COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00034061 a eRV.5 Columbia (ini»f ttitp intt)f(£itpofltnigi)rk College of Sto^^iiinnsi anCi ^urgconsi Itibratp Digitized by tine Internet Arcinive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/clinicallecturesOOmurc DISEASIS OF THE LIVER &C. LOXDOS : rniSTEO BY SPOTTISWOODE AXI) CO., NEW-STUKKT SQUAKB AND I'ABLIAJIENT STRKKT CLINICAL LECTUEES ON DISEASES OF THE LIVER JAUNDICE AND ABDOMINAL DEOPSY INCLUCmG THE CEOONIAN LECTUKES ON FUNCTIONAL DERANGEMENTS OP THE LIVER DELIVERED AT THE ROYAL COLLEGE OF PHYSICIANS EsT 1874 BY CHARLES ^UECHISON, M.D. LL.D. F.E.S. FELLOW OF THE ROYAL COLLEGE OP PHTSICLUfS ; PRESIDENT OF THE PATHOLOGICAL SOCIETY OF LONDON ; PHYSICIAN AND LECTURER ON THE PRINCIPLES AND PRACTICE OP MEDICINE, ST. THOMAS'S HOSPITAL ; VICE-PRESIDENT AND CONSULTING PHYSICIAN, LONDON FEVER HOSPITAL; AND EXAMINER IN MEDICINE, UN^^^;RSITY OP LONDON; FORMERLY PHYSICIAN ANT) LECTURER ON MEDICEfE, MIDDLESEX HOSPITAL, AND ON MEDICAL STAFF OF H.M. BENGAL ARMY SECOND EDITION NEW YORK WILLIAM WOOD AND CO., PUBLISHERS 27 GREAT JONES STREET 1877 •i .w TO WILLIAM MUEEAY DOBIE, M.D. PHYSICIAN TO THE CHESTEE INFIEMAET THIS WORK IS DEDICATED BY THE AUTHOR IN ADMIRATION OF HIS TALENTS AS A SCIENTIFIC PHYSICIAN AND IN TOKEN OF A FRIENDSHIP OF THIRTY YEARS PREFACE THE SECOND EDITION. As WAS STATED iu tlie first edition, these Lectures have no pretension to be a systematic treatise on Diseases of the Liver. Their sole object is to assist the student and prac- titioner in the diagnosis and treatment of these maladies. The favourable reception accorded to the first edition encourages me to hope that the work answered the piurpose for which it was intended. Five years have now elapsed since the last copy of a large impression was disposed of. The delay in the preparation of this edition has been occasioned by other avocations of a literary and profes- sional character, and by my desire to include the results of the labours of my contemporaries, as well as those of my matured experience derived from hospital and private prac- tice. The Lectures have been in great measure re- written. Of the 96 cases which were published in the first edition 6 have been omitted, and in this edition 90 cases appear for the first time, making a total of 180, Most of these additional cases have been the subject of clinical remarks, which have been incorporated with the original Lectures. The wood- cuts have been increased from 25 to 37. Vlll PREFACE TO THE SECOND EDITION. To the twelve Lectures which appeared in the fii'st edition a fresh Lecture on some of the rarer forms of enlargement of the liver has been added (Lect. VIL), and likewise the three Croonian Lectures on ' The Functional Derangements of the Liver,' which I had the honour of dehvering before the Eoyal College of Physicians in 1874. Although some of the remarks in these last Lectures must be regarded as merely suggestive, and subject to modification with the advance of our knowledge of the healthy functions of the liver, yet, from the extensive correspondence with my medical bretliren which they have called forth, I have the satisfaction of feeling that, at all events for the time, they meet a want in medical literature, and that the views expressed in them are con- firmed by the observations of practical men. 79 WiBiroLE Street, London, W. April 1877. PEEFACE THE FIEST EDITION. These Lectures were originally delivered to the Students of the Middlesex Hospital, and the first four have already, in part, appeared in the pages of the * Lancet.' It is hoped that their publication in the present form may be useful, not merely to those for whom they were originally written, but likewise to other members of the Medical Profession. It is not their object to set forth a complete account of diseases of which they treat, but rather to put prominently forward the characters on which their diagnosis is based, and, in particular, to point out the diagnostic import of those signs and symptoms — such as enlargement of the fiver, jaundice, dropsy, and pain — ^which are common to many different hepatic disorders, but the precise cause of which is often unrecognized. The original descriptions have in many instances been illustrated by the introduction of diagrams showing the altered size and relations of the diseased organs. With the third Lecture has been incorporated a portion of the matter contained in an essay on 'The Dangers, Diagnosis, and Treatment of Hydatid Tumours of the Liver,' which was X PREFACE TO THE FIRST EDITION. published in the ' Edinburgh Medical Journal ' for December 1865 ; and to the last Lecture have been added the results of an inquiry into the pathological consequences of gall-stones, commenced many years ago, and part of which appeared in a memoir on abdominal fistulse, published in the ' Edinburgli Medical Journal' for July and August 1857. To all of the Lectures has been appended a history not only of those cases on which each Lecture was originally founded, but of others which have occurred subsequently and been the subject of clinical remarks in the wards. These histories have been condensed from notes taken at my dictation by my clinical clerks, whose kind and ready assistance I take this oppor- tunity of acknowledging. The records of these cases will, it is believed, be useful to the medical practitioner who meets with others of a like nature, for, as the founder of patho- logical anatomy long ago observed : ' Nulla est alia pro certo noscendi via, nisi quamplurimas et morborum et dissecti- onum historias, tuni aliorum, tum proprias, collectas habere, et inter se comparare.' — Morgagui, de Sed. et Causis Morbor. Lib. IV. Prooemium. 79 WiMPOLE Stkeet, Cavendish Square, W. June 1868. CONTENTS. LECTURE I. ENLARGEMENTS OP THE LIVER. PAGE Introductory Remarks — Normal Dimensions and Boundaries of the Liver — Circumstances under which Enlargement of the Liver is simulated and the means of distinguishing such spurious Enlargements : 1. Congenital Malformations : 2. Early Life ; 3. Rickets ; 4. Tight Lacing ; 5. Certain Diseases of the Cheat ; 6. Tumours &c. between the Liver and the Diaphragm ; 7. Abnormal Conditions of the Abdominal Viscera ; 8. Abnormal Conditions of the Abdominal Parietes — Cases in Illustra- tion ............. 1 LECTURE II. ENLARGEMENTS OP THE LIVER. True Enlargements of the Liver: Subdivision into painless and painful: I. The Waxy, Lardaceous, or Amyloid Liver ; II. The Fatty Liver ; III. Simple Hypertrophy 30 LECTURE III. ENLARGEMENTS OF THE LIVER. IV. Hydatid Tumour 55 LECTURE IV. ENLARGEMENTS OP THE LIVER. V. Congestion. VI. Interstitial Hepatitis. VII. Inflammation of the Bile-ducts. VIII. Obstruction of Common Duct .... 131 LECTURE V. ENLARGEMENTS OF THE LIVER. IX. Pyaemic Abscesses. X. Tropical Abscess ... . . 164 Xll CONTENTS. LEOTUEE VI. ENLARGEMENTS OF THE LIVER. PACK XI. Cancer 208 LECTURE VII. ENLARGEMENTS OF THE LIVER. XII. Spindle-cell Sarcoma; XIII; Myxoma; XIV. Epithelioma; XV. Cystosarcoma ; XVI. Multilocular Hydatid; XVII. Simple Cysts; XVIII. Tubercle ; XIX. Lymphatic Growths ; XX. Enlargement with Xanthelasma ; XXI. Enlargements of Gall-hladder . . . 235 LECTURE Vra. CONTRACTIONS OF THE LIVER. Conditions simulating Contraction of Liver — True Contractions ; I. Simple Atrophy ; II. Acute or Yellow Atrophy ; HI. Chronic Atrophy (Cirrhosis — Simple and Syphilitic Induration — Red Atrophy, &c.) . 253 LECTURE IX. JAUNDICE. Definition — Importance of recognising Causes — Spui'ious Jaundice; 1. Chlorosis ; 2. Cancerous Cachexia ; 3. Malaria and Poisons ; 4. Sub- conjunctival Fat; 5. Icterus Neonatoriun ; 6. Addison's Disease; 7. Exposure to Sun ; 8. Pigments in Urine ; 9. Feigned Jaundice. Phe- nomena of Jaundice: — L Localities, &:c ; 2. Secretions; 3. Bitter Taste ; 4. Derangements of Digestion ; 5. Pruritus ; 6. Cutaneous Eruptions ; 7. Temperature ; 8. Pulse ; 9. Ilfemorrhages ; 10. General Debility and Annemia ; 11. Yellow Vision ; 12. Cerebral Symptoms — Theory of Jaundice 310 LECTURE X. JAUNDICE. Classification of Causes of Jaundice — Jaundice from Obstruction of the BUe-duct 334 LECTURE XI. JAUNDICE. Jaundice independent of Obstruction of the Bile-duct — Diagnosis of the Causes of Jaundice 394 CONTENTS. Xlll LECTURE XII. FLUID IN THE PERITONEUM. PAGK Its Signs — The Conditions whicli Simulate it, and how to distingiiisli them : 1. Ovarian Cyst; 2. Hydatid Cyst; 3. Renal Cyst; 4. Distended Urinarj^ Bladder ; 5. Pregnant Uterus — Causes of Fluid in Peritoneum : I. Acute Peritonitis ; II. Tubercular Peritonitis ; HI. Chronic Peri- tonitis; rV. Cancer; V. Colloid; VI. Simple Dropsy: 1. From Disease of Kidneys ; 2. From Disease of Heart or Lungs ; 3. From Portal Ohstruction 434 LECTURE XIII. A. HEPATIC PAIN. Simulated by : 1. Pleurodynia ; 2. Intercostal Neuralgia ; 3. Pleurisy ; 4. Gastric Dyspepsia ; 5. Intestinal Colic ; 6. Renal Colic — The Varieties and Causes of genuine Hepatic Pain ..... 482 B. GALL-STONES. Their various Consequences, Symptoms, and Treatment .... 487 C. ENLARGEMENTS OF GALL-BLADDEPw Their Causes, Clinical Characters, and Treatment 523 LECTURE XIV. THE CROONIAN LECTURES ON FUNCTIONAL DERANGEMENTS OF THE LIVER. Notice of Doctor Croone — Present Notions as to Functional Derangements of Liver unsatisfactory— A. Functions of the Liver in Health. Historical Sketch ; Galen's Views ; Obsequies of Liver by Bartholin ; Modern Views ; Functions of Liver Threefold : I. Sanguification and Nutrition ; II. Disintegration of Albuminous Matter; HI. Secretion of Bile — Composition, Origin, Quantity, and Uses of Bile — b. Functional De- rangements of Liver — Objections to Existing Classification — Proposed Classification: I. Abnormal Nutrition: 1. Corpulence; 2. Emaciation — A. Deficiency of Bile ; B. Diabetes ; c. Other Varieties of Emaciation. II. Abnormal Elimination ; Symptoms of Retained Bile ; Cholestearsemia 530 LECTURE XV. THE CROONIAN LECTURES ON FUNCTIONAL DERANGEMENTS OF THE LIVER. IH. Abnormal Disintegration : 1. Lithsemia ; 2. Gout ; 3. Urinary Calculi ; 4. Biliary Calculi ; 5. Degenerations of the ludneys and Albuminuria ; 6. Structural Diseases of the Liver ; 7. Degenerations of Tissue throughout Body ; 8. Local Inflammations ; 9. 'Constitutional Diseases' — ^IV. Derangements of Organs of Digestion : 1. Tongue ; 2. Appetite ; 3. Taste ; 4. Dyspepsia ; 5. Constipation and Diarrhcea ; 6. Vitiated XIV CONTENTS. PAGE Stools ; 7. Intestinal Haemorrliage ; 8. Hsemorrlioids ; 9. Hepatic Pain ; 10. Jaundice, its Patliology — V. Derangements of the Nervous System : 1. Aching Pains in Limbs; 2. Burning Patches; 3. Neuralgia; 4. Cramps ; 5. Headache — Megrim ; 6. Vertigo ; 7. Convulsions ; 8. Mania ; 9. Paralysis ; 10. Noises in Ears ; 11. Sleeplessness ; 12. Depression of Spirits ; 13. Irritability : 14. The Typhoid State . . 562 LECTURE XVI. THE CROONIAN LECTURES ON FUNCTIONAL DERANGEMENTS OF THE LIVER. VI. Derangement of the Organs of Circulation : 1. Palpitations and Flutterings of the Heart; 2. Exaggerated Pulsation of the Large Arteries ; 3. Irregularities and Intermissions of the Pulse ; 4. Feeble Circulation ; 5. Anasmia ; 6. Angina Pectoris ; 7. Venous Thrombosis — VII. Derangements of Organs of Respiration : 1. Chronic Catarrh of Fauces ; 2. Bronchitis ; 3. Spasmodic Asthma — VIII. Derangements of the Genito-Urinary Organs : 1. Deposits of Lithic Acid and Lithates in Urine ; 2. Renal Calculi ; 3. Diseases of Kidneys ; 4. Cystitis ; 5. Urethritis ; 6. Chordee ; 7. Orchitis — IX. Abnormal Conditions of Skin: 1. Eczema, Lepra, Psoriasis, and Lichen; 2. Urticaria; 3. Boils and Carbuncles ; 4. Pigment-spots ; 5. Xanthelasma ; 6. Pruritus — c. Causes of Functional Derangements of the Liver : I. Secondary. 1. Structural Diseases of the Liver ; 2. Disorders of Stomach and Bowels ; 3. Diseases of the Heart and Lungs ; 4. Pyrexia — II. Primary : 1. Errors in diet ; 2. Deficient supplj-- of Oxygen ; 3. High Temperature ; 4. Nervous influences ; 5. Constitutional Peculiarities ; 6. Poisons — D. Treatment of Functional Derangements of the Liver: 1. Diet; 2. Free Supply of Oxygen ; 3. Diluents ; 4. Baths ; 5. Aperients — Cholagogues ; 6. Alkalies ; 7. Chlorine, Iodine, Bromine, and their Salts ; 8. Mineral Acids ; 9. Tonics ; 10. Opium. — Concluding Remarks 594 APPENDIX 629 INDEX 635 LIST OF WOOD-ENGRAVINGS. Fia. PAGE 1. Natural positiou of the Liver, as seen after removal of tlie Anterior Wall of tlie Ohest and Abdomen 2 2. Natural position of the Liver, as seen after tlie removal of the Vertebrae and the Posterior Wall of the Chest and Abdomen . . 3 3. Normal area of Hepatic Dulness, viewed anteriorly .... 4 4. Normal area of Hepatic Dulness, viewed from right side ... 5 6. Normal area of Hepatic Dulness, viewed posteriorly .... 5 6. Apparent enlargement of the Liver resulting from Tight-lacing . . 9 7. Area of dulness caused by effusion into the Right Pleura, depressing the Liver ........... 10 8. Displacement of the Liver downwards by extensive effusion into the Pericardium . . . . . . , , , . ,11 9. Tumour in right hypochondrium caused by circumscribed peritoneal effusion between Liver and Diaphragm ...... 24 10. Increased area of Hepatic and of Splenic Dulness from Waxy Disease, anterior view .......... 32 11. Increased area of Plepatic Dulness from Waxy Disease, lateral view . 32 12. Area of Hepatic Dulness in a case of Hydatid Tumour of the Liver . 87 13. Area of Hepatic Dulness in a case of Hydatid Tumour of the Liver . 89 14. Appearance of Abdomen in a case of Multiple Hydatid Tumours of Liver and Peritoneum . . . . . . . . .103 15. Appearance of Abdomen in a case of Multiple Hydatid Tumours of Liver and Peritoneum . . . . . . . . .106 16. Area of Hepatic Dulness in a case of Enlargement of the Liver, and Distension of the Gall-bladder from obstruction of the Common Bile-duct 163 17. Area of Hepatic Dulness in a case of Tropical Abscess of the Liver . 193 18. Area of Hepatic Dulness in a case of Cancer of the Liver . . . 209 19. Microscopic appearances in a case of Fungating Cancerous Tumour of the Liver, showing transitional forms between the Glandular EpitheHum and ' Cancer-cells ' 230 20. Group of Spindle-cells from Tumour of Choroid in a case of Spindle- cell Sarcoma of Liver 238 21. Appearance of Liver in a case of Spindle-cell Sarcoma . . . 239 a XVI LIST OF WOOD-ENGRAVINGS. FIG. I'AOK 22. Microscopic appearances of Spiudle-cell Sarcoma of Liver . . . 240 23. Area of Hepjitic Dulness in a case of Acute Atrophy of the Liver . 260 24. Microscopic needle-shaped Oiystals of Tyrosin adhering in bundles and in stellate groups 264 25. Microscopic globular masses composed of Rcicular crystals of Tyrosin . 264 26. Microscopic, laminated, crystalline masses of Leucin .... 264 27. Shows the hepatic and ascitic Dulness in a case of Cin'hosis of the Liver . > 278 28. Microscopic crystalline masses of Carbonate of Lime from the Gall- bladder 308 29. Microscopic appearances of the Blood in a case of Chronic Atrophy of the Liver with Leukaemia ........ 308 30. Percussion-sounds over the Abdomen in a case of Ascites from Cirrhosis of the Liver 436 3L Percussion-sounds over the Abdomen in a case of Tumour of the Left Ovary 437 32. Crystals of Glycocholate of Soda from the bile of the Ox . . • 544 33. Glycocholate and Taurocholate of Soda fi-om the bile of the Ox . . 544 34. Crystalline plates of Oholesterin 545 35. Laminated crystalline masses of Leucin ...... 563 36. Ciy^tals of TjTosin adhering in bundles ...... 563 37. Globular masses composed of acicular crystals of Tyrusiu . . . 503 TABLE OF CHEMICAL EQUIVALENTS. Albuminoids (Lieberkiilin) O^aHnjNigSOoa Excretin G,,TI,,,SO, Taurocliolio acid OoeH^jNO^S Glycocholic acid O^gH^gNOe Oholicacid O24H40O5 Taurin OaH.NOgS Glycocin O2H5NO2 Eili'^'i^i^ G.eiiAO, Biliverdin CieH.oN^Og Tyrosiu O9H11NO3 Leucin G,B.,,m, Hippuric acid O9H9NO3 Xanthiu O^H^N^O., Cy3tiii OgH.NSOj Kreatin O^HgNgO^ Kreatinin O^H.NgO Uric or litHc acid . OgH^N^Oj Urea . . . . . OH^N^O Oxalic acid O2H2O4 Starch 0,H,,0, Dextrin . O^H^A Glycogen, or animal starch ....... OgHj^Og Cane-sugar Oi^H^jOu Glucose, or grape-sugar OgHjoOg Lactose, or milk-sugar OgHj^Og Inosite, or muscle-sugar OgHjoOg LaeTulose G^R^JO^ Oholesterin G^&^^fi Corrigenda. Page 60, line 28, for Case XCVI. read Case XCII. „ 142, „ 12, for Case CLXXVI. read Case CLXXVUI. „ 156, „ 8, omit See Case CXXI. „ 18;J, „ 1 8, ./b?" usually ««.&«^!Ym^i3 occasionally. „ 260, „ 10, insert at end of paragraph See Lect. XI. p. 407. LECTUEE I. ENLARGEMENTS OF THE LIVER. INTRODUCTORY REMARKS — NORMAL DIMENSIONS AND BOUNDARIES OF THE LITER CIRCUMSTANCES UNDER WHICH ENLARGEMENT OF THE LIVER IS SIMULATED, AND THE MEANS OF DISTINGUISHING SUCH SPURIOUS ENLARGEMENTS : 1. CONGENITAL JLALFORMATIONS ; 2. EARLY LIFE ; 3. RICK-ETS ; 4. TIGHT-LACING ; 5. CERTAIN DISEASES OP THE CHEST ; 6. TUMOUR BETWEEN THE LIVER AND DIAPHRAGM ; 7. ABNORMAL CONDITIONS OF THE ABDOMINAL VISCERA ; 8. ABNORMAL CONDITIONS OF THE ABDOMINAL PARIETES — CASKS m ILLUSTRATION. Gentlemen, — In systematic lectures on Medicine, it is the custom to describe in detail the numerous symptoms which characterise different disorders. It requires, however, little ex- perience to discover that there are symptoms and signs which are common to many diseases, and that no small difficulty is often encountered in determining to which of its many sources a particular symptom ought to be referred. Yet this deter- mination must always be your first object in practice. You must never rest satisfied with treating merely a symptom without endeavouring to acquire some definite notion of the local or general disease upon which it depends. In all cases of disease presenting some prominent symptom, you ought to ask yourselves two questions: 1. What are the different causes which may give rise to the symptom in question ? and 2. Which is the most probable cause in the individual case before you ? Not until you have given a satisfactory reply to these enquiries will you be in a position to speak with any confidence as to prognosis, or to adopt a rational method of treatment. To no class of maladies are these remarks more applicable than to diseases of the liver. There are few diseases more difficult to discriminate, and perhaps none in which an erro- neous diagnosis is oftener made : while symptoms depending upon disease of the stomach, the intestines, or the kidneys, or even of the heart, the lungs, or the brain, are constantly ascribed to derangements of the liver. It will be my object in B 2 ENLARGEMENTS OP THE LIVEE. lect. i. these lectures to point out to you the chief signs and symptoms resulting from hepatic disease, the different morbid conditions from which each of them may arise, the rules by which you must be mainly guided in determining the precise disease in each case, and the conclusions to which you ought in this way to be led respecting prognosis and treatment. We shall com- mence, for instance, by discussing the different causes of En- largement of the Liver ; and in subsequent lectures, the causes of Atrophy of the Liver, of Jaundice, Hepatic Pain, Hepatic Dropsy, &c., will be duly considered. ENLAKGEMENTS OF THE LIVER. Before proceeding to consider the various causes of true enlargement of the liver, it is necessary to have an accurate knowledge of its normal dimensions and boundaries, and also to keep in view certain conditions which during life may simulate enlargement. Fig. 1. Natural Position of the Liver, as seen after removal of the anterior wall of the chest and abdomen. Modified from JSibson's Med. Anatomy. A, Liver, b, Ascending colon, c, Transverse colon. D, Descandinp colon, e, Small intestines. F, Stomach, o, Heart, ii, Right lung. I, Left lung. Normal situation and dimensions of the liver. — The liver is situated in the right hypochondrium,the convexity of the right LBCT. I. NORMAL DIMENSIONS AND BOUNDARIES. 3 lobe corresponding to the concavity at the base of the right lung with the diaphragm interposed, and the under surface being opposed to the stomach and large intestine, the right kidney and supra-renal capsule. The convex upper surface projects up into the right side of the chest, and a great part of Fig. 2. Natiiral Position of the Liver, as seen after the removal of the posterior wall of the chest and abdomen. Modified from Sibson's Med. Anatomy. The liver is covered by the diaphragm, beneath which, on the left side (b) there is also the spleen and a portion of the stomach. A, Eight lobe of liver, c, Ascending colon, d, Descending colon. it is in immediate juxtaposition with the ribs, but the upper- most portion (in a vertical direction) is separated from the wall of the chest by the thin lower margin of the right lung. (See fig. 1.) Accordingly, in percussion during life, the upper B 2 4 ENLARGEMENTS OF THE LIVER. lect. i. margin of hepatic dulness may be said to be twofold, one boundary limiting the region where the organ is in close ap- proximation to the walls of the chest, and where the dulness is absolute, the other corresponding to the extreme height of the liver, and including the space where it is overlapped by the thin layer of lung, and where the sound on percussion constitutes a transition from the hepatic dulness to the pulmonary resonance. It is the latter which is usually regarded as the true upper margin of the liver (fig. 3). There is a peculiarity in the upper margin of hepatic dulness which is of some practical importance — namely, that it / V Fig. 3. Area of Hepatic Diilness, viewed anteriorly. rt-O, Riglit mammary line, c-d, Median line, e, Fplenic dulness. /, Cardiac dulness. is not horizontal, but arched. Commencing posteriorly about the tenth or eleventh dorsal vertebra, it ascends slightly towards the axilla and the nipple, and then again descends gradually towards the median line in front. The arched cha- racter of the upper surface of the liver is shown in the annexed diagrams (figs. 3, 4, 5). In determining the upper margin of hepatic dulness we must trust to percussion alone. In ordinary cases it is suffi- cient to note the upper limit in what is called the right mam- mary line, or a line descending perpendicularly from the riglit nipple (fig. 3). Here, in a healthy adult, the true ujiper margin of the liver is situated in the fifth intercostal space, or in rare cases behind the fifth rib or in the fourth space. In this line, NORMAL DIMENSIONS AND BOUNDARIES. 5 the liver is overlapped by lung to tlie extent of about one incb. But in all cases of suspected hepatic disease, the upper margin of hepatic dulness ought to be determined in its entire course. In the median line in front, it usually corresponds to the base of the ensiform cartilage, or rises slightly above this. To the left of the median line it is difficult or impossible to define the upper limit of hepatic dulness from the lower boundary of the heart, the two being in apposition, but a line drawn from the upper margin of hepatic dalness in the median line to the apex of the heart will usually correspond to the line of separation. In the ricjht axillary line (fig. 4), or a line Fig. 4. Area of Hepatic Dulness, Fig. 5. Area of Hepatic Dulness, Tie^wed viewed from right side. posteriorly. a-h, Eight axillary line. a-l. Right dorsal line, c, Splenic dulness. d, Left kidney, e. Right kidney. /, Descending colon. g. Ascending colou. falling perpendicularly from the centre of the axilla, the upper margin of hepatic dulness corresponds to the seventh intercostal space, or more rarely, to the seventh rib. In the right dorsal line, or a line falling perpendicularly from the lower angle of the scapula (when the arm is dependent), it corresponds to the ninth intercostal space, or the ninth rib (fig. 5). The lower margin of hepatic dulness may be determined by 6 ENLARGEMENTS OF THE LIVER. lf.ct. i. percussion, and also, if diseased, by means of palpation. When healthy, the lower margin of the liver cannot be distinctly felt, except in the epigastrium. Even when the organ is diseased, it is, as a rule, less easily defined than the upper margin, being often obscured by a distended condition of the stomach or intes- tines, or by fluid in the peritoneum. Hence it is always most satisfactorily examined when the stomach is empty, and after the bowels have been freely moved. The liver may then be dis- tinguished from the intestines by the greater resistance it offers to pressure by the hand. In the right mammary line, the lower margin, in health, usually corresponds with the margin of the costal arch, or is half an inch above or below this ; in the right axillary line, it corresponds to the tenth intercostal space ; and in the right dorsal line, to the twelfth rib, although here it is usually difficult to define it from the dulness of the kidney. In the epigastrium, the lower margin of the right and left lobes usually descends to nearly half-way between the ensiform cartilage and the umbilicus. The ordinary extent of hepatic dulness, in an adult of average size, is 4 inches in the right mammary line, 4h or 5 inches in the right axillary line, 4 inches in the right dorsal line, and 3 or 4 inches in the median line anteriorly. But it must not be forgotten that, even in the same indi- vidual, the liver is constantly liable to slight alterations in its position consistently with health. During the act of inspira- tion the whole organ is slightly lowered — about half an inch — and its upper surface is somewhat flattened, whereas during expiration the organ ascends. Again, in the erect position, the lower margin will extend somewhat lower than when the patient is recumbent. If in the mammary line it correspond to the lower margin of the costal arch in the latter position, it may be a half or a quarter of an inch lower in the former. These variations however are slight, and are not likely to em- barrass the diagnosis. But difficulties in diagnosis may sometimes arise from the boundaries of the liver, as above defined, being greatly ex- ceeded without any real enlargement of the organ. After death it is often found that a liver which during life had been thought to be greatly enlarged is even smaller than it ought to be. Hence, in all cases of suspected enlargement of the liver it is important to keep in view the possibility of its being of a spurious character. SPURIOUS ENLAEG-EMENTS. CIRCUMSTANCES UNDER WHICH ENLARGEMENT OF THE LIVER IS SIMULATED DURING LIFE. The cliief of these conditions are the following : — I. Congenital wialformations, &c. — In rare cases, in conse- quence of congenital malformation, the liver is more square or globular than natural, and a larger portion of it is in apposi- tion to the abdominal and thoracic wall. In other cases the left lobe is proportionately large, as in the foetus. In cases of still greater rarity the liver is protruded into the right side of the chest through an opening in the diaphragm, which may be congenital, or the result of accident. Not long ago a case came under my notice, where, owing apparently to an opening in the diaphragm of long standing, the greater portion of the right lobe of the liver was lodged in the right pleura, and the hepatic dulness in consequence ascended as high as the third rib. The particulars of the case will be found in the Patho- logical Society's Transactions (vol. xvii. p. 164). The diagno- sis of such conditions during life must of course always be difficult, and will rest mainly on the following conditions : — 1 . The absence of any symptom indicative of disease of the liver. 2. The absence of other circumstances likely to produce spurious enlargement. 3. The fact of the increased hepatic dulness persisting from early life (except in diaphragmatic hernia resulting from accident). II. Early life. — The liver is proportionally much larger in. infancy and adolescence than in adult life. The organ does not grow in proportion to the rest of the body. In the adult the average weight of the liver is one-fortieth of that of the entire body, whereas previous to puberty it may be as much as one-thirtieth, or even one-twentieth. The dimensions vary accordingly, so that the upper margin of hepatic dulness is often higher in the child than in the adult, and the lower margin descends below the costal arch in the right mammary line. It follows, therefore, that an extent of hepatic dulness which in the adult would be abnormal, may be perfectly nor- mal in the child. In the wards of the hospital I have had frequent opportunities of pointing out to you this peculiarity of the liver in early life. 8 ENLAEGEMENTS OF THE LIVEE. lect. i. III. Rickets, causing lateral distortion of the spine, and the deformity known as the ' pigeon breast,' may lead to appa- rent enlargement of the liver, owing to the organ being de- pressed and elongated in its vertical diameter from lateral compression. The resemblance to hepatic enlargement may be further increased by there being a disproportionate reces- sion of the ribs immediately above the liver, as the result of which there is an apparent bulging of the hepatic region. Hence, in lateral distortion of the spine and in the * pigeon breast,' care must be taken not to arrive at any hasty conclu- sion as to enlargement of the liver. IV. The 'practice of tight-lacing may cause displacements and malformations of the liver, which may simulate enlarge- ment, and give rise to difficulties in diagnosis. Tight-lacing may act on the liver in three ways, according to the situation, the tightness, and the duration of the constricting cause. a. The liver may be displaced upwards or downwards, according as the pressure is applied below or above the organ. The precise situation where the pressure is applied will vary with the prevailing fashion of dress ; but most commonly in this country the displacement is downwards, and this may be to such an extent that the lower margin of the liver reaches the ilium, and the organ appears to fill up the whole of the right side and front of the abdomen (fig. 6). h. In consequence of lateral compression, the liver may be elongated in its vertical diameter, so that a larger portion of it is brought into apposition with the abdominal and thoracic walls. This is a very common result of tight-lacing (fig. 6). The narrower the lower portion of the chest, the greater will be the extent of liver opposed to the thoracic and abdominal walls. c. When the pressure is exerted by a tight cord, it may produce deep fissures in the substance of the liver, as the result of which portions of the organ may be more or less detached, and may be felt as movable tumours separated from the he- patic dulness by tympanitic portions of bowel. Apparent enlargements of the liver from tight-lacing are far more common than is generally believed. You cannot pay many visits to the post-mortem room without observing examples of this malformation, which accounts for not a few movable tumours in the abdomen that are a source of anxiety both to the j)atient and the medical attendant. Moreover, LKCT. J. SPUKIOUS ENLARGEMENTS. 9 tliese acquired malformations of the liver, although most common in females, are occasionally observed in the male sex. I show you here the liver of a man with a deep furrow, from indentation of the ribs, which resulted apparently from the practice of wearing a very tight belt. I may also call your attention to the case of a man, aged 23, lately under your Fig. 6, Apparent enlargement of the Liver resulting from Tight-lacing. Modified from Frerichs. The Liver is depressed, and its vertical diameter elongated. A deep transverse furrow corresponds to the site of constriction. observation in the hospital, with a firm movable tumour in the epigastrium, which there was reason to believe was a portion of the liver partially detached from a similar cause. Apparent enlargements of the liver from tight-lacing may usually be recognised by the following characters : — 1. Evident signs of tight-lacing in the walls of the chest and abdomen. 2. Occasionally the existence of a distinct transverse fur- row in the substance of the liver, appreciable through the abdominal parietes on palpation. 10 ENLARGEMENTS OP THE LIVER. 3. The absence of symptoms of disease of the liver, or of serious disease in the chest or abdomen. 4. In the case of movable tumours from tight-lacing, their situation and the absence of any evidence of hydatid tumour or of disease of the gall-bladder will assist the diagnosis. V. Certain diseases in the chest may cause great dei^ression of the liver into the abdominal cavity, and lead to the idea that the organ is enlarged. This remark ap^jlies particularly to extensive effusion into the right pleural cavity, or to pneumothorax on the right side. In these affections the natural convexity uj)wards of the diaphragm may be reversed, and the lower margin of the liver may descend to the umbili- cus (fig. 7). Depression to a less extent may result from Fig. 7. Effusion into the Eight Pleura depressing the Livor. a, Hepatic dulness. b, Dulness from pleuritic effusion causing bulging of the right side of chest, and displacing the heart to the left ; its upper margin horizontal, c, Cardiac dulness. d, bplenic dulucss. intra-thoracic tumours, effusion into the left pleura or into the pericardium (fig. 8), or a dilated heart; and even in pulmonary emphysema and acute pneumonia ' the liver may ' See a ease of acute pneumonia of the right lung, referred to by Dr. Stokes in his work on ' Diseases of tiie Heart and Aorta,' p. 453. ' So great was the enlargement of tlie lung that the di;ip]iragni and liver were pushed far down into the alidominal cavity.' Dr. bright speaks of disj)laceme)it of the liver downwards hy pneumonic consolidation as a frequent occurrence (Abdom. Tumours, Syd. Soc. ed., p. 255) ; but Stokes regards it as exceptional, and this also is tlie result of my own oliservation. In extensive pneumonia, however, the liver is usually more or less congested, and en- larged accordingly. SPURIOUS ENLARGEMENTS. II be lowered to the extent of an inch or more. A dilated heart causes great depression of the liver far oftener than is com- monly believed ; not unfrequently from this cause the rounded upper surface of the liver becomes visible through the abdo- minal parietes below the ribs. In all cases, however, where the liver is depressed in consequence of disease in the chest, Fig. 8. Displacement of the Liver downwards by extensive Effasion into the Peri- cardium : after Sibson. A, Liver, b, Pericardium greatly distended ■n-ith fluid. the descent of its lower margin is probably due to a combina- tion of causes ; for when there is disease in the chest sufficient to depress the diaphragm, there is usually also congestion with slight enlargement of the liver. Apparent enlargements of the liver from the causes now referred to have the following distinguishing features : — 1. A previous history of pleurisy, pericarditis, bronchitis and emphysema, pneumonia, chronic cardiac disease, or of phthisis ending in pneumothorax. At the same time it is well 12 ENLARGEMENTS OF THE LIVER. lect. i. to remember tliat extensive effusion sometimes takes place into the pleura in a very latent manner. 2. A degree of dyspnoea far greater than would be ac- counted for by the amount of enlargement of the liver, even if real. 3. The physical signs of the various thoracic diseases above referred to. In the case of emphysema and pneumo- thorax, there is no difficulty in defining the upper margin of the liver, and in ascertaining that the extent of hepatic dulness is not increased, so that percussion will at once reveal the nature of the case. The signs of dilated heart also are usually sufficiently clear. But in pleurisy it may be impossible to say where the dulness of the pleuritic effusion ends and the hepatic dulness begins ; and here, as in some forms of true hepatic enlargement, there may be bulging of the ribs and obliteration of the intercostal spaces (Cases I. II.). Under such circumstances there are several characters of considerable importance in diagnosis — viz. : a. The bulging of the side of the chest is more uniform in pleurisy, and not abruptly limited to the lower part, as in diseases of the liver. An empyema, however, may be so cir- cumscribed that the bulging is restricted to the lower part of the chest. (See Case I.) h. In pleuritic effusion, the upper margin of the dull space is horizontal (fig. 7), instead of arched as in enlargements of the liver. c. In pleuritic effusion, the upper level of the dull space will often be found to vary with the position of the patient. In enlargement of the liver, it is the same in all positions. d. In pleuritic effusion, the lower margin of the liver does not ascend and descend with expiration and inspiration, which is the case in enlargements of the liver, unless there be firm adhesions to the abdominal wall. e. Eversion of the lower costal cartilages would indicate hepatic enlargement, rather than pleuritic effusion. (But see Case II.). /. When there is sufficient effusion into the pleura to cause downward bulging of the diaphragm, a depression may be sometimes observed between the lower margin of the ribs and the upper surface of the liver, which is not met with in hyper- trophy of the liver. Effusion into the pericardium wiU be recognised by the LECT. I. SPURIOUS ENLARGEMENTS. 1 3 outline of the area of dulness on percussion. It is the left lobe of the liver that is mainly displaced by it. In arriving at a diagnosis, it must not be forgotten that inflammation of the pleura or of the base of the right lung may coexist with real enlargement of the liver. This is a not uncommon occurrence in hydatid tumours or abscesses of the liver, and often precedes their bursting upwards through the diaphragm. So also after a hydatid tumour of the liver has burst into the pleura, extensive empyema may coexist with great enlargement of the liver. I shall hereafter have an opportunity of bringing under your notice the particulars of cases in which this occurred. VI. A tumour or collection of fluid hetween the wpjper surface of the liver and the diai^hragm, or in the substance of the diaphragm, may also cause great depression of the liver and apparent en- largement of the organ. The upper margin of dulness may then be arched, and it may be impossible during life to dis- tinguish the case from one of real enlargement of the liver. Tou will find a case recorded by the late Dr. Bright, where a large abscess situated between the diaphragm and the liver produced apparent enlargement of the liver ; ^ and more than once I have l^nown enlargement of the liver simulated by an encysted collection of peritoneal fluid between the liver and the diaphragm, when the organ was in reality atrophied. Such cases, however, are rare. Case V. is an interesting example of this difiiculty in diagnosis. VII. Various abnormal conditions of the abdominal viscera may displace the liver upwards, so that it encroaches upon the cavity of the chest and appears to be enlarged. This happens not unfrequently in cases of ascites, and in ovarian and uterine tumours, in aneurism of the abdominal aorta,^ &c. ; and hence elevation of the liver above its usual height must not, under such circumstances, be regarded as a sign of enlargement. Greater difiiculty, however, in diagnosis may result from tu- mours in the omentum or of the right kidney, being in the im- mediate proximity of the liver, and appearing to be tumours of the liver itself. The difiiculty will be increased if such tumours compress the common bile-duct, so as to occasion jaundice. The diagnosis of an omental tumour under such circumstances must mainly depend on the want of all uniformity in the ap- ' Clinical Memoirs on Abdominal Tumours. Syd. See. ed. p. 257. * Stokes. Op. cit. p. 617. 14 ENLARGEMENTS OF THE LIVER. lect. i. parent hepatic enlargement, the dimensions of the liver in every other direction being normal. Moreover, in both tumours of the kidney and of the omentum, when the patient lies on his back, the finger can usually be inserted between the ribs and the upper part of the tumour ; there is often a clear space on per- cussion between the tumour and the liver ; and the lower margin of the tumour does not ascend and descend with expiration and inspiration ; while the diagnosis will often be assisted by the direction in which the tumour has grown, and by the history of the case. There are, however, certain difiiculties in the dia- gnosis which must be kept in view. (Case VIII.) An omental tumour adherent to the liver may descend with it on inspira- tion. The kidneys, and particularly the right one, may be felt when healthy to descend slightly on deep inspiration, but this rarely occurs in the case of a renal tumour large enough to be mistaken for an enlarged liver. On the other hand, an enlarged liver may be prevented by peritoneal adhesions from moving with expiration and inspiration. Again, the liver may be pressed to the right by a distended colon or stomach, so as to simulate an enlarged kidney, or the transverse colon may pass in front of an enlarged liver, so as apparently to divide it into two distinct solid tumours. Accumulations of faeces in the transverse colon also consti- tute a condition which it is often most diflBcult to distinguish from enlargement of the liver. Such cases are constantly occurring in practice, and it is well to bear in mind that, if you are to rely on the patient's statements, these accumulations are far from being necessarily associated with constipation. The resemblance to hepatic disease in these cases may be further increased by the hardened scybala imparting to the tumour a nodulated character like that of cancer, and by the development of such symjDtoms as jaundice, vomiting, and hiccup. The diagnosis of these cases from true enlargement of the liver must rest mainly on — 1. The occurrence of simsmodic pains like those resulting from obstructed bowels, &c. 2. The disappearance of the tumour, and the amelioration of the symptoms under such treatment as poultices and fomen- tations, purgatives, enemata, and belladonna. Lastly : — VIII. Abnormal conditions of the abdominal parietes may simulate enlargements of the liver. LECT. I, SPUEIOUS ENLARGEMENTS. 1$ Firm contraction of the bellies of tlie recti muscles, owing either to inflammation of the subjacent peritoneum or viscera, or, in cases of increased muscular irritability, to the mere application of the hand, is apt to be mistaken for hepatic en- largement, or tumour ; and the difficulty is increased by the circumstance that the upper division of the rectus is sometimes larger on one (usually the right) side than on the other. It is distinguished by : — 1. The situation, size, and form of the apparent tumour corresponding to one of the divisions of the rectus muscle. 2. The sound on percussion being usually more clear and tympanitic than it would be over a solid tumour. 3. When the patient is made to sit up in bed, the swelling contracts and becomes thicker. 4. When the patient is placed on his back, with his shoulders raised and his thighs flexed on the abdomen, and his attention is engaged by conversation or by making him count, the tumour may disappear ; and it will certainly do so if he be placed under the influence of chloroform. The diagnosis may also be considerably embarrassed by an inflammatory swelling in the abdominal parietes over the liver. This has often been mistaken for an abscess of the liver itself. Several remarkable instances of this sort have come under my notice, in which, for some days, the diagnosis has been very doubtful. ' The following characters usually suffice to distinguish this condition from hepatic disease :- — 1. The margin of inflammation and of dulness on percussion is ill-defined, and does not correspond to the boundary of an enlarged liver. 2. There is a greater amount of hardness and tightness of the superimposed integuments. 3. The constitutional symptoms are comparatively slight ; rigors and profuse sweatings rarely occur, and there are no indications of severe hepatic derangement. 4. The lower margin of the swelling does not ascend and descend with respiration, but this character may hold good in adherent hepatic abscess. Keeping in view these sources of fallacy, we proceed to consider the various causes of true enlargement of the liver. The following cases illustrate some of the ways in which enlargement of the liver may be simulated. Cases I. and II. 1 6 ENLARGEMENTS OF THE LIVER. lect. i. are examples of a circumscribed empyema pointing below the ribs and causing great depression of the liver. Case I. — Circumscribed Empyema of right side, displacing liver down- boards, and simulating hepatic disease. Paracentesis belotv ribs and introduction of a drainage-tube. Recovery. Charlotte T , aged 8, admitted into St. Thomas's Hospital May 22, 1872. Always delicate, but present illness had commeuced six weeks before with rigors followed by pyrexia, loss of appetite, and emaciation ; she had lain continnally on right side. Her con- dition on June 1 was as follow^s : Liver appears enormously enlarged, npper part of abdomen distinctly bulging, especially on right side, and lower margin of liver descending to umbilicus. Abdominal veins un- usually distinct and apparently much enlarged ; no ascites and abdo- minal walls move freely in respiration. On right side of chest, dul- ness on percussion from liver to upper edge of nipple ; above this clear percussion-sound and vesicular breathing, but below the nipple dis- tinct circumscribed bulging of ribs and of intei"costal spaces, with fluctuation between the ribs and also below them in right hypochon- drium. Posteriorly, the dulness, absence of breathing, and bulging of intercostal spaces extend over lower two-thirds of right chest. Upper margin of dulness distinctly arched and has not ascended since patient's admission, but lateral bulging has increased much. Respira- tions 50 ; much pain and distress on slightest movement. Pulse 150 ; apex of heart felt between 5th and 6th ribs, half-an-inch outside left nipple. Temperature since admission has ranged from 99 6° to 102"8° ; no rigors ; for last three nights has perspired profusely. After an exploratory puncture, a large trocar was introduced into the swelling beloio the right ribs in front, and 53 ounces of pus drawn off; the first that came was thin, but the last thick and opaque. Tlie opening was enlarged and a drainage-tube fastened in. The breath- ing was at once relieved, and it was observed during the operation that the lower margin of liver ascended at least two inches, but that no change took place in level of upper margin of dtdness in right chest. Next day child was much better. Pulse 114 ; respirations 30 ; tem- perature 97-8°. June 22. — Continued to improve for a week after operation, but for last 13 days temperature has varied from 98'4° to 103°, and pulse from 120 to 150, and for several days pus discharged by tube has been fetid, although cavity has been washed out daily with Condy's fluid. Sleeps Avell ; takes food -well ; and has had no rigors. Under chloroform a counter-opening was made at back between ninth and tenth ribs, and a perforated elastic drainage tube was passed through the two openings. About six ounces of very fetid pus came away during operation, and nearly a pint, also fetid, within next two days. LECT. I, CASES OF SIMULATED ENLARGEMENT. 1/ The cavity was now washed out daily with a solution of carbolic acid (t-Jht)- The qaantity of discharge gradually diminished, until by the middle of August there was only a slight oozing of yellowish serum. The tube might have been now removed, but daring my absence from town it was retained until Sept. 28 ; within a few days of its removal both openings healed. From a few days after counter-open- ing was made, patient steadily improved in general health, and when she was discharged on Nov. 1, she was plump and hearty, and for several weeks had been running about the ward. There was no dif- ference on measurement, and scarcely any on inspection, between the two sides of the chest ; if any, it was a slight excavation below right nipple. Hepatic dulness commenced at upper margin of sixth rib, 1-g- inch below nipple, and extended 3 inches downwards, but not below edge of ribs. Clear percussion on right side posteriorly, with vesicular breathing do>vn to normal level. Case II. — Circumscribed Empyema, pointing at Epigastrium and depressing Liver. Paracentesis in Epigastrium. Recovery. On Dec. 23, 1875, I was requested to see a butcher, aged 40, who was supposed to have some serious disease of liver — hydatid or cancer. On careful enquiiy, following history was elicited. For six or eight months he had complained of flatulent distension of stomach, but ex- cepting this he had been in good health and attending to business, until beginning of November, when, after a chill, he was seized with severe pain across loin's and general illness. After three days he sent for a doctor, who noted dulness over back of right lung and dry cough. Seven or eight days after this, during doctor's visit, he suddenly coughed up for first time a quantity of yellow matter ; the expectora- tion continued for about a week, when it suddenly ceased. About Dec. 14 a swelling appeared at epigastrium with considerable pain, and about same time dulness at back of right lung receded. At time of my visit, lower margin of liver was about one inch below umbilicus, its position not influenced by inspiration ; in epigas- trium was a circumscribed fluctuating bulging five inches in diameter, tender, but less so than it had been. Lower right costal cartilages everted. At base of right lung feeble breathing and some crackling sounds. Resp. 24. Pulse 100. Temp. 100°; no rigors or profuse perspirations. Appetite bad ; sleep disturbed. An exploratory punc- ture was made in epigastrium, and a tablespoonful of thick fetid pus escaped. Next day nearly two pints of pus were drawn ofi" through a larger opening, a piece of elastic tube was tied in, and through this the cavity was washed out, first with three fluid ounces of a solution of chloride of zinc (30 grains to ounce), and subsequently with a weak 1 8 ENLARGEMENTS OF THE LIVER. lect. i. solution of cai'bolic acid. Tube at first passed straight back into cavity to extent of 8 or 10 inches. After tapping, patient never had a bad symptom ; he ate and slept well, and on Jan. 7 discharge from opening was reduced to two di'achms daily. On Feb. 6 he came down stairs, ate and slept well ; on Feb. 17 there was only a little glairy discharge from wound, and tube was removed. In Case III. the liver appeared to be enlarged in con- sequence of displacement by a psoas abscess. Case III. — Caries of Spine. Psoas Abscess. Displaced Liver simvJating Enlargement. Sypliilitic Peri-hepatitis. Catherine F , 27, admitted into St. Thomas's Hospital, May 28, 1875, supposed to be suffering from enlargement of liver. Father, mother, and probably one brother had died of phthisis. Married 3 years ; no children and no miscarriages. Six months before admis- sion had ulcerated sore throat and swelling of glands in neck which were lanced. About same time began to have a dull pain in back. This would often come on when going about house, and would compel her to sit down for a few minutes. It continued until six weeks be- fore admission, when she was seized with severe pain in lower right chest, increased by inspiration, and accompanied by dyspnoea, cough, expectoration of phlegm mixed with blood, vomiting, constipation, and for first week rigors every night. After three weeks cough ceased, but pain persisted. Ten days before admission, first noticed swelling in right hypochondrium, which advanced towards umbilicus with in- creased pain. On admission, pale, thin, and anxious. Much pain in right side of abdomen, and swelling distinctly felt below right ribs extending down to umbilicus, Avhere it turns rather abruptly upwards to left side of ensiform cartilage. To right, it extends as far as free end of twelfth rib. Whole of this space tense and tender. Upper margin of hepatic dulness extends to upper border of fourth rib, making entire dulness in r. m. 1. 8^ in. Distinct bulging of right lower ribs, and obliteration of intercostal spaces in front. Posteriorly, what appears to bo hepatic dulness extenils fully two inches above normal level, but above this vesicular breathing without rale. In right lumbar region below last rib, a distinct elastic bulging apparently containing fluid. Marked tenderness on pressure over three or four of lower dorsal spines. Tongue dry, red, and glazed ; no appetite ; much thirst ; occasional vomiting ; bowels confined. Temp, varies from 90° to 103°; night-sweats : rigor last night. Pulse 132. Glands in right groin large and tender. Albumen (^) in urine. Treatment consisted in quinine, mineral acids, opium, and ape- rients. Continued to get worse. June 0, abscess pointing below. LECT. I. CASES OF SIMULATED ENLARGEMENT. I9 Poupart's ligament on right side ; pain in micturition ; temp, varies from 99-5° to 104-6°. June 22. No albuminuria. On June 29, 8^ oz. of thick yellow pus drawn off by aspirator from swelling in right lumbar region, and swelling in groin at once collapsed. The eflPect of this was to relieve pain and lower temperature ; but after a few days swelling in groin returned, with much pain ; and on July 5 severe pain and tenderness in splenic region and general distension of abdomen. On July 6 one pint of pus let out by incision from swelling in groin, and there was abundant subsequent discharge. Pain and fever greatly abated ; but patient became rapidly weaker ; vomiting be- came urgent, aphthae formed in mouth, and on July 22 she died. Autopsy. — Liver occupied whole of upper part of abdomen in front, but weighed only 58 oz. and was not at all enlarged, being displaced forwards by a large abscess in connection with caries of right trans- verse processes and adjoining parts of bodies of 10th, 11th, and 12th dorsal vertebree, and of proximal ends of last three right ribs. Ab- scess communicated below with opening in right groin, and above by a ragged ulcerated opening with a circumscribed cavity containing six ounces of pus in left pleura. Surface of liver marked by several deep (syphilitic) scars. Spleen 8 oz. Kidneys apparently healthy. In Case IV. a great enlargement of the liver was simulated by an aortic aneurism, which had ruptured and given rise to a large collection of blood pressing the liver downwards and forwards. The case was remarkable for several other reasons. The history and autopsy left little doubt as to what was the sequence of events :' 1. An aneurism formed at the lower part of the thoracic and upper part of the abdominal aorta, without causing any symptoms. 2. On January 1 this aneurism ruptured and caused syn- cope, and blood burrowing from, the mediastinum behind right pleura excited pleuropneumonia. 3. The pressure of the aneurism eroded the bodies of the vertebree, and accounted for the persistent dorsal pain. 4. In August the aneurismburst in a downward direction, and the blood pressing forward the liver and the peritoneum appeared at the epigastrium, excited chronic peritonitis, and interfered with the portal circulation. But during life the diagnosis was rendered difficult by the absence of the ordinary physical signs of aneurism. An empyema, an abscess of the liver, or an abscess in connection w'ith carious vertebrae, was excluded b}^ the absence of pyrexia ; and hydatid cyst was negatived by the rapidity of growth, coupled with the absence of pyrexia, which c 2 20 ENLARGEMENTS OF THE LIVER. lfxt. t. ■would have resulted from a hydatid that had taken on inflamma- tion. But peritonitis, extending over many weeks and leading to great accumulation of fluid in the peritoneum, is in most instances the result of cancer, and this was likewise indicated by the constant vomiting, the attacks of severe abdominal pain, the presence of a large tumour in the abdomen, and the emaciation ; while the separate collection of fluid in the epi- gastrium might have been explained by a portion of the peri- toneal fluid being encysted above the liver. The only sym- ptoms pointing to aneurism were the syncope which preceded the attack of pleuropneumonia and the persistent dorsal pain. Case IV. — Diffuse Aneiirism of ThoracAc and Abdominal Aorta, termi. nating in Chronic Peritonitis, with coinous liquid Effusion. James D , aged 42, coachman to a surgeon, admitted into Middlesex Hosp., Sept. 13, 1869, suffering from peritonitis. His father and mother had both been strong and healthy, and had both lived to over seventy : they had left a family of twelve children, of whom all were alive, and only one sister was delicate. Excepting the usual infantile diseases, patient had always enjoyed excellent health. He had formerly been engaged in the ice trade, and had then been accustomed to drink much beer and spirits, but for two years he had been a gentleman's coachman and had lived more temperately. On Jan. 1, 1869, while cleaning brougham, he suddenly felt very ill ; he was able to lie down upon some straw, but he then became quite un- conscious, and according to his master's (a surgeon) account he re- mained in a state of profound syncope for half an hour. Immediately after this he had an attack of right pleuropneumonia, by which he was laid up nine weeks ; but in beginning of March he was able to resume work, and for nearly five months he drove out every day. Still all this time he complained of a severe and constant aching pain in back and right shoulder ; his appetite was good, though not so good as before ; he had no pain in abdomen, and no sickness. At beginning of August, without any strain or unusual exertion, or in fact any obvious exciting cause, patient was suddenly taken with urgent vomiting and severe pain and distension of abdomen, with con- stipation ; these symptoms lasted about a fortnight, when they gra- dually passed off and he recovered his appetite. On Sept. 4 sickness i-eturned and was attended by pain in stomach, but less severe than on former occasion. Tlie patient, however, had severe pain in right shoulder and great thirst, and abdomen began to enlarge. After two or three days he felt better again, and for two days be was able to go out for a little, but on 10th he became worse, and since then he had suffered acute pain, and had vomited everything he swallowed. For LECT. I. CASES OP SIMULATED ENLARGEMENT. 21 nine days iiis bowels had been relaxed, and shortly before admission he had passed a considerable quantity of semi-coagulated blood from bowel, which his wife compared to clots passed after childbirth. Ho had never suffered from piles. The patient's ' state on admission ' was noted as follows : ' Very emaciated. Still suffers much from constant aching pain in back, but at present chief complaints are of pain and swelling of abdomen, and of inability to retain anything on stomach. Abdomen is considerably distended, tense, and tender ; it measures at umbilicus 32 inches, this enlargement beiiig due partly to fluid in peritoneum, but mainly to a tumour occupying centre and upper part of abdomen, and apparently connected with liver. Hepatic dulness in right mammary line 6^ inches ; in sternal line, it extends to 3 inches below umbilicus, and measures 10 inches. The lower 4 inches of this mass feel smooth and firm ; its edge is well defined and does not ascend and descend with respiration ; but above this, in epigastrium, there is distinct fluctuation with a circumscribed bulging over a space 6 or 6 inches in diameter. The fluid in this situation is evidently encysted and dis- tinct from that in peritoneum ; the thrill produced by tapping other parts of the abdomen is not propagated to it, and the bulging at epi- gastrium does not vary with position of patient. The abdominal walls scarcely move in respiration. Patient lies for the most part on right side, and says pain is always increased when he turns on left ; he is also liable to paroxysms of severe abdominal pain irrespectively of position. 1^0 enlargement of abdominal veins ; no obvious enlarge- ment of spleen ; no jaundice ; tongue moist and white ; says he vomits almost immediately after eating ; bowels open three times to-day. Pulse 108, regular and feeble ; apex of heart elevated, beating in nipple line ; no abnormal pulsation or bellows-murmur anywhere over chest or abdomen. Occasional cough ; respirations 36 ; perceptible respiratory movement almost entirely confined to left side of chest ; over whole of right lung there is marked dulness on percussion, with very feeble tubular breathing ; in front vocal resonance, and still more vocal thrill, are exaggerated ; posteriorly they are absent. Skin covered with a clammy sweat ; temperature 97'8° ; slight oedema of feet and ankles. Urine contains ^ (in volume) of albumen and much lithates.' Patient was ordered ice, lime-water and milk, with brandy, a grain of opium twice a day, and poultices to abdomen. Subcutaneous in- jections of morphia were afterwards substituted for the opium pills. Under this treatment diarrhoea was at once checked, and by Sept. 20 vomiting had also ceased, and patient's general appearance at first improved. The abdomen, however, slowly but steadily increased in size, and on Sept. 29 parietes were tense and glistening, and girth at umbilicus 33| inches. On Oct. 2 skin and conjunctivae were slightly yellow, and there was bile-pigment in urine. On Oct. 18 girth at 22 ENLARGEMENTS OP THE LIVER. lect. i. nmbilicns had increased to 35 inches, and patient complained mncli of paroxysmal pain and tightness in abdomen, and of increasing weak- ness. Pulse was usually about 96, and temperature about 97'5°. On Oct. 22 there Avas a great increase of abdominal pain, attended towards evening by vomiting. He gi*adually sank, and died on morning of 23rd. On j7os/-7»or^e7/i examination several quarts of turbid alkaline serum, having a specific gravity of 1020, and containing flakes of lymph and pus-corpuscles, in peritoneal cavity. Intestines and other iibdominal viscera, and peritoneal lining of abdominal wall, coated with a thin layer of recent lymph easily peeled ofi". Nowhere any sign of tubercle or cancer. Liver extended downwards beyond umbilicus ; its tissue was firm, but did not seem abnormal. Between liver and diaphragm was an enormous cyst, quite distinct from jDeritoneum, and containing fluid red blood. On opening chest, right lung was found to be everywhere firmly adherent, collapsed, dense, and carni- fied. Posteriorly, beneath thickened pleura, and extending as high as third rib, and outwards to angles of ribs, was another collection of fluid blood ; and on further examination this blood, and that above liver, were found to be contained in a common sac, formed by a large nneurism of lower jmrt of thoracic aorta originating immediately above diaphragm, and terminating below at origin of superior mesenteric artery. This aneui'ism consisted of a large rounded sac formed by a dilatation of entire aorta over two or three inches of its course. The arterial trunk entered this sac abruptly above, and passed ofi" from it as abruptly below. The coeliac axis was given ofi' from near lower end of sac. On right side the sac had given way, and blood was infiltrated between its coats for a short distance, but entire coats had also rup- tured behind peritoneum, and blood escaping had dissected its way in diff'erent directions. The main portion was that seen at epigastrium above the liver, but it had also burrowed upwards behind right pleura. ]t contained several pints of blood, and its walls were formed partly liy expanded coats of the vessel, lined with laminated fibrin at some l)laces nearly an inch thick, and partly by diaphragm, liver, vertebra3, libs, and pleura. The bodies of lower dorsal vertebrae were eroded iind rough, and right ribs, at their origin, were also bared. The en- tire liver was displaced forwards, so that its upper surface was op- posed to anterior abdominal wall ; in this way organ appeared to be enlarged, but its weight was only 54 ounces. Heart not enlarged, and valvos healthy ; extensive atheroma of aorta. Loft lung voluminous and healthy. Kight kidney compressed and altered in shape by aneurism, and its cortex at point of contact opaque and white. Mu- cous membrane of stomach was intensely injected, and studded with hasraorrliagic erosions. In Case V. it liad been supposed that the patient was I.RCT. I. CASES or SIMULATED ENLARGEMENT. 23 suffering- from a tumour of the liver, but more probably this was simulated by a collection of fluid between the liver and dia]ohragm. If the tumour originated in the liver, it could only have been an abscess or a hydatid. The former was ex- cluded by the absence of constitutional symptoms and the transparency of the tumour, to say nothing of the rarity of a large solitary abscess in a boy who had never left this country ; while hydatid was rendered improbable by the rapid growth, the absence of any trace of echinococci in the contents, and the fact that a cup-shaped indurated base could be felt after the sac was emptied. The anatomical relations negatived a renal cyst, and a chronic abscess of the abdominal parietes was excluded by the absence of pyrexia, by the effect upon the tumour of coughing, inspiration, pressure, and position, by the e version of the ribs and the displacement of the heart, and by the direc- tion which the probe took after the bursting of the sac. The diagnosis which seemed most in accordance with all the facts of the case was that there was a circumscribed inflammatory effusion between the liver and the diaphragm ; and it seemed possible that the ' ascites ' which followed the varicella might have been tubercular, and that the injury to the back rekindled a fresh but localised inflammatory process. In reference to this case, the following remarks of Wilks and Moxon are of interest: — 'We have seen several cases of large abscesses between the liver and diaphragm, or between the liver and stomach ; the liver-tissue being only compressed by, and not involved in, the abscesses, which lay quite outside of it. Some of these were traced to injuries, but for others no cause could be assigned.' * Case Y. — Circumscribed Peritoneal Effusion between Liver and Diaphragm, depressing Liver. John J , aged 10, was admitted into Middlesex Hosp. under my care, June 29, 1869. His father and mother were in good health ; a brother and a sister had died of scarlet fever, and he had two brothers and two sisbers alive and well. In infancy he had passed through measles and scarlet fever, and early in 1867 he had what was supposed to be an attack of varicella followed by temporary ascites. Since this last attack he had been rather weakly. About May 1868, he was struck on the back by a truck ; he did not seem to experience any uneasmess from this at the time, but in September he becarae ' Lect. on Path, Anat., 2nd ed., p. 446, 24 ENLARGEMENTS OF THE LIVER. ■weaker, and began to complain of pain in the region of the liver, in- creased hj taking a. deep breath, and Dr. Schulhof, who then saw him, found a slight bulging of the right lower ribs, and noticed that the boj always leant to the right side. At end of December he contracted a second mild attack of scarlatina, and about middle of February, when Dr. Schulhof saw him again, there Avas a fluctuating painless swelling about the size of a hen's egg below right ribs, which could be forced up under the ribs when the boy lay on his back. From this time the tumour gradually increased in size without causing any pain. On admission, there was found to be a globular tumour in right liypochondrium, commencing immediately below, and not overlapping, the right ribs, and extending to about 3 inches below level of um- bilicus (see fig. 9). It measured six inches over its convexity ver- Fig. 9. Shows tumour in right hypochondrium of Case V. tically, G^ inches transversely, and the circumference at its base was 14 inches. The cartilages of lower right ribs were slightly everted, and girth here was ^ inch more than on left side. The tumour was painless and distinctly fluctuating thi-oughout, and there was no in- duration at its base. It exhibited a slightly bluish translucent ap- pearance, and the light of the sun or of a candle was distinctly trans- mitted through it. When patient coughed, an impulse was conveyed to tumour, and when he lay on his back and plaster of Paris was applied over tumour, with the object of taking a cast, a portion of tumour seemed to disappear beneath ribs ; the tumour was always largest when he sal^ up. There was clear vesicular breathing at base of right lung, which descended to normal level both anteriorly and LECT. I. CASES OP SIMULATED ENLARGEMENT. 25 posteriorly. The lower edge of liver could not be felt tlirough tumour, which descended slightly on patient's taking a deep inspiration. There was tympanitic percussion noted between tumour and right kidney ; no tenderness or curvature of spine ; apex of heart beat be- tween 4th and 5th ribs, immediately below lelt nipple. The boy's general health was good ; he was rather thin and. pale, but had no pyrexia, and ate and drank well ; he had no sign of pulmonary, car- diac, or renal disease, and. no jaundice. On April 14 the tumour was punctured with a trocar, and 15 fluid ounces drawn off of thin pus, having a specific gravity of 1028 and separating on standing into two layers of about equal volume, the upper clear and straw-coloured, the lower opaque and yellow, and under microscope exhibiting pus-corpuscles and compound granular bodies, but no traces of echinococci or cholesterin. The chemical examination of the matter gave the following result : Total solids 9*7 per cent. Organic „ 8*64 „ Ash „ -86 Chloride of sodium .... '6 „ The rest of the ash consisted of sulphate of soda and phosphate of lime. The operation was followed by no constitutional disturbance, but in less than two days it was clear that the sac was again filling, and on April 29 the tumour was almost as large as before it had been emptied. On this day it was tapped a second time and 15 fluid ounces of fluid were drawn off, similar to that on first occasion, bnt with. less sediment, and baying a specific gravity of 1022. On May 7 a third tapping brought away 9 ounces of fluid more viscid than the former, and containing compound granular corpuscles adhering in flakes, but no distinct pus-corpuscles, and having a specific gravity of 1020. A fourth tapping brought away 7 ounces of fluid still more viscid, specific gravity 1019, and becoming perfectly solid on boiling. On each occasion after the tumour was emptied, a cup-shaped indura- tion could be felt all round its base. After the fourth opening the tumour increased again very slowly, and on May 24, while patient was lying upon it, it opened spontaneously at a spot below where it had been tapped, but where for some time the integuments had been thin and dark. This spontaneous opening continued to discharge a clear viscid fluid containing white flakes until the patient left the hospital on June 29. A probe could be passed through the opening inwards, downwards, and outwards beneath the abdominal wall to the extent of an inch-and-a-half, but upwards beneath the ribs and above the liver to fully 3 inches. During the boy's residence in hospital he had gained flesli and improved greatly in strength and appearance. On Oct. 5 he presented himself as an out-patient. His general health, was still good. He brought with him a large quantity of cal- 26 ENLAEGEMENTS OF THE LIVER. iect. i. careons flakes (not effervescing with nitric acid) which had come away from the opening shortly after he had left the hospital. The opening had not yet closed, but a probe could not' be passed in any direction farther than 2 or 3 lines. Shortly after this the opening permanently closed, and one day in 1873 the boy presented himself at St. Thomas's Hospital in good health and haying experienced no further trouble from the swelling. Case YI. — Apparent Enlargement of Liver due to Peritoneal Adhesions. Elizabeth H , aged 44, admitted into Middlesex Hosp., July 15, 18G8, suffering from cardiac dropsy and other indications of disease of mitral valve. There was moderate ascites, and apparently great en- largement of liver, which could be felt as a solid tumour filling upper part of abdomen, and extending down to an inch below umbilicus, hard, smooth, and very slightly tender. Hepatic dulness seemed to extend upwards to about its normal level in front, but the presence of fluid in pleurse made determination of this somewhat doubtful. A hard tumour could also be felt obscurely beloAv left ribs. The dropty and dysjDnoea gradually increased, and on Aug. 12 patient died. At autopsy liver was found to be slightly, if at all, enlarged ; but its upper surface was bound by firm adhesions to diaphragm and ab- dominal parietes to below umbilicus. Its capsule was much thickened and its structure was dense and fibrous ; it weighed Gl oz. The spleen was also large, weighing 9 oz., and its capsule much thickened. In tlie next case enlargement of the liver was simulated by a phantom tumour. Case VII. — Fhantom Tumour of Abdomen simulating Hydatid of Liver. On Feb. 17, 1869, Miss Hester D , aged 11, a healthy-looking child, was brought for my advice as to tapping what Avas believed to be a hydatid of the liver. Two years before, on recovering from a low fever, a tumour had first been noticed in the epigastrium, which con- tinued to increase for a year, and since then had been stationary. She had suffered from dyspeptic symptoms, but not from pain, and her general health had 1 een good. There was a prominent rounded swell- ing extending from lower end of sternum to below umbilicus, rather straight on either side apparently from contraction of recti muscles. It was for the most part dull on percussion ; surface smooth and elastic, bat not fluctuating ; no tenderness except at one spot over ensiform cartilage, where slightest pressure caused much pain. The degree of bulging varied somewhat, according as patient's attention was directed to it or not. On Feb. 20 child was put under influence of chloroform ; the LECT. I. CASES OP SIMULATED ENLARGEMENT. 2/ tumour disappeared, and no turaonr or enlargement of liver could be felt. When the effect of chloroform passed off, tumour returned ; but under use of iron and belladonna it gradually diminished, and several years afterwards she vs^as in excellent health. Case yill. illustrates the possibility of mistaking a large renal cyst ^ for a cystic tumour of the liver. The history of an injury was not incompatible with hj'datid of the liver, for in many cases of hydatid the patients date their origin from an injury, which has been the means of drawing attention to a tumour already existing. There was no history of hEematuria, of pus in the urine, or of other symptoms of urinary disturbance, such as can be elicited in the case of many renal cysts. Unfor- tunately the fluid drawn off during life was not examined for urea, but none was found in that which remained in the sac after death. Moreover, although Mr. Stanley has recorded two cases of renal cyst where the fluid contained urea,^ none has been found in several other cases which are on record.^ Lastly, although after death the ascending colon and coils of small intestine were found in front of the cyst, these could not be made out before paracentesis, when the cyst was tense. The operation was resorted to merely as a palliative, and contri- buted in no way to the fatal result ; the inflammation of the sac and the secondary deposits in the lungs had commenced previously. Case VIII. — Enormous Cystic Tumour communicating with Pelvis of Bight Kidneij, existing for eight years, and simulating Hydatid Tu- mour of Liver. Joseph , aged 16, was admitted into Middlesex Hosp. under my care Dec. 19, 1867. Eight years before he had been thrown with great force against a wall, injuring his back and right side. For a week after he vomited everything he swallowed, and altogether he was laid up for two months, but he never was observed to pass blood in his urine, or to have urinary symptoms of any sort. He then went to school for a month, when he was seized with severe pain in his back and right side, for which leeches were applied. ' Similar cases are recorded by Mr. Csesar Hawkins (Med. Chir. Trans., vol. xviii. p. 175); Mr. Stanley (ib., vol. xxvii. p. 1); Sir Henry Thompson (Path. Trans., vol. xiii. p. 12S); and Dr. H. Cooper Rose (Med. Chir. Trans,, vol. li. p. 167). 2 Med. Chir. Trans., 1844, vol. xxvii. p. 1. ^ There was none in Dr. Cooper Rose's case, or in others referred to by Mr. Spencer Wells in the discussion upon Dr. Rose's case at the Medico-Chirurgical Society on May 12, 1868. 28 ENLARGEMENTS OP THE LIVER. lkct. i. He was in bed for five months, and during this time he had freqnent vomiting and nine fits of convulsions, the movements being limited to left side of the body. Shortly after this his mother noticed that his right side had 'grown out,' and the swelling increasing she took him to the London Hospital, where he remained for four months, and where his general health underwent great improvement. His health continued good, and he was able to go about, but the swelling slowly increased, until about a week before admission, when, after getting thoroughly wet outside a cab, he was seized with severe pain in back, cough, and febrile symptoms. On admission, patient was anfemic and emaciated, and complained of cough and shortness of breath, and of great pain and tenderness in lower part of spine. Pulse 108 ; respirations 48 and thoracic ; bron- chitic rales over whole of both lungs, with dulness and friction over lower fourth of left. Tongue clean ; appetite bad; temperature 101"4°. l^o anasarca ; and urine contained no albumen. But the most re- markable feature about the boy was the enormous size of abdomen, which measured 33^ inches at umbilicus, the bulging being greatest in right flank. This enlargement was almost painless, and was evi- dently due to an encysted collection of thin fluid on right side, ex- tending from liver down into pelvis, and as far forwards as middle line, but clearly shut oS'from general cavity of peritoneum, as the rest of abdomen was tympanitic in whatever position patient lay. Hepatic dulness ascended to nipple in front, and to lower angle of scapula behind. After admission, tumour increased in size, and dyspncea became so urgent that, on Dec. 23, it was resolved to tap cyst, which was ac- cordingly done by Mr. Hulke, midway between ribs and crest of ilium, and 170 ounces of fluid drawn off. The fluid which first came away was clear, but of a brownish colour ; its specific gravity was 1010, and it contained much chlorides, and about one-sixth of albumen. The last two pints contained much pus, forming on standing a creainy de- posit, of about one-half of the entire bulk. No portion of the fluid contained either echinococci or booklets. At first the operation was followed by great relief to d3'spna3a, and at no time afterwards had patient either rigors, profuse perspirations, pain in tumour, or albumen in urine. The prostration, however, in- creased daily ; tongue became dry ; temperature varied from 100° to 103"2° ; much restlessness with sleeplessness and occasional delirium ; and the signs of pleurisy at base of left lung noted before operation extended. He gradually sank, and died Jan. 2, 18G8. Autnpsy. — No signs of recent peritonitis, but on right side of ab- domen, lying behind intestines, was a cyst, with thick fibrous walls, about size of an adult human head. It was firmly attached by fibrous adhesions to under surface of liver, to false ribs, and to abdominal wall. It extended downwards to brim of pelvis, and slightly beyond r.ECT. I. CASES OF SIMULATED ENLARGEMENT. 29 middle line to left. Right kidney was expanded over its outer and posterior aspect, and the renal tissue was attenuated and wasted. The sac contained 65 ounces of thin pus; its inner wall presented a fibrous puckered aspect, with no trace of hydatid structure, and it communi- cated by three openings, oblique and valvular, but large enough to admit a full-sized catheter, with pelvis of kidney.^ Right ureter was rather small, but pervious throughout ; it ran for some distance in wall of cyst immediately beneath its lining membrane, and then passed down to bladder, which was quite normal. Upper part of right kidney was converted into a cicatrix-like fibrous tissue, intimately in- corporated with cyst. Left kidney was double normal size, but other- wise normal. Liver fatty ; spleen very large and soft. Recent pleurisy over lower lobe of left lung, which contained a patch of red hepatisation ; and in lower lobe of right lung were several small patches of lobular pneumonia, with yellow centres, l^o pus in joints, and no sign of old fracture of ribs, or of disease of bodies of vertebrae. ' It is remarkable that notwithstanding these openings the urine, up to the day of death, never contained any pus or a trace of albumen. A similar observation was made in the case recorded by Mr. Csesar Hawkins and already referred to (p. 27). In that case also, although the cyst communicated with the pelvis of the right kidney, no urea could be found in the contained fluid, which is also said to have been devoid of albumen, although it contained pus. 30 ENLARGEMENTS OF THE LIVEPw LECTUEE II. ENLARGEMENTS OF THE LIVER. TETJE ENLARGEMENTS OF THE LIVER: STJBBIVISION INTO PAINLESS AND PAINFUL: 1. THE ■WAXY, LARDACEOXJS, OR AMYLOID LITER ; 2. THE FATTY LIVER ; 3. SIMPLE HYPERTROPHY. Bearing in mind the various circumstances under which I have told you that liypertrophy of the liver may be simulated during life, we are now prepared for considering those cases in which an increased area of hepatic dulness is due to real enlargement of the organ. And first of all it may be observed that enlarge- ment is a character common to many different diseases of the liver, so that some classification will be a material aid in dia- gnosis. The late Dr. Bright, whose researches on diseases of the abdomen are scarcely less valuable than those on diseases of the kidneys, with which his name will for ever be associated, divided enlargements of the liver into two classes, according as their form was smooth or irregular.^ But this subdivision is, in my opinion, open to the objection that in certain diseases (e.g. waxy liver) an enlargement which is usually regular and smooth may assume a lobular or nodulated character, whereas in others (e.g. cancer) an enlargement which is for the most part nodu- lated, may occasionally be perfectly smooth. A subdivision which appears to me to be, on the Avhole, preferable, is that into 'painless and painful enlargements. Painless enlargements are further characterised by an absence of jaundice and ascites, and by a chronic course ; but in painful enlargements jaundice and ascites are common symptoms and the progress is more rapid. Among painless enlargements we have the so-called amy- loid liver, the fatty liver, hydatid tumour of the liver, and simple hypertrophy. Among enlargements in which pain is a prominent symptom Abdominn,! Tumours. Syd. Soc. ed. p. 242. WAXT LIVEE. 31 we have congestion, catarrh of the bile-ducts, obstruction of the common duct and retention of bile, interstitial hepatitis, pysemic abscesses, tropical abscess, and cancer. There are other enlargements of the liver besides those now mentioned, such as tubercle, spindle-cell sarcoma, etc., the anatomical and clinical characters of which are less known. I purpose in a separate lecture to bring some of these rarer forms of enlargement under your notice, but in the first place we may consider in detail the distinguishing characters of the several forms of enlargement with which we are best acquainted. I. THE WAXT, LARDACEOUS, OR AMYLOID LIVER. The liver undergoes greater enlargement from the so-called waxy, or amyloid, deposit, than from any other disease, except- ing, perhaps, cancer. I have known the liver of an adult affected with this disease weigh upwards of 180, instead of 50 or 60 ounces ; and the liver, of which I show you here a por- tion, weighed one-seventh, instead of a twenty-fifth, of the entire body of the child from Avhich it was taken. Enlarge- ment of the liver due to waxy or amyloid deposit may be re- cognised during life by the following characters : — 1. The enlargement is often great, so that the liver fills up a large portion of the abdominal cavity. 