irjmxmm.mmmmmi- i :';i!|i ,!"|il|H I*! *— i<* 4...... ..fl. ....... ., ....Km i" B7—><■ hi i illnii" i i ii'iHii i - ce^ ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C. "* ""FK* eBOM l.AST DATE />' r /■ £~~- ) :> h 'Tt> <...... *, < DI 9 ON DISEASES OF THE LIVER. Ba the same Author. ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. One Vol. Octavo. ON DISEASES OF THE LITER. BY GEORGE BUDD, M.D., F.R.S., PROFESSOR OF MEDICINE IN KING'S COLLEGE, LONDON J LATE FELLOW OF CAIU8 COLLEGE, CAMBRIDGE. ,it\ Cflbnfo 'Shin axtXr Ma^-tuU. THIRD AMERICAN, FROM THE THIRD AND REVISED LONDON EDITION PHILADELPHIA: BLANC HARD AND LEA 1857. wic \SV7a. >, h* \JLt? PHILADELPHIA ! T. K. AND P. G. COLLINS, PRINTERS. AMERICAN PUBLISHERS' NOTICE. The present volume has been reprinted without altera- tion from the Third English Edition. As but few weeks have elapsed since its appearance in London under the careful revision of the author, it will doubtless be found fully brought to the present state of the subject, and entitled to the continued confidence of the profession, as the standard authority on this class of diseases. Philadelphia, October, 1857. 1* 426135 PREFACE TO THE FIRST EDITION. The materials of which the present volume is composed accu- mulated gradually during eight years in which I had been engaged in hospital practice. For the first three of those years, I was the visiting Physician to the Seamen's Hospital, Dreadnought, where my attention was especially called to diseases of the liver, which are there very frequent among men who have been much in India, and other hot climates. The chapter on abscess of the liver formed the substance of the Grulstonian Lectures, which I had the honor to deliver at the Col- lege of Physicians, in 1842, and which were printed in the Medical Gazette. In pursuing my investigations, I have had great help from my friend and former colleague, Mr. Busk, the accomplished surgeon of the Dreadnought, who was not only ever ready to give me his most valuable aid when we were acting together, but who has ever since continued to call my attention to all cases of special interest occurring in his practice. All who are versed in the recent progress of anatomy may form some judgment of the great value of Mr. Busk's assistance, in a scientific point of view, but only those who have the happiness to enjoy his friendship can ap- preciate the singular disinterestedness with which it was given. I am also much indebted to my friend, Mr. Bowman, for micro- scopic specimens illustrating the structure of the liver, and for some interesting cases which he has placed at my disposal, as well as for the readiness with which he has on several occasions aided me by his intimate knowledge of structure. To Dr. Inman, of Liverpool, and to Dr. James Russel, of Bir- Vlll PREFACE. mingham, my former pupils, I am likewise indebted for some valuable cases which they have been kind enough to send me. This account of the opportunities I have had of studying the diseases of the liver, and of the great assistance I have derived from others, will, I fear, lead the reader to expect more information in the following pages than he will find. To prevent disappoint- ment, it is right, therefore, that I should add, that while I was in office at the Dreadnought, many opportunities were turned to little profit, from the ignorance which then prevailed as to the real structure of the secreting element of the liver; and that, since, many have been quite lost from my time and attention having been absorbed in the business of teaching. It is hoped, however, that, with all its imperfections, of which no one can be more sen- sible than myself, the work will contribute to render the diagnosis of diseases of the liver more certain, and their treatment, therefore, more rational and satisfactory. Dover Street, June, 1845. In publishing the Second Edition of this work, I am desirous of expressing my obligations to Dr. L. S. Beale, for the readiness with which, on numerous occasions, he has made for me chemical analyses requiring much labor and skill. March, 1852. CONTENTS. INTRODUCTION. PAGE Vagueness of our knowledge of liver diseases—Structure of the liver— Cause of the variations in its form, size, and color—Physical qualities and composition of the bile—Sources and uses of the bile—Cholagogue medicines . . . ... . . . .17 CHAPTER I. ON CONGESTION OF THE LIVER. Congestion of the liver from impediment to the flow of blood through the lungs or heart—Effects of this—Congestion from other causes—Hemor- rhage ......... 73 CHAPTER II. ON THE INFLAMMATORY DISEASES OF THE LIVER. Section I. General remarks on the classification of inflammatory diseases of the liver—Suppurative inflammation, and abscess of the liver . 84 Section II. Gangrenous inflammation—Appearances sometimes mistaken for gangrene—Circumstances in which gangrene of the liver really occurs . 140 Section III. Adhesive inflammation of the capsule and of the substance of the liver—Cirrhosis—other forms of inflammation of the substance of the liver ......... 146 Section IV. Inflammation of the veins of the liver—Suppurative inflamma- tion of the portal vein—Adhesive inflammation of branches of the portal vein—Inflammation of branches of the hepatic vein . . . 181 Section V. Inflammation of the gall-bladder and gall-ducts—Catarrhal and suppurative inflammation—Croupal, or plastic, inflammation—Ulcerative inflammation—Effects of inflammation of the gall-bladder and gall-ducts —Fatty degeneration of the coats of the gall-bladder . . . 197 X CONTENTS. CHAPTER III. ON DISEASES WHICH RESULT FROM FAULTY NUTRITION OF THE LIVER, OR FAULTY SECRETION. PAGE Section I. Softening of the liver—Destruction of the hepatic cells—Sup- pressed secretion of bile—Fatal jaundice . . . • .250 Section II. Fatty degeneration of the liver—Partial deposit of fat in the liver—Waxy liver—appearances caused by deficiency of fat in the liver 299 Section III. Scrofulous enlargement of the liver, and other kindred states . 320 Section IV. Excessive and defective secretion of bile—Unhealthy states of the bile ......... 345 Section V. Gall-stones . . . . . . .365 CHAPTER IV. ON DISEASES WHICH RESULT FROM SOME GROWTH FOREIGN TO THE NATURAL -STRUCTURE. Section I. Cancer of the liver—Origin of cancerous tumors of the liver— Their growth, dissemination, and effects—Encysted, knotty tubera of the liver.......... 394 Section II. Hydatid tumors of the liver ..... 428 CHAPTER T. On Jaundice ......... 468 APPENDIX. The liver-fluke—Its effects on sheep and other graminivorous animals__ Flukes found in the gall-ducts, in the duodenum, and in branches of the portal vein, in man ....... EXPLANATION OF THE PLATES. PLATE I.—Gall-stones. The drawings for these plates, with one exception, were taken from preparations in the museum of King's College, to which reference is made. Fig. 1—Represents small, irregular gall-stones, composed of inspissated and altered bile, cemented by mucus. From a dry preparation (No. 263), which ex- hibits 279 gall-stones, all of this kind, in the bladder in which they were found. The bladder is enlarged, but its coats seem not to have been thickened. Fig. 2—Represents a section of a large calculus, composed almost entirely of cholesterine. It existed alone in the gall-bladder, and weighed three drachms. (Prep. 264.) Fig. 3—Sections of two gall-stones from the same bladder, composed chiefly of cholesterine, stained by the coloring matters of bile. There were three other gall- stones, precisely of the same kind, in the bladder. (Prep. 280.) Fig. 4—Three calculi from the same bladder, two of them sawn through to show their structure. The bladder contained a great number of calculi (some have been lost, and thirty-two are still left in the preparation) of the same kind; all of them having a crust of pure cholesterine, and all those of which a section has been made having a hollow in the centre. (Prep. 284.) PLATE II.—Gall-stones. Fig. 1—Sections of two gall-stones of peculiar structure, from the gall-bladder of a woman who died in King's College Hospital, of cancer of the liver, at the age of 51. The bladder was somewhat contracted at its middle, so as to form two pouches in which the stones were contained, and its coats were much thickened. (Prep. 279.) xii EXPLANATION OF THE PLATES. Fig. 2—Gall-bladder and cystic duct containing calculi. The calculi have all a crust of pure cholesterine. (Prep. 269.) Fig. 3—Gall-bladder filled with calculi, which have all a crust of pure choles- terine. From a man, 64 years of age, who died in King's College Hospital, of softening of the brain. No disease of the liver was suspected. (Prep. 261.) PLATE III. Fig. 1—Represents small abscesses which formed in the liver in consequence of injury done to an hydatid cyst. See p. 109. Fig. 2—Represents one of the encysted tumors of the liver described in page 421. PLATE IY. Fig. 1—Represents a portion of liver thickly studded with minute spots of melanotic cancer. From a preparation in King's College Museum. (Prep. 324.) I Plate 1 V ^Sk ^* T.SincUir'j lith Ruk \ V. Sindciri lith PhUa. Plate 3 T.Sindair's lith rhik.' TSsackiMiithPtuk ON DISEASES OF THE LIVER. INTRODUCTION. Vagueness of our knowledge of Liver Diseases.—Structure of the Liver — Cause of the variations in its form, size, and color.—Physical qualities and composition of the bile.—Source and uses of the bite.— Cholagogue medicines. In writing a book on Diseases of the Liver, I shall hardly be accused of having undertaken a needless task. There are no other diseases of such frequent occurrence which it is so difficult to dis- criminate, and for the treatment of which the medical practitioner has so few trustworthy guides. There is, again, no class of diseases at all equal to this in importance on which so few treatises have lately been written. Diseases of the liver occupied a much larger space in the medi- cal literature of former times than they do in that of our own. Before the functions of the liver had been much investigated, and before its intimate structure was known, physicians saw, in the large size of this organ, in its existence in animals differing widely in organization and habits, and in the obvious relation of its secre- tion to the process of digestion, sufficient evidence of its great im- portance in the animal economy, and of the serious evils that must result from derangement of its functions. This evidence has been confirmed and extended by the more explicit results of modern inquiry. Guided by the comparatively recent discovery, that a gland may be regarded as being essentially 2 18 INTRODUCTION. a network of capillaries investing a secretory duct, anatomists have found a liver, in the form of csecal tubes opening into the intestinal canal, in almost the lowest animals, and have thus furnished in its favor the surest testimony that can be given to the importance of any organ—namely, its all but universal presence in the animal kingdom. The circumstance, then, that so few treatises on diseases of the liver have lately appeared, must be owing, not to their being con- sidered less important, but to the unsatisfactory state of our know- ledge respecting them. The precision lately given to our know- ledge of many other diseases by the employment of new methods of investigation, has created a demand for more exact information on diseases of the liver than any one has possessed. The unsatisfactory state of our knowledge of these diseases will scarcely be wondered at, if we reflect that many circumstances have conspired to render the study of them peculiarly difficult. One of the most influential of these circumstances is, that, owing to the color and the close texture of the liver, it is difficult, with the' imperfect means of research hitherto employed, to recognize and distinguish in the dead body the various effects of disease, unless it has gone on to disorganization or complete change of structure. In an organ whose texture is spongy, as the lung, disease pro- duces such striking changes, that we can at once distinguish their different forms, and thus learn to connect them with the symptoms observed during life; but in organs naturally solid, and also nearly of the color of blood, as the liver and the kidney, these changes, and especially the traces of the various kinds of congestion and inflammation, are far less obvious, and to detect and discriminate them requires a knowledge of intimate structure which has only lately been obtained, and, even with that knowledge, a very close and attentive inspection. In the case of the kidney, the impediment which these conditions offer to the morbid anatomist is well illustrated by the fact, that a disease so common and so fatal as granular degeneration of this organ, and signalized during life by such marked symptoms as general dropsy and albuminous urine, has been left to immortalize, by its discovery, the name of a living physician; and that even now, notwithstanding the interest it has excited for seventeen years, and the attention given to it by the best anatomists of this and INTRODUCTION. 19 other countries, the real nature of the morbid change in which it essentially consists is a matter of doubt.1 Another circumstance unfavorable to the study of diseases of the liver is, that we can obtain but little direct evidence of its physical condition during life. When the lungs are the seat of disease, we may discover, by the sense of hearing, whether any portion of them near the surface con- tain the natural quantity of air, or whether this, in whole or in part, be displaced by some denser matter; whether the surface of the pleura be roughened by fibrine, or its sac distended by fluid; whether the bronchial tubes be free, or more or less choked by secretions. If the heart be the organ affected, we may not only trace its out- line, and estimate the strength of its ventricles, but, by the same sense of hearing, we may penetrate its interior, and ascertain the condition of its valves. The whole physical structure of the organ is, as it were, laid open to us. We have it in our power, indeed, to explore the liver by touch, and by percussion, but we cannot, by these means of investigation, penetrate its surface, and discover changes in its consistence and texture. They only enable us, in some cases, to trace its outline, to discover any striking inequalities of its surface, and to form a tolerable estimate of its bulk. This, indeed, is valuable information, and more than we can learn of the kidneys by similar means. But in investigating the diseases of the latter organs, we have the more than equivalent advantage that, day by day, we can measure the quantity, and ascertain the composition of the urine secreted; that is, we can tell precisely the manner in which their functions are performed. The secretions of the liver, on the contrary, cannot be collected and analyzed during the life of the patient; indeed, until lately, they could scarcely be analyzed at all, as the most celebrated che- mists were not even agreed as to what are the normal constituents of bile. Thus, to detect and distinguish the diseases of the liver, practi- tioners had little more than the signs of functional disturbance— ' Since this was written, much has been done to elucidate the morbid changes in Bright's disease of the kidney; especially by Dr. George Johnson, whose ad- mirable papers on this subject have been published in the Medico- Chirurgical Transactions. 20 INTRODUCTION. signs, in all cases, of doubtful import, and here, if we except that of jaundice, more than commonly obscure and equivocal. We can- not, then, feel surprised that our knowledge of these diseases should be more imperfect, our diagnosis of them less sure, and our treat- ment, consequently, more tentative and empirical, than of the dis- eases of any other organ of equal importance. Very recently, two of the impediments to the study of diseases of the liver have been in some degree removed. By the researches of chemists, we have obtained more precise knowledge of the com- position and uses of bile; and by the labors of Kiernan and Bow- man in this country, and of Miiller and Henle in Germany, we have been taught the intimate structure of the organ; so that now, by the naked eye or the microscope, we can distinguish the various changes of its texture produced by disease. It is impossible to explain or to understand the morbid appear- ances of the liver, without referring to its intimate structure, and as some points relating to this have been only lately made out, I shall commence with a short account of it. Perhaps the best way to get an idea of the structure of the liver, is to examine under the microscope— 1st. A thin slice of liver in which the portal and hepatic veins are thoroughly injected. 2d. A small particle taken from the lobular substance of a fresh liver, in which the bloodvessels are empty, as in an animal killed by bleeding. From the first specimen, we may learn the distribution of the minute portal and hepatic veins, and the intermediate capillaries. The annexed wood-cut (Fig. 1) has been made from a portion of the liver of a frog, which I selected from numerous specimens of injected liver made by Mr. Bowman. It represents, on a magnified scale, a small branch of the hepatic vein, two or three small branches of the portal vein, and the intermediate capillaries. It appears that the capillaries have nearly the same relation to the branches of the portal vein as they have to those of the hepatic vein. It is difficult, from this specimen, to tell which branch is portal, which hepatic; the smaller branches of both being, as it were, hairy with capilla- ries, springing directly from them on every side, and forming a close and continuous network. If we imagine views similar to that in the wood-cut, made by DISTRIBUTION OF VESSELS, x 21 Fig. 1. a a, twigs of the portal vein ; d, twig of the hepatic vein ; 6, intermediate capillaries. slicing the liver in various directions through the branch of the hepatic vein, or through one of the branches of the portal vein, there represented, we shall perceive that the entire organ, abstract- ins: the canals in which the trunk and branches of those veins run, is occupied by a close network of capillary bloodvessels, continu- ous in every direction throughout its substance. The capillary * vessels of this network are immediately concerned in secretion. The vessels of larger size serve merely to convey the blood to them, or carry it from them. These capillaries are of comparatively large size, being always one-third wider than the diameter of the blood-globule, and some- times nearly twice as wide, and their coats, which have no areolar tissue about them, appear very thin and delicate.1 But although the capillaries form a continuous network through- out the substance of the liver, no part of the portal blood traverses the entire network. The whole mass of capillaries is divided by the minute branches and twigs of the portal vein into small, tole- 1 See an admirable article on Mucous Membrane, by Mr. Bowman, in Todd's Cyclopaedia of Anatomy and Physiology, in which several points in the minute structure of the liver, noticed in this chapter, were first published. 22 INTRODUCTION. rably defined masses ; and is likewise partitioned in a similar way by the minute branches and twigs of the hepatic vein, which are intermediate to, or, as it were, dovetailed with, the branches and twigs of the portal vein. In effect of this, the blood conveyed through any branch of the portal vein to a small mass of capil- laries, having performed its part in secretion, and been drained of the principles of bile, passes out of the liver through an interme- diate or adjacent branch of the hepatic vein; so that the entire mass of capillaries is duly supplied with fresh portal, or biliary, blood. In tracing even large branches of the portal and hepatic veins, it is seen that they generally run transversely, or that the directions of the two orders of vessels cross each other. In consequence of this arrangement of the minute vessels, if we cut into a liver in which, as is usual after death, the branches and twigs of the hepatic vein and the capillaries immediately termi- nating in them are full of blood, while the branches and twigs of the portal vein and the capillaries immediately springing from them are empty, the cut surface will be mapped out into small, tolerably equal, and somewhat pentagonal spaces, having the out- line, formed by the portal twigs, pale, and the centre, into which a twig of the hepatic vein enters, red. The small masses, of which these pentagonal spaces are sections, have been termed lobules of the liver. They have been described by Malpighi, Kiernan, Miiller, and others, as isolated from each other, and each invested by a layer of areolar, or, as it used to be named, cellular, tissue. In the pig, in which the lobules of the liver were first noticed, and, ac- cording to Miiller, in the polar bear, they are thus invested, but in man, as is clearly shown by the injected preparations of Mr. Bow- man, and in most other animals, they are not distinct, isolated bodies, but merely small masses defined more or less distinctly by the ultimate twigs of the portal vein and the injected or uninjected capillaries immediately contiguous to them. The ultimate twigs of the vein are, as it were, hairy with capillaries, springing directly from them on every side, and forming a close and continuous net- work. The lobules appear distinct isolated bodies only when seen by too low a power clearly to distinguish the capillaries. The real nature of the lobules, and the manner in which they are formed, will perhaps be better understood by reference to the an- LOBULES. 23 nexed wood cut (Fig. 2), for which I am indebted to the kindness of Mr. Bowman. It represents on a magnified scale six lobules of the liver, and was made from a drawing under the microscope of the section of the liver of a cat, partially injected through the por- tal vein, and also through the hepatic vein ; a a a, represent minute twigs of the portal vein injected ; b b b, capillaries, like- wise injected, immediately springing from them, and serving with them to mark the outline of the lobules; d d d, capillaries in the centres of the lobules, injected through the hepatic vein ; e e, places at which the size injected into the portal vein has met that injected into the hepatic vein, so that all the intermediate capillaries are colored and conspicuous; I I, centres of lobules into which the injection has not passed through the hepatic vein. It has been stated that the capillaries have nearly the same re- lation to the small branches and twigs of the hepatic vein as they have to those of the portal vein. This statement requires some qualification. The branches of the portal vein are each accom- panied to their smallest twigs by a branch of the hepatic artery, and by a branch of the hepatic duct. Frequently, with a branch of 24 INTRODUCTION. the vein there are two branches of the artery and two branches of the duct. These vessels, which are very much smaller than the corresponding portal vein, run up (as seen in Fig. 31) on one side of it, and of course on that side the capillaries do not spring so immediately from the venous trunk; in other words, the lobules are not in such immediate contact with the vein as on other sides. The capillaries terminate in twigs which go to the vein through the space which the presence of the artery and duct necessarily in- terposes between the lobules and the vein. With the, artery and duct in the portal canals there is also some areolar tissue, which surrounds these vessels, and is continued in a Fig. 3. Longitudinal section of a small portal vein and canal. P, the portal vein ; a d, the accompanying artery and duct; a a, portions of the canal from which the vein has been removed ; 6, orifices of ultimate twigs of the vein springing immediately from it. thin layer round the branches of the portal vein itself. This layer separates by a small space the lobules from the branches of the vein, and makes the coats of the latter appear thicker than those of the hepatic veins, and their outline more distinct; and also allows them to collapse when empty. 1 This diagram and the two following are copied from the admirable paper on the Liver in the Transactions of the Royal Society for 1833, by Mr. Kiernan, to whom we are in great part indebted for the exact knowledge we now have of the distribution of bloodvessels in the liver, and of many other points of its structure. HEPATIC VEINS. 25 The hepatic veins are not accompanied by any other vessels, and are not surrounded by areolar tissue. They are, in consequence, everywhere in immediate contact with lobules, and do not collapse when cut across. In the small branches, the coats are thin and transparent, and capillaries, or the ultimate twigs formed from the capillaries, enter them directly on every side. In the larger branches, the coats are thicker and opaque, and the ultimate twigs unite to form larger twigs before they enter the vein. This is shown in Fig. 4, copied on a smaller scale from a diagram by Mr. Kiernan. The trunks and large branches of the hepatic vein, like the iliacs and the inferior vena cava, contain longitudinal (muscular) fibres. Fig. 4. n, longitudinal section of an hepatic vein ; a a, portions of the canal, from which the vein has been removed ; 6 b, orifices of ultimate twigs of the vein, formed by the capillaries of single lobules. To complete our view of the bloodvessels of the liver, we must now consider the hepatic artery. We have already seen that a branch of the artery accompanies each branch of the portal vein and hepatic duct. It has been shown by Mr. Kiernan, that the hepatic artery is distributed to, and nourishes, the coats of the gall-bladder and gall-ducts, the liga- ments of the liver, its capsule, and the coats of the portal and 26 INTRODUCTION. Fig. 5. hepatic veins; and that the blood conveyed to all these parts by the artery passes into veins which terminate in branches of the portal vein, and thus traverses the capillary plexus of the lobules/ like blood returned from the other abdominal viscera.1 These veins, which originate in the liver, and feed the portal vein with the blood brought by the hepatic artery, constitute what Mr. Kier- nan has called the hepatic origin of the portal vein. No arteries enter the lobules of the liver. The blood brought by the hepatic artery is distributed chiefly to the ducts. Mr. Kiernan remarked that " when the arteries are well injected, the larger ducts, from the extreme vascularity of their coats, may be mistaken for in- jected arteries, whilst in the coats of the vein, no vessels will be detected without the aid of the mag- nifying glass." The blood of the hepatic artery not only nourishes the coats of the excretory por- tion of the ducts, but furnishes the materials of their proper secretion. The ducts, as we have seen, accompany the portal veins, and their ramifications, like those of the veins, can be traced to the lobules of the liver. The finest interlobular branches of the ducts are the arrangement of very small, being, according to Dr. Beale, only 3 g^u the follicles in a ..'.,. -■ . , D ■. smaii gaii-duct. of an inch m diameter, and consist 01 a simple tubular membrane lined by a delicate epithelium. The large ducts have a complex structure, leading to the inference that they must have some important function besides serving as channels for the bile. Their coats are thick, and their inner sur- face presents a great number of small cavities or follicles, which, except in the largest ducts, where they are distributed irregularly, are arranged in two lines on opposite sides of the canal. The large ducts are, besides, connected by numerous tortuous branches—the vasa aberrantia—which have likewise follicles in their walls, and which anastomose so as to form a network not immediately con- aected with the lobular structure.2 Diagram representing 1 It appears from specimens injected by Mr. Bowman, that some of the arterial capillaries of the capsule return their blood, not into a branch of the portal vein, but immediately into the adjacent capillary plexus of that vein. 2 For further particulars regarding the structure and arrangement of the ducts, and other points in the minute anatomy of the liver, the reader is referred to an NUCLEATED CELLS. 27 Fig. 6. Having obtained a conception of the distribution of vessels in the liver, we may next consider the other elements of its structure. This is, perhaps, best done by examining under the microscope a small particle taken from the lobular substance of a fresh liver, empty of blood and uninjected. In such a specimen there is seen under the microscope a mass of nucleated cells, with here and there a fibre from one of the torn vessels. When the animal died fasting no other objects are visible, but when it was killed while digestion was going on, and in a state of health, the cells are surrounded by fine granular matter, having an active mole- cular (Brownian) movement.1 The cells are flattened, irregular in form, but somewhat spheroidal, and have each a nucleus, which again contains a central pel- lucid spot, the nucleolus. They are of various sizes. The largest are usually about the one thousandth of an inch in diameter ; others are very much smaller, as if not yet fully developed. In some livers the cells, generally, are smaller than in others. The cells contain oil-globules and amorphous granular matter. Their color and transparency depend on the color and quantity of the matter they contain, which vary very much in different cases, partly according to the nature of the food and the time, with refer- ence to the digestive process, when death occurred. They are usually of a light brown, and almost transparent, but in some sub- jects we find them yellowish and opaque. If, while looking at this mass of nucleated cells, we imagine the delicate and now invisible capillaries to be filled with blood or colored size, and thus rendered conspicuous, we shall perceive that the whole liver, excluding the canals in which the portal and hepatic veins run, is a solid plexus of capillary bloodvessels, the meshes of which are filled with nucleated cells. Nucleated cells of the liver, a, the nucleus; 6, the nucleo- lus ; c, fat-globules ; d, cells of small size, detached. elaborate paper by Dr. Beale, published in the Phil. Transactions for 1856, and entitled " On the Minute Arrangement of the Biliary Ducts, and on some other points in the Anatomy of the Liver of Vertebrate Animals." 1 Bernard, Le9ons de Physiologic Experimental, p. 162, 1855. 28 INTRODUCTION. These spheroidal cells are not, however, the only nucleated cells found in the liver. Nucleated cells of the gall-bladder, as seen under a high power, a, pavement formed by the union and apposition of the cells ; 6, side view of four cells ; c, the basement membrane ; d, a detached cell. The mucous membrane of the gall-bladder and gall-ducts, like the excreting ducts of other glands, in fact, like all mucous mem- branes, is composed, as Mr. Bowman has shown, of an extremely thin, transparent membrane, without pores or visible structure, whose external or secreting surface is coated with nucleated cells. These cells, by their apposition and union, form a kind of pave- ment on the transparent membrane, which, serving as their basis of support, has for this reason been named by Mr. Bowman the basement-membrane. The bloodvessels, lymphatics, and nerves ramify on the opposite, deep, or inner surface of the basement membrane.1 But although mucous membranes are alike in structure, being all composed of a basement membrane, paved, if we may so express it, with nucleated cells, yet the ceils differ much in form and appear- ance in different situations. In the convoluted, or secreting tubules of the human kidney, the cells, like those of the lobules of the liver, are spheroidal. In the gallbladder and large gall-ducts, as on the villi of the small intes- tine, the cells have the form of prisms. If the gall-bladder be slightly bruised, a portion of the bile taken from it exhibits under the microscope hundreds of these prismatic cells, and the opaque mucus sometimes found in an inflamed gall- duct is almost made up of similar cells. In the smaller ducts the cells are shorter and smaller, and in the finest interlobular branches 1 For ample details on this point I may refer the reader to the article Mucous Membrane, in Todd's Cyclopaedia. OFFICE OF THE CELLS. 29 they are flattened and very small, forming a delicate tessellated epi- thelium, and presenting a striking contrast to the much larger cells in the lobular substance.1 The researches of Purkinje, Henle, Bowman, and Goodsir, leave no doubt that the nucleated cells are the immediate agents of secre- tion. , It is not in the liver only that the cells perform this office, for it seems established as a general law, that all true secretion, whether in animals or in plants, is effected by the agency of cells; that, " however complex the structure of the secreting organ, these nu- cleated cells are its really operative part." In each secreting organ, the secreting cells have a peculiar power to form, or to withdraw from the blood, the secretion proper to the part. In such of the glands of animals as have excreting ducts, the nucleated cells withdraw from the blood the peculiar principles of the secretions, which they elaborate more or less, and then, in one way or another, whether by bursting, or dissolving, or by some unknown mode, discharge through the excreting ducts.2 The cells in the lobular substance of the liver sometimes undergo very strik- ing changes from the exercise of this secreting function. On examining these cells of the liver under the microscope, it is seen that most of tfhem inclose small spheroidal globules, which are recognized by their dark outline, or high refractive power, to be globules of oil or fat. In ordinary livers these oil or fat globules are small, and few in number ; but in the fatty condition of the livef so often found in persons dead of phthisis, and in that induced by keeping animals exclusively on fatty substances, they are so large and numerous as to distend the cells to double their natural size, and consequently to cause a great increase in the volume of the liver.3 The cells at ! See the paper by Dr. Beale, before referred to. 2 It appears that cells are not only the immediate agents of secretion, but that they are concerned in all active vital operations. It has been proved by the re- searches of Schwann and others, that all tissues possessing distinctly vital endow- ments originate, directly or indirectly, in the transformation of cells ; and it has been further stated by Dr. Carpenter, " that all the most active vital operations in the animal, as in the vegetable organism, are performed by tissues which retain their original cellular constitution with little or no change." See a paper by Dr. Carpenter, On the Mutual Relations of the Vital and Physical Forces, in the Phil. Trans. for 1850, part ii. 3 See Lancet, January, 1S42. 30 INTRODUCTION. the circumference of the lobule usually contain a larger amount oil than the cells near its centre. Fig. 8. Nucleated cells, from a liver in a state of fatty degeneration, a, nucleus ; b, nucleolus ; e c c c, fatty globules. (Bowman.) From the high refracting power of oil-globules, ocular proof is thus afforded that fatty matters taken into the system in too great quantity pass from the blood into the nucleated cells in the lobules of the liver. There can be no doubt that after undergoing more or less change, they pass in some way or other from these cells into the excreting ducts. Again, the cells, instead of having their usual light brown tint, are sometimes deeply stained by the biliary pigment. In cells taken from the roundish yellow masses in cirrhosis, or from any portion of a liver that has a well marked yellow or green tint, yel- low or green particles can be seen, having, under the microscope, exactly the same appearance as the precipitated* coloring matter of the bile. The usual light brown color of the cells is most proba- bly due to the biliary pigment. Mr. Goodsir has given a long list of animals in which he observed in the cells of the liver, or of csecal tubes supplying the place of a liver, matter of an amber tint, or of various shades of brown, according to the animal exam- ined, but in each having nearly the color of the bile. It is, there- fore, most probable that the coloring matter of the bile is formed or withdrawn from the blood by the cells in the lobular substance, and that in some way or other it passes from these into the excret- ing ducts. It has long been a subject of discussion, how the bile, supposed to be secreted in the lobules, passes into the ducts—in other words, how the ducts terminate on reaching the lobules? Mr. Kiernan inferred that the duct is continued for some distance into the lobule, forming there a plexus which interlaces with the plexus of capillary bloodvessels, and, in the paper which has been so often referred to, has given a figure representing this arrangement. But he meant the figure to be a diagram only; and confesses that he TERMINATION OF THE DUCTS. 31 failed to obtain such a view of the ducts as is there represented. He was led to believe that the ducts terminate in this way, partly by the appearances presented by specimens in which the ducts had been well injected, and partly from observing that the ducts dis- covered by Ferrein in the left lateral ligament (which Mr. Kiernan regards as a rudimental liver where the elements of the organ are unravelled), divide, subdivide, and at length terminate in plexuses of minute ducts, having bloodvessels ramifying on their outer sur- face. Dr. Handfield Jones and other observers have believed that the ducts terminate in blind extremities on reaching the lobule, instead of forming a plexus within it, and that the chief agents in the secretion of bile are the cells lining these ducts, and not the cells in the lobular substance. The latest researches on this point are those of Dr. Beale, and they have convinced him that the inference of Mr. Kiernan is cor- rect. By pouring a continuous stream of water into the portal vein, he not only succeeded in emptying the liver of blood, but a portion of the water returned by the ducts, and almost entirely emptied them of bile. In a liver thus prepared, after allowing the water to drain off, he injected, in succession, the hepatic duct and the portal vein by differently colored fluids, and thus obtained specimens in which some of the lobules were to a certain extent injected from the duct as well as from the vein. In these speci- mens, he says, in some situations, the cell-containing network in the lobules is seen to have a limitary membrane distinct from the walls of the capillary bloodvessels, but in the greater part of the lobule, where the two membranes come into close contact, they are incorporated, so that really the majority of the cells in the lobules, except where they are in contact with each other, are only sepa- rated from the blood in the vessels by one thin layer of delicate, structureless membrane. From these and other observations, Dr. Beale is led to the inference that the lobule is originally composed of two distinct interlacing networks—one containing the secreting cells, the other the blood—as Kiernan supposed; but that the walls of these two sets of tubes gradually become incorporated, except in those situations where the capillary network is less dense, or where the meshes of the cell-containing network are more widely separated from each other, in which situations the tubes containing 32 INTRODUCTION. the liver-cells have permanently a limitary membrane distinct from the wall of the capillary bloodvessels. If the duct be continuous with the network within the lobule the tube widens, and its function must change, when it begins to form the lobular network, for the duct where it reaches the lobule is much narrower than the cell-containing network within the lobule, and contains cells several times smaller and of a different kind. We have already alluded to the areolar tissue of the liver. This tissue, which serves to protect the essential elements of the organ is, in man, spread in a dense layer over its surface, forming the proper capsule of the liver, and is continued into its interior in the portal canals. It is in greatest quantity on that side of the portal vein on which the duct and artery run, but a thin layer of it completely invests the branches—at least all the considerable branches—of the vein. It gradually diminishes in amount as the vessels get smaller, and cannot be traced into the capillary net- work. To make up the rest of the organ there remain the lymphatic vessels and the nerves. The liver is very richly furnished with lymphatic vessels, some of which are of large size. The superficial lymphatics ramify in the proper capsule of the liver. Mr. Kiernan states that after injecting these vessels in the human liver, the peritoneal coat may be removed without injuring them; or the peritoneal coat may be first removed, and the absorb- ents afterwards injected. They are spread over the whole surface of the liver, forming a close network. Those on the convex surface unite to form branches, some of which pass through the diaphragm to lymphatic glands in the posterior or anterior mediastinum; while others (chiefly those of the left lobe) run to the glands about the cardiac orifice of the stomach and the adjacent portion of the vena cava. The lympha- tics on the concave surface of the liver also take different courses: those on the right lobe run chiefly to glands between the vena cava and aorta, just above the origin of the inferior mesenteric artery; those on the left lobe, to the glands situated along the lesser curve of the stomach. The deep-seated lymphatics of the liver ramify in the portal canals, beyond which they have not been traced. No vessels of LYMPHATIC VESSELS AND NERVES. 33 this kind accompany the hepatic veins. They seem to be very closely connected with the ducts. If the ducts be injected, bile and the matter of injection are frequently forced into the lympha- tics. About the gall-bladder, too, the lymphatic vessels are very numerous and large. The lymphatics of the gall-bladder pass to glands adjacent to the duodenum and pancreas; those from the interior of the liver run some of them to these glands, others to glands situated on the lesser curve of the stomach, near the cardiac orifice.1 The nerves (derived from the hepatic plexus) enter the liver at the transverse fissure, and run in the areolar tissue in the portal canals. According to Dr. Handfield Jones, nervous threads, which have the usual character of organic nerves, consisting almost wholly of " gelatinous" fibres, are spread in great number over the branches of the portal vein and of the hepatic artery. The larger threads, most of which are parallel to the vessels, continually divide and unite with other threads, so as to form a plexus with elongated meshes. The gall-ducts and the branches of the hepatic vein are also supplied, but very much more sparingly, with nerves of the same kind. The liver also receives some nervous filaments, which come directly from the phrenic nerve, and are distributed to the coats of the hepatic veins. It is conjectured by M. Bernard that these fila- ments from the phrenic nerve govern the contraction of the longi- tudinal fibres which the coats of the hepatic veins contain. No nervous filaments have been traced into the lobules of the liver.2 A knowledge of the structure of the liver enables us to explain the variations so often met with in its size, form, and texture, as well as the various shades of color of which it-is susceptible, and which have so taxed the descriptive powers of morbid anatomists. The mass of the liver is, as we have seen, made up of a plexus of capillary bloodvessels, the meshes of which are filled with nucleated cells containing the peculiar principles of the biliary secretion. 1 Beautiful plates, showing the course of the lymphatics of the liver, may be seen in Mascagni's work on the lymphatic vessels. " Vasorum Lymphaticorum Historia et Iconographia," 1787. 2 Medical Gazette, July 14, 1S4S. 3 34 INTRODUCTION. The size of the liver will, of course, vary in some measure with the degree of congestion; that is, with the quantity of blood in the capillary bloodvessels; but it depends much more on the num- ber and volume of the cells. If, as in fatty degeneration of the liver, the cells are distended with oil-globules, the lobules are large and unusually distinct, the edges of the liver are rounded, and the liver is much increased in size, and thickened. If, on the contrary, the cells be few and small, the lobules will be small, and the lobular structure distinguished with difficulty, unless different portions of the lobules be differently colored by partial injection of the capil- laries ; and the whole liver will be small and thin, or, as it were, flattened. The size of the liver may also be increased by the interstitial deposits of the various products of inflammation; by dilatation of the ducts; and by the growth of cancerous or other tumors. But independently of conditions affecting its structure, the liver may be much altered in form by external pressure. By tight lacing, for instance, the length of the liver from above downwards is often much increased, and its lower portion flattened. The portion of liver above an aneurismal tumor may also be very much flattened, without any marked change of structure. Flatulent distension of the large intestine, even, if long continued, may much alter its out- ward form.1 The firmness of the liver varies, not only with the firmness of the capillary vessels, the quantity of blood they contain, and the proportion of fibrin in the blood, but also in some measure with the state of the cells. A large quantity of oil in the cells tends to render the liver unusually soft. The liver is, however, liable to be much changed in texture by other conditions. It is sometimes extremely soft and frangible, in consequence of chemical changes that there is reason to believe may take place after death; and, in spirit-drinkers, it is often rendered hard, and tough, and granular, by the contraction and induration 1 A short time ago, I met with a remarkable instance of this in a man who died, after having been paraplegic many months, in consequence of disease of the dorsal vertebrae. The large intestine, which had been greatly distended with gas from the commencement of the paraplegia, was found of very large size, and lodged in a deep groove which it had formed in the liver. A cast of the liver was taken, which is now in the museum of King's College. COLOR OF THE LIVER. 35 of coagulable lymph; deposited, in consequence of inflammation, in the areolar tissue in the portal canals. The color of the liver depends on the quantity of blood in the capillary vessels, and on the quantity of oil, and of biliary coloring matter, in the cells. The tint due to the blood varies from pale to a deep venous red, according to the empty or congested state of the capillaries; that due to the cells from a light fawn to a deep olive, according to the quantity of oil-globules and of biliary coloring matter they con- tain. The actual tint of the liver is the combined effect of the tints due to the vessels and the cells, respectively. In persons who haVe died of hemorrhage from the stomach or intestines, or of chronic dysentery, or in great general anaemia, as in the advanced stage of granular kidney, the liver is always found very anaemic, and its color depends almost entirely on the state of the cells. In portions of liver of an orange or green tint, the coloring matter on which this tint depends may always be seen in the cells. It very commonly happens that the capillaries are only partially injected after death, and that the liver, in consequence, presents two colors—a yellowish color, and a red; the former belonging to the uninjected portion, the latter to the injected portion, of each lobule. This gave rise to the notion, which, until the researches of Mr. Kiernan, was held by all anatomists, that there are two sub- stances in the liver—a yellow substance, and a red; which were supposed to constitute, respectively, the medullary and the cortical part of each lobule. It was Mr. Kiernan who first showed conclusively that the mot- tled appearance so frequently observed in the liver is owing to part only of its bloodvessels being full of blood; and that in the great majority of cases in which it exists, the hepatic veins and the capillaries that terminate in them are the full vessels; the portal veins and the capillaries that spring from them, the empty ones. When the twigs of the hepatic vein and the capillaries that ter- minate in them are filled with blood, while the portal twigs and the capillaries that immediately spring from them are empty, the cen- tral portions of the lobules, where the vessels are full, form isolated red spots, while the margins of the lobules, where the vessels are empty, have a color which varies from yellowish white to greenish, 36 INTRODUCTION. according to the quantity of oil-globules and of coloring matter which the cells contain. This appearance is represented in Fig. 9. Fig. 9. Rounded lobules on the surface of the liver, a, centre of the lobules, red from congestion of the hepatic twigs and adjacent capillaries; c, margins of the lobules, pale, from the capillaries being there empty; B, spaces between the lobules, occupied by twigs of the portal vein. (Dia- gram after Kiernan.) When more of the vessels forming the capillary network are filled, the appearances are somewhat different. As the injection extends backwards from the hepatic to the portal twigs, it passes, as before remarked, from lobule to lobule at those points where adjacent lobules are connected by their capillaries; and when the injection has nearly, but not quite, reached those twigs of the portal vein that go to define the lobules, all the capillaries of the lobules will be full, except those immediately surrounding the portal twigs. A section of the liver will still present a mottled appearance, but now the pale portions will be in spots, where the uninjected twigs of the portal vein are divided, and the red portion will form a band continuous throughout the liver. (Fig. 10.) When the entire capillary network is filled, the whole liver is red, but, as was observed by Mr. Kiernan, the central portions of the lobules are still usually of a deeper red than, the marginal portions. It appears, then, that after death the blood in the liver tends to collect especially in the central portions of the lobules. An opinion has been expressed by Mr. Bowman, that this circumstance is owing to the capillaries in the marginal portions of the lobules being sub- ject to greater pressure, in consequence of the cells being there often more distended with oil and larger. COLOR OF THE LIVER. 37 Fig. 10. Lobules on the surface of the liver, a, centres of the lobules, red from congestion of the hepatic twigs and adjacent capillaries; C, places where capillaries uniting contiguous lobules are con- gested ; b, pale spots, where the capillaries springing from the portal twigs are uninjected. (Diagram after Kiernan.) Many circumstances, to be noticed in the following pages, leave little doubt that this opinion is true. When, for example, the liver is in a state of fatty degeneration, and the cells in the lobules are everywhere gorged with oil, and also in what has been termed the scrofulous enlargement of the liver, where the lobules are enlarged by the infiltration of some morbid deposit, the capillaries of the. lobules are usually empty throughout, and the entire substance of the liver is, in consequence, unusually pale. Again, when, from the retention of biliary matter, the cells in the marginal portions have a yellow tinge, it often happens that while the centres of the lobules are deeply injected, and are consequently of a deep red, the marginal portions, or parts of them, are quite empty of blood, and have the yellow color that is due to the cells only. A section of the liver presents, in consequence, that striking contrast of colors which suggested the term " nutmeg" liver. It occasionally happens, however, that the portal veins, and the capillaries, immediately springing from them, are found alone in- jected. The margins of the lobules, and the interlobular spaces, are then red, forming a continuous red band, while the centres of the lobules appear as isolated pale spots. (Fig. 11.) From the pale, uninjected portion being in isolated spots, this condition looks very like that represented in Fig. 10. It was remarked, however, by Mr. Kiernan, that the injected substance 38 INTRODUCTION. Fig. 11. Lobules on the surface of the liver. A, twigs of the hepatic vein in the centres of the lobules, sur- rounded by uninjected capillaries ; c, margins of the lobules, red from the capillaries there being congested ; b, spaces between the lobules, occupied by injected twigs of the portal vein. (Dia- gram after Kiernan.) never has the deep red color that it has when the central portions of the lobules are the part injected. All that is known of this form of partial injection of the capilla- ries is contained in the few observations of Mr. Kiernan, who states that it is very rare, and that he has met with it in children only. Having examined the structure of the liver, we may next con- sider the composition and uses of the Bile. We have seen that the gall-ducts—the channels of the bile—if they do not form terminal plexuses within the lobules, can at least be traced to them ; and it is therefore a fair inference that the con- stituents of the bile are derived, at least in part, from the nucleated cells in the lobular substance. In its passage through the ducts the matter furnished by the lobules becomes mixed with that secreted by the ducts themselves, which, if we may judge from the large quantity of blood the ducts derive from the hepatic artery and the numerous involutions of their mucous membrane, must be considerable in amount. Secretion is always going on, both in the lobules and in the ducts, and the compound fluid derived from these two sources probably passes continuously along the ducts as far as the junction of the hepatic duct with the cystic. When the stomach and duodenum are empty, part only of the bile flows along the common duct into the duodenum ; the remain- der passes down the cystic duct into the gall-bladder. BILE. 39 During digestion, on the contrary, the gall-bladder contracts, and part of the bile accumulated in it, together with all which is brought by the hepatic duct, is poured into the duodenum.1 In the gall-bladder, the bile loses, by absorption, some of its more watery parts, and is further modified by the addition of the proper secretion of that cavity. After death, if it be not soon re- moved from the body, it becomes still further altered. Its more liquid part continues to pass out, giving a greenish stain to the tissues in contact with the gall-bladder, while the serum of the blood and the gaseous and liquid contents of the intestines and the juices of the liver itself pass in the opposite direction through the intervening tissues into the gall-bladder, and become mixed with the bile. The bile in the gall-bladder is of a greenish-yellow color, which varies much in depth, according to the composition of the bile itself and its degree of concentration. If much diluted or thinly spread over a white surface, its color is yellowish, but if concen- trated and seen in mass, it is of a dark green or olive, sometimes approaching to black. It has been described as having a peculiar sickly odor, somewhat like that of melted fat, but the odor of healthy human bile, when fresh and not mixed with intestinal gases, is scarcely perceptible. Bile has a nauseous bitter taste, which leaves behind it- a smack of sweetness. It is more or less viscid, has an unctuous feel, and in many of its physical properties has much in common with soap. It combines readily with water in any proportion, mixes freely with oil or fat, and foams, when stirred, like soapy water; and is, indeed, like soap, in common use for cleaning articles of dress, and especially for taking out grease. It will be seen, hereafter, that these properties are probably closely related to one of the physiological uses of bile. When evaporated, it leaves inspissated mucus, and a variable proportion of a yellow- ish-green matter, which is very bitter, and which dissolves almost completely in water and in alcohol. Bile is heavier than water but its density varies much according to its composition and degree of concentration. That from the gall-bladder of the ox has usually a specific gravity between 1.026 and 1.030. Cystic bile has been generally supposed to have an alkaline reaction, but M. Bouisson and Dr. Kemp, who have lately made observations on this point, 1 Bouisson—De la bile et de sea varietes physiologiques, et de ses alterations morbidus. Paris, 1843. 40 INTRODUCTION. state that when fresh and perfectly healthy, it is neutral—a state- ment confirmed by the still more recent as well as more extensive observations of Gorup-Besanez. Under the microscope, bile, if diluted, gives a yellow stain to the glass, but often presents no definite objects. If, on the contrary, it be dark colored and concentrated, it shows amorphous particles of yellowish-green matter, which is usually collected into small round- ish masses, and is the matter obtained by evaporating the bile.1 In addition to this, a few prismatic cells from the mucous mem- brane of the gall-bladder may be seen, and now and then some oil- globules or small plates of cholesterine. The oil-globules are, pro- bably, usually derived from the lobules of the liver. The plates of cholesterine are generally, if not always, formed in the gall-bladder. They may be there formed, by precipitation, from the bile, which usually contains a certain quantity of this substance in solution; or they may be derived from the coats of the gall-bladder itself. When the coats of the gall-bladder are, as it is termed, ossified, or when the mucous coat is much thickened or otherwise altered in struc- ture, the bile in the gall-bladder generally contains visible cholesterine. The bile in the hepatic ducts is less viscid, and much less bitter, than that in the gall-bladder, and is usually of a bright yellow, even when that in the gall-bladder is dark-green or olive-colored. Under the microscope, it gives a light yellow tinge to the glass, and presents some prismatic cells, but seldom any other object. In the numerous specimens of bile taken from the hepatic ducts that I have examined, I have never seen plates of cholesterine. The darker color and bitterer taste of cystic bile are, no doubt, mainly owing to its greater concentration. In persons who have fasted some time before death, the bile in the gall-bladder is usually very viscid and dark-colored. There are probably more important differences between cystic and hepatic bile than those which result from different degrees of concentration, but little is known on this point.2 It is very diffi- cult to collect bile from the hepatic ducts in quantity enough for a 1 See Bouisson, op. cit., p. 16. 2 Dr. Kemp has lately communicated to the Royal Society some researches which show that the mucus of the bile and the mucous membrane of the gall- bladder exert a highly catalytic action on the constituents of the bile, and that the analysis of bile left in contact with this mucus must consequently lead to varying and unsatisfactory results. See Proceedings of the Royal Society for May 1S56. COMPOSITION OF BILE. 41 complete analysis, and consequently chemists, in their study of this fluid, have confined themselves almost exclusively to bile taken from the gall-bladder. Most chemists, indeed, have been content with bile from the gall-bladder of the ox, which can be obtained in a healthy state, and in sufficient quantity for analysis, more readily than human bile. Cystic bile contains water, the proportion of which, of course, varies very much according to the time the bile has remained in the gall-bladder, or rather according to its degree of concentration. In the often-quoted analysis of bile from the gall-bladder of the ox, by Berzelius, the water amounts to 904.4 parts in 1000. The quantity of water may be readily ascertained by evaporation. Bile also contains mucus, derived from the gall-bladder and gall- ducts, the relative quantity of which, like that of the water, varies very much in different specimens. In the ox-bile analyzed by Berzelius, it amounted to 3 parts in 1000. Lehmann states that the relative quantity of mucus in any specimen of bile varies very much with the manner in which the bile is withdrawn from the bladder; that if it be pressed from the bladder with force, a large quantity of epithelium is detached from the lining membrane of the bladder, which counts in the analysis as mucus; and that when he used every precaution to avoid this source of error, he found in ox-bile only 1.34 parts in a thousand, and in human bile 1.58 parts in a thousand.1 The quantity may be determined by adding to bile a sufficient quantity of alcohol, which precipitates the mucus in flakes, while it dissolves the proper biliary matter. The mucus may also be precipitated by acetic acid. It is chiefly to this ingre- dient that bile owes its viscidity. When the mucus is in large quantity, the bile can be drawn out into threads. Bile likewise contains a considerable proportion of soda, and cer- tain organic constituents, to which last it owes its color and its bitterness. The organic constituents are very readily decomposed, and enter into new combinations with the substances employed to separate them. In consequence of this, different chemists, by em- ploying different methods of analysis, have obtained very different results, but all agree that these organic ingredients are allied to fat in composition, and contain a large proportion of carbon. Late researches have shown that they also contain a certain quantity of sulphur. 1 Lehmann, Physiological Chemistry, translated by Dr. Day, vol. ii. p. 68. 42 INTRODUCTION. The principles to which bile owes its color may be separated from those to which it owes its bitterness. The coloring matters are entirely removed by filtering bile through animal charcoal, and are also thrown down from solution by precipitates of barytes and other earthy salts. In addition to these constituents, bile contains chloride of so- dium, and in smaller proportions phosphate of soda and the earthy phosphates. Chemists have also obtained from bile a small quantity of cho- lesterine, and of other forms of fat, for the most part saponified. In certain states of disease, cholesterine exists in large quantity in the bile of the gall-bladder, forming the chief part of most gall- stones; but in healthy bile it is in very small quantity, and in solution. It is not seen under the microscope. The following is the composition of bile from the gall-bladder of the ox, according to the analysis by Berzelius already referred to:— Water.........90.44 Biliary matter, with fat ..... . 8.00 Mucus of the gall-bladder ...... 0.30 Osmazome, chloride of sodium, and lactate of soda . 0.74 Soda..........0.41 Phosphate of soda, phosphate of lime, and traces of a substance insoluble in alcohol ..... 0.11 100.00 There has been, of late years, an active controversy respecting the state and relations of the organic constituents of bile. The subject has engaged the attention of many distinguished chemists, and their labors have led to several successive changes of opinion, which it is both interesting and instructive to consider. Berzelius, in his later researches, separated from his biliary mat- ter a green and a yellow coloring matter, and small quantities of fat and fatty acids, and obtained a matter which he termed biline, and which he considered the chief and the peculiar constituent of bile. Biline, which is composed of carbon, hydrogen, nitrogen, sulphur, and oxygen, is a soft substance, of a light yellow color, without smell, and having a bitter, and at the same time a sweetish, taste.1 It is soluble in water and in alcohol, insoluble in ether, 1 Berzelius conjectured that the sweet taste might be due to glycerine, engen- dered by saponification of the fat contained in the bile. COMPOSITION OF BILE. 43 and, when obtained by evaporation from alcohol, reddens litmus- paper. It is readily metamorphosed by various agents, and espe- cially by heat and acids. Most chemists have inferred that the organic constituents of bile are combined in some way with the soda. M. Demarcay, in an elaborate paper published in 1838,1 advanced the opinion that bile is not a very complex secretion, as it was then generally supposed to be, but that its essential principles consist of a single resinous acid, which is combined with the soda, forming a substance analogous to soap. He termed this resinous acid choleic acid, and consequently considered bile, abstracting the mucus and coloring matters, to be little more than choleate of soda. This view of the composition of bile brought us back to the doctrine which, before the elaborate researches of Thenard ancj others, was generally held, that the bile is an animal soap whose base is soda: a doctrine which seemed sanctioned by the physical qualities of bile already noticed—by its solubility in water, its consistence, its ready frothing, the readiness with which it takes up spots of grease or fat, and by the fact, then known, that it con- tains a fatty matter and an alkali. The subsequent researches of Dr. Kemp, Liebig, and others, tended to confirm the conclusions of Demargay; but the organic substance which is united with the soda, from being readily decom- posed, was found to vary somewhat in its properties, according to the process by which it was obtained. In ox-bile, this compound of the organic principles of the bile with soda (that is to say, bile freed from water, mucus, coloring matter, and fat) consists, according to the analysis of Dr. Kemp,2 of the following ingredients: . 59.90 . 8.90 Carbon . Hydrogen Nitrogen Oxygen Sulphur Soda Chloride of sodium 3.40 17.63 3.10 6.53 0.54 100.00 1 Annales de Chimie et de Physique, torn, lxvii. p. 177. 2 Chemical Gazette, vol. iv. p. 472. 44 INTRODUCTION. The opinion that the organic constituents of bile are combined with the soda, was to some extent further confirmed by Dr. Plat- ner, of Heidelberg, who succeeded in causing fresh ox-bile, which had been dried by evaporation in a water-bath, and freed from mucus, and from the greater parts of its salts, by repeated solution in alcohol, to crystallize. He says: "For this purpose nothing further is necessary than to add ether repeatedly to as strong an alcoholic solution of the bile as possible, and then to set it aside in a cool place. The principal and most important constituent of the bile then crystallizes; but from one-sixth to one-fourth of the bile used does not crystallize, but remains as a yellowish-brown syrupy liquid. I have not been able to separate this in any manner from the crystals; consequently, I can say nothing more concerning its pature. It is, however, evidently a different substance from the principal constituent of the bile, perhaps even a product of its decomposition."1 Crystals thus obtained have been analyzed by F. Verdel, under the direction of Liebig. After separation of the chloride of sodium, with which they are contaminated, he found that they were com- posed of2— Carbon . . 59.37 Hydrogen Nitrogen Oxygen Sulphur Soda 8.91 4.22 16.18 3.83 6.99 100.00 It will be seen that the result of this analysis does not differ much from that of the analysis of the dried and purified bile, by Dr. Kemp, which is given above. _ Many attempts have been made to elucidate the composition of bile by studying the products of its decomposition. It was found by Mulder that when ox-bile undergoes decompo- sition spontaneously, or by the prolonged action of hydrochloric acid, it is resolved (with the exception of the fats, coloring matters, 1 Chemical Gazette, vol. iii. p. 186. Muller's Archiv. 1844. Chem. Gaz., vol. ii. p. 515. Muller's Archiv. 1844. Heft ii. 2 Chemical Gazette, vol. iv. p. 480. Heft v. See also COMPOSITION OF BILE. 45 and salts) almost entirely into three products—taurine, ammonia, and a substance which forms various acids, differing from each other merely in containing different proportions of the elements of water. All these acids pass into a well-characterized acid, cho- loidic acid (Demarcay), and, as the ultimate product of decomposi- tion, into dyslysine} Taurine, which contains nitrogen and all the sulphur of the bile, is a neutral body, and forms beautiful transparent six and four sided prisms, with oblique terminal faces. It is readily dis- solved in water, but is insoluble in alcohol. The composition of taurine, which is expressed by the formula C4H7NS206 is as fol- lows :— Carbon..... . 19.28 Hydrogen ..... . 5.73 Nitrogen..... . 11.25 Sulphur..... . 25.70 Oxygen..... . 38.04 100.00 Choloidic acid, which contains no nitrogen or sulphur, is a white substance, easily reduced to powder, insoluble in water, and very sparingly soluble in ether, but readily soluble in alcohol. It com- bines with alkalies, forming salts, which are soluble in water and in alcohol, but insoluble in ether; and which have a purely bitter taste. It consists (dried at 212° F.) of— Carbon......72.18 Hydrogen......9.77 Oxygen......18.05 100.00 and is expressed by the formula C48H3909. Dyslysine is a tasteless, resinous substance, insoluble in water and in cold alcohol, sparingly soluble in boiling alcohol, but soluble in ether. Its composition is expressed by the formula C48H3606. Some researches on ox-bile, recently made by Dr. Strecker,2 in 1 Chemical Gazette, vol. v. p. 317. 2 See Chemical Gazette, vol. vi. p. 49 ; or, Comptes Rendus, Decembre 13, 1847. Chem. Gazette, vol. vi. p. 149; or, Comptes Rendus, xxvi. p. 38. Chem. Gazette, vol. vii. p. 49; or, Ann. der Chem. und Pharm., lxvi. p. 1. 46 INTRODUCTION. the laboratory of Liebig, have given us more insight into its con- stitution. They have shown that the biliary matter which is com- bined with the soda (the choleic acid of Demarc,ay), may be resolved into two acids; both containing hydrogen, and one of them con- taining sulphur. The acid that is free from sulphur (CS2H43N012) may be further resolved into glycine, the sugar of gelatine (C4H5N04), and an acid, which contains no nitrogen, to which Dr. Strecker has given the name cholalic acid. This acid, which is the cholic acid of Demar§ay (C48H40O10), when boiled with strong hydrochloric acid, or when exposed to a high temperature, is converted, by the loss of part of its water, into choloidic acid, and ultimately, by a still further loss of water, into dyslysine. The sulphuretted acid of ox-bile (C52H4JNOi4S2) may, in like manner, be resolved into cholalic acid and taurine. It has, there- fore, a similar constitution to its fellow acid, with taurine in the place of glycine. When acted on by strong acids it yields taurine, choloidic acid, and dyslysine. If we use the simpler term, cholic acid, to express the cholalic acid of Strecker, the two acids above mentioned, of which glycine and taurine are respectively the adjuncts, may therefore be termed glyco-cholic and tauro-cholic acid. Tauro-cholic acid contains six per cent, of sulphur. Now, as the dried and purified bile of the ox contains only three per cent. of sulphur, it follows that, in ox-bile, glyco-cholic and tauro-cholic acids exist in nearly equal proportions. Dr. Strecker has further shown that tauro-cholic acid, and its compound with soda, dissolve cholesterine very readily; while glyco- cholic acid has very little solvent action upon it. He has thus ren- dered it probable that tauro-cholic acid is the chief solvent of the cholesterine of the bile. An admirable test for cholic acid, whether it exist alone or in combination with glycine and taurine, or in the form of its deriva- tive, choloidic acid—which may, therefore, be considered a test for bile—was discovered a few years ago by Pettenkofer, in the change of color produced in it by addition of sugar and sulphuric acid. The following are directions for applying the test:— Dissolve the alcoholic extract of the fluid to be tested for biliary matter in a little water; then mix with it a drop of a solution of any kind of sugar (in the proportion of one part of sugar to four COMPOSITION OF BILE. 47 parts of water); and afterwards add to the mixture pure sulphuric acid, free from sulphurous, in drops. If biliary matter be present, the fluid now becomes turbid, but on the gradual addition of sul- phuric acid it clears again. For the first few moments its color is yellowish, but it soon becomes red, and passes through purple to a deep violet. In using the test, care must be taken not to employ too much sugar, which is rendered brown or black by sulphuric acid; and also properly to regulate the temperature of the fluid, which should nearly reach, but not much exceed, 120° F. Sufficient heat may generally be produced by the addition of the sulphuric acid. The bile of the ox, when perfectly fresh, seems to be very con- stant in composition. In the numerous specimens, analyzed by different chemists, at different times and in different countries, the chief constituents have been in very nearly the same relative pro- portions. The same is probably true of other animals. Dr. Strecker could find no difference between the bile of a dog fed upon flesh, and that of a dog which had been kept on a vegetable diet. It was long ago stated by Dr. Kemp {Cambridge Phil. Trans., vol. viii. p. 1), that human bile differs in some respects from that of the ox. After the discovery of sulphur in bile, it was found that this ingredient exists in very different proportions in the bile of different animals. Dr. Bensch found that while dried ox-bile, free from mucus and coloring matter and fat, contained, after deduction of the ash which it leaves on calcination, from 3.5 to 4 per cent, of sulphur:1— Sulphur. The bile of the calf contained......5.62 per cent. sheep goat bear wolf fox chicken dog serpent Dr. Strecker has analyzed the bile of various kinds of fish, and of many of our domestic animals, and his investigations show that 6.46 5.55 6.38 5.03 5.56 5.57 6.21 7.20 1 Chemical Gazette, vol. vi. p. 50; or, Comptes Rendus, Dec. 13, 1847. 48 INTRODUCTION. the bile of most animals contains essentially the same organic con- stituents, but that, in different animals, the organic substance con- taining sulphur, and that which contains no sulphur, are in different proportions. The most striking deviations were found in the bile of the pig, which contains an extremely small quantity of sulphur, and in the bile of marine fish, where the soda of ox-bile is replaced in great part by potash. It is certainly, as stated in the account of Dr. Strecker's investigations, published in the Chemical Gazette, vol. vii. p. 430, "a remarkable circumstance that the bile of marine fish living in sea-water, which is so abundant in soda, principally con- tains potash; whilst in the bile of the ox, the food of which abounds to such an extent in potash, the ash consists of a large quantity of soda, with mere traces of potash." Few complete analyses have been made of human bile, which it is more difficult to obtain fresh, and in sufficient quantity, and when wanted, than the bile of many of the lower animals. Human bile resembles ox-bile in its physical qualities, and on decomposition yields the same products—taurine, ammonia, and choloidic acid. There is every reason, therefore, to infer that it is formed of the same constituents, though most probably in somewhat different relative proportions. Little has been yet said respecting the coloring matters of bile. These, however, are very important, at least with reference to medi- cal practice, because, when they are not duly eliminated by the liver, they tinge the complexion, and impart a darker color to the urine, and thus give early intimation that the secretion of the liver is defective, or that the course of the bile into the intestine is im- peded. Of defective action of the kidney, we have no such obvious ocular proof, and it often happens, in consequence, that the various ill effects of it are not traced to their source. The coloring matters of bile have different tints, of green, yel- low, and brown, in different animals. The bile of herbivorous ani- mals is usually green; the fresh bile of carnivorous animals gene- rally varies from a yellow to a yellowish-brown. In animals, how- ever, whose hepatic bile is yellow or brown, the concentrated bile found in the gall-bladder, after long fasting, has always more or less of a green tint. In the bile of the ox, which has been most frequently chosen for analysis, there have been distinguished a green pigment and a yellow pigment; and it has been shown, by COLORING MATTERS OF BILE. 49 Berzelius, that the green pigment, of which the yellow pigment is probably a modification, is identical with chlorophyl—the green coloring matter of plants. This matter is very readily modified by chemical influences, and its exact composition has not been determined; but it contains a large proportion of carbon and hydrogen, and from seven to nine per cent, of nitrogen. The brown bile-pigment of other animals seems to be also a modifica- tion of the same substance. When exposed to the air, it absorbs oxygen, and becomes of a dark green.1 Nitric acid, also, by its oxidizing influence, renders it of a dark green, which soon, how- ever, passes into various shades of red. A similar change of color is produced, by similar influences, in the leaves of plants. The various shades of yellow, brown, and pink, which the leaves present in autumn, are all owing to the action of oxygen on their coloring matter, when, at the appointed time for their decay, they can no longer resist the chemical influence of the air. Dr. Bence Jones has given various good reasons for believing that the urine mainly owes its color to the same source; and that the various shades of yellow, brown, and pink, which the sediments of the urine present, like the similar tints of the autumnal leaves, are due to different degrees of oxidation of the peculiar matter to which the green color of plants and of the bile is owing. This hypothesis may serve to account for the influence, frequently to be noticed in the following pages, which organic diseases of the liver have in causing red and pinkish sediments in the urine. The successive shades of blue, green, and yellow, which are seen in a bruise-mark on the skin, and which are so like the tints of the bile, long ago suggested the hypothesis, that the coloring matters of bile are derived immediately from the red coloring matter of the blood.2 Late researches tend to confirm this hypothesis, and thus 1 It has been inferred by Lehmann that the green tint acquired by yellow or brown bile, when long retained in the gall-bladder, likewise depends on the influ- ence of oxygen, which it then abstracts from the circulating blood.—Physiological Chemistry, vol. ii. p. 505. 2 M any considerations render it probable that the coloring matter of bile is de- rived from that of the blood. Saunders says : " Green and bitter bile being in common to all animals witli red blood, and found only in such, renders it probable that there is some relative connection between this fluid and the coloring matter of the blood, by the red par- ticles contributing more especially to its formation." A few years ago, Professor Schultz revived this notion, and dressed it up with •f? 50 INTRODUCTION. render it probable that the peculiar colors of bile, urine, and blood, result from different modifications of the same pigment. The color- ing matter of the bile has a strong tendency to combine with bases —with alkalies, metallic oxides, and alkaline earths. With the alkaline earths it forms insoluble compounds, of which the nuclei of gall-stones mainly consist. The bile, in man, has been supposed to be ultimately derived from two sources. It is clear enough that, in most circumstances, a large proportion of the proper principles of bile is derived from the waste of the body, and is a product of the metamorphosis of the tissues and of materials stored away in the system. In the hybernating animal during its winter sleep, in the foetus, and pro- bably in the carnivora, these materials are its only source. And under certain conditions, the same must be the case in man also. In protracted abstinence, for example, bile continues to be formed, and sometimes in considerable quantity. Here, the living tissues gradually waste away, and their materials are discharged in the excretions. The three principal outlets at which they make their appearance, are the liver, the lungs, and the kidney. Nitrogen predominates in the compounds which escape through the last- named organ, while the two former separate principally carbon and hydrogen. But while the liver and the lungs have thus much in common, there is this important difference between them : that in the lungs the carbon and hydrogen pass off burnt—that is, fully combined with oxygen, as carbonic acid and water—while in the liver they escape only partially combined with oxygen, and still combustible. From which it would appear, that the larger the amount of these elements discharged by the lungs as carbonic acid and water, the less, ceteris paribus, must remain unburnt, to form the constituents of bile. So that here we already meet with a fundamental and important relation between the secretion of bile much fanciful speculation. He is of opinion that in the liver the blood sheds the coloring matter of the effete blood corpuscles, and thus becomes revivified. Bouisson, again, says : " Burdach fait observer, que lorsqu'il se forme du sang rouge dans l'ceuf de poule, le jaune fixe au feuillet mnqueux acquiert une colora- tion verdatre, en sorte qu'il reste demontre qu'il a coincidence entre la sanguifica-; tion et la separation d'une matiere verte." Quite recently the same opinion has been advocated on various grounds by Polli, an Italian physiological chemist, by Lehmann, and by G. Besanez, who considers a strong confirmation of it to be the presence (which he has ascertained on several occasions) of a notable quantity of iron in bile. QUANTITY OF BILE SECRETED. 51 and the great function of respiration. I shall not, however, dilate upon this topic at present, as we shall again have to consider it in endeavoring to follow the bile to its final destination. To return from this digression. It appears, then, sufficiently clear, that the proper principles of bile are in part derived, like those of the urine, from the waste of the tissues. There can be little doubt that the nitrogen of the bile is always derived from the metamorphosis of the nitrogenous tissues ; but it has been supposed that in man, and in all animals which live on a mixed diet, those articles of food which are devoid of nitrogen also contribute di- rectly to the elements of bile. Liebig, indeed, imagines that, as regards the horse and the ox, he has fully established this by means of quantitative analysis—showing that the bile these animals se- crete in a day contains more carbon than all the albumen, fibrin, and casein of their food (the protein-elements of modern chemists) put together; more carbon, therefore, than can be derived from the waste of the tissues which these elements go to repair; and that, consequently, the remainder, at least, must needs be furnished immediately by the food, and by those constituents of it which con- tain no nitrogen. If this be so, there is every reason to presume that these same principles, which form a large and staple ingredient in the food of man, play in him, also, the same part. But the calculations of Liebig are open to very serious, if not fatal, objections. The calculations are founded on the supposition that a horse or an ox secretes daily thirty-seven pounds of bile, as concentrated as that usually found in the gall-bladder. This would yield about forty ounces of carbon; whereas the animal consumes in the form of vegetable albumen, fibrin, and casein, only about four ounces and a half of nitrogen, which, reckoning from the known composition of these substances, would give not quite six- teen ounces of carbon. The carbon of the bile is, therefore, greater in amount than all the carbon in the protein elements of the food, in the proportion of 40 to 16. Such is the argument. Its weight all depends on the truth of the assumption, that thirty-seven pounds of bile, as concentrated as that usually found in the gall-bladder, are secreted daily—an assumption which, without much stronger evidence of its truth than we have at present, surely ought not to be made the basis of important doctrines, which confessedly rest solely on relations of quantity. Considering the size of the gall- bladder of the ox, thirty-seven pounds seem an enormous quantity 52 INTRODUCTION. of bile to be secreted in a day, and if the daily secretion should turn out to be only a quarter the amount—and few physiolo- gists, we imagine, would rate it nearly so high even as this—the argument falls to the ground.1 It,is clear that before we can draw any safe conclusions on this point, or trace the bile to its ultimate destination, by means of quantitative analysis, we must have some estimate of the quantity of bile daily secreted under ordinary circumstances. This must necessarily be one of the starting points in any such inquiry. Many attempts have been made to estimate the quantity of bile daily se- creted by a man in a state of health; but, as might have been expected, the conclusions come to are wide apart, and little confi- dence can be placed in the greater number of them. Some phy- siologists, believing the bile to be chiefly excrementitious, and looking to the small size of the gall-bladder and the small quantity of bile ordinarily discharged from the bowels, have estimated it at a very few ounces; while others, regarding the large size of the liver, and believing that most of the bile secreted is again absorbed from the bowel to serve ulterior uses in the body, have rated it, with Burdach and Haller, at from seventeen to*iwenty'rfour ounces. It is plain that the amount of the proper principles of bile se- creted in a day must, like that of urinary ingredients, vary widely in different persons, and in the same person under different circum- stances. The amount may be modified by the degree of waste in the body; by the activity of respiration ; by the quantity of matter thrown off by the kidneys and the skin; and, directly or indirectly, by the quantity and quality of the food. In some circumstances, a quantity of bile, as large as the esti- mate of Burdach or Haller, may certainly be secreted for a con- siderable time together. A very interesting case showing this, was read to the Medico-Chirurgical Society in the spring of 1844, by Mr. W. E. Barlow, of Writtle, Essex. 1 The hypothesis that a horse or an ox secretes thirty-seven pounds of bile in a day has no other foundation than a calculation by Schultz, that, in an ox, it would take as much bile as this to neutralize the acid of the chyme. It is strange that Liebig should have adopted the estimate so unhesitatingly on the authority of Burdach, who not only states this to be the ground of it, but also draws the infer- ence, that if the estimate be correct, and the ox secrete daily ten pounds of saliva, the quantity Schultz supposed to be secreted by the horse, the quantity of the two fluids secreted in a day would together equal the whole mass of the blood ! (See Burdach's Phys'ologie, t. vii. p. 439.) QUANTITY OF BILE SECRETED. 53 A strong healthy man, a thatcher, fifty-four years of age, injured him- self by lifting a heavy ladder, on the 28th of August, 1843. When seen by Mr. Barlow, the same day, he complained of so much pain in the region of the liver that a rupture of that organ was apprehended. He was very taint, in a cold sweat, and the pulse could scarcely be felt. Some brandy and water was given him, and he recovered sufficiently to be taken to his own house, which was about three miles distant. Five grains of calomel and a grain of opium were given him at night, and-an ounce of castor oil the following morning, which operated and produced several natural evacuations. On the 29th he was bled, and continued the calomel and opium, with a dose of saline mixture, every five hours. On the 30th it was observed that the evacuations from the bowels were white and without bile, while the urine was dark, as in jaundice. Five grains of blue pill were ordered every six hours. As the pain in the region of the liver continued, the bleeding was re- peated at different times, and a blister was applied over the right hypo- chondrium. The same medicine was continued till the 15th of September, when a swelling of the size of a walnut was observed over the region of the liver. This gradually increased, and on the 9th of October was so large, and caused so much pain from distension, that it was thought proper to tap it. Seven quarts of fluid were drawn off, which from its color and taste appeared to be pure bile. The pain was instantly relieved, and the swelling entirely subsided. The fluid collected again, and it was necessary to repeat the tapping on the 21st of the same month, when six quarts and a half of fluid were drawn off. This fluid was analyzed by Dr. Pereira, Dr. Gr. 0. Rees, and Mr. Taylor, and found to be composed in great part of bile. Dr. Rees guessed the proportion of bile in the fluid to be at least eight parts in ten. On the 31st of October he was tapped again, and seven quarts were drawn off. On the 9th of November the operation was repeated for the fourth time, when six quarts were withdrawn. On the 18th of November he was taken to St. Bartholomew's Hospital, and tapped again, when nine pints of fluid escaped. On the 26th of November he was tapped for the last time, when only three pints escaped. The cyst was not emptied as in the former operations, and he suffered extreme pain from the tapping, which he had not previously done. On the following day, bile appeared in his stools, and the urine was lighter colored. On the 3d of December, the motions were of proper color, containing plenty of bile. The swell- ing gradually subsided, and towards the end of the month he became quite convalescent. In the beginning of February he was able to walk eight or ten miles; and, when an account of his case was presented to the Soeiety, appeared to be in good health.1 It appears here that in twelve days, from the 9th of October to the 21st, thirteen pints of fluid accumulated in the sac. If, as Dr. Rees believed, four-fifths of this consisted of bile, nearly ten pints and a half of bile must have been discharged—not very far short 1 The Medico-Chirurgical Transactions, vol. xxvii. p. 378. 