalescence, the more or less perfect restoration of the hepatic functions. The following hints will, however, be no doubt useful to all actively engaged in practice. 1127 CHAPTER XXVII. HINTS TO AID IN THE DIAGNOSIS AND PROGNOSIS OF DISEASES OF THE LIVER. As upon correct diagnosis success in practice chiefly depends, this chapter will perhaps by some be re- garded as not the least important in my book, from there being no doubt whatever that treatment is, com- paratively speaking, easy when diagnosis is correct. And it may be truthfully said that a patient's life, and with it probably the well-being of a family, may entirely depend upon his medical attendant's ability to early recognise the true nature of the hepatic affection under which he labours. As the hints now about to be given must of necessity, on account of space, be put forward with- out explanatory details, it is clear that they will be more particularly useful to those who have made themselves acquainted with the cases, facts, and theories given in the text ; and therefore it may be as well for me to inform those of my readers who may feel disappointed at the absence of explanatory infor- 1128 DISEASES OF THE LIVER. mation that they can themselves readily remedy this defect by turning to the chapter to which the in- dividual hint specially refers, where they will find all the particulars connected with it given in abundant detail. It may also, perhaps, be as well for me to inform the reader who has not already gleaned the fact from the text, that the writer, rightly or wrongly, im- plicitly believes in^the truth of the subjoined cluiical aphorisms : — a. That science enables one to accomplish in the domain of practical medicine what empirical means totally fail to do. h. That true science gives the clue not only to the shortest, but at the same time to the easiest, way of arriving at a correct diagnosis. c. That while a knowledge of science reconciles us to the inevitable, it at the same time pre- vents us attempting the impossible, even in the domain of practical medicine. d. That an apparently obscure case in the so- called ' practical diagnostic ' sense may become as clear as noonday when the teachings of ex- perimental physiology are brought to bear upon it. e. That errors in diagnosis, leading to mistakes not alone in prognosis but in treatment, are frequently capable of immediate correction by GENERAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1129 the application of a chemical test to some one or other of the excretions. /. That moderate abilities, when aided by scientific knowledge, often succeed in unravelling the pathology of obscure hepatic diseases, where transcendental abilities, even when coupled with great experience, are found to be utterly helpless. These being the views I entertain, the following are the main facts on which I rely. 1. Mostly all liver diseases are hereditary. Even many of those apparently accidentally acquired — such as gall-stones — are no exception to the rule. 2. Babes are liable to be attacked with precisely the same forms of liver disease as adults, even true malignant disease being no exception to this rule. 3. Several hepatic affections have a distinctly pre- natal origin, not alone such as malformations of the bile-ducts, but even hydatids, syphilitic and cancerous growths, hepatitis, and biliary concretions. 4. Pain is a symptom common to almost all the varied forms of hepatic disease — at least at some part or another of their course. To wit, hepatitis, cu'rhosis, inspissated bile, gall-stones, abscess, and cancer. Indeed the only generally 5. Painless affections are hydatids, embolisms, fatty and amyloid degenerations of the liver. But even 1130 DISEASES OF THE LIVER. these may be associated with acute pain. As, for example — a. When the hydatid cyst inflames or suppurates. h. When hydatid vesicles block up the bile-ducts. c. When fatty, amyloid, or syphilitic livers become attacked with hepatitis. 6. The KIND of the pain, as well as its accom- paniments, is an imj^ortant aid in making a differen- tial diagnosis. For while in a. Malignant disease the pain is of a dull con- tinuous and decidedly subacute character, that from h. Biliary concretions or entozoa blocking up the bile-ducts is acute and iq general paroxysmal. c. The pain of hepatitis is not only acute but continuous, and d. When the capsule of the liver is implicated, especially the part covering the upper convex surface in contact with the diaphragm, an in- crease of paia accompanies each deep insjoira- tion. e. When suddenly developed excruciating hepatic pain exists without jaundice, it usually arises from a foreign body impacted in the cystic duct. 7. As there are no less than six causes of right hypochondriac pain which are liable to be mistaken for GENERAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1181 that arising from the presence of a biliary concretion, before forming a diagnosis, founded chiefly upon the symptom of hepatic pain, even when it is of a dis- tinctly colicky character, it is necessary to bear in mind the fact that it may not be due to a biliary concretion at all, but to — a. A urinary calculus lodged in the infundibulum , of the pelvis of the right kidney, or in the right ureter. h. An attack of pleurodynia ; or of c. Pleurisy of the right side. d. Acute gastritis. e. Duodenitis ; and /. Partial peritonitis. 8. Shoulder pain is an unreliable symptom of any form of hepatic disease whatever. 9. There are hepatic enlargements both of a pain- ful and a painless kind. Their differentiation may, in a measure, be assisted by a knowledge of the facts that — a. The most rapid form of painless enlargement — occurring sometimes within a couple of months — is the fatty. h. The painless amyloid kind is of much slower growth than the fatty, taking from six months to nearly as many years for marked develop- ment. 1132 DISEASES OF THE LIVER. c. While a painless fatty liver seldom extends below the umbilicus, an amyloid one occa- sionally reaches as far down as the crest of the ilium. d. The only other form of painless enlargement of the liver is that caused by a hydatid. This last form of painless enlargement, from its being circumscribed, ununiform, and in general only implicating the lower edge of the liver, is less likely to be confounded with the above-named forms of hepatic painless enlargements than with four forms of disease yet to be alluded to. 10. The hydatid enlargement of the liver is usually at its lower margin. On account of the cyst always growing in the direction of the least resistance, it projects downwards into the free abdominal cavity. The hydatid enlargement is apt to be confounded with an ovarian tumour, a dilated stomach, a phan- tom tumour, pregnancy, and a distended gall-bladder. The hydatid tumour may be differentiated from a. An ovarian tumour, by not bemg movable along with the uterus, nor palpable to a vaginal examination. h. A DILATED STOMACH, by not being associated with great gastric disturbance. c. A PHANTOM TUMOUR, by not disappearing on GENEEAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1133 the patient being put under the influence of chloroform. d. Pregnancy, by the sound of a fcetal heart being detectible after the third month. e. A gall-bladder distended with bile, by the absence of jaundice and other signs of biliary derangement. 11. The painful forms of hepatic enlargements are all the acute and chronic varieties of hepatitis, hiliary concretions, idiopathic and traumatic abscesses, and cancers. These may, in a measure, be differ- entiated by paying attention to the following facts — in addition to their ordinary characteristic symp- toms : — a. In simple hepatitis, acute or chronic, the liver seldom extends below the umbilicus ; while h. In inalignant disease it may reach the crest of the ilium, and has usually, at the same time, a nodulated surface. c. AU forms of hej^atitis and suppurations are associated with more or less febrile disturbance. d. Malignant disease is associated with a cancerous cachexia, and very often has e. A cancerous family history, as well as f. An absence of pyrexia. (J. The pain of cancer is continuous, though sub- acute. 1134 DISEASES OF THE LIVER. h. That of biliary concretions is paroxysmal as well as acute. 12. Great enlargement of tlie liver, with subacute pain, in general proceeds from encephaloid disease. 13. An advanced and softened encephaloid of the liver communicates to the hand of the examiner an indistinct feehng of fluctuation, which, by the inex- perienced, is apt to be attributed to suppuration. From suppuration it is easily differentiated by re- mem bermg that while along with a softened cancer there is sure to be a cancerous cachexia, along with suppuration of the hepatic parenchyma there is equally certain to be a rapid pulse, a furred tongue, and great febrile disturbance. 14. The only other form of hepatic disease a suppurating liver is at all likely to be confounded with is hydatid. From which the followmg characteristics are in general suflicient to differentiate it : — a. The suppurating enlargement is painful on pressure. b. Is accompanied by great constitutional disturb- ance. c. The fluctuating part is usually surrounded by a resisting inflammatory ring. d. An abscess never, by any chance, gives a vibratory thrill when percussed — the so-called hydatid fremitus — whereas a hydatid occasion- ally does. GENERAL HIXTS OX DIFFERENTIAL DIAGNOSIS. 1135 e. A suppurating hydatid is tantamount to an abscess as regards its signs and treatment, and consequently has only a differential prognostic importance from its being much less fatal. 15. Whenever, in the course of acute or chronic hepatitis, rigors supervene without any more probable cause, the advent of suppuration may be diagnosed. For abscess of the liver is liable to occur in every chronic as well as acute form of hepatitis. 16. All chronic inflammatory painful enlarge- ments of the liver are invariably followed by atrophy — if the patient survives sufficiently long for the pres- sure of the inflamed, and subsequently hjrpertrophied, connective tissue to act deleteriously on the secreting cells. 17. As jaundice is not only a common accom- paniment of hepatic disease, but at the same time, as regards its modes of appearance and disappearance, an invaluable sign in forming a diagnosis and pro- gnosis, as well as a useful guide in the selection of remedies, I shall here give some hints as to the difl'eren- tial diagnosis of its various forms and phases. 18. Although jaundice frequently proceeds from a suppression of the biliary function arising from all the various forms of hepatitis — idiopathic, malarial, toxic, and traumatic — the most common causes of a yellow condition of the skin are, in this country at least, those of the obstructive variety. For — 1136 DISEASES OF THE LIVER. 19. A yellow discoloration of the skin, with pipeclay-coloured stools and safFron-tinted urine, makes its appearance whenever an obstruction to the flow of bile into the intestines has existed for a few days — even occasionally for so short a time as seventy- two hours. Thus jaundice arises from : — A congenital deficiency of ducts, accidental obstruction in course of common bile-duct — inspissated bile, gall-stones, hy- datids, and other forms of entozoa — closure of outlet of the common-bile duct from pressure of pregnant uterus, abdominal tumours, impacted f£eces in transverse colon, disease of pancreas or of neighbouring organs, ulcer of duodenum, inflammatory stricture of common bile- duct. 20. In this country, and probabl}* in all equally temperate as well as colder climates, jaundice, as the result of obstruction by biliary concretions, occurs, I believe, in at least 58 per cent, of all the cases of jaundice met with. Yet be it remembered that jaun- dice NEVER arises from the presence of gall-stones either in the gall-bladder or in the cystic duct. 21. Every case in which there is a history of a pre- vious attack of temporary jaundice, and the patient complains of acute pain in the region of the liver of a paroxysmal character, may be put down as one of impacted biliary concretion. For in ninety out of every hundred of such cases this diagnosis is almost sure to be the correct one. GENERAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1137 22. In every case of jaundice the result of ob- struction caused by the presence in a duct of a biliary concretion, no matter whether it be inspissated bile or a true gall-stone, the jaundiced condition of the skin is preceded by and associated with pain. 23. Paroxysmal pain — hepatic colic, as it is commonly called — is never, or scarcely ever, absent when a gall-stone is doing sufficient mischief to be able to induce jaundice. 24. Gall-stones, and even large ones, may exist for years in the gall-bladder and other parts of the body of patients, not alone without producing jaun- dice, but without causing pain, at least sufficient pain to call for treatment. So that their presence may not even have been so much as suspected, and their exist- ence be only accidentally discovered at the post- mortem of their proprietor. 