2. It is uniform in every direction, so that the form of the organ is not essentially altered. The area of hepatic dulness on percussion is increased in the median, dorsal, and axillary lines, as well as in the right mammary. The increase is greater in front than behind, because in the former situation there is greater room for growth (figs. 10 and 11). It is increased in an upward as well as in a downward direction, although mainly in the latter, the lower margin often reaching the umbilicus, or even the right groin ; but nowhere is there any outgrowth from the normal contour. The abdomen is enlarged, and often there is a visible bulging below the right costal arch and in the epigastrium, but rarely, if ever, is there any bulging of the ribs themselves; for waxy enlargement of the liver moulds itself over adjacent organs, and has little tendency to cause displacement of the ribs by excentric pressure. 3. On palpation, the portion of liver which extends below the margin of the ribs is very dense, firm, and resisting. There is no elasticity, and still less any feeling of fluctuation. 32 ENLAKGEMENTS OF THE LIVER. 4. The outer surface is smootli, and the lower margin is somewhat more rounded than natural, regular, and free from indentation. In this respect, however, rare exceptions occur, an ignorance of which may lead to errors in diagnosis. Occa- sionally waxy deposit in the liver coexists with cirrhosis, or with what are known as syphilitic cicatrices, and then the surface of the organ may be nodulated, or even broken up into irregular Fig. 10 shows the increased area of hepatic and of splenic dulness in the case of Henry D : anterior view. Between the two is a space yielding the clear tympanitic sound of tlio stomach; and above the liver is the normal area of cardiac dulness. Compare this with fig. 3, wliich shows the normal boun- daries of the liver and .spleen. Fig. 11 shows the increased area of hepatic dulness in Henry D : view on right side, border is gradually the spine, with fig. 4. The upper arched, and falls towards Compare this lobes, separated by deep fissures, the existence of which may lead to the suspicion that the enlargement is due to cancer. In cases also of extreme enlargement there may be an exaggera- tion, so to speak, of the lobes into which the liver is naturally divided, deep fissures corresponding to the attachment of the ligaments. Some years ago I had an opportunity of observing a case of this sort under the care of Dr. Greenhow in the LECT. n. WAXY LIVER. 33 Middlesex Hospital, the particulars of whicli I shall relate to you presently. Cases have also been recorded by Professor Frerichs, of Berlin, in which a waxy liver has presented a more or less lobnlated form. 5. Waxy deposit in the liver has but little tendency to obstruct the portal circulation, and consequently ascites and enlargement of the subcutaneous veins of the abdominal wall are not common phenomena in its clinical history. When such indications of portal obstruction do occur, they are usually due to pressure exerted on the trunk of the portal vein by lymphatic glands in the fissure of the liver enlarged from waxy deposit. Occasionally, also, fluid is effused into the peritoneum as the result of general anaemia, concurrent disease of the kidneys, or secondary peritonitis. 6. Jaundice also is a rare symptom in waxy disease of the liver ; and when it occurs, it is due, for the most part, to the pressure on the bile-ducts of enlarged lymphatic glands, or to the co-existence of catarrh of the bile-ducts. 7. Pain and tenderness are never prominent symptoms. The liver can be manipulated with impunity and the patient complains only of a feeling of weight or tightness in the right hypochondrium, or of uneasiness from the pressure to which the stomach and intestines are subjected. But occasionally, and particularly where there is a syphilitic history, there is an attack of acute pain from intercurrent peri-hepatitis. In the patient now under your notice, with paralysis of the right fifth nerve from syphilitic disease,^ the liver and spleen, which are much enlarged from waxy deposit, were intensely tender for a time, owing to inflammation of their peritoneal covering ; and in another case which I met with some years ago (Case X.), the enlargement commenced in India with severe pain in the right side, for which numerous leeches were applied, but the en- larged liver subsequently exhibited its usual painless character. Prerichs also has recorded a case where waxy liver supervened on protracted ague, and where ' the first symptom was persis- tent cutting pains in the side.'^ Lastly, the presence of acute tenderness in waxy disease of the liver from the concurrence of peri-hepatitis was demonstrated in Case XI. by post-mortem examination. ' Case in St. Thomas's Hospital, November, 1875. 2 Diseases of the Liver, Syd. Soc. Transl. vol. ii. p. 200. D 34 ENLAEGEMENTS OF THE LIVER. lect. it. 8. The growth of tlie tumour is slow and imperceptible. It often extends over several years. 9. Constitutionally, the symptoms are chiefly those of anajmia. Thei'e is no pyrexia ; but the countenance is pale and sallow, the patient suffers from general debility, and the propor- tion of white corpuscles in the blood is somewhat increased. Other characters of no small moment in diagnosis are de- rived from the spleen, the kidneys, the stomach, or the intes- tines being the seat of a similar morbid deposit to that pro- ducing the hepatic enlargement. 10. The spleen in most cases is enlarged, and often greatly, as well as the liver. The enlargement, like that of the liver, is uniform, hard, smooth, and painless. 11. As a rule, waxy disease produces enlargement of the liver before there is any evidence of its existence in the kid- neys. Wetzlar found no albumen in the urine of any one of 18 patients suffering from syphilitic waxy enlargement of the liver.' When present, waxy disease of the kidneys has charac- ters of its own, the presence of which in any case of hepatic enlargement would alone make it very probable that this en- largement was due to waxy dejjosit. These characters are : — a. An increased quantity of urine. Not uncommonly the patient voids from three to five pints of urine in the twenty- four hours. This is the rule throughout the greater part of the course of the disease. Towards the termination only is the quantity diminished.^ h. The urine is of a pale lemon colour, of moderately low specific gravity (about 1014), free from any smokiness, and con- tains a considerable amount of albumen. In the early stage, however, there may be no albuminuria (Case XI.). c. Casts of the renal tubes are often absent. When present, the}' may be of an epithelial or hyaline character, usually the latter, and most of them, from their size, appear to have come from tubes not denuded of their epithelium. These hyaline casts, so far as my observation goes, never yield the so-called amyloid reaction with iodine and suliDhuric acid ; but in excep- tional cases this reaction may be observed in some of the cast- off renal cells. ' 'Glasgow Med. Journal.' May, 1869. ' To Dr. fJraiiiL'or Stewart, of Ediiilnirprli, wc are mainly indebted for pointing out the characters of the urine in waxy disease of the kidneys. My own obser\ation.s coincide with his in every essential point. tECT. n. "WAXY LIVER. 35 d. During the greater part of the disease, when the urine is increased in quantity, there is no material diminution in the excretion of urea, and consequently the tendency to ursemia is much less than in other forms of kidney disease. Even in the advanced stage ursemic symptoms are comparatively rare, and death is more often the result of an exhausting diarrhoea. • e. According to Warburton Begbie, the urine contains uroxanthin in greater or less quantity, and when treated with an acid or exposed to the air, there is developed in it an indigo- blue, or indigo-red.' The persistent secretion of a large quantity of urine con- taining much albumen by a person who has never had general anasarca will of itself warrant the presumption that he is suffering from waxy disease of the kidneys. In the contracted or gouty kidney there may also be no dropsy, and the quantity of urine may be increased ; but here the specific gravity is remarkably low (often not exceeding 1010 or 1005) and al- bumen is usually present as a mere trace, or may be entirely absent. 12. The implication of the stomach and intestines in the waxy disease induces a tendency to vomiting and to obstinate diarrhoea from slight causes. Occasionally this diarrhoea is accompanied by tenesmus, and the patient may be thought to labour under dysentery ; but post-mortem examination reveals no evidence of inflammation of the bowel. 13. The breath and skin in advanced cases often exhale a disagreeable odour, which is characteristic, and which Begbie has likened to that of musty indigo. 14. Here, as in many other maladies, the circumstances under which the disease usually makes its appearance are of considerable importance in diagnosis. There are certain con- ditions which pre-eminently favour the advent of waxy disease. Among them may be mentioned the following : — a. Long-standing purulent discharge, such as is particu- larly apt to happen in connection with diseased bones or joints, dysentery, tubercular cavities in the lungs, and after surgical operations when the wound does not readily heal. In several cases of syphilitic ozsena I have met with waxy disease of the liver and other organs (Case XII.). b. Constitutional syphilis. In a large number of cases of waxy disease the patients have been the subjects of constitu- » Eeynolds's Syst. of Med. iii. 966. D 2 36 ENLARGEMENTS OF THE LIVER. lect. ii. tional syphilis, which appears to act as a predisposing cause independently of its inducing disease of the bones or protracted discharges, and independently of any abuse of mercury to which waxy liver was attributed by Graves and G. Budd. c. Tubercle of the lungs and of other organs must be re- garded as a predisposing cause of waxy degeneration, although the enlargement of the liver common under such circumstances is oftener fatty than waxy. Of 52 cases of persons dying from tubercle, and whose autopsies I have recorded, the liver was fatty in 20, and waxy in 6, and in 3 of the 6 there was like- wise caries of the bones. Still, of the 52 cases, 14 had waxy disease of either the kidneys, the liver, or the spleen, or 1 in 3^. The proportion of tubercular males in whom waxy disease was found was more than double that of females. Thus, of 33 tubercular males, there was waxy disease in 11, or 1 in 3 ; whereas of 19 tubercular females, only 3, or 1 in 6^ had waxy disease. It should be added that waxy disease from all causes is much more common among males than among females. Of 68 cases collected by Frerichs, 53 were males. d. Many chronic diseases which impair the general nutri- tion seem to predispose to waxy degeneration, which has thus been met with as a sequel of protracted ague,^ cancer, &c. Treatment. — The following rules comprise those measures which experience has shown to be most useful in the treatment of waxy disease of the liver. In many cases, unfortunately, when the disease is already in an advanced stage, and when the kidneys and intestines are involved in the waxy degenera- tion, all treatment is of little avail, and the patient dies of exhaustion, wliich may be oftea ascribed to the copious drain of albumen in the urine or to the occun-ence of profuse diarrhoea (as in Case XIII.). But, on the other hand, in not a few cases the progress of the disease appears to be arrested by appro- priate treatment, and in some, as in Case X., there is reason for believing that the waxy deposit may be in great measure removed. In any case the danger is great in proportion to the extent to which the kidneys and intestines are involved. I. Prevention. — The prevention of diseases in general has not yet received from the practical physician the attention which it deserves. The more we study the causes of disease, the more apparent it is that we possess a power in this direc- tion which has hitherto been too much neglected. Bearing in ' See Lecture IV. LECT. II. WAXY LIVEE. 3/ mind the causes whicli we have found to lead to waxy en- largement of the liver, the means for its prevention will at once suggest themselves. First and foremost, it is always advisable to arrest as early as possible copious suppuration from any part of the body, and in particular from diseased bone, and, if necessary, to have recourse to surgical interference for this purpose. It ma}^ indeed be a question whether some of those operations, which what is called ' conservative surgery ' has of late years substituted for amputation, from entailing protracted suppuration, have not sacrificed the life of the patient to the endeavour to save his limb. The death of the patient is ascribed to a bad constitution, which may, however, possibly be the result of internal disease engendered by the operation. In cases where the disease of the liver comes on in the course of phthisis, our treatment must be directed to the primary disease, and every means should be employed to arrest the purulent discharge from the lungs, the diarrhoea, and the exhausting sweats^ Again, the symptoms of constitu- tional syphilis must always be met by appropriate treatment,, and measures must be taken to prevent the condition of general cachexia which is apt to supervene on such exhausting diseases as ague and dysentery. Lastly, it may be mentioned that in cases where there is a copious suppurative drain from the system, alkalies. have been proposed as a means of prevent- ing the waxy deposit. Chemistry is said to have shown that the waxy material is dealkalised fibrin ; and it is argued that as a large quantity of alkali passes off with the pus, the waxy deposit may be prevented by restoring this alkali to the system.^ II. When waxy disease is already present, we must combat it by such measures as the following : — 1. The diet ought to be of as nutritious a character as is compatible with the digestive powers of the individual. A moderate allowance of alcoholic stimulants is generally useful. Considering the ansemic condition of the liver, alcohol is less likely to be injurious than in most other enlargements of the organ. When the disease is not too far advanced, and when the means of the patient permit, removal to a mild and equable climate is generally advisable. 2. Alkalies. — From my own experience I am not in a posin tion to make any dogmatic statement as to the effects of alka- > Dr. Dickinson, Med.-Chir, Trans. Vol. L. p. 55. 38 ENLAEGEMENTS OF THE LIVEE. lect. ii. lies in waxy disease, but I am assured by Dr. Dickinson that not only in cases of purulent discharge from diseased bone has he found that the salts of potash compensate for the dis- charge and prevent waxy disease, but that he has also known patients with advanced waxy disease of the liver and albumi- nous urine get better under their use. The treatment is one which certainly deserves a trial, and you may prescribe a mixture containing the liquor potassse with the phosphate and citrate of potash and tartrate of iron. 3. Tonics. — Most patients suffering from waxy disease derive benefit from the use of tonics, and particularly from the various preparations of iron, such as the perchloride and the iodide. In more than one case I have known marked im- provement take place under the continued use of nitric acid, in combination with such vegetable bitters as gentian or quinine. The external use of nitro-muriatic acid in the way to be described to you in a future lecture (Lect. IV.) also de- serves a ti-ial. Cod-liver oil is of questionable utility ; Frerichs states that he has known cases where waxy liver was developed under its continuous use. 4. Iodine and its preparations are of undoubted utility in the treatment of waxy disease, and particularly when there is a clear syphilitic history. No preparation, I believe, is supe- rior in this respect to the tincture of iodine of the British Pharmacopoeia, which may be given in doses of 10 or 15 minims, diluted, three or four times a day. You will remem- ber the marked improvement, not only in the general symptoms, but in the size of the liver, which took place under its use in the case of H. D. (Case X.). In cases with a syphilitic history great benefit is also said to be derived from small doses of perchloride of mercury in conjunction with the baths and mineral waters of Aix-la-Chapelle.^ 5. Budd ^ has observed cases where a marked improvement with diminution in the size of the liver has occurred under the use of the salts of ammonia, such as the carbonate and the chloride. In one case where the chloride of ammonium was given in doses of from 5 to 10 grains three times a day, a great enlargement of the liver, which had existed for nine months, and was accompanied by emaciation, pallor, and irri- tative fever, and where mercury, iodine, taraxacum, and nitro- muriatic acid had been tried in turn without success, was ' Wetzliir, loc. cit. - Dis. of Liver, 3vd ed. p. 335. LECT. n. WAXY LIVEE. 39 entirely reduced. Warburton Begbie also has observed a great reduction in waxj enlargement of the liver effected bj chloride of ammonium, in doses of from 15 to 30 grains thrice daily. ^ 6. In all cases of waxy liver, you must be on the look-out for complications, and meet them when they arise. Those which you have chiefly to expect are diarrhoea, vomiting, albuminuria, dropsy, and uraemia. The diarrhoea must be met by mineral and vegetable astringents with opium, the pernitrate of iron, and counter-irritation to the abdomen. Even in cases where the kidneys are involved, opium is less to be dreaded than in other forms of kidney disease. But not unfrequently the diarrhoea resists all treatment and cuts off the patient. Persistent vomiting also is a serious complication, and is often unaffected by treatment; ice, bismuth, hydro- cyanic acid, and counter- irritation to the epigastrium are the most useful remedies. The albuminuria requires no special treatment apart from that of the diseased liver. Dropsy must be met by diaphoretics and diuretics, the liquor ammonise acetatis with warm baths, and the bitartrate or acetate of potash with digitalis. With these remedies it will be well to combine the salts of iron, such as the perchloride with the liquor ammon. acetat., or the acetate of iron with the acetate of potash. Drastic purgatives must always be given with caution in this form of dropsy, for fear of inducing uncon- trollable diarrhoea. Lastly, in those rare cases where ursemia occurs towards the close of the disease, the remedies indicated are diaphoretics, the vapour bath, diuretics, and, if necessary, a brisk purgative. In illustration of the remarks now made I show you in the first place a portion of the liver which I removed from the body of a patient who died in the Middlesex Hospital some years ago, and in whom the clinical history and post-mortem appearances were as follows : — Case IX. — Caries of Hip-joint — Waxy Liver, weighing nearly one- seventh of entire body — Waxy Spleen — Fatty Kidneys. H. L , aged 7, adm. into Middlesex Hosp. under care of Mr. Shaw, Nov. 30, 1858, having suffered from disease in left hip- joint for about nine months. He was emaciated and of scrofulous habit, head and joints being large in proportion to rest of body. Considerable pain in left hip, increased on movement, so that he walked with difficulty. Soon after admission, abscesses opened iu ' Eeynokls's System of Medicine, iii. 968. 40 ENLAEGEMENTS OP THE LIVER. lect. ii. neighbourLood of left hip, and sinuses continued to discharge until his death on Jan. 27, 1861. During life there was great tumidity of abdomen, obviously due to enlargement of liver, lower margin of -which extended to below umbilicus, and surface of which was dense, smooth, and painless. Splenic dulness also increased, and the boy passed urine containing much albumen, but he had no dropsy. He was also liable to intercurrent attacks of diarrhoea, and tongue was preternaturally clean, red, and glazed. Post-mortem examination. — Body extremely emaciated, joints being large in proportion to limbs. Total weight of body only 311b. 3oz., or 499 oz. avoird. ; length of body was 3^ ft. Abdomen remarkably tumid and hard, particularly in right hypochondrium. Much swelling about left hip-joint, with numerous sinuses passing into bone. Left thigh flexed forwards and immovable. Entire head of left femur absent, and end of bone carious; acetabulum likewise diseased, bone being exposed and carious, and at one part deficient, so that there was an opening into pelvic cavity. Head was rem ai'kably large, its circumference being 21-^ in. Brain weighed 55-| oz. ; its structure normal. Each of lateral ventricles contained three drachms of serum, and at base were two fluid ounces. Membranes normal. Heart and lungs normal. Liver enormously enlarged and very dense. Its weight was 09 oz. avoird., or nearly one-seventh of weight of whole body, the normal ratio for a child nine years of age being only about 1 to 25. It reached as far as umbilicus, and moulded itself over the different organs in its vicinity. Its tissue was very firm, so that the organ retained its form when laid with its convex surface on table. Its external surface perfectly smooth and free from all adhesions, but exhibited impres- sions of adjacent organs. Its cut surface was of a grayish-pink colour and translucent, and presented a network of opaque yellowish streaks composed of fibrous tissue, apparently corresponding to outline of enlarged lobules, and enclosing the firm translucent material in its meshes. Iodine and sulphuric acid developed the so-called amyloid reaction in a marked degree. On microscopic examination, the hepatic cells appeared to be coherent into flat scales, and could not be isolated. The nuclei were distinct, but outlines of cell-walls were scarcely appreciable at many places, the nuclei appearing interspersed through a translucent homogeneous mass : at some places even the nuclei could not be distinguished. Towards circumference of lobules the cells were more distinct, and at some places contained an unusual amount of oil. Spleen weighed II'] oz., and 2)rescnted a dense, glistening surface on section, which became deeply tinged when treated with iodine and sulphuric acid. Kidneys large, right weighing o oz., and left 5^ oz. They were not I.ECT. 11. WAXY LIVER. 4 1 at all dense, but, on the contrary, very flabby. Their capsules were non-adherent, and surfaces "were perfectly smooth and pale yellow, with a network of injected veins. Cortical substance hypertrophied, pale yellow, opaque, and soft. Renal epithelium throughout kidneys loaded with fine molecules and oil- globules, and at many places uriniferous tabes appeared blocked up with oil. Iodine and sulphuric acid produced a decided tinging of minute arteries and Malpighian bodies in cortex. Mesenteric and Peyerian glands slightly enlarged, and the applica- tion of iodine to mucous membrane of the bowel jaroduced numerous brownish-red puncta, corresponding to the villi. The co-existence of fatty kidneys with, waxy disease of the liver and spleen, in this case, is worthy of notice. It is to be observed, however, that even in the kidneys the minute vessels yielded the so-called amyloid reaction. Many of you have had an opportunity of examining the patient whose case I am now about to relate. Case X. — Constitutional Syphilis, folloived by Symptoms of Waxy Disease of Liver, Spleen, and Kidneys, H. D , aged 28, adm. Dec. 27, 18G6, into Middlesex Hosp. As a young man he appears to have enjoyed good health, and to have been temperate. But six years ago he contracted syphilis, followed by buboes, which were opened, and scars are still visible in groins. Wound soon healed up, discharging only for about two weeks. He does not remember having had sore-throat or pains in bones. In 1858 he joined a cavalry regiment in India. With the exception of one or two slight attacks of diarrhoea, his health still kept good until about Nov. 1864, when he was seized with pain in right hypochondvium, which confined him to bed for six weeks. The pain was increased on taking a long inspiration ; and he had leeches and blisters applied. At end of six weeks he returned to his duty ; but his liver enlarging and his strength failing, he was discharged from the service, and arrived in England in June 1865. Since his return to England he has been able to earn his living as a labourer ; but he has suffered each winter from cough, and expectoration occasionally slightly streaked with blood. Eight weeks before admission he lost his appetite and strength, and was sent as a case of ' fever ' to London Fever Hospital, where he took mer- cury and iodide of potassium, with the object of reducing size of liver. On leaving the Eever Hospital he came here. He does not remember having had any form of fever in India, and at no time of his life has he had dropsy in any part of his body. On admission, patient was thin and anaemic, and had a decided sallowness of countenance, without any jaundiced tint of conjunctivae. 42 ENLARGEMENTS OF THE LIVER. lect. ii. Over back were numerous small scars and cojoper-coloured discoloura- tions. But what was most remarkable Avas the enlargement of liver, upper margin of which rose as high as fourth intercostal space, while lower margin reached as low as lower edge of umbilicus (see fig. 10, p. 32). The organ appeared large in every direction, its dimensions being as follows : In median line, 8j in. ; in right mammary line, 9| in. ; in x'ight axillary, fi^iu.; in right dorsal, 5^ in. The upper margin of hepatic dulness was arched (fig. 11), that in axillaiy line being an inch lower than in right mammaiy ; in right dorsal line it rose to eighth intercostal space, and from this it gradually fell towards spine. No bulging of ribs, and portion of liver below margin of costal arch very firm and resisting, not at all tender, and perfectly smooth. The only appreciable inequality was a transverse furrow situated 3^ in. above umbilicus, and apparently due to pressure of some article of clothing. Lower margin of liver considerably depressed when patient took a long breath, so that surface of organ was probably not adherent, or only slightly so. Dimensions of spleen likewise increased (see fig. 10) ; it did not project beyond the margin of costal arch, but dimensions of dulness were — vertically, 5^ in., and transversely, 6^ in., instead of 2 in. vertically and 4 in. transversely, as in normal state. No evidence of ascites or of anasarca. Appetite bad ; tongue coated with a white fur, and for some weeks after admission a tendency to vomiting and diarrhoea, there being three or four relaxed motions daily. Patient did not complain of pain in abdomen, except of occa- sional transient attacks, which appeared to be due to flatulence. Chief complaint was of weakness in limbs. Blood and urine were carefully examined. Blood was found to contain a slight but decided increase in proportion of white corpuscles, while many of the red corpuscles were of irregular outline and had a tendency to tail. Quantity of urine voided daily was ascertained for several weeks, and was always considerably above healthy standard ; average quantity was from three to four pints, and occasionally there was more than four pints. Specific gravity varied from 1010 to 1015 ; urine always contained much albumen, but it was perfectly clear, of an amber colour, and without any palpable deposit. Microscopic ex- amination for casts for the most part yielded negative results ; on one occasion a few small hyaline casts were detected. For first five days after patient's admissitm there was slight febrile disturbance. Pulse ranged from 110 to 120 ; temperature rose to 102°*4 ; moist and dry bronchial rales could be heard over back of both lungs. Patient had also sleepless niglits, but without any rigors or per.spirations. After this pulse and temperature were normal, and patient slept well ; but a little coarse crepitus could generally be heard at bases of lungs. No evidence of heart disease. The treatment up to March 13, 1867, consisted in mineral acids, bitter tonics, and a generous diet. At first, sulphuric acid and small lECT. 11, TVAXT LIVER. 43 doses of laudanum were prescribed, with the object of checking diaiT-hoea. On Jan. 9, nitric acid was substituted for the sulphuric, and was given with small doses of laudanum in the compound infusion of gentian. On Feb. 8 opium was omitted, and a grain of quinine substituted for the compound infusion of gentian. The diarrhoea, which had quite ceased, at once returned, but was again held in check by the restoration of laudauum to the mixture on Feb. 13. Under this treatment patient steadily and greatly improved. He had a good appetite, and was much stronger. His weight on admission was only 7 st. 10^ lb. ; but on March 13 he had gained 16 lb. Ajjril 3, 1867. — On March 13 the nitric acid was discontinued, and 15 minims of compound tincture of iodine substituted. After this patient continued to improve. He has now gained 20 lb. since ad- mission. There has been no diarrhoea, and quantity of urine has diminished almost to natural standard. No material change, however, in size of liver. Ajjril 29. — Patient was discharged from hospital to-day, greatly improved in strength and appearance, No diarrhoea, and urine was of normal quantity, with only -^-^ albumen. Size of liver also greatly diminished, as will be obvious from following dimensions. In median line, 6 in. ; in right mammary line, 7j in. ; in right axillary, 6^ in. Vertical splenic dulness only 4ji]i. The circumstance of the enlargement of the liver, in this case, commencing in the tropics with acute pain, might have been thought to indicate abscess ; but opposed to abscess were, the duration of the enlargement, its uniform character, its great density, the absence of fluctuation, and the fact of the patient having been able to work as a labourer for more than twelve months prior to his admission into the Fever Hospital. On the other hand, the physical characters of the hepatic swelling, the enlargement of the spleen, the excretion of a large quantity of very albuminous urine without any history of dropsy, the tendency to diarrhoea, the condition of the blood, and the syphilitic history, all pointed to waxy disease as the cause of the enlargement. As regards the pain, also, it may be stated that Frerichs records a case of waxy disease of the liver, in which ' the first symptom was persistent cutting pains in the side, and soon his strength diminished to such an extent that he felt it necessary to give up his work. Almost at the same time he observed a swelling in the right hypo- chondrium and epigastrium.' The cause of the pain was no doubt an intercurrent attack of peri-hepatitis, as was observed after death in Case XI. 44 ENLAEGEMENTS OF THE LIVEK. lect. ii. Case XI. — Constitutional Syphilis, followed by Waxy Liver, Spleen, and Kidneys — No Albuminuria — I'tri-liepatitis. Thomas S , aged 23, a gardener, adm. into Middlesex Hosp. March 4, 1868. At beginning of 18GG he had conti'acted syphilis, and from Aug. 2 to Dec. 2, 1867, he had been a patient under my care, suffering from ulcerated throat, rupia, and periostitis of many of his bones, -svith attacks of pyrexia. Liver then was not enlarged. He came under my care the second time on account of urgent diarrhoea, Avhich had lasted about a fortnight. He Avas then greatly emaciated, and had periosteal SAvellings on frontal bone, both clavicles, both tibiae, bones of forearms, &c. Tongue dry and brownish ; no appetite ; much thirst; occasional vomiting; pi'ofnse watery diarrhoea; stools very offensive. Liver much enlarged, measuring 8 in. in right mammary line ; enlargement imiform ; surface smooth and hard, and for two days, but not before, intensely tender. No jaundice ; no ascites ; no obvious enlargement of spleen ; no albuminuria ; and no anasarca. The diarrhoea was checked by a mixture containing tannic acid and a few drops of laudanum, but from time to time it returned. The tongue became dry, red, and fissured; abscesses formed over the jaw and in the hip ; on the night of March 15 he had a severe attack of convulsions, from which he recovered, but on morning of the 31st he had a second tit, and remained unconscious until his death, eight honrs after. Urine throughout contained no albumen ; that passed on day before death was copious, and had sp. gr. of 1007. Autopsy. — Liver greatly enlarged, extending down to umbilicus ; its whole surface covered Avith a thin film of recent lymph, which could be easily scraped off; surface smooth, moulded over adjacent parts ; structure extremely dense, and presenting the typical characters and reaction of Avaxy disease ; Aveight, 131 oz. About one fluid ounce of amber-coloured gelatinous mucus in gall-bladder. Spleen, 12^ oz., firm and Avaxy, Avith appearance of sago-grains on section. Kidneys apj)arently healthy, but distinct ' amyloid ' reaction of Malpighian bodies. Mucous membrane of intestine from jejunum to end of ileum presented marked ' amyloid ' reaction of minute vessels in villi and elscAvhere. Cranial bones greatly thickened, and diploe filled Avith dense bony matter ; a soi't node over frontal bone, and corresponding bony surface rough and bare. Cerebral arteries had their coats thickened, but were not stained by iodine ; about one ounce of fluid in lateral ventricles. Base of right lung carnified from compression by liver. Case XII. — Disease of Nasal Bones — Ozo'na and Epistaxis — Great Enlargement of Liver — A Ibmninuria. Philip A , aged 41, labourer, adm. into Middlesex Hosp. Feb. 14, 1871. He stated that he had enjoyed good health until 16 LECT. n. WAXY LIVER. 45 rnontlis before, •when he began to have an offensive discharge, with frequent bleeding from nose, and a troublesome cough. The quantity of blood lost was often considerable, and it would form large coagula in left nostril, which he would pull out. He became thin and weak, and had to give up work, and for nine months he had been an inmate of another hospital. He had never suffered from night-sweats, diarrhoea, or dropsy, but for two years he had been in habit of getting up two or three times in night to void water. He denied ever having had syphilis. On admission, patient was thin, sallow, and anaemic, but there was no trace of jaundice or dropsy. He had a fetid discharge from nostrils, and left nostril was narrowed from projection into it of what appeared to be a portion of left nasal bone, quite bare and slightly loose. Over abdomen and legs were a good many small, copper- coloured, scaly spots. Abdomen large and prominent, girth at umbilicus being 31 in. ; the prominence entirely due to an uni- formly enlarged liver, the rounded lower margin of which could be felt two inches below umbilicus, and the hepatic dulness extending from nipple 10^ in. downwards. Surface of liver smooth, hard, and painless. Splenic dulness covered twice the normal area, but lower edge of spleen could not be felt projecting beyond ribs. Urine, while patient was in hospital, was examined almost daily ; its quantity was increased sometimes to 97 oz. ; its specific gravity varied from 1010 to 1015 ; and it usually contained albumen, sometimes as much as -^ in volume, but no tube-casts. Slight flattening, dulness, and prolonged expiration below right clavicle. Pulse 80-100 ; heart dis- placed upwards, but in other respects normal. Tongue red and rather devoid of epithelium ; appetite good ; bowels regular. White corpuscles of blood considerably increased. During patient's stay in hospital, temperature in evening frequently rose two or more degrees, and once it was as high as 102'5° ; he frequently complained of frontal headache and pains in limbs ; for several days he had a slight attack of diarrhoea ; and on April 11 he had a sudden and rather alarming attack of acute cedema of the glottis. The treatment consisted in mineral acids and the pemitrate of iron, "while nostrils were washed out daily with solutions of Condy's fluid, or sulphurous acid. When the frontal headache was most severe he took iodide of potassium, and the attacks of cedema of the glottis yielded speedily to leeches and hot poultices to throat, glycerine of tannin applied to rima glottidis, and pernitrate of iron internally. When patient left hospital, on May 24, he was considerably better. The liver was smaller, but hepatic dulness in right middle lobe still measured 9^ in. ; the albuminuria had for some time disappeared ; proportion of white corpuscles in blood had diminished ; evening temperature was normal, and discharge from nostrils was less. 46 ENLARGEMENTS OF THE LIVER. lect. ii. Case XIII. — Si/p^iilitic Necrosis of Lower Jaw — Alhvmimiria — Diar- rhoea — Pleurisy and Pericarditis — Waxy Liver and Kidneys. Jolm R , aged 38, adm. under my care into Middlesex Hosp. Dec. 17, 1867. Six or seven years before he had contracted syphilis, and four years before he had been con6ned to bed for three months with a painful affection in joints, which he believed to have been rheumatism, and ever since he had been liable to pains in bones and joints. Twelve months before he had been a patient in same hospital with albuminuria and slight cedema of legs, and at that time the alveolar process of right side of lower jaw had exfoliated. Ten weeks before admission, he had been seized with cough, dyspnoea, and pain in right side of chest. On admission, patient had an angemic, chlorotic countenance, with slight general anasarca. The urine contained a very large quantity of albumen — about one- half — but no tube-casts ; it was passed in con- siderable quantity, and had a specific gravity of 1015. Absolute dulness over whole of right lung, with all the signs of pleuritic eflfu- sion. Cardiac dulness also increased, but could not be isolated from that of right lung ; sounds of heart feeble, but no abnormal murmur could be detected. Pulse 9G. Tongue clean and red ; breath ex- tremely offensive ; no appetite, and frequent vomiting. Hepatic dulness extended downwards uniformly, about fwo inches below normal boundary ; above, it could not be well defined from dulness over right lung. The portion of liver projecting below right ribs was smooth and free from tenderness. Splenic dulness not increased. Patient suffered much from want of sleep. Treatment proved of no avail in relieving patient's condition. On Jan. 2, profuse diarrhoea, with watery, very offensive motions, came on. This continued until patient's death occurred, on Jan. 7, by exhaustion rather than by coma. On examining body, there Avas great thickening with firm adhesions of right pleura in front ; posteriorly, right lung was separated from chest-wall by about thirty ounces of turbid fluid. Right lung extremely dense from fibroid change. Pericardium con- tained about twelve ounces of turbid scrum, and surface of heart coated with a thick rough layer of rather firmly adherent lymph. Liver, spleen, and base of right lung all firmly adherent to diaphragm. Liver weighed 66 oz. ; it was extremely dense, and presented the naked eye appearances and chemical reaction of waxy deposit. Spleen of natural size and rather soft. Kidneys of about normal size ; their surfaces slightly granular ; cortices extremely dense and pale, and the straight vessels and Malpighian bodies exhibited in a characteristic manner the so-called ' amyloid reaction.' Mucous membrane of small intestine intensely injected, but exhibited no 'amyloid reaction.' In the following case which occurred some years ago in lECT. II. WAXY LIVEE. 47 the Middlesex Hospital, the diagnosis was rendered difficult by the irregular, nodulated lorm of the enlarged liver. The case was under the care of Dr. Greenhow, and is recorded in the ' Pathological Transactions,' vol. xvi. p. 147. Case XIV. — Waxy Liver, enlarged and nodulated, simulating Cancer. The patient was a baker, 33 years of age at time of bis death, on Oct. 12, 1864. ISTo cause could be assigned for the disease, but a scar of doubtful nature was noticed in right groin. He first came under observation about four months before his death, and althouo-h liver was then about as large as when he died, it had never been seat of pain or discomfort, and indeed patient was unaware of existence of any tumour in abdomen until it was discovered at the hospital. The tumour extended from right to left side, so as to occupy both hypo- ebondria. Absolute dulness on percussion from fourth right rib to an inch above level of umbilicus. The tumour was not in slio-htest degree tender, and its surface was perfectly smooth. A smooth globular prominence in epigastrium, however, simulated somewhat a deeply-seated hydatid tumour, while a nodulated border and ascites subsequently gave rise to suspicion of cancer. Still, the absence of pain or of usual phenomena of cancerous cachexia negatived suppo- sition of cancer ; while the density of epigastric tumour, the enlarge- ment of the spleen, and the condition of urine were in favour of waxy disease rather than of hydatid. A fortnight before patient was first seen, his feet had beo-un to swell, and the anasarca gradually extended up to thighs and scrotum. About two months before death fluid began to collect in peritoneum but dropsy never invaded arms or upper part of body. The urine was copious, about three pints, and contained much albumen, but rarely any casts. At no time was there jaundice. Towards the last patient became greatly emaciated, and he finally died exhausted. Liver weighed 1841 qz., and was in an advanced stage of albu- minous or waxy disease, yielding a most characteristic reaction with iodine. Spleen, kidneys, and lymphatic glands in portal fissure were also greatly enlarged, and had undergone a similar change. Both lobes of liver were equally enlarged, but they were prolonged upwards and backwards, so as to leave a fissure five inches in depth at posterior margin, corresponding to the attachment of suspensory ligament. Anterior border was much thickened, and was also indented by two deep fissures, corresponding to the notches of suspensory ligament and gall-bladder, which imparted to it a lobulated character. On upper surface, also, corresponding to epigastrium, there was a semi- globular elevation three inches in diameter. Under surface was marked by deep depressions, corresponding to right kidney and 48 ENLARGEMENTS OF THE LIVEE. lect. ii. spleen. Surface of liver generally smooth, but capsule mucli thickened, and superiorly adherent to diaphragm. Stomach, intestines, and heart normal. II. THE FATTT LIVER. The second form of painless enlarg-ement of the liver is that -which is due to the accumulation of oil, or ' the fatty liver.' This form of hepatic enlargement has the following- clinical characters : — 1. The enlargement may be considerable, but is rarely so great as that often attained by the waxy liver. It is not often that the anterior or lower border reaches down beyond the umbilicus, or even so far. Occasionally, however, the vertical hepatic dulness is increased out of proportion to the actual amount of enlargement, in consequence of the organ being so soft and flabby that it bends upon itself and sinks downwards, and thus the anterior margin is depressed and a larger portion of the organ is brought into apposition with the abdominal parietes. 2. As in waxy disease, the enlargement is tolerably uni- form in every direction and there are no circumscribed bulg- ings, so that the natural form of the liver is but little altered. There is no expansion or bulging of the lower ribs. 3. The enlarged liver is less resisting to pressure, and is doughy and of softer consistence than in the waxy disease. When the abdominal parietes are thin, the soft, doughy consistence of the enlargement may be readily appreciated; but when the parietes are thick it may be difficult to determine its phy- sical characters. 4. The outer surface is smooth, and the lower margin even and rounded, except where there is some more important disease such as cirrhosis, in conjunction with the fatty de- generation. 5. There is no ascites or enlargement of the superficial veins of the abdomen. A large accumulation of oil in the liver interferes with the circulation so far as to lead to an anaimic condition of the liver itself, but never to such an extent as to cause ascites. G. Even in extreme cases bile continues to be secreted, and its secretion is not arrested or impeded. Jaundice, therefore, is not a symptom of uncomplicated fatty liver. 7. The same remark applies to pain. Tatty enlargement FATTY LIVEE. 49 of the liver is painless from first to last. The organ can be freelj manipulated with impunity, although in extreme cases the patient may complain of a feeling of weight or distension in the abdomen, increased by turning on the left side. 8. From the absence of symptoms, few opportunities are afforded of watching the growth of fatty enlargement of the liver, but this is usually slow and imperceptible. 9. The constitutional symptoms of fatty liver are few and not characteristic, and those which have been noted are often due for the most part to co-existing fatty degeneration of other organs, and more especially of the heart. General de- bility, great ansemia, and want of tone in the nervous and vascular systems are amongst the most prominent symptoms. The patient suffers from languor, is easily tired, and bears depletion or the inroads of acute disease badly. The late Dr. Addison described a condition of the integuments which he believed to be pathognomonic of fatty degeneration of the liver. ' To the eye,' he says, ^ the skin presents a bloodless, almost semi-transparent, and waxy appearance. When this is associated with mere pallor it is not very unlike fine polished ivory, but when combined with a more sallow tinge, as is now and then the case, it more resembles a common wax model. To the touch, the general integuments, for the most part, feel smooth, loose, and often flabby ; whilst in some well-marked cases all its natural asperities would appear to be obliterated, and it becomes so exquisitely smooth and soft as to convey a sensation resembling that experienced on handling a piece of the softest satin.' ^ These appearances are chiefly met with in females, and although they are far from being invariably present, yet in most cases of fatty liver the countenance and general integuments are more or less pasty and anaemic, and sometimes the skin appears greasy from increased action of the sebaceous follicles. Patients with fatty liver also suffer often from dyspeptic symptoms, such as flatulence, hypochon- driasis, irregular action of the bowels — usually constipation, but occasionally profuse diarrhoea from slight causes. 10. Enlargement of the spleen is rarely present. The portal circulation is not obstructed to such an extent as to lead to enlargement iof this organ from stasis of blood ; and the spleen is not liable, as in waxy disease, to a deposit of the same material as that which causes the liver to enlarge. 1 Guy's Hospital Eeports, First Series, vol. i. 1836, p. 479, E 50 ENLAEGEMENTS OP THE LIVER. rECT. ir. There are, however, certain other organs which are apt to undergo fatty degeneration as well as the liver, and the disease in each of these organs has symptoms of its own, which, when present, will throw light on the nature of the hepatic en- largement. Thus— 11. When there is concurrent fatty degeneration of the heart, in addition to the signs already enumerated, there are often — a. A very feeble, or even inappreciable, cardiac impulse. 6. Very faint, or even inaudible, cardiac sounds, the first sound in particular being short and feeble. c. A very slow, or a quick, feeble, and irregular radial pulse. d. Attacks of vertigo, syncope, or pseudo-apoplexy. e. Dyspnoea or sternal pain on slight exertion, and a feeling of sinking at the epigastrium. •12. When there is concurrent fatty degeneration of the kidneys, in addition to the signs already enumerated, there will usually be — a. Urine below the normal standard in quantity, oftener turbid than clear, containing much albumen, and depositing numerous oil-casts. 6. A tendency to general anasarca. c. Extreme pallor and pastiness of countenance. 13. As in waxy disease of the liver, the diagnosis will often be materially aided by attending to the circumstances under which the enlargement occurs. Many different conditions of the system may give rise to fatty enlargement of the liver, but most of them may be referred to one of the following heads : — a. Large accumulations of fat beneath the skin throughout the body, in persons who for the most part are large feeders and lead indolent lives. It is in this condition that the heart is most likely to participate in the fatty change, and that you will expect to discover the symptoms of fatty heart already referred to. It is persons in this state who are most prone to die of rupture of the heart. In the ' Pathological Transac- tions ' you will find several cases recorded in which patients died of rupture of the heart, and where not only was the heart found in a state of fatty degeneration, but the liver was enor- mously enlarged from fatty deposit, and there was a large accumulation of fat throughout the body.' ' See particiiliii'ly case by Dr. Quain, vol. iii. p. 2G2 ; and case by Mr. Pollock, vol. XV. p. 84. XECT. 11. TATTY LIVEE. 51 h. Alcoholism. — Persons ■who drink immoderately of ardent spirits, particularly if tliey take little exercise, are very subject to fatty liver. Of thirteen persons who died of delirium tremens, Frerichs found the liver very fatty in six. Of two fatal cases of delirium tremens in which an autopsy was made by me in the Middlesex Hospital some years ago, there was considerable fatty enlargement of the liver in both : in one the organ weighed eighty-three ounces; in the other ninety-six ounces. It is under these circumstances that the kidneys often participate in the fatty degeneration ; the quantity of fat also which some of these patients accumulate, notwithstanding the small amount of solid food which they consume, is remarkable. When the practice is persisted in, the fatty liver is apt to be- come complicated with cirrhosis. c. Phthisis. — The great frequency of fatty enlargement of the liver in persons suffering from pulmonary consumption has been already referred to under the head of the waxy liver (p. 36). In consumptive females it is much more common than in males. In this disease, it is not a little remarkable that, while fat disappears rapidly from almost every tissue in the body, it should accumulate in such large quantities in the liver. d. Other wasting diseases besides phthisis — such, for in- stance, as cancer,^ simple ulcer of the stomach,^ and chronic dysentery^ — are likewise often attended by fatty enlargement of the liver. It appears, then, that fatty liver is met with under two opposite conditions : one, in which there is an increased supply of material capable of being converted into oil, and where fat often accumulates in all the tissues of the body ; the other, in which there is a rapid absorption of fat from all the tissues,, with consequent emaciation. Its mode of production in the former case is sufficiently obvious ; in the latter, the blood becomes loaded with oily matters derived from the jDatient's own tissues, and this oily matter is separated from the blood in its passage through the liver. The impaired absorption of oxygen in phthisis, interfering with the proper metamorphosis of the ^ See case of cancer of the larynx, by Mr. C. Heath, Pathological Transactions, vol. xiii. p. 28 ; and case of extensive cancerous ulceration of groin, by Dr. Budd, Diseases of Liver, p. 299. 2 Case by Mr. E. Eobiuson, Path. Trans, vol. iv. p. 133 ; and by Sir H. Thompson, id. vol. vi. p. 186. ^ Case by Dr. Bright, in Hospital Eeports, vol. i. p. 117. B 2 52 EKLAEGEMENTS OF THE LIVER. i.ect. it, oil, accounts for fatty liver being more common in pulmonary than in other -wasting diseases ; and the greater frequency of fatty liver in women may be accounted for by their having in general a larger quantity, than men, of fat to be absorbed. Treatment. — It is not often that fatty enlargement of the liver causes such a derangement of functions as in itself to call for treatment. As a rule, treatment must be directed against the conditions in -which the enlargement in question is known to occur. 1. When the disease is developed in persons who are large feeders and of indolent habits, the fat will usually disappear from the liver, as well as from the rest of the body, on the individual adopting an opposite mode of life. He must rise early and take active exercise in the open air, and live princi- pally on lean meat, fish, bread, and green vegetables, with light claret, hock, or plain water to drink, and avoid butter, fat, oil, fermented drinks, strong wines, and all substances rich in starch or sugar. Under such a regimen, the fat will not only disappear, but the nutrition of the muscles will be improved, and the patient's strength increased. In cases, however, where there is reason to suspect the existence of fatty degene- ration of the muscular tissue of the heart, the change of regi- men here recommended must not be too sudden, and its effects must be carefully watched, while caution must be exercised in withdrawing the accustomed allowance of alcoholic stimulant. 2. When fatty liver is the result of alcoholism, a simple withdrawal of the cause will usually be sufficient to effect a diminution in the size of the liver. o. Alkalies, alkaline carbonates, or compounds of the alkalies with the vegetable acids, in combination with some ve""etable bitter, such as taraxacum or gentian, have generally been found useful for correcting the digestive derangements resulting from fatty liver ; and if the bowels be constipated, recourse may also be had to occasional doses of the compound rhubarb, or colocynth pills of the Pharmacopeia, in combuia- tion with blue pill and extract of henbane, or to a dinner pill containing the watery extract of aloes and nux vomica. Eating large quantities of common salt with the food has sometimes appeared useful; and, when circumstances permit, it may be advisable to recommend a trial of the alkaline or saline mineral waters of Carlsbad, Marienbad, Kissingen, Ems, or Vichy. lECT. II. SIMPLE HTPEETEOPHT. 53 4. The preparations of iron are often of great service in cases where there is marked ansemia, and those which are best suited are the ferrnm redactum, the ferri et quinise citras, the ferri et ammonise citras, and the mistura ferri composita. Thej are often advantageously combined with alkalies. The chalybeate mineral waters of Tunbridge or Moffat, or of Spa, Pyrmont, or Schwalbach on the Continent, are useful for the same object. 5. Lastly, when the disease appears in the course of phthisis, it rarely calls for any special treatment, but its pre- sence is a contra-indication to the use of cod-liver oil, or other oleaginous remedies. In the following case, I had several opportunities of demon- strating to you in the wards the clinical characters of the fatty liver. The absence of albuminuria or of enlargement of the spleen made it improbable that the enlargement was due to waxy deposit. Case XV. — Acute FMMsis — Fatty Liver.. Charles C , aged 57, was adm. into Middlesex Hosp. under my care, June 11, 1867. He had enjoyed good health until about two months before, when he began to suffer from frequent cough, emacia- tion, and night-sweats, and subsequently from diarrhoea. On admis- sion he was very thin and prostrate ; frequent cough, with purulent expectoration ; marked dulness for several inches below right clavicle, and coarse moist rales audible over whole of both lungs. Bowels very relaxed. Liver much enlarged ; hepatic dulness in right mammary line measuring 7 in., and reaching fully 3 in. below margin of ribs. Enlargement was uniform ; its outer surface smooth, but much softer and less resisting than that of waxy liver, and it was devoid of all pain or tenderness. No jaundice, albuminuriaj or enlargement of spleen. The patient rapidly sank, and died on June 16. On examination of body, both lungs infiltrated throughout with yellow tubercle, breaking down at apices into small caYities. At right apex pulmonary tissue had entirely disappeared. I^umerous small ulcers, without tubercular deposit at edges or base in large intestine. Kidneys and spleen healthy. Liver much enlarged, weighed 78 ounces, smooth, pale yellow, opaque, a;nd extremely friable ; the secreting cells throughout loaded with oil. III. SIMPLE HTPEETEOPHT. By ' simple hypertrophy ' is understood an enlargement of the liver, due to an increased size of the lobules and an in- 54 ENLARGEMENTS OP THE LIVEK. i-ect. ii. creased size or number of secreting cells, without any altera- tion of structure. The enlargement of the liver is uniform and rarely great ; and, as might be expected, it is not attended by any prominent symptom. The condition is comparatively rare, and has still to be studied. It has chiefly been observed in: a. Leukaemia; and in h. Exceptional cases of saccharine diabetes.^ Hence, when the liver is found enlarged in either of these maladies without any obvious derangement of its functions, simple hypertrophy may be suspected. It has been suggested that the enlargement of the liver arising from protracted residence in hot climates may be of this na.ture ; but in most cases this is due to hypersemia or to waxy disease (see Lecture IV.). ' See Frericlis' Diseases of Liver, Syd. Soc. Transl. vol. ii. p. 210. According to Budd, the liver in diabetes is often unusually small, and the lobules shrunken, from the quantity of oil being below the normal ttiindard (Diseases of Liver, 3rd ed. p. 310). In many cases after death from diabetes the liver presents nothing abnonnal. 55 LECTUEE III. ENLARGEMENTS OF THE LIVER. IV. HYDATID TUMOUR. The fourth form of painless enlargement of tlie liver is that which is due to the presence of hydatid tumour. Although the disease is less common in this than in some other countries,^ I have frequently had opportunities of pointing out to you its clinical characters, which are mainly the following : — 1. The enlargement may be very great, so as to fill the greater part of the abdominal cavity, or reach upwards to near the clavicle, but in its earlier stages the hydatid may form a globular tumour at one part of the liver, not larger than an orange ; or from its situation and size it may altogether elude observation. 2. Unlike any of the enlargements already considered, it is not uniform in every direction, but usually it follows one direction in particular ; so that the natural form of the liver is greatly altered (figs. 12 and 13). If it grow upwards, the natural arched outline of the upper boundary of hepatic dulness will be exaggerated ; if it grow downwards, the lower boundary ' Out of 2,100 post-mortem examinations recorded at tlie Middlesex Hospital be- tween April 19, 1853, and August 25, 1863, hydatids were found in only 13, or once in 161 cases; and in only 7 of the 13 cases, or once in 300 cases, were they the cause of death. But in Iceland, Eschricht has calculated that about one-sixtli of the entire population are afflicted with hj'datids : and according to Hjaltelin, they are found in nearly one-fifth of all adult dead bodies. {Brit. Med, Journ. Aug. 14, 1869.) In Australian hospitals, hydatids are the cause of one in every 139 deaths. (Macgillivray, Aicstralian Med. Journ. March 1867.) On the other hand, hydatids are much rarer in Scotland than in England. Dr. Scott Orr has searched the records of the Glasgow Koyal Infirmary from the earliest periods, but has only found three cases, one in the mamma, and two in the liver, {Glasgow Med. Journ. Jan. 1876.) Dr. Grairdner also states that among many thousand dissections, which he had either performed or seen performed, during his connection with the Edinburgh Royal Infirmary, in only one instance had a hydatid been found in any part of the body, and that was in the upper part of the right lung. The patient came apparently from Newcastle. {Clinical Medichie, p. 431.) Can this immunity be due to the non-importation of foreign sheep into Scotland ? $6 ENLARGEMENTS OF THE LIVEE. i-ect. hi. of hepatic dulness will be found to be natural at some places, wliile at others there is an abrupt protuberance or tumour (see fig. 12). Not unfrequently it takes a lateral direction, and causes more or less bulirino- of the ribs ; and then the disease is apt to be mistaken for empyema, which is distinguished bj the characters already enumerated (see page 12). It is the right lobe of the liver from which the tumour commonly grows. 3. It is neither dense nor doughy, but elastic, or even fluctuating. If the hydatid be deeply seated, with much he- patic tissue sej)arating it from the outer surface, the tumour will be onl}'- elastic ; but if it approach near to the surface there will be distinct fluctuation, with a thrill as from fluid, on pal- pation. Occasionally there is the sign known as ' hydatid vibration.'' This is a peculiar trembling sensation, experienced when three fingers of the left hand are laid flat on the tumour, and the back of the left middle finger is struck abruptly with the point of the middle finger of the right hand. This sign is not due, as is commonly stated, to the secondary cysts in the interior striking the wall of the parent ; it may be detected in barren hydatids,^ and it is not peculiar to hydatid tumours. It is elicited when any large cyst, with thin tense walls and watery contents, is treated in the manner above described. But, inasmuch as the only tumours of the liver answering to these characters are hydatids, the sign referred to, when pre- sent, is of considerable value in the diagnosis of hydatids in the liver. Unfortunately, in a large ^jroportion — probably the majority — of cases of hydatid tumours of the liver, it is alto- gether wanting. 4. The surface of the tumour is smooth, and free from irregularities of every sort. In rare cases, when there are several distinct cysts projecting from the surface of the liver, this organ may appear through the abdominal parietes to have somewhat of a lobulated character, which may occasion con- siderable embarrassment in diagnosis. The possibility of this source of fallacy must be kept in view. 5. Ascites, oedema of the lower extremities, enlargement of the superficial veins of the abdomen, and haemorrhoids are not distinguishing characters of hydatid enlargement of the liver. Their occurrence in rare cases must be regarded as in some measure accidental, and duo to comijression by the tumour of the trmik of the portal vein, or of the inferior vena cava, or of the ' Sco also Troussciiu's Clin. Lect. Syd. Soc. Ed. iv. 27.5. XECT. III. HYDATID TUMOUR. 5/^ iliac veins. Care must be taken not to mistake for ascites an enormous hydatid tumour projecting* down from tlie liver and filling tlie fore-part of the abdominal cavity. Tliis is dis- tinguished by a history of growth from above downwards, and by the portions of the abdomen yielding tympanitic percussion not being the most elevated in any position of the patient. For instance, when the patient lies on his back, there may be dul- ness on percussion and unmistakable evidence of fluid in the most elevated part of the abdomen, while in both flanks the percussion is tympanitic (see Case XXXYIII.). When hydatid tumour of the liver co-exists with ascites, and no opportunity has been afforded of examining the patient prior to the ascites, the diagnosis will be extremely difficult, if not impossible. 6. Enlargement of the spleen is not a common consequence of hydatid enlargement of the liver, but may occur under condi- tions similar to those which occasion ascites. In very rare cases, the spleen may be enlarged from the presence of secon- dnYj hydatid tumours. 7. Jaundice is also an exceptional, and, so to speak, acci- dental symptom of hydatid enlargement of the liver. When present, it is due to pressure by the tumour on the common bile-duct, which is thereby narrowed or even obliterated, to catarrh of the bile-ducts, or to the bursting of the tumour into the ducts, which become obstructed by its contents. I show you here a specimen taken from the body of a gentleman under my care, in whom jaundice was due to the last of these causes (Case XXXIV.), and you have had opportunities of studying the symptoms in similar cases, which have proved fatal in the hospital (Cases XXXI to XXXIII.). 8. Enlargement of the liver from hydatid tumour rarely interferes with the functions of the kidneys, and hence we do not meet with those alterations in the urine so common in waxy, and of frequent occurrence in fatty, enlargements. In. rare cases, however, the kidneys also may be the seat of hyda- tids, or pyelitis may be induced by the pressure of a large hydatid tumour of the liver on the ureter. Under these circum- stances the urine may contain large quantities of pus, as hap- pened in a patient who was under my care in this hospital a. few years ago, and the particulars of whose case I shall narrate to you presently (Case XLII.). Occasionally the urine contains albumen, apparently from pressure on the renal vein, as it dis- appears after the cyst has been tapped. 58 ENLAKGEMENTS OF THE LIVEB.. lkct. iir. 9. The growth of a hydatid tumour is slow and impercep- tible, and, when the tumour is large, it has usually existed for years before the patient has recourse to medical advice. Dr. Eudd mentions the case of a lady who died at the age of 73, and in whose body two hydatid tumours of the liver were found, which there Avas reason to believe had existed since she was eight years old.^ 10. The latent character of hydatid enlargement of the liver is one of its chief characteristics. It often attains a great size without causing any pain or uneasiness, and often indeed without the patient being aware of its existence,^ and unless the sac be inflamed on its inner or outer surface, the tumour can usually be manipulated freely without causing tenderness. The first local indications of its presence are those resulting from pressure on adjoining parts, a feeling of weight or disten- sion, of dragging pains, or of embarrassment of the breathing. Then, and not till then, it may become the seat of occasional attacks of acute pain and tenderness, in consequence of inflam- mation of the superimposed peritoneum. But now and then, a comparatively small tumour causes pain, by projecting in a direction where there is little space for its growth, or by com- pressing some nerve (Case XXI,). 11. There may, in like manner, be an absence of all con- stitutional symptoms. Even when of large size, the tumour often does not interfere Avith the functions of the liver. There is no pyrexia or impairment of the general health, and the chief symptoms are those due to pressure on adjoining organs, and interference with their functions. Some years ago a patient came to me complaining of cough and shortness of breath, and fearing that she was consumptive. On examining the chest, I found an enormous hydatid tumour of the liver compressing the right lung, and causing great bulging outwards of the ribs, as well as a prominent tumour in the abdomen. The patient had suffered nothing except the cough and dys- pnoea, and was not aware of the existence of any tumour (Case XLII.). Instances also are not uncommon of patients who have died from acute inflammation excited by the bursting of a larg(; hydatid tumour of the liver, Avho, previous to the ' Disejises of Liver, Srd cd. p. 433. * Of 17 .specimens of liydatid of tlio liver in llio Berlin Patliologicnl Institute, 13 liad given rise to uo byniptonis. (/elkr, in Zieins.suu's Cyclop, of Med. vol. iii. p. 693.) LECT. 111. HYDATID TUMOUE. 59 attack of fatal inflammation, liave been tliouglit to be in perfect Jiealtli (Case XXXTX.). 12. The diseases most readily confounded with hydatid of the liver are abscess, distended gall-bladder, effusion into the right pleura, aneurism, cancer, cystic tumour of the kidney, phantom tumour, and ovarian cyst. a. The absence of symptoms, both constitutional and local, and the slow growth of hydatid tumour form a marked dis- tinction between it and abscess, which, so far as its physical characters are concerned, is the form of hepatic enlargement most closely resembling hydatid. There is one source of fal- lacy, however, which must be kept in view, although an accurate diagnosis under the circumstances would not materially modify the prognosis or the treatment. A hydatid tumour of the liver occasionally inflames and suppurates, and then it may present all the constitutional and local phenomena of abscess. The diagnosis of this condition must depend entirely on the patient's previous history — the fact of a painless tumour having long preceded the symptoms of abscess, the absence of exposure to the ordinary causes of tropical a,bscess, and the absence of any history of dysentery. h. A distended galL-bladder may closely resemble a pendu- lous hydatid of the liver, and may also be free from pain. It is recognised by its shape and position, by its development being usually preceded by attacks of biliary colic, and by the fact that in most cases there is jaundice, from obstruc- tion of the common duct. It must not be forgotten, how- ever, that when a hydatid opens into a bile duct, the contents of the cyst in their passage along the duct may give rise to all the phenomena of biliary colic, including jaundice. Sir Thomas Watson has recorded a remarkable instance of this sort,^ and several have come under my own notice, the j)articulars of which I shall presently relate to you. c. Extensive effusion into the right pleura, with bulging of the ribs and obliteration of the intercostal spaces, may closely simulate a large hydatid tumour ; but, on the whole, a hydatid of the liver is more likely to be regarded as an example of pleuritic effusion, than pleuritic effusion mistaken for hydatid. The hydatid is mainly distinguished by its insidious growth, and by the absence of constitutional symptoms. The chief physical distinction is derived from the upper boundary of the Lectures, otli edition, 1871,11., 632 j also Trousseau, op. cit. IV. pp. 23", 276. 6o ENLARGEMENTS OP THE LIVER. i.Kcr. iii. dull space. In pleuritic effusion this is horizontal (page 10) ; in hydatid tumour it is arched, the convexity of the arch varying in its position with that of the tumour in different cases, but always fixed in the same patient. The possibility, however, of a hydatid of the liver co- existing with pleuritic effusion must not be lost sight of (see Cases XXXIX., XL.) ; under such circumstances the diagnosis may be extremely difficult. Moreover, an encysted pleurisy may simulate hyda- tid hj producing a circumscribed bulging of the lower ribs, not- withstanding what Trousseau' says to the contrary (see ]). 16). d. An aneurism of the abdominal aorta, or of the hepatic artery, may present a smooth, globular tumour, very like that of a hydatid. Its main distinctive characters are pulsation, bellows-murmur, and the fact that it is usually the seat of acute neuralgic pains, owing to pressure on the branches of the solar, or of the hepatic, plexus. An aneurism of the hepatic artery is further distinguished by its being accompanied by jaundice from compression of the bile- ducts. e. Cancer of the liver is mainly distinguished by its irregu- lar surface, tenderness and hardness, and by the absence of elasticity or feeling of fluctuation. The diagnosis may be embarrassed by the circumstance that several hydatid tumours projecting from the surface of the liver may impart to it an uneven surfiice (Case XLV.), or that the nodules, or an exten- sive infiltration, of medullary cancer may exhibit a degree of elasticity approaching to fluctuation, or that in rare cases a large cyst may be developed in the liver in conjunction with cancer (Case XCVI.). Under such circumstances, the dia- gnosis of hydatid must mainly depend on its slower growth and on the absence of constitutional cachexia. /. Renal Cyst. I have already had occasion to refer to the difficulties in distinguishing between a large renal cyst and an enlarged liver (page 14). A renal cyst is distinguished from a hydatid of the liver by: — 1, its place of origin and direction of groAvth ; 2, the presence of colon in front of the cyst ; and 3, its position being little, if at all, influenced by deep inspiration. The characters of the fluid obtained by exploratory jiuncture will not assist you much in diagnosis. There will of course be no echinococci or fragments of hydatid cyst, but you may fail to find these in the fluid drawn off from a hydatid. On the other hand, the fluid may have a specific gravity of 1010, and may contain no urea, but abundance of chlorides with pus and > Op. cit. iv. 267. XECT. III. HYDATID TUMOUE. 6 1 albumen, characters wlaicli are quite compatible witli tlie fluid from an inflamed hydatid (Case VIII.). g. A circumscrihed Phantom Tumour in the epigastrium or right hypochondrium may be mistaken for a hydatid. Not long ago I saw a case in my private practice where this mistake was committed (Case YII.). It is distinguished by the absence of fluctuation or vibration, and by the circumstance that the tumour disappears when the patient is put fully under the influence of chloroform. h. Ovarian Cyst. There is rarely any difficulty in dis- tinguishing between a cjsi of the liver and an ovarian cyst. The main distinguishing characters of a hepatic cyst are :— 1. Its growth from above downwards ; 2, the hand can be passed between its lower margin ard the brim of the pelvis; 3, its lower margin is depressed by deep inspiration ; 4, the enlargement is usually greater above the level of the umbilicus than below ; 5, the examination of the fluid obtained by ex- ploratory puncture would at once remove all difficulty in the diagnosis. There may, however, be some difficulty when a hepatic cyst is seen for the first time after it has attained a large size ; and not long ago a case was recorded in one of the medical journals where the operation of ovariotomy was com- menced in what proved to be a cyst of the liver. ^ If there be any doubts as to the nature of the case, they may in most cases be removed by an exploratory puncture. The fluid which escapes from a hydatid, even if it contain no echinococci or shreds of striated hydatid membrane, will reveal its nature with absolute certainty. If the sac be not inflamed it is limpid, when running in a stream, with a slight opalescence when viewed in bulk ; it is alkaline, and has a s^^ecific gravity of 1009 (1007-1011) ; it contains neither albumen nor urea but throws down a copious white precipitate with nitrate of silver, owing to its strong impregnation with common salt. These characters apply to no other fluid in the body, whether healthy or morbid.^ Even if the case should turn out to be an ' Brit. Med. Journ., Dec. 5, 1874. lu this case, the slow progress, the absence of irregularities from the surface, and the decided fluctuation were, in my opinion no arguments against hydatid tumour, as Avas contended, - The contrast between the fluid in the hydatid cysts described in CaseXLIV. and the surrounding peritoneal fluid, in which they were floating, is worth}- of notice. According to Naunyn, hydatid fluid has a specific gravity of 1010 to 1013, and con- tains some albumen, hut tliis is contrary to my experience except when tlie sac is in- flamed, or blood has become mixed with it. 62 ENLARGEMENTS OF THE LIVEE. ikct. hi. aneurism or a cancer, no harm is likely to result from an exploratory puncture. Modes of Termination of Hydatid Tumours of the Liver. — It may be tliouglit tliat a tumour which causes so little incon- venience, that even when of large size the patient himself may be ignorant of its existence, requires little interference in the way of medical treatment. In reference to practice it is there- fore important to have a correct knowledge of the natural modes of termination of hydatid tumours of the liver. The chief of these are as follows : — ^Spontaneous Cure. — In the first place, there can be no doubt that some of these tumours undergo a spontaneous cure. The parasite may die from calcification of the parent cyst prevent- inn- further growth, from inflammatory action lighted up by the entrance of bile or by some other cause, or from the secon- dary vesicles increasing out of all proportion to the fluid in which they float (Case XLYII.) ; the parent cyst slowly shrivels up, and in place of the hydatid we find a putty-like material, the real nature of which is disclosed by its containing shreds of the striated hydatid membranes or booklets of echinococci. But, unfortunately, this favourable result is confined for the most part to tumours of so small a size that the}^ are not recoo-nised during life. Case XL VIII. is a remarkable excep- tion to the general rule in this matter. Watson also {op. cit. ii. 635) diagnosed a hydatid cyst in a young nobleman, who died 22 years afterwards, when a shrivelled hydatid was found in the liver. When the tumour is sufficiently large to give rise to symptoms and be diagnosed, such an event is so excep- tional that it cannot be calculated on. The tumour then continues to increase in size. Its growth may be slow ; it may extend over years ; but almost as surely as the tumour grows will it one day burst, or lead to an equally dangerous though less sudden result. Even a cyst which has undergone apparently a spontaneous cure, may, as Dr. Church has shown, light up fatal inflammation.^ The directions in which a hyda- tid tumour of the liver may burst are very various, and the danger will vary accordingly. 1. Into til c Pleural Cavity or Pulmonary Tissue. — This direc- tion is more common than any other. It is almost always the right lung and pleura that are invaded. When the contents of the hydatid are discharged through an opening in the dia- ' Treatment of Hydatid Tumours of Liver, 1868. See also Case XLI. XECT. in. HYDATID TUMOUE. 63 pliragm into the pleura, acute and almost invariably fatal pleurisy is the result.^ After death the pleural cavity is found full of pus containing numerous hydatid cysts (Case XXXIX.). Trousseau has recorded cases in which an empyema thus induced has subsequently burst into a bronchial tube. Fatal pleurisy may also result from a hydatid tumour of the liver, without any perforation of the diaphragm.^ If adhesions form between the diaphragm and the base of the right lung prior to the bursting of the hydatid, the contents of the latter may escape along with bile by the bronchial tubes, and the patient may recover f but even here, in most cases, fatal inflammation or gangrene is set up in the lung,.:* or the patient dies of suffocation from occlusion of the bronchi by hydatid cysts, or of exhaustion, owing to profuse discharge from one or several cavities excavated in the lung.^ From Case XLI., also, it will be seen that an obsolete hydatid cyst of the liver may inflame, and, after establishing a communica- tion with the bronchial tubes, may give rise to all the phenomena of gangrene of the lung. 2. Into the Pericardium. — This is, fortunately, a very rare direction, as the cases in which it has been noticed have been always fatal, either instantaneously by embarrassment of the heart's action, or within a few hours by acute pericarditis.^ 3. hito the Peritoneum. — The tumour collapses, and violent and almost always fatal peritonitis is at once excited. This accident must not be confounded with the attacks of partial peritonitis which are so common before the tumour bursts in other directions. The rupture of the sac is often caused by external violence, in the form of a blow, fall, or strain. In the museum of St. Mary's Hospital is the calcified cyst of a hydatid, taken from the body of a man who dropped down dead after 1 See Cases XXXIX. and XL. ; also Frerichs, Dis. of Liver (Syd. Soc. Ed.), ii. 235 ; Ogle, Path. Trans, xi. 299 ; Bristowe, Path. Trans, iii. 341 ; H. Davies, Path. Trans. i. 278 ; Davaino, Traite des Entozooaires, p. 437 : into left lung, P. W. Latham Lancet, Ang. 16, 1873. 2 See Murchison, Ed. Med. Journ. Dee. 1865, Case XL, and case hj Dr. Pollock, Path. Trans, v. 301. ' For examples, see Bright, Abdom. Tiim. (Syd. Soc. Ed.), p. 49 ; Todd, Med. Times and Gazette, Jan. 5, 1854 ; Path. Trans, iv. 44 ; v. 303 ; viii. 92 • ix. 28 • Davaine, op. cit. p. 449. '' See cases by Peacock, Path. Trans, ii. 72 ; Pollock, ib, xvi. 155. * Frerichs, op. cit. ii. 264 ; Peacock, Path. Trans, vol. xv. p. 247 ; Cayley, ib. xxvii. 171 ; Davaine, op. cit. p. 443. " Two cases of nipture into the pericardium will be found in Davaine's work (p. 408); a third is recorded 1 ly Wuuderlich (Med. Times and Gaz. Nov. ]2, 1859, p. 488). 64 ENLAEGEMENTS OF THE LIVER. lect. tit. receiving a slight blow on the epigastrium from a comrade with whom he was sparring. The blow ruptured the cyst; the contents of the cyst escaped into the peritoneum, and the man died from shock. Many years ago Andral reported a case of hydatid of the liver terminating fatally by rupturing spon- taneously into the peritoneum. ^ Three cases of fatal rupture in consequence of a fall are recorded by Mr. Csesar Hawkins.^ Three similar cases are mentioned by Frerichs ; in two the rupture was caused by a fall, and in the third it was due to a strain ; in one of the cases, death occurred within a quarter of an hour of the rupture. Eight additional cases have been collected by Davaine in which death ensued within a few hours or days of the rupture of a hydatid of the liver into the perito- neum ; in several of the cases the rupture was caused by a fall or strain, and in one it occurred while the patient was wrestling with a comrade.^ Eupture into the peritoneum was probably the cause of the fatal event in Case XLII. On the other hand. Bright records a case where what appeared to be a large hj-da- tid tumour of the liver burst into the abdomen, without being followed by a fatal result."* Ogle also mentions the case of a patient who recovered after the symptoms of peritonitis result- ing from the rupture of a hydatid cyst in the omentum.'* Lastly, Dr. Fagge and Mr. Durham have found that, when needles were introduced into a hydatid of the liver, the fluid contents of the cyst seemed to ooze through into the peritoneum without any bad result.*^ These different results are, perhaps, due to the presence or absence of scolices and secondary cysts in the fluid which escapes, the entrance of the simple hydatid fluid into a serous cavity being, as Malgaigne has contended, harmless.^ But, inasmuch as it is the exception for a hydatid to be barren, and there are no means of determining during life whether it be so or not, its rupture into the peritoneum must always be regarded with dread. 4. Througli the Abdominal Parietes or Lower Intercostal Spaces. — This is not a common mode of termination, although several cases are on record. The contents of the hydatid may be discharged by an opening at the umbilicus or in some other part of the abdominal parietes, or in one ofthe lower intercostal spaces, and the patient may get well. Even here, however, the ' Clin. Med., Malad. do rAbdonicn, xliv. ubs. * Med.-Chir. Trans, vol. xviii. p. 124. ^ ]);iv;ii)ie. op. cit. p. 493. * Abdom. Tumours, Syd. Soc. Ed. p. 47. " I'atli. Trans, xi. p. 295. « 3Ied.