54 INTRODUCTION. of a pint a day. The quantity of fluid discharged at the two subse- quent tappings was still larger in proportion to the time, but of this fluid no analysis seems to have been made. In a note appended to the account of this case in the Society's Transactions, Dr. Cursham gives references to other cases of a similar kind. One of these, by Mr. Fryer, of Stamford, in the fourth volume of the Medico-Chirurgical Transactions, accords in almost every particular with the case just related, except that the subject of it was a boy thirteen years of age, and that the quantity of fluid discharged at the successive tappings was still larger in proportion to the intervals between them. The fluid was not analyzed, but had, it is stated, the appearance of pure bile. In this case, as in the former, mercury was given. We should not, of course, be warranted in assuming from these cases that the same amount of bile is secreted under ordinary cir- cumstances; or, at any rate, in drawing from such an estimate any important physiological inference not warranted by other reasons. The secretion of bile is continuous, but varies in amount accord- ing to the state of digestion. Bidder and Schmidt, in an extensive series of experiments on cats, found that in these animals it attained its maximum from ten to twelve hours after a full meal; and that in continued starvation it gradually and continuously diminishes.1 It has long-been a question whether the peculiar principles of the bile are formed in the liver, or whether they exist ready-made in the blood, as the result of the waste of the tissues in other parts of the body, and are merely strained off from the blood in the liver. There is now little doubt that the peculiar biliary acids are formed in the liver, through the agency of the secreting cells, for the most distinguished chemists have failed to detect them in the portal blood, and even in the blood of persons affected with jaundice.2 1 See Lehmann, vol. ii. p. 87. 2 Lehmann states, that he has constantly failed to detect the peculiar biliary acids, even in large quantities of the portal blood of horses, and supposes that chemists who have imagined they have detected these acids in the blood, have been led into error by the circumstance that olein and oleic acid give a reaction on Pettenkofer's test very like that of bile. He states that the reaction of oleic acid differs from that of the bile only in this, that it takes place more slowly, and requires the entrance of atmospheric air. It has also been ascertained, that oil of turpentine, oil of cumin, and some other volatile oils, give a similar reaction on Pettenkofer's test. The rich brown color that must result from the action of the sulphuric acid on the sugar, when cane-sugar is employed in the test, is also likely to mislead. FUNCTION OF THE LIVER. 55 Again, the peculiar coloring matters of bile cannot, according to Lehmann and other chemists, be detected in the portal blood, and must, therefore, at least for the most part, be formed in the liver itself. It has been clearly shown that the coloring matters of bile are most probably derived from those of the blood, and we are, therefore, led to the inference that the transformation is effected, at least for the most part, in the liver. It will be seen in the follow- ing pages that very extensive structural changes in the liver—in the fatty liver, the gin-drinker's liver, the scrofulous liver—may exist without jaundice; and that in those cases in which jaundice results from permanent closure of the common duct, the jaundice sometimes lessens after the lapse of many months, and when the secreting cells of the liver are almost entirely destroyed. In secreting bile, the liver serves unquestionably very important purposes. The large size of the liver, and its existence in all animals, down almost to the lowest in the animal scale, leave no doubt on this point: but it has long been a question among phy- siologists—What these purposes are ? At one time it was supposed that the chief purpose of the liver, like that of the kidneys, is to purify the blood, by separating from it noxious and effete principles that result from the waste of the tissues. There can be no doubt that the liver effects a purpose of this kind. Much of the sulphur of the bile, and much of the color- ing matters of the bile, are discharged from the intestine, and must be regarded as a real excretion, the result of waste of the organic constituents of the blood or tissues : and the liver must further tend to maintain the purity of the blood, by ridding it of other matters foreign to its composition. It will be remembered that all the blood sent to the stomach and intestines has to pass through this organ before it can again mix with the venous blood from other parts of the body. Now the blood that has come from the stomach and intestines must necessarily be charged with many impurities besides those derived from the mere decay of the tissues. Along the extensive mucous tract with which everything we eat or drink is brought in contact, absorption is constantly going on, and vari- ous matters must therefore enter the portal vessels, not fit by their nature to form blood or to serve any other purpose in the body. Many of these substances are intercepted, at least in part, in their transit through the liver, and, according to their kind, are either DJ INTRODUCTION. fixed there, or are gradually cast out of the system with the bile. This, indeed, has been fully proved with respect to many of the metallic salts. In animals poisoned by arsenic, antimony, the solu- ble salts of lead, and corrosive sublimate, these substances have been found in greater quantity in the liver than in other organs, even when death occurred a considerable time after they were swallowed; and copper, derived probably from cooking utensils and food, has often been found in human bile and gall-stones. The retention of noxious matters in the liver, and their elimination through it, are doubtless the cause of many biliary disorders. It was long ago conjectured that the liver is a blood-making organ—that, in some way or other, it is instrumental in the gene- ration or restoration of the blood-corpuscles—but no distinct evi- dence that such is the case was adduced. Modern physiologists and chemists, especiaDy Bernard and Lehmann, have investigated the changes which the blood undergoes in its passage through the liver, by making a chemical and microscopic examination of the blood as it enters the liver by the portal vein, and as it issues from it by the hepatic vein, and their investigations have led to very remarkable results. One of the results of microscopic observation is, that in blood drawn from the hepatic vein the colorless corpus- cles are very much more numerous than in blood drawn from the portal vein, leading to the inference that the colorless corpuscles, which appear to be the first stage in the formation of the red cor- puscles, are generated in great quantity in the blood in its passage through the liver. Again, the red corpuscles differ in their ap- pearance, and in their chemical and vital properties, in the two kinds of blood. The red corpuscles, in blood drawn from the hepa- tic vein, have not the same color as those in blood drawn from the portal vein ; their capsules, according to Lehmann, do not disappear so readily on the addition of water; and they are not so apt to arrange themselves in rolls. The red corpuscles of the hepatic blood have a sharp outline, and do not exhibit the spotted appear- ance and irregular forms that have been remarked in the portal blood. These observations show that the visible organic constitu- ents of the blood are much modified in their passage through the liver, and they probably justify the opinion that the chief office of the organ is the generation, or, as it has been termed, the rejuvene- scence of the blood-corpuscles. The blood in its passage through the liver undergoes other changes made known to us by chemical analysis. It has been FUNCTION OF THE LIVER. 57 lately discovered by M. Bernard that sugar is habitually formed in considerable quantity in the liver, and that there are, if we may so speak, two secretions going on in the liver—the secretion of bile, which escapes by the gall-ducts, and the secretion of sugar, which is absorbed into the blood. The sugar formed in the liver is the sugar of diabetes, which closely resembles the low sugar of grapes —it turns brown when boiled with liquor potassae, reduces the salts of copper in Trommer's and Barreswil's tests, rapidly under- goes fermentation on the addition of yeast, and in the polarizing apparatus turns the luminous ray to the right. M. Bernard has investigated with singular ability the conditions which increase or diminish the formation of sugar, and his discovery is one of the most remarkable and most promising achievements of modern science. The following are the principal points established in this in- quiry :— 1. That, in a state of health, sugar exists in the liver of man, and of other classes of animals, carnivorous as well as herbivorous, down to the lowest in the animal scale, but exists in no other organ, except during foetal life. In the fresh liver of the ox, the quantity of sugar amounts to 1.79 parts in 100. In the livers of two men who had died by the guillotine, it amounted respectively to 1.79 and 2.142 parts in 100. 2. That sugar exists in the liver in animals kept many days without food, and in dogs and other animals long fed entirely on flesh, in whom no sugar is formed in the stomach during the pro- cess of digestion—showing that the sugar which exists in the liver is not introduced from without, but is formed in the body, and that independently of the nature of the food. 3. That sugar exists in the blood which has passed through the liver in carnivorous animals and in animals kept some days without food, when there is no sugar in the blood which enters the liver by the portal vein or by the hepatic artery: and that in other circum- stances, when sugar exists in the blood entering the liver, there is much more sugar in the blood leaving the liver—showing that the sugar is formed in the liver itself. Other observations show that the sugar so formed is secreted by the cells of the lobular substance, that it may be formed in the liver in certain amount even after death, and that it is carried out of the liver, not only in the current of blood, but also by the 53 INTRODUCTION. lymphatics. It has not been discovered in the bile, even in ani- mals in whom a biliary fistula has been established, and therefore either does not pass off by the gall ducts, or is absorbed or rapidly transformed in them. The quantity of sugar secreted varies according to the stage of digestion. Whatever be the nature of the food, the secretion of sugar increases as soon after a meal as intestinal absorption begins,1 and attains its maximum in about four or five hours; it then gra- dually diminishes until the next meal. In a dog fed on flesh, the proportion of sugar in the blood of the hepatic vein varies from 1 per cent., which is about its amount in the fasting state, to 1| or 2 per cent., when the formation of sugar has reached its height. We have already seen that the secretion of bile has similar varia- tions in amount, dependent on the digestive process; but it appears from Bernard's researches that the oscillations in the secretion of sugar are not synchronous with the oscillations in the secretion of bile, the greatest secretion of sugar, in dogs, taking place in about four or five hours after a meal, while, according to extensive re- searches by Bidder and Schmidt, the greatest secretion of bile takes place in these animals from 13J to 15J hours after the last meal.2 The phenomena of disease show that the two secretions are not commensurate. An abundant secretion of bile is not attended with saccharine urine, and an excessive secretion of sugar in diabetes is not, as far as we can judge, necessarily attended by an excessive secretion of bile. The sugar passing out of the liver by the veins and lymphatics at once enters the general current of blood, and is rapidly trans- formed. In a healthy animal, the quantity that enters the blood in the intervals of digestion is all transformed in the lung, so that not a trace of it can be found in the arterial blood. During digestion, when its quantity increases, some of the sugar may escape trans- formation in the lung, and be sent in the arterial blood to every part of the body; but it is not then found in the urine or other 1 Starchy or saccharine articles of food increase the quantity of sugar in the system, because the sugar absorbed from the intestinal canal is then added to that which is formed in the liver. According to the observations of Bernard, cane- sugar absorbed from the intestinal canal is transformed into diabetic or liver-sugar in passing through the liver. 2 See Bernard, Lecons, 1854-5, p. 93; Lehmann, Physiological Chemistry, vol. iii. p. 506. FUNCTION OF THE LIVER. 59 secretions, and must therefore be transformed in the blood. It is only when the secretion is so increased as to constitute disease that the sugar passes off in the urine, and the diabetic state is produced. What precise transformation the sugar undergoes in the blood is still uncertain. From some experiments made to determine this point, Bernard concludes that its transformation is not effected by the immediate influence of oxygen—that the sugar is not burnt in the lung, and exhaled as carbonic acid—and that it must undergo transformation by the lactic, or some other fermentative process. The most remarkable results which Bernard has arrived at are those which relate to the influence of the nervous system in con- trolling and modifying the secretion of sugar. The principal of these results are the following:— 1. That division of the pneumogastric nerves in the neck arrests the formation of sugar. If this operation be performed on a dog, and the animal be killed three days after, not a trace of sugar can be found in the blood of the hepatic vein or in the substance of the liver itself. 2. A second result, which, on its first announcement, was very startling, is, that in all animals in which he could perform the ex- periment (dogs, rabbits, guinea pigs), lacerating the floor of the fourth ventricle between the auditory nerves and the par vagum increases the formation of sugar to such a degree that a large quan- tity of sugar passes .off in the urine, and the creature is rendered diabetic. The diabetic state continues some days, until the injury is repaired, after which sugar can no longer be found in the urine. Bernard states that the experiment which led to this singular re- sult was suggested by his having noticed, in making experiments with another purpose, that pricking the pons Varolii at the origin of the fifth nerve caused an abundant secretion of tears and saliva. He further found that irritation of the floor of the fourth ventricle increases the secretion of sugar in the liver when the par vagum has been divided in the neck—showing that the nervous influence exciting the secretion is transmitted to the liver, not down the pneumogastric nerves, but down the spinal marrow. This last conclusion was confirmed by another result, that division of the spinal marrow below the brachial enlargement puts a stop in all cases to the production of sugar. Bernard hence infers that the nervous influence that ordinarily excites the secretion of sugar is a reflex influence—that it passes up 60 INTRODUCTION. the pneumogastric nerves to the nervous centre (medulla oblongata or brain), and thence down the spinal marrow, and along the spinal nerves and the branches of the great sympathetic communicating with them, to the liver. This inference has been confirmed by the observation that when the pneumogastric nerves are divided in the neck, an operation which usually arrests the secretion of sugar, the secretion may be excited again by galvanizing the upper or central ends of the divided nerves. The fact that division of the pneumogastric nerves in the neck ordinarily arrests the formation of sugar, shows that an influence is ordinarily transmitted along them to the liver, and Bernard in- fers that this influence has its origin in the lungs, and that it is excited by the impression made by the air on the nervous filaments in the lung. He states that although the formation of sugar is stopped when the pneumogastric nerves are divided in the neck, it goes on just as usual when the nerve is divided lower down be- tween the lung and the liver. The readiness with which the presence of sugar can be detected has enabled him to determine the influence of other conditions in increasing or lessening the formation of sugar, and to ascertain that its formation, like the secretion of the salivary and other glands, is increased during the apoplectic state, and that it is arrested by long-continued abstinence from food, by severe pain, and by fever. This last circumstance explains the fact, that sugar cannot generally be found in the livers of persons who die of disease. The formation of sugar coincidently with the rapid development of the colorless corpuscles of the blood in the liver has suggested to Bernard the theory that, in animals as in plants, the presence of sugar is requisite for the most rapid development of cells; and that whatever other purposes in the animal economy the sugar may serve, its chief use is in the formation of the blood-corpuscles. It is a curious fact, in connection with these researches, that diabetes may exist when much of the lobular substance of the liver has been destroyed by cirrhosis, and when, in consequence of this disease, the secretion of bile is defective and the passage of blood through the liver much impeded. In the winter of 1840, a man who had long been addicted to spirit-drinking was admitted, under my care, in King's College Hospital, with great ascites and all th FUNCTION OF THE LIVER. 61 other symptoms of the gin-drinker's liver; but, in conjunction with these symptoms he had saccharine diabetes. At the time of his admission to the hospital he was passing daily from ten to twelve pints of urine, of sp. gr. 1040—1045, and containing a large quan- tity of sugar, the existence of which was ascertained by fermenta- tion. The diabetes continued, without causing any diminution in the quantity of liquid in the peritoneal sac; and on his death, which happened about a month after he entered the hospital, the liver was found to be very large, and to have in a striking degree the "hob-nail" surface that results from cirrhosis. Many other differences than those yet mentioned have been found between the blood as it enters the liver and as it issues from it. The blood which enters the liver contains much more fat, espe- cially more oily fat, than the blood which issues from it. Accord- ing to Lehmann, the solid residue of blood from the portal vein contains, on an average, 3.225 per cent, of fat, while that of blood from the hepatic vein contains only 1.885 per cent.1 Another very remarkable difference relates to the fibrin, which almost entirely disappears from the blood in its passage through the liver. In the experiments of Lehmann and Bernard, the fibrin in the portal blood was often in just as large amount, and as con- tractile, as in the blood of the general venous current, while in the hepatic blood drawn at the same time scarcely a trace of fibrin could be found. Lehmann conjectures that the fibrin which disap- pears in the liver may help to form the glycine and taurine—the' nitrogenous and sulphurous adjuncts of the cholic acid—in the bile. Again, the blood as it issues from the liver contains much less albumen, less water, and a smaller amount of salts than the blood which enters the liver. The full extent of the changes which the blood undergoes in the liver has probably not even yet been made out, and our compre- hension of the purport and meaning of the changes is very vague, but enough has been discovered to show that the liver modifies and elaborates in a wonderful way the materials of the blood. Coincident with the chemical changes in the blood is an elevation of its temperature. Bernard found that, in the dog, the tempera- 1 Physiological Chemistry. Translated by Dr. Day, vol. ii. p. 88. 62 INTRODUCTION. ture of the blood in the hepatic vein is nearly |-° F. higher than in the portal vein, and more than a degree higher than in the aorta, and he concludes that the liver, among its other uses, is one of the chief sources of animal heat.1 But the uses of the liver are not confined to the changes which it immediately produces in the portal blood. The fact that the bile is poured into the intestinal canal, so near its upper end, is sufficient to show that it is not a merely excrementitious fluid, but that, when it has arrived in the intestine, it has important offices to serve. These offices are related to the function of digestion, on the one hand, and (according to Liebig) to that of respiration, on the other. It was formerly supposed that the one great use of the bile is to complete the process of digestion, and for this end it was considered quite as essential as the gastric juice itself. That the bile has, in- deed, an important relation to digestion is evident from the fact that man and other animals that feed at intervals by large meals have a gall-bladder which allows bile to accumulate when the sto- mach and duodenum are empty, so as to be poured into the digest- ive canal in greater quantity when they are full. But there can be no doubt that the part which bile plays indigestion has been much overrated. The recent investigations of chemists have much sim- plified our views of this process. Since the important discovery that complex nitrogenous principles (albumen, fibrin, casein) iden- tical with those of the blood and tissues of animals exist in plants, and that in the food of herbivorous animals they exist in sufficient quantity to supply the waste of the body, we have been led to the inference that these principles are not formed, as was formerly sup- posed, during the process of digestion, but that they are com- pounded only by plants, and that they exist ready-made in the food. With respect, then, to these nitrogenous elements of the food, all that appears necessary to digestion, as far as mere chemi- cal changes are concerned, is to effect their solution. Now experi- ments of a conclusive kind have shown that the gastric and intes- tinal juices can accomplish this object. Of the non-nitrogenous substances we take as food—the sugar, starch, fat, and oil—sugar is already soluble enough, and starch is altered by the saliva and the pancreatic juice, and thus rendered soluble in the fluids found 1 Bernard, Lecjons, &c, p. 198. USES OF THE BILE. 63 in the stomach and intestines, from which, like the dissolved albu- minous matters, it is absorbed into the bloodvessels to be carried to the liver. Fatty matters are not digested in the stomach, and must require, therefore, after they pass into the intestine, some preparation in order to become easily absorbed; for membranes absorb with great difficulty those fluids which do not penetrate them by imbibition, or which, in more familiar phrase, do not wet them. But it has been shown by M. Bernard that fatty matters undergo the needful modification by mixing with the pancreatic juice, which acidifies them, and rapidly makes with them a persist- ing emulsion, and thus enables them to be absorbed both by the veins and by the chyle-vessels of the small intestine. It appears, then, that all the staminal principles of the food may be digested, or rendered fit for absorption, without the aid of the bile—a fact, indeed, sufficiently established, as regards man, by the observed effects of permanent closure of the common gall-duct. In a future chapter, cases will be related in which the common gall- duct was completely and permanently closed by a gall-stone, so that no bile could flow into the intestine; yet, in spite of the com- plete absence of bile in the intestine, and of the deep and permanent jaundice which results from this condition, the body was tolerably well nourished for more than twelve months, clearly showing that all the staminal principles of the food must have been digested and absorbed. A case still more remarkable will be related, in which a poor woman lived more than eight months in a state of deep jaundice from obstruction of the common gall-duct, and not only kept up her nutrition during this time well enough to be able to attend to the common duties of life, but, five months after the oc- currence of the jaundice, gave birth to an infant, which she con- tinued to suckle up to her death. Such cases are quite as convincing as the results of direct experiments, and show conclusively that all the staminal principles of the food may be digested and absorbed without the aid of the bile. But it does not follow from this that the bile is of no use in digestion ; for the very cases in question show that permanent closure of the common gall-duct destroys life in the end, and gene- rally in little more than twelve months, by causing a gradual impairment of nutrition. Some experiments made by M. Bernard have led him to the conclusion that the gastric juice, when mixed with the pancreatic juice and the bile, has a more solvent action on 64 INTRODUCTION. albuminous substances than the gastric juice alone; and there are many reasons for believing that if the fatty matters which pass out of the stomach can be made into an emulsion and be so fitted for absorption by the pancreatic juice, their absorption is in most cases much promoted by the bile. Another effect commonly attributed to bile is-that of neutralizing the acid that passes from the stomach into the intestines, after having performed its part in digestion. As healthy bile is itself neutral, or but very slightly alkaline, it can only neutralize the acids of the chyme by becoming decomposed. In that case the soda of the bile would unite with the muriatic and lactic acids of the chyme, and bile-acids would be set free. There would be as much free acid in the bowel as before, but this acid, instead of being a sour liquid, like muriatic acid, would be an acid sparingly solu- ble in water, and probably much less irritating to the bowel. There can be little doubt that a substitution of this kind does take place; for it has been shown by Lehmann, Yon Bibra, and others, that choloidic acid, and even dyslysine, are formed from the bile in its passage through the intestine; but the substitution can only take place to a certain extent. The quantity of soda in the bile is too small, even if it were all employed for this purpose, to neutralize the acid of the chyme.1 The chyme is most probably neutralized, at least in chief part, by the pancreatic juice, and by the secretions of the intestinal canal. The bile may contribute to it also in- directly, by stimulating the coats of the canal, and rendering their secretion more active. If the soda of the bile unite with the acid of the chyme, the characters of the bile as a soap must be destroyed, and, consequently, the bile cannot at the same time perform this office and promote the absorption of fatty matters in the way usually supposed. Bile has been supposed to prevent by its bitter principle the development of gas in the intestines, and the occurrence of putre- factive changes in the nitrogenous constituents of the food during their passage through the intestines. FVom the readiness with which bile undergoes decomposition, such an office might seem improba- ble ; but it has been ascertained that bile, out of the body, arrests alcoholic fermentation, and prevents for some time the putrefaction 1 It was the supposition that the office of the bile is to neutralize the acid of the chyme, that led to the extravagant estimate by Schultz before referred to, viz., that an ox secretes daily 37 lbs. of bile. USES OF THE BILE. 65 of flesh; and it is an observed fact that in jaundice the bowels often become flatulent, and the stools unusually fetid, while, in cases of stricture of the pylorus, when the bowels are confined for days together and bile continues to flow into them, flatulent distension of the intestines seldom occurs. Collaterally, the bile forwards in various ways the great business going on in the alimentary canal. One of the most obvious of its uses is, to promote the due discharge of the contents of the bowel. If such a phrase may be used—bile is the natural purgative. If poured into the intestine in too large quantity it causes diarrhoea, and if its secretion be deficient, constipation generally follows. Eberle further observed that, in animals, which he made the sub- ject of experiment, and especially in such as had fasted for some time before death, the mucus of the intestine was much more abundant, as far as bile had reached, than below this point. We have next to consider the final destination of the bile itself. It seems clear that, in man, under ordinary circumstances, the bile which is voided by the bowel can be but a small proportion of the whole amount secreted. For the quantity thus voided is very trifling, and consists chiefly of modified bile-pigment, with choles- terine and taurine. The greater part of the resinous matter of the bile and the soluble salts must therefore be reabsorbed. Liebig states, that in the carnivora the whole of the bile is reabsorbed. The excrements of these animals contain neither bile nor soda; for water extracts from them no trace of any substance resembling bile, and yet bile is very soluble in water, and mixes with it in every proportion. It has been lately advanced by Liebig, on the authority of quantitative analysis, that the portion of the bile re- absorbed is eventually discharged through the lungs, as carbonic acid and water; thus supplying fuel for respiration and supporting animal heat. On account of the novelty and importance of this doctrine, and the high reputation of its author, it is right that the calculations on which the doctrine is based should be closely exa- mined. Liebig adopts the estimates of Haller and Burdach, that a man in health secretes daily from 17 to 24 ounces of bile; and he as- sumes that this bile contains 90 per cent, of water, which gives from 816 to 1152 grains of dried bile.1 ' See Liebig's " Organic Chemistry, in its Application to Physiology and Patho- logy," pp. 64, 65. 5 66 INTRODUCTION. Now Berzelius found in 1000 parts of fresh human feces, only 9 parts of a substance similar to bile. Reckoning from this pro- portion, the daily feces of a man, which do not, on an average, weigh more than 5J ounces, contain only 24 grains of dried bile at most. So that, according to this computation, the whole quantity of bile secreted exceeds the quantity that can be detected in the matters discharged from the alimentary canal in at least the proportion of 816 to 24, or 34 to 1. The chief part of the bile is therefore reabsorbed, and as (Liebig argues) no traces of it are found in the other excretions, the carbon and hydrogen it contains must evidently be discharged through the lungs in union with oxygen, as carbonic acid and water. What- ever intermediate purposes it may serve, this must be the ultimate fate of these, its chief elements. The estimate of the amount of bile daily secreted—namely, from 17 to 24 ounces, as concentrated as bile usually found in the gall- bladder—is higher than most physiologists would admit. But the proportion it gives of bile secreted to that found in the excrement is so large that even a considerable error in this direction would not vitiate the conclusion, although it would, of course, give too high an estimate of the amount of fuel for respiration furnished from this source. Even at this estimate, the carbon furnished by the bile would be but a small proportion of that given out in res- piration. It has been computed that in a grown-up person, taking moderate exercise, 13T9o oz. of carbon escape daily through the skin and lungs as carbonic acid. Now 816 grains of dried bile, which does not contain more than 69 per cent, of carbon, gives only 563 grains of carbon, or about l£ oz.1 These considerations tend to show that it can hardly be one of the chief purposes of the bile to support respiration, although it seems established by the reasoning of Liebig, that the bile that is reabsorbed, after having served other uses, is applied to this purpose, for which, indeed, it seems singularly fitted by its solubility and the large amount of carbon and hydrogen it contains. 1 Liebig has made a calculation of this kind with reference to the ox, and con- cludes that in that animal the bile daily secreted contains 40 ounces of carbon, but he starts with the extravagant estimate of 37 lbs. (as concentrated as that in the gall-bladder) for the amount of bile daily secreted. USES OF THE BILE. 67 Before these researches of Liebig, the opinion was generally held that the bile is mainly excrementitious, and voided by the intestine; and it was supposed to be the chief office of the liver to rid the system of all matters, rich in hydrogen and carbon, that result from the waste of the tissues and are not discharged by the lungs in union with oxygen. The lung and the liver were thus consi- dered to be directly and strictly vicarious in their office, and in support of this view it was alleged that, throughout the animal scale, whenever the lungs are large and active, the liver is small, and vice versa. Thus it was remarked that in all cold-blooded ani- mals—creatures in which respiration is very feeble—the liver is very large and excessively developed when compared with the lungs. But it is a very formidable objection to this theory of vicarious action, that in serpents, whose respiration is extremely feeble, the excrement does not contain a particle of bile. Great stress is laid on the case of the mollusca, animals whose liver is generally immense in proportion to their other viscera. But even if their bile be excreted, that would not disprove Liebig's theory of the use of bile in man and the higher animals, since this professes to rest on entirely independent evidence. The same may be said with regard to the instances of animals in which the bile is poured into the rectum, and is, therefore, probably voided by the intestine. But, although the old doctrine of vicarious action can no longer be maintained, it is plain enough, especially since the discoveries of Bernard, that there is a direct and fundamental relation between the function of the liver and that of the lung. Fortunately, the activity and effects of the respiratory process are largely under our control. In the vast power we have of modifying these by appro- priate regulations, having reference to the great conditions of air, exercise, temperature, and food, we have means much more effectual than any other, in dealing with biliary disorders. Of these disorders, on the other hand, the neglect of such regu- lations is by far the most fruitful source. Thus, for example, may be explained many of the bilious disor- ders of hot climates. If, in such climates, the food be not regulated in accordance with the smaller needs of the economy as to animal heat, an excess of bile is formed, and disorder of the stomach and intestines—bilious vomiting, and diarrhoea—is the consequence. Hence, also, the general repugnance to rich meats, and the greater tendency which these and spirituous liquors unquestionably have OS INTRODUCTION. to produce diseases of the liver, in hot seasons and in tropical cli- mates. In the same way may be explained the greater frequency of bilious disorders in middle life, when men begin to take less exer- cise, and their respiration becomes less active, while, on the other hand, the tendency to indulgence at table but too often increases. We may also often see inverse evidence of these relations in the effect of pure air and active exercise, in relieving various disorders that result from repletion, and from the retention of principles which, if not burnt in respiration, should pass off by the liver as bile. Every sportsman must have remarked the effect of a single day's hunting in clearing the complexion. It has, no doubt, much the same effect on the liver as on the skin. The secretion of the bile is influenced not only by the general conditions just mentioned, but also by the state of the liver itself, and especially by the number and activity of the cells in its lobular substance. Not unfrequently, in bodies examined in our hospitals, consider- able portions of the liver are found atrophied, from adhesive inflam- mation in or about branches of the portal vein. In consequence of the obstruction of those vessels, the portions of liver to which they carried blood, waste, and if such portions be near the surface, the capsule is drawn in, and the surface appears puckered, or fissured, according to the size and direction of the obstructed veins. Again, hydatid and other tumors may cause atrophy of portions of the liver, by the pressure they exert on its substance, or on the vessels which supply it. But in effect of acute disease, without any permanent obstruction of vessels, the vitality of the cells may be permanently damaged, and their power of reproduction perhaps impaired. In persons who die of yellow fever, the liver presents various morbid appearances, which have been minutely described by Louis, that depend not on the products of inflammation, or on the state of the vessels, but on the condition of the cells. The damage done to the liver in this way may last for years. It is probable that the bilious disorders of many men on their return to this country from India and other hot climates, are in great measure owing to perma- nent injury done to the secreting element of the liver. In most persons, perhaps, a portion of the liver may waste or become less active, without sensible derangement of health. They MEDICINES. 69 have more liver, as they have more lung, than is absolutely neces- sary. In others, on the contrary, the liver, from natural conforma- tion, seems only just capable of effecting its purpose in favorable circumstances. They are born with a tendency to bilious derange- ments. This innate defect of power in the liver has its counterpart in the deficient respiratory power in persons with vesicular em- physema of the lungs, and like this latter defect, and most other peculiarities of physical structure, is no doubt frequently inherited. Persons who inherit this feebleness of the liver, if we may so term it, or in whom, in consequence of disease, a portion of the liver has atrophied, or the secreting element of the liver has been damaged, may suffer little inconvenience as long as they are placed in favorable circumstances and observe those rules which such a condition requires; but whenever from any cause—as a hot climate, gross living, indolent habits, constipation—a more abundant secre- tion of bile is requisite to purify the blood, the liver is inadequate to its office, and they become bilious and sallow. In the manage- ment of such cases, we have two objects to fulfil—first, to enjoin those conditions and rules of life that render a plentiful secretion of bile less needful; and secondly, to endeavor to render the liver itself more active. The chief conditions to diminish the quantity of matter which the liver is called on to excrete, are, a light diet, with water for drink; active exercise; early rising; and a cool or temperate climate. Various medicines seem to fulfil to a certain extent the second object, that of rendering the liver more active, and increasing in this way the secretion of bile. Mercury, iodine, the salts of soda, muriate of ammonia, and taraxacum, when given in proper doses, have undoubtedly an action of this kind. The first and the last of these medicines, especially, have long been in this country the chief resources of the physician in the treatment of chronic hepatic disorders. The marked temporary benefit often resulting from mercury given for this effect has, from the difficulty of distinguish- ing the various diseases of the liver, and the consequent indiscrimi- nate use of the drug, led to great evils. This medicine was at one time, by English practitioners, given almost indiscriminately, and long persevered in, for disorders of digestion, many of which did not depend on fault of the liver at all, but on local disease of the stomach or intestines, or on faulty assimilation, the result of de- 70 INTRODUCTION. bility, which the prolonged use of the mercury but too often in- creased. Of late, these evils have much abated; but still, before the real nature of the disease is ascertained, mercury is often tried in cancer, and other incurable organic diseases of the liver, in which this and other powerful and lowering remedies can only do harm. Pepper, ginger, and other hot spices, are also supposed, and per- haps justly, to render the liver more active and increase the secre- tion of bile. The great relish with which they are eaten by our countrymen in the East and West Indies gives considerable sanc- tion to this opinion. Most purgatives, especially rhubarb and senna, have perhaps an effect of the same kind, and may fitly be styled, in the language of our fathers, cholagogues. Many persons have succeeded in warding off bilious attacks to which they had been long subject, by taking habitually before dinner a few grains of rhubarb. A rhubarb pill will often relieve a slight bilious disorder, even before it has purged. We may suppose these medicines to excite the secretion of the liver, either by virtue of the impression they make on the stomach and duodenum, or by their becoming absorbed in the stomach and intestines, and subsequently excreted by the liver. Spices proba- bly act chiefly in the former way, and excite the secretion and flow of bile, as they do that of saliva, by the impression they make on the mucous membrane adjacent. Mercury, iodine, and other medi- cines, probably excite the secretion of the liver chiefly, if not solely, by becoming absorbed into the blood, and passing out of the sys- tem with the bile. We have, indeed, little positive evidence in favor of this theory, by regarding the liver merely, because not many analyses of any kind have been made of human bile, and very few attempts have been made to discover different medicines in it. Autenrieth and Zeller1 state that they found mercury in the bile of animals treated by mercurial frictions; and copper, derived probably from cooking utensils and food, has often been detected in human bile and gall-stones. Bouisson2 states, that the coloring principles of madder and some other substances pass off in the 1 Bouisson, p. 14, who takes this fact from Reil's Archiv. fur die Physiologie, vol. viii. p. 252 ; 1807, 1808. 1 Bouisson, p. 303. MEDICINES. 71 bile; a fact which, if established, would lead us to expect that some principles of rhubarb, senna, and taraxacum might pass off in it likewise. Iodide of potassium and prussiate of potash have been injected into the blood of animals, and been subsequently detected in the bile.1 Most medicines that act as diuretics are" no doubt excreted by the kidneys. Nitre, iodide of potassium, asparagus, and most other medicines of diuretic action, for which we have chemical tests, or which we can detect by our senses, have been found in the urine. The active principle of squills, our chief expectorant, probably passes off by the lungs, for all the onion tribe, of which squills is one, taint the breath. It would seem, indeed, not only that most medicines that increase the secretion of a gland pass out of the sys- tem through it, but conversely, that nearly everything foreign to its own secretion, that drains off through a gland or mucous mem- brane, excites its secreting function.2 Medicines that pass off in this way through a gland, not only increase its activity, but may also alter the qualities of the secretion, and act directly on the surfaces over which the secretion passes; and when the secretion is unhealthy, or these surfaces are diseased, these latter effects of the medicines may be far. more important than the first. We have examples of this in the efficacy of alkalies in prevent- ing the deposit of lithic gravel in the urine; and in that of the balsams and of various vegetable astringents, in certain diseases of the bladder and urethra. As might have been expected, our know- ledge of the effects of different medicines on the qualities of the bile, and on the mucous membrane of the gall-bladder and gall- ducts, is very scanty. We cannot ascertain during life the com- position of the bile, and of course cannot tell in what way, or in what degree, our medicines change it. But there are, unquestion- ably, medicines which do change it. Experience long ago led physicians to infer that if some medicines, as mercury, owe their chief virtue, in hepatic disorders, to their increasing the quantity of the bile, there are others, whose chief merit consists in their altering its quality. Alkalies, especially soda, ether, and turpen- 1 Bernard, Lecons, 1854-5, p. 301. 2 On the same principle, undoubtedly, various abnormal matters that find their way into the portal blood, cause sudden and copious fluxes of bile. 72 INTRODUCTION. tine, have been supposed to render the bile thinner, and have, on this account, been at various times recommended as remedies for gall-stones. Hitherto, it has been impossible to fix the value of medicines of this class. They are given empirically, generally with a vague notion only of what is amiss; and according to the chances of individual experience, or the fashion of the day, are rated at one time much above their worth, and at another time, in effect probably of this very over-estimate, are altogether discarded. Medicines which alter the urine, or act on the bladder or urethra, have more permanent favor, because, from being always able to collect and analyze the urine, we have better opportunities of fixing their value. 73 CHAPTER I. CONGESTION OF THE LIVER. Congestion of the liver from impediment to the flow of blood through the lungs or heart—Effects of this—Congestion from other causes— Hemorrhage. One of the simplest morbid conditions of the liver is Congestion— that is, an undue accumulation of blood in the capillary vessels. Congestion of the liver, as of other organs that have an active function, may arise from various causes, and be, if we may so speak, of different kinds. The simplest kind, and which may therefore be fitly considered first, is that which results from some mechanical impediment to the return of blood through the veins to the heart. Examples of congestion arising from this cause are most fre- quently met with in persons with organic disease of the valves on the left side of the heart. In such persons it often happens that when the circulation becomes much impeded the liver grows larger, so that its edge can be felt two or three inches below the false ribs. If the circulation be relieved by bleeding, or by diuretics, or by rest, the liver returns to its former size. This enlargement, from what may be termed passive congestion, often takes place, and again subsides, very rapidly, according to the varying conditions of the general circulation. Without any unnatural impediment to the passage of the blood through the chest, a transient congestion of the liver of this kind is produced in man by running, or other violent bodily exertion. Under the influence of such exertion the circulation is very much quickened, more blood is brought to the liver than can pass readily through its dense plexus of capillary vessels, and the liver becomes gorged with blood. This happens especially after meals, when the 74 CONGESTION OF THE LIVER. vessels of the portal system are charged with the products of diges- tion, and when more blood is detained in the liver by the activity of its secreting function. The gorged state of the vessels of the liver impedes the passage of blood through the splenic vein, and thus leads to temporary engorgement of the spleen. It has been conjectured that this rapid and transient engorgement of the liver is the cause of the stitch in the side which fast running so com- monly causes. In horses, dogs, and other animals, made for fast running, there is, as Bernard has pointed out,1 a special provision to meet this emergency. Some vessels of considerable size pass directly from the trunk of the portal vein to the vena cava, so that some of the blood of the portal vein can enter the general current of the vena cava without traversing the capillary plexus of the liver. Enlargement of the liver from passive congestion is, in general, unattended with pain, and the only complaint made by the patient is of a sense of weight or fulness in the right hypochondrium. The turgid state of the capillary vessels in the lobular substance of the liver, and the slowness of the current through them, must, how- ever, tend to lessen the functional activity of the liver, and it im- pedes the elimination of bile, so that it often happens that after a few days the symptoms above mentioned are succeeded by a sal- lowness of the complexion, which, in some cases, passes into decided jaundice—the jaundice, like the enlargement, soon disap- pearing when the general circulation is relieved. In all organs, a state of congestion produces analogous effects. The unnatural fulness of the capillary vessels, and the slowness of the current through them, lessens the activity of the nutritive pro- cesses, and causes the organ to do less of its proper work, and do it more slowly. If the brain be congested, the sensations are blunted, volition is less vigorous, and the mental power is dimi- nished ; if the lungs be congested, the exhalation of carbonic acid is lessened; if the kidney be congested, the urine is more scanty ; if a muscle be kept congested, it soon tires, and only slowly reco- vers its fatigue. It is, then, in accordance with a general law, that when the liver is kept in a state of passive congestion, the secretion of bile is diminished. The jaundice in such cases does not, however, seem 1 Lecons de Physiologie, 1854-5, p. 164. EFFECTS OF PASSIVE CONGESTION. 75 to depend on diminished activity of the secreting cells, but rather on impediment to the passage of bile from the lobules and through the small gall-ducts, caused by the pressure exerted upon the ducts by a gorged state of the bloodvessels. When the liver is examined after death, it frequently contains not only an unusual quantity of blood, but also, as was remarked by Mr. Kiernan, an accumulation of biliary matter in the lobular substance. This biliary congestion, as Mr. Kiernan termed it, like the gorged state of the bloodvessels, of course tends to increase the size of the organ. Enlargement of the liver must take place in some measure in all cases where the vessels are turgid, but the degree of enlarge- ment will depend on the time the congestion has lasted, and on the previous condition of the organ. The longer the vessels are kept distended, and the more yielding the surrounding tissues, the greater, of course, will be the enlargement. In young persons, and in persons in whom the liver is healthy and its capsule thin, it will necessarily enlarge much more for a given force of disten- sion, than in persons in opposite circumstances. When, in conse- quence of an interstitial deposit of lymph, the liver has become unnaturally firm and tough, an impediment to the free passage of the blood from it towards the heart, unless it be long continued, will produce but little increase of its size; but will cause the same, or even greater, pressure on the other elements of its texture, and be as apt, therefore, or even more apt, to cause secondary biliary congestion. The changes in the appearance and texture of the liver produced by congestion are such as these considerations would lead us to expect. The liver, from the turgid state of its bloodvessels, is more or less enlarged, somewhat more friable than it otherwise would be, and of a deep red color: the central portions of the lobules having, however, a deeper hue than the marginal portions. Occasionally, the liver is at the same time in a state of biliary con- gestion, and, in consequence, if any portions of the lobules be un- injected, they have a deeper yellowish or greenish hue than is natural to them. If the biliary congestion be long kept up, the function of the cells in the congested lobules is arrested, or rendered less active, and the cells seem to become impaired in their vitality and powers of reproduction: the liver is thus permanently injured in its secreting element. Now and then, in persons who die of 76 CONGESTION OF THE LIVER. valvular disease of the heart of long standing, the liver is found much diminished in size and weight, without presenting any marks of inflammation or other striking change; and this may occur in persons who have led temperate lives—where, consequently, the atrophy can only be explained by the influence which the long- continued congestion has had in impairing the functional activity and nutrition of the cells. The wasted condition of the muscles of the legs that so constantly results from serious valvular disease of the heart affords another and familiar example of atrophy thus produced. Andral, and many other writers, have remarked that congestion of the liver from impeded circulation through the chest, when long continued, often leads to organic disease; and they have thus ac- counted for the frequent association of organic disease of the liver with organic disease of the heart. The changes in the liver really attributable to disease of the heart consist, at first, in distension of the capillary bloodvessels, and in accumulation of biliary matter in the lobules, resulting from impediment to its escape through the small gall-ducts. If this impediment be kept up, the biliary matter, as long as there are cells enough to separate it from the blood, goes on accumulating faster than it can escape; but when- ever the cells are long prevented from discharging their contents, they seem to lose their fertility, and consequently diminish in number. In another chapter cases will be related where from the passage of bile through the common gall-duct having been long stopped, the liver had entirely lost its lobular appearance, and con- tained no nucleated cells in the lobules—so that when a portion of it was examined under the microscope nothing was seen but free oil-globules and irregular particles of greenish or yellow biliary matter. Many writers have stated that disease of the heart produces cirrhosis of the liver; meaning by that term the hardened and granular state of the liver so frequently found in drunkards, which is caused by the interstitial deposit of fibrin from adhesive in- flammation, and which often, like congestion of the liver, leads to accumulation of biliary matter in the lobules, by impeding its escape through the small gall-ducts. But disease of the heart does not of itself lead to this form of disease, or, indeed, to inflammation of any kind. Among the many persons who die in our hospitals of diseased heart consequent on rheumatic fever, the liver is seldom EFFECTS OF PASSIVE CONGESTION. 77 found tough and granular from the presence of foreign fibrous tissue, except in such of them as have drunk spirits to excess. But although disease of the heart does not directly lead to inflam- mation of the liver, it yet, by causing more or less stagnation of the blood in the capillaries of the liver, gives greater effect to spirituous liquors, or to any other deleterious agent that is absorbed from the intestinal canal, and thus mixed with the portal blood. This point will be again noticed in a subsequent chapter on Adhe- sive Inflammation of the Liver. Congestion of the liver, from mechanical impediment to the on- ward current of the blood, is generally brought under our notice, not as a disease of itself, but as a consequence and a complication of valvular disease of the heart, or of some other condition that pre- vents the free passage of the blood through the chest. But although a secondary disorder, its results are very important. If it continue long, it leads to bilious contamination of the blood, often already impure by defective action of the lungs and the kidneys; and in other ways much aggravates the condition of the patient. The congestion of the liver may be relieved directly by general or local bleeding, or by medicines, such as sulphate of magnesia and bitartrate of potash, which cause a copious drain from the portal system of veins; and, indirectly, by medicines, such as small doses of blue pill, which increase the secretion of bile. In cases of dropsy from disease of the heart, when the liver is gorged and the complexion sallow, small doses of blue pill, in conjunction with diuretics or purgatives, are often productive of extraordinary benefit. Under such circumstances, it is almost needless to remark, it is very important that the patient should take very sparingly of fer- mented drinks, and abstain from rich dishes, and, indeed, from all articles of food likely to add to the congestion of the liver. Hitherto we have considered only that kind of congestion which results from mechanical hindrance to the backward current of the venous blood. But congestion—that is, undue accumulation of blood in the vessels—may result from totally different conditions. The large vessels serve merely as channels to convey to the dif- ferent tissues of the body the blood from which the materials of their nutrition are drawn. The process of nutrition is dependent on a mutual affinity between the blood and the tissues, by virtue of which each part withdraws from the blood, through the thin 78 CONGESTION OF THE LIVER. walls of the capillary vessels, those materials which its proper nu- trition requires: and the equable distribution of the blood through the body depends not merely on its more obvious conditions—on the propulsive power of the heart, on the suction power of respira- tionKand on there being a free passage for it through the arteries and the veins—but also on this mutual action, or affinity, between the blood and the tissues, which is being constantly exerted in every part of the body as long as its nutrition continues. Modi- fications of this affinity, leading to congestion, or undue fulness of the vessels, may result from changes either in the tissues or in the blood. Thus, if a part be injured in any way—if the skin be cut, or a bone be broken—provided the vitality of the tissues be not destroyed, there is immediately set up a process of inflammation, or of repair, and one of the first results of this process is an in- creased flow of blood to the part, and a turgid state of its vessels. So, again, if any part be the seat of a cancer, or of any other morbid growth, there is, at once, by virtue of this increased and faulty nutrition of the tissues, an increased flow of blood to the part, and, after a time, the vessels of that part are found to have grown larger. So, indeed, it is generally: wherever an important vital process is going on, there is an increased flow of blood to the part, and a congestion, if it may be so termed, or an accumulation of blood in the vessels, by which the vital action is maintained. And there can be no doubt that this increased flow of blood, and this turgescence of the vessels, is secondary to the vital action, and the result of it; and that it is caused by the modification of the affinity between the blood and the tissues which the action in ques- tion produces. Congestion of the liver originating in changes in its tissues need not detain us here. It is a mere concomitant of the process of in- flammation, or of the growth of a cancer, or of some other struc- tural change, and belongs, therefore, to those conditions—condi- tions which will be considered in subsequent chapters. But, as already observed, congestion may result, not only from a change in the tissues which the blood nourishes, but also from a change in the blood itself. All abnormal changes in the relation of the blood to any organ affect the circulation through that organ. Foreign matters in the blood, which are eliminated by a gland, necessarily affect in some way or other the circulation through it—sometimes causing a more active nutrition of the gland, and thus increasing OTHER KINDS OF CONGESTION. 79 its functional activity—sometimes causing more or less stagna- tion, and consequently accumulation, of blood in the capillary vessels, and thus arresting or diminishing its function. If the natural elements, even, of any secretion, be in undue quantity in the blood, they may lead to a state of congestion of the secret- ing organ. All this is strikingly illustrated by the kidney. Diuretic medicines, when given in proper doses, like the natural constituents of the urinary secretion, cause, for a time, more active nutrition of the kidney, and increase the quantity of urine. Other foreign matters, and, indeed, these same diuretic me- dicines in too large doses, and even the natural elements of the secretion when in undue quantity, clog the kidney, by leading to more or less stagnation of blood in the capillary vessels; and the congestion so produced has the same effect as congestion caused by mechanical hindrance to the return of the venous blood, and leads to hemorrhage from the kidney. The liver, from its situation and office, is peculiarly exposed to congestion from such causes. All the matters absorbed by the bloodvessels in the intestinal canal have to pass through it. Its lobular substance is the first filter, if we may so term it, through which the impure liquid must strain. All the alcoholic drinks, all the noxious ingredients that may chance to be present in our food, and such hurtful products of faulty digestion as are readily soluble, are immediately—before they have been diffused throughout the whole mass of the blood, and before they have been submitted to the influence of oxygen— carried to the liver, and more or less influence the circulation through it. Without any excesses in diet the liver, in accordance with the general law just stated, contains much more blood after meals, when the products of digestion are conveyed to it and its secreting functions are actively performed. Amid the continual excesses at table of persons in the middle and upper classes of so- ciety an immense variety of noxious matters find their way into the portal blood that should never be present in it; and the mis- chief which this is calculated to produce is enhanced by indolent or sedentary habits. The consequence often is, that the liver be- comes habitually gorged. The same, or even worse effects, result in the lower classes of our larger towns, from their inordinate con- sumption of gin and porter. Different persons are, of course, affected in different degrees by excesses of this kind. Persons of large frame, with active respira- 80 CONGESTION OF THE LIVER. tion, engaged in active pursuits, and who, from natural conforma- tion, have a vigorous liver, can indulge almost with impunity in habits that would be fatal to others. The congestion of the liver we are now considering has the same effects as the congestion produced by impediment to the return of venous blood to the heart. It causes enlargement of the liver, a sense of fulness and of weight in the right hypochondrium, and, after a time, by diminishing the secreting activity of the liver, and by impeding the passage of bile through the small gall-ducts, causes also a bilious tinge of the complexion, which, in some cases, passes into decided jaundice. These disorders are, of course, often accompanied by disorders of other organs, and by such derange- ment of the general health as the faulty habits of life mentioned above are apt to engender. If the congestion be long kept up, it seems permanently to impair, like the simpler kind of congestion we have before considered, the vitality and the power of repro- duction of the secreting cells: and thus permanently lessens the power of the organ, and in some degree changes its structure. In congestion of the liver so produced, great benefit results from saline purgatives, especially the sulphate of magnesia or of soda, in conjunction with senna; from occasional small doses of blue pill; from active exercise, and exposure to the fresh air—es- pecially horse exercise, which combines exercise of the most exhil- arating kind, with free exposure to the air—and from a restricted diet. Under the influence of such measures, the congested state of the liver speedily subsides; the bile is secreted more abundantly, and flows more freely; the sallowness of complexion disappears; and if the congestion have not lasted long enough to cause per- manent damage to the liver, the health, as far as this organ is con- cerned, is restored. The articles of food which tend most to clog the liver__from which, therefore, persons with congestion of the liver should most carefully abstain—are rich dishes and fermented liquors; which, like the organic principles of bile, contain a large proportion of hydrogen and carbon. Congestion of the liver from unhealthy states of the blood now and then occurs in other circumstances. Thus, in the hot state of ague, in some instances, great congestion of the liver, as of the spleen, comes on rapidly, and again rapidly subsides when the fit of ague is past. HEMORRHAGE. 81 Congestion so produced, like the forms of congestion already considered, causes more or less enlargement of the liver, but is of too short duration to give a tinge of yellow to the skin. We have most efficient means of preventing this kind of conges- tion in quinine and the other antidotes to the marsh poison. Congestion of the liver occasionally results from other morbid states of the blood, the nature of which is unknown, and which have not been traced to their source. In a person dead of purpura haemorrhagica, I have found the liver and the spleen very large, and of the dark color of a Morello cherry, from the great quantity of blood they contained. From the researches of M. Andral, it would seem that a great diminution in the proportion of the fibrin in the blood is an occasional cause of such congestions. There is reason to believe that, independently of any primary change in the blood or in the tissues of the liver, the current of blood through the liver may also be modified and a state of con- gestion be induced by causes of disturbance which have their origin in the nervous system;1 but, at present, our knowledge on this subject is very vague. Nothing has yet been said of hemorrhage of the liver as a result of congestion. Hemorrhage is a common result of congestion in many other organs, but in the liver it is extremely rare. Now and then, however, it does occur; more especially, according to the observations of Rokitansky, in children, when the liver is much congested from suffocative catarrh, or some other condition that im- pedes the passage of the blood through the chest. The hemorrhage may take place in the substance of the liver or at its surface, or in both situations at once. When it takes place in the substance of the liver it may cause but little pain, and do but little other mischief. After a time, the blood, like blood effused elsewhere, is absorbed, and no sign of the accident remains; or the only sign of it that remains is a scar, the origin of which can seldom be traced. The hemorrhage thus escapes detection. When hemorrhage takes place at the surface of the liver, the blood may collect under the 1 It has been shown by Bernard that irritation of the floor of the fourth ven- tricle, while it increases the production of sugar in the liver, causes increased vascularity of it; that the apoplectic state increases the various secretions, and therefore the vascular fulness of the secreting organs ; and that division of the sympathetic nerve in the neck in rabbits immediately causes persisting vascular congestion of the corresponding side of the head. 6 82 CONGESTION OF THE LIVER. capsule, and form a palpable tumor; or may even rupture the in- vesting membranes, and thus become effused into the peritoneal sac. It then, of necessity, causes much pain and tenderness, which are more or less widely diffused, according to the nature of the in- jury. The pain and tenderness are, however, seldom of long con- tinuance. The effused blood does not inflame the serous membrane, and, in consequence, the pain and tenderness disappear entirely, or much abate, in the course of a few days. Hemorrhage of the liver may result from other conditions. A few years ago, through the kindness of Mr. Busk, I had an oppor- tunity of examining the liver of a man who died of apoplexy, from softening of the brain, in the last stage of granular disease of the kidney, and in whom profuse hemorrhage of the liver occurred six weeks before death, in consequence, as it seemed, of some excess in eating and drinking. The symptoms resulting from this hemor- rhage were intense and continuous pain and tenderness in the epi- gastric region, and in the left side of the belly. The pain abated much at the end of two days, and soon ceased to excite complaint: but some degree of tenderness remained almost up to the time of death. Two days after the accession of these symptoms a deeply-seated, firm, tender tumor was detected in the epigastric region. At some subsequent examinations this tumor was felt, but it seemed to have diminished in size. The liver was of natural size, although the left lobe was larger in pro- portion than usual, and descended in front of the stomach, so that it could be felt in the epigastrium during life. It had no unusual adhesions to the surrounding parts. The surface was of natural color and appearance, except in two places ; one on the inferior surface of the left lobe, and the other on the anterior part of the convex surface of the right lobe. In these two places, the proper capsule of the gland was separated from its substance by very firm coagula, which in some parts presented the appearance of the fibrinous lamina? met with in aneurismal sacs, while other portions of the coagula were more recent. The clot on the convex surface of the right lobe occupied a space about four inches in diameter, and was about half an inch thick in the middle. The clot under the left lobe was not quite so large, but was thicker, and the capsule of the liver by which it was covered had been ruptured towards the anterior edge of the liver, during life ; and, in con- sequence of this rent, blood had been effused in considerable quantity in the peritoneal sac. This effused blood formed moulded coagula of various sizes, and of various degrees of firmness and decoloration, as if they were of various dates. A large mass of this kind, remarkably firm, was situated between the liver and the stomach, which was very small, and completely hidden by the liver and coagula. The substance of the liver and the gall-bladder appeared to be sound. HEMORRHAGE. 83 In such a case as that just related it seems impossible to recognize hemorrhage of the liver during the life of the patient. The symp- toms, indeed, correspond exactly to the nature of the injury; but there were no circumstances that rendered such an injury probable. When, however—as from disease of the heart, or in a fit of ague— the liver is known to be greatly congested, and when there is no reason to presume that it is the seat of any other organic disease, such a train of symptoms as that mentioned above might, perhaps, lead to the suspicion, or even justify the opinion, that hemorrhage had occurred; but, as already observed, such an event, under any circumstances, is very rare. 84 CHAPTER II. INFLAMMATORY DISEASES OF THE LIVER. Sect. I.— General Remarks on the Classification of Inflammatory Diseases of the Liver—Suppurative Inflammation and Abscess of the Liver. The inflammatory diseases of the liver are usually divided into acute and chronic; but this division is essentially faulty in practice, because the terms are applied, not with reference to the kind of inflammation or the rapidity with which it works its effects, but to the severity, merely, of the local symptoms. Now, inflammation of the liver running rapidly into abscess, if deep-seated and of small extent, may give rise to but few and obscure local symptoms, and would consequently be styled chronic during the life of the patient; while inflammation involving the surface of the liver, even when causing the slow effusion of coagulable lymph only, will be attended with well-marked local symptoms—with great pain and tenderness —and would be termed acute. We shall never have faithful descriptions of inflammatory dis- eases, or unerring rules for their treatment, until we arrange them, not according to their mere outward characters or the prominence of particular symptoms, but according to the nature of their causes; for it is a truth that cannot be too strongly enforced, that it is the nature of the cause of an inflammatory disease that mainly deter- mines its course and character and the influence of remedies over it. To take, for example, the inflammatory diseases of the knee- joint :— If inflammation of the synovial membrane of the knee-joint be excited by a penetrating wound and the consequent admission of air, it causes speedy suppuration, and generally destroys the joint. If it be occasioned by the presence of pus in the blood, it is at- CLASSIFICATION. 85 tended with very little effusion and swelling; but, as in the former case, it leads to the formation of pus; and that so soon, and with such slight local symptoms, that pathologists have even inferred that the pus, instead of being formed by a process of inflammation in the joint, is actually deposited there, ready made, from the • blood. If the inflammation be excited by the peculiar cause of rheu- matism, it is attended with severe pain, and often with much ef- fusion ; but the fluid effused is never purulent, and is almost always absorbed after some days, leaving the motions of the joint free and its structure uninjured. If the inflammation be gouty, it is attended with still more severe pain and with greater effusion; but the fluid effused here differs in quality from the fluid effused in rheumatism, and when its aqueous part is absorbed, particles of lithate of soda are often left on the synovial membrane, and in the areolar tissue about the joint. These, perhaps by mechanical irritation, occasion fresh at- tacks of inflammation, which lead to fresh deposits of lithate of soda, and, at length, the joint is completely crippled. If the inflammation be excited by the specific poison of gonor- rhoea, it is attended, like gouty inflammation, with abundant effu- sion, which distends the synovial capsule, and causes great swell- ing. There is seldom much pain or fever, but the disease is very obstinate—the swelling, in spite of all the remedies we yet know of, often lasting weeks or months. Thus we may have—to take the last two examples—to treat two cases of inflamed knee. The appearance of the joint is exactly alike in the two cases, and in both there is great swelling from fluid effused into the synovial capsule. We give colchicum in both ; in one case the inflammation rapidly subsides under the re- medy, and the effused fluid is quickly absorbed ; in the other the malady pursues its course as if nothing had been done. And why this difference ? The parts affected are the same, and the changes, in outward appearance, exactly alike in the two cases. One might readily be mistaken for the other. The reason is simply this—the morbid changes are, in one case, the effect of the specific principle of gout; in the other, that of the poison of gonorrhoea; and although they are alike in the two cases in those characters that most strike the eye—in the distension of vessels and the effusion of fluid—they differ in more essential particulars. 86 SUPPURATIVE INFLAMMATION OF THE LIVER. The instance here adduced is a simple one, but every depart- ment of pathology abounds with illustrations of the same truth ; thus leading to the conviction that we can never foresee clearl}r the result of an inflammatory disease, or foretell the effect of our remedies on it, unless we have ascertained its cause, or know at least the particular character of the inflammation. It is, in a great measure, our ignorance of the causes and particular characters of the diseases we have to treat that renders the practice of medicine so uncertain. At present it would be premature to attempt to arrange the inflammatory diseases of the liver with reference solely to their causes; but, as the nature of the cause mainly determines the character of the inflammation and its mode of termination, some approximation to such an arrangement will be obtained by class- ing them according to their effects. I propose, therefore, to range the inflammatory diseases of the liver under the following heads:— 1st. Suppurative inflammation, or that which leads to suppuration and abscess; 2d. Gangrenous inflammation; 3d. Adhesive inflammation, or inflammation that causes effusion of coagulable lymph; 4th. Inflammation of the veins of the liver; 5th. Inflammation of the gall-bladder and gall-ducts; And to consider, as far as our present knowledge permits, the various causes of these different forms of inflammation, and the modification of each form according to the particular cause that excites it. In following out this plan, I shall speak first of the causes of that form of inflammation of the liver which leads to sup- puration and abscess. Suppurative Inflammation and Abscess of the Liver. With the view of discovering the causes of inflammation of the liver that leads to suppuration and abscess, I have tabulated the chief circumstances of sixty-two cases in which one or more ab- scesses were found in the liver after death. Seventeen of these cases occurred in my own practice—fifteen at the Seamen's Hospi- tal, in sailors, most of whom had been in the East, and two in King's College Hospital; sixteen are published in the works of CAUSES. 87 Andral1 and Louis,2 and were most of them collected in the hospi- tals of Paris; and twenty-nine are recorded in the splendid work by Annesley, on the Diseases of India. In the following remarks frequent reference will be made to these cases. The most obvious cause of abscess of the liver, and which may therefore be fitly placed first, is— 1st. A blow, or other mechanical injury. But this is by no means a frequent cause. In the sixty-two cases of abscess of the liver to which I have alluded, there is only one—a case recorded by Andral—in which the disease was clearly traced to a blow. In this case {Clin. Med., torn. iv. obs. xxviii.) there were two large ab- scesses on the convex surface of the right lobe—the usual seat, probably, of abscesses produced in this way. The rarity of inflammation and abscess from accidental injury shows how effectually the liver, when of its natural size, is shielded by the ribs.3 2d. A second and far more frequent cause of abscess of the liver is suppurative inflammation of some vein and the consequent con- tamination of the blood by pus. Very soon after morbid anatomy began to be studied, it was noticed that, in persons who die some days after a severe injury or surgical operation, there are often collections of pus in the lungs, the liver, the joints, between the muscles, and in various other parts of the body. These collections of pus form very rapidly—in some cases in three or four days—and often with very slight local symp- toms; and, when occurring in the lung, are strictly circumscribed, or immediately surrounded by perfectly healthy pulmonary tissue. These circumstances suggested the notion—at one time generally received and still held by some eminent pathologists—that the pus is not formed by a process of inflammation in the parts in which we find it, but that it is all brought with the blood from the original seat of injury and merely deposited in those parts. The abscesses 1 Clinique Medicale, t. iv. 2 Memoires ou Recherches Anatomico-pathologiques sur diverses maladies. 3 Since the analysis in the text was made, I have been consulted by a gentleman in whom an abscess of the liver resulted from a blow received through a fall in hunting; and notes of another case in which abscesses of the liver seemed to have resulted from a blow have been kindly sent me by my friend, Mr. Erlin Clark. The strange thing is that the event is not of more frequent occurrence. 88 SUPPURATIVE INFLAMMATION OF THE LIVER. found in the lungs and liver in such cases have in consequence been very generally spoken of as deposits of pus. An examination of pus through tlje microscope is sufficient to show that it cannot be deposited in the way supposed. Pus-glo- bules are larger than blood-globules, and therefore could not escape bodily from the vessels without the blood-globules escaping as well. This circumstance is perhaps of itself sufficient proof that the pus of these scattered abscesses is not simply deposited from the blood, but that it is formed, as in other cases, by a process of inflammation in the parts in which we find it. Other and more conclusive evidence on this point has been fur- nished by the researches of MM. Dance and Cruveilhier. They have shown that although in most of such cases fully formed ab- scesses immediately surrounded by perfectly healthy pulmonary tissue exist in the lungs after death, yet in other cases in which death happens earlier, instead of abscesses there are small circum- scribed, indurated, or hepatized masses. In some instances the ab- scesses are formed in succession, so that in the same lung there may be found all intermediate stages between commencing induration, or hepatization, of a small circumscribed portion of the pulmonary tissue and a small circumscribed abscess. This circumstance, in- deed, did not escape the observation of Morgagni,1 whose sagacity nearly led him to the discovery of what at present seems to be the true mode of formation of these abscesses.2 He inferred that pus carried to the viscera from distant parts is 1 Speaking of abscesses of the same kind that result from injuries of the head, Morgagni says— " Fac enim relegas quas tibi novissime descripsi, Valsalvae observationes. Nempe tubercula plerumque invenies sive in pulmonibus, sive in ipso etiam jecore non omnia fuisse suppurata, quin plura interdum glandulosi corporis firmitudinem adhuc referentia. Quid ? si aegro moriente, necdum ulla essent quae pus habere inciperent." (Epist. Ii. art. 23.) 2 His words are— " Videtur autem secundum eas observationes, quibuscum, ut puto, Molli nellii conjungi potest observatio, pus in viscera aliunde invectum, non puris forma semper deponi, sed haud raro saltern nonnullas ejus particulas cum sanguine per- mistas, et prorsus disjunctas, in angustiis quibusdam, fortasse glandularum lym- phaticarum, haerere, easque, ut in venereorum bubonum productione fit, obstru- endo, aut irritando, eoque humores prseterituros retinendo distendere, et multo copiosioris quam quod advectum est, puris generationi, a rigoribus illis, et horrori- bus significatae, causam praebere. Qua ratione illud quoque intelligitur, quomodo multo plus puris in visceribus, et caveis corporis saepe deprehendatur, quam modi- cum vulnus dare potuisset." CAUSES. 89 not always deposited as pus, but that often some of its globules become arrested in the narrow channels of the body, and there, by obstruction or irritation, cause congestion, and give occasion to the formation of a much greater quantity of pus than is brought there by the blood. The mode of formation of these abscesses is well illustrated by an experiment made more than half a century ago by Dr. Saunders, and related by him in his admirable work on the structure and diseases of the liver. He injected 3ij of quicksilver into the crural vein of a dog. No ill effects were observed the first day, but at the end of this the dog became feverish, and after two or three days had cough and difficulty of breathing, which continued until its death. On examination after death, Dr. Saunders found the lungs studded with small indurated masses, which he calls tubercles, and small circumscribed abscesses. In the centre of each was a small globule of mercury. Here the globules of mercury, like the globules of pus in suppu- rative phlebitis, became arrested in the capillary vessels of the lungs, and each globule, acting perhaps by mere mechanical irrita- tion, caused circumscribed inflammation and abscess. The inflam- mation was circumscribed because the irritation that excited it acted only at particular points. In the dog experimented on by Dr. Saunders the lungs were the only organs in which abscesses were found. The reason of this is obvious. All the mercury conveyed directly to the lungs became arrested in their capillaries. No globules passed through to cause inflammation and abscess of other organs. In the same way, in some cases of suppurative phlebitis conse- quent on injury of the head or limbs or on amputation, abscesses are found in the lungs only; and they are usually found in the lungs in greater number than in other internal organs. After the lungs, the liver is the organ in which they are most frequent—a circumstance attributable in some measure to the large quantity of blood that flows to the liver, and to the slowness of the current through its capillary network, but perhaps still more to those vital or other attractions by which matters of particular composition are there detained and excreted. In the liver the abscesses are often scattered, as in the lungs, but they are usually larger and less regular in their outline—a conse- quence, it would seem, of the anatomical fact noticed by Mr. Bow- 90 SUPPURATIVE INFLAMMATION OF THE LIVER. man, that the lobules of the liver are not distinct bodies, separated from each other by a layer of areolar tissue, but that their capil- laries form a continuous network throughout the entire organ. For a long time it was strongly objected to the doctrine that the scattered abscesses consequent on injuries and surgical operations are formed in the way here supposed, that in many such cases no inflamed vein can be detected after death. This objection was much weakened by the important observation made by Mr. Arnott, that the effects of suppurative phlebitis bear no relation to the size of the vein or to the extent of the portion inflamed, and that even in cases rapidly fatal the portion of vein inflamed is often very small. Mr. Arnott infers, no doubt rightly, that in many cases we fail to discover the source of the mischief on account of the small size of the vein or the small extent of the portion inflamed. Another important observation has been made by Cruveilhier, which almost entirely removes the objection I have stated. It is that, after operations or injuries, where a bone has been divided or broken, the portion of vein inflamed, the source of the subsequent mischief, is often within the bone. He maintains that operations and injuries that involve bones are those most frequently followed by scattered abscesses, and that inflammation of the veins in the interior of bones is more apt to cause them than inflammation of the veins of other textures. He accounts for this by the circum- stance that the vascular canals of bone cannot collapse like the vessels of other textures, and further supports his opinion by the following experiments:— The marrow was removed from the thigh-bone of a dog, and mercury put in its place. At the end of five days the dog died, and the mercury was found strewed through the lungs. Each glo- bule was the centre of a small hepatized mass. {Cruv., liv. xi.) In another dog, a single globule of mercury was placed in the medullary cavity of the femur. A month afterwards it was found in the lungs, divided into many very small globules, each the centre of a small abscess. The observation of Cruveilhier, that injuries which involve bones are those most frequently followed by scattered abscesses, includes, as a particular instance, the fact, long ago noticed, that injuries of the head are often followed by abscesses of the liver. From the researches of Mr. Arnott in this country, and of MM. Dance and CAUSES. 