25. Although, as soon as a concretion leaves the gall-bladder and becomes impacted in the cystic duct, acute pain, excruciating it may even be, immediately occurs, no jaundice supervenes. No sooner, how- ever, does the stone reach the common bile-duct, where it prevents bile reaching the intestines, both from the gall-bladder and the hepatic duct, than jaundice makes its appearance. Moreover, I may further remark that while the stone is impacted in the cystic duct, although there is no jaundice, the pain is associated with quite as much sickness, febrile 4 D 1138 DISEASES OF THE LIVER. disturbance, and nervous depression, as when marked jaundice is present. 26. A stone is known to have passed from the cystic (after having been impacted there) into the common bile-duct, by the sudden supervention — in addition to the paroxysmal jDain and febrile disturb- ance — of pipeclay stools and high-coloured urine, along with a jaundiced condition of the skin. 27. After having said that a gall-stone may be impacted in a duct without inducing jaundice, I ought to add that I have never seen, heard, or read of a case of any biliary concretion whatever becoming impacted in a bile-duct without being associated with pain. 28. Immediately after a gall-stone passes out of the common bile-duct, the previously existing pipe- clay-coloured stools vanish, and a dark, bilious-look- ing motion immediately takes their place. The skin and conjunctivae, however, retain their jaundiced hue for some days. 29. Neither the presence of jaundice, pipeclay- coloured stools, saffron-tinted urine, nor the amount of pain, depends so much upon the number, the size, or the shape of the gall-stones as upon the actual position they occupy in the liver and its. appendages.^ ^ That the above hints are abundantly necessary was strikingly dis- played in the discussion which followed the reading of a paper on ' Choleo- GENERAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1139 30. The dangers accruing from biliary concre- tions do not always terminate with thefr safe ex- trusion either from the gaU-bladder or bile-ducts, for they sometimes adopt strange ways of quitting thefr bii'thplaces. For example : — a. Gall-stones make abnormal outlets for them- selves through the coats of the gall-bladder or bile-ducts. The pressure of the stones against the walls of the gall-bladder or ducts setting up a sufficient amount of inflammatory action to give rise to a perforating ulcer, and the artificial formation of a direct channel between the biliary appendages and the stomach, in- testines, peritoneal cavity, or pelvis of the kidney, through which the stones pass. h. When a stone passes into the stomach, it is in general ejected by vomiting ; the ulceration heals up, and the j)atient gets well. There are, however, exceptions to this favourable ter- mination. As, for example, was shown in the cited case where gastric juice escaped through the opening made by the stone, and digested the living liver (page 1040). c. If the stone passes into the intestines, it is usually safely expelled along with the stools. cystotomy,' at the Royal Medical and Chirurgical Society, November 10, 1879, when some of the speakers showed that they possessed not only very hazy notions regarding bile-duct obstructions, but even of the uses of a human gall-bladder ! See report in journals. 4 D 2 1140 DISEASES OF THE LIVEK. Sometimes, however, the stone is so large that it sticks fast in the ileum, or lodges in the ileo- caBcal valve, and induces fatal peritonitis or ileus. d. A stone, after having ulcerated its way into the intestines, may become encysted in a cul-de- sac^ and give rise to no further trouble ; its existence being only discovered after death. e. When stones ulcerate their way directly from the gall-bladder into the intestines, the duode- num is in general the seat of the intestinal com- munication. Whereas, when a cancerous growth is the cause of the perforating ulceration be- tween the gall-bladder and the intestines, the colon is the usual seat of the communication. /. Sometimes stones ulcerate into a blood-vessel, and a fatal haemorrhage is the immediate result. g. Cases have occurred where a sudden and fatal collapse has supervened upon the transposition of a stone from the bile-duct into the peri- toneum. 31. The dangers arising from gall-stones do not necessarily terminate even after their safe expulsion from the body. For : — 32. A fatal occlusion of the duodenal orifice of the ductus communis choledochus may occur after the safe passage of a gall-stone into the intestines and its equally safe extrusion from the body. This GENERAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1141 fatal form of occlusion occurs when the irritation caused by the transit of the stone through the bile- duct has been sufficient to set up an adhesive in- flammation, or to induce ulceration, during the cica- trisation of which a permanent occlusion in the chamiel or at the mouth of the duct takes place. 33. It is of the greatest importance to the patient that a permanent occlusion of the common bile-duct — either from adhesive inflammation of its internal walls, a stricture, or the cicatrisation of an ulcer at its orifice — should not be confounded with a persistent jamidice from an impacted gall-stone, as in the two sets of cases not only is the prognosis, but the treat- ment entirely different. For so long as the jaundice is due to the presence of an impacted gall-stone, there is hope of a perfect recovery taking place. Whereas when the jaundice is due to occlusion of the channel of the duct, either by inflammatory adhesion of its walls, a stricture, or by the cicatrisation of an ulcer at its orifice, a fatal issue is inevitable. 34. Although it is comparatively easy to diagnose the supervention of a permanent organic occlusion of the bile-duct after a Q:all-stone is known to have passed through it, it is quite another matter to attempt to differentiate between an occlusion arising from a simple stricture of the bile-duct and one arising from the cicatrisation of an ulcer at its orifice, except in one particular class of cases For example : — 1142 DISEASES OF THE LIVER. a. Whenever, after the extrusion of a gall-stone, the disappearance of jaundice is only temporary, and the skin slowly, gradually, and ^^am/cs-s/^ resumes a Well-marked and permanent icteric tint, in nine out of every ten of such cases the return of the jaundice is not due to another gall-stone blocking up the duct, but to the duct becoming permanently and inevitably fatally closed up, either by a constriction or an adhesive inflammation of its internal walls, or by the cicatrisation of an ulcer at its duodenal orifice. b. When an ulcer at the duodenal orifice of the bile-duct cicatrises, it almost invariably in- cludes in its cicatrix the orifice of the pancreatic duct. So that when this double occlusion occurs, the diiferential diagnosis is simplified by the fact that not only are the stools pipeclay- coloured, but when cold covered over with a layer of fatty matter. And when cod-liver oil is administered to the patient by the mouth, the surface of the fseces assumes the appearance of 'Windsor soap.' (See page 771.) 35. From a naked- eye examination of an extruded gall-stone, useful information may be gleaned. Even its shape alone tells us much. Thus, for example, if it possesses many facets, it has not been a solitary occupant of the gall-bladder or bile-ducts, but is one GENERAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1143 of a multitude, and, if at the same time of small size, it may be one of a dozen, or of a dozen hundreds. If it has only two or three facets upon it, there are not likely to be many more stones left behind. If it is circular or oblong, and has no facets, although the presumption is that it is a solitary stone, this is by no means invariably the case ; for I once, as previously said, saw four gall-stones, as large as small hazel-nuts, pass within a few days from a patient, all of which were globular, and without a single facet upon them. 36. A concretion of inspissated bile is distinguished from a gall-stone by assuming a. purple-red tint when, after being crushed into powder, strong sulphuric acid is poured over it. 37. When in any case of jaundice there is a sudden cessation of the pipeclay -coloured stools, the cause of the jaundice is almost sure to have been one of two things — a biliary concretion or an ento- zoon, blocking up the hepatic or the common bile duct. 38. The obstruction to the outflow of bile caused by entozoa may not only occur from — a. A hydatid tumour closing up the channel of the common bile-duct by external pressure ; but from h. The parasite growing in or penetrating into its interior and blocking it up. 1144 DISEASES OF THE LIVER. c. Even cases have been recorded where an ob- struction to the common bile-duct has been occasioned by the presence of liver flukes (^Di- stoma hepaticurii) in the common duct. Also d. Others, in which the obstruction of the duct is said to have arisen from the entrance into it of worms from the intestines. Cases of this kind are exceedingly rare, as well as difficult of diagnosis, from the symptoms they present being in no way characteristic, except when a large hydatid is the obstructing cause. In which case its diagnosis is aided by a know- ledge that the obstructivejaundice was preceded by a painless tumour, and the supposition is of course reduced to an axiomatic certainty when cyst vesicles are found in the faeces. 39. The supervention of jaundice arismg from an obstruction within the duct caused by entozoa, although much slower than that arising from gall-stones, is nevertheless more rapid than when the obstructing cause is the slow development of a morbid growth or a cicatrising duodenal ulcer. 40. When jaundice supervenes suddenly, without pain, and there is no other assignable cause, the pro- bability is that it is due to the pressure of a hydatid tumour on the duct. 41. Cases of jaundice arising from obstruction caused by entozoa, either in the form of hydatids or GENEEAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1145 worms, are always perplexing in their diagnosis, for the following reasons : — a. When the parasite is impacted within the bile- duct, it produces precisely the same symptoms and signs as a biliary concretion does when it is impacted in a similar situation, even to the symptoms of paroxysmal colic and itching of the skin. h. The signs and symptoms of both impacted entozoa and gall-stones may suddenly dis- appear, and not a vestige of either be detected in the patient's stools. So that both the exist- ence of the signs and the symptoms, and their mode of disappearance, may be equally well accounted for on the supposition that they were due to the presence of a living animal parasite or of a dead crystalline concretion. c. If, however, any other part of the j^atient's body be infested with hydatids, the diagnostic scale is to be turned in that direction. But in all other cases, when there is no proof of the patient being the subject of hydatid disease, it is wise policy to give the benefit of the doubt in favour of a biliary concretion being the fons et origo of the jaundice, for the simple reason that while cases of jaundice induced by entozoa are exceeduigly rare, those arising from biliary concretions are proportionately common. Hence 1146 DISEASES OF THE LIVEE. I may say that there are ninety-nme chances out of every hundred that if a biliary concretion is blamed for doing the mischief the diagnosis is likely to be correct. 42. Jaundice of a well-marked and permanent character may not only arise from malignant and other tumours affecting the secreting substance of the liver itself, but from precisely the same forms of growths attacking the stomach, intestines, pancreas, the left kidney, and supra-renal body, through the tumour inducing a stoppage to the flow of bile into the intestines from causing its occlusion by external pressure on its walls. In the majority of these cases the differential diagnosis between the jaundice arising from gall-stones and morbid growths is, compara- tively speaking, easy enough ; from the fact that in the latter set of cases the jaundiced condition of the skin comes on very slowly, and is in most of the cases preceded by the usual train of symptoms de- noting the presence of cancerous disease in the other organ or organs affected. For example, if the disease has commenced in the stomach, duodenum, kidney, or pancreas, it will have been preceded by the charac- teristic symptoms of disease in these parts. 43. Occlusion of the bile-duct, besides occasionally arising from the implication or external pressure of cancerous and other growths beginning in the hepatic parenchyma and neighbouring organs, may GENEEAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1147 also arise from a cancerous or other pathological form of tumour primarily developing itself within the com- mon bile-duct. 44. There is as yet no known way of making a differential diagnosis between jaundice arising from the external pressure of a tumour on the bile-duct, and that produced by the formation of a growth, either primarily or otherwise, in its interior. Fortunately, however, for both doctor and patient, the treatment to be followed is in both sets of cases the same, so that the being able to make a differential diagnosis in these cases is of no importance in a clinical point of view. The line of treatment being simply to alleviate distressing symptoms and retard as far as possible the inevitable fatal result. 