-Chir. Trans, vol. liv., 1871. ; Traite do Med. Opdrat. 6™-= cd. p. 521. LECT. III. HYDATID TUMOUR. 65 cyst is apt to take on suppuration, and the patient may die from exhaustion or from peritonitis, or from extensive suppu- ration and sloughing of the abdominal parietes ; or fatal liBemorrhage may occur from the interior of the sac, as in a case recorded by Dr. Bright. Of twelve cases where a spontaneous opening occurred, and of which I have collected notes, five at least terminated fatally, and in a sixth there remained, at the date of the report, a fistula discharging bile. Four also out of eleven cases observed by Finsen in Iceland were fatal. ^ 5. l7ito the Stomach or Intestine.- — This is the most favour- able direction in which the tumour can burst, although death sometimes results from the peritonitis which is set up around the opening, or from secondary abscesses of the liver,^ and unfortunately it is not a common mode of termination. The tumour becomes flattened or disappears ; and according as it opens into the stomach or the intestine, the hydatids are vomited or evacuated per anum-,^ sometimes they escape in both direc- tions. The opening is usually small, so that the hydatids are discharged slowly. Davaine has collected eleven cases where a hydatid tumour of the liver appeared to open into the stomach, of which six were fatal ; and fifteen cases where there was reason to believe that it had opened into the intestine, of which only one was fatal. In one of Davaine's cases the tumour opened through the abdominal parietes, as well as into the stomach. In a case of large hydatid tumour of the liver which occurred in the Middlesex Hospital in 1859, under the care of my friend Dr. A. P. Stewart, where the liquid contents were drawn off by a trocar, the tumour subsequently burst into the bowel, discharging numerous cysts -per anum, and the patient made a good recovery. In the ' Gazette des Hopitaux ' for 1850, a remarkable case is recorded where three hydatid cysts of the liver opened spontaneously, the first, in 183S, into the bronchi ; the second, in 1845, into the stomach ; and the third, in 1848, into the intestine : the patient recovered. Russell also has recorded the case of a man aged 36 who had two large ' Eudd, Dis. of Liver, 3rd. ed. p. 437; Frerichs, op. cit. ii. p. 237; Hawkins, Med.-Chir. Trans, xviii. pp. 153, 158 ; Bright, op. cit. p. 50 ; Griffiths, Lond. Med. Gaz. 1844, vol. xxxiv. p. 585 ; Davaine, op. cit. p. 384, Obs. V. ; Ogier Ward, Path. Trans, iii. 100 ; Kansom, Brit. Med. Journ. 1873, ii. 376. 2 See a case under Dr. Owen Rees, Med. Times and Gaz. June 20, 1857. ' For examples, see Frerichs, op. cit. ii. p. 237 ; Budd, op. cit. p. 452 ; Bright, op. cit. p. 49 ; Davaine, op. cit. p. 496. P 66 ENLAEGEMENTS OF THE LIVEE. I-ect. tit. hydatid tumours of the liver, one of which opened into the right pleura, and the other into the stomach and the bronchial tubes of the left lung-.' 6. Info the Urinary Passages. — Although hydatid tumours of the abdomen or pelvis occasionally open into the urinary passages, echinococci and shreds of hydatid membrane being found in the urine,- I have met with no case where this has happened when the primary cyst has been in the liver. In 1868 a case of this sort is said to have occurred in one of the London hospitals,^ but it is not clear that the cyst was in the liver, or that it was a hydatid. 7. Into the Biliary Passages. — It is not uncommon for a communication to be established between a hydatid tumour of the liver and one of the bile-ducts. In several cases where this has occurred, I have found the secondary cysts ruptured, empty, and more or less stained with bile. The entrance of bile, as was long ago stated by Cruveilhier, appears to be fatal to the life of the parasite, and in many cases probably consti- tutes the commencement of a spontaneous cure, while in other cases it lights up severe and even fatal inflammatory action in the cyst (Case XXXII,). Not only does bile enter the cyst, but occasionally the contents of the C3^st pass into the bile- ducts and gall-bladder, causing obstruction of these passages, Avith persistent and often fatal jaundice. In several instances the passage of secondary cysts along the bile-ducts has given rise to all the symptoms produced by passing a gall-stone. You have had opportunity of watching cases of this sort (Cases XXXI. to XXXIV.), and several others will be found in Davaine's work.'' In one of the cases which have been under your notice, the jaundice almost disappeared, although the stools remained colourless, in consequence of the bile draining away through the opening in the abdominal parietes (Case XXXII.). Mr. Hawkins has recorded a case where the common bile-duct was obstructed by hydatids, without jaundice, o\ving to the bile > Med. Times and Gaz. 1873. i. 439. 2 For several cases see Med. Times and Gaz. 1855, i. 169. » Brit. Med. Journ. Nov. 7, 1868. ♦ Op. cit. p. 462. In rave instances a hydatid tumour appears to be developed in tlie bile-duct, although the possibility of such an occurrence is denied by Davaine. Dr. Dickinson has recorded tlio case of a hydatid developed in the ri Med.-Chir. Trans. xTiii.p. 148. * Path. Trans, vii. p. 222, ■ s Clin, med., Paris, 1874, p 412. •' Path. Trans, xi. p. 128. ' Op. cit. ii. p. 231. ^^ ,. "E H Tl 6S ENLARGEMENTS OF THE LIVEE. tlect. hi. then vomited a hydatid as large as a pigeon's egg. This attack Avas followed by pulmonary symptoms, and in August he began to expectorate hydatids with large quantities of bile. The liydatids ceased to appear towards the end of November ; the bile in the second week of February, 1848. After this he recovered ; and twenty- three years afterwards he was alive and i]i good health, and in active practice as a medical man.' In a case referred to by Trousseau, the opening of the cyst into the bile-duct gave rise to biliary colic, which lasted for three -weeks ; upwards of three years afterwards there was a second attack of hepatic colic, followed by rupture of the cyst into the pleura and death. ^ Quite recently a very similar case has been observed by Di-. George Johnson,^ but the patient died of acute peritonitis. The only other case of recovery, under like circumstances, which I have met with, is one referred to by Davaine, where there was reason to believe that a hydatid of the liver had ruptured into the gall-bladder, and where the patient recovered after a severe attack of biliary colic and jaundice, accompanied by the passage per anum of both hyda- tid cysts and gall-stones.^ 8. Into the Portal Vein. — A hydatid of the liver occasionally opens into the portal vein or one of its branches. In a case where this had occurred, Leudet found numerous secondary abscesses in the liver.^ 9. Into the Vena Cava Inferior. — In exceptional cases, a hydatid of the liver bursts into the inferior vena cava, and its contents, reaching the right side of the heart, become impacted in the pulmonary artery and cause instant death. Three cases of this sort are mentioned by Frerichs.*^ But, independently of rupture, there are various ways in which a hydatid tumour may destroy life. 1. By Marasmus and Exhaustion. — This was the mode of death in Case XXXVIII., where a hydatid of the liver became so large that the entire abdomen was enormously distended by it, and respiration was seriously embarrassed. This case was further remarkable from the circumstance that there were dul- ness and fluctuation over the greater part of the front of the ' Lectures Sth ed. 1871, ii. 631. « Op. cit. iv. 285. " Med. TJmcHand G;iz., Jan. ], 1876, p. 2. * Op. eit. p. 477. • Op. cit. p. 16. • Op. cit. ii. p. 238. Two of these cases arc related at greater length bj Davaino (op. cit. p. 405). LECT. iir. HYDATID TUMOUR. 69 distended abdomen, while the epigastrium and both flanks were tympanitic on percussion. 2. By Pressure upon important Organs and Interference with their Functions. — A hydatid tumour of the liver may compress the vena cava so as to cause anasarca and varices of the lower extremities,^ or the portal vein, so as to induce ascites and necessitate recourse to j)aracentesis.^ By pressure upwards also it may rise as high as the second rib or the clavicle and greatly embarrass the respiration and the action of the heart ; and by pressure on the stomach and intes- tines it may interfere with the function of assimilation, and cause various dyspeptic symptoms, emaciation and cachexia. 3. By Suppuration or Gangrene of the Cyst, or Suppuration external to the Cyst, with or ivithout Pywmia and Secondary Purulent Deposits.— Cases XXXII. XXXIII. XXXV. and XXXVI. afford illustrations of these modes of termination, and many similar cases are on record.^ Bristowe has recorded a case where the secondary abscesses appeared due to obstruction of one of the ducts,'' and in many cases pus has been found in the vein in the neighbourhood of the suppurating hydatid. 4. By the Formation of Secondary Hydatid Tumours.^ — Secondary hydatid tumours may form in the liver or mesentery ; ^ by a process of exo^'enous growth, such as happens more fre- quently in the hydatids which infest some of the lower animals. Cases have been observed in the human liver in which a second- ary cyst budded from the outer surface of the parent hydatid ; ^ and, if they be large or numerous, they may interfere with the patient's nutrition, and cause death by exhaustion, by perito- nitis, or by uraemia from compression of the ureters, as in Case XLIII. Not uncommonly they form in the lung, and destroy life by inducing pneumonia. Cases XXVII. to XXIX. are examples of secondary hydatids of the peritoneum and ' A case of this sort is recorded by Dr. Habershon, in Guy's Hospital Eeports, 3rd ser. vol. vi. p. 182. 2 See cases by Dr. Barker, Path. Trans, vol. vii. p. 225, and by Dr. Budd, Dis. of Liver, p. 451, and Hawkins in Med.-Chir. Trans, xviii. p. 149. 3 For examples, see Bright, op. cit. p. 37 ; Budd, op. cit. p. 444 ; and Frerichs, op. cit. ii. p. 245. * Path. Trans, vol. ix. p. 290. * See cases recorded by Bright, op. cit. pp. 13, 23, and 30 ; Jones, Path. Trans, v. 298 ; Peacock, ib. 247 xv. ; Gibb, ib. xvi. 157. ^ This statement, which appeared in the first edition of these lectures, has been denied, but I have the authority of Dr. Cobbold for its correctness. ' Lect. on Path. Anat., Wilks and Moxon, 2d. ed. p. 460. 70 ENLARGEMENTS OF THE LIVEE. lect. hi. mesentery ; Case XXIX. was remarkable for the successful removal of the secondary cysts by Mr. Spencer Wells. Case XXIV. is an instance of a secondary hydatid tumour compress- ing the spinal cord, and causing- paraplegia.' Dr. Barker relates the particulars of a case where death was due to the formation of a secondary hydatid in the brain.^ An interesting case is recorded b}^ Dr. Wilks, of a girl, aged nineteen, who died suddenly, having previously been in good health ; a hyda- tid was found in the liver, and another at the apex of the left ventricle of the heart; the latter had burst, and discharged a loose hydatid into the cavity of the left ventricle.^ The treatment of hydatid tumours of the liver may be con- sidered under the following heads. 1. Their prophylaxis is based on a knowledge of their cause. Hydatid tumours in man are develoj^ed from the eggs of a tape- worm which enter the body from Avithout. This tape-worm, the Twnia echinococciis, the entire length of which does not exceed a quarter of an inch, inhabits the intestine of the dog and wolf, and is in no way connected with the jDig, as is com- monly believed to be the case. It has only four joints, and the ova are contained in the last, or proglottis, are voided with the faeces of the dog, and subsequently find their way into the human body with the food or drink. Arrived in the intestines, they are developed into embryos, which penetrate into the liver or other parts, in a way not yet satisfactorily explained, and are there developed into hydatid tumours. But the ova of the Twnia echinococcus develope hydatids in other animals than man, and especially in the sheep. The hydatids of human beings, as Dr. Thudichum'' observes, most frequently accompany them to their graves, or, at all events, the}^ are not permitted to continue their dangerous existence, but the echinococci of sheep are again set free in the process ' Another case of a hydatid of the spinal column pressing on tlie cord is recorded by Dr. Ogle, Path. Tiaus. p. xi. 299. ■^ I'atli. Trans, x. p. 6. » Patli. Trans, xi. p. 71. See also Path. Trans, xv. p. 247. Cases of hydatid tumours of the heart, without any implication of the liver, are recorded by Haberslion (Path. Trans, vi. p. 108), I3udd (Putli. Trans, x. p. 80), Peacock (Path. Trans, xxiv. p. 37), and DaTaine, op. cit. p. ."^M. In Uudd's case a hydatid tumour at the apex of the heart had burst, and loose liydatids were found in the right ventricle and iu the pulmonary artery. * Report on Parasitic Diseases in Quadrupeds used as Food, in Seventh Report of Med, Off. of Privy Council, Loudon, 1865. XECT. III. HYDATID TUMOUK. J \ of slauglitering', and are devoured b}' dogs, to be again deve- loped into tape-worms. While, then, man does not contribute to the multiplication and propagation of echinococci, his con- stant liability to the disease is kept up by the cycle of infection which subsists between dogs and sheep. It follows, therefore, that for the prophylaxis of hydatid tumours in man it is necessary : — a. To prevent dogs feeding on the offal of sheep and of other animals infested with hydatids. Dogs ought to be rigidly excluded from all slaughter-houses or knackeries, and *■ dogs' meat ' ought always to be thoroughly boiled. h. To destroy, as far as possible, the tape-worms gene- rated in the dog, for which purpose it would be well that all dogs were periodically physicked, and their excreta buried in the ground or burnt. These are measures which are of national importance in such countries as Iceland, where the sheep-dog, during the long nights of winter, occupies the crowded dwelling of his master, and where hydatids are said to be the cause of one- seventh of the human mortality, and which merit attention even in our own country. 2. Medicines. — It must be confessed that little or no reliance can be placed on any medicinal agent for effecting a change in the size or in the structure of a hydatid tumour. Among the many remedies that have been proposed, common salt and iodide of potassium are the two which have been most relied on for destroying the life of a hydatid, but there is no evidence that either the one or the other is endowed with such a pro- perty. It is difficult to conceive how chloride of sodium can be unfavourable to the growth of a hydatid, when it is remem- bered how large a quantity of this salt is contained in the fluid contents of the cyst, and that, therefore, it must be compatible with, if not necessary to, the healthy existence of the parasite. And with regard to the preparations of iodine, there is not only no proof of their power to destroy the life of the parasite,^ but ' The following are references to instances in which iodide of potassium was thought to have effected the cure of a hydatid cyst : — Med. Times and G-az. April 7, 1860. p. 34i, and Oct. 19, 1872, p. 437 ; Lancet, Oct. 16, 1868; Brit. Med. Journ. 1871, i. 499. In one, at least, of the cases, the disappearance of the tumour appeared to be due to its having burst. The others may be viewed in connection with a case related by Dr. P. McGillivray, where a hydatid tumour, which it was intended to tap, disappeared spontaneously, a few days after the patient's admission into hospital (Austral. Med. Journ. Aug. 1865). As Dr. M. remarks : ' K the patient had been 72 ENLARGEMENTS OF THE LIVER. XECT. in. there is positive evidence that tlie iodine does not reach it. Frerichs was unable to discover a trace of iodine in the fluid of a hydatid cyst, removed from a woman wlio had taken iodide of potassium for many weeks, and similar observations were made in Cases XVI. XVII. XVIII. XIX. Kamala, which was ad- vocated some years ago by Dr. Hjaltelin of Iceland,- has been tried in Australia by Dr. Mac-Gillivray, and found to have ' no influence Avhatever on the disease.' '-^ After the life of the para- site has been destroyed by opei'ation, it is quite possible that such remedies as the iodide and bromide of potassium may be of use. 3. Evacuation of the Fluid Contents of the Cyst hi/ a fine Trocar and Cannula, and Closure of the Opening. — Although medicines are of little or no avail, there is, happily, one expe- dient which holds out a fair chance of effecting a permanent cure, and that is puncture of the cyst and removal of its liquid contents. It is now many years (1822) since hydatid tumours of the liver were tapjied by Sir Benjamin Brodie, and the patients made a good recovery. •'^ Successful cases were after- wards published by Dr. Bright,'' and by many other observers. It is only of late years, however, that the operation has been often resoi-ted to, and even still it is ver\^ doubtful if most prac- titioners would not prefer leaving the patient to thf very un- certain chances of a spontaneous cure, or would limit the opera- tion to cases where the tumor.r is of a, size rarely attained. The fears expressed are not unnatural, for in not a few cases the opera- tion has been followed by dangerous symptoms or even death. The dangers of the operation are mainly two; viz. 1. Acute peritonitis, owing to the escape of a portion of the hydatid contents into the peritoneal sac ; and, 2. Suppuration of the cavity, owing to the admission of air, and to the collapse of the parasite entailing an exudation of inflammatory products from the vessels in the outer cyst. These dangers have mainly arisen in cases where an open- ing has been made with a scalpel or a large trocar, on the mistaken supposition that it w^as necessary to remove the getting iodifle of potassium, common salt, or any other rpputod specifip, the medicine would, no doul.t, have pot the credit of the euro.' Certain it is that in hundreds of cases, iodide of potassium lias lieeii taken in large quantities, without producing tlie slightest change in the tumour. ' Kdinh M<'d. Journ., Aug. 1867. "^ Australian Med. Journ. July, 1872. " Med.-Chir. Trans, vol. xviii. p. lit). * Op. cit. p. 42. IKCT. III. HYDATID TUMOUR. 73 secondary cysts as well as tlie liquid, or because tlie tumour was believed to be an abscess. But the dangers in question may be in a great measure avoided by employing a very fine trocar; and, in the case of a large cyst, by removing only a portion of the liquid. From Avhat I have already stated (p. 64), it is obvious that the danger from the escape of the hydatid liquid, without scolices or se- condary cysts, into the peritoneum has been exaggerated. Ex- perience also has shown tha.t the removal of a portion of the liquid contents (say one-half or two-thirds) is all that is neces- sary to kill both the parent hydatid and its offspring, and accordingly this is all that is necessary to be done. When a laT-ge hydatid is completely emptied, there is a corresponding outpouring from the vessels of the portion of liver forming the outer wall, and a greater risk of subsequent inflammation. The administration of chloroform before the operation is not advisable, as the pain is but momentary, and the vomiting sometimes induced by the chloroform interferes with that perfect rest of the parts which ought always to be insisted on for forty-eight hours after the puncture ; but if the patient be young or nervous, it may be well to induce local anaesthesia by the ether-spray. The point selected for puncture ought to be that where the hydatid .fluid appears to approach nearest to the sur- face. The injection, after removal of the fluid, of such substances as alcohol, iodine, oil of male fern, or bile, is unnecessary, and may be injurious, by exciting excessive inflammatory action. Care ought to be taken to prevent the entrance of air, and for this purpose it is well, even in the case of a small cyst, to remove the cannula before the whole of the fluid has been drawn off, or as soon as the fluid ceases to flow in a full stream, first passing a wire through the cannula to ascertain whether the stoppage be due to the closure of its orifice by a hydatid vesicle. Dr. G. Budd^ recommended that the fluid be drawn off by means of an exhausting syringe, adapted to the cannula, and more recently Dieulafoy's aspirator has been employed for the same purpose; but on several occasions (Case XVI.) when I have seen Dr. Budd's apparatus or the aspirator employed, the patient experienced so much pain from the suction action of the syringe, or blood has come away with the liquid, that I have preferred the simpler method above mentioned. After removal of the cannula, the opening should be covered with a 1 Med. Times and Gaz. May 19, 1860, p. 494. 74 ENLAKGEMENTS OF THE LIVER. lect. in. piece of lint steeped in collodion, over which a compress and bandage are apjjlied, and for forty-eight hours the patient ought to be kej)t in a recumbent posture, and every movement of the body be strictly prohibited : it may be well also to give an opiate at once, and, if there be the slightest pain, this may be repeated after a few hours. One advantage of using a fine instrument is that it is unnecessary to wait for the formation of adhesions between the tumour and the abdominal wall, or to endeavour to induce them by measures not always free from danger before puncturing, or to leave the cannula in for twenty-four hours as practised by Jobert de Lamballe.' The walls of the cyst are so elastic that the small opening closes immediately that the instrument is withdrav^n, and prevents subsequent oozing from the interior. If there be no adhesions, however, one precaution ought never to be neglected, viz. during the removal of the cannula to press the punctured portion of the abdominal wall against the cyst. By neglecting to do this the abdominal wall will be pulled away from the cyst in the extraction of the cannula, and the fluid in the cannula, perhaps containing scolices, ma}' drop into the peri- toneum. The patient often experiences immediate relief from the sensation of tension and other unpleasant symptoms, from which he may previously have suffered, and within three or four days he is usually up and walking about. Not unfre- Cjuentl}' an eruption of urticaria'- is the source of some annoy- ance for the first day or two ; in most cases the temperature is elevated from two to four degrees for several days ; and more rarely the operation is followed by a feeling of uneasiness in the tumour, or by considerable pain and constitutional disturb- ance ; but if the above rules be attended to, these symptoms soon pass off, and the patient makes a good recover3\ It not unfrequently happens, however, that about a week or ten days after the operation the tumour again enlarges. This enlarge- ment is not due to a re-accumulation of the hydatid fluid, but to inflammatory products thrown out between the collapsed jiarasite and the surrounding hepatic tissue, which yre slowly re-absorbed. Under these circumstances it is well not to be ' Trousseau, op. cit. iv. p. 294. - Tliis iiiiiy 1)0 due to the escape of sonic of flic liqirul contents of the stic into the peritoneum, for the same symjitoin lias been coiiiniunly observed Avlien a hydatid has burst into the peritoneal cavity. LECT. III. HYDATID TUMOUE. 75 hastily tempted to liave recourse a second time to paracentesis. A certain degree of fulness may remain for many months, or even longer, in the site of the tumour, the existence of which has been cited as a proof that the operation has been unsuc- cessful. Yet inasmuch as the operation does not profess to remove the parent and secondary cysts, but only to kill the hydatid, and thereby avert those dangers which have been shown to result from its prolonged vitality, and to induce that slow process of atrophy which sometimes occurs independently of an oj^eration, the fulness referred to is only what might be ex- pected. If by the operation we can prevent the dangers likely to arise from a hydatid tumour, nothing more is necessary. Occasionally, however, the secondary enlargement of the cyst does not subside, and a fresh puncture becomes necessary. The fluid obtained by the second tapj)ing has a higher specific gravity than normal hydatid fluid ; it is no longer clear and free from albumen, and it always contains more or less pus. If the proportion of pus be small and the fluid not fetid, and if there be no severe constitutional symptoms, the first operation may be repeated with a reasonable hope of success ; otherwise the case must be dealt Vv^ith in the same way as an abscess, by making a free and permanent opening. The safety and efhciency of the operation now recommended may be regarded as established. You have had many oppor- tunities of satisfying yourselves on this matter in the cases under my care and that of my colleagues, during the last few years. In addition to the ten cases which I have from time to time brought under your notice (Cases XVI. to XXVI.), I would ]3articularly direct your attention to two which were under the care of Dr. Greenhow, and which are reported in the eighteenth volume of the ' Pathological Transactions,' p. 127; in one of these the quantity of fluid drawn off amounted to 110, and in the other to 148 fluid ounces ; five years after the opera- tion in the former case, the patient was free from all signs or symptoms of the tumour. These and many other similar cases which might be quoted afford the best answer to the objection that the operation is only effectual where the tumour is small. It is true, that the operation, in killing the parasite, occa- sionally excites a certain amount of inflammation between it and the cavity of the liver in which it is embedded, but in most cases this, after a short time, spontaneously subsides, and it is only in exceptional cases that a second operatic:! for the evacua- ^6 ENLAEGEMENTS OF THE LIVER. lect. in. tion of pus becomes necessary. I have collected the particulars of 103 reported cases in -which the operation was performed (see Tables at pp. 77-80) . In 80 of the cases the operation appears to have been perfectly successful : in sixteen cases it was followed by suppuration, and a free opening was made into the sac, but all of the sixteen ultimately made a good recovery, and in several it appears to me that the necessity for a second operation was very doubtful. In seven of the cases (Table III.) the operation was followed by a fatal result ; but in four, if not five, of the cases death was due to causes independent of the operation. In one of the remaining cases death was caused by sudden collapse twenty minutes after the puncture, and would probably have followed any operative interference ; only about a drachm of fluid was drawn oif ; no fluid had escaped into the peritoneum, and there was no sign of peritonitis. In one case the patient died of peritonitis within twenty-four hours of the operation, but he was in a state of extreme prostration and emaciation before it was performed, and thepropriety of having recourse to any operative procedure under the circumstances may be doubted. In estimating the results of the operation, those cases only ought to be taken into the calculation where it was resorted to as a curative measure, and those ought to be excluded where it was performed merely as a palliative, and where death was inevitable. I have therefore excluded from the Tables (appended to this lecture) several such cases, and others where the operation was j^erformed with a large trocar, where caustic was employed to procure adhesions before puncturing, or where some irritating substance was injected after the Avitlidrawal of the fluid, and also those where the hydatid had suppurated or been contaminated with bile before the oi:>eration, and where a different mode of procedure was advisable. The operation here recommended is only adapted for those cases where the fluid retains its natural limpid character, and the results of other operative procedures ought not to be confounded with it. 17 Tai?le I. — Cases of Hydatid of Liver in which the operation of puncture with a fine trocar and closing the orifice luas followed by cure. Quantity No. Authority Sex Age SizG of Tumour of fluid in ounces removed Eeforences and Eemarks 1 Murchison M 28 Moderate 5 &20 Case 16, p. 87- 2 Do. F 31 Do. 12 Case 17, p. 89. 3 Do. F 6 Do. 14 Case 18, p. 92. 4 Do. F 31 Large 20 Case 19, p. 93. 6 Do. P 25 Do. 40 Case 20, p. 93. 6 Do. F 60 Small 6 Case 21, p. 94. 7 Do. M 8 Do. 6 Case 22, p. 94. 8 Do. M 25 Moderate 8 Case 23, p. 95. 9 Do. M 36 Large 16 Case 24, p. 96. 10 Do. M 34 Multiple hydatid 4. 7, & U Case 26, p. 99 Three distinct cysts were tapped. 11 Sir B. Brodie M 12 Large 30 Med. Chir. Trans, vol. xviii. 12 Do. F 20 Do. 60 lb. p. 119. [p. 118. 13 Do. M 14 Do. 60 lb. p. 121. U Key F young Do. 80 Bright on Abd. Tumours, Syd. Soe. ed. p. 42. 15 Boinet F 19 Moderate 20 Traitement des Tum. hyd. du Foie, Paris, 1859, p. 13. 16 Do. F 31 Small 4 lb p. 14. 17 Do. M 20 Moderate 20 & 15 lb. p. 18. Two punctures were made at an interval of some 18 Demarquay M 45 Do. 20 lb. p. 30. [months. 19 Frerichs M 46 Very large 120 Dis. of Liver, Syd. Soc. Ed. 20 Langenbeck ? ? ? ? lb. p. 269. [vol. ii. p. 268. 21 Do. ? ? ? 9 lb. p. 269. 22 Eecamier F young woman Moderate ? Eev. Med. 1825, tom. i. p. 28. 23 Eobert M ? ? ? Gaz. desHopitaux, 1857, p. 147 24 Do. F •? •? ? lb. p. 147. 25 Cruveilhier ? ? 9 V lb. p. 147. 26 Kichard F 42 Large 40 Bull. Gen. de Therap. 1855, p. 414. Two drachms of alcohol were injected. 27 Greenhow M 25 Very large 21 & 110 Path. Trans, vol xviii. p. 127. Five years afterwards was still in perfect hfalth. 28 Do. F 30 Do. 148 lb. p. 130. Dead sis years afterwards from a return of the disease (another cy.st.) • Path. Trans, vol. xxv. p. 130. 29 Duffin M 27 Moderate 28 Trans. Clin. Soc. vol. vi. p. 23. 30 Do. F 26 Do. 21 lb. p. 24. 31 Do, F 39 Do. 28 lb. p. 27. 32 Do. M 61 Large 72 lb p. 29. Fluid was partially 33 Do. M 50 Do. 64 lb. [purulent. 34 Church F 23 Very large 120&114 Treatment of Hyd. Tum. of Liver. 1868, p. 15. 35 S. H. Ward F 36 Large 37 Some affections of Liver ; 1872, p. 69. More than a year afterwards another tumour appeared, which ultimately burst into stomach. 36 Brinton F 19 Do. 30 Lancet, 1862, vol. ii. p. 639. 37 J. Hutchinson F 30 Do. 30 ■ lb. 1862, vol. ii. p. 389. 78 ENLARGEMENTS OF THE LIVER. Table I. {continuecT). Quantity No. Authority Sex Age Plze of Tumour of fluid in ounces removed References and Remarks 38 J. Hutchinscn F 33 Large 40 Brit. Med. Journ.Feh.20, 1864. 39 Do. F 36 Do. 60 lb. 40 \V. Budd M 35 Moderate 23 lb. 18.i9, p. 270. 41 I Fearn M 30 Very large 85&40 lb. Nov. 7. 1868. Second punc-' ture, four months after first, broughtaway whey-hkefluid. 42 Hoaton F 23 Largre 40 lb. Ap. 3, 1869. 43 Do. F 20 Small 10 Tb. 1874, ii. 557. Aspirator was used and blood came at end of operation. 44 Sympson M 29 Moderate 16 lb. Ap. 30, 1870. 45 Southey and M 24 Very large 53 lb. Aug. 6, 1870. Savory 46 Ransom F 20 Moderate ^ lb. Sept. 28, 1872. For some days probable percolation 47 Do. F 21 Larire 13.', lb. [into peritoneum. 48 Do. F 25 V^ery large 33 & 72 lb. Second tapping nearly six months after first. Fluid at first ■ tapping contained bile and albumen. 49 Savory ? ? ? ? Church, op. cit. 1868, p. 20. 50 Do. p ? ? •? 11). 51 Phillipson M 14 Moderate 23 Brit. Med. Journ. 1874, ii. 557- 52 BradViury F 23 Do. 16 ib. 1874, ii. 558. 53 Do. F 32 Do. 16 lb, 1874, ii. 589. 54 G. Budd M 25(?) Very large 156 Med. Times and Gaz. Mav 19, 55 Holthouse M 56 bo. 100 Ib. Jan. 6, 1855. [1860. 56 Sibson F 33 Two 50 &? Lancet, July 18, 1868. Two Tumours tumours tapped in succes- sion, at an interval of six 57 AnstiR F 6 Small 7 Tb. Aug. 13, 1870. [weeks. 58 Whittel :\i 18 Do. 10 Ib. Oct. 15, 1870. 59 G. Hett F 7 Moderate 14 Ib. Feb. 18, 1871. Doubtful if cyst in liver. Was punc- tured below umbilicus. 60 Scott Orr M 20 Large 46&35 Gla.sgowMed. .Jour. Jan. 1876. 6i McGillivray M 56 Do. 30&20 .\u.stralian Med. Journal, Aug. 1865. Caseiii. Second tajiping two weeks after first. 62 Do. M 27 ? ? Ib. Case vii. 63 Do. M 45 Very large 180&100 Ib. Case xv. -Second tapping six weeks after first bri)Ught away fluid tinged with bile. 64 Do. F 23 Do. 114 Ib. March, 1867. Case xxiv. 65 Do. ^l 5 Three cysts 20,20,10 Ib. Case xxvi. Three dis- tinct cysts were tapped, none of which refilled. 66 Do. M 6 Small 2 Ib. Case XXX vi. 67 Do. 1' 11 Moderate 18 Ib. Case xxwii. 68 Do. .\r 17 Large 70 Ib. Case xxxviii. 69 Do. M 51 ? 9 Ib. July 1872. Case xl. 70 Do. M 8 ? ? Ib. Ca.se xli. [tapped twice. 71 Do. 1' 28 ? ? Ib. Casexlvii. 72 Do. F 30 9 ? Ib. Cas.. hi. 73 Do. F 44 ? V Ib. Case Iviii. 74 Do. M 59 ? ? Ib. Case lix. 1 HYDATID TUMOUE. Tari.e I. {continued). 79 Quantity No. Authority Sex Age Tumour in ounces removed References and Remarks 75 McGillivray M 49 ? ? Australian Med. Journ. July 1872. Caselx, 76 Do. M 32 ? ? Tb. Case Ixvii. 77 Do. M 3 •? 9 lb. Case Ixx. Tapped twice. 78 Do. ¥ 13 ? 9 IIj. Case Ixxiii. i79 Eradbury M 16 Large 22 Brit Med. .Journ. Nov. 18,1876. 80 Do. M 36 Do. 40 & 30 lb. Tapped twice. Table II. — Cases of Hydctticl of Liver in loliieh the operation of puncttcre with a fine troca); and closinc/ the orijice, was followed hy suppuration of the Sac, a second free and permanent opening, and ultimate recovery. Authority Grarrod Owen Kees Boinet Demarquay Babington and Ccck T. S}Tnpson Bradbury C. Brook Duffin Sex M McGillivray F Do. Do. Do. Do. Do. 16 Murchison M 19 31 50 36 39 35 23 32 ? 12 13 61 49 32 Size of Tumour Small Lai'ge Do. Very large Large Do. Do. Moderate [cyst Multiple Moderate Do. Do. ? ? ? Large Quantity of fluid in ounces removed 4 38 40 160 10 & 8 60 & 30 24 & 80 6& 12 11 20 & 20 References and Remarks 10 30 ? ? ? 60 Lancet, Sept. 1, 1860. Guy's H( sp. Eeports, ser. ii. vol. vi. p. 1 7. Gaz. Hebdom. de Med. ser. ii. 1864, i. p. 86. . [p. 82. Gaz. des Hop. Fev. 19, 18.09, Guy's Hosp. Reports, ser. iii. vol. vi. p. 179. The object of the operation was not to remove all the fluid at once, but by repeated punctures. Brit.Med. .Jour. April 30, 1 870. Sei'ond operation, five weeks after first, was probably un- necessary. On second occa- sion fluid partly fiirulent and tube was fixed in. lb. 1874, ii. 494. Second ope- ration isix weeks after first. Albuminuria before first puncture. Lancet, 1868, vol. i. p. 262. Second operation was proba- bly unnecessary. Trans. Clin. Soc. vol. vi. p. 31. Australian Med. .J5ur. Aug. 186-5. Case xiv. Doubtful if the cyst which suppurated was that wliich bad been first tapped. In first case cy&t was close to surface ; in second, matter was 3 inches from s-urfacp. lb. March 1867. Case xix. lb. Case xxxiii. lb. July 1872. Case xxxix. lb. Ca!>e xliii. lb. Case Ii. Tapped three times with fine trocar. Case XXV. p. 97. Ho ENLARGEMENTS OF THE LIYEE. Table III. — Cases of Hydatid of Liver in rohich the operation of puncture ^vith a fine trocar, and closing the orifice, 7vas followed by death. Aiitliority Molssenet Martineitii Dr. Scott Crr Bradbury "Wiltshire Murchison Do. M M M M M Age 42 31 18 29 26 21 4.5 12 A few grammes 38 Two cysts Quantity of fluid" in ounces removed repeated Large quantity 60 28 References and Remarks Arch. Gen. de Med. Fev. 1859, p. 144. The patient was extremely prostrate before the operMtion. and died of peri- tonitis eighteen hours after. London Med. Record, June 23,' 1875. Sudden collapse and denth, twenty minutes after operation. Three da,^s before, severe pain in epigastrium and r. hypochondrium. No sign of peri- tonitis at autopsy. Gla.sgow Med. Journ. .Jan 1876. Pa- tient had cirrhosis, and for two months before operation deep jaundice, and shortly be'ore operation severe pain in tumour. Eleven days after punc- ture fever set in and persisted till df-ath, twenty-six days after puncture. Two cysts found after death^one in right lobe, which had be^n tapped, containing 3 pints of j)us, and a se- cond in le't lobe containing 32^ oz. of turbid greenish fluid. Brit. Med. Journ. 1874, ii. 525. Re- peated punctures made with fine tro- car. Only about an ounce of fluid drawn oif each time. There were three large cysts, and death was due to one of them opening into lung. Lancet. Sept. 1, 1860. Liver contained three other cysts, each containing about one pint of fluid, besides the one that was punctured. Deith ap- peared duo to the pressure of the enormous liver upon neighbouring organs. Casexxvii.p. 100. There were multiple hydatids of liver and peritoneum, and death was due to suppuration of a cyst, distinct Ironi that which was punctured. Case xxviii. p. 102. There wore multiple hydatids of li«er and prritoneum, ami ascites, &c., and death was quite in- dependent of operation. LECT. in. HYDATID TUMOUE. 8l A careful consideration, then, of the whole matter — of the dangers of the disease when left alone, of the inutility of medicines on the one hand, and of the success hitherto obtained from a simple puncture on the other, leads to the practical conclusion that, in all cases where a hydatid tumour is large enough to be recognised during life and is increasing in size, it is advisable to puncture it at once. If the tumour appear to be diminishing in size, it maybe well to wait; but it is unne- cessary to wait for the formation of adhesions, or to endeavour to induce them. A hydatid tumour is not prone to form adhesions over its outer surface, like an abscess. By the time that adhesions form in the natural way, the tumour has attained a large size and is probably eating its way into some of the adjoining cavities ; the chances are increased of its becoming inflamed and converted into an abscess ; its walls also are much less elastic than at an earlier stage, and a puncture through them will close up less readily, so that there is a greater risk of fluid escaping into the peritoneum after removal of the cannula if there be no adhesions. While the walls are still elastic, the opening made by a fine trocar may be expected to close immediately that the instrument is withdrawn, and the exist- ence of adhesions is therefore unnecessary. 4. Evacuation of the Contents of the Cyst hy a large Permanent Opening. — In Case XXXII. you have had opportunities of study- ing the dangers to which a person must be subjected who has a large suppurating, or perhaps gangrenous, hydatid of the liver communicating by a free opening with the external atmosphere, and I have already pointed out to you that nearly one-half of the cases where an external opening forms spontaneously are fatal. The dangers are mainly four; viz. a. Exhaustion from the pro- tracted discharge ; h. Pyaemia and secondary inflammations ; c. Hsemorrhage from the cavity in the liver; d. Peritonitis. Of 89 cases of which I have collected the particulars, where an opening of this sort occurred spontaneously (23 cases and 9 deaths) or was made by caustic, by a large trocar, or by incision, 28 were fatal, or the mortality was at the rate of 31*46 per cent. Many of those patients, also, who ultimately recovered, endured a protracted and exhausting illness. When, however, the symptoms, or an exploratory puncture, show that the sac has undergone suj)puration and that its contents are fetid, or that there are the constitutional sym- ptoms of retained pus, a large permanent oxDening is the G 82 ENLARGEMENTS OP THE LIVER. lect. in. only justifiable mode of operating, and the operation ought, if possible, to be performed before the patient has become exhausted and cachectic from fever and retained pus. The opening should be made with a large trocar, and a silver cannula or india-rubber tube secured in the wound until the whole of the hydatid contents have come away. The cavity ought to be washed out in the first instance with a strong solution of chloride of zinc (20 grains to the ounce), and subsequently at least once a day with an aqueous solution of carbolic acid (2 per cent.). In cases where the operation is followed by protracted suppuration, or when there is difficulty in keeping the pus free from fetor, it will be advisable to make a counter-opening and introduce a drainage-tube, in the man- ner recommended by Boinet • and as commonly practised in empyema. Before operating in this way, it will always be well to ascertain the existence of adhesions, and, if necessary, to produce them by an incision over the tumour plugged with lint, by the application of caustic potash, or b}'- multi- plied acupuncture with thirty or forty needles arranged in a circle close to one another as practised by Trousseau ; or an opening may be made by successive applications of caustic potash, in the manner recommended by Recamier in cases of abscess.^ 5. Acupuncture. A third plan of operating on hydatid tumours remains to be considered. In a communication made to the Royal Medical and Chirurgical Society of London on November 8, 1870, Dr. Hilton Fagge and Mr. Durham recorded eight cases of hydatid of the liver treated by electrolysis, in all of which the result was most satisfactory.' The operation con- sisted in passing two electrolytic needles into the cyst one or two inches apart, both of which were connected with the negative pole of a galvanic battery of ten cells. A moistened sponge formed the termination of the positive pole, and this was placed on the patient's skin at a little distance from the points of en- trance of the needles, and its position was changed from time to time during the operation. The current was allowed to pass for ten or twenty minutes. In several of the cases the operation was followed by the signs of fluid in the pleura or peritoneum, so • Gaz. mid. do Purls, 18G0, No. 4/5. • FrericliH, Dis. of Liver, Syd. Soc. Ed. ii. p. 148. • Many years before, this operation had been tried successfully in Iceland. (Frerichs, op. cit. ii. 2."<1). HYDATID TUMOUE. 83 that there was reason to suspect that the electrolysis acted as a kind of subcutaneous tapping, with effusion of the cyst fluid into a serous cavity, and this view was confirmed by the fact that in one case equally good results seemed to follow the in- troduction of needles into the cyst without the galvanic current. It is to be noted that the operation was in every instance free from danger ; it was liable to be followed by some pyrexia and temporary refilling of the sac, but it did not set up active sup- puration. Whether it be superior in this respect to puncture with a fine trocar has yet to be decided, but it certainly merits a further trial. ^ Note. — The treatment of hydatid tumours advocated in the above lecture was recommended by me, in a memoir published in the ' Edinburgh Medical Journal ' for December 1865, but has met with opposition from Dr. John Harley, of London, and from Dr. Finsen, of Copenhagen. Dr. Harley,^ who advocates the treatment of hydatid tumours of the liver by a large and permanent opening, gives a Table of ' 84 cases which were treated by a single puncture, evacuation of a portion or of the whole of the fluid, and immediate closure of the wound,' and states that, ' there were 11 cures, 13 recoveries, i.e. cases which were relieved by the operation, but which, since the tumour was not wholly removed, or the result sufficiently certified, cannot be regarded as radical cures, and 10 deaths.' Inasmuch as the parent and secondary cysts can never be ' wholly removed ' by the operation of simple puncture, it is difficult to understand how Dr. Harley can admit that there was a ' radical cure ' in any of the 34 cases. It is necessary, therefore, to explain that he seems to look upon the result as a recovery, and not a ctore if any trace of the tumour can ie felt some time after the operation (as in my own case, No. 26 in his Table). The introduction of the 10 fatal cases into the Table, however, throws, in my opinion, an illegitimate discredit upon the operation in question, and it is, therefore, necessary to advert to them in detail. Case 4. — In this case the tumour filled up the whole abdomen and the operation of paracentesis (loitJi alargetrocar) was resorted to with the object of relieving the impending asphyxia, and not as a cura- tive measure. The patient, moreover, before the operation, was in a state of extreme marasmus and prostration, and the immediate cause of death was miliary tubercles in the lungs, and empyema. See G-reenhow, ' Lancet,' 1862, ii. p. 476, and Murchison, ' Ed. Med. Journ.' Dec. 1865 ; also Case XXXVIII., p. 122 of this work. Case 8. — There is no evidence that this case was fatal. Dr. Harley quotes the case from Mr. Caesar Hawkins, and Mr. Hawkins fi'om Dr. ' Med. Chir. Trans, vol. slix. 1866. G 2 8^ ENLARGEMENTS OP THE LIVER. lkct. ill. Thomas's ' Practice of Physic' Mr. Hawkins observes, ' The result is not mentioned, so that it may probably be concluded that the case ended fatally,' but Dr. Thomas says nothing to warrant such a conclu- sion. ' Med. Chir. Trans.' vol. xviii. p. 121. (jase 9. — The operation was resorted to merely as a palliative mea- sure : 8 pints of flu.id were withdrawn from one cyst, and a second cyst containing 12 pints, was found after death between the liver and the diaphragm. Dr. Abercrombie adds, ' The two cysts had so much injured the patient's constitution, that, although he was relieved by the operation, his strength quickly failed him.' Abercrombie, ' Dis. of Stomach,' p. 356. Case 10. — In this case the opening Avas evidently a large one, and it is not stated whether it was closed up or not. But what is more important, the hydatid had suppurated before the operation. Hawkins in ' Med -Chir. Trans.' vol. xviii. p. 157. Case 11. — From the original account of thite case in the ' Edin. Essays and Observ.' vol. ii. p. 299, it is clear that the boy was almost moribund at the time of the operation, and that, in addition to hydatids of the liver and spleen, he had ascites, general dropsy, and orthopnoea. It seems probable also that the peritoneum, and not the hydatid, was tapped. Case 13. — In this case there was great constitutional disturbance, and the hydatid had suppui^ated before the operation. The patient also was pregnant and miscarried, and sank after this. Dr. Brighton ' Abdom. Tumours,' Syd. Soc. Ed. p. 41. Case 15. — In this case there were two hydatid tumours. Three pints of fluid were drawn from one. This cyst did not again become enlaro-ed and the patient fancied herself cured, when death occurred from the rupture of the other cyst through the diaphragm into the lungs. Davaine, ' Traite des Entozoaires,' p. 447. Case 16. — In this case the patient was in a state of extreme pros- tration before the operation. He was seized with syncope within five minutes, and died at the end of eighteen hours. Traces of recent peritonitis were found after death. The fatal result was no doubt determined in this case by the operation, but a large opening left patent is not likely to have led to a more favourable termination. Table III., No. 1, p. 80 of this work, and Archiv. Gen. de Med. ser. V. torn. xiii. p. 145. Case 19. — In this case the puncture was simply an exploratory one, preparatory to the application of caustic potash seven days afterwards. Death was due io tetanus twenty-five days after the puncture, and Recaraier .states, ' aucun accident n'a suivi la ponction.' Davaine, op. cit. p. 590. Case 32. — In this case, according to Dr. Harley, no attempt was made to relieve the sac of its contents after the first puncture, and the hvdatid fluid escaping into the peritoneum caused peritonitis and ex- tension of the disease ; but he omits to mention that the presence of a LBCT. in, HYDATID TUMOUR. 85 lar^e and increasing amount of fluid in the peritoneum was diagnosed before the operation. Moreover, caustic potash was applied to the integuments before the cyst was tapped. Rogers in ' Brit. Med. Journ.' 1862, vol. i. p. 71. It maj seem surprising that as the data for my statistical Tables are in part derived from the same sources as Dr. Harley's, I should have been led to so diflPerent a conclusion. It is satis- factory therefore to me to find that Dr. Hilton Fagge and Mr. Durham have taken some pains to compare our Tables with the original data, and have entirely confirmed, in all essential par- ticulars, the accuracy of my tabular statement.^ Dr. Finsen also advocates the operation of Recamier — viz. establishing adhesions by means of caustic, and then a free opening. I have not had the advantage of reading what he has written upon the subject, but I am informed by my friend Dr. Hjaltelin, of Iceland, that Dr. Finsen can only account for my success with the simple puncture, on the supposition that I have ' purposely concealed my unsuccessful cases.' In reply, I have only to state that all the cases in which I have been re- sponsible for the operation are appended to this lecture, and that they will speak for themselves. How far Dr. Finsen is competent to designate the simple puncture of hydatid tumours a ' useless and dangerous operation,' I must leave to Dr. Hjaltelin, physician in chief, Reykjavik, Iceland, to decide. - On the other hand, the success of the operation has been generally admitted by those who have had most opportunities of watching its effects. It is the treatment commonly practised in Iceland, where the disease is so common. The following- passage from one of Dr. Hjaltelin's papers is worth quoting : ' I resolved myself to try the method of Eecamier in some cases, which seemed to me more favourable for it than others, but am sorry to say that nearly one third of all those operated upon died. .... After I had quite given up the method of Eecamier, and had returned to my old method of puncturing hydatid cysts, I happened to read Dr. Murchison's article '*' On Hydatid Tumours of the Liver, their Diagnosis and Treatment, 1865." As the ex- perience of this physician is quite in accordance with my own, my faith in the treatment by puncture became strengthened, and I have since that time operated in a great number of cases 1 Med. Chir. Trans. 1871, vol. liv. p. 41. "^ See papers by Dr. Hjaltelin, Brit. Med. Journ., Aug. 14, 1869, and Edin. Med. Journ., Feb. 1870. 86 ENLARGEMENTS OF THE LIVEE. lect. in. with the best results.' Mr. Savory, of St. Bartholomew's Hospi- tal, writes : ' The operation is 7iiuch less likely to be followed by any untoward consequences than wlien a large trocar is era- ployed So convinced am I, from what I have hitherto seen, of the superiority of the fine trocar, that I would use it over and over again, in cases where the cyst refilled, before I would employ a large instrument.'^ Mr. Durham, of Guy's Hospital, in the discussion upon his and Dr. Fagge's paper on the treatment of hydatid by electrolysis, stated that he had tapped eight cases by simple puncture with perfect success. ^ Dr. Duffin, of King's College Hospital, has recorded 7 cases of hydatid of the liver treated by simple puncture; all recovered, although in two the sac suppurated.^ The treatment by puncture with a fine trocar and cannula was also strongly advocated by Dr. W. S. Church in his Oxford Graduation Essay published in 1868.'* Lastly, in Australia, where the disease is very preva- lent, the operation of puncture with a fine trocar is the treat- ment commonly adopted. Dr. McGillivray, among others, has pointed out the superiority of this plan to that of making a large and j)ermanent opening. He has himself operated by the former method in 28 cases of hydatid of the liver, 24 of which made a good recovery, although in 6 the sac suppurated (see Tables I. and II). Four of the patients died; but in three of the four the operation was performed merely as a palliative, and the patients were previously the subjects of other maladies (disease of heart and dropsy, disease of lung and dropsy, and diphtheria) of which they died : in the fourth case the fluid drawn off by the primary puncture was ' brown bilious-looking stuff,' the sac suppurated, a lai-ge opening was made, and the patient died from gangrene of the liver.^ The records of the following cases may serve to impress upon you more forcibly the symptoms and the dangers of hy- datid tumours of the liver, and their appropriate treatment. Tn the first eleven cases (Cases XVI.-XXVI.) the cyst was punctured with a fine trocar, and after partial evacuation of the contents the opening was closed. ' Tho Lancet, 1866, i. 524. '' See also Mod. Chir. Trans, vol. liv. p. 40. » Trans. Clin. Soc, 1873, vol. vi. p. 23. * On tho Treatment of Hydatid Tumours of tlie Liver. * Australian Med. Journ., Aug. 1865 ; March 1867 ; and July 1872. HYDATID TUMOUR. 87 Case XVI. — Hydatid Tumour of the Liver — Paracentesis — Recovery. You have had an opportnmty of studying the clinical characters of hydatid tumour of the liver, which have now been described, in the case of John InT , aged 28, who was admitted into Middlesex Hos- pital, under my care, on Dec. 3, 1866. He was a clerk, and had been in the Crimea for fourteen months, in 1855 and 1856. His previous health had always been good. In Sept. 1864 he had sore-throat and slight aching pain in his right side, and it was then discovered by Mr. Churton, of Erith, that he had a tumour in epigastrium, which was almost as large then as when he came under your notice. After that he suffered no uneasiness in tumour until Feb. 1866, when it became Fig. 12. Outline of Hepatic Dulness in case of John N , at time of his admission into hospital, Dec. .3, 1866. a, hepatic dulness ; 6, tumour ; c, spleen ; d, heart. the seat of occasional darting pains, and on this account he was a pa- tient in this hospital, under my care, from March 31 to April 18, 1866. Excepting these pains, which were very transient and unaccompanied by any tenderness, the patient's general health was good, and he had not the slightest fever. On April 7, an attempt was made to empty the cyst by means of a small trocar and cannula and an exhausting syringe, the puncture being made to the left of the middle line, where the tumour was most prominent. The action of the syringe, however, caused much pain in back and faintness, and the operation was aban- doned after obtaining only four or five ounces of fluid, a quantity evidently much less than the tumour contained. Excepting an attack of urticaria, the operation was followed by no bad symptom. Patient was readmitted Dec, 3, partly on account of a return of the slight pain from which he had previously suffered, but mainly 88 ENLARGEMENTS OP THE LIVER. lect. hi. with object of Laving what was probably a second cyst emptied. At time of readmission, following note was taken of his state : — 'Patient has a healthy appearance, and his only complaint is of a prominent tnmonr in epigastrium, extending into both hypochondria, and evi- dently connected with liver. It fills up space between sternum and umbilicus, and causes a slight bulging of ribs on both sides, particu- larly on the rigM. Its lower margin is about one inch above umbilicus. It measures about 6 inches transversely, and 5 inches from above downwards. Hepatic dulness is G inches in mesial line, and 5 inches in right mammary line ; in right axillary and dorsal lines it is normal. These dimensions exactly correspond with those noted when, patient left hospital last April. Upper margin of hepatic dulness is not more arched than natural. Tumour is globular, perfectly smooth, and not at all tender. It is very elastic, distinctly fluctuates, and pre- sents the character known as ' hydatid vibration ' in a marked degree It does not appear to be adherent, as its position varies with respira- tory movements. No jaundice, no ascites, no enlargement of the spleen, and no albumen in urine. Tongue clean ; bowels regular ; no vomiting or pain after food ; pulse 72.' On Dec. 7, Mr. Moore introduced a fine trocar into most prominent part of tumour, to right of middle line, and drew ofi" by cannula, with- out any syringe, twenty fluid ounces of fluid. This fluid was opales- cent, colourless, and alkaline, with a specific gravity of 1009 ; it con- tained no albumen, but yielded a copious white precipitate with nitrate of silver ; numerous booklets and several entire echinococci were dis- covered with microscope. Although patient had been taking large doses of iodide of potassium for several days before both operations, on neither occasion did fluid contain a trace of iodine. The operation was not followed by slightest febrile excitement or unfavourable symptom of any sort. On Dec. 12, patient got up, and on 18th he left hospital apparently well, tumour showing no tendency to enlarge, and hepatic dulness in right mammary line being only 3f inches. On IMarch 18, 18G7, I again saw John N , who informed me that four days after leaving he had been attacked with typhus fever, which he had probably contracted in hospital, and with which he had been dangerously ill. At commencement of the fever tumour ap- peared to enlarge, but by the time of his convalescence the swelling had quite subsided again, and now not the slightest trace of it can be discovered, vertical hepatic dulness in median line being only three inches. March 9, 18G8. — Patient presented himself at hospital, and was examined by Dr. H. Thompson, Dr. Greenhow, Mr. Moore, and a large number of students, but no trace of a tumour could be discovered. HYDATID TUMOUR. 89 Case XVII. — Hydatid Tumour of Liver, threatening to hurst — Para- centesis — Recovery. On Aug. 3, 1864, Hannali S , a very nervous woman, aged 31, consulted me about a tumour in region of liver. She was a cook in a medical man's family. In summer of 1863 she had been laid up for three weeks with a pain across stomach ; but, with this exception, she had never suffered from any symptom of abdominal disease until about nine weeks before she came to me. She was then seized suddenly with acute pain in region of liver, which lasted about two hours. For several days she vomited everything she ate, and she had great pain in right side when she attempted to cough or to turn in bed. She kept her bed for a week, and did not resume her work for three weeks. Fig. 13 represents the outline of Hepatic Dulness in the case of Hannah S , in August 1864. a, tumour ; 6, spleen ; c, heart. Liver was then first observed to be enlarged and prominent, but pa- tient was unable to say whether this enlargement had existed before attack of pain or not. On examination, a slight bulging was found in right hypochondrium below ribs, this bulging being apparently con- tinuous above with liver, extending to half an inch below umbilicus, and, transversely, from one inch to left of mesial line to about 3 in. to right. Vertical hepatic dulness two inches within right nipple was 7 in., 4^ in, of the dull space being below edge of ribs. Tumour was tense, bnt elastic, and almost fluctuating. It was slightly tender on deep pressure. It did not appear to be adherent to abdominal wall. Posteriorly, hepatic dulness did not extend too high and upper margin not preternaturally arched. Respiratory sounds 90 ENLAEGEMENTS OF THE LIVER. lect. in. at right base were normal. Patient -was slightly sallow, but had no decided jaundice. Tongue clean ; appetite good ; bowels regular. No ascites and no anasarca ; urine contained neither albumen nor bile- pigment. Pulse 84. On Aug. 7 patient had a return of pain in tumour, accompanied by vomiting and purging, lasting for two or three days. For several days after this attack tumour was tender, and over its surface coarse friction could be both heard and felt during respiratory movements. On Aug. 19 Hannah S was admitted, under my care, into ]\Iiddlesex Hospital, and placed on iodide of potassium, five grains three times a day. On Aug. 2-i tumour was noted as more tense and tender. On night of Sept. 2 patient had an attack of acute pain in right side, greatly increased by pressure, movement, or a long inspiration, and accompanied by much nausea, but by no vomiting or rigors Pulse 06. Under use of opium, poultices, and rest, these symptoms gradually subsided, but tumour continued tender, friction was again distinguish- able for several days, and pulse did not fall beloAv 96. On Sept. 9 patient had another similar attack of pain, but more severe ; pulse rose to 116, and friction returned. On Sept. 14 pain was less, but tumour was observed to extend more to right side, and was less rounded. On Sept. 17 another severe attack of pain ; and indeed, since Aug. 24, tumour had never been free from tenderness, while patient felt herself gradually getting weaker, pulse being rarely beloAv 108. Although there was no evidence of firm adhesions over tumour, it was now determined to puncture it. From first, tumour had been diagnosed as a hydatid, and indeed the object of patient's admission into hospital was to have it punctured. All Avho examined it were agreed that it contained fluid, and the only other aSections at all likely to produce appeai'ances observed were a distended gall-bladder and an abscess of liver. The tumour did not occupy quite the situation, and latterly did not present shape of a distended gall-bladder, and there had never been jaundice. The persistent pain and tenderness noted for several weeks pointed rather to abscess, but there had been no rigors or perspirations, and, moreover, the tumour had not increased much in size since it had been first observed. Supposing the tumour to be hydatid there was reason to fear that it was about to burst. On Sept. 20 Mr. Hulke tapped tumour with a fine trocar, the cannula of which was scarcely so large as a No. 1 catheter, and drew off about twelve fluid ounces of clear limpid fluid, specific gravity of which was 1009. No echinococci or booklets could be discovered in it, but it was found to contain a larcre amount of chloride of sodium and no albumen. It did not contain a trace of iodine, although iodide of potassium had been taken almost continuously for several weeks. In removing cannula, abdominal parietes were pressed down against tumour, and puncture was afterwards covered with collodion and a M5CT. III. HYDATID TUMOUR. 9 1 pad. Patient was kept on her back for forty-eiglit hours, and not per- mitted to move. Twenty drops of laudanum were administered im- mediately after operation, and for two days an opiate was given about once in four or six hours. The night after the operation, patient slept well. On following day, urine was retained, and was drawn ofl' by catheter ; and on Sept. 22 abdomen was distended and tympanitic, skin hot and dry (temperature 101°), pulse 120, and much thirst. Still there was much less pain and tenderness over tumour than before operation. Bowels had not been open for two days. An enema of turpentine and confection of rue brought away a large quantity of flatus, and patient at once began to improve. On Sept. 26, pulse 96, tongue clean and moist, and appetite returning. For first time for several weeks', patient could tolerate free manipulation of tumour, dimensions of which were much reduced. On Sept. 27, pulse 84 ; collodion was removed from wound, from which not a drop of discharge had escaped. On Sept. 30 patient was able to get up. Convalescence was retarded by an attack of facial neuralgia and other trifling ailments ; but on JSTov. 22, patient was able to leave hospital. Dimensions of tumour were gradually diminishing, so that dulness from upper margin of liver to lower margin of tumour did not exceed 5| inches. Tumour also was quite soft and free from tension, and could be manipulated without causing pain. Tongue clean and moist ; appetite and digestion good. Pulse 100. June 3867. — Nearly three years have now elapsed since operation, and during most of that time patient has been able to follow her occupa- tion as a cook, subject -only to flatulence and other symptoms of dyspepsia and hysteria. Only a slight fulness is now perceptible in epigastrium. Early in 1868, patient wrote that she was quite well and was about to be married. In autumn of that year she had a child, who died soon after birth. After this she fell into low spirits, and she was again under my care in Middlesex Hosp. during Jan. 1868. She was then suff'ering from dyspepsia, flatulence, and hysterical pains. A hard mass about size of an orange could still be felt in site of tumour ; it was quite painless, and did not seem to be connected with patient's symptoms. July 1873. — Patient wrote to say that she was much in same con- dition and that tumour was no larger. Case XVIII. was remarkable for the early age of the patient.' Trousseau has recorded a case where the patient was also only six, and adds that Davaine, in his great work on Entozoa, had not been able to collect more than 14 cases in subjects under fifteen years of age ; but in one of Davaine's cases which he quotes from Cruveilhier, the subject was a child > Clin. Med., Syd. Soc. Trans, iv. 26i. 92 ENLAEGEMENTS OF THE LIVER. lect. hi. only twelve dai/s old, and the cyst had already opened into the descending colon. (See also Case XXIT. and Tables I. and II.) Case XVIII. — Hydatid Tumour of Liver — Puncture with fine Trocar — Hecoverij. Elizabetli C , aged 6, adm. into Middlesex Hosp. under my care Dec. 3, 1867. With exception of whooping-cough at age of 3, she had always enjoyed excellent health ; but her niother, almost since she was an infant, had noticed that she was larger about the waist than natural. Three months before, the girl had been seen by Miss Garrett, M.D., who diagnosed hydatid of liver. Since then mother thinks that tumour has been increasing, but the only uneasiness child has experienced has been an occasional feeling of sickness, a morning cough, and slight pain in region of liver. On admission, patient was a robust, healthy, looking child, who seemed to have nothing amiss with her, with ex- ception of a swelling in epigastrium, extending vertically from loAver end of sternum to umbilicus, and 2\ inches laterally to either side of mesial line. The tumour was globular, smooth, painless on manipu- lation, and with distinct fluctuation, and ■■ hydatid vibi'ation.' It was quite movable over subjacent parts, and did not appear to be adherent to abdominal parietes, as it descended readily with inspiration. Al- though evidently connected with liver, area of hepatic dulness was not generally inci'eased, its extent in right mammary line measuring only 2^ inches. Girth of abdomen over tumour was as follows : At umliilicus At eiisifurm cartilage . Ualf-way between umbilicus [^S-TS 24-66 25-25 24- 22-5 and ensiform cartilage . ) Tongue clean, appetite good, bowels regular. There was neither ascites nor jaundice. Pulse 96. She was ordered a draught containing two grains of iodide of potassium three times a day. On Dec. 10 Mr. Hulke punctured tumour with a fine trocar, and drew ofi' fourteen fluid ounces of fluid. This was colourless, slightly opalescent, with a specific gravity of 1010, and contained no albumen, but a large quantity of chlorides ; neither echinococci, nor booklets, nor any trace of iodine could be detected in it. Two hours after opei-a- tion patient Avas sitting up in bed laughing and talking as if nothing had happened. During following night, however, she had several attacks of vomiting (whicli was, perhaps, the effect of chloroform that had been administered), and for two days the pulse rose to 14-0, and the temperature was as high as 1008° ; but there was no tenderness of abdomen, nor thoracic breathing. On Dec. 13 temperature and pnlse were again normal, and after this patient had no bad symptom, except that from Dec. 20 till Jan. 14 tumour appeared to increase again slowly in size, so that the question Dec. 3. Dec. 20. Jan. 16. Jan. 24. :March 9. 24-3 23-3 24-5 22-75 22-0 24-5 23-5 23-5 23-75 23-5 LECT. 111. HYDATID TUMOUE. 93 of performing paracentesis a second time was entertained. Tliis, how- ever, was abandoned, for tumour began to diminish spontaneously, as will appear from table of measurements. On March 9 there was no perceptible bulging and scarcely any tumour to be felt. Case XIX. — Hydatid Tumour of Left Lohe of Liver — Paracentesis — Becovery. Emma H , aged 31, adm. into Middlesex Hosp. Dec. 4, 1868. Married and had five children ; youngest child born sixteen months be- fore had survived birth only three days. After this suffered from languor, prostration, and low spirits, and while in this state attention, was first drawn by a feeling of heat to a swelling in left hypochondrium, which, however, had not materially increased in size since it had been first noticed ; nor had it prevented her following her ordinary household occupations. On admission, there was a tumour filling epigas- trium, extending to 2^ in. below umbilicus, measuring 7-^ in. verti- cally, and 10 in. transversely, bulging forwards, tense, smooth, fluc- tuating, with distinct ' hj^datid vibration,' and slightly tender. The tumour evidently grew downwards from liver, which did not extend too high upwards ; it did not appear to be adherent to abdominal wall. The patient was anaemic, but her general health was in other respects good. Dec. 6, ordered 5 grains of iodide of potassium three times a day. Dec. 10, paracentesis with fine trocar : one pint of fluid drawn off, limpid, sp. gr. 1009, and containing much chlorides, but not a trace of albumen or of iodine ; last few ounces had a sp. gr. of 1012 and contained blood -and bile-pigment. No bad symptom followed operation ; pulse never exceeded 80, and skin was cool. On Dec. 18 patient got up, and on 28th she left hospital. July 19, 1872. Patient called at my house. Has had two children since operation, and is now suckling second, aged 12 months. A small hard, non-elastic, painless tumour can still be felt in. epigastrium, but this is the source of no inconvenience. Case XX.— Hydatid of Left Lobe of Liver — Paracentesis — Becovery. Mrs. R , aged 25, consulted me on Dec. 29, 1871, on account of a smooth painless tumour in hypochondrium, apparently gi'owing from left lobe of liver, and reaching down to umbilicus, which had been first noticed two years before and which had since slowly increased. Girth over most prominent part of tumour 29^ in. : right side, 14 in. ; left, 15;^. Chief complaint was of constant pain in back, and atonic dyspepsia. Improvement took place under use of nitro-muriatic acid and strychnia ; and on March 5, 1873, patient was stouter and stronger, but tumour was larger ; girth on left side over tumour 16 in. ; right side, 14 in. March 24. Paracentesis with fine trocar. Drew off' 40 fluid ounces of limpid fluid, containing much chlorides but no albumen ; 94 ENLARGEMENTS OF THE LIVER. lect. hi. sp. gr. 1010. March 25, no pain; pulse 74; temp. 98'4°. March 27, pulse 96 ; temp. 102'5°. March 31. Up and going about, but tumour appears to be sligbtly larger again ; pulse 84 ; temp. 101*5°. Ap-'d 7. Tumour smaller again, and has got on stays first time for years. Less pain in back than she has had for a long time. Pulse 90 ; temp. 101°. May 7. Much better, and gained flesh. Girth equal on two sides ; viz. 14^ in. July 1875. Patient is in enjoyment of excellent health, and there is no sign of tumour. Case XXI. — Hydatid of Rigid Lobe of Liver — Neuralgic Pain — Paracentesis — Recovery . On Oct. 30, 1873, I saw in consultation with Mr. R. Phillips, of Leinster Square, a lady, Mrs. M , aged sixty, who had a large smooth tumour in right hypochondrium, connected with liver. Hepatic dul- ness in front arched up to nipple, measured 8 in. in right nipple line, bat did not ascend too high at back. Lower margin of right lobe de- scended to level of umbilicus. Lower right ribs and cartilages formed a visible bulging forwards ; girth over most prominent part from spine to middle line in front 17 in., and at corresponding part of left side ISj- in. Over most prominent part ©f swelling between ribs, as well as below them, decided elasticity and even obscure fluctuation ; no tenderness. Tumour had been first observed ten months before, and had not materially increased. Ever since she had been liable to severe neuralgic pains, and a disagreeable feeling of tightness about liver ; and four months after she became aware of tumour she had an attack of pleurisy on right side with effusion, which had been absorbed. Her only other symptoms were some nausea and loss of appetite. I advised a puncture with a fine trocar between the ribs, and a few days afterwards Mr, Phillips drew off from swelling by aspirator six ounces of fluid. This was faintly opalescent, had sp. gr. of 1010, was unchanged by boiling, but became slightly opaque on adding nitric acid, formed a dense white deposit with nitrate of silver, and contained numerous echinococci. The tightness and neuralgic pains were at once relieved, and lower mai'gin of liver receded almost to margin of ribs. No bad symptom followed, and in July 1875 patient was in good health, and had no sign of tumour. Oct. 1876. Still in good health. No pain, or swelling. Case XXII. — Hydatid Tumour bulging from upper surface of Liver, and pressing it down — Paracentesis — Recovery, Albert D , aged 8, a pale rather thin boy, was brought to St. Thomas's Hosp. Jan. 1, 1874, on account of a swelling in upper part of abdomen, which had been first noticed between two and three years before, and which had slowly increased in size, without pain or other uneasiness. The swelling extended from ribs to 1 ^ in. below umbi- i-ECT. in. HYDATID TUMOUR. 95 licus. Its surface was marked by a transverse furrow, 3 in. above umbilicus. Below this its consistence was firm, and what was felt appeared to be the liver ; while between furrow and ribs was a globular prominence, smooth, painless, fluctuating, and yielding dis- tinct ' hydatid vibration ' on percussion. There was dulness over right lower ribs, rising to about level of normal hepatic dulness, but its upper margin was too much arched. Hepatic dulness in r. m. 1., in- cluding liver, 9^ in. ; girth of abdomen round most prominent part of tumour 25 in. ; from ensiform cartilage to umbilicus 7 in. ; from um- bilicus to pubes 4^ in. Pulse 84 ; apex of heart elevated, beating be- tween third and fourth ribs. Tongue clean ; appetite good ; bowels regular ; no jaundice ; no pain ; no ascites or cedema of legs. Ordered Fer, et quin. cit. gr. iij t. d. s. Jan. 8. Paracentesis at 10 a.m. with fine trocar ; 6 ounces of clear fluid drawn off, containing much chlorides, but no albumen ; sp. gr. 1011. The operation was followed by no pain or uneasiness, but temperature same evening rose to 102'8°, and on the three successive nights it was 103-1°, 101-8°, and 101-5°. On morning of 9th it was 101-2°, but on other mornings it was normal. During night of 9th patient was some- what restless and thirsty, but by 12th fever had subsided, and wben patient left hospital on 22nd girth over most prominent part of tu- moiir was 24^ in., and swelling was much less prominent and tense, but to right of cyst wMch had been tapped appeared to be a second, in which, however, fluctuation was not very distinct. This was not inter- fered with. Case XXIII. — Hydatid of Liver commencing to suppurate — Paracentesis — Recovery. On March. 11, 1876, I saw, in consultation with Dr. Barker, of Hornsey, Mr. P , aged 25, who had a tumour, presenting all cha- racters of hydatid, projecting downwards from right lobe of liver. It formed a distinct prominence, whicli measured 7^ in. both verti- cally and transversely. It had been discovered about previous Christ- mas, when it first became seat of slight pain. Since first noticed it had increased unmistakably, but not greatly. I tapped it with a fine trocar, and drew off eight ounces of thin fluid, which was turbid, of 1010 sp. gr., contained much chlorides and a little albumen, and threw down a creamy deposit made up of pus, oil, cholesterin, booklets, and shreds of hydatid membrane. April 25. — For three or four days after puncture, much pain and sickness, but all subsided under opium and efiervescing draughts. At end of two weeks tumour much smaller, but in last fortnight has been enlarging again, and now measures 6 in. vertically and 7-|- in. trans- versely. General health good. June 8. — Gained flesh and colour, and tumour much smaller, mea- sures 4^ in. vertically, and 5^ in. transversely. 96 ENLARGEMENTS OF THE LIVER. lect. hi. Oct. 3. — Much stouter, and general liealth excellent. Has no dis- comfort from tumour, which continues to get smaller, and feels much harder. Case XXIV. — Hydatid of Liver — Paracentesis — Becoverjj. Deacon B., aged 36, railway station-master, adm. into St. Thomas's Hosp. June 1, 1876. Tertian ague at 18, in Cambridgeshire. Except- ing this, health had been good. For eight yeai^s had complained of a feeling of weight and occasional slight pain in region of liver; six months ago these symptoms attracted more attention, and three months ago first noticed a swelling which had slowly increased in size. Six weeks ago had an attack of acute pain in tumour, subsiding in 24 hours, but leaving him weak, so that he kept his bed for a fortnight. Lost about a stone in weight, but regained it before admission. On admission, a distinct prominence between costal cartilages and umbilicus, more on right side than left, evidently due to a growth from liver, smooth, rounded, painless, tense but elastic ; no thrill or vibra- tion ; its lower margin reaching to umbilicus. Liver generally not enlarged; upper margin not too high ; dulness in r, m. 1. 7 in., in mesial line 9 in. ; girth of abdomen over tumour 36 j in. Body well nourished ; no pyrexia or perspiration ; appetite good, and sleeps well. Chief inconvenience from swelling is some dyspnoea on exertion, and a feeling of tightness after food or when he stoops. June 5. — Paracentesis with fine trocar ; 16 ounces of clear fluid drawn off; sp. gr. 1009 : abundant chlorides ; not a trace of albumen, even with cold nitric acid test. June 17. — Got up after two days, and has not had a bad symptom. Temp, on night of June 7 rose to 100'8°, but with this exception has been normal throughout. No pain ; no urticaria. No evidence of cyst refilling ; lower margin 2^ in. above umbilicus ; girth over its most prominent part 35 in., same as day after tapping. July 15. — Came to show himself at hospital. Has had flatulence and uneasiness about tumour, but this has not increased in size ; girth over it still 35 in., but patient has got stouter. Oct. 20. — Examined him again. Tumour imperceptible, and ex- cepting flatulent dyspepsia general health good. Has followed em- ployment for last three months. In Case XXV. the operation of simple puncture was followed by suppuration of the sac, with much fever, and it was neces- sary to make a free openinj^. It is to be noted, however, that before the operation the patient had symptoms of congestion of the liver, and that the immediate cause of the severe inflamma- tion of the sac was a chill. The case further illustrates the good effects of antiseptic treatment in dealing with alarge abscess of the liver, full of fetid pus. LECT. in. HYDATID TUMOUR. 97 Case XXV. — Hyilatld of Liver — Paracentesis — Suppuration — Free Opening — liecovery. Hannah B , aged 32, adm. into Middlesex Hosp. Nov. 30, 1869. In Kov. 1866 began to suffer from occasional pain, not severe, in right side. In N'ov. 1868 first noticed a fulness in right side, which has con- tinued to increase. One month before admission lost appetite, began to suffer from nausea, vomited bile occasionally, and became slightly jaundiced (hepatic congestion). On admission, liver greatly enlarged, extending in front from upper border of fourth rib to 2 in. below umbilicus ; measurement in r. m. 1. 12 in. and in mesial line 11 in. Posteriorly, upper margin of hepatic dulness not higher than natural. Girth over most prominent part of tumour one inch below lower end of sternum, right side \Q\ in., left 15;^ in. Surface of tumour below ribs smooth, elastic, painless, except close to ribs, where it is slightly tender and distinctly fluctuating, but no ' vibration.' Slight jaundice. Urine contains same bile-pigment, but no albumen ; motions contain bile. Dec. 9. — Jaundice and dyspeptic symptoms have almost disappeared, but urine still contains bile. Cyst tapped with fine trocar, and 60 ounces of alkaline limpid fluid drawn off, containing much chlorides, but no albumen ; sp. gr. 1009 : no echinococci or booklets found. On evening of same day felt chilly ; pulse 102 ; temp. 102-2° : but no pain. After 24 hours the febrile symptoms subsided, and patient felt more comfortable than before operation, but the urine still contained bile. On Dec. 16 she got up. Dec. 22. — On evening of Dec. 20 had headache, but yesterday was up all day and went down to Board Room to pass for discharge, when she fancied that she caught cold. Last night she began to suffer from thirst, and to-day pulse 120 : temp. 103"8°. No rigors, but felt chilly this morning ; no abdominal pain. Next night she had no sleep, per- spired profusely, and had frequent retching. On Dec. 23 she had slight pain in region of tumour on taking a deep breath ; pulse 118 ; temp. 101 "4°. In the evening she had a severe rigor followed by perspira- tions. Dec. 24. — Jaundice increased. Urine contains a trace of albumen and much lithates. Pulse 110 : temp. 104"4°. Jan. 1. — Still very ill. Pulse has varied from 106 to 120, and temp, from 101*2° to 105°. No return of rigors, but perspires freely at night. Urine always contains albumen (^V)- Occasional retching and jaun- dice continue. For several days has had frequent cough, and to-day there are coarse moist sounds over lower two-thirds of both lungs at back, and sibilant rales in front. Tumour is evidently enlarging again. Sleeps little. Jan. 10. — Early this morning had a second slight rigor followed by perspiration, but is on the whole better. Temperature for several days H q8 enlargements op the LIVEE. lect. m. has "been falling and is now normal. Less jaundice. Urine still contains albumen. Still much congestion of lungs. Jan. 26. — General condition much improved. Temp. 98°, and has rarely exceeded 100°. Cough much less, breathing easier; very few- rales in lungs. No albumen in urine. For two days has had rather severe pain in tumour, which continues to enlarge. Feb. 2. — Pain continues, and pyrexia has increased, temp, varying from 98° to 101'8°. Pulmonary congestion increased. Girth half- way between sternum and umbilicus is now 37 in. No albumen in urine. About a pint of thin fetid pus was drawn off from tumour by a small trocar, and a piece of Vienna paste about size of shilling was on Feb. 3 applied at spot where puncture had been made. Feb. 6. — An incision was made into eschar produced by paste, a large trocar was thrust in, and 90 ounces of fetid pus containing numerous large shreds of hydatid membrane were drawn off. The cavity was washed out with a solution of chloride of zinc (gr. x ad 5j) until the liquid returned almost clear ; the opening was covered with lint soaked in carbolic oil, outside which was placed a quantity of carded oakum. Feb. 8. — Much better. Pain much relieved. Temp, normal. Since Feb. 4 urine has again contained albumen (Jjy to 4o). Girth at level of opening 31 in. After a few days the opening became choked up, and the general symptoms became worse. The congestion of the lungs increased and there was great dyspnoea. On Feb. 17, 60 ounces of pus (not fetid), with hydatid membranes were let out by opening, into which a per- forated drainage tube was fastened, and cavity was again washed out with solution of chloride cf zinc. Pus without any fetor was dis- charged in large quantity by the tube. The general symptoms slowly improved. On Feb. 18 albumen, and on Feb. 21 bile-pigment dis- appeared from urine, but both returned on March 2 for a few days, during which the discharge was occasionally fetid until the cavity was again washed out with chloride of zinc. The patient, however, still suffered much from cough and dyspnoea, and perspirations at night, and from March 8 to 15 she had frequent retching. Between March 14 and 17 enormous masses of thick tough hydatid membrane (parent cyst), came away while the cavity was being washed out, and after this there was a rapid improvement. On March 24i the discharge had almost ceased. On April 1 patient got up. On May 6 tube was removed, and on June 6 she left hospital with Avound almost cicatrised. The urine was free from albumen ; lungs sound ; and daily gaining flesh and strength. Lower edge of liver felt 2 in. above umbilicus ; hepatic dulness in r. m. 1. 