91 Cruveilhier in France, no doubt remains that the abscesses in such cases result from suppurative inflammation of a vein, either in the soft parts or between the tables of the skull. Many false theories of the mode of formation of the abscesses of the liver, consequent on injuries of the head, have been maintained under the erroneous impression that abscesses exist in the liver only. It was, however, long ago remarked by Morgagni that, in these cases, there are often abscesses in the lungs, heart, spleen, and other organs, as well as in the liver. The abscesses in the liver attracted more attention than those in the lungs, on account, perhaps, of their larger size, and of their being more conspicuous from the stronger contrast between the color of pus and the natural color of the organ. There is a close analogy between the secondary abscesses from phlebitis and secondary masses of cancer. A cancer of the breast may be the source of cancerous tumors in the lungs and liver, just as an inflamed vein in the arm may be the source of abscesses in the same parts. The abscesses and the secondary cancerous tumors will be scattered in the same manner, and immediately surrounded by healthy pulmonary or hepatic tissue. The lungs and the liver are the organs in which secondary cancerous tumors, as well as the abscesses from phlebitis, are most frequent. The cancerous tumors and the abscesses have in each organ the same form and seat; and, in the lungs, both have a great predilection for the surface. These points of resemblance can hardly be explained, except on the supposition that the germs of the two diseases—cancer-cells and pus-globules—are disseminated in the same manner through the veins. It may be considered then established, that the abscesses which form in the liver and other organs, after surgical operations and injuries of the head or limbs, are owing to suppurative inflamma- tion of a vein and the consequent contamination of the blood by pus. The globules of pus, mingled with the blood, are conveyed to the capillary vessels of the lungs, and, it would seem, by becom- ing mechanically arrested there, excite each circumscribed inflam- mation and abscess. If any of the globules pass through the capillaries of the lungs to the left side of the heart, they are sent in the arterial current to other organs, and becoming arrested in the 92 SUPPURATIVE INFLAMMATION OF THE LIVER. capillaries of these organs, excite, as in the lungs, inflammation of limited extent, rapidly passing on to abscess. These scattered abscesses are most commonly found after opera- tions or injuries, because suppurative inflammation of the inner surface of a vein is most commonly caused by mechanical injury of its coats ; but they may obviously result from suppurative phlebitis set up in any other way. I have met with two instances in which scattered abscesses in various organs seemed to result from a col- lection of pus that had formed, from some cause which I could not discover, between the periosteum and bone of the upper arm; an- other instance, in which their source was probably a large tubercu- lous cavity in the lungs. Perhaps, then, we are justified in concluding in all cases in which we find collections of pus rapidly formed in different parts of the body, that the immediate cause of these scattered inflammations is some irritating substance conveyed there by the blood; and in most of the cases where the abscesses in the lungs are small and circumscribed, that this irritating substance is pus, derived from inflammation of the inner surface of a vein. In cases in which we cannot find the inflamed vein, the facts, that the abscesses are scattered in the same way, and occupy the very same anatomical seat as in those cases in which the source of the pus is known—that this kind of dissemination and the ana- tomical seat occupied are also the same as in the case of injected mercury and secondary cancer—are conclusive in showing that the agent arrives by the blood, and almost conclusive, when abscesses are found in the lungs, that this agent is a pus-globule. The proportion of cases of this kind, in a given number of cases of abscess of the liver, will, of course, vary with the frequency of abscess of the liver from other causes. In India, where other powerful causes of abscess of the liver are in operation, the proportion will be small. In the cases published by Annesley, there is not one that we can, from his description, place in this category. In the seventeen cases that have fallen under my own care in the Seamen's Hospital and in King's College Hospital, there is only one that clearly belongs to this head. In that instance abscess of the liver, with abscesses of the lungs and collections of pus in various joints, resulted from phlebitis caused by the operation of bleeding. CAUSES. 93 In sixteen cases collected by Louis and Andral, in Paris, where abscess of the liver from other causes is less frequent, there are four which may be placed in this category; one, in which the abscesses were consequent on venesection (Louis, Obs. 2); another in which they were consequent on childbirth (Louis, Obs. 1); a third (An- dral, Obs. 23) where with abscesses of the liver there were lobular pneumonia of the left lung, gray hepatization of the right, and pus between the vertebral column and pharynx: a fourth (Andral, Obs. 26) in which there was gray hepatization of the lower lobe of the left lung, and pus in the mediastinum. As yet, I have alluded only to inflammation of those veins that return their blood immediately to the vena cava, in which case the pus formed in the inflamed vein is at once conveyed to the capil- laries of the lungs. Sometimes it is all arrested there, and abscesses form in the lungs only. More generally, however, some of the pus passes through the capillaries of the lungs to be distributed with the arterial current, and abscesses, though commonly still most numerous in the lungs, are found also in other parts of the body. But when pus is formed in one of the veins that feed the vena porta?, it will be carried directly to the liver, will generally all be arrested in the close plexus of capillary vessels that goes to make up its lobular substance, and abscesses will be found in the liver only. The liver, from the closeness of the vascular network in its lobu- lar substance, or from the affinities which are there at work, has a remarkable power to arrest and to fix or eliminate foreign substances conveyed to it by the blood. Cruveilhier found, that if mercury be injected into one of the veins that feed the vena portae, it will be stopped in its course through the liver, and will cause circum- scribed abscesses there, just as it does in the lungs when injected into the crural vein. He injected mercury into one of the mesenteric veins of a dog. At the end of twenty-four hours the dog died, and the surface of the liver was found sprinkled with small spots of a deep red color, which extended four or five lines into its substance. In the centre of each of these red masses was a small globule of mercury. {Cruv., liv. xi.) In another instance, having met with a dog having an umbili- cal omental hernia, he injected mercury into one of the small veins of the omentum. The dog was killed about ten weeks after, 94 SUPPURATIVE INFLAMMATION OF THE LIVER. and the liver found studded with a countless number of what Cru- veilhier ealls tubercles, in the centre of each of which was a globule of mercury. Some of these tubercles had two distinct layers: the outer, albu- minous or tuberculous ; the inner, puriform. In these two experiments the different stages of suppurative in- flammation are seen. At first, there is a spot of a deep red color; this passes to suppuration and abscess; and the matter of this ab- scess, acting as a source of irritation, excites around it inflammation of a kind which leads to effusion of albumen or fibrin, and thus forms a cyst for the matter. The veins that feed the vena portae are little exposed to acci- dental injury, but some of their branches are divided in operations on the rectum and for strangulated hernia ; and, as might have been anticipated, these operations are sometimes followed by abscess of the liver. Cruveilhier relates a case where abscesses of the liver were im- mediately consequent on repeated attempts to return a prolapsed rectum. The patient, a man of sixty, had been subject to prolapsus many years. The bowel protruded at the first effort to empty it, but was usually returned without difficulty. When he sought assist- ance on the last occasion, it had been down twenty-four hours, and was replaced only after repeated and violent attempts, which gave him much pain. The same day the expression of his countenance altered, and his pulse became small and unequal. He soon fell into a state of pros- tration, with a cold skin, vomiting, hiccough, stupor, but without pain, and died on the fifth day. A great number of small abscesses, some superficial, others deep- seated, were found in the liver. The hepatic tissue for a short distance round each of them was of a brown slate-color, and soft- ened. {Cruv., liv. xvi.) Dance mentions a case in which abscesses formed rapidly in the liver after an operation for cancer of the rectum, where cauteriza- tion was practised: another, in which they were consequent on a simple operation for fistula; and two others, in which they fol- lowed the operation for strangulated hernia, where a portion of CAUSES. 95 irreducible omentum suppurated externally. {Archives Generales, t. xix. p. 172.) Since the publication of the second edition of this work, Dr. J. Jackson, formerly of Calcutta, has sent me notes of three cases, in which abscesses of the liver that proved fatal seemed to have re- sulted in Europeans in India from operations for the removal of piles. There can be little doubt that in most of these cases, if not in all, the abscesses in the liver were the consequence of phlebitis caused by the operations. It is an important circumstance, and one to which I shall again have to refer, that in none of the cases were abscesses noticed in other organs. The pus furnished by the inflamed veins was, it would seem, all stopped in its passage through the liver; and ab- scesses formed in the liver only.1 3d. The consideration of these cases leads us naturally to a third cau'se—I believe by far the most frequent cause—of abscess of the liver : namely, ulceration of the large intestine, or, more generally, of the intestines, the stomach, the gall-bladder, or gall-ducts—parts which return their blood to the portal vein, to be thence transmit- ted through the capillaries of the liver. A connection between abscess of the liver and dysentery has long been noticed, but the two diseases are associated far more fre- quently than has been generally imagined. Of the twenty-nine cases recorded by Annesley, there are twenty-one, or nearly three- fourths, in which there were ulcers, more or less extensive, in the large intestine; and two other cases in which the large intestine was contracted or strictured, in consequence, no doubt, of dysentery at some former period. It is not unlikely that in some of the remaining cases ulceration of the intestines existed but was not noticed. Of the fifteen fatal cases which fell under my own observation at the Seamen's Hospital, the state of the intestines was not noticed in two. In eight of the remaining thirteen cases there were ulcers 1 In some instances the abscesses in the liver may cause inflammation of the hepatic vein, and thence disease of the lung, or some pus may traverse vessels establishing a direct communication between the portal vein and the vena cava. According to Bernard a free communication of this kind exists in the horse and some other animals made for running, and is not entirely wanting in man.—Ber- nard, Lecons de Physiologie Experimentale, 1855, p. 165. 96 SUPPURATIVE INFLAMMATION OF THE LIVER. in the larger intestines, and, in one other case, two ulcers in the stomach; so that, in nine of thirteen cases, or in nearly three- fourths, there were ulcers in the large intestine or stomach. In another of these cases, without ulceration of the stomach or intes- tine, there was ulceration of the common gall-duct. Of the two cases that have fallen under my care in King's Col- lege Hospital, the abscess of the liver was associated with dysentery in both. Yet the condition of the two patients, in other respects, was very different. One of them was a man who had served seven years in the army in India, and who became affected with dysen- tery in that country; the other, a poor woman who had long lived in London, and whose disease came on in this city. In the sixteen cases collected by Andral and Louis, who seem not to have suspected any connection between abscess of the liver and ulcerated intestine, ulcers are noticed in the large intestine and in the lower end of the ileum, in two cases;1 in the lower end of the ileum only, in one case ;2 in the stomach, in four cases ;3 in the gall-bladder, in one case.4 In one of the cases in which the stomach was ulcerated, the ulcer communicated with the abscess, which was in the left lobe of the liver. It is fair to conclude, as Andral does, that in this case (Andral, Obs. 31) the ulcer was caused by the abscess opening into the stomach. Excluding this case, there are still seven cases out of fifteen, in which there was ulceration of some part of the exten- sive mucous surface that returns its blood to the portal vein. The fact will appear still stronger, if we recollect, that in one of these sixteen cases the abscess of the liver was caused by a blow; that in four others it seemed the consequence of phlebitis; and that in none of these five cases were there any ulcers in the stomach, intestines, or gall-bladder. So that in seven out of eleven cases, in which the abscesses were not the consequence of a blow or of general phlebitis, there was ulceration of the stomach, the small or large intestine, or the gall-bladder. It is impossible to suppose that this is a mere coincidence of diseases having no relation to each other. In another of these eleven cases (Andral, Obs. 32) the abscess of the liver was obviously consequent on chronic disease of the stomach, and after death, the 1 Andral, Obs. 25 ; Louis, Obs. 3. a Andral, Obs. 24. 3 Andral, Obs. 27, 30, and 31; Louis, Obs. 4. * Louis, Obs. 5. CAUSES. 97 lining membrane of the stomach was found in some parts so soft- ened as to resemble liquid mucus. In this last case, and in the three cases in which there was an ulcer in the stomach, the state of 'the large intestine is not noticed. Here, again, I may adduce, as a further support to my position, the analogy of cancer. Cancer of the stomach is frequently fol- lowed by disseminated cancerous tumors in the liver, and in no other organ. In a subsequent chapter I shall refer to numerous instances of this kind from those storehouses of pathology—the CUnique Medicate of Andral, and the Anatomic Pathologique of Cru- veilhier. It would seem that cancer cells, like pus-globules, usually, if not always, become arrested in the liver, and do not pass through to become the germs of cancerous tumors in other organs. The association of dysentery with abscess of the liver is noticed by most physicians who have treated of either of those diseases. Dr. Cheyne, speaking of the dysentery of Ireland, says, that in the majority of his dissections the liver was apparently sound; but that in two cases he found abscesses in its substance. {Dublin Hospital Reports, vol. iii.) In two of the four cases of abscess of the liver, published by Dr. Abercrombie, there were ulcers in the large intestine.1 It is re- markable that Dr. Abercrombie should have considered the asso- ciation of the two diseases accidental. He says: " Dysentery is often accompanied by diseases of neighboring organs, especially the liver, in which are found in some cases abscesses, and in the pro- tracted cases chronic induration. These are to be regarded as accidental combinations, though they may considerably modify the ' symptoms." {Diseases of the Stomach, &c, 2d edition, p. 266.) Annesley, much struck with the frequent association of the two diseases, and impressed with the importance of establishing their true relation, confesses his inability to do so. He supposes that, in some cases, the abscess is consequent on the dysentery; that, in others, the dysentery is the mere consequence of the disease of the liver; while, in a third order of cases, the disease of the liver and that of the larger intestine are coeval, or so nearly coeval, that it is almost impossible to decide which had priority. {Annesley, vol. ii. p. 199.) And, indeed, in India, it must be extremely difficult to discover the relation between the two diseases, on account of the 1 Diseases of Stomach, &c. ; 2d edition : cases 93 and 130. 7 98 SUPPURATIVE INFLAMMATION OF THE LIVER. great prevalence of other disorders of the liver that are not easily distinguished from abscess during the life of the patient. In the cases that fell under my own care in the Seamen's Hos- pital I experienced the same difficulty, and generally found it im- possible to tell, from the history of the case, which had priority— the disease of the liver or the dysentery. In some cases, however, it was impossible to resist the conclu- sion, that the abscess of the liver was not only consequent on the dysentery, but caused by it. On the 12th of March, 1838, four men, Brown, Flett, Crere, and Davies, were brought into the hospital from the same vessel, the Renown, in a dreadful state of dysentery. The Renown had just come from Calcutta, and had lost many of her crew from dysentery between Calcutta and the Cape. At the Cape, having but five men before the mast remaining, she shipped seven fresh hands, among whom were Brown, Flett, Davies, and Crere, at that time in perfect health. Some of the original crew continued to suffer from dysen- tery after leaving the Cape, but these new hands had good health until, between the Western Islands and the Channel, when they had got into cold weather, they were attacked, one after another, with dysentery of the most severe kind. Two of these men died soon after their admission to the hospital; the others recovered sufficiently to leave it. In the two fatal cases, I found the state of the large intestine exactly the same. From the ileo-csecal valve to the rectum, the mucous membrane was almost entirely destroyed by sloughing. In one of these cases, the liver contained three small abscesses, not encysted, and evidently quite recent; in the other, the liver, as far as I could then judge, was perfectly healthy. Now, the primary disease in the two cases was obviously the same, produced by the same cause; and as disease of the liver was only found in one of them, we must infer that it was secondary, the consequence of the dysentery. Among many cases of dysen- tery, there may be only one in which abscesses form in the liver, just as among many cases of amputation or of injury of the head, there may be only one in which abscesses form in the lungs and other organs. In another case that fell under my care in the Seamen's Hospital, the patient had dysentery at the Isle of France. The violent symp- toms subsided after two months, and he continued his work for CAUSES. 99 four years. At the end of that time, while on his passage home from the East, diarrhoea recurred, and he had, for the first time, pain in the right side and shoulder. These symptoms had lasted three months, when he was brought into the hospital. He died soon afterwards. On examination, I found a superficial abscess on the convex sur- face of the right lobe of the liver. The mucous membrane of the small intestine was quite healthy to within two inches of the ileo- csecal valve. Immediately above that valve were three ulcers (the largest about the breadth of half a crown), in most part of which the muscular coat of the intestine was laid bare. In their imme- diate vicinity were many other ulcers, about the size of smallpox marks, which had not eaten through the mucous membrane. The mucous membrane about these ulcers was not softened or unusually vascular. In the cascum was a single ulcer, the size of a crown- piece, having the same appearance as the larger ulcers in the small intestine. The mucous membrane in the whole caecum was much softened; in the rest of the large intestine, it was in all respects healthy. The mesenteric glands in the neighborhood of the caecum were enlarged, and softened to a pulp, of a pinkish color. There was no ulceration of the stomach or gall-bladder; no enlargement of the patches of Peyer or of the solitary glands of the small intes- tine. The sequence of events, in this case, seemed to be dysentery, which had left a few chronic ulcers in the caecum and lower end of the small intestine; at the end of four years, recurrence of dysen- teric symptoms; inflammation and abscess of the liver. The ab- scess of the liver clearly dated from the recurrence of the dysen- teric symptoms, when the patient first felt pain referable to the liver. An abscess so superficial could not have existed without manifest symptoms.1 Ifvthe liver-disease had been the cause of the dysentery, it would, in all probability, have produced more extensive ulceration. Irri- tating bile might cause ulcers of the large intestine, and scattered ulcers, but it could hardly affect, so exclusively, such a small por- tion of the gut. I might adduce other instances, which I should, perhaps, weary 1 Compare this case with Obs. 25 of Andral, where suppurative inflammation of the liver occurred in the course of chronic enteritis. 100 SUPPURATIVE INFLAMMATION OF THE LIVER. the reader by relating, in which there could be little doubt that the abscesses in the liver were secondary to dysentery. % We are led, then, to the conclusion, admitted by Annesley, that abscess of the liver is in some cases consequent on dysentery, and caused by it. The question now arises: Is it not so caused in all the cases, or in most of the cases, in which the two diseases are associated ? Annesley thought not, from the circumstance that, in India, the symptoms of liver-disease sometimes appear as soon as those of dysentery; in other cases, even before them. The circumstance that the symptoms of liver-disease appear as soon, or nearly as soon, as those of the dysentery, does not prove that the former disease is not dependent on the latter. In the case above cited from Cruveilhier, in which abscesses in the liver were caused by the rough handling of a prolapsed rectum, the symptoms commenced almost immediately after the injury, and at the end of five days, when the man died, the matter in the abscesses was fully formed. After an amputation or injury, inflammation of a vein may occur, pass on to suppuration, and contaminate the system, in less than forty-eight hours. Supposing, then, the suppurative in- flammation of the liver to be excited in the same way in dysentery, it might be expected that its symptoms would, in some cases, appear almost as soon as those of the primary disease. But, in India, it sometimes happens that the symptoms of liver- disease precede those of dysentery. This, also, is what might have been expected. In India, derangements of the liver, consisting in excessive and perhaps vitiated secretion of bile and inflammation of the gall- ducts, are very common; the consequence, it would seem, of the heat of the climate and the free living in which the English in India indulge. Adhesive inflammation of the liver, terminating in induration and cirrhosis, is also very common there, as in this country, from spirit-drinking. Now, although neither of these disorders may terminate in suppurative inflammation of the liver and abscess, yet they present nearly the same symptoms, and may be readily mistaken for it. If, then, a person with any such derangement of the liver should be taken with dysentery, and have abscess of the liver in consequence, it is very natural that the dysentery CAUSES. 101 should be ascribed to pre-existing suppurative inflammation of the liver.1 If the explanation I have offered be rejected, we are almost driven to conclude, as Annesley does, that the dysentery in these last cases is caused by the passage of irritating bile. Now, if this were the case, we should expect to find the most evident marks of disease in the gall-ducts and the upper part of the small intes- tine—parts with which the irritating secretion comes first in con- tact; but, instead of this, these parts are almost always perfectly healthy in cases in which abscess of the liver is associated with the most destructive forms of dysentery. The whole of the large in- testine may be a complete slough, while the gall-bladder and gall- ducts and the small intestine almost down, or even quite down, to the ileo-caecal valve, are perfectly healthy, and the bile in the gall- bladder is of its natural consistence and color. Annesley, indeed, makes a distinction between what he calls simple dysentery and hepatic dysentery; and states that in simple dysentery, or dysen- tery unconnected with liver-disease, the inflammation of the large intestine generally stops abruptly at the ileo-caecal valve, while in hepatic dysentery the lower part of the small intestine is often in- flamed as well as the large intestine. He believes that in the latter cases the small intestines become diseased from the irritating qual- ity of the bile. Annesley is right in stating that in dysentery con- nected with abscess of the liver, the lower extremity of the ileum is often found diseased as well as the large intestine. It was so in five of the fifteen fatal cases of abscess of the liver I treated at the Seamen's Hospital, but it not unfrequently presents just the same marks of disease in cases of simple dysentery. I have met with many cases of simple dysentery in which the ulceration of the bowel did not stop short at the ileo-cascal valve, but extended twelve or eighteen inches up the small intestine. Cruveilhier has given a plate in which this is very faithfully re- presented ; and in three out of eight cases of simple dysentery, in which Annesley has given an account of the dissections (vol. ii. Cases 172, 173, 179), the lower end of the ileum was diseased as well as the large intestine. The proper reading of these facts seems to be, that the disease 1 Cases 71, 75, 77, of Annesley, are probably examples of this sequence—chro- nic disease of the liver, dysentery, abscess of the liver. 102 SUPPURATIVE INFLAMMATION OF THE LIVER. of the bowel in dysentery is, in some cases, strictly limited to the large intestine, while in others it creeps a little way up the small intestine; in some cases, it causes abscess of the liver, in others not. In no case, whether of simple or hepatic dysentery, is the upper part of the small intestine ulcerated. The ulcers of the small intes- tine, if any exist, are always near the ileo-caecal valve. There can be no doubt that a copious flow of irritating bile may cause diarrhoea, and may prevent the ulcers of dysentery from healing; it may, perhaps, cause ulceration of the bowel; but it is very improbable that it causes the early and extensive ulceration and gangrene of the large intestine, which occurs in Asiatic dysentery, and often destroys life in a few days, while the small intestine, almost in its entire length, remains perfectly healthy. The more probable explanation is that which I have before given; namely, that in these cases the patient had some derange- ment of the functions of the liver, which was followed by dys- entery, and then by abscess; and, consequently, that in all the cases, or most of the cases, in which abscess of the liver and dys- entery are associated, the former disease is the consequence of the latter. If irritating bile cause ulceration of the intestine, it may be the remote cause of abscess of the liver, through the disorder it first occasions in the intestine. Admitting dysentery, or ulceration of the bowel, to be a source of abscess of the liver, it is obvious that the liver does not become involved by spreading of the inflammation, but through injury to the nervous filaments of the sympathetic, or, which is much more likely, by some contamination of the portal blood. The portal blood may be contaminated either by pus, formed by suppurative inflammation of one of the small intestinal veins; or by matter of other kind resulting from softening of the tissues; or by the fetid gaseous and liquid contents of the large intestine in dysentery, which must be absorbed and conveyed immediately to the liver. It seems probable that contamination of the first kind usually gives rise to small scattered abscesses; of the last, to diffuse inflammation, and a larger, perhaps single, collection of pus. If the morbid matter be such that it does not mix readily with the blood —as globules of pus or mercury—it will cause small, circumscribed CAUSES. 103 abscesses, the rest of the liver being healthy. If, on the contrary, the morbid matter be readily diffusible in the blood, all the blood will be vitiated, and diffuse inflammation result, which may or may not be suppurative, according to the quality or concentration of the contaminating matter and the general state of nutrition at the time. In the course of dysentery the liver is very generally disordered, and congestion of it and inflammation that does not go on to sup- puration not unfrequently occur. The admission of this explanation of the relation of abscess of the liver to dysentery, would lead us to expect that abscess of the liver might occasionally be consequent on ulceration of the stomach or gall-bladder—parts which, like the larger intestine, return their blood to the portal vein—and this is found to be the case. It has been already remarked that in the sixteen cases of abscess of the liver recorded by Andral and Louis, there are three in which the stomach was found ulcerated, without any ulceration being no- ticed in the intestines or gall-bladder. In the first of these cases (Andral, Obs. 27), the patient, a man about forty-one years of age, died of ulcerated cancer of the sto- mach. The liver was enlarged, and contained scattered through it a great number of small, firm, red masses, the result, it was sup- posed, of partial inflammations. In the centre of one of these red masses was an abscess the size of a hazel-nut. In another of these cases (Andral, Obs. 30), the patient, a man about sixty, had presented for a considerable time the symptoms of chronic gastritis—loss of appetite, vomiting, sour eructations, and a sense of weight at the epigastrium. He became sallow, and lost strength and flesh. He was somewhat benefited by milk diet and soothing measures, when, all at once, his pulse became frequent, he fell into a state of prostration, with a brown tongue, and died at the end of some days. The coats of the stomach, for the breadth of five or six fingers in front of the pylorus, were much thickened; the mucous membrane was ulcerated; and, in place of the underlying coats, there was a uniform gristly substance of a dead white color. The stomach was united to the liver by bands of false membrane. The liver was of its usual size. In the left lobe was a cavity the size of a small apple, filled with pus, and lined by a thick and tough membrane. The hepatic tissue surrounding the abscess was in a state of gangrene. 101 SUPPURATIVE INFLAMMATION OF THE LIVER. In this case, the abscess of the liver could not have caused the ulcer of the stomach ; but the ulcer may fairly be presumed to have been the cause of the abscess. The abscess had existed for some time. The state of prostration marked the occurrence of gangrene about it. In the third case (Louis, Obs. 4), the patient, a man of fifty, had had for four years disordered digestion, irregular appetite, occa- sional slight pains in the left hypochondrium, now and then nausea and purging, and frequent alternations of leanness and moderate embonpoint. Seventeen days before his admission to the hospital he became much worse than usual, and a set of new symptoms appeared—heat of skin, jaundice, complete loss of appetite, severe pain at the epigastrium, and in the left hypochondrium, and slight oppression. These symptoms continued, and for the last eight days he had, besides, purging and some nausea. He died a fortnight after he entered the hospital. The liver was somewhat larger than natural, and contained a great number of small abscesses lined by a thin and soft false membrane. Its tissue was softened throughout. The gall-bladder was small, and obliterated at its neck. The cystic duct contained a gall-stone. The coats of the gall-bladder and cystic duct were much indurated and thickened; the hepatic duct and the ductus communis perfectly healthy. In the portion of the stomach intermediate to the splenic and pyloric extremities, the mucous membrane was thicker than natural, and presented many deep ulcers three or four lines in breadth. Here, as in the former cases, we cannot ascribe the ulcers in the stomach to the disease of the liver, but the abscesses in the liver may be fairly attributed to the disease of the stomach. There was likewise, indeed, disease of the gall-bladder and cystic duct; but this, which was of long standing, presented no marks of recent activity, whereas it was obvious that the abscesses in the liver were of recent date. In another case by Andral (Andral, Obs. 32), to which I have already alluded, an abscess of the liver was found associated with softening of the mucous membrane of the stomach. Here, symptoms of disease of the stomach had lasted eighteen months before the patient had any symptoms of disease of the liver. The circumstance that the abscess was not encysted goes to prove that it was of recent date. CAUSES. 105 In the Provincial Medical Journal for December 3,1842, the case of a man is related who died at the age of forty-eight, with ulce- rated cancer of the stomach. The liver contained seven or eight abscesses. In the Medical Gazette for Nov. 24, 1843, there are two cases by Dr. Seymour, where a simple ulcer of the stomach had caused cir- cumscribed abscess of the peritoneum. The patients were young maid-servants. In one, there was a large abscess in the upper part of the right lobe of the liver, which, during life, had burst through the diaphragm into the lung. I am indebted to the kindness of Dr. Addison for.the case of a man who died under his care in Guy's Hospital, in 1849, with ulceration of the mucous membrane of the duodenum, from colloid cancer, involving the head of the pancreas and the contiguous por- tion of the gut. In the liver, which had no other organic disease, were several phlegmonous looking abscesses, one of which had opened, a few days before death, through the lung. Ulceration of the gall-bladder or gall-ducts seems just as efficient as ulceration of the stomach in causing abscess of the liver. I would cite, as a probable example of this, the last case given by M. Louis (Louis, Obs. 5). The liver contained from thirty to forty abscesses, varying from the size of a pea to that of a filbert, not encysted, and evidently of recent formation. There was no ulceration of the stomach or intestines, but in the gall-bladder, which contained some small calculi, there were six round ulcers— three superficial and three deep. The mucous membrane of the gall-bladder was three times as thick as it should be. A case very similar to this is given by Dr. Bright in the first volume of Guy's Hospital Reports {p. 630); gall-stones, ulceration of the gall-bladder, numerous abscesses in the liver. With these cases may be classed one of the cases I had to treat at the Seamen's Hospital. The patient, aged 33, was brought into the hospital on the 2d of December, immediately on his return from Quebec. At Quebec he had ague, and this was succeeded, three weeks before his admission, by jaundice and pain below the ensiform cartilage. The jaundice continued, but he had gained strength, when, on the 26th of Janu- ary, just eight weeks after he was brought into the hospital, he was 106 SUPPURATIVE INFLAMMATION OF THE LIVER. suddenly seized with symptoms of peritonitis, which carried him off in four days. On the convex surface of the right lobe of the liver was a large irregular abscess, lined by a buff-colored, and moderately firm, false membrane. The gall-bladder was firmly adherent to the duodenum, and its coats were thickened. Its cavity, which was no larger than a hazel-nut, was filled by a yellow, friable gall-stone, having a firm, dark-green nucleus. The cystic duct was much dilated, and con- tained a similar gall-stone, the size of a small bean. The common duct was also much dilated, and communicated with the duodenum by an ulcerated opening rather larger than a split pea, about two or three lines from the natural termination of the duct. The hepa- tic ducts were very large, and were readily traced a long way into the liver. There was no ulceration of the stomach or of the intes- tines, with the exception of this ulcerated opening in the duodenum, which, as well as the dilatation of the ducts behind and the jaun- dice, was, no doubt, caused by a gall-stone which had stuck for some time in the common duct, and then passed, by ulceration, into the bowel. In 1817, a liver, in which numerous small scattered abscesses formed in sequel to disease of the gall-bladder and gall-stones, was presented to the Pathological Society of Birmingham, by Dr. Mac- kay, and was afterwards sent to me, together with notes of the case, by Dr. James Russel, who was at that time secretary of the Society. The patient, a lusty woman, 64 years of age, previously in good health, was seized with pain at the pit of the stomach, attended with some fever. The pain yielded to purgatives, but two or three days afterwards recurred with greater severity, attended, as before, with fever, but not with vomit- ing, or with other signs of the passing of a gall-stone. The epigastrium was now tender, and the liver was found to be enlarged. Leeches and a blister were applied to the side, and purgatives, and afterwards, for two days, calomel and opium were given. At the end of a week, the pain, and tenderness, and fever, had ceased. Jaundice, attended with complete absence of bile in the intestinal discharges, then came on, and continued till her death, which happened three weeks afterwards from gradual sink- ing, without the occurrence of rigors, or of any other striking symptom, excepting the jaundice. The liver contained numerous small scattered abscesses, evidently recently formed; and other circumscribed portions of its substance were softened, but not yet broken down into abscess. The hepatic duct, just above its junction with the cystic, was blocked up by a gall-stone, the size of a hazel-nut, which was plainly the cause of the jaundice. The gall-bladder was much thickened, and partially ossified; CAUSES. 107 and a portion of its inner surface was in a state of slough. It contained no gall-stones. To these cases may be added a case for which I am indebted to Mr. Bowman, and which is given at length in another chapter. A large hydatid cyst opened into the gall-bladder. In a remote part of the liver was a small abscess. There was no ulceration of the stomach or intestines. In the twenty-nine cases related by Annesley, to which I have so often referred, there are, as I have already remarked, twenty- three in which there were ulcers, or the scars of ulcers, in the large intestine. In four only, of these twenty-three cases, does Annesley notice any morbid change in the gall-bladder or gall-ducts, while he remarks it in three of the remaining six cases. In one of these three cases (Case 81), the gall-bladder was very small, and seemed to be divided by a stricture in the centre. In another (Case 93), the common duct was much compressed and obstructed, by enlargement and hardening of the pancreas, which completely enveloped it. On laying open the cystic duct, the mouth of the gall-bladder was found much constricted by a cartilaginous band. The intestines, small and large, were quite sound. In the third case (Case 126), the gall-bladder completely adhered to the wall of the abscess, and communicated with it. The ducts were impervious, being involved in the adhesive inflammation of the parts that bounded the abscess; and the bile secreted by the liver was either retained in the abscess or discharged by the wound. (The abscess had been opened.) There was no other appearance of disease in any of the viscera. Abercrombie, in his work on Diseases of the Stomach, &c, has given four fatal cases of abscess of the liver. In two of these cases, to which I have already referred (Cases 93 and 130), there were numerous deep ulcers in the large intestine, but no mention is made of disease of the gall-bladder or gall-ducts, or of gall-stones; in the other two cases (Cases 128 and 129), there were large or numerous gall-stones in the hepatic or common ducts, or in the gall-bladder, but there was no disease of the intestinal canal. In the latter cases, the gall-stones, probably by causing ulceration of the ducts, seem to have taken the place of the ulcerated intestine, in setting up suppurative inflammation of the liver. The gall-ducts, the gall-bladder, and the capsule of the liver, are 108 SUPPURATIVE INFLAMMATION OF THE LIVER. nourished by the hepatic artery, and blood flows, not from the por- tal vein to them, but from them to the portal vein. This circum- stance explains how ulceration of the gall-bladder, like ulceration of the stomach or intestines, may cause abscess of the liver, and it also explains the fact, noticed by many physicians who have written on abscess of the liver, that, in this disease, the gall-bladder, the large ducts, and the capsule, are seldom involved. The suppura- tive inflammation is confined to those parts of the liver that receive blood from the portal vein. The frequent absence of every trace of inflammation of the capsule, in cases of abscess of the liver, has been expressly noticed by Annesley and by Dr. Stokes, as very important in reference to treatment. Having collected instances of abscess of the liver apparently originating in a vitiated state of the blood brought from the mucous surfaces that feed the portal vein, we require, to complete our cata- logue of abscesses of the liver produced by contamination of the portal blood, other instances in which the contaminating matter is brought by the splenic vein. My friend, Mr. Busk, has furnished me with notes of the appearances after death in a case which seems to have been of this kind. The liver contained a great number of abscesses, about the size of walnuts, containing thick white pus. The intermediate hepatic substance did not seem inflamed. It was pale, firm, and of natural appearance. The splenic vein was much dilated. The branches by which it arises from the spleen, and all that part of it which runs on the pancreas, were inflamed, and contained a puriform fluid and an irregular deposit of lymph. A large portion of the spleen was pale, and partially separated as a gangrenous mass from the rest of the organ, which was of a deep red color, and very soft. There were no ulcers in the intestines; no abscesses anywhere but in the liver. The most probable supposition is, that the disease in this case originated in the spleen, that the splenic vein subsequently became inflamed, and that the disseminated abscesses in the liver were caused by the noxious matter brought to it by the vein. If this matter were pus, we have another instance of pus brought in large CAUSES. 109 quantity to the portal vein being all arrested in its passage through the liver. A curious and striking illustration of the principles maintained in the preceding pages is afforded by a case which fell under my care in King's College Hospital, in the spring of 1849, in which scattered abscesses of the liver resulted from the accidental rupture of an hydatid cyst. On account of its singularity, I have not in- cluded this case with those of which an analysis has been given above. The patient, a large and very muscular man, a pugilist, while boxing with the gloves, was felled by a blow from the fist under the right false ribs. He was in good health before, but from that time had continuous pain in the right side, and was never, to use his own expression, the same man again. About six weeks after the blow, the pain in the right side became suddenly severe, and this fresh accession of pain was soon followed by headache and nausea, without actual vomiting. He lost his appetite, grew weak and languid, and his bowels became much relaxed. These symptoms persisted, and at the end of two days he noticed that his skin was yellow. The diarrhoea ceased, but the headache and nausea con- tinued, and the jaundice grew deeper. On the 4th of April, five days after the occurrence of the jaundice, and about seven weeks after receiving the blow, he was brought into King's College Hospital, under my care. At that time he was deeply jaundiced, and complained of severe pain, with much tenderness, in the right hypochondrium. The belly was dis- tended, and the liver was considerably enlarged, extending a hand's- breadth below the false ribs. These symptoms were attended with much fever. The skin was hot and dry ; the tongue dry, fissured, and deeply furred ; and the pulse above 100. He had no appetite, and much thirst, and felt drowsy, and complained of headache and nausea. The disease was considered to be active inflammation of the liver, the result of the blow. Leeches were applied to the side, which produced for a short time some alleviation of the pain and tenderness ; and he was fur- ther treated by salines, and small doses of blue-pill, with occasional purgatives. The mouth was made sore by the blue-pill, but no amendment took place. The pain and tenderness of the side, the fever, and the jaundice, continued ; the liver grew somewhat larger, and the patient often com- plained much of pain in the right shoulder and down the right arm. The pulse was always rapid, and the tongue dry and furred. Notwithstand- ing the deep jaundice, the discharges from the bowels were stained with bile. On the 16th of April, twelve days after his admission to the hospital, the liver extended two or three inches below the umbilicus on the right side, and when the hand was placed there a distinct creaking was felt. On listening there, a rubbing sound, like that of pleurisy, was heard. The other symptoms were just the same as before. The next morning he was just in the same state : but at 3 P. M. he was found by the clinical clerk very much worse, complaining of great 110 SUPPURATIVE INFLAMMATION OF THE LIVER. pain at the epigastrium, with an anxious expression, breathing very quickly, with a rapid and very feeble pulse, and bathed in a cold, clammy sweat. He gradually sank, and died at 10 P. M. On examination, the liver was found greatly enlarged ;. extending on the right side as low as the umbilicus. Its surface was covered with soft lymph, but there were no marks of peritonitis elsewhere in the belly. On raising the liver, a clot of blood was found in the epigastric region, and on withdrawing this, I pulled out with it a large hydatid cyst, which must have escaped from its sac, entirely or in part, before death. The cyst was collapsed, and contained no small hydatids. The sac from which the cyst came was situated on the under surface of the liver, between the right and left lobes, was as large as a shaddock, and was full of clotted blood. Its walls were unusually thin for a hydatid tumor of that size. In the substance of the liver were a great number of abscesses,, varying in size from a small pea to a large walnut, the pus of which had an orange or yellow tinge. All these abscesses were in the neighborhood of the hydatid cyst, and in the upper portion of the liver between the cyst and the diaphragm. There were none in all the lower portions of the right lobe. Interspersed with these abscesses were small spots, some having a yellow tinge, others of a dark brown. On examining sections of the liver under water, it was evident that the morbid change, which ended in suppuration, had commenced in the lo- bules. In the first stage of disease the lobules were of a dark brownish color. In a subsequent stage they had a deep yellow tinge, which con- tinued until they were broken down by the suppurative process, when the yellow tinge was communicated to the pus. (See plate iii. fig. 1.) The hepatic and portal canals and vessels, as far as could be ascertained, were in a healthy condition. A microscopic examination of the lobules (in making which I had the assistance of my friend, Dr. Johnson) confirmed the inpression which had been given by inspection with the naked eye. 1. In many of the lobules, whose color and general appearance were natural, the hepatic cells had their usual characters : they were of the normal size, their nuclei were distinct, and they had the usual appear- ance of granular biliary matter and oil-globules, little, if at all, exceeding the healthy standard. 2. In the dark-brown lobules the cells appeared to be more crowded, as if from a process of rapid cell-formation ; and they were, many of them, smaller than in the healthy lobules. In addition to this, many of them presented an unusual appearance : they were remarkably opaque, and seemed to be filled with solid matter, which in some cells had a glistening, whitish appearance (without any oil or biliary matter). In these cells no nucleus was visible. 3. In the lobules, which had a decided yellow tinge, some cells had the appearances described above : others contained a large amount of deep yellow biliary matter, and there was a quantity of the same matter free (not contained in cells) and mixed with pus-corpuscles and oil-globules. In the larger abscesses the pus was more abundant in proportion, being mixed with yellow biliary matter, oil-globules, and amorphous par- ticles, which were probably the debris of hepatic cells and of broken-down tissue. CAUSES. Ill From the history of the case, and from the situation of the ab- scesses in the neighborhood of the hydatid tumor and in the upper portion of the liver between this and the diaphragm, there can be no doubt that the series of changes above described resulted from the injury done to the hydatid tumor. The probable explanation of these changes is, that the hydatid cyst was ruptured by the blow, or by blood afterwards effused into the sac which contained it, and that the proper fluid of the cyst was then gradually absorbed and carried with the portal blood to the lobules. It there led to a mo- dification of the secreting cells, by which an effort was made to eliminate it, and subsequently to the suppurative process. It may at first seem improbable that such serious mischief should be caused by the fluid of an hydatid cyst, which is limpid and co- lorless as the purest water, and which, on chemical analysis, is found to consist of little more than water holding common salt in solution. But, as will be seen in a subsequent chapter, this fluid, simple as it may seem, is very irritating to particular tissues. When by the bursting of an hydatid tumor, it is effused into the perito- neal sac, it sets up peritonitis almost as severe and as rapidly fatal as that which results from the bursting of the gall-bladder or of an abscess. An old encysted abscess of the liver may also give rise, through ulceration of the walls of its sac, to a fresh crop of scattered ab- scesses. My attention has been called to a case which, if I am not mistaken, was of this kind. A circumstance strongly confirmatory of the view I have taken of the different sources of abscess of the liver in the cases that have been adduced, is, that not more than one of these probable sources existed in the same subject. Where the abscess could be traced to a blow or to suppurative inflammation of some vein that returns its blood immediately to the vena cava, there were no ulcers in the stomach, intestines, gall-bladder, or gall-ducts. When ulcers were found in the intestines, by which the occurrence of abscess in the liver could be explained, there were no ulcers in the stomach or gall-bladder. When the stomach was ulcerated, there were no ulcers in the intestines or in the passages of the bile. When there were ulcers in the gall-bladder or gall-ducts, there were none in any part of the intestinal canal. It is not, perhaps, every form of ulceration of the stomach and intestines that gives rise to abscess of the liver. I have never seen 112 SUPPURATIVE INFLAMMATION OF THE LIVER. abscess of the liver noticed in conjunction with ulcerated intestine, in fatal cases of typhoid fever. This fact is very striking when we consider how prevalent and fatal typhoid fever is ; how generally it is attended with extensive ulceration of the bowels; and how attentively all the morbid appearances in this disease have been observed and recorded, of late years, in this country and in France. Abscess of the liver is not noticed in any of the cases (ten in number) of ulceration of the duodenum after burns given by Mr. Curling in his paper in the Med. Chir. Trans., for 1842. It is very rare in conjunction with ulceration of the intestine in phthisis. In two of the cases given by Andral, in which abscess of the liver was associated with ulceration of the intestines, there were tuber- cles in the lungs, and the ulcers were probably of tuberculous origin. But these form an insignificant proportion in the immense number of fatal cases of phthisis with ulcerated intestines in which the morbid appearances have been observed and recorded. It is also rarely consequent on simple ulcer of the stomach. The only instance I have met with of this sort is the case already cited from Dr. Seymour. Abscess of the liver seems to occur chiefly in conjunction with the sloughing ulceration in acute dysentery and with chronic ulcers, attended with thickening and induration of the submucous areolar tissue. In the latter cases, the inflammation of the liver occurs on some exacerbation of the gastric or dysenteric symptoms. It occurs also occasionally in conjunction with ulceration resulting from cancer. The causes that have here been assigned for abscess of the liver will, I believe, be found to apply to a great majority of cases—at least, of the cases that are met with in this country. There will remain, then, if I am right in my conclusions, but few cases that require us to admit the agency of other conditions. Yet various other conditions have been very confidently assigned as causes of suppurative hepatitis. Among these may be mentioned— 1st. Inflammation of the duodenum. Great importance was attached to this presumed cause by Broussais and his followers. Broussais, having remarked that the lymphatic glands in the vicinity of ulcerated mucous membranes are often enlarged and inflamed, and dwelling on the known sympathy between some CAUSES. 11:3 secreting glands—the lachrymal, the salivary—and the adjacent mucous membranes, was led to generalize, and to assign inflamma- tion of the duodenum as the most frequent cause, indeed, as almost the only cause, of inflammation of the liver. This opinion is not borne out by facts. In most of the cases collected by Andral and Louis, and in those observed by myself, the condition of the duo- denum was noticed, and in hardly one did it present any trace of disease. Ulceration or organic disease of the duodenum may, no doubt, cause abscess of the liver, like similar disease of other parts which transmit their blood to the portal vein, but such disease is very rare in the duodenum. 2d. Another cause assigned for hepatitis is spirit drinking. But this produces adhesive inflammation and induration of the liver, not suppurative inflammation and abscess. Notwithstanding the great prevalence of the habit of gin drinking among the lower orders in this metropolis, years often pass away without a single case of abscess of the liver being admitted into a large London hospital. Not one was received into King's College Hospital for five years from its establishment. 3d. A third cause confidently assigned by Annesley and many other writers, is congestion of the liver. Congestion of the liver, as we have seen, may result from some mechanical impediment to the flow of blood through the chest, or from an unhealthy state of the portal blood. Congestion of the former kind certainly does not produce sup- purative inflammation of, the liver. Abscesses of the liver are never met with as a consequence of the congestion caused by the organic diseases of the heart so common in our hospitals; and in not one of the cases recorded by Louis, or Andral, or Annesley, could the abscesses be attributed to this condition. When conges- tion results from noxious matter in the blood, it may, as the cases before referred to sufficiently testify, be followed by abscess; but in such cases the abscess is the result, not of the mere state of con- gestion, but of the inflammation which the noxious matter excites. A particular injury, and probably a particular unhealthy state of the blood, may cause either congestion merely or suppuration, ac- cording to the state of the general health. Congestion may also result from injury of the nervous system, and in unhealthy states of the system this may go on to suppuration. Bernard states, as 114 SUPPURATIVE INFLAMMATION OF THE LIVER. the result of his experiments,1 that division of the sympathetic nerve in the neck of a healthy rabbit causes vascular fulness (con- gestion) of the corresponding side of the head; but that if the rabbit be weak or unhealthy, it immediately causes inflammation and suppuration of that side of the head. 4th. In India great influence is attributed to the heat of the cli- mate in causing inflammation and abscess of the liver. A hot climate, no doubt, deranges the functions of the liver, and causes increased secretion of bile, which often is irritating in quality and produces inflammation of the gall-ducts and intestines, and in this indirect way it may lead to suppurative inflammation of the sub- stance of the liver. It may perhaps also lead directly and without such intervention to suppurative inflammation and abscess; but I feel persuaded that it does so far less frequently than is generally imagined, and that the notion had its origin in the prevalence of dysentery, which we have seen to be a frequent cause of abscess in many tropical climates. The heat of our own summers or of those of France never brings on abscess of the liver, which is very rare in the civil hospitals of London and Paris. Sailors employed^ the trade to the west coast of Africa are exposed to heat perhj,* as great as those in the trade to India, and suffer much more in health, but they are not equally liable to abscess of the liver or to dysentery. Men employed in japanning and other processes in the arts are often exposed to heat much greater than that of India, and their health suffers in consequence, yet we never find them coming into our hospitals with abscess of the liver. 5th. Another condition brought forward to explain the fre- quency of abscess of the liver in India is remittent or intermittent fever, or more correctly the malaria that produces these fevers. It seems established that in some of these fevers the liver, like the spleen, becomes congested and much enlarged in consequence, and in yellow fever and the severe forms of remittent fever it is much aud permanently damaged in its secreting element; yet it may be doubted whether suppurative inflammation of the liver takes place in these cases without ulceration of the stomach or gall-bladder or intestines, which so often occurs in some climates in the course of the severe forms of marsh fever. During the time I was visiting 1 Bernard, Lemons, 1855, p. 352. CAUSES. 115 physician to the Seamen's Hospital, I had continually to treat men in the most deplorable state from fever caught on the west coast of Africa, but none of these men had abscess of the liver. Louis, in his elaborate account of the yellow fever, which he was sent by the French Government to observe at Gibraltar in 1823, says he constantly found the liver of a pale slate color from anemia, but without any marks of inflammation. Annesley, indeed, notices abscesses in the liver among the mor- bid appearances of the remittent fever of India, but he also notices ulceration of the intestine. {Annesley, vol. ii. p. 456.) Sir G. Blaue, in his account of the Walcheren fever, remarks that the liver was occasionally the seat of abscess; but here, as in India, the fever was associated with dysentery. It is probable that in both cases the abscesses occasionally found in the liver were the consequence of the dysentery and not the immediate effects of the fever. It may be, however, that in some parts of India a peculiar ma- laria—aided perhaps by the heat of the climate, and, as regards the English residents, by habits of life unsuited to it1—produces abscess of the liver independently of ulceration of any part of the mucous surface that returns its blood to the portal vein. We know that marsh-fevers differ very much in type, and damage different organs in different seasons and climates, and even according to dif- ferent degrees of concentration merely of the poison by which they are produced. The question once asked will soon be answered by men practising in India, who in general show the most praiseworthy zeal in collecting facts and adding to our knowledge of all subjects connected with medicine. Having considered the causes of suppurative inflammation of the substance of the liver, we may proceed to the changes of struc- ture resulting from it. 1 It is a remarkable fact that in the Indian army abscess of the liver occurs in much higher proportion among the English affected with dysentery than among the natives. This circumstance has been generally attributed to the difference of diet in the two classes. The English in India live as freely as they do in this country, while the native Indian soldiers eat no animal food and drink no wine, but subsist almost entirely on vegetable food and milk. I have been informed by Dr. J. Jackson, who practised at Calcutta with much distinction for twenty-five years, that among the natives of Bengal who have adopted the European manner of living abscess of the liver is not uncommon, and that in most instances the inflammation in the liver has come on during the course of dysentery. 116 SUPPURATIVE INFLAMMATION OF THE LIVER. The earliest perceptible changes in the appearance and texture of the liver from suppurative inflammation, involving its substance, are uniform redness and softening. These were the earliest changes observed by Cruveilhier in his experiments of injecting mercury into the mesenteric veins of dogs. When the dogs died before sufficient time had elapsed for the formation of pus, the mercury wa3 found strewed through the liver, and the hepatic tissue around each globule was of a deep red color, and softened. In the human subject, when abscess of the liver proves speedily fatal, the hepatic tissue about the abscess is generally of a bright red, and softened. This preliminary stage is, however, of very short duration. The inflammation soon passes, in some cases in a few days only, to sup- puration and abscess. As suppuration takes place, the inflamed substance becomes yellowish, and of course still softer than before. At first the pus is disseminated through the lobules, the outline of which can still be distinguished; but the pus-corpuscles become rapidly more and more abundant, the softened tissue breaks down, and an abscess is formed. The state of yellow softening, or purulent infiltration, is there- fore very transitory, and, in consequence, is seldom observed, except for a distance of two or three lines, about a recently formed abscess. Such are the more obvious and striking changes. Microscopic examination of the diseased lobules would, doubtless, from the first, show, in most cases, some morbid change in the secreting cells. The inflammation we are considering commences in the lobular substance of the liver, and is often confined to it; the capsule of the liver, the trunks of the vessels and of the ducts, being perfectly healthy. But if the inflamed part reach the surface of the liver, adhesive inflammation of the capsule is generally set up in the por- tion immediately above it, and coagulable lymph is poured out, which causes permanent adhesion between that portion of the liver and the parts with which it is in contact. This adhesive inflamma- tion is usually of small extent, being confined to the portion of the capsule immediately above the abscess. It sometimes happens, too, when the portion of the liver inflamed reaches a trunk of the hepa- tic vein, that inflammation is set up within the vein. In two instances in which abscesses had formed in the liver after amputa- tion of the leg, I found one or two branches of the hepatic vein blocked up by soft fibrin; and in each, I ascertained that an CHANGES OF STRUCTURE. 117 abscess reached the vein, where it ceased to be obstructed by the fibrin. Backwards from this point, all the twigs were blocked up that went to form the obstructed branch. It would seem that the abscess, reaching the thin coat of the vein, had set up inflammation within it (just as it sets up inflammation of the capsule at parts where it reaches the surface), and that the vein, being blocked up at that point by the effused fibrin, all the twigs that went to form it became obstructed in consequence. I have never found a branch of the portal vein inflamed in such cases, but Dr. James Russel, of Birmingham, has sent me notes of a case in which abscesses formed in the liver and other parts after amputation of the leg, and in which he found lymph and pus in a branch of the portal vein contiguous with one of the abscesses. The branches of the hepatic vein are perhaps more apt to become inflamed secondarily, in this way, than those of the portal vein, from their coats being thinner, and from their not being surrounded, like the branches of the portal vein, by areolar tissue. Abscesses of the liver sometimes attain an extraordinary size. In one instance, I estimated the quantity of matter in an abscess of the liver at two quarts. # A case is related by Annesley, in which an abscess in the liver contained ninety ounces of matter; and Dr. Inman, of Liverpool, has sent me an account of one still more extraordinary, that fell under his own observation, in which the quantity of matter was found by measurement to be thirteen pints. The matter in a hepatic abscess is usually white or yellowish, and is free from odor, unless when it is in close proximity to the lung, whence it sometimes becomes decomposed and fetid, from the admission of air. Many of the old writers describe the pus of abscess of the liver as being generally red or claret-colored, but this description is incorrect. In all the abscesses of the liver that I have examined, the pus was white or yellowish, just like that of a phlegmon. The error of those who have described it as being reddish resulted, per- haps, from their having met with a case in which the abscess opened into the lung, and in which the pus, in its passage through the lung, became mixed with blood and broken down pulmonary tissue. They describe the matter expectorated, and not the matter contained in the abscess. It is not very uncommon for an abscess of the liver to open into the lung. Several instances of the kind have fallen under my own notice, and in all of them the matter expectorated 118 SUPPURATIVE INFLAMMATION OF THE LIVER. was a dirty-red, or brownish pus. The reddish color of the pus was acquired in its passage through the lung. The matter in the abscess was yellowish or white. Rokitansky states that in old abscesses of the liver there is always an appreciable quantity of bile mixed with the pus. I did not remark this in any of the dissections I made at the Seamen's Hospital; perhaps from my attention not being directed to it. In cases that have proved speedily fatal, the abscess is bounded simply by red and softened hepatic tissue; but in others it is lined by a false membrane or cyst. The structure of this cyst varies very much in different cases—depending in some degree, perhaps, on the general condition of the patient, but chiefly on the date of the abscess, and on its size. In small abscesses, and in abscesses recently formed, the pus is surrounded by a layer of albuminous matter, a line or two in thickness, resembling concrete pus, and beyond this the hepatic tissue has its natural texture ; while in old abscesses of large size the cavity is bounded by a dense gray sub- stance, like cartilage, three or four lines in thickness; and the hepatic tissue for a line or two even beyond this is pale and con- densed, obviously in consequence of pressure exerted by the abscess upon it. The following seems to be the mode in which these cysts are produced. At first, the pus becomes circumscribed by a layer of concrete albuminous matter. The abscess then acts as a foreign body, causing pressure on the surrounding parts, and an inflamma- tory action which leads to the effusion of plastic lymph. This lymph, becoming firm and more or less organized, forms the car- tilage-like layer described. When an abscess in the liver has become thus isolated by a firm cyst, it may, especially if it be of small size, remain a long time without further change; but in most cases, after being, perhaps, some time stationary, it grows larger, apparently through secretion of fresh matter from the inner surface of the now organized cyst. By the pressure exerted on it by the distending force, the cyst may become ulcerated, and in this way, as well as by mere distension, the abscess may grow larger. It would seem that, by the process of ulceration, a gall-duct imbedded in the cyst, or lying on it, may bo opened, and a small quantity of bile become mixed with the pus. Rokitansky thus accounts for the bile which he constantly found mixed with the pus in old abscesses of the liver. He says, SYMPTOMS. 119 the large gall-ducts about the abscess break down by the spreading of the suppuration, and open obliquely into the cavity on the distal side, but only exceptionally, and in very large abscesses, on the side towards the intestine. When an abscess of the liver in its first formation, or by its sub- sequent growth, reaches the surface of the liver, it may have various issues. The abscess may burst into the cavity of the peri- toneum, causing inflammation of that membrane, which proves speedily fatal. But this seldom happens. In a great majority of instances, when the matter gets near the surface of the liver, adhe- sive inflammation is set up in the portion of peritoneum imme- diately above it, and lymph is poured out, which glues the liver to adjacent organs—to the abdominal parietes, the diaphragm, the stomach, the duodenum, the colon, according to the seat of the abscess—and the matter is discharged, not into the peritoneal sac, but outwards, or into the lung, or pericardium, or pleura, or the different portions of the intestinal canal just specified. Livers containing abscesses are found of all shades of color that can be produced by different degrees of congestion, and by differ- ences in the quantity of oil and in the quantity and color of the biliary matter retained in the cells; but they are seldom indurated from interstitial deposit of fibrin. The inflammation which termi- nates in abscess, and that which leads to effusion of fibrin and in- duration, or cirrhosis, are not different in degree merely, but in kind. Abscesses are never found in the hob-nail livers of the gin- drinking population of our large towns; and it happens seldom, and then, I believe, only by coincidence, that there is much indu- ration of the liver in persons who return from India with abscess of this organ. We may now consider the symptoms of suppurative inflammation of the liver. In most works on medicine these have been described as being much more uniform than they really are. A picturesque group is sketched, which it seems very easy to identify; but in actual prac- tice it is far otherwise. The physicians who have had most expe- rience in this disease confess their inability, in many cases, to dis- tinguish it from other diseases of the liver; and, in some, even to pronounce that the liver is the seat of disease at all. Here, as in the diseases of other internal organs, our diagnosis will be much aided by knowledge of the circumstances under which the disease 120 SUPPURATIVE INFLAMMATION OF THE LIVER. arises: knowledge which will make us observant of symptoms that would otherwise escape our notice, and will enable us to inter- pret them rightly. The symptoms are most in accordance with the descriptions usually given, when the inflammation is caused by a blow, or some direct injury from without. The injury is usually inflicted on the convex surface of the liver, and then the local symptoms are well marked. There are pain and tenderness in the region of the liver, and a sense of fulness and resistance under the false ribs, from in- creased size of the organ. The liver becomes enlarged, and if the abdomen be flaccid and the intestines empty, its edge can be felt some inches below its natural limit. The secretion of bile may be defective, or its flow through some of the ducts impeded, and the patient be jaundiced. In addition to these symptoms, which may be called special, from their pointing to the liver as the seat of disease, there soon appear, as in simple inflammation of other organs, the general symptoms of inflammatory fever: the pulse is frequent and full; the skin hot; the tongue furred and yellowish; appetite is altogether absent or much diminished. The patient is thirsty, and there is occasion- ally vomiting of bilious matter, while the urine is scanty, high co- lored, and deposits a red sediment. These general symptoms, together with the special symptoms— pain and tension in the region of the liver, and jaundice—occur- ring after an injury to the side, and perhaps, in the absence of evi- dence of disease of the lung or pleura, are sufficient to characterize suppurative inflammation of the liver. But, as before remarked, the liver is so well shielded by the ribs, that the disease is seldom caused in this way. It occurs much more frequently after injuries done to other parts of the body, and after surgical operations, from suppurative inflammation of some vein, and the consequent contamination of the blood by pus. In such cases, the general symptoms do not aid us in detecting it. There is already high fever, which rapidly assumes a typhoid character—the consequence of the contamination of the whole mass of blood, and of the various local inflammations to which this gives rise. We can only infer that abscesses are forming in the liver by the occurrence of special symptoms—pain in the region of the liver, and jaundice—in the midst of the general disorder. But these SYMPTOMS. 121 special symptoms do not exist in all cases. There may be no jaundice; and pain, even, may be wanting, or the typhoid state into which the patient falls may prevent his distinctly perceiving or expressing it. In such cases, the abscesses in the liver can be discovered only after the death of the patient. In the same way, when inflammation of the liver occurs during the acute stage of dysentery, or on the recurrence of acute symp- toms in chronic dysentery, the general symptoms do not aid us in discovering it, because they are fairly attributable to the primary disease. The diagnosis must be founded on local symptoms chiefly —pain and tenderness referable to the liver, tension in the right hypochondrium, and jaundice. Our knowledge of the connection between the two diseases enables us to attach due importance to these symptoms, and to ascribe them to their actual cause. Pain and tenderness in the region of the liver, slight increase in its volume, and jaundice, which, in other circumstances, might excite little alarm, and be attributed to their most frequent cause—inflam- mation and obstruction of the gall-ducts—when they occur in the course of dysentery, will lead us to dread suppurative inflammation and abscess. But these special symptoms are far indeed from being all present in every case; and in some cases they are entirely wanting. On the 2d of October, 1839, a Lascar, 62 years of age, was ad- mitted into the Seamen's Hospital, with general emphysema and catarrh. He complained only of weakness, but sweated at night, and had hectic fever, which led to the suspicion that he had miliary tubercles. He grew weaker, and died of the catarrh on the 12th of November. While in the hospital he made no complaint of pain or tenderness in the right hypochondrium, had no vomiting, no diarrhoea, no jaundice—not a symptom to lead me to suspect that his liver was diseased. On examination, an abscess, contain- ing more than a pint of matter, was found in the substance of the liver. The abscess was bounded by a moderately firm cyst, and the hepatic tissue for a line or two beyond this was pale and con- densed. The rest of the liver was healthy, and the capsule pre- sented no marks of having been inflamed. The stomach and small intestines were sound. In the large intestine there were numerous scars, traces of former dysentery, but no actual ulcers. The lungs were extremely emphysematous, and the bronchial tubes choked by mucus. There were no other marks of disease. 122 SUPPURATIVE INFLAMMATION OF THE LIVER. My friend and former pupil, Dr. Inman, of Liverpool, has sent me notes of an interesting case, in which abscesses of the liver occurred in consequence, it would seem, of dysentery, without any symptom immediately referable to the liver. The patient, a woman 45 years of age, was admitted into the Liverpool Infirmary, on the 21st of June, 1843, in a state of extreme weakness, from bad livino- and from constant diarrhoea, which had then lasted nine or ten weeks. The diarrhoea came on without urgent symptoms, and was unattended by griping or tenesmus. The stools were occa- sionally tinged with blood. The belly was drawn in, and not tender on pressure. She died on the 12th of July. There was extensive ulceration of the large intestine from the ileo-caacal valve to the rectum. The stomach, the small intestines, the kidneys, and the spleen, were healthy. The liver was larger than natural, and near the lower surface Of the right lobe were three abscesses, containing in all about twenty ounces of pure yellow pus. The abscesses were not encysted, and their walls were rough and jagged. There were no marks of inflammation of the capsule of the liver. The lungs were oedematous; otherwise healthy. In the account he sent me, Dr. Inman observes: " No pain in the side or shoulder had been noticed, no vomiting, nor any other symptom that led to the suspicion that there were abscesses in the liver. The abscesses were discovered by accident in the examination of the body." Andral, Abercrombie, and indeed all writers who have published a series of cases of suppurative inflammation of the liver, have noticed the same fact—that, occasionally, in this disease, the patient has no symptoms immediately referable to the liver. Annesley says: "The supervention of abscess of the liver" (in dysentery) "is often not manifested by symptoms of a decided nature." " The formation of matter may commence and terminate without the appearance of any of those signs on which the inex- perienced are taught to rely." In another place he says : " When the disorders of both viscera are nearly coeval, the inexperienced observer may not detect the presence of biliary derangement until the disease is hastening to a fatal termination, and unequivocal signs of abscess are present. In cases of this description, the violence of the dysenteric symptoms absorbs the whole attention of both patient and practitioner, and the complication is over- looked." SYMPTOMS. 123 The presence or absence of the symptoms directly referable to the liver depends chiefly on the situation and extent of the part of the liver inflamed. These symptoms are, as before remarked, ful- ness of the right hypochondrium, from enlargement of the liver; pain or tenderness; and jaundice. The degree of enlargement must evidently depend in some mea- sure on the extent of the part inflamed. If only a small portion of the liver be inflamed, the inflammation, though attended with con- siderable distension of vessels, may run through all its stages without producing any enlargement of the organ discoverable by touch. But in this kind of inflammation there is seldom, I believe, much increase in volume even of the part inflamed. Enlargement of the liver is much more common in adhesive inflammation—that is, in inflammation which terminates in effusion of coagulable lymph, and causes permanent induration, or cirrhosis. This latter kind of inflammation, at least when produced by spirit-drinking, usually involves the entire organ, and, apparently by causing an interstitial deposit of lymph, often much increases its size; while suppurative inflammation is generally limited to a small part of it, and before pus is formed, even this part may be little increased in volume. The circumstance that suppurative inflammation is generally partial serves also to explain the occasional absence of jaundice. A portion only of the liver is inflamed, and as any part can per- form its function independently of the rest, the sound parts may be adequate to free the blood from the principles of bile. The presence or absence of pain seems to depend not so much on the extent as on the situation of the portion inflamed. As long as the inflammation is confined to deep-seated parts and is not sufficiently extensive nor attended with sufficient congestion to cause enlargement of the liver and stretching of its capsule, there is little or no pain. The substance of the liver, like that of the lungs and other parenchymatous organs, is little susceptible of pain. The sharp and severe pain that frequently attends inflam- mation of those organs has its seat in their fibrous or serous covering. The occasional absence of symptoms directly referable to the liver is not then so inexplicable as might at first appear. It is satisfactorily accounted for by the circumstance which dissection has already disclosed to us, that suppurative inflammation is gene- 124 SUPPURATIVE INFLAMMATION OF THE LIVER. rally partial, and often involves only the substance of the liver, the natural sensibility of which is slight. When suppurative inflammation involves all the secreting sub- stance of the liver there is deep jaundice, and the patient dies from oppression of the functions of the brain. A case which seems to have been one of this kind is given by Andral {Clin. Med., iv. p. 381). When an abscess in the liver has become encysted, if small and deep-seated, it causes but little constitutional disturbance, and, pro- vided it remain stationary, the patient may enjoy even tolerable health for years. I had clear proof of this in the case, to which I shall again refer, of my late colleague Mr. Lawson, consulting sur- geon to the Seamen's Hospital, who for ten years before his death had undoubtedly his liver studded with abscesses, but was still competent to all the duties of his profession. If, however, the ab- scess be large, the health is usually much broken. Even when there is neither pain nor tenderness there is yet some degree of fever, the pulse is frequent, there are night-sweats, the patient does not recover strength, and not unfrequently the urine deposits a pinkish sediment. The complexion, too, has in most cases lost its natural clearness, and is sallow or muddy. But besides the general symptoms of inflammatory fever and the special symptoms, pain and tension in the right hypochondrium and jaundice, which occur in well-marked cases of suppurative in- flammation of the liver, and which, when found in conjunction with the circumstances in which suppurative inflammation is known to arise, are perhaps sufficient to characterize it, there are some other symptoms occasionally observed, which cannot be referred to either of the preceding heads, and which frequently continue after the feverish symptoms are past. These symptoms are pain in the right shoulder, vomiting, a short dry cough, and permanent rigidity of the muscles of the abdominal parietes, but especially of the right rectus muscle. Pain in the right shoulder has long been noticed—indeed, from the time of Hippocrates—as an attendant on hepatic disease, and considerable importance has been attached to it as a sign of hepatic abscess. M. Louis, in his paper on Abscess of the Liver, states that none of his patients (they were five in number) had any pain in the shoulder, and he hesitates to believe that this symptom really be- longs to disease of the liver. He conjectures that when present it SYMPTOMS. 125 may depend on concomitant disease of the lung or pleura. Nearly the same opinion has been expressed by M. Andral. Pain in the right shoulder is, indeed, far less frequent in cases of abscess of the liver than is generally imagined, but it existed in five of the fifteen cases I had to treat at the Seamen's Hospital, and in some of these cases there could be no doubt that the pain in the shoulder was dependent on the disease of the liver. In one of these five cases there was a small abscess on the con- vex surface of the right lobe, and the peritoneum covering the abscess adhered for the space of a shilling to the reflected layer of the peritoneum. There were some old adhesions of the lung to the pleura costalis, but no trace of recent pleurisy. Both lungs were pale and perfectly sound. In another of these cases, in which the abscess was on the con- vex surface of the liver and formed a prominent tumor, the pain of the shoulder was so severe as to cause the patient to moan. The pain continued extremely severe for a long time, and at length was relieved on ou.r opening the abscess. In a third case, where the abscess likewise formed a prominent tumor, the patient complained of an aching pain in the right shoulder, extending to the shoulder-blade and up to the right side of the neck. In a fourth case, pain in the shoulder varied in intensity with pain in the right side. When the side was easy, the shoulder was easy also. The two pains were evidently related. In this case there were five or six abscesses of various sizes in the liver; one opened into the lung; another was on the convex surface of the right lobe. In the fifth case, the abscess was single, and was likewise situated on the convex surface of the right lobe. There was no recent in- flammation of the lung or pleura. In two of these cases, the pain in the right shoulder continued for months; and in all of them it was associated with pain in the region of the liver. In all the cases there was an abscess on the convex surface of the right lobe, and adhesions had formed be- tween the peritoneum covering this abscess and the layer of peri- toneum reflected over the diaphragm or abdominal parietes. These cases tend to bear out a statement made by Annesley, that pain of the right shoulder is a sure indication that the disease is in the right lobe; and they explain how it happened that pain 126 SUPPURATIVE INFLAMMATION OF THE LIVER. in the right shoulder was supposed to be so much more frequently associated with abscess of the liver than it really is. Pain in the right shoulder occurs chiefly in those cases in which the abscess is situated on the convex surface of the right lobe.1 Now, before the practice of opening bodies had become general, it was only when the abscess was so situated, and when it formed a prominent tumor, that its existence was detected. The physicians of those times, therefore, observed pain in the shoulder in a large proportion of the cases in which they discovered an hepatic abscess; whereas the frequent dissections made of late years have taught us that abscess is more frequently seated deep in the substance of the liver than on its surface, and that pain of the right shoulder is more fre- quently absent than present. The pain is usually described as a gnawing, aching pain, about the top of the shoulder. There is no swelling or redness of the shoulder, and the pain is not much increased by pressure—some- times, indeed, it is relieved by holding or pressing the shoulder— but it is often increased by pressure on the liver. The pain is, in fact, as it has always been represented to be, a sympathetic pain, like the pain of the knee from disease of the hip. This sympathetic pain in the shoulder is occasionally felt in other diseases of the liver. It now and then occurs in cancer of the liver, and in cases of hydatid tumor, and it may even be pro- duced by a tumor compressing the liver from without. It was complained of by a man who was admitted into King's College Hospital under my care in April, 1843, with aneurism of the ab- dominal aorta. The man died suddenly from bursting of the aneu- rism, between four and five weeks after his admission. The aneu- rism, which sprung from the side of the artery opposite the origin of the casliac axis, formed a tumor as large as a man's head imme- diately behind the liver. It had partially destroyed the bodies of the first, second, and third lumbar vertebrae, and had very much flattened the liver. The tissue of the liver was quite healthy, and the capsule presented no marks of ever having been inflamed. The cough and the vomiting are symptoms of the same kind. Irritation of the liver, like irritation of the stomach, produces a 1 Andral gives a case (t. iv. obs. 32) where there was pain in the right shoulder, with abscess on the under surface of the right lobe. SYMPTOMS. 