45. The disease most commonly mistaken for cancer of the liver is gall-stone impacted lq the com- mon bile-duct, especially when it is ulcerating its way into the intestines. 46. Another form of disease which occasionally, though rarely, produces jaundice from obstruction to the outflow of bile through the common duct, is enlargement of the glands in the portal fissure. Although the cases recorded are but few in number, I observe that almost every one of them has been noted as being associated with ascites. 47. Yet another and almost equally rare source of jaundice is that caused by the presence of faeces 1148 DISEASES OF THE LIVER. impacted in the flexure of the colon, which, fortu- nately, is of easy diagnosis from its being associated with all the usual symptoms of intestinal obstruction. 48. A case of obstructive jaundice the result of an aneurismal tumour is reported to have been attri- buted to gall-stones, from its pulsations havmg been mistaken for the normal throbbing of the abdominal aorta communicated through the tumour to the hand of the examiner. An error which I think might possibly have been avoided by the employment of the stethoscope ; for, to the trained ear, a true aneurismal is quite different from a normal aortic murmur. 49. The presence of bile acids in the urine, in any case of jaundice whatever, is crucial proof that there is reabsorption of secreted bile going on ; and the knowledge of this fact is such an important dia- gnostic agent in all obscure cases, that whenever the rough and ready method of testing the urme for bile acids does not yield clear evidence of their presence or absence, the urine ought to be subjected to a proper and complete chemical analysis. 50. It must never be forgotten, in differentiating cases of obstructive jaundice, that : — a. The suppressive form of jaundice occurs in all cases of hepatitis. No matter what the cause of the hepatitis may be. b. That in most cases of atrophy, when jaundice is present, it is due to suppression. ISTotwith- GENERAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1149 standing that the feces may be of a dark, tarry, bihous hue. For in such cases the dark colour of the stools is, as m contagious jaun- dice (yellow fever) and acute atrophy, not due to the presence of bile, but of blood. c. After the jaundice has been ascertained to be due to obstruction, the cause of the obstruction may be suspected to be : — d. Gall-stones, if it be associated with paroxys- mal pain, and itching of the skin. e. Cancer, if the pain be a mere dull ache, the organ enlarged, and a cancerous cachexia pre- sent. /. A stricture or ulcerative occlusion of the com- mon bile-duct, induced by the passage of a gall-stone, if, after colicky pains and the tempo- rary disappearance of the jaundice, the skin gradually and slowly resumes the icteric tint. g. Cirrhosis, or tumour, aneurismal or other, im- plicating the veins, if there be ascites. A. While if there be evidence of a hydatid or any of the other tabulated diseases which produce obstructive jaundice, the cause of the occlusion of the duct may be, in the absence of other evidence to the contrary, attributed to it. i. When the jaundice is the result of pressure upon the common bile-duct from cancerous tumours or enlarged glands in the portal fis- 1150 DISEASES OF THE LIVEK. sure, there is usually enlargement of the super- ficial abdominal veins, as well as more or less ascites. j. When jaundice supervenes very slowly, and is unattended with pain, its cause is probably due to the existence of a cicatrising ulcer or to a morbid growth. k. It is to be remembered, however, that no matter whether the case be a complicated or a simple one, if jaundice exists with it at all, and is not the result of suppression, unless there be a complete obstruction to the outflow of bile from the common bile-duct, it can never be severe. I. Itching of the skin in a case of jaundice is in all cases, in my opinion, a pathognomonic sign of obstruction. m. In cases of cancer of the liver, the daily amount of uric acid excreted is often higher than, but seldom below, the normal standard. n. Hydatids, especially the multilocular variety, have been occasionally erroneously diagnosed as cancer. 0. So also has amyloid degeneration of the liver. 2?. In almost every case where jaundice super- venes within four days after an attack of colic, the cause is the impaction of a gall-stone in the common bile-duct. GENERAL HINTS ON UIFFEKENTIAL DIAGNOSIS. 1151 q. There are four sometimes equally acute, and ill general fatal, forms of jaundice, which so closely resemble each other in their symptoms as to be frequently mistaken for each other ; but the mentioning of their names will be sufficient to guard the reader, when the his- tories of the cases are known to him, from con- founding them with each other. They are the more virulent forms of — (1) Acute atrophy of the liver. (2) Contagious jaundice. (3) The jaundice from mental emotion, and (4) The jaundice from poisons. 51. As a knowledge of the proportional frequency with which jaundice is met with m different forms of disease is of great service in making a differential diagnosis, I subjoin my views of the matter as follows : — a. Jaundice occurs in about 99 per cent, of the cases where a gall-stone is in the common bile- duct. h. Jaundice occurs in about 90 per cent, of the cases of chronic atrophy of the liver. c. Jaundice (ia a greater or less degree) occurs in about 70 per cent, of cases of hepatic abscess. d. Jaundice (at least m a modified form) is met with in about 30 per cent, of the cases of con- gested liver. 1152 DISEASES OF THE LIVER. e. Jaundice only occurs in 6 per cent, of the cases of cancer of the liver. /. Jaundice occurs in about 2 per cent, of the cases of hydatids of the liver. g. Jaundice (that is to say, marked discoloration) only occurs in 1 per cent, of the cases of amy- loid and fatty degeneration of the liver, though a sallowness of the complexion is present in nearly all of them. 52. While the presence of jaundice is a pathogno- mionic sign of hepatic derangement, its entire absence is no proof whatever of the non-existence of even grave hepatic disease. . 53. Many fatal forms of hepatic disease are fre- quently unattended with either yellow skin, pipeclay - coloured stools, or saffron- tinted urine. Such may be the case in cancer, abscess, amyloid, syphilitic, and other hopelessly incurable degenerations of the paren- chyma of the liver. 54. When jaundice occurs in the course of any disease, be it hepatic or other, it either arises from a suppression of the biliary secretion, or from an ob- struction to the outflow of the secreted bile. 55. Jaundice arising from suppression is almost always — I might even go so far as to say invariably — attended with more or less grave constitutional symptoms. a. In that arising from enervation, although the GENERAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1153 attack may be exceedingly sudden, it is, from its very onset, accompanied by cerebral disorder. b. Those forms of jaundice depending on acute or subacute atropli37- of the liver, though little less sudden in their onset, are always equally at- tended with cerebral disorder. c. Jaundice arising from blood-poisoning, whether it be from an animal, vegetable, or mineral poison, is invariably associated with marked febrile symptoms. d. Jaundice from hepatitis in any form is in- variably accompanied by more or less acute constitutional inflammatory symptoms. e. Dark stools in cases of jaundice from suppres- sion, even when there co-exists bile-coloured urine, is indicative of the presence of blood ^ not of bUe, in the faeces. 56. Variations in the intensity of the discolora- tion of the skin are met with in almost all forms of permanent jaundice, possibly from the elimination of the pigment through the skin proceeding more rapidly at one time than at another. 57. Be it remembered that the depth of the jaun- diced tint of the skin is more proportionate to the duration of the disease than to its pathological cause. 58. When ascites is present in a case of liver disease, it is in all cases the direct result of a mechanical 4 E 1154 DISEASES OP THE LIVER. interruption to the flow of the venous blood out of the abdomen, caused by pressure on the vena cava inferior, either by a tumour, or by a contracted con- dition of the liver itself. 59. CEdema of the lower limbs, as well as enlarge- ment of the abdominal veins, is always absent in uncomplicated cases of abscess, hydatids, gall-stones, cancer, fatty, amyloid, and other forms of parenchy- matous degeneration of the liver. When there is an exception to this rule, it probably arises from the con- stricting effects of the external pressure on the as- cending cava. 60. It is well always to remember that the pal- pable existence of one form of disease of the liver does not necessarily preclude the co-existence of another. Thus gall-stones, for example, may be associated with almost any form of hepatic affection, hydatids, cancerous tumours, fatty livers, &c. So again a hy- datid may be associated with a cancer, a cancer with cirrhosis, syphilitic gummata with hepatitis, and so on through the whole round of diseases. 61. The presence of blood in the stools, either in the form of pure blood, grumous matter, or coffee- grounds, is in hepatic cases not necessarily the result of active hasmorrhage. It may equally be the direct result of a passive congestion of tlie ^^ortal veins, or rectal htemorrhoidal vessels, caused by atrophy or any other form of hepatic disease inducing venous obstruction. GENERAL HINTS ON DIFFERENTIAL DIAGNOSIS. 1155 62. The right lobe of the liver is more prone to he aiFected with disease than the left ; and that too not with one specific form of disease only, but with several — differing widely in their pathological nature — to wit, abscess, cancer, and hydatids. 63. In cases of tumour of the liver, when there exists a doubt as to its true nature, the exploring needle ought to be had recourse to, as the fluid or solid withdrawn immediately reveals its probable nature. Thus, should it be a hydatid, the liquid is of a specific gravity of from 1007 to 1012, limpid, loaded with chlorides, and not coagulable by heat. If ascitic or ovarian, it is of a specific gravity of above 1012, and coagulable by heat and nitric acid. Should the licjuid be from a hydronephrosis, it contains (like true urine) both urea and chlorides, but not necessarily albumen. If again the tumour chance to be an abscess, the liquid withdrawn is purulent ; but it must be borne in mind that hydatids suppurate, and gall-bladders are occasionally filled with pus. While, lastly, if pure bile comes away, the case is one either of distended bile-duct or gall-bladder. For further information refer to the chapter on the ex- ploration of the liver. Additional Hints to aid in forming a Prognosis. 64. In no case of hepatic disease whatever can the amount of danger to life be estimated either by 4 >; 2 1156 DISEASES OF THE LIVER. the depth of the jaundice or by the intensity of the pain. For even in the case of gall-stones inducing a fatal perforation, jaundice may be totally absent, and in the case of inevitably fatal occlusion of the com- mon bile-duct by the cicatrisation of an ulcer, there may be scarcely any pain complained of by the patient. 65. A patient who has once suffered from an attack of jaundice from biliary concretions, unless careful prophylactic treatment be adopted, is almost certain to be affected with it again. Q6. A hydatid tumour once emptied never refills^ 67. Although cases of suppurating hydatids are dangerous, they are by no means always fatal. 68. Patients labouring under malignant disease of the liver usually die within a year after the ap- pearance of the cancerous cachexia. 69. When jaundice has become so persistent and intense as to leave no doubt of its beino; due to a permanent obstruction to the outflow of bile into the intestines, the patient may in general be expected to succumb, from the deleterious action of the pent- up bile — even under the most favourable collateral circumstances — within two or two and a half years from its commencement,^ and within six or ten ^ At page 16 of the second edition (1821) of his work on disorders of the liver, Dr. Ayre says : — ' About a year ago, a gentleman of this town died, who, during eight years, was jaundiced from a permanent obstruction existing in the biliary duct. During the whole of this time HINTS TO AID IN FOKMING A PROGNOSIS. 1157 months after the hepatic parenchyma has begun to shrink and atrojDhy. 70. When, after a long- continued jaundice (asso- ciated with dull aching pain towards the latter period of its duration) the stools become of a natural colour, and then slowly resume a j^ipeclay appearance, the patient is likely to die within six or ten months after the temporary improvement has ceased, as it is most probable that the cause of the jaundice was at first a gall-stone impacted in the common bile- duct, which ulcerated its way out of it. While the resumption of the pipeclay stools is in its turn due to an occlusion of the duct, either by stricture, ad- hesive inflammatory action, or the cicatrisation of an intestinal ulcer induced by the perforating stone. 