5 in., and girth over wound 20 in. In spring of 1875 Hannah B. was free from all sign of her former disease, but she had become enormously fat, and was a conhrmed spirit, drinker. i,ECT. 111. HYDATID TUMOUR. 99 In the following case there were numerous hydatid cysts in the liver. Three of these were tapped with success, but there was reason to suspect the existence of a larger cyst deeply seated. It is to be regretted that the patient left the hospital before an attempt was made to reach this by an ex- ploratory puncture. Case XXVI. — Multiple Hydatid Tumours of Liver — Jaundice and Diarrlicea — Paracentesis of three Cysts. Henry A , aged 34, labourer, adm. into Middlesex Hosp. Feb. 16, 1869. Five years before had sustained an injury of right side, from wheel of a waggon pressing against it, but he had not suffered much inconvenience from this, and had enjoyed good health till one day in Aug. 1868, while unloading a van in the sun, he fell and was unconscious for three minutes, after which he was laid up for three weeks with vomiting and diarrhoea and light drab-coloured motions, but without jaundice, headache, or giddiness. After this he returned to work, but suffered from flatulence, pain in stomach after food, and occasional pricking pains in situation of liver. One month before ad- mission he was again seized with violent diarrhoea, this time accompa- nied with jaundice, but without vomiting. About same time he first noticed a swelling in right side, and a feeling of weight, which was much increased whenever he lay on left side. The jaundice had in- creased in intensity up to time of admission, and in five weeks he had lost 7 lbs. in weight: On admission, patient was fairly nourished, and with exception of being rather deeply jaundiced, did not appear ill. Liver greatly en- larged, its dnlness in r. m. 1. extending from ^ in. above nipple to 4 in. below ribs, and measuring 10^ in. Corresponding to gall bladder was a rounded projection, about size of an orange and distinctly fluc- tuating ; and fluctuation could also be made out to right of this below edge of ribs, the two fluctuating spaces being separated from one another by a depression in which no fluctuation could be felt. Lower margin of liver could be felt below seat of fluctuation, hard and sharp. Posteriorly hepatic dulness did not ascend too high, but fluctuation was tolerably distinct between tenth and eleventh ribs. Veins of abdominal parietes unusually distinct, and splenic dulness increased ; no ascites ; diarrhoea persisting, five motions on morning of admission ; motions clay-coloured and devoid of bile. Much flatulent distension of abdomen. Appetite good. Urine 1024, free from albumen, but loaded with bile-pigment. Pulse 40, regular ; heart displaced upwards ; no bellows-murmur. Dyspnoea on exertion and slight cough, but physical signs of lungs normal. Feb. 25. — Pulse 72. Diarrhoea abated. Under ether spray a fine trocar was introduced into anterior fluctuating space, and about 4 H 2 ICX) ENLARGEMENTS OP THE LIVER. i.f.ct. in. ounces of hydatid fluid drawn off; clear, sp. gr. 1011, and containing no albumen, but abundance of chlorides. A wire could only be passed in two inches through cannula, and draining away x)f the liquid made no difference in tension of fluctuating swelling to the right. March 5. — Pulse has varied from .56 to 72, and temp, has been nor- mal, but dian-hcea has returned. A puncture was made into fluctuating space to right of first, and 7 ounces of fluid let out ; clear, sp. gr. 1009, and containing no albumen, but much chlorides. March 19. — Pulse has varied from 66 to 72, and temp, has been normal. Diarrhoea and jaundice continue, and motions contain no bile. A rounded elastic tumour about size of a turkey's e^^ can be felt in left groin, which patient first observed about a fortnight ago. Since March 10 there has been slight increase of fulness in situation of cyst first tapped, but no tenderness or fluctuation. Urine free from al- bumen. April 2. — Slight fluctuation without tenderness at site of first puncture. May 7. — A puncture was made into fluctuating space between 10th and 11th ribs at back, but only 1^ ounce of clear hydatid fluid, con- taining booklets and echinococci, could be obtained. June 8. — Patient left hospital of his own accord, feeling a good deal better, and "with much less uneasiness in his side, but still jaundiced, and suffering from diarrhoea and flatulence. In tlie three following cases there were numerous cysts in the liver, and in the peritoneum. From tlieir size and other cha- racters, those in the peritoneum appeared to be secondary in point of age to those in the liver. In Case XXVII. one large cyst in the liver was punctured with a fine trocar, and a free opening was made into a second cyst wliich suppurated. Case XXVII. — Multiple Hydatid Ttimours of Liver and Peritoneum — Paracentesis of one Cyst — Suppuration of a second Cyst — Free opening —Death. Mary H , 21, adm. into St. Thomas's Hosp. Sept. 25, 1873. Both father and mother had died of consumption. Four years ago noticed a swelling in right hypochondrium, which has continued to in- crease. A year later observed a second tumour in right inguinal region, and a third to right of umbilicus. For three years there has been swelling of veins of right leg, and for one year she has suil'ered from dyspnoea on exertion. Quite recently she has complained of sharp pain in right hypochondrium, and she has been losing flesh. On admission, very weak ; much pain in right side. Abdomen greatly enlarged; girth at umbilicus 40 in., and 2 in. above this 3Hi in. ; from ensiform cartilage to umbilicus 8 in., and from um- LECT. III. HYDATID TUMOUR. 10 1 bilious to pubes 6^ in. In right hypocliondrinm and epigastrium is a large swelling, smooth, tense, fluctuating, and not tender. A second tumour, about size of an orange and quite movable, can be felt in right inguinal region ; a third, somewhat smaller, to right of umbilicus, and two others in left iliac region. All these tumours are smooth, rounded, elastic, and distinct from one another. I^To ascites. Veins in walls of abdomen and chest enlarged. In front of right chest there is dulness on percussion, continuous below with that of aforesaid tumour, and ascending to second intercostal space. Posteriorly lungs resonant. Considerable dyspnoea. Apex of heart beats in fifth intercostal space, 2^ in, outside and on level with nipple. Appetite good ; bowels regular. Oct. 20. — Three pints of fluid drawn off" by aspirator introduced at most prominent part of large swelling, 3 in. below ensiform cartilage and ^ in. to right of middle line. Fluid clear, alkaline ; sp. gr. 1010; no albumen; much chlorides; no booklets. After operation, girth at umbilicus 39 in., and two inches higher 37^ in. ; from ensiform cartilage to umbilicus 7 in. Oct. 22. — Much less pain, and breathing easier than before operation. Appetite good. Yesterday afternoon temperature rose to 100"6° and to-day it is 101-2°. Nov. 13. — During last three weeks patient has had much fever, temperature varying from 99° to 104° ; has often felt chilly, but has had no rigors or sweating. On Oct. 24 vomited once and had slight jaundice, which after a few days disappeared. On JN^ov. 3 patient still felt better than before operation ; girth two inches above umbilicus 38f inches ; but after this pain returned in large swelling, which grew rapidly until to-day, when girth 44 in., some oedema of legs, but no albu- minuria. Aspirator introduced at same spot as before, and two pints of thin opaque yellowish fluid drawn ofl". Xo more could be obtained, as cannula became blocked. A free opening was now made into cyst by Mr. MacCormac, and nine pints more of fluid let out, but cyst was not emptied. A large perforated drainage-tube was fixed in opening. There was now clear percussion for 4 in. below right clavicle. Patient did not rally ; temp, did not rise above 100°, but pulse kept at 140 and was small and weak, until death on Nov. 15, 48 hours after operation. Autopsy. — Peritoneum contained no fluid and was nowhere inflamed. Liver much displaced downwards and to left, and in great measure concealed by a large cyst, attached to its upper surface, which also en- croached extensively on thorax. The external puncture had penetrated this cyst, the walls of which were collapsed, thin, and fibrous. It con- tained one large thick gelatinous hydatid, but no secondary cysts. It showed no sign of inflammation except a few small flakes of lymph adherent to its inner surface (outside hydatid). Behind this cyst was another, almost as large, and with much thicker walls, which had also I02 ENLAEGEMENTS OP THE LIVER. lect. lit. "been penetrated by the puncture. This cyst was also firmly attached to liver and was in contact with posterior wall of abdomen ; it contained one large hydatid, but no secondary cysts ; its inner surface was in- tensely inflamed, partly villous, and plastered with large flakes of yellow lymph. Attached to under surface of left lobe of liver was a third cyst, size of a tennis ball, with thick walls, and full of cheesy matter and dried-up hydatid cysts. No cysts in interior of liver. Attached to peritoneum numerous cysts. Just below liver in front of rio'ht kidney were two — one as large as a cocoanut and containing clear fluid and numerous secondary cysts, and another somewhat smaller. Six or seven, of size of hen's egg or smaller, were attached to great omentum, and two grew from fundus of uterus and broad ligament, of which one contained cheesy matter and shrivelled cysts. Lower part of both lungs, esj^ecially right, collapsed. Other organs healthy. In Case XXVI EI. the history seemed to leave little doubt tliat tlie disease commenced in the liver, and that it was not until after many years that the peritoneum was secondarily in- vaded. The large cyst was punctured merely with the object of diminishing the abdominal distension and affording relief. But the cyst was already before death much smaller than it had been before the operation, and the 2>ost-mortem exsLvamntion showed that its size was mainly kept up by secondary cysts in its interior. Case XXVIII. — Multiple Hydatid Tumo7crs of Liver and Peritoneum — Ascites — Puncture of two Cysts and Paracentesis Abdominis. Charles M , set. 45, a teacher of languages, adm. into Middle- sex Hosp. under my care, March 30, 1871. He had been a gymnast and a man of great muscular strength, and had never ailed in any way until 1857, when he noticed one morning while washing himself a tumour over left lobe of liver. This tumour was about size of half an orange, and quite painless ; in fact, he would ont have been aware of its presence had it not been visible. It did not seem to grow, and in 1859 he first felt a little out of health, complained of pain under left scapula, of occasional dyspnoea, and of a stitch in region of tumour. In 1860 these symptoms got better, and he continued well until 18G3, when, one morning, while rubbing his back with a towel, he expe- rienced a dull pain in epigastric region, which increased and lasted for three weeks, and continued to recur occasionally for three years. During 1807 he sufibrod a good deal of pain in region of bladder, with frequency of micturition, and urine was high-coloured and deposited a reddish sediment. Early in 18G0 he had first noticed a tumour similar" to first in umbilical region, but this had never been seat of any pain. HYDATID TUMOUR. 103 For two years he had been very susceptible of cold, and in Jan. 1870 he bad suffered from loss of appetite, cough, and from a severe pain in left side of chest, increased on inspiration. For twenty-five years pa- tient had. lived in Russia and in difierent parts of Europe, and had eaten food of countries in which he travelled. On admission into hospital patient was of rather spare habit, but of unusually good muscular development. Hia sole complaint was of large size of abdomen, which presented a distinctly nodulated or botryoidal appearance. In first place there was a large prominence occupying space between sternum and umbilicus, but more to left than to right of middle line. This appeared to project from left lobe of liver, and to be as large as a child's head. It was fixed, and presented distinct fluctuation, but no vibration. A smaller rounded mass, about Fig. 14. The pointed prominence corresponds to tlie sixth tumour. From a photo- graph, size of a cricket-ball, projected immediately below umbilicus ; this was freely movable, and could be pushed to right or to left of middle line. A third, larger than an orange, could be felt projecting from margin of right lobe of liver, and separated from first by a distinct depression. A fourth, which seemed as large as a man's fist, was in left iliac region, but more deeply seated than the others. Two and a half inches below and to right of the umbilicus, was a fifth, about size of a hen's egg, freely movable and not causing any prominence on surface of abdomen . A sixth, movable and about size of half a walnut, appeared to be in abdominal parietes, over most prominent part of first, immediately to left of middle line (fig. 14). Other tumours of a similar nature could be obscurely felt in diiferent parts of abdomen. All of tumours were rounded, soft, and elastic, and painless even on free manipulation. There was no ascites, and no jaundice. Girth of abdomen over most 104 ENLAEGEMENTS OP THE LIVER. lect. hi. prominent part of first tumour 2 in. below sternum was 36^ in., and 1 in. below umbilicus it was 3G in. Measurement from lower end of sternum to umbilicus 6^ in. ; from umbilicus to pubes 7^ in. The chief inconvenience which patient experienced from state of his abdomen was that of weight. Hepatic dulness did not ascend too high into chest, eitlier in front or at back. Tongue clean ; appetite good ; occasionally slight acidity, but no other symptoms of indiges- tion ; bowels regular ; pulse 60 ; heart and lung signs healthy, except that breath-sounds were feeble at bases of lungs ; urine free from albumen. On April 3 a small trocar was introduced into small superficial cyst (sixth in above enumeration), and there escaped one and a half drachm of clear alkaline fluid, containing abundance of chlorides, but no albumen. On microscopic examination there were no booklets or other signs of echinococci. The puncture was not followed by any pain or tenderness, and within a week the little swelling had almost disappeared. Patient would not consent to any further interference, and left hospital on April 10 in much the same state as on admission. On March 6, 1872, he was admitted into St. Thomas's Hospital under my care. His condition was now much worse. His girth was 40 in. at umbilicus, and 40^ in. halfvsray between umbilicus and sternum. This increase was partly due to slight ascites, but mainly to an increased size of tumours ; that in left iliac region now seemed to be as large as a cocoanut ; the distance between umbilicus and lower end of sternum was now 8^ in., and the hepatic dulness in right nipple line now rose to level of nipple, and measured altogether 9^ in. Liver at some places felt extremely hard, while at others it was elastic and fluctuating. Veins in abdominal parietes much en- larged, and considerable oedema of both legs below knees. No jaun- dice ; the abdomen nowhere tender ; and patient's chief complaints were of occasional tightness of abdomen, and of pain in right shoulder. Pulse 84. Urine contained a small quantity of bile-pigment, but no albumen. Abdomen continued to increase in size, so that on March 27 it measured 43 inches at umbilicus, and breathing was beginning to be embarrassed. A puncture was made on this day with a fine trocar into large cyst between umbilicus and sternum, and 28 fluid ounces of hydatid liquid were drawn off", having an alkaline reaction and a spe- cific gravity of 1009, and containing much chlorides, but no albumen ; no traces of echinococci on microscopic examination ; but it was noted that there were constant interruptions to escape of the fluid by cannula. Girth at umbilicus immediately after tapping was reduced to 40^ in. On March 29 temperature rose to 1034°, and for a week it ranged between 101° and 102°, but no retching nor abdominal tenderness. The ascites, however, and enlargement of abdominal veins rapidly tECT. III. HYDATID TUMOUR. IO5 increased, and there was also a considerable increase of oedema of legs. On April 1 girtli at umbilicus 44 in., and on the 10th, 46 in. Orthopncea set in ; patient was obliged to sleep sitting up in a chair ; and he occasionally suffered from severe attacks of suffoca- tive dyspnoea. Under these circumstances paracentesis abdominis was resorted to, and 140 fluid ounces of serum were drawn off from perito- neum ; alkaline, specific gravity 1016, and loaded with albumen. The operation gave great relief, and, what was remarkable, fluid did not reaccumulate in peritoneum. On morning after paracentesis girth at umbilicus was 41 inches, and on April 29 it was only 37i inches. On latter date, also, girth round most prominent part of tumour in epigastrium was only 38 in., being 2^ in. less than at time he was admitted into hospital. The distance also from umbilicus to sternum measured only 7^ in., being 1 in. less than on admis- sion. (Edema almost disappeared from legs, and patient was able to get up and walk about a little. Both before and after paracentesis patient took diuretics, including blue pill, squill, and digitalis. On May 1 he seemed to be as well as usual, and got up for a short time in evening, but after getting into bed, his breathing became sud- denly embarrassed, and in twenty minutes he was dead. His con- sciousness continued to the last, and he complained of no acute pain. Autopsy. — Peritoneum contained less than a pint of clear straw- coloured serum, Nowhere any traces of recent peritonitis. Two enormous cysts in liver, one in front growing down from under surface of left lobe, and containing an enormous number of hydatid cysts, with a small quantity of thin pus, the entire contents measuring six pints. This was the cyst which had been tapped. The other cyst was in back part of right lobe, and contained between four and five pints of thin opaque fluid, in which there was bile-pigment, with a few hydatid cysts. Numerous smaller cysts were found in liver, and growing from omentum and other parts of peritoneum. Altogether there must have been many hundreds of them. There was one as large as a man's fist in spleen, and another still larger in left iliac region ; another of size of a large orange, and quite globular, was attached by a narrow pedicle just below umbilicus ; and two, as large as oranges, and with thick opaque white coats, lay quite loose in peritoneal cavity in right flank. ^ Heart small and flabby ; it contained no hydatids, and there was no thrombosis of the pulmonary artery. Lower part of both lungs condensed, apparently from pressure ; and left lung everywhere firmly adherent to wall of chest. Nothing was found to account for patient's sudden death. Case XXIX. is remarkable for the successful excision by Mr. Spencer Wells of an immense number of hydatid cysts from the peritoneum. ' See also Case XLIV. io6 EISTLARGEMENTS OP THE LIVER. Case XXIX. — Multiple Hydatid Tumours of the Liver (?) a7td Peri- toneum, in part successfally removed by operation. Elizabeth C , agt. 29, adm. into Middlesex Hosp. under my care on December 12, 1870. She had previonsly been in Samaritan Hos- pital, under care of Mr. Spencer Wells, who was good enough to transfer her to me. On admission patient was pale, weak, and thin, but her countenance was not expressive of pain or cachexia. Her sole complaint was of swelling of abdomen, which measured 33^ inches at umbilicus. Ab- domen generally was soft and elastic, and nothing like a solid tumour could be felt ; neither was swelling due to an accumulation of gas in bowel, for greater part of it was dull on percussion ; nor was it due to ascites, for as patient lay on her back there was tympanitic percussion in left flank. On careful inspection of abdomen swelling was seen not to be uniform, but was marked by a number of small rounded pro- minences, corresponding to rounded movable tumours, from size of a cheny to that of an orange, which could be felt in large numbers, and some of which were even visible tbrovigh abdominal parietes (fig. 15.) Fig. 15. From a photograph. Several of these could be felt projecting from below right ribs, but whether they were attached to liver or not could not be determined. All of them were rounded and very elastic, and in one of largest, situated to right of umbilicus, distinct vibration could be made out on percussion. Hepatic dulness reached to upper border of fourth rib, but lower margin of liver could not be defined from dulness duo to the nodular mass filling abdomen. Abdomen was nowhere tender on pressure, and only pain patient complained of was that of abdominal distension, increased after a full meal. Appetite fair; no evidence of disease of kidneys, or of thoracic organs ; but patient suffered a good LECT. Til. HYDATID TUMOUE. lO/ deal from dyspnoea, owing to pressure upwards against diapliragm, and apex of heart could be felt beating as high as third intercostal space. The history which the patient gave was this : — Her father, mother, and three sisters were alive and in good health, and there was no history of phthisis or of cancer in family. Excepting diseases of child- hood, patient herself had enjoyed good health until age of nineteen. She was married at eighteen ; twelve months afterwards she gave birth to a child, and three months after this she awoke one night with severe pain below right ribs, vomiting, and faintness, and she discovered for first time a swelling of size of a hen's egg in situation of pain. After several days pain and vomiting subsided, but from that time patient had never been so well as she had been before ; she had no definite illness, but felt weak and languid. The swelling below right ribs con- tinued, without increasing notably in size, and three or four years after- wards she noticed a similar swelling in left iliac region, painless from the first, but which gradually increased in size. After this she had at varying intervals paroxysms of abdominal pain, not limited to situation of the appreciable swellings, but general. The pain would last for several days, and while it lasted she would scream out and retch very much . Nine months before admission she first noticed the numerous lumps scattered over abdomen, and about same time she began to lose flesh. After commencement of her disease patient became four times pregnant, and of her five children four were alive and in good heali-h, the fifth having died of convulsions at age of a month. In intervals of her pregnancies catamenia had been regular, but for two years before ad- mission, uterus had prolapsed when she walked about. The diagnosis arrived at was that abdominal swelling was due to multiple hydatid tumours of liver and peritoneum, and that liver had in all probability been primarily affected. It was pi-oposed to test this diagnosis by tapping one of largest tumours with a fine trocar, but the patient would not consent to this, and left hospital on Dec. 19. On Dec. 31 she was re-admitted into Samaritan Hospital under care of Mr. Spencer Wells, who, on Jan. 12, 1871, tapped large cyst to right of umbilicus, and obtained one fluid ounce of clear hydatid fluid containing much chlorides, but no albumen. Finding no cyst large enough to make any difierence in size of abdomen by tapping, Mr. Wells proceeded to make a small incision through abdominal parietes, and through this he removed three or four pounds of hydatid cysts ^ from omentum and mesentery, leaving at least as many more scattered all over abdominal wall, omentum, mesentery, and coats of intestines. The condition of liver and spleen was not observed during operation. Patient had no bad symptom ; within ten days wound healed, and in less than a month she left hospital considerably relieved of the uncomfortable feeling of abdominal distension. For nine months patient continued much relieved, but gradually ' Now in museum of St. Thomas's Hospital. I08 ENLARGEMENTS OF THE LIVER. i.ect. hi. abdomen again became enlarged, and about middle of October Mr. Wade, of Greenwich, who was called to see her, found her very prostrate, with great enlargement of abdomen, which had a distinctly nodulated appearance. After this she had persistent vomiting and purging, and she died at last by astbenia. There was no post-mortem examination, 111 Case XXX. a hydatid of the liver was evacuated by a large and permanent opening. The patient ultimately recovered, but from the history it seemed clear that subsequently to the ope- ration a cyst in the liver discharged itself through the right lung. It is impossible to say whether this was the cyst which had been punctured. The fact that bile was expectorated, and that none was ever observed in the discharge from the external opening, suggests that it was not. Case XXX. — Hydatid Tumour of Liver — Evacuation hy a large opening — Subsequent htirstivg of Hydatid through diaphragm into Lung. Elizabeth R , 39, lady's-maid, adm. into St. Thomas's Hosp. July 25, 1874. Father died at 71, and mother at 75. Two sistei-s and one brother died of consumption ; two brothers and one sister alive and well. Although not very strong, patient had never been ill from childhood till two months ago, when she began to feel a sharp pain and a sensation of dragging down from shoulders in epigastrium and right hypochondrium, accompanied by occasional vomiting, and after a few days by slight jaundice. The jaundice and sickness soon subsided, but the pain persisted. A few days after commencement of pain, she first noticed a swelling below right ribs — considerable at first, but which gradually increased up to admission. On admission, still complains of pain as described above. Pro- jecting downwards from right lobe of liver is a tumour, about size of a cocoanut, globular, smooth, very elastic, and not tender. No jaun- dice or ascites. Pulse 108. Temp. 100-4°. During August and September I was absent from hospital, and but few notes of patient's case were recorded. On Aug. 15 tumour was noted as tender ; and on Aug. 24, patient having again become slightly jaundiced, tumour was punctured, first with a small and then with a large trocar, and the contents evacuated. These consisted of a clear fiuid with a number of hydatid cysts and echinococci. A cannula was tied in, the cavity was washed out from time to time, and an ice-bag applied over part. On Sept. 5 it was noted that patient was very weak and anoemic, and pulse feeble. Since Aug. 28 there had been no jaundice. On ^ept. 14 she again complained of great pain in right side, with fever (temp. 101"). She had also frequent cough and expectorated mucus of a briglit yellow colour from admixture of bile. Over lower half of right lung at back there was dulness on percussion with feeble breath- LECT. III. HYDATID TUMOUE. IO9 ing, diminished vocal fremitus, and distant crepitation. Anteriorly also there was dulness as high as nipple. The pain and fever subsided after about a week, but on Oct. 6 she was still expectorating bile, and the dulness and other signs remained at base of right lung. The ex- ternal opening was now closed, and at no time had there been any dis- charge of bile by it. ISTo hydatid membrane or signs of echinococci had been found in sputum, but it contained bile up to Oct. 12. Pa- tient continued for a long time very weak, and was not able to leave her bed until Nov. 21, by which time base of right lung had become clear. On Dec. 18 the catamenia returned after an absence of six months, and by the end of the month she was able to leave the hospital. In tlie four following cases a hydatid of the liver opened into the bile-duct, which became obstructed by hydatid vesicles, so that jaundice resulted. In Case XXXI. the liver contained three cysts, two of which communicated with one another, and had suppurated before the patient came under observation. Paracentesis was resorted to solely as a palliative. The case was also interesting from the circumstance that the patient's brother had also a hydatid of the liver. Case XXXI. — 8v.ppurating Hydatid Tumours of Liver, one opening into Lung and another into Bile-duct — Jaundice — Temporary relief from Paracentesis. Charles W , aged 24, adm. into Middlesex Hosp. May 19, 1869. Had enjoyed good health until 12 months before, when, after getting wet in a thunderstorm, he was laid up for two months with inflamma- tion in chest, on recovering from which he suffered for a week from headache and vomiting, and ever since he had complained of general debility and lassitude. Eight months before admission he began to complain of vomiting in morning, and drowsiness and tightness at epigastrium after meals, but notwithstanding persistence of these sym- ptoms he continued at work until three weeks before coming to hospital, when symptoms became worse, he lost flesh and suffered from great itchiness of skin, and first became aware of a swelling in right hypo- chondrium, which had continued to enlarge up to admission. Ten days before admission, jaundice appeared, and his motions became slate-coloured. On admission, patient was deeply jaundiced, prostrated, thin, and with anxious pinched features. Liver appeared enormously enlaro-ed, so as to cause a visible bulging of upper part of abdomen. Following measurements were taken in recumbent posture. Girth at umbilicus 36 in. ; half-way between umbilicus and sternum, 38;| in. ; at lower end of sternum, 37^ in. ; from lower end of sternum to umbilicus, 7^ in. ; from umbilicus to pubes, 6 in. Hepatic dulness in r. m. 1. commenced no ENLARGEMENTS OF THE LIVER. lect. m. an inch above nipple and extended to half an inch below umbilicns, measurino" 12 j in. Lower margin of liver rounded ; surface smooth and painless, and to right of middle line distinctly fluctuating and yieldintr ' hydatid vibration.' Projecting from lower margin of left lobe Avas a circumscribed fluctuating bulging about size of an orange, apparently distinct from cyst in right lobe. Also, behind large cyst on right side could be felt another rounded projection from liver, without any distinct fluctuation. Peritoneal hepatic dulness ascended as high as 5th dorsal spine. Subcutaneous veins in right axillary and lumbar re- gions enlarged, and evidence of slight ascites. Tongue clean ; appe- tite fair, but afraid to eat much on account of painful feeling and dis- tension ; 3 or 4 loose motions daily, devoid of bile. Urine loaded with bile-pigment, but free from albumen. Pulse 80 ; heart elevated, its apex beating between 3rd and 4th ribs. Considerable dyspnoea, and slight crepitation at base of right lung. May "7. — Diarrhoea has persisted, but dyspnoea and feeling of abdo- minal tightness have increased. An exploratory puncture was made to-day into cyst in right lobe of liver. Seven ounces of fluid were drawn off, viscid, yellowish, and containing pus-corpuscles, shreds of hydatid membrane, booklets, and rhomboidal blood crystals. May 29. — Pulse 84 ; temp. 98'2°. To-day a tine trocar was passed into cyst in left lobe. Only a few drops of bright yellow matter of the consistence of clotted cream could be squeezed out ; this con- tained oil-globules, nuclei, and abundance of booklets, and minute red rhombic crystals. June 3. — Cyst in right lobe was again opened with a large ti'ocar under ether spray. Eighty ounces of yellow pus were let out, con- taining numerous collapsed hydatids and fragments of cysts ; last few ounces were deeply tinged with blood. In consequence of haemorrhage cannula was withdrawn and wound closed with collodion, although cavity did not appear nearly emptied. June 8. — Pulse 96 ; temp. 98'2°. Great relief followed last opera- tion, but, cyst apparently filling again, it was determined fco make a free opening into it. On again introducing large cannula, much blood, partly clotted, escaped with hydatid membranes, and after 4 ounces had been drawn ofi" opening was again closed. June 18. — Patient left hospital at his own request. Still deeply jaundiced and suffering from diarrhoea. Temperature since last opera- tion has never exceeded normal standard. Girth over most prominent part of tumour, 38 in. June 28. — After discharge, tumour continued to enlarge, and to-day patient's wife came to say that he had been suddenly seized with most profuse diarrhcea and had ])asscd ' pieces of skin ' and ' bits of jolly ' in motions, while at same time swelling in side had become suddenly less. Juli/ 3. — Much thinner and weaker, and has no appetite and much thirst, but jaundice almost gone. Girth over most promineut part of lECT. ni. • HYDATID TUMOUR. I I I tumour now only 34^ inches. Right lobe of liver comparatively flat, so that cyst in left lobe appears much more prominent. Diarrhoea con- tinues, but less profuse. The same evening patient became suddenly collapsed, and died on evening of July 4. Autopsy. — Girth of abdomen over most prominent part of tumour, 33f in. Abdominal parietes and transverse colon firmly adherent to right lobe of liver, and also some recent lymph over rest of liver and adjacent bowels. Peritoneum contained a pint of fluid. Mucous membrane of adherent colon intact. Duodenum contained bile aud several small hydatid cysts, and dark green bile could be squeezed into it through dilated orifice of bile-duct. Common bile-duct greatly dilated, so that a JSTo. 8 bougie could be passed with ease through duodenal opening into large cyst in right lobe. This cyst was as large as a child's head and contained much reddish-brown pus, with nu- merous hydatid cysts up to size of a small orange, some collapsed, but others full and plump. The parent cyst was collapsed and ruptured, having sepai-ated from wall of cavity, which was lined with flocculent lymph. This large cavity communicated with another almost as large, also in right lobe of liver, but higher up, by a well-defined circular opening just large enough to admit tip of finger. This cyst had simi- lar contents to first, and was firmly adherent to diaphragm, which in its turn adhered firmly to base of right lung. The diaphragm was at this part perforated, and in the opposed part of lung was a cavity, the size of an apricot, with ragged walls of pulmonary tissue and traversed by bands of disintegrating lung. There was no fluid or hydatids in right pleura. These two cysts occupied greater part of right lobe of liver. Left lobe of liver was also much enlarged, and projecting from its anterior margin was a third cyst, larger than a man's fist, with thick walls infiltrated with calcareous matter, and its interior full of a bright yellow pulp containing innumerable booklets of echinococci and blood-crystals. Other organs healthy. In June 1870, Thomas W., aged 27, brother of above patient, con- sulted me on account of an elastic fluctuating tumour in epigastrium, the size of a cocoanut, and causing a bulging of costal cavities on both sides. He had first noticed it four months before. It was unattended by pain or constitutional symptoms. He had lived for a short time with his brother 2^ years before, but never before then during 14 years. He would not consent to any operation. In the following case, whicli you must all have watched with much interest, we were enabled to diagnose during the patient's life that a communication had been established be- tween the tumour and the common bile-duct. The fact that the tumour had undergone suppuration and that the contents were fetid contra-indicated the ordinary operation, and com- pelled us to substitute a large permanent opening. 112 ENLAEGEMENTS OF THE LIVER. LECT. in. Casr XXXII. — Hijclatid Tumour of Liver, opening into the common Bile-duct. — Jaundice and Suppuration of Cyst — Puncture u-ith a large Trocar, and permanent Opening — Pneumonia — Death. On February 4, 1868, I was requested by Dr. Ayling, of Great Portland Street, to see Mrs. C , aged 30, who was suffering from jaundice and enlargement of liver. Her mother stated, that ever since she had been fourteen there had been a fulness in epigastrium and left hypochondrium, but that, with exception of occasional pain after food and other svmptoras of indigestion, she had enjoyed good health until present illness. She had been married for eleven years, and during that period catamenia bad been regular, and she had had no children or miscarriages. Eighteen days before I saw her, she had been sud- denly seized with severe pain in back and upper part of abdomen, which almost bent her double. This was relieved by warm poultices &c., but was soon followed by pyrexia, and four days later by jaundice, which soon became intense, with dark porter-coloured urine, and a com- plete absence of bile from motions. The fever continued ; the swelling in epigastrium and left hypochondrium was observed to increase, and patient was so prostrate that some days before I saw her she was thought to be sinking ; but she had no vomiting, rigors, or night- sweats. I found patient much emaciated, and with deep jaundice of con- junctivae and whole surface of body. There was a distinct tumour in epigastrium, extending apparently into both hypochondria. It pro- jected forwards fully 1^ in. beyond natural level, and pushed forward lower end of sternum, and lower ribs on both sides, but particularly on left. When patient lay on her back, lower margin of tumour was 1 in. above umbilicus. Tumour was evidently connected with liver, dulness of which in mesial line was 9 in., in right mammary line 5 in. and in left 6 in. Posteriorly and laterally hepatic dulness did not rise higher than natural on right side, but on left posteriorly, it was fully 2 inches higher than on right, and the dulness in left axillary line was 9 in. The tumour, where it presented itself at epigastrium, was rounded, smooth, and slightly tender. Distinct fluc- tuation could be felt in it, and a thrill, as from fluid, could be made out in epigastrium when percussion was made over the dull part at back of left side of chest. Tongue very red and clean, with enlarged papilln^ at tip ; centre smooth and deeply fissured. Motions clay- coloured, without a trace of bile-pigment. Pulse 108. Apex of heart elevated by tumour to between fourth and fifth ribs. Respirations 28, and slightly embarrassed, but pulmonary signs normal. Temperature 100-6°. LFrine 1027, containing both bile-pigment and bile-acids (Harley's test), but no albumen. The fact that tumour contained fluid, and had probably existed for years without giving rise to symptoms, indicated hydatid; the acute HYDATID TtMOUR. 113 pain, followed by janndice, with disappearance of bile from stools, made it probable that this hydatid had communicated with and obstructed the main bile-duct ; while the enlargement of tumour, with fever and great prostration, was accounted for by inflammation of tumour con- sequent on entrance of bile. This was the diagnosis. On following day patient was admitted, under my care, into Middlesex Hospital, and as her condition became daily more critical it was determined to have recourse to puncture of the tumour, as holding out the only chance of safety. Accordingly, on Feb. 7, a fine trocar was introduced by Hulke in left side of epigastrium, and about six ounces of fluid drawn off". This was deeply tinged with bile and very fetid, and contained numerous pus-corpuscles and scales of cholesterin but no booklets or echinococci. On ascertaining nature of fluid small cannula was withdrawn, and a full-sized trocar substituted. Several hydatid vesicles escaped through the larger tube, but only about eight ounces more of fluid, although a probe could be passed in 6 or 8 in. It appeared, therefore, that contents of cyst consisted mainly of hydatid vesicles. A solution of carbolic acid (2 per cent.) was injected into cavity, and a large tube was tied into wound. During the ten days that followed operation, several pints of the carbolic acid solution were injected three times a day through an elastic catheter passed into cavity, and on each occasion large numbers of hydatid vesicles (with booklets and echinococci in some) came away with a fetid, purulent fluid, containing a large quantity of green bile. While this was going on, abdomen returned to almost its normal dimen- sions, and the jaundice in a great measure disappeared from integu- ments and urine, but motions remained as light as before. Patient had repeated doses of morphia after operation, and for four days pulse was about 108, temperature was normal, and no very bad symptom, except development on tongue and inside of mouth of numerous aphthous ulcers on a raised base, which caused excruciating pain whenever she took food or drinks ; but both pain and ulcers almost disappeared after repeatedly washing out mouth with Condy's ' ozonised water.' During night of Feb. 11, patient suS"ered from re- peated rigors, and after this pulse rose to 140, respirations became quick, and tongue dry ; occasional vomiting, and prostration rapidly in- creased. On morning of 18th delirium set io, and at 6 p.m. she died. On opening abdomen, peritoneum contained no fluid, and there was no sign of recent peritonitis, but there were firm adhesions between tumour and diaphragm and abdominal parietes in front. Left lobe of liver had disappeared, and its place was occupied by an enormous hy- datid cyst. This cyst contained about two pints of very fetid thick green fluid, with large fragments of parent hydatid cyst lying loose in cavity. It opened externally through wound in abdominal wall, while internally it communicated with common bile-duct by an opening large enough to admit a full-sized catheter. On slitting open duodenum I I 14 ENLARGEMENTS OF THE LIVER. MiCT. in. orifice of duct was found sufficiently dilated to admit a goose-qnill, but obstructed by a large hydatid cyst, partially protruded into duodenum.' Between this and the opening into cyst, duct was distended with hydatid vesicles. Bile-ducts throughout liver greatly dilated, and liver itself very fattv and intensely jaundiced, with a tight-lace prolongation down- wards of right lobe. No trace of bile-pigment in intestinal contents. Spleen adherent to tumour, but otherwise normal ; kidneys healthy. Recent pneumonia, at some places passing into condition of grey hepatisation, of back of lower lobe of both lungs and of upper lobe of right. The following case was in some respects very similar to the last. The attack of diarrhoea was probably due to the partial discharge of the contents of the cyst through the bile-duct into the bowel. Case XXXIII. — Hydatid T^imo^ir of Liver opening into Bile-dud — Jaundice frovi obstruction of duct hy Hydatid Membrane — Pycemia. Jane R., 33, charwoman, admitted into St. Thomas's Hosp. Nov. 13, 1874. Nothing of importance in family history. Married and had five children, of whom three are alive and well. Had ' typhoid fever ' two years ago, but on whole had good health till eight months ago, when she began to complain of an occasional gnawing pain in right hypochon- drium, which after three months spread up to the shoulders. These pains did not prevent her going about following her work, but she was usually ailing and she lost flesh. A month before admission the pain became much increased, and after a fortnight she was suddenly seized with very acute shooting pain in right hypochondrium attended by rigors and vomiting, and followed after two days by jaundice, urine like porter, and white stools. She had kept her bed from commencement of this acute attack until admission. Six weeks before admission, she first noticed a tumour in right lumbar region, which was then comparatively small, and appeared to be movable. This rapidly increased in size, especially during last three weeks. State on Admission. — Very prostrate and emaciated, but did not complain of much pain. Decided jaundice of skin and conjunctivae. No dropsy. Tongue clean, but dry down centre; sordes on lips ; no appetite ; bowels confined ; an enema brought away some white fnccal matter. Hepatic dulness much increased, commencing | inch below nipple and extending 9^ in. downwards, or to 2 in. below level of um- bilicus. Portion of liver below ribs causes a distinct bulging of 1 Tlie pre}>fir;if,ion is in th(^ museum of Middlespx Hospital. In the museum of St. Bartholomew'H IloHpifal is a 8p(!eimL-n (xix, 12) of liydatid tumour of ripht lolie of liver openinip; into bilc-iiuct, wliich is blocked up by lijdatids, one of ■which projects from the orifice of the duct into duudenum, as above. LECT. m. HYDATID TUMOUR. I I 5 abdominal parietes ; its surface firm, smooth., and somewhat tender. Left lobe of liver not enlarged, the tumour turning abruptly upwards at umbilicus towards ensiform cartilage, No induration of integu- ments around umbilicus ; no ascites ; no enlargement of abdominal veins ; splenic dulness not increased ; no sign of any bowel in front of tumour and distinct tympanitic percussion behind it. Thoracic organs healthy ; resp. 20; pulse ranges from 92 to 128, and temp, from 97° to 100°. Urine retained, or passed involuntarily, 1017, contains much bile-pigment and lithates and ^ albumen, and also a few blood-cor- puscles and epithelial scales, but no leucin or tyrosin. Occasionally delirious, and mind at all times so confused that it is impossible to obtain a clear account of her illness. On N'ov. 17 patient had rather a severe attack of diarrhoea, wbich lasted for about three days, during which sh.e passed in bed numerous black, liquid, very oifensive motions, which, unfortunately were not carefully examined. On Nov. 20 diarrhoea had ceased, and motions were again noted as light and solid. On Nov. 21 patient appeared slightly better and her mind was clearer ; but after this h.er pros- tration increased and she gradually passed into a state of stupor, with dry tongue and sordes about mouth, which, continued until death on Nov. 25. Autopsy. — Right lobe of liver greatly elongated, extending 9 in. below level of lower end of sternum. Projecting from its anterior margin, and looking very much like gall-bladder, was a hydatid cyst, about 2 in. in diameter. Another cyst, larger than a man's fist, was embedded in substance of right lobe, projecting slightly from upper and anterior surface. This cyst contained a thin purulent-looking fluid coloured with bile and several smaller cysts, and the cavity in which it was lodged communicated with the bile-ducts. A large mass of hydatid membrane blocked up the termination of common duct, and partially projected into duodenum. The common, cystic, and hepatic ducts were all greatly dilated, and in interior of liver ducts were also dilated into cyst-like cavities filled with opaque orange-coloured fluid. Gall- bladder contained three calculi and several small hydatid cysts. Kidneys congested and stained with bile, but otherwise healthy. Stomach, spleen, heart, and brain normal. Lower lobe of right lung ad- herent to diaphragm, much congested, and containing several solid blocks, one hemorrhagic, and the others dark red with a drop or two of dirty pus in interior. Lower lobe of left lung congested, but free from blocks. The following case, XXXIV., is remarkable no less for the fact that the patient recovered after discharging the contents of a large hydatid of the liver through the bile-duct into the bowel, than for the extraordinary manner in which death ultimately occurred. I 2 Il6 ENLAEGEMENTS OF THE LIVEE. lect. iii. Case XXXIV. — Hydatid Tumour of Liver, bursting into Bile-duct — Jaundice — Discliar ge of numerous Hydatid Membranes per Anmn — Recovery — Attacks of Biliary Colic from passage of Cysts remaining in Liver through Bile-duct — Rupture of old Adhesions of Liver during act of Vomiting— Peritonitis — Death. On October 29, 1861, I was consulted by Mr. G. W , a solicitor, aged 63. For some weeks lie had been suffering from flatulence and a feeling of tigbtness and oppression after meals, and three days before he had been attacked with severe pains in abdomen, resembling colic. The countenance was somewhat sallow ; motions were pale, but con- tained bile ; no bile in urine, which was scanty and dark, having a specific gravity of 1027, and depositing much lithic acid. Vertical he- patic dulness in the right mammary line extended about an inch below edge of ribs, and all along right hypochondrium there was slight ten- derness on pressure. Pulse 64. His digestion had always been good, except once, about seven years before, when he had several attacks of colicky pain in abdomen, similar to those from which he had recently suffered. The remedies prescribed by myself, and afterwards by Sir Thomas Watson, who met me in consultation, failed to give relief. On Nov. 24 patient had an attack of vomiting, followed by an atro-ravation of the dyspeptic symptoms, and by increased tenderness in right hypochondrium. On Dec. 6 he was much worse. The tenderness in right side had increased greatly, and there was also constant pain there, which became very acute when he took a long breath or coughed. Tongue furred and moist ; bowels very costive ; considerable tympanitic distension of abdomen, and increased sallowness, but no sickness. Pulse 88 ; respi- rations 30, and thoracic. Fifteen leeches were applied to seat of pain ; twelve more on Dec. 8, and eight more on Dec. 10, with poultices in the intervals, and bowels were kept open by castor-oil and turpentine enemata. On Dec. 12 pain was much less, but there was still considerable tenderness and a stitch in right side on taking a breath or coughing. Countenance very sallow, but no decided yellowness of conjunctiva, and motions, though pale, contained bile. Vertical hepatic dulness in right mammary line 5 in. Nothing like a defined tumour could be felt, and there was no bulging of ribs. Breathing at base of right lung normal. Pulse 88. On Dec. 16 and 17 patient passed, for first time, several hydatid cysts in a bilious motion. On Dec. 18 he was much Avorse. There was decided jaundice of integuments; urine loaded wilh bile-pigment, and not a trace of bile or of hydatid membranes in motions. Constant pain in right side, in addition to occasional jiaroxysms, like colic ; lips parched ; tongue furred ; much perspiration in night, and great pro.^^tration. Pulse 100. LECT. III. HYDATID TUMOUR. I I / Treafcment consisted in constant application of poultices to side, and in administration of blue pill and opium. Dec. 19. — Is mncli easier. Has passed a large quantity of hydatid vesicles, from a pin's head to an orange in size, per anum. Skin and urine still jaundiced, and no bile in stools. 20. — Faeces to-day are tinged with bile, and still contain numerous hydatid cysts. 21. — Jaundice almost gone. Motions still contain hydatids and abundance of bile. Below and to left of right nipple, tympanitic per- cussion over a space the size of a crown-piece. Both above and below this there is hepatic dulness. Pulse 88; pain much less; tongue cleaning. The patient continued to pass a few hydatid vesicles with each motion up to Dec. 31, and the tympanitic percussion sound above noted remained a few days later than this. He had occasional sharp, but temporary, attacks of pain in abdomen, resembhng colic. On Jan. 6, 1862, he was quite convalescent. Pulse 72. The tympanitic sound noted above could no longer be distinguished, and upper border of hepatic dulness was an inch lower than before. At end of Jan. Mr. W was able to drive out ; and on Feb. 19 he went to Ventnor for change of air, returning to London on March 11. Once, while at Ventnor, he had a severe attack of colicky pain lasting for an hour and a half, and ' bending him up double.' He had a similar attack, but less severe, a few days after his return to London. Both attacks were unaccompanied by vomiting. Every day he gained strength, and on his return to town he was able to resume his business. On April 2 he went down to Essex on business. He walked about the country several miles every day, feeling none the worse, and returned to town on April 6. On April 8 he went to his business as usual, and walked several miles. Shortly after dinner, about 7 p.m., he was suddenly seized with severe pain in abdomen, which returned in paroxysms, and this time was accompanied by vomiting. There was slight tenderness at epi- gastrium, but no jaundice. Pulse only 84. Repeated doses of opium and chloric ether were prescribed, and poultices were kept constantly applied over abdomen. On following day, the paroxysms of pain had ceased, but there was more tenderness at epigastrium and in right hypochondrium, and con- siderable pain when he coughed or moved. The vomiting had not quite ceased. There was slight sallowness, but stools contained bile. Pulse 86. Ten leeches were ordered to be applied to side, and the poultices and opiates were to be continued. The patient did not apply the leeches, as he felt better. In the afternoon, he had two severe attacks of rigors, after which he felt so much better and free from pain that he thought it unnecessar to send for me. I 1 8 ENLARGEMENTS OF THE LIVEK. lect. hi. On the morning of April 10 he said that he felt so much better that he had eaten a good breakfast, and he wished to get up and go down stairs ; but he was in a state of extreme prostration, and evidently sinking. The pulse was 120 at the elbows, and imperceptible at the wrists. The sickness had ceased, but the features were pinched, and the skin was cold and covered with clammy sweat. He gradually sank, and died at 8 p.m. Autoj)sy. — Abdomen only was examined. On opening this cavity intestines appeared healthy, but distended with gas. No exudation or increased vascularity in general cavity of peritoneum. Large intes- tines contained a quantity of pulpy material of colour of cream, and without any tinge of bile. Small intestines contained bile. Left lobe of liver was healthy and non-adherent. Both the upper and under surfaces of right lobe were firmly adherent to adjoining parts. Near right edge of liver a few of the bands of adhesion fasten- ing it to ribs appeared to be ruptured, and at this point there was a patch of recent lymph not larger than a square inch, with slightly in- creased vascularity round about. In substance of right lobe was an irregularly-shaped, collapsed cavity, the size of a large orange ; walls of this cavity were partly formed by ribs and surrounding adhesions ; its inner surface consisted of indurated hepatic tissue, presenting a shreddy appearance, and not lined by hydatid membrane. The cavity was almost empty ; but it contained four or five collapsed hydatid vesicles about size of a shilling. Communicating with it was a greatly dilated bile-duct, passing directly on to the common duct. The entire duct, from the cavity to the orifice in duodenum, was large enough to admit tip of little finger.' Fui-ther back, in right lobe, and quite dis- tinct from cavity now described, was another, about size of a plum, which was lined by an obsolete and cribriform hydatid cyst, presenting a tough, opaque yellow appearance. The contents of this cavity had escaped during the hurried division of the liver. (This tumour may have been the source of the symptoms from which patient had suffered seven years before his death). Case XXXV., like Case XXV., illustrates the good eflFects of antiseptic treatment after the free opening of a large hydatid which had undergone suppuration. Case XXXV. — Suppurating Hydatid of lAver. Free Incision — Itecovery. Miss M , aged 24, consulted me on Nov. 24, 1869. She stated that for two years she had noticed a bulging of the lower right libs. This had come on without pain, and had not increased much since it had been first observed. The bulging was quite obvious: the ' Tho preparation is in museum of Middlesex Hospital. LECT. III. HYDATID TUMOUR. I I9 girth of the right side of the chest below the breast was 15^ in., of the left 13^ in. The hepatic dulness in the right nipple line ex- tended from the nipple 8 in. downwards ; it did not rise too high at the back, and its upper border was arched. The intercostal spaces over the bulging were obliterated, but nothing like fluctuation could be made out. There was no tenderness on pressure, and the general health was good. I saw nothing more of the patient until Feb. 4, 1873, when she stated that for two months she had been liable to attacks of severe pain, shooting from the back to the front of the swelling, which made her scream and prevented sleep. These attacks were very apt to come on when she lay down. She had also uneasiness in the stomach after food, and was losing flesh. The swelling had increased especially in an upward direction. Below the breast the girth on the right side was 16 in. and on the left 14| in. The hepatic dulness in front rose to 1^ in. above the nipple, and from this extended 9|^in. downwards, to 3 in. below the ribs ; posteriorly also the hepatic dulness rose an inch or two above its normal level, and air entered imperfectly into lower lobe of right lung. No perceptible fluctuation, Pnlse 108, temperature somewhat elevated. I expressed the opinion that the tumour was hydatid, and advised that an exploratory puncture should be made into it. Sir W. Jenner, who saw the patient with me on Feb. 22, coincided in this opinion and advice. On Feb. 24 the swelling was punctured between the sixth and seventh right ribs in front ; 3 drachms of pus escaped ; the opening was closed, and on Feb. 26 a free incision was made at the same spot by Mr. De Morgan, and 4 pints of pus containing numerous large hydatid cysts were evacuated. The cavity was washed out with a solution of chloride of zinc (20 gr. to §j), and a piece of elastic tube was left in the open Id g, through which a weak solution of carbolic acid was daily in- jected, and external opening was covered with carded oakum. The severe pain from which the patient had previously suffered was at once relieved. Much pus and hydatids continued to be discharged until March 17, when what appeared to be the parent sac escaped. After this the discharge rapidly diminished, and the patient began to gain flesh. On April 28 the tube was removed, and soon after opening closed. On April 8, 1875, patient was in enjoyment of excellent health. In Case XXXYI. tlie hydatid tumour not only suppurated, but induced pyaemia, with secondary deposits of pus throughout the liver. Case XXXVI, — Supjpurating Hydatid Tumour of Liver — Pyoemia, with secondary Deposits of Pus. Thomas B , aged 35, was admitted into the London Fever Hosp. on Jan. 20, 1866. He had lived for twenty years in Tasmania, but for the last four jears in England, His previous health had always 120 ENLAEGEMENTS OF THE LIVER. lect. iu. been srood. His illness commenced five weeks before admission with severe pain in right side, followed three weeks later by jaundice and diarrhoea. When seized with the pain, he first noticed a swelling in right side ; but this was as large then as at time of admission. Patient was emaciated and jaundiced, and liver was much enlarged, vertical dulness in right mammary line being eight inches. The portion of Jiver projecting below right ribs was smooth, painless, elastic, and almost fluctuating, but yielded nothing like ' hydatid vibration.' Moderate ascites. Pulse 9G ; tongue moist and red ; no appetite ; six or seven liquid stools daily, containing little or no bile. Considerable sweating at night. Three or four days after admission, irregular attacks of rigors set in ; diarrhoea continued ; emaciation and perspirations in- creased ; tongue became dry and brown ; and on Feb. 22 patient died. On two occasions (Jan. 31 and Feb 7) an exploratory puncture was made into tumour. On first occasion nothing came away, owing to trocar being too short ; on second occasion about six ounces of thin purulent bilious fluid were drawn ofi*, which, unfortunately, was not submitted to microscopic examination. No bad consequence appeared to follow either operation. At the autopsy, a hydatid cyst, as large as a child's head, and full of pus and secondary hydatids, was found projecting from under sur- face of Hver, compressing portal vein and bile-ducts. The liver was studded with numerous small abscesses, and its outer surface was coated with recent lymph. Traces of the punctures were discovered with difiiculty, and there was no evidence of increased inflammatory action in their neighbourhood. In the following case tlie suppuration of a hydatid appears to have induced pyaemia, with secondary gangrenous abscesses in the liver. The anatomical characters of the liver agreed with those of 'gangrene of the liver' as described by Roki- tansky.' This disease, however, is so rare that experienced observers have denied its occurrence, and !Frerichs makes no mention of it. Even Rokitansky had met with only one ex- ample, and there it was associated with pulmonary gangrene. Budd reports one case, and quotes another from Andral.^ Con- sidering the rarity of such cases, the remarkably fetid odour observed during life is of clinical interest. Case XXXVII. — Suiiptiratlng Hydatid — Fycemia, with secondary Gangrenous Abscesses in Liver. A man, aged 27, was adm. into London Fever Hospital under my care, Feb. 23, 18(57. He was so prostrate that he could give little « Path. Anat. Syd. Soc. Trans, vol. ii. p. 136. « Budd, op. cit. 3rd ed. p. 129. LECT. III. HYDATID TUMOUE. 121 account of himself, and all that could be ascertained was that he had been a soldier in the West Indies for about seven years, but that his health had been good until about a month before admission, when he was seized with pain in epigastrium and right hypochondrium, with nausea and vomiting, and about sarae time he first noticed a tumour below right ribs, pain in which made it difficult for him to button his tunic over it. On admission he lay on his back, with his legs drawn up ; abdomen full and tender all over ; friction heard distinctly over liver, which appeared large, extending downwards to crest of ilium, and upwards to lower border of third rib. Tongue dry and brown ; frequent vomiting ; but no jaundice, and bowels stated to be regular. Splenic dulness increased. Pulse 132 and feeble ; heart's sounds normal ; i-espirations quick and thoracic ; dulness on percussion over back of right lung, and moist sounds heard over greater part of both lungs. Skin hot, face pale : features pinched. On following morning prostration had increased, and, in addition, there was noted slight jaundice of conjunctivas, and a peculiar, very fetid odour — sui generis, which appeared to proceed from entire body, and not from breath in particular. This was noted in case-book before patient's death, which took place on same day. On post-mortem examination, which was made on day after death, considerable evidence of recent peritonitis, particularly in neighbour- hood of the liver. Projecting from under surface of right lobe of liver, and but slightly embedded in it, was a hydatid cyst, larger than a cocoa- nut. The wall of the parasite was opaque, tough, and cribriform, from presence of numerous large openings, and its interior was filled with dirty brown purulent fluid, having a very ofiensive odour. En- tire liver studded with numerous softened masses from the size of a nut up to that of a small orange, in which hepatic tissue was softened, and consisted of a spongy material, corresponding to the fibrous stroma and vessels, saturated with a greenish, extremely fetid, pulpy fluid. Embedded in substance of liver, near anterior edge of right lobe, was a healthy hydatid cyst, about the size of a chestnut, containing clear fluid and ecchinococci. Lungs congested, but nowhere inflamed or gangrenous. In the following case the hydatid tumour was so large as to almost fill the abdominal cavity, and bile had entered the cyst. The real nature of the case was not recognised during the patient's life, and paracentesis was resorted to merely as a palliative to relieve the patient's extreme distress, and with no idea of effecting a cure. 122 ENLAEGEMENTS OP THE LIVEK. iect. in. Case XXXVIII. — Enormous Hydatid Cyst of Liver, passing down through Foramen of Winslow, and filling almost whole of Abdominal Cavity — Paracentesis — Pleurisy — Tubercle of Lungs — Death from Exhaustion. Elizabeth C , aged 15, adm. into Middle.sex Hosp. under Dr. Greenhow, August 26, 1862. She had been a very healthy infant, but at ao-e of 3 she had a severe fall on her right side, and since then she had never been well. For nine or ten years a swelling had been observed in rio"ht side of abdomen. Three years before admission she had been a patient in a London hospital, but she bad left on account of some operation having been proposed. The tumour increased gradually in size without causing pain, while at sa.nie time patient became thin and weak. Four weeks before admission she had been attacked with scarlatina, and during convalescence or for the last few days before admission, a very rapid increase had taken place in size of tumour, and there had been occasional pain in abdomen. At time of admission, face and extremities were greatly emaciated ; countenance had a haggard, anxious expression, and conjunctivae were slightly tinged yellow. Abdomen enormously enlarged, and yielded distinct fluctua- tion ; but the remarkable fact was that there was resonance on per- cussion in both flanks, as well as in epigastric and both hypochondriac regions. Patient suffered from attacks of dyspnoea and of severe pain in abdomen. Pulse 100, and feeble ; no abnormal sound with heart ; respirations hurried and thoracic ; appetite good ; bowels regu- lar ; urine very scanty and loaded with bile. On Sept. 3 the abdo- minal pain and dyspnoea had become so distressing that the operation of paracentesis abdominis was performed as a palliative measui'e, and 248 ounces of a dirty brownish fluid were drawn off. The fluid was, unfortunately, not submitted to the microscope or to chemical reagents. The immediate effect of operation was great relief to the pain and dyspnoea ; but within three days the swelling was observed to be rapidly increasing, and on Sept. 26 its dimensions were larger than before operation, although dyspnoea was not nearly so urgent. On following day, patient died from exhaustion. Autopsy. — On dividing abdominal parietes, about 14 pints of straw-coloured serum escaped. Greater part of abdominal cavity, as far down as pubes, was lined with a closely adherent gelatinous mem- brane, forming part of an enormous hydatid cyst, by which stomach and intestines were pressed up closely against under surface of diaphragm and liver, where they were matted together, their peritoneal surface being considerably injected. Floating in the fluid, in the large abdo- minal cyst, was a secondary cyst containing about a pint of fluid and what appeared to be the debris of other cysts. Several cysts of smaller size were likewise found in cavity of the large sac. On trac- ing the large primary cyst, it was seen to be continuous with a cyst about the size of a child's head projecting from, and attached ta LECT. III. HYDATID TUMOUE. 1 23 under surface of liver. The two cavities, in fact, constituted one cyst, with an hour-glass constriction, the channel of communication being large enough to admit three fingers, and apparently corresponding to foramen of Winslow. Gall-bladder compressed, empty, and atrophied. Attached to anterior border of left lobe of liver, by a thin fibrous peduncle, was another tumour about size of a goose's egg, which, on being opened, was found to contain a crumpled-up hydatid cyst, filled with a putty- like material, in which were numerous booklets of echino- cocci. A third tumour was found attached to upper surface of right lobe of liver, and firmly adherent to under surface of diaphragm, which was pressed up into cavity of right pleura. This tumour was lined with a cyst, containing about a pint of straw-coloured serum, and inner surface of which was studded with ecbinococci. Right pleural cavity contained about a pint of semi-purulent fluid, and op- posed surfaces of pleura, at base of right lung, were coated with a deposit of recent semi-organised lymph. Both pleural cavities were much diminished in calibre by elevation of diaphi-agm, and both lungs contained numerous scattered miliary tubercles. Heart small, but, in other respects, normal. Spleen pale and shrunken. Kidneys lai'ge and congested. In th.e next three cases a hydatid of the liver proved fatal by opening into the pleura or lung. The first case, which occurred while I was pathologist to the Middlesex Hospital, illustrates the absence of all symptoms in a large hydatid tumour of the liver prior to its bursting into the pleura, and also the difficulty in diagnosis likely to arise from the CO- existence of empyema with hydatid enlargement of the liver. Case XXXIX. — Hydatid Tiimour of Liver, hursting into Right Pleura — Empyema — Death. Louisa R , aged 17, adm. into Middlesex Hosp. under Dr. H. Thompson, -March 23, 18G1. She was a servant, and until a fort- night before she had continued at her work, enjoying good health, and not sufiering any pain or uneasiness. She was then suddenly seized with acute pain in upper part of abdomen and on both sides of chest, which was increased by inspiration, and was accompanied by cough, dyspnoea, febrile symptoms, and great prostration. On admis- sion, pulse 112, small and weak. Slight cough. Dulness and ab- sence of breathing over whole of right side of chest, except in infra- clavicular space. There was likewise dulness, with feeble breathing, at base of left lung. Hepatic dulness in right mammary line extended nearly four inches below margin of ribs. No jaundice and no ascites ; but urine contained albumen. Hectic fever, with great prostration, set in, and death occurred on April 8, one month after first symptom of illness. 124 ENLARGEMENTS OF THE LIVER. lect. hi. Aiifojjsij. — Heart normal. Left lung firmly and Tiniversally ad- herent : its lower lobe hyperffimic, and near base its tissue sank in water ; but it was not granular on section, and it was unusually firm and tenacious. Right pleural cavity filled with pus, floating in which were innumerable hydatid vesicles, from size of a pin's head to that of an orange. Right lung completely collapsed and carnified, except at apex, which contained a little air. Liver much depressed, its lower margin reaching to more than half-way between umbilicus and pubes. Projecting from posterior margin of right lobe was a cyst as large as a child's head, and firmly connected to diaphragm ; liver not adherent at any other part of its surface. At upper part of cyst there was a rupture through diaphragm, measuring one inch and a half in dia- meter, by which cyst communicated with right pleura. The interior of cyst was lined with a hydatid membrane ; its cavity was filled with pus and vesicles. A large number of the vesicles were examined with micro- scope, but no echinococcus or booklet could be discovered. No other hydatid tumour either in liver or ia any organ of body. Pelvis and calices of right kidney and upper part of right ureter dilated, appa- rently owing to pressure below of the displaced liver ; secreting tissue of right kidney much atrophied ; left kidney normal. Case XL. — Hydatid Tumour of Liver, opening into Bdght Pleura — Emjnjem a — Pericard it is . George K — — , aged 54, a gardener, of sober habits, adm. into Middlesex Hosp. under Dr. F. Hawkins, April 25, 1854. He had al- ways enjoyed good health until four months before admission, when he was suddenly seized with pain all over abdomen, but particularl}^ in right hypochondrium, and extending thence to right shoulder. About same time he became slightly jaundiced. The pain and jaundice con- tinued ; and at time patient came under observation he was very weak and emaciated, and suffered from incessant cough. Liver much enlarged, extending down to umbilicus. Considerable bulging of right side of chest, which was universally dull on percussion, and de- void of respiratory murmur, except at upper and back part close to spine. Patient gradually sank, and died on May 10. Autnjisy. — Right pleural cavity was filled with a yellowish, turbid, semi-purulent fluid containing masses of a gelatinous substance, which proved to be hydatid cysts. Right lung compressed and flattened against vertebral column, and at its base was firmly bound by adhe- sions to diaphragm. It did not crepitate in the least ; it sank in water, and was completely caniiCed. Liver enormously enlarged, ex- tending down as far as umbilicus, and weighing 90 ounces ; it was firmly adherent to diaphragm. In posterior part of right lobe was a cavity as large as a swan's egg, lined with a hydatid cyst, and con- taining similar cysts in its interior. Upper wall of this cavity was LECT. in. HYDATID TUMOUE. I25 formed by tlie diapliragm, and here there was a large opening by which the cavity in the liver communicated with right pleura. The liver was much congested. Pericardium glued to heart by recent soft adhesions. Left lung, spleen, and kidneys healthy. Case XLI. — Old Hydatid (?) of Liver, commuwicaUng with Base of Right Lung — Lobular Fneiwionia and Gangrene of Lung. Robert J , aged 72, was sent to London Fever Hospital, August 21, 1864, as a case of ' fever.' On examination, he was found not to be suffering from any form of idiopathic fever. The man stated that he had had a bad cough for two months, and had kept his bed for two days. His breath had a most decidedly gangrenous odour • sputa of a dirty greenish muco-purulent character, and extremely fetid. Dry bronchial rales audible over chesit, and at right base slight duhiess, with increased vocal resonance, and large moist rales, but nothing approaching to cavernous breathing. Pulse 96 ; respirations 36. IS'o change took place in physical signs of chest ; but tongue be- came dry and brown; diarrhoea supervened; and patient gradually lost flesh and strength until death on Sept. 11. On post-mortem examination, there was lobular pneumonia of lower lobe of right lung, and quite at base a gangrenous portion about size of an orange. Lung was here firmly adherent to diaphragm and diaphragm to liver, and the broken-down tissue of the gangrenous lung communicated by several openings with a cavity in upper part ^f right lobe of the Hyer, measuring about three inches in diameter. This cavity contained much calcareous matter and a quantity of a dirty greyish, very fetid, pultaceous substance. On careful examina- tion, no booklets of echinococci could be discovered. Rest of Hver and the intestines healthy. The absence of booklets may be thought to negative the opinion that the tumour of the liver was originally an hydatid. But though these booklets resist the changes which occur in the interior of the body for an indefinite period, they do not resist the putrefactive changes resulting from exposure to atmospheric air, and such expo- sure must have existed here for many weeks before death. An obso- lete abscess is the only other lesion that could have produced the appearances described, but the man had never suffered from the sym- ptoms of abscess of the liver. In the two following cases, and also in Case XXXIX., the tumour appeared to compress the ureters. Case XLII. — Hydatid of Liver — Pyelitis — Pus in Urine — Sudden Death. Ellen C , aged 21, came under ray care as an out-patient at Mid- dlesex Hospital, in April 1861. She stated that for about eighteen 126 ENLARGEMENTS OF THE LIVER. lect. hi. months she had been getting very weak and losing flesh, and that latterly she had suffered from dyspnoea. She had no cough, but lier father had died of consumption. She had also suffered from irregular menstruation and leucorrhoea. On examining chest, there was found to be a bulging of right side, commencing at upper border of fifth rib, attaining its maximum at false ribs, and then as gradually declining. Hepatic dulness in right mammary line extended for 3 in. below margin of ribs, and its total length was 6^ inches. The bulging below ribs occupied right hypochondrium and epigastrium, and extended over to left hypochondrium ; it was slightly tender, and presented an elastic, almost fluctuating consistence, and on percussion commu- nicated to finger the peculiar sensation known as ' hydatid vibration.' These characters were most marked in epigastrium. Superficial veins about epigastrium and hj'pochondrium much enlarged. Movements of respiration mainly confined to left side of chest. On right side, respiratory murmur could not be heard below fourth rib in front, or below lower angle of scapula posteriorly. Above this breathing was harsh and expiration prolonged. On left side dulness and ab- sence of respiration up to Avithin half an inch of lower angle of scapula. Patient could give no information as to length of time tumour had existed. In fact, she was quite ignorant of existence of any unusual swelling until it was pointed out to her. Her complexion was slightly sallow, but she had never suffered from jaundice or vomiting, and her bowels were regular ; appetite very bad. In addition to tumour on right side, a painful swelling, apparently the displaced left lobe of liver, could be felt in left lumbar region in situation of kidney, and there was a copious discharge of pus in urine. The patient remained under my observation for nearly twelve months. The dimensions of the tumour did not alter much, but, on the whole, they became slightly larger. From time to time she suffered severe pain in swelling in left lumbar region. At these times urine was clear, or almost so, and relief was always attended with a sensation of bursting and a return of pus in large quantity. Urine was repeatedly examined with microscope, but no pus, casts, or trace of echinococci could be discovered. The treatment — which consisted in administration of tonics and iodide of potassium, and external application of iodine — failing to give relief, patient was admitted into hospital on Jan. 14, 1862, with the object of having a puncture made into the tumour in right hypochon- drium. After remaining in hospital for six weeks she refused to give her consent, and was discharged at her own request. I did not sec the patient after this : but I ascertained that, on Nov. 6, 18G3, she was admitted into University College Hospital, under care of Dr. Hare, to whom I am indebted for the particulars noted while she was under his observation. Towards the end of 18G2 she had first suffered from pain in region of tumour in right hypo- LECT. III. HYDATID TUMOUR, 127 chondrinm. The pain was intermittent in its character, ceasing after a few days. For this she had been treated at the Female Hospital in Soho Square. The dimensions of tamonr noted in University College Hospital showed that it had increased considerably. Although right costal angle was still greater than left, there was bulging of ribs on both sides as high as nipple, and dulness on percussion up to third rib on right side, and up to third intercostal space on left side. The heart was displaced upwards, its apex beating in third left intercostal space. Vertical hepatic dulness in a line with right nipple was Hi in., in mesial line 9f in., and in a line with left nipple 9^ in. Dis- tinct fluctuation could be felt in epigastrium over a space measuring 4^ in. transversely and 2^ in. vertically ; but there was now no hydatid fremitus. N"o oedema of legs. Patient was sallow ; her urine contained no bile-pigment, but was still loaded with pus. She still suffered from attacks of pain in region of left kidney, which were always relieved by a sensation of bursting and a copious discharge of pus in urine. On admission, there was a considerable amount of pain and tenderness in region of tumour near umbilicus. This pain recurred from time to time, but was always relieved by leeches, poul- tices, and morphia. Patient also had an attack of pain and stiffness in left groin and knee, accompanied by enlargement of lymphatic glands in groin, and slight oedema in upper part of thigh. On Jan. 26, 1864, it was noted that she was free from pain, but that she had lost flesh and strength. On Feb. 9 she was discharged for unruly conduct. The patient was confined to bed after leaving hospital, and died rather suddenly and unexpectedly at end of ten days. An hour before death she seemed tolerably well, and the probability is that the fatal event was due to the bursting of a hydatid ej^st. Case XLIII. — Hydatid Tumours of Liver and Peritoneum, compressing Ureters, and causing Degeneration of Kidneys. Mary Ann W , aged 45, adm. into Middlesex Hosp. Dec. 15, 1864, under cai^e of Dr. H. Thompson, and died Jan, 15, 1865, For a year before death she had suffered from headache and impairment of mental faculties, and seven weeks before death she had a fit of uncon- sciousness, followed by right hemiplegia, involuntary evacuations, and bed-sores. There were no symptoms referable to liver. The arteries at base of brain were atheromatous, and there was an apoplectic cyst, with a patch of white softening in left corpus striatum. Liver, spleen, and diaphragm were adherent by fibrous bands. In the adhesions between spleen and liver was a cyst the size of a walnut, filled with soft putty-like matter, and lined by portions of a gelatinous hydatid membrane. In right lobe of liver was another cyst, the size of a small cocoanut, partly embedded in its substance and partly 128 ENLARGEMENTS OF THE LIVEE. lect. in. projecting from its upper surface, where it was firmly adherent to diaphragm. Its outer wall was partly calcified, and its interior was full of fragments of secondary gelatinous cysts and soft putty-like matter. Secreting tissue of liver healthy. In folds of mesentery of small intestine were three partly calcified cysts, varying in size from a hazel-nut to a walnut, and containing putty-like matter and second- ary cysts. Greater part of pelvis was occupied by another large cyst, situated behind and above uterus, which was forced down so as to appear at vulva. This cyst contained a clear fluid and innumerable small cysts, varying in size from a pea to a walnut, all of them gelati- nous and filled with a clear fluid Another cyst, not so large, in right side of pelvis. Ureters were compressed by these cysts, and pelves of kidneys somewhat dilated. Kidneys small and granular, and cortices w^asted and hardly distinguishable from cones. All of cysts in ab- domen contained booklets of echinococci. In the following case secondary hydatid cysts were formed in the omentum and peritoneal cavity. Case XLIV. — Hijdafid Cysts of Liver and Peritoneum — Ascites and Anasarca of Loiver Extremities — Albuminuria — Death. Catherine C , a hawker, aged 45, was a patient in Middlesex Hospital from Jan. 10, 1865, until her death on June 21. With excep- tion of an attack of rheumatism, she had enjoyed good health until about a month before admission, when she had been seized with violent pain in abdomen and loins, and at same time her legs and abdomen had begun to swell. While in hospital, she had ascites and great anasarca of lower extremities ; urine contained albumen. She was treated with diuretics and purgatives, and her legs were punctured. On examination of body, legs were very cedematous, and abdomen was greatly distended. Both lungs very cedematous, and right lung firmly adherent and carnified at its base. Peritoneal cavity contained upwards of a gallon of clear serum, floating about in which were six nearly transparent hydatid cysts, with tremulous gelatinous walls, the largest about size of a hen's e^^, and smallest about that of a walnut. The fluid in the floating cysts had a specific gravity of 1010, and contained no albumen ; that in peritoneal cavity had a specific gravity of 1020, and was highly albuminous. Left lobe of liver partly atrophied, and between it and spleen, and firmly adherent to both and to stomach was a hydatid cyst the size of a foetal head, containing a little clear fluid and innumerable smaller cysts of various sizes pressed together. In great omentum were three or four similar cysts the size of chestnuts, and attached to right kidney was another cyst as big as an orange. Echinococci were found in the larger cysts. Both kidneys much enlarged and fatty. LECT. III. HYDATID TUMOUE. 