127 short, dry, sympathetic cough; and, like irritation of most of the abdominal viscera, it may occasion vomiting. M. Louis has not only thrown discredit on pain of the shoulder as a symptom of hepatic abscess, but has advanced similar opinions respecting the vomiting and cough. The vomiting he supposes to arise from inflammation of the mucous membrane of the stomach, and the cough, to be the consequence of bronchitis. I have had several opportunities of satisfying myself that the opinion of this eminent pathologist on these points is incorrect; and that the cough and vomiting, so frequently observed in abscess of the liver, do not depend on any disease of the lung or stomach, but are, what I stated them to be, sympathetic disorders, depending solely on irritation of the liver. In the autumn of 1837, a sailor, 29 years of age, was admitted into the Seamen's Hospital immediately on his arrival from Cal- cutta. He was much emaciated, and stated that he had been ill thirty days of fever, and that during the last ten days he had vomited everything he had taken. His belly was much drawn in, and the parietes were extremely rigid, but there was no tenderness on pressure. He was somewhat thirst}7-, but afraid to drink, on account of the vomiting immediately excited by doing so. My impression was that his disease was gastritis, and I prescribed for him accordingly. The symptoms increased, and at the end of a fortnight he could be got to take little besides toast and water, which he sipped rather than drank. He died about a month after his admission to the hospital. The stomach was found apparently sound, but the liver was the seat of a large abscess, the presence of which had not been even suspected. It has been mentioned that in this case, although there was no pain or tenderness, the abdominal parietes were constantly in a state of rigidity. I remarked the same condition in several of the other cases. In one of them it was very striking; the abdominal parietes were hard like board, especially on the right side, with the skin loose over them. Rigidity of the right rectus muscle was, I find, noticed by the late Mr. Twining, and considered by him, and by some other sur- geons in India, as one of the surest indications of deep-seated abscess of the liver. Like the other symptoms with which it is here associated, it is a purely sympathetic affection. It is now and then met with in other diseases besides abscess of the liver. I 12S SUPPURATIVE INFLAMMATION OF THE LIVER. observed it in a case of long continued jaundice from closure of the common duct, which is related in another chapter, and also in a very striking degree in a case where a cancerous ulcer of the stomach had eaten into the liver, to which the stomach adhered. It is noticed in a case of inflamed gall-bladder, published by Dr. Graves, of Dublin, to which further reference is made in a subse- quent chapter. These sympathetic affections—the pain in the right shoulder, the vomiting, the cough, the rigidity of the abdominal muscles—are of very doubtful import in the early stage of suppurative inflamma- tion while there is yet much fever; but when they exist after the acute stage has passed, and the fever has subsided, and, at the same time, present the characters above noticed—when the pain is seated about the top of the shoulder, is unattended by redness or swelling, and is not much increased by pressure on the shoulder, but by pressure on the side—when the cough is short and dry, and cannot be explained by the condition of the lung—when the vomit- ing occurs immediately after food or drink has been taken, which is a general character of sympathetic vomiting—when, in fact, these syrrfptoms have the characters of sympathetic affections, they are strong indications of the existence of an hepatic abscess. The symptoms that have now been enumerated are almost the only symptoms of suppurative inflammation of the liver, or of its termination—abscess—while the abscess is confined to the sub- stance of the organ. But, when the abscess is large and near the surface, it may, according to its situation, discharge itself in various ways. If situated on the outer surface of the liver, it may either burst into the cavity of the peritoneum, or, by means of adhesion, make its way through the abdominal parietes; if it be situated on the upper part of the liver, in contact with the diaphragm, it may perforate the diaphragm and burst into the sac of the pericardium or the pleura, or adhesions may form between the lung and the portion of diaphragm covering the abscess, and the abscess may open into the lung and be discharged through the bronchial tubes; if the abscess be near the edge, or on the under surface of the liver, adhesions may form between the peritoneum covering it and the stomach, duodenum, or large intestine, and the matter be discharged through the intestinal canal. SYMPTOMS. 129 There will, of course, be a variety of symptoms indicative of these several results. If the abscess burst into the cavity of the peritoneum, there will be sudden accession of pain, vomiting, and all the symptoms of peritonitis from perforation. The patient will speedily fall into collapse, and survive but a few days at most. If, however, the matter escape by oozing merely, it may not become diffused over the surface of the peritoneum, so as to excite general peritonitis. It will spread over the liver, and will be limited by adhesions so as to form a circumscribed abscess in the cavity of the peritoneum. This mode of termination is noticed by Cruveilhier, and happened in two of the cases that fell under my own observation in the Seamen's Hospital. If the abscess open into the stomach, there will be sudden vomit- ing of purulent matter; if into the intestines, sudden diarrhoea, with discharge of pus; and, in either case, the occurrence of these symptoms will be attended by subsidence of the palpable tumor, if any exist. If the abscess perforate the diaphragm, it may burst into the cavity of the pleura, and suddenly set up extensive suppurative pleurisy; but this seldom happens. In almost all cases in which the abscess is making its way through the diaphragm, it excites inflammation of the pleura immediately above it, and adhesion, which is sometimes singularly limited, takes place between the dia- phragm and the lung. The abscess then opens into the lung, and the matter is discharged through the bronchial tubes. When this happens, it is marked by very characteristic symptoms—by a new train of stethoscopic phenomena, which it is, perhaps, unnecessary to detail, and by the sudden expectoration of a dirty red or brown- ish puriform matter. The peculiar color of this matter, which has been already noticed, arises from the pus, in its passage through the lung, becoming mixed with blood and broken down pulmonary tissue. There is no matter like it expectorated in any disease of the lung itself, and I believe that its appearing is pathognomonic of abscess of the liver, or, at least, of abscess perforating the lung. I observed it in several instances in the Seamen's Hospital, and more than once was led by it to detect an abscess in the liver, of which I had previously no suspicion. When the abscess is large, this matter may continue to be spit up for a great length of time. {) 130 SUPPURATIVE INFLAMMATION OF THE LIVER. It generally comes up very easily, in some cases by mouthfuls, almost without effort on the part of the patient. When an abscess of the liver opens into the intestines, or into the lung, all the matter may be discharged, the cavity may close up, and the patient recover. In 1847, I was consulted by an officer in the Indian army, in whom, eight years before, an abscess of the liver had burst through the lung. Symptoms, which led to the inference that he had abscess of the liver, came on while he was suffering from dysentery, in 1839. About three months after their occurrence, while on the deck of a ship, he was suddenly taken with spitting of a mahogany- colored matter, and, in the course of the day, brought up as much as a pint. The spitting continued for three weeks (the matter gradually diminishing in quantity, and losing its dark color), and then ceased. From that time he had occasional pain in the side, but no other illness referable to the liver, and when I saw him, his recovery from the abscess seemed to be perfect. At the Seamen's Hospital, I met with another instance, in which a man, who had all the symptoms of abscess of the liver discharg- ing through the lung, so far recovered that he left the hospital apparently well. But such a happy result is very rare, except when the abscess is small or recently formed. In the majority of other cases, the patient dies, exhausted by protracted suppuration and hectic. The protracted suppuration depends on the nature of the walls of the abscess. The hepatic tissue, and the hard gristly substance that always surrounds an old abscess of large size, cannot contract so as to close the cavity, which must consequently continue to be filled wdth pus. The case is analogous to those cases of old empy- ema, in which the lung is condensed and irrecoverably bound down against the vertebral column. In such cases, the fluid, if serous, continues to be absorbed, as long as the contraction of the side, the encroachment of the opposite lung, the dilatation even of the bronchial tubes of the compressed lung, continue to diminish the pleural cavity of the diseased side; but when all these means have reached their limit, and the cavity can be made no smaller, an end is put to the absorption of the fluid. It is a physical impossibility that a drop more of the fluid can be absorbed. In the same way, in old abscesses of the liver, if the hardened tissue about the abscess TREATMENT. 131 cannot contract so as to close the cavity, the cavity must continue to be filled by pus. It is, then, to the unyielding nature of the walls of the cavity that we must ascribe the protracted suppuration, and the fatalness of hepatic abscess, even in cases in which the free discharge of the pus would seem to promise a more favorable issue. The fatalness does not result from the matter being discharged through the lung. I have met with several cases in which the abscess opened through the abdominal parietes, and all of them, with one exception, to be presently mentioned, proved fatal; so that it seems doubtful whether such an opening is more favorable than one into the intestine or lung. The abscess, if large, may discharge through more outlets than one. In one of the cases I treated at the Seamen's Hospital, the abscess discharged first through the lung, and afterwards through the abdominal parietes also. The reason of this is, that from its sides not collapsing, the abscess is not emptied through the first opening. It has been supposed by some medical men in India, that the pus in an abscess of the liver may be absorbed and eliminated, as pus, in the urine. But this notion is evidently erroneous. Pus-glo- bules, from their large size, cannot directly enter the bloodvessels or escape from them. The matter in the urine supposed to be pus, was probably a deposit of phosphates. During the severe constitu- tional disorder that attends suppurative phlebitis, there is often a sediment of this kind in the urine—having to the naked eye much the appearance of pus, but under the microscope, showing, instead of pus-globules, beautiful phosphatic crystals. The treatment of suppurative inflammation of the substance of the liver is very unsatisfactory. When the inflammation is caused by phlebitis consequent on a wound or injury of the head or limbs, the whole mass of venous blood is contaminated by pus, suppurative inflammation is likewise set up in many lobules of the lungs, perhaps in some of the joints, and, it may be, in various other parts of the body; and the patient soon falls into a typhoid state, which bleeding and other lowering measures would only make worse. The inflammation thus excited 132 SUPPURATIVE INFLAMMATION OF THE LIVER. passes rapidly on to suppuration, and we have little, if any, power to arrest it. The chief objects of treatment should be to prevent, where this is possible, the passage of any more pus into the blood from the injured part, and to support the strength of the patient. When suppurative inflammation of the liver is caused by a blow, the lungs and other organs do not suffer as in purulent infection of the blood: neither are they thus implicated when it is induced by ulceration of the stomach, or intestines, or gall-bladder, since, in these cases, the noxious matter, whatever it may be, which excites the inflammation, is detained in the liver, or drained off through it. Here, the strength of the patient is not so profoundly sunk, and we may hope, by means of depletion, especially by local bleed- ing, to control the inflammation, and limit its extent; and, by ren- dering the abscesses smaller, to protract, at least, the patient's life. In some cases we may, perhaps, by active measures employed early, prevent matter from forming; but we have no evidence that this can be done when the inflammation is caused by pus and is the consequence of inflammation of one of the veins that return their blood to the portal vein. In this country, mercury has generally been resorted to, when the local symptoms have led to the "suspicion that the liver was diseased; but, I fear, with no benefit. It has been well observed by Abercrombie: " In the liver diseases of this country mercury is often used in an indiscriminate manner, and with very undefined notions as to a certain specific influence which it is supposed to exert over all the morbid conditions of this organ. If the liver be supposed to be in a state of torpor, mercury is given to excite it; if in a state of acute inflammation, mercury is given to moderate the inflammation and reduce its action." This indiscriminate use of mercury has resulted from its unques- tionable efficacy in some derangements of the liver, and from the difficulty of distinguishing the different disorders of this organ. I n doubt as to the real nature of the malady, the practitioner is naturally anxious to give his patient the chance of a remedy that occasionally produces marked benefit; but often, in doing so, he aggravates the disorder it is his object to relieve. This misapplication of mercury will continue until the various diseases and derangements of the liver are better discriminated, and practitioners have ascertained those in which mercury has a TREATMENT. 133 curative influence. There can be no doubt that much of our un- certainty as to the action of this and other medicines arises from our confounding under the same name, and treating in the same manner, diseases that result from different conditions and are essen- tially different in their nature. Mercury seems, on many grounds, to be peculiarly unsuited to the disease we have been considering—suppurative inflammation of the liver. One objection to its employment in this disease is the short time allowed for its action. When the inflammation is consequent on a wound or injury, and also, in all probability, when it occurs in the course of dysentery, it passes on to suppuration in two or three days; and when suppuration has once taken place, and abscess has formed, it is agreed by most practitioners who have had experience on the subject, not only that mercury does no good, but that in whatever quantity it be given it seldom produces its usual consti- tutional effects. Annesley says: " There can be no doubt that the system will not be brought under the full operation of mercury, or that ptyalism will not follow on the most energetic employment of this substance, where abscess exists." He repeats this opinion again and again, and even considered resistance to the action of mercury a proof that abscess had formed in the liver. It is only, then, before suppuration has taken place that mercury can do any good, and during this time, from the presence of high fever, the system is with difficulty affected by it. When abscesses have formed and become encysted, the time for active treatment by medicine has of course passed away. The wisest course then is, I believe, merely to regulate the bowels by rhubarb, or rhubarb and aloes, to recommend habits of strict tem- perance, and, where the circumstances of the patient allow, resi- dence in a mild climate, and other measures that tend to improve the general health. If the complexion be sallow or dusky, the nitro-muriatic acid, as recommended by practitioners in India, will often be productive of benefit. Whenever there is reason to infer, from increase of pain and fever, that fresh inflammation is set up within the cyst, and that the abscess is growing larger, blood should be taken from the side by leeches or cupping, or a blister should be applied there. Many physicians have recommended that abscesses of the liver should be opened; but there is much danger in the practice. 134 SUPPURATIVE INFLAMMATION OF THE LIVER. One source of danger noticed by Annesley, Dr. Stokes, and many other writers, is the difficulty of distinguishing an hepatic abscess, and our liability to mistake a distended gall-bladder for an abscess. Such a mistake is almost immediately fatal to the patient. A distended gall-bladder is seldom adherent to the abdominal parietes, and if it be punctured, the bile escapes into the cavity of the peritoneum, the patient is seized with vomiting, falls rapidly into a state of collapse, and generally dies at the end of a few hours. Two cases of this kind are alluded to by Dr. Stokes in the fifth volume of the Dublin Hospital Reports, and many others are on record. This source of danger may, however, be avoided by attention to the situation and character of the tumor. The tumor formed by a distended gall-bladder is globular, and circumscribed, and hard, and equally resisting in every part, while the tumor from abscess is more diffused, and is soft and fluctuating at its summit, while its base is hard and resisting. A source of far greater danger is the circumstance, which has been before noticed, that the inflammation which leads to abscess is often confined to the substance of the liver and does not involve its capsule. As the abscess approaches the surface, adhesive in- flammation of the peritoneum immediately above it usually takes place, and a small quantity of lymph is poured out, which causes adhesion between the wall of the abscess and the parts with which it is brought into contact. These adhesions are often of very small extent. Sometimes they do not form at all, and, as I have before remarked, the abscess bursts into the cavity of the peritoneum, causing speedy collapse and death. By opening an abscess of the liver before adhesions have formed, we may be directly instru- mental in bringing on this fatal issue—the pus may escape into the sac of the peritoneum, and the patient die in a few hours, ob- viously in consequence of the operation. It is, therefore, very important, before opening the abscess, to make out whether the liver adheres to the abdominal parietes or not. This may sometimes be done, when the liver is large, and the abdominal parietes are thin, by feeling the edge of the liver, or some prominent part of its surface, and marking the place of this with a pen on the surface of the belly. If the liver be adherent to the abdominal parietes the line or spot so marked will correspond to the edge or prominence of the liver in all positions of the body. If it be not adherent, the liver will slide along the wall of the belly TREATMENT. 135 when the patient draws a deep breath or changes his posture; the liver will fall, for example, towards the left side when he turns from his back over to that side, and the line or spot will no longer cor- respond to the edge or prominence in question. When there is a circumscribed oedema, or a slight blush on the skin, over the abscess, we may be sure, not only that the liver is adherent, but also that the abscess is making its way to the surface. When, on the contrary, the skin has its natural appearance and color, and other signs that the liver is adherent are wanting, if we thrust a knife into the abscess, we run the risk of discharging the matter into the peritoneal sac. Dr. Graves has ingeniously recommended a mode of proceeding by which he supposes this danger may be obviated. It is: not to open the tumor at once, but to make an incision across the most prominent part of it through the abdominal muscles, so as to reach the peritoneum, without dividing it, and to fill up the wound with a pledget of lint. The object of this is to excite circumscribed inflammation of the peritoneum, which may produce adhesion between the reflected layer of the peritoneum and the layer cover- ing the abscess. The abscess may then be opened, or be allowed to open of itself. I have tried this mode of proceeding twice, with unsatisfactory results, and have come to the conclusion that it is very inadequate to the purpose. But in opening an abscess in the substance of the liver, there is another, and greater, and more unavoidable source of danger, which has not been noticed by the writers to whom I have referred. It is, that the solid hepatic tissue cannot readily collapse, so as to close the cavity when the abscess is opened. When, then, a free opening is made, even into a recent abscess, air almost necessarily enters the cavity, and, from the sudden removal of pressure, or, it may be, from the manipulation employed to empty the cavity, violence is done to the walls of the abscess, and there is often some degree of hemorrhage from them. Air and blood thus become mixed with the pus in the abscess, decomposition takes place, and the air, or the decomposed pus, sets up fresh inflammation of the inner surface of the sac. This causes, of course, a fresh accession of fever, and of other constitutional disturbance, and if the abscess be large, a profuse, and fetid, and continuous discharge, which may soon ex- haust the strength of the patient. The secondary inflammation thus excited by the presence of air, 136 SUPPURATIVE INFLAMMATION OF THE LIVER. or by the decomposed pus, may even lead to gangrene, and speedily destroy life. This happened in one of the cases that fell under my care in the Seamen's Hospital. An abscess that pointed out- wardly was opened, with considerable temporary relief to the pain which the patient suffered in the side and shoulder. But the dis- charge soon became fetid and dark, of the color of coffee-grounds, and at the end of a week the patient died. The walls of the abscess, and the hepatic tissue immediately around them, were found in a state of gangrene. A similar case is noticed by Cruveilhier. {Anat. Path., liv. 40.) In consequence of the dangers of this secondary inflammation, it is, I think, generally best, when an abscess of the liver projects at the side, to allow it to open of itself. The prominent part should be poulticed, and the matter be allowed to escape in the poultices, but should not be squeezed or pressed out. Nature performs the operation better than the surgeon. When the abscess opens of itself, it is usually by a very small aperture, like those in worm- eaten wood, which never closes, and the matter gradually oozes out as the sac contracts. No air gets mixed with the matter of the abscess, and no violence is done to its walls; and, consequently, no fresh inflammation is set up. The discharge is very gradual, and as small in quantity as it can be. There is less shock to the sys- tem, and less drain from it, than when the abscess is freely opened by the knife. The advantages of this proceeding were well shown in the following case, which fell under my care through the recom- mendation of my friend, Dr. Paget, of Cambridge:— A country gentleman, about 60 years of age, whose health had been impaired by asthma, from which he had suffered for 25 years, had an attack of typhoid fever, in November, 1846. At the same time, two of his chil- dren also had the fever, which was of the kind common in the neighbor- hood of Cambridge, and which is attended by ulceration of Peyer's glands. From that time he had more or less pain or uneasiness in the region of the liver, and, in the spring of 1848, had the side repeatedly blistered on account of it. When he first consulted me, on the 19th of January, 1849, the liver was enlarged or pushed down, and over the right lobe, just to the _ right of the epigastric region, was a prominent tumor, as broad as the palm of the hand, which both Dr. Paget and myself took to be an abscess of the liver, making its way to the surface. It was recommended that the tumor should be poulticed, and that the abscess should be allowed to open of itself. On the 25th of February, I received a letter from him, telling me that this had happened. He says :— " On the 15th inst., you gave it as your opinion that the swelling in my TREATMENT. 137 side would probably break at the end of a week, or before a fortnight. I now beg to inform you that, on Saturday morning, we discovered that a moderate quantity of matter had discharged during the night, and it still continues slowly running from two very small apertures that might almost be compared to the pores of the skin. The quantity we could not well ascertain, it was so much mixed with the poultice; but some had escaped down the side. Whenever it is fresh dressed, we observe always a mix- ture of matter. During the day I have four changes. " I think your directions at our last interview were to continue the poultices, and this we shall do, unless I hear from you to the contrary. " I feel convinced you have arrived at the result we could have desired, with the least possible suffering to myself. " I feel, perhaps, a little languid, but my general health and spirits are good." The pain and tenderness of the side, and the fever, which had existed previously, soon disappeared, and the general health improved much ; but an oozing of matter from the side continued. In October, 1850, the dis- charge ceased, doubtless from the channel becoming blocked up; and matter collected again, so as to form a tumor, which pointed two or three inches higher up than the original tumor. This tumor, like the former, was allowed to open of itself, and from that time there was a slight oozing of matter from the second aperture (which did not cause more disturbance of the health, or more inconvenience, than would be caused by a small issue) till the beginning of 1853, when the drain ceased, and no further annoyance from the side was felt. Since the abscess first broke, the asthma has several times recurred, as before. From what I have seen and read of hepatic abscess, it seems to me that the proportion of recoveries has been just as great, if not greater, when the abscess has opened into the lung or the bowel, as when it has made its way through the side; and I can only explain the circumstance by the fact that, when the abscess has pointed at the side, it has seldom been allowed to open of itself. When the abscess is large, and has existed long, its walls are thick and unyielding, and it has, in consequence, still less disposi- tion to close up. When an abscess of this kind opens of itself, either outwardly or into the intestine or lung, matter continues to be dis- charged, and the patient generally dies, worn out by the protracted suppuration. When the abscess is opened by the knife, the same thing of course happens, and the patient dies the earlier for our meddling. In India, it seems now to be a common practice to thrust a long exploring needle into the liver, where the presence of an abscess is suspected; and, now and then, perhaps, the disease may be cured in this way. A single abscess may be opened, when it is of mode- 138 VARIOUS FORMS OF rate size, and before its walls are too thick and firm to fall together, and the cavity may be closed up. But there are many objections to the practice, that to me seem quite decisive against it. First, there is the danger of hemorrhage, and of setting up fresh inflam- mation by the mechanical injury thus done to the liver. This danger may, perhaps, be small for a single puncture, but if the abscess be deep-seated, it may not be hit at the first thrust. Again, from the difficulty of distinguishing the different diseases of the liver, if the operation be commonly adopted, it must often be per- formed where there is no abscess at all. It will readily be imagined that much mischief may be done in this way. Often, too, there is more than one abscess. This was the case in thirteen of the twenty- nine cases recorded by Annesley, and in a still larger proportion in the cases collected by Andral and Louis, and myself. We can hardly hope to reach all the abscesses, and, unless we do, we can- not cure the patient. Then there is the danger that has been before alluded to, of letting the matter escape into the sac of the perito- neum, and setting up peritonitis, that may prove speedily fatal. An occasional instance of success will, I fear, be a poor set-off against the cases in which the operation has done mischief, or failed of doing good. Hitherto, we have considered only suppurative inflammation ori- ginating in the lobular substance of the liver. There are several other forms of suppurative inflammation of this organ, but they are much more rare. 1st. One of these is where the inflammation originates in the areolar tissue in the portal canals, and where the pus, instead of forming a circumscribed abscess, is diffused through the areolar tissue that surrounds the portal vein, and the accompanying artery and duct. A case of this kind is given by Cruveilhier. A professional flute-player, of intemperate habits, after long anxiety, fell into a state of extreme weakness, attended with feverishness, for which he sent for Cruveilhier, on the 18th of December, 1818. His face was then pale and thin ; he had distaste for food, a short dry cough, and a slow fever, with evening exacerbations. Cruveilhier examined the chest and abdomen, without discovering the cause of illness. The symptoms continued, the patient grew thinner, the tongue became very dry and brown ; and, at length, the patient fell into a typhoid state, and died on the 5th of February. On examination, pus was found diffused through the areolar tissue surrounding the branches of SUPPURATIVE INFLAMMATION OF THE LIVER. 139 the portal vein, in the substance of the liver. The lobular substance of the liver was perfectly healthy. There were also small abscesses along the vessels in the meso-colon and meso-rectum. The state of the intestines is not mentioned. 2d. Another form is where suppurative inflammation is set up in the capsule of the liver, or in the peritoneum covering it. This may take place without suppurative inflammation of the substance of the liver, and, at first, without inflammation of the rest of the peritoneum. But, when pus has formed on the surface of the liver, it becomes diffused over the surface of the peritoneum, and causes general and rapidly fatal peritonitis, just as when discharged by the bursting of an abscess. A case of this kind is given by Andral {Clin. Med., iv. 310). It would seem that in such cases the material cause of the inflammation is conveyed by the arterial blood. 3d. A third variety of suppurative inflammation, is where the inflammation originates in the portal or hepatic veins. This variety is so important that I shall consider it in a separate chapter. 4th. A fourth variety is where suppurative inflammation occurs in the gall-bladder or ducts, without similar disease in the secreting substance of the liver. This, too, is so important that I shall speak of it in a separate chapter. 5th. There is still another variety, where suppurative inflamma- tion is set up in the interior of an hydatid cyst, converting it into an abscess. This, considering the rareness of hydatids in the human liver, is not of unfrequent occurrence. Two instances of it have fallen under my own notice. Three are recorded by Andral, and two or three by Cruveilhier. The fragments of hyda- tids were found floating in pus. The observations of Cruveilhier render it probable that, in most of such cases, the suppurative inflammation is set up by the entrance of bile into the cyst. These cases will be again referred to in a subsequent chapter on hydatids of the liver. 140 Sect. II.— Gangrenous inflammation—Appearances sometimes mistaken for gangrene—Circumstances in which gangrene of the liver really occurs. The infrequency of gangrene of the liver has been remarked by Annesley, Dr. Stokes, and many other writers. Annesley states that he did not meet with a single instance of gangrene in all the subjects he examined with abscess and other diseases of the liver, and supposes that medical men have often mistaken for gangrene, changes that occurred after death. I have little doubt that Annes- ley is right in this opinion. If the abscess be recently formed, and not encysted, and the body be examined after the matter in the abscess has become partly decomposed, the hepatic tissue imme- diately surrounding the abscess will be found blackened by the sulphuretted hydrogen formed by decomposition of the pus, and will thus present very much the appearance of gangrene. In the month of July, 1837, I met with a striking instance of this, in a man who died, under my care, in the Dreadnought, with a recently formed abscess of the liver, and whose body was examined forty hours after death. The hepatic tissue about the abscess was black and ragged, just as it would be from gangrene. Where the patient has died in a low typhoid state, and decomposition is unusually rapid, this change of color may occur much sooner after death, and in colder weather, and, of course, be still more likely to be mistaken for gangrene. It will, however, here, as in other cases, be associated with a greenish color of the skin of the belly and neck; or with the presence of gas in the veins; or with some other changes cha- racteristic of decomposition. A black stain is often found on that part of the surface of the liver which touches the intestine, and is produced in the same way by the intestinal gases, which, after death, permeate the coats of the bowel. In persons who die of suppurative peritonitis, the whole surface of the liver soon acquires a black color, which extends a line or GANGRENE OF THE LIVER. Ill two into its substance, the deeper, the longer after death the body is examined. Now and then, in cutting across a liver, a black stain of the same kind may be seen in the portions of liver in contact with the gall-ducts, produced, no doubt, by permeation of sulphu- retted hydrogen, or other gases, through the coats of the ducts. When an abscess is old and bounded by thick and dense false membrane, this change in the color of the surrounding hepatic substance is less likely to take place after death, and as an effect of mere chemical change; and, consequently, a blackish-green color is here a surer sign of gangrene. In the last chapter, mention is made of a case which fell under my care, in the Seamen's Hospital, where gangrene of the liver resulted from opening an abscess, and reference is given to a simi- lar case noticed by Cruveilhier. An instance of gangrene occurring about an old abscess, which has also been referred to in the preceding chapter, is given by Andral; the only instance, he tells us, in which he had then met with gangrene of the liver. The patient, a laboring man, about 60 years of age, was much emaciated, in consequence of an extensive chronic ulcer of the stomach. The gangrene, or death of the part, was probably the result of defective nutrition. It occurred around the abscess, just as a bruise-mark or ulcer occurs in the place of an old scar in scurvy, because the vitality of that part having been previously impaired, it gives earlier tokens of defective nutrition than the sound parts. The following case, for which I am indebted to Mr. Busk, is the most striking instance of gangrene of the liver I have met with, and offers besides many points of great interest. Case. Mortification of the toes from cold—Removal of the dead parts— Severe rigors, followed by typhoid symptoms—Death on the sixth day— Gangrene of the liver, the lung, and the spleen ; necrosis of the thyroid cartilage ; idceration of the pharynx; pus in the shoulder-joint. A Scotchman, 35 years of age, was admitted into the Seamen's Hos- pital, the 14th of January, 1841, with the extremities of the two great loes, and of several other toes, in a state of gangrene, from exposure to cold in coming up channel, after a voyage to the West Indies. He had good health while in the West Indies, but, with the rest of the crew, had drunk rum to excess in the voyage home. There was little appearance of inflammation, and but little pain in the IVct. and he was otherwise in good health—spare, muscular, and rather florid. In a few days, under the use of warm fomentations, the dead parts 142 GANGRENE OF THE LIVER. began to separate from the living, and on the 25th of January, the sepa- ration was nearly complete at the junction of the second and last pha- langes, which were then removed, sufficient flaps being left to cover the bones. The day after this little operation he had rigors, followed by in- cessant vomiting and great general disturbance. The rigors recurred very frequently, and the vomiting continued incessant. No pain or ten- derness could be detected in any part. In a day or two he became jaundiced, and expectorated rusty-colored, viscid matter. The motions were clay-colored. The tongue was dry and brown. On the 29th, several joints, especially the right shoulder, were painful and tender, but he had no pain or tenderness of the abdomen or chest. The following day, mild delirium ; finally, stupor, and death on the 1st of February (the 6th day from the rigors). The body was inspected twenty-four hours after death. The body was lean, muscular, universally rigid, jaundiced, with dark purple mottling on the back and on the sides of the neck and ears. Head. The dura mater on the outside looked healthy. Its inner sur- face was minutely vascular, and covered by a thin film of fibrinous matter, of a bright yellow color, and presenting many minute spots resembling ecchymoses. On examination, these spots were found to be entirely in the effused matter. The cerebral arachnoid was also covered, but over a smaller surface, by a similar film of transparent, yellow, gelatinous-looking fibrin, which, however, was not vascular, and but very slightly opaque. There was a small quantity of liquid of a bright yellow color in the cavity of the arachnoid, and also some colorless fluid beneath it. The vascularity of the arachnoid and the film of fibrin were alike on the two sides, and were confined to the upper surfaces of the hemispheres. At the base of the brain there was no unnatural vascularity, and no lymph effused. The cerebral substance, when sliced, presented large bloody points, more numerous in the back part of the brain, but otherwise it looked healthy, and it had its natural consistence. There was a very small quan- tity of colorless liquid in the lateral ventricles. Chest. Both lungs were everywhere united to the side by firm old tissue. The upper and front part of the right lung was congested, but still crepitant, and slightly infiltered with reddish frothy fluid. The lower and back part of the lung was more solid, and gorged with thin red fluid; and in the midst of the lower lobe, which was quite solid, was a portion, the size of an orange, completely gangrenous. The gangrenous part was of a pale ash color, mottled by infiltration of white pus, and had the ex- tremely offensive odor of gangrene of the lung. This dead portion was separated by a well-defined line from the surrounding pulmonary tissue, which was of a deep purple color, solid and friable. Many other portions of the lung were quite solid, and beginning to lose their color, and others were in the first stage of inflammation, but none had exactly the usual ap- pearance of pulmonary purulent deposits. The left lung was in a similar state, but less advanced. Both lungs had a most disgusting smell. The mucous membrane of the right ventricle of the larynx was ulcer- ated, and of a deep purple color. The mucous membrane of the air-pas- sages was injected throughout, the color becoming deeper in the small CAUSES. 143 tubes. There was a large ragged abscess outside and in front of the thyroid cartilage, which was bare and carious. The pericardium contained a large quantity of red fluid, and the right auricle and ventricle were filled with very fluid blood, and a few yellowish flakes of fibrin. The valves and the lining membrane of the heart were perfect and unstained. The blood in the large vessels was dark-colored and fluid, with small, soft coagula. No pus-globules could be distinctly observed in the blood examined by the microscope. Digestive organs. The mucous membrane of the pharynx presented one or two small superficial ulcers or abrasions, covered with a thin fibrin- ous effusion, and was of a deep purple from minute vascularity. The deep color ceased on a level with the upper edge of the thyroid cartilage. The mucous membrane of the oesophagus was pale and healthy. The stomach was not examined. The intestines, small and large, were healthy throughout, without any enlargement of either Peyer's patches or the solitary glands. The fecal matter was of a pale clay color. The liver was large and closely united to the under surface of the dia- phragm by firm old tissue. On the outside it was not discolored, and presented no marks of recent inflammation. When it was cut into, nume- rous ragged cavities of various sizes were found, containing hepatic sub- stance in a state of complete gangrene, and reduced in many of them to a semifluid, ash-colored, flocculent matter, separated by a very defined line from the surrounding substance, which, in immediate contact with the gangrenous portions, was of a deep greenish slate color. In other spots less completely disorganized, the hepatic substance was of a pale ash color, apparently quite dead, but the lobular structure could be plainly seen ; thus proving clearly that there was little or no deposit of foreign matter. Other portions again, alike in size and shape, were of a deep purple, and slightly softened ; and this probably the first step in the changes leading to the complete disintegration first described. The coats of the large veins, where they came in contact with the gan- grenous portions, partook in the change, in consequence of which their inner surface had a mottled appearance, the dead portions being of a dull yellowish-white, separated from the healthy part by a very delicate red line. The inner surface of the vein was not roughened, or otherwise altered, either in the dead or living parts, and had no lymph on it, either adherent or free; but in some of the larger veins pus was found. Several small, gangrenous spots of the liver were found, which had a small vein in their centre, and there the coats of the vein in all their circumference were dead and discolored. The gangrenous portions of the liver were horribly fetid, but still less so than those of the lung. The gall-bladder contained a small quantity of thick, viscid bile. The spleen was closely united to all the surrounding parts by firm old tissue. Its middle portion was reduced to a grumous pulp. Nearer the surface, its substance was firmer, and of a dark purple color, and had the smell of gangrene. The kidneys were healthy and pale. The right shoulder-joint was filled with thick, fetid pus. 114 GANGRENE OF THE LIVER. In this case, the existence of gangrene, both in the liver and in the lung, was clearly shown by the defined line surrounding the gangrenous portions. The source of the mischief here was, no doubt, the gangrene of the toes produced by cold. The man was in the prime of life, of spare habit, muscular, florid, and in good health at the time of the frost-bite. The case shows us what a serious thing a small patch of gangrene in any part of the body may become. The dissemination of the gangrenous masses—the existence of a number of them isolated and at a distance from one another—proves that the septic agency was conveyed by the blood. The noxious matter thus disseminated, destroyed the vitality of the tissues on which it acted most strongly. The chemical theory of these septic changes is now well known. All parts in which they are taking place, have a tendency to affect other parts brought into contact with them, with the same mode of transformation. The case just related—and it is by no means a solitary one—offers one of the most interesting illustrations of this theory in the whole range of pathology. But whatever be the ex- planation adopted, the fact is certain, and it is one of extreme im- portance, that gangrene of the extremities, or of any part of the surface of the body, produced by cold, by pressure, or in any other way, has a tendency to infect other and remote parts of the body with the same change. The occasional occurrence of gangrene in remote parts of the body in low fevers, after sloughing of the skin of some one part has been caused by pressure, was particularly noticed by Dr. Graves, in his remarks on a case in which gangrene of the lung was conse- quent on sloughing of the sacrum thus caused. The patient, a man, twenty-four years of age, died in Sir Patrick Dun's Hospital, the twenty-ninth day after the first appearance of confluent smallpox. Dr. Graves says: " It is probable that this case would have terminated favorably had not extensive gangrene of the sacrum taken place, to which the nurse did not direct my attention until it was of an alarming extent. It was first pointed out to me on the eighteenth day, at which time he labored under hoarseness and bronchitic symptoms, unattended, however, by any difficulty of respiration. In the course of a few days, however, dyspnoea came on ; the wheezing in his chest increased, and seemed to accelerate the period of death, which appeared, to all those who CAUSES. 115 had witnessed the progress of the case, to be the result of consti- tutional prostration, induced by the external gangrene. On dis- section, two large and two smaller gangrenous sloughs were de- tected in the right lung. The gangrenous portions of the pulmo- nary tissue were insulated, being separated from the surrounding substance of the lung by a whitish membrane, apparently formed of coagulated lymph. The question here occurs, whether these internal gangrenes were a consequence of the external one, or whether they were the result of the same fatal constitutional de- rangement that predisposed the external parts to become gangrenous from pressure? The former supposition seems the most probable ; at the same time, we must admit that gangrene often takes place, in fever, in external parts not liable to pressure, as, for instance, the soles of the feet. It is to be observed, however, that I never knew such parts to become gangrenous, except after some other portions of the integument had mortified, evidently in consequence of pressure.1"1 {Clini- cal Medicine, p. 781.) In the case I have before given, there can be no doubt that the gangrene of the liver and lungs was caused by the gangrene of the toes. There was no other influence acting to produce it. M. Dance published a case in many respects similar, where gan- grene of the spleen was consequent on gangrene of the uterus. In another chapter, I shall relate a case sent me by Dr. Inman, of Liverpool, and interesting on several accounts, in which gan- grene of the lung was consequent on gangrenous sloughing of the vagina. Cruveilhier (Liv. xxxvii. pi. 2, p. 3) has given a case where gan- grene of the gums and cheek was consequent on gangrene of the uterus from cancer. I might, if it were needful, adduce many other instances, show- ing that gangrene of one part, produced by some cause acting only on that part, has a tendency to cause gangrene in other parts remote from it, and not subject to the same influence. It is in this way, in effect of gangrene of some other part, that true gangrene of the liver is most frequently produced. 10 146 Sect. III.—Adhesive inflammation of the capsule, and of the substance of the liver—Cirrhosis—Other forms of inflammation of the sub- stance of the liver. Adhesive, or plastic inflammation, that is, inflammation which causes effusion of coagulable lymph, may, as we have seen, be set up around an abscess in the liver. When the process of suppu- ration is over, the pus, collected into a cavity, becomes bounded by a layer of soft albuminous matter. Around this, again, coagu- lable lymph is effused, which becomes firm and tough, and more or less organized, and thus forms a cyst for the matter. It has already been shown that the texture of the cyst varies chiefly with the date of the abscess, and with its size. In small, and in recently formed abscesses, the walls of the cyst are soft and thin; whereas, in large abscesses of long standing, the matter is usually bounded by a substance three or four lines in thickness, having the look and the toughness of cartilage. The adhesive inflammation is here limited to the immediate vicinity of the abscess, because it is excited by the abscess, and because the lymph poured out there cannot be diffused through the substance of the organ. When the abscess is near the surface of the liver, it sometimes sets up adhesive inflammation of the peritoneum covering it, and lymph is poured out, which unites the peritoneum above the abscess to the parts—the diaphragm, the abdominal parietes, the stomach, the colon—with which it happens to be in contact. The adhesions thus formed are often of very small extent. The wall of an abscess on the convex surface of the liver may adhere to the diaphragm, or to the abdominal parietes, in a space no larger than a shilling. From this, and other circumstances, many writers have inferred that the peritoneum is less liable to adhesive inflam- mation than the pleura. But such does not seem to be the case. The adhesion is limited, because the irritation that excites it is ADHESIVE INFLAMMATION OF THE LIVER. 147 limited, and because the matter poured out does not become diffused over the surface of the membrane. Under similar circumstances, adhesions of the pleura may be of equally small extent. In a case in which an abscess of the liver discharged through the lung, I found that the space in which the lung was adherent to the portion of the diaphragm covering the abscess was not larger than a shilling. Where small circumscribed abscesses form in the lungs from contamination of the blood by pus, the lungs are now and then found adherent to the pleura costalis in a great number of points, corresponding to superficial abscesses, without any diffuse inflammation of the pleura. In the same way adhesive inflammation of the pleura, from the presence of tubercles, is often of very small extent. When lymph is effused in greater quantity on the surface of the liver it causes adhesion of greater extent; and if any of the lymph fall down among the intestines, it may glue adjacent folds of the intestine together. When an abscess excites adhesive inflammation of the substance of the liver, the lymph can never be diffused in this way. It all remains where first deposited, immediately around the abscess, and forms a cyst for the matter. An hydatid tumor in the liver, like an abscess, may excite ad- hesive inflammation in the substance of the liver about it, or on the capsule and peritoneum above it; but it does not always do so, and in consequence an hydatid cyst, like an abscess, may burst into the sac of the peritoneum. Adhesive inflammation of the surface of the liver now and then occurs also over cancerous tumors. The lymph effused in such cases is usually in very small quantity and transparent, and the false membranes found uniting the liver to the diaphragm and the adjacent organs are, in consequence, very white, and thin, and filmy —passing merely from the summits of some of the prominent can- cerous masses to the opposite surface of the peritoneum. But, over cancerous tumors on the liver, inflammation, even to this extent, is the exception and not the rule. Cancerous tumors seem never to cause effusion of fibrin, and consequent induration, in the sub- stance of the liver; and the liver may be enormously enlarged and much deformed by them without any inflammation of its capsule. Small miliary tubercles are occasionally found in great numbers in the livers of persons dead of phthisis. I have never met with 118 ADHESIVE INFLAMMATION OF THE LIVER. an instance in which they seemed to have caused adhesive inflam- mation of the substance of the liver, and have met with only one instance in which they had excited inflammation of its capsule. The rarity of marks of inflammation of the liver in conjunction with a tubercular deposit is remarkable, considering the tendency tubercles have to set up inflammation of the different tissues of the lung. In the livers of monkeys, dead of phthisis, masses of white tuberculous matter as large as a small bean are often met with; and not unfrequently, as in cancer in the human subject, some thread-like false membranes pass from some of the superficial tu- mors to the opposite surface of the peritoneum. Adhesive inflammation of the capsule of the liver of much greater extent than that set up by the local causes that have been just mentioned occurs very frequently in this country, among the lower orders in large towns, in conjunction with deep-seated adhesive in- flammation of the liver, especially where this involves chiefly the areolar tissue in the large portal canals. Deep-seated adhesive inflammation of the liver produces different effects, according to the parts it principally involves. Sometimes the lymph is effused almost exclusively into the areolar tissue in the portal canals of considerable size, and if the person die long after this has occurred, all the considerable branches of the portal vein are surrounded, in some places to a distance, it may be, of half an inch, by a tough fibrous tissue, which by its contraction has drawn in and puckered the adjacent portions of the liver. The rest of the liver may be little, if at all, altered in texture, and may be readily scraped away from these indurated portions. The main branches of the vein are pervious, but many of the small twigs that spring from them are obliterated. The parts of the liver which these twigs supplied are atrophied, and the liver is proportionally reduced in bulk. Where such parts are near the surface, the capsule is some- what drawn in and puckered. Together with these changes, there are usually, if not always, thick false membranes on the capsule of the liver, or extensive adhesions, by means of old tissue, between the liver and adjacent organs. Usually, too, there are old false membranes on the surface of the spleen, and marks of adhesive inflammation of other parts—especially the pericardium and the pleura. CIRRHOSIS. 149 I have several times met with this form of disease in persons who had drunk hard of spirits. It comes on with well-marked symptoms of inflammation of the liver—pain in the side, vomiting, fever, and perhaps jaundice. These symptoms subside after a time, but the patient does not regain his former health. The liver has been permanently damaged; part of its secreting substance becomes atrophied from closure of the small portal veins; and it is no longer adequate to its office. The patient has difficult digestion, looks sallow, and does not recover his former strength. In other cases of deep-seated adhesive inflammation of the liver, the lymph is not effused solely, or chiefly, in the large portal canals. The fibrous tissue is not found about the large branches of the portal vein especially, but about the small twigs that separate the lobules. All the substance of the liver is rendered tough by this new fibrous tissue, which, when the liver is sliced, is seen to form thin lines between small irregular masses of lobules. At the parts on the surface of the liver which correspond to these lines, the capsule is drawn in, so that the surface has a "hob-nailed" appear- ance. The tissue of the liver is paler than natural, from the pre- sence of this white fibrous tissue, and from its containing but a small quantity of blood; and it is often yellowish from accumula- tion of biliary matter in the cells. When such is the case, a section of the liver has the grayish and yellow color of impure beeswax, and, in consequence, the disease has been called by the French cirrhosis. In other cases, again, the quantity of this adventitious fibrous tissue is much greater, and by its contraction the lobular substance of the liver is drawn into round nodules, which being of a deep yellow color from accumulation of biliary matter, are in strong contrast with the gray fibrous tissue between them. This state has been described by Abercrombie, who says the yellow matter of cirrhosis is sometimes in small nodules, like peas, dispersed through the substance of the liver. He adds, " A case is described by Clossy, in which the structure of the liver was wholly consti- tuted of a congeries of little firm globules, like the vitellarium of a laying hen; it occurred in a boy of fifteen, who had immense as- cites. In a case by Boismont, these nodules were as large as peas, and the liver was much diminished in size; the case was chronic with ascites. The French writers have a controversy whether the cirrhosis, or yellow degeneration of the liver be a new for- 150 ADHESIVE INFLAMMATION OF THE LIVER. mation, or a hypertrophia of the yellow substance which they suppose to constitute a part of the structure of the liver in its healthy state. No good can arise from such discussions, as it is impossible to decide them." {Diseases of the Stomach, &c, 2d edi- tion, p. 369.) The disease is seldom met with in this degree, and as the changes of structure are very remarkable, I venture to subjoin the following case, in which this condition of the liver is more fully described. Case. — Spirit-drinking—Jaundice—Vomiting of blood—Ascites and oedema of the legs—Extreme degree of cirrhosis. Gilbert Campbell, aet. 40. was admitted into King's College Hospital, under my care, the 16th of June, 1843. At the age of thirty he became a commercial traveller, and continued so seven years, during which he drank hard of wine and spirits. The last three years he had been a com- mission agent, and had drunk much less, his chief beverage being ale. He had very good health till he became a commercial traveller, but from that time had frequently pain in the stomach and vomiting after excess in drinking. In the month of February, 1841, when travelling to Birmingham, he became jaundiced. The jaundice went off in about a fort- night, and after that he had no particular ailment, till the summer of 1842, when he was laid up two or three weeks with gout in the left foot. This was his first attack of gout, and he had no return of it. In addition to these ailments, he had for several years suffered from stricture of the ure- thra, and from a winter cough. Lately, has had occasional bleeding from the nose. He followed his usual occupations till three weeks before his admission to the hospital, when he was taken in the street with vomiting of blood. The vomiting recurred several times during the day. He thinks he brought up, in all, as much as four quarts of blood, and was very faint in consequence. Two days afterwards he noticed that his belly was swelled, and in a day or two more he had also swelling of the ankles. When he came into the hospital he had a sallow, cachectic look, his conjunctivas were yellowish, his skin hot and dry, his mouth parched, his lips chapped and bleeding. His legs and thighs were very cedematous, but there was no oedema of the hands or face. The belly was much dis- tended with fluid, but it was not painful or tender, and his chief complaint was of a sense of tightness across the loins. The cutaneous veins of the belly were not enlarged. Pulse 100, regular, tolerably full. Inspirations, twenty a minute. He had some cough, and spat up viscid mucus. No pain of the chest. A soft, systolic bellows-sound was heard at the base of the heart and along the arteries. The urine was of natural color, clear, of sp. gr. 1015, free from albu- men. His intellect and his senses were unimpaired, and he slept well. The following day he complained more of the feeling of tightness across the loins, and, as he had passed but little water, the physician's assistant CIRRHOSIS. 151 imagined the bladder was distended. A catheter was introduced in con- sequence, but only a small quantity of urine was drawn off. The opera- tion was very difficult, on account of the stricture, which was found to be a close one. It was followed by considerable bleeding from the urethra; and for three or four days afterwards some blood came away before the urine each time he passed it. From this time to the 26th of August no striking change took place. The pulse ranged from 96 to 114. The appetite was uncertain and the bowels were irregular. He vomited the day after the catheter was passed, but at no other time. He had now and then some bleeding from the nose and from the gums. His skin was hotter than natural, and his tongue was generally dry and somewhat glazed, but he did not complain much of thirst. The urine was always clear, and free from albumen, and its sp. gr. ranged from 1015 to 1022. He had, throughout, the same sallow, cachectic look as at first. At the end of this time the cutaneous veins of the abdomen had become much enlarged, and the ascites, which had been gradually increasing, was enormous. The legs, too, were enormously swelled, and the scrotum and penis were very cedematous. He complained much of the sense of dis- tension and of pain in the loins. The belly was then tapped, and twelve pints of serous fluid were drawn off. The fluid had a sp. gr. 1013 ; and according to my friend Dr. Miller, who made an analysis of it, contained in 1000 parts— Water ...... 966.95 Albumen. ..... 22.51 Salts and extractive matter . . .8.54 998.00 It contained phosphates of lime and magnesia; chlorides of potassium and sodium ; sulphate of potash and free soda ; a trace of iron, and a trace of silica, but not a trace of urea. After the tapping, he was for some time much more comfortable, but the ascites came on again ; and by the 18th of September, had reached its former degree. He suffered much from the great oedema of the penis and scrotum, and to relieve this some punctures were then made in the legs. The discharge from the punctures was very profuse, and the oedema of the scrotum and of the legs diminished. The skin about the punctures in the left leg became red and painful, symptoms of sinking came on, and he died on the 26th. On his admission to the hospital he was put on milk diet, which, with a few extras, was his diet throughout, and he was ordered a saline draught with nitre and henbane. On the 21st of June he was given, in addition, two grains of calomel with a quarter of a grain of opium, three times a day, till the 26th of June, when, the month being sore, the calomel was ordered to be taken only occasionally. The mouth was kept sore till the 3d of July, without any benefit. The medicines he had been taking were then left off, and he was ordered instead to take a diuretic draught, con- taining three grains of iodide of potassium, three times a day, and to rub in over the liver some compound iodine ointment every, night. This treatment was continued till the beginning of August, without 152 ADHESIVE INFLAMMATION OF THE LIVER. producing any appreciable change in his condition. It was then left off, and afterwards be took only a simple diuretic mixture, with a saline pur- gative now and then, when the bowels were confined, or when he felt unusual distension. The body was examined thirteen hours after death. The legs were very cedematous, and on the skin about the punctures in the left leg were some vesications, as if from commencing gangrene. There was no oedema of the hands or face. The abdomen contained a large quantity of straw-colored serous fluid. The liver was small, and weighed only two pounds and eleven and a half ounces. Its under surface was whitened by a very thin false mem- brane, and its upper surface had an opaline tint, apparently from an ex- tremely thin false membrane extended over it. It was united to the diaphragm by a few threads of false membrane near the suspensory liga- ment, but had no other unnatural adhesions. Its edges were rounded, and its surface was roughened by the projection of small, round nodules. When sliced, it was found to be generally pale, from containing but little blood, and the cut surface had a mottled appearance from being thickly studded with roundish bodies, varying in size from the smallest perceptible to that of a small pea, and contrasting in color with the intervening sub- stance, the color of the round bodies or nodules being yellow in various shades, from pale yellow to brown ; that of the intermediate substance being pale without any yellow tint. The rounded bodies were pretty uniformly distributed throughout the substance of the liver. They were not generally larger or more numerous deep in its substance than near the surface. The matter of these round yellow nodules, examined under the micro- scope, showed a mass of the nucleated cells of the liver tinged yellow. Some cells were yellow throughout; in others, there was a spot of yellow about the nucleus, or rather about the centre of the cell, while the portion near the circumference had its usual appearance. The quantity of yellow matter in the cells was greater the deeper the color of the nodule from which they were taken. Some cells from the lighter colored nodules, or from the substance about them, had no yellow tint, and were perfectly natural. Some cells contained a good deal of oil, in globules, which was very unevenly distributed; the cells in some portions containing little, in others much. The gray substance intermediate to the nodules was tough, and seemed a modification of white fibrous tissue. It was opaque, and had a confused granular appearance under the microscope. When a drop of acetic acid was placed on the specimen under the microscope, it became much more transparent, and exhibited a great number of distinct granules. The gall-bladder and gall-ducts, as far as they could be readily traced, and the portal veins, seemed quite healthy. The gall-bladder contained olive-colored bile, so viscid that it could be drawn out in threads. The spleen was rather large, and its surface was mottled with white, by a very thin coating of contracted lymph. Its substance was tolerably firm, and of its natural color. There were no marks of inflammation of the peritoneum investing the stomach and intestines. The mucous membrane of the stomach was healthy, and nowhere softened. There was some thickening and iudura- CIRRHOSIS. 153 tion of the submucous areolar tissue, forming a ring, not above two lines in breadth, about the pylorus. No thickening of the areolar tissue in other parts of the stomach. The coats of the intestines were pale, and those of the small intestine were thin ; but the mucous membrane was healthy throughout. The ascending and the transverse portions of the large intestine were much distended with gas. The kidneys were quite healthy. The cavity of the left pleura contained a considerable quantity of serous fluid, and on the lower lobe of the left lung, and the corresponding part of the pleura costalis, there was a thin coating of recently effused lymph. The lower lobe of the lung was compressed by the liquid, but the lung was otherwise healthy. The right lung was united to the pleura costalis by a few threads of old false membrane, but presented no other marks of disease. The heart was small, and the pericardium and valves were quite healthy. The aorta was healthy. The brain was not examined. The right branch of the portal vein was injected for me by my colleague, Mr. Simon. The size did not flow freely, and the left lobe of the liver was not at all colored by it. The larger of the nodules in the right lobe were, however, colored by the size, and, under the microscope, the capil- lary vessels in their interior were seen to be injected. I could not discover that any portal veins of a size to be readily traced were obliterated. In this case, the appearance of the liver corresponded exactly to the description given by Abercrombie of one form of cirrhosis, where the yellow matter is dispersed through the substance of the liver in small nodules like peas, or, to take the comparison of Glossy, as in the vitellarium of a laying hen. An examination through the microscope showed at once that this yellow matter was the original lobular substance of the liver, which was drawn into these round nodules by the adventitious tissue between them. The nodules were empty of blood, and tinged with bile from the impediment the new tissue caused to the entrance of blood by the portal veins, and to the escape of the bile through the ducts. The adventitious tissue (which had much the appearance of false mem- brane at an early stage of organization) was formed, no doubt, from coagulable lymph. The small size and weight of the liver, notwithstanding the ex- istence of this new tissue, shows to what an extent the original lobular substance of the liver had shrunk. It is worthy of remark, that notwithstanding this great atrophy of the lobular substance, there was no decided jaundice. 154 ADHESIVE INFLAMMATION OF THE LIVER. In the winter of 1850, I met with another instance of the same kind, in which the disease existed in still higher degree, and caused deep jaundice. The patient was a man, sixty-four years of age, who for great part of his life had been in the habit of drinking enormous quantities of gin. The liver was very small and very tough, and its surface was roughened by the projection of small round nodules. When sliced, the cut surface presented a mottled appearance, from being studded with very small, roundish bodies, the largest no bigger than a small pea, which were of various shades of yellow, and which, in consequence, were in strong contrast with the intervening substance, which had no yellow tinge. These vari- ously colored nodules were all that remained of the original secret- ing substance of the liver. The gray intervening substance, to which the liver owed its toughness and great part of its bulk, was mainly composed of adventitious tissue. Some conception of the degree of atrophy which the proper structure of the liver had undergone, may be formed from the fact, that although the man was of very large frame, the whole organ weighed only thirty-seven ounces, and only a small portion of it consisted of the original hepatic substance. Atrophy of the lobular substance of the liver may result, as we have seen, from mere passive congestion, long continued; it may result also from spirit-drinking, without the aid of inflammation, through the direct influence which the spirit has in lessening the vitality and the power of reproduction of the liver-cells; it may result, in like manner, from the action of many other poisons, and, I believe, from depressing mental emotions, and whatever else is capable of long impairing its secreting function—and the texture of the liver may be altered in consequence; but the ordinary ap- pearances in cirrhosis, and the remarkable changes above described, are mainly the consequence of adhesive inflammation in the areolar tissue about the small twigs of the portal vein, by which serous fluid and coagulable lymph are poured out. The serous part of the effusion gets absorbed, and the lymph contracts and becomes converted into dense fibrous tissue, which divides the lobular sub- stance of the liver into well-defined masses, gives great density and toughness to the organ, and by compressing the small twigs of the portal vein and the small gall-ducts, and thus impeding the flow of blood and the escape of bile, induces great atrophy of the original CIRRHOSIS. 155 hepatic tissue, and causes the grayish and yellowish tints which a section of the liver presents. The appearance and consistence of the liver is sometimes further altered by the supervention of what is termed "the fatty degenera- tion ;" in other words, by an accumulation of oil globules, in the cells and between the cells, in the lobular substance. This intersti- tial deposit of oil swells out the lobules, or the small defined masses of lobules into which the liver is divided, and thus makes the liver still more nodulous, or more coarsely granular, and at the same time renders the lobular substance softer, so that it can be more readily scraped away from the fibrous tissue, and of a paler yellow than it otherwise would be. In the chapter on suppurative inflammation of the substance of the liver, it was remarked that where the inflammation results from contamination of the portal blood, the capsule of the liver, and the peritoneum covering it, are often exempt from disease; that it is only when the abscess approaches the surface that adhesions form between the liver and adjacent organs; and that even in such cases the adhesions are often of small extent, being limited to the portion of peritoneum covering the abscess. In adhesive inflammation of the liver, brought on by spirit- drinking, the physical cause of the inflammation is likewise brought by the portal blood, and the capsule is not primarily affected. In some cases, even of hob-nail liver, the peritoneum covering the liver presents no trace of disease, and the capsule has its natural appearance, and can be readily stripped off. In other cases the - capsule is hard to remove, and frequently there is an extensive false membrane on the surface of the liver, or there are tufts of newly- formed tissue, uniting the liver to adjacent organs. In the form of disease before described, where the newly formed fibrous tissue is found in great quantity, but solely or chiefly in the portal canals of considerable size, false membranes on the surface of the liver are perhaps constant, and are certainly, in most cases, much thicker than in ordinary hob-nailed, or granular liver, where the new fibrous tissue is more interstitial. The size of a liver in a state of cirrhosis is very variable. The lymph effused into the areolar tissue of the portal canals, from which all the changes result, of course tends, at first, to augment the size of the liver; and if much of this lymph be poured out at once, the liver may for a time be much enlarged. But, by degrees, 156 ADHESIVE INFLAMMATION OF THE LIVER. the serous part of the effusion is absorbed, the lymph contracts, and the organ again diminishes in bulk. When this happens, the dimi- nishing bulk of the organ is not owing simply to the diminishing bulk of the lymph itself. The lymph, in contracting, compresses the portal veins, and impedes the passage of the blood to the secret- ing substance of the liver, diminishing its vascularity, and, conse- quently its bulk. Many small branches of the portal vein it entirely obliterates, and, by so doing, causes complete atrophy of the portions of the liver which these branches supplied.1 It is to the contraction of the lymph itself, and to the diminished vascularity of the organ, and to the complete atrophy of portions of its secreting substance, that the shrinking of the liver is owing. Dr. Bright says that, in some cases, he has been able to follow distinctly the enlargement of the liver early in the disease, and its gradual diminution afterwards. On account of the slowness of the change, and the difficulty of ascertaining the exact size of the liver, we can seldom obtain this direct evidence of the fact. But if adhe> sions have formed between the liver and adjacent organs, we may frequently assure ourselves that the liver has greatly shrunk, by simply inspecting the bands of adhesion. Some time ago, in a case of advanced cirrhosis, I found a band of areolar tissue, some inches in length, uniting the liver to the spleen. The adhesion must have taken place when the organs were in contact, and the band have been drawn out as one or the other contracted. In another case of advanced cirrhosis, I found the convex sur- face of the liver united to the diaphragm by tufts or bands of false membrane, an inch in length. The parts of the liver at which these tufts were inserted were hollow or depressed, and when all the tufts were divided the surface of the liver was very uneven. Here, as in the case in which the liver and spleen were united, the adhe- sions must have taken place when the surfaces were in contact, and the bands have been drawn out as the surfaces receded from each other. In both cases, these tufts or bands were evidence of the contraction of the liver, after adhesions had formed. The degree of contraction being different in different parts, the surface of the liver becomes uneven. 1 See remarks on adhesive inflammation of the portal vein in a subsequent chapter. CIRRHOSIS. 157 The small gall-ducts, like the branches of the portal vein they accompany, are compressed, and perhaps sometimes completely ob- structed, by the new fibrous tissue—and such obstruction is, as will be shown further on,1 an additional cause of atrophy of the lobular substance—but the mucous membrane of the gall-bladder and of the larger ducts is generally healthy. The outer coats of the gall- bladder are sometimes found thickened, and the gall-bladder con- tracted, from the deposition of lymph, which has subsequently be- come organized or contracted ; but this change, like the adhesions of the capsule of the liver, which are generally found along with it, seems to be secondary;—the consequence of inflammation propa- gated from the deep-seated tissues. If the inflammation of the capsule be extensive, and much lymph be poured out, some of this may fall among the intestines, and cause adhesion of contiguous folds. The coagulable lymph poured out in inflammation of a serous membrane seems to cause adhesive inflammation and effusion of lymph of the same kind at every part of the membrane to which it may be mechanically transferred. In this way, perhaps, cirrhosis may lead to adhesive inflammation of the entire surface of the peritoneum. In persons who have died of ascites, apparently the result of cirrhosis, the entire surface of the peritoneum investing the liver and intestines has now and then been found covered by a dense false membrane. I have met with one or two instances of this kind, and some others are recorded by Dr. Bright in his Hos- pital Reports. It is possible that in some such cases adhesive in- flammation of the peritoneum was the primary disease, and that the diminished size and increased firmness of the liver, and ob- struction to the circulation through it, were caused by the contrac- tion of the dense false membrane upon it. The bile found in the gall-bladder in persons dead of cirrhosis presents various appearances. Often it is thin or serous, and of an apricot or orange color (Andral, Obs. 21); in other cases, where the change in the texture of the liver seems just the same, it has its natural appearance (Andral, Obs. 18). Sometimes it is inspissated, and of a dark olive. In consequence of the impediment to the passage of the portal 1 See cases of complete obstruction of the common gall-duct related in a subse- quent chapter. 158 ADHESIVE INFLAMMATION OF THE LIVER. blood through the liver, the intestinal veins which feed the vena portos are found distended, and,, when there is no false membrane on the peritoneum, the minute veins in those parts of the peri- toneum to which the blood gravitates are seen beautifully injected and varicose. It now and then happens in such cases that the coats of the intestine are cedematous; and in a case related by Andral there was oedema of the coats of the gall-bladder. In a subject examined by Carswell, the trunks and branches of the portal vein were found blocked up by fibrinous coagula. The condition of the liver is described by Carswell, and represented in (plate 2, fasc. Atrophy) his work on Morbid Anatomy. With such evidence of impediment to the passage of the portal blood through the liver, we might expect that the spleen would always, or generally, be congested and enlarged in cirrhosis. But it is not found to be so. The appearance of the spleen does not indeed seem to be much modified by the existence of cirrhosis. It may be of natural size and appearance (Andral, t. iv. Obs. 18); or small and soft (lb., Obs. 17); or small and firm (lb., Obs. 19). How is this to be accounted for? The skin, without exhibiting any other striking change, is almost always dry and unperspiring; and sometimes remains so when the cirrhosis becomes complicated with tuberculous disease of the lung or other conditions that usually induce free sweating. Spirit-drink- ing, which is the most common cause of cirrhosis, injures the tex- ture of the skin, and seems, as it does with the liver, to impair the nutrition and impede the development of its secreting cells, and thus to lessen its secreting power. Morbid changes are often found in the kidneys and other organs in persons dead of cirrhosis—produced in part by the habits of life that caused the cirrhosis, in part by the unhealthy state of the blood and the unusual stress on other secreting organs, especially the kidneys, which necessarily result from defective action of the liver and skin. The most common of them are the small serous cysts on the surface of the kidneys, atheromatous disease of the arteries, and marks of slight adhesive inflammation on the surface of the heart. No such changes, however, are peculiar to cirrhosis, or so constantly accompany it that they can be considered essential, or that they need be specified in a general description of the disease. Causes.—There are perhaps various conditions capable of pro- CIRRHOSIS. 159 ducing, or that may help to produce, the different forms of adhesive inflammation of the substance of the liver under consideration, but the most common and most powerful cause in this country, indeed the only cause whose influence is apparent, is spirit drinking. These forms of disease are in consequence most frequent in large manufacturing towns, among the poorer classes, many of whom spend great part of their earnings in gin; and for this reason the granular and the hob-nailed liver, known to the French as cir- rhosis, has been familiarly termed by English practitioners, the gin-drinker's liver. The liver is more liable to inflammation from spirit-drinkino- than other organs, because the spirit when absorbed by the blood- vessels of the stomach is at once conveyed to it, without change, and without undergoing further dilution than by admixture with the portal blood from other sources: whereas, before it can reach other organs, it must filter through the liver, where much of it may be retained, or excreted, or changed by the chemical affinities there at work, and must, besides, be still further diluted by diffusion through the whole mass of venous blood that is returned from the rest of the body. The influence of spirituous liquors in causing cirrhosis depends not merely on the quantity of alcohol drunk, but on its degree of dilution and on the times at which it is taken. It is well known that sj)//-^-drinkers are the especial victims of cirrhosis, and that wines and malt liquors have little tendency to produce it. Now, in wine and malt liquors the alcohol exists in a state of mere admixture with their other constituents, and there can be little doubt, there- fore, that the more injurious effects of ardent spirits on the liver depend mainly on the circumstance, that the victims of spirit- drinking not only drink large quantities of spirits, but often drink them "neat," and when the stomach is empty—so that the alcohol is rapidly absorbed and conveyed to the liver with comparatively little dilution. In wine and beer the alcohol is already largely diluted, and the beverages, when drunk to excess, are usually drunk at, or soon after meals, when the alcohol is still further diluted with the other contents of the stomach. Some interesting observations on the effects of poisoning by alco- hol were published a few years ago by Dr. Percy, in an Essay which obtained one of the gold medals annually given in the Uni- versity of Edinburgh. Dr. Percy found that in dogs poisoned by 160 ADHESIVE INFLAMMATION OF THE LIVER. alcohol he could recover alcohol from the blood, the brain, and various other organs, but, as might have been expected, in greatest quantity from the liver. The inflammation of the areolar tissue in the portal canals is probably owing to the diffusion of alcohol through it from the portal veins. We can readily fancy such diffusion taking place, if we consider how readily alcohol permeates animal membranes and tissues. This property of alcohol, and the readiness with which it mixes with water, also explain the circumstances noticed by most pathologists, that in cirrhosis the whole liver is changed in struc- ture, and the different parts of it generally in pretty equal degree. If globules of mercury or of pus find their way into the veins that feed the vena portae, they become arrested at particular points in the lobules of the liver, and excite at each of those points cir- cumscribed inflammation and abscess, while the rest of the liver may continue healthy; but alcohol, mixing readily with water, becomes equally diffused through the whole mass of portal blood flowing through the liver, and the inflammation it excites involves in consequence the entire organ. There are various circumstances that seem to favor the action of alcohol in producing cirrhosis. One of them is obstructed circula- tion through the lungs or heart. This, by lessening the activity of respiration, causes the alcohol in the system to be expanded more slowly, and, by retarding the course of the blood in the capillaries of the liver, it may cause the alcohol mixed with the blood to have greater effect on the tissues. M. Becquerel, in an elaborate paper on Cirrhosis, published in the Archives Generales, in 1840, states that the heart was diseased in twenty-one out of forty-two cases of cirrhosis of which he has given an analysis; and that in these cases the heart was diseased before the liver. But he also states that in thirteen of these twenty-one cases the cirrhosis was at what he calls the first degree, and gave rise to no symptoms, or to very trifling symptoms. It is perhaps fair to infer that in some of these cases M. Becquerel mistook for the first stage of cirrhosis the nutmeg ap- pearance of the liver produced by partial congestion of the capil- laries. If we exclude these doubtful cases, there still remain a con- siderable number in which some disease of the heart was found associated with the disease of the liver, and, if we may credit M. Becquerel, was antecedent to it. M. Becquerel, indeed, maintains CIRRHOSIS. 101 that disease of the heart, by producing long-continued congestion of the liver, is, of itself, the most common cause of cirrhosis. But it is far more probable that obstructed circulation through the chest has no direct influence in causing the disease, and that it con- tributes to it only by giving greater effect to the influence of alcohol and other efficient causes. There is no reason to believe that mere passive congestion of other organs has any direct influ- ence in causing active inflammation of them; and disease of the heart would surely lead to oedema of the.legs and general dropsy, before it would cause extravasation of the fibrin of the blood into the substance of the liver. The frequent association of disease of the heart with this disease of the liver, however, may be in part accounted for by the great prevalence of disease of the heart, from rheumatism and other causes, among the lower classes in our large towns, who are the chief victims of spirit-drinking; and also by the fact that this de- structive habit has a tendency to produce disease of the heart and large bloodvessels, as well as of the liver. Another condition that favors the influence of alcohol in pro- ducing cirrhosis is a hot climate. In cold countries ardent spirits may be drunk with impunity, sometimes perhaps with benefit, in quantities that would be very injurious in hot countries. The reason of this is, that in cold countries the alcohol is rapidly ex- pended in keeping up the temperature of the body. When it has once passed into the general circulation, its carbon and hydrogen combine with the oxygen absorbed in the lungs, and are then exhaled in the form of carbonic acid and water. In hot climates, where respiration is less active, the alcohol accumulates more in the system, and has a more injurious effect on the tissues. It is well known that in India, and in other tropical countries, hard drinking produces the most baneful effects. It must be remembered, how- ever, that alcohol has always to pass through the liver before it can be consumed in the respiratory process. It has thus an imme- diate effect on this organ, which is in a great measure independent of climate, and readily produces fatal disease of it even in the coldest countries. Coldness of climate, indeed, may indirectly lead to greater frequency of the disease we are considering, by causing a more general desire for ardent spirits, and thus inducing a freer consumption of them. Cirrhosis is more common in Eng- land and Scotland than in France. 