71. In cases of jaundice from obstruction, with intermissions, there is no immediate danger to life ; for so long as the gall-bladder can occasionally, even partially, empty itself, or bile flow directly from the liver into the intestines (as it is oftentimes able to do, even in severe cases of obstruction from impacted the bowels were often excessively and variously disordered ; yet at no period, as I learnt from him —and as I had often occasion to observe my- self — were the discharges from the bowels black.' This eight years' case of jaundice from obstruction in no way militates against what I said regarding the patient's usually succumbing to the deleterious effects of the pent-up bile within two years after comiilete stoppage to it« flow into the intestines ; for in Dr. Ayre's case there is nothing to show that the obstniction was associated either with a distended gall-bladder or bile- ducts, and consequent backward pressure on the secreting structure of the liver. (See remarks in paragi-aph 71.) 1158 DISEASES OF THE LIVER. gall-stones, in consequence of the stone accidentally changing its position and allowing the bile to flow past it), the patient (other thmgs being favourable) may live almost to his natural term of life. I have known cases go on for six or more years, and, as I previously said, I have a certain Lady N now (1882) under treatment who has been intensely jaun- diced for seven years, from impacted gall-stone, and who, though still dark in colour, is otherwise never- theless both in good healtii and spirits. 72. Acute abscess of the liver, occurring in tem- perate, is not less dangerous than in hot climates. Unless opened early (that is to say, before the hectic stage has begun), a fatal issue, in the majority of in- stances, may be foreboded. 73. Chronic abscess of the hepatic tissue may exist for years, may open spontaneously into the intestines, then either heal up entirely, or reform and again burst into the bowels, lungs, or elsewhere ; in the end killing the patient, either suddenly, or slowly by hectic and exhaustion. 74. Acute, or, as it is sometimes called, yellow, or malignant, atrophy is by no means the inevitably fatal disease it is in general pictured to be, for under a judicious system of treatment many cases recover. 75. The appearance of ty rosin and leucin in the urine in the course of any hepatic disease may be HINTS TO AID IN FOKMING A PROGNOSIS. 1159 regarded as indicative of atrophy of the liver — acute, subacute, or chronic. 76. When, after the administration to the patient of benzoic acid or the benzoate of soda, hippuric acid appears in the urine, as it invariably does under normal circumstances, it may be taken for granted that a part of the hepatic tissue is still performing its proper functions ; for when the hepatic functions are entirely arrested this chemical transformation ceases. 77. "When sugar appears in the urine in a case of persistent jaundice, a fatal termination may be suspected of not being very far off. 78. The supervention of cerebral symptoms in the course of jaundice — either of a delirious, convul- sive, or comatose character — is always a sign of danger. Finally. Although sociologists tell us that it is a thankless task to proffer unasked-for advice, I shall on the present occasion lay aside all fear of the un- asked-for advice I am about to offer being either received with ingratitude or contempt, from the simple fact that it is only intended for those of my professional brethren who are just entering on the threshold of practice, and if it does them no good it will assuredly do them no harm. It is this : — Always begin the investigation of a case of hepa- tic disease by listening attentively to the patient's 1160 DISEASES OF THE LIVER. own ideas of its nature and origin. For, practical medicine, as I said before, being simply common sense on a scientific foundation, and all patients being neither hypochondriacs nor fools, very often a clue to the pathology of the case may be directly gleaned from the patient's own lips. Never interrupt a patient during the narration of his symptoms, unless yon have a particularly clear- headed one to deal with, or you will almost for a certainty set his ideas off at a tangent, and, like a clock that is being continually wound up, his narra- tive will never cease. In gauging the value of symptoms, remember that it does not entirely depend upon their particular nature, but also potently on the mental capacity, physical courage, and veracity of the patient who describes them. Never pooh-pooh a patient's ideas either of the cause or nature of his case. For some grave hepatic diseases have strangely trifling exciting causes ; as for example, mental emotion, a blow, an indigestion, and such like. Do not begin the physical until you have com- pletely exhausted your verbal examination of the case. When drawing conclusions from the result of a physical examination, bear in mind that, just as the value of symptoms depends on the intelligence and HINTS ON EXAMINATION OF PATIENTS. 1161 veracity of theii' narrator, in like manner does the in- trinsic value of physical signs depend on the manual skill and medical knowledge of the examiner. So much so, indeed, is this the case, that an accom plished examiner will elicit valuable diagnostic data in an obscure case, where an untutored one, even though, perchance, more highly mentally gifted, will fail to elicit anything likely to lead to a correct diagnosis. Never until after having carefully considered the symptoms described by the patient along with the visible signs and personally elicited data in connection with the historical career of the illness, venture to give an opinion as to the nature of the disease. (I think that this last piece of advice will scarcely be considered superfluous by any one who has pe- rused the seventy-eight hints I have tabulated as aids in the differential diagnosis of hepatic diseases.) Having made up your mind that you thoroughly understand the pathology of the case, and can give to it an appropriate name, then unhesitatingly state, either to the patient himself or to his friends, as may appear under the special circumstances to be best, the opinion you have arrived at. But when in doubt, equally frankly and unreservedly say that you desire to consult with a professional brother, before venturing to express a decided opinion as to the nature of the case. For depend upon it, in pro- 1162 DISEASES OF THE LIVER. fessional as in commercial matters, honesty is always in the long run the best policy. In fact, my expe- rience of consulting practice has given me ample opportunity of noting that it is only the dishonest and ignorant who ever decline to take counsel with their medical brethren. INDEX. AAC A ACHEN, mineral springs of, ^ 215, 231 Abdominal parietes, gall-stones perforating, 629-633, 073, 1080 — hepatic portion shot away ex- posing liver, 1036 Aoscess of the liver, 803 — etiology, 803-815 — idiopathic, a misnomer, 805 — not necessarily associated -with jaundice, 806 — hepatitis most usual producer of, 807, 809 — pathology not affected by cli- mate, 808-810 — gluttony and intemperance chief exciting cause of, 809 — more common among men than women, 812 — general symptoms, 815 — diagnostic signs and symptoms tabulated, 819-824 differential, 825-833 — bursting of, 822-3 ■ — red pigment in, 833 — traumatic, 840 — metastatic and pysemic, 845 — gangrenous, 854 — perforating into stomach, 870 — caused by biliary concretions, 834-8 embolism, 838 pins, 846 tish-boues, 849 stricture of rectum, 851 gonorrhoea, 852 hydatids, 852 dysentery ? 857 AMY Abscess of the liver, treatment, 861 tapping, 864 after tapping, 870 diet, 872-3 Acetate of lead, stops biliary secre- tion, 237 Acetonsemia, cause of death in diabetes, 424-5 Acids, treatment by, 173 Aconite, action in pyrexia, 458 Aitken, definition of pyrexia, 433 case of blood-poisoning, 511 Aix-la-Chapelle, mineral springs of, 215 analysis, 231 Albuminoid liver, 63, 1023 Albuminm-ia, hepatic, 793-9 Alcoholic stimulants, treatment by, 269-270 Ale, as prepared for Arctic regions, 261 Alkalies, treatment by, 172-6 in gall-stone, 640-3 Alkaline baths in jaundice, 142-3 — drink in gall-stone, 650 Amenorrhcea, in liver disease, 133-5 Ammonia, treatment by, 361 , 657 — carbonate of, remedy for fatty Uver, 1022 Anmionium, chloride of, 176-7, 1028 — bromide in head symptoms, 361 — iodides and bromides in syphi- litic liver, 937 Amyloid liver, 1023 — cause of, 03 1164 INDEX. AMY Amyloid liver, pathology aud etio- logy, 1024 — signs and symptoms, 1027 — treatment, 'l028 Ansestbetic, to be used in tapping abscesses, 865 Anderson (Dr. Chas.), on tyrosin and leucin, 752 Animals, saccharine function of livers of, 61 — having no gall-bladder, and others having two, 81 — jaundice in, 124-5 Anstey (Christopher), on the waters of Bath, 227 Anstie (Dr.), case of hydatid tap- ping inducing scarlatina, 1005 Anteverted liver, 54 Anti-vivisection, mischief and igno- rance of the movement, 34-36 Aries (M.), case of hydatid, 980 Ascites (hepatic), etiology, 1044 — an accompaniment of chi'onic atrophy, 476 — signs and symptoms, 1045 — ditferential diagnosis of, 1047 — in children, 1049 — treatment, 1053 tapping, 481, 1054-9 Ascitic fluid, 969 Aspirator, in tapping abscesses, 867 — in suppurating hydatid, 950 Atkinson (Prof.), on heat deve- loped by fermentation, 444 Atrophy, acute, of liver, 389 pregnant women liable to,391 symptoms, 392, 394 treatment, 395-413, 428-431 compared with contagious jaundice, 410-2 bacilli in, 411 analysis of urine in 746 — subacute, 460-7 — chronic, 467-488 symptoms, 469-471 etiology, 472 varieties of, 472-486 perihepatitis, 475 hobnail liver, 475-8 in childi'en, 478-9 syphilitic, 480 typical case, 481-0 BIL Atrophy, chronic, treatment, 486-8 — permanent occlusion of bile- duct cause of, 719-720 — tyrosin and leucin as aids to diagnosis of, 750, 781-2 — of gall bladder, 1070 Auspecht (Dr.), on phosphorus poisoning, 709 "D ACILLI, disease-germs, in acute ^ atrophy, 44 Bannister (Dr.), typical case of chronic atrophy, 481 Bantock (Dr.), on Listerian method of surgery, 457-8 Baptisin, hepatic remedy, 183 Barlow (Dr.), case of distended gall-bladder, 1076 Barnes (J. J. F]-ed.), on jaundice of pregnancy, 341 Baths, alkaline, in jaundice, 142-3 — various kinds of, 230 Beale (Prof. Lionel), analysis of liver, 39 — case of suppurating hydatid, 978 Beale (Mr.), case of hydatid, 955 Becker (Dr.), case of hydatids, 636-7 Belladonna, in gall-stones, 654 Bennett (Prof), case of impacted gaU-stone, 601 Bentley (Dr.), case of abscess bursting into pericardium, 823 Benzoates, as remedy in hepatic disease, 210 — in contagious jaundice, 358 — formula for, 662 Benzoic acid, a germicide, 205, 358 — in jaundice, 207-211 Benzoin, not a germicide, 201 Bernard, experiments, 77, 173 — on etiology of pyrexia, 433 Beruays (Mr.), case of bullet lodged in child's liver, 1039 Bidder, experiments on dogs, 87 Bileemia, cause of cerebral sjTnp- toms, 413 Bile, nature and composition of, 68-72 — colouring matter, 68-79, 118 — specific ffravitv of. 72 INDEX. 1165 Bile, reaction of, 72 — con\erts boiled starch into su- gar, m — composition of, 82-3 — essential to life, 83-4 — uses in animal economy, 84-8 emulsioning' and saponifying fats, 89, 727 cliecks intestinal putrefac- tion, 727, 776 — used as condiiuent, 91 — injected into subcutaneous cel- lular tissue, 776 — secretion of, 72 82 influenced bv ner^-e force, 73-78 quantity of, 78-80 restored by mercury, 159, 161, 166 stopped by acetate of lead and opiates, 237-8 — excretion of, 160-1 — suppression of. 104-111 — obstruction of, 112-117 causing atrophy, 472 — re-absorption of, 89, 114, 743 — absent in fatty degeneration, 1020 — toxic effects of, 413, 740-5, 777 — action of alkalies and acids on, 172-6 — pig's, in treatment of jaundice, 1112 — acids in urine, 733-8, 789, 918 — inspissated, 115. 