1 29 Case XLY. shows how closely hydatid of the liver may simu- late cancer. Case XLV. — Hydatid Tumour of Liver simulating Cancer — Discharge of Hydatids per anum, and temporary recovery. On Nov. 1, 1871, I saw, in consultation with Dr. Mackintosh, of Brompton Road, Mr. C , aged 33, jobmaster, but formerly a pub- lican. His illness was believed to have commenced only three or four months before with an attack of pleurisy on right side attended by effusion. Since then had lost flesh, and, two weeks before I saw him, abdomen had begun to swell. Never had syphilis ; had not been in- temperate, and no history of cancer in family. Over lower four-fifths of right chest there was dulness continuous with that of liver, and absence of breath-sound and of vocal thrill. Heart displaced to left, but no bulging of right side, and measurement of two sides equal. Mode- rate ascites. Lower margin of right lobe of liver, three or four inches below ribs, distinctly nodulated and tender. Occasional vomiting, but no jaundice. Four days after this feet began to swell, and oedema rapidly in- creased ; and on Nov. 8, when I saw patient a second time, temp. 101°, and pericardial friction over heart. I did not see patient again, for, soon after my second visit, he was removed to Brighton. Here, I am informed by Dr, Mackintosh, he passed a large quantity of hydatid cysts per anum, the dropsy disap- peared, and he got so much better that he was able to return to his employment in London. He died, however, about a year afterwards, while under the care of another medical man. Case XLVI. — Hydatid Tumour of Liver — Secondary Hydatid Tumours in Spinal Canal — Paraplegia. The preparation of this case is in the museum of Middlesex Hos- pital (v. 15), and the following particulars are extracted from the Catalogue : — ■ ' Vertebrse with spinal cord from dorsal region. The canal and dura-mater laid open. The pleura is separated from the ribs, and the sides of the bodies of the vertebrse by two hydatid cysts, one on each side. The hydatids have been opened in sawing through the laminae of the vertebrse ; but their walls remain, and the spinal cord is at this place considerably smaller than elsewhere. ' The patient was a woman aged 40, who had been admitted into the hospital with paraplegia and retention of urine. She died with a large slough on the sacrum, and the bladder was found to be inflamed. There was also a large hydatid cyst in the liver.' In the following case a process of spontaneous cure appears K I 30 ENLARGEMENTS OF THE LIVER. lect. hi. to have commenced in the tumour, and the observation is in- teresting in connection with the manner in which a c;ire is probably effected in a hydatid tumour, when the fluid contents are drawn ofi" by means of a small trocar and cannula (see pages 73 and 83). Case XLVII. — Large Hydatid Tumour of Liver, full of secondary Cysts, hut containing no Fluid. This liver was taken from body of a man, aged 36, who was ad- mitted into the Fever Hospital on Dec. 2, 1866, with hsemorrhagic small-pox, of which he died on Dec. 5. He was too ill to give any particulars of his previous history. After death, a hydatid tumour, the size of a child's head, was found in posterior part of right lobe of liver. The chief points of interest in the case were that this cyst was tightly packed with secondary cysts, and that it contained no fluid. The secondary cysts were collapsed ; but still they exhibited their natural gelatinous appearance. They were not at all opaque or mixed up with any putty-like material. The outer cyst, however, at several places presented an atheromatous calci- fied appearance. Case XLVIH. — Large Hydatid of Liver undergoing ^spontaneous cure ' froin calcification of cyst, and discovered after forty -five years. On Feb. 10, 1873, I was requested by Dr. W. Steer Riding to see Mr. W , aged 56, on account of a remarkable tumour connected with the liver. Liver did not ascend too high in front or at back ; but lower margin of right lobe descended to two inches below umbilicus, and the portion below ribs felt as hard as bone, and was smooth and painless. Patient had no symptoms referable to tumour, and had led an active life, until a trifling ailment of lungs led to discovery by Dr. Riding of tumour, as to existence of which patient himself was igno- rant. He remembered, however, that when a child, at least 45 years before, he had been brought a long distance from the country to London to see Sir Astley Cooper and another surgeon ; that his liver had then been said to be four times its proper size, and had been thought to contain fluid, and that there had been a question of per- forming an operation. It had been decided not to interfere, and the tumour bad gradually got smaller as he had grown older. CONGESTION. I3I LECTUEE IV. ENLARGEMENTS OF THE LIVER. CONGESTION — INTERSTITIAL HEPATITIS INFLAMMATION OF BILE-DUCTS — OBSTRUCTION OP COMMON DUCT. Gentlemen, — In tlie previous lectures I have called your at- tention to the distinguishing characters of the four enlarge- ments of the liver which are for the most part unattended by pain. Those in which pain is a prominent symptom remain to be considered. Seven diseases are included under this head ; viz. 1. congestion of the liver ; 2. interstitial hepatitis ; 3. in- flammation of the bile-ducts; 4. obstruction of the common duct and retention of bile ; 5. pysemic abscesses ; 6. tropical abscess ; 7. cancer. Speaking generally, it may be said that jaundice, which is a rare symptom in painless enlargements of the liver, is present to a greater or less extent in the class of enlargements now to be noticed ; tropical abscess is the one in which it is oftenest absent. Ascites is also a common symptom. First among the enlargements of the liver attended by pain comes — V. CONGESTION OP THE LIVER. In the first place, it is necessary to bear in mind in reference to the pathology and treatment of this condition, that the quantity of blood in the liver varies greatly at different times consistently with health, and that even these healthy variations may influence to some extent the size of the organ. For instance, the amount of blood in the liver and its size are greatly influenced by diet, both being temporarily increased after a meal, and particularly when the food has been too large in quantity, or has contained an excess of fatty, saccharine, or alcoholic ingredients. By morbid congestion of the liver, we mean something more than this. The phrase "^ congestion of the liver ' is too often used very vaguely, and applied to cases of K 2 132 ENLARGEMENTS OF THE LIVEE. lect. rv. indio-estion where there is probably little amiss with the liver. True congestion of the liver is distinguished bj the following characters : — 1. There is enlargement of the liver which is uniform in character — not greater in one direction than in another — and which is rarely very great. The liver may project an inch or more below the margin of the ribs in the right mammary line. In the venous engorgement from mechanical obstruction of the circulation, the enlargement is usually greater than in active congestion, where the engorgement commences in the arteries. Another peculiarity of this enlargement is that it is rarely per- manent, but that after a time it usually disappears. Even when the cause of the congestion is most permanent, such as me- chanical obstruction of the cardiac circulation from valvular disease of the heart, the enlargement of the liver gives place after a time to an opposite condition of contraction. The pressure exerted by the constantly distended hepatic veins causes atrophy of the central portions of the lobules, and induces a form of granular liver, different from true cirrhosis, where the atrophy commences at the circumference of the lobules. 2. The surface of the portion of liver projecting below the ribs is smooth. 3. The patient complains of a feeling of tightness or painful distension in the region of the liver, and there is more or less — but rarely very acute — tenderness on pressure below the margin of the right ribs. The pain and feeling of uneasiness may, in consequence of the connection of the subclavius nerve with the phrenic, stretch up to the right shoulder, and they are almost always increased after meals or by lying on the left side. In the latter case there is usually a sense of dragging or weight in the hepatic region. The patient consequently sleeps for the most part on his back, or on his right side. 4. Jaundice is present in most cases after two or three days, but is rarely intense, and it is not often that bile is altogether absent from the motions. When there is intense jaundice with absence of bile from the stools, catarrh of the ducts is probably present, as well as congestion of the hepatic tissue. 5. There is usually nausea, with loss of appetite, headache, furred tongue, a bitter taste in the mouth, flatulence, and other symptoms of indigestion, and not unfrequently there is vomiting or diarrhoea, or both. The same cause that produces congestion of the liver may induce a similar condition of the stomach and i.ECT. IV. CONGESTION". 1 33 intestines; slight irritation then suffices to induce catarrhal inflammation of the mucous membrane of these parts, of which vomiting and diarrhcea are the prominent symptoms. With these derangements of digestion it is not uncommon to find ana3mia, general languor and debility, emaciation, depression of spirits, drowsiness, and hypochondriasis. 6. More or less dyspneea is not uncommon, even in cases where the primary disease is not in the chest, and many patients are harassed by a frequent dry cough. The dyspnoea may be so great as to raise the suspicion of serious mischief in the heart or lungs, but it is often entirel}'' removed by free purgation. 7. Signs of obstructed portal circulation are not uncommon. In acute cases there may be tension in the left hypochondrium, and an increased area of splenic dulness ; while in more pro- tracted cases there may be haemorrhoids or ascites. 8. The urine is usually scanty and high-coloured, and besides containing more or less bile-pigment, often deposits a copious sediment of lithates or lithic acid. Temporary albuminuria is not uncommon. 9. As in other forms of enlargement of the liver, the cir- cumstances under which the enlargement appears constitute an important aid to the diagnosis of the real nature of the case. Hepatic congestion may be mechanical, active, or passive, and the chief conditions under which it occurs are the following : — A. Mechanical. — Among the most common causes of hepatic congestion in this country is mechanical obstruction of the circulation in the chest, and particularly that consequent on disease of the mitral or tricuspid valves of the heart. In many cases of valvular disease of the heart, a time arrives when the chief symptoms are those of hepatic congestion, and the main treatment must be directed to their relief. B. Active. — Several causes contribute to the development of active congestion : — a. Irritating ingesta, in the form of alcohol, fermented liquors, spices, or food which errs in being habitually too rich in quality or in excessive quantity may cause congestion of the liver. The temporary increase of blood in the liver always present after a meal may become morbid in degree and permanent, if the ingesta be habitually of an irritating character. Conges- tion of the liver is more likely to result from these causes in weakly persons who lead indolent and sedentary lives, than 1 34 ENLARGEMENTS OF THE LIVER. lect. iv. in persons of a robust constitution who take plenty of muscular exercise in tlie open air. h. A high temperature is usually reckoned among the causes of congestion of the liver, but probably rarely leads to such a result except in conjunction with irritating ingesta. It is to this combination of causes that must be attributed the frequency of active congestion of the liver among Europeans in ■warm climates. (See Lect. XVI.) c. A sudden or protracted chill may induce congestion of the liver, especially in warm climates, in persons who have been free livers, or after violent exercise. d. Malaria and Blood-Poisons. — Persons who suffer from malarious fevers, or live in malarious districts, are very prone to have congestion of the liver, which may persist long after the febrile symptoms have passed away. Officers and soldiers not uncommonly return from India with enlargement of the liver from this cause. But when great and permanent enlargement of the liver succeeds to ague or remittent fever, it is more probably the result of waxy deposit, or of interstitial hepatitis, than of simple congestion.' There a,re other blood-poisons, besides ma- laria, which may induce congestion of the liver, such as the yellow fever of the tropics, and the relapsing fever of our own country. e. Active congestion of the liver may have a traumatic origin, and result from contusions, wounds, &c. C. Passive. — Passive congestion of the liver may be due to:— a. Suppression of habitual discharges, as of the catamenia, or of the bleeding from piles. I have repeatedly known conges- tion of the liver, and even cirrhosis, follow a successful operation for piles. h. Habitual constipation. c. Torpor of the portal vascular system from paralysis of the sympathetic nerves or from any other cause. d. Insufficient muscular exercise. Treatment. — In the treatment of hepatic congestion, you must be guided by the following rules : — 1. In all cases it is well to commence by removing, if pos- sible, the cause. The measures to be adopted for this object will be apparent from what has already been stated. 2. In most cases of any severity advantage will be derived ' Sec paj^e 36 and Case X., and also Morehead, Res. ou Dia. in India, 1860, p. 42S ; and Sir Ii.iiiald Martin, in Lancet, 1865, ii. p. Gir>. lECT. IV. CONGESTION. 1 35 from the employment of local depletion in the form of leeches or of cupping to the region of the liver, or, what is still better, the application of a few leeches around the anus. If depletion be deemed inexpedient, sinapisms may be applied over the liver. After the leeches or the sinapisms, their place ought to be supplied by linseed or bran poultices. Tepid baths are sometimes useful. 3. The diet should be of the least irritating character. Only small quantities of milk, beef- tea, or farinaceous articles ought to be taken at a time. Alcohol, wine, fermented liquors, spices, fat, and all rich or indigestible articles ought to be rigidly interdicted. In modern practice much mischief is often done by compelling patients with heart-disease and congestion of the liver to swallow large quantities of brandy. 4. Purgatives are in most cases of great utility, unless there be spontaneous diarrhoea, which ought not to be too speedily or completely checked. Purgatives in fact are the best means of checking the frequent, but fruitless, calls to stool from which the patient often suffers. The best purgatives are those salines which increase the watery exhalation from the mucous membrane of the bowels, such as the sulphates of magnesia, potash, and soda, the tartrate of potash and soda, seidlitz powders, Carlsbad salt, and Priedrichshall or Piillna water. These salts ought to be dissolved in warm water and taken in the morning on an empty stomach. Their action is often materially assisted by an occasional dose of calomel, blue-pill, or podophyllin, which bring away copious bilious motions.^ 5. When the congestion is traceable to irritating ingesta, an emetic in the early stage sometimes appears to do good, by clearing out the stomach and duodenum. The pressure also to which the liver is subjected during the act of vomiting may squeeze out of it some of the superfluous blood. 6. During the persistence of the symptoms of congestion — enlargement and tenderness of the liver with jaundice — and especially in those cases where there is much gastric derange- ment, alkalies and their salts with the vegetable acids ought to be prescribed. They may be taken two or three times a day ' The increased biliary excretion after the calomel in these cases is not due to an increased secretion of bile by the liver, but probably to the mercury acting upon the upper part of the small intestine, so that the bile is propelled onwards, instead of being reabsorbed (see Lect. IX). If calomel acted by stimulating the liver to increased secretion, it would be injurious in cases of hepatic congestion. 1 36 ENLARGEMENTS OF THE LIVER. xect. it. shortly before meals. The alkaline mineral waters, such as those of Vals, Vichy, and Ems, or the artificial effervescing Vichy salt, may often be advantageously substituted for the alkaline preparations of the Pharmacopoeia. 7. The chloride of ammonium has been found to be of great utility in hepatic congestion in this country as well as in India.' In doses of twenty grains two or three times daily, it induces free diaphoresis, increases the flow of urine, diminishes portal congestion, and relieves hepatic pain. It is believed also to stimulate the absorbents, especially those in the liver, and thus to effect the absorption of hepa,tic abscess. It may be given in combination with either alkalies or acids. 8. Ipecacuanha has been recommended by Dr. C. Maclean ^ as one of the best and safest remedies in the acute hypersemia of the liver, which in tropical climates is so often the precursor of suppurative inflammation. He believes it to be a blood- depurant ; it increases the secretion of the liver and skin, and so there can be no doubt as to its beneficial action in the cases referred to. It is a notable fact that since ipecacuanha has come into general use in the treatment of dysentery in India, abscess of the liver has become much less frequent. As in dysentery, it must be given in large doses (20 to 30 grains) every six or twelve hours according to the severity of the case. Quarter of a grain of tartar emetic and 15 grains of nitrate of potash, given every half-hour until the pain is relieved, is said to act in a similar manner. 9. When the more urgent symptoms have passed off, and the patient suffers chiefly from debilit}', anaemia, and dyspepsia, with a slight increase of the hepatic dulness, with or without hypochondriasis, the treatment may be modified. The mineral acids and vegetable tonics are now often useful, such as the mineral acids with taraxacum, nux vomica, or gentian. Quinine and iron are particularly indicated in patients who have suffered from malarious fevers ; but ought to be given with great caution to persons of gouty habit, or who have been free livers. The diet ought also to be more generous, although care must be taken to exclude from it every source of irritation. Fermented liquors ought still to be interdicted, and if wine be • Although this drup; had been long used in various hepatic disorders, its value in the trfatment of hepatic congestion was first made known in 1869 by Dr. William Stewart, of II. M. Army. * Eeynolds's System of Med. iii. 337. LECT. IV. CONGESTION. 1 37 allowed at all, it should be given in small quantities, and diluted. Hock, claret, and dry sherry are the best. Kegular exercise in the open air ought to be enjoined; if there be much debility, the advantages of exercise without fatigue may be derived from riding on horseback. The bowels will still require attention, and great benefit will often be obtained from the use of mineral waters which combine chal3^beate with purgative properties, such as the springs of Harrogate, Cheltenham, Leamington, Homburg, and Kissingen. 10. It is in the chronic condition last referred to that advan- tage is sometimes derived from the use of the nitro-muriatic acid bath, as recommended by Sir Ranald Martin.^ The bath should consist of two ounces of strong hydrochloric and one ounce of strong nitric acid to two gallons of water, at a temperature of 96° or 98°. Both feet are to be placed in the bath, while the inside of the legs and thighs, the right side over the liver, and the inside of both arms, are sponged alterjiately, or the abdomen may be swathed in flannel soaked in the fluid. The process is to be continued for half an hour night and morning.^ In obstinate cases advantage is sometimes derived from the hydro- pathic belt, or from inunction with the ointment of biniodide of mercury. As an example of congestion of the liver resulting from mechanical obstruction of the circulation in the chest, I may call your attention to the following case : — Case XLIX. — Mitral Stenosis — Dropsy and Congestion of Liver — Death. Emma F , aged 13, adm. into Middlesex Hosp. Oct. 24, 1865, suffering from mach cough, great dyspnoea, and considerable anasarca of lower extremities. Cardiac dulness had double its normal area, and a prolonged bellows-murmur was audible over left apex. There were all the signs of general bronchitis ; and, in addition, conjunctiva and general surface had a slightly jaundiced tint ; hepatic dulness was much increased, measuring in right mammary line more than 5 in. and extending down nearly to umbilicus. Splenic dulness also 1 See Lancet, Dec. 9, 1865, p. 641. * The bath, as above prepared, may be kept in use for a few days, 1 drachm of hydrochloric and half a drachm of nitric acid, with a pint of water, being added daily to make up for waste. About a fourth of the fluid is to be well heated in an earthen pipkin, so as to bring up the temperatiire of the whole to 96° or 98°. Glazed earthen or wooden vessels should be used, and the sponges and towels should be kept in cold water, lest the acid corrode them. 138 ENLARGEMENTS OF THE LIVER. lect. iv. increased. Considerable tenderness below right ribs. Tongue furred. Much, nausea and occasional vomiting, and bowels relaxed about four or five times a day ; motions pale, though coloured with bile. Urine contained a small amount of bile-pigment, but no albumen. Five or six years before, this patient had an attack of scarlet fever, followed by articular rheumatism and dropsy. Ever since, she had suffered fi-om dyspnoea and palpitations, increased by any exertion. About ten days before admission she began to complain of cough, headache, and vomit- ing, and swelling appeared in ankles, which gradually extended upwards. The treatment consisted in administration of purgatives and diuretics, and particularly the bitartrate of potash and tincture of digi- talis, while leeches and mustard and linseed poultices were applied over right hypochondrium. At first there was a manifest improvement in all the symptoms ; but about a fortnight after admission the indications of obstructed cardiac circulation became aggravated ; dyspnoea and dropsy increased, lips and face were livid : jaundice was more marked, vomiting more urgent, and motions contained less bile. Pulse was very rapid, and on Nov. 10 scarcely perceptible. At 11 p.m. of this day the girl died. On examination of body, heart was much enlarged, weighing 13 oz. ; mitral valve much thickened and its margins adherent, so that orifice was contracted, and its circumference measured only fifteen lines. Both lungs much congested, and presented the ordinary anato- mical characters of bronchitis ; but they were nowhere consolidated. Peritoneum contained about a pint of clear serum. Liver very large for patient's age, weighing nearly 4 lbs ; outer surface smooth ; and, on section, roots of hepatic vein gorged with dark blood, con- trasting strongly with intermediate pale-yellow hepatic tissue. On microscopic examination, quantity of oil in secreting cells did not seem increased. Spleen weighed 6^ oz., and was firm and dark on sec- tion. Pyramids of kidneys much congested, but renal tissue in other respects healthy. Mucous membrane of pyloric half of stomach pi-e- sented ordinary characters of catarrhal inflammation. As an illustration of congestion of the liver arising from other causes I may narrate to you the following case : — Case L. — Indigestion from Hohitual Surfeit- — Residence in Tropics — Exposure to Chill — Congestion of Ldver. Mr. C , aged 30, a gentleman much addicted to the pleasures of the table, coTisulted me in June 1867, on his return from India. He had for several years suffered from constipation, flatulence, and a feeling of weight and oppression in region of liver. About six weeks before I saw him, he was attacked with pain in region of liver followed by vomiting and jaundice, after sleeping on a verandah in the night LECT. IV. INTERSTITIAL HEPATITIS. 139 air in India. He had leeches applied over liver, and was ordered home at once. I found him still moderately jaundiced ; liver enlarged, mea- suring 6 in. in right mammary line, and slightly tender ; no vomit- ing, but bowels constipated ; a bitter taste in mouth, and nausea. Motions light but contained bile. Urine scanty, dark, contained bile- pigment, deposited much lithates, and became very dark on addition of nitric acid after heating. He was treated with saline purgatives and occasional pills of the comp. colocynth mass (gr. vi), podophyllin (gr. ^), and extract of henbane (gr. ii) ; an effervescing mixture of citrate of potash was ordered to be taken three times a day ; a warm bath three times a week ; moderate exercise ; and a simple diet, from which alcohol in every form was excluded. At the end of ten days patient was much improved, jaundice had almost gone, and hepatic dulness diminished. A mixture with nitric acid and compound infu- sion of gentian was now substituted, and in two or three weeks more patient had regained his usual health. VI. ENLARGEMENT OP LIVER PROM INTERSTITIAL HEPATITIS. This form of enlargement of the liver is a common sequel of chronic hvpersemia. Its clinical characters are these : — 1. The enlargement is uniform in every direction, and may be much greater than in simple congestion. The liver may reach up to the nipple and down to the navel, or even lower, but its lower margin is often obscured by tympanites or ascites. 2. Its surface is smooth, or slightly uneven, dense and re- sisting, and more or less tender. Occasionally there is acute tenderness from intercurrent attacks of peri-hepatitis. 3. The symptoms in the first instance are the same as those of active hypersenriia, which I have already described to you, so that sometimes it may be difficult to say whether there is con- gestion only, or congestion plus interstitial hepatitis. 4. But when the disease is more pronounced, its prominent features are sallowness or slight jaundice, venous stigmata on the cheeks, nausea and retching, especially on first rising in the morning, loathing of solid food, particularly in the early part of the day, diarrhoea alternating with constipation, hsemorrhoids, scanty dark urine loaded with lithates, and in some cases tem- porary albuminuria, depression of spirits, sensations of sinking and a craving for stimulants. Occasionally there is slight pyrexia. 5. In a still more advanced stage there will be the various symptoms of portal obstruction, which I shall have to describe to you in detail when we come in a future lecture to consider I40 ENLARGEMENTS OF THE LIVER. lect. it. cirrhosis under the head of contractions of the liver. The en- largement in fact which I have now described is the disease known as cirrhosis, although when the symptoms of this disease are well pronounced the liver is more commonly contracted. In opposition to the opinion of the late Dr. Todd,' several observers, such as Saunders, Bright,^ Budd, Frerichs^ have ex- pressed the opinion that in cirrhosis the contraction of the liver is occasionally preceded by a stage of enlargement, but as far as can be judged from medical writings such an enlargement is believed to be excej^tional. Gee has recorded two cases of * cirrhotic enlargement of the liver,' in which the organ weighed 100^ and 104 ounces respectively.'* Habershon has met with an inflammatory induration of the liver, in which the organ becomes greatly enlarged f and Duckworth has described a 'hypertrophic cirrhosis.'^ From my own experience I have been led to believe that in a considerable proportion of cases of cirrhosis, the liver is still much enlarged (very often from the presence in the organ of a large quantity of fat) after ascites and other symptoms of portal obstruction have set in, and that patients often die in this condition with jaundice, hsemorrhages, and symptoms of blood-poisoning (the prognosis being no better than if the liver were contracted). In this opinion I am confirmed by the independent observations of Professor Leudet, of Eouen,^ who observes : ' On est arrive par I'anatomie pathologique a reconnaitre que I'augmentation du volume de la glande n'etait pas toujours I'indice d'une lesion recente du foie, d'un processus aigu encore curable.' This is the reason why I have brought the disease under j^our notice on the present occasion, but I shall have occasion to return to it in a future lecture. It is a matter for investigation, whether, if the patient lived long enough, the enlargement in all these cases would be followed by marked cirrhotic contraction. M. Ollivier, in fact, is of opinion that cirrhotic enlargement is a distinct affection from cirrhotic contraction.^ There can be no doubt, however, that it occurs under the same conditions and gives rise to the same symptoms. It seems probable, therefore, that the ' Clin. Lect. on Urinary Diseases and Dropsies, 18.)7, p. 113. ^ Uuy's IIosp. Rop., 1st ser. vol. i. p. 612. ' Dis. of Liver, Syd. Soc. Transl. vol. ii. pp. 35, 37, 53. * St. Earth. Ilosp. Kep. 1869, vol. v. p. 108. * Lettsoniian Lectures, 1872, p. 56. « St. liarth. IIosp. Kep. vol. x. ' Clin. Med., Paris, 1874, p. 541. * L'Uniou Med. Sept., 1871, pp. 3G1, 400, 44'J. I^CT. IV. INTESSTITIAL HEPATITIS. I4I same causes sometimes lead to contraction, and sometimes to enlargement of the liver. 6. The causes of interstitial hepatitis may be said to be these : a. In a large proportion of the cases presenting the clinical features which I have now described, you will find that the patient has been addicted to a free use of alcoholic drinks. You must beware of being deceived in this matter. Such patients may tell you, and even really believe, that they lead regular and temperate lives, because they never drink a sufficient quantity of alcohol at one time to obscure their intellects ; but it is the practice of ' nipping ' — of taking frequently small quantities of spirits, or a glass of sherry, under the mistaken notion that this better fits them for work, — that keeps the liver in a con- stant state of congestion, and most surely leads to cirrhosis. Moreover, you must not gauge one man's capacity for alcohol by that of another. One person may take with impunity, what in another will induce serious disease. h. The congestion of the liver which results from venous obstruction may also lead to an interstitial hepatitis presenting most of the clinical characters which I have now described (Case LY.), but distinguished from true cirrhotic enlargement by the presence of chronic cardiac or pulmonary disease, and of the signs of obstructed systemic circulation. In rare cases I have known the liver from this cause not only enlarged, but nodu- lated. c. Interstitial hepatitis resulting in enlargement of the liver may also have a syphilitic origin, although more commonly in these cases the liver seems to contract from the first. These cases will be distinguished by the history of constitutional syphilis, and by the greater tendency to attacks of severe peri- hepatitis causing much pain and tenderness. The liver also has a greater tendency to become uneven or nodulated from the cicatrix -like depressions which form upon its surface, or from the projection of enlarged and softened gummata. In the latter case the disease may be mistaken for abscess * or hydatid ; and indeed, from what was observed in Case LYII. and in a case recorded by Dr. Moxon^ where a syphilitic gumma in the liver softened into a puriform fluid and burst into a bile-duct, it seems not improbable that a tumour of this sort may occasionally discharge itself by the stomach or bowels. In other cases there ' Wilks, British Med. Journ. 1876, i. 239. - Path. Trans, vol. xxiii. p. 153. 142 ENLARGEMENTS OF THE LIVER. i;ect. iv. may be a difficulty in distinguishing the disease in question from waxy enlargement with peri-hepatitis. d. Lastly, a chill, independently of intemperate habits, would appear to be in rare instances sufficient to excite inter- stitial hepatitis ending in great enlargement of the liver. Dr. Wilson Fox has communicated to me the particulars of such a case, where there was a persistent though slight elevation of temperature, and I have observed one or two similar instances, in which, however, the diagnosis was not, as in Dr. Fox's case, verified by post-mortem examination. It is probable that in these cases some constitutional dyscrasia predisposes to the action of the chill. (See Appendix, Case CLXXVI.) The treatment of interstitial hepatitis in its early stage will be the same as that which I have already indicated as appro- priate for congestion ; that for the advanced stages will be more conveniently discussed when I come to speak of cirrhotic contraction. Syphilitic cases will of course call for specific remedies, and especially for mercury and iodide of potassium. The four following cases are examples of cirrhotic enlarge- ment of the liver resulting from alcohol. The first three are illustrations of the good effects of treatment ; while Case LIV. illustrates the appearances found after death. Case LI. — Cirrhotic Enlargement of Liver from Alcohol {and Malaria /) — Great Ascites — Paracentesis — Recovery under treatment. On Jan. 6, 1873, I saw, in consultation with Dr. A. Simpson, of Highgate, Mr. L., aged 35, an indigo-planter, just returned from India, -where he had been born, and where he had lived all his life. Had been a free liver and drunk much spirits, but excepting several attacks of malarious fever had good health until June 1872, when he began to have considerable hepatic pain, followed by ascites and swelling of legs. Girth at umbilicus on Jan 5, 37^ in. ; much fluid in peritoneum ; great a3dema of legs. Liver large, projecting nearly 4 in. beyond right ribs, very hard and distinctly nodulated. Urine had contained albu- men, but was now free from it. Bowels confined. Face sallow, with venous stigmata. On supposition tliat patient might be suffering from effects of malarial cachexia, iron, quinine, and strychnia were prescribed, with an aperient dranglit every morning containing sulphate of magnesia and iodide of potassium. Dropsy, however, increased. On Jan. 13 girth of abdomen 38| in. ; legs more swollen ; and penis and scrotum very oodematous. On Jan. 26 girth of sibdomcn 41 in. and respiration em- barrassed. A mixture of digitalis, bitartrate of potash, and juniper was LECT. IV. INTERSTITIAL HEPATITIS. I43 now substituted for the quinine and iron, and the purgatives were continued. Abdomen was also fomented with a strong infusion of digitalis. On Feb. 22 the mixture was changed for one of percbloride of mercury and digitalis. Under this treatment at first slight and temporary improvement, but on March 3 girth of abdomen 42^ in. ; signs of fluid in lower fourth of both pleural cavities ; orthopnoea ; urine only 30 oz. Ordered podophyllin pills and a mixture of digitalis, squill, and juniper. On March 5 about two gallons of fluid were drawn ofl" by paracentesis, with immediate relief. At first ascites seemed to be collecting again, and on March 8 girth oE abdomen 38 in. ; but after this swelling of abdomen slowly receded, and on March 31 girth only 32 in. ; no fluid in pleures. Liver still reached down to umbilicus, hard and nodulated. Purgatives were continued, and a pill three times a day containing gr. ^ of green iodide of mercury was substituted for diuretic mixture, and red iodide of mercury ointment was rubbed in over liver. The iodide of mercury was continued for two months, dose being gi'adn- ally increased to gr. ^. Under this treatment he steadily improved. On April 29 he was able to drive four miles to my house. On May 30 girth still 32 in., but no sign of ascites, no oedema of legs, and liver a little smaller. He was now ordered nitro-muriatic acid, bark and taraxa- cum, with aperients, and he went to Devonshire. From this time there was no return of the dropsy, and he steadily improved ; in IS^ovember he weighed more than ever he had done in his life. On March 17, 1874, liver scarcely exceeded normal dimensions. In October 1874 he returned to Tirhoot in India, where he remained nntil following April ; and on June 11, 1875, when I last saw him, he was still in good health, free from dropsy, and liver of about natural size. Case LII. — Cirrhotic Enlargement of Liver — Ascites — Good Effects of Treatment. On March 29, 1873, I was consulted by Capt. M., aged 40, of R.I^., on account of enlargement of liver and ascites. He was a short spare man, had been long on the Indian seas, and had drunk freely of brandy. About a year before, when in China, he began to have pain in liver and morning sickness and diarrhoea ; and at end of J^ovember 1872 abdo- men began to swell, until when he left China in February its girth was 38 in., and the legs were also swollen. When I saw him girth was re- duced to 32 in. but still much ascites ; liver 8 in. in r. m. ]., of which four inches below ribs. Spleen hard, and somewhat tender, also much enlarged. Heart sound. No albuminuria. Face sallow, with venous stigmata. Ordered to abstain from stimulants ; Carlsbad salt every morning ; blue pill, squill, and digitalis twice daily ; and a mixture of iron and nitrous ether ; and on April 9 ordered to rub red iodide of mercury oint- 144 ENLARGEMENTS OF THE LIVER. lect. iv. ment every night over liver. Under this treatment he slowly improved, and on April 15 no fluid in peritoneum ; girth of abdomen 29 in. ; liver in r. m. 1. 7-5^ in. During summer he drank waters at Hombnrg for five weeks, and on Aug. 20 liver in r. m. 1. 6^ in., and could walk several miles without any oedema of legs. From this time he felt fairly well until October 1874, when he had again uneasiness about liver with loss of appetite and diarrhoea. For these symptoms he consulted a medical man, who prescribed astringents and opium with port wine, and after a fortnight abdomen again swelled. On Dec. 14 much ascites and enlargement of abdominal veins ; girth of abdomen 34^ in. ; legs oedematous ; bowels costive ; occasional retching ; liver 6 in. Port wine was at once stopped ; Carlsbad salt ordered every morning ; and a mixture of iron, bitartrate of potash, and digitalis. Ascites at first increased, and on Jan. 7 girth nearly 37 in. A mixture of per- chloride of mercury and digitalis was now substituted for the iron &c. Under this treatment, modified somewhat from time to time, great im- provement again took place ; urine became very copious ; and on May 6, girth 29 in., no ascites, and liver in r. m. 1. 6 in., of which 2 in. below ribs. He again went to Homburg for five weeks, and on his return on July 14, 1875, he appeared to be in excellent health, without an}' sign of dropsy, but liver still 6 in. in r. m. 1. and hard. Case LIU. — Cirrhotic Enlargement of Liver. — Ascites and Albuminuria — Weak Heart — Good effects of Treatment. On April 15, 1873, I was consulted by Mr. James V., aged 56, on account of disease of liver and dropsy. He was a large corpulent man, who had been a free liver, and had drunk much wine and spirits. Seven years before, he had an attack of congestion of liver and had passed much blood per anum. For years he had had occasionally slight swelling of legs, but one month before I saw him abdomen began to swell, after which legs increased rapidly. For six months before abdomen began to swell, had suffered from dyspeptic symptoms and despondency. Liver very large (8 in. in r. m. 1.) hard and uneven ; much ascites ; girth 48 in. ; enormous swelling of penis and scrotum ; gi'eat oedema of legs, with numerous large ulcers ; urine contained | albumen and hyaline casts ; heart's sound weak, but no bellows-murmur. Stimulants were restricted to a pint of hock or claret daily ; patient was oidered a black draught with jalapine every morning, and a mixture of bitartrate of potash, squill, and digitalis. Under this treatment, modified from time to time, and with occasional courses of iron, great improvement took place. Urine became copious and free from albumen ; ascites and dropsy of legs disappeared ; and liver was reduced. On June 3 girth of abdomen only 40^ in., and on July 29, 39^ in. For many months after this, patient enjoyed good health and went about town, although he was less prudent than he ought to have INTERSTITIAL HEPATITIS. 145 been. There was occasionally a return of albuminuria, and once or twice urine contained much sugar and specific gravity rose to nearly 1040 ; but usually urine contained neither sugar nor albumen, and specific gravity was under 1020. In July 1874 there was a return of ascites, and girth of abdomen rose to 44 in. ; it again disappeared Tinder similar treatment, and on Oct. 18 girth only 40 in. In January 1876 there was again a slight and temporary return of ascites, brouo-ht on apparently by imprudence in diet. In August 1876 he had another more severe attack of ascites and dropsy of legs ; but under use of elaterium and diuretics this completely disappeared, and by middle of October patient was walking about London, with a good appetite and free from dropsy and albuminuria, but with a large hard liver stiU reaching almost to umbilicus. Case LIV. — Large smooth Cirrhotic Liver simulating Waxy Disease — Ascites — Persistent Diarrhoea — Death. Elizabeth R , aged 40, adm. into St. Thomas's Hosp. Sept. 11, 1875. I^othing remarkable in family history. Married ; five living children from 16 to 5 ; three miscarriages, first 12 months after mar- riage, a three months foetus ; last, four months before admission. General ichthyosis, but no history of syphilis. Habits not very temperate ; admitted to 1^ pt. beer daily, besides some spirits ; had suffered from morning sickness independently of pregnancies. Nine months before admission, vomiting became more frequent ; had great pain across stomach and in back, with persistent diarrhcea, cough, loss of appetite and flesh, and abdomen began to swell. Remained in hospital until Oct. 25, and during this time conditiou was as follows : — Emaciated ; venous stigmata on cheeks ; jaundiced tint of conjunctivae; abdomen enlarged, measuring 39 in. at umbilic as- liver much enlarged, measuring 9 in. in r. m. 1., and lower maro-in felt hard, sharp, and even, below umbilicus ; surface smooth ; moderate ascites ; frequent vomiting and constant diarrhoea ; no sign of car- diac disease, but slight dulness and tubular breathing at apex of rio-ht lung ; temp, at night usually 101° ; occasional attacks of profuse epistaxis. N'o albuminuria. On leaving hospital, seemed better ; no ascites and no diarrhoea. One month after leaving hospital abdomen began to swell again. Towards end of January 1876 diarrhoea returned, and on Feb. 29 patient was readmitted into hospital. Her condition was as follows. Very weak and emaciated ; girth of abdomen at umbilicus 37^ in. • liver still very large, measurin in r. m. 1. 9^ in., and extendino- from nipple to belovp- umbilicus ; surface hard and slightly tender, generally smooth, but a large projecting mass felt in epigastrium : spleen en- larged ; moderate ascites ; constaut diarrhoea, 8 or 10 watery motions, without pain, daily ; no vomiting ; tongue unnaturally red and clean • L 146 ENLARGEMENTS OF THE LIVER. lkct. it. appetite bad. Sallow and anaemic ; no decided jaundice, but urine contained bile-pigment and ^ albumen. Almost constant epistaxis and great fetor of breath. Pulse 120. Heart healthy. Patient was ordered milk diet, and a mixture of bismuth and opium, and subsequently pernitrate of iron, but she became daily worse. On March 2 she vomited about a pint of dark blood ; the ascites diminished slightly, but the diarrhoea and epistaxis persisted, and on Marcb 16 she died from exhaustion. Autofsy. — Six pints of ascitic fluid in peritoneum. Liver very large, weighed 74 oz., firmly adherent to transverse colon, stomach, &c. Capsule greatly thickened, and on upper surface two loculated cj'-sts of ascitic fluid ; lower margin rounded ; typical cirrhotic structure on section ; no amyloid reaction. Spleen 12^ oz., congested. Kidneys firm, but yielded no amyloid reaction. Right lung adherent. Case LV. appeared to be an example of great enlargement of the liver from interstitial hepatitis consequent on mitral disease. Case LV. — Great E7ilargeinent of Liver and Ascites, secondary to Mitral Disease. Edwin F , aged 11, adm. into St. Thomas's Hosp. Nov. 3, 1871. Had enjoyed good health till last July, when he was laid up for several weeks with a severe attack of rheumatic fever, and since then he had suflPered from palpitations and dyspnoea. On admission heart greatly enlarged, measuring 3^ in. transversely, its apex beating be- tween 6th and 7th ribs outside nipple. At apex was a loud whistling systolic bellows-murmur, heard also at lower angle of left scapula and in fact all over chest. Pulse 108, small and weak. Occasional cough, but langs healthy. Liver slightly enlarged. Slight oedema of legs. Albumen (|) in urine. Was ordered digitalis and iron, and on Nov. 9 appearance greatly improved, and albumen disappeared from urine. On Dec. 14, while still in hospital, was seized with a second attack of articular rheumatism, which became complicated with pericarditis and pleuro-pneumonia. For several weeks he was extremely ill, and the disappearance of the pericarditis and pneumonia was followed by a great aggravation of the cardiac symptoms. On Jan. 22 transverse dulness of heart 4 in., breath very short, much cardiac pain and palpi- tation ; considerable oedema of legs and some ascites, but no albumen in urine. Diuretics and iron were of little use, and on !March 18 both legs, which were enormously enlarged, were punctured with consider- able relief. On Ajjril 1 fomentation of abdomen with infusion of digitalis four times the PliarmacopaMa strength had the efPect of in- creasing flow of urine and reducing dropsy. After a few days, how- ever, dropsy again increased in abdomen, until, on April 22, girth at XECT. IV. INTERSTITIAL HEPATITIS. 1 47 umbilicus was 33 inches, but there was little or no oedema of leg-s. Liver was greatly enlarged, extending from right nipple to umbilicus, its surface smooth, hard, and slightly tender ; abdominal veins enlarged ; no jaundice ; much albumen in urine ; dyspnoea urgent. By paracen- tesis abdominis 172 oz. of fluid were now drawn off, with great and immediate relief. The albuminuria at once ceased; and under use of digitalis with other diuretics, blue pill, purgatives, and suljse- quently iron, ascites did not again collect ; liver diminished somewhat in size, and cardiac symptoms improved. On Aug. 6 left hospital free from dropsy, and girth at umbilicus only 25 in. Was again a patient in hospital from Nov. 13 to Dec. 5, 1872, with albuminuria, slight ascites, (abdomen measuring 27| in.) but no oedema of legs. Under use of blue pill, digitalis, diuretics, purgatives, and iron, albuminuria and ascites again completely disappeared ; and boy, on leaving hospital, went to sea-side. Liver was still large. ^ Cases LYI. to LXI. are examples of syphilitic enlargement of tlie liver v^^itli gummata. In Case LVI. the syphilitic nature of the disease in the liver was not suspected during life. The concurrence of great enlargement of the spleen, persistent diarrhoea, copious albu- minuria without general dropsy, and great anasmia, suggested that the enlargement of the liver was due to waxy disease, and the ascites was referred to compression of the portal vein by lymphatic glands enlarged from waxy deposit. The profase catamenial discharge was, however, the only cause that could be assigned for waxy disease.^ Case LVI. — Syphilitic Hepatitis and Gummata of Liver — Waxy Spleen — Ascites — Diarrhoea — Jaundice. Sarah B , aged 25, was a patient in Middlesex Hosp. from April 21 to June 2, 1868, for anaemia, enlargement of liver and spleen, albuminuria, ascites, and diarrhoea. Since first appearance of catamenia at age of 12, when she had copious flooding, she had suf- fered from anaemia and chlorosis, and she had been much worse since her marriage in 1866. She had never been pregnant, and after most careful enquiry nothing could be elicited pointing to a syphilitic history. Her father had died at 40 of effects of an accident : her mother and one sister had died of consumption. At commencement of 1866 abdomen had begun to swell and diarrhoea set in. At time of admission girth of umbilicus was 34^ in. ; hepatic dulness in r. m. 1. rose to nipple and measured 4|- in. ; vertical splenic dulness 6 in. ; urine contained ^ albumen ; bowels open ten to twelve times 1 See also Case LXXXIX. p. 488, in 1st edition. L 2 148 ENLARGEMENTS OF THE LIVER. lect. iv. a day. Heart elevated but healthy. Under the use of nitric acid and opiuna, diarrhoea ceased ; albumen was reduced to a mere trace, and ascites disappeared, although abdomen still measured 33 in. Was ai^ain a patient in Middlesex Hosp. from Nov. 2 to Dec. 1, 1868. Had then slight jaundice, distinct ascites ; liver 5 in. in r. m. 1. ; spleen projected 5 in. beyond ribs ; 6 stools daily ; no albumen in urine during whole time ; but systolic murmur at base of heart. Was again relieved by same treatment as before. Was a third time a patient in hospital, from July 9 to Aug. 10, 1869. Still ascites and slight jaundice. Liver dulness 5 in. and spleen 5 in. beyond ribs. Girth of abdomen 35^ in. Urine contained a trace of albumen ; 8 to 10 stools daily ; menorrhagia ; anasarca of legs. Under same treatment diarrhoea again ceased, and patient gained flesh and strength. Was a fourth time a patient in hospital with same symptoms from Nov. 23, 1869, to Jan. 8, 1870. Girth of abdomen 36 in. ; 7 or 8 stools ; albumen ^V- Soon after leaving hospital on Jan. 8, diarrhoea returned and ab- domen became larger. Came several times as an out-patient, and on March 17, 1870, was admitted for a fifth time. Girth of abdomen was now 43 in., and corresponding to umbilicus was a protrusion as large as an orange, integuments of which were red, thin, glistening, and tender ; but abdomen generally not tender. Superficial veins of thorax and abdomen much enlarged. No appetite ; much flatulence ; three or four stools daily ; occasional retching. Considerable dyspnoea ; resp. 48, and thoracic. Pulse 108 ; no bellows-murmur with heart. Urine contained fully one-half albumen and some bile-pigment ; no casts. Slight oedema of legs. Marked chlorosis. No jaundice. All treatment on this occasion proved useless. Patient became rapidly worse. On March 21 passed very little urine, was restless and wan- dered ; on 22nd unconscious ; on 23rd pulse intermittent and diarrhoea increased. On 24th she died. Auf()2)sy. — No visible cicatrices on vulva or on vagina, but a deep cicatrix on anterior lip of uterus. Peritoneum contained 100 oz. of clear yellow serum, with a few flakes of lymph ; entire membrane presented signs of recent peritonitis, vessels being intensely injected and intestines plastered with soft yellow lymph. Firm adhesions be- tween liver and diaphragm and right kidney, &c. Liver rather small, its capsule thickened and its outer surface marked by numerous deep cicatrix-like depressions, and on cutting into several of these they were found to be connected with characteristic syphilitic gummata, some as large as cherries. Hepatic tissue pale and friahle, fatty, and with no amyloid reaction. Much fibrous tissue in portal fissure, com- pressing but not obliterating portal vein. Considerable hypertrophy of connective tissue in interior of liver. Hound ligament much thick- ened. Spleen 30^ oz. ; capsule much thickened ; its tissue firm and LECT. IV. INTEESTITIAL HEPATITIS. I49 waxy, with distinct amyJoid reaction. Kidneys large and pale (7 oz. each), with amyloid reaction of small arteries. No ulceration and no amyloid reaction of intestines. Case LYII. — SyphiUHc E7ilargement (Gummata) of Liver — Gummafa in one arm — Periostitis of one tibia. On July 28, 1875, I was consulted by Mrs. R , aged 37, on account of a tumour of liver, regarding which different opinions had been expressed by the many medical men whom she had seen. Some had said that it was hydatid ; others, abscess ; others, cancer ; and one distinguished physician had pronounced it an adenoid tumour. The liver was very large, extending from nipple to navel, and portion below liver bulged forward and was very soft and elastic but painless ; its surface was distinctly nodulated, one nodule in epigastrium very like cancer, most prominent parts being the softest ; there was jaun- dice, which came and went, and was sometimes attended by white stools ; no ascites ; spleen much enlarged, projecting four inches be- yond ribs. No albuminuria. Slight oedema of legs, and some perios- titic swelling of left tibia, not of right. Temp, normal, appetite good. History was this : — Mother had died of cancer of uterus. Married 16 years ; no children ; one doubtful abortion six weeks after marriage, but with this exception never pregnant. More than four years ago began to have a vaginal discharge, for which, on medical advice, she took much mercury and was salivated. Two years ago noticed first one, and then a second, small lump below right ribs in front. These lumps had increased steadily from first, but more rapidly of late. Although it was not supposed that the tumour contained fluid, it was determined to remove all doubt by making an exploratory punc- ture. This was done, but only blood escaped. Nitro-muriatic acid, nux vomica, and saline aperients were ordered. Under this treat- ment she felt better and stronger, and there was no increase of swell- ing. On Oct. 31 she vomited a little blood, and for several days after- wards she had much nausea and was deeply jaundiced. About this time first observed a lump about size of half an orange in soft parts of left upper arm. This increased slightly and became red and soft in centre, and very painful, and for this I was again consulted on Jan. 18, 1876. Iodide of potassium was prescribed, but two days afterwards patient had an attack of very profuse haemorrhage from stomach and bowels, and medicine was suspended. Swelling in arm increased, and on Feb. 7 a slough, size of half-a-crown, had formed in centre of lump, circumference of which was still very hard and tender. Iodide of potassium was resumed (gr. iij ter die). On Feb. 28, slough sepa- rating ; a distinct periostitic node on left tibia ; no return of haemor- rhage ; liver apparently not larger than six months before ; girth over most prominent part 34^ in. 5 appetite good, but painful distension 150 ENLARGEMENTS OF THE LIVER. lect.iv. after food. No albumen in urine. "Was ordered iodide of potassium, ten grains, with sarsaparilla, three times daily. Under this treatment, alternated occasionally with small doses of perchloride of mercury and bark, patient greatly improved. On March 27 slough had separated from arm and sore was healing, jaundice less, and girth only 33|- in. On May 2 sore in arm quite healed, leaving deep cicatrix ; but severe pcriostitic pains in right ulna and fingers, and in right tibia. On June 1 periostitic pains gone ; scarcely any jaundice ; up, and going about. July 19 : has driven out five or six times ; gaining flesh ; girth 35 in, ; severe periostitic pain over right elbow. July 20 : something seemed to burst inside, and she vomited a quantity of yellowish matter, which was not preserved. Had nausea for several days after, but then continued to improve. Sept, 26 : liver decidedly smaller ; girth only o3|- in., although she has grown very much stouter. Spleen not diminished in size. No jaundice ; appetite good. Still has periostitic pains in right ulna preventing sleep. Case LVIII. — Sijijldlltic Enlargement of Liver- — Gumma in left leg. Mr. J , about 47, consulted me for first time on May 4, 1874. About 16 years before he had syphilis. The sore was slight, and he does not remember having had constitutional symptoms. Six years after- wards he married ; his wife had no children or miscarriages. In 1871 he began to feel stuffed up in nose, and soon after he noticed an offensive discharge, with occasional clots of blood, from nose. The discharge also passed backwards. After ten months a piece of bone, size of sixpence, came away from right nostril and discharge ceased. About same time gums were in a very bad state and he had five teeth drawn. Soon after this he got better, and remained well until Nov. 1873, when one day after lunch he got squeamish, had pain in region of liver with slight jaundice, and for five weeks was unable to go to busi- ness. Ever since he had suffered from flatulence and other symptoms of indigestion, and also from piles ; but, although he had been in habit of drinking a good deal of whisky, he never had nausea or morn- ing sickness, and had always a good appetite for breakfast. There was dilatation of capillaries of cheeks, but no jaundice. Liver very large, measuring 8 in. in r. m. 1. ; enlargement uniform ; smooth, hard, and painless. Spleen also somewhat enlai-ged; no ascites. Tongue preternatu rally clean and red ; bowels usually costive. Urine 1024, usually loaded with lithates, but free from albumen. Pulse 96 ; heart normal. He was ordered to abstain from stimulants, except a little claret and water, to take a dose of Carlsbad salt every alternate morning, and a mixture of perchloride of mercury and chloride of ammonium three times a day. Under this treatment urine became copious and clear, symptoms greatly improved, and liver was slightly reduced in LECT. IV. INTERSTITIAL HEPATITIS. 15 I size. On Oct. 24 it measured only 7^ in. in r. m. 1., but there was a small painful ulcer on left tonsil, and often in morning a little blood was discbarged from nose. After this he took iodide of potassium occasionally, but he always felt better while taking the perchloride of mercury. In Dec. 1874 he first noticed a lump in middle of left leg over tibia, but quite unconnected with bone. This increased to size of an egg and softened ; in May 1875 it was opened ; no pus, but much clotted blood, escaped. Wound was many months in healing, and patient was unable to walk much on account of pain in left ankle. On healing, a deep scar remained, covered by a scab, and surrounded by considerable induration. In Feb. 1876 this was seen by Sir James Paget, who at once pronounced it to be a syphilitic gumma. Liver still large, but measurement in r. m. 1. not more than 6^ in. ; surface smooth. Still has pain about left ankle which prevents him walking much, but appetite and digestion are good. He was ordered a mixture of perchloride of mercury with bark ; and in October (1876) I heard that his health had greatly improved. Case LIX. — Enlarged Fibrous Syphilitic Liver ivith Gummata — Ascites. Harriet E. , aged 28, adm. into St. Thomas's Hosp. Feb. 1, 1875. Nothing noteworthy in family history. Had enjoyed good health until three years before admission, when she had for some weeks an obscure attack of pain and swelling in lower part of abdo- men ; but after this got quite well and married in Jan. 1873. One miscarriage, but no living child. Early in 1874 began to suffer from dry cough, flatulent distension of abdomen, and retching from slight causes ; but no morning sickness, and habits temperate. In November . 1874 abdomen became swollen and painful ; and since then excessive vomiting brought on by sight or smell of food ; increase of cough ; loss of appetite ; emaciation ; and attacks of abdominal pain, some- times so severe as to keep her in bed for a week. On admission, emaciated and countenance expressive of pain ; no jaundice or venous stigmata on cheeks ; pain and tenderness of abdo- men, which measured at umbilicus 48^ in. Much ascites ; abdominal veins but slightly dilated ; neither liver nor spleen could be felt, but upper margin of hepatic dulness reached almost to nipple ; tongue too clean and red ; frequent retching ; bowels costive. Urine contained phosphates, but free from lithates or albumen. Pulse 96, small and feeble ; apex of heart elevated, but no abnormal murmur. Frequent dry cough ; respiration thoracic and somewhat laboured ; but lung signs normal. Slight pitting of legs. Temp. 99°. Was treated with purgatives and diuretics, including digitalis ; but as no improvement resulted, and patient was suffering great pain and distress of breathing from abdominal distension, paracentesis was performed on Feb. 6, and 19 pints removed of straw-coloured serum ; 152 ENLAEGEMENTS OF THE LIVER. lect. iv. sp. gr. 1016. Operation gave great relief. After removal of fluid, upper margin of hepatic dulness still nearly reached nipple. Lower margin of liver could be felt projecting more than three inches beyond ribs in r. m. 1., hard, indented, and tender, but surface smooth. Girth 36 in. On Feb. 10 was ordered iodide and citrate of potash, with digitalis and decoction of broom- tops ; and for this on Feb. 20 a mixture of perchloride of mercury, squills, and digitalis was substituted. Fluid gradually re-accumulated, and on Feb. 24 girth 43 in. ; urine scanty; paracentesis; 18 pints drawn off; sp. gr. 1015. Operation again gave immediate I'elief, and on both occasions was followed by great increase in flow of urine. From March 3 to 13 bad erysipelas of face and scalp spreading to abdomen, during which pulse rose to 160, temperature to 104°, dry tongue, and much delirium. After this extreme prostration, large abscesses, one containing more than a pint of pus, formed beneath skin on different parts of body, and girth of abdomen increased to 45|^ in. On April 2, five pints, and on 9th, 24 pints of fluid (sp. gr. 1015) drawn off by paracentesis. Died from exhaustion on April 27. Autopsy. — Peritoneum contained 24 pints of serum. Liver en- larged ; weighed 62 oz. ; firmly adherent to all adjacent organs ; cap- sule thickened ; substance indurated from interstitial hepatitis ; nume- rous firm syphilitic gummata, some as large as cherries, mainly distri- buted along course of portal vein and of its branches, some of them forming projections from surface of liver. Portal vein in fissure of liver much dilated. Spleen 14 oz.; firm. No amyloid reaction in liver, spleen, or kidneys. Kecent pleurisy on both sides ; both lungs oede- matous. VII. INFLAMMATION OP THE BILIARY PASSAGES. This condition is usually associated v^^ith more or less con- gestion of the hepatic tissue, and accordingly its clinical characters are those of congestion, which I need not recapitu- late, with those peculiar to catarrh of the bile-ducts and gall- bladder superadded. Thus we have — 1. Enlargement of the liver, which, like that from congestion, is uniform in every direction, and rarely very great ; but which is sometimes accompanied by enlargement of the gall-bladder in the form of a more or less pyriform tumour projecting from the anterior margin (see fig. 16, page 163). In some cases no enlargement can be made out. 2. The portion of liver projecting below the right ribs is smooth on palpation. 3. There is at first a feeling of tightness and distension in the right hypochondrium, with tenderness on pressure, particularly LECT. IV. INFLAMMATION OF BILE-DUCTS. 1 53 over the enlarged gall-bladder. Sometimes, however, there is little or no pain or uneasiness. The pulse is usually abnormally slow. 4. Inasmuch as the bile-ducts are obstructed from the tumefaction of the mucous membrane, as well as from the injflammatory products thrown off from its free surface, the jaundice, after a day or two, is much more intense than in simple congestion, and the motions contain no bile. 5. Here, again, the circumstances under which the attack occurs are of great assistance in diagnosis. a. In a large majority of cases the attack is preceded by symptoms of catarrh of the stomach and duodenum. The inflammation, in fact, commences in the mucous membrane of the digestive canal, and extends thence to the common bile- duct. Accordingly there are to be noted, in the first place, a furred tongue, loss of appetite, flatulence, nausea or vomiting, pain and tenderness at the epigastrium, and sometimes diarrhoea, these symptoms being often accompanied by slight pyrexia. After a few days or longer, jaundice appears, and the fever, if present, may subside, although the dyspeptic symptoms remain. Attacks of this sort are very common in children as the result of eating indigestible food, or of a surfeit ; and, in that case the jaundice and other symptoms usually subside at the end of ten days or three weeks. h. Catarrh of the bile-ducts (like catarrh of the bronchial tubes) is not uncommon in persons of more advanced age of a gouty constitution, and more than once I have met with cases of this description, where the frequent vomiting, the emaciation, and the jaundice persisting ior many weeks, have led to the sus- picion of cancer, but have soon subsided under the use of purgatives with colchicum and alkalies. c. Catarrh of the bile-ducts is one of the diseases of the liver consequent on syphilis. The jaundice which is not un- common during what is known as the secondary stage is usually due to this cause, and it is especially in cases of this nature that acute atrophy of the liver is apt to supervene. d. Inflammation of the biliary passages may be secondary to congestion or other diseases of the liver, and then its symptoms may be persistent. It is probable that catarrh of the ducts may not onlj^ excite congestion of the hepatic tissue, but may result from it. In any case, where congestion of the liver is developed under the circumstances already mentioned, and where, in addition to the symptoms of simple congestion, there is 154 ENLAKGEMENTS OF THE LIVER. tECT. iv. intense jaundice, with an absence of bile from the motions, we ma}^ infer that there is catarrh of the ducts as well as congestion. Other diseases of the liver, also, such as the waxy liver and hydatid tumour, are occasionally complicated with catarrh of the ducts ; and in this way jaundice may appear in the course of diseases of the liver in which it is usually absent. In another lecture (Lect. VII.) I shall have occasion to mention an example of enlargement of the liver from tubercular deposit where the jaundice was apparently due to inflammation of the common bile-duct. e. Inflammation of the bile-ducts and gall-bladder may be due to the irritation of gall-stones or of other foreign bodies. Under these circumstances it will usually be distinguished by a previous history of biliary colic, which, however, was notably absent in the case of one patient who lately died in the wards (Case LXV.). /. Certain poisons, such as those of pyaemia and phosphorus, have been stated by Yirchow to excite catarrh of the bile-ducts.^ The cause of that form of catarrh of the bile-ducts known as ' epidemic jaundice ' is probably some poison contained in iihe air or in drinking water. Speaking generally, it may be said that in young people catarrh of the bile-ducts is the most common cause of jaundice ; whereas in persons of middle or advanced life, if we can exclude syphilis and a gouty habit, jaundice is probably due to some other cause than catarrh. Treatment. — The rules already laid down for the treatment of congestion of the liver are also applicable to catarrh of the bile-ducts. Little more need be added except that — 1. Leeches and cupping are less necessary in simple catarrh. In most cases sinapisms and warm fomentations, with purga- tives, alkalies, and chloride of ammonium, suffice for subduing the disease. The propriety of employing local depletion must be decided by the degree of pain and amount of congestion existing in each case. 2. When there is reason to suspect that the affection is of a gouty nature, great benefit will often be derived from the ad- dition of colchicum and iodide of potassium to the remedies already mentioned. In these cases also it will be necessary to adopt such measures as are calculated to correct that disordered condition of the digestion, which, if neglected, will before long lead to a recurrence of the hepatic attack. ' Virchow's Arch. 1865, xxx. lift. 1. lECT. IT, INFLAMMATION OF BILE-DUCTS. 155 3. In syphilitic cases the most useful remedies are the per- chloride of mercury and chloride of ammonium, in conjunction with purgatives. 4. The treatment must occasionally be modified by the presence of other diseases of the liver, of which the catarrh of the bile-ducts is merely a complication. When T come to lecture on Jaundice, I shall have to return to the subject of catarrh of the bile-ducts (Lect. X) ; but in the meantime I would direct your attention to the follow- ing cases of painful enlargement of the liver accompanied with jaundice, apparently due to catarrh of the ducts. Case LX. — Painful Enlargement of Liver, ivith Jaundice due to Catarrh of Bile-ducts. Elizabeth L , aged 21, a maid-servant, was admitted into Middlesex Hosp. on Dec. 7, 1866. For nine months she had been weakly and unable to take a place, and had also suffered from dys- peptic symptoms. Ten days before admission, at the cessation of last catamenial period, which had its usual duration, she had been seized with great nausea and vomiting, but she had no diarrhoea. Five days after this she began to complain of pain and tenderness in region of liver, but pain was never very severe. About same time jaundice made its appearance," which increased in intensity, and was accompa- nied by much itchiness of skin. On admission, deep jaundiced colour of entire skin and conjunc- tivEe ; urine very dark, and gave characteristic reaction of bile-pig- ment ; tongue thickly coated ; no appetite, but vomiting and pain in side had much subsided ; lower margin of liver was ascertained to project about an inch below margin of ribs in right mammary line, and here there was slight tenderness on pressure ; bowels rather con- stipated ; motions clay-coloured, without a vestige of bile-pigment ; pulse 100 ; skin rather hot (temp. 100° F.) ; respiration slow and easy ; physical signs of heart and lungs normal. The treatment consisted in the frequent administration of saline purgatives (sulphate of magnesia), and a blue pill occasionally at bed- time, together with the application of mustard and linseed poultices to region of liver. Bowels were freely purged, and on Dec. 17 the symptoms had con- siderably improved ; pulse had fallen to 68 ; tongue clean ; neither nausea nor vomiting ; appetite returning ; urine contained less bile- pigment. No change, however, had taken place in colour of skin and conjunctivae, which were still deeply jaundiced. An alkaline mixture, containing bicarbonate of soda, chloric ether, and tincture of orange, 156 ENLARGEMENTS OF THE LIVER. lect. iv, was now substituted for the sulphate of magnesia ; a purgativ^e was still given occasionally, and patient had a warm bath twice a week. On Dec. 20 jaundiced tint was first noticed to be giving way, and from this date it gradually faded until Jan. 7, 18G7, when it had quite disappeared. A tonic mixture with nitric acid and quinine was now ordered, and on Jan. 22 patient left the hospital in good health. The following cases are cited as illustrations of catarrh of the bile-ducts occurring in gout}' individuals. (See also Case CXXI.). Case LXI. — Gouty Dyspepsia — Enlargement of Liver, and Jaundice from Catarrh of Bile-duds. In autumn of 1865 I was consulted by Mr. C. D , a gentleman aged 30. His father had been a martyr to gout, and a younger brother had suffered from it early in life. He had never had well-marked gout himself, but he had long been liable to gastric derangements charac- terised by nausea and flatulence and transient pains in small joints. About three weeks before I saw him he had been seized about an hour after dinner, with a pain at the epigastrium, followed by vomiting and nausea. A few days later jaundice appeared, and gradually increased in intensity ; the nausea continued without vomit- ing, and patient became much emaciated. On examination I found lower margin of liver projecting more than half an inch beyond edge of ribs in right mammary line, and slightly tender on pressure ; in- tense jaundice of a deep olive tint ; great itchiness of skin, and com- plete absence of bile from motions. Urine dark, like porter. Pulse 60 ; no appetite, nausea and flatulence after everything swallowed. Patient was extremely weak and thin, and his appearance in an older man would certainly have suggested the existence of malignant disease of stomach or liver. The treatment adopted consisted in application of mustard and linseed poultices to region of liver, warm baths, blue pill with saline purgatives, a mixture with citrate of potash and vinum colchici, and a diet restricted to milk, beef-tea, and farinaceous articles. After two days symptoms began to improve, and by end of three weeks jaundice had quite disappeared and ])atient was restored to his usual health. Case LXII. — Go%t — Catarrh of Bile-ducts — Jaundice. Alfred B , 38, leather-cutter, adm. into St. Thomas's Hosp. Oct. 17, 1874. Six years before liad left facial paralysis for twelve months. Ton years before, eldest brother (lour years older) had gout, and patient himself had been in habit of drinking much beer. Five weeks before admission, wrists, fingers, ankles, and knees became HwoUeu and painful. After about a week or ten days, pain and swell- LECT. IV. INFLAMMATION OF BILE-DUCTS. 1 57 ing subsided, bat skin and conjunctivae became very yellow, and he bad mncb itchiness of skin and occasional vomiting. State on Admission. — Deep jaundice. Liver slightly enlarged, measuring 5 in. in right nipple line ; lower edge smooth and painless. Tongue white ; moderate appetite ; much flatulent distension after meals ; bowels costive ; motions white ; no vomiting for a fortnight. Urine clear, but loaded with bile pigment. Pulse 108. Heart and lungs sound. Temp. 101° F. Treatment consisted of a mixture, three times daily, containing ci- trate of potash, iodide of potassium, and vin. colchici, and compound rhubarb and blue pills on alternate nights, followed by a black draught next morning, with milk diet. At the end of a week bile ap- peared in stools and jaundice began to fade. On Nov. 12 jaundice had quite disappeared, and two days later patient left hospital well. In the two following cases catarrli of the bile-ducts with jaundice appeared to result from syphilis. Case LXIII. — Consiitutional Syphilis — Catarrhal Jaundice. Edwin R , aged 25, adm. into Middlesex Hosp. Dec. 8, 1868. Had good health until four months before, when he contracted primary syphilis, followed by enlargement of inguinal glands and a roseolar rash. Four weeks before admission, he began to suffer from nausea, occasional vomiting, pain about right shoulder-blade, a feelino- of weight in head, dimness of sight, and general debility ; a week later he became jaundiced,- and had diarrhoea with much flatulence. On admission, great weakness ; jaundice of skin and conjunctivge, and numerous copper-coloured spots of psoriasis upon skin. Tono-ue white ; moderate appetite ; pain in abdomen and eructation of gas after food ; vomiting and diarrhoea ceased ; no bile in stools. Liver enlarged, measuring 6 in. in r. m. 1. and extending 2 in. beyond ribs ; surface smooth and slightly tender. Pulse 84, regular, Temp. 100*1°. Urine 1020 ; no albumen, but much bile-pigment. Was ordered pil. coloc. CO. with podophyllin, sulphate of magnesia and senna draughts, and a mixture containing potass, bitart. and sp. Eeth. nit. Under this treatment the bowels and kidneys acted freely, but no material improvement took place ; and on Dec. 16 jaundice not at all diminished, urine loaded with bile-pigment, and stools clay-coloured. The patient was now ordered liq. hydrarg. perchlor. 5j ter die. On Dec. 21 there was decided evidence of bile-pigment in urine, and patient was ordered a warm bath and Dover's powder at bed-time. A few days later the jaundice began to fade ; and on Dec. 30 there was only a trace of bile-pigment in the urine, the liver was reduced in size, and the jaundice had almost disappeared. 158 EIS'LAEGEMENTS OF THE LIVER. Case LXI\^. — Catarrh of BiU-duds from Syphilis {or Arsenic ?) Jaundice. Josephine S , 29, nurse, adm. into Middlesex Hosp. May 30, 1871. "Within three years had passed through attacks of small-pox, relapsing fever, and scarlatina. A widow ; had borne four children, of whom one stillborn and another died within a month of birth. Denied syphilis, but six weeks ago had a sore throat which lasted for some days. On May 19 noticed an eruption on arms, neck, and chest, for which on 2Gth she consulted a doctor, who gave her a solu- tion of arsenic, of which she was to take 5 drops three times a day. On May 27, after taking fourth dose of medicine, had great nausea, and next day after dinner, and also after medicine, she vomited and bowels acted four times. She now discontinued medicine, but on 29th she again vomited and complained of pain and tenderness about liver, and in the evening she became jaundiced. On morning of ad- mission had vomiting and slight purging. State on admission. — Decided jaundice. An eruption of elevated copper-coloured, scaly spots over arms, back, front of chest, and neck. Tongue moist, with white fur and red edges ; much thirst ; no appe- tite, motions clay-coloured. Has dull pain in right hypochondrium, with some tenderness below right ribs ; liver projects about an inch beyond ribs in r. m. 1. Urine 1025 ; much bile-pigment, but no al- bumen. Temp. 100-101-5°. Pulse 112 ; over third left intercostal space distinct rougbness of first sound of heart. Patient was ordered 6 grains of calomel, an occasional ' black draught,' and an effervescing alkaline mixture, and had mustard and linseed poultices applied over right side, while diet was restricted to milk, bread, and beef-tea. On June 3 the cutaneous eruption had increased, and patient complained of sore throat and a deep ulcer was discovered on right tonsil. This was touched with solid nitrate of silver, and mixture was changed for one containing iodide and bicar- bonate of potash. On June 1 a little bile was observed in stools, but no material improvement took place until June 8, when bile was passed freely from the bowel. On June 9 no trace of bile-pigment could be found in urine, and after this jaundice rapidly faded. On July 4 patient was discharged free from jaundice, with ulcer of tonsil healed and eruption almost gone. In the following case deatli was due to uraemia from diseased kidneys, but the hepatic symptoms appeared to result from in- flammation of the gall-bladder and bile-ducts excited by gall- stones which was subsiding before death. LECr. IV. INFLAMMATION OF BILE-DUCTS. 1 59 Case LXV. — Inflammation of Biliary Passarjes excited hy Gall-stoves — Gangrene of Foot — Diseased Kidneys — Death hy Unemia. Many of you will remember the patient J. K , aged 49, who was a patient in Middlesex Hospital from Oct. 27, 1866, nntil his death on Nov. 21. His story was that he had enjoyed good health until the previous June, when he began to suffer from loss of appetite, lowness of spirits, and pain and flatulence after meals. About same time he got a rusty nail into his left big toe. This resulted in an abscess, which burst and continued discharging until a few days before admission. He had continued working, however, as a labourer until within the last three weeks. During his illness his weight had diminished from 12 st. to 11 st. 5 lbs. On Oct. 20 he had a severe rigor, lasting for three hours, and followed by a rather severe constant ' gnawing ' pain, with tenderness in region of liver, vomiting of bitter green fluid, and headache. Two days later his skin became jaundiced, and he suffered from itchiness oE skin and loss of sleep. About same time that jaun- dice appeared, left big toe became black, and the ulceration extended. At no time of his life had he suffered from symptoms of biliary colic. On admission it was noted that patient had rather deep jaundice of skin and conjunctivee. He complained of general itchiness, and of dull pain in region of liver, which was uniformly enlarged, dalness in right mammary line being 5^ in. There was also decided tenderness at a spot corresponding to gall-bladder, which was also enlarged. Abdomen distended and tympanitic ; ingesta were constantly vomited within half an hour; tongue moist, jaundiced, and furred; bowels costive ; motions clay-coloured. Urine of the colour of porter and contained a large quantity of bile-pigment, and also of albumen, with granular and a few oil-casts. On dorsum and sole of left bio- toe were several large sloughy ulcers, the surrounding soft parts being much swollen and livid. Pulse 72 ; skin cool ; there had been no rigors or perspirations. Patient was treated with blisters and mustard and linseed poultices to region of liver, while bismuth, chloric ether, pur- gatives, &c., were given internally. For some time there appeared to be considerable improvement : jaundice diminished, and bile reappeared in considerable quantity in motions. But about Nov. 12 vomiting became more urgent, and pros- tration increased. On Nov. 19 left foot was found to be much swollen and livid lines marking course of lymphatics passed up leo-s. On Nov. 20 an abscess was opened above left ankle, from which fetid pus and gas escaped. On same day the man was seized with a fit of con- vulsions, followed by coma. These fits recurred in rapid succession so that he had nearly thirty before his death at five p.m. on Nov. 21. On examination of body after death, brain audits membranes were found to be normal, except that there was a considerable amount of flaid, which contained urea, at base and in lateral ventricles. Kidneys l60 ENLAEGEMENTS OP THE LIVER. i-ect. it. enlarged, and much fatty and granular deposit in secreting cells. Liver large, weighing 80 ounces ; secreting cells loaded with oil ; lobules unusually distinct, giving a granular appearance to organ on section. Gall-bladder contained a soft black concretion as large as a walnut, and many small, irregularly-shaped fragments of same material. These were siispended in a small quantity of dark-green viscid fluid, which, on microscopic examination, was found to contain a large number of pus-corpuscles. Mucous surface of gall-bladder had a stretcbed, white appearance, and at fundus was deeply injected, granular, and excori- ated. Bile-ducts contained a similar viscid fluid to that in gall-bladder, with minute particles of black inspissated bile. This could be squeezed into duodenum without much difiiculty. Mucous membrane of stomach and duodenum minutely injected, with numerous small ecchymoses, and surface coated with much viscid mucus. Great oedema and congestion of both lungs. Fat was deposited in large quantity throughout body, and all the soft tissues were deeply jaundiced. The next form of enlargement of tlie liver, attended by pain and jaundice, to which I wish to direct your attention, is — VIII. ENLARGEMENT FROM OBSTRUCTION OF THE COMMON BILE-DUCT BY CALCULI, TUMOURS, ETC. Obstruction of the common bile-duct may lead to enlarge- ment of the liver in two ways. a. By causing dilatation of the biliary passages with ac- cumulation of bile in them. It is not uncommon to find the ducts larger than the middle finger, and many instances are on record where the dilatation has been even greater than this. 1). By inducing inflammation of the biliary passages asso- ciated with more or less congestion and an overgrowth of the connective tissue. The liver in these cases is of a deep bilious or olive-o-reen colour, and its consistence is increased. It must not, however, be forgotten that, if the obstruction be of long standing, the liver may ultimately contract to less than its natural size, its secreting tissue becoming atrophied from the pressure of the distended bile-ducts and of the newly formed connective tissue. On microscopic examination the secreting cells are found to be reduced in size and very often to contain an undue amount of oil, and in cases of long standing they may be completely de- stroyed : while in the capillary bile-ducts bile may sometimes be seen crystallised in the form of irregular, ruby-red, shining bodies, differing in form from crystals of hamatoidin. The primary enlargement is usually followed bj' atrophy in about three or four months, but the time varies in different cases. LECT. IV. OBSTRUCTION OP COMMON DUCT. l6l The distinguishing characters of the enlargement of the liver that occurs under such circumstances are as follows : — 1. The enlargement is rarely great, and, with one important exception, it is uniform in every direction. The exception re- ferred to is due to tlie enlargement of the gall-bladder, which can often be felt as a pyriform tumour projecting from the lower margin of the liver. This enlargement is due, in the first place, to an accumulation of bile, but after a time not unfrequently to the admixture or substitution of inflammatory products. The late Dr. Bright has recorded a case in which such an enlarge- ment of the gall-bladder formed an oval tumour descending nearly to the crest of the ilium ; and you have had an oppor- tunity of examining a similar, though smaller, tumour in the case of J. W . (Case LXVI. and fig 16.) 