11 162 ADHESIVE INFLAMMATION OF THE LIVER. There are, perhaps, various other conditions that give greater effect to habits of intemperance in inducing disease of the liver. A congested state of the liver, from whatever cause, or a feverish state of the system, in all probability disposes to it. The influence of ardent spirits in producing cirrhosis accounts for the fact that the disease is more common in men than in women, and much more common in persons above the age of thirty than below it. Cirrhosis is occasionally met with in some of our domestic ani- mals. Dr. Carswell has given a drawing of a portion of a cow's liver in which this disease existed. He states that the cow had ascites, but says nothing of the food upon which it had been kept. I have found the same disease in the liver of a pig. It is also sometimes met with in temperate persons—so that there must be other causes for it besides spirit-drinking. There may be other substances, among the immense variety of matters taken into the stomach, or among the products of faulty digestion, which, on being absorbed into the portal blood, causes, like alco- hol, adhesive inflammation of the liver. What these substances are is as yet, however, only matter of surmise. In a considerable proportion of the published cases of cirrhosis there was organic disease of the stomach: and in many of those published by Andral—the most detailed to which I can refer— the illness seems to have commenced with vomiting and purging, which was followed, after some time, by ascites. Many cases seem certainly to show that the disease is occasionally produced by some product of faulty digestion, or by some errors of diet other than the undue consumption of ardent spirits. This inference is strongly borne out by the experience of prac- titioners in India. Adhesive inflammation of the liver, leading to enlargement and induration of it, and consequently to chronic de- rangement of its functions, is a common form of hepatitis in that country, and seems to result in part from the use of alcoholic drinks, which are the more injurious from the heat of the climate, in part from the large quantities of curries, and of hot spices of various kinds which the English in India consume.1 1 I have pleasure in referring the reader who is desirous of information on thia point, to the admirable treatise by Dr. Parkes, " On the Hepatitis and Dysentery of India." CIRRHOSIS. 163 Symptoms.—Cirrhosis usually comes on very insidiously; and when the inflammation does not involve the capsule of the liver, the symptoms are in most cases few and obscure, until the lymph effused in the substance of the liver has caused impediment to the flow of the portal blood and to the secretion and escape of.bile. Some enlargement of the liver, a dull pain in the right hypo- chondrium, and disordered digestion, are the chief symptoms in the early stages, and some of these even may be wanting, or be so slight as to escape our notice. In some cases, however, the onset Of the disease is more sudden, and the symptoms at first are more striking and more indicative of active inflammation. The patient has fever, with loss of appetite, perhaps occasional vomiting, and, it may be jaundice, and his urine is high colored and charged with lithates. There is much pain and tenderness in the region of the liver, and the liver is readily felt to be enlarged. The disease begins in this way when much lymph is effused at once and the inflammation involves the capsule of the liver. When the acute symptoms are subdued by treatment, or sub- side of themselves, the patient follows his usual occupations, and presents only the slight tokens of disease before mentioned. But he finds that he gradually grows weaker and thinner, his appetite is uncertain, his skin becomes dry and rough, and his complexion sallow and earthy. After the lapse of some weeks, or months, or years—according to the quantity of lymph first effused, the success of the treatment then adopted, and the subsequent habits of the patient—the fibrin poured out has become so contracted and is in such quantity that the free passage of the blood through the liver, and perhaps also the free escape of bile from it, is prevented. There then occur a different train of symptoms, which are so characteristic that there is seldom much difficulty in detecting the disease. The belly becomes enlarged by a dropsical fluid, which collects, without pain or tenderness, in the peritoneal sac, and gradually in- creases so as to cause great distension of the belly, and often, by impeding the movements of the diaphragm, much difficulty of breathing. In some cases this dropsy of the belly is followed by oedema of the legs, but there is no oedema of the hands or face, un- less there be likewise disease of the heart or kidneys. At the same time the veins on the surface of the belly grow 164 ADHESIVE INFLAMMATION OF THE LIVER. larger, and the patient becomes liable to hemorrhage from the sto- mach and bowels. This enlargement of the superficial veins of the belly shows clearly that the current of the portal blood is impeded, and is very characteristic of cirrhosis. The complexion is sallow and earthy, or of a slightly greenish cast, and the skin is almost invariably dry and rough. The appetite is uncertain and often entirely gone; the skin is hotter than it should be; the patient has occasional thirst; the tongue is slightly furred; the lips are frequently redder than natu- ral, and contrast strongly with the pale and sallow face; digestion is painful or disordered, often attended with heartburn and sour eructations; and the urine is almost always scanty and high-co- lored, and generally throws down a deep-red, sometimes a pinkish, sediment of lithate of ammonia. There is likewise tendency to hemorrhage from the nose and other parts in which there is no particular stress on the vessels. Small purpuric spots often appear on the face or forehead, some- times on the distended belly; and if the patient be cupped, ecchy- mosis is apt to take place about the punctures. When ascites has once occurred, it persists; the patient con- tinues to lose flesh and strength, and after the lapse of some months, or perhaps a year or two, dies, usually from gradually increasing exhaustion. In some cases, when the patient is much reduced, death is hastened by the occurrence of colliquative diarrhoea, or by the drain from the system caused by tapping, to which recourse is had to relieve the distress of breathing, or the other evils occasioned by the great distension of the belly. The intellect and senses are usually free from disorder to the last. It will readily be seen that the most distinctive symptoms in the advanced stage of cirrhosis result from obliteration or compression of the small twigs of the portal vein, and the consequent obstacle to the circulation in the liver. The blood in the portal vein cannot pass through the liver with its usual freedom, the veins that go to form the portal vein become, in consequence, distended, and vaiious effects are produced. 1st.—The most striking of these is ascites, or dropsy of the belly, which is an immediate effect of the distension of the veins that re- CIRRHOSIS. 165 turn the blood from the peritoneum. In consequence of this dis- tension, the serous part of the blood transudes through the vessels, or absorption by those vessels is less active than it should be, and serous fluid—of much less density, however, and containing much less albumen, than the serum of the blood—collects in the peritoneal sac. Ascites constantly exists in the advanced stages of cirrhosis, and is the more important as a distinguishing sign of this disease, be- cause it occurs in few other diseases of the liver. In abscess of the liver, in hydatids of the liver, in the fatty liver, in diseases of the gallbladder and gall-ducts, the course of the blood is not impeded, or is not sufficiently impeded to cause ascites. Ascites is, however, not unfrequently produced by cancerous masses in the liver, but here the dropsy seldom attains the degree that it does in cirrhosis. It may likewise be produced by obliteration of branches of the portal vein, which is found now and then the only morbid change in the liver—very seldom, however, to such extent as to produce this effect. Ascites occurs also in what has been termed scrofulous disease of the liver, but this disease also, at least in the degree re- quisite to produce dropsy, is very rare. So that in most of the cases in which considerable dropsy of the belly depends on the liver it depends on cirrhosis. The dropsy in many cases is confined to the belly, which may be enormously distended with fluid, while there is no oedema what- ever of the face or arms, or even of the legs. Frequently, how- ever, together with ascites, there is oedema of the legs, but unless there be some disease of the heart, or of the kidneys, the oedema of the legs is always consecutive to the ascites. This circumstance may be readily explained. An obstacle to the flow of blood through the liver acts at first almost exclusively on the portal system of bloodvessels. It has no direct effect on the general cir- culation, except through the anastomoses between the basmor- rhoidal veins, and the branches of the internal iliac vein. It causes, therefore, little direct impediment to the return of blood from the legs. The oedema of the legs, observed in some cases of cirrhosis, not only comes on after the ascites, but is caused by it, and is the effect of compression of the vena cava, and of the iliac veins by the fluid distending the peritoneal sac. Another effect of permanent obstruction to the flow of blood 166 ADHESIVE INFLAMMATION OF THE LIVER. through the liver is a constantly congested state of all the vessels of the intestinal canal, which often gives rise to piles,1 and not un- frequently to hemorrhage from the stomach or bowels. The dis- tension of the vessels, although frequently productive of hemor- rhage, does not, except perhaps in advanced stages of the disease, cause any drain of serous fluid through the mucous membrane. The serous part of the blood does not anywhere escape from mucous or from synovial membranes, as it does from serous mem- branes and in the areolar tissue, from mere passive distension of the bloodvessels. Instead of there being a flux from the bowels in cirrhosis, the natural secretions of the mucous membranes are lessened, and the bowels are sometimes confined throughout the whole course of the disease. When hemorrhage takes place it is seldom that much blood is vomited or discharged from the bowels at once. The blood escapes in small quantities, by oozing from the unbroken surface of the mucous membrane, which may continue for many days, or even weeks, in succession. If the stomach be the seat of hemorrhage, the patient during this time has constant pain at the epigastrium, and may vomit daily a small quantity of blackened blood, which is generally mixed with mucus, or in very small distinct coagula. But it often happens that the extravasated blood passes out of the body unnoticed. Too little is poured out at a time to cause vomiting. It is therefore voided by the bowels, and in its passage through them gets mixed with other matters, and is, besides, so much altered that it is no longer recognized as blood. The blood of the portal system, when thus impeded in its course through the liver, finds another passage to the heart through the superficial veins of the belly, chiefly by means of the anastomoses between the haemorrhoidal branches of the inferior mesenteric vein and branches of the internal iliac vein; and these superficial veins, 1 The disposition to piles that results from the obstructed circulation through the liver is most probably increased by the scanty secretion of bile. It is well known that piles are especially frequent in persons in whom, from any cause, the action of the liver is defective. The bile probably tends to prevent the occurrence of piles by its purgative action, and by some more special influence exerted by the taurine, which, together with the coloring matters and the cholesterine of bile, is voided by the bowel, and which contains more than 25 per cent, of sulphur, one of our best remedies for piles. CIRRHOSIS. 167 in conseqtence of having to transmit an increased quantity of blood, grow rapidly larger and longer. When adhesions form between the surface of the liver and the abdominal parietes, they become organized and traversed by nu- merous vessels, which can be readily injected from the hepatic artery,1 and which establish additional channels between the cap- sular branches of the portal vein, and the superficial veins of the trunk. It is very common in cases of advanced cirrhosis to see large cutaneous veins on each side of the belly and chest. Gene- rally they are most marked on the right side, and become larger at the hypochondrium, but can be traced upwards from the flank. More than once, however, I have seen a large vein emerge abruptly immediately below the right false ribs, and pass up, in a varicose condition, over the chest. Blood likewise finds its way to the heart circuitously by means of anastomoses between the capsular branches of the portal vein and branches of the phrenic vein. These indirect channels are also often increased in number by means of adhesions between the liver and the diaphragm. Such adhesions, then, so far answer a good purpose that they favor the return of blood to the heart, and lessen the distension of the portal veins. The sallowness of complexion so generally observed in cirrhosis most probably results chiefly from the impediment to the escape of bile from the lobules and through the small bile-ducts, which the indurated tissue in the portal canals occasions—an impediment of the existence of which there is often sufficient evidence in the un- equal biliary congestion of the lobules found after death. A sallow, jaundiced complexion is much more constant in cir- rhosis than in abscess of the liver, but the jaundice is seldom decided, and, even in advanced stages of the disease, the discharges from the bowels are colored by bile. The change in the complexion takes place gradually, as the con- traction of the effused lymph impedes more and more the secretion and escape of bile. Dr. Bright, speaking of such cases, says, " The change from the natural color is usually gradual; and the yellow tinge of the conjunctiva often precedes for some weeks any more decided indication. In time, however, the bronzed appearance of the forehead, or the darkened areola of the eye, bespeak the ap- 1 Kiernan, Phil. Trans., 1833. 168 ADHESIVE INFLAMMATION OF THE LIVER. proaching change; and a jaundice, bearing the lighter tints, from a saffron suffusion to a fainter or more decided lemon hue—still, however, liable to considerable fluctuation—establishes itself over the whole body." The sallow cast of the complexion in the advanced stage of cir- rhosis depends, like the ascites, on an organic change in the texture of the liver, which does not admit of remedy. When the effused lymph has become organized, it forms part of the living tissues, and is incapable of removal. The sallowness, then, like the ascites, although it may vary somewhat in degree, never disappears when it has once come on at this stage of the disease. When observing the complexion, we must take care not to be misled by the permanent bronzed appearance of the face, so com- mon in persons who have been much in hot climates, which is pro- duced by mere exposure to the sun, without any disease of the liver. In such persons, the skin of the chest, and parts covered by clothing, have their natural healthy tint. We must also take care not to be misled by the sallowness of the face, that results from mere deficiency of red globules in the blood. The sallowness thus produced is readily distinguished by the cir- cumstance that the conjunctiva is of a bluish-white and pearly, while in that which results from deficient secretion of bile, the con- junctiva is more decidedly yellow than the skin. The emaciation and the loss of strength that occur in cirrhosis, may depend, in part, on direct injury to the stomach and other organs caused by the habits of life that induce cirrhosis; but they are, no doubt, mainly owing to atrophy of the lobular substance of the liver, and to the impediment which the disease creates to the pas- sage of blood through the liver, and to the escape of bile from it. The obstructed circulation impedes the absorption of water and other nutritive substances by the veins of the stomach and intes- tines ; keeps the mucous membrane of this portion of the intestinal canal, and the glands associated with it, in a permanent state of con- gestion, and thus enfeebles the digestive power; and when the obstruction is so great that blood is diverted from its appointed channel, it must tend directly to produce an impure condition of the blood. That part of the portal blood which does not pass through the liver, but finds another way back to the heart, cannot be freed from the principles of bile, and be otherwise purified, as it CIRRHOSIS. 169 should be, and must, therefore, contaminate to a certain degree the whole mass of blood with which it is mixed. Impediment to the escape of biliary matter from the lobules, and through the small bile-ducts, impairs nutrition directly, by causing a deficiency of bile in the intestinal canal, and a bilious impregna- tion of the blood; and it has a more remote injurious effect, by being an additional cause of atrophy of the lobular substance. Destruction of the lobular substance of the liver tends to impair nutrition, by rendering the secretion of bile defective, and thus deranging the work of the intestinal canal, and, by leading directly to an unhealthy and impoverished condition of the blood, which, in consequence of this destruction of the lobular substance, is im- perfectly filtered in the liver, and does not undergo there, to their full extent, those reparative changes which the action of the healthy liver causes. Whenever, from any cause, much of the lobular sub- stance of the liver is destroyed, a state of anemia results. The loss of flesh and strength, then, like the ascites and sallow complexion, depends, in great measure, on changes of structure which we cannot remedy; and although it may be hastened by lowering treatment, or other causes, and may be in some degree stayed by judicious measures, it is, of necessity, when the disease has attained a certain degree, constantly, though slowly, progres- sive. Diagnosis.—In the early stage of cirrhosis, the symptoms are often few, and present no distinctive, and, to common eyes, no alarming characters, so that it is only by considering the circumstances in which they arise that we are led to perceive their true significance. Slight shallowness of complexion, a dull pain, or some degree of tenderness in the right hypochondrium, with occasional feverish- ness, in a person above the age of thirty, who has been long in the habit of drinking spirits to excess, are almost conclusive evidence of the existence of cirrhosis, even before there is any direct proof that the circulation through the liver is impeded. The symptoms in themselves may be slight, but knowledge of the habits of the patient enables us to regard them as tokens of organic disease. Here, as in so many other cases, it is only by knowing the causes of the disease, or the circumstances under which it usually occurs, that we become watchful of its earliest tokens, and learn to inter- pret them rightly. 170 ADHESIVE INFLAMMATION OF THE LIVER. When, by the progress of the disease, the course of the blood through the liver is so impeded as to cause ascites, the diagnosis is much more easy; because ascites from other conditions is generally associated with a train of symptoms different from that of cirrhosis, and does not occur especially in spirit-drinkers. The conditions, besides cirrhosis, that most frequently give rise to persistent ascites are, great enlargement of the spleen, chronic peritonitis, and malignant disease of the liver or omentum. When ascites results from enlargement of the spleen, the super- ficial veins of the belly are enlarged, the complexion may be some- what sallow, there may be occasional hemorrhage from the stomach or bowels, and there is usually, as in cirrhosis, slow and progres- sive loss of flesh and strength. But the disease may generally be distinguished from cirrhosis by its not occurring especially in spirit-drinkers, by the perspiring or moist state of the skin, and by the existence of a large tumor in the left side of the belly, which, from its form and position, and from the notches on its anterior edge, is readily recognized as the spleen. The course of this dis- ease is often different from that of cirrhosis. The ascites, after having attained a high degree, and lasted a considerable time, may entirely disappear, and although the spleen remains large, the patient may regain health enough for his former pursuits. Now and then, however, the ascites persists and attains the highest pos- sible degree—preventing the descent of the diaphragm, and causing terrible distress—the loss of flesh and strength continues, and the disease destroys life just in the same way as cirrhosis. After death, no cause for these symptoms may be found, except a firm, fleshy, and enormously enlarged spleen.1 When ascites results from chronic or adhesive peritonitis, it is attended with wasting of flesh, and the urine, as in cirrhosis, is usually high-colored and highly charged with lithates. But in chronic peritonitis there is not the sallow look of cirrhosis, and there are pain and tenderness all over the belly, with hectic fever and sweating—symptoms which are usually wanting in the ad- vanced stages of cirrhosis. 1 It may be that in these cases the liver is diseased as well as the spleen. The ascites may depend on obliteration of some branches of the portal vein, and may gradually disappear as the requisite freedom of circulation is restored through other channels. CIRRHOSIS. 171 Again, in peritonitis the fluid poured out is seldom so abundant as in cirrhosis. The belly may be as much distended, but this is owing in great part to the intestines being distended by gas—which they always are in peritonitis. The ascites, too, does not persist as it does in cirrhosis. If the fluid be serous, it soon becomes absorbed. There is not the same impediment to the absorption of the fluid in peritonitis as in pleurisy. In cases of pleurisy, when the lung has been much com- pressed, and is irrecoverably bound down by false membranes, the fluid in the cavity of the pleura, even if serous, cannot be absorbed faster than the space it occupies can be filled up by the contraction of the side and the encroachment of the opposite lung. When these means have attained their limit, it is physically impossible that a drop more of the fluid can be absorbed; and consequently a collection even of serous fluid may remain in the cavity of the pleura for years. But in peritonitis there is no such impediment to the absorption of the fluid. The abdominal parietes can con- tinue to fall in so as to close up the cavity occupied by the liquid. The obliteration of this cavity is further aided by flatulent disten- sion of the bowels. When the fluid is absorbed, the folds of intestine, which are united to each other and to the parts with which they have been brought into contact, are always distended with gas. The abdomen is large, and gives out a tympanitic sound on percussion. Moreover, in peritonitis, even when there is much fluid in the sac of the peritoneum, the sense of fluctuation derived from per- cussion is usually much less distinct than in ascites from disease of the liver. In peritonitis, contiguous loops of intestine are glued together, and the fluid is contained in pouches, so that the shock communicated by percussion is propagated through it less perfectly than when it is contained in a single cavity. We are still further guided in distinguishing the two diseases by knowledge of the most common circumstances in which they re- spectively occur. Cirrhosis, as we have seen, is rarely met with in persons of temperate habits, or under the age of thirty. Chronic peritonitis occurs at all ages, without any marked relation to par- ticular habits of life, and in grown-up persons is almost always dependent on the presence of tubercles, which are deposited in the lung as well as on the peritoneum. If there be no evidence of the presence of tubercles in the lung, we have strong presumption that 172 ADHESIVE INFLAMMATION OF THE LIVER. the fluid in the peritoneum is not the result of chronic inflamma- tion of that membrane.1 Cancer of the liver has also, in some cases, many points of re- semblance with cirrhosis. The patient may have the same sallow look as in cirrhosis; there may be some degree of ascites, with loss of strength, disordered digestion, and scanty, high-colored, and turbid urine; and the disease occurs at a time of life when cirrho- sis is common. But in cancer of the liver the ascites seldom attains the degree it has in cirrhosis. The fluid is seldom in sufficient quantity to render the walls of the belly tense. In cancer, too, as the disease advances, the liver always grows larger, and, in most cases, where the cancerous tumors so obstruct the circulation through the liver as to cause ascites, the liver can be felt extending far below its natural limits. In the advanced stages of cirrhosis, on the con- trary, the liver shrinks, and is generally smaller than in health. In cancer, there is usually hectic fever with sweating; in cirrhosis, the skin is dry and rough. The diseases may be still further distinguished by considering the previous habits of the patient. Cancer has no marked depend- ence on particular modes of life, and is perhaps as common in the higher classes as in the lower. Confirmed cirrhosis, on the con- trary, is rare in the higher classes, and is seldom met with in any class, except among those who have been long in the habit of drinking spirits to excess. Cancer of the omentum, like cirrhosis, may cause great ascites, with very distinct fluctuation and enlargement of the superficial veins of the belly: and the thickened and uneven omentum may form a tumor at the epigastrium, which, being indistinctly felt through the liquid, may be taken for a large and nodulous liver. The disease may be distinguished from cirrhosis by the greater emaciation and more rapid wasting; by the higher degree of fever; by the absence of jaundice or sallowness; by the more diffused pain in the belly; by the perspiring skin; and, it may be, by want of clear evidence of spirit-drinking. 1 Many of the distinguishing marks of cirrhosis here noticed were pointed out by M. Becquerel, in the elaborate paper in the Archives Generales before re- ferred to. CIRRHOSIS. 173 I have also known ovarian dropsy, where the fluid has been contained in a single thin cyst, mistaken for ascites, supposed to result from cirrhosis. The following circumstances sufficiently distinguish the two diseases :— 1. Ovarian dropsy does not occur especially in spirit-drinkers, and in this disease the skin is not generally dry and sallow, and the superficial veins of the belly are not generally enlarged, as in the advanced stages of cirrhosis. 2. In ovarian dropsy the fluid is contained in a cyst, which is in contact with the walls of the belly in front, and pushes the intes- tines into the epigastric and lumbar regions; so that, in any pos- ture of the patient, the front part of the belly, from the pubis upwards as high as the tumor rises, is dull on percussion, and there is resonance only along the epigastric region, and, on strong per- cussion, in the lumbar regions: whereas, in ascites, the intestines usually float to the surface of the liquid, and, when the woman is lying on her back, there is usually resonance on percussion in the umbilical region, which is then uppermost, and dulness in the epi- gastric and lumbar regions, which are below the surface of the liquid. 3. A pouch of an ovarian tumor occasionally extends into the pelvis; and its firm, elastic surface may be felt in the vagina. Treatment.—From what has been already said of the nature of cirrhosis, it is quite clear that it is only in the early stage of the disease that we can materially benefit the patient. During this stage, while the inflammation is active, it may perhaps be in our power to lessen the amount of effusion, and, before the lymph effused has become organized, even to cause its removal by absorp- tion. But when lymph has been thrown out in large quantity, and when it has become organized, or is otherwise incapable of removal, and has already by its contraction caused much impedi- ment to the flow of the portal blood and materially impeded the elimination of bile, medical treatment can be only palliative. It is, therefore, of the utmost importance that the disease should be detected early, in order that we may be able to obviate such serious and irremediable effects. But, as we have seen, the detec- tion of the disease in its early stages is sometimes very difficult, as the symptoms are then often slight and equivocal, and it is only by considering the previous habits of the patient that we are led 174 ADHESIVE INFLAMMATION OF THE LIVER. to perceive their real significance. In the person of a spirit- drinker, pain and tenderness in the region of the liver should never be neglected, especially if associated with some degree of fever. At the commencement of the disease the most efficient remedies are—cupping, or leeches, over the liver; cooling saline purgatives, such as sulphate of magnesia or bitartrate of potash; iced drinks; and a very low diet. While there is much tenderness, and some degree of fever exists, nothing produces so much relief as the local abstraction of blood. It must not be forgotten, however, that hard drinkers bear bleeding ill, and care must be taken not to push this remedy too far. Delirium tremens, or other alarming disorder, may be the consequence of its rash and inordinate employment. When bleeding is not considered safe, much benefit may be derived from the application of a blister. When the fever has abated, and the liver is still large, mercury and iodide of potassium are the medicines from which most benefit may be expected. Blue pill may be given in moderate doses, so as slightly to affect the mouth; or iodide of potassium may be given internally, and the iodine ointment be rubbed into the side. At the same time we should endeavor to prevail upon the pa- tient to give up his pernicious habit of drinking. We may infer, from the slight degree of fever and the slight pain that often attend the early stages of cirrhosis, that the lymph is thrown out, not all at once, from a single attack of inflammation, but by little at a time, in successive attacks, of which no one is sufficiently severe to cause serious illness. The mischief is done gradually, under the gradual and repeated operation of the cause. By changing the ha- bits of the patient future attacks may be prevented, and the disease be stayed before it has produced fatal organic changes. Very often our powers of persuasion will fail. The patient will pursue his ruinous course in spite of all our warnings. Often, too, from the insignificant character of the early symptoms, and from general disregard, among the laboring classes, of ailments that do not stop them from working, advice is only sought after the occur- rence of ascites. And then the disease has proceeded so far as to be in great measure beyond the power of remedy. The presence of ascites proves that there is already a mechanical obstacle to the passage of the blood through the liver, and this ob- stacle we can seldom succeed in removing. The case is analogous CIRRHOSIS. 175 to that of stricture of the intestine from the contraction and organ- ization of lymph effused under the mucous coat, or to that of dis- ease of the valves of the heart. There is a permanent mechanical impediment to the due performance of the functions of the organ. The disease will most inevitably, sooner or later, prove fatal. At this time, that is, after the occurrence of ascites, we can do little good, and may do much harm by bleeding, and other mea- sures that much lessen the power of the heart. It not unfrequently happens, indeed, that, after the disease of the liver has existed a long time, and without any recent aggravation of it, the ascites comes on suddenly or increases suddenly, when by loss of blood or any other cause the power of the heart is much lowered. It must be remembered that there is an impediment to the current of blood through the liver, and that one of the agents to overcome this im- pediment is the muscular power of the heart. Even at this stage of the disease, if there have been any recent inflammatory action in the liver, and there be lymph within it that can still be absorbed, good may result from small doses of blue pill or iodide of potassium, which may be given in conjunction with mild diuretics. If diuretics be given alone they generally fail of effect, because when, from cirrhosis or any other condition, much ascites exists, the liquid in the peritoneal sac compresses the kid- neys, and prevents their action. The influence of this pressure is made very manifest by the operation of tapping. It is almost con- stantly found that when by tapping the liquid in the belly is with- drawn, there is a more abundant secretion of urine, and that the quantity of urine again diminishes as the liquid in the belly collects again. This circumstance shows how important it is, in disease of the heart, to get rid of dropsy before much fluid collects in the peritoneal sac to impede the action of the kidneys. When the cirrhosis is in high degree, a flow of urine, however copious, will not remove, or even very much reduce, the ascites. Of this I had clear proof in a patient admitted into King's College Hospital in the winter of 1840. He was a broker's porter, had drunk hard of spirits, and had long suffered occasional pains in the right hypochondrium. A month before his admission to the hos- pital he noticed that his belly was much swelled, and soon after- wards swelling of the legs came on. At the time of his admission he had great ascites, striking enlargement of the superficial veins of the belly, and other symptoms of the advanced stage of cirrhosis. 176 ADHESIVE INFLAMMATION OF THE LIVER. On further inquiry, we learnt that he had also diabetes. He had a craving appetite, with great thirst, and passed daily from ten to twelve pints of urine, which was of light amber color, transparent, and of sp. gr. 1040—1045: containing no albumen, but a large quantity of sugar. He remained in the hospital rather more than a month, when he died of phlegmonous erysipelas of the right thigh. Notwithstanding the large quantity of urine passed daily, there was not the slightest diminution of the ascites. The belly was enormously distended to the last. After death the liver was found very large and hob-nailed, and united to the diaphragm and to the abdominal walls by bands of adhesion of long standing. The gall- bladder was filled with bile, of a pale orange color. All the capil- lary vessels in the posterior part of the peritoneum, to which the blood had gravitated, were beautifully injected and varicose. The heart was small, and had no other mark of disease than a white spot on its outer surface. The kidneys were healthy. In a few instances, after mercury and diuretics have failed, I have seen the ascites removed for a time by hydragogue purga- tives. A good purgative of this class is an electuary made by mixing cream of tartar and jalap in equal parts with confection of senna, and it is best given, as are all medicines of similar action, in a single dose in the morning before breakfast, as it then, besides the drain it causes from the coats of the bowel, only sweeps away the refuse of digestion, whereas, if it be given in divided doses during the day, it sweeps away the food that has been digested, but the nutritious particles of which have not been absorbed. It sometimes happens, especially in hard drinkers, that a disposition to nausea exists in the morning, and the medicine is then best given at night. The action of hydragogue purgatives is much in- creased by giving them in a concentrated form, and by restricting as much as possible the quantity of liquids consumed by the patient. In many instances hydragogue purgatives, like diuretics, fail to remove the ascites, and they may do much harm by weakening the patient, when his assimilating powers can scarcely maintain his actual position. If they be given at unseasonable times, and when the patient is much reduced in flesh and strength, they cause great prostration, render the tongue dry and brown, and, by lowering OTHER KINDS OF INFLAMMATION. 177 the force of the circulation, tend to increase the ascites rather than diminish it. It sometimes happens that the ascites, by impeding the descent of the diaphragm, causes great distress of breathing, especially in asthmatic and emphysematous persons, or when the breath is already shortened by catarrh. This distress may be relieved for a time by letting out the fluid by tapping. After the operation the patient draws his breath more freely, and feels as if a weight were taken off his chest. Usually, owing to pressure being removed from the kidneys, he makes more water after the operation than he had been making before. But this relief is in most cases only temporary. The fluid accumulates again in the belly, and, after a time—varying, according to the degree of obstruction, from a few days to three or four weeks—reaches its former amount. The operation should never be had recourse to unless the diffi- culty of breathing, or the other evils that result from distension of the belly, are very distressing; for the ascites speedily returns, and the operation has consequently the effect of withdrawing a large quantity of serous fluid from the vessels. By repeating the operation frequently, the system may in this way be completely drained of the serous part of the blood. The patient will fall into a state of great prostration, with complete loss of appetite, and with a dry and brown tongue—and will die much sooner than if nothing had been done. In the advanced stages of the disease considerable comfort may often be given to the patient by the judicious employment of sedatives. Suppurative inflammation of the liver and adhesive inflamma- tion, the forms of inflammation hitherto considered, leave perma- nent traces—collections of pus and contracted fibrin—that may be readily discovered after the death of the patient. But there are probably various morbid states of the secreting substance of the liver, which, in the latitude usually given to the term inflammation, should be comprehended under this title, in which, as in erysipelas of the face, and in the affection of the joints in rheumatic fever, the fluids poured out during the inflammatory process become again absorbed, leaving no permanent traces, or only such traces as cannot well be distinguished. In such cases, the nature of the morbid 12 178 OTHER KINDS OF INFLAMMATION process can be judged of by the symptoms only, unless the patient happen to die during the acute stage of the malady, and while its effects are still present. Such a morbid process in the liver often occurs in pneumonia of the right lung, perhaps from the heat developed in the seat of the neighboring inflammation. The patient is sometimes jaun- diced, and, if the disease prove speedily fatal, the upper part of the right lobe of the liver is found softened and much altered in texture. This change in the condition of the liver was noticed by Aber- crombie, who has described it under the term—simple " ramollisse- menf of the liver. He says: "This consists of a broken-down, friable, and softened state of a part of the substance of the liver, without any change of color. It is, in general, most remarkable on the convex surface, extending to a greater or less depth; it is accompanied by a separation of the peritoneal coat at the part, and sometimes there appears to be a loss of substance, as if a portion had been torn out, leaving a ragged irregular surface below. The softened portion has commonly so far lost its consistence that the finger can be pushed through it with very little resistance; and in some cases the affected part is infiltrated with sanious or puriform fluid, not collected into abscesses, but mixed irregularly through the substance of the softened part. This appearance we have every reason to consider as the result of inflammation. It is found in combination with abscess or other marks of inflammation, and I have very often observed it on the upper surface of the liver in connection with extensive inflammation of the right lung. In these cases there was not, in general, any symptom indicating that the liver was affected. Mr. Annesley states that this appearance is fre- quently met with in India, in persons who have died rapidly from cholera or dysentery." I have often met with this softening of the part of the liver next the diaphragm, in cases of extensive inflammation of the right lung, but have never found pus in the softened portion. I imagine that suppuration takes place seldom, and that in almost all those cases in which the patient recovers from the pneumonia the liver regains its natural texture. It is probable that inflammatory disease of other adjacent organs, and especially of the right kidney, sometimes causes a similar change in the texture of the liver, now and then terminating in the formation of pus. Among the cases of abscess of the liver published OF THE SUBSTANCE OF THE LIVER. 179 by Andral, there is one {Clin. Med., iv. obs. 29) in which it is, I think, probable that the inflammation originated in this way. It certainly, however, very rarely happens that inflammation of the right lung or kidney causes abscess of the liver by the heat developed during the process of inflammation. If this excite any morbid process that can be comprehended under the term inflamma- tion, it is such as to leave, in general, no permanent traces. Dr. Craves has remarked that symptoms indicative of inflamma- tory action in the liver—enlargement of the liver, with pain or tenderness, and jaundice—sometimes come on during the course of scarlatina. In one of his clinical lectures {Clinical Medicine, p. 569), he re- fers to two cases of this kind that happened in the same week in the Meath Hospital. One of these patients, a little boy, was seized with scarlatina in a very severe form, with high fever, and a bril- liant eruption all over the body. After two days he had evident symptoms of disease and enlargement of the liver. The other pa- tient was a young man, who had scarlet fever of a milder form. " On the third day he likewise got inflammation of the liver, but was cured by general and local antiphlogistic treatment." Dr. Graves states that in persons whom an attack of scarlatina has left in a feverish condition, he has often found the liver in a state of inflammation—as proved by the benefit derived from local antiphlogistic measures—but inflammation " of rather a chronic character, without any of that remarkable pain and tenderness which characterize acute hepatitis." He considers that this condi- tion of the liver retards and prevents convalescence. My own observation confirms that of Dr. Graves. I have met with several instances in which enlargement of the liver has come on, and more than one in which jaundice has come on, soon after the disappearance of the rash in scarlatina; but I have never had an opportunity of inspecting the liver in a case of this kind. It is most probable that the disease of the liver is analogous to the dis- ease of the kidney, which so often occurs in scarlatina, after the disappearance of the rash; and that the enlargement of the liver results from rapid development and shedding of the secreting cells, caused by the elimination of some noxious matter through the gland. This occasionally happens both in the kidney and in the liver, in the course of typhoid fever. In the winter of 1846, a young 180 OTHER KINDS OF INFLAMMATION. man, about twenty years of age, who had led a sober life, and had not previously exhibited any signs of liver disease, was admitted at King's College Hospital, under my care, with typhoid fever. The fever was not very severe, and he was convalescent from it, and about to leave the hospital, when he died, almost suddenly, from erysipelatous inflammation of the larynx (cynanche laryngea). The liver was enlarged, and presented a curious mottled appearance, from being studded with small irregular white masses, which, to the naked eye, looked very much like small masses of tuberculous matter, but which, on microscopic examination, were found to con- sist of hepatic cells. The cells were opaque, and contained a good deal of granular matter, and about the normal quantity of oil. I had, some time before, observed a similar appearance of the liver, where death had occurred during convalescence from fever. 181 Sect. IV.—Inflammation of the veins of the liver—Suppurative inflam- mation of the portal vein—Adhesive inflammation of the branches of the portal vein—Inflammation of the branches of the hepatic vein. Inflammation of the veins of the liver.—Inflammation in veins, as in other textures, may be suppurative, that is, it may lead to the formation of pus: or it may be adhesive, and lead only to the effu- sion of coagulable lymph, which blocks up and obliterates the vein. But in the inflammation of veins that leads to the formation of pus, coagulable lymph is usually poured out, as well as pus; and the pus does not fill all the inflamed portion of the vein, but is inter- rupted, here and there, by plugs of fibrin, or coagulated blood, so as to form a string of abscesses along the vein. Inflammation of the trunk of the vena portae is of very rare occurrence. From being so deep-seated, this vein is not liable to wounds or other injuries—the most common causes of inflammation of other large veins. The following case, published by M. Lambron in the Archives Generales de Medecine, for June, 1842, is the most complete case of the kind I have found recorded. Inflammation of the trunk of the vena portae was here caused by a fish-bone, which passed through the pyloric extremity of the stomach and the head of the pancreas and stuck in the superior mesenteric vein. The patient, a man 69 years of age, was admitted into the hospital La Pitie, on the 4th of June, 1841. For some weeks he had been suffering pain in the stomach, with occasional nausea, and his bowels had been much confined. On account of these ailments, a week before his admis- sion, he took a grain of tartar emetic, which produced no amendment. The day he entered the hospital, he was seized with shivering and nau- sea, and on the following night he slept ill. On the morning of the 5th, he was carefully examined. His pulse was nearly natural, and his breathing quite tranquil. His tongue was white, he had some degree of nausea, and his bowels were confined. He com- plained of constant uneasiness, with paroxysms of pain, which he com- pared to very severe cramp, in the right hypochondrium, but pressure on 182 SUPPURATIVE INFLAMMATION that part gave hardly any pain. The liver and the spleen were of natural size. The other functions seemed duly performed. (Wine-lemonade; low diet.) The 6th and 7th of June he had no rigors. The pain in the right hypo- chondrium was very severe, but there was no tenderness. The tongue was covered with a whitish coat, there was some nausea, and the bowels were still costive. (A grain of tartar emetic ; veal broth ; julep.) On the 8th he suffered still more, and the skin and conjunctiva had become slightly yellow. On the 11th the jaundice was more marked, and the urine, as tested by nitric acid, contained bile. The pain in the right hypochondrium persisted, with exacerbation from time to time. About f^vj of blood were taken from the side by cupping. On the 12th, the pain was less, but he had nausea, and in the evening a shiver, followed by heat and sweating. His tongue was dry, and covered with a blackish coat Hiccough, and some greenish liquid evacuations. Pulse, 96. The spleen was not perceptibly enlarged. (Quinse sulphat. gr- "JO On the 13th he was nearly in the same state. Some rigors occurred during the night, but they were not succeeded by a hot stage, and the sweating was less profuse than before. Occasional hiccough. Pulse, 80. (A blister was applied, to the stomach ; the quinine was continued.) The rigors and the hiccough continued to recur. On the 15th the fits, like those of ague, recurring more or less regularly, and not yielding to sulphate of quinine, the hiccough, the jaundice, the pain in the right hypochondrium, the absence of disease in other parts of the body, and the nearly natural size of the spleen, led to the inference that the disease was hepatic phlebitis. The 17th the patient was in a typhoid state. The 18th he was a little better, and the jaundice less marked. The 21th he felt better, and asked for something to eat. In the even- ing, he was seized with violent shivering, with fever, but now the different stages were confounded, and he shivered while his body was covered with sweat. The urine contained much less bile. The 25th the fever had not ceased, and seemed likely to become con- tinued. The skin was covered with sweat. The tongue, which had been moist for some days before, had become again dry; and the pain, which had ceased for five or six days, came on again. The 26th and 27th the shivers recurred, with occasional hiccough, the fever became remittent, the pulse was firm and tolerably full, but the pa- tient was much depressed. The 28th and 29th he sank lower and lower, and became slightly deliri- ous. Pulse 104, small, and compressible. He died in the night of the 29th. The body was examined thirty hours after death. All the tissues were slightly jaundiced. There was no serous fluid in the abdomen. The liver was of a natral size, and of a dark, greenish-yellow, or bronze color. It adhered, at some points, to the diaphragm, but its investing membranes were otherwise healthy. The gall-bladder was of natural size, and had also formed some adhesions to contiguous parts. It was filled with bile, which had all the characters of ordinary bile. The gall-ducts were healthy. OF THE PORTAL VEIN. 183 The trunk of the vena portae contained a sanious fluid, with some flakes of pus. On tracing the mesenteric roots of the vein, a fish-bone, the size of a large pin, was found stuck into the trunk of the superior mesenteric vein. The bone, implanted in the head of the pancreas, transfixed the vein from above downwards, and from before backwards. At the point where it was pierced by the bone, the mesenteric vein was blocked up by false membranes, which adhered firmly to its inner coat. The false membranes extended from the mouths of the small veins which come directly from the upper part of the duodenum to the orifice of the splenic vein, becoming less and less firmly adherent. Below this obstruction, the roots of the mesenteric vein contained some fibrinous coagula for an extent of some inches, but were otherwise healthy. The splenic vein was healthy, but contained some reddish fluid like that in the portal vein, from which it had probably flowed into the splenic vein after death. The trunk of the portal vein was not closed, but was narrowed by false membranes adhering slightly to its coats, which were only a little thickened. It contained pus mixed with blood, and, at some points, pus like that of an abscess. The hepatic divisions of the vein were some of them filled with the same reddish liquid ; their coats being in some parts healthy, in other parts inflamed, thickened, and coated by false membranes. Others contained only clots of blood, which extended to very small ramifications of the vein. Other branches again were perfectly healthy. The liver contained no abscesses, but its tissue about the transverse fissure was very soft. In parts of the liver supplied by those branches of the portal vein that remained healthy, there was no change of texture. The lobules, of a greenish-yellow color, were distinct, and the interlobular spaces, as well as the intralobular vein, were red from the blood they con- tained. In the parts supplied by those branches that were filled with coagula, the lobules were likewise distinct, but were less red at their margins and centres. Lastly, in the parts supplied by the branches of the vein that contained pus and were inflamed, the form of the lobules was still preserved, ' but the interlobular tissue was very soft, and the divided intralobular veins seemed empty of blood, and gaping. The hepatic veins were quite healthy, and contained very little blood. On the posterior wall of the stomach, near the pylorus, was a brownish spot, corresponding to one end of the fish-bone, and on the inside, at the same spot, there was a slight depression capable of lodging the head of a pin. It was clear that the bone had passed through the stomach at this spot, pierced the head of the pancreas, and, going still onwards, had stuck into the mesenteric vein, and caused all the subsequent disorder. The kidneys, the spleen, and the intestines, were healthy. In the right lung there was some degree of hypostatic pneumonia, but neither lung contained anything like an abscess. The heart was large, and contained some clots. The right ventricle contained a fibrinous clot, which extended into the pulmonary artery. This case is very simple. The inflammation of the vein was caused by a mechanical injury, and there was no other disease to 184 SUPPURATIVE INFLAMMATION interfere with or to mask its effects. The vein most probably be- came inflamed on the 4th of June, when the patient first shivered. The pain at the stomach and the occasional nausea he had some weeks previous, were most likely caused by the fish-bone then passing through the stomach and pancreas. After the 4th of June the symptoms were just those which might have been expected. There were frequently-recurring rigors, followed by heat of skin and sweating, and, after a short time, typhoid symptoms—as in suppurative inflammation of other large veins—while the pain in the region of the liver, the nausea, the hiccough, the jaundice, and the absence of marked disorder of other organs, showed that the liver was the chief seat of the local disease. The deep situation of the vein explains the absence of tenderness. In the following case, for notes of which, as well as an opportu- nity of examining the parts after death, lam indebted to Mr. Busk, the inflammation of the portal vein had a different origin, and led to somewhat different results, but was marked by nearly the same train of symptoms. I cannot describe the case better than in Mr. Busk's own words:— May, 1844. I have sent you what I think you will consider a very interesting speci- men. It was procured from a man who died last Sunday, after an illness of seven weeks. He was a patient of Mr. Sherwin's, and I have seen "him frequently for the last six weeks. His case was extremely obscure, but I surmised from the first that we should find suppuration in the liver. He was a very robust man, an engineer in the dockyard at Woolwich, and had never been out of England, and was of very sober, temperate habits, married, with one child. Had always enjoyed good health, with the exception of occasional pain in the abdomen, which was not con- sidered of any importance till his last attack. He never had ague. Seven weeks ago he was seized rather suddenly with severe pain in the abdomen, which obliged him to keep his body bent forward, and he had a severe rigor. I saw him about a week afterwards, and he had then the appearance of great depression. He complained of severe, but only occa- sional, pain in the epigastric region, predominating on the right side. The pain was not increased by pressure. It did not appear to be of a piercing character, but was attended with a feeling of extreme sinking and distress, and relieved by morphia. It recurred several times a day at irregular intervals, and about twice in twenty-four hours he had a severe rigor, followed by most profuse sweating. There was no distension of the belly, and no enlargement of the liver could be detected on the most careful examination, nor was there any tenderness in the hepatic region.1 When I first saw him the evacuations from the bowels were light- colored and very fetid, but he was not jaundiced. Soon afterwards, how- OF THE PORTAL VEIN. 135 ever, he became jaundiced, and the urine contained bile. The jaundice went off in a few days, and the evacuations became of natural color and consistence. At the same time the urine lost the bile, and threw down a very copious lateritious sediment, which continued to the last. The jaun- dice passed off suddenly, and the change in the character of the evacua- tions was preceded by a copious discharge of nearly pure bile. The symptoms continued with little change to his death. He gradually sank, becoming much emaciated. He never vomited, and had a great desire for oysters, which were almost his whole support. On examination of the body the lungs were found perfectly sound. The peritoneum contained several pints of straw-colored serous fluid, mixed with flakes of coagulable lymph ; and the stomach, transverse colon, and great omentum were all glued together by soft lymph. The liver was large, and extended to the left side. Its convex surface had a coating of puriform matter, and was of a dark color. On raising the anterior margin, it was found that the concave surface, including the portal fissure and behind it, was adherent to the stomach and surrounding parts : and on separating the adhesions, the substance of the left lobe was found to be occupied by numerous abscesses, which were bounded exter- nally by the adhesions and by the wall of the stomach. The upper sur- face of the left lobe was closely adherent to the diaphragm, and in the middle of this portion of the diaphragm there was a circular space, about the size of a shilling, having a semi-gangrenous appearance, opposite to which, on the upper surface of the muscle, the base of the lung was firmly adherent, and pus was deposited in its substance. On detaching the liver from the other parts, a very large collection of thick pus was found in the portal fissure. Pus could be pressed out in great quantity from the dilated portal vein, and was also deposited in the areolar tissue sur- rounding it. The whole of the left lobe was occupied by innumerable abscesses of all sizes, so as to resemble a coarse sponge filled with pus. In most of these abscesses the pus was thick and white, but in a few it was of a bright yellow. There were also numerous abscesses, some of them of considerable size, in the right lobe. The portal canals, in the left lobe especially, were thickened, white and firm; and, as far as I could ascertain, the gall-ducts were healthy. I have no doubt the abscesses were connected with branches of the portal vein. In a portion of the surface of the liver which I have sent you, near the fissure in the anterior margin, you will observe a chain of small abscesses, apparently following the course of a vessel, and showing in a very striking manner the real nature of the disease. The gall-bladder was distended by a very pale mucous fluid, and, like the ducts, was perfectly healthy. The spleen was of natural size, and except two small superficial ab- scesses on that part of the surface which bounded an abscess beneath the liver, was quite healthy. The pancreas was healthy. The splenic and superior mesenteric veins were healthy, but immediately after their junction the vena portae was extensively ulcerated, and what remained of its inner surface was covered by a buff-colored false mem- brane. The tissue in which this part of the vein was lodged was indurated and black ; and immediately in contact with the vein were large and sup- 186 SUPPURATIVE INFLAMMATION purated mesenteric glands. The whole mesentery was much thickened, and the glands much enlarged, and in a state of suppuration. I have sent you the mesentery with the pancreas and duodenum, and as much as I could get of the vena portae, and of the splenic and superior mesenteric veins. You will see the commencement of the diseased part of the vena portae, and its apparent connection with the suppurated glands, which I am inclined to believe were the origin of the inflammation of the vein. The stomach and intestines were carefully examined throughout, and no morbid appearances were found in them. The kidneys were pale and quite healthy. The origin of the disease in this case is very obscure. The most probable supposition is, that the man had long had disease of the mesenteric glands (perhaps the result of fever), which caused only the occasional pain in the belly to which he had been subject, till an abscess in one of these glands burst into the trunk of the portal vein, and occasioned the inflammation of the vein and the conse- quent disease of the liver of which the man died. The inflamma- tion of the vein came on, no doubt, seven weeks before death, when he was seized suddenly with such severe pain in the belly, and had, for the first time, a severe rigor. After this the symptoms were very like those in the case before related; and the frequent recurrence of rigors, followed by profuse sweating, together with the sense of sinking and general distress, the pain in the right epi- gastric region, and the jaundice, were enough to justify the opinion Mr. Busk at once formed, that the liver was the seat of suppura- tion. The formation of pus in the areolar tissue about the portal vein was perhaps consequent on ulceration of the vein. From there having been no vomiting, and no tenderness of the belly, at least at first, it would appear that the general inflammation of the peritoneum was likewise consecutive to inflammation of the vein, and that it occurred but a short time before death. In January, 1853, I visited, in consultation with Dr. Gull, a lady in whom suppurative inflammation of the portal vein appears to have resulted from ulceration of the gall-ducts caused by the irri- tation of a gall-stone. The symptoms of inflammation of the vein were very like those in the cases before related, but the malady was much more protracted—irregular aguish attacks, most probably arising from partial suppurative phlebitis, having continued to re- cur for seventeen months before death. For the following notes of the case, which presents many points of interest, I am indebted to the kindness of Dr. Gull:— OF THE PORTAL VEIN. 187 Mrs. P----, aged thirty, married, and the mother of three children, was in good health until three years ago, when she had an illness supposed to be due to the passage of gall-stones. It was attended with much pain at the epigastrium and jaundice. The irritation was so severe as to give rise to symptoms of local inflammation, for which leeches and mercurials were prescribed. After two or three weeks, convalescence took place, but she was never again in her former good health. She remained, however, free from any particular ailment until seventeen months before her death. Being then at Scarborough, in October, 1851, she began to have aguish attacks, which recurred at irregular intervals, varying from a few days to a week. These attacks were generally attended with pain about the liver, and a degree of jaundice often very decided. After these symptoms had lasted for eight months, I saw her in consultation with Mr. Ingoldby. The skin was then icteric, the spleen large, and the right lobe of the liver extended down to the crest of the ilium. The infusion of calumba with ammonio-citrate of iron was prescribed, and the patient went for change of air to Guernsey, where she remained many weeks. The result was a great improvement in the general health, and a less frequent return of the aguish paroxysms. These, however, still continue to recur, but with much irregularity as regards both their inter- vals and type—sometimes returning after two or three days, and some- times being absent a week : sometimes the chills and shivering were decided and prolonged, and at other times transient, and followed by con- siderable sweatings. On her return from Guernsey, in the autumn of 1852,1 was again called to see her by Dr. Rooke. The spleen was then smaller than it had been three months before. The liver appeared in the same state, the right lobe extending downwards to the crest of the ilium. The same plan of treatment was persevered in, and she was ordered to take an ounce of the " mistura ferri composita" twice a day, and three grains of the neutral sulphate of quinine in a pill every night at bedtime. After a short time the aguish paroxysms became regular in their re- turns, assuming a quartan type, and the general health continued to im- prove greatly. Unfortunately, towards the end of the year, her health became again seriously impaired by anxiety and watching, and her spirits depressed by the death of one of her children. I was now a third time called to see her. She had then passed several sleepless nights, and her nervous system was greatly depressed. Sulphuric ether and camphor were prescribed with extract of lettuce at night, with direct benefit, but the amendment was of short duration, for in a few days very severe symp- toms, like those caused by the passage of a gall-stone, came on, and were soon followed by deep jaundice. After thirty-six hours the pain subsided, and the bile reappeared in the stools. In the first of these containing bile, a laminated gall-stone was found, of the size of half an almond. The jaundice gradually subsided as the bile flowed freely into the intestine, but at the same time the aguish paroxysms returned with greatly increased severity, and at intervals more irregular than before. This exacerbation of all the symptoms began on the 8th of January, 1852. The shiverings were intense, and attended with a remarkable tendency to collapse—the pulse becoming scarcely perceptible at the wrist, and very rapid. This state would last from twenty to thirty minutes, and be followed by a short stage of reaction, which would be often interrupted by a return of the 188 SUPPURATIVE INFLAMMATION shivering and collapse, and then a most profuse perspiration would break out, which lasted until the cold stage returned again; this sequence of events would be repeated three or four times in the twenty-four hours. In the intervals, when such occurred, there was complete apyrexia; the respiration was natural, and the pulse 100. As this state of things con- tinued, the spleen, which had been decreasing in size, became greatly en- larged. From day to day the case was carefully watched, in the hope that some indications of an abscess making its way to the surface might be discovered. There was no tenderness at any part, but a slight uneasi- ness at the epigastrium and about the region of the gall-bladder. The urine was abundant, high-colored, but free from purpuric or lateritious deposits. The bowels were relaxed—the evacuations containing a large amount of bile. There was no sickness or nausea : the stomach retained well all the nourishment given. The expression of the face was placid, the eye bright, the pupil dilated. The remedies employed were quinine, opium, and wine. The symptoms remained unchecked, and the patient was seen by Dr. Addison, and sub- sequently by Dr. Budd—all agreeing as to the existence of suppuration either in or about the liver. It was determined that nothing was to be done beyond supporting the powers of life and allaying irritation. At the end of January, diarrhoea came on, with an inclination to the typhoid state. The rigors continued, but with less frequency, though equally severe, and with no local signs of an advancing abscess. In the begin- ning of February jaundice returned, but with only slight pain at the epi- gastrium. This jaundice continued till death. As soon as the bile ceased to flow into the intestine, the diarrhoea, which had been hardly kept in check by opium and astringents, such as infusion of catechu and decoction of logwood, was at once arrested, and marked constipation followed Two days before death a slight pain was complained of in the lower part of the right side of the chest, and on auscultation a well-marked friction-sound was heard there. In the night of the next day the patient complained of a sudden increase of the pain, fell into a state of collapse—with symptoms of rupture of the peritoneum—and died in nine hours. Post-mortem.—When the abdomen was opened, the peritoneum was found covered with recently effused lymph. On the convexity of the right lobe of the liver, was a slough of the peritoneum over an irregular abscess, surrounded by gangrenous liver-substance, and on slicing the liver in different places, irregular dep6ts of pus were laid open. These were found to be branches of the portal vein in a state of suppuration. In some the disease appeared to be of long standing, and the coats of the vessels were thickened; in others, it was of more recent date. The larger trunks of the vein near the transverse fissure were filled with firm recent coagula. The gall-bladder contained a nearly colorless watery mucus, and its coats were healthy. At its orifice there was the cicatrix of an old ulcer, and externally, corresponding to this part, were firm old in- flammatory adhesions, highly vascular. The cystic and the common ducts were greatly distended, so that the little finger could be easily introduced into them, and about an inch from the duodenum a gall-stone, the size of an acorn, was firmly impacted. There was no trace of recent ulceration in any of the ducts examined, although this was carefully looked for. The ducts appeared everywhere healthy, but dilated. The hepatic veins con- OF THE PORTAL VEIN. 189 tained no pus, nor was there in the chest or elsewhere any trace of second- ary phlebitis. The liver was generally increased in size, probably weighing between five and six pounds, and the right lobe, as above described, reached to the crest of the ilium. The spleen was about ten inches in length and uniformly enlarged, flabby, and of a light brownish red color. The superior mesenteric and the splenic veins were distended by soft recent coagula. There were old firm adhesions of the pleura on the right side, and some chalky deposits in the lung, but no recent disease of any kind in the chest. The preceding cases afford strong confirmation of the opinion I have already expressed, that pus-globules brought to the liver by the portal vein usually become all arrested there, and do not pass through, as they often do through the lungs, to cause scattered abscesses in other organs. It is for this reason that suppurative inflammation of a vein that feeds the vena portae kills less quickly than suppurative inflammation of a vein that returns its blood im- mediately to the lungs. The blood is filtered, as it were, of pus in passing through the liver, and the local disease is confined to that oue organ. A case very similar to the preceding was published by Dr. Ormerod, in the Lancet for May 30,v 1846. The inflammation was in this case supposed to result from ulceration of the vermiform appendix, caused by the intrusion of a gall-stone. The trunk of the portal vein was filled with pus, and abscesses were found in the liver, but in no other organ. There were frequently recurring rigors and jaundice. The patient, a man 23 years of age, lived a month after the occurrence of the mischief in the vein. If, instead of involving the trunk of the portal vein, the inflam- mation involve only some of its hepatic branches, the patient may recover, and may enjoy tolerable health for years after. This hap- pened, I think, in the person of my late colleague, Mr. Lawson, consulting surgeon of the Seamen's Hospital, who died of dropsy from granular kidney in the spring of 1840. Mr. Lawson had in early life been much in India, but returned to England ten years before his death, and was soon after appointed resident surgeon to the Seamen's Hospital. He continued in this office several years, and then settled in the city. He occasionally vomited, especially after having eaten or drunk more than usual, and had an occasional fit of gout, but otherwise his health was 190 SUPPURATIVE INFLAMMATION pretty good till some months before his death. He had a strong impression that he had some disease of the liver, the result of an acute attack he had in India; but few of his medical friends thought so. He was stout and cheerful, had no pain in the side, and his complexion was remarkably clear. The examination of the body was made by Mr. Busk, in pre- sence of Dr. Bright and myself. The liver had no unnatural adhe- sions, and there were no marks of inflammation of the capsule, but its surface was deformed by deep linear fissures. On cutting across these fissures, there was found at some points a small stellar cicatrice, of white cartilaginous substance; at other points a small abscess containing white pus. A great number of these abscesses existed, but all were in the lines of the fissures, and all were small ; not one was larger than a filbert. The capsule and the peritoneum covering the liver had undergone no change of structure even at the fissures. They were merely drawn in from atrophy of the hepatic substance beneath. The lungs were not adherent to the pleura costalis, and pre- sented no marks of former inflammation. The stomach was large, and the pylorus was somewhat con- tracted by a cartilage-like tissue under the mucous coat—changes which accounted for the vomiting to which Mr. Lawson had been subject. The vessels of the liver were not traced, and at the time the examination was made the precise seat of the abscesses was not ascertained. The linear fissures on the surface of the liver scarcely, however, leave a doubt that the abscesses were in branches of the portal vein. There had been inflammation of some branches of the vein, a string of small abscesses had formed along them, sepa- rated here and there by a plug of lymph, or coagulated blood, the parts of the liver which those branches supplied became atrophied, and, in consequence, the capsule was drawn in, and the surface marked by fissures corresponding to the obliterated branches of the vein. Enough of the liver was left for the purpose of secretion, and the portal blood passed freely through it, so that no serious disorder of health resulted. Inflammation of a large branch of the portal vein may be caused by an abscess of the liver consequent on phlebitis of some distant part. This happens, however, very rarely; probably on account OF THE PORTAL VEIN. 131 of the coats of the vein being thick and surrounded by areolar tissue. The only instance of the kind I can cite is one of which notes were sent me by my friend, Dr. James Eussel, of Birming- ham. The patient, a man of middle age, had his leg amputated on the 18th of March, on account of gangrene occurring after a compound fracture. Three days after the operation he had a rigor, followed by sweating. The rigors recurred, other constitutional symptoms of contamination of the blood by pus came on, he got gradually lower, and died on the 20th of April. Occasional pain at the epigastrium was the only sign that the liver was diseased. An abscess was found in the apex of each lung, and there were three or four abscesses in the liver. A large branch of the portal vein, in contact with one of the abscesses, contained a hollow cylin- der of lymph, about two inches in length, filled with pus. The abscess, reaching the coats of the vein, had probably excited inflammation of its lining membrane, just as an abscess reachino- the surface of the liver excites inflammation of the peritoneum above it. Mere adhesive inflammation of branches of the portal vein does not prove fatal, like suppurative inflammation ; and on this account, and from the difficulty of distinguishing the different inflammatory diseases of the liver during life, we cannot yet give its clinical history. The patient recovers, and when he dies, perhaps some years after, of another disease, we see merely the ultimate changes to which obliteration of branches of the portal vein leads. These changes are very striking and characteristic. The surface of the liver is marked by deep linear fissures, corresponding to the ob- literated branches of the vein, and caused by atrophy of those portions of the liver which the obliterated branches supplied. Rokitansky, who has well described these appearances, states that they are very common in persons who die in the hospitals in Vienna. They are by no means uncommon in this country. During the past year (1844), I have had an opportunity of examin- ing three good specimens of this disease. The first was in a liver, which was sent me by my brother, Dr. William Budd, of Bristol. The person from whom it was obtained was a sailor, who died in St. Peter's Hospital, Bristol, of dropsy from granular disease of the kidney. 192 ADHESIVE INFLAMMATION He had been a hard drinker, had been in hot climates, and had had remittents—one attack not many months before his death. There was considerable nausea, but no ascites. There had been deep jaundice about a week before death. This had lessened a good deal, but there was still a light yellow stain of the skin. He died of cerebral disorder, apparently the result of poisoning of the blood by urine and bile. The liver was much deformed by deep linear fissures across its upper and its under surface. On the upper surface of the right lobe were two spots, nearly the size of a half-crown, covered by a false membrane, a line in thickness, having the toughness and the look of cartilage. From these spots the false membranes shaded away to a thin film, but this did not cover the whole of the convex surface of the right lobe ; and on the convex surface of the left lobe, and on the under surface of the liver, there was no false mem- brane, although the surface was much fissured. On separating the fissures, and tearing and scraping away the hepatic substance with the handle of the scalpel, solid fibrous twigs were left, which were found to be continuous with branches of the portal vein. The trunk of the portal vein and its first divisions appeared healthy. About the small divisions still pervious the areolar tissue seemed thickened, and the artery and duct were more adherent to the vein than natural. The impervious twigs of the vein, in a section of the liver made across them, looked like small stellar cicatrices, and in many of them could be seen a yellow point, the orifice of a divided gall-duct. The lobular substance of the liver was of a uniform deep chocolate color, and rather soft, so that it was readily scraped away from the fibrous twigs. The disease was not confined to one part of the liver. One surface was just as much fissured as the other. The hepatic artery and the hepatic veins appeared healthy. The gall-bladder and the large ducts were stained with bile, but healthy. The liver was adherent to the diaphragm and abdominal walls by bands of old tissue at the spots covered by thick false membrane. The spleen was large and indurated. There were no adhesions, or other traces of peritonitis, anywhere in the abdominal cavity, except on the surface of the liver. The duodenum was much stained by deep olive bile, and from the opening of the common duct to six or eight inches down, there was deep crimson injection of the mucous coat. The right lung was universally adherent to the costal pleura; the left lung was quite free. The heart was immensely hypertrophied. There was no important disease of its valves, but much " atheromatous" deposit in the aorta. Both kidneys were in a very advanced stage of granular disease. Another instance of the same disease fell under my notice in King's College Hospital, in a man who died of cancer of the penis. This man, who was a soldier, and had served in the Peninsula, had been at one time a hard drinker. He had neither ascites, jaundice, OF THE PORTAL VEIN. 193 nor other symptom of diseased liver. The liver, as in the instance just related, was crossed by deep fissures, but there were fewer of them, and there were no marks of inflammation on its capsule. The tissue of the liver seemed healthy, and could be readily scraped away from the obliterated twigs of the portal vein. The spleen was large and firm, and on its capsule, which was everywhere much thickened, there were some cartilaginous-looking plates. Another specimen, precisely similar, was sent me by Mr. Busk. It was obtained from a sailor, who died of phthisis, much emaciated. There was no mention of hepatic disease in the notes taken of his case. The liver weighed only two pounds one ounce and a half, and, as well as the spleen, adhered to all the surrounding parts by means of old tissue. There were no traces of former peritonitis elsewhere. It appears, then, that obliteration of branches of the portal vein causes complete atrophy of those parts of the liver which the ob- structed branches supplied, and consequent diminution of the size of the organ. When an obliterated branch is near the surface, the capsule gets drawn in by the atrophy of the intervening lobular substance, and the surface is marked by a linear fissure. The lobular substance supplied by other branches of the vein may remain uninjured. A portion of the liver is lost, proportionate in amount to the number and size of the obliterated branches of the vein—and the person must suffer all the evils which such a loss entails. The disease, in its effects, is like that form of adhesive inflammation of the substance of the liver which leads to new fibrous tissue in the portal canals of considerable size, and in two of the three instances I have mentioned was attended by marks of disease in the capsule of the liver and in the spleen, such as are usually found in that affection. In these instances it was probably brought on by spirit-drinking. Rokitansky is of opinion that this disease of the liver is in many cases the result of direct communication between the venous system of the liver and that of the body, in consequence of the umbilical vein remaining pervious. It is probable, from the observations of Mr. Henry Lee, before referred to, that obliteration of branches of the portal vein is sometimes produced, not by inflammation of the vein and the effusion of lymph from its inner surface, but by mere coagulation of the blood within it, caused by the absorption of some noxious matter from the stomach or bowels. 13 194 INFLAMMATION OF BRANCHES When many branches of the vein are thus obstructed, the im- pediment to the passage of blood through the liver, as in high degrees of cirrhosis, may cause ascites and slight jaundice, and may lead to great enlargement of the superficial veins of the belly. After a time the enlargement of the superficial veins may form a sufficiently free channel for the blood to the heart, and the ascites may gradually disappear. In the autumn of 1844 I witnessed, in the Seamen's Hospital, a case which I imagine to have been of this kind. The patient, a sailor, was in the hospital eight years before for what was supposed to be some affection of the stomach. The symptoms which led to this inference were soon followed by slight jaundice and by great ascites, for which he was tapped three times in quick succession. The ascites recurred again, but after a time slowly and gradually disappeared of itself. When I saw him he had been long free from ascites or jaundice, but had an enormous bunch of large tortuous veins, which emerged from the belly just above the umbilicus, and ran thence up the chest. He told me that he first noticed these veins four years before, after the ascites had disappeared. It sometimes, though very rarely, happens that the main trunk of the portal vein becomes completely obstructed in the same way. This usually leads to profuse hemorrhage from the stomach and bowels, the result of the great congestion of their mucous membrane; to great ascites; to deep and persistent jaundice; and to rapid shrinking of the liver. An instance of this, in which, at the end of a month only, the liver was found to be no larger than the two fists of the subject, was published in 1849, by M. Monneret, in a French periodical {L1 Union Mklicale, 1849, No. 13); and several other cases of the same kind are on record. Complete obstruction of the trunk of the portal vein soon destroys life, not, perhaps, so much by stopping the office of the liver, as by prevent- ing the return of blood from the intestinal canal. Inflammation of a branch of the hepatic vein is, as already re- marked, occasionally produced by a small abscess in the liver, consequent on phlebitis of some distant part. The abscess touching the thin coat of the vein, sets up inflammation on its inner surface, just as it sets up inflammation of the peritoneum above it when it reaches the surface of the liver. Lymph is effused within the vein at the point where it is touched by the abscess, the canal of OF THE HEPATIC VEIN. 195 the vein becomes closed at that point, and all the branches that feed it, even back to their capillary divisions, become subsequently and in consequence, choked with fibrin and coagulated blood. If' as more frequently happens, the abscess cause ulceration of the coats of the vein before its canal is blocked up, a small quantity of the pus oozes into the vein. The pus coagulates the blood, and thus chokes the vein, and also sets up suppurative inflamma- tion of its inner surface. After death, the vein, backwards from the ulcerated point, is found filled with fibrin and coagulated blood, with here and there a little purulent matter. I have observed these marks of inflammation in a branch of the hepatic vein in two instances in which small abscesses had formed in the liver after amputation. In a portion of liver sent me by Mr. Busk in Novem- ber, 1843, which was taken from a man who died of phlebitis after amputation of the thigh, several branches of the hepatic vein were inflamed in this way, and obviously from this cause. The liver contained many abscesses of the size of peas, and lined by a distinct, but very thin membrane. Dr. James Russel, of Birmingham, has sent me notes of a case in which the same changes were observed. The patient died in the Birmingham Hospital, in 1836, eighteen days after amputation of the leg. A somewhat similar case has been published by M. Lambron, in the Archives Generates for June, 1842 ; but here the abscesses in the liver were most probably caused by a cancerous ulcer of the stomach. From these instances it is probable that inflammation of one or more branches of the hepatic vein is not uncommon in cases where abscesses form in the liver after injuries of the head or limbs. From want of careful dissection this disease of the vein must be often overlooked. Inflammation of the hepatic vein from other causes is, I believe, extremely rare. The only instance in which I have seen evidence of it was in a man who died in King's College Hospital in February, 1844. All the hepatic veins seemed thicker and more opaque than natural, and, on examining them closely, I found a thin false mem- brane on their inner surface, which in the large veins could be readily stripped off". There was a great deal of new fibrous tissue in all the portal canals of considerable size, and some in the small 196 INFLAMMATION OF BRANCHES OF HEPATIC VEIN. ones also—enough on the whole to render the liver tough, but not distinctly hob-nailed or granular. The liver and the spleen were united to all the adjacent parts by means of old tissue—and there were some adhesions, apparently of the same date, between adjacent coils of intestine. The pericardium adhered to the heart by means of a thick layer of tough fibrous tissue; and both lungs were every- where adherent to the pleura costalis. The patient was a tailor, fifty-two years of age, and for many years had been in the habit of drinking enormous quantities of gin. It was this probably that caused the adhesive inflammation of which so many traces were found.1 1 There can be little doubt that the adhesive inflammation of which so many traces are found in bodies examined at our hospitals—cirrhosis, obliterated portal veins, thickened capsule of the spleen, puckering of the surface of the kidney from obliterated vessels, stricture of the pylorus, from contracted lymph in the sub- mucous areolar tissue, and, in many cases, adhesions of the pericardium and pleura—are mainly attributable to spirit-drinking. The inflammation which this causes is always adhesive. 197 Sect. V'.