524, 635, 791, 834 — in distended gall-bladders, 1073 — white bUe, 1088 Bile-ducts, stricture of, 104-117 — white mucous secretion, 107 — functions of, 107-9 — congenital deficiency in, 299, 714-6 — in case of yellow fever, 354 — obstructed, cause of atrophy, 474 by inspissated bile, 554-572 by gall-stones, 584-638 bv hydatid cysts and intes- tinal "worms, 635-8, 949 by viscid mucus, 697-701 by cicatrising duodenal ulcer, 710 BLO Kle-ducts, obstructed by inflamma- tory thickening mistaken for can- cer, 880, 909-915, 920 by pressure of cancerous masses, 926 — distended, 1093 — cancer of, 1123-4 Biliary concretions, 523 specific gravity of, 530-535 diagnosis of, 1137 how to detect in stools, 535- 546 chemistry of, 546-554 cause of hepatic abscess, 834-8 mistaken for cancer, 924 distending gaU-bladder, 1091 extraction of, 1101 See ' GaU-stones,' ' Inspissated Bile' Biliousness, 273 — etiology, 274-7 — symptoms, 277-9 — treatment, 289-294 Biliverdin, 68, 79-80, 118-119 — eliuaination of, 122-4 — in urine, 730-3 — absence from bile, 1020, 1088 Birds' gall-bladders, 81 Bisshopp (Mr.), case of acute atrophy, 403 Bladder, urinary, gall-stones ul- cerating into, 633 Blair (Dr.), treatment of contagious jaundice, 356 Bleicher, blue mucous menibrane^ in case of jaundice, 139 Blindness, in liver disease, 131 Blood, sugar in, 60-1 — hsematin, biliverdin derived from, 68, 79-80, 118-119 action of poisons upon,l 19-120 imperfect oxidation of, caus- ing chloro.sis neonatorum, 297 — bile poison in, 413, 740-5 — disease-germs in, narcotic action, 415 preventing tissue oxidation, 419-428 — injection of, in cases of gall- stone with haemorrhage, 669 — in stools, mistaken for biliary matter, 362, 726 1166 INDEX. BLO Blood, bile pigment in, 732 — in jaundice from suppression, 742 — extravasations, 1030 — coagula, 1030 — serum, ascitic fluid, 1045 — action of mercury upon, 167 Blood-filnin, livpoxauthin a pro- duct of, 769 ' Blood-vessel, transfixed in tapping, 993 Booth (Mr.), case of passage of biliary concretions tbrougb fistu- lous opening, 676 Borelli (Dr.), on interstitial hepa- tites, 330 Bouchut (Dr.), on chloroform, a remedy for gall-stone, 645 Boutroux, on fermentation, 262 Bowels, their condition in liver disease, 127-9 — death from inspissated bile blocking intestinal canal, 571-2 — see ' Intestines ' Brain, disease-germs preventing tissue oxidation of, 419-428 Breath, fcetor in disease, 507-514 Breathing, influence upon position of liver, 50 Bristowe (Dr.), case of hepatic abscess from gonorrhoea, 862 — on connection between intes- tinal ulcerations and hepatic abscess, 859 — case of jaundice from scirrhous tumour of lesser omentum, 926 — case of phthisis, hsematoidin crystals in, 968 — cases of cystic disease of the Hver, 1012 — case of gall-stone ulcerated into blood-vessel, 634 — on treatment of ascites, 1059 Brookes (Thos.), abdominal pari- etes shot away, 1036 Brown (Graham), on toxic effects of bile acids, 742 Brown (Prof. Geo.), fatty degene- ration in cat, 1015 Brown (G.),case of distended gall- bladder, 1079 CAN Brownian granules, in encephaloid cancer, 886, 892 — ■ — in sputa of phthisis, 894 Brvant (Thos.), case of hydatids, 1006 — tapping ending fatally, 993 — case of gall-stones and abscess of gall-bladder, 1079 — case of calculus in gall-bladder, 1103 Budd (Dr.), theory of jaundice, 100-1 — gall-stone mistaken for cancer, 663 — on abscesses, 808 BuUen (Mr.), case of hydatids, 1004 Burrows (Sir Geo.), obscure case of obstruction diagnosed as cancer by, 910 (■ ACHEXIA, Cancerous, 905, 916 — mercurial, 146 — Syphilitic, 936 Cartres, bile drunk by, 91 ('alculi, oat-hair intestinal, 534 — see ' Gall-stones,' ' Urinary Cal- culi ' Calomel, remedy for biliousness, 287 Calorifying hepatic function, 65-7 Calvert (Crace), on germs, 212-214, 505 Cameron (Dr. J. C.),on puncturing enlarged liver, 824 Cancer of liver, 874 — pathology, 877 — etiology of, 892 — differentiated from scirrhus, 881, 886 — characteristics of, 885, 890 — proof of cancer, 881, 884, 905 — inoculability of, 887 — a germ disease, 891-2, 897 — connection with cancer of sto- mach, 906 — hereditary predisposition, 892 — common in tuberculous families, 893 — hepatitis as cause of, 895 — coexistence of soft and hard tumour, 897 INDEX. 1167 CAN Cancer of liver, coexistence of allied forms of cancer, 898 — signs and symptoms, 898-907 jaundice not a sign, 899, 918 pain, 900 size, 901, 917 nodulation, 004, 91G cancerous cachexia, 146, 905, 916 — negative signs and symptoms, 907 — errors in diagnosis and patho- logy, 919 — ditferential diagnosis, 925 — colloid, 877 — melanotic, presence of melanin in diagnosis of, 754-6 — fungus haematodes, 917 — of gall-bladder, 1119-1123 — of common bile-duct, 1123-4 — encephaloid, 916-17 — connection -nith gall-stones, 918 — inspissated bile mistaken for, 564-571 — gall-stone mistaken for, 663, 924 — hydatids mistaken for, 962 — diagnosed as functional derange- ment, 767-761 — mistaken for cysts, 1013 — may cause complete occlusion of vena cava, 927 — death from haemorrhage in, 927 — treatment, 928 — diet and regimen, 930 Canton (Mr.), case of intra-uterine syphilitic liver, 934 Cara, or Kava, a Fijian beverage, 259 Carbolic acid, poisoning from, 191-2 — a germicide, 200, 212, 457 — solution, vfashing hydatids with, 1003 Carbolised oil, tapping instruments to be dipped into, 1054 Carden (Mr.), case of hydatids, 987 Carlsbad, mineral springs of, 216 analysis, 231 (Jatamenia, in jaundice, 143 <'athartics, cholagogic, in pyaemie jaundice, benefits and dangers of, 493 Cayley (Dr.), case of hydatids, 963 CHO Cells, hepatic, morbid condition in case of obstructive jaundice, 785 — cancer, encephaloid, with Brown- ian granules, 880 — pus and mucus, 1087 Champagne, 249-258 Cheadle (Dr.), case of svmpathetic hepatitis, 327 Chemistry, physiological, applied to study of disease, 13-19, 24 — applied to obscure case, 913 Cherr^'stones, supposed cause of jaundice by obstruction, 037 Che\Tie (Watson), ' New Method of arresting a Gonorrhcea,' 856-57 Chicken-cholera germs, M. Pasteur's experiments, 415 Children, acute atrophy in, 407-9 — chronic atrophy in, 468-9 — hepatic ascites in, 1049 — see Infants Chiouanthus virginica (• old man's beard ') prescribed for hepatic disease, 182 Chittenden, experiments on hypo- xanthin, 769 Chloasma, liver spots, 1066-8 Chloiide of ammonium, treatment of hepatic disease with, 176-77 Chloroform, for treatment of biliary calculi, 644-47 Chlorosis neonatonim, etiology of, 297 — differentiated from congenital jaundice, 298 — treatment, 305 Chlorotic and bloodless patients, yellow complexion of, mistaken for jaundice, 146 Cholesterin, 65 — constituent of bile, 71, 79 — gall-stones composed of, 550, 577-588 — nature and chemical properties of, 551 — formation of, counteracted, to prevent gall-stone, 639-643 Choleo-cystotomv, recommended, 672-7 — performed for distended gall- bladder due to calculus, 1102-6 1168 INDEX. CHU Churton (Mr.), case of jaundice from enervation, 312 Cinchona, a germicide, 200 Cirrhosis, or hobnail liver, 467 — in a child, 477-8 Clark (Dr. Andrew), case of hepatic abscess from embolism, 838 Clark (Le Gros), case of impacted gall-stone, 624 Clements (Dr.), report of case of acute atrophy, 405 Climate, effect on liver, 146, 813 Cobbold (Dr.), 'Entozoa,' 942 Cockle (Dr.), case of h_ydatids, 952 Coffee, causing diarrhoea, 246 Cold, as germicide in pyrexia, 459 Coles (Dr, Thos.), case of gall- stones, 585, 599 Coley (Dr.), case of gall-bladder hydatid, 1082 Colic, differential diagnosis of he- patic from other kinds of, 678- 695 Colloid cancer of liver, case of, 877 Colouring matter, see ' Biliverdin,' ' Pigment ' Coma, due to disease- germs, 419 — in diabetes, 424 Congestion of liver, 260, 320 — action of mercury in, 166-170 Cooke (Benj.), on hereditary jaun- dice, 301-2 Cookson (Mr.), case of passage of calculi through fistulous opening, 674 Copaiba, as diuretic for ascites, 1060 Corville (M.), account of jaundice epidemic, 339 Coupland (Dr. Sidney), autopsy of case of gall-stone, 623 — — case of cancer of gall- bladder, 1122 Cousins (Dr. W.), case of hydatid mistaken for ovarian cysts, 956 Creosote, a germicide, 200 Cresswell (Mr.), case of idiopathic hepatic abscess, 826 Cripps (Ml'.), case of inspissated bile mistaken for cancer, 564 Crisis of disease, death and sudden elimination of disease-germs, 199 DIB Crisis of disease, foetor in, 509-514 Crisp (Dr.), paper ' On the Morbid Conditions of the Bile and Gall- bladder,' notice, 81 — gall-stones in sheep, 579 CuUingworth (Mr.), case of sub- acute (miscalled acute) atrophy, 466-7 Curling (Mr.), case of perforating gall-stone, 631 Cyr (Dr. Jules), on sudden death in diabetes, 424 Cystic disease of liver, 960, 1010 — due to congenital structural tissue malformation, 1011 — coexists with cystic disease of kidney, 1012 Cystin, 767 Cysts, hydatids, dilated bile-ducts, and cancer, mistaken for, 1013 rjEATH, sudden, from hydatids^ -^ 986-8 — prognosis of, 1 155-1161 Delirium, treatment of, 428-431 Denham (Admiral Sir H.), on the Fijian drink, Cara or Kava, 259 Deodorisation of patient's room and person, 268-9 Deposits, lime, in gall-bladder, 1118-1120 Diabetes, caused by abnormal ac- tivity of saccharine function of liver, 61-63 — etiology of cerebral symptoms, 423-428 Diagnosis of liver disease, hints to aid, 1127-1161 — by chemistry, 722-800, 912-3 — differential, of dropsies, 1047 Diaphragm, liver forced through,. 1037 Diarrhoea, in germ-disease, 496 Dickinson (Dr.), case of jaundice from obstruction by hydatids,. 635-6 Diet and regimen, 239-264 — in abscess, 808, 873 — amyloid liver, 1029 — biliousness, 248-9, 291-2 — fatty Hver, 1021 INDEX. 1169 DIE Diet and regimen, gall-stone, 639 — syphilitic liver, 936 — of Europeans in India, exciting cause of abscess in liver, 808-815 Digestion of living liver, 1040-4 Digitalis, action in pyrexia, 458 Distoma hepaticum (liver fluke) in man, 1008-9 Diuretics, in ascites, 1050 — atrophy, 487 Dobell (Dr.), prescription of podo- pbyUin by, 179 Doran (Mr.), on cystic disease, 1013 Douglas (Dr. H.), case of distended bile-ducts, 1094 Down (Dr. L.), case of renal cal- culus, 682 Drainage-tube, Roper's, 1058 Dropsy, differential diagnosis of, 1047 — treatment by tapping, 1055- 1060 — distended gall-bladders erro- neously described as, 1071 Drugs, baneful, in hepatic disease, 237 Duckworth (Dr.), case of dis- tended gall-bladder, 1086 Duke (Dr.), case of malarial jaun- dice, 365 Duncan (Dr, Matthews), case of meuori'hagia, 135 Durham (A.), on treatment of hydatids by electrolysis, 1001 Dysentery, in connection with ab- scess, 810, 857 rClIIXOCOCCUS hominis, 941-2 — in cases, 988 — natural death of, leading to spontaneous cure, 988 Eiselt (Dr.), on melanin in the urine, 754 Elaterium, in ascites, 1053 Electrolysis, treatment of hydatids by, 1001 Elias (Dr.). case of hydatids, 972 Embolism, a cause of hepatic ab- scess, 838 — cases of, 1031-4 FAG Emetics, treatment of catarrhal jaundice by, 701 Emphysema hepatitis, 355 Ems, mineral springs of, 216 analysis, 231 Encephaloid tumours, 884 — cancer cells, 885-7 Enervation, jaundice as result of, 310-319 Enlargement of liver, causes of error in testing, 51-57 — anteverted small liver mis- taken -for, 54 — differential diagnosis of, 1131 — in fatty liver, 1022 — amyloid, 1027 — as sign of cancer, 901-4, 917 Enteric fever, treatment of, 195-6 Enteritis, gall-stones induce, 626 Entozoa, the Echinococcus homi- nis, 941 — obstruction caused by, 1143-6 Epidemic jaundice, in temperate zones, 336-9 ■ of pregnancy, 344-7 Ether, sulphuric, for treatment of gall-stone, 644-7 Euonymin, vegetable hepatic re- medy, 183 Evacuation, of distended gaU-blad- der, 1081 Evans (Dr.), on ' surra,' horse- jaundice, 449 Ewart (Dr.), case of cancer from hepatitis,'896 Excretions, chemistry of, 722-800 Exploring needle, hints for the use of, 1155 Extravasations, blood, 1031 Eyes, defective vision symptom of liver disease, 131 — yellow vision in jaundice, 137 fAGGE (Dr. H.), case of acute atrophy in male child, 408 - on jaundice of acute atrophy, 412-3 - on size of gall-stones, 600 - case of small cancerous liver, 902 - on treatment of hydatids by electrolysis, 1001 4f 1170 INDEX. FAE Farre (Dr.), mercurial treatment of jaundice by, 169 Fat-modifyiug hepatic function, 63-5 Fats in ffeces, 727 Fatty liver, etiology and patho- logy, 65, 134, 1014-1020 — in 'phthisical patients, 1016 — in suckling women, 1019 — in infants, 1019 — absence of bile in, 1020 — symptoms, 1020 — treatment, 1021 Favrer (Sir Jos.), on connection of dvsentery with hepatic abscess, 8b9 Faecal matter, hardened, in colon, mistaken for enlarged liver, 51 Faeces in liver disease, 127-9 — acute atrophy, 392, 395, 429 — subacute atrophy, 463-5 — pyaemia and septicaemia, 490 — jaimdice, 136 — contagious jaundice, 362 — malarial jaundice, 364 — jaundice from poisons, 704 — test of spurious jaundice, 147 — chemistry of, 724-8 — fatty acids in, 772 — under mercurial treatment, 165 — gall-stones in, 635-545, 665-6 — dark-coloured, by blood or me- dicines. 429, 725-6, 1153-4 — fcetor in disease, 511 Fear, salivary secretion arrested by, 73 Fearn (Mr.), case of hydatids, 970 Febris Ictevodes, contagious and malarial jaundice, 346, 349, 363 Feltz and Hitter on eholesterin, 583 — on toxic effects of bile-acids, 777 Fermentation germs, 417 — inebriation, 417-18 — of koji, 444-8 Fern, male, injection of, after tap- ping hydatid, 999 Fever, enteric, treatment of, 195-6 — yellow, 119-120, 346-370 Fibrous degeneration, 938 — remnants of old blood coagula, 1030 FRA Filaria Strongylus, undergoing cal- careous degeneration in the lung of a sheep {%voodcut), 201 Filaria, causing j aundice in horses, 449 — infinitesima, 450-1 Finlayson (Dr.) on connection of dysenterj^ with hepatic abscess, 858 Fish-bones inducing hepatic abscess, 849 Fistula, biliary, spontaneous, and after incision, 673, 1080, 1098, 1099, 1119 for relieving distension in per- manent occlusion, 1098, 1107- 1112 death from slow starvation in animals with, 84 Flatidency, as symptom of liver disease, 129 Fluke, li^er, in man, 1008-9 Flint (Dr. Austin), on olive oil remedy for gall-stone, 656 — case of distended gall-bladder mistaken for floating Iddney, 1075 Fcetor of disease, 497-514 — does not communicate infection, 501 — arises from disease-germs, 504- 514 Foetus, action of liver in receiving blood from maternal placenta, 58 — in case of atrophy, 405 Food, life prolonged by, in obstruc- ted gall-ducts, 84 — influence on colour of bile, 69 — the urine, 730 — causing biliousness, 245 — see Diet Foot (Dr.), on quantity of uric acid in urine, 764 Foster (Dr. B.), on acetonaemia as cause of death in diabetes, 424 Fothergill (Dr. Milner), on liver pulsation, 55 Fox (Prof.), case of paroxysmal hepatic haematuria, 374 Frank (Dr.), caseof jaundice limited to one-half of body, 140 INDEX. 