2. There is jaundice, which if the cause of obstruction be a gall-stone, like the pain about to be referred to, is often in the first instance paroxysmal, but by the time that the liver becomes enlarged is permanent and usually intense, and is accompanied by a total disappearance of bile-pigment from the motions. In cases of persistent jaundice, where from the colour of the motions it is clear that the flow of bile into the bowel has been cut off for many weeks, there can be little doubt that there is obstruction of the common duct; and if the jaundice has been preceded by paroxysmal pain, the cause of that obstruction is probably an impacted gall-stone. But if there be no evidence of the jaundice having been preceded by paroxysmal pain, it may be difiicult to say whether the obstruc- tion be due to an organic obliteration of the duct at its duodenal opening from an ulcer or from a cancerous growth in the duodenum, or to a tumour in some other part of the course of the duct, or to pressure by a tumour on the duct from without. The rules for your guidance under these circumstances will be best considered when I come to describe the various forms of jaundice arising from obstruction of the common bile- duct. 3. Pain and tenderness in the region of the liver, and par- ticularly in the situation of the enlarged gall-bladder, are pre- sent in most cases. The pain is greatest in those cases where there is peri-hepatitis, or cancer of the liver, or where the bile- duct is compressed by a tumour which at the same time com- presses and stretches the hepatic plexus of nerves. When the obstruction is due to the impaction in the duct of a gall-stone, M 1 62 ENLARGEMENTS OF THE LIVER. i.ect. iv. there will be a history of attacks of paroxysmal pain with the other phenomena of biliary colic, but all pain may have ceased before the patient comes under observation. 4. The diagnosis will usually be assisted by the presence of those symptoms which mark the various morbid conditions producing obstruction of the bile-duct, and which will be con- sidered hereafter under the head of Jaundice. The treatment of this form of enlargement of the liver, or rather of its various causes, will also be best considered under the head of Jaundice. In the meantime, I may recall to your recollection the following case, which has been under your observation for some weeks, and which is a good illustration of enlargement of the liver and jaundice, apparently from gall-stones, except that the patient's age is considerably under that at which gall-stones are ordinarily met with. The enlargement of the gall-bladder and many of the other symptoms appeared to be due to catarrhal inflammation of the bile -ducts and gall-bladder, excited by a gall-stone. Case LXVI. — Enlargement of Liver and Dilatation of Gall-bladder fram Ohstruction of Common Bud by a Calculus. John W , aged 30, a stone-cutter, adm. into Middlesex Hosp. Feb. 5 1807. He had enjoyed good health until six months before, -when he began to suffer from acute paroxysms of pain in abdomen. For a week he would have several paroxysms daily ; then he would be free for a week, and during this interval he would be able to re- sume his work. The attacks were not accompanied by vomiting, but the first was followed by jaundice, which had never left him. Tiie paroxysms continued to recur for six weeks, but subsequently to this he had none ; he had suffered much, however, from flatulence and itchiness of skin, and had lost flesh. On admission, universal jaundice of moderate intensity : urine loaded with bile-pigment, but motions contained none. Hepatic dulness moderately and uniformly increased, measuring five inches in right mammary line. No tumour corre- sponding to gall-bladder could be discovered, but possibly this was ob- scured by the flatulent distension of bowels ; no ascites. Tongue moist, and but slightly furred ; appetite good, and no vomiting ; but patient was obliged to be very careful as to diet, as he suffered much from flatulence and pain after eating ; pulse 72. About a fortnight after patient's admission he became much worse ; and on Feb. 20 it was noted that jaundice was more intense, urine OBSTRUCTION OF COMMON DUCT. i6- darker, and hepatic dulness increased, measuring fully 5^ in. in right mammary line. In addition, there was now in situation of gall-bladder a distinct tumour (see fig. 16), extending 1^ in. behjw margin of liver, measuring 2^ in. transversely, and tender on pres- sure. Temperature had risen to 104'2'' F., and pulse to 96. Tongue somewhat dry, motions perfectly devoid of bile. These symptoms continued, with occasional vomiting, for several days ; but on Feb. 25 Fig. 16. Shows the Enlargement of Liver and Tnmour in case of J. W., on Feb. 20. Compare this with Fig. 3, at p. 4. temperature had fallen to 99-2°, and on 27th to 97°. On March 1 pulse "was down to 72, and tumour in region of gall-bladder had dis- appeared. On March 4 motions contained much bile, and jaundice was fading. By beginning of April jaundice had almost disappeared, and in May patient was able to resume his employment. The motions were carefully searched for gall-stones for ten days subsequent to Feb. 24, but none were found. Possibly a gall-stone may have either become disintegrated, or slipped back into gall-bladder. During acute stage the patient was treated with alkalies, ammonia, ether, belladonna, and opium. During convalescence, strychnia ap- peared to relieve flatulence, and disappearance of jaundice was en- couraged by warm baths and diaphoretics. K 2 164 ENLARGEMENTS OF THE LIVEE. LECTURE Y. ENLARGEMENTS OF THE LIVER. SUPPURATIVE INFLAMMATION — PYEMIC ABSCESSES — TROPICAL ABSCESS. Gentlemen, — The first form of enlargement of the liver to which I desire to draw your attention to-day is that due to IX. PYEMIC ABSCESSES. The abscesses which are often developed in the liver in the course of pysemia are for the most part many in number and small in size, and in these respects they differ from the tropical abscess, which is usually single and often attains a large size, so as to form a distinct tumour. The clinical characters vary in accordance with this anatomical difference, and with the different conditions under which the hepatic disease occurs. Those of the pysemic abscess are as follows : — 1. There is enlargement of the liver, usually of moderate extent but sometimes so great that the lower margin of the organ reaches to the umbilicus. 2. The enlargement is uniform in every direction, and does not produce any bulging of the ribs. In exceptional cases only one of the abscesses enlarges somewhat more than the others and forms a small bulging tumour at the epigastrium ; and in cases of still rarer occurrence, the lower margin of the liver, as felt through the abdominal parietes, has a nodulated character from the presence of several small abscesses or inflammatory deposits along its free margin. 3. No fluctuation can be felt in the enlarged liver. The abscesses are rarely large enough to admit of this. Only in those rare cases where one of the abscesses enlarges so as to form a bulging' in the epigastrium, or where a small quantity of pus J.ECT. V. PYEMIC ABSCESSES. 1 65 becomes encysted between the liver and abdominal wall (Case LXX.), is anything approaching to fluctuation perceptible. 4. Pain and tenderness are always present. They are often among the first symptoms noted, and are usually acute in con- sequence of some of the abscesses being near the surface of the liver, and of the inflammatory action being propagated from them to the superimposed peritoneum. The pain is often increased by coughing or by along inspiration, so that in conse- quence the respirations are quick and short, and mainly thoracic. 5. Jaundice is present in the majority of cases — in fully four-fifths ; but the possibility of its absence must be kept in view in diagnosis. The intensity of the jaundice varies. In most cases it is due to the morbid condition of the blood to which the term pysemia is applied, just as jaundice is known to result from other blood-poisons, and then it is usually slight, and the motions are still tinged with bile-pigment ; but if the inflammation be due to an ulcer of the biliary passages, excited by the pressure of an impacted gall-stone, the jaundice may be intense and the excrement devoid of bile-pigment. 6. Pyaamic abscesses of the liver rarely interfere with the portal circulation. Accordingly there is no enlargement of the veins of the abdominal parietes, and only in exceptional cases (from implication of a large branch of the vein), ascites. Occa- sionally fluid is thrown out into the peritoneum as the result of peritonitis. The spleen is usually enlarged, owing, not to obstructed circulation, but to the tendency of that organ to enlarge in consequence of the morbid condition of the blood, as happens in most diseases originating in a blood-poison. 7. The constitutional symptoms are important in diagnosis. They are mainly those of fever, at first hectic and ultimately typhoid in its type. Rigors afford material assistance in dia- gnosis ; but it is well to remember that they are not a necessary symptom. The rigors at first occasionally recur at such regular intervals that the attack simulates ague ; errors in diagnosis are constantly committed from this fact not being remembered (Case LXYIII). On the other hand, the possibility of rigors and even pyrexia, resulting from the passage of a gall-stone, without any secondary inflammation of the liver, must not be lost sight of. The temperature exhibits great oscillations ; sometimes it is normal, at others it reaches 104° or 106° ; m rare cases there appears to be no elevation of temperature, perhaps from the fever paroxysms being so short as to escape 1 66 ENLARGEMENTS OF THE LIVER. lect. v. detection (Case LXXII.). Profuse perspirations during sleep are less frequently absent than rigors. Day by day the patient becomes more emaciated and prostrate, and not unfrequently there is vomiting and attacks of diarrhoea. As the disease advances, typhoid symptoms such as a dry brown tongue, rest- lessness, delirium, involuntary evacuations, &c., make their appearance. 8. The course of the disease is rapid, usually ranging from two or three weeks to three months. I have never known the latter limit exceeded, although Leudet mentions a case which lasted as long as five months.' This rapid course may be of service in diagnosing cancer, in which the duration is usually more protracted, from pysemic abscesses of the liver. 9. The diagnosis will also be assisted by keeping in view the circumstances under which the disease usually occurs. Among them the following hold a prominent place : — a. External injuries and surgical operations. When sym- ptoms like those above described follow either of the causes now mentioned, there need be no difficulty about the diagnosis. The most of the cases, however, which come under the care of the physician depend upon internal causes, and then the difficulty is increased. h. Ulceration of the stomach or intestine. I have in several instances known pyijemic abscess of the liver supervene upon simple ulcer of the stomach, and I shall relate to you imme- diately the particulars of a case where this occurred. It may also follow ulceration of any portion of the intestine, such as an ulcer of the appendix vermiformis, or dysenteric ulceration of the colon, or even cancerous ulceration of the stomach or bowel. Pysemic deposits in the liver, however, only occur in exceptional cases of intes^tinal ulceration, probably for the same reason that general pyajmia only occurs in exceptional cases of external injury (see p. 178). c. Ulceration of the gall-bladder or of the bile-ducts may give rise to pyemic abscesses of the liver, which in this way may be a sequel of gall-stones. I shall narrate to you presently cases where an ordinary attack of biliary colic came in this way to be followed by fatal inflammation of the liver (Case LXXI.). It may be added that when the common bile-duct is obstructed by a gall-stone or from any other cause, the ducts in the interior ' Clin. M6d., Paris, 1874, p. 33. LECT. V. PYEMIC ABSCESSES. 1 6/ of the liver may become dilated into irregular cavities full of pus,^ or may rupture and form small abscesses, and in either case there may result many of the symptoms of pysemic hepatitis.^ d. In a former lecture I brought before your notice instances in which a suppurating hydatid cyst appeared to be the starting point of pysemic abscesses in the liver (see pp. 1 14 and 1 19). e. Lastly, any suppurating ulcer or cavity on or near the outer surface or in the interior of the body, especially if in con- nection v^^ith diseased bone or communicating with the external atmosphere, may induce pyaemia with secondary deposits in the liver. On more than one occasion, for instance, I have found these deposits in the liver resulting from a tubercular vomica in the lungs, ulcerative endocarditis, calculous pyelitis, &c. When the signs and symptoms already enumerated super- vene on those of any of the maladies now referred to, the pro- bability of pysemic abscesses of the liver ought at once to suggest itself. But occasionally the primary disease is latent, and the first symptoms are those of inflammation of the liver. Even then, however, the probability of pysemic abscesses ought to suggest itself in English practice, inasmuch as, with extremely rare exceptions, this is the only form of hepatic abscess met ■with, in this country in persons who have never been in a tropi- cal climate. Treatment. — In pysemic abscesses of the liver, medical art, it is to be feared, is powerless to avert the fatal result, and can only mitigate the patient's suffering. 1. By hygienic arrangements, by the antiseptic treatment of open sores and wounds, and by evacuating decomposing pus pent up in any part of the body, much can be done in the way of preventing general pyaemia in surgical injuries ; but unfortunately in a large number of cases of pysemic abscesses in the liver that come under the physician, the primary disease is inaccessible. 2. Depletion, both general and local, is contraindicated ; but if the pain be very acute it will often be materially relieved by the application of a few leeches to the region of the liver. ' Dr. Legg has recorded an interesting case where in consequence of a gall-stone in the common duct, all the bile ducts became greatly dilated, and an abscess formed in the left lobe of the liver, which found its way into the pericardium and right pleura. Path. Trans, xxv. 133. 2 It is even said that dilatation of the ducts into suppurating cavities may result from disease of their walls, independently of obstruction. See Dr. Grainger Stewart, Edin. Med. Journ., Jan, 1873, p. 631, 1 68 ENLARGEMENTS OF THE LIVER. lect. v. Mustard and linseed poultices are also useful for relieving the pain. 8. Since the discovery of bacteria in the blood of pyaemia much has been written about the internal administration of antiseptics, but proofs are still wanting of their utility. Pro- fessor Polli, of Milan, has strongly recommended the sulphites of potash and soda as antidotes for the pysemic poison. The power which these substances possess of arresting putrefaction or fermentation out of the body it is believed that they can exercise in the living blood. I have tried them repeatedly, and I regret to say that in my practice, in doses of twenty or thirty grains every four hours, they have signally failed. The sulphocarbolates of lime and soda, and the subcutaneous in- jt^ction of carbolic acid have also been tried, but without any permanently good result. 4. Quinine and mineral acids have appeared to me to be the remedies most generally useful. They support the patient's strength, keep the tongue moist, postpone the paroxysms of pyrexia, and tend to diminish the profuse sweating. 5. The hydrate of chloral, opium, or morphia will be neces- sary in most cases to relieve pain or procure sleep. If there be much retching, the subcutaneous injection of morphia will be jDreferable to administering oj^iates by the mouth. 6. The treatment must often be modified in such a way as to counteract various distressing symptoms which are apt to arise, and more especially vomiting and diarrhoea. For the vomiting, the best remedies are ice, bismuth, hydrocyanic acid, effervescing alkaline draughts, and the application to the epigastrium of sinapisms or of a small blister, followed by the sprinkling of a quarter of a grain of morphia on the blistered surface. For the diarrhoea you must have recourse to vegetable and mineral astringents, and particularly the acetate of lead and mc»rphia, and to opiate enemata and suppositories. 7. The diet must be of as nutritious a character as is com- patible with the patient's digestive powers. It ought to consist of such articles as milk, beef tea, and eggs, given frequently, but in small quantities at a time. In most cases it will be necessary to give small quantities of wine or brandy, which ought to be well diluted. I shall now proceed to relate to you the particulars of a few cases in illustration of the foregoing remarks. In the first case the hepatic disease was the result of an external injury. LECT. V. PYEMIC ABSCESSES. 1 69 Case LXVII. — Injury of Cranmm, followed hij Pycemia and MuUijjle Abscesses in Liver. Thomas D , aged 21, was admitted into one of surgical wards of Middlesex Hosp. Aug 16, 1867, with lacerated wonnds of scalp, fracture of sixth left rib, and bruise of left shoulder— injuries which he had received from being run over by a cab. He had so far re- covered that on Sept. 3 he was able to be out in garden ; but on same day he was seized with rigors, followed by febrile symptoms, headache, and loss of appetite. During next two days he had several attacks of severe rigors, like those of ague, fallowed by moderate perspiration and frequent vomiting. When he first came under my care, on Sept. 6, he had all the .symptoms of blood-poisoning, but without any eruption on skin. Pulse 120 ; resp. 36 ; temp. 103°. Alternate fits of chilliness and perspira- tion. Countenance heavy and depressed ; great lassitude ; throbbing headache, but mind quite clear ; great prostration, and tendency to syncope on sitting up ; frequent retching, with tenderness in epigastrium and right hypochondrium. Tongue moist, and but slightly furred. Bowels had been freely opened by medicine. Cardiac and respiratory signs normal. Urine contained a small quantity of albumen, with blood-corpuscles and epithelial casts. A wound in left temporal region was covered with a hard scab, from beneath which about a teaspoonful of dirty, not fetid, pus could be squeezed. Soon after patient's admis- sion he became very restless and delii'ious ; there was no paralysis, but hearing was preternaturally acute. Tongue became dry and brown, and there was frequent vomiting with a tendency to diarrhoea. Ten- derness in epigastrium and right hypochondrium continued, and hepa- tic dulness became much increased, extending down almost to umbi- licus ; surface smooth. Skin sallow, but no decided jaundice. Patient was treated mainly according to plan recommended for pyaemia by Professor Polli, of Milan, with large doses of sulphites. Sulphite of soda was given in doses of fifteen grains every four hours. No improvement, however, was observed ; and the symptoms above noted continued almost till death, at 9.45 p.m. on Sept. 9. On examination of body about a square inch of bone, correspond- ing to wound in scalp, was bare and discoloured. The bone ap- peared scratched on surface. It was not fractured ; but between its under surface and corresponding dura-mater there was about a drachm of pus ; veins leading from this to longitudinal sinus contained pale, soft, non-adherent coagula. Liver very large, extending down to umbilicus, and weighing 104 oz. Its tissue was dark and in- tensely injected, and riddled with innumerable pyaemic deposits breaking down into pus, from size of a pin's-head up to that of a walnut. Spleen large, weighed 10^ oz., and was dark and firm, but contained no infarctions. Both kidneys much enlai'ged, weighing I/O ENLAEGEMENTS OF THE LIVER. lect. v. together 18 j ounces ; surfaces smooth, and capsules non-adherent ; cortical substance greatly hypertrophied and deeply injected, but free from pyaemic deposits. Sixth left rib was fractured at about two inches from cartilage ; edges overlapped, and were enveloped in callus ; but there was no trace of laceration of lung, or of pleurisy — old or recent — in neighbourhood. Slight traces of recent pericarditis, and numerous minute ecchymoses beneath pericardium. In the second case the hepatic inflammation followed a simple ulcer of the stomach. Case LXVIII. — Multiple Abscesses in Liver secondary to simple Ulcer of StomachA John P , aged 51, was admitted into London Fever Hosp. on Oct, 6, 1865. For six weeks he had been suffering from pain, tender- ness, and flatulence in abdomen after food, followed occasionally by vomiting. He had suffered from similar symptoms on former occasions, but had always recovered. Hepatic dulne.ss 4-^ in. in right mammary line ; no jaundice. Pulse 84. Bismuth and a milk diet were prescribed. Three days after admission it was noticed that patient had a daily febrile accession about one p.m. ; and it was ascer- tained that twenty-two years before (but never since then) he had suffered from ague in Kent. Quinine was accordingly administered in large doses. It had no effect, however, on paroxysms. On the contrary, they became more severe, came on at irregular intervals, and were followed by profuse perspirations and great prostration. Tongue also became dry and brown, pain and tenderness at epigas- trium were greatly increased, and bowels were very loose. On Oct. 16 it was noted that he was much lower and greatly emaciated, and that skin and conjunctivae had a decidedly jaundiced tint, although motions contained plenty of bile. Hepatic dulness in right mammary line was now 5^ in., but enlargement was uniform, and free from nodulation ; considerable tenderness on pressure below lower margin of right ribs. Splenic dulness increased. Pulse 96 ; temp. 101°. The symptoms above narrated became gradually aggravated. He still had irregular paroxysms of rigors, followed Ijy fever and sweating. On Oct. 21 jaundice was noted as deep, although bile was still present in motions ; mind was slightly confused, and he had occasional low delirium. He gradually sank, and died on Oct. 24. On post-mortem examination, near pyloric end of stomach, on its lower and posterior surface, was a circular ulcer size of a crown-piece, with its edges slightly elevated and indurated, but containing none of microscopic elements of cancer. From base of this ulcer a small fis- ' A second case of a bimilar nature is recorded Ly nie iii the Path. Trans, vol. xvii. p. 146. tECT. V. PYEMIC ABSCESSES. • I/I tulous channel passed into an abscess almost the size of a "walnnt in head of pancreas. Liver generally enlarged, and weighed 81 oz. ; posterior half of right lobe studded with minute abscesses, from size of a pin's-head up to that of a pea, containing thick yellow pus ; intervening hepatic tissue very hypereemic ; no peritoneal inflammation over surface of liver. Spleen large, dark, and firm. Other organs healthy. In Case LXIX. pysemic hepatitis followed ulceration of tlie appendix vermiformis. Case LXIX. — Ulceration of Appendix Vermiformis — Pycemic Hepatitis. Richard S , aged 15, adm. into Middlesex Hosp. Oct. 19, 1869. Had been in the hospital from April 30 to May 25 under Dr. Good- fellow, for some obscure febrile attack with pain and tenderness in right loin. Between 1 and 2 a.m. of Sept. 29 had been seized suddenly with bilious vomiting, acute paia in right side of abdomen, and pyrexia. Vomiting had subsided after 36 hours, but other symptoms persisted until Oct. 10, when he had severe rigors lasting quarter of an hour. From this date he daily became worse, and on Oct. 17 and 18 there were recurrences of rigors. On admission, emaciated ; features pinched and expressive of pain ; frequent moaning from pain referred to right side of abdomen, which was very tender, especially over caecum ; no appreciable tumour and abdomen not at all distended, but respiration mainly thoracic. Tongue white, but at tip red and dry ; bowels not acted for a week. Pulse 96 ; temp. 98°, but next morning 101°. Signs of heart and lungs normal. Urine free from albumen. The treatment consisted in a simple enema, laudanum poultices to abdomen, and a grain of opium, at first every four, and afterwards every eight, hours. Enema acted freely but gave no relief to pain, which abated under use of opium. Xo improvement, however, took place in patient's general condition. Some days he was better, and some days worse. On Nov. 5 liver was noted as enlarged and tender, measured 6 in. in r. m. 1. ; and throughout temperature was liable to great and sudden variations (99° to 105"3°) but there were no rigors, jaundice, albuminuria, or profuse general perspirations, although face was covered with large drops of moisture during sleep. Tongue mostly dry, red, and preternaturally clean ; bowels confined ; after the first relief, notwithstanding several ene'mata, they did not act for ten days. On Xov. 10 signs of consolidation of lower third of right lung were discovered. About Nov. 15 abdomen began to in- crease in size, and on 24th there was distinct evidence of fluid in peri- toneum, but still no rigors, jaundice, or return of vomiting. On Xov. 29, pain, which had abated, became very intense, and was referred more to left side of abdomen. After this, appetite failed, prostration in- creased, temperature fell, and was often subnormal (on Dec. 3 only 172 ENLARGEMENTS OF THE LIVER. iect. v. 9o-2°), and pulse was from 84- to 92. A bedsore formed over sacrum, and patient gradually sank and died on Dec. 11. A^iUipstj. — Extreme emaciation. Two pints of flaky fluid in perito- neum. Intestines deeply injected and coated with recent lymph, most abundant over caecum and ascending colon. Mucous membrane of caecum and colon free from ulceration or cicatrix. Appendix venni- formis unusually long, its upper two inches pervious and healthy, but the distal half thickened, indurated, impervious, and adherent to cajcum. No foreign body or concretion found. Both lobes of liver studded with numerous small circumscribed abscesses, several of them in back part of right lobe merging into one. Glands in fissure of liver enlarged and suppurating. Gall-bladder distended with about two fluid ounces of thin mucous fluid ; no calculus, abrasion, or redness of lining mem- brane of gall-bladder or of ducts. No ulceration of stomach, or of intestine. Granular consolidation of lower lobe of right lung. Other organs healthy. In the next case a cancerous ulcer of the stomach appeared to be the exciting cause of the disease in the liver. The case has additional interest from the fact that there was a small fluctuating tumour at the epigastrium, caused by a circum- scribed collection of pus between the liver and abdominal parietes. Case LXX. — Cancerous Ulcers of Stoviach followed hy Pycemic Abscesses of the Liver. In June 18G7 I was requested by Dr. Rogers, of Dean Street, to see a patient under his care. He was a man, aged 45, whose father and sister were said to have died of cancer. For several months he had been losing flesh, and had suffered pain after food, and other sym- ptoms of indigestion, but not vomiting. About May 19 his symptoms became worse, and he first consulted Dr. Rogers. He then began to suffer from a constant pain in right side, febrile symptoms, dyspnoea, and a frequent dry cough, and on May 23 and again on the 28th he had severe attacks of vomiting. About June 2 a slight swelling was first noticed iu epigastrium, and he became slightly jaundiced, and when I sa\y him on June 8 with Drs. Anstie and Rogers, there was considerable jaundice, with great emaciation and prostration. Pulse quick and feeble, and a tendency to nocturnal perspiration, but no rigors. Tongue moist, clean, and red ; no vomiting or diarrhoea, and motions contained bile. Liver much enlarged, and in epigastrium there was a very painful prominent tumour, about size of half an orange, extremely elastic, and indeed apparently fluctuating. An exploratory puncture was made into this tumour, but only a few drops of blood came away. Patient becamo daily more emaciated and prostrate ; LECT. V. PYEMIC ABSCESSES. 1 73 tongue became dry and brown, and jaundice increased although stools still contained bile-pigment. On June 24 he died from exhaustion. Throughout there had been no rigors, and only slight perspiration during sleep. On examining body, liver was found of almost twice normal size ; signs of recent peritonitis over its outer surface ; glandular tissue was extremely congested, and was studded with inflammatory (not can- cerous) deposits up to size of a walnut, which were pale yellow, granular, and very friable, but which had not yet softened into pus. Between left lobe and abdominal wall there was about an ounce of pus circum- scribed by firm adhesions. This accounted for fluctuating tumour felt during life ; the fine trocar had probably passed through the abscess into liver, and thus no pus had been obtained by the puncture. On opening stomach an ulcer was found about 2 in. from the pylorus ; edges and base of this ulcer were indurated from what microscope showed to be cancerous tissue, and surface of the ulcer was ragged and sloughy. The next case whicli I shall refer to is that of a ladj 23 years of age, whom I saw in consultation with the late Mr. Young, of Sackville Street, in November and December 1861. It affords an illustration of pyeemic abscesses of the liver supervening on gall-stones. Case LXXI. — Attacks of Biliary Colic followed by Pyeemic Abscesses in Liver. On November 30, 1861, I was called to see Mrs. , aged 23, who had been married only four or five months. Two years before she had suffered for several weeks from jaundice, with severe attacks of biliary colic. Ten days before I saw her the jaundice had returned, and dur- ing same period she had been suffering from severe paroxysms of pain, in right hypochondrium, often accompanied by vomiting. Although, notwithstanding patient's age, her history was clearly one of gall-stones, yet, after making allowance for her hysterical temperament, the symptoms led to the suspicion that there was something more. The pulse was 100, and there was an unusual amount of tenderness in region of liver, and particularly in situation of gall-bladder. Hepatic dulness was increased ; there was also great increase of splenic dulness. The jaundice was of moderate intensity ; and motions, thoug-h very pale, were not entirely devoid of bile-pigment. Leeches, followed by warm fomentations, were appliedto right hypochondrium, and repeated doses of opium were prescribed. During first week in December patient had frequent attacks of vomiting, and on 4th she miscarried at third month. After this she became much worse. She had repeated attacks of rigors, lasting for 174 ENLARGEMENTS OF THE LIVER. lect. v. half an hour or more, and often followed by involuntary discharge of light-yellow fluid from bowels. She had also frequent and severe paroxysms of retching, and the pain in right side became so intense that she could not take a long inspiration without ci-ying out. Patient was never free from pain and tenderness in region of duodenum, but the intense pain was decidedly paroxysmal ; sometimes, but not al- wavs, the paroxysms seemed to be induced by patient moving or tak- ing a long inspiration. Pulse varied from 100 to 120 ; cheeks fluslied, but no perspirations ; much thirst, but even fluids were at once re- jected from stomach. Jaundice diminished ; motions always contained bile, and at last were almost natural in appearance. All treatment failed to give relief ; patient became rapidly emaciated, and was occa- sionally delirious during night ; and towards the end tongue was dry and brown, and sordes collected on lips and teeth. Death took place on Dec. 23. On post-mortem examination liver was found to be large, and en- tire substance of both lobes studded with an immense number of cir- cumscribed abscesses, vaiying in size from a pea to a small orange, and filled with yellow flaky pus ; outer surface glued by recent lymph to diaphragm and adjoining organs. Hepatic and common ducts pervious and contained bile. Gall-bladder collapsed, its cavity being scarcely larger than a hazel-nut, and its coats much thickened. A gall-stone, somewhat larger than a pea, was found impacted at commencement of cystic duct, and mucous membrane in contact with the concretion was ulcerated, and partly converted into a blackish slough. Beyond this cystic duct vras obliterated. Gall-bladder contained about a dozen calculi of smaller size, but no bile ; fundus firmly adherent to duode- num, and between these two viscera was a closed cavity containing gall-stones, equalling in size and number those found in gall-bladder itself ; corresponding mucous surfaces of duodenum and of gall- bladder marked by an extensive cicatrix. These appearances were pro- bably the result of a dire ct passage of gall-stones through the fundus of the gall-bladder into the bowel in the attack two years before death. Mucous membrane of first three inches of duodenum intensely injected but not ulcerated ; inner surface of the stomach and intestines pre- sected nothing abnormal. Spleen was four times its normal size. In addition to the coating of recent lymph, cajisule of liver at several places presented old thickening and firm adhesions. Lungs congested, but otherwise normal. The following case is interesting from its remarkably latent character, and for the absence of pyrexia. The coexistence of plugging of tlie femoral vein with enlargement and tenderness of the liver, bile-pigment in urine, and sallowness of the skiii suggested that the patient might be suffering from pyaemic in- flammation of the liver, and this diagnosis was made, notwith- LECT. V. PYEMIC ABSCESSES. I75 standing tlie absence of rigors or perspirations, which are not unfreqnently absent in pyseniia arising from internal causes. I was, however, scarcely prepared to meet with pjsemic inflamma- tion of the liver with no elevation of temperature, during at least five successive days, which this case shows to be possible. Case LXXII. — Gall-stones causing Ulceration and Perforation of Cystic Duct — Pt/oemic Hepatitis and Thrombosis of Femoral Vein — Absence of Pyrexia. Mary Ann S , aged .53, adm. into Middlesex Hosp. April 13, 1869. I^ever had any symptoms pointing to gall-stones, and except- ing diseases of childhood, had enjoyed good health, and been able to work as charwoman till three months before admission, when she began to complain of excruciating pain and swelling in right leg, and lost appetite and flesh. She continued going about, however, till ten days before admission, when she was seized with rather severe pain in epi- gastrium, nausea, vomiting, thirst, and increased prostration. On admission patient was of stout habit, very prostrate, dejected and apathetic. She was also very restless and sleepless at night, but she had no headache or delirium and her memory was good. Her chief complaint was uncontrollable vomiting, so that she could retain nothing on her stomach. Much thirst ; tongue red and dry all over. Decided tenderness in epigastrium and below right ribs ; liver extended 2 in, beyond ribs in right nipple line, where it measured vertically 5 in. ; its surface smooth. No' ascites or enlargement of spleen ; bowels regular. Pulse 84, feeble ; physical signs of heart and lungs normal ; skin cool ; no eruption ; temp. 98° Fahr. Urine contained bile-pigment, but no albumen. Face slightly sallow, but conjunctivee white. Right thigh and leg swollen throughout ; and great tenderness along whole course of right femoral vein. Treatment consisted mainly in giving milk and ice by mouth, and brandy and beef-tea by rectum ; but patient continued to sink. On April 16 hiccup set in, with coffee-ground vomiting, and watery motions containing blood. Death occurred on April 18, Neither before nor subsequently to admission into hospital had pa- tient at any time rigors or perspirations ; and during whole time that she was under observation, although temperature was taken twice daily, at no time did it rise above 98° Fahr, in axilla, and only once did it reach 99f° under tongue. Autopsy. — Two and a half inches of fat in abdominal parietes. Right iliac and femoral veins plugged throughout, coagulum for 3 or 4 in. at brim of pelvis being decolorised and adherent, but below this black and non-adherent. Liver adherent to duodenum and colon, and on removing it gall-bladder was torn across, allowing a number of poly- hedral gall-stones about size of plum-stones, and covered with pus, to 1/6 ENLARGEMENTS OF THE LIVER. lect. v. escape. These gall-stones had been enclosed in a cavity bounded by- liver and surrounding parts, with its' internal surface ulcerated, and communicating by a large ragged opening with cystic duct. Beyond this, cystic duct was closed by adhesions, but hepatic duct was per- vious. No bile in gall-bladder. Liver studded with numerous inflam- matory deposits, up to size of a cherry, most of them consisting of a firm, translucent, greyish material, which in some instances was soften- ing into an opaque fluid, like pus. The firmer material was made up of branched fibre-cells ; and the yellow fluid of oil-globules and com- pound granular bodies, but no true pus-corpuscles. The intervening portions of liver, spleen, and kidneys were soft, apparently from rapid decomposition. Heart flabby, its lining jnembrane stained with blood- pigment. Lungs congested, with small sub-pleural ecchymoses. Case LXXIII. was remarkable for the large size attained by the liver, and for the absence of any cause of the hepatic in- flammation, excepting the softening tubercle in the mediastinal glands. Case LXXIII. — Multiple Abscesses of Liver — Softening Tubercle in Mediastinal Glands. Ann C , aged 5'/, a cook, adm. into Middlesex Hosp. under my care Jan. 13, 1868. Her father and mother had both lived to upwards of 80, and, with exception of an umbilical hernia and a great tendency to vertigo, she herself had always enjoyed good health until her present illness, which commenced a week before Christmas with acute pain in region of liver, stretching round back to left side. This pain was accompanied by febrile symptoms, loss of appetite and sleep, and by a swelling and tightness in upper part of abdomen, which increased daily. On Jan. 5 her face and eyes had been noticed to be slightly yellow. On admission patient was an extremely corpulent woman, whose skin and conjunctivae presented a slightly jaundiced tint, and who was so weak as to move her great bulk with ditficulty in bed. The abdo- men was enormously enlarged, measuring 53 in. at umbilicus. Mode- rate oedema of both lower extremities, but no distinct thrill of fluid in abdomen, and percussion yielded a clear sound in both flanks. The great size of abdomen appeared due partly to an enormous subcuta- neous deposit of fat, and partly to enlaroementof liver, which measured 9 in. in right mammary line, and which reached fully 5 in. below margin of right ribs. 8o far as an examination could be made through the thickened abdominal parietes, enlargement of oman appeared to be uniform in every directioTi, and its surface was hard and smooth. On pressure over it there was decided tenderness, and a pain shooting from point of pressure to back. Tongue dry and red down centre ; much thirst ; no vomiting ; bowels regular. Pulse 108. Heart's sounds i^ECT. V. TROPICAL ABSCESS. I// very feeble, but no bellows-murraur. Respirations embarrassed and thoracic ; sonorous rales at bases of both. Inngs. Urine of a dark ' amber colour, with a copious deposit of litbates ; no albumen. Mind clear. Temperature 98° Fabr. Patient was ordered the day after admission a draught containing a drachm of sulphate of magnesia three times a day, but on Jan. 15, after three doses, bowels were so purged that a mixture of nitro-hydro- chloric acid and gentian was substituted. Diari-hoea, however, per- sisted, motions being watery and dark-brown ; tongue continued dry ; temperature rose to 101 '4° ; on nights of Jan. 17 and 18 patient had much low delirium ; and in afternoon of Jan. 19 she died suddenly by syncope while attempting to get out of bed. Autopsy. — Fat in abdominal parietes measured fully 4 in. in thickness. Peritoneum contained about three pints of turbid serum, with small flakes of lymph. Liver enormously enlarged, its lower margin projecting about 5 in. beyond that of right ribs ; it weighed 266 ounces, and was studded throughout with innumerable minute abscesses, the projection of which from outer surface gave to this a coarsely granular aspect. The portions of hepatic tissue which re- mained were in an advanced state of fatty degeneration, but there was scarcely a quarter of an inch of organ free from purulent deposit. Gall-bladder much distended with innumerable black polygonal con- cretions, from size of a small cherry to that of a grain of sand; ma- jority were small, and resembled grains of coarse gunpowder ; the larger ones were found on section to be white internally, and to be composed of cholesterin. Common bile-duct patent, and after careful examination, no ulceration could be discovered in lining membrane of gall-bladder or of any of ducts, nor in mucous membrane of stomach or intestines. No pus in portal vein or embolism of hepatic artery. Spleen large and soft. Kidneys rather large and pale, but appeared normal. Right Fallopian tube dilated into a cyst the size of an orange, containing a dark thin fluid, and with several small vegetations at- tached to its lining membrane. A fibrous tumour size of a walnut in walls of uterus. At apices of both lungs there were old tubercular cicatrices, but no cavities, and in anterior mediastinum were two or three collections of pns, formed by suppuration of tubercular lymphatic glands. Heart pale, flabby, and friable, and in an advanced stage of fatty degeneration. X. TROPICAL HEPATITIS AND ABSCESS OF THE LIVER. The pathology of tropical abscess of the liver has been a subject of much discussion, and one on which opinions are still divided. The frequent coexistence in the tropics of abscess of the liver with dysentery has naturally led pathologists to con- N 178 ENLARGEMENTS OP THE LIVER. lect. v. nect the two lesions, some, like Annesley, maintaining that the dysentery is the result of the hepatitis ; others, that the hepa- titis is the result of the dysentery ; while a third class, like Dr. Abercrombie, have suggested that the frequent concurrence of the two maladies is merely the result of accident. The doctrine now most generally accepted in this country is that propounded nearly thirty years ago by Dr. G. Budd, viz. that the hepatic inflammation is the result of purulent absorption from the ulcerated colon, or in fact that the pathology of tropical abscess is identical with that of the pysemic abscesses of this country.* Considering how frequently in this country abscess of the liver is secondary to ulcers of the bile-ducts, stomach, or bowels, or other sources of purulent absorption, it would indeed be extraordinary if dysenteric ulceration of the colon never led to a like result, as some have contended. The fact that fatal dysentery with ulceration uncombined with hepatic abscess is a common occurrence in India is no argument against hepatic abscess occasionally resulting from dysentery, any more than that, in Europe, pysemic abscesses only occur in exceptional cases of intestinal ulceration, or of the other sources of purulent absorption already enumerated. Something more than an open sore is necessary for the formation of pysemic deposits. The discharges from the sore must be in a peculiar state of decom- position. The causes of this decomposition may be extrinsic or intrinsic, but where there is no such decomposition there is no pyaemia. But a large number of the abscesses of the liver met with in tropical countries cannot be ascribed to dysentery, or to a pysemic origin, or to mechanical injury. More than twenty years ago, I stated that this was the result of my observations on the diseases of Burmah,'^ and the facts, which have since been published by Morehead,^ Bristowe,* Frerichs,* McLean,^ and others, appear to me to be perfectly conclusive on the matter. These facts are of a fourfold nature. 1. Cases are not uncommon in tropical countries where there has been abscess of the liver, and where the j^atient has ' Dis. of Liver, 3rd ed. ]>. 82. - Oliscrv. on the Climaii; and Diseases of Burmali. Edin. Med. and Surg. Joiirn. 1854, pp. 215-7. ' Researches on Diseases in India, 1856, ii. p. 10. « Path. Trans. 1858, ix. p. 260. ' Frerichp, Treatise on Dis. of Liver, Eng. Ed. ii. p. 116. • Article on Suppurative lufl. of Liver, in Jiycnoldss System of Med. iii. p. 324. LECT. V. TROPICAL ABSCESS. 1 79 recovered without any symptoms of dysentery before, during, or after the hepatic malady. I shall give you the particulars of such a case immediately (Case LXXIV.). 2. In many cases where there has been a concurrence of hepatic abscess and dysentery, the symptoms of the former malady have preceded those of the latter. A case of this sort was recorded by me in the eighth volume of the ' Pathological Transactions' (p. 237), and similar cases are referred to by Morehead, Waring, and Bristowe.* It may perchance be argued that in the cases included under these two heads dysenteric ulceration was really present, but that its symptoms were latent. Dr. Dickinson, for instance, has recorded a case where extensive dysenteric ulceration and a large abscess of the liver were found after death without any symptoms during life to lead to a suspicion of either malady.^ But although such an explanation may apply in a few excep- tional eases, it is obviously inapplicable to such results as those obtained by Mr. Waring, who states that of 300 cases of hepatic abscess proving fatal in India, in only 82 cases, or in 27*3 per^ cent., was the hepatitis preceded by symptoms of dysentery.^ 3. The most conclusive cases, however, are those in which the patient has died of hepatic abscess, and no sign of dysen- teric ulceration has been found after death. I shall give you immediately the details of a case of this sort, in which, it is important to add, there had been a considerable amount of diarrhoea during life (Case LXXIV.). Morehead observed 21 fatal cases of abscess of the liver ' without any sign of intestinal ulceration,'^ while in 204 cases of abscess of the liver collected by Waring there were no ulcerations, cicatrices, or abrasions in 51, or in exactly one- fourth.^ Lastly, in the Pathological Museum at Netley there are 48 specimens of tropical abscess of the liver, of which in 34 the abscess was uncomplicated with any intestinal lesion.^ It is clear, therefore, that although dysenteric ulceration of the bowel may occasionally lead to pysemic deposits in the liver similar to those met with in this country, many cases of tropical abscess are independent of such an origin. Few Indian ' Dr. James Finlayson has pointed out how hepatic abscess may lead to congestion and even ulceration of the colon. Glasgow Med. Journ., Feb. 1873. 2 Path. Trans. 1862, vol. xiii. p. 120. ^ An Enquiry into the Statistics and Pathology of Abscess of the Liver. Trt^van- drum, 1864. * Op. cit. ii. p. 12. ' Op. cit. « McLean, op. cit. iv. 324. N 2 l80 ENLARGEMENTS OF THE LIVER. iect. v. physicians wouW, I think, admit the validity of Dr. Moxon's argutnent that intestinal ulceration or cicatrices would be found in all cases of tropical abscess of the liver if the bowels were examined with sufficient care.' 4. It appears to me that the etiolosry of hepatic abscess receives further elucidation from an anatomical point of view. The abscesses of the liver which are met with in this country, and which are the result of absorption from an open sore, are usually, if not always, small but numerous. On the other hand, in most cases where abscess of the liver is met with in the tropics, there is but one abscess which attains to large dimen- sions, or in exceptional cases there may be two or three. In a case recently under my care 160 ounces of pus were drawn off by tapping during life. Abscesses of the liver, answering to this description, are almost unknown in this climate or in temperate climates generally, except in persons who have sus- tained some local injury of the liver, or who have at one time resided in the tropics — an extraordinary fact, if their cause be the same as that of multiple abscesses. Even when dysentery occurs in temperate climates no such abscesses are found iu connection with it. Out of many hundreds of cases of dysentery which occurred in Millbank Prison during thirty years, we are told, on the authority of the late Dr. Baly, that not one was complicated with hepatic abscess.'^ In Germany, it is stated by Heubner, that hepatic abscesses are sometimes met with after dysentery ; ' they are, however, multiple and of embolic source,' and it is added that these abscesses ought not to be confounded with the ordinary abscess of the tropics.^ These facts alone are sufficient to show that tropical abscess of the liver is inde- pendent of dysentery. To argue that the large size and singleness ' P;ifh. Trans., 1873, xxiv. 116. ^ ' Wlien the close relation subsistinpr between dysentery and suppurative di.sease of the liver is considered, it cannot but appear remarkable that amongst the many hundreds of ca.se.s of dysentery which have occurred in the Millbank Prison durinfrthe last seven years, rot one has been complicated witli hepatic abscess. The medical records of the establishment, too, which reach back to the year 1824, afford no grounds for even a suspicion that such cases ever occurred amongst the prisoners.' Yet, ' in this dysentery in the Millbank Prison the disease of the mucous surface, both as to it« seat and in its nature, has lioen the same as in the dysentery of India, with which hepatic abscess is so frequently as.tociated.' Gulstonian Lectures on Dysentery, 1847. » On Dysentery. Ziemsscu's Cyclop, of Med., Anier. Ed. 1875, i. 546. 556. Roki- tansky also, in his dissections of casps of dysentery, never found the liver visibly diseased ; while in I'rance, T?roussais, who reported 17 fatal cases of dysentery with dissections, does not mention his having found al'.scess of the liver in any one instance, although the condition of this organ is frequently mentioped. Baly, op. clt. XECT. V, TROPICAL ABSCESS. l8l of the tropical abscess is due to the longer time it lasts as com- pared with the swift course of the multiple abscesses met with in pytemia ^ is, it appears to me, to disregard the clinical history of the two maladies ; in the tropics one enormous abscess may form in a fortnight, but both m tropical and temperate climates small multiple abscesses may be found after an illness which has lasted for months. For these reasons I have proposed to designate the single large abscess so common in warm climates the Tropical Abscess, to distinguish it from the Pycemic Abscess which is the com- mon form in this country. In suggesting these designations it is not contended that small multiple abscesses of the liver are unknown in the tropics ;^ but, so far as i have been able to ascertain, this form is never met with except in connection with dysentery, or with some other source of purulent absorption. It must not be forgotten that a single large abscess, like a suppurating hydatid in the liver, may be a source of infection and of small secondary abscesses. The single tropical abscess may also coexist with dysentery, but from the large number of cases in which both dysentery and hepatic abscess are independent of each other, it follows that when they coexist, they are either the effects of a common cause, which in certain persons will produce either of the diseases separately, or of a concurrence of causes which indi- vidually will cause only one of the diseases. The latter view is favoured by the fact that a single large abscess is not found in connection with dysentery in temperate climates. Supposing, for example, what is probably the truth, that dysentery is the result of a poison inhaled, or swallowed in drinking water, and that hepatitis may be caused by a chill in a person whose liver has been congested by a residence in a hot climate, aided by intemperance, irritating ingesta, and exposure to the malaria of tropical fevers (see p. 184), it is readily conceivable that in a country like India where these causes so often operate simul- taneously, attacks of dysentery and hepatitis — combined as well as separate — should not be uncommon. The distinction drawn above between pysemic and tropical ' Moxon, loc. cit. ^ Of 300 cases of abscess of the liver in India collected by Waring, the number of abscesses was not stated in 12 ; of the remaining 288, there was one abscess in 177 ; two abscesses in 33; three in 11 ; tour in 17 ; five to ten in 10; more than ten m 40. An Enquiry into the Statistics and Pathology of some Points connected wich Abscess of the Liver, as met Avith in the East Indies. Trevaadrum, ISoA, p. 125. l82 ENLARGEMENTS OF THE LIVER. lect. V. abscess is far from being one merely of pathological curiosity ; it has a most important bearing both on prognosis and treat- ment. The pysemic abscess is much the more serious and fatal malady of the two ; the danger is from the blood-poison and not from the local disease ; and recovery from it rarely, if ever, occurs. The tropical abscess again is a local malady, not un- frequently recovered from ; the abscess may discharge itself through the lung, the stomach, or the bowel, or externally, and thus the patient may recover — terminations not met with in the case of pysemic abscesses ; and lastly, one of these natural modes of termination of the tropical abscess is advantageously imitated by the surgeon, when he evacuates the abscess by an external opening — a procedure which would obviously be worse than useless in the pya3mic abscess. It follows, therefore, that it is of some practical importance to be able to distin- guish during life between the pysemic and the tropical abscess. The characters of the former have been already detailed ; those of the latter remain to be considered. They are as follows : — A. In the early stage of the disease, the main clinical features are those of hepatic congestion already described (see p. 131). There is chilliness followed by pyrexia, often of a re- mittent type, accompanied b}' pain and tenderness, or oftener by a feeling of weight, fulness, or uneasiness in the region of the liver, and occasionally by pain in the right shoulder, defective respiratory movement of the right ribs, dry cough, a uniformly augmented area of hepatic dulness, and slight jaundice. The enlargement, however, is on the whole less, and the jaundice much rarer than in the congestion of the liver resulting from disease of the heart or lungs. This is due to the circumstance that the branches of the hepatic and portal veins, which are gorged in the latter case, are much larger than those of the hepatic artery, which are the main seat of the congestion that precedes the formation of abscess. But in not a few cases there are no local signs of mischief in the liver, and in fact the only symptoms may be those of an intermitting or remitting fever which may be thought to be malarious, B. When the inflammation goes on to suppuration, which iiuless it terminate previously by resolution, often occurs at the end of a week or twelve days, the characters are as follows : — 1. There is enlargement of the liver, which is no longer uni- LECT. V. TROPICAL ABSCESS. 1 83 form. The natural outline of the area of hepatic dulness is altered, and will bulge upwards, downwards, forwards, or outwards, according to the direction which the abscess takes in each case (see fig'. 17, page 193). Not unfrequently there is a bulging of the ribs, with obliteration of the intercostal spaces, or there is a prominence in the epigastrium, or in the right hjpochondrium, such as occurs in hydatid tumours. 2. This bulging or tumour is tense, rounded, smooth, and free from any inequalities. In the advanced stage, however, of exceptional cases the margin of the enlarged liver may be nodulated from the development in it of small secondary pysemic abscesses. 3. Fluctuation can usually be detected in the tumour, which will be more or less distinct according to the distance of the abscess from the surface. The feeling of vibration, however, which can often be appreciated on tapping with the finger over a hydatid tumour (page 56), cannot be elicited in an abscess, owing to the greater thickness of its contents. Another dis- tinctive character of abscess is, that the fluctuation is usually surrounded by a mass of inflammatory hardness. But although tropical abscess is a common cause of enlarge- ment of the liver, an abscess of considerable size, if deeply seated, may cause no apparent fluctuation, bulging, or even en- largement. This is a fact which I cannot too strongly impress upon your memories. 4. Pain and tenderness are very often absent. Pain, when present, is dull and heavy, and not of that acute chara.cter, in the first instance, at all events, so common in the pysemic abscess. This is because the abscess is usually at first in the interior of the liver. The pain only becomes acute like that of pleurisy, and the tenderness great, when the matter approaches the surface of the liver and excites peri-hepatitis, or stretches the integuments. Thus it is that acute pain often marks the last stage, instead of the commencement, of the morbid process. Some cases are remarkably latent, as far as pain is concerned, throughout their whole course ; while in others pain is only produced when the patient takes a long breath, and at the same time pressure is made below the margin of the ribs, or over the lower end of the sternum. A sympathetic pain in the right shoulder is not uncommon, especially when the abscess is situated on the convex surface of the right lobe ; but in most cases it is absent. The presence of pain in the shoulder will 184 ENLAEGEMENTS OF THE LIVER. lect. v. undoubtedly increase, althougli its absence will not diminish, the importance of other symptoms. 5. Ascites, oedema of the lower extremities, enlargement of the superficial veins of the abdomen, and haemorrhoids are not distinguishing characters of tropical abscess, any more than of hydatid of the liver. Their occurrence in rare cases is accidental, and due to compression by the tumour of the trunk of the portal vein or of the inferior vena cava. Occasionally, fluid is thrown out into the peritoneum as the result of peritonitis. 6. Enlargement of the spleen is rarely present in tropical abscess. 7. Jaundice is a much rarer symptom in the tropical than in the pysemic abscess. Its occurrence, in fact, if we except a slight icteric tint during the primary stage of congestion, is quite exceptional. Morehead has noted it in only five out of up- wards of 120 cases. ^ When it occurs, it has mostly a mechani- cal origin, and is due to the concurrence of catarrh of the bile- ducts, or to the direct compression of the large ducts by the abscess. 8. The constitutional symptoms are important, as serving to distinguish the tropical abscess from hydatid tumour, and also from the fact that in the absence of local signs the diagnosis must be founded upon them alone. After the occur- rence of suppuration, they are mainly progressive emaciation and fever of the hectic type. The frequency of the pulse may be little, if at all, increased ; but (unless the abscess has become encysted and quiescent) there is almost always an elevation of temperature to several degrees at some period of the twenty- four hours. Rigors and night-sweats are less prominent symptoms than in the pysemic abscess. The tongue becomes covered with a grey or yellowish coat, and in the advanced stage it may be preternaturally red and dry and coated with aphthae. Loss of appetite is a common, but far from invariable, symj)tom. Obstinate vomiting is present in many cases,^ and ought always to excite suspicion of abscess of the liver in a tropical climate; it is very apt to occur when the abscess is about to discharge into the stomach or duodenum, and the exhaustion which it entails may be tbe immediate cause of death. Diarrhoea, or even dysentery, occurs in some cases. The urine is loaded with » Res. on Dis. in India, 2nd. ed. 1860, p. 37-3. •^ See Dr. W. C. Maclean and Sir Josopli Fayrer, Brit. Med Journ. 1874, ii. 138, 4(11. LECT. V. TROPICAL ABSCESS. 1 85 lithates or litliic acid, and contains mucli pigment; the urea is greatly increased, but when the hepatic tissue has been in great measure destroyed, it may be deficient. Temporary albuminuria, often considerable, is not uncommon. Very often there is a short dry cough, and the respirations are quickened, especially when the abscess is about to perforate the diaphragm, and then also friction may be heard at the base of the right lung. It is important to remember, however, that a tropical abscess of the liver may be so latent as to reveal itself by neither local signs nor constitutional symptoms. Not unfre- quently the only symptoms are debility and paroxysms of fever, which are believed to be malarious, but the real nature of which is first suspected by their failing to yield to large doses of quinine. In some cases, as we shall presently find, even pyrexia may be absent. 9. The duration of tropical abscess of the liver is a matter of some importance in diagnosis. Although it may terminate fatally, or may discharge in some direction within three weeks of the commencement of the symptoms, yet, on the whole, the course of the disease is less rapid than that of the pysemic abscess. Very often it extends over two, three, or even six months ; and cases are not uncommon where a small tropical abscess with thick organised walls has existed for months, or even years, in a quiescent form, and has then undergone enlargement and burst. Some of the cases met with in this country, where a large abscess forms in the livers of persons years after their return from India admit of this explanation ; while others are perhaps what Sir James Paget^ would call ' residual abscesses,' or abscesses formed in or about the residues of former inflammation. 10. The circumstances under which ' tropical abscess ' occurs may sometimes be of material assistance in diagnosis : — a. Its frequency in certain parts of the tropics, and particu- larly in India and China, and its extreme rarity in temperate climates, except in persons who have visited tropical countries. In the West Indies, curiously enough, it is comparatively rare. h. It is chiefly met with between the ages of 20 and 45. c. It is most common in persons of indolent habits, and who have been excessive eaters or intemperate in the use of alcohol. Of 40 cases in which the habits were noted by Waring, 6 7 '5 per cent, were intemperate. d. The concurrence of dysentery. ' On Residual Abscesses, St. Earth. Hosp. Eep. 1869, v. 73. I S6 ENLARGEMENTS OF THE LIVER. lect. v. 11. The diseases most likely to be confounded with tropical abscess are hydatid tumour, inflammatory enlargement of the gall-bladder, pysemic abscesses, and abscess of the abdominal parietes (see p. 15). a. A hydatid of the liver is the enlargement most likely to be mistaken for abscess. In both there may be a local projec- tion from the general contour of the liver, presenting flluctuation and occasionally causing bulging of the ribs or a semiglobular tumour in the epigastrium. Tropical abscess is mainly to be distinguished from hydatid by the presence of pain, by its much more rapid course, by its constitutional symptoms, and by the circumstances under which it occurs. The possibility, however, already referred to, of a hydatid tumour suppurating or becoming converted into an abscess must not be lost sight of. An error in diagnosis from this cause is all the more likely to arise if the patient, as often happens, has been ignorant of the existence of the hydatid tumour prior to the occurrence of the acute symptoms due to its taking on inflammatory action. Any doubt will usually be removed by an exploratory puncture, while the treatment in both cases will be the same. h. The circumstances under which enlargement of the gall-bladder may simulate hepatic abscess and its distinguishing characters will be considered in a subsequent lecture. It niay be here observed, however, that a large abscess connected with the liver in a person who has never left this country is in most cases either a suppurating hydatid or an inflamed gall-bladder, c. The constitutional symptoms of tropical and pynemic abscesses may be identical. For distinguishing them, we must rely mainly on the form of the enlargement, the circum- stances under which each occurs (see pp. 166 and 185), and the greater tendency in the pysemic abscess to jaundice and symptoms of blood-poisoning. Treatment. — A. Before suppuration. Until a comparatively recent date the two remedial measures mainly relied on in the treatment of tropical abscess of the liver were general blood- letting and mercury. With regard to bloodletting there can be no doubt that in the case of plethoric Europeans but recently arrived in the tropics, in whom the disease often sets in acutely, with full firm pulse and high temperature, it often relieved pain and reduced the fever, but there is no evidence that it prevented suppuration and some suspicion that it hastened it, while all its good effects will be obtained by the application of a few leeches LKCT. V. TROPICAL ABSCESS. 1 87 over tlie liver or round the anus. The same may be said of mercury. Pushed to salivation, it is more likely to favour suppuration than to prevent it, and it will certainly increase the tendency to malarial cachexia and anaemia. Except as an occa- sional aperient, it ought never to be given. The rules for the treatment of the early stage of tropical hepatitis are the same as those which I laid down in my last lecture for congestion of the liver (p. 134), the remedies on which reliance is mainly to be placed being the chloride of ammonium and ipecacuanha in large doses. The liability to diarrhoea or dysentery makes it necessary to be more cautious in the use of purgatives than in the ordinary hepatic congestions of this country. B. After suppuration. In tropical abscess of the liver, not only may we hope to prevent suppuration by appropriate treat- ment, but even after it has occurred the case is far from being, as in the pysemic abscess, necessarily fatal. The treat- ment, however, for the stage antecedent to suppuration is no longer suitable. 1. Warm fomentations and poultices are still to be applied to the region of the liver ; and in the event of acute pain super- vening, although this usually indicates an advanced stage of the disease, a few leeches will often give relief. 2. The patient's strength must be supported by mineral acids and vegetable tonics, and in particular by the sulphuric or nitric acid with quinine. 3. Opium is in most cases necessary to relieve pain, to procure sleep, or to allay the harassing cough. 4. Purgatives are no longer called for. If the bowels be constipated, a mild laxative may be given from time to time, but more commonly there is diarrhoea or dysentery, necessitating the use of vegetable and mineral astringents, with opiate enemata or suppositories. 5. The diet must be of a more generous nature than that which is permissible in the stage of congestion ; and when the circulation is weak, small quantities of wine or brandy will be necessary. 6. In multiple abscesses, which must be regarded as a local manifestation of a general disease, it is clear that no advantage is to be derived from operative interference, but when there is a single large abscess, the general symptoms being here the result of the local disease, the propriety of evacuating the pus may fairly be entertained. It is no doubt true that a large 1 88 ENLARGEMENTS OP THE LIVER, lect. V. abscess of the liver may become encysted and shrivel up, and in this way undergo what may be called a spontaneous cure, in- dependently of rupture, but this is an event so rare that it cannot be calculated on. Eecovery also takes place occa- sionally in consequence of the abscess emptying itself through a bronchial tube, into the bowel, or externally through the abdominal parietes ; but the process is tedious, and even when it occurs many patients die of exhaustion from fever, pneumo- nia, or diarrhoea, to say nothing of their liability to destruction at any moment from the abscess bursting into the pericardium, the pleura, or the peritoneum. In a large proportion of cases, however, the patient dies while the abscess is still confined to the liver. ^ Under these circumstances the expedienc}"" of hasten- ing the evacuation of the matter naturally suggests itself. You will find nevertheless that professional opinion is divided on this important question. Dr. Budd, in his standaid work on ' Diseases of the Liver,' considers the dangers of operating so many and so great, that it is better to let matters alone and allow the abscess to open of itself.^ Some authorities, again, such as Frerichs^ and Morehead,'* advocate opening the abscess in selected cases ; while others, like Dr. Murray, for- merly Inspector-General of Hospitals in Bengal, Dr. Cameron,^ and Sir Ranald Martin,*' maintain that ' when we have just grounds for believing that abscess of the liver exists, we ought not to lose a day in evacuating it by puncture, and that we are both justified and safe in endeavouring to hit upon it with a trocar when deep-seated, avoiding the gall-bladder and large veins.' ^ Dr. Cameron, in fact, goes so far as to recommend exploring the liver with a trocar in cases where the existence of an abscess is suspected, though not certain, and has published cases where no pus was found, and yet the patient's symptoms subsided, instead of being aggravated, subsequently to the ex- ploration. Amid such conflicting opinions we may be aided in ' Of 300 fatal cases of licpatic absi'css collected by Mr. Waring, the aljscess, at the time of death, had not extended beyond the boundaries of the liver in 169 ; in 48 it had been opened by operation ; in 42 it had opened spontaneously into the rigiit lung or thoracic cavity ; in 15, into the peritoneum ; in S, into the stomach or colon ; in 3, intfj the hepatic vein, &e. Op. cit. « Op. cit. 3rd ed. ISoZ, p. 124. ' Dis. of Liver, Syd. Soc. Kd. ii. p. 147. < Kes. on Dis. in India, 2nd cd. 18G0, p. 410. » Lancet, Juno 6 and 13, Aug. 8, 1863. • Lancet, Aug. 20 and 27, 1804. ' Cameron. Liincet, June G, 1863, p. 631. IKCT. V. TEOPICAL ABSCESS. 1 89 forming- a just judgment by considering, on the one hand, the dangers of the operation, and, on the other, the dangers of non- interference. The main objections raised against the operation are as follows : — a. That pus is apt to escape into the peritoneum and excite fatal peritonitis. In most cases, however, when the abscess is near the surface, there would be adhesions which would pre- vent the entrance of pus into the peritoneum. Morehead speaks of the absence of adhesions as quite exceptional (in only 3 of 76 fatal cases). Moreover, if desirable, it is always possible to produce adhesions. h. That air will enter the abscess and excite fresh inflam- mation, or pyaemia. This is an undoubted source of danger ; but it is as likely to be incurred if the abscess opens spon- taneously into the bowel, a bronchial tube, or externally. More- over, it may be in a great measure prevented by the use of antiseptics. c. That the mechanical injury of the puncture is apt to produce haemorrhage and fresh inflammation in the hepatic tissue. So far as I have been able to ascertain, this is an ob- jection founded on theoretical considerations rather than on actual observation. I have had several opportunities of con- firming Dr. Cameron's statement to the effect that a fine trocar can be plunged into the liver without any ill result, and with- out, in fact, any trace of the puncture being discernible when death occurs shortly afterwards (see Case LXXXII.). d. That the fatal event may be hastened by gangrene of the tissues arcund the wound spreading inwards to the liver.' This accident has been chiefly observed when the opening has been made in an intercostal space, and then, as Morehead has shown, it occurs alike when a spontaneous rupture takes place, and when a puncture is made.^ The gangrene is most probably connected with the caries or necrosis of the ribs, which is almost always present in these cases, and which would probably not occur were the abscess opened before the ribs became implicated. This danger might also be averted by opening from below the ribs and by the use of antiseptics. The chief dangers of non-interference are these : — a. The abscess daily becomes larger, more and more of the hepatic tissue is destroyed, and ultimately the gland may be ' Maclean. Lancet, July 18, 1863. ^ Op. cit. p. 410. 1 90 ENLARGEMENTS OF THE LIVER. lect. v. reduced to a mere sac containing pus, while adjacent organs are compressed and the ribs are eroded. h. The patient may die suddenly from the abscess bursting into the pericardium, the peritoneum, or the pleura. Not long ago I saw a patient with abscess of the liver beginning to point at the epigastrium. I advised paracentesis, but as the case was not considered urgent this was delayed. Two days after- wards the gentleman died quite suddenly. The abscess, in process of opening into the colon, had leaked into the peri- toneum. c. The majority of patients with abscess of the liver die of exhaustion from hectic fever or diarrhoea, either while the abscess is still confined to the liver, or after it has burst. Statistics have been appealed to with the object of proving the uselessness of operative interference. Of 81 cases where the abscess was opened, collected by Mr. Waring, only 15 (or 18-5 per cent.) recovered, and of 24 cases recorded by Morehead, only 8, or one-third, recovered. But in many of these cases death was due, not to the operation, but probably to this having been too long delayed, or to proper precautions not having been adopted ; while several of Waring's cases were examples of multiple abscesses, for which an operation was ob- viously unsuited. Moreover, of 203 cases collected by Rouis, where the abscess was not opened, 162 (or 80 per cent.) died.' After duly balancing, then, the dangers of operation against the dangers of expectancy, I do not hesitate to recommend to you the propriety of evacuating the pus, with proper precau- tions, in a large number of cases of tropical abscess of the liver. The operation may not be free from danger, but to wait in these cases upon Nature, as it is called, is to wait upon Death, and I would suggest for your guidance the following rules : — a. In all cases where there is a visible fluctuating tumour, operate at once. h. In cases where the symptoms of abscess of the liver are present, with a distinct tumour projecting from the normal contour of the liver, or causing bulging of the ribs, though there be no perceptible fluctuation, it will be well to operate. c. When symptoms of abscess coexist with uniform enlarge- ment of the liver, but with no distinct tumour or bulging, if there be any local oedema, or obliteration of an intercostal space, ' Frerichs, op. cit. ii.p. 136. TROPICAL ABSCESS. 191 or pain localised to one spot when pressure is made on it, or when the patient takes a fall inspiration, it will be well to operate. d. Where there are no local signs of abscess, but where the constitutional symptoms leave little doubt of its existence, and are severe, one or more exploratory punctures with the aspirator will be advisable (see Case LXXXII.). Even if the abscess be not reached, the direct abstraction of a small quantity of blood from the liver sometimes gives great relief. e. When from the presence of jaundice or other symptoms there is reason to fear that there are numerous abscesses, it will be better to abstain from any operation. When the operation is resolved on, it may be performed as follows — a. When there is distinct pointing with an inflammatory blush of the skin, and the abscess is small, an opening may be made with a bistoury. h. Under other circumstances a small trocar will be pre- ferable, and it ought to be introduced wherever there is the slightest fulness, superficial oedema, or tenderness. c. When the abscess is small, not holding more than ten or twelve ounces, it may be completely evacuated, and a drainage- tube fastened in for some days. On the removal of the tube, a tent of lint dipped in carbolic oil may be substituted. d. In all cases where an external opening is made the antiseptic measures recommended by Professor Lister ouo-ht to be rigidly enforced, and when the abscess is very large, reco- very will sometimes be hastened by making a counter-openino" and passing a drainage-tube through both openings. e. When the abscess is very large, it will be better to evacuate it by instalments at short intervals, carefully excluding the air on each occasion. For this purpose Bowditch's syringe or Dieulafoy's aspirator are well adapted.' /. In the exceptional cases where no adhesions exist, it will be prudent to produce them by the local application of caustic potash before puncturing, but when the puncture is made in an intercostal space this proceeding is unnecessary. The first of the following cases is an excellent illustration of tropical abscess of the liver independent of dysentery, not- ' The reader is referred to an interesting case recorded hy Professor Maclean, C.B. where recovery followed the removal of 108 ounces of pns by the aspirator. Lancet 1873, ii. 39. 