—Inflammation of the gall-bladder and gall-ducts—Catarrhal and suppurative inflammation—Croupal, or plastic, inflammation— Ulcerative inflammation—Effect of ulceration of the gall-bladder and gall-ducts—Effect of permanent closure of the cystic and common ducts—Fatty degeneration of the coats of the gall-bladder. The inflammatory diseases of the gall-bladder and gall-ducts, although of frequent occurrence, have been but little studied, and at present we have not materials for anything like a complete history of them. This is to be ascribed, in part, to the ambiguous character of the symptoms of all diseases of the liver; in part, to the small size of the gall-ducts, which causes them to be often overlooked in dissection. It should ever be borne in mind that the ducts, though small, are very important, from being the only outlets for the bile secreted in those portions of the liver to which they lead. Permanent closure of the cystic duct entirely destroys the office of the gall-bladder;—that of the common duct destroys, in the end, the office of the liver itself. Inflammation of the gall-bladder and gall-ducts probably arises from various causes, each of which determines in great measure the character and course of the inflammation, and its mode of termina- tion—so that we cannot expect a satisfactory account of the differ- ent kinds of inflammation until we can arrange them according to the agencies by which they are respectively produced. To attempt such an arrangement at present would be premature. We must be satisfied with what seems the nearest approach to it, viz., an arrangement based on the appearances found after death. The different forms of inflammation of a mucous membrane, considered with reference to their effects, are, 1st. What may be called catarrhal inflammation, which merely increases the quantity and changes the quality of the natural mucus, often rendering it viscid, whitish, and opaque. This form of inflammation seems to correspond in degree with the adhesive 198 INFLAMMATION OF THE GALL-DUCTS. * inflammation of other textures, but it is not adhesive in the sense before given to that word, because, by a wise provision, the matter poured out on the free surface of a mucous membrane very rarely becomes organized or permanently adherent to the membrane; 2d. Suppurative inflammation, where the matter secreted is puru- lent; 3d. Croupal, or plastic inflammation, where the matter effused forms a solid, albuminous layer on the diseased surface, of which, when this is a tube, it becomes a cast; 4th. Ulcerative inflammation, if, indeed, the process which leads to ulceration can with propriety be classed with those leading to the results before mentioned, and be comprehended with them under the generic term inflammation. All these different forms of inflammation have been observed in the mucous membrane lining the gall-bladder and gall-ducts, but not with equal frequency in its different parts. Inflammation seldom produces changes sufficient to attract notice in the hepatic duct, or in the branches that go to form it. The coats of the gall- bladder, and of the cystic and common ducts, are not unfrequently found ulcerated, or much thickened and otherwise changed in tex- ture; but such changes have been seldom observed, in man, in branches of the hepatic duct. It might have been anticipated that the gall-bladder and the cystic and common ducts would be more liable to inflammation than the branches of the hepatic duct. They are much more liable to be fretted and otherwise injured by gall-stones, which are usually formed in the gall-bladder, and much more liable to irritation from other unhealthy products of secretion. The bile always becomes more concentrated, and, if unhealthy, more irritating, in the gall-bladder, and when unduly detained there, the mixture of bile and mucus undergoes decom- position, and may thus give rise to the formation of matters very hurtful to the mucous membrane.1 Undue retention, and the con- sequent decomposition of the contents of the gall-bladder, may 1 When bile undergoes spontaneous decomposition exposed to the air, oxalic acid is one of the ultimate products, as it is of many other animal substances. Some time ago, Dr. L. S. Beale showed me, in a specimen of ox-bile in an ad- vanced stage of decomposition, a great number of octohedral crystals of oxalate of lime, exactly like the crystals of this substance, which are so commonly found in urine. INFLAMMATION OF THE GALL-DUCTS. 199 result from various conditions—from a mechanical impediment to its escape through the cystic or the common duct; from long fast- ing ; from a disordered state of the nervous system, especially such as exist in low forms of continued fever; and from earthy degene- ration of the coats of the gall-bladder itself, which is not an un- frequent condition in persons advanced in life. On these accounts it is, perhaps, best to consider the diseases of the gall-bladder and of the different portions of the ducts separately, as far as this can be done. Catarrhal inflammation of the gall-ducts is, probably, not un- common. It is not a fatal disease, and, like catarrhal inflammation of other mucous membranes, may cause no permanent changes, so that it may often have occurred where no traces of it are found. It happens, however, not very unfrequently, that, on squeezing the hepatic ducts, a viscid whitish fluid oozes out, which, on examina- tion through the microscope, is seen to be chiefly made up of the prismatic epithelial cells of the gall-ducts. The symptoms we should expect in catarrhal inflammation of the hepatic ducts are some degree of feverishness, with slight pain in the region of the liver, and, if many of the ducts become closed by thickening of their coats, or be choked by the viscid secretion, slight enlarge- ment of the liver and jaundice. Many of the cases of simple jaundice coming on in healthy persons, and attended with slight pain and fever, are probably cases of this kind. In a severer form of inflammation, the matter secreted is puru- lent, but it has seldom the visible characters of pure pus. The pus is mixed with opaque mucus secreted at the same time, and, it may be, with bile also; and the result is a viscid, greenish, or yel- lowish fluid, very different in appearance from pure pus. Inflammation of this degree may likewise subside without leav- ing permanent traces, and the only evidence of its existence may be an attack of jaundice, attended with more or less pain in the region of the liver, and with some degree of fever. It happens, however, now and then, in catarrhal or suppurative inflammation of the hepatic ducts, that many of the small ducts become temporarily blocked up at some point, and that the portion behind gets dilated into an irregular pouch, which is filled with a 200 INFLAMMATION OF THE glairy or purulent fluid, more or less tinged with bile. A remark- able instance has been recorded by Cruveilhier (liv. xl. pi. 1), in which, it is reported, there were distributed throughout the liver thousands of small irregular cavities, formed by partial dilatation of the gall-ducts, and containing thick purulent mucus variously tinged with bile. In this instance there were marks of former inflammation about the liver—firm adhesions between the liver and adjacent organs, obliteration of the cystic duct, and narrowing of the duodenal end of the common duct—and the inflammation of the ducts which led to the formation of the sacculated pouches in question was probably the result of permanent obstacle to the free escape of the bile. The hepatic gall-ducts were generally dilated, and in the common duct, above the narrowed portion, was a calcu- lus which did not completely close the canal. The chief symptoms noticed in the ultimate stage of the disease were—jaundice, occa- sional pain in the region of the liver, a quick pulse, with a sense of general illness, and daily increasing weakness. At length nu- trition became very much impaired; there was sloughing at the sacrum, sloughing of the gall-duct, white softening of the brain— and the patient died of exhaustion. It would seem that sacculated pouches, formed, as in this case, by inflammation of the small hepatic ducts, may, by permanent closure of the duct at the point of obstruction, be converted into small permanent cysts, filled with a glairy fluid, more or less tin- ged with bile. It is difficult to account in any other way for the cysts of this character that are now and then found in the liver. Firm, white, nodulous tumors, surrounded by a distinct cyst, and composed of a cheese-like substance, are also now and then found in the liver, and are formed, I believe, in the same way. These cysts are evidently situated in portal canals, and the cheese- like substance of which they consist contains in its middle a small mass of concrete biliary matter, or has solid particles of biliary matter diffused through it which can be seen by means of the mi- croscope. There is usually a false membrane on the surface of the liver at the points where these tumors reach it. In another chap- ter, a fuller account will be given of these cheesy tubera, which have been generally confounded with cancer. The cheesy matter is very like that of a scrofulous gland, and is probably formed in COMMON DUCT. 201 the same way, by inflammation of the mucous membrane in these portions of the ducts. These knotty tumors seem, indeed, to differ from the biliary cysts before mentioned only in the consistence of the matter within the cyst—which varies according to the kind and degree of the inflam- mation by which it is produced. If a small gall-duct become obstructed in the same way by thick biliary matter, or otherwise, the portion behind may, perhaps with- out inflammation at all, become dilated into a small, irregular, or sacculated cavity, containing mere mucus and bile. Cruveilhier (liv. xii. pi. 4, fig. 3) has given a plate taken from a specimen of this kind. A great number of cysts of various sizes were scattered through the liver, some in its substance, others rising above the surface, completely isolated from the gall-ducts, but containing a deep yellow liquid. Tumors formed in this way never attain a very large size, and are perhaps generally multiple. The large, solitary, encysted tumors, containing a glairy fluid tinged with bile, which are now and then found in the liver, are most of them hyda- tid cysts (which in man are usually single), in which suppurative inflammation has been set up by the entrance of bile. The green- ish glairy fluid is formed by the mixture of bile and pus. The irregular cysts formed by dilatation of the small gall-ducts, when they contain merely a thin mucous fluid mixed with bile, may contract from absorption of the watery part of their coutents, and the cyst may at length close upon a small mass of concrete mucus and bile. Marks of inflammation and other disease are, as has been already stated, much more common in the gall-bladder and in the cystic and common ducts than in the hepatic ducts. Inflammation of the mucous membrane may be confined to the lower part of the common duct, or to the gall-bladder; or it may commence in the gall-bladder, and extend down the cystic and com- mon ducts. The following case, recorded by Andral, is a very instructive example of inflammation of the common duct only ; because here, from the disease proving speedily fatal, the source of the symptoms was cleared up by dissection. I have ventured to give the case at length, because a consideration of it may suggest the right inter- pretation of the symptoms in other cases of the same kind, which usually terminate in recovery. 202 INFLAMMATION OF THE A shoemaker, thirty-five years of age, was admitted into La Charite, the 8th of November, 1821. Six days before, after over-indulgence at table, he was taken with sharp pain at the right of the epigastrium, a lit- tle below the edge of the ribs. The next day he remarked that his skin was yellow. On the 9th of November, the seventh day of illness, the con- junctiva and the entire surface of the body had a yellow tint, and there was a dull pain in the right hypochondrium. Below the cartilage of the eleventh rib a pear-shaped tumor was felt, the broad end of which ex- tended a little below the umbilicus, while the narrow end was lost behind the ribs. This tumor, which was supposed to be the gall-bladder distended, was movable under the finger, and not tender. The tongue was natural. The patient had some thirst; no appetite. The bowels moved seldom; the stools were not colored with bile. The pulse was quick ; the skin hot and dry. (Leeches to the anus; whey, with acetate of potash ; diet.) The four following days the tumor grew larger, but no other change took place. On the 13th of November, the eleventh day from his first feeling the pain in the side, the patient was seized, all at once, with a much more severe pain, which, starting from the region of the liver, soon spread over the whole belly. The pain continued extremely severe, and was much increased by the slightest pressure; the features became pinched, the pulse small and very frequent, and the extremities cold ; and the patient died in the afternoon of the next day. The sac of the peritoneum was filled by a puriforra liquid, everywhere yellow, but much more so in the right flank than in other parts. The in- ner surface of the duodenum was intensely red. The entrance of the com- mon duct was marked by a small round tumor, rising three lines above the surface of the intestine, and pierced at its summit by a capillary ori- fice, the opening of the duct. The coats of the common duct were much thickened and easily torn, and the canal almost closed. The hepatic and the cystic ducts and the gall-bladder were dilated. In the hepatic duct, just above its junction with the cystic, was a perforation, having an irregular, roundish outline, and large enough for the passage of a small pea. Around the perforation the texture of the coats of the duct did not seem altered. The tissue of the liver exhibited nothing re- markable. In the stomach were some spots in which the mucous membrane was red. The rest of the alimentary canal, and the other organs, seemed healthy.—(<7/i'«. Med., t. iv. p. 495.) This case seems to have been an instance of acute inflammation of the duodenum and of the common duct, caused by over-indulg- ence at table. The symptoms were, pain in the situation of the inflamed duct, soon followed by jaundice and by dilatation of the gall-bladder; loss of appetite, thirst, fever. The disease had lasted eleven days when rupture of the hepatic duct took place, causing peritonitis and rapid collapse. The inflammation does not seem to have extended above the COMMON DUCT. L03 common duct. The distended gall-bladder was not painful or ten- der; and the coats of the hepatic duct about the perforation were not sensibly altered in texture. The early jaundice and the distension of the gall-bladder were the effect of closure of the common duct by inflammatory swelling of its mucous coat. From the small size of the gall-ducts the pas- sage through them must be completely closed by a very slight thickening of their lining membrane. Andral gives another case {Id., p. 499), which did not prove fatal, but which, judging from the symptoms, was of the same kind; and two or three similar instances have fallen under my own notice. The symptoms in these cases were pain in the situation of the duct, followed at the end of one or two days by constipation and jaun- dice, and by distension of the gall-bladder so as to form a large globular or pear-shaped tumor, not painful or tender. The symptoms are very like those of obstruction of the common duct by a gall- stone; but the pain occurs less in paroxysms, and vomiting and nausea are, I think, less frequent than when the duct is obstructed by a gall-stone; and the illness usually occurs after over-indulgence at table, or after eating some unwholesome food, sometimes in young men who have had symptoms of gall-stones, and in whom, from their age and mode of life, it is unlikely that gall-stones exist. In some such cases, especially where active treatment by leeches and blisters has been promptly had recourse to, the inflammation subsides in a few days; the channel of the duct becomes again free; the pent-up bile flows into the bowel, causing griping pain and diarrhoea: and the tumor formed by the distended gall-bladder les- sens, and soon completely disappears. In other cases the inflammation persists, and the jaundice, vary- ing, it may be, in degree, continues for several weeks or months, without much febrile disturbance, but with constant uneasiness in the site of the common gall-duct, and sometimes with occasional severe pain, especially an hour or two after meals, when the food is passing through the duodenum. When the disease is neglected, the inflammation may permanently change the texture of the tube, perhaps permanently narrow its channel; and, by long impeding the passage of the bile, it may give rise to gall-stones, or to de- structive inflammation of the mucous membrane of the gall-bladder. 204 INFLAMMATION OF THE The jaundice and the pain or uneasiness in the side will then per- sist in varying degrees, and the health will be permanently broken. The illness may be perpetuated in another way still. The inflam- mation of the ducts, or the absorption of their retained and irritat- ing contents, may lead to enlargement of one of the lymphatic glands that are contiguous to the common duct, and the compres- sion of the duct by the enlarged gland may be a further cause of jaundice. I have met with more than one instance in which jaun- dice, long continued and ultimately fatal, was ushered in by what was taken for a common bilious attack, and in which, after death, the jaundice was found to be caused by an enlarged lymphatic gland compressing the common duct. But inflammation may commence in the mucous membrane of the gall-bladder, and for some time may not extend to the ducts. The inflammation is then excited by the irritating nature of the contents of the gall-bladder, and occurs when, from obstruction of the common or the cystic duct, from thickening and induration of the coats of the gall-bladder itself, or from the state of the nervous system, the gall-bladder does not completely empty itself—so that the retained mucus and bile become decomposed, and, when de- composed, irritate the mucous membrane. The inflammation is especially apt to occur when, from a state of fever or any other cause, the secretion of the gall-bladder itself is unhealthy. The chief symptoms of inflammation confined to the gall-bladder are, pain and tenderness in the region of the gall-bladder, vomiting or nausea, and a certain degree of fever. If the inflammation of the gall-bladder be the result of closure of the common duct, these symptoms are of course associated with jaundice. If, from ob- struction either of the common or the cystic duct, the bile and the products of inflammation cannot escape, the gall-bladder may be- come distended so as to form a globular tumor, and, in cases in which the inflammation is suppurative, there are usually recurring rigors. A very remarkable instance (to which I shall have again to refer) of catarrhal or plastic inflammation, at first confined to the gall-bladder, is related by Dr. Graves in his work on Clinical Medi- cine (p. 463). The patient, a fine healthy maid-servant, twenty years of age, was attacked with pain in the right hypochondrium, extending into the epi- gastrium, which was followed at the end of a fortnight by jaundice. GALL-BLADDER. 205 After the skin got yellow the pain in the side diminished; but during the whole time it lasted she had constant vomiting and nausea. The jaun- dice continued, with tenderness and slight pain in the region of the gall- bladder, and with great irritability of the abdominal muscles, which were thrown into spasm by any attempt to examine the abdomen minutely, but without any other symptoms indicative of especial danger. After the jaundice had lasted about a month she became delirious, and soon after died in a state of coma. " The liver," Dr. Graves says, "was not by any means enlarged, and a section of it disclosed no excess of blood. It was of a light-brown color, tinged with yellow, as if from a superabundance of the coloring matter of the bile. The gall-bladder was distended, and on being opened was found completely filled by a dark green mass of a tenacious viscid nature, appa- rently lymph. This substance was of the same pyriform shape as the gall-bladder, and terminated by its narrow extremity at the commence- ment of the gall-duct. On its removal, the lining membrane of the gall- bladder presented a bright scarlet color and villous appearance, and the natural and beautiful 'honeycomb' arrangement of the mucous membrane was completely effaced. There was no softening or ulceration of the membrane, nor was the color different in any part. It resembled very much the appearance of the mucous membrane in acute laryngitis. The walls of the gall-bladder were much thickened. There was no obstruc- tion of the ductus choledochus, the cystic or hepatic ducts, and their lining membrane was quite free from any unusual vascularity; the duo- denum and stomach were stained with the coloring matter of the bile, but in other respects were healthy; no gall-stones or other obstruction; the kidneys were natural." No morbid appearances were found in the brain. In this case the disease seems, for the first fortnight, to have been confined to the gall-bladder, and, during that time, the chief symptoms were pain and tenderness in the region of the gall-blad- der, with constant nausea and vomiting. Jaundice then came on, and, when it had lasted about a month, the patient became deli- rious, and soon after died in a state of coma. From the mode of death, and from the circumstance that the liver was not enlarged and that there was no obstruction in the course of the gall-ducts discoverable after death, it is probable that the jaundice and the fatal issue resulted, not from inflammation extending from the gall- bladder to the gall-ducts, but from suppressed or defective secre- tion of bile. Suppurative inflammation of the mucous membrane of the gall- bladder, no doubt the result of the undue retention of unhealthy and decomposed secretions, now and then occurs in the course of typhoid fever. M. Louis, in his elaborate work on Typhoid Fever, has given three cases {Obs. 1, 11, and 28), in wbich he found a 206 INFLAMMATION OF THE purulent fluid in the gall-bladder mixed with very unhealthy look- ing reddish bile. In one of these cases {Obs. 28), the mucous membrane was a little thickened; but in the others, it presented no other change than slight redness. In not one of them did the gall-ducts exhibit any marks of disease. In the cases related by M. Louis, the inflammation of the gall-bladder gave rise to no symptoms that could be distinguished amidst the general disorder of the fever. In the following case, which fell under my care in 1849, inflam- mation of the gall-bladder, occurring during the course of fever, extended to the outer surface of the bladder, and the symptoms were more significant; but here there was an additional cause of disturbance in the presence of numerous gall-stones, one of which had blocked up the cystic duct. The case is further remarkable as affording an instance of gall-stones forming at an unusually early age. Eliza Smith, a dress-maker, eighteen years of age, was admitted into King's College Hospital on the 17th of March, 1849. She was un- married, had always lived well, and her health had been habitually good. Her illness began ten days before with the usual symptoms of typhoid fever—with rigors, followed by noise in the head, pain in the back and limbs, flashes of light before the eyes, loss of appetite, thirst, and great prostration of strength. On her admission to the hospital, she had the look and the usual symp- toms of typhoid fever. The skin was hot, the tongue furred and dry, the pulse 110, and she had great thirst. A few of the maculae common in typhoid fever existed on the abdomen and back. She appeared restless, but required to be spoken to sharply before she would answer. She had some cough, and on auscultation rhonchus was heard all over the chest, and slight crepitus over the lower part of the left lung behind. The only symptoms different from those common in typhoid fever were, that the bowels were much confined, and that she lay on her back with her legs drawn up, and complained of pain when the belly was pressed. She was ordered 3tj of castor oil, and draughts of citrate of ammonia, milk, and beef tea. The castor oil not operating, three grains of calomel, with five of compound extract of colocynth, were afterwards given. This had little effect, and on the 20th, another dose of castor oil was given, which produced several dark and offensive stools. On the 21st, the tongue was dry and brown ; the pulse 120; and the inspirations 30 a minute. She had been delirious during the night. 3SS of aromatic spirits of ammonia, every four hours, was now ordered, instead of the citrate of ammonia, which she had hitherto taken. On the 23d, gvj of wine daily, were ordered in addition; and on the 24th, gxij. For some days, no particular change took place. She was delirious at night, and occasionally passed her water unconsciously. The bowels GALL-BLADDER. 207 were confined, but were readily moved by the warm water enema. She always lay with her legs drawn up, and gave signs of pain when the region of the liver was pressed. On the 26th, she was much in the same state; but when I made pres- sure on the belly to the right of the epigastrium, she uttered a loud shriek. I now discovered a fulness in that part of the belly, and inferred that there was inflammation of the gall-bladder, or that an abscess exist- ed in the liver. For several days, there was no further change worth noting. She was generally slightly delirious, took no notice of what was going on around her, and passed her urine and feces under her in bed. On the 31st, diarrhoea came on, in consequence of which 3ss of tinc- ture of krameria was added to each dose of the medicine. The diarrhoea ceased in a few days, and did not again recur. The breathing, which had been quick from the beginning, became more op- pressed, the respirations being from forty to fifty-six in the minute. On the 6th of April, she had a distinct shivering fit. On the 8th, vomiting was noted for the first time; and it recurred on the following days. She gradually sunk, and died on the 12th. Up to the time of death, there was constantly some degree of fulness in the site of the gall-bladder, and she always gave signs of pain when this part of the belly was pressed. There was no jaundice. On examination after death, the gall-bladder was found distended, pro- jecting an inch and a half below the margin of the liver, and united to all the surrounding parts by lymph, which had been recently effused and was readily broken through. There were no marks of peritonitis elsewhere. The gall-bladder contained a puriform matter, and fourteen gall-stones, one of which completely blocked up the cystic duct. The coats of the bladder were much thickened, and flakes of lymph and concrete pus ad- hered to its inner surface. The gall-stones were of the ordinary kind, consisting of cholesterine, stained by bile, and having a nucleus of inspis- sated biliary matter. The liver itself presented no unusual appearance. There was (as is usual in typhoid fever) extensive ulceration of the patches of Peyer and of the solitary glands in the lower part of the small intestine. The posterior part of the lower lobe of the left lung was in a state of red hepatization ; other parts of the lungs were sound. No marks of disease were discovered in the brain, or in other organs of the abdomen and chest. I Here, notwithstanding the existence of the fever, it was plain enough from the posture of the patient, and from the constant ten- derness and fulness at the right hypochondrium, there was some active inflammatory disease of the gall-bladder or liver. The constipation that existed for some time, the fit of shivering on the 6th of April, and the vomiting that occurred a few days before death, were probably due to this disease. * 208 INFLAMMATION OF THE GALL-BLADDER. Suppurative inflammation of the gall-bladder seems especially liable to occur when, by any cause, the cystic duct is permanently closed. A case in illustration of this fell under my observation in King's College Hospital in 1848. A woman, sixty years of age, was ad- mitted into the hospital on the 23d September, in that year, much emaciated; with jaundice, which had then lasted twelve months, and with other well-marked symptoms of cancer of the liver. The liver was much enlarged, extending an inch below the umbilicus on the"right side, and through the wasted walls of the belly it could be felt that the convex surface of the liver was nodulous, and that its lower edge was rounded. At the margin of the liver, near the umbilicus, a firm globular tumor was felt, which was taken to be a distended gall-bladder. The patient remained in the hospital five weeks, during which she had frequent vomiting and much pain in the region of the liver, and then went to her home, where she died on the 7th of December. The liver was found to contain firm cancerous tumors, of con- siderable extent, and small masses of cancer were scattered through- out both lungs. The gall-bladder was much distended, and pro- jected beyond the margin of the liver. It contained pus, and many gall-stones ; and its mucous membrane, which had quite disappear- ed in many spots, presented very much the appearance of mucous membrane in the big end of the stomach when corroded by the gastric juice after death. Two gall-stones, moulded upon each other, blocked up the cystic duct. The gall-ducts throughout the liver were dilated. There was much scirrhous matter around the duodenum, through which the common bile duct could not be traced. Cruveilhier (liv. xxiii. pi. 5) has given a plate of a liver studded with cancerous tumors, in which the cystic duct was obliterated, and the gall-bladder inflamed and full of pus. No notes of the case are given. A similar instance is recorded by Andral {Clin. Med., iv. 518), in the case of a woman, who died at the age of forty-seven with numerous cancerous tumors in the liver. The gall-bladder was full of pus, and its mucous membrane inflamed. Further on, other instances will be related and referred to which serve to illustrate the same fact. Suppurative inflammation of the gall-bladder seldom proves fa- tal of itself, except when, from closure of the cystic or the common INFLAMMATION OF THE GALL-BLADDER. 209 duct, there is no outlet for the matter ; or when from previous disease of its coats the gall-bladder cannot empty itself completely, so that some irritating matter is constantly contained in it; or when from any other cause the inflammatory process leads to ulceration. Under other circumstances the inflammation subsides after a time, and the general health is restored. In some instances of recovery no traces of the disease remain ; in others, in which the inflamma- tion was more protracted, or in which it involved the outer coats of the bladder, some visible changes of structure are left. I have twice found the gall-bladder and cystic duct contracted, and their coats thickened, in young persons who died of other diseases, and in whom there were no gall-stones, nor any trace of inflammation of the common or hepatic ducts, or of the capsule or substance of the liver. I refrain from giving any details of these cases, as no particulars were noted that can serve to mark even the date of dis- ease of the gall-bladder. Occasionally the coats of the common duct, as well as those of the gall-bladder and cystic duct, are found thickened and indurated, without gall-stones or trace of inflammation in other tissues of the liver. It is probable that in most cases of this kind inflammation is set up first in the gall-bladder by long retention of irritating bile, and afterwards in the ducts by the passage of this together with irritating secretions from the bladder. In persons dead of granular liver, with ascites, it is not very uncommon to find the gall-bladder and cystic duct much contracted, and their coats thickened and indurated. The canal of the duct is much narrowed, and now and then completely closed, so that the duct is transformed into a fibrous cord. When this is the case, the gall-bladder contains yellowish mucus, or is moulded on a gall- stone, formed of mucus and the yellow matter of the bile. In some cases the gall-bladder and cystic duct become inflamed, secondarily, like the capsule of the liver {Clin. Med., iv. obs. 51 and 52); and the inflammation is seated in the outer coats. From the presence of other disease of the liver, it is difficult to determine in what degree the symptoms depend on disease of the gall-bladder and gall-duct. Sometimes the coats of the common duct, as well as those of the cystic, are thickened and indurated, and the canal much contracted. When this happens, the hepatic duct and its branches are found dilated and filled with thick yellow bile; the tissue of the liver is 14 210 ULCERATION OF THE GALL-BLADDER. greenish or olive {Clin. Med., iv. obs. 49, 50); and there is a deeper jaundice than belongs to mere cirrhosis. Another and much more common cause of inflammation of the gall-bladder, and of the cystic and common ducts, at least among the rich, is the mechanical irritation of gall-stones. But this gives rise to ulceration, rather than to the diffuse catarrhal or suppurat- ive inflammation we have hitherto chiefly considered. Croupal or plastic inflammation of the mucous membrane of the gall-bladder and gall-ducts is very rare. Eokitansky says he has observed it in the ducts within the liver, in what has been called the secondary fever of cholera, and as a sequel of ordinary typhoid fever. It produces within the gall-ducts membranous tubes, in which the bile forms tree-like concretions; and this, again, by blocking up the passage, causes distension of the capillary ducts behind. Ulceration of the Gall-bladder and Gall-ducts. Ulceration of the gall-bladder has been more commonly remarked than the forms of inflammation yet considered, and occurs in vari- ous circumstances. It has been noticed by more than one observer among the morbid appearances of remittent fever. Sir G. Blane, in his account of the Walcheren fever, states that the mucous membrane of the gall-bladder was frequently found inflamed and ulcerated; the ulcers having in such cases the conical or tubercular form sometimes seen in dysentery. The gall-bladder was generally distended with bile, which, in those persons who died early, was of a deep green or dark brown, but in more protracted cases had the consistence and the color of tar. This tar-like fluid did not taste bitter like bile, and when mixed with water did not impart any yellowness to it, while it was often so acrid as to excoriate the lip. (Williams' Morbid Poisons, vol. ii. p. 470.) Mr. Boyle, speaking of the Sierra-Leone fever, says there were in almost all cases traces of inflammation in the pyloric extremity of the stomach, extending thence along the duodenum to the entrance of the gall-duct, about which, for the space of a Spanish dollar, the inflammation seemed to have attained the greatest height. The duct was ordinarily choked by dark-colored, viscid CAUSES. 211 bile. The gall-bladder was probably not examined. The other abdominal viscera are stated to have been congested, but otherwise healthy. {Id., p. 478.) In the yellow fever at Barcelona, in 1821, there were usually traces of inflammation of the stomach, small intestine, and duode- num, not unfrequently extending to the gall-bladder. {Id., p. 473.) The acrid quality of the bile in the Walcheren fever, and the circumstance that in Dr. Boyle's dissections the strongest marks of inflammation in the intestinal canal were about the entrance of the common duct into the duodenum, render it probable that the inflammation of the gall-bladder and duodenum, in remitteut fever, is caused by unhealthy or decomposed and irritating bile. As in typhoid fever, the symptoms of inflammation of the gall-bladder are not distinguishable in the midst of the general disorder that constitutes the fever and the symptoms of inflammation of other parts that likewise occur in its course. In this country, ulceration of the gall-bladder is produced, perhaps not unfrequently, by the irritation of gall-stones. Ulcerations of the gall-bladder and gall-stones are often found together, but it must not be inferred, in all such cases, that the ul- cers were produced by the gall-stones. Both the ulcers and the gall-stones may have originated from unhealthy or decomposed bile. When there is only one ulcer in the bladder and a large or hard gall-stone is found resting upon it, it is perhaps safe to infer that the mechanical irritation of the stone was the cause of the ulcer. Gall-stones too large to pass through the cystic duct, not unfre- quently cause ulceration of the lower or depending part of the gall-bladder; lymph is poured out on the peritoneal coat below the ulcer; the gall-bladder becomes united by this means to the duo- denum or colon ; the ulcer eats likewise through the coats of the intestine at this point; and the gall-stone escapes into the intestinal canal. The processes of ulceration and adhesion take place very slowly, and are seldom attended by alarming symptoms. Often, indeed, the first clear intimation that such an event has happened is the discharge of a large gall-stone from the bowel. In other cases we find many small round ulcers in the gall-blad- der, and perhaps in the common duct, and small gall-stones in the bladder not resting on the ulcers. AVhen it is considered that 212 ULCERATION OF THE GALL-BLADDER. most human gall-stones are so light as to float in bile—since they almost float in water, which is of much lower specific gravity—and that, consequently, they can exert no pressure on the coats of the gall-bladder from their weight, when there is bile enough in the bladder to keep them afloat;—it seems most reasonable to infer both ulcers and gall-stones in these cases to an unhealthy state of the bile. Extensive ulceration of the gall-bladder sometimes occurs with- out gall-stones, when from any condition the passage of bile into the duodenum is stopped, so that bile and mucus are long retained, and undergo decomposition in the gall-bladder. An instance of this occurred in the following case, which fell under my care in King's College Hospital, in the autumn of 1856, and which is fur- ther interesting as showing the effects of obliteration of both the pancreatic duct and the common gall-duct, uncomplicated at first with other disease. I was out of town when the patient was ad- mitted into the hospital, so that the account of his condition then, and for three weeks afterwards, is derived from the hospital case- book :— Michael Donaghan, a working tailor, forty years of age, was admitted into King's College Hospital on the 6th of September, 1856. He stated that he had been rather a hard drinker—generally drinking to excess at the end of each week, from Saturday till Monday—and that he had of late had a good deal of anxiety and suffered from lowness of spirits, but that his health was good until seven weeks before his admission into the hospital, when jaundice came on, together with a dull pain in the hepatic region, but without any severe pain or spasm. The jaundice persisted. The dull pain in the hepatic region also continued, but in less degree than at first. His appetite remained tolerably good, but he had, he said, great ✓ thirst, and drank large quantities of water to appease it. The bowels were generally costive; the motions constantly pale, and the urine dark- colored, as is usual in jaundice. From the commencement of his illness he had gradually lost flesh and strength. On his admission to the hospital he was deeply jaundiced, and com- plained of a dull pain about the ensiform cartilage. He complained also of a sense of fulness in the stomach, and of nausea, but had no vomiting. The tongue was somewhat dry, but clean, and he was very thirsty. The appetite was tolerably good. His spirits were much depressed, his sleep was interrupted by troubled dreams, and he had occasional headache. The pulse was counted 64, the inspirations 18, in a minute. No distinct enlargement of the liver seems to have been made out. The urine, which was deeply stained with bile, contained no albumen. He was ordered five grains of blue pill, night and morning.and a drachm of sulphate of magnesia, with ten minims of dilute sulphuric acid, three times a day. CAUSES. 213 From this time there was no appreciable change in his condition till the 16th of September. He complained constantly of a dull pain across the stomach, of great thirst, and of a sense of nausea—but did not vomit. In the daytime he was observed to be generally somewhat drowsy. On the 16th of September, at 4 P. M., he had a severe rigor. The fol- lowing day he was much in the same state as before. The pulse was 80 in the minute, and it was noticed that the urine had a greasy film of phosphates on the surface. The former medicines were then left off, and he was ordered ten minims of dilute nitro-muriatic acid, with infusion of quassia, three times a day. From this time he went on much as before till the 24th of October. His appetite was tolerably good, his bowels moved regularly, and he com- plained chiefly of pain across the epigastrium. The urine, which continued to be deeply stained with bile, constantly presented a greasy film on its surface. Nothing more was remarked in the discharges from the bowels than the continued absence of bile. The skin was perspiring. The dose of the dilute nitro-muriatic acid was increased to twenty mi- nims three times a day, but the greasy film on the surface of the urine still continued to appear. In the evening of the 24th of October he had another rigor, followed by heat of skin and sweating, and afterwards for two or three successive nights he had a similar aguish attack. It was ascertained that he had never pre- viously had ague. On the 27th it was noted that the liver extended a little below the false ribs, but that no unevenness of its surface could be detected. In the right iliac fossa a globular tumor was felt, extending three or four inches below the edge of the liver, but traceable to it, and somewhat tender to the touch—which tumor, from its form and position, and from the evident stoppage to the flow of bile, was inferred to be the gall-bladder distended. The skin was frequently perspiring, but Donaghan complained of great general chilliness, and could not bear to be a moment uncovered. He was now ordered, instead of his former medicines, 5ss of aromatic spirits of ammonia, every four hours, and four ounces of wine daily; and from this time no rigors occurred for several days. The appetite was still tolerably good, and the bowels were disposed to be costive. It was subsequently noted that on the 3d of November he had a shiver- ing fit, which began at 11 A. M. and lasted an hour, and another at 1 P. M., lasting fifteen minutes; that he had another shivering fit in the evening of the 5th, beginning at 8 P. M , and lasting about two hours; and another in the morning of the 6th, beginning at 8 A. M., and lasting three-quarters of an hour. The tumor in the right iliac fossa remained of the same size, and the urine was constantly covered with a greasy film of phosphates. He con- tinued to lose flesh. The pulse was latterly more frequent than at first, having been counted 80 and 84 in the intervals of the aguish attacks. In consequence of these irregular aguish attacks, it was inferred that suppu- ration had occurred in the liver. In the morning of the 8th of November a considerable quantity of blood, about a pint it was said, was ejected from the mouth, part of it in clots. On the 10th it was found that there was some ascites, slight cedema of both feet, and oedema of the right side of the belly and right thigh, on which he had been lying; and that the superficial veins of the 214 ULCERATION OF THE GALL-BLADDER. belly were enlarged. No fresh shiverings had occurred since the morn- ing of the 6th. In the morning of the 13th, he was in a drowsy state, and answered questions incoherently ; and in the afternoon of that day he died. Since the 28th of September he had constantly had the milk diet of the hospital, with an extra daily allowance of a slice of meat, and half a pound of potatoes. The body was examined twenty-three hours after death. It was extremely emaciated. The abdominal parietes were very thin, and contained hardly any fat. On opening the abdomen, about three pints of serous fluid, tinged with bile, escaped. The tumor on the right side of the belly was found to be the gall- bladder greatly distended, reaching four inches below the edge of the liver. There was no inflammation of the peritoneum either of the gall- bladder or liver, or elsewhere, and there were no unnatural adhesions of the liver. The common gall-duct was obliterated by inflammatory thick- ening about it just as it enters the coats of the duodenum, and above this was dilated to the size of a large thumb. The larger hepatic ducts were also greatly dilated, but there was very little dilatation of the cystic duct. The gall-bladder contained thirteen ounces of a dirty chocolate-colored fluid, which, under the microscope, exhibited pus-globules, detached epi- thelium, and small plates of cholesterine. In that portion of it which was undermost in the recumbent posture of the body, the mucous mem- brane was almost entirely destroyed by ulceration in a space equal to half its extent; and around this space were many round or oval detached sloughing ulcers, varying in size from the diameter of a pea to that of a florin. The liver itself was of a mottled dark olive color, and rather more friable than natural, and exhibited under the microscope cells charged with biliary coloring matter, but containing very little oil. The pancreatic duct was involved in the same condensed tissue as the gall-duct, and was likewise obliterated just before it enters the duodenum ; and the duct behind this was dilated and filled with a yellowish, puriform fluid. The head of the pancreas for an inch in length seemed to be converted for the most part into fatty tissue by the wasting of the gland-structure and the formation of fat. Behind this portion the gland was a good deal atro- phied about the dilated ducts. On examining the duodenum, an ulcer was found partially cicatrized about an inch and a half in length, and half an inch broad, commencing immediately above the papilla which marks the entrance of the gall and pancreatic ducts, and extending lengthwise up the intestine. In the sto- mach, also, an oval ulcer was found, about the size of a florin, situated on the posterior surface, very near the lesser curvature, and within an inch of the cardiac orifice. This ulcer, which had entirely destroyed the mu- cous membrane, appeared to be recent, as there was no thickening or induration at its margin. No other disease was found in the body. In this instance the pancreatic duct and the common gall duct were involved in a small mass of condensed tissue—apparently the result of inflammatory effusion—and were in consequence perma- nently closed, just at their point of entrance into the duodenum. CAUSES. 215 The ultimate effect was the same as if, without violence or other injury, a ligature had been there placed on the ducts. The obstruction of the gall-duct caused, as it necessarily does, persisting jaundice and dilatation of the hepatic ducts; and also caused, after a time, great dilatation of the gallbladder and slough- ing ulceration of its mucous membrane. The effects of oblitera- tion of the pancreatic duct may have been equally important, as regards the general condition of the patient; but they were less striking, and during life less distinctive. The conjoint obliteration of the two ducts caused, directly and by its after-effects, continuous wasting—so that, although the diet was sufficient for the mainte- nance of health, and the appetite continued tolerably good, and there was neither diarrhoea nor vomiting, the patient died, about four months after the occurrence of jaundice, in a state of extreme emaciation. It is difficult to fix the time when inflammation of the gall-blad- der set in, but it no doubt existed on the 16th of October, nearly a month before death, when the first distinct rigor occurred. Ulceration of the gall-bladder is sometimes caused by irritating bile, independently of fever or gall-stones, and when there is no stoppage of the common or the cystic duct. A very remarkable instance of this kind, recorded by Dance, will be related further on. Ulceration of the gall-bladder seems especially liable to occur in persons in whom the gall-bladder has suffered from former disease. The following case, which fell under my care in 1837, affords an instance of this, and further shows that an ulcer in the gall-bladder, like an ulcer in the stomach or duodenum, may cause profuse vomiting of blood :— John Sibston, ast. 18, a collier, was admitted into the Seamen's Hospital, the 21st of September, 1837, on account of vomiting of blood, which had come on that morning. He stated that he was quite well previously. During the 21st, he suffered great pain at the epigastrium, vomited blood several times, and had several loose stools. Eighteen leeches were applied to the epigastrium, and he was ordered dilute sulphuric acid, ttLvij every four hours. On the 22d, he did not vomit. He was bled from the arm to ^viij, and xij leeches were applied to the epigastrium. On the 23d, the first time I saw him, the skin was hotter than natural; the pulse 100. There was still tenderness, and some tension, at the epi- gastrium. The tongue had a yellowish paste on its middle, but was red 213 ULCERATION OF THE GALL-BLADDER. at the edges; he was thirsty, and had no appetite; had vomited once that morning, but no blood; had slept tolerably. The blood drawn the day before was not buffed or cupped. He was put on fever diet; and the sul- phuric acid was continued. On the 25th, the epigastrium was still tender, and the skin hot; but the pulse was 90 ; there was less thirst; and the coat on the tongue was white. No vomiting had occurred since the morning of the 23d. The bowels were rather confined. The sulphuric acid was left off, and common effervescing draughts were given instead. 26th. Tenderness at the epigastrium had ceased; no vomiting; bowels confined; some appetite ; no thirst; has slept well. A dose of salts and senna was given, and the effervescing draughts were continued. 28th. No vomiting; bowels rather confined; appetite good; sleeps well. Beef-tea, Oij. On the 4th of October he was put on meat diet. He continued on this diet, walking about the wards, seemingly in full convalescence (his appetite good, bowels regular, sleep sound), until the evening of the 10th of October, when he was taken with malignant cho- lera. He soon fell into a state of collapse, and died early in the morning of the 12th. At that time cholera prevailed in the Seamen's Hospital. Twenty-one of the patients fell ill of it in the course of three weeks. The body was examined ten hours after death. The cardiac extremity of the stomach was united to the under surface of the left lobe of the liver by a false membrane, in which were some chalky bodies, the size of small peas. The pyloric end of the stomach and the colon were firmly united to the gall-bladder, whose coats were much thickened. The gall-bladder contained some pus, and its mucous membrane was extensively ulcerated. On the surface in contact with the liver, there was an ulcer as large as a shilling, and several smaller ones. On the opposite surface, there were some very small circular ulcers, scarcely larger than a pin's head. The ulcers had eaten through the mucous coat. There were no gall-stones, and the tissue of the liver appeared to be healthy. The mucous membrane of the stomach in its splenic extremity was soft and thin, and red from the injection of small vessels, visible to the naked eye. The rest of the intestinal canal presented only the appearances usual in persons dead of cholera. The mesenteric glands were enlarged. In the transverse meso-colon were many bodies, about the size of a hazel-nut, composed of matter resembling soft cheese or glazier's putty, in a very distinct capsule. The spleen was firmer than usual, but of the usual size. The left lung was united to the pleura costalis by old tissue; the right lung was free. Both lungs were healthy. The heart and the kidneys were sound. There were yellow fibrous clots in the right auricle and ventricle, but none in the left chambers of the heart. In this case inflammation of the gall-bladder seems to have come on in the midst of apparent health. The symptoms, at first, were vomiting of blood, which recurred several times, severe pain, with tenderness and some tension, at the epigastrium, some fever, with RESULTS. 217 loss of appetite, thirst, and a foul tongue. These symptoms passed off in a few days, and the patient seemed convalescent, when he fell ill of malignant cholera, of which he soon died. The case shows that there may be extensive ulceration of the gall-bladder without any special symptoms to denote it. For a fortnight before the attack of cholera, there was no pain or tenderness at the epi- gastrium, and no vomiting, although there can be little doubt that the ulcers of the gall-bladder then existed. Andral has published a case {Clin. Med., t. iv. p. 500) in which ulceration of the gall-bladder, or sloughing of it from defective nutrition, occurred in a man 64 years of age, in whom the coats of the cystic and common ducts had been much thickened, and their channel much narrowed by former inflammation. Perforation of the gakl-bladder took place, and the patient died speedily of the resulting peritonitis. Cruveilhier (liv. xxix.), has published another case, in which suppurative inflammation and ulceration occurred in a gall-bladder previously diseased; but here there was an additional cause for disease of the gall-bladder in the cystic duct being closed by a gall-stone. The patient was a strong woman, 34 years of age, and death resulted from peritoneal inflammation, caused by the perfora- tion of the gall-bladder. I am indebted to Mr. Bowman for notes of a case observed by himself in which sloughing ulceration of the mucous membrane of the gall-bladder occurred during typhoid fever, in a housemaid, 16 years of age. The coats of the gall-bladder were somewhat in- durated and thickened, and the cystic duct has been obliterated by previous disease. As in the cases recorded by Louis, already alluded to, in which suppurative inflammation of the gall-bladder occurred during typhoid fever, there were no symptoms by which the disease of the gall-bladder could be detected amidst the general disorder. Thickening and other changes of texture in the coats of the gall- bladder, and°narrowing of the cystic or the common duct, dispose to ulceration of the gall-bladder, just as paraplegia, or stricture of the urethra, or enlarged prostate, disposes to inflammation of the urinary bjadder, by preventing the bladder from completely empty- ing itself, so that its contents undergo decomposition, and thus become irritating to the mucous membrane. 218 ULCERATION OF THE GALL-BLADDER. An ulcer in the gall-bladder, however it may have originated, is very difficult to heal while the cystic duct remains open, because the bile with which the ulcer is then constantly bathed is very irritating to a raw surface. An ulcer in the stomach or in the urinary bladder is in the same way constantly fretted by irritating fluids, and is consequently very difficult to heal. Ulceration of the gall-bladder and gall-ducts may have various results. 1st. An ulcer, commencing in the mucous membrane of the gall- bladder, or of the common duct, may eat through its different coats until the peritoneal coat is laid bare. The bile brought in contact with this coat causes it to slough, and the contents of the gall- bladder are poured suddenly into the cavity of the peritoneum. When this happens, diffuse suppurative inflammation of the peri- toneum is set up, which destroys life in a few hours; quicker, perhaps, in most cases, than the peritonitis that follows rupture of the bowel. If, however, the cystic duct has been long closed, and the gall- bladder contain no bile, its contents may escape into the cavity of the peritoneum by oozing. When the mucous coat is eaten through, the matter may filter between it and the other coats, and may escape by a rent of the peritoneal coat, at a point that does not correspond to the ulcer of the mucous coat. The matter escaping drop by drop causes inflammation of the serous membrane, which is limited to the vicinity of the gall-bladder by adhesions of coagu- lable lymph, so as to form a circumscribed abscess in the cavity of the peritoneum. I have before referred to a case recorded by Cruveilhier, in which this happened. When the gall-bladder contains bile this never occurs, because when the bile reaches the peritoneum it causes it to slough, and the contents of the bladder are discharged at once. 2d. When an ulcer of the gall-bladder or gall-ducts is caused by a gall-stone, adhesive inflammation of the serous membrane is usually set up before perforation takes place; the gall-bladder or gall-duct becomes united to some adjacent part, generally the duo- denum or the colon ; the coats of the intestine are eaten through after those of the bladder or duct; and the gall-stone passes into the intestinal canal. CAUSES. 219 Inflammation of the gall-bladder from gall-stones is less exten- sive, is attended with less severe symptoms, and is less dangerous in its results, than inflammation from other causes. The processes of ulceration and adhesion are slow, and give rise to no violent symptoms. I have met with no instance of ulceration of the gall-bladder ex- tending in this way through the coats of the bowel, except when produced by a gall-stone. 3d. Ulceration of the gall-bladder or gall-ducts, like ulceration of other mucous surfaces that return their blood to the portal vein, may lead to scattered abscesses in the substance of the liver. In the chapter on suppurative inflammation of the liver, several cases are referred to in which abscesses in the substance of the liver seemed to have their origin in ulceration of the gall-bladder or gall-ducts. The abscesses in such cases are probably the imme- diate consequence of suppurative inflammation of a small vein in the vicinity of the ulcer, or of the absorption of the ichorous matter of the ulcer. In the large ducts, which lie close on the large branches of the portal vein, an ulcer may eat into a branch of the vein, and set up suppurative inflammation within it; and the consequences will, if possible, be worse than those of ordinary suppurative inflammation of the portal vein, because bile, as well as pus, will be mixed with the portal blood. The dreadful effects of this are fully exhibited in the following case, published by Dance {Archives Generates, t. xix. p. 40, 1828), in which an ulcer in the common duct ate into the portal vein :— A hairdresser, aged twenty-five, of lymphatic temperament, was taken, without known cause, in the beginning of October, 1828, with lassitude, loss of appetite, thirst, and pain at the epigastrium. Some leeches ap- plied there produced only slight relief. The 12th of October he was brought to the Hotel Dieu, with these symptoms, but the pain at the epigastrium had increased, and the tongue was then red and dry, yet the pulse was but little quicker, the skin little hotter, than natural. Twenty leeches were applied to the anus ;—little amendment. The next day fifteen leeches were applied to the epigastrium ;—considerable abatement of pain. During five days he continued to mend, the tongue became nearly natural. Later, at two different times, the severe symptoms recurred, probably from errors of diet. The first time they were calmed by leeches to the epigastrium ; the second, they subsided without treatment. 220 ULCERATION OF THE GALL-BLADDER. At the end of October the patient seemed convalescent, but he still suffered at the epigastrium, and there was something in his condition altogether that we could not explain. At this time pain in the right hy- pochondrium, at first obscure, then more distinct, accompanied by bilious vomiting, and by purging; moderate fever, tongue natural. (Twenty leeches to the anus; bath.) Abatement of pain, continuance of vomiting and purging; the skin gradually acquired the tint of decided jaundice. The patient continued nearly in this state till the 12th of November; then rigors, recurring at irregular intervals, followed by frequency of pulse, heat, and dryness of skin. Two days later acute deep-seated pain about the right shoulder came on suddenly, swelling and tenderness of the soft parts about the joint, movements of the arm very painful. (Poultices; v. s. Jviij.) The blood not buffed. Eight days had elapsed from the appearance of this new train of symp- toms, when, all at once, the middle of the forehead became the seat of severe pain, soon followed by swelling and tension, without change of color in the skin. At the end of two days the same phenomena at the left temple. The swelling extends, by degrees, to the face and to the en- tire head, which acquires an enormous size. In the midst of these varied and serious disorders the pulse is small, not very frequent, compressible; the heat of the skin moderate; the vomiting, purging, and jaundice continue ; the pains in the belly have ceased. The swellings at the middle of the forehead and at the left temple,go on increasing; bulla? filled with bloody serum appear here and there, and, bursting, leave small spots where the skin seems mortified. These spots extending, run together and form a single one, on the forehead and on the temple, as large as a crown-piece, the surface of which is riddled with small openings, from which small drops of pus can be pressed. Some days before death the tongue becomes red and dry, then black; the lips and teeth become covered with sordes; the skin of the nose ac- quires a brownish tint. Petechia? and small nodulous swellings appear on the skin, and in the subcutaneous areolar tissue of the limbs and of the trunk; the patient falls into a state of prostration and quiet delirium, and dies at 3 P. M., on the 2d of December. Sectio cadaveris eighteen hours after death. Limbs not rigid. The surface of the skin sprinkled with petechias. By the side of the petechial spots are blackish, lenticular pustules, some containing a sanious fluid, others a white homogeneous pus. These last extended into the subcutaneous areolar tissue, which was there infiltrated with pus. This eruption was thicker on the legs than on the arms; in front of the trunk than behind. Head and face enormously swelled. Nose covered with a blackish crust, involving the skin, which here appeared gangrenous. On the middle of the forehead, on the left temple, and behind the left ear, soft, grayish, fetid sloughs, under which the areolar tissue is infiltered with pus. The skin of the forehead and of the anterior left half of the skull was trans- formed into a substance resembling bacon-rind, an inch thick, in the midst of which could be distinguished many veins filled with pus. These veins went to form the temporal veins, which, in the midst and on the surface of the temporal muscle, in the zygomatic and pterygoid fossae, formed an immense plexus, of which all the branches were filled with pus, and EFFECTS. 221 bounded above by the black and softened fibres of the aforesaid muscle, below by dense yellowish areolar tissue. The left parotid, quadrupled in size, exhibited, when cut across, a granular surface, from which pus flowed, by a thousand different points, in small round drops, that came solely from the orifices of the numerous veins in the substance of the gland, many of whose branches were traced, all filled with pus. These branches terminated in the external jugular vein, which was inflamed as low as the middle of the neck, and offered on the outside an unnatural volume and hardness; on the inside, a reddish, roughened surface, covered with thick false membranes, and, lower down, with clots of blood mixed with pus. On the right side of the head, and under the scalp, abundant infiltra- tion of yellowish lymph, of the appearance of gelatine ; the temporal muscle pale and soft; the parotid and external jugular veins healthy ; the anterior branch of the temporal vein and all its divisions contain pus, col- lected into masses by small whitish bands; interrupted here and there by small clots of blood. The deltoid muscle on the right side blackish, soft- ened, traversed by a considerable number of veins containing thick yellow pus. Muscles in other parts of the body brownish, and easily torn. The right shoulder and elbow joints contained shreds of false membrane, and a small quantity of puriform synovia. The other joints healthy. Brain.—Sinuses of the dura mater distended with black grumous blood, without change of their coats. The cerebral substance pale, and as if cedematous. The ventricles distended by colorless serum. The membranes healthy. Chest.—Heart of the usual size, color, and consistence, containing a small quantity of black fluid blood, presenting no trace of inflammation in its cavities or in the coats of the vessels that terminate in it. Pleura not inflamed, and free from adhesions. The lungs sprinkled with millions of small solid masses (" engorge- mens"), of various forms and sizes, more numerous irt the right lung than iu the left, and in greatest number near the pleura, under which they formed prominences visible to the eye. Some of these solid masses had a blackish tint, others were whitish and granular, and broken down into a puriform matter by slight pressure. None of them were converted into abscesses. The pulmonary tissue around them was healthy, or slightly engorged with bloody serum. It was ascertained, by a careful dissection, that these masses were formed, in great part, of a mass of pulmonary veins, filled with pus in their smallest ramifications. The veins of the lung contained pus in no other points. Abdomen.—The liver of a dark brown color, likewise containing many purulent masses (" noyaux"), most of them visible on the surface of the organ, but without projecting above it. These masses appeared to be formed of veins filled with pus, or, at least, to be the termination of them. We ascertained their continuation with the radicals of the vena portas. Many branches of this vein and its trunk were full of a pulpy and puri- form matter, of a yellowish color, like that of bile, mixed with liquid blood and with black or colorless clots, free or adherent. The inner membrane of these vessels was covered by a thick layer of pus, and had felow this a rough and granular aspect; but, in the greatest part of its extent, it retained its natural polish, and was only whiter and more opaque than usual. Matter of the same kind was contained in the 222 ULCERATION OF THE COMMON DUCT. mesenteric veins which come from the small intestine, in those which come from the pancreas, and in the splenic vein. The coats of these vessels offered the same changes as those of the former vessels. All these veins, before reaching the trunk of the portal vein, traversed a considerable mass (d'engorgement), formed, in front of the vertebral column, and in the whole length of the mesentery, by a collection of large red glands, suppurating at the centre, and surrounded by dense areolar tissue infiltered with pus. The gall-bladder, filled with turbid serous bile, presented, towards its base, four small, round, blackish ulcers, extending through the mucous membrane. The common duct was destroyed in its entire length, and converted into an oblong winding cavity, containing membranous shreds detached from its coats, and stained with bile. Behind, this canal offered several deep ulcers, which extended through all its coats, and also through those of some large veins adjacent. One of these ulcers opened into the superior mesenteric vein by an orifice a line in breadth, presenting a pro- jecting and greenish edge in the inner surface of the vein. The others might easily admit a moderate-sized probe. The mucous membrane of the stomach and of the intestines everywhere in its natural state, of good consistence, remarkably white, only coated by thick, grayish mucus. About the entrance of the common gall-duct into the duodenum, for the space of a half-crown, the mucous membrane was of a slate color, softened, and presented four or five small deep ulcers. The spleen was of a black-brown, and softened, but contained no pus. Kidneys firm, pale, healthy. Bladder healthy, filled with urine. In the history of this case, the different stages of the disease are marked out with tolerable distinctness. During the month of Oc- tober, it seems to have been confined to the mucous membrane of the gall-bladder and gall-ducts, and the symptoms were pain— which was twice relieved by leeches to the epigastrium—lassitude, loss of appetite, and thirst, without much fever. At the end of October, during apparent convalescence, inflammation seems to have been set up outside the common duct by the ulcers eating through it, and fresh symptoms occurred—return of pain in the right hypochondrium, bilious vomiting, purging, increased fever, jaundice. On the 12th of November, one of the ulcers had pro- bably eaten into a branch of the portal vein; rigors recurring at irregular intervals, frequent pulse, and hot dry skin—the phe- nomena then noted—being constant symptoms in suppurative in- flammation of a large vein. In the cases of suppurative inflammation of the trunk of the portal vein before related, the local mischief was confined to the liver. The pus globules seemed all to be stopped there. In this case, at the end of two days, the patient was seized suddenly with EFFECTS. 223 pain and swelling about the right shoulder; at the end of eight days, with pain and swelling at the middle of the forehead; at the end of ten days, with pain and swelling of the left temple. Later still, petechiae appeared on the skin, and gangrenous pustules on the limbs and trunk, and the patient died in a low typhoid state on the 2d of December. After death, shreds of lymph and puru- lent synovia were found in the right shoulder and elbow joints, and small circumscribed masses in different stages towards suppuration, in the lungs and liver. The effects resembled those of suppurative phlebitis occurring after injury of the head or limbs, but the inflammation set up in so many distant points was more gangrenous than that consequent on ordinary phlebitis. The dissection rendered it clear that the disease of the parts remote from the liver resulted from contamination of the blood with bile and pus, and that the morbid changes in those parts began in inflammation of the minute veins. The circumstance that there were no gall-stones, and that ulcers were found in the duodenum, immediately around the opening of the common duct, as well as in the gall-bladder and in the duct, scarcely leaves a doubt that the ulcers, from which all the subsequent mis- chief resulted, were caused by irritating bile. It is worthy of remark, that there were no ulcers in the large intestines, or any- where in the intestinal canal, except immediately about the opening of the common duct. It would seem that the bile, mixed with the food, and diluted, if we may so speak, with the pancreatic juice and the secretions of the bowel itself, became less irritating as it moved downwards. The case confirms in a striking manner the opinion advanced in a former chapter on the relation between abscesses of the liver and dysentery. It shows, too, how serious may be the consequence of faulty states of the bile, which in themselves may be transient, and of which at present nothing is known. Another occasional effect of the diseases we have been consider- ing is permanent closure of the cystic or of the common duct. This may, indeed, arise from various causes besides inflammation. Permanent closure of the cystic duct is not unfrequently caused by a gall-stone. The stone forms in the gall-bladder, and grows too 224 CLOSURE OF THE CYSTIC DUCT. large to pass through the duct. It is carried with the bile, in which it floats, into the mouth of the duct, and gets firmly lodged there. Circumscribed inflammation of the duct about the gallstone is then set up, by which the duct is in general permanently closed beyond the stone, in the direction of the hepatic ducts. Sometimes the channel of the duct is thus obliterated on the other side also, so that the stone is inclosed in the cyst. Now and then the common duct is closed in the same way, but much less frequently, because the common duct is larger and straighter than the cystic duct, so that when a gall-stone has passed through the cystic duct, it in most cases passes through the common duct. The common duct is also liable to be closed by cancerous and other tumors, especially by cancerous or other enlargement of the lymphatic glands that lie upon it, and by malignant disease of the head of the pancreas. Further on a case will be related in which the duct, near its duodenal end, was completely obstructed, so as to cause persisting and fatal jaundice,*by a wart-like body, the size of a small bean, growing from the lining membrane of the duct. A few instances have been recorded in which the common duct was permanently closed by some foreign body getting into it from the duodenum. The effects of mere closure of the ducts are just the same, what- ever be its cause, and it is as well, therefore, to speak of them once for all. Closure of the cystic duct destroys the office of the gall-bladder, and leads to various changes in it, which depend chiefly on the length of time the duct has been closed, and on the previous con- dition of the gall-bladder. When the cystic duct is closed by adhesive inflammation of the capsule of the liver, and the mucous membrane of the gall-bladder is healthy, the bile in the gall-bladder soon gets absorbed, and its place occupied by a glairy fluid, of the consistence of mucus or synovia, and not at all tinged, or but very slightly tinged, with bile. After a time, this fluid is secreted in less abundance, and the gall-bladder contracts and shrivels—in some cases almost to the size of an almond. When the coats of the gall-bladder were previously diseased and secreting cholesterine, which is generally the case when the cystic duct is closed by a gall-stone, the gall-bladder, after the closure of the duct, contains a viscid mucus, sparkling with scales of choles- EFFECTS. 225 ferine, or is moulded on calculi almost entirely composed of that substance. If, at the time of the closure, the gall-bladder contained unhealthy mucus or bile, this may undergo decomposition and set up, as we have already seen, suppurative inflammation of the mucous mem- brane, so that the gall-bladder may become filled with pus. It would seem from the cases before related that closure of the cystic duct impairs the nutrition of the gall-bladder, and in this way also renders it more liable to inflammation and sloughing than in its natural state. The effects of closure of the cystic duct on digestion and the general health are much less serious than might have been expected, and sometimes are of very little import. I have lately met with a striking instance of this in a man, 64 years of age, who died in King's College Hospital of extensive softening of the brain, and of inflammation of the urinary bladder which was consequent on the cerebral disorder. I did not expect to find anything amiss in the liver. The man's complexion was remarkably clear, and in the notes of his case, which were taken with much care, there was no mention of any disorder of digestion.. The gall-bladder was filled by a mass of small stones, which choked the mouth of the duct, and completely prevented the entrance of bile. (See plate 2, fig. 3.) From subsequent inquiry among his friends, I learnt that he had never had jaundice, and never complained of disordered di- gestion. Another instance of the same kind fell under my observation in King's College Hospital, in 1851. The gall-bladder was contracted upon an oval gall-stone, and seemed to have been long obliterated, in a woman who died of phthisis, and in whom no disease of the liver was suspected. My friend, Dr. Scott Alison, some time ago sent me a gall-blad- der, in which the orifice of the cystic duct was closed, and appa- rently had been closed long before death, by a gall-stone, the size of a hazel-nut. The bladder was filled with viscid mucus, sparkling with scales of cholesterine, and its coats were diseased. It was taken from a lady who died, at the age of 79, of acute bronchitis, of eight days' date, and who, before this illness, had been particularly healthy. She was of very temperate habits, and had never had jaundice or other symptoms to lead to the inference that the liver was diseased. 15 226 CLOSURE OF THE COMMON DUCT. It has been stated that closure of the cystic duct, by causing the bile to flow continuously into the duodenum, increases the appetite in a remarkable degree {Diet, de Med., t. v. p. 241)—but this effect was not noticed in the cases just mentioned, nor in many others to which I could refer. Closure of the common duct has far more serious effects. The most immediate of these are deep jaundice, dilatation of the gall-bladder and hepatic ducts, and retention of bile in the lobular substance of the liver, which acquires in consequence a deep olive color. By the retention of bile the liver at first grows larger ; but when the duct has been closed for some months it ceases to enlarge further, and subsequently, from atrophy of the lobular substance and from absorption of the retained bile, it may shrink again, and in the end, notwithstanding the dilatation of the gall-ducts, may become even smaller than in health. When the liver is enlarged from the mere retention of bile, its edge is not rounded as in the fatty or scrofulous enlargement, but remains sharp and thin; and if the patient be much wasted, the sharp thin edge can sometimes be distinctly felt through the walls of the belly. If the closure of the common duct occur suddenly, the gall-blad- der, or one of the ducts behind the obstruction, may be distended so rapidly as to burst. Several cases of this kind are recorded. When the obstruction occurs gradually, the bladder and ducts are distended more slowly, and when the duct has been long com- pletely closed, are sometimes found of enormous size. Abercrom- bie {Diseases of Stomach, &c, 2d edition, p. 364) cites from Bois- mont, a case in which the hepatic gall-ducts were so distended in this way, and the lobular substance of the liver was so wasted, that the liver had the appearance of a large undulating cyst. The closure of the common duct was caused by a membranous band which passed over it. The ultimate effect of closure of the common duct on the lobular substance of the liver is very remarkable. The cells which go to form this substance, and which secrete the bile, are destroyed; the capillary vessels of the lobules, which minister to secretion, become atrophied; the liver, in consequence, no longer presents an appear- ance of lobules; and the office of the lobular substance can no longer in any degree be performed. The destruction of the proper cells of the liver was first noticed EFFECTS. 227 by Dr. Thomas Williams, in a paper "on the Pathology of Cells," published in Guy's Hospital Reports, for October, 1843. Dr. Wil- liams remarked it in a man who died in Guy's Hospital of malig- nant disease of the duodenal end of the pancreas, which so pressed upon the common duct that the bile could have passed into the duodenum only in very small quantity and very slowly. The gall-bladder and gall-ducts were extremely distended, and the whole organ was considerably enlarged. " The liver had lost its fragile, solid character, and had become soft, flabby, and not capable of be- ing easily broken down by pressure. On the application of the microscope for the purpose of examining the ultimate structure, the extraordinary fact was developed, that scarcely a single nucleated glandular cell in a perfect state could be found. Different portions of the organ were carefully and repeatedly prepared, in order to remove every possibility of mistake or misobservation; the conclu- sions were uniformly the'same, that the true parenchymal cells of the organ were certainly not present. These preparations were also seen and examined b,y several excellent obser- vers about the hospital. In each portion g" *" of the organ mounted for inspection no- thing more than minute free fatty parti- cles, and equally free, floating amorphous, granular matter, could be discovered : it ° ' a, a, fat particles, free. was very seldom that a whole nucleated cell could be seen. The following cut may serve to convey a con- ception of the microscopic characters of these objects." In the spring of 1844 I met with a case in which, from lono- closure of the common duct, the cells of the liver were perhaps even more completely destroyed than in the case related by Dr. Williams. I shall give the case in detail, because from there being no disease elsewhere to render the result ambiguous, it shows, clearer than any of the experiments made on animals, the effect of closure of the common duct. Case.—Ann Diprose, aged sixty-three, a sempstress, was admitted into King's College Hospital on the 18th of May, 1843. She was born in London, and had passed her life in it; of temperate habits, never taking spirits; married; had had six children, and five miscarriages; the cata- nienia appeared at the age of seventeen, were regular, except when inter- rupted by pregnancy and suckling, and ceased at the age of thirty-eight. Enjoyed good health till about fifteen years ago, when, after a fire which destroyed much of her husband's property, she was seized with violent 228 CLOSURE OF THE COMMON DUCT. pains, extending from the feet to the thighs, which continued for some time. A year after this the muscles on the right side of the face were spasmodically contracted for six weeks. About eleven years ago she fell down suddenly in the street, with loss of sensation and motion, from which she perfectly recovered in six weeks. She had no further illness till five years ago, when she suffered from pain and swelling in the right iliac region, attended with constipation. The pain gradually became very severe. It yielded to leeches, blisters, and low diet, after continuing from three weeks to a month. She perfectly recovered from this attack, and her health was good till her present illness, which began seven months ago, after great fatigue and anxiety in attending her mother, who was then, in her 91st year, operated on successfully for strangulated hernia. At this time her face and body became gradually of a deep yellow color, which, with some diminution for one interval of three weeks, has continued ever since. The jaundice came on without pain, but with some degree of nausea, and was followed, at the end of two months, by vomiting, which has recurred at intervals up to the present time. The appetite, at times, has been quite gone ; at other times ravenous. She has always found herself worse, and the jaundice deeper, after anxiety or fatigue. Four months ago was salivated, without relief. Has wasted much since her illness. On her admission to the hospital, the conjunctivae and the whole sur- face of the body were of a greenish color. She was thin, but not ema- ciated. There was much itching of the skin ; surface cold; frequent shivers. Pulse, 88; regular. Respiration, 22. Nothing discovered amiss in the heart or lungs by auscultation and percussion. The tongue was clean ; the appetite very variable, and sometimes vora- cious ; occasional nausea, but no vomiting for the last week ; bowels con- fined ; evacuations clay-colored and fetid. Great tenderness over the whole belly, but no pain. There was dulness on percussion over the epigastrium, and for some distance below the right false ribs, which was ascribed to enlargement of the liver. No ascites. The abdominal mus- cles irritable. The urine was of dark color ; s. g. 1015 : nitric acid produced at first a deep green, and when added in excess, a purple color. Some headache and depression of spirits. Sleep good, but easily dis- turbed. She was ordered ttlxx of dilute nitric acid, three times a day ; and compound colocynth pills, when necessary, to keep the bowels open. She remained in the hospital till the 8th of June, and during this time the symptoms underwent no material change. There was no fever ; the skin was cool; the tongue moist, pallid, and indented ; and she was seldom thirsty; the pulse ranged from 86 to 90 ; the s. g. of the urine from 1015—1020. She complained often of tenderness at the epigastrium, and at times of a gnawing pain there, which was relieved by taking food. Had frequent nausea, especially when the stomach was empty, but only vomited once—and then in the morning, in consequence, as she thought, of having taken the night before a draught containing the fourth of a grain of muriate of morphia. A few days after she left the hospital she was much troubled by her husband returning to her ill—and from that time she became much weaker, EFFECTS. 229 and did not afterwards leave her bed, except for a short time in the even- ings. She continued to take the nitric acid, which she thought did her good. There was great tenderness over the epigastrium and right hypo- chondrium, with rigidity of the abdominal muscles ; she was unable to lie on the right side, and generally preferred the supine posture. She was very nervous—the least noise, or even sewing or reading, producing a " fluttering of the chest;"—and her sleep was more disturbed than it had been previously. She often became hot and feverish about night-fall, and continued so during the night. Complained at times of pain in the ankles and wrists, but these joints were not red or swollen. She had no vomit- ing. Her appetite was at times voracious; and she had a craving for oysters and small shell-fish, which, even in large quantities, never disa- greed with her. She had an aversion to meat, and porter, and milk,— which she said disordered her. One evening, after imprudently eating gooseberry tart, she was seized with violent pain and spasm under the right false ribs, which exhausted her very much, but did not cause vomiting. On the 27th of June the nitric acid was exchanged for sulphate of quinine and dilute sulphuric acid; and this, again, was soon exchanged for nitro-muriatic acid, which she continued to take, with short interrup- tions, till the end of December. During this time she grew weaker and thinner, and was harassed by occasional hectic at night. In other respects, her symptoms underwent little change. Her appetite was almost constantly craving, and she still had great desire for mussels and oysters. There was no vomiting. Her bowels habitually required purgative medicines; but in the middle of December she had diarrhoea, which lasted for a week, during which she felt better. She always complained of pain and tenderness of the belly, and often of itching of the skin. Slept badly by night, and was drowsy by day. The pulse ranged from 88 to 100 ; the respiration from 20 to 24. She had frequent coUgh, but did not expectorate. The urine was ever high-colored, fetid, stained linen yellow, and, on the addition of nitric acid, became first of a beautiful green, and then of a purple color. It was sometimes clear, at other times turbid, but never deposited a sedi- ment approaching to pink. A little before Christmas she suffered much from thirst, and efferves- cent draughts were given to allay it. She relished them very much, and continued to take them till her death, which happened on the 10th of March. In the beginning of February she lost one of her sons, who died rather suddenly, from disease of the heart. From this time her appetite began to fail, and the last few weeks of her life she ate very little. She com- plained of nausea, and now and then vomited. Often had shivers, fol- lowed by burning heat of skin. Complained greatly of pain and soreness of the belly; and at times of pain of the head of a throbbing character. About a week before her death vomiting of blood came on, and recurred two or three times. The last week her mind wandered a little at night; but, with this exception, she continued rational up to her death, which seemed to result from exhaustion. The urine was examined for the last time on the 21st of February. It had the same characters as previously, and its s. g. was 1012. 230 CLOSURE OF THE COMMON DUCT. Two or three times morphia and conium were given to procure sleep, but these medicines disordered her, and increased her sufferings. The body was examined twenty-two hours after death. It was much emaciated, and of a greenish-yellow color. The belly was large. The cavity of the peritoneum contained three or four pints of a serous fluid, and the intestines were much distended with gas. The colon was closely united to the gall-bladder by false membranes of old date ; but its canal was not contracted at this point. The duodenum also adhered firmly to the gall-bladder for a very small space, about an inch and half below the pylorus. The canal of the intes- tine was a little curved by this adhesion, but not sensibly contracted. There were a few threads of false membrane uniting contiguous loops of intestine. The mucous membrane of the stomach and intestines presented no sen- sible change of structure. The duodenum contained a whitish pulpy matter; the large intestine firm white fecal matter, and much gas. The liver was smaller than natural, and looked flattened. It was of a deep olive, finely mottled with yellow. Its surface presented no traces of peritonitis, except about the gall-bladder, and was readily thrown into fine wrinkles. The hepatic gall-ducts were enormously dilated, every sec- tion of the liver presenting some of the size of goose-quills. The tissue of the liver was flabby, but not easily broken down by the finger. The cut surface was of a deep olive, finely sprinkled with yellow—having some- what the appearance of fine grained granite—but the lobules could not be distinguished in it. When some of the tissue from any part of the liver was examined under the microscope, nothing was seen but numerous oil globules, and irregu- lar particles of yellow and orange biliary matter, which was in many places agglomerated into roundish masses. No distinct cells were visible. The matter taken from the yellow points appeared to differ from the matter of the olive portions only in containing more oil globules and less biliary matter. The tissue of the liver was in the same state throughout. The gall-bladder and the cystic duct were enlarged, the latter to the size of the little finger. Their coats were much thickened. The outer coat had a dead-white color, and was of the firmness of cartilage, but presented no calcareous plates. Both were stuffed with small irregular tetrahedral calculi, the interstices of which were filled by a light yellow fluid, of the consistence of thin cream, which, under the microscope, pre- sented nothing but a mass of very minute crystals of cholesterine (some of which were stained yellow), with here and there a particle of biliary matter. The thickened coats of the gall-bladder and cystic duct exhibited under the microscope oil globules and plates of cholesterine. The common duct was completely closed just below the point where the cystic duct enters it. Between this point and its opening into the duodenum it was very narrow, just admitting a small probe. Its coats not at all thickened or diseased, and not stained with bile. Immediately above the entrance of the cystic duct, the hepatic ducts were dilated to the size of a man's thumb. Their coats were stained of a deep olive, but EFFECTS. 