1171 FRA Fraser (Dr.), on action of alkalies on bUe, 175 Fremitus, hydatid, 948 Frerichs (Prof.), analysis of human bile, 83 — on causes of jaundice, 99 — theory of decomposition of bile- acids in blood, 734 — on absence of bile in fatty de- generation, 1020 Friedrichsliall, mineral waters of, 216-17 analysis, 231 Fry (Mr.), case of fatty liver, 1022 Fimgus bisematodes, 917 Furnell (Dr.), on the use of thermo- meter in diagnosis of hepatic abscess, 819 QABRIEL (Surgeon), case of supposed yellow fever, 351-3 Gall-bladder, animals having none, others two, 81 — excretion of bile from, 161-164 — diseases of, 1069 — absence or atrophy of, 1070 — distended, by liquids, 1071 bile, 1073 — — pus, 1078 white liquids, 1082 white mucus, 1083 biliary concretions, 1091 mistaken for floating kidney, 1075 treatment, 1093 tapping, 1098 choleocystotomy, 1101 fistulie,'ll07 — suppurating hvdatids of, 1081 — white bile in, 1088 — sloughing, gangrene, and rupture of, 1116 fatal hfemorrhage from, 635 — carbonate of lime deposits, 1118 — cancerous growths ol^ 1120 — in jaundice from obstruction, 114, 116,610-522,718 morbid condition, 786 — faradisation of, for catarrhal jaundice, 699 GAL GaU-stones, diiFerentiated from inspissated bile, 524-530, 553 — physical properties of (size, shape, &c.), 526-530 — specific gra-vity of, 630^ — voided by stool, how to detect, 535-545 — prognosis of number of, 546 — chemical composition of, 548- 550 — gall-stone affections, 573-4 — etiology, 574-588 hereditary, 575 more frequent in women, 575-6 statistics of age, 577 hvdrocarbons in food as cause of, 577-582 predisposition to, 587 — symptoms and signs of, 588-592 pain, 592-9, 1137-1143 — spurious symptoms, 635-8 — mistaken for cancer, 663, 924 — facets, sign of number of, 652 — number unlimited, 583 — two combined, 583 — in biliary ducts and tissue of liver, 584 — impacted in rectum, 627 — in gall-bladder, 1095 in case of colloid cancer, 878 — danger not in proportion to size of, 599-602 — danger not proportionate to in- tensity of j aundice, 602-3 — exist without jaundice, 603-8 — impacted in bile-duct without jaundice, 613-4 — colic of, simulating peritonitis, 608-613 differentiated from other kinds, 678-695 — may be vomited, 627-9 — causing hsemorrhage, 471, 634 rupture, 1116 tissue degenerations, 1120-3 hepatic abscess, 834-8 enteritis, 626 — perforating, 615-621 abdominal parietes, 029-633 urmary organs, 633 intestines, 615-624 F 2 1172 INDEX. GAL Gall-stones, perforating, danger of, 624-6 — treatment, 638-677 prevention, 639 dissolution, 643 expulsion, 654 of head symptoms, 657 of impacted, 657, 669 of perforating, 667-9 artificial removal (choleo- cystotomy), 672-7, 1102 sounding for, 1105 Galvanism, treatment of catarrhal jaundice by, 699 Gamgee (Prof.), examination of liver and urine in case of subacute atrophy, 466 Gastric juice, digesting living liver, 1042 Gay (John), case of gall-stone, 637 Gerhardt (Dr.), on treatment of catarrhal jaundice, 699 Germicides, as hepatic remedies, 183 — Crace-Calvert's experiments to ascertain respective powers of, 212-3 — snake venom as a gei-m-ldller, 359 — in contagious jaundice, 360 — action in pyrexia, 457-9 Germs (disease;, 183-214 — their eflfects, 189-90, 193 — destruction of, 194, 211-3 — vitality of, 197 — elimination of, 199-202 — causing jaundice, 119, 333-6 contagious jaundice and acute atrophy, 411 specific yellow fever or con- tagious jaundice, 348, 351 pyrexia, 435-443 cerebral derangements in febrile hepatic disease, 414-431 secondary hepatic abscesses, 856-7 — jaundice as complication, 492 — cancer, 890-2 dormant, 897 — maintain heat in body after death, 439, 454-6 GEE Germs (disease), pysemic and sep- ticeemic, 488-497 — narcotic theory, 415 — fermentation theory, 416 — diminish tissue oxidation, 419- 428 — foetor of disease arises from, 504-514 — odour of, 605 Gibb (Dr.), case of gall-atone, 660 — case of midtiple hydatids, 944 Gibson (Mr.), case of distended gall-bladder, 1076 Gil (Dr.), the originator of spel- ling reform, 11 Gill (Wm.), case of hepatic abscess, 832 Giraffes, found without, and others with two gall-bladders, 81 Gladstone (Dr.), on the need of spelling refoi-m, 3 Glandular secretion, suspended, 73- 77 Glycocholate of soda, 70, 641-3 Glycocholic acid, 70, 79 Gooch (Dr.), on jaundice of preg- nancy, 3-39 GonorrhcBa, as cause of hepatic abscess, 852 Goodfellow (Dr.), case of hepatic cancer causing haemorrhage, 927 Goodridge (Dr.), elevation in tem- perature in case of softening of the Pons Varolii, 434 Gordon (Dr.), case of enlarged liver in encephaloid disease, 902 Grandidier, on connection of um- bilical hsemorrhage with infan- tile jaundice, 303 Gravity, specific, of liver, 39-40 — of human bile, 72 — of biliary concretions, 530-4 — of urine, diagnostic value of, 792-9 in ascites, 1048, 1050 Green (Dr.), benzoic acid in jaun- dice, 208 Greenfield (Dr.), and Dr. Leggatt case of so-called yellow fever, 353-4 INDEX. 1173 GEI Griffiths (Dr. T. B.), case of ante- verted small liver mistaken for enlarged, related by, 54 Grouse (Dr.), case of infantile hepatic cancer, 899 Groves (Dr.), tapping of hydatid, 998 Gull (Sir Wm.), gall-stone case, 539 Giiterbock, case of gall-stone ul- cerating into bladder, 633 JTABERSHON (Dr.), case of jaundice from phosphorus poisoning, 710 Haenisch (Dr.), cases of catarrhal jaundice, 697 Haematin, see ' Blood ' Hsematoidiu, crystals, in hydatid, 833, 969 Hsematuria, paroxvsmal congestive hepatic, 370-389 — treatment, 388-9 Haemorrhage from bowels in liver disease, 129 — in jaundice from suppression and stricture of bile-duct, 106 — malarial jaundice, 367 — atrophy (acute) 392, 411 (chronic), 471 — gall-stone, 471, 634, 668 — cancer, 927 — hydatid, 972, 986 — treatment for, 266 — umbilical, connection with in- fantile jaundice, 303 — cases of jaimdice following upon, 144-5 Hare (Prof. Chas.), case of small cancerous liver, 902 Harley (Dr. John), case of trau- matic hepatic abscess, 841 — case of hydatid, 973 Haydon (Dr.), on epidemic of jaimdice, 338 Head (Dr.), acute atrophy, 404-5 Headache, symptom of liver dis- ease, 131 Heart disease in relation to liver disorders, 54-5 Heat, calorifyiug hepatic function, 66-7 HUM Heat, developed by germs, 442-3 — develops nerve disorder, 422 — (climatic), doubtful cause of hepatitis, 369 not essential to epidemic jaimdice, 338 Hepatitis, 320 — poisons producing, 709 — cause of abscess, 807 cancer, 895 jaundice, 320-24 — symptoms, 324 — treatment, 325 — peri-hepatitis, 325 — sympathetic, 326 — interstitial, 329-332 — and psoas abscess associated in case of supposed yellow fever, 351 — emphysema, 355 — elimination of uric acid and urea in, 763 Hereditary jaundice, 301 — predisposition, most common cause of hepatic cancer, 892 Hertz (Dr. J.), case of human bihary fistula, 1100 Her vie ux (M.),case of sympathetic hepatitis, 328-9 Hiccup, treatment for, 270-1 Hicks (Wale), case of chronic atrophy, 470 — on case of simiiltaneous gall- stone and inspissated bUe, 653-4 HiHier (Dr.), case of chronic atro- phy, 479 — case of jaundice from phos- phorus poisoning, 712 — case of hydatids, 986 Hilyer, bile-acids, 736 Hirschberg (Dr.), theory that jaun- dice in some cases is vicarious menstruation, 143 Hogg (Jabez), case of hydatids simulating cystic disease of the liver, 961 Holden (Dr. Sinclair), case of hyda- tids, 980 Ilooklets in hydatid fluid, 970 Hiunble (Dr.), case of distoma he- paticum in a man, 1008-9 1174 INDEX. HUM Humboldt (Dr.), discovery in snake venom of prophylactic against yellow fever, 359 Hunter (Dr.), on intermediary con- dition of bile before inspissation, 555-6 Hydatids (hepatic), 939 — etiology, 939 — connection with dog's tape- worm, 939 — the Echinococcus hominis, 941 — multiplication of hydatids, 944 — signs and symptoms, 945 pain, 946 h^^datid fremitus, 948 — jaundice from, 948, 950 not in proportion to size of, 952 — simulating dilated stomach, 955 — mistaken for ovarian cysts, 956 — simulating pregnancy, 960 — simulating ' cystic disease of liver,' 960 — mistaken for cancer, 962 — differential diagnosis, 964, 1132 — how to explore, 966 — examination of withdrawn fluids, 967 — crystals of hsematoidin in, 833 — associated with other hepatic disease, 971 — cause of abscess, 852 — implicating blood-vessels, 972 — suppurating, 956, 976 of gall-bladder, 1081 biu-sting of, 977, 1119 into intestines, 980 into lungs, 983 death from, by inducing secondary pulmonary disease, 984 sudden, 986 — spontaneous cure of, 988 — treatment, 989 by evacuation, 991 ■ danger of tapping, 993, 1003-8 how to tap, 995 injections after tapping, 997, 999, 1002 Hydrochloric acid, test of urine for biliverdin, 730 INS Hydronephrosis, mistaken for en- larged liver, 51 — fluid, 969 Hypodermic svringe, in tapping, 1055 — needle for sounding for gall- stones, 1105 Hypoxanthin, in human urine, 767 — forming uiiuary calculi, 769 TCE, in htemorrhage from per- forating gall-stone, 668 Ice-bags, for lowering temperature, 265 Icterus neonatorum, spurious form of jaundice, 296 Indian liver cases, 243 — malarial hepatitis, 368 Inebriation, fermentation, 417-8 Infants, hepatic disease in, 295 — amyloid liver, 1026 — cancer, 809, 907 — fatty liver, 1019 — gall-stones, 576, 590-1 — hj^datids, 945 — inspissated bile, 559 — jaundice, 295-305 mercurial treatment, 306-7 Inflammation of liver, 269, 320-329 Injuries, to liver, 1035-1040 — local, causing cancer, 894 — hvbrid form of pyrexia produced by, 456 Inspissated bile, differentiated from gall-stones, 524-530, 553 — physical properties of, 526-530 — specific gravity of, 530-4 — voided by stool, how to detect, 535-545 ' — chemical composition of, 547-8 — cause of hei^atic abscess, 834^8 — blocking up the intestinal canal, death from, 571-2 — inspissated biliary affections, 554-5 etiology of, 655-6 symptoms of, 556-572, 1143 spurious, 635-8 mistaken for cancer, 664- 671 treatment, 572-3 INDEX. 1175 INO Inoculation of cancer, 887 Intestines, gall-stones ulcerated into, and encysted there, 615, 621-4 fetal effects, 624-6 — hepatic hydatids bui'sting into, 980 — see ' Bowels ' Intolerance of remedies, 193—4 Iodide of potassium, supposed specific for hepatic hydatid, 989 Iodine, used in treatment of hy- datids, 1001 — test of urine for hiliverdin, 730 Iridin, hepatic remedy, 183 — in gall-stone, 644 Iron, baneful in hepatic cases, 238 — in contagious jaundice, 361 Irritation of skin in jaundice, 142-3 Irving (Dr. Pearson), case of perfo- rating hepatic abscess, 823 Itching, symptom in gall-stone, 589 JACKSON (Hughlmgs),on bilious vomiting in optic neuritis, 704 Jacob (E.), obsciu'e case of obstrac- tion, 910 Jaundice, etiology of, 94, 337-9, 342 — causes of, {table) 96-8 theory of Frerichs, Murchi- son, and Legg, 99 Dr. Budds theory, 100-1 from congestion, 320 enervation, 310-319 hydatids 635-8, 948 inspissated bile, 564, 557-9 syphilis, 935 disease-germs, 333-6 from cancer elsewhere than in liver, 925 — as a complication of germ diseases, 492 — pvaemic and septicjemic, 488- 497 treatment, 492-7 — intra-uterine and congenital, 295-300 treatment, 305-7 JAU Jaundice, hereditary, 300-2 — infantile, 303-5 — epidemic, of temperate zones, 336-9 — of pregnancy, 339-344 epidemic, 344-6 — epidemic and contagious, of the tropics, 346-363 treatment, 356-363 compared with atrophy, 390, 410-2 — malarial, 363-389 paroxysmal congestive he- patic heematuria, 376-389 treatment, 388-9 — catarrhal, 696-701 treatment, 699 — from poisons, 702-712 due to biliary suppression, 706-712 phosphorus, 709-712 — treatment, 712 — signs and symptoms, 136-148 mistaken, 146 — limited to one half of body, 140 — in chronic atrophy, 470, 482 — in hepatic cancer, 899 — as sign of gall-stone, 588 — gall-stones without, 603-8 — from hydatids simulating that from gall-stones, 963 — fi-om obstruction, 112-115, 209- 307, 713 axioms regarding mechanism of, 515-522 poisons as cause of, 702-6 hydatids cause of, 635-8 owing to congenital malfoi*- mation of bile-ducts, 714 caused by pressure of cancer- ous mass, 925 — — slow, pathology of, 717 morbid anatomical con- ditions in, 783 connection with atrophy, 719 — chemistry of excretions aid in diagnosis and treatment of, 722- 800 — differential diagnosis of, 1136- 1153 1176 INDEX. JAU Jaundice, tabular view of patho- logy of, 801 — treatment, by mercury (see Mer- curials), 168-172 by benzoic acid and benzoates («ee Benzoates), 207-211 by pig's bile, 1112 — causes of yellow skin, 119, 120- 124 — xanthelasma in, 1062-6 — from suppression, 104-111, 307, 412 differentiated from jaundice result of obstruction, by presence of bile-acids in urine, 735, 770 poisons cause, 706-712 Jeaffreson (Mr.), case of vomited gall-stone, 628 Jenner (Sir Wm.), case of inspis- sated bile, 566-571 Johnson (Dr. G.), on tube-casts, 798 — case of ascites, 1055-8 Jones (Dr.), on paroxysmal hepatic hsematuria, 387 Jones (Dr. H.), case of 'universal jaundice ' from obstruction, 559 Jones (Dr. Macnaughten), ' a case presenting the symptoms of acute yellow atrophy,' 461-5 Jones (W. O.), case of occlusion of bile-duct mistaken for cancer, 920 Juglandin, vegetable hepatic re- medy, 183 Jungle fever, inducing malarial he- patitis, 369 ■gANE, on food customs, 260 Kava, or Oara, a Fijian bever- age, 259 Kidney, as eliminator of bile-pig- ment, 123 — changes and disease induced by occlusion of bile-duct, 728, 732 — pelvis of, calculi in, 1092 gall-stones ulcerate into, 633 — floating, distended gall-bladder mistaken for, 1076 — morbid condition of, in case of slow obstructive jaundice, 787 LEP Kidnej^ renal differentiated from hepatic colic, 678-696 — see Urine, Urinary Calculi Kissingen, mineral waters of, 217 Klingelhoeffer (Dr.), record of jaundice epidemic, 338 Koji, fermentation of, 444-8 Kratschmer (F.) and Seegen, on saccharine function, 62 Krumptmann, case of distended gall-bladder, 1081 Kuhlmann (M.), experiments on carbonate of ammonia as an anti- fat, 1022 Kilhne, test for bile-acids in iu:ine, 734 — on tyrosin and leucin, 762 Kurs, the various German, 229 Kussmaul on acetonsemia, 425 TACING, tight, effects upon the -^ liver, 48, 51-2 Lammiman (Mr.), case of impacted gall-stone, 625-6 Lardaceous liver, nature of the disease, 65, 1023 Lawrence (Z.), on cancer, 888 Lawson (Geo.), case of collsid can- cer of liver, 878 Lead, acetate of, on secretion, 237 Leared (Dr.), case of perforating gall-stone, 616 — case of fatal haemorrhage from gaU-stone, 635 — case of ruptm'ed gall-bladder, 1116 Legg (W.), on causes of jaundice, 99, 102 ' — blood tinted with bile in cases of jaundice 141 — ligatured bile-ducts causing atro- phied livers in animals, 472-3 — on 'Nutmeg Liver,' 473 — on sugar in urine, 780 Leggatt (Dr.) and Dr. Greenfield, case of so-called ' yellow^fever,' 353-4 'tieoiifi >^ Lenz on transformation of neutral fats into fatty acids, 87 Leptandrin, vegetable hepatic re- medy, 183 INDEX. 