192 ENLARGEMENTS OF THE LIVER. lect. v, withstanding that after the formation of pus diarrhoea was a prominent symptom. It is a matter of regret that the abscess was not punctured ; but twenty-three years ago this operation was rarely practised. Case LXXIV. — Tropical Ahscess of Liver — No Dysenteric Ulceration of Boivel. Private H. C , aged 33, of the 2nd European Bengal Fusileers, was admitted under my care into the Military Hospital at Prome, on Nov. 12, 1853. His habits had been very dissipated ; he had suffered from many attacks of fever and congestion of liver, and shortly before his admission he had been exposed almost continuously for three weeks to wet on the decks of steamers, during passage from Calcutta to Ran- goon and from Rangoon up the Irrawaddi to Prome. He had never had dysentery. He began to suffer from fever and pain in right side in first week of October during passage from Calcutta, but his condi- tion f1id not prevent bim attending to his duty until a few days before admission, when pain in side became much more severe. On admission, pulse 112 ; skin hot. Much pain in region of liver, and stretching up to right shoulder ; pain was greatly increased by coughing or taking a long breath, and there was considerable tencicr- ncss on pressure over epigastrium and below right ribs. Hepatic dul- ness in r. m. 1. measured 6 inches. Posteriorly and upwards margins of liepatic dulness were normal, and the increased size appeared due to a bulging from the lower margin. No fluctuation and no jaundice or ascites, but there was less movement of ribs in respiration on right side than on left, and frequent cough. Tongue moist and coated white; frequent vomiting ; a day or two before admission bowels had been relaxed, but at time of admission they were costive. Some scalding in micturition; urine was high-coloured; sp. gr. 1027; it contained no albumen, but deposited crystals of lithic acid. Patient was cupped to 8 oz. over liver, and during first week after admission was treated with calomel and opium, and subsequently with nitro-muriatic acid, quinine, opiates, and wine. On Nov. 18 diarrhoea came on, with profuse night-sweats, but no rigors. Vomiting continued, and tongue was clean, very red, and deeply fissured. Cough and scalding in micturition had abated, but vomiting and diarrhoea persisted, notwithstanding use of remedies. On Nov. 20 tongue dry and brown. Patient became very emaciated, but was comjiaratively free from pain until Nov. 2G, when he was seized Avitli acute pain, shooting up from region of liver to right shoul- der. On following day this had subsided ; and after this there was but little vomiting or purging, and symptoms Avere mainly those of hectic fever, with increasing prostration, until Dec. 1, when there was noticed below right ribs, rather to right of mammary line, a distinct smooth LECT. T. TEOPICAL ABSCESS. I93 rounded bulging, with obscure fluctuation in centre. Hepatic dulne.ss in riglit mammary line was now 8 in., increase being due to a pro- jection downwards from lower margin of normal area of hepatic dul- ness. There was also considerable bulging of lower right ribs. Pa- tient was now free from pain ; vomiting and purging had ceased ; but Fig. 17 represents the outline of Hepatic Dulness, and the bulging of the ribs (a) in H. C. — — , on December 2, 1853. cheeks were sunken and presented a hectic flush, fever and night- sweats continued, tongue was dry and brown, and teeth coated with sordes. On Dec. 8 patient was in a state of extreme prostration ; on following day mind was wandering, and at 9.30 p.m. he died. On examination of body ten hours after death, one enormous abscess was found in right lobe of liver. It contained upwards of four quarts of pus, having a reddish tint, and composed of pus-corpuscles, with oil-globules and hepatic cells undergoing disintegration. Walls of abscess were formed by ragged masses of hepatic tissue coated with inflammatory products ; at two places walls were very thin, one situated below margin of right ribs, and corresponding to tumour observed during life, and the other posteriorly near mesial fissure. Stomach and intestines presented no trace of cicatrices or of recent ulceration. Spleen, lungs, and heart normal. Old adhesions between apposed surfaces of left pleura ; and cavities of heart, but particularly right, contained large masses of decolorised fibrin. Case LXXV. is another example of tropical abscess inde- pendent of dysentery. Death was due to the supervention of pyaemia and secondary abscesses upon the opening. The good o 194 ENLARGEMENTS OF THE LIVER. zf.ct. v. effects which immediately followed the operation make one regret that the matter was not drawn off by instalments with a fine trocar, and that more thoroughly antiseptic measures were not adopted. Case LXXV. — Tropical Abscess of Liver independent of Dj/sentenj — Free Opening — Secondary Abscesses and Diarrhoea — Death by Exhaustion. Foogeek Kitche, aged 39, a Japanese juggler, adm. into Middlesex Hosp. Jan. 5, 1871. Left Japan 16 months before and went to Madras, where he remained a month and drank much gin. Never had dysen- tery and had always enjoyed good health until three months after reaching this country in July 1870. He then began to suffer from weakness, loss of appetite, perspirations during sleep, and occasional pain in right side, and since then he had lost flesh. One month before admission he was obliged to give up work, and at this time he first noticed a swelling below right ribs, which had increased considerably. On admission was emaciated and complained of pain and swelling in right side. In epigastrium and right hypochondrium was a tumour projecting from liver about size of a cocoanut, causing slight aversion of lower right ribs, dull on percussion, smooth, very elastic but yield- ing no vibration, and but slightly tender even on free manipulation. Hepatic dulness in r. m. 1., including tumour, 6^ in. ; posteriori}' liver did not rise above normal level. Tongue moist and furred ; moderate appetite, and no retching ; considerable thirst ; no jaundice ; bowels regular. Pulse 80 ; heart and lungs normal. Temp. 101^° ; still per- spires during sleep. Urine 1030, loaded with lithates, but free from albumen. Was ordered quinine and nitric acid. Jan. 9. — Is weaker, and has had more pain in tumour, which is larger. Has required morphia to make him sleep. No rigors, but still perspires profusely at night. Pulse has varied from 68 to 84 ; and temp, from 99° in morning to 103° at night. After a preliminary exploratory puncture a large trocar was introduced into tumour, and 30 oz. of thick ])ns of a brick-red colour let out. Cavity was washed out with a solution of chloride of zinc (gr. x ad |j), and cannula was left in and covered with lint soaked in carbolic oil and with carded oakum. Jan. 13. — Operation was followed by great relief. Patient slept without morphia, had no night-sweats, and temperature became normal in evening as well as morning. List night, however, sweating returned, and to-day pulse 96 and temp. 1003° ; very little discharge. On with- drawing cannula 10 oz. of pus, not fetid, escaped. Cavity was again washed out with a solution of chloride of zinc, and a piece of elastic tube was substituted for cannula. TEOPICAL ABSCESS. 1^5 Jan. 20. — During last week patient, thougli weak, has felt much better. There has been very free discharge from opening ; pulse has varied from 60 to 84, and temp, has never been above normal. Appe- tite has been excellent, and for last three days patient has had meat, eggs, and porter. To-day, for first time, discharge has been slightly oflFensive, and patient does not feel quite so well. Porter was discon- tinued, and cavity was ordered to be washed out daily with a weak solution of carboKc acid. Jan, 27. — Is weaker, but appetite has continued good ; has had no rigor, very little perspiration, and free discharge, not fetid, from wound. Temp, has been normal, except for a few hours on Jan. 21, when it rose to 101°. On Jan. 23 he had four loose stools, and since Jan. 24 there has been a troublesome cough. Yesterday evening, on commencing to syringe out cavity, patient was seized with severe pain in hepatic re- gion and profuse perspiration, which lasted an hour. Only a very little reddish matter came away, but this morning discharge is free and deeply tinged with bile. Pulse 64 ; temp. 96 "8°. Indiarubber tube was withdrawn, and a piece of lint soaked in carbolic oil inserted in wound instead. Feb. 1. — Very little discharge has come away from wound, and on Jan. 29 little that came was fetid, but to-day discharge is more co- pious. Patient has occasionally complained of rather severe pain in region of liver, and night-sweats have returned. ISTo rigors, and temp, has always been normal until to-day, when it is 101°. Bowels are re- laxed, and patient is getting much thinner. Patient nowbecame rapidly weaker. N^ight-sweats and diarrhoea were uncontrolled by treatment. Temp, varied from 99° to 102*8°, but at no time were rigors noted, and pulse was usually 120 ; urine free from albumen. Death took place on Feb. 4. Autopsy. — Right lobe of liver was glued by soft adhesions to abdo- minal parietes over a space about 3^ in. in diameter, and was more firmly connected to diaphragm above and behind where abscess came close to surface ; but greater part of surface of liver presented no sign of inflammation, old or recent. Sac of abscess had evidently con- tracted, for it would not have held more than 16 oz. of fluid. Its walls were very thick, and composed of an external firm fibrous layer several lines in thickness, and of an internal lining of softer honeycombed material. In remaining portion of liver were several abscesses from. size of cherry to that of walnut, with no thickened walls and evidently quite recent. Base of right lung was glued to diaphragm by soft lymph, and right pleura contained about an ounce of flaky fluid. Spleen healthy ; kidneys congested ; large intestine presented no trace of cicatrices, thickening, or other sign of old dysentery ; but in csecuna and ascending colon mucous membrane was intensely injected, and rugae were plastered with large flakes of granular exudation, two small patches of which were also found in ilium just above valve. o 2 in6 EKLAEGEMENTS OF THE LIVER. i-ect. v. In Case LXX^H!. the abscess discharged itself through the right lung, and the patient made a rapid recovery. It is a good illustration of the most favourable direction that the abscess can take. Case LXXVI. — Abscess of Liver discharging through right Lung — RHCOvery. On May 2, 1874, I was consulted by Dr. L., about 35. Eight ■weeks before he had returned from Gold Coast, where he had .suffered from fever and pain in right side. On reaching this country he had felt quite well, and had gone about. Three weeks after arrival he had got a rigor one night after going to theatre, and ever since he had been laid up with fever. Temperature had been as high as 105°. At first there had been considerable delirium, and latterly profuse night-sweats, but no return of rigors. At my visit great prostration ; pulse 108 ; temp. 102° ; resp. 48. Hepatic dulness reached up to right nipple ; it did not come too low, but there was distinct bulging of right lower costal cartilages. Frequent dry cough ; crepitation at base of both lungs ; and sharp stitch in right side. Tongue thickly coated vnth yellow fur ; bowels confined, and had been so throughout ; urine dark, and loaded with lithates. Ordered ammon. chlor. gr. xx, pot. bicarb, gr. xv, and tinct. op. v\ V, every six hours ; colocynth and calomel pills. Quin. sulph. gr. X while perspiring. Milk, beef-tea, and claret. On morning of May 6 he suddenly began to cough up pus of a reddish-brown colour and mawkish smell, and in next 24 hours brought up about two pints. Breath had odour similar to that of pns. A mixture of quinine and mineral acids was now substituted for chloride of ammonium &c. Almost immediately after bursting of abscess into king there was a fall in pulse, temperature, and respirations ; night-sweats diminished and general condition improved. Expectoration of pus continued for about ten days. On May 11 temp, rose for a few hours to 104°, but after this it was normal ; and on June 2 patient had so far recovered that he was able to go to Scotland. He had no relapse, and 16 months afterwards (Sept. 25, 1876) he was well and stout, and on examination, no trace of former illness could be discovered, except sliglit impair- ment of breath sound at base of right lung. Oct. 1876 ; still well. In Case LXXVII. the abscess also burst upwards through the diaphragm, but the result was fatal. Case LXXVII. — Abscess of Liver opening upwards through Diaphragm — Secondary Abscess of Lung. I show you here a specimen which I removed some years ago from the body of a patient — a man, aged 34, who died in this (Middlesex) LECT. V TEOPICAL ABSCESS. I97 liospital — and which illustrates the bursting of a large abscess upwards through the diaphragm. In this case patient had suffered some years before from dysentery in India arid Malta. His symptoms during the nine days that he was in hospital before his death were hectic fever and emaciation, dyspnosa, cough, and purulent expectoration, with a pain- ful enlargement of liver producing an outward bulging of ribs. Hepatic dulness extended only 2 in. below margin of ribs in r. m. 1., but upwards it reached to third intercostal space. The enlargement felt smooth, but did not involve whole organ uniformly. Tongue un- usually red ; no vomiting, jaundice, or diarrhoea, but abdomen generally tender, and distinct evidence of fluid in peritoneum. After death, three or four pints of flaky serum were found in peri- toneum. Liver firmly adherent to diaphragm and abdominal parietes, and in upper part of right lobe was an abscess as large as a cocoanut, which had perforated diaphragm so as to be bounded above by base of right lung. The abscess was enclosed in a dense capsule of areolar tissue, and contained yellow pus with large fibrinous flakes. In lower lobe of right lung was another abscess, the size of a large orange, dis- tinct from former, and containing pinkish pus. Descending colon and sigmoid flexure much contracted ; their coats thickened ; mucous mem- brane slate-coloured, but presented no recent ulcers or distinct cica- trices. Ill the two following cases the abscess opened into the bowel — probably the colon ; but there was a subsequent history of refilling of the cavity and discharge on repeated occasions. I do not remember having seen this occurrence referred to by authors, but from my experience I am inclined to think that it is a not uncommon sequel of the bursting of a large hepatic abscess into the bowel. Of nine cases where the abscess seemed to open into the bowel, and of which I have notes, there was a similar history in six ; and in a tenth case the abscess opened first into the bowel and then into the lung. Case LXXVIIE. — Abscess of Liver opening into Bowel — Frequent refilling of Cavity with Pus. Death by Diarrhcea and Exhaustion. On May 25, 1871, 1 was consulted by Mr. K., aged 50, on his return from Ceylon, where he had been for 25 years. He had been suffering for nine months from bilious diarrhoea and occasional vomiting. He had considerable pain about the liver, which was somewhat enlarged and tender, and with this there was loss of appetite, pyrexia, night- sweats, occasional rigors, prostration, and emaciation. After this I saw him from time to time until his death in February 1875. At first he improved much under treatment, but on April 9, 1872, after several weeks of great agony an abscess burst, and he discharged at one. 198 ENLARGEMENTS OF THE LIVER. lbct. v. sitting three quarts of pus from the bowels, and almost a like quantity on twelve different occasions during the next fortnight. After this he was nerer well. He had constant diarrhoea. But now and then, three or four times in course of the year, diarrhoea would stop for 10 or 14 days, and then he would have rigors, pyrexia, enlargement and pain of liver, all of these symptoms ceasing with a free discharge qf pus from bowels. On one occasion after rigors and pyrexia he vomited several ounces of pus and blood. The tongue and mouth at last became red and aphthous, so that he could take little food, and death from exhaus- tion ended his sufferings. There was no post-mortem examination. Case LXXIX. — Tropical Abscess of Liver opening into Boivel — Frequent Relapses — Superficial Foiriting — Free Incision — Recovery . Mr. N , aged 44, was sent to me on April 7, 1873, by Dr. R. J. Black, of Canonbury. He had returned on 14th of previous No- vember from China and Japan, where he had not been very temperate. On voyage home, when at Aden, he had been first seized with symptoms of acute congestion of liver, but he was not obliged to take to bed until Dec. 20, about which time a painful swelling appeared below right ribs, and he suffered from rigors and night-sweats. Swelling con- tinued to increase until beginning of Februaiy, whenhedischargedalarge quantity of pus by bowel. Swelling subsided, and general symptoms improved. When I saw him he was thin and weak, but he was free from pain and fever, and liver was not enlarged. Three or four days after seeing me he was again seized with rigors and pyrexia, and there was pain in hepatic region and some bulging of right costal cartilages and epigastrium ; and when I saw him again on April 22, although more acute symptoms had subsided, bulging per- sisted, and he perspired much during sleep. After this he got much better, swelling again subsided, and for a fortnight he was able to go to business in City ; but on May 24 he was once more seized Avith rigors and pyrexia, followed by a return of painful swelling in same situation as before. Swelling increased and became soft and fluctuating in centre, while patient had profuse night-sweats and grew daily thinner and weaker. On June 25 a free incision was made by Mr. De Morgan into swell- ing, and nearly two pints of thick pus of a brick-red colour let out. Cavity was washed out with a strong solution of chloride of zinc (gr. X ad ^j), and a piece of elastic tube was introduced into cavity and secured ; and through this, cavity was washed out daily with a weaker solution of chloride of zinc (gr. iij ad |j) : end of tube was covered with carded oakum. On Juno 30 tube was removed and wound dressed with lint and carbolic oil. The operation gave imme- diate relief; fever and pain at once ceased; and within a week night- Hweats had also ceased, appetite was good, and patient was beginning LECT. V. TEOPICAL ABSCESS. 1 99 to gain flesh and strength. He had several relapses of fever after this, but ultimately he made a good recovery, and in January 1875 he was in enjoyment of good health and attending to business. Case LXXX. is an illustration of a large hepatic abscess in a person who had never been out of England, although there Mvere doubts at the time whether the abscess had originated in the liver or in the areolar tissue about the kidney. There was ulceration of the colon, but this appeared from the history and post-mortem appearances to be secondary to the abscess of the liver. The specimen was exhibited by me to the Pathological Society, and the case is recorded in the eighth volume of the ' Transactions.' Case LXXX. — Large Abscess of Liver opening into Ascending Colon. J. P , a man aged 40, was admitted into St. Mary's Hospital, under care of Dr. Sibson, on April 18, 1856. He stated that he had always enjoyed good health and that, although he had been in habit of drinking a good deal of malt liquor, he had never been addicted to spirits, and had, on the whole, been a temperate man. He had never been abroad. About a month before admission he ' took cold,' and was seized with a shooting pain in right hypochon- driac region, which on second day became so extreme as to prevent his working. He went to bed, where he remained until day of admission, pain in right side' continuing without intermission except when relieved by opium. After admission, there was found to be a great fulness in right hypochondriac and lumbar regions, with a feeling of a resisting mass extending downwards as far as crest of ilium, and forwards to within 3 in. of linea alba. This space was universally dull on percussion, and dulness was continuous with that of liver ; upper margin of hepatic dulness was not elevated and dimensions of left lobe appeared normal ; swelling was of a doughy consistence, and presented indistinct fluctua- tion. Tongue loaded ; bowels rather confined. Urine voided three or four times a day, and acid ; sp. gr. 1020. Pulse 108, weak. Poultices of linseed meal were applied over swelling, while iodide of potassium (gr. ij ter die), gentle laxatives, opiates, and stimulants were prescribed internally. On April 24 he had an attack of erysipelas of face which continued for four or five days. On April 26, during this erysipelas, he was seized with violent diarrhoea. This ceased in a great measure after four or five days, and he then felt himself greatly better ; appetite had improved, pain had gone, swelling and dulness were much diminished, and calls to make water less frequent. He continued to improve until May 11, on which day he had a return of severe pain and diarrhoea, 200 ENLAEGEMENTS OF THE LIVEE. XECT. v. with purulent stools. Pain was referred chiefly to a spot about two inches below margin of ribs, in a line with right nipple. Stools were of a light bufi* colour and very offensive. This diarrhoea resisted all treatment, and soon, patient's strength began to give way. He had febrile exacerbations towards evening, and profuse perspirations during night. Pulse varied from 100 to 125, and was very weak ; tongue be- came dry and brown ; and he gradually sank until death at 10 p.m. on May 27. Four days before death swelling in right side was observed to have greatly diminished, dulness in right lumbar region not extending farther forward than a perpendicular line drawn from middle of Crest of ilium to ribs. Post-mortem examination forty-one hours after death. — On opening abdomen, extensive adhesions of viscera and other indications of peri- tonitis, entirely limited to right side, peritoneum on left side being normal. These adhesions of viscera on right side rendered their examination extremely difficult ; whole of anterior margin of right lobe of liver firmly adherent to peritoneal surface of abdominal wall, while under surface of anterior edge, along with gall-bladder, was in intimate union with transverse colon. Texture of liver was pale. In lower part of right lobe was an abscess as large as two fists, containing a quantity of fluid feeculent matter of a light yellow colour. This abscess involved almost whole of that portion of lobe to right of fissure of gall-bladder, and extended to within half an inch of its upper surface ; upper two-thirds of walls of abscess formed by hepatic tissue, rough and ragged without any limiting membrane ; lower part was completed by kidney, anterior layer of fascia lumborum, and about 3 in. of ascending and transverse colon. This portion of colon communicated freely with cavity of abscess. Its upper wall next abscess presented a cribriform appearance, all that remained of it being a few narrow bridles, passing transversely and easily torn across. Extensive ulceration of adjacent portion of ascending colon, and slight ulceration of Peyer's patches in ileum. Kidneys anaemic, spleen soft and friable. Thoracic organs healthy, left cavities of heart containing blood, right being empty. The next case whicli I shall mention is a good illustration of the benefit which may often be derived from evacuation of the abscess. Case LXXXI. — Tropical Abscess of Liver — Puncture with a large Trocar — Becovery. Mr. C. D , aged 23, consulted me on Juno 11, 18G7. He had arrived from Calcutta the day before, and gave the following account of himself. He had resided in Calcutta for about three years, and had lived freely, but had never sufiered from dysentery. He had been taken ill about end of March with fever and rapidly increasing pro- LECT. V. TROPICAL ABSCESS. 201 stration. He had no pain in side, no diarrhoea, and no jaundice, but about April 12 a tumour made its appearance below right ribs, which rapidly increased until 19th, when it was opened with a large trocar and upwards of a pint of matter let out. The cannula was left in the wound, and on 21st the patient was put on board the overland steamer in so prostrate a state that he was hardly expected to recover. He slowly improved, however, during voyage, and cannula was removed at Aden about a fortnight afterwards. I found an opening with pout- ing granulations about half-way between umbilicus and ribs, and 2 in. to right of mesial line, from which about two drachms of thin pus escaped daily. The patient was weak and anaemic, but in other respects appeared to have nothing amiss. He was treated with mineral acids, quinine, and iron, and within three months he had regained his usual health and strength. There was then no evidence of enlarge- ment of liver, and the opening had permanently closed. (With the exception of an attack of gout in January, which he had previously suffered from, and of which disease his father had died, he remained in good health until he returned to India in February 1868.) Case LXXKII. is an example of tropical abscess of the liver without local signs, and it shows also that the liver may be freely probed for pus with a fine instrument without any harm resulting. Case JjXXXIl.-^Beep-seated Abscess of Liver — Exploratory Punctures without result — Pleuro-pneumoyiia — Death. Mr. 0. B , aged 42, consulted me on March 22, 1873. He had just returned from India, where he had resided for nine years, and where he had enjoyed fair health until 3rd of last January, when he had been seized with dengue fever, followed by an attack of acute dysentery which had quite ceased by Jan. 25. Ever since, however, he had suffered from weakness, uneasiness in right hypochondrium, slight perspirations during sleep, cold creeping sensations down back, and audible pulsation in right ear on lying down, which kept him awake at night. He had also a feeling of heaviness at epigastrium after meals ; bowels rather costive ; urine dark, and loaded with lithates ; pulse 108. flight lobe of liver slightly enlarged, measuring 5 in, in r. m. 1. Ordered a scruple of chloride of ammonium three times a day ; occasional aperient of blue pill and rhubarb ; to rub red iodide of mercury over liver ; and to avoid stimulants. On March 31 he returned a good deal better and complaining chiefly of atonic dyspepsia, for which he was ordered nitro-muriatic acid with quinine and pep- sine. After this he got very much better and married. On May 8 he returned, and stated that five days before (during cold east winds) he had been seized with ' ague ; ' severe rigors every afternoon followed 202 ENLARGEMENTS OF THE LIVER. lkct. t. by great heat and profuse sweating, and that ever since lie liad lost appetite. Urine was again loaded with lithates and contained a trace of albumen ; bowels confined. Ordered an aperient of calomel and rhubarb, an effervescing alkaline draught, and gr. xv of quinine during sweating stage. These large doses of quinine, followed first by gr. v, and subsequently by gr. x, three times a day, failed to arrest the parox- ysms of fever, which recurred once or oftener every day, and at irregu- lar hours. Careful observation showed that he was never entirely free from pyrexia, pulse varying from 84 to 108, and temperature from 100° to 102°. Urine was still loaded with lithates and contained a trace of albumen ; there was profuse sweating during sleep, and patient became daily thinner and weaker. Although there was no local bulging, oBdema, or tenderness over liver, an abscess in that organ appeared to ofier the only solution of the symptoms, and it was determined to ex- plore for it. Accordingly, on May 27 a small trocar was introduced by Mr. De Morgan to depth of three inches into right side of epigastrium where liver appeared to be slightly enlarged, and on June 12 two other punctures to depth of 4 or 5 in. were made, one in front a little above first, and the other at back between eighth and ninth ribs, and the aspirator was applied. On both occasions only a few drops of blood escaped. The punctures were not followed by any pain or aggravation of general symptoms, but patient became daily weaker. On June 20 signs of pleuropneumonia of lower lobe of right lung set in ; after this rigors and perspirations ceased, hepatic dulness in r. m. 1. receded one inch from nipple, and prostration rapidly increased until death, which was preceded by slight hemoptysis on June 28. AutoiJsy, by Dr. H. W. Hubbard, who had attended patient since May 12. — An abscess containing about 10 ounces of thick yellow pus in upper and back part of right lobe of liver, within half an inch of surface. Rest of liver congested, but otherwise healthy. Not the slightest sign of peritonitis or extravasation in situation of punctures, nor in fact anything to show where they had been made. Upper sur- face of liver corresponding to abscess, and also base of right lung, ad- herent to diaphragm by recent lymph. Extensive pneumonia of lower lobe of right lung. The abscess was still confined to liver, and diminu- tion of hepatic dulness in front, observed during life, was due to liver having bulged less forward, and pointed more up towards lung. M}' main object in di-awing your attention to the following case is that an absence of any elevation of teniperatui'e led, in the first instance, to an error in diagnosis. Notwithstanding the previous history of dysentery and diarrhoea, and the evidence of gastric and hepatic derangement immediately before the acute attack, the severity and the paroxysmal character of the pain, associated with tenderness and obscure swelling in the JLECT. V. TROPICAL ABSCESS. 203 region of tlie gall-bladder, but unattended by any sign of fever, pointed to a calculus in the cj'stic duct as the probable cause of the attack. The progress of the case, however, made it probable that the cause of the pain was an abscess, which ulti- mately discharged itself into the bowel. The precise seat of the abscess is somewhat doubtful. The fact of the pain being at first referred to the lower part of the abdomen, and the almost instantaneous discharge of matter per rectum after the sensation of bursting, suggested that it might be in the neighbourhood of the rectum ; whereas the previous history of dysentery, the symptoms of hepatic derangement immediately before the acute attack, and the circumstance of there being an obscure swelling with tenderness in the region of the liver, which disappeared after the discharge of matter, were in favour of a hepatic abscess. The supposition of an abscess in the gall-bladder, secondary to obstruction of the cystic duct by a gall-stone, was rendered improbable by the fact of the abscess discharging it- self, without any evidence of antecedent obstruction of the common duct (jaundice), although it is possible that an inflamed gall-bladder distended with pus might have discharged itself into the colon. But whatever was the seat of the abscess, the point of interest was the same, viz. that an abdominal abscess existed, which for dsijH caused intense pain, but none of the usual constitutional symptoms of pyrexia. The cessation of the symptoms in the second attack, without any obvious discharge of matter, was probably due to the discharge being less sudden, and to the pus being obscured by feecal matter. Case LXXXIII. — Hepatic (?) Abscess, without Elevation of Temperature, On Feb. 18, 1875, I was called to see Mr. A , aged 40, in con- sultation with Dr. Collyer, of Enfield. Mr. A had been in China for a good many years, bnt for last five years he had resided in London, or in neighbourhood. About 1865 he had contracted dysentery in China, and ever since he had sufiered from chronic dysenteric diarrhoea, from three to five stools daily, often containing blood and mucus, and sometimes attended by tenesmus. Still his appetite had kept good, and his body was fairly nourished. Nine weeks before I saw him he began to complain of loss of appetite, nausea, and occasional vomiting, and he became sallow, his bowels acting as usual. He went about, how- ever, untd five days before my visit, when he was seized with severe pain in abdomen, which gradually increased until night of Feb. 17, when he was rolling about in agony for several hours, and was only 204 ENLARGEMENTS OP THE LIVER. lect. v. relieved after repeated and large doses of opium. The pain at first had been referred rather to lower part of abdomen ; but when I saw patient it was restricted to region of gall-bladder, where a distinct, but not well-defined, prominence, about size of an orange, could be felt. With the pain there had been frequent rigors and retching, but repeated observations with thermometer failed to discover any eleva- tion of temperature, and there were no perspirations. At time of my visit, temp. 90' 5° F. ; pulse 70 ; tongue thickly coated, yellowish ; much flatulent distension of abdomen. Patient was ordered rest, hot poultices to abdomen, and an efferves- cing soda draught, with liq. op. sed. ]]\ xv, every four hours while pain continued severe. ■ Pain was but little relieved by treatment. It continued intense until evening of 21st, when, while sitting in an easy-chair before fire, he experienced a sensation as if something had given way in region of gall-bladder, and immediately a large quantity — about a pint — of yellow matter was discharged per rectum. This was examined microscopically both by Dr. Collyer and by his partner, and was found to consist of true pus. A good deal of matter came away next day, and a smaller quantity on 2ord, but from moment of first discharge pain ceased. On Feb. 24 patient passed only a little blood and mucus. After this stools became more natural ; appetite returned ; swelling and tender- ness disappeared ; and patient went on well until March 8, when pain returned in severe paroxysms as before, and again no elevation of tem- perature. On March 13, when I paid a second visit to patient, pulse 68 ; temp. 99"2° ; still paroxysms of intense pain and retching ; tender- ness and obscure swelling in region of gall-bladder. Pain persisted for five or six days longer, and then subsided — this time without any obvious discharge of matter. On April 1 patient visited me in town, and then complained of nothing except his usual diandioja, which by April 14 had greatly abated under the use of creasote and opium. Whatever was the seat of the abscess in Case LXXXIII., there can be no doubt that in the following case an enormous abscess existed in the liver, and was rapidly increasing in size, without any elevation of temperature. The case in this respect was no doubt exceptional, but I am inclined to think that it is far from unique. At the very time at which this patient was under notice I saw another in whom a similar observation had been made. It is difficult to account for the absence of pyrexia while extensive suppuration is going on in these cases, except on the supposition that the morbid process here entails the destruction of an organ which contributes in part to the main- tenance of the animal heat; and yet, so far as we know, the temperature is elevated in most large abscesses of the liver* I.ECT. V. TROPICAL ABSCESS. 205 But, whatever be the explanation, the possibility of a large abscess existing in the liver without any elevation of tempera- ture is a fact of great clinical importance. The case was further interesting as showing the origin of the secondary- abscesses in inflammation of the small branches of the portal vein. Case LXXXIV. — Tropical Abscess of Liver — History extending over 3-|- years — Absence of Pyrexia — Paracentesis — Death. Lieut. M., aged 25, consulted me on Dec. 1, 1873. In Nov. 1868 he first went to India. During 1869-70 he had ague repeatedly, and in 1871-72 he had repeated attacks of congestion of liver, but it was not until Dec. 1872, after much exposure to sun, that he first began to get seriously out of health. He then got enlargement with pain in liver, loss of appetite, retching, and obstinate constipation, jaundice, and sleeplessness, and after some weeks attacks of shivering followed by sweating. After three months the more acute symptoms subsided, but he remained very weak, and the left lobe of liver was still large and painful. In April 1873 he left India on sick leave, and in June he arrived in England. He continued to improve until middle of November, when he was seized with pain in right lobe of liver, increased by lying on left side, loss of appetite, and great prostration, and when I saw him. liver measured 6 in. in r. m. 1., but no sign of fluctuation, retching, or diarrhoea. Pulse 108 ; great pallor. He was ordered saline aperients and large doses of chloride of ammonium, and occasional doses of blue pill. Under this treatment he speedily improved, and I did not see him again ; but he had an attack of a similar nature in his liver about once a month. In one of these attacks he kept his bed for six weeks, had profuse sweating every night, and lost nearly 2 stone in weight. After attack was over he quickly rallied, and could go through much hard work, but with the return of the attack he M'as at once prostrated. During attacks liver alwaj^s enlarged, and urine became very dark and turbid, but in intervals it was pale and clear. He had no rigors with attacks. In Aug. 1875 he returned to India, but attacks continued to recur ; in intervals he had sometimes diarrhoea, and he was agaiu sent home on sick leave in March 1876. On April 27 I saw him for the second time in one of the attacks. He was very prostrate ; great pallor ; liver large — 6 in. in r. m. 1. ; decided tenderness over right floating ribs at back, but no bulging or fluctuation. Temp, normal. No jaundice. Four days before he had been so well that he had felt none the worse for walking fifteen miles ; and two days afterwards (April 29) Ije appeared again perfectly well, and liver was reduced to 5 in., its upper border in front still ascending about an inch too high. On May 12 he had another attack ; much pain in liver, which agaiu became enlarged ; great thhst ; obstinate constipation ; urine loaded with brick- dust sedi- 206 ENLARGEMENTS OF THE LIVER. lect. v. ment: pulse 100 ; sleeplessness, but no elevation of temperature ; no niglit-swcats, rigors, or retelling. After about a fortnight a fluctuating swelling began to appear in right loin, which rapidly increased. Patient became wasted and worn ; slept none, owing to gi'eat pain ; tongue dry and red ; and on May 30 diarrhoea set in, five or six stools a day ; but all this time temp, never rose above normal, even under tongue ; no rigors, and scarcely any sweating. On June 6 he was admitted into St. Thomas's Hospital. Very prostrate. P. 122. T. 98-4° to 99-2°. Kesp. 30. Hepatic dulness in front extended from nipple to one inch below ribs = 7 in. ; lower margin very tender. In right loin was a prominent fluctuating swelling mea- suring 8 in. by 9, very tender. Girth of abdomen over this swelling 19^ in. on right side, lof on left. Much pain and restlessness. T. coated and red ; bowels loose. Urine turbid, and contained albumen. On June 7, 18 ounces of thick reddish-brown pus were drawn off from abscess by aspirator. No relief followed. Jiine 8.— P. 124 ; T. 98-4° to 98-G°. Tongue dry, red, and glazed : five or six loose motions ; 17 oz. of similar pus drawn off by exhausting syringe. June 10.— No improvement. P. 124 to 150. Temp. 98-2° to 99-5°. An incision Avas made into swelling, and a pint of pus let out ; cavity was washed out with a solution of chloride of zinc (xx gr. to 1 oz). and a drainage-tube fastened in, and wound dressed antiseptically. This operation gave great relief, but diarrhoea persisted. On June 12 he be^an to have frequent retching ; on June 13 constant hiccough ; on June 16 rapid breathing ; tongue dry and glazed, and latterly aphthous, total loss of appetite ; albumen and lithates in urine, and daily increasing prostration until death on June 19. After operation temp, never exceeded 99'6° and varied between this and 97'6°. The principal remedies employed were large doses of quinine, opium, bis- muth, and stimulants. Autopsy. — No recent peritonitis, but general adhesions on lower sur- face of liver and over upper surface of right lobe. Lower margin of right lobe of liver did not extend beyond margin of ribs in front ; but posteriorly, projecting from its under surface, was a large abscess cavity, extending upwards to lovver border of seventh rib, and downwards to crest of ilium, lying in front of right kidney, and bounded in front by a thin layer of peritoneal adhesions. Immediately adjoining this, but more in substance of liver, was an irregular abscess about 1^ in. in diameter, communicating on the one hand by a fistulous passage with the large abscess cavity, and on other by a narrow sloughy opening (apparently recent) with neck of gall-bladder. This abscess contained several small gall-stones, and in gall-bladder were about a dozen black gall-stones, size of peas, and some thin pus. Throughout liver were several smaller abscesses, one near anterior end of falciform ligament, which had almost burst and was covered by a layer of recent lymph ; another, size of an LKCT. V. TROPICAL ABSCESS. 20/ apple, near upper surface of left lobe ; and on under surface of left lobe, near anterior margin, a rounded depressed cicatrix. On cutting into liver also were a number of sliarply defined pale yellowisb patcbes, from 6 to 18 lines in diameter, surrounded in some instances, but not in all, by a narrow congested zone. Lobules in pale patches were defined, though here and there outline confused ; appearance seemed due to local angemia, but some of patches were softened in centre. On micro- scopic examination. Dr. Greenfield ascertained that all the vessels in the pale arese were filled with coagula. The branches of the portal vein were filled with adherent coagula, and their coats thickened and infiltrated with leucocytes, which were also accumulated around them. The branches of the hepatic artery exhibited the reaction of amyloid degeneration. The hepatic cells were swollen and full of granular or fatty matter ; many appeared to be breaking up. The hepatic vessels were tilled with coagulum, but coats were not thickened. Liver weighed 111 oz. Numerous minute round and oval cicatrices of former ulcers throughout colon and rectum, and also in lower part of ilium ; walls of bowel not thickened. Some glands in fissure of liver, large and softened in centre into pus. Kidneys slightly enlarged, soft, and flabby ; cortices swollen ; amyloid reaction of Malpighian tufts. Spleen 11 oz., firm, with early waxy degeneration. Patches of recent bronchial pneumonia in lower lobe of both lungs ; heart healthy. 2o8 ENLARGEMENTS OF THE LIVER. LECTURE VI. ENLARGEMENTS OF THE LIVER. CANCER. Gentlemen, — The next form of enlargement of the liver, the clinical characters and treatment of which have to be considered, is that which is due to cancerous deposit. XI. CANCER OF THE LIVER. Cancer of the liver may be recognised by the following clinical characters. 1 . The size of the liver is increased, and not uncommonly the enlargement is very great, so that the organ fills a great part of the abdominal cavity. A cancerous liver has been known to weigh 384 ounces, or about seven times the normal weight.' The enlargement is progressive, and in the softer forms of cancer may be so rapid that a weekly increase may be noted. On the other hand, it must be remembered that the liver ma}" contain a considerable amount of cancer, and yet the enlargement may not be appreciable during life. The liver may have been originally a small one, and the addition of the cancer may not cause it to project beyond the costal arch, or the lower margin may be overlaj^ped by a distended bowel. You will remember the case of Mary T , a very fat woman, 54 years of age, who died recently in the hospital, of apoplexy supervening upon white softening of the brain (with hemiplegia), and whose liver was unexpectedly found to be studded with large cancerous nodules, although the organ did not project be- yond the costal arch, and there had been no symptoms during life of disease of the liver. A similar observation was made in two other cases, which I shall detail to you (Cases XCV. and XCVI.). I have known a cancerous liver weigh only 27 ounces. 2. The enlargement is usually irregular, from the presence ' See Budd, Dis. of Liv. 3rd ed. p. 407, hihI Piith. Trims, xviii. p. 145. CANCER. 209 of nodular excrescences of cancer projecting fi'om the surface or from tlie margin of the liver, which can often be felt on jjalpation, and are sometimes even visible through the abdo- minal parietes. Occasionally the cancerous deposit forms one In.rge excrescence or tumour at a particular part of the organ. Dr. Bright has recorded some remarkable eases in which the tumour was confined to the left lobe, and projected downwards into the abdomen, or upwards into the left side of the chest ; ' and the specimen I show you here, obtained from tbe body of a patient wbo died under my care in tlie Fever Hospital, is another illustration of the same condition (Case XCIV.). More commonly a number of nodular outgrowths, about the size of cherries or small oranges, project from the portion of liver which is opposed to the abdominal parietes (see fig. 18). Oarc must Fig. IS. Shows area of Hepatic Dullness, in Hannah C — ■with nodidated lower margin. — (Case LXXXV.), be taken not to mistake for such excrescences the rio-id bellies of the recti muscles (see page 15). It is necessary also to re- member that a nodular character is not essential, as might be inferred from some descriptions, to cancerous enlargement of the liver. In certain cases the cancer is not deposited in the liver in isolated nodules, but is infiltrated through the hepatic tissue in such a way that, although the organ may be greatly enlarged, its natural outline is but little altered ; and even in ' ALclom. Tumours, Sjd. Soc. Ed. pp. 261 and 308. 2IO ENLAKGEMEHTTS OF THE LIVER. lect. ti. the nodular form of cancer, the portion of liver below the ribs is sometimes quite smooth (Cases LXXXVl. and LXXXVIIL). 3. The enlargement feels very hard and resisting- on palpa- tion, and nowhere exhibits any fluctuation. In rare cases some of the cancerous nodules may be so softened as to present ob- scure fluctuation. Now and then the excrescences develope and grow while the patient is under observation. This circum- stance, or the feeling of a depression in the centre of the ex- crescences, will plaije their cancerous nature beyond a doubt. 4. A cancerous liver is very often painful and tender on pressure, and the pain radiates to the shoulder, back, and loins. At first there may only be a feeling of weight and uneasiness in the right hypochondriaim, but after a time there are paroxysms of lancinating ^pain awaking the j)atient at night, and acute tenderness ; and both are particularly severe in cases where the growth is rapid, or where, as often happens, there is inflammation of the superimposed peritoneum. The tenderness is usuall}^ most marked over the prorninent nodules. But many cases of cancerous liver are met with in which there is little or no pain from first to last. Not long ago I had three patients under my care at one time in which this was the case. 5. Jaundice is present in a large number of cases, and when once develojoed it rarely disappears. The coexistence of en- largement of the liver with persistent jaundice ought always to raise the suspicion of cancer. The jaundice is in rare cases independent of obstruction of the bile.-duct ; far oftener it results from the compression or Obliteration of the bile-duct by a can- cerous mass in the liver or by enlarged glands in the portal fissure. If the ducts be ndtiJhus compressed, almost the whole of the secreting tissue may be destroyed without any jaundice resulting. Of 91 cases of cancer of the liver collected by Frerichs, 52 died without ever having been jaundiced. 6. Fluid in the i^eritoneum is observed in more than one-half of the cases of cancer of the liver before tlie fatal result. Most commonly it concurs with jaundice, or each symptom may exist indepcnd.M.tly (see Cases LXXXV., LXXXVl., and LXXXVII.). The fluid when copious is usually a simple dropsical collection, due to compression or obstruction with cancerous matter of the trunk or large branches of the portal vein, but the amount is usually small as contpared with what is observed in cirrhosis, although now and th^n it collects with a rapidity rarely seeii in cirrhosis. Considering how often the trunk or branches of the portal vein become obstructed with cancerous matter, it is LECT. VI. CANCEE. 211 remarkable that the branches of the hepatic vein usually escape. Very often small collections of fluid are the i-esult of a chronic peritonitis originating on the surface of the liver, and I have known a collection of this sort become encysted above the liver so as to embarrass the diagnosis. Now and then, as in Cases XCIIT. and XCI.V., blood is throvN^n out into the peri- toneum from a rupture in a fun gating or softened cancerous mass in the liver. 7. The superficial abdominal veins are only enlarged in. those comparatively rare cases where the portal circulation is seriously obstructed. 8. Enlargement of the spleeii is rare, and this constitutes an important distinction of the cancerous from the waxy or cirrhotic liver. 9. The constitutional symptoms, in the first place, are mainly those of deranged digestion, such as nausea, flatulence, and constipation, and occasionally attacks of vomiting or diarrhoea, with aching pains in the muscles and joints and progressive emaciation. A short dry cough is not uncommon. When the cancer grows rapidly, there may be a certain amount of pyrexia (Case XCI.) . The urine is invariably scanty and high- coloured, and deposits abundance of lithates and dark pigment unless the patient has been exhausted by vomiting or diarrhoea. Before the disease has lasted long, the patient presents in a marked degree the phenomena of the cancerous cachexia — extreme anaemia, with an earthy chlorotic colour of the integu- ments (unless there be jaundice), and rapidly increasing debility and emaciation. These symptoms are always aggravated by the coexistence of cancer of the stomach. As a rule, constitu- tional symptoms precede for some time both pain and jaundice, and for a long time they may be the only evidence of the disease, there being no enlargement of the liver, pain, jaundice, or ascites. A temporary gain in weight and strength under treatment is, however, not incompatible with cancer of the liver. 10. Cancer of the liver is, in most cases (fully three- fourths), secondary to cancer of some other organ, such as the stomach, uterus, the female breast, the rectum, or the vertebrae.^ In more than one-third of the cases it is secondary to cancer of the stomach.^ The sjmiptoms of cancer in these various organs will • The nodular variety is most commonly secondary. ^ According to Sir W. Jenner (Erit. Med. Jnum 1869, 1., 205) cancer passes from p '2 212 ENLARGEMENTS OF THE LIVER. i.kct. vi. therefore materially aid the dia<2;nosis. Even when the cancer is deposited first in the liver, other parts, such as the coeliac, mediastinal, inguinal, and cervical glands, and the lungs, are apt to become affected, and thus throw fresh light on the primary disease (see Case LXXXVII.). The diagnosis is also in many cases greatly assisted by the presence of a small mass of cancerous induration in the abdominal wall around the navel. 11. Cancer of the liver alwnys runs a rapid course. The medullary cancer often grows very rapidly,' and is fatal within a few weeks or months ; and although scirrhus is said sometimes to last for two years, ^ it is rarely prolonged beyond twelve months. The very fact of an enlargement of the liver having lasted much longer than this would be an argument against its being due to cancer. 12. The diagnosis is often assisted by the circumstances under Avhich the disease occurs. a. The age of the patient is sometimes of assistance in diagnosis. Cases are extremely rare where the liver is primarily affected with cancer before 35 or 40. Secondary cancer of the liver, it is true, may occur at any age, but then the primary disease will point to the nature of the case. h. In a large proportion of cases there is no difficulty in tracing a history of cancer in the family. In the course of my practice I have known two sisters die of cancer of the liver, in one instance within a fortnight, and in another within a few months of one another. c. In a large proportion of cases it will be found, whether a family taint can be traced or not, that the first symptoms uf indisposition have been preceded by protracted grief or anxiety. 13. The diseases most likely to be mistaken for cancer of the liver are waxy disease, interstitial hepatitis or cirrhosis, syphilitic disease, catarrh of the bile-ducts, impacted gall-stone, multilocular hydatid, and pysemic abscess (p. 224.) Case XCII. also shows how it might be possible to mistake cancer of the liver for even simple hydatid. a. The smooth infiltrated form of cancer may be mistaken for waxy degeneration. In both there is a smooth, uniform, very hard enlargement of the liver; but in the waxy enlarge- the liver to the stomach oftcnor th.-in in the opposite direction, but this is contrary to my experience. ' In one case Dr. Farre calculated that in ten days tlic liver acquired an addition equal to 5 lbs. Mori, id Aratomy of tlio Liver, p. 28. 2 Budd, Dis. of Liver, 3rd ed. p. 413. lECT. VI. CANCEE. 213 ment the progress of tlie disease is slow, there is an absence of pain or of the cancerous cachexia, and there is usually also enlargement of the spleen, with albuminuria, and a history of constitutional sj^philis, caries of bone, or protracted discharge from a suppurating surface ; whereas in cancer there is no en- largement of the spleen or albuminuria, but the course of the disease is rapid, and there are pain, cachexia, and often signs of cancer elsewhere. Rare cases, where cirrhosis and waxy disease coexist (see pp. 32 and 47), may be mistaken for nodular cancer. In both there may be a nodulated hard enlargement of the liver with ascites. The points of distinction are the same as between the smooth form of waxy disease and cancer. h. In cirrhosis the liver may be large, nodulated, and tender, and there may also be jaundice and ascites (see p. 139). It will be distinguished from cancer by the previous habits of the patient, a history of alcoholic dyspepsia with morning sickness, and the venous stigmata on the cheeks. c. Syphilitic enlargement of the liver — either interstitial hepatitis with projecting gummata, or waxy liver indented by deep cicatrices — may be mistaken for cancer (see p. 147). In both affections there may be a large nodulated tender liver, with jaundice, ascites, and severe pain ; but the syphilitic disease may often be distinguished by the comparatively early age of the patient, the previous history, and the existence of other evidences of syphilis. d. Jaundice from catarrh of the bile-ducts, when it persists for several months, and is associated, as it may be, with nausea, retching and emaciation, may be mistaken for cancer (see p. 153). It is true that in catarrh of the bile-ducts there is little or no pain and rarely much enlargement of the liver. Still, when jaundice supervenes for the first time in an elderly person who is not the subject of gout or of constitutional syphilis (see p. 154), and is persistent, it is most probably due to cancer of the liver or in its vicinity, notwithstanding the absence of pain, vomiting, or any physical signs of tumour, and in any case this view would be favoured by a family history of malignant disease. e. A gall-stone impacted in the common bile-duct may be mistaken for cancer of the liver. In both affections there may be intense jaundice with paroxysms of severe pain, vomiting, emaciation, and loss of strength. But in cancer the emacia- tion and failure of health precede for some time the pain and 214 " ENLARGEMENTS OF THE LIVER. lkct. ti. jaundice, wherefis in gall-stone the patient has been in his usual health until his sudden seizure with biliary colic, and very often there is a history of previous attacks. In cancer the vomiting and pain may occur independently, whereas in cancer thej' are more commonly simultaneous. The concurrence of ascites could of course not be accounted . for by gall-stones alone; but in a future lecture I shall have occasion to point out to you that gall-stones are not unfrequently followed b}"- cancer of the gall-bladder and liver. (See also Case LXXXIX.) Occasionally it will be tolerably clear from the symptoms that the patient is the subject of malignant disease, although the seat of the disease may be doubtful, whether it be in the liver or in some adjoining part, such as the stomach or omen- tum : but this is a difficulty of little moment as regards either prognosis or treatment. /. A multilocular hydatid tumour of the liver may present all the clinical characters of cancer, viz. a hard nodulated tumour, intense and persistent jaundice, ascites, oedema of the legs, and rapidly increasing emaciation and prostration. Vomiting is a common symptom in cancer, but has rarely been observed in multilocular hydatid ; whereas in the latter affection there is almost invariably considerable enlargement of the spleen, which Frerichs noted in only 12 out of 91 cases of cancer. A duration much in excess of twelve months would be opposed to cancer ; but although multilocular hydatid has been known to last for years, in most cases its course is as rapid as that of cancer. It follows that an absolute diagnosis between the two affections would in many cases be impossible ; but considering its rarity, multilocular hydatid is not often likely to embarrass the diagnosis (see Lecture VII.). Treatment. — The treatment of cancer of the liver must be entirely palliative. There is no known remedy which can arrest or retard its progress. Mercur}', iodine, arsenic, and the Sanguinaria Canadensis, which at different times have been recommended for the purpose, have been shown to be worse than useless. In none of the many diseases of the liver for which it has been the fashion to give mercury, has it been pro- ductive of so much injur}' as in cancer. TJie treatment must be restricted to supporting the patient's strength and nutrition by appropriate food, correcting errors in digestion, relieving pain, and procuring sleej). 1. Tlie diet ouirht to be nutritious, but moderate and LKCT. VI. CANCER. 215 digestible, and ought to contain a large proportion of the nitro- genous principles of food, and comparatively little of saccharine and oily substances which are calculated to increase the work thrown upon the liver. Alcoholic stimulants will often be necessary in the advanced stages of the disease, but ought to be given in moderation and well diluted. It must not be for- gotten that an excess of nutriment or stimulants may feed the disease instead of nourishing the patient. In those hopeless cases where the primary disease is cancer of the stomach, the diet must consist mainly of milk and animal soups and jellies. 2. Various remedies will often be necessary to correct errors in digestion. For vomiting, bismuth, hydrocyanic acid, lime- water, creasote, nux vomica, or ice, will be useful, and likewise the occasional application to the epigastrium of a sinapism or small blister ; in the latter case, advantage is sometimes also derived from sprinkling over the blistered surface a qua^rter of a grain of morphia. The use of blisters for any other object can do little good, and may weaken the patient besides putting him to unnecessary pain. Flatulence will be relieved by the ethers and essential oils, but better still by sach remedies as charcoal, creasote, or carbolic acid, which absorb the gas, or, by arresting decomposition, prevent its formation. A dose of from ten to thirty minims of a saturated aqueous solution of carbolic acid, with a few drops of chloric ether in peppermint water, is sometimes a most effectual remedy for this symptom. The bowels are often constipated, and will require relief, but care must be taken to avoid castor- oil and powerful purgatives, which will either nauseate the stomach or lower the patient b}""^ producing copious watery discharges. Four or five grains of the compound rhubarb pill with a grain of blue pill and a grain of extract of henbane, will usually produce the desired result satis- factorily and safely, or the bowels may be cleared out from time to time by a simple enema. The compound liquorice powder of the Prussian Pharmacopoeia is also useful for the same purpose. 3. Sooner or later, in most cases, anodynes will be necessary to relieve pain or procure sleep. The hydrate of chloral, belladonna, conium, or Indian hemp, will often be found useful for these objects, and ought to receive a trial in the first in- stance ; but in most cases it will be necessary to have recourse ultimately to one of the various preparations of opium or mor- phia. The solution of the bimeconate of morphia, which is of the same strength as laudanum^ has less tendency to derange 2l6 ENLAEGEMENTS OF THE LIVEK. lect. ti. the stomach or constipate the bowels than most other forms in which opium is given ; and these disadvantages of opium will also be, in a great measure, avoided by the subcutaneous injec- tion of morphia. In many cases I have known great relief obtained from a silvered pill containing one drop of creasote, quarter of a grain of extract of nux vomica, and from a sixth to half a gi-ain of morphia, twice or three times daily. Lastl}', poultices and warm fomentations, with or witliovit a few leeches, may be required for intercurrent attacks of peri-hepatitis. The following cases, which, with three exceptions, have been under your observation, illustrate the remarks that have now been made on cancer of the liver. Case LXXXV. — Cancer of Liver and Ovanj — Jaundice, hut no Ascites. Hannah C , aged 50, a cook of large build and rather stout, married, a mother of one child, adm. into Middlesex Hosp. on July 28, 1803. She stated that for many years she had been subject to ' bihous attacks' (vomiting and headache), but that about two years before admission, these had become much less frequent and severe, and she had enjoyed good health until about ten weeks before admission, when slie had been attacked somewhat suddenly with pain in epigastrium and right hypochondriura and in both shoulders, accompanied by great languor, and followed next day by diarrhoea, which lasted a week. A mouth before admission, pain had become much increased, and urine was noticed to be of a dark greenish-brown colour ; a week later skin became yellow, and since then patient had suff&red much from itchi- ness. From first she had been losing flesh. 'I'lie symptoms, while patient was under observation, were as follows. Skin, conjunctivae, and serum of a blister of a bright orange colour, and great itchiness of entire surface. Tongue, at first clean, became afterwards coated with a thin white fur. At first there was no vomiting, but frequent attacks of nausea and a feeling of distension and oppression after meals. Appetite vciy bad. Motions destitute of any trace of bile, pnltaceou.s, clay-coloured, and veiw offensive. Much pain in both shoulders and in epigastrium and right hypochondrium ; this was much greater a few days after admission than subsequently. Liver jiiuch enlarged, hepatic dnlness in right mammary line extend- ing from ^ an inch below nipple to 1^ in. below ribs, and measuring C)^ in. ; portion of liver below ribs hard, tender, and distinctly nodu- lated (fig. 18, p. 200). No ascites. Urine scanty, only about one-half of norn)al quantity, sp. gr. 1030, acid, dark like porter, and threw down a copious (lepohit of lithatcs; it contained abundance of bile-pigment, but no bile-acids (by Harley's test), and no albumen. LKCT. VI. CANCEE. 217 Pulse GO ; cardiac and respiratory signs normal, exce25t that occasionally ' crackling sounds ' were lieard over base of right lung. On Aug. G, and again on Aug. 15, it was noted that patient vomited after her medicine. On Aug. 29 there was a considerable increase of paiii and tonderness in abdomen, with vomiting and pinched features. Under treatment, these symptoms abated somewhat, but vomiting returned from time to time, while the languor and prostration i-apidly increased. On Sept. 28 vomiting became incessant, and from this date patient gradually sank until death on Oct. 3. Treatment consisted in bismuth, hydrocyanic acid and opiates, sinapisms to epigasti'ium, and nutritious but digestible food. Autopsy. — Body well nourished, and a thick laj^er of fat everywhere beneath skin, in omentum, and around kidneys. Tissues throughout body deeply stained with bile. I^o fluid in peritoneum, and no sign of recent peritonitis. Mucous membrane of stomach and intestines normal, but contents of bowel contained no trace of bile, and none could be squeezed from gall-bladder into duodenum. Liver very large, weighing 97 oz., and its right lobe measuring 13 in. from before backv/ards ; surface studded with elevated yellowish- white, moderately firm nodules, varying in size from a pea to a walnut, and many of them depressed in centre. Similar masses seen in interior of liver on sec- tion ; one mass, size of a large orange, occupied entire thickness of right lobe in front, extending back to transverse fissure, and in contact with upper surface of gall-bladder. These masses yielded a creamy juice on section, which contained characteristic ' cancer-cells ; ' some of them softened in centre into a yellow pulp, and here cancer-cells contained much oil, and there were many compound granular cells. Hepatic lobules between cancerous masses had a peculiar appearance ; the central third of each lobule had a dark olive-green colour, and hepatic cells in it contained much bile-pigment ; the outer two thirds were pale-yellow, and there the secreting cells were loaded with oil. Several stellate crystals of tyrosin were found in secreting tissue. Gall-bladder contained no bile, but was filled with facetted gall-stones. Hepatic ducts considerably dilated, but common duct passed into a mass of dense areolar tissue and enlarged glands in portal fi.ssui'e, through which its continuity could not be traced. Capsule of Kver at many places adherent by firm fibrous bands. Uterus normal. Left ovary as large as .a walnut, rather soft, and nodulated; it contained a little semi-flaid dark blood, and its substance was soft and yellow, and exuded a creamy juice containing ' cancer- cells.' A cancerous nodule, size of a pea, projected from surface of left ovary. Mesenteric and lumbar glands presented no abnormal appearance. Lungs and heart normal, with exception of pulmonary congestion and patches of atheroma in mitral flaps and in commencement of aorta. No cancerous deposits in either spleen or kidneys. 2l8 EXLAECtEMENTS of the liver. lect. vr. Case LXXXVI. — Cancer of Uterus andLiccr — Ascites^ hut no Jaundice. On Oct. 18, 18G6, Charlotte D , aged 06, was transferred to my care in Middlesex; Hosp., having been for two months before under care of Obstetric Physician for cancer of uterus. She was married, and mother of nine children ; catamenia had ceased at age of 49. Three years before she came under my care, she had an attack of what ap- peared to be gall-stones, sudden spasmodic pain in right side, with vomiting and slight jaundice, and ever since she had suffered from a feeling of ixneasiness and fulness below right ribs. Twelve months before, she first noticed a slight but very offensive and persistent yellow discharge from vagina, and ever since she had suffered from costiveness and pain in deffecation and some difficulty in micturition. On two oc- casions, nine months and three naonths before she came under my ob- servation, she had rather copious uterine hsemorrhage, lasting for about a fortnight. Two months before, she first noticed her abdomen to swell, and she began to suffer from vomiting after food. She had been losing flesh for twelve, and rapidly for three months. On admission patient was weak and emaciated, and her countenance was expressive of pain. Extensive induration and ulceration of cervix uteri and upper part of vagina, with a fetid discharge. Abdomen much distended, nieasai'ing 3of in. at iimbilicus, and exhibiting all the signs of fluid in peritoneum. Liver much enlarged, in r. m. 1. measuring (j^ in., and projecting fully 2 in. below costal margin ; portion that could be felt hard and tender, but had no feeling of nodulation. Superficial abdominal veins slightly enlarged, but no jaundice. Tongue moist and slightly furred ; vomiting had ceased, but bowels had not acted for several days. Urine loaded with lithates, but contained no albumen. No anasarca of trunk or extremities. Pul-se 108 and feeble ; no dyspnoea; cardiac and i-espiratory signs normal, with exception of slight dulneas and fine crepitation at end of inspiration at base of right Patient was treated with bismuth and chloric ether, subcutaneous injections of morphia, mild laxatives, and a nutritions diet, with a small allowance of brandy. Vomiting did not return ; but every night she suffered from intense pain in abdomen, which was only partially relieved by morphia injections. Belly slowly increased in size ; prostration became daily greater, until death occurred on Oct. 30. Autopsy. — Peritoneam contained several quarts of turbid scrum, with flakes of soft lymph, chiefly on fundus uteri and in pouches be foi-e and behind. Cervix uteri entirely destroyed by cancerous ulceration, which extended for 1^ ia. down anterior wall of the vagina; lower two-thirds of uterus infiltrated Avitli cancerous matter. Lumbar glands slightly enlarged from cfincerous deposit, and in the portal fissure was a mass of enlarged cancerous glands pressing on portal vein. Liver of enormous size, weighing 11^ oz., and jiortiou ojjjiosed to thoracic j.KCT. Ti. CANCER. . 219 and abdominal wall meastiring 7 in. ; it was studded tlironghout with numerous isolated nodules of cancer, from a pea up to a walnut in size, but none of them mucli raised above outer surface, so that portion of organ projecting beyond ribs was perfectly smooth and even. On section, many of nodules were found to be softening in centre into a flaky serous fluid. On microscopic examination, nodules, both at cir- cumference and in centre, were seen to consist mainly of nuclear ele- ments, with but few cells ; hepatic tissue intervening between nodules free from cancerous infiltration. Mucous membrane of stomach and intestines healthy, but small nodules of cancer, up to size of a chei"ry, were scattered through lower lobe of right lung. Although no opportunity was afforded for a post-mortem examination m the following case, the diagnosis, as I frequently pointed out in the wards, was sufficiently clear. Case LXXXVII. — Cancer of Liver, Lunrfs, and Cervical Glands — Jaundice and Ascites. John B , aged 47, a coAvman, adm, into Middlesex Hosp. Aug. 2ri^, 1866. Twelve years before admission he had been confined to bed for a week with rheumatism ; and two years before he had sufi'ered for two months from severe pain at epigastrium, usually worse after food. With these exceptions, he had enjoyed good health until eight weeks before he came to hospital, when he was seized somewhat suddenly, while at work, with violent pain in region of liver and stomach, which never ceased, although it had been sometimes more severe than at others. Eight days after this he noticed that his motions had lost their colour, and that urine was very dark, and after six more days, conjunctivae, and then skin, became yellow. On admission patient was weak and emaciated, and had intense jaundice of entire surface. He complained of severe pain in region of liver, coming on in paroxysms, which would last for many hours, were sometimes attended by vomiting, and often prevented sleep. Liver enlarged, measuring 5^ in. in right mammary line ; in epigastrium it felt hard and obscurely nodulated, and was very tender. No tumour felt corresponding to gall-bladder. There was neither ascites nor en- largement of abdominal veins or spleen. Tongue coated with a creamy far ; bowels costive ; motions clay-coloured and very offensive ; urine of colour of porter, and contained abundance of bile-pigment but no al- bumen. Pulse 96 ; cardiac and respiratory signs normal ; no dropsy. Patient was treated with mineral acids and gentian, anodyne draughts wibh drachm doses of tincture of henbane, and mild laxatives. On Aug. 28 he first noticed a tumour on left side of neck, imme- diately above clavicle, about size of a hen's Bggi hard, nodulated, and slightly tender. This tumour increased in size, and soon became seat of severe pain, like that in liver. Patient also complained often of 220 EXLAllGEMEXTS OF THE LIVEE. lkct. yi. severe pain down back, but no tenderness of spine. Indian hemp and henbane failed to give relief to these pains, and on Sept. 9 subcu- taneous injections of morphia "were resorted to, at first with great benefit. On Sept 5 ascites was first noticed, which from this date continued to increase, and on Sept. 24 both feet and lower half of both legs were noted as SAVollen and oedematous. Tumour in neck now filled up whole of lower triangle, and at its circumference were several large and movable glands quite distinct from general mass : patient vomited occasionally after breakfast, and became daily thinner and weaker. On Oct. 1 he was noted as vomiting almost everything he swallowed. Pulse 84, weak, and intermittent. Ascites and tumour of neck continued to increase ; liver ajjpeared larger and more dis- tinctly nodulated ; and pains Avere only relieved by morphia injections, Avhich were repeated twice daily. No cough, and respiration slow and easy, but over middle of left lung posteriorly marked dulness over a space 3 or 4 in. square, with absence of vesicular murmur, but no friction or crepitation. On Oct. 5 left arm and hand oedematous, and vomited matter, which from first had resembled yeast, was found to con- tain abundance of sarcinas. A mixture was ordered every six hours, con- taining ten minims of chloi'ic ether and one drachm of a satui*ated aqueuus solution of carbolic acid in peppei-mint water. Patient was now so weak that he obviously could not live many days, but his wife came, and insisted on removing him to country. Case LXXXVIII. — Primarij Liji It rated Cancer of Liver — Great Enlanje- ment, hut surface suiuoth — No Jaaiidlce or Ascites. On Jan. 5, 1876, Ann G , aged 42, was sent to Samaritan Hosp., supposed to be suffering from ovarian disease. On Jan. 7 she Avas transferred to St. Thomas's- No history of malignant disease in family. ^Mother of eight children and had three miscarriages. Cata- menia had ceased five years before, after birth of last child. Left eye- ball had been remoA'ed 3iyears before, owing to eti'ects of a blow. Six months before, Avhen ap^jarently in perfect health, first noticed swell- ing below riglit ribs which gradually tilled abdomen, and at same time she lost flesh and strength. For two months had suffered much pain in abdomen, and for five days had noticed swelling of legs and thighs. On admission : Very emaciated. Abdomen greatly enlai-ged, bulg- ing aljruptly forwards beloAV ribs ; enlargement greater in up})er tlian in lower part ; integuments stretched and shining. Girth at navel ^■i\ in., and half-way between this and sternum 33 in. ; from ensiforui cartilage to navel H^ in. ; from navel to pubes (j\ in. No sign of fluid in j)eritoneum, and swelling evidently caused by a very large liver, lower margin of AvJiicii can be felt on both sides, 2^ in. below level of umbilicus ; margin of right lobe more rounded than that of left, and the two separated by a deep indentation rising to above navel. Upper margin of liver does not rise too high in chest ; total hepatic dulness i.ECT. VI. DAXCEE. 221 in r. m. 1. 11 in., and same m mesial line. Surface of swelling slightly undulating, but free from excrescences, and not tender Consistence tense, but rather elastic. Suffers much from constant tightness in tumour, worse after meals and preventing sleep, and has occasionallj attacks of severe 'scraping' or cutting pain. Tongue coated; no appetite ; no vomiting ; bowels costive ; no jaundice. Urine 1026, loaded with lithates ; no albumen. Pulse 96, A few dry bronchial rales over lungs. Became rapidly weaker ; vomiting came on ; and died on Jan. 13. Autopsy. — Liver greatly enlarged, corresponding to tumonr observed during life ; weighed 198 oz. ; shape normal ; non-adherent ; surface smooth ; left lobe as large as an ordinary right ; great exaggeration of central fissure. Enlargement of liver due to extensive cancerous in- filtration of left lobe and to a considerable extent of right ; on section a few isolated nodules, from size of a pin's head to an inch in diameter; but none projected from surface. No cancer in any other part of body. Spleen 7oz., dark and soft; lungs congested. On section of infiltrated new growth in liver it was pale like a fatty liver, outlines of acini being distinct. Microscopic examination showed that it had ordinary structure of encephaloid cancer. The two follov^ing cases are remarkable for the mode of commencement. In Case LXXXIX. the disease seemed to commence in the gall-bladder and bile- ducts, and the history in the first instance pointed to biliary colic and gall- stones rather than to cancer; while in Case XC, where the disease perhaps originated in the right kidney, one of the first symptoms of illness was ascites. Case LXXXIX. — Cancer of Gall-hladder, Bile-ducts, Liver, ^'c, com- "inencing ivith severe ]jain liJce that of Biliary Colic— Jaundice — No Ascites. Anne G , 63, adm. into St. Thomas's Hosp. Xov. 19, 1875. Xo history of malignant disease in family. Had seven children, all of whom, as well as husband, had died of consumption. Had been of temperate habits. Had suffered now and then for a year or two from flatulence, but with this exception she had been in her usual good health until three weeks before admission, when one day, while out washing, she had been suddenly seized with a sharp shooting pain be- low right ribs in front. Pain was so severe that she could scarcely walk home. It kept coming on in paroxysms, and was attended by shivering but not by vomiting ; after four days it ceased, but a day or two after this she was noticed to be deeply jaundiced, and she had much nausea. On cross-examination patient admitted that for two or three months before attack of pain strength had failed a little, but she had followed her work as usual, and had not noticed any loss of flesh. 222 ENLARGEMENTS OF THE LIVEE. lect. vi. On admission, deeply jaundiced ; skin vei'y itchy ; urine loaded witli bile-pigment, but none in stools ; hepatic dulness not increased ; slight bulging and some tenderness corresponding to gall-bladder ; no ascites ; no appreciable abdominal tumour. Tongue clean ; fair appe- tite ; pulse 70. Four days after admission had an attack of severe pain in liver, lasting about half an hour. These attacks recurred first at intervals of a few days and then more frequently ; they were not attended by vomiting. Day by day patient grew weaker and thinner, and there was loss of appetite and much nausea. The liver gradually increased in size, until, on Jan. 22, it measured 7 in. in r. m. 1. No inequalities could be felt on its surface ; no tumour appreciable anywhere, but always much tenderness over gall-bladder ; no ascites. Death by exhaustion on Jan. 26. Autopsy. — No fluid in peritoneum. Colon and duodenum di'awn up and adherent to an irregular cancerous mass projecting from liver, occupying situation of gall-bladder, infiltrating adjacent part of liver and extending downwards so as to involve head of pancreas. Im- mediately above pancreas another cancerous mass due to infiltration of glands in that region. Duodenum where adherent to mass narrowed, but mucous membrane both of it and colon healthy. Gall-bladder shrunken ; walls ^ in. thick, infiltrated with cancer ; inner surface rough, shaggy, and very vascular ; cystic duct obliterated ; a small rounded oi'ifice surrounded by granulations at fundus where it had been adherent to abdominal wall. Walls of common and of hepatic duct from ^ to I" in. thick from infiltration with new growth, this infil- tration extending both downwards towards bowels, and upwards for 4 in. into substance of liver, where it became obliterated and em- bedded in hard new growth. No gall-stones. On cutting into liver, bile-ducts greatly dilated behind seat of stricture, forming cystiform sacculations filled with glairy, colourless fluid, free from all colour of bile. Scattered through substance of liver were numerous nodules of new growth ; and in centre of many of them a small orifice from which a drop of glairy fluid exuded on squeezing, as if they were formed by infiltration of walls of bile-ducts. Portal vein not obstructed. Weight of liver 7o oz. Spleen 6| oz. Commencing granular degeneration of kidneys ; in upper lobe of right lung a circumscrilied ncAV growth, size of a walnut; lower lobe studded with new growths from size of a pin's head to that of a pea. Case XC. — Cancer of rigid Kidney, Liver, Si'leen, ami Tjungs. Ascites tlie first symptom, of illness. John !M , aged 37, adm. into St. Thomas's Hosp. March 9, 1875. No evidence of malignant disease in family. Habits temperate; no history of syphi'i.s, and general health good. For three f.r four months Ixjfore Oiristmas 1874 had felt occasionally a fulness and tightness of LECT. Ti. CAISTCER. 223< abdomen, bnt had not paid much attcBtion to it. On Dec. 28 liad a more severe attack than usual of this tightness, and after this it be- came more constant and was increased af er food. Still appetite con- tinued good ; no nausea or vomiting ; no appreciable emaciaiion ; and followed employment as a platelayer until Feb. 28, when he was sud- denly seized with great tightness and pain in abdomen ; could take no food ; and was compelled to give up work and t-ake to bed. From this date abdomen continued to enlarge, and ho was slightly yellow. On admission, sallow and anaemic, and conjunctivae slightly yellow. Still complains much of tightness in abdomen and of dyspnoea on exer- tion. Girth at umbilicus 36 in.; moder-c^te ascites; slight oedema of legs. Liver much, enlarged, dulness commencing ^ in. below rio-ht nipple, and from this to lower margin, 3 in. below ribs in r. m. 1. 7 in. • enlargement uniform ; surface smooth, hard, and painless ; left lobe also muck enlarged. Splenic dulness increased ; and lower end of spleen felt projecting 1^ in. below x'ibs. Abdominal veins slightly en- larged. Tongue clean : appetite faic- ; no vomiting ; bowels confined. Complains much of painful tightness of abdomen after food. Pulse 78 • heart signs normal. Lungs normal. Urine 1017 ; no albumen, but some bile-pigment. Temp. 99°. •The treatment at first consisted in the perchloride of mercury and bark, with aperients ; while mercurial and belladonna ointment was applied to abdomen, and morphia w^as given occasionally to relieve pain and procure sleep. On March 12 two srrall excrescences were discovered on surface of liver, one just below ensiform cartilao-e and the other on left lobe. On March 31 a mixture of nux vomica and acid was substituted for the mercurial. On April 12 patient had o-ained 9 lbs. in weight in ten days and 12 lbs. since admission, but this increase was probabl}^ due to greater accumulation of fluid in abdomen, which now measured 40 in. ; parietes attenuated and glazed ; more oedema of legs ; jaundice scarcely appreciable. April 19 : Seven pints of fluid drawn cfi" by aspirator, reducing girth to 35 in. and givino- great relief. Fluid rapidly accumulated again ; much pain in abdomen • occasional epistaxis. On April 28 girth of abdomen ao-ain 40 in. ■ patient's weight 16 lbs. more than on admission. On May 7, 16 pints of serum removed by paracentesis, and after this liver could be seen forming a large prominent tumour between sternum and umbilicus hard and nodulated. Pain again relieved by operation, but exhaustion increased, and deatli on May 13. Autopsy. — Eight pints of serum in peritoneum. Liver o^reatly en- larged ; weighed 161 oz. ; studded with cancerous nodules, many of which projected from surface. Portal vein much dilated, and on tracino- it into liver cancerous masses were found moulded to shape of veins and branching with them, but not adherent to their walls. Gall-duct pervious ; spleen, 17-|- oz., contained several masses of cancer. Eio-ht kidney entirely deslroyed, being simply a bag of soft disintegrating 2 24 EXLARGEMEXTS OF THE LIVER. lect. vi. cancer. Vessels of right kidney compi'essed by cancerous nodules projecting from liver, and veins extremely dilated. Left kidney mnch cnlaro-ed, but healthy; stomach and pancreas healthy. Lungs congested and studded with cancerous masses. The next case to Tvhicli I shall direct your attention was re- markable not only for the early age of the patient and the rapid course of the malady, but more particularly for the py- rexia which marked its course. Little is known as to the range of temperature in cancer. Wunderlich makes the following observations upon the subject. 'It is a peculiarity of cancer cases that elevated temperatures are comparatively rare, and that the temperature generally maintains itself on a normal, or even subnormal, plane, which, however, by no means precludes the occurrence of high temperatures through intercurrent complications, or at the close of the disease. But fever tem- peratures of long duration are at least rare in cancer patients.' In confirmation of this opinion, Dr. Woodman, the translator of Wunderlicli's treatise, quotes cases observed by Drs. Finlay- son, Da Costa, and E. B. Baxter, and adds : ' The few obser- vations I have myself made of carcinoma of the liver, uterus, and breast, before marasmus had set in. only show very slight elevations of temperature, or none at all ; never above 101° Fahr. unless from some complication ; whilst I have found subnormal temperatures with rapid pulse in several cases of advanced cancer witli emaciation.' ' My own experience coincides with the opinions now quoted, and, I believe, with those of most observers, viz. : — that in cancer, unless there be some inflammatory complication, the bodily temnerature is at or about the normal standard,^ and accord- ino-ly in the case of any obscure internal disease, a continuous elevation of temperature would in itself be opposed to the dia- gnosis of cancer. But the case now related proves that this rule is not absolute. In this case, moreover, the age of the patient, 24, was opposed to cancer of the liver ; while not only the pyrexia, but the rigor, the previous injury and enlargement of the testicle, the rapid course, and the cerebral symptoms, all favoured the diagnosis of pyajmic inflammation, in preference to cancer of the liver. ' On the Tcmpcmturc in Discascp, by C. A. "Wiuulcrlicli, Syd. Soc. Transl. 1871, pp. 429, 430. 