231 were not thickened. Some of the dilated ducts contained a little dark green fluid. The gall-bladder was not quite closed to the hepatic ducts. Some of the contents of those ducts might soak into the gall-bladder through the impacted mass of calculi. The hepatic artery appeared to be of its natural size. The portal vein was healthy, and did not seem compressed by the gall-bladder and cystic duct. In the loose areolar tissue, near the entrance of the portal canal, were some lymphatic glands of a dark olive color. The thoracic dnct was small; in the posterior mediastinum not larger than the quill of a hen. The spleen had thick white spots of false membrane on its capsule, but was firm, and not enlarged. The kidneys were healthy. The heart healthy. Its ventricles, which were contracted, contained only very small fragments of fibrin. The lungs were sound, but were united to the pleura costalis on each side by a few threadlike bands. There were no false membranes uniting the lower lobe of the right lung to the diaphragm. There was some serous fluid in each pleural cavity. In the case just related, closure of the common duct was evi- dently the chief, if not the sole, cause of the woman's sufferings during more than the last year of her life. The gall-bladder and the cystic duct were indeed stuffed with small gall-stones, but there were no marks of recent inflammation about them, and there was no disease elsewhere by which the symptoms could have been produced. It is difficult to fix the precise time when the duct became completely closed. From the circumstance that the jaun- dice came on gradually and without pain, the inference can scarcely be avoided that the occlusion took place gradually, for the sudden closure of the common duct by a gall-stone usually gives rise to a train of more urgent symptoms—to vomiting and paroxysms of severe pain, soon followed by deep jaundice. It is not improba- ble that in this case the first occurrence of vomiting, about two months after the onset of the disease, and about fifteen months before death, marked the completion of the process. Among the many points of interest which the case presents, we may notice first, the effect which this long closure of the common duct had on the liver itself. Great dilatation of the gall-ducts and a dark green color of the liver are results which might have been predicted; but results far more curious and interesting are, the shrinking and flattening of the liver, the absence of distinct lobules 232 CLOSURE OF THE COMMON DUCT. in its substance, and the complete disappearance of the nucleated cells by which the bile is secreted. The substance of the liver was made up of vessels and areolar tissue connecting them with the free oil-globules and solid particles of yellow and orange biliary matter that were left when the watery and more soluble parts of the retained bile were absorbed. The objects seen when some of the tissue from any part of the liver was examined under the microscope were just the same as in the case related by Dr. Wil- liams, and confirm in almost every respect Dr. Williams's account, Destruction of the proper cells of the liver seems to occasion atrophy of the capillary vessels subservient to their secretion, and the two circumstances combined explain the shrinking of the liver in this case, and the absence of any appearance of lobules. Other points worthy of notice in the history of the case, and which were among the effects of closure of the common duct, are:— 1st.—The constipation, and the relief derived from purgatives, and once from diarrhoea, that occurred without purgative medicine. Much of the pain and tenderness of the belly complained of was probably owing to distension of the intestine by feces and gas, and to irritation of its mucous membrane by the contact of matters chemically different from those natural to it. 2d.—The ravenous appetite that so long existed, which probably depended, as in diabetes, on imperfect digestion. I have known the same thing happen where the common duct was closed by the pressure of a cancerous tumor. 3d.—The desire that existed for shell-fish, especially oysters and mussels, which, in quantity to satisfy a craving appetite, never caused disorder. 4th.—The fetid urine; which was at times turbid with pale lithates, but never had a pinkish sediment. The absence of a pink sediment may help to distinguish such cases from cases in which the common duct is closed by the* pressure of a cancerous tumor, and in which a sediment of this tint is often observed in the urine. 5th.—But perhaps the most striking circumstance of all was that although for a long time before death the liver must have ceased to separate bile from the blood, there were no symptoms of cere- bral poisoning, and the mind remained clear to the last. This circumstance will appear still more remarkable if we compare this case with other cases in which suppressed secretion of bile is EFFECTS. 233 attended with delirium, or with stupor and convulsions, soon end- ing in fatal coma. Dr. Alison, in a paper published in the Edin- burgh Mediqal and Surgical Journal, for 1835, has collected many cases of this latter kind, and, from a review of them, he concludes that it is jauudice from suppressed secretion,'and not from obstructed gall-ducts, that is peculiarly, if not exclusively, liable to be followed by delirium, coma, and speedy death. He explains this by suppos- ing that " the retention in the blood of matter destined to excretion is much more generally hurtful to the living body than the re-absorp- tion into the blood of matters which have been excreted at their appropriate organs, but not thrown out of the body, in consequence of obstruction at their outlets." The fact is, I believe, correct, but Dr. Alison's explanation is not satisfactory, since, in this case, for a long time before death, there could have been no bile secreted, and yet there was no disorder of the brain. 6th.—The case further shows that life may continue for fifteen months after bile has ceased to flow into the intestinal canal; and thus proves that all the staminal principles of the food may be digested and absorbed without its aid. The absence of bile in the intestine, or destruction of the secreting element of the liver, proves fatal, however, in the end, by impairing nutrition, and causing slow but progressive wasting. The time requisite to wear out life must depend on the age and previous strength of the patient, his powers of digestion and assimilation, the nature and quantity of the food taken, and the various other circumstances that influence nutrition. It will, of course, be shortened by the injudicious employment of lowering measures. In Mrs. Diprose, the cells in the lobules of the liver had probably disappeared, and the organ ceased altogether to secrete bile some months before death. In the summer of 1851, a very remarkable case of complete clos- ure of the common duct by a gall-stone fell under my observation at King's College Hospital. The patient, a poor woman, became deeply jaundiced from this cause, when four months gone in preg- nancy; yet, in spite of the deep and persisting jaundice, she brought forth, at the proper time, a living child, and suckled it up to the time of her death, which happened three months after the birth of the child, and between eight and nine months after the occurrence of the jaundice. She often came to see me, as an out-patient; but, from an unwillingness to leave her young children, constantly 234 CLOSURE OF THE COMMON DUCT. refused to come into the hospital. The following notes of the case were partly entered in my hospital case-book by Mr. Jordan, who was physician's assistant at the hospital when the poor woman first applied there, and partly procured for me by Dr. Henry Salter, who held the same office at the time of her death. Case.—Margaret Beglin, aged twenty-nine, married, and the mother of five children, is a native of Ireland, but has lived in London the last six- teen years. Her husband has secondary syphilis; she has miscarried once (six years ago) at the third month. She has always been of temperate habits, and was living in comparative comfort until the last two years, when, from her husband's illness (epilepsy from syphilitic cranial periosti- tis), she became poor, and has since suffered much privation. She is now living in a wretched place in Clement's Lane. She was a stout, hearty girl, when she came to London, and had good health until her marriage at the age of nineteen. Three years ago, she went to Dublin, and during her stay there caught a severe cold, which confined her to bed for three weeks. She recovered from this illness, but remained very weak, and could not get proper nour- ishment, and in about two months after had an attack of jaundice. There was then very severe pain in the right side, extending to the right shoul- der, and swelling of the belly came on, which has continued ever since. The bowels were always loose and the stools white. She has never been "regular" from that date, though she had always previously been so. The jaundice continued for about four months, at the end of which time she recovered her health, but the belly remained large. She came to Eng- land, and remained free from jaundice for nine months. Eight months ago jaundice recurred, and has continued ever since. At its recurrence, there was pain in the chest, and in the right side and right shoulder, and slight cough. Ever since, the bowels have been loose, as before, and the stools white. About three months ago, she had a child at full term. The jaundice, therefore, came on in the fourth month of pregnancy. The child was "yellow as a guinea" when born, but acquired the natural color in two or three days. This child she is now suckling. Her milk has been, and is, per- fectly white. After her confinement, she had severe flooding for five days. At present (August 12, 1851), she is attending the hospital as an out- patient, deeply jaundiced. She lives badly, and is very weak, and suffers a good deal from giddiness and headache, but is yet able to walk about well, and suckles her baby. She complains of itching of the skin, which has existed from the commencement of the jaundice, and of pains in "the small of the back," and in different parts of the limbs, along the thigh and in the hip, which are not worse at night. She likewise complains of almost constant pain in the region of the liver, and of occasional severe pain in the right shoulder. At times, she has had pain, amounting to agony, stretching from the navel to the chest; and, during these paroxysms, has vomited a sour watery fluid. She has cough, and spits dark-colored catar- rhal mucus, and catarrhal sounds are heard on the chest. The diarrhoea, which has existed ever since the occurrence of the jaun- dice, has been much checked by infusion of logwood and chalk mixture, EFFECTS. 235 which have been given her at the hospital; but the bowels are still moved two or three times a day, and the stools are loose. Her skin is generally damp and perspiring; and her expression cheerful. She sleeps badly, but her appetite is very good. She has a sense of distension of the stomach after meals, but no pain. Feels occasionally sick and faint, but does not vomit. Has piles, and has lost a small quantity of blood from them. Has lately had many fits of shivering, and sweats much at night. Never had ague, and the spleen is not enlarged. Since .her confinement, her legs and feet have swollen a little. The pulse 98, the inspirations 20, in a minute. The belly is protuberant, like that of a woman eight months advanced in pregnancy, and the liver is much enlarged. The lower edge of the liver can be traced, stretching from the left hypochondrium, in a curved line, to a spot about half an inch below the umbilicus, and thence down into the right iliac region, a great part of which it occupies. To judge from percussion, it does not encroach much on the lungs. Its outer surface seems quite smooth to the touch ; and its lower edge, which can be grasped between the fingers for some distance near the umbilicus, is felt to be sharp. The liver does not appear to be adherent to the abdominal parietes, since, by pressure, it can be shifted from its position and moved up. There is but little pain on pressure over the liver, the greatest being in the right iliac region. The superficial veins of the belly are not en- larged, and there does not seem to be any fluid in the peritoneal sac. There is no rigidity of the recti or other abdominal muscles. Half a drachm of aromatic spirits of ammonia was ordered to be taken in an astringent mixture three times a day ; and she was urged, in vain, to wean the baby, and to come into the hospital. From this time she was not seen by any of the medical officers of the hospital until her death, which happened on Sunday, the 24th of August. The following statement of her condition during this interval was obtained from her husband :— She first appeared to get worse about a week before her death. The pain in the right side then became much more severe, shooting down to the bottom of the belly, and being much aggravated by any movement, so that she was hardly able to walk, and suffered great pain in getting in and out of bed; and a difficulty in passing her water, which existed for some weeks before her death, increased, so that at times she would sit on the urinal in great agony for a quarter of an hour, and pass none. Towards the close of her life, the diarrhoea, which had existed for some months, likewise increased greatly. During the last week her appetite failed, and she was in a state of extreme weakness, hardly able to move about, and occasionally for a minute or two losing her sight. On the evening of the 21st, when her husband came home, he found her very ill, sitting by the fire. She said she had been very ill all day, and had been passing from the bowels "black lumps" mixed with blood. The pain in the side was worse, and pain in the head, which subsequently be- came very severe, also came on. She continued to past "black lumps" from the bowels up to the time of her death, and was very faint and thirsty, but was quite sensible to the last, except during a short fit, in which she lost her speech, and fell out of bed insensible. After the fit she was sick, and threw up a dark brown matter like coffee. She seemed to suffer most from pain in the head, and at last did not complain of pain 236 CLOSURE OF THE COMMON DUCT. in the side or belly—the pain in the head appearing by its severity to obscure all the other pains. On the evening of the 23d she looked and spoke somewhat better, ate a biscuit, and then slept for two or three hours. The rest of the night she complained of pain in the head, and was tossing about, seeming very faint. At six A. M., on the 24th, she became insensible, and, at seven, died very quietly. Two or three hours before her death she suckled her child. On the morning of the 27th the body was examined by Mr. Jordan and Dr. Salter. On opening the belly, a small amount of fluid was found in the cavity of the peritoneum, but no more than was probably cadaveric. The intes- tines, large and small, were blown out with gas. The intestinal canal throughout was stained of a dark purple, and on cutting into it the cause of this was revealed, the whole of the intestines being filled with blood; the entire alimentary canal was taken out and washed ; but, though stained with blood, as before stated, no ulcer or abrasion of the mucous membrane was detected. The liver was about three times the natural size, very flat, and not thickened, and its lower edge was very sharp. It looked fatty, and its texture was mottled and uneven. On examining the gall-duct, the secret of the disease was explained. A gall-stone, as large as a walnut, was found firmly impacted in the common duct, about two inches from its duodenal end. The duct was hard, like a cord, below the obstruction towards the duodenum, and very much dilated above. Its coats were much thickened, and all its ramifications in the liver were enormously dilated, so as to look like sinuses as large as the branches of the portal vein. The cystic duct and the gall-bladder were atrophied and quite shrivelled up. No ulcer could be found anywhere in the ducts, and the mucous membrane, even where the gall-stone was impacted, was perfectly unbroken. On examination under the microscope, the liver was found to contain a great deal of oil, in globules of various sizes, but no cells belonging to the lobular substance were seen. The kidneys were large, soft, and congested, and looked fatty. The brain and other organs were not examined. In this case, as in the preceding, closure of the common duct by a gall-stone was the primary cause of illness; and the effects of this were, in the main, the same—deep and persisting jaundice; very slow, but progressive, wasting; destruction of the cells in the lobular substance of the liver; after a time, more or less fever, of the character of hectic; and, finally, hemorrhage from the intes- tinal canal, and death from exhaustion—the mind remaining clear almost to the last. This case differs, however, from the preceding in the existence of almost constant diarrhoea; and in the circumstance, that the liver, instead of being smaller than natural, as it was in the preceding case, was much enlarged by the dilatation of the ducts and the ac- cumulation of oil and biliary matter within it. EFFECTS. 237 It will be seen that in both cases the portion of the common duct, between the obstructing gall-stone and the duodenum, was found very much contracted after death. In the first case it only just admitted a small probe; and in the second it was like a hard cord. When the common duct is thus completely closed by a gall-stone, contraction and atrophy of the lower end of the duct necessarily take place; and as it renders the future passage of the stone along the duct impossible, the prognosis in such cases is very unfavorable when the closure of the duct has existed for some months. The course of the bile can then be restored only by the gall-stone work- ing its way, by ulceration, into the intestinal canal. The case last related shows quite as clearly as the one before it, that all the staminal principles of the food can for a considerable time be digested without the presence of bile in the alimentary canal; for the poor woman, although her health was doubtless impaired by the former attack of jaundice, which had left the liver enlarged, and although she lived badly and suffered many hard- ships, and lost much blood after her confinement, lived between eight and nine months after bile had ceased to flow into the duodenum, and during this time not only supported herself, but brought to maturity and suckled an infant. I have since met with another instance quite as conclusive in showing that fatty matters at least—to the digestion of which bile is supposed especially to contribute—may, under certain circum- stances, continue to be sufficiently absorbed for a long time after bile has ceased to flow into the intestinal canal. A gentleman, about fifty years of age, fell under my care in the beginning of November, 1854, on account of jaundice, which came on towards the end of June preceding, in consequence, as he supposed, of a bilious attack. A short time before I saw him he had undergone an operation for fistula, and there was still, and for several months afterwards, a considerable discharge of pus from the rectum. At the epigastrium a large tumor was felt, which turned out to be the omentum thickened and contracted, and the liver, as a post mortem examination showed, was in a state of cirrhosis. Notwithstanding these conditions and continued complete obstruction of the common gall-duct, he lived till the end of March, 1856,—or for more than twenty months after the occurrence of jaundice. A short time before death, ascites came on—the result of the cirrhosis—on account of which he was tapped twice. The strength slowly 238 CLOSURE OF THE COMMON DUCT. declined, but at the time of death the body was still tolerably fat. The obstruction of the gall-duct was caused by the pressure of a tumor, the size of a walnut, which proved to be an enlarged lymphatic gland. It is worthy of notice that, in two of the cases just related, hemorrhage took place from the intestinal canal a short time before death. Since these cases fell under my observation I have met with several other instances of long-continued and ultimately fatal juandice from obstruction of the common gall-duct, in which the same thing happened; and have no doubt that permanent closure of the duct, after it has existed a long time, has, in some way or other, an especial tendency to cause hemorrhage from the bowel. The intestinal hemorrhage in these cases occurred without hemor- rhage elsewhere, and cannot therefore be attributed solely to a gene- ral disposition to hemorrhage, which is not unfrequently seen in cases of jaundice. The question then arises, On what other condition did the hemorrhage depend ? If it has resulted from pressure on the trunk of the portal vein by the gall-stones, or by a tumor, obstructing the common duct—or from mechanical impediment to the passage of blood through the liver, caused by wasting of the capillary vessels in the lobular substance, consequent on the destruction of the cells—there would, probably, as in cases of cirrhosis, have been a greater degree of ascites. A sudden impedi- ment to the passage of the blood through the liver may cause great congestion of the mucous membrane of the intestinal canal, and hemorrhage from it, without ascites; but an abiding impediment, as is seen in cases of cirrhosis, and in those cases of cancer of the liver in which the trunk or a large branch of the portal vein is com- pressed by a cancerous tumor, causes ascites rather than hemorrhage, and usually leads to a high degree of ascites before any hemorrhage takes place. As no ulceration of the intestine had been observed in these cases, my impression at one time was that the hemorrhage resulted from a state of congestion of the mucous membrane, and that this congestion of the secreting membrane of the stomach or intestines was caused in some way or other, not by mechanical impediment to the passage of the blood through the liver, but by cessation of the process of secretion in it. EFFECTS. 239 In the summer of 1855 a case fell under my observation, in King's College Hospital, which in some degree shook my belief in the truth of this explanation. The patient, a man fifty-three years of age, became rather suddenly affected with jaundice in the month of January. The jaundice continued, and he died on the 6th of July following. A short time before death he vomited a large quantity of blood. On examination of the body, the jaundice was found to be caused by a wart-like growth of the mucous membrane of the common duct, which completely blocked up the duct, about half an inch from its duodenal end. In the duodenum there was a large ragged ulcer. There was no ulceration elsewhere in the in- testines, and no disease worthy of note was discovered in other parts of the body. In the autumn of the present year (1856) I met with another instance (the case of Donaghan, before related, p. 212), in which, after jaundice from obstruction of the duct had existed many months, vomiting of blood occurred. In this instance, both the pancreatic duct and the common gall-duct were obliterated just at their point of entrance into the duodenum by being involved in a small mass of indurated tissue—apparently the result of inflam- matory infusion. In the duodenum an ulcer was found partially cicatrized, an inch and a half long and half an inch broad, com- mencing immediately above the papilla, which marks the entrance of the gall-duct, and extending lengthwise up the intestine. In the stomach there was another ulcer, about the size of a florin, that had the appearance of having been recently formed. In these instances the ulcers were certainly the most probable source of the hemorrhage; and the coincidence of the ulcers with long-continued obstruction of the duct raises the suspicion that the ulcers may have been caused by the obstruction, and that in some of the other cases of long-coutinued obstruction of the duct, in which intestinal hemorrhage occurred, an ulcer may have existed in the duodenum and have escaped notice. It is possible, however, that both explanations may be in part true—that permanent stop- page of the common gall-duct may lead, after a time, to congestion of the mucous membrane of the duodenum, and subsequently to ulceration, and that hemorrhage may occur in either stage of dis- ease A careful examination of the duodenum and stomach in a few more cases of long-continued jaundice from obstruction of the duct will settle the point. Simple closure of the common gall-duct, when it occurs in a per- 240 CLOSURE OF THE COMMON DUCT. son previously well nourished and placed in favorable circum- stances, sometimes causes very slight constitutional disorder, and no great loss of strength, for several months. The patient, in some instances, would hardly consider himself ill, if he were not jaundiced, and I have more than once known a man in whom deep jaundice from this cause had lasted six or seven months, still able to walk several miles without fatigue. After a time, however, digestion becomes a good deal disordered; slight fever, of the character of hectic, sets in ; the loss of flesh and strength, though still very gra- dual, becomes greater than before; and at length—usually after the lapse of from twelve to twenty months from the occurrence of the jaundice—the patient dies from exhaustion, which, as we have just seen, is sometimes hastened by hemorrhage from the intestinal canal. A short time before death, slight dropsical effusion now and then occurs—the result, probably, of the joint influence of an impoverished state of the blood and of feeble propulsive power in the heart. In cases of this kind the deepest possible jaundice may exist for many months—the skin may be of a brownish green, instead of yellow, from the accumulation of biliary pigment and the action of the air upon it—and no disorder of intellect whatever, may occur. The patient gradually loses flesh and strength, and having become very thin and anemic, at length dies—simply from exhaustion. These facts are sufficient to justify the inference that in cases of jaundice which prove rapidly fatal from delirium and coma—and many such cases will be related in the next chapter—the fatal cere- bral disorder is owing, not to the mere suppressed secretion of bile, but to some peculiar noxious matter developed in the system. When permanent closure of the duct occurs in a person in a faulty state of nutrition, or in one who has insufficient means of support, the hectic fever sets in earlier, the wasting is more rapid, and the strength may be exhausted in seven or eight months. In some instances, as we have seen, the retention of the mucus and bile causes suppurative inflammation of the gall-bladder, and death is still further hastened by the severe constitutional disorder which this occasions. It sometimes happens that, after complete closure of the common duct has existed many months, and while no bile flows through it into the intestine, the jaundice of the skin becomes very much less deep, and the urine very much less deeply stained with bile. I EFFECTS. 241 have, indeed, more than once known the jaundice gradually diminish and almost entirely disappear after the lapse of twelve months, to the great satisfaction of the patient, although the color of the intestinal discharges, and an examination of the body after death, showed that the closure of the duct was still complete. These facts strongly support the opinion that the coloring matters of the bile are formed primarily, at least for the most part, within the liver—as the resinous acids of the bile appear to be—through the agency of the cells in its lobular substance. In other cases of the same kind, the jaundice, perhaps from retention of the biliary matter in the skin, remains deep to the last. The question may here be asked—in what degree does the pro- gressive anemia, and the gradual loss of flesh and strength endino- in death, in cases of simple closure of the common gall-duct, result from the want of bile in the intestinal canal; and in what degree from the unhealthy condition of the blood and from the impair- ment of digestion caused, more directly, by the total destruction of the cells in the lobular substance of the liver? Destruction of the hepatic cells leads to an unhealthy condition of the blood, not only by preventing the elimination of those effete matters which con- tribute to form the bile, but also by preventing those reparative changes which the blood naturally undergoes in its passage through the liver; and the suppressed secretion of bile, which is a conse- quence of destruction of the hepatic cells, directly impairs diges- tion by lessening, or vitiating, the secretions of the stomach and other parts of the intestinal canal. The opinion was advanced by Dr. Prout, that the principal digestive organs, taken together, form a kind of galvanic apparatus, of which the mucous membrane of the stomach and intestinal canal generally may be considered the acid or positive pole, the hepatic system, the alkaline or negative pole. There is much in favor of this opinion, but whether the relation between the stomach and the liver be electrical or not, there can be no doubt that there is an intimate relation between them, and that cessation or derangement of secretion in one of those organs affects more or less the secretion of the other. If we consider that for many months from the commencement of illness, in cases of this kind, the strength is often tolerably main- tained, and the signs of disordered digestion are slight, that the strength usually declines more rapidly, and the disorder of diges- 16 242 CLOSURE OF THE COMMON DUCT. tion becomes greater as time wears on, it seems most probable that the defective regeneration of the blood and the gradual wasting of flesh are owing much less to the mere absence of bile in the intes- tinal canal than to the other conditions just mentioned. This inference is confirmed by the result of an experiment per- formed by M. Blondlot, in which he succeeded in tying the common gall-duct in a pointer bitch, between three and four years old, and afterwards establishing a biliary fistula from the gall-bladder, so as to allow the bile to escape from the gall-bladder through the side. After the operation, the stools had no tinge of bile, but the bitch had an excellent appetite, and her health was so good that she lit- tered every year, and occasionally hunted with eagerness. The bile continued to flow from the fistula with its habitual characters, but in a manner in some degree intermittent. When the animal was fasting no more than a few drops escaped, while some minutes after taking food it issued in abundance, and continued to do so during the whole time of digestion. This state of things continued for five years, after which the animal wasted for some time, and then died without the occurrence of any remarkable incident. On examination after death, the common gall-duct was found perfectly obliterated, so that all the bile secreted by the liver must have passed out of the body through the fistula. The gall-bladder, although adherent to the abdominal walls, and having a fistulous opening through them, had preserved its natural form and dimen- sions. The cystic duct was very much dilated. The liver itself was contracted and hard, and had the appearance of a liver affected with cirrhosis.1 In three of the cases related above, the patients lived at least fifteen months after the closure of the duct. Other cases have oc- curred in which, judging from the duration of complete jaundice or the state of the liver after death, life must have continued much longer after this had happened. Some months ago my attention was called by Mr. Busk to a pa- tient in the Seamen's Hospital, who had then been jaundiced for four years, and, as I imagined, from closure of the common duct. During this time but little bile seems to have passed into the bowel. The feces were reported to have been always pale; and the year before I saw him he had taken strong emetics, which produced free 1 Comptes Rendus de FAcademie des Sciences, 23 Juin, 1851. EFFECTS. 243 vomiting, but, as he stated, nothing bilious was brought up. He was still tolerably stout and muscular. In the case related by Bois- mont, already alluded to, where, from extreme dilatation of the gall-ducts and wasting of the lobular substance, the liver had the appearance of a large cyst, the cells in the lobular substance must, for the most part, have disappeared, and the action of this portion of the liver could have been performed but to very small extent, long before death. 4 These cases might lead us to expect (what indeed happens) that persons who, from obliteration of branches of the portal vein, or from the changes so frequently produced by long residence in tropical or malarious climates, have very little liver left,—to use a common expression, but which, if we consider the liver as a mere agent of secretion, is strictly correct — might often, by careful management, enjoy tolerable comfort for many years. Complete atrophy of the cells in the lobular substance of the liver, from permanent closure of the common gall-duct, is not a singular fact in pathology. When the ureter is completely stopped, as it sometimes is by a calculus formed in the pelvis of the kidney, the secreting structure of the kidney wastes, and at length entirely disappears, so that the organ is reduced to a cyst, which may not be larger than a small apple.1 Wasting of the gland-structure of the pancreas results from stoppage of the pancreatic duct—and probably the same thing happens for other excreting glands. In the liver, for complete disappearance of the cells in the lobular substance after closure of the duct a variable time is required. In the case of Donaghan, before related (p. 212), where death occurred from closure of the pancreatic duct and the common gall-duct, be- tween six and seven months after the gall-duct was completely and permanently stopped, every particle of the liver that was examined under the microscope contained a great number of perfect cells, highly charged with biliary matter. Atrophy of the liver-cells takes place the more slowly, when the common gall-duct is stopped, because the products of their secretion are still taken up and car- ried out of the liver by the capillary vessels of the lobular network and by the numerous lymphatics which are spread over the hepatic ducts, and consequently the cells can, to some extent, continue in 1 Two preparations, which exemplify this fact, are preserved in King's College Museum—one of them placed there by myself. 244 FATTY DEGENERATION OF THE GALL-BLADDER. the performance of their appointed function—which, doubtless, prevents their decay. In glands where the secreted products are not carried off with the same facility by the bloodvessels and lymphatics, closure of the excreting duct probably causes a much earlier atrophy of the gland-structure. Another circumstance worthy of notice in the first of the cases of closure of the common duct related above, is the state of the coats of the gall-bladder, which were thickened and opaque, and, when examined under the microscope, exhibited numerous oil globules and transparent scales of cholesterine. This disease of the gall-blad- der is analogous to the " atheromatous" disease of arteries, which Mr. Gulliver has lately designated "fatty degeneration of arteries," from having discovered that the atheromatous matter is chiefly composed of fat, in the form of oil-globules and scales of choles- terine. This disease of the gall-bladder may therefore be termed, with equal propriety, fatty degeneration of the gall-bladder—an expression which has the merit of involving no theory as to the cause of the disease, but merely announcing the fact. In the gall- bladder, as in the arteries, phosphate of lime is often deposited with the fatty matter, and sometimes in such quantities as to form large bony plates, which on the inside of the gall-bladder are usually bare, or merely covered by a soft pulpy matter, which may be readily scraped away. Sometimes the earthy matter is in such quantity that the gall-bladder is almost converted into a bony cyst. In some cases the entire gall-bladder has undergone this change; in other cases, merely a part of it. In a gall-bladder sent me by " Dr. Alison (of which I have already spoken), which was taken from a lady who died at the age of 79, much of the under and free surface was rigid from calcareous plates, which on the inside were covered only by a soft pulpy mass, composed of fatty matters and mucus. About the neck of the gall-bladder, and on the side of it attached to the liver, the coats were not at all thickened, and seemed healthy. The diseased part was limited by a well-defined line, readily seen on the inside of the bladder. The mouth of the cystic duct was blocked up by a calculus, composed almost entirely of cholesterine, and the bladder was filled with a viscid matter of a dirty yellowish-green and sparkling with small scales of choles- terine. This disease of the gall-bladder, according to my own obser- EFFECTS. 245 vation, is much more common, as gall-stones are, in women than in men. It occurs especially in the decline of life, like the athe- romatous disease of arteries, and seldom exists in the highest degree under the age of 50. Sedentary habits, and modes of life conducive to fatty degeneration of other tissues, doubtless favor its produc- tion ; but some local condition directly affecting the nutrition of the coats of the bladder—such as inflammation, or prolonged irri- tation by unhealthy bile or gall-stones—seems generally to have contributed to bring it on. It does not always co-exist with athe- romatous disease of the arteries, as it probably would do if it depended entirely on general or constitutional causes. I have met with it in the highest degree when there was little disease of the arteries; and have met with atheromatous disease of the arteries in the highest degree in persons advanced in life, in whom the coats of the gall-bladder were sound. The disease is very important, because it is not uncommon in the decline of life, and may have very serious results. It is always attended with an abundant secre- tion of cholesterine in the gall-bladder, which frequently leads to the formation of gall-stones, and thus to all the evils which gall- stones occasion. After a time, it causes sloughing of the lining membrane of the bladder, and by rendering the coats of the bladder rigid, prevents it from ever being completely emptied. The bile and the unhealthy secretions of the bladder being retained there, undergo decomposition, and set up persisting inflammation of its inner surface. If the cystic duct should become blocked up by a gall-stone, or otherwise, which not unfrequently happens, the gall- bladder is converted into an abscess, with rigid and uncontractile walls, which almost necessarily causes great and protracted suffering, and may destroy life in various ways. The cases that have been related in this chapter exhibit the chief forms of inflammation of the gall-bladder and gall ducts. We may gather from them, that when catarrhal or suppurative inflammation is confined to the gall-bladder, or to the gall-bladder and cystic duct, the chief symptoms are, pain and tenderness in the site of the gall-bladder, vomiting or nausea, and a certain degree of fever. When from the first the inflammation is not severe, or when its first flush has passed by, these symptoms may be very slight, and excite little attention, or be even entirely disregarded. When, again, inflammation of the gall-bladder occurs during typhoid fever 246 INFLAMMATION OF GALL-BLADDER AND DUCTS. or in the midst of other severe constitutional disorder in which sensation is blunted, pain is little complained of, and the other symp- toms lose almost all their significance. Ulceration of the gall-bladder, when it involves only a small part of the organ, may exist without fever or other constitutional disturbance, and with only occasional pain, and may be almost unheeded, till, by sloughing of the peri- toneal coat, the contents of the bladder are poured into the cavity of the peritoneum. The symptoms that precede this accident are not such as to impress us with a notion of danger, and we require fuller knowledge than we now have of the circumstances in which ulceration of the gall-bladder occurs, to make us alive to their true meaning. When inflammation involves the hepatic ducts or still more the common duct, and, by causing thickening of their mucous membrane or secretion of viscid mucus, prevents the passage of bile, in addition to the symptoms mentioned above—that is, more or less pain and tenderness, which we may expect to be more diffused than when the gall-bladder alone is diseased; vomiting, perhaps, or nausea ; and more or less fever—there will be jaundice. The jaundice, attended by slight pain in the region of the liver and by slight fever, that occurs in young and previously healthy persons, depends, perhaps generally, on an inflamed state of the gall-ducts, which, from their small size, must be readily closed by swelling of their mucous membrane or by a viscid secretion from it. When inflammation involves the lower end of the common duct only, and is of such a nature as to close it, the symptoms are very peculiar—pain confined to a small spot in the situation of the com- mon duct, early jaundice, and early distension of the gall-bladder, so as to form a large, movable, pear-shaped tumor, which, at first, is not painful or tender. In the treatment of inflammation of the gall-bladder and gall- ducts, a most important principle is the early employment of local depletion. Leeches, as was seen distinctly enough in some of the cases that have been related, relieve the pain and tenderness, and no doubt mitigate the inflammation, and, in consequence, lessen the danger of perforation and of permanent closure of the ducts. The value of this practice has been more or less vaguely recognized in jaundice, but its importance in the class of cases we have been con- sidering has not perhaps been sufficiently inculcated. It should always be borne in mind, that, here, a disease attended with but little pain and fever, and, at first, with no alarming symptoms, and TREATMENT. 247 indeed trivial in itself, may, from its situation, prove mortal. The precept to be drawn from this truth may be made general. In all cases where canals form an essential part of vital organs, mechani- cal considerations come to be paramount, and give an importance to diseases which in themselves are trivial. In stricture of the pylorus from thickening and induration of the submucous areolar tissue, and in the endocarditis of acute rheumatism, this truth is strikingly exemplified. In such cases our object must be, not so much to relieve the present symptoms, which are often slight, as to prevent those changes of structure which, slowly it may be, but inevitably, and with much suffering, destroy life. How valuable, then, is that insight which enables us to perceive the danger be- fore it is revealed to other eyes, and when alone we can effectually guard against it! This insight we can derive only from knowledge of the circumstances under which these forms of disease occur; knowledge, which gives meaning to symptoms otherwise vague, and perhaps so slight as to be scarcely regarded. Blisters have the same kind of efficacy as leeches. Like these they often greatly relieve the pain and tenderness, and, therefore, we may infer, tend also to prevent permanent changes of structure. The proper time for blistering is when the pain and fever have abated under leeches and other measures, and it is no longer deemed advisable to take away blood. Another important principle in the treatment of these diseases is the strict enforcement of a simple diet. In certain cases the free use of diluents may have some peculiar advantages. By filling the stomach, they help to empty the gall-bladder by the pressure they exert upon it, and, after absorption, they pass out of the circulation again, in part, by the liver, and thus dilute the bile. In cases in which the ducts are still pervious, signal benefit often results from the judicious use of mercury, which probably acts beneficially in two ways—first, by increasing the quantity and pro- moting the flow of bile; and secondly, by causing changes in its quality, which render it less irritating. These are the objects to be kept in view in its administration, and they are best attained, not by the more powerful and constitutional action of the drug—which should be studiously avoided—but by small doses of its milder preparations, repeated as need may be. It is to the striking influ- ence in increasing the secretion of bile, which mercury, used in this 248 INFLAMMATION OF GALL-BLADDER AND DUCTS. way, sometimes has, that this medicine owes the high reputation it has long had as a remedy in liver diseases. Soda, like mercury, is much in use in the treatment of such cases, and there is reason to believe that it deserves the esteem in which it is generally held. Soda, which is a natural constituent of bile and readily excreted by the liver, not only, when given in appro- priate doses, increases the secretion of bile, but probably renders the matter secreted by the inflamed gall-ducts less viscid, and has the same sort of efficacy in these cases as in catarrhal diseases of the lungs, in which this and other alkalies have been long used as expectorants. The muriate of ammonia is another medicine which is often of service in inflammatory diseases of the gall-bladder and gall-ducts. It has a less special action on the liver than the salts of soda, but a more general action on other secreting organs; and does good, not only by increasing the flow of bile, but also by the indirect re- lief it gives to the liver by exciting the action of the kidneys and skin. As most diseases of the biliary passages may be traced to a faulty condition of the bile, so it may be stated, as a general prin- ciple, that, as far as medicines are concerned, the best remedies for them are to be found among those agents which modify the quali- ties of that fluid. Among these, taraxacum holds an important rank. Its powers in increasing the secretion and modifying the qualities of the bile are very variously estimated, but reasons have already been given for believing that its efficacy, like that of cho- lagogue medicines generally, is more likely to be under than over- rated. That it should continue to be held in such high esteem by so many accurate observers is a strong testimony in its favor; and as it has the further advantage of being perfectly safe and harm- less, there is every motive for giving it an extensive trial in the treatment of these forms of disease. In cases of long-continued jaundice from obstruction of the com- mon gall-duct, the treatment should be regulated by the opinion formed of the cause of obstruction. In many such cases all active treatment is obviously injurious. When, for example, the com- mon duct is obliterated, or when it is closed by the pressure of a cancerous tumor, or by a calculus irremovably impacted in it, mercury and other lowering measures must do positive mischief, and the rule of treatment should be that of avoiding all active in- TREATMENT. 249 terference. In such cases there is little more to be done than to regulate the diet; to endeavor to control, by the appropriate reme- dies, whatever disorder there may be of the stomach and bowels; to keep up the action of the kidneys and skin ; and to obviate all avoidable causes of exhaustion. In other cases, where the closure of the duct is caused by the pressure of an enlarged gland, or by inflammatory effusion and thickening about the duct (and several such cases have been referred to in this chapter), benefit may result from mercury, cautiously administered, even when the jaun- dice has lasted many months. The great question is—How can the actual cause of obstruction be ascertained ? When for a long time the jaundice has been complete—that is, when the discharges from the bowels have exhibited no trace of bile—this circumstance is, of itself, almost proof that the jaundice results from mechanical obstruction of the common duct; and the cause of the obstruction must be inferred from the symptoms attending the onset of the jaundice, from the history of the illness, and from the age and general condition of the patient. It must now and then happen that with all the information that can be derived from these differ- ent sources the precise cause of obstruction will be a matter of doubt. In that case it may be right to give the patient the chance afforded by the more active treatment, and in the endeavor to do good we must run the risk of doing harm. This is but one of the countless questions which continually call up the remark, that, in diseases of the liver, beyond all others, diagnosis is the very foun- dation of treatment, and that to render our diagnosis more sure, should, for the present, be the chief object of our researches. This end will be best attained by more perfect knowledge of the healthy action of the liver, and by a more accurate study of the circum- stances under which its various diseases arise. 250 CHAPTER III. DISEASES WHICH RESULT FROM FAULTY NUTRITION OF THE LITER, OR FAULTY SECRETION. Sect. I.—Softening of the liver—Destruction of the hepatic cells— Suppressed secretion of bile—Fatal jaundice. Having considered the inflammatory diseases of the liver, we may pass on to a class of diseases quite as important, but at pre- sent less understood—diseases in which, without any process to which the term inflammation can be rightly employed, the secret- ing power, or the nutrition of the hepatic cells, is seriously disor- dered. These diseases may be divided into two principal groups. One of these groups is characterized by suspension of the secretion of bile; the distinctive peculiarity of the other is, that the hepatic cells separate from the blood some abnormal matter, which, instead of passing freely out of the liver in the bile, is retained there, adding to the size of the liver, and more or less changing its ap- pearance and texture. To understand how changes in the appearance and texture of the liver are produced in this way, we must again refer for a moment to the intimate structure of the organ. We have seen that the lobules of the liver are spaces mapped out by the ultimate twigs of the portal vein, which are hairy, as it were, with capillaries springing from them on every side and form- ing a close and continuous network; and that the interstices of these capillaries are filled with nucleated cells. It is in these cells that the vital chemistry of secretion goes on. It is seen by the microscope, that in different livers the cells vary in size; that in some they are almost transparent, in others opaque, and apparently more solid; that in some they contain but a few very small oil- globules, while in others they are distended almost to bursting with globules of oil; that in some they are colorless or nearly so, FATAL JAUNDICE. 251 and in others yellow with bile; that in some specimens, again, as in cases before related, they are broken down and destroyed. It is probable, too, that in some cases the cells are only slowly repro- duced ; so that at length the number of active cells in the lobular substance is much diminished. These differences in the condition of the cells cause, of course, corresponding differences in the size, color, and texture of the liver—differences which were noticed long before that knowledge of the intimate structure of the organ was obtained by which we are now enabled to explain them. When the cells are small, or few in number, and the spaces between the capillaries in the lobules are not distended with the products of secretion, the lobules are small and indistinct, and the liver is small and flattened, and its lower edge is thin. When, on the contrary, the cells or their interstices are distended with oil, or with any other product of secretion, as in the fatty and the scrofu- lous liver, the lobules are larger than natural, and the liver is large and thick, and its lower edge is blunted. The most remarkable and most serious change is where the cells are completely broken down and destroyed. It has been seen that this may result from long retention of the secreted bile from clo- sure of the common gall-duct. In consequence of this, the hepatic gall-ducts become enormously dilated, and the whole liver acquires a deep olive color. Its tissue is then flabby, but not readily broken down by the finger, and presents no appearance of lobules. Every part of the liver is affected alike, and exhibits under the microscope, in the place of the secreting cells of the lobular sub- stance, nothing but free oil-globules and irregular particles of solid biliary matter. The liver contains but little blood, and partly from this, but chiefly from loss of the cells, it may be smaller than in health, and its surface wrinkled, notwithstanding the biliary matter accumulated in it. But destruction of the hepatic ceils may take place rapidly, without any obstruction of the gall-ducts, and instead of being con- sequent on protracted jaundice, the impaired nutrition of the cells may be the cause of jaundice that proves rapidly fatal from dis- order of the functions of the brain. It has been long known that cases of jaundice now and then occur which prove fatal in this way; and that in such cases it fre- quently happens that no obstruction can be found in the gall- 252 SUPPRESSED SECRETION OF BILE. ducts—which are pale and empty of bile—and no effusions charac- teristic of inflammation in any part of the liver. In some such cases, no change of structure has been remarked in the liver, and the disease has been described as fatal jaundice from suppressed secretion. In other cases, the liver has been found unusually small, much softened, and changed in color, and the disease has been spoken of as softening of the liver, or simple softening, or black softening, according to the color of the liver in the individual case. The two following cases, published by Dr. Alison, in the Edin- burgh Medical and Surgical Journal for 1835, are examples of this terrible form of disease. Case 1.—Peter Schread, aged about twenty-five, a German sailor, was admitted into the clinical ward the 26th of February, 1826, in a state of complete delirium, with tendency to violence, but alternating with drowsi- ness. His skin and the tunica conjunctiva of the eyes were of a bright yellow color; he had no tenderness of abdomen ; his pulse was 60, of irregular frequency ; tongue moist; extremities rather cold ; he had occa- sional singultus; he passed a copious bilious stool, and also urine in bed, soon after his admission. His companion reported that he had a severe attack of flux in Java, in the summer previous ; that he had been in good health at Antwerp from September till December, but that since the 1st of January, when he arrived at Leith, he had complained often of pain and heat in the abdo- men, chiefly towards the right side, with thirst and chilliness ; that eight days before admission, he had become jaundiced, and two days before ad- mission, had become delirious. His head was shaved, bathed, and blistered, and he had one dose of calomel, and several of tartar emetic (the only medicines that could be got down), which produced copious bilious stools, all passed in bed; but the delirium passed into complete coma, with dilated pupils and stertor; his pulse rose to 120, and became feeble; some purplish spots appeared on the skin, and he died on the evening of the 28th—ten days after the appearance of jaundice. The following account of the dissection was drawn up by Dr. C. Henry, of Manchester, then one of the clinical clerks in the infirmary :— " The skin and subjacent cellular tissue were universally of a bright yellow color. This tinge extended also to the pericranium, and to both surfaces of the dura mater, which was rather more vascular than natural. The other membranes of the brain were dry and glistening. The bloody points were somewhat more numerous than usual. There was very slight distension of the left lateral ventricle, the contained serum not exceeding half a drachm. That found in the right was still less considerable, and there was hardly any at the base of the brain, which appeared somewhat vascular. The consistency of the cerebral structure was perfectly healthy. The surfaces and central points of the cartilages of the ribs were tinged with bile, as were the peritoneum and pleura. FATAL JAUNDICE. 253 "The liver, when incised, appeared of a light yellow color; it was smaller than natural, its structure dense and resisting compression, but in mass it was remarkably loose1 and flexible. The calibre of the cystic duct seemed to be in part obliterated, but the hepatic and common biliary ducts were quite pervious. Their mucous membrane was unnaturally white. The gall-bladder contained a greenish, viscous, semi-fluid matter. "The spleen was somewhat firmer than natural. The pancreas was healthy. The contents of the intestinal canal were tinged, though slightly, by a greenish bile—those of the lower part of the ileum less than of the larger intestines. There was no vascularity of their lining membrane, but that of the great intestines appeared somewhat thicker than usual. The mucous coat of the bladder had acquired a deep yellow tinge, and contained urine of similar appearance." Here the patient seems to have been ailing for several weeks, often complaining of pain and heat in the abdomen, with thirst and chilliness, before he became jaundiced. When the jaundice had existed six days, delirium came on, and life ended in a state of complete coma four days afterwards, that is, ten days from the first appearance of jaundice. On examination after death, it was evident that the jaundice resulted from suppressed secretion, and not from an impediment to the passage of the bile through the ducts; for the liver was of a light yellow color, and smaller than natural, and the hepatic and common ducts were found to be quite pervious, and their lining membrane was unnaturally white. The man was under medical observation only two days before death, and after the occurrence of delirium, so that no full report of the illness was made. It was noted, however, that after his ad- mission to the hospital, he was in a state of depression, the pulse being 60, of irregular frequency, and the extremities rather cold; that he had no tenderness of the abdomen; that he had occasional singultus ; that he had copious bilious stools, which were passed in bed; and that before death some purpuric spots appeared on the skin. Case 2.—Agnes Anderson, aged thirty-five, was admitted into the clinical ward on the 10th of December, 1830, with symptoms of jaundice (of a fortnight's standing), and occasional pain across the epigastrium, hut little constitutional disturbance. She had recently suS'ered much mental distress, having been abandoned by a man with whom she had co- 1 In Dr. Alison's paper, it is printed " large and flexible," which, considering what goes before, does not make sense. "Large" is probably a misprint for "loose." 254 SUPPRESSED SECRETION OF BILE. habited, and was in a state of agitation, and, being apprehensive of catch- ing fever, she suddenly left the house the same day. After this, as we subsequently learned, the pain at the epigastrium increased ; on the 14th, she was observed to stagger in walking, and became drowsy and occasion- ally incoherent, without complaining of headache. On the 11th, she was re-admitted, deeply jaundiced and perfectly comatose; her pulse was 118, soft; the surface rather cold ; the respiration somewhat stertorous, but of natural frequency ; the pupils somewhat dilated; the teeth firmly closed, and inclosing the apex of the tongue, which was bleeding. There was no rigidity of other muscles; she had occasional fits of hurried breathing, with partial spasm, during which the pupils became quite immovable. Her bladder was much distended, and five pounds of deep yellow-colored urine were drawn off by the catheter. Blistering and enemata were tried without any effect. The breathing became more rapid and heaving, and the pulse feebler, and she died twenty- four hours after admission—three weeks after the first appearance of jaundice. The following report of the appearances on dissection was drawn up by Dr. J. Reid, then clinical clerk:— "The skin had assumed a deeper tinge of yellow since death. Upon removing the skull-cap, the dura mater was observed to have also a yellow- ish tinge. The veins upon the surface of the brain were somewhat tinged. There was no effusion under the arachnoid, or at the base of the brain; but a small quantity of yellowish serum was contained in the ventricles. Upon cutting the brain in thin longitudinal slices, every part of it appeared quite healthy, and nothing presented itself about which there was the slightest doubt, except the appearance of the choroid plexus, which was of a dark red color, and a vein distended with blood was seen running along each of its portions situate in the lateral ventricle. Along with the red points which usually appear upon the cut surface of the brain, a little yellowish serum exuded. "The liver was small, soft, and of a peculiar brownish-yellow color. The gall-bladder was collapsed, and contained a small quantity of bile. All the bile-ducts were of the usual color, at no point more dilated than another, perfectly pervious throughout, and almost completely empty of bile. It was doubtful whether the mucous membrane of the duodenum was very slightly thickened or not; but there was certainly no decided change upon it.,} In this case, a woman, thirty-five years of age, after much mental distress, became affected with jaundice. The jaundice was attended with occasional pain at the epigastrium, but with little constitutional disturbance. After it had lasted eighteen days she was observed to stagger in walking, and became drowsy and incoherent. The drowsiness was followed by clenching of the jaws, and other occa- sional partial spasms, and she died in a state of coma, three days after the occurrence of cerebral disorder, and three weeks after the first appearance of jaundice. On examination of the body it was clear, as in the former case, that the jaundice resulted from sup- FATAL JAUNDICE. 255 pressed secretion; the liver was small, soft, and of a peculiar brownish-yellow color; and the gall-ducts were perfectly pervious throughout, and almost completely empty of bile. Here, also, the patient was under continuous medical observation only for a short time, and the account of the illness is very imperfect. It was noted, however, that after her admission to the hospital, five pounds of deep yellow-colored urine were drawn off by the catheter, so that, while the secretion of bile was suppressed, the state of coma seems to have had on the kidneys the effect of increasing secretion—an effect which Bernard has shown it usually has on all secreting organs. Most medical men who have been some years in practice have probably witnessed this form of disease. More than one instance of it fell under my own notice, when I was not sufficiently alive to their interest, and my notes of them are very imperfect. I shall not, therefore, relate them, but cite instead the two following cases, which were published by Dr. Bright, in an excellent paper on jaundice, in the first volume of Guy's Hospital Reports, and which are counterparts of the cases already quoted from Dr. Alison. Case 3.—Keatrina Pfifrein, aged eighteen, was admitted into the clinical ward January 11, 1832, laboring under icterus. She was an assistant to a German broom-maker, and was unable to speak any English. The skin was of a brilliant yellow; and the cheeks, which were flushed, were of the color of a very ripe apricot; she appeared exhausted; and though she answered questions pretty readily, we were cautioned by a woman who brought her that her replies were incorrect. Pulse 120, very small and weak; feet and body very cold. We learned, that when she came to London, about a fortnight ago, she had been already unwell about a fort- night ; and her skin had a decidedly yellow tinge, which had daily increased, attended by an inactivity amounting almost to torpor; so that, when removed from her bed, and placed by the fire, which was all she could bear of late, she sat constantly in a kind of doze. We were told that her bowels had been relaxed, without much abdominal pain; and she had not suffered from sickness. She had complained but little of headache; tongue moist, and slightly furred; the papillae prominent. She was ordered a moderate dose of hyd. c. creta, three times a day, and light nourishment and warmth; and should it not prove, as had been stated, that her bowels were relaxed, she was to take some colocynth pills at night. Jan. 12th.—She was sick yesterday evening, vomiting a good deal; she lay in a perfectly torpid state the whole night, apparently suffer- ing no pain; but towards the morning became delirious, so that it was with difficulty she could be restrained in her bed. At the time of the visit she was very restless, and seemed to suffer pain; but was unable to 256 SUPPRESSED SECRETION OF BILE. answer any questions; indeed, except that she swallowed what was given to her, she seemed scarcely conscious; and it was quite uncertain whether pressure on the abdomen gave her any pain. The pupils were dilated; the bowels had not been opened, although she had taken two compound colocynth pills; pulse 106, thrilling, and compressible; tongue moist and clean. She was ordered two grains of calomel every two hours, and the ammo- nia julep every four hours, besides wine, if she became more depressed. Her head was shaved, and a blister applied over the liver; mustard poul- tices to the feet; and camphor mixture was to be given freely, in case the delirium should return; injections were to be repeated till the bowels acted freely. During the night, the purging injections, with colocynth and castor oil, were administered three times; she lay completely comatose the whole night; the pulse sometimes at 140, and extremely weak, when not raised by stimulants. No dejection having been passed at ten o'clock in the morning, another colocynth injection was administered, which produced copious, rather dark, unhealthy, feculent motions, mixed with some sanguinolent fluid; and there was likewise an appearance like pus. The blister discharged very abundantly; the urine was passed involuntarily, and in considerable quan- tity; mouth and lips covered with sordes; pulse 120, weak. A blister to the crown of the head; the calomel to be repeated. She continued to sink during the day, and died at ten o'clock in the evening. Sectio cadaveris.—The whole external surface of a deep yellow color; the adipose matter was also yellow, as were the cartilages of the ribs. The lungs were healthy, but the posterier portions gorged with blood, probably the result of her having been lying for two days on the back. The pleura of the left lung of a slight yellow tinge ; the heart healthy. The whole of the abdominal viscera, when first exposed to view, were remarkably tinged with bile ; the stomach of a vivid yellow; the intestines looked green; the liver was unusually small, and, for the most part, of a brightish yellow color, with portions marked with purple or deep brown; and, in parts, a finely spotted appearance was yielded by the acini. On cutting into the liver, the same yellow color, with fine dark spots, pervaded it. The gall-bladder was very small aud collapsed, and contained less than a teaspoonful of thick ropy mucus, of a bright green color. The cystic duct appeared to be quite contracted; so that neither could a fine probe, nor the point of a scissors, be carried along more than two-thirds of its length upwards; nor could the tenacious mucus of the gall-bladder be forced down it. However, there was no appearance of thickeuing, or of morbid deposit, either within or around the duct, which, when laid open with the scalpel, presented the corrugated valvular appearance pecu- liar to that part of the duct. The lower part of the cystic duct, as well as the whole of the hepatic duct and the common duct, quite into the duo- denum, were pervious, and not at all thickened or diminished from the natural calibre. There was no trace of bile in either of the ducts; and following the hepatic ducts quite into the substance of the liver, no bile was detected ; but, on squeezing the liver, the small secondary and tertiary FATAL JAUNDICE. 257 subdivisions of the ducts were seen filled with thick tenacious mucus, of an exceedingly faint lemon-yellow color. The mucous membrane of the alimentary canal was perfectly healthy, but the contents were very unnatural; in some parts of the ileum and jeju- num, there was yellow mucus ; in others, an olive-green mucous excre- ment; and in the colon, a drab-colored and gray mass, characteristic of that which usually composes the feces of jaundiced patients. The spleen soft; pancreas healthy. Kidneys tinged throughout with bile. Bladder somewhat distended, rising to view above the pubis, and containing, probably, a pint of clear yellow urine. The thoracic duct quite empty. The arteries deeply tinged with bile. The dura mater was of a brilliant yellow color; the arachnoid not vas- cular, and quite untinged with bile; there was no unnatural effusion of serum beneath it, but the small quantity which collected in a few of the sulci was very slightly tinged with yellow, as were the few drops which collected in the base of the skull, when the brain was removed. When slices of the brain were taken horizontally, a moderate number of cut ves- sels were seen ; many of the small points of blood gave a stain of beauti- fully yellow bile around them ; and some points gave out the yellow serum without any blood appearing. The ventricles contained an unusually small quantity of serum, and that was not tinged with bile. The quantity of serum throughout the whole brain was decidedly deficient. There was no structural lesion nor irregularity in the brain. Here, as in the two former cases, the patient was under medical observation only a short time before death, and the account of the illness is, in consequence, very meagre; but the body was carefully examined, and the state of the liver is fully described. The poor broom girl had been jaundiced from two to four weeks, when she was brought to the hospital in a state of much exhaustion, and with the mind wandering. It was stated that, for the fortnight preceding, she had been in a state of inactivity, almost amounting to torpor; that the bowels had been relaxed, without much abdo- minal pain; and that she had not suffered from sickness. She vomited a good deal the evening of the day on which she was brought to the hospital, and the next morning was violently delirious. The delirium passed into coma, in which she died the evening of the following day. The bowels were confined, after her admission to the hospital, but the day on which she died, copious feculent stools, mixed with some sanguinolent fluid, were brought away by purgative injections. As in the preceding case, the action of the kidneys was probably increased during the state of coma, for, on the morning of death, urine was passed in considerable quantity, and at the time of death, the urinary bladder was somewhat distended. 17 258 SUPPRESSED SECRETION OF BILE. The liver was found to be unusually small, as in the former cases, and, for the most part, of a brightish yellow color, with portions marked with purple or deep brown. The hepatic and the common gall-ducts were pervious throughout, and quite empty of bile. It was clear, from these facts, that the jaundice resulted, not from a mechanical obstruction in the gall-ducts, but from defective action of the secreting apparatus of the liver. No change in the texture of the kidneys was noticed. Case 4.__Sarah----, aged 28, was admitted into Guy's Hospital, as a surgeon's patient, on the 6th of August. She was a married woman, and had borne two or three children ; but had latterly been separated from her husband, and was said to be much addicted to drinking. As she had sores of a very suspicious character, she was ordered to take sarsaparilla three times a day, with five grains of the compound ipecacuanha powder, and of the Plummer's pill, every night, which she continued for a consid- erable time. On the 13th of November, I was requested to take charge of her, as she was apparently very ill; had been complaining of abdo- minal pain for the last week ; and during the last two days had become jaundiced. I found the bowels rather confined; urine tinged with bile; pulse moderate, but quick ; slight tenderness at the pit of the stomach. (Fourteen ounces of blood were ordered to be drawn by cupping from the region of the liver; the belly to be fomented : five grains of mercury with chalk to be taken immediately, and ^ss of castor oil four hours after, and to be repeated until the bowels should be relaxed.) 14th.—There is still some tenderness on pressure at the pit of the stomach, and accelerated pulse. (Fifteen leeches to the pit of stomach; the mercury with chalk, and the castor oil to be repeated.) The yellowness increased; the stools continued of a pale clay color; the tenderness of the upper part of the abdomen continued. It is unnecessary to give a detail of all the daily symptoms. Cupping, mercurial purges, and blue pill, with fomentations, were continued ; and during ten days no very remarkable change occurred. 24th.—Slight tenderness over the whole abdomen ; color very intense; pulse 96, small, and rather sharp ; respiration, 27 ; bowels confined ; thirst; occasional sickness; and occasional pains in the abdomen, much relieved by the fomentation. 28th.—She generally prefers the sitting posture in bed. Lips dry; tongue moist and red; some sluggishness in her mode of speech, and a plaintive tone ; pulse, 88 ; no sickness ; six or seven loose dejections. (Twelve leeches to the pit of the stomach ; a linseed poultice to the belly.) 29th.—One copious lumpy white'stool. Pulse, 96 ; slight tenderness of pit of stomach ; respiration tranquil; tongue moist, but more red at the edges. December 1st.—Her pupils are rather dilated ; her mode of utterance is dull and indistinct; complains of loss of power in the left hand ; the right is already disabled by disease. FATAL JAUNDICE. 259 2d.—Is lying on her right side, drowsy, with her legs drawn up, mov- ing her left hand with a kind of jactitation, often raising it to her head ; she is capable of being so far roused as to put out her tongue when pressed to do so. Tongue moist, and red at the edges ; the pupils are dilated. (A blister to the crown of the head ; a cathartic enema.) 3d.—Yesterday evening she was screaming loudly, with her tongue pro- truded between her teeth. To-day she is in a state of perfect coma, with the eyes turned np. She is incapable of being roused, and has taken no nourishment or medicine since yesterday. She died the following day. Sectio cadaveris.—The color of the whole body of the brightest yellow which jaundice yields. Not less than an inch of adipose matter over the whole abdomen. On removing the calvaria, the dura mater was found tinged of a brilliant yellow color, and very vascular ; raising this, the surface of the brain showed the vessels loaded with blood; and beneath the arachnoid, in the convolutions, lay a small quantity of serum, proba- bly not more than natural, of a decidedly yellow color. As the brain was sliced away, numerous points of fluid blood appeared ; and from many of them the serum which issued with the blood was of a bright gamboge yellow, presenting points of that color mingled with red points. The whole of the vessels and the sinuses of the brain were unusually loaded with blood ; the ventricles unnaturally dry; scarcely could a drop of serum be discovered. The heart healthy. The pulmonary and other vessels deeply tinged with bile. The peritoneum, also, was peculiarly dry. The omentum was beautifully spread over the viscera. The colon, when the omentum was turned back, was seen contracted and very yellow; while the portion of the omentum, closely attached, was spotted with ecchymosis, and loaded with fat. The liver weighed only two pounds five ounces. It was soft or flaccid to the touch ; quite free from any mark of peritoneal inflammation. Its external appearance was mottled dark-red liver-color, with yellow stone- color. The acini were pretty distinctly to be traced throughout—red at their centres, and yellow in their circumferences ; and in most parts the yellow bore a large proportion to the whole. The gall-bladder was con- tracted ; and contained about half a drachm of mucus, very slightly tinged with green. The ducts were all pervious and healthy, and were not evlsn stained with bile Pancreas, quite healthy. Spleen, large. Kidneys remarkably lobulated, and tinged throughout with bile, particularly the membrane lining the pelvis. Ovaries, externally very yellow. Uterus, also yellow, with some ecchymosis in its fundus. This case is more complete than the three preceding cases, as the patient was under observation long before the occurrence of jauudice, and during its entire course. The jaundice was preceded for some days by abdominal pain ; and throughout its course there was some tenderness at the pit of the stomach, with occasional pains in the belly. The pulse was quicker than natural; the bowels were generally confined, and the stools of a pale clay color; and it 260 SUPPRESSED SECRETION OF BILE. is once mentioned that there was occasional vomiting. When the jaundice had lasted twenty days cerebral disorder came on, and the woman died three days afterwards, in a state of complete coma. The gall-ducts were pervious and healthy, as in the former cases, and not even stained by bile. The liver was small, weighing only two pounds five ounces, and soft or flaccid to the touch, and quite free from peritoneal inflam- mation. It was of a mottled red and yellow color, and the lobules were pretty distinctly to be traced throughout. I had been for some time looking out for an instance of this form of disease, wishing to examine the liver minutely, when an oppor- tunity of doing so was afforded me by Mr. Busk, who at once ob- served that in the portions of the liver that were most diseased the cells were completely destroyed. The following notes of the patient's illness were kindly fur- nished me by Mr. Clapp, then assistant surgeon of the Seamen's Hospital:— Case 5 —Abdul, a lascar, aged 50—60, was admitted into the Seamen's Hospital, the 16th of January, 1844, jaundiced, and with constant hic- cough, which was stated to have lasted three days. He was in a state of half stupor, and but little concerning his feelings could be elicited from him. He appeared, however, to have some pain in the region of the liver, but there was no tumor in that situation. A few hours after his admission, Mr. Clapp observed his pupils to be much con- tracted, and, from his look, suspected that he had taken opium; and on searching his clothes and bed, a small tin box containing opium was found. No cough or other symptom of pulmonary disease was observed; and the hiccough continued the only prominent symptom to the time of his death, which happened on the 18th. The body was examined on the 20th, about forty hours after death. The rigidity of the muscles was nearly gone. The surface was deeply jaundiced. No hardness or fulness in any part of the abdomen. The head was carefully examined, but no morbid appearance noticed, except the yellow tint of jaundice. Chest.—The right lung adhered slightly to the diaphragm, in a small space at the centre of its base, and the greater part of its lower lobe was in a state of red hepatization. The other lobes of this lung were con- gested, and infiltrated with red frothy fluid. The small bronchial tubes were filled with a thin mucus fluid, brownish, and also tinged with bile. The left lung was nowhere adherent to the pleura costalis. Its lower lobe was of a dark purple, from extreme congestion, but was not solid. The upperlobe slightly congested, but not otherwise altered. There was no fluid in either pleural cavity. There was a large, irregular, superficial FATAL JAUNDICE. 261 ulcer on the back of the larynx, just below the base of the arytenoid car- tilages, and the mucous membrane over the cartilages was slightly raised by effusion into the areolar tissue beneath it. The ulcer was surrounded by a narrow vascular zone. The mucous membrane of the trachea and bronchi was injected, and the surface covered with thin brown mucus. Heart, large and fat. Valves perfect. Muscular substance colored in parts by bile. Left cavities empty. Small fibrinous clots, colored with bile, in the right cavities. Blood, grumous and clotted. (Esophagus, pale, and healthy throughout. Stomach.—Mucous membrane grayish and "mammillated;" everywhere of natural thickness and firmness. Duodenum perfectly natural, as was also the small intestine, to within a few feet of the lower end of the ileum, below which it exhibited a few vascular patches, and some serous fluid was infiltrated in the submucous tissue. The ileo-caecal valve at first sight appeared to be slightly ulcerated; but nn looking closer, this appearance was found to be caused by the edges of the folds of the mucous membrane being of a dark purple from congestion, and having shreds of lymph on the surface. Large intestine.—Mucous membrane having the edge of the ruga? of a deep red, and with small shreds of lymph on their surface ; but every- where else of natural color, thickness, and consistence. There was no bile in any part of the intestinal canal, nor did the mucous membrane appear jaundiced in any part. A large quantity of fecal matter, of a pale clay color, was found in the large intestine. The kidneys were jaundiced, but otherwise perfectly natural. Bladder empty. Spleen, large, firm, rather pale. Pancreas, healthy. The liver was rather large, and weighed four pounds four ounces. The whole gland, except a very small portion of the extreme right, was re- markably soft, flabby, and easily torn. This condition was most marked in the lobulus Spigelii and adjacent parts. There was no disease in the gall- bladder or gall-ducts, which were carefully examined, nor any obstruction at the duodenal orifice of the common duct. The bile could be very readily made to flow into the intestine. The gall-bladder contained about an ounce of thick bile, sparkling with distinct scales of cholesterine, but otherwise of natural appearance. On examination by the microscope, Mr. Busk found that in the firm portion the proper cells of the liver contained a good deal of bile, but were otherwise quite natural; while in the softened portion there were hardly any cells to be found. Nothing was seen but a confused mass of amorphous particles and oil-globules. Here, as in the former cases, the jaundice resulted from defective secretion, for the large gall-ducts were pervious and healthy. The illness seems to have been of short duration ; and this circumstance will probably serve to explain the fact, that the liver, instead of being small, as in the former cases, was rather large. A great por- tion of the liver was remarkably soft and easily torn, and in this 26^ SUPPRESSED SECRETION OF BILE. Fig. 13. portion hardly any hepatic cells could be found, while in the firmer portion the cells presented nearly their natural appearance. The objects seen when these two portions of the liver were ex- amined under the microscope are represented in the annexed wood- cut, which was made from a drawing by Mr. Busk. {a) Represents cells from the firm por- tion of the liver. The dark spots within them are particles of biliary matter, which was in greater quantity than usual. Some cells contain small oil-globules, marked by the clear rings. Between the cells are seen small free oil-globules and particles of gra- nular matter. {b) The appearance presented by a par- ticle from the softened portion of the liver, showing an irregular aggregation of oil- globules, particles of solid biliary matter, and amorphous granular matter. Mr. Busk sent me the liver to examine, and I was enabled to satisfy myself that the description of the microscopic appearances which he sent with it, and which is given above, was perfectly accurate. All I ob- served besides was, that the firm portion was hardly so firm as is natural, and was of a mottled yellowish, nutmeg appearance, the lobules being distinct to the eye. The soft portion was of a uni- form dirty color—a compound of yellowish-brown and red—and presented no appearance of lobules. It had no smell of gangrene. It may, perhaps, be supposed, from the time after death at which the body was examined, that these changes resulted from common putrefaction, but it was clearly not so. The secreting cells of the liver do not break up quickly after death. In ordinary cases they present no such appearances as are described above, even when the decomposition of the body is much further advanced; and in the solid part of this liver, which was kept, and several times examined by Mr. Busk and myself, the cells were distinctly visible two days afterwards. Destruction of the cells was doubtless the result of disease, and took place, or at least commenced, during life. The existence of jaundice, which could not be accounted for by any im- pediment to the passage of the bile through the ducts, is sufficient DESTRUCTION OF THE HEPATIC CELLS. 263 proof that in great part of the liver the secreting cells did not ade- quately perform their office. In this case the cells were broken down, just as they were in the case of Mrs. Diprose, related in the preceding chapter (p. 227), in which this change was a remote effect of closure of the common gall-duct; but the condition of the liver in the two cases was in many respects different. 