1177 LES Lesions, traumatic, 1035-1040 Leucin, its connection with tauro- cliolic acid, 739 — in lu-ine, diagnostic value of, 466, 475, 745-753 — globules of, 748-9 Lime, carbonate of, deposits of _gaU-bladder, 1118 Lithates in urine, 484 Litten (Dr.), on pressure of move- able kidney on gall-duct, pro- ducing icterus, 344 Little (Dr.), elevation of tempera- ture in case of cerebro-spinal meningitis, 434 — case of cancer causing occlusion of vena cava, 927 Liveing (Dr. R.), on tonic treat- ment of ascites, 1059 Liver, remarks on study of diseases of, 21-36 — ciiemical composition of, 37-9 — specific gravity of, 39-40 — weight of the, 40-43 — size of, 43-57 conditions likely to give rise to erroneous signs of diminution in, 48-50 causes likely to lead to the idea that the liver is enlarged when it is not, 51 — liver as a sugar manufacturer, 59-65 — fat-modifying hepatic function, 63-5 — calorifying hepatic function, 65-7 — bUiaiy function, 67-93 — jaundice in diseases affecting the, 96 — signs and sjonptoms of hepatic disease, 125-145 — treatment by mercurials,l 56-172 alkalies,'l72-176 chloride of ammonium, 176 vegetable remedies, 177-183 germicides, 183-214 mineral waters, 214-237 baneful drugs, 237-9 dietetics, 239-263 general remarks on special forms of treatment, 263-272 LON Liver, galvanic treatment of, 699 — jjost mortem in jaundice from suppression, 106-7 in jaimdice from obstruction, 113-116 — morbid anatomical conditions of, in case of slow obstructive jaundice, 783 — pathological conditions of, in so- called yellow fever, 353-5 — malarial disease, 364, 365 — acute atrophy, 389-413 — chronic atrophy, 467-488 — dram-drinker's or hob-nail, 475 — inspissated bUe in bile tubes of the parenchyma, 560-4 — gall-stones in tissue of, 584 — strange and rare form of cal- careous deposit in, 584, note — fatty degeneration from phos- phorus poisoning, 711 — effects of slow obstruction upon, 718-9 — diagnostic value of chemistry of excretions, 722 — abscess of, 803-873 — influence of climate upon, 813 — cancer of, 874 — right lobe of, infested with parasites, 944, 946 — left lobe of, its immunity from disease, 879 — syphilitic disease of, 932 — benign forms of hepatic disease, 938 — fibrous degeneration, 938 — hydatid disease of, 939-1008 — distoma hepaticum (liver fluke), 1008-9 — cystic disease of, 1010-1013 — fatty degeneration, 1014 — amyloid, 1023 — fibrous growths, emboHsms, and blood extravasations, 1030 — traumatic aftections of, 1035 — digestion of living, 1040-1044 — ascites, 1044 — spots, 1061 — hints to aid in diagnosis and prognosis, 1127 Longmore (Prof.), on medical edu- cation, 23, note 1178 INDEX. LUN Lung, right, and pleura, disease mistaken for enlarged liver, 63 — bursting of hydatids into, 978, 983, 986 Lush (Dr.), case of distoma hepa- ticum in a man, 1008-9 MACALDIN (Dr.), on cham ■^ pagne,253 — case of hydatid, 991 Mackenzie (Dr.), case of digestion of living liver, 1042 Macleod (Dr.), case of hepatic ab- scess, 830 — opened antiseptically, 868 MacMunn (Dr. C. A.), letters on urinary colouring matter, 68 note — bile pigment in blood serum, 90 Macpherson (Dr. John), on action of mineral waters, 222-4, 228 Magrath (Dr.), case of pyaemic hepatic abscess, 855 — effects of prussic acid on, 503 Majendie, on effect of poisons after loss of blood, 193 Malaria poison, tenacity of, 368 — causing renal as well as hepatic congestion, 370 — disease germs, vitality of, 197-8 Malmgren (Dr. J. A.), poisoning by carbolic acid, 191-2 Manziui, on inoculation with snake venom against yeUow fever, 359 Marcet (Dr.), comparative analysis of human and sheep's livers, 39 — on transformation of neutral fats into fatty acids, 87 — on amyloid disease, 1026 Marienbad, mineral waters of, 217 analysis, 231 Markham (Dr.), case of cancer of gall-bladder, 1122 Martin (M.), on epidemic jaundice, 337 Mason (Mr.),urinary calculus, 684 Maumene, on oxidation and fermen- tation, 262 Medicines, making the skin and urine yellow, 147 — colouring faeces, 429, 725 urine, 729 MOX Meigs (Dr.), case of enteric fever with emphysema hepatitis, 355 Meissner, on uric acid and urea, 764 Melanin, containing iron, 755 — in urine, 754-761 — in melanotic cancer, 754 Mercvuialism, sallow complexion in, mistaken for jaundice, 146 Mercmials, treatment by, 156-172, 211 — in cases of congenital jaundice, to be given to wet-nurse, 305-6 hepatitis, 325 contagious jaundice, 356 — when to be avoided, 360 malarial jaundice, 388 pysemic jauodice, 494 gall-stcne, 656 — syphilitic liver, 937 — cause of jaundice in syphilis, 935 Miasma, cause of hepatic conges- tions, 369 Milk, sugar in, manufactured by the liver, 60 Milkweed, as remedy for dropsy, 1060 Mineral waters, their use in he- patic disease, 214-237 — constituents of, (table) 231 — in treatment of gall-stones, 653 Moore (Dr. N.), case of abscess of liver in child, following dysen- tery, 810 — autopsy statistics, 811 — case of cancer of gall-bladder, 1123 Morgan (J. N.), case of jaundice from obstruction, 115 Morphia, in contagious jaundice, 361 Mouillot (Dr.), case of cirrhosis and scirrhus, 902 IMovable liver, 49 Moxou (Dr.), case of jaundice from suppression, 104-111 — hereditary jaundice, 301 — congenital cirrhosis and perihe- patitis, 480 — on abscesses, 820 INDEX. 1179 MUC Mucus secretion of bile-ducts, 107 — distending gall-bladder, 1083 — cells, 1087 Murchison (Dr.), rationale of Mr. Curling's ease of perforating gall-stones, 632 — on size of liver in Dr. Moxon's case of hereditaiy jaundice, 301 — with Dr. George' Harlev, report on atrophied liver, 406 — cases of hvdatids, 952, 988, 1003 — case of embolism, 1033 — case of gall-bladder deposits, 1118 — case of 'functional derangement,' afterwards diagnosed melanotic cancer, 767-761 — mistaken diagnosis of case of hepatic albuminuria, 794 Murray (Dr. J.), case of fibrous tumour, 1031 Murraj' (Dr. Wm.), case of inspis- sated bile, mistaken for cancer, 665-571 jJARCOTICS in blood from dis- ease-germs, 415 Nassi, on action of alkalies on bile, 176 Needle, exploring, in diagnosis of hydatids, 965 Nerves, action of germs in prevent- ing nom-ishment of, 414, 419- 428 — abnormal action of, inducing pyrexia, 433-8 Nettle-rash, a concomitant of jaun- dice, 142 Neuralgia, hepatic, 138 Nixon (Dr. J. C), case of ascites, in which tapping caused death, 1058 Nodiilation, as sign of hepatic disease, 904 Nodules, syphilitic, 933 Nordenstrom (Dr.), case of poison- ing by carbolic acid, 192 Norway, gall-stones in, 581 Nothnagel on renal tube casts, 797 PAG Xunneley (Dr.), case of infantile jaundice from obstruction, 307 — (Mr.), case of cancer co-existing with tumour, 897 NuttaU (Dr. Henry), case of hy- datid, 981 BRE (Mr.), case of traumatic hepatic abscess, 840 Odours of disease, 497-514 Ogle (Dr.), on fluctuations of temperature in health, 432 — case of gall-stone perforating ab- dominal parietes, 630 — case of biliary concretion caus- ing hepatic abscess, 834 — case of cancer mistaken for cysts, 1013 Oil-globules, in liver-cells of child, 1052 Old-man's beard, prescribed for hepatic disease, 182 Olive oil, in gall-stone, 656 Operations, hybrid form of pyrexia produced by, 456 Opiates, to be avoided, 237, 267 — in gall-stone cases, 655 Oppolzer, on Uver enlargement in relation to heart disease, 55 Ord (Dr.), case of gall-stone, 600 Ossification, so-called, of gall- bladder, 1118 Otto (Dr.), number ©f gall-stones in gall-bladder, 583 Ovarian cysts, hydatids mistaken for, 956 — fluid, 968 Oxalate of lime, in urine, in hepatic disease, 767 Oxen, fed on red madder, having red bile, 69 Oxidation of tis.sue prevented bv germs, 419-428, 442-3 blood, diminished by germs, 419-428 pAGET (Sir James), case of ex- •^ trusion of gall-stones through fistulous opening, 673 1180 INDEX. PAI Paiii, hepatic, and shoulder pain as symptoms of disease, 131-2 diagnostic value of hepatic, of, 598-9 — differential diagnosis of, 588, 815, 822, 900-1, 908, 1130-1 — paroxysmal, 592-4 — amount of, no criterion of size or number of gall-stones, 594-5 — as cause of death, 595 — danger not always proportionate to, 596-8 Pancreas, occlusion of pancreatic duct, complicating case of ob- structive jaundice, 772 autopsy, 787, 788 Pancreatic secretion, function of, 89, 727 Panum (Prof.), biliary calculi, 529 Parasite Germs, 421 — destruction of, 199-201 — see ' Germicides ' Parietes, abdominal, perforated by gall-stones, 629-633, 673, 1080 — hepatic portion shot away, ex- posing liver, 1036 Parkes (Dr.), etiology of pyrexia, 433 Parkinson (Watts), on the use of salicylate of soda in acute rheu- matism, 203 Partridge (Mr.), case of hepatic lesion, 1036 Pasteur (M.), on killing germs of chicken cholera by dilute sul- phuric acid, 213-4 — theory of narcotic action of disease-germs, 415 Paterson (Dr.), case of haemorrhage from gall-stone, 471-2 Pavy (Dr.), case of hydatids, 999 Payne (Dr.), case of hepatic abs- cess from pins, 847 — case of fibrous tumour, 1032 Peacock (Dr.), case of perforating gall-stone, 616 Pearse (Mr.), case of perforating gall-stone, 617 Pepper (Dr.), case of distended gall-bladder, 1079 Percussion, employed to test size of liver, 44-57 PRO Percussion, hydatid fremitus, 948 Periodicity of disease, 448 Peritoneal cavity, gall-stones en- cysted in, 623 Peritonitis, gall-stone colic simu- lating, 608-613 — fi'om bursting of hydatid into abdomen, 979 — following upon tapping, 1057, Perspiration in jaundice, 137, 268, 269 — odour of, as sign of disease, 498 Phillips (R.), case of malarial hepatitis, 369 Phosphorus, poison, causing jaun- dice, 705, 709-712 Phytolaccin, vegetable hepatic re- medy, 183 Pick (Thomas), on haematoidin, in hydatid of liver, 833 Pigment, red, in hepatic abscesses, 833 — bile, see ' Biliverdin ' — see ' Melanin ' Pig's bile, treatment of biliary occlusion by, 1112 Pins, as cause of hepatic abscesses,, 846-9 Pityriasis, differentiated from chlo- asma, 1066-7 Pleura, right, bursting of hydatid into, 977 Podophyllin, as a remedy in he- patic disease, 178-181 — injudicious use of, in gall-stone cases, 648 Poisons, as causes of jaundice, 98, 119-120, 702-712 Politzer, report of acute atrophy in an infant, 408 Potash, picrate of, making skin and mine j^eUow, 147 Prance (Dr.), obscure case of he- patic disease, 770 Predisposition, most common cause of hepatic cancer, 892 Pregnancy, jaundice of, 339-346 — hydatids simulating, 960 Prognosis, hints in forming a, 1165-1161 Proiit (Dr.), on predisposition to gall-stone, 642 INDEX. 