2 Since this case occurred, I have met wiili another capp, n lady aged 56, with primary uncomplicated cancer of the liver, and a tcniiieratnre of 102°. CAXCEE. --^5 Case XCI. — Acide Cancer of Liver tvitlt Pyrexia in a man aged 24. James C , 24, carpenter, adm. into St. Thomas's Hospital Nov. 6, 1872. No history of malignant disease in family, and previous health good. Six months before, strained himself whilst turning a crane ; left testicle swelled and was- tender, but general health appeared unatFected. Six weeks before admission first complained of pain in right side of abdomen and began to lose flesh and strength. Soon after a doctor discovered a swelling in right hypochondrium, which rapidly increased. Had no rigors, but twice during sleep had per- spired profusely. On admission, emaciated; hectic flush on cheeks ; temp. 101'o° F. Suffered much from pain in region of liver, and from dyspnoea. On right side of abdomen was a visible bulging, continuous apparently with liver, its lower margin extending almost to brim of pelvis, and upper margin of hepatic dulness reaching to \\ iii. below nipple ; surface of swelling firm, smooth, and moderately tender. Distinct jaundice of skin and conjunctivae ; na ascites nor enlargement of ab- dominal veins. Tongue moist, slightly furred ; no appetite ; much thirst ; no vomiting ; bowels open but not loose ; bile in stools. Urine 1018 ; contained copious lithates, some bile-pigment, and a. trace of albumen. Lay on right side ; respirations 32, thoracic ; some cough, but no ex- pectoration ; sibilant rales over both lungs, and over back of both lungs, but chiefly on right side, breath sound feeble and slight impairment of resonance on percussion. Pulse 120 ; heait's sound normal. Left testicle twice size of right, hard but not tender. Patient was ordered a milk diet and an effervescing saline mix- ture. He had also morphia draughts and subcutaneous injections of morphia, and laudanum poultices to relieve pain, but he got rapidly worse. Nov. 8.- — Pulse 134. Vomited last night a greenish flocculent matter containing no food. Nov. 11. — Has repeatedly vomited green bilious matter, and jaundice is now very decided. Liver increased in size, more bulging below ribs, and its dulness extending to within \ in. of nipple ; surface smooth and firm. Tongue red and dry ; bowels open daily. Very prostrate, and occasionally delicious. No rigors or night-sweats. Pulse 120 ; a systohc bruit audible at base of heart and propagated upwards to clavicles and neck. Nov. 13. — De- lirium, jaundice, and enlargement of liver increased. Swelling below ribs is more elastic, but there is no distinct fluctuation. Yesterdtiv had a decided rigor, followed by heat and perspiration. Nov. lo. — Much more prostrate, but no more shivering. Skin dry. Still deli- rious. Got rapidly weaker, and died on Nov. IG. The following is a note of observations of the temperature : — 226 Nov. ENLARGE MENTS OP THE LIVE: I. J.ECT. VI Morning Evening 6. . . . — . 101'2 7. . 1011 . 103- 8. . 99- . 101-4 9. . 98o . 101-2 10. . 9«- . 100- 11. . 100- . 103- 15. . 98-i Autopsy. — Liver much enlai-ged, and before removal measured 12^ in. vertically. Its entire substance was studded witli numerous masses of cancerous deposit, intensely vascular, and varying in size from a pea to a chestnut. Many of them were at the surface of the organ, batdid not project from it. The cancerous masses were not softened. On section they yielded a milky juice containing numerous cells with large nuclei, such as are common in cancer. A mass of similarly affected glands was found in neighbourhood of left kidney and extending along vessels to left testicle, which also contained a vascular tumour of size of a cherry. Both lungs also contained numerous tumours similar to those in liver. No sign of recent inflammation in any part of body. Heart healthy. The chief interest in the following- case consists in the fact that a lai^g-e cyst containing bloody fluid was developed in a cancerous liver, probably from obstruction of one of the intra- hepatic ducts. This cyst formed a prominent tumour above the liver, and was repeatedly tapped during life, to relieve dys- pnoea. Had such a cyst formed in the early stage of the dis- ease, and I have met with, a case Avhere this seemed jjrobable, the disease might have been mistaken for hydatid. Here the collateral signs pointed unequivocally to cancer ; and the only question was whether the collection of fluid above the liver was in a cyst originating in the 'gland, or in a cavity between the liver and diaphragm circumscribed by peritoneal adhesions, as may sometimes be observed in connection with cirrhosis &c. (See Cases XCIV. and CIX.) Case XCII. — Cancer of Liver — Ascites and Jaundice — Large Cyst projectiufj from upper surface of Liver. On Oct. 9, 1873, Mr. F , aged 51, was sent for my advice b}- Dr Dobie of Chester. He had lived generously, but had not been intem- perate. His health had been good until three months before, Avlien he began to have pain in region of liver and in right shoulder, and since then ho had sufi'crcd from loss of flesh and strength, constipation and fliitiileiice, and latterly from swelling of abdomen, dyspna'a on exertion, and cough. On examination, considerable ascites ; girth of abdomen 42 in. No oedema of legs. No decided jaundice, but the sallow countenance of cir- rhosis. Dimensions of liver could not be made out. Pulse 108 ; sounds LKCT. Ti. CANCER. 227 of heart healthy. Urine dark and loaded with lifchates, but no albu- men. He was treated with saline purgatives and diuretics, including chloride of ammonium, digitalis, and blue pill, and he had also different preparations of iron. At first there was considerable improvement, ascites diminished, and then both liver and spleen appeared to be con- siderably enlarged and liver was also tender. On 'Nov. 5 a bulging, size of large orange, was discovered in right side of epigastrium, evi- dently due to fluid distinct from that in peritoneum. This swelling increased, as did also flatulence and dyspnoea after meals. On]S"ov. 12 liver was noted as larger, and nodulated on surface. On Nov. 13, after dinner, while stooping to take off stockings, was seized with alarming dyspnoea and sent for me, I found him livid, and swelling in epigas- trinm larger. This was punctured with a flne trocar, but only about two drachms of bloody flaky serum came away. This contained numerous cells with large nuclei (cancer- cells). Gradually dysj)ncea subsided, and on Nov. 15 patient was able to return to Chester. On Nov. 25 he had another severe attack of dyspnoea, and Dr. Dobie drew off from cyst in epigastrium 30 oz. of red fluid, of specific gravity 1020, and containing numerous blood-corpuscles. The opera- tion was followed by great relief to the breathing, but the fluid collected again, and on Dec. 5, 47 oz. were drawn off. Ascites also increased, though slowly; pain in liver persisted; and early in December legs began to swell and intense jaundice set in, with complete anorexia. Patient gradually sank, and died on Jan. 1, Autopsy. — Eight pints of turbid yellow serum containing flakes of lymph in peritoneum. Liver greatly enlarged, and both lobes exten- sively infiltrated with soft cancer. Projecting from convex surface of right lobe, and evidently originating in liver, was a large cyst con- taining bloody fluid which had been tapped during life. No enlarge- ment of spleen ; this had been simulated during life by left lobe of liver reaching far downwards and to left. Other organs healthy. The preparation which I now show you was removed from the body of a patient in this hospital (Middlesex) while I was pathologist, and was exhibited to the Pathological Society (Trans, vol. xiii. p. 100). It illustrates a rare mode of fatal termination of cancer of the liver. ^ Case XCIII.- — Frimanj Cancer of Liver — Death from HcemorrJiaqe into Peritoneum. Patrick S— — , aged 50, became an out-patient at Middlesex Hos- pital, under Dr. Greenhow, in August 1861. At a former period of ' For additional cases, see Frerichs, Dis. of Liver, Syd. Soc. Trans, ii. p. 333 ; Murchison, Path. Trans, xiii. p. 102; also Budd, Dis. of Liver, 3rd ed. p. 396. In Frerichs' case, the hfemorrhage seemed to commence three days before death, and the appearances in the liver were very similar to those above described. Q 2 228 ENLAEGEMENTS OF THE LIVER. lrct. vi. his life lie had been very intemperate, and he had been in the habit of drinking a large quantity of spirits. For some months he had been losing flesh, and he had been suflfering from occasional nausea and other dyspeptic symptoms, and from pains in epigastrium. Dr. Green- how discovered that liver was enlarged and distinctly nodulated below marcrin of right ribs, and recognised the peculiar physiognomy charac- teristic of the cancerous cachexia. There was no jaundice, and little or no ascites ; and nothing was observed to indicate an immediate fatal termination. On Aug. 26 the patient was brought to hospital, and admitted under Dr. Goodfellow, his condition having become suddenly worse about two days before. His symptoms on admission were great pros- tration and cachectic countenance ; marked jaundice of skin, conjunc- tivae, and urine ; complete loss of appetite, urgent vomiting, intense pain and tenderness in region of liver, which was much enlarged, hard and nodulated ; abdomen much distended and fluctuating: small, rapid pulse. ISTo improvement took place ; and day after admission patient vomited a large quantity of dark bloody-looking fluid. During night of 27th he fell into a state of collapse, which con- tinued until death at 2. BO p.m. of August 28. Autopsi). — Moderate emaciation ; marked jaundiced tint of conjunc- tivje and skin and of tissues generally, including the internal organs and bones. Between five and six quarts of dark-red bloody serum in peritoneal cavity, and lying on upper surface of right lobe of liver, to- wards its right extremity, between it and diaphragm, was a dark coagu- lum of blood which weighed 5 oz. avoirdupois. Sei^ous coat of in- testines, which was Viathed by the bloody fluid, presented no abnormal injection or deposit of lymph. Liver weighed 72 oz. ; right lobe was relatively much enlarged, measuring 9 in. transverselj', while left lobe was much atrophied, and a mere appendage to right, not exceeding H in- in its transverse diameter ; greater part of diminu- tive left lobe granular on surface, and pi-escnted on section appearances characteristic of cirrhosis. Corresponding to lobus quadratus was a rounded mass, about size of a large walnut, attached by a narrow pedicle, and likewise composed of cirrhotic glandular tissue. Whole surface of right lobe of liver covered with prominent nodules, varying in size fi-om a pea to a large cherry, the largest being very clastic or almost fluctuating ; they were most developed near anterior margin of right lobe on upper surface. The coagulum on surface of right lobe was adherent at one spot near right extremity of organ, corresponding to one of softened nodules, which was ruptured. The sti-uctnre of rifht lobe of liver was extremely dense ; and on making a section, it appeared to consist of two abnormal elements, a groundwork of firm grey scirrhus-looking tissue, infiltrated with a creamy yellowish juice, and containing a number of cavities up to size of a cherry, filled with a soft pulpy bright yellow substaiicc ; whole of right lobe appeared to i.ECT. VI. CAiSTCEE. 229 be made up of these abnormal elements, and scarcely presented at any part a trace of natural glandular tissue or of bile-ducts. The scirrhous structure had encroached to some extent along anterior margin of left lobe. On examining with microscope juice scraped from denser scirrhous portions, it was found to contain a multitude of rounded, elliptical, and fusiform cells, up to J-^ of an inch in diameter, with one or sometimes two large nuclei about one-third size of cell ; many of cells, likewise, included brownish pigment-granules. In softened portions, similar cells were discovered, mixed up with a large quantity of oily and pig- mentary matter, both inside aiid outside cells. Other abdominal organs normal. Heai-t normal. Apices of both lungs condensed and puckered, and contained encysted calcareous masses up to size of a pea. In Case XCIY. the immediate cause of death was also pro- bably liEemorrhage into the peritoneum. The preparation which I show you appears to be an illustration of that rare form of disease described by Dr. Bright and other writers as ' fungus hsematodes ' of the liver, where the growth projects greatly from the general surface of the organ. The transition between the secreting cells of the liver and the large cells of the growth, determined by myself and Dr. Cayley, is likewise a matter of considerable pathological interest. Case XCIY. — Cancerotis Ttcmour (Fungus Hcematodes), projecting from topper siorface of Liver — Hrmnorrhage into Feritoneum. Luke T- — • — , aged 57, was sent to London Fever Hospital on Jan. 20, 1868, supposed to be suffering from ' fever.' He had no friends, and could give no account 1 if his previous history. On admission he had a heavy .stupid countenance, and his mind was confused. He was very emaciated ; pulse varied from To to 88, and was very weak. Tongue dry and brown ; bowels rather loose ; abdomen slightly dis- tended, partly from tympanites, but partly also from fluid in peritoneum. Hepatic dulness appeared to be normal. Occasional coug-h, with thin frothy expectoration ; slight dulness over both lungs posteriorly, with rather fine crepitation, but no tubular breathing. ISTo night-sweats ; neither jaundice, dropsy, nor albumen in urine. Patient was treated with ammonia, and subsequently with iron and mineral acids, along with beef-tea, milk, and brandy ; but symjDtoms became gradually worse, emaciation and ascites increased ; frequent low muttering delirium ; and on Feb. 2 slight jaundice, but motions still contained bile. Pulse rarely exceeded 80. Patient became every day weaker, but no fresh symptom of importance appeared. He died on Feb. 16. 230 ENLAttGEMfijSrTS OP THE LIVER. Autopsy. — Peritoneum contained between three and four quarts of dark sanguinolent fluid. Liver was separated from diaphragm in front and from anterior abdominal wall for 2 or 3Jn. by a space filled with this sanguineous fluid ; suspensory ligament elongated in a correspond- ing degree. Liver weighed 64 02. ; capsule slightly thickened and opaque, but surface smooth. On section it appeared unusually dense and tenacious. Projecting from upper and back part of right lobe was a rounded tumour as big as a man's fist. This was embedded in a hollow in diaphragm, to which it was so firmlj' adherent that part of it was left behind in removing liver. This tumour was of pulpy soft- ness, and reflected over it was the thickened capsule of liver, from inner surface of which the pulpy mass could be easily scraped with handle of knife. On section there was seen to be a sharp line of separation between it and the deilse tissue of the rest of liver. The pulpy substance was torn with greatest facility, and was very vascular, so that it was obviously the source of blood in peritoneum. On micro- scopic examination, it was found to be made up of large nucleated cells, with an average diameter of -^^^ inch, or about three times that of a Fig. 19. Shows microscopic appearances of tumour of liver in Case XCIV. a, Large nucleated cells of various shapes, and some ■with a douMe nucleus ; /), similar cells containing oil-glolmles ; c, large coll containing bile-pigment ; d, cells resembling in every respect glandular epithelium of liver ; c, transitional forms between these last cells and the large cells. hepatic gland-cell. The cells were i-ounded, pyriform, or caudate, and each contained one or sometimes two nuclei, with much fine granular matter ; some were full of oil-globules, and some contained brown pigment-granules exactly like wliat is seen in gland-colls of liver. Along with these large cells, which were much the more numerous, were others of smaller size, and not to be distinguished from, secreting cells found in other parts of liver (fig. 10). Stomach and intestines healthy ; walls of heart thin and soft ; both LECT. Yi, CANCEE. 231 lungs firmly adherent, and much congested in dependent parts. No- thing noteworthy in any other organ. Case XCV. is an illustration of cancer implicating the liver, without producing any symptoms or signs which could lead to its existence being suspected during life. One of the supra- renal capsules also was destroyed by cancer^ and yet there was no vomiting or bronzing of the skin. It is now well known that the suprarenal capsules may be destroyed by cancer, with- out any of the symptoms of Addison's disease resulting, so that these symptoms must be ascribed, not so much to the destruction of the capsules, as to the morbid process by which this is effected. Case XCV. — Cancer of VertehrcB, Suprarenal Capsule, Liver, and Lung — No symjptoms of Disease of Liver. Alfred T ■, aged 55, admitted into Middlesex Hosp. under my care, Jan. 28, 1868. He was very weak and emaciated, and not very connected in his replies. Seventeen years before admission he con- tracted syphilis, followed by constitutional symptoms, but his ' present attack ' commenced only three months before admission with severe pain in spine, accompanied by emaciation and weakness. His symptoms while under observation were as follows : — Pro- gressive emaciation and debility, and angemic chlorotic colour of face ; but no jaundice, or bronzing of skin, or discoloration of mucous mem- brane of mouth, or perspirations. Persistent pain and tenderness on pressure over spinous process of third and fourth lumbar vertebrae, but no sign of tumour or of paraplegia, excepting retention of urine for last two or three weeks of life. Tongue dry, red, and fissured ; no vomiting; constipation alternating with diarrhoea. Abdomen distended and tympanitic, with slight tenderness on deep pressure to left of um- bilicus : a few days before death abdominal swelling subsided, and aorta could be felt passing along spine, but no appreciable tumour. Hepatic dulness 4 in. in r. m. 1. At no time was there tenderness, or a feeling of nodulation in region of liver, or ascites. Pulse varied from 84 to 120, always small and weak ; cardiac dulness diminished ; at no time any cough or expectoration, and at time of admission no notable sign of mischief could be discovered in lungs. Urine alkaline, and contained phosphates, but no albumen or bile-pigment. Tempera- ture either normal, or but slightly increased. Throughout mind was confused, and there was a tendency to low muttering delirium, increas- ing towards death, which occurred on March 22. Autopsy. — A soft cancerous tumour of bodies of third and fourth lumbar vertebrse, projecting about half an inch from surface, chiefly on left side, where it invaded texture of psoas muscle, and encroaching about half-way to the spinal canal, which, as well as the spinous pro- 232 ENLARGEMENTS OF THE LIVER. lfxt. vi. cesses, appeared normal. Cancerous enlargement of lumbar and bron- chial glands, and a mass 'of soft -cancer-, size of a large walnut, com- pressing a large branch of pulmonaiy artery in upper part of lower lobe of right lung. Liver not enlarged, and its lower margin did iiot project beyond edge of 'ribs, but it contained from a dozen to twent}^ isolated cancerous nodules, from size of a pea to that of a walnut, several of which were excavated in centre. One of these nodules was in a portion of liver which was firml}- adherent to right supi'arenal capsule; latter organ greatly enlarged, and converted into amass of hard cancer, measuring -2:^ in. in diameter. Left capsule, kidneys, and brain presented nothing abnormal. The following case eame under my notice while I was House Snrg-eon in the Edinburgh Royal Infirmary. It is an example of a rare form of cancer implicating the liver, but causing no symptoms of hepatic disease. Case XCVL — Melanotic Cancer of Fenis, Lyvriiliatic Glands, Liver, Pleura, etc. James L , aged 54, a butler, was admitted into Royal Infirmary, Kdinburgh, on Feb. 4, 1851. He was a tall, robust man ; hair was dark brown, and eyeballs were remarkable for their prominence, and for a bluish tint of sclerotics. Attacl^ed to lowerand onter surface of prepuce, and extending a considerable way along its free margin, was a tumour, size of a chestnut, of a dark brown, almost black colour, its surface nodulated and covered with a fetid, dirty yellow, puriform discharge. When pricked with a pin, it bled profusely, and it was often the seat of acute paiii, especially during, and for a short time after, micturition. It had been growing for two years, and had (;onimenced as a small black wart on the outer surface of prepuce, about an inch from its i'ree margin ; this wart for six months remained stationary, but afterwards increased more rapidly. On I'efiecting pre- puce, which was done with some difficulty, there were displayed on surface of glans several warty excrescences of a bluish-black colour, and varying in size from a pin's head to half a pea. In each groin was a swelling of size of a hen's Ggg, which had first appeared about three months before admission. For three months patient had complained of dyspnoea and cough ; and on examining chest, left side presented a uniform bulging, measuring fully 1 in. more in circumference than right ; there was also on this side marked dulness (m percussion, imperfect expansion, and absence of respiratory murmur and of vocal thrill. Apex of heart displaced to left margin of sternum. Physical signs of right lung normal. Pulse 00, very feeble. After this, patient got rapidly worse ; he lost all reli.sh for food, and became very prostrate. The tits of dyspnoea increased in frequency i.ECT. VI. CAKCER. 233 and in severity, lasting sometimes for several liours, and. dulness "with -suppression of respiratory murmur was observed over base of right lung. Tumour on penis and swellings in groins increased slightly in size. 'No jaundice, ascites, or enlargement or pain of liver. On morniug of March 26 he had an unusually severe attack of dyspnoea ; pulse 84, and almost imperceptible ; extremities cold ; face livid and eyeballs more prominent. These symptoms continued until death on evening of 27th. Autopsy. — Tumour on perils presented on section a smooth black surface, yielding on sectioia a, copious inky juice. Lumbar, inguinal, and femoral glands enlarged -and infiltrated with black matter ; and some of them entirely converted into a pulpy black fluid. Lymphatics of spermatic cord contained one or two small melanotic nodules. Along whole of abdominal aorta w^as a chain of enlarged glands. Some of these exhibited, on section, a black pulpy mass ; while others, which were but slightly enlarged, presented normal glandular structure, with circumscribed brownish-black points. Hypogastric and sacral lym- phatics normal. Left pleura distended with several quarts of fluid tinged with blood and black pigment, which pushed apex of heart towards right side. Scattered over whole of parietal and pulmonaiy pleura were masses of a dark deposit, varying in size from smallest appreciable point to half an inch in diameter, and, for most part, presenting a circular outline ; largest of these nodules projected about one-sixth of an inch from surface of pleura ; smallest were not appreciably elevated, presenting a punctiform appearance not unlike shading of a chalk drawing. The large nodules were almost black, while punctiform de- posit had a brownish-black tint, tinged more or less with purple. Most of nodules were covered by ej)ithelial layer of pleura, but at back part of cavity, where they were confluent and aggregated into flattened masses, this membranous lining was at some places wanting, and masses exhibited a pulpj irregular surface, and yielded on pressure a large quantity of dark juice very like liquid sepia. Left lung com- pressed and carnified ; at reflection of 'pleura from root of lung upon ribs was a layer of recently extravasated blood, at some parts half an inch in thickness. Right .pleura contained a few ounces of fluid simi- lar to that in left ; and its surfa<;e exhibited nodules of deposit of same character, but less extensive. Embedded in substaaice of right lung were a few circumscribed black nodules, the largest about size of a cherry : around them, pulmonary tissue was normal and crepitant. Bronchial glands were all black, but not much enlarged ; in posterior mediastinum glands were greatly enlarged, and a cluster of them, forming a mass, size of an orange, was situated in angle of bifurcation of trachea, in front of oesophagus ; deep cervical glands contained black pigment. Between mucous and muscular coats of oesophagus were one or 234 ENLAEGEMENTS OP THE LIVEE. lect. ti. two rounded nodules, size of a barley-corn, containing black pigment ; rest of alimentary canal and mesenteric glands normal. On surface of liver were seen about a dozen nodules of black deposit, about one- third of an inch in diameter ; numerous similar masses embedded in substance of organ, which was but slightly increased in size. In spleen "was a single mass of black deposit, size of a pea. Kidneys contained in cortical substance several melanotic nodules, size of a swan-shot. Between muscular and mucous coats of bladder and of urethra were a few black nodules, size of barleycorns. Gltemical Examination of Melanotic Matter. — The following analysis of the pigmentary matter was raade by the late Dr. James Drum- raond : — ' It was insoluble in water, alcohol, and ether. When treated with hydrochloric, nitric, and sulphuric acids, it was dissolved ; the solution being nearly colourless. When chlorine gas was passed through it suspended in water, it was bleached to a certain extent, bat not entirely. When boiled with potash, it dissolved, with disengagement of ammonia. The ultimate analysis yielded the following result: — Carbon 6701 Hydrogen .......... 6'4-o Nitrogen .......>-. 11'45 Oxygen ,. 8-36 Ash 6-73 100-00 'The ash consisted, in great part, of peroxide of iron.' Microscopic Exatnination of Melanotic Matter. — The dark juice from tumour on penis contained a large quantity of gra»nular matter of a sienna-brown colour ; granules were solid and angular, and refracted light strongly ; acetic acid produced no change upon them, but strong nitric acid rendered them much lighter. Mixed up with these granules were a few nucleated cells, having a circular or oval outline, and a diameter of about ^J-jj of an inch. Some of cells were more elongated, and one or two exhibited a caudate appearance. Most of them were loaded with coloured granules, which quite obscured all appearance of a nucleus. In some of cells, however, which contained little or none of coloured granules, one and sometimes two nuclei could be detected, with one or two distinct nucleoli. When a small particle of tumour was torn out with needles and examined, it exhibited a network of fine filamentous tissue, infiltrated through meshes of which were the elements of the dark-coloured juice just described. The melanotic deposits in pleura and in lumbar and inguinal glands were subjected to careful microscopic examination, and were all found to possess a structure similar to that of tumour on penis. 235 LECTURE VII. i^NLAROEMENTS OF THE LlVEIt. SPINDLE - CELL SARCOMA — MYXOMA EPITHELIOMA CYSTO-SARCOMA MULTILOCULAK HYDATID — SIMPLE CYSTS — TUBERCLE — LYMPHATIC GROWTHS ENLARGEMENT WITH XANTHELASMA — ENLARGEMENTS OF GALL-BLADDER. Gentlemen, — In this lecture I purpose to bring- under your notice certain diseases which occasionally lead to enlargement of the liver, but which are of comparatively rare occurrence, and as to the clinical history and diagnostic characters of which our knowledge is as yet imperfect. XII. SPINDLE-CELL SAECOMA OP THE LIVER. •5* The following case is an example of a form of enlargement of the liver hitherto (1873 ^) undescribed. It illustrates the im- portance, on clinical grounds, of distinguishing the anatomical characters of the different lesions still too commonly grouped under the common designation of ' cancer.' Until within the last few years, the disease in this case would, from a structural point of view, have been regarded as a variety of cancer. Structurally, it is now acknowledged by pathologists to be dis- tinct from cancer, while it will be seen that the clinical history of the patient was very different from that of true cancer of the liver. 1. There was no evidence of the so-called cancerous cachexia. The patient had never the appearance of a man suffering from malignant disease ; four months before his death his weight was exactly the same as it had been twelve months before, although all this time the disease in the liver had been progressing; and he continued to go about and follow his employment until within two or three weeks of his death, the cause of which was obscure. 2. Cons.idering the size of the tumour, there was much less pain than might have been expected on the supposition that the disease was true cancer. * The case was communieated to the Pathological Society, Jan, 21, 1873. 236 ENLARGEMENTS OP THE LIVER. lect. vii. The severe, but rare and transient, attacks of pain in the right side were more like what might have been expected to result from the calculus found after death in the right kidney, than from the disease in the liver. For a time a burning pain was complained of in the liver, but for many months before death this had quite ceased, and latterly the chief complaint was a feeling of tightness due to the size of the tumour. 3. There was neither jaundice nor ascites. 4. The similarity in structure between the tumour of the eyeball and that of the liver pointed to a constitutional origin; but the interval between the primary and secondary lesion was much greater than in true cancer, unless Ave are to suppose, what would have been equally incompatible with cancer, that the disease had been going on in the liver for eight or nine years, without giving rise to sym- ptoms, until it produced an appreciable tumour. 5. Primary cancer of the liver is not common at so early an age as that of my patient. It remains to be seen whether these clinical characters will hold good in other cases of tumour of the liver presenting the same anatomical structure. It is to be regretted that the post-mortem examination was far from being comj^lete, and in particular that it failed to account for the patient's somewhat sudden death. Case XCVII. — Sfindle-cell Sarcoma of Liver. Mr. L. N , aged 30, firs^t consulted me at my house on Oct. 9, 1871. He stated that 18 iiioutlis before he had been attacked with a sliarp pain between right ribs and iHum. The paiu came on in severe paroxysms, but after two days it ceased ; it was not attended by vomit- ing, nor followed by jaundice. Nine months afterwards he had a second similar attack of about the same duration. For two months he had been losing flesh, but not to a great extent, and one month before he came to me Dr. Brown of Whitchurch had found the liver to be considerably enlarged, and in the interval this enlargement had much increased. He was a man of very temperate habits, and had never had syphilis. On examination, I found a tumour filling the right side of abdomen to within two inches of pubes, continuous upwai'ds with liver, percussion dulncss of which ascended as high as nipple in front, but not too high behind. Behind tumour, in both flanks, there was tympanitic per- cussion sound. The tumour formed a perceptible prominence in right side of abdomen, and right lower ribs bulged out considerably. At umbilicus girth of right side of abdomen was 10^ in., and of left, 15| in., and girth of chest, 2 in. below nipple, was 17 in. on right side, and 16^^ in. on left. Tlie surface of the tumour was uneven from the presence LECT. vii. RPINDLE-CELL SARCOMA. 237 of several semi-globular elevations ; its consistence was doughy, es- pecially over most prominent parts, but tbere was nowhere any feeling of fluctnation, vibration, or elasticity, or any tenderness on pressure. The patient complained of a frequent burning pain in tumour, which often kept him awake at night, and of a feeling of weight after meals ; bnt he did not suffer from nausea or vomiting; his appetite was good, and bowels regular, and he had not lost strength. He could walk five or six miles a day without fatigue. Urine deposited a copious sedi- ment of lithates, and became almost black on addition of nitric acid after boiling ; but it contained no albumen, nor did it exhibit ordinary reaction of bile-pigment with nitric acid. Heart was pushed up, its apex being felt between fourth and fifth ribs, just below nipple. An opinion had already been expressed by several physicians who had been consulted that the tumour was hydatid, but this view was negatived by : — 1. The absence of any fluctuation or elasticity in the prominences on its surface; 2. Its rapid growth ; 3. The burning pain ; and, 4. The patient's statement that on April 2, 1862, his left eyeball had been excised by Mr. Hulke for what had been called ' a malio-nant tumour.' On the other hand, it seemed clear from its consistence that if the tumour was cancer it must be a rapidly-growing soft cancer, and this view was negatived by : — 1 . The healthy appearance and strength of the patient; 2. His good appetite and but slightly impaired digestion ; 3. His family history. His father and mother were both alive and well, and no member of his family had suffered from cancer ; 4. His age ; 6. The long interval of good health between excision of eyeball and com- mencement of disease in liver. The opinion given to the patient was ihat the tumour was something more solid than hydatid, and that no benefit would be derived from paracentesis. As the tumour appeared to be of an unusual nature, I wrote to Mr. Hulke to ascertain the nature of growth in eyeball removed in 1862. N"ot regarding my opinion as satisfactory, the patient went on the same day to Sir W. Gull, whose opinion was that the tumour was not hydatid, and pro- bably cancer. By the same post which brought my letter, Mr. Hulke received another from Sir W. Gull, making a similar enquiry. Mr. Hulke had fortunately preserved copious notes and microscopic drawings of tumour in eyeball. For two years before patient had consulted him in March 1862 there had been a progressive decrease of the visual field in left eye, and for three months complete loss of sight. At first there had been no external signs, but for one month there had been redness and oedema of the conjunctivae and intense pain. On consulting Mr. Hulke the man looked healthy, except that left eyeball was distended and hard, and pupil widely dilated and motionless ; iris was discoloured and pushed forwards, and at temporal side of fundus oculi could be seen a solid buff-coloured tumour, advancing nearly to lens, and covered by retina and choroid. After enucleation, a tumour was found in the choi'oid in the situation observed during life. It was 238 ENLARGEMENTS OF THE LIVER. lkct. vii greyisli, and on section there exuded a viscid yellowish, rather than a creamy juice. It consisted mainly of small fusiform nucleated fibre- eells (fig. 20), the prolongations of which were woven into a tangled web, whose meshes w^ere filled with a hyaline albuminoid matrix. Mr. Hulke added that in accordance with the views then held, the tumour was called a medullary cancer, but that ' its structui-e was character- istic of what vpe now% in Virehow's terms, call a spindle-cell sarcoma.' The man made a rapid recovery, and there was never any return of tumour in the cicatrix. On obtaining this information, I wrote to the patient's medical attendant. Dr. Brown of Wliitchnrch, expressing the opinion that the tumour of liver, like that of eyeball, was probably a spindle-cell sar- coma, and that the case was one of nnusual interest. The patient continued to follow his employment as an upholsterei', and I heard nothing more of him until June 10, 1872, when he again came to London to consult me. The tumour had increased in size, girth at umbilicus being 34 instead of 32 in., and upper margin of hepatic dulness in front having risen to above nipple. It extended across middle line as far as left lumbar region. At many places, es- pecially those which were most prominent, it felt much more tense and elastic than it had done previously, but nowhere was there any distinct fluctuation or vibration. In beginning of April patient had experienced a third attack of severe spasmodic pain below right ribs, but this had ceased after the use of chloral and subcutaneous injections Fig. 20. Group of spindle-cells from tumour of choroid, x 240. From a drawing by Mr. Ilulke. of morphia. He was now also free from the burning pain of which he had complained eight mouths before. As long as he was quiet he had no pain whatever, but when he moved much, or stooped in his ])usiness, he had a good deal of pain below right ribs. He also suffered from dyspnoea on exertion, and a feeling of fulness after meals. At the same time patient did not look anj^ worse than when I had first seen him, and his weight was exactl}'^ the same as it had been twelve months before. His tongue was cloiin and appetite good ; no jaundice, no as- cites, and no enl:irg(!ment of abdominal veins. He was still following his business, and he could walk an hour without fatigue. Although the circumstances of the case now pointed somcAvhat more to hydatid, the same opinion was expressed to patient as before ; LECT. vii. SPINDLE-CELL SAECOMA. 239 but as he was very desirous to have something done, he was told that no harm could result fi'om an exploratory puncture, which would remove all doubt on the matter. I advised, however, that he should previously have the advantage of a consultation with Sir W. Jenner, who accord- ingly saw the patient with me on June 12, and who concurred in the difficulties of the case, and in the advisability of solving them by para- centesis. A small trocar was accordingly introduced into the most elastic portion of the tumour below right ribs ; only a few drops of blood came away, which exhibited nothing but blood- corpuscles under microscope. 'No bad effect followed puncture, and in a few days patient returned to his home and resumed his business, which he con- tinued to follow until Oct. 8, the tumour slowly increasing. On Oct. 8 he had a severe attack of spasmodic pain over whole surface of tumour, which was relieved by application of hot- water bags and repeated doses of hydrate of chloral. He continued, however, to suffer from a feeling of tightness, due to presence of the tumour, and, experiencing no relief, he left his home on Oct. 16 to try the effect of hydropathy. He had throughout his illness consulted a great many medical men, both in London and in the provinces, and even taken the opinion of a female clairvoyante respecting his case. On Oct. 25 he died at the Turkish Baths, Bristol. All that I could learn of the symptoms which preceded death was that for 36 hours before he had suffered from in- tense pain over the tumour to right of the umbilicus, which was some- what relieved by subcutaneous injections of morphia. The pain was unattended by vomiting. The body was examined by Dr. T. D. ISTicholson, of the Turkish Bath establishment, Bristol, to whom I am indebted for the following' particulars, and for sending to me portions of the diseased structures for examination. The peritoneum was adherent at several places to surface of en- larged liver, but there was no recent lymph. Projecting from anterior AND MASSES CF TUMOUR Fig. 21. Sho^u's tumours projecting from liver. From a sketch by Dr. Nicholson. surface of each lobe of liver was a rounded soft, apparently cystic tumour, about 2 in. in diameter, and pressing against the abdominal wall. Projecting from under surface of liver, and intimately connected with it, was an enormous mass of morbid structure, composed of cyst- 240 ENLARGEMENTS OP THE LIVEE. I.ECT. vir. like bodies, varying in size from that of a cherry to that of a child's head (tig. 21). This mass, together with the liver, weighed 20 lbs. and 1 oz. avoird. The contents of the small tumours on upper surface of liver were dark grey and gelatinous ; those of the large masses on under surface were of lighter colour and of pultaceous consistence. Some of lumbar glands were as large as beans, and contained a soft grey material. Spleen and kidneys were healthy, except that right kidney contained a dark rough calculus about size of half a walnut. Heart and lungs were normal. The portions of the tumour forwarded to me were submitted to Mr. Henry Arnott for microscopic examination. After hardening in a solii- l^'ig. 22. E'.'prescnts a section of the ffrovtli Iroin the liver, x 220. I'rom a drawiiifj liy Mr. Henry Arnott. tion of chromic acid, the gelatinous material of which the tumours were composed was found to be a typical example of spindle-cell sarcoma, as will be seen by the annexed drawing by Islv. Arnott (fig. 22). XIII. MYXOMA OP THE LIVEE. The clinical characters of this orrowth in the liver are not yet sufficiently known. Mr. Nunn has recorded a case in which a tumour of this nature, as large as a foetal head of the full period, occupied the posterior part of the right lobe of the liver and projected from its upper surface, where it Avas closely ad- lierent to the under surface of the diaphragm. Tlie patient was a female aged 38, Avho within twelve months of lier death had been twice operated upon for a recurrent niyxom.a of the breast.' ' Path. Trans. 1872, vol. xxiv. i'. 120. LECT. vn. SPINDLE-CELL SARCOMA. 24 1 XIV. EPITHELIOMA OF THE LIVER. In the 25th volume of the ' Pathological Transactions,' Dr. Greenfield has described a case of primary columnar epithelioma of the liver. The patient was a female aged 33, whose clinical history was identical Avith that of cancer. It is not improbable that in many cases of ' cancer ' of the liver the new growth has a similar anatomical structure. XV. CTSTOSARCOMA OP THE LIVER. Naunyn has recorded a case in which the liver was found studded with small tumours having a structure similar to that of Cystosarcoma of the mamma. The liver, which was of normal size and shape, was obtained from the body of a female aged 62, who had been for a long time under the care of Professor Prerichs and whose chief symptom was marasmus.' XVI. MULTILOCULAR OR ALVEOLAR HYDATID TUMOUR. This is a very rare form' of tumour ; only about eighteen cases have been recorded, not one of which has occurred in this country. It is composed of numerous minute hydatids contained in cavities interspersed through a hard, almost cartilaginous, matrix of fibrous" tissue, and not, as in the case of an ordinary hydatid, enveloped in a parent cyst. Its clinical characters are very different from those of an ordinary hydatid tumour of the liver. It forms a rounded tumour, varying in size from that ol- a hen's egg' to twice that of a man's head, and in most cases is situated in the right lobe. When small and deeply seated it may be inappreciable during life. In most cases it can be felt or it causes a distinct bulging. The tumour is not smooth elastic, fluctuating, and painless, but nodulated, hard, of even cartilaginous consistence, and tender. In almost all cases there is considerable enlargement of the spleen, and early supervenino- intense jaundice. Ascites is somewhat less common than jaundice, and in many cases there is oedema of the legs in the advanced stage. Progressive emaciation and prostration and deranged digestion (but not vomiting) are constant symptoms, while attacks of partial peritonitis and hsemorrhages are not uncommon towards the end. In many cases the tumour ultimately suppurates in the centre and induces symptoms of ' Eeichert unci dn Buis Eeymond : Archiv 1866. E 242 ENLARGEMENTS OF THE LIVER. lect. vti. liectic fever. The disease for w'liich multilociilar hydatid would be most readily mistaken is cancer, and like this it sometimes runs a rapid course of a few months (see p. 214) ; but in other cases it has been known to exist for ten years and more prior to death. The treatment recommended for ordinary hydatid tumours is obviously inapplicable here, and our efforts must be limited to the relief of symptoms as they arise.' XVII. SIMPLE CYSTS OF LIVER. Several writers hare described simple cysts in the liver, containing a clear watery fluid or thick mucus. They are usually very numerous and of small size, tbe largest not exceed- ing- thot of a hazel nut ; and they are sometimes associated with similar cysts in the kidneys.'^ I Trnow no case, however, in which cysts of this sort have enlarged and suppurated, so as to be distinguishable during life. In the following case the precise nature of the disease was obscure. During life the diagnosis was suppurating hydatid. It was clear that there was suppuration somewhere. A circumscribed empyema was negatived by the history, and by the fact that the fluctuation was below aiid not above the solid liver. Opposed to tropical abscess was the fact that the patient had never been out of England, nor suffered from dysentery ; while j^ysemic inflamma- tion never leads to the large collection of pus which was obvi- ously present. For suppuration outside the liver no <}ause such as disease of the spine or ulcer of the stomach could be dis- covered. In fact all causes other than hydatid appeared to be excluded ; and the appearance of the cysts at the post-mortem examination was believed at first to confirm the diagnosis made during life. But the failure to find any trace of hydatid struc- ture in the contents of the cysts rendered this view scarcely tenable, for even in a sterile hydatid some trace of the parent membrane would have been present. Fa;iling hydatid, we are reduced to view the case as one either of primary abscess or of suppurating cysts ; and in this difficulty it is much to be re- gretted that the intestines were not carefully examined. As to abscess, there are not only the objections already referred to, ' Tho most complete account of imilfiloeuliii- liyil.itid lumoiirs will lio found in the two following memoirs, — Do la Tiimeur llyl line^ 9 in. in right mammary line, and 10 in. in axillary line, where' it reached down to crest of ilium. Liver was- seat of constant pain, and portion vrhich projected beyond ribs was smooth, dense, and slightly tender ; lower-margin sharp and'hard. Spleen much enlarged ; its lower margin distinctly felt projecting three inches beyond margin of left ribs. No ascites, and no enlargement of superficial, abdominal veins. Tongue moist,, and ceaited with a white fur. Still occasional vomiting of food. Bowels regular ; motions formed, and well coloui-ed with bile-pigment. Urine contained much bile-pigment and a trace of albumen, but no sugar, leucin, or tyrosin ; specific gravity 1012. Pulse 84 ; cardiac dulness slightly increased ; a systolic bellows-mur- mur heard distinctly over third left costal cartilage. Slight dulness, with feeble breathing, over lower and back part of right Inng. After admi.ssion vomiting became worse, but was relieved for a time by pills containing creasote and morphia. It continued, however, to recur until death, and on August 23rd and 21th patient vomited a T.ECT. VII. ENLARGEMENT "WITH XANTHELASMA.. 25 1 considerable' quantity of sanguineous liquid. He had also repeated attacks, of diairrlioea, motions always containing bile, and occasionally a little red Hood. Tongue was usually dry and brown. Liver was always seat of much pain, and very tender, but no material change took place in its size while under observation, although as patient lost flesh enlargement of liver became more a,pparent ; its margin could be distinctly seen through abdominal parietes moving np and down with respiration. Jaundice became darker and assumed somewhat of a bronzed hue, but conjunctiva? became less yellow, and there was no increase or alteration of light-coloured patches on the- eyelids. Urine was examined on several occasions for leucin and tyrosin, but neither was found ; usually, but not always, it contained a trace of albumen. Patient continued to lose flesh, and became greatly exhausted. About end of August he began to suffer from hicco^Jgh, restlessness, and delirium. When thwarted in the least he kept shouting at top of his voice, so that it was necessary to remove him to the d;elirious ward. On Sept. 4th aphthse were noticed on tongue and on roof of mouth ; diarrhoea recurred, and motions were passed in bed. O.i Sept. 19th teeth and tongue became coated with sordes, and on Sept. 20th the man died. Autopsij. — Sections were made with a Valentin's knife through cream-coloured patches in eyelids in situ. The colour was found to be due to deposit in meshes of cutis of a large quantity of oily grannies, both isolated and aggregated in masses, and always most abundant in neighbourhood of hair-follicles, which in other respects, however, ap- peared normal. When stained with carmine a distinct nucleus could be seen in centre of the oily masses. The epidermal cells were not affected. The oily matter was in such quantity in cutis that it poured out like a milky fluid from a section placed in water, A few ounces of fluid in peritoneum. Liver very large, its lower margin reaching to below umbilicus ; it weighed 80| oz. ; outer sur- face smooth, capsule thickened, and at many places attached to sur- rounding parts by firm old adhesions ; structure firm, and on section presented a smooth dense surface of a pale greyish colour, with ver}'- little appearance of ordinary secreting tissue, but apparently a great increase of fibrous element. Here and there were darker islands of a jaundiced tint, which seemed to be remains of secreting tissue. On microscopic examination denser material, of which gi^eater portion of liver was composed, was found to consist of nuclear and fibroid tissue in portal canals and between lobules ; nuclear element was particularly abundant ; groups of rounded nuclei, or bodies resembling tymphatic corpuscles, were aggregated round minute vessels between lobules. In some parts of dense structure the nuclear, and in others the white fibrous tissue, predominated. At some places nuclei seemed club- shaped or oat-shaped, and appeared to pass into fibres ; this appearance, however, was quite exceptional. Yellow portions of liver were found 252 ENLARGEMENTS OF THE LIVER. i.ect. vii. to be made up of hepatic lobules, cells of which were loaded with oil and bile-pigment. Green bile was found in duodenum, and bile could be squeezed with ease from gall-bladder along bile-duct into bowel. Glands in fissure of the liver along spine, and along course of iliac arteries, were much enlarged and jaundiced. Spleen greatly enlarged ; weighed 23 oz. ; capsule much thickened, and in its interior numerous opaque yellow embolic deposits up to size of a large pea. On posterior wall of stomach, a fevv inches from pylorus, was a simple ulcer, size of a crown-piece, base of which was formed by tissue of pancreas ; its sur- face had a glazed cicatrized appearance, and there was slight pucker- ing of edges. Both kidneys large ; they weighed together lOJ oz. ; right contained numerous opaque yellow embolic deposits, one of them as large as a walnut ; left kidney contained two or three similar but smaller deposits. Heart was not hypertrophied ; it weighed II5 oz. ; aortic valves competent, but two of them grown together, and their point of attachment to aorta partially separated, so that they seemed to form one valve ; several small rough vegetations on their ventricu- lar surface. XXI. ENLARGEMENTS OF THE GALL-BLADDER. The gall-bladder maj be enlarged from various causes, so as to form a tumour attached to the liver, and appreciable through the abdominal parietes. The causes, the sjnnptoms, and the ti'eatment of these enlargements will be considered in a future lecture. (Lecture XIII.) 253 LECTURE VIII. CONTRACTIONS OF THE LIVER. SIMPLE ATROPHY ACUTE OR TELLQ-W ATROPHY CHRONIC ATROPHY (ciRRHOSlS SIMPLE AXD SYPHILITIC INDURATION — RED ATROPHY). Gentlemen, — In previous lectures I have described to jou the normal limits of the area of hepatic dulness (p. 2), as well as the principal causes of apparent and real enlargement of the liver, with the means of recognising- them. "We have now to consider the chief causes of a diminution in the area of hepatic dulness, and their distinctive characters. And in the first place you must remember that the area of hepatic dulness often appears diminished, although the organ in reality retains its normal weight and bulk. SPURIOUS CONTRACTIOISrS OP THE LIVER. The main conditions likely to indu.ce an apparent diminution in the size of the liver are as follows : 1 . Tympanitic distension of the bowels, and particularly of the transverse colon and stomach, may prevent the lower margin of the liver being felt, and diminish the area of hepatic dulness in several ways : a. A portion of stomach or intestine distended with gas may become interposed between the surface of the liver and the abdominal parietes. h. When the lower margin of the liver is thin, and when there is excessive tympanitic distension of the subjacent boAvels pushing the liver forwards and rendering the abdominal parietes tense, the lower edge of the liver may escape detection on palpation, and its dulness on percussion may be imper- ceptible. c. In excessive tympanites the antero-posterior diameter of the abdominal cavity is increased, and the lower portion of 254 OONTK ACTIONS OF THE LIVER. lv.ct. tiii. the liver may be elevated so tliat a smaller portion of it than is natural is in contact with the abdominal parietes. In one or more of these ways the normal hepatic dulness may be diminished or may even entirely disappear, so that the pulmonary sound is immediately succeeded by that of the bowel. The liver may thus appear greatly diminished, although its size is not in reality altered. You will find a remarkable case of this sort recorded by Dr. Bright, where, on opening the body, neither the liver nor the colon presented itself to view, but, in their stead, the convolutions of the small intestines, which were found to have come completely in front of the liver, the colon and the omentum doubling over the liver and press- ing it back, and having made deep furrows on its anterior surface.' The fact of hepatic contraction being of this spurious character ought always to be suspected under the folloAviug circumstances : — a. The very fact of there being tympanitic distension of the bowels ought to suggest caution in inferring the existence of real atrophy of the liver from a diminished area of hepatic dulness. The same caution is necessary in cases of ascites. The fluid in the peritoneum pushes up the bowels which may be only moderately distended with gas, but which may thus come to produce the same result as more extensive tympanites ; and this fallacy is of the greater importance inasmuch as: ascites is a common consequence of real atrophy of the liver. h. Variation in the extent of hepatic dulness at different times is a character of spurious atrophy of the liver most useful in diagnosis. The dulness of the liver will vary in its extent according to the amount of gas in the stomach and bowels, or of fluid in the peritoneum. The diagnosis will therefore be facilitated by oft-repeated examinations, and particularly by examinations made before meals, and after the bowels have been cleared out by a purgative. c. Variation in the extent of hepatic dulness at different places is not uncommon in cases of spurious atroph}'. Tym- ])anitic distension of the stomach and bowels may diminish or obliterate the hepatic dulness in the mesial and right mammary lines, but is not likely to affect it materially in the axilhiry or dorsal lines. Occasional!}', too, the space where the hepatic dulness is obscured may be even more circumscribed, as when a ' Abdom. Tumo'jrs, Syd. Soc. Kd. p. 2o9. I.ECT. VIII. SPURIOUS COKTEAOTIONS. 255 knuckle of intestine intervenes bet-vveen the liver and the abdominal wall. d. The absence of other signs or symptoms of real disease of tbe liver. The possibility of there being ascites independent of hepatic disease niQst be kept in view. 2. General or partial accumidations of gas in the iJeritoneMl cavity, such as may result from perforation of the stomach or bowels, may obseoire, to a greater or less extent, the area of hepatic dulness ; but usually the nature of these cases will be sufficiently clear from — a. The arched tympanitic distension of the abdominal parietes ; and 6. Antecedent history of peritonitis from j)erforation. 3. The hepatic tissue may be jpreternatiirally soft, so that the organ may fold on itself and collapse against the spine and the back part of the abdomen, and be covered more or less in front by the stomach and bowels, which may not be abnormally distended with gas. I have already pointed out to you that in fatty degeneration the enlargement may from this cause appear to be increased, a larger portion than natural of the liver beino- in apposition with the abdominal wall (p. 4S) ; but if the folding be carried a stage further, so as to jDermit the super- position of bowel, a contrary result may take place. Lastly, in acute atrophy of the liver the organ is not only reduced in size, but it may be so soft as to collapse against the spine, all trace of it disappearing from the abdominal wall in front so that it may appear smaller than it really is. Keeping in view these sources of fallac}', which are T)erhaps more calculated to mislead than the sources of fallacy in the case of enlargement (see p. 7), we may proceed to consider the causes of real atrophy of the liver, which may be con- veniently arranged under the three following heads : I. Simple Atrophy. II. Acute Atrophy. III. Chronic Atrophy ; under Avhich head will be included the disease commonly designated ' Cirrhosis,' ' Simple Indu- ration,' and ' Eed Atrophy.' I shall now endeavour to describe to you the leadino- clinical characters and the appropriate treatment of these several forms of atrophy. 256 CONTEACTIONS OF THE LIVER. lkct. vim. I. SIMPLE ATROPHY. By ' simple atropby ' is understood a diminution in the size of the liver, iu dependent of any alteration in its structure, except a diminished size of the lobules, which may be so small as to be distinguished with difficulty, the cut surface present- ing a smooth appearance and often a uniform tint. The liver in this state may be reduced to less than one-half of its normal weight and bulk. Although this condition of liver is not of much practical importance, more or less of it is far from uncommon, and ignorance of its nature and characters may lead to errors in diagnosis. You will recognise this form of atrophy then by the following characters : — 1. The circumstances under which it occurs. These are mainly two, viz. Old age and Inanition. a. Old Age — Simple atrophy has been sometimes described as ' senile atroj^hy.' With the advance of life, the tendency of the various organs and tissues throughout the body is either to degenerate or to waste. In some persons the several forms of degeneration (fatty, calcareous, &c.) predominate ; while in others we observe a simple wasting. In the latter case, the power which prevailed over the waste of the body in childhood and youth, and which maintained the balance in the vigour of manhood, has failed, and waste now prevails over development. Considering the important part played by the liver in the nutrition of the bod}^ it is not surprising that its reduction in old age is in advance of that of the body generally, and oc- casionally the liver is reduced by senile atrophy to one-half of its normal size and weight. h. Inanition may also induce simple atrophy. There is little or no supply- to compensate for the constant waste. When you remember the increase in the bulk of the liver produced by every meal (see p. I'U), you will readily under- stand how, in cases of inanition, the liver often wastes out of proportion to the rest of the body. It is difficult to say why it is that the effect of wasting disease is in some persons to cause wasting of the liver, while in others it leads to the accumulation in the organ of a large quantity of oil (see p. 51). Inanition may arise in two wa^'s, either from, an insufficient supply of food or from diseases which interfere with the assimilation of food. Accordingly you will find simple atro]")hy of the liver extremely common in the bodies of persons who have died of LECT. VIII. SIMPLE ATEOPHT. 257 stricture of the pylorus, or of stricture of the oesophagus or of the cardiac orifice of the stomach. I shall relate to you imme- diately the particulars of a patient, aged 54, with a cancerous tumour of the lower end of the oesophagus, in whom the area of hepatic dulness was reduced to one half of the normal standard, and whose liver after death was found to weigh only 32 oz., instead of 54 oz., the average weight for his age (Case CI.). You will remember also the case of Samuel H., aged 63, who died of a cancer of the oesophagus involving the apex of the left lung, and whose liver was very small and weighed only 42 oz. ; and the case of Eliza P., aged 48, who died of cancer of the pharynx and whose liver weighed only 35 oz. All these were good examples of simple atrophy. c. External Pressure by tight lacing, pleuritic or pericardial effusions, circumscribed peritoneal exudations, or enlargement of those portions of the bowel nearest to the liver, may likewise produce simple atrophy of the liver. The atrophy, however, under these circumstances is usually partial and is of little clinical importance, unless the bile-ducts or large blood-vessels have been subjected to the pressure. 2. There is an absence of any sign of hepatic disease or de- rangement. With the diminution in the size of the liver, there is, no doubt, a loss of functional power, but sufficient secreting tissue remains for the diminished work to be done. Care, how- ever, 7Tiust be taken not to mistake for symptoms of diseased liver those of the primary disease on which the atrophy de- pends. Simple atrophy of the liver requires no special treatment beyond that aolapted to the circumstances under which it occurs. The following case will serve to impress on your memories the clinical characters and post-mortem, appearances of simple atrophy of the liver. The case is also interesting as an illus- tration of cancerous and tubercular deposit taking place simul- taneously, of which other examples have been reported by Mr. Sibley,^ Dr. Bristowe,^ and myself.^ It is difficult to account for these cases on the ordinarily accepted view, that tubercle anol cancer depend on a * peculiar diathesis,' regulating the nature of the exudation, for then the diathesis must vary in different parts of the same body. ' Med. Chir. Trans, vol. xlii. p. 149. - Trans. Path. Soc. vol. x. p. 2S4. 3 Ibid. vol. XV. p. 104. S 258 CONTRACTIONS OF THE LIYEE. iect. viii. Case CI. — Co- existence of Cancerous Strichire of Q^sopJiagus with rece^it Tubercle in Lungs. ISimple Atrophy of Liver. Augustus T , aged 54, a tailor, adm. into Middlesex Hosp. on July 24, 1863. He was of average height, and naturally of spare habit. He had led a very intemperate life, drinking large quantities of gin, but he had always enjoyed good health, until about four weeks before admission, when he began to suffer from sickness, comiug on immedi- atelv after eating, sometimes even before he thought the food had been swallowed. He had never observed blood in the vomited matters, but he had rapidly lost both flesh and strength. On admission, very emaciated ; an anxious expression of counte- nance. He could swallow solid food ; but it was usually rejected, either immediately or within a few minutes. He also brought up from time to time large quantities of clear acid fluid. He complained of pain between shoulders, but there was no tenderness of spine, and no abnormal physical sign in either lung. Abdomen nowhere tender, and nothing like a tumour could be felt in any part of it. Hepatic dulness much diminished, not exceeding 2^ inches in right mammary line. Splenic dulness normal ; no ascites or jaundice. Tongue furred ; bowels costive. Pulse 61 and feeble ; no abnormal bruit over heart ; no anasarca ; no albumen in urine. All remedial measures failed to relieve the vomiting, and patient got rapidly thinner and weaker, while hepatic dulness was reduced to 2 inches. Oa Aug. 30, vomiting abated, but this was due to patient's taking scarcely any nourishment. He died on Sept 7. At no period of his illness had he cough ; lungs not examined after July 24. Autrq^sij. — Entire absence of fat beneath integuments and throughout body. Oesophagus, 1^ inch above cardia, had its calibre narrowed to that of a goose-quill for about half-an-inch. A hard tumour, size of half a walnut, was firmly attached to constricted portion, and formed part of its posterior wall ; mucous membrane con-esponding to tliis presented a puckered cicatrix-like aj)pearance. Substance of tumour dense, fibrous, white, and slightly translucent, and dotted over with softer, more opaque, yellow specks. It yielded an opaque juice on scraping. On microscopic examination, the firmer portions of tumour were found to contain numerous ' cancer cells,' varying in size up to ^Jjy inch in diameter. They were rounded, elliptical, and caudate, and contained one or two large nuclei with a diameter about one-third of that of cell. Some of cells had smaller cells in their interior. In softer portions of the tumour, cells were ill-defined and mixed with much oily and granular matter. Neither bronchial glands, nor lymphatics in neighbourhood of tumour were enlarged. Stomach small, but otherwise normal. Liver presented ordinary characters of simple atrophy ; it weighed only 32 ounces ; its outer surface was smooth ; only abnormal appearance seen on section was that acini were reduced LECT. VIII. ACUTE ATROPHY. 259 to one half of tlieir usual size ; secreting cells were small, and con- tained scarcely any oil, but were otherwise normal. Spleen weighed only three ounces ; kidneys were also small and anaemic, but in other respects normal. Both lungs were very small, right weighing 9^ ounces, and left 8| ounces. Apices of both were firmly adherent to thoracic walls, and marked externally with cicatrices. Several cretified deposits as large as peas, as well as one or two small cavities with thick walls and con- taining pus, were disclosed on cutting into cicatrices. Scattered through upper lobes of both lungs were a number of translucent greyish granules, isolated and collected into groups, as large as a hazel- nut, and presenting all the naked-eye and microscopic characters of miliary tubercles. Heart weighed only 6J ounces, and was destitute of fat, but in other respects was normal. II. ACUTE OR TELLOW ATROPHY. * MALiaNANT,' ' TYPHOID,' OR ' HEMORRHAGIC JAUNDICE.' This is a rare but very remarkable disease, in which the liver becomes rapidly atrophied with the development of jaundice and cerebral symptoms, and where after death what remains of the organ is found to be extremely soft and yellow, with no appearance of lobules, and with the secreting cells in a great measure, or wholly, broken up into granular matter and oil- globules. The rarity of the disease in this city is attested by the fact, that although a brown tongue and delirium formerly con- stituted a certain passport for the transmission of all diseases to the London Fever Hospital, out of about 25,700 cases ad- mitted during nine years, I believe that the only example of the disease which was noticed was one of which I shall narrate to you the particulars immediately. The disease, however, is one of the most interesting that can engage your attention, and may be recognised by the following clinical characters : — 1. Premonitory symptoms are noticed in many cases, but they are usually slight and variable in their nature and they are sometimes absent. The most common are those of gastro- enteric catarrh, such as furred tongue, nausea and loss of appetite, occasional vomiting and irregular bowels — diarrhoea or constipation, and slight pyrexia. At other times, the patient complains only of rheumatic pains, of an uneasy sensa- tion in the region of the heart or stomach, or of a feeling of uneasiness which he is unable to define. These synjptoms may last three or four days, or as many weeks, but withal there is s 2 26o CONTEACTIONS OF THE LIVER. not, as a rule, thought to be much amiss, while in not a few cases the patient has no feeling of indisposition until the super- vention of symptoms of a more decided character. 2. Jaundice is invariably present, and is usually the first svmptom that attracts attention to the patient's condition. The jaundice, however, is rarely intense, and is sometimes confined to the upper part of the body. Like the jaundice of pycemia (see p. 105) it appears to be due to a morbid condition of the blood, and is independent of any obstruction of the bile-duct, and bile is found throughout in the stools. (See Lect. XI.) 3. A rapid diminution in the area of hepatic dulness is one of the most remarkable features of the disease. In the course of a week or ten days, one-third, or even more than one-half of the liver may disaj)pear (see fig. 23). Bright has recorded a case where the liver after death weighed only nineteen ounces, Fig. ?,3. Area of Hepatic Dulness in ]\Iary Ann M (Case CII.),"on the day before death. and its weight in one case which I shall bring under your notice was only twenty-eight ounces. It must not, however, be inferred that a diminished area of hepatic dulness is necessary for the diagnosis of the disease known as ' acute atrophy.' It may happen that the liver has been enlarged by previous disease (Case CIII.) ; but independently of this, a considerable number of cases have been observed in which the liver at the commencement of the morbid process, and consequent upon it, LECT. Till. ACUTE ATEOPHY. 261 has been found to be considerably increased in size. Lieber- meister ^ and Trousseau ^ refer to cases of this sort ; and similar observations liave been made by Sieveking-,^ TMoxon,* Tuckwell/ &c. Still, even in these cases, the preliminary enlargement is followed, if the case be sufficiently prolonged, by a rapid diminution in the size of the liver. It has been lately suggested that the a.trophy in these cases is a chronic process, though unattended by symptoms until the final explosion ; but this view is opposed by most of the known facts in reference to the etiology of the disease, and also by the circumstance that it may be ascertained by percussion that the atrophy is going on during life. Careful examination of the gland after death shows that the atrophy is due to a destructive process com- mencing at the circumference of the lobules and advancing to the centre, as the result of which the secreting cells disappear and in their place we find nothing but granular matter and oil. The disease, in fact, is believed to be nothing more nor less than an acute fatty degeneration of the liver, resulting from a difi'use inflammatory process ; for, previous to bursting, the cells may often be seen distended with oily and granular contents. During life the atrophy of the liver may apj)ear greater than it really is, because the gland is not only reduced in size, but also softened, so that it folds upon itself and col- lapses towards the vertebral column, the space corresponding to it in front being occupied by intestines containing gas. 4. Pain at the epigastrium and in the region of the liver is present in most cases. This pain often comes on spontaneously, and can almost always be elicited by pressure, even when the patient is almost unconscious. There is rarely, however, any tympanitic distension of the abdomen, unless there be (as in Case CII.) concurrent peritonitis, in which case the pain and tenderness may be acute. Muscular and arthritic pains are also not uncommon and occasionally the joints seem swollen ; while some patients complain of suffocative sensations, or there is dyspnoea not accounted for by any lesion in the heart or lungs. 5. Vomiting occurs in most cases, the vomited matters consisting of the ingesta mixed with mucus or bile, but often also containing much blood, and resembling the ' black vomit ' > Virohow's Jahresbericht, 1870, ii. 165. 2 Clin. Med., Syd. Soc. Ed. iv. 299, 308. * Path. Trans, vol. xxiii. » Lancet, 1872, ii. 224. * Earth. Hosp. Eep. vol. x. 262 CONTRACTIONS OP THE LIVER. lect. vui. of yellow fever. The bowels are described as being usually constipated, but in the case from which this liver was taken (Case CII.) there was a considerable amount of diarrhoea. The stools in the first instance are often pale, but in other cases they contain bile ; in the advanced stage they not unfrequently contain blood and are very offensive. 6. The area of splenic dulness is usually increased, except in cases where the portal system has been drained by diarrlioea or by hasmorrhage from the stomach or bowels. 7. The cerebral symptoms of the 'typhoid state' constitute one of the most frequent and striking peculiarities of acute atrophy. As a rule, they appear simultaneously with the jaundice, but occasionally not for two or three weeks subse- quently, the jaundice at first having all the characters of what is commonly known as ' catarrhal.' At first there is headache, with despondency, irritability, and great restlessness ; and this condition is succeeded by low muttering delirium, tremors, subsultus, muscular rigidity and carphology, retention or in- continence of urine, involuntary passage of fseces, stupor, coma and convulsions. These symptoms are said to be sometimes associated with fatty disintegration of the cerebral tissue, but, like the analogous symptoms in typhus fever and in the typhoid state generally, to which I have directed your attention on a former occasion,' they probably result from the circulation through the brain of blood poisoned by the accumulation in it of urea and other products of tissue-metamorphosis which ought to be eliminated by the kidneys. 8. Acute atrophy of the liver is not attended by pyrexia. The pulse varies. In cases ushered in with gastro-enteric catarrh the pulse is usually accelerated at first, but falls to the normal standard, or below this, on the appearance of jaundice, and again rises on the supervention of cerebral symptoms, its frequency often varying at different hours of the day. In Case CII. it rose to as high as 144, but here there was peritonitis. The temperature in the early stage of the disease may be slightly elevated, but it rarely much exceeds 101°. But when the symptoms are well pronounced, the temperature is usually not elevated, and sometimes it is subnormal. In Case CIII. it fell to as low as 95*5° and a similar observation has been made ' On the Patliolopy and Treatment of the Typhoid State in different Diseases. Abstract of Lecture in IJrit. Med. Journ. Jan, 4, JSG8. LECT. Tin. ACUTE ATROPHY. 263 by Duckworth.^ The temperature of 101° noted shortly before death in Case CII. was probably due to the peritonitis. This absence of pyrexia is of the utmost importance in the diagnosis of acute atrophy from other diseases characterised by the typhoid state. After the appearance of cerebral symptoms, the tongue is almost invariably dry and brown, and the teeth crusted with sordes, exactly as in a bad case of typhus fever. 9. The urine undergoes important changes. Its quantity is not materially altered ; it is of acid reaction ; and its specific gravity varies from 1012 to 1024. Its colour is usually dark, but the ordinary reaction of bile-pigment may be faint or in- distinct. It often contains albumen or even blood ; but after the removal of the urinary pigment, it yields no reaction of bile-acids to Petteukofer's test. The most remarkable altera- tions, however, consist in the great diminution or even total disappearance of the urea and uric acid, and also of the chlorides, sulphates, and earthy phosphates, and the substitution of two new substances of a peculiar nature, leucin and tyrosin. These substances are products of the metamorphosis of nitro- genous matter intermediate between the protein principles (albumen and fibrin) at one extreme, and the less coDiplex bodies, urea, uric acid, kreatin, &c. at the other, as will be seen by a comparison of the following formulte : — Albuminoids = C72H,i2Ni8S023 Tyrosin = CgHnISrOg Leucin = CcHigN'Oa Uric Acid = C,,H4N4 03 Urea = CHRIS'S Leucin and tyrosin, in the crystalline forms represented in the annexed figures (figs. 24, 25, and 26), are found in the tissues of the liver, spleen, and kidneys in cases of acute atrophy, and they are usually also secreted in large quantity in the urine, from which they separate as a distinct deposit on standing, or they may be obtained by evaporating a few drops of the urine, on a glass slide. ^ The detection of these crystalline bodies in ' Earth. Hosp. Eep. vol. vii. Briglit and Alison long ago noted that the skin was cool. - Tests for Leucin and Tyrosin. A. For Leucin. Concentrate urine and dissolve in alcohol. Evaporate alcoholic solution and dissolve in water, from which the leucin ought to crystallize in spherical globes. B. For Tyrosin. 1. Hoffmann's Test ^ A solution of the nitrate of the protoxide of mercury, nearly neutral, is to be added to the suspected solution. If tyrosin be present, a reddish precipitate is produced, and 264 CONTRACTIONS OF THE LIVER. LECT. VIII. the urine of a case of jaundice may be said to clencli tlie diagnosis of acute atrophy of the liver, but the failure to detect them must not exclude acute atrophy from the diagnosis. For instance, they were not present in the urine of Case CII., at all events in such quantity as to reveal their existence by simply evaporating the urine, although they were found in consider- ..Ui^""-'-/o Fig. 24. Microscopic needle-shaped crys- Fig. 2.'). Microscopic glolnilar mapses tals of tyrosin adhering in bundles and composed of acicular crystals of ty- in stellate groups. rosin. able quantity in the liver and kidneys after death. It is true that in this case death was accelerated by acute peritonitis ; had the patient survived a little longer, leucin and tyrosin would probably have been found in the urine. Fig. 26. Microscopic laminated crystalline masses of leucin. 10. Haemorrhages are very common, and particularly haemorrhage from the stomach, bowels, or nose. Blood is often vomited in large quantit3\ Petechise, purpura-spots, and vibices often appear on the slcin, or in rarer cases there is uterine haemorrhage. After death ecchymoses are found in different parts of the body. From the frequency of these hajinorrhages the supernatant lif|nid is of a dark rose colour. 2. Freric/is Test. Add U) suspected liquid a solution of acetate of lead until no more precipit;ite is produced. .Sulphur- etted hydrogen gas is then to be passed through tlie filtered fluid. Separate the sul- phurot of lead by filtration, and concentrate the clear solution by evaporation, -when, if tyrosin be present, it will crystallise out as long white needles. LECT. VIII. ACUTE ATROPHY. 265 tlie disease has been sometimes designated ' hsemorrhagic jaundice.' 11. Pregnant females, who constitute a large proportion of the cases, almost invariably abort or miscarry before dying. 12. The circumstances under which acute atrophy of the liver occurs constitute not the least interesting part of its clinical history. The causes of the disease still require inves- tigation, but I shall briefly mention those that are at present known. Among predisposing causes, then, we have — a. Age. Most persons attacked with the disease are under the middle age. Of 31 cases collected by Frerichs, 26 were under 30, and all but 2 under 40. Of 4 cases which have come under my notice, two were females, aged 19 and 30 ; and two were males, aged 2l< and 62; in a fifth case (Case CIIL), where the disease was secondary to obstruction of the bile-duct, the patient was a male, aged 66. All writers agree as to the rarity of the disease in children. ITeither Niemeyer, Prerichs, nor Trousseau ever met with the disease in early life. West, in his extensive experience, has only seen the disease once, in a girl aged 4^ years ; but three other cases in children have been recorded by Duckworth ' and Tuckwell.^ h. Sex. The disease is much more common in females than in males. -Of the 31 cases collected by Frerichs, 22 were females. c. Pregnancy must be regarded as a predisposing cause, for of the 22 female patients referred to by Frerichs, one half were attacked while pregnant. Prom the third to the sixth month is the most common period of pregnancy at which the disease shows itself. In the pregnant state it is said to be frequently associated with fatty degeneration of the kidneys and albumi- nous urine. d. Dissipation, including drunkenness and venereal excesses, precedes the disease in a considerable number of cases. Leudet is of opinion that its origin maj' sometimes be traced to the absorption of a large quantity of undiluted alcohol. ^ e. Constitutional syphilis appears to be a predisposing cause in some cases. Most writers on syphilis have noted the frequent occurrence of jaundice about the commencement of what is known as the secondary stage ; in most cases the con- stitutional symptoms are slight and the jaundice soon passes ' Loc. cit. 2 Log_ cit. = Clin. Medicale, Paris, 1874, p. 67. 266 CONTRACTIONS OF THE LIVER. lect. viii. away (p. 153) ; but now and then what appears to be at first a slight catarrhal jaundice becomes rapidly developed into the symptoms of acute atrophy.' Among causes that appear to act more directly in exciting the disease are the following : — a. Nervous influences, such as severe mental emotions, and particularly anxiety, fear, and grief. Sir Thomas Watson, in his lectures, states that scores of instances are on record, where jaundice has suddenly appeared under such circumstances, and adds that 'these cases are often fatal, with head symptoms, convulsions, delirium, or coma, supervening upon the jaundice.'^ In these cases an impression made upon the nervous system may be directed to the liver and derange its nutrition, or perhaps more probably it excites in the first instance morbid changes in the blood. h. Malaria. There are other cases where the disease has apparently resulted from some malarious poison, acting probably through the blood and the nervous system. Instances have been recorded by Graves,^ Budd,'' and others, where several cases of what appears to have been unquestionably this disease occurred in the same house, or where it has been even epidemic in certain localities (See Lecture XI.) ; and when it is considered what a rare disease acute atrophy is, it is impossible to escape from the conclusion that in these cases there must have been some local cause to which all the patients were subjected in common. c. The blood-poisons of typhus fever and allied diseases have been known to give rise to acute atroj)hy of the liver.* Jaundice is a very rare complication of typhus and scarlet fever, but in more than one instance where it has occurred,** I have found crystals of leucin and tyrosin in the tissue of the liver and kidney. The liver in these cases has been in a state of fatty degeneration, but without marked atrophy. Most writers on the yellow fever of the tropics have described latty degeneration of the liver as one of its most characteristic lesions, and it is well known that there is a deficient elimination ' See LeVjert in Vircliow's Arcliiv, 18;)4, hSoo; Andri'M', in Path. TraiiB. xvii. p. 158; aud Faggo, lb. xviii. p. 138. * Locturcs on tlio Practice of Physic, 5th od. ii. p. G8'2. ' Clin. Lcct. 2nd ed. ii. p. 255. ♦ Op. cit. 3rd od. pp. 255, 270. * See Frericlis' Tre.itiso on Diseases of Livor, Sy