1st. The liver was here readily torn or broken down by the finger; while that of Mrs. Diprose, though feeling equally flabby, was not. 2d. The softened portion of the liver was brown or reddish- brown, and not much colored with bile; while in Mrs. Diprose the liver was throughout of a deep olive, mottled with yellow, solely from the presence of bile. 3d. The liver seemed to contain more fluid, certainly contained more blood, than that of Mrs. Diprose; and under the microscope it exhibited more amorphous granular matter, and less solid biliary matter and oil. 4th. In the one case a small portion of the liver remained toler- ably healthy, and continued to secrete bile of natural color and ap- pearance ; in the other, the secreting cells of every part of the liver were disorganized. There are still greater differences in the symptoms, and in the state of other organs, in the two cases. The case of obstructed gall-duct was very lingering; the patient died much emaciated, and all organs besides the liver were sound. Here, the disease proved fatal very quickly; and besides this change in the liver, there was hepatization of the right lung, and a large ulcer in the larynx, and the folds of the mucous membrane of the large intestine were pur- ple, or of a deep-red, and covered with lymph. No cause could be assigned for this terrible disease, and but lit- tle is known of its real pathology. The symptoms and the marks of inflammation in various parts of the body are sufficient evidence that there was a poisoned or unhealthy state of the blood; but it is impossible to say in what degree this resulted from defective action of the liver and the rapid disorganization of a part of its substance, and in what degree from the noxious influence, whatever it might be, by which this defective action of the liver and change in its texture were brought about. Up to this time such cases have been considered cases of jaundice, depending, not on obstructed gall- ducts, but on suppressed secretion of bile; and the changes in the 264 SUPPRESSED SECRETION OF BILE. liver have been overlooked, or their outward and obvious charac- ters only have been noticed. It would appear that the disease is not necessarily fatal. It happened that, on the 21st of January, four days after the admis- sion of Abdul, another lascar was brought into the Seamen's Hos- pital from the same ship, who was also jaundiced and semi-coma- tose, passing blood in considerable quantity from the bowels, and with very evident tenderness in the right hypochondrium, but without hiccough or vomiting. His disease was considered to be the same as that of Abdul, and the same issue was expected; but in a few days he got very much better, and soon recovered suffi- ciently to leave the hospital. Numbers of other lascars from the same ship were brought into the hospital, and several of them were observed to be more or less jaundiced, so that it is not improbable that these also had the same disease in a less degree. All these men lived in the same way, and were subjected to the same influ- ences of diet and locality. Since my attention was called to the facts related above, I have examined the livers of three persons, who died in a state of jaun- dice from suppressed secretion. The first was that of a sailor, aged twenty-four, who died in the Seamen's Hospital, on the 10th of December, 1844. The particu- lars I learned respecting the patient were these:— Case 6.—He arrived in the port of London in the middle of October, and when he had been ashore about a fortnight he was taken ill with pain in the right side of the belly, and headache. A week afterwards he be- came jaundiced, and began to vomit. On the 16th of November he was brought to the hospital in deep jaundice. From that time there was ten- derness in the region of the liver, and occasional vomiting. The stools were generally clay-colored, but for a few days were stained with bile. After the jaundice had lasted about a month, violent delirium came on, soon followed by death. The liver was rather small, and of a pale yellowish color, but was not softened. The lobules were indistinct. The secreting cells, which con- tained fine granular matter, and a few very small oil-globules, were smaller than usual. The gall-bladder and gall-ducts were pervious, and empty of bile. The next fatal case of this kind to which my attention was called occurred about a year afterwards. On the 28th of November, 1845, I went to the Seamen's Hospital, at the request of Mr. Busk, FATAL JAUNDICE. 265 to see a lad who had been jaundiced for some time, and who was then in a state of delirium. The lad died the next day, and on the 30th the liver was sent to me for examination. The following par- ticulars of the illness were recorded:— Case 7.-—George Chambers, aged seventeen, was admitted into the Sesunen's Hospital, under Mr. Busk, on the 17th of November, 1845, with several ash-colored non-indurated sores on the glans penis and pre- puce, and also with deep jaundice, which commenced without apparent cause three weeks before. He belonged to one of the Scotch steamers, but had lately been living at Greenwich, and was reported to have been leading a dissolute life. The black-wash was applied to the sores, and he was ordered 5ss of acetate of potash three times a day. The following notes were afterwards taken :— Nov. J8th.—No better; in fact, the color of the skin is darker. Urine very high colored. Stools perfectly white, and very fetid; has never had any pain or uneasy feeling in the abdomen, except from wind ; sleeps badly, but does not dream. Nausea, anorexia, thirst; bowels relaxed (two or three stools daily). No fulness or tenderness in the region of the liver; no pain in the shoulder; no pain in the region of the kidneys; tongue clean, clammy. E. Ammonia? sesquicarb. gr. v; sodas bicarb, gr. x ; aquas carui 3j ; sextis horis sumendus. Empl. lyttee regioni hepatis. Milk diet. 19th.—No change ; color of the skin, if anything, more intense. Urine less highly colored. Two stools, without bile. Has vomited several times. K. Uvdrarg. chlorid. gr. x, statim. 20th— Color of the skin rather higher; urine much lighter; feels less bloated with wind. Has had one copious stool. R. Repet. hydrarg. chlorid. gr. x. 21st.—Has passed a large quantity of feculent matter, of a pale clay color. R. Ext. colocynth. co. gr. x. 22(1.—Much the same, except that he vomits more frequently. One stool of the same pale color; urine of a bright yellow. No pain. R. Hydrarg. chlorid. gr. v; ext. colocynth co. gr. viij ; statim. Magnes. sulphat., sodas bicarb., aa 9j; tinct. card, co. 3ss ; aquas |ij, 6tis horis, cum acid, tartaric gr. xviij. 23d.—No change. One clay-colored solid motion; frequent vomiting, which always occurs after taking food. Matters vomited contain no bile. Urine not "high colored, though still bilious. Pulse 60—soft, irregular both in frequency and in force. 21th.__No stool, though he has continued the sulphate of magnesia in effervescence, every six hours. The vomiting is less frequent; there is a yellowish tinge from bile in the matters vomited. He is very dull this morning, and not altogether rational. Lies with his eyes closed, and 2 )6 SUPPRESSED SECRETION OF BILE. frequently grinds his teeth. No headache ; pupils natural; pulse 60, re- gular, soft. R. Hydrarg. chlorid. statim; enema terebinth, statim. 25th.—-More comatose. Yesterday morning was very noisy for a short time. Is now roused with great difficulty, and then will not speak, but throws himself about in a sullen way, trying to hide his face in the bed. 26th.—No bile in the motions, of which he has had two, one imme- diately after the enema, and one since. Pulse 54 ; pupils natural. R. Hydrarg. chlorid. gr. ij, 4tis horis. Empl. lyttas nuchas. On the 28th, when 1 saw him, he was confined in a strait waistcoat, in a state of raving delirium, and constantly grinding his teeth. There was no enlargement of the liver, and no expression of pain was elicited by pressing on the belly. The feces were slightly tinged with bile. He gradually became more and more insensible, and died in a state of coma at 3 P. M., on the 29th. The body was opened the next day, twenty-two hours after death, and the liver and omentum were immediately sent to me. The liver was small, weighing only 2 lbs. 2^- oz., extremely flabby, and great part of it (all the right lobe towards the diaphragm) was of a uni- form yellowish-brown, and so much softened that, when the capsule was removed, it tore with the greatest readiness in any direction, and broke down under slight pressure into a soft, pulpy mass, like a soft spleen. The rest of the liver (the left lobe, and the right lobe near its lower edge) had more of the purple tint of venous blood, and was firmer, so that it resisted slight pressure ; but even these parts were much softer than natural. The softened yellow portion projected slightly above the level of the darker and firmer portion, and the lobules were visible in it through the transparent capsule of the gland. When the capsule was divided, the subjacent substance projected through the incision. The darker and firmer portions seemed to be much wasted, especially the left lobe, which was very thin, and no lobules could be distinguished in them. The hepatic substance looked very much like compressed lung. When a particle of the softest part, prepared with the greatest care to avoid disintegration, was examined under the microscope, a confused granular mass was seen, in which were scattered numerous liver-cells, of the natural size, filled with a brown granular matter. Here and there were seen cells containing oil, but not much more than natural. In a particle taken from the firmer part, the cells were very few in number, and much smaller than natural, and did not contain so much of the brown matter. Here, the two parts of the liver so distinguished by difference of color and consistence doubtless presented different stages, or different degrees, of the same morbid processes. The circumstance that in the dark-colored part, which was much thinner than natural, the lobules could not be distin- guished and the cells were very few and small, led to the inference that this part had undergone atrophy through the destruction or diminished fertility of its cells. The capsule of the liver could be readily stripped off, and presented no marks of inflammation or other disease. The gall-bladder was empty, its inner surface being only just moistened with olive-colored bile. The gall-ducts were not dilated, and their inner FATAL JAUNDICE. 267 surface, like that of the gall-bladder, was tinged with bile. Some of the bile taken from them exhibited under trie microscope only the prismatic cells of the ducts. The omentum presented a curious appearance from being sprinkled with numerous clots of blood, each of the size of a split pea, or rather smaller, which were all situated in the course of the vessels. The spleen was small, and adherent to contiguous organs. Its capsule was thickened by an irregular deposit of false membrane of old date, and its substance was soft, affording a creamy purple fluid on the slightest pressure. There was no fluid in the peritoneum, and the stomach and intestines were healthy throughout. The kidneys were large, soft, and easily torn. The capsule readily de- tached, but bringing up here and there portions of the cortical substance. The surface and the cortical substance throughout were of a pale yellow ; the tubular portions of a deep purple. Examined microscopically, the cortical substance afforded, on the slightest pressure between the glasses, a large quantity of opaque fluid, which was composed of cells, more or less perfect, filled with granular matter; fragmentary remains of cells ; a large proportion of irregular amorphous particles of various sizes ; a great abundance of oil-globules ; and some particles of yellow biliary matter. Besides these objects, there was occasionally seen a more adherent mass, composed of the above constituents, evidently moulded in a uriniferous tube. There were no marks of recent disease in the lungs. The pericardium contained several ounces of a deep brownish-red serum, but exhibited no traces of inflammation. The head was not examined. The body, twenty-two hours after death, showed that decomposition was already considerably advanced. The surface of the belly was green, and the course of the superficial veins was marked by purple lines. In this case, a lad, seventeen years of age, who had been leading a dissolute life, became jaundiced. The jaundice had continued three weeks before he came under observation, and, it would seem, before he was compelled to lay up. At the end of that time it was attended with much depression and with considerable gastric and intestinal disorder; but there was no tenderness in the region of the liver, nor pain of any kind. The matters discharged from the stomach and bowels were seldom tinged with bile. At the end of another week, without any other striking change having occurred, delirium came on, and he died five days afterwards in a state of coma. On examination after death great part of the liver was of a yel- lowish-brown color, and much softened, presenting disintegrated cells, but not entirely disorganized, and still showing the lobular structure. The rest of the liver, which was firmer, and of the dark 268 SUPPRESSED SECRETION OF BILE. color of venous blood, seemed already to have undergone atrophy from destruction of the cells. The lobules could not be distin- guished in it, and when a particle from it was placed under the microscope, only a few small hepatic cells could be seen. The cortical substance of the kidneys was large, soft, and friable; and was clearly the seat of a morbid process analogous to that which had so changed the texture of the liver. Hemorrhage from the stomach or bowels, which occurred in some of the preceding cases, was not noticed; but the omentum was thickly sprinkled with ecchymosed spots. Other circumstances worthy of note are, the early decomposition of the body, and the entire absence of any marks of recent in- flammation in the liver. In 1848, the following case, which is of the same kind, fell under my observation in King's College Hospital:— Case 8.—John Granfield, aged twenty-two, was admitted into King's College Hospital on the 13th of March, 1848, jaundiced, and in a state of raving delirium. The following particulars respecting him were learned from his father: He was bred up at Portsmouth, but had lived the last four years in Lam- beth ; was single; very temperate in his habits ; and, with exception of an attack of typhus fever, three years before, his general health had been good. He was a house-painter by trade, but had been for some time out of work, and had been living badly in consequence. Three weeks before his admission to the hospital, while in the act of stretching himself, he was struck rather violently at the pit of the stomach, and from that time had pain there, which he felt especially on coughing, and some degree of tenderness. The pain, however, was not severe enough to prevent him from living as before. Four days after the blow, he made a very hearty supper, which was followed by much sickness and faintness. The next day, Feb- ruary 29th, he went to live as a waiter in a public house, at the back of Exeter Hall; still so ailing that he applied to a medical man, who told him he had had a surfeit, and gave him some aperient medicine. After this, some red blotches (urticaria?) appeared on the skin, but they soon went away. On the 2d of March, slight yellowness of the skin was noticed, which became deeper day after day. From this time his bowels were much relaxed, and he often complained of faintness and nausea, and sometimes vomited, especially after a full meal. Notwithstanding these ailments, his spirits were good, and he continued to work hard. On the 12th of March, the day before his admission to the hospital, he felt so ill that he was obliged to give up his work. His manner was then noticed to be strange, and soon afterwards active delirium came on. When brought into the hospital, he was raving violently, but became FATAL JAUNDICE. 269 more tranquil on being placed in bed. I saw him soon afterwards, and he was then totally unable to answer questions; his skin was of a rich yellow; his features were pinched; and his mouth was clenched. The belly was drawn in, and the liver was clearly not enlarged. There was no unnatural heat of skin, and the pulse was very feeble. The body was in a state of good muscular nutrition. He was ordered to take 3ss of aromatic spirits of ammonia every four hours, and sxij of wine daily, and a turpentine enema was directed to be given immediately. Before the enema was administered, he had one stool, which was loose and yellow. During the night and following morning, he had four stools more, which were clay-colored. During the 14th, he was very-quiet, but never rational. He took, with apparent satisfaction, wine and beef-tea, when they were presented to him. The pupils were of the natural size. He was reported to have slept well the following night. At five A. M., on the 15th, he was fed, and then slept again till eight. When he awoke at the latter hour, it was evident that a change for the worse had taken place. He was weaker and more comatose ; his breath- ing was quicker, and mucus, which he was unable to spit up, collected in the bronchial tubes. He soon passed into a state of complete coma, and died at half-past eleven A. M. When seen by the clinical clerk at eleven A. M., he was lying on his back quite insensible, and with the pupils much dilated. His breathing was laborious, the inspirations forty a minute. The pulse was ninety ; the sounds of the heart were very feeble; the belly was still drawn in. The liver was smaller than natural, and weighed twenty-three ounces. It was flaccid, so that its surface could be readily thrown into wrinkles, and its color was a reddish-brown, mixed with yellow. Some patches in the upper part of the right lobe were reduced almost to a pulp, so that irregular cavities were formed when they were gently pressed by the finger. Other portions of the liver were not remarkably soft. In the softened.portions, scarcely any entire hepatic cells could be found, all that appeared under the microscope being irregular granular matter, apparently consisting of disintegrated cells. In the rest of the liver, the cells were entire, and contained a variable quantity of oil and of biliary coloring matter. Most of them were pale, and contained less oil than usual. The gall-bladder was flaccid, and con- tained a very small quantity of dark-green bile, which presented under the microscope no visible objects. The gall-ducts were very small, and but slightly tinged with bile. There were no marks of inflammation on the capsule of the liver, or anywhere in its substance. The spleen was small and tolerably firm, and its surface was wrinkled. The stomach in the big end had been slightly acted on by the gastric juice after death, but, in other respects, was sound and had its natural appearance. The intestines contained nothing more than fecal matter, tinged with bile, and their inner surface was quite sound. The kidneys presented to the naked eye their natural appearance, but 270 SUPPRESSED SECRETION OF BILE. the tubules were stained with bile, and contained an excess of epithelium, which rendered them opaque. The lungs were healthy, except in the lower and posterior part, which was, in each, gorged with dark blood, and unnaturally friable, though it still crepitated under the finger. There were no marks of recent inflam- mation of the pleura. The brain, when sliced, presented many bloody points, but had every- where its natural consistence. No other marks of disease were discovered in the body. Small fibrinous coagula were found in the cavities of the heart. Here a young man of very temperate habits, and seemingly of sound constitution, but who had been for some time out of work, and, in consequence, had been living badly, and been probably de- pressed in mind, receives, while in the act of stretching himself, a rather violent blow on the pit of the stomach. From this time he complains of pain and tenderness at the pit of the stomach, but the pain is not severe enough to make him change his mode of life. At the end of four days, after a hearty supper, he becomes very sick and faint. The next day, still ailing, he goes to a new situation—that of waiter at a public-house. Two days afterwards (March 2) jaundice comes on, which grows gradually deeper. From this time his bowels were relaxed, and he felt occasionally sick and faint; but he continued to work hard for ten days longer, till the 12th of March, when violent delirium came on. The delirium passed into a state of coma, and he died on the 15th, just a fortnight after the occurrence of jaundice. On the examination after death portions of the liver were found disorganized in the way described above ; and it was clear that the jaundice resulted, not from an impediment to the flow of bile into the duodenum, but from defective secretion. In 1817,Dr. Handfield Jones presented to the Pathological Society the liver of a girl who died in St. George's Hospital, and the fol- lowing interesting report of the case was published in the Medical Gazette for December 31 of that year :— Case 9.—The patient, a girl, aged 18, was admitted into St. George's Hospital on the 17th of November, 1847. She complained of amenorrhcea, slight cough, and palpitation, and was weak and cachectic. When eight years old she had a rheumatic attack, with pain in the chest, and ever since had been subject to palpitation and dyspnoea. FATAL JAUNDICE. 271 At the apex of the right lung some degree of dulness was noticed on percussion ; and here, also, the breathing was coarse, the expiratory sound prolonged, and there was increased vocal resonance. The heart's action was increased, there was extended dulness in the cardiac region, the sounds were audible over the whole chest, and there was a loud murmur accompanying the first at the apex. The tongue was clean and moist, and the bowels were open. During four days she remained in much the same state. On the 24th, vomiting occurred, and continued incessantly in spite of various remedies. At this time the urine was examined (not microscopically), and found appa- rently healthy; the cough increased; the sputa became muco-pnrulent, and afterwards somewhat rusty ; the action of the heart very turbulent. On the 29th jaundice made its appearance, the stools also being white ; diarrhoea succeeded, and the vomiting continued till the 4th of December, when it subsided, and she expressed herself as feeling better; but the jaun- dice did not diminish, the features became collapsed, and she sank on the 6th of December, a slight attack of erysipelas having occurred on the face a day or two before death. Post-mortem examination.—The mucous membrane of the fauces, and of the upper part of the pharynx and larynx was red, covered with tenacious mucus, and with a thin layer of lymph in some parts. The lungs were very much congested throughout; in some parts there almost appeared to be extravasation of blood, forming numerous dark but small patches, the lower lobe of the left lung being incompletely hepatized. A portion of one of the lungs, where it was least congested, was examin- ed by the microscope, which showed a very great increase in the epithe- lium lining the air cells ; multitudes of pale granular cells being found in this situation, together with a few exudation corpuscles, instead of the mere nuclei or feebly developed cells which should normally exist. A mo- derate quantity of serum, with some flakes of lymph floating in it, existed in the pericardium. The heart was large, its cavities distended with coa- gula; the left ventricle much dilated, its walls slightly thickened, its cavi- ties occupied by a large firm fibrinous coagulum ; small fibrinous fringes on the aortic valves, the mitral valve thickened, and the orifice of the aor- tic valves somewhat narrowed. The liver was of a deep yellow color ; on making a section, the inter- lobular veins were seen highly congested, the lobules themselves not at all; the gall-bladder was full of bile, the ducts quite pervious. On ex- amining these sections under the microscope, it was immediately seen that the secreting structure was seriously affected. On the margins of the lobules cells still existed, and their nuclei were distinctly visible, though they were gorged with bile of a deep yellow tint; in by far, how- ever, the greatest extent of the lobules no cells could be discerned ; a densely aggregated group of oil-globules formed a zone concentric to the marginal one, where the bile-laden cells still retained their forms; within this there was nothing but coarse granular and amorphous matter, with a few groups of oil-globules. The relative size of this interior part, where the degeneration was most complete, varied in different lobules, but in some it occupied nearly one-half of the whole extent. The spleen was unusually firm, many of its nuclei developing fibres from the opposite extremities. 272 SUPPRESSED SECRETION OF BILE. The kidneys were very firm, not congested, but perhaps rather pale; microscopic examination showed the tubuli of the left kidney tolerably healthy, but the granular matter of the epithelium perhaps rather coarse. On cutting into the right kidney, there was seen a large patch of yellow color, extending throughout the cortical substance, and which was accu- rately bounded and separated from the surrounding healthy part by a broad line of deep red color, which was happily compared by Dr. Nairne to the boundary line of gangrene which had ceased to spread. The dis- coloration of the tissue extended to the surface of the organ ; the corre- sponding part of the capsule was similarly discolored, and also evidently thickened. On viewing these sections of the altered portion, it was very apparent that the secreting tubuli were principally affected, in some speci- mens being completely destroyed ; numerous coarsely granular cells, the remains of their epithelium, being alone visible. In the majority of in- stances, however, the tubes still remained, but were so bloated and opaque as to be evidently unfit for the discharge of their functions—resembling in many respects the diseased tubes which are found in a kidney which has suffered consecutively to scarlatina. On close examination, several of these tubes were still seen to be invested by a basement membrane, in the interior of which were dense masses of large, coarse epithelial cells, which completely filled the cavity and obstructed the passage. The matrix was unaffected ; in particular the capsules of the Malpighian tufts were beau- tifully seen ; no trace of any fibrinous or other deposits could be found in the portions examined by Dr. Jones and Mr. Simon, though Dr. Bence Jones had found a considerable quantity of free oily matter in a specimen from this same kiduey. The Malpighian tufts themselves separated with great readiness from their capsules ; their capillaries had quite lost their natural aspect, and appeared of an indistinct fibrous or granular texture. In this case, a girl, aged seventeen, with valvular disease of the heart, most probably the effect of an attack of rheumatism, which she had nine years before, was brought into the hospital on the 17th of November, weak and cachectic, and complaining of amenor- rhoea, slight cough, and palpitation. No particular change in her condition was noticed till the 21st, when she was taken with vomit- ing, which continued incessantly in spite of various remedies. The sputa now became muco-purulent, and afterwards somewhat rusty. On the 29th jaundice came on, succeeded by diarrhoea. The vomiting continued till the 4th of December, when it subsided, and she expressed herself as feeling better. The jaundice, however, did not diminish; erysipelas appeared on the face; and she died on the 6th, fifteen days after the occurrence of vomiting, seven days after the occurrence of jaundice. No mention is made of delirium or other cerebral disorder. On examination after death marks of recent inflammation, which was probably erysipelatous, were found in the fauces and in the upper part of the larynx, and also in the pericardium. FATAL JAUNDICE. 273 The lower lobe of the left lung was completely hepatized, and the lungs were very much congested throughout. The liver had undergone the same morbid process as in the preceding cases; but, from the shorter duration of the malady, the disorganization of the cells was complete only in the central portions of the lobules. The kidneys exhibited, in different degrees, changes in the secreting tubules like those found in kidneys that have suffered from scarlatina; and in the right was a large patch of yellow, which extended through the cortical substance, and which was separated from the surrounding part by a broad, deep red line. In this yellow portion the tubes were blocked up, and the circula- tion had evidently ceased some time before death. I have twice found a similar pale spot in the cortical substance of the kidney, separated from the rest of the organ by a red line, where death had resulted from acute dropsy, consequent on cold and fatigue. The disease of the kidney doubtless came on after the occurrence of the gastric disorder, which was followed by the jaundice; for, on the 21st of November, when the vomiting occurred, the urine was submitted to the ordinary examination, and considered to be healthy. The most probable supposition is, that it was consecutive to the jaundice, and that it was caused by the elimination of some noxious matter through the kidneys. In the month of July, 1850, one of my brothers sent me the following brief account of a case of fatal jaundice from suppressed secretion, in which the additional fact was observed, that the bile in the gall-bladder, and the liver itself, had an acid reaction:— Case 10.—A few days ago I was called to a case of jaundice, the particulars of which may have some interest for you. The subject of it was a married lady, thirty-seven years of age, delicate, but sound. On Monday, July 1, she was quite well; on Tuesday, ailing; on Wednesday, jaundiced, but not ill enough to keep her bed. On Thursday and Friday she kept her bed, and was frequently very sick, but was sprightly and cheerful, and without a single alarming symptom. Little or no fever, or, indeed, general disorder of any kind. In the course of Friday even- ing she bacame worse, chiefly in the way of sickness. All the early part of the night she was harassed by almost'incessant vomiting. At five in the mornino- she became suddenly incoherent, knowing no one, and making continual efforts to get out of bed. At eight o'clock she was quite un- conscious. It was about half-past eight that I first saw her. She was 18 274 SUPPRESSED SECRETION OF BILE. then lying in a state of profound stupor; her surface very yellow, her lips and nose livid, her extremities cold, her pulse scarcely to be felt. The pupils were much dilated, and the right was sensibly larger than the left. The mouth was drawn to the left side. To say the truth, she was already moribund. She never recovered consciousness, and died at a quarter before nine the same evening—that is to say, in less than fourteen hours after the supervention of the first head-symptoms. For some time before her death her breath had a peculiar and sickening smell. I made the post-mortem examination thirty-six hours after death, and although, from circumstances, it was not so complete as could be desired, the particulars are worthy of notice. In the first place, the liver pre- sented no single mark of inflammation. It was not swelled, but, of the two, rather small than large. The capsule smooth, and peeling readily; its edges sharp. In mass the organ was flaccid, but its substance was pretty firm and not readily broken up. It presented but one color, and that color was red. It did not contain much blood. There was about a drachm of chocolate-colored bile in the gall-bladder. The ducts were empty, and all pervious. Blue litmus-paper placed in contact with the liver was immediately changed to a bright red, and the bile in the gall- bladder appeared also, by the same test, to be intensely acid. The stomach contained about three pints of black fluid, identical in appearance and character with that which is known as " the black vomit." This fluid had been poured out when there was no longer power to eject it. In the small intestine there was mucus, abundantly stained with green bile; and I may here add that, during life, the stools were never entirely devoid of bile. There were three other circumstances especially worthy of remark: rapid tendency to putrefaction; a fluid state of the blood; and an immense number of large ecchymoses. With the exception of a very small fibrinous clot in the left ventricle, the blood was everywhere fluid. Hundreds of ecchymoses, varying in size from that of a split pea to large blotches as broad as a shilling, were scattered over the mesentery. Similar extrava- sations had occurred in the fat of the abdominal parietes, as also in the anterior mediastinum. There was a great number under the parietal pleura on both sides, and the whole surface of the heart was variegated by them, It was probable that something of the same kind had occurred in the brain. but unfortunately the head was not allowed to be opened. The marks of rapidly progressing putrefaction were everywhere conspicuous. The blood in the right ventricle was frothy from evolution of gas; the mesentery, near the upper part of the duodenum, was emphysematous, and the whole of the mucous membrane of the small intestine was blown up, and par- tially separated from the coats beneath by a similar change. The kidneys and spleen were sound ; the lungs much gorged in their posterior or un- dermost half, but not diseased. I had no time to make a microscopic examination of the liver until the next morning. There was not then a single cell to be seen, but decomposition had gone on so rapidly, that no inference could be drawn from the fact. There can be no doubt that in this case, as in the former cases, the jaundice resulted from defective secretion; and as there appears to have been no moral influence at work that could have arrested the action of the liver, we can hardly avoid the inference that it was FATAL JAUNDICE. 275 caused by some special poison introduced from without, or engen- dered in the body by faulty digestion or assimilation. The disor- der of the brain occurred, as in Case 5, only a few days after the occurrence of jaundice, and proved more speedily fatal than in any of the preceding cases. On the Thursday and Friday this lady was ill enough to keep her bed, but was sprightly and cheerful, without a single alarming symptom. Early on the Saturday morning she became suddenly incoherent, and the same evening she died in a state of coma. The strongly acid reaction of the bile in the gall-bladder and of the juices of the liver is a remarkable fact, and probably will turn out to be very important when the true explanation of this terrible disease is discovered. The instances that have been related serve to show the remark- able changes which the lobular substance of the liver undergoes in fatal cases of jaundice from defective secretion. When death occurs early, the liver is softer than natural, and of a dirty yellowish, or yellowish-brown color, but is nearly of its former size, and the lobules are distinctly visible. The secreting cells are entire, but contain fine granular matter, and are conse- quently more opaque than natural. From the beginning the liver ceases almost entirely to secrete bile, and before long the secreting cells break down, or are not re- produced; and, in consequence, the lobules, which owe much of their bulk to the cells and the products of secretion, waste, and the liver shrinks rapidly. At the end of some weeks the liver is much diminished in size and weight, and the lobules are very indistinct. Different parts of the liver may present different stages of the dis- ease. In one part the lobular substance may be slightly raised above the general level of the surface, and soft, and of a dirty yel- low, or yellowish-brown, and the lobules may be distinct. In an- other part the substance may be firmer, but more wasted, and its color may be more owing to the blood in the vessels. In this part the lobules are very indistinct, and the secreting cells are few and small. In some cases portions of the liver are found extremely soft, and the secreting cells in them completely destroyed. The observation of Dr. Handfield Jones (Case 9) tends to show that this process of disorganization begins in the centres of the lobules. In two or 276 SUPPRESSED SECRETION OF BILE. three of the cases related, in which the secreting cells in portions of the liver were completely destroyed, the adjacent tissues were so softened that they were reduced to a soft pulp by the slightest pres- sure of the finger. In these cases it is probable that the vessels and other tissues were softened by some chemical agency after death; for it is difficult to conceive how the circulation could be carried on in vessels so rotten, and in none of the cases was there any blood effused in the softened portions. The question then arises, was there not some noxious matter retained in the liver in these cases, which excited a solvent action on its tissues after death ? In one of the cases there were numerous purpuric spots on the omentum, and in one or two others, shortly before death, sanguin- olent matter was passed from the stomach and bowels, without other hemorrhage. A tendency to hemorrhage is common in jaundice, and is probably owing to the unhealthy state of the blood; but in these cases the occurrence of hemorrhage in the abdominal cavity solely or chiefly seems to show that the hemor- rhage was owing, not so much to the state of the blood, as to a special congestion of the alimentary canal, caused by the arrest of secretion in the liver. In two or three of the cases urine was secreted plentifully up to the time of death, and the kidneys, on superficial examination, presented no marks of disease. In other cases, after a time, the secreting tubules of the kidneys became diseased, evidently in consequence of the elimination of some noxious matter through them. In Case 7 the softness and frangibility of the kidneys after death, and the microscopic appearances, lead to the inference that the change in those organs was of the same kind as that of the liver. In all the cases in which the kidneys were diseased the morbid change in them seems to have been consecutive to that in the liver. The question then occurs, did the disease of the kidneys result from the absorption, and the elimination through them, of matter furnished by the disorganized cells of the liver ? or did it result from noxious matter, introduced from without, or engendered by faulty digestion or assimilation, which was first detained in the liver ; but which, when the liver had become disorganized, and had consequently ceased to detain it, was carried to those great outlets for noxious matters in the blood—the kidnevs ? FATAL JAUNDICE. 277 In considering the details of the cases related above, two circum- stances arrest attention as having probably had influence in pro- ducing the disease. 1. The first is, that, with the exception of Abdul (Case 5), whose case differed in many respects from those of the others, none of the patients had attained middle age. Of the nine remaining cases seven occurred between the ages of 17 and 30, one at the age of 35, and one at the age of 37. It would seem from this that the disease belongs especially to youth and adolescence. 2. The second circumstance worthy of attention is, that most of the patients had been leading irregular lives, and had been subject to depressing influences just before the jaundice came on. The subjects of these cases were five women and five men. Of the women, one had been recently separated from her husband, and had been in hospital under treatment for syphilitic sores ; one had been recently abandoned by a man with whom she cohabited; one was a poor broom girl, wandering in a strange country, igno- rant of its language; one weak and cachectic, with long-standing disease of the heart. Of the men, one had been for some time out of work; one was a sailor who had lately led a dissolute life, and had syphilitic sores; two others were sailors, who had been a short time ashore, and had most probably led the irregular and dissipated life that sailors too commonly do on their arrival in port. These facts favor the inference, that grief, anxiety, dissipation, and other depressing conditions are influential in producing the disease. Before the occurrence of cerebral disorder there were in most of these cases no constant or peculiar symptoms that could serve to distinguish them from ordinary cases of jaundice occurring in young persons. In six of the cases there was some degree of pain or tenderness in the region of the liver. In the remaining four no pain or tenderness seems to have existed. In most of the cases there was some gastric or intestinal disorder: in eight, there was vomiting, which in some was very distressing; in two, there was protracted hiccough; in several, more or less diarrhoea. The stools were generally claj'-colored; but occasionally, in some of the cases, they were more or less tinged with bile. This is explained by the circumstance, that some parts of the liver continued to secrete bile; and that, in consequence of the gall-ducts being pervious, the bile 278 SUPPRESSED SECRETION OF BILE. accumulated in the liver at the commencement of the disease could flow freely into the bowel. In many of the cases the symptoms for several weeks were not of an alarming character. Some of the patients seem to have walked about; one continued to work hard; one was sprightly and cheerful, until the occurrence of delirium. This terrible kind of jaundice seems, then, to occur especially in youth or adolescence; in persons of both sexes, especially in those who are depressed from grief, mental anxiety, or dissipation. It is generally attended with some pain or tenderness in the region of the liver, with some degree of gastric or intestinal disorder, and with signs of exhaustion, but seldom with active inflammatory symptoms. Often the disease presents no alarming characters till the occurrence of delirium, which happens at various times—from a few days to several weeks—after the appearance of the jaundice. The head symptoms, in such cases, which are different in kind and more constantly and promptly fatal than those which result from exhaustion, have been generally attributed to the retention of the principles of the bile in the blood; but there is abundant evi- dence to show that the mere retention of bile in its natural state produces no such effects. Cases have been related in a former chapter in which, in consequence of permanent closure of the common gall-duct, the secreting cells of the liver were entirely destroyed; in which it was clear that no bile could have been secreted for some time before death; and yet no appreciable dis- order of the intellect existed. The patients were of an olive-green, from the long-continued jaundice, and grew gradually weaker; and at length died, not from disturbance of the functions of the brain, as in the cases just related, but from sheer exhaustion. If this supposition be dismissed, two others suggest themselves. The first is, that these symptoms are caused by the direct action of the poison which caused the jaundice. A great difficulty in the way of this supposition is the sudden and unexpected occurrence of the head symptoms, in some of the cases related above, after the jaundice had lasted for some time. It is clear from the symptoms that some deadly agency—sufficient, in one case, to destroy life in fourteen hours—came then suddenly to act on the nervous system. If this were the poison that had before arrested the secretion of the liver, and caused the jaundice, the poison must at first have FATAL JAUNDICE. 279 been retained in the liver, like globules of pus or mercury, and from some cause or other have been suddenly liberated to exert its action on the nervous system. It is well known that poisons which kill by stupefying the nervous system take effect rapidly on their passing into the blood; and in some of the preceding cases there was no sign, for several days or even weeks after the occur- rence of jaundice, that the brain was under the action of a narcotic poison. Another supposition that offers a better explanation of the facts than either of the others is, that, in consequence of decomposition, some peculiarly noxious agent is evolved in the lobular substance of the liver, which is the real cause of the malignant symptoms. Circumstances much in favor of this supposition are, that the cerebral disorder occurs rather suddenly, at very variable times after the occurrence of the jaundice; and that, sometimes, jaundice caused by fright proves fatal exactly in the same way. It has been stated that one of the cases (Case 5) differed in many respects from that of the others. The peculiarities of this case are, that the patient was much more advanced in life; that the dis- ease was of shorter duration; that striking morbid changes recently produced, were found in various organs besides the liver; and that several persons living with the patient, and exposed to the same influences, had jaundice about the same time. These circumstances render it probable that here the jaundice was produced by unwholesome food, or by some noxious effluvia, to which all these persons were exposed. Many remarkable instances have been recorded of jaundice from suppressed secretion of bile, occurring in several members of a family in succession, and in some of them proving rapidly fatal, with delirium and coma. The following instance was published by Dr. W. Griffin, of Limerick, in the Dublin Journal of Medical and Chemical Science, for 1834, in the first of a series of excellent papers entitled, "Medi- cal Problems." I give it in Dr. Griffin's own words:— "A poor woman requested me to visit her daughter, Mary Barry, aged 20 years, who, she informed me, had been three days ill, and was now speechless, and she believed dying. On entering the cabin in which she lived, I saw her make a faint expiration, which 280 SUPPRESSED SECRETION OF BILE-. proved to be her last, as she was quite dead when I reached the bed. Her skin was still warm, and universally tinged with a deep yellow color. The countenance was hydropic, and the pupils were dilated. On inquiring, I found the girl's ailment had set in with languor and heaviness; on the second evening, she was seized with sickness of stomach, vomiting, and appearances of jaundice, and next morning complained much of her head. She then looked so very ill, that her mother began to get alarmed, and insisted on her going to the dispensary for advice; the poor girl shook her head despond- ingly, and said she was too weak to walk there, but she would go into the room and lie down on the bed. These were the last words she uttered. "When the mother went in afterwards, there was an appearance of stupor about her, from which she endeavored to rouse her, but could get no reply. She was in profound coma. " In about three weeks after, I was called to see Ellen Barry, a sister of the former, and found her laboring under an affection pre- cisely similar. She had been attacked with languor and heaviness, followed by sickness of stomach and vomiting, with universal yel- lowness of the skin. She was now in perfect coma; conscious when roused, but unable to speak, and very unwilling to be dis- turbed. From this very dangerous state she was rescued by active and continued purging; the yellow tinge gradually disappeared, and in a few days she regained her usual health. "Within a very short period afterwards, another member of the same family was attacked—a boy of about 13 years of age. My brother was requested to see him, and found him moaning, and comatose; his belly tender to the touch, his pulse slow, and his skin of a saffron color; his breathing was not stertorous. This case was more sudden than either of the foregoing; the boy was seized with sickness of stomach and vomiting at night, and in the morning was jaundiced and insensible. In this state he lay until nearly the end of the second day, without medical aid, up to which period his bowels had not been moved. An ineffectual effort was then made to purge him, but he was unable to swallow, and died in a few hours. " The parents were now, it may be supposed, highly apprehen- sive for their remaining children, and, the event proved, not with- out just reason. After the lapse of a few months, their next boy, John Barry, aged 11 years, showed symptoms of jaundice. He grew languid and heavy, and in two days the tunica albuginea and skin FATAL JAUNDICE. 231 were of a deep yellow. There was great sluggishness of the bowels, and slight tenderness of the abdomen, but very little pain. He did not complain of his head, but, like the others, was seized with sickness of stomach and vomiting. I had early notice of this attack, and was vigilant in looking for the supervention of coma, although, from existing symptoms, there was no greater reason to apprehend it than in any common case of jaundice, if I except some slight dilatation of the pupils, and sluggishness in their move- ments. The boy was up and about, and did not, in fact, appear to be very ill; but the fate of his brother and sister left a lesson not to be forgotten, and I accordingly warned the mother to give me instant notice of the occurrence of the slightest stupor; he was in the mean time actively purged. There was little change in him that night or the next, but on the succeeding morning, I had a messenger with me at an early hour, to say that he had fallen into a state of insensibility in the night, and could not now be roused. I found him quite comatose, with slow pulse, dilated pupils, and almost a total loss of sensation and voluntary motion. On pinch- ing his hand severely, however, he evinced signs of consciousness, moaning slightly, and slowly drawing his hand away. Ten ounces of blood were immediately taken from the temporal artery; the head was shaved, and kept wetted with refrigerant washes, and castor oil was administered every fourth hour. As the bowels were slow in acting, injections were given at night, and large blis- ters applied to the nape of the neck. These had the desired effect. He was copiously purged for several hours, and in the morning evinced signs of returning consciousness; from thenceforward there was, day after day, a steady and progressive improvement, until his recovery became fully established. "Some time after, the friends were once more alarmed by a recur- rence of the vomiting and jaundice; but the progress of coma was arrested, and the complaint readily removed by purging alone. "These four cases of jaundice, running rapidly into coma, which in two of them terminated in death, when we consider that they occurred in one family, within a few weeks of one another, and without any unusual or remarkable symptoms which could indicate the impending danger, suggest a very important question with regard to the pathology of the disease: ' On what morbid state did the occurrence of coma in these particular instances depend?'' 282 SUPPRESSED SECRETION OF BILE. Another, and almost parallel instance, except that the different members of the family were attacked after long intervals, and that the jaundice was attended by more fever, is related by Dr. Graves, in his work on Clinical Medicine. The account was sent to Dr. Graves by Dr. Hanlon, of Portarlington, his former pupil, of whose assiduity and zeal he speaks in high terms. The cases appear to me so interesting, when taken in conjunc- tion with those before related, that, notwithstanding its length, I have ventured to transcribe the account entire. Case 1.—Saturday, July 25, 1840, I was called to visit Miss Maria B----, aged seventeen years. On the preceding Wednesday she com- plained of languor, and in a few hours was attacked with bilious vomiting, which had returned three or four times in every twenty-four hours since. When the vomiting commenced she became jaundiced, and the color in- creased in intensity until it assumed a greenish-yellow tint. The bowels were constipated for two days before the vomiting began, and had remained so, notwithstanding that the apothecary in attendance had given her re- peated doses of purgative medicines. Effervescing draughts and other medicines intended to allay the vomiting, had been given without success. I found the tongue thickly coated with a yellow mucus ; tenderness of the epigastrium and hypochondrium ; thirst; abdomen not tender on pressure ; urine scanty and high-colored ; pulse, 80; slight headache ; pupils natural; complains of want of sleep ; and appears fretful and anxious. Calomel, combined with compound extract of colocynth, aided by pur- gative enemata, caused a small, dark, and offensive motion towards even- ing. Leeches were applied to the epigastrium and region of the liver, followed by stupes, three grains of calomel every four hours, and a purga- tive draught, consisting of infusion of senna, and tincture of senna, jalap, and cardamoms, after every second dose of calomel. Sunday.—Vomited twice since yesterday evening : the bilious matter of a darker color ; tongue still loaded ; thirst diminished ; tenderness of epigastrium and right hypochondrium much less ; bowels moved twice in the course of the night; motions larger, but still very dark in color; pulse 80; headache relieved; pupils natural; color of skin the same; slept for two or three hours in the night; same treatment continued. Monday morning, five o'clock.—I was called up in haste to visit her. It appeared that, two hours before my arrival, she complained of violent headache and intolerance of light, and vomited a dark brown matter re- sembling coffee grounds ; soon afterwards became very restless, and gra- dually fell into a state of stupor. I found her in imperfect coma, the pupils excessively dilated and insensible to light, the eyelids closed. She flung herself every minute or two from one part of the bed to another, and uttered a faint, subdued scream ; she was very unwilling to be interfered with ; pulse 60, and oppressed ; skin of a still deeper tint of greenish- yellow. The assistance of Dr. Tabuteau and Dr. J. Jacob was procured in con- sultation. Fourteen leeches were applied to the temples; the head shaved, FATAL JAUNDICE. 283 and cold cloths applied to it; twelve grains of calomel in the first dose, and five grains every second hour afterwards; purgative enemata were employed every second hour. Cold affusion on the head was subsequently used to a great extent, but without producing any change in the state of the pupils or the coma ; mercurial inunction in the region of the liver and insides of the arms was commenced, and a large blister applied to the scalp. At eleven o'clock A. M., she was seized with violent convulsions, which lasted about a minute, and were accompanied by shrill screams ; the right extremities appeared more strongly convulsed than the left, the mouth was drawn to the left side. The convulsions returned every thirty or forty minutes with the same violence and screaming, until three o'clock P. M., when they became less violent, but more protracted, and gradually passed into a continued spasm, or jerking, of the extremities. She threw up occasionally a mouthful of dark matter like that which she had pre- viously vomited. The administration of the calomel was relinquished, as every attempt to give it brought on a return of the convulsions. The mercurial inunction was assiduously continued, but no mercurial fetor could be detected in the breath ; the coma became more profound; the pulse rose to 108, small, fluttering, and finally intermitting; sordes col- lected on the teeth ; the urine and feces passed involuntarily ; the breath- ing towards the close became stertorous ; and she expired at eleven o'clock the following morning. No examination of the body was permitted. Case 2.—Monday, March 29,1841,1 was requested to visit Miss Char- lotte B----, aged eleven years, sister of the former. She had been pre- viously healthy; for the last two days, has had the usual symptoms of a feverish cold, which is attributed to her having wetted her feet. I found the tongue loaded; tenderness of the epigastrium—none in the region of the liver ; thirst; bowels confined; urine scanty and high-colored ; pulse 120; no headache ; pupils natural; no discoloration of the eyes or skin. Six feeches to the epigastrium, to be followed by stuping; purgatives; diaphoretic mixture and diluents prescribed. Tuesday morning, nine o'clock.—Appears better; slept some hours in the course of the night; tongue cleaner; thirst diminished; tenderness of the epigastrium much less; no tenderness on strong pressure in the- right hypochondrium ; bowels have been strongly acted on four times ; motions dark and offensive ; urine more copious and paler ; pulse 92 ; no headache ; pupils natural; no discoloration of the conjunctiva or skin. Having been absent from home during the day, I hastened, on my return at eight o'clock in the evening, to visit; and was greatly surprised to find her in the same state as her sister had been. It appeared that about three o'clock she became heavy and languid, and the skin became slightly jaun- diced. She complained of headache and intolerance of light; vomited a dark brown matter resembling coffee grounds ; tossed about from one part of the bed to another ; refused to answers questions, and fell into a state of insensibility ; the bowels had been moved twice, the motions dark, but not offensive. I found her in a state of imperfect coma, the eyelids closed, the pupils excessively dilated, and insensible to light; pulse 64, and oppressed; skin jaundiced. In a few minutes after my entering the room, she was seized with violent convulsions, which were accompanied bv shrill screams, and lasted about a minute. Pressure on the right hypo- 284 SUPPRESSED SECRETION OF BILE. chondrium appeared to give her pain. Upon my requesting that addi- tional medical aid should be procured, her friends declined having it, on the ground that the case appeared precisely the same as her sister's, and all our efforts on that occasion had been unavailing. Under these circum- stances, 1 had recourse to the same plan of treatment as that adopted in the preceding case; cold affusion on the shaven head ; ten leeches to the right hypochondrium ; mercurial inunction on the right side and inside of the arms, in the intervals between the convulsions ; strong purgative ene- mata frequently repeated, and a large blister on the scalp. The disease, quite uncontrolled by these means, pursued precisely the same course, in every particular, as the former one. The convulsions continued most vio- lent for two hours, when they began to be less violent, but much more protracted, until they passed into continued twitchings of the muscles of the extremities. The coma became more profound ; the breathing ster- torous ; sordes collected on the teeth, and she expired at seven o'clock the following morning. Her friends being now alarmed for the safety of her surviving brothers and sisters, became very desirous that the body should be examined. Dr. Tabuteau, who had seen the former case in consultation, assisted me in making the examination. The following are the results : examination made thirty hours after death ; surface of the body jaundiced. Head.—Pacchionian glands preternaturally vascular; venous tumes- cence generally over the surface of the brain, with increased vascularity of the middle, and especially the left anterior lobes; substance of the brain much more vascular than usual; great vascularity of the choroid plexus; none of the optic thalami, or corpora pyramidalia; the entire surface of the base of the brain highly vascular, particularly at the crura cerebri, pons Varolii, and medulla oblongata; no fluid fouud in the ven- tricles. Abdomen.—Numerous spots of extravasated blood in the omentum; several small patches of inflammation along the small intestines; stomach apparently healthy. Liver.—Size natural; color, externally of a dull yellow, with several dark spots about the size of a half-crown piece ; consistence, less than usual; structure, minutely granular, and of a very peculiar crimson- orange color, somewhat resembling what might be supposed to result from an intimate mixture of arterial blood and bile; gall-bladder distended with bile of the usual appearance. Thorax not examined. I endeavored to preserve portions of the liver in a dilute solution of corrosive sublimate and diluted alcohol, but they gradually lost their cha- racteristic appearance in both fluids. Case 3.—Friday, June 18th, 1841, I was called to visit Miss Jane B----, aged eight years, sister of the two former. I was informed that she had been previously healthy. This morning she appeared languid, and was seized with bilious vomiting. No cause can be assigned for her ill- ness. I found the skin jaundiced slightly; the tongue loaded; tenderness of the epigastrium and right hypochondrium ; thirst; bowels confined; pulse 108; no headache ; no intolerance of light; pupils natural; urine scanty and high colored. Eight ounces of blood were immediately taken from the arm, which afterwards proved to be buffed and cupped; eight leeches applied to the region of the liver, followed by stuping; twenty FATAL JAUNDICE. 285 grains of calomel given at once, and a strong purgative draught every fourth hour until the bowels are fully acted on ; three grains of calomel, and one and a half of James's powder every third hour after purgation ; cold to the head. Saturday.—Slept none ; skin more deeply jaundiced ; tenderness of the epigastrium diminished; heat of the right hypochondrium still remains ; tongue yellowish ; vomited twice since yesterday evening; urine tinged with bile, and more copious ; bowrels moved four times ; motions dark and offensive; pulse 110; headache and some intolerance of light; consider- able restlessness. Six leeches to the right side; four to the temples; cold to the head; a blister to the nape of the neck ; mercurial inunction ; five grains of calomel and one of James's powder every second hour. I now watched the case with the greatest interest and anxiety. Sunday Evening.—Slight mercurial fetor of the breath ; tongue begin- ning to clean; tenderness of the right side diminished; bowels moved three times; motions less dark and offensive; pulse 90, and soft; head- ache and intolerance subsided ; restlessness entirely gone ; some return of appetite. Calomel and James's powder were continued every fourth hour until a slight salivation was established, and cold carefully applied to the head. No unfavorable symptoms subsequently appeared. The tongue became clean, the pulse fell to the natural standard, the motions became more healthy in appearance, the appetite returned, and under the use of four grains of calomel at night, and a strong dose of black draught the following morning, repeated every third night for three weeks, the jaun- dice disappeared, and she has remained quite well up to this period.— Graves's Clinical Medicine, p. 459. The cases that have now been related all bear a certain resem- blance to each other. In all of them jaundice occurred, not from any impediment to the flow of bile through the ducts, but because the secreting function of the liver was imperfectly performed; no bile, or but a small quantity of bile, was secreted. In all, with one exception, in which death resulted from exhaustion, the jaundice was followed by delirium, or stupor, which in some soon passed into coma, with or without convulsions. In all in which the body was examined, the liver was found altered in structure, and in the same way; it was diminished in size (in all except the Case 5), soft or flabby, and of a light yellow, or brownish yellow, or crimson orange, or some kindred tint. In none of them were any marks of inflammation noticed in the capsule of the liver, or in the gall- ducts. In some of the cases, where the liver was examined by the microscope, the hepatic cells were found to be in some parts com- pletely destroyed. But although the cases here brought together present so many points of resemblance, it must not be inferred that the disease under which the patients were laboring was essentially the same in all. 286 SUPPRESSED SECRETION OF BILE. Disorganization of the hepatic cells, or suspension of their secreting power, may be the effect of a variety of morbid causes, essentially different from one another in character, and in their other effects on the system. In the second case related by Dr. Alison, and in the second of those which I have cited from Dr. Bright, jaundice seems to have been consequent on mental distress, and was probably caused by it. We should not be justified in drawing this conclusion from those cases taken by themselves. But so many instances have been re- corded, in which jaundice immediately followed a sudden alarm, or shock, or other strong and depressing mental emotion, that no doubt can remain of the influence of such emotions in producing it. Dr. Watson, in his admirable lectures, after relating some striking instances of this sequence of events, observes: " There are scores of instances to the same effect; and this is observable of such cases, that they are often fatal, writh head symptoms : convulsions, delirium, or coma, supervening upon the jaundice." Morgagni, in his 37th epistle, has related several cases in which jaundice, soon followed by delirium and fatal coma, came on after mental distress, or fright; and in the first of these cases, which he cites from Valsalva, the liver seems to have presented much the same appearances as in the cases related in this chapter. "Ventre aperto, jecur inventum est flaccidum, et ad subpallidum vergens; in ejus vesiculet, bilis sub- obscura." In some of the other cases related above, the disease seems to have been the effect of some peculiar poison introduced from without. It is difficult to explain otherwise the occurrence of several cases of jaundice about the same time, among the crew of a vessel; or, at short intervals, in the different children of a family; more especially when the illness attending the jaundice is so peculiar, and so uniform in character, as it was in the instances recorded by Dr. Griffin and Dr. Hanlon. It is worthy of remark, that the symptoms attending the jaundice, though almost exactly alike in the children of the same family, were in many respects different in the different families. In the instance related by Dr. Griffin, no symptoms are noticed but jaundice and vomiting, with languor and oppression, soon passing into coma. In the instance recorded by Dr. Hanlon, the jaundice was attended by other symp- toms like those of a severe form of remittent fever. Now and then jaundice occurs in several members of a family in quick succession, FATAL JAUNDICE. 287 without being attended by any alarming symptoms. An instance of this, in the family of a clergyman, in a country parish in Devon- shire, fell under the notice of my brother, Dr. Christian Budd, who has sent me the following account of it:— " On the 2d of July, 1843, I was sent for to see Miss----, aged 6, who had been for a day or two suffering from general disorder ; slight shiverings, headache, listlessness, loss of appetite, and restless- ness at night. She had complained of no fixed pain, and had not vomited. When I saw her, she was slightly flushed, her skin was hotter than natural, pulse rather frequent, but not very so, tongue furred; she complained of headache, had a dull, heavy look, and rested her head continually on the sofa or a chair. She had no appetite, and not much thirst. I observed nothing peculiar in the color of the skin. I ordered a purgative—mercury and chalk, and senna. The senna she vomited. The next day, her skin was manifestly yellow, urine porter-colored, and motions clay-colored. I gave her gentle purgatives, and she soon got well. Her skin, however, remained yellow for some little time after. " The last day or two of the same month, her elder sister, a»-ed 10, fell ill in the same way, and on the 3d of August I visited her. Her symptoms were precisely the same as those just detailed, and a yellowness of the skin could already be discerned. The next day she was completely jaundiced. Her convalescence was much slower than that of her sister, and she remained yellow much longer. Before she was quite well, her brother, aged 11, went to London with his father, but the day after his arrival there, complained of being very poorly: was listless, took no notice of the sights around him, sat down whenever and wherever he could, and ate nothing. This state was at first attributed to the fatigue of the journey, but in a short time he also became jaundiced. His convalescence was more rapid than that of his sisters. He took, I believe, some pur- gatives merely, and soon got well." Many other instances have come to my knowledge of jaundice occurring in several children of the same family, or in several persons living in the same locality, in quick succession, without being attended by any unusual or alarming symptoms. In all these instances the disease was limited to a small space, so that it cannot be ascribed to a peculiar state of the general atmo- sphere. The miasm, or whatever it was that caused it, had a local source. 288 SUPPRESSED SECRETION OF BILE. Another reason for believing that the jaundice in these cases was the effect of some poison is, that jaundice of the same kind, that is, from suppressed secretion, occurs in other diseases, which ob- viously depend on poisoning of the blood. I have met with two instances of suppurative phlebitis, with scattered abscesses in various parts of the body, in which slight jaundice occurred, without there being abscesses or other marks of inflammation in the liver, and in which the jaundice clearly resulted from suppressed secretion; for there was no obstruction in the ducts, and the gall-bladder contained a pale citron-colored fluid. In one of these cases I remarked that the liver was extremely soft. Jaundice, with pain at the stomach and vomiting, is one of the effects of the poison of serpents, and is produced, it would seem, not by obstruction to the flow of bile from inflammation and closure of the gall-ducts, but by suspension of the secreting power of the liver. Jaundice occurs, too, in some malignant forms of fever, obviously produced by the action of a poison. The yellow fever, which owes its name to the concomitant jaundice, has many points of resem- blance with some of the cases before related, especially those recorded by Dr. Hanlon. In Dr. Hanlon's cases there was bilious vomiting, with pain at the epigastrium, and fever, and jaundice, followed by the vomiting of altered blood, which is so character- istic of the yellow fever of the West Indies. In these cases, too, as in yellow fever, the blade vomit proved the harbinger of speedy death. Epidemics of a peculiar form of fever, of which vomiting and jaundice were frequent symptoms, have at times prevailed in certain districts of this country. A fever of this kind was epidemic in Glasgow in the summer of 1843. In most of the cases of fatal jaundice recorded in the first part of this chapter, which occurred singly, it is much more doubtful how the disease originated. In some of these cases the jaundice was undoubtedly produced by depressing emotions: in some it may have resulted from fatigue or from exposure to cold and wet, which so frequently disturbs the chemical and vital processes that minister to nutrition; and when we consider the relation of the liver to the intestinal canal—when we consider that the stream of blood from the intestinal canal, charged with all the foreign matters which have been there absorbed, has to filter through the liver before it is poured into the general current—it seems probable that in some, FATAL JAUNDICE. 289 where the stomach and the liver seemed to be the organs primarily and for some time exclusively at fault, the disease was the effect of some noxious matter absorbed from the intestinal canal, and either swallowed with the food, or engendered within the body through faulty digestion. It appears from some of the instances that have been adduced, that this form of jaundice is not necessarily fatal, even after the patient has fallen into a state bordering on coma. The shipmate of Abdul (Case 5), whose disease was undoubtedly of the same nature as his, was brought into the hospital jaundiced, semi-coma- tose, and passing blood in considerable quantity from the bowels, but yet recovered. Of the four children of the same family whose cases are related by Dr. Griffin, two recovered—one, after being in imperfect coma, conscious when roused, but unable to speak; the other, after being quite comatose, with slow pulse, dilated pupils, and almost total loss of sensation and voluntary motion. It is impossible to say what amount of damage had occurred in these cases; or whether in them the cells in any part of the liver had been completely destroyed, as in some of the fatal cases. Still less, therefore, can it be determined what are the ulterior effects of the disease, where recovery takes place. It may be, that in favor- able cases the cells are not disorganized, and that they resume after a time a healthy action; or, if some of the cells be disorganized, that others are generated, just as fresh blood-cells are generated in persons who recover from losses of blood or from chlorosis; or the disease may end in flattening and atrophy of a lobe, an alteration which is now and then met with, and is generally supposed to be congenital; or the liver may remain long after, perhaps ever after, somewhat altered in appearance and texture, as seems to happen after severe forms of remittent fever. The cases related above, numerous as they are, do not exhibit all the varieties of this affection. 1st. Instances of jaundice of the kind we are considering now and then occur in which the patient dies exhausted by gastric hemorrhage, before the occurrence of cerebral disorder. In proof of this, I may cite the following case recorded by Abercrombie:— A lady, aged about fifty, of a full habit and florid complexion, was sud- denly seized in the beginning of June, 1821, with verv deep jaundice, for 19 290 SUPPRESSED SECRETION OF BILE. which no cause could be traced. There was no pain, no tenderness, and no fulness, in the region of the liver; the pulse was natural, and rather weak ; there was little appetite and some nausea, but no other complaint. The bowels were easily moved, and the motions were dark or brownish. After the free use of purgatives, &c, she began to take a little mercury. For a week after this, she seemed to be improving, but she then became more oppressed, with frequent complaints of nausea, and a feeling of lan- guor ; the tongue was white, but the pulse was natural. No other symp- tom was complained of, and nothing could be discovered in the region of the liver. On the 16th she began to have some vomiting, which occurred occa- sionally for three days, without any other change in the symptoms, until the 19th, when streaks of a black substance were observed in the matter which was vomited. The vomiting now became more and more urgent, with increase of the quantity of this black matter, and she died, gradually exhausted, on the morning of the 21st. Inspection.—The liver was reduced to a little more than a third of its natural size ; it was of a very dark, almost black color, and internally soft and disorganized, like a mass of coagulated blood. The gall-bladder was empty and collapsed. The stomach and bowels contained a considerable quantity of black matter, similar to that which had been vomited, but were in other respects quite healthy.—Diseases of the Stomach, &c, 2d edition, p. 361. 2d. Softening and discoloration of the liver with partial suppres- sion of bile may take place more slowly than in any of the cases related above, and the disease may prove fatal by inducing gradual exhaustion, without either delirium or hemorrhage. A case which appears to have been of this kind has been recorded by Andral {Clin. Med., iv. p. 322). 3d. Fatal disorder of the brain, having the same character as in the preceding cases, and therefore probably produced in the same way, sometimes comes on in the course of jaundice arising from a mechanical impediment to the passage of the bile through the large ducts. An instance of this, recorded by Dr. Graves, has been cited in the preceding chapter; and another instance is exhibited in the following case, which has also been mentioned in the preceding chapter, in reference to a different subject:— Henry Varley, fifty-three years of age, was admitted into King's Col- lege Hospital on the 2d of May, 1855. He had spent his life in London, latterly employed as a foreman of paviors, and acknowledged that for ten years he had drunk freely of spirits, but mostly in a diluted form. -Two years before his admission he first had an attack of gout in the left great toe and left ankle, and since that time had had three other attacks, the last of which occurred in the beginning of the January preceding. He was just recovering from this attack, after a confinement of three days, when he felt one afternoon a sense of tightness, not amounting to actual FATAL JAUNDICE. 291 pain, fixing itself in the hepatic and epigastric regions. He had for some time previously suffered a good deal of mental worry. In the course of the evening the sense of constriction increased to such a degree that, to use his own expression, he " could hardly bear himself." He felt, he said, very much as if a cord were drawn very tightly round his waist, below the ribs. The aggravation of pain appears to have been rather, but not very sudden. Concurringly with this he had some slight pain, not unlike that of rheumatism, referred to the right scapula. He had no sickness or nausea at the time, but felt as if his stomach were full of wind. The pain continued very severe for about eight hours, and then gradually subsided, ceasing altogether in about eight hours more. At the end of this time he found that he was jaundiced. It appears that for some years he had repeatedly suffered slight attacks of the same constricting pain, but none of these former attacks had lasted more than an hour, and none of them were followed by jaundice. Since the severe attack in January no fresh attack of severe pain had occurred, but the jaundice had continued, the motions were constantly clay- colored, and he had lost flesh considerably. The bowels, which, before the occurrence of jaundice, were very costive, had ever since been rather relaxed. At the time of his admission to the hospital, when the jaundice had lasted about four months, he was rather thin, his face and body were of a deep dusky lemon color, and his conjunctiva were deeply tinged with bile. He had no pain, vomiting, or nausea, had a clean tongue, and a fair appe- tite, but did not eat much at a time, as the food, he said, lay heavy on his stomach. The bowels moved on an average twice a day, and the motions were always clay-colored. The liver was found to be enlarged, reaching half way between the false ribs and the umbilicus, and its edge was felt to be thin. No tumor could be discovered, and there was no rigidity of the recti muscles. There was no evidence of disease of the lungs, heart, or kidneys. During the day, there was absence of fever—the pulse being usually under 70—but about 10 p. m. slight fever came on, which lasted great part of the night, and, while it lasted, prevented sleep. He was ordered a mixture containing bismuth, hydrocyanic acid, and dill-water, to take before meals: and a dose of morphia, to take at night. The diarrhoea was checked by these remedies, but in other respects the symptoms underwent no material change until the 14th of May, when he complained of pain in a small space in the situation of the gall-bladder, and an ill-defined swelling was remarked there, which suggested the sus- picion that the gall-bladder was distended. A small blister was applied over the painful space, and kept open for a long time. The swelling increased, notwithstanding, and the pain and tenderness became greater. He complained that if it were much handled the pain lasted for several hours. From this time, the pulse became higher, being usually above 80 in the minute; feverishness, from which he was free in the day-time, constantly came on in the evening, and continued during great part of the night; and he evidently continued to lose flesh. He complained of nothing except the tenderness and occasional pain in the vicinity of the gall-bladder, and the nightly accessions of fever : and l 292 SUPPRESSED SECRETION OF BILE. often told us that if it were not for these ailments he should feel quite well. On the 1st of June, in the evening, he felt a burning sensation in the stomach, and soon after vomited and brought up, as was reported, a great quantity of bile. After this he slept well, and the next morning felt refreshed, and was free from all pain and uneasiness, except a slight feel- ing of constriction across the stomach. For a few days after this he had no feverish attacks at night, and slept well. The fulness about the gall-bladder continued—he began to complain much of weakness, had often some nausea, and the pulse gradually got higher, being often from this time onward between 90 and 100. He complained occasionally of general pain and uneasiness in the back and loins. On the 25th of June it was remarked that his legs were swelled from oedema. Nothing else worthy of note happened till the evening of the 3d of July, when he had a severe attack of shivering, which lasted an hour. During the shivering he was slightly delirious, and the next day he lay in a dozing state, and ate nothing; the pulse was 100, and very weak. In the afternoon he vomited a dark-colored matter, consisting of altered blood. Vomiting recurred at intervals, he became unconscious, and, on the morning of the 6th, died in a state of coma. On examination of the body there was found to be considerable ascites and some oedema of the legs. The fluid in the belly was considerably tinged with bile. The obstruction of the common gall-duct was caused by a tumor, the size of a small bean, which grew from the mucous mem- brane of the duct, about half an inch from its duodenal end, and com- pletely blocked up the passage. An examination by the microscope led to the conclusion that this tumor was a simple wart-like growth, and not malignant. The liver was of a dark green. The gall-bladder was dis- tended with dark-colored bile, and the hepatic gall-ducts were enlarged to ten times their natural size. As is usual in cases of long-continued obstruction of the common duct, the cells in the lobular substance were, for the most part, broken up; and scattered throughout the liver were small soft spots—from the size of a pin's-head to that of a pea—in which there appeared to be disintegration of the other tissues. In the duodenum there was a large ragged ulcer, which was most pro- bably the source of the blood vomited shortly before death. There was no ulceration elsewhere in the intestinal canal, and no disease worth noting was detected in other parts of the body. In this instance, the jaundice resulted from obstruction of the common gall-duct by a wart-like body growing from the mucous membrane of the duct, near its duodenal end ; but the disease did not prove fatal by gradual exhaustion—the usual mode of death in cases of permanent jaundice from obstruction of the common duct. About six months from the accession of the jaundice the patient has a severe rigor, and soon after becomes unconscious, FATAL JAUNDICE. 293 vomits blood, and dies in a state of coma. After death there were found scattered throughout the liver small spots in which the hepatic tissue was softened and apparently disorganized. This cir- cumstance and the mode of death, when considered in conjunction with the cases before related, favor the inference that the state of insensibility, ending in fatal coma, was owing to contamination of the blood by some poisonous matter generated by decomposition in the gland-structure of the liver, and that this case, though dif- fering from the cases before related as regards the origin of the jaundice, resembled them in its result. The mental distress caused in susceptible persons by long-continued jaundice may exert the same kind of injurious influence on the liver, when it is already the subject of any disease, as mental anxiety from other eauses occasionally does when the liver was previously sound.1 The softness and frangibility of the liver, noticed in so many of the preceding cases, does not depend on destruction of the secret- ing cells, but on the softness and frangibility of the vessels and other tissues of which the liver is made up. The cells, as has been seen in the preceding chapter, may be completely destroyed from permanent closure of the common gall-duct, and the liver may be small and flabby in consequence, but it will not necessarily be readily broken down or torn: and, on the contrary, the liver may be found after death unnaturally soft and frangible when the cells are entire, and when, up to the time of death, bile enough was secreted to prevent the occurrence of jaundice. In a woman, who died under my care in King's College Hos- pital, in June, 1844, of tubercular peritonitis, all the upper part of the liver, thirty hours after death, when the body was examined, could be torn by the slightest effort, like a piece of rotten sponge. The portions near the lower edge were very much firmer. The liver was very large, and throughout of a yellowish-green; but there was no jaundice, and the only symptom that the liver was diseased was its large size, which it owed to the presence of a large quantity of oil. Andral {Clin. Med., iv. p. 320) has given the case of a man who 1 I have met with several instances of jaundice, which I took to be of this kind coming on in young and sensitive persons affected with syphilis, and resulting, I imagine, from the mental distress which the primary disease occasioned. 294 SUPPRESSED SECRETION OF BILE. died of phthisis, without jaundice or other symptom of disease of the liver, in whom the liver, which was rather large, was softened to an extreme degree—so that in many points it was a mere pulp. In the kind of jaundice we have been considering, the shrinking of the liver, the small quantity of bile that passes into the intestine, and the small quantity of bile found in the gall-bladder and gall- ducts after death in the fatal cases, show clearly enough, what we have hitherto assumed, that the secretion of bile is greatly dimi- nished, and that in some cases it ceases almost entirely before death occurs; and the question naturally arises—How does the coloring matter of the bile come in such cases to be present in the blood so as to cause jaundice? Two suppositions may be offered in explana- tion of the fact. One is, that the coloring matters of the bile are not all formed in the liver, as Lehmann and other physiologists have lately inferred, but that they are formed, at least in part, as a result of the processes of nutrition in other parts of the body; and, consequently, that when the liver ceases to eliminate them, they accu- mulate in the blood. The other supposition is, that the bile-pigment from which the jaundice results is formed in the lobular substance of the liver, but that, from the secretion being faulty and defective, instead of being taken up and carried away, as it should be, by the radicles of the gall-ducts, it is directly absorbed by the bloodvessels and lymphatics in the liver. I have brought together from different sources the cases related in this chapter for the sake of showing that the secretion of bile may be suppressed, and the secreting substance of the liver be more or less disorganized in various circumstances, and without the occurrence of any process that we are warranted in designating inflammation. There is evidence enough to prove that this suspen- sion of the secreting process and disorganization of the liver may result from various perturbing influences—some acting primarily through the nervous system, others through the blood. It may result from powerful and depressing emotions, or from long-con- tinued anxiety or overwork, and probably from other more local causes of disturbance in the nervous system; and it may also result from some poison, introduced from without or engendered in the body by faulty degeneration or assimilation. It appears, too, that various poisons—pus, the poison of serpents, the poison of some DIAGNOSIS. 295 forms of fever, and many others—may alike stop the secretion of the liver, and lead to the same kind of disorganization of its struc- ture, while their other effects on the system are very different. These circumstances may serve to explain the different characters of the illness that attended the suppression of bile in the different cases related. They were many of them cases of essentially differ- ent diseases, and having merely this one effect, and the consequence of this effect in common. Almost all the cases related in this chapter proved fatal; but it must not be inferred from this that jaundice resulting from sup- pressed secretion has necessarily, or indeed generally, a fatal issue. We collect the fatal cases because they are more impressive, and because an examination of the body after death gives us an assur- ance, which is wanting in other cases, that the jaundice was thus produced. When jaundice does not prove fatal, who can always pronounce positively that it resulted from defective secretion, and not from inflammation of the gall-ducts, or some other of the various conditions from which it may arise? Who, in many of the cases related above, could have said positively, before the fatal head symptoms occurred, that the jaundice resulted from suppressed secretion ? It has been clearly shown above that jaundice thus produced does not necessarily prove fatal, even after alarming cerebral dis- order has come on; and that among many cases occurring at the same time and in the same place, and plainly the effect of the same condition, one or two may be rapidly fatal with the most malignant symptoms, while others may be mild. There can, I think, be little doubt that in a large proportion of cases where jaundice occurs during youth or adolescence—when gall stones and organic diseases of the liver are rare—the fault is in the secreting cells, and the jaundice results from suppressed or defective secretion. The question then arises—How can the jaundice thus produced be distinguished from jaundice arising from temporary closure of the gall-ducts ? When the jaundice immediately follows a power- ful emotion in a person under the age of thirty, and when it comes on as a consequence of some known poisoning, or in conjunction with other symptoms indicative of a poisoned state of the blood