1181 PEU Pruritus, an accompaniment of jaundice, 142 Prussia acid, toxic properties do not exist in odour of, 502-3 Psoas, abscess, in case of jaimdice, 363 Puerperal fever, benzoate of soda specific in, 358 Piillna, mineral waters of, 217 ■ — — analysis, 231 Pulmonary disease, secondary, in- duced by hepatic hydatid, 984 Pulse, in jaundice, 137 — in treatment of hepatic disease, 130, 265 Purpm'ic blotches on skin, 496 Pus, gonorrhceal, cause of hepatic abscess, 852, 856 — evacuation by tapping, 864 — gall-bladders distended with, 1078 — cells, before and after treat- ment with acetic acid, 1087 Pyaemia, in connection with jaim- dice, 488^97 — treatment, 492 Pyrexia, etiology of, 431-459 Aitken's definition, 433 increased tissue change and abnormal nerve action theory, 433-8 germ theory of, 435, 448 heat maintained by germs after death, 454-6 — hybrid form, caused by injuries and operations, 456- 9 QUAIN (Dr.), child's lobulated ^ liver exhibited by, 478 — case of biliary concretions : in- spissated bile mistaken for gall- stones, 525 Quinine, in hepatic disease, 201, 205,211 — as germicide in pyrexia, 468 — in contagious jaundice, 358 Quinlan (Dr.), case of chronic atrophy with fatal intestinal hse- ■ morrhage, 471 PADZIEJEWSKI on leucin and •"■^ tyrosin, 753 SAD Ealfe (Dr.), case of acute atrophy, 407 — on urea in acute atrophy, 762 Ramskill (Dr.), case of jaundice from suppurating hydatids, 950 Rectum, gall-stones impacted in, 627 — stricture of, as cause of hepatic abscess, 851 Rectus muscle, right, rigidity of, as sign in hepatic abscess, 8i6 Reichardt, on change in sugar by oxidation, 262 Remedies for hepatic diseases, 149- 155 Renal colic, differentiated from hepatic, 678-695 — calculi, see ' Urinary Calculi ' Resin, hepatic, a constituent of bile, 71 Riggall (Mr.), case of renal calcu- lus mistaken for hepatic disease, 680-2 Rigors, sign in hepatic abscess, 817- 818 — diagnostic value of, 1135 Risel (Dr.), case of painful hydatid, 947 Ritter, on bile without biliverdin, 1088 Roberts (Dr. C), case of gall-stone, 600 Robertson (Dr.), case of perforating gall-stone, 630 Robinson (Dr.), case of acute atro- phy, 406-7 Rohrig, on action of alkalies on bile, 175 Rokitansky's red atrophy, 460-7 Roper's (PI. J.) drainage tube, 1068 Rose (Mr.), case of hydatids, 953 Rothe (Dr. C. G.), treatment of enteric fever, 195 Rupture of liver, 1040 Russia, gall-stones in, 579-582 Rutherford (Prof.), on action of al- kalies on bile, 175 QACCHARINE function of liver, ^ 41, 59-63 Sadler (Dr.), case of hydatids simu- lating pregnancy, 960 1182 INDEX. SAI Saint- Vel (Dr.), on epidemic jaun- dice of pregnancy, 344 Salicin, not a germicide, 201, 203 Salicylate of soda, as a remedy, 206 Salicylic acid as a remedy, 202 — manufacture of, 204 — a powerful germicide, 205 Salivary secretion, arrested by fear, 73 Salomon, experiments on hypo- xantlun, 769 Santonin, case of skin and urine made yellow by, 147 Sappey, on congenital cirrhosis of liver, 479 Sargent (A.), case of death from pain in gall-stone, 595-6 Saundby (Dr. Robt.), on hypertro- phic cirrhosis, 473 Scarlet fever, induced by opening hydatids, 1005 SchifF (Dr. M.), on dissolution of gall-stones, 643 Schmidt, experiments on bile, 87 Scirrhus, differentiated from cancer, 886-7 — not inoculable, 888 Scott (Su- Walter), anecdote of his bad orthography, 5 Seegen and F. Kratschmer, on saccharine function, 62 Septicaemia in connection with jaundice, 488-497 — treatment, 495 Serum, blood, ascitic fluid, 1045 Sex, different position of liver in each, 48-49 Sharkey (Dr.), specimens of cys- tic disease of the liver, 1012 Sharpey (Prof.), oat-hair intes- tinal calculus mistaken for gall- stone by, 533 Shaw (Alex.), on influence of re- spu'ation on portal circulation, 328 Shell-fish, effects on bilioiis people, 248-9 SheUy (C. E.), treatment of en- teric fever, 195 Shingles, a concomitant of jaundice, 142 SOD Shoulder pain, as symptom of liver disease, 132 Sieveking (Dr.), case of hydatid inducing secondary pulmonary disease, 984 Silver (Dr.), case of hepatic hy- datid, cirrhosed liver, and can- cer of stomach, in one subject, 971 Simon (Mr.), case of perforating gall-stone, 630 Simpson (Dr. Alex.), case of con- genital abscess of gall-bladder, 517 Sims (Dr. J. M.), case of calculi in gaU-bladder, 1104 Sinety (Dr.), on fatty liver in suckling women, 1019 Size of liver, 43-67 Skhi, yellow discoloration of, in fevers, due to hepatic disorder, 119-120 — irritation of, in jaundice, 142-3 — purpuric blotches, 496 — of infants suffering from so- called icterus neonatorum, 296-7 Skoda, case of hydatid treated with iodine, 1001 Smith (Dr. Ed.), on different effects of brandy, whisky, gin, and rum, 247 Smith (Dr. Geo.), case of impacted gall-stone, 658 Smith (Dr. Pye), case of inspissated bile blocking intestinal canal, 571-2 — case of hepatic cancer from a fall, 895 — specimens of cystic disease of kidneys and liver, 1012 Smith (Thos.), case of hydatids mistaken for ovarian tumoui', 957 Smith (Wm.), cases of jaundice following upon haemorrhage, re- lated by, 144 — test of m'ine for bile-pigment, 730 Snake venom, inoculation against yellow fever, 359 Soda, carbonate, for treatment of gall-stone, 641 INDEX. 1183 SOD Soda, sulphate of, remedy for fatty liver, 1022 — chelate, for biliary concretions, 643 Southey's (Dr.) capillary drainage trocar, 1054 Spelling reform, medical aspects of, 1-12 Spleen, enlarged and displaced, mis- taken for enlarged liver, 51 — abnormal size and condition in case of congenital cirrhosis, 480 Spm-way (Dr.), on milkweed as cure for dropsy, 1060 Statistics, value of, in medicine, 811-12 Stewart (Dr. G.), case of inspissated bile, 558-9 — on connection of acute atrophy of kidneys and liver, 393 Stewart (Dr. "\Vm.), chloride of ammonium as hepatic remedy due to, 176 Stimulants, when to be adminis- tered, 269-270 Stokvis, on testing urine for biliver- din, 730 Stomach, empty and full, influence upon position of liver, 50 — cancer of, connection with hepa- tic cancer, 906 — protected from gastric juice by mucus secreted by epithelial lining, 1042 Stools, see Faeces Stork (Dr.) on foetor in typhus cases, 509 Strassburg, test for bile-acids in urine, 737 Stricture of bile-ducts in cases of jaundice, 104-117 Strychnia, remedy for biliousness, 292-3 Strychnine, prevents tissue oxi- dation and nerve nourishment, 422 Sugar manufactured by the liver, 69-65 — constituent of bile, 71-72 — in urine, fatal prognostic, 779- 783 TEA Sulphur, liver substance, source of ui'inary calculi, 768 Suppm-ation of gall-bladder, 1078 Syphilitic disease of the liver, 932 TABLES, average weights of hu- man liver and body from birth onwards, 41 — weight of human liver in pro- portion to age and weight of body, 42 — composition of human bile, 83 — causes producingjaundice, 96-8 — comparative chemical analytical table of alkaline, saline, and aperient mineral waters of the most celebrated continental springs, 231 — diurnal fluctuations in tempe- rature of fermenting koji, 448 — liver substances and their pro- ducts, 768 — Dr. George Harley's tabular view of the pathology of jaun- dice, 801 — comparative, of amyloid tests, 1025 Tait (Lawson), case of distended gaU-bladder, 1102 Tapeworm (dog's), connection with Echinoccus hominis, 939- 943 Tapping of hepatic abscesses, 864- 871 — ascites, 1053, 1055-1060 — gall-bladder, 1098-1101 — hepatic hydatids, 991-1008 Taraxacum, as a remedy in hepatic disease, 181 Taurin, convertible from tauro- cholic acid, 71 — transformed into cystin and eliminated by kidneys, 767 Taurocholate of soda, 71, 641-3 Taurocholic acid, constituent of bile, 71-2, 79 Tea, contrary effects to coffee, 246-7 Teale (Mr.), elevation of tempe- rature in case of concussion of the brain, 434 1184 INDEX. TEE Teevan (Mr.), case of stone in bladder escaping detection, 683 Temperature, fluctuations of, 432 — mode of reducing, 264 — of patients' rooms, 267 — in liver disease, 131, 137 — in treatment of hepatic abscess, 872 Tests, of urine for bile-pigment, 730-1 for bUe-acids, 734-7 — amyloid, comparative table of, 1025 Thermometer, its use in diagnosis of hepatic abscess, 819 Thompson (Dr.), case of suppu- rating hydatid, 977 — on tonic treatment of ascites, 1059 Thompson (Sir H.), case of urinary calculus in infant, 686-9 Tissue change, increased, as cause of pyrexia, 433-8 Todd (Dr.), case of distended bile- ducts, 1093 Tongue, condition in liver disease, 126 — — jaundice, 137 hepatic abscess, 819 Tonics, for treatment of ascites, 1059 Traumatic affections of liver, 1035- 1040 Treatment of hepatic disease, 149, 263 — abscess, 861-873 — ascites, 1053-1060 — atrophy, 486-8 — acute atrophy, 395-413 cerebral cases, 428-431 — subacute atrophy, 462-5 — biliousness, 289-294 — cancer, 928 — fatty liver, 1021 — diseases of gall-bladder, 1081 — - gall-stone, 638-677 — hepatitis, 325 — hydatids, 989-1008 — inspissated bile, 572-3 -— catarrhal jaundice, 699 — congenital jaundice, 305-7 — contagious jaundice, 356-363 Treatment, contagious jaundice, head and nerve symptoms, 360-1, 428-431 — malarial jamidice, 388 cerebral cases, 428-431 — pysemic jaundice, 492-7 — occlusion, bOiary, by pig's bile, 1112 — syphilitic liver, 936 Trocar, use in tapping abscesses, 864, 867-8 — recommended in evacuation of hydatids, 991, 995, 999, 1054 — evacuation of gall-bladder, 1081 Tube casts, in hepatic albuminuria, 797 — hyaline and granular, 798 Tumours, abdominal, likely to lead to mistaken notion that liver is enlarged, 51 — fibrous, so-called, remnants of old blood coagula, 1030-4 — of liver, mistaken for cancer, 879, 886 — characteristics of, 883-5 Turpentine, with sulphuric ether, as remedy for gall-stone, 644-7 Tyrosin, its connection with glyco- cholic acid, 739 — in urine, in atrophy, 466, 475 diagnostic value of, 745-753, 781 may be obtained in pure state, 747-8 TTLCER, cicatrised, flow of bile obstructed by, 114 — of stomach penetrates liver, 1043 Umbilical haemorrhage, in connec- tion with infantile jaundice, 303-4 Unua (Dr.), on comedones, 1065 Urea, diagnostic value of, 761-764 — diminished in proportion to destruction of liver tissue, 762 Uric acid, diagnostic value of, 761- 768 • — quantity eliminated in hepatic disease, 764, 913 INDEX. 1185 URI Urinary calculi, due to disordered hepatic function, 130 — mistaken for gastric derange- ment and liver disease, 680 gall-stone, 682 — size of, passed by natural pas- sage, 684 — symptomatology more reliable than metallic somid, 685 — colic of, differentiated from other kinds, 680-695 — sulphur, have their source in liver, 768 — formed from hypoxanthin, 769 Urinary organs, gall-stones ulcerate into, 633-4 Urine, in liver disease, 130 amyloid liver, 1028 acute atrophy, 397, 402, 406 analysis, 746 subacute atrophy, 464-6 chronic atrophy, 475, 483-5 urinary calculi, 693-5 gaU-stone, tendency to de- posit, 642 paroxysmal congestiA'e he- patic htematuria, 370 jaundice, 136, 138 suppression of, in contagious jaundice (yellow fever), 362 malarial jaundice, 364 pyaemia and septicjemia, 490 — lithates in, 484 — colour of, diagnostic value of, 729-733 — tests for bile-pigment in, 730 — bile acids in, diagnostic value of, 733-8 — tyrosin and leucin in, 745-763 — melanin in, 754-761 — urea and uric acid in, diagnostic value of, 761-765 — chemistry of, in obscure cases, 773, 912 presence of sugar, 779-783 specific gravity, differen^^iates renal from hepatic albuminuria, 793 renal tube casta, 797 — tested witli tincture of iron, for salicylic acid, 204 — foetor in disease, 511-4 WEA Urine, in diagnosis of dropsies. 1048 Urohsematin, 729 VALS, mineral waters of, 218 analysis, 231 Yanderbyl (Dr.), case: gall-stone impacted in intestine, 624 — case of colloid cancer of liver, 877 — hospital statistics showing rarity of jaundice in cancer, 000 — case of cancer of common bile duct, 1124 Vegetable remedies in hepatic disease, 177-183 Vena cava, cancer of liver causing occlusion of, 927 Vertigo, symptom of liver disease, 13i Vichy, mineral water of, 218 analysis, 231 Vidal (Dr.), his theory of pains in dorsal vertebrae as symptoms of liver disease, Sec, 132-3 Virchow, on cause of pyrexia, 433 — obstruction theory of jaundice from poisons, 702-5 Voit, on urea, 761 WAKEFIELD (Mr.), case of hepatic ascites, 1049 Walker (Dunbar), case of gall- stones in infant, 590 AValker (H. F.), case of gall-stone impacted in rectum, 627 Ward (Mr.), case of enteritis in- duced 1)y gall-stones, 626 Ward (Dr. Ogier), case of gall- bladder deposits, 1118 Washington (Dr.), old-man's-beard for hepatic disease prescribed by, 182 Waters, mineral, in hepatic disease, 214-237 analytical table of, 231 Watson (Sir T.), on treatment of ague, 379 I Waxy liver, 63, 1023 Wear (A.), successful case of eva- I cuating abscei^s, 866 G 1186 INDEX. WEB We'ber (Dr. F.), case of inspissated bile, 560-4 Weight of liver, 40-43 — in acute atrophy, 404-407 — in subacute atrophy, 466 — in chronic atrophy, 471, 478-9 — in cancer, 895, 901-4 Wells (Spencer), case of gall- stone, 539 West (Dr.), infantile jaundice, 303 — infantile hepatic cancer, 907 Wettergren (Dr. Carl), case of hepatic abscess from fish-bone, 849 Whipham (T,), case of hepatic abscess from plus, 848 White liquids in gall-bladder, 1082-1091 Whittaker (Dr.), on sounding for gall-stones, 1105 Wilks (Dr.), case of hepatic abscess from stricture of the rectum. 851 ■- acute atrophy, 402 hobnail liver, 477 suppurating hydatid, 952 hepatic fibrous growth, 1030 — ■ — jaundicefromob3truction,715 Winge (Dr. E.), case of hepatic abscess from lish-bone, 850 Wittich (Von), his discovery that fresh bile converts boiled starch into sugar, 62 AVoman, position of liver in, 48 Wood (Mr.), case of atrophied gall-bladder, 1071 ZYM Worgan (Sm-geon), treatment of enteric fever, 196 Wunderlich (Prof.), case in which temperature after death not only maintained but increased, 488 Wyss (Dr. Oscar), on effects of phosphorus poisoning on dogs, 708 "V-ANTHELASMA,104-111,1061 — etiology and pathology of, 1062-6 Xanthoma, liver spots, 1061 Xanthopy, or yellow vision, 137 ' Y^^-LLOW ' atrophy, 409 Yellow fever, due to disease germs causing jaundice, 119-120 — specific and malarial, 346 differentiated, 348 — specific, properly contagious jaundice, 349-355 — malarial, properly malarial jaun- dice, 363-370 — case of supposed, associated with hepatitis and psoas abscess, 351 — snake venom a prophylactic against, 359 Young (Dr. P. A.), on iridin spe- cific against gall-stone, 644 7INC chloride, test of urine for ^ biliverdin, 730 Zymotic disease, jaundice in, 97 I.OXDOX : PIMXTED By ISPOTTISWOOUH A.M) 10.. XKW-STBEET SQUAEB AND PABLIAMEKT STBEET COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROV/ED DATE DUE DATE BORROWED DATE DUE C28 (747) M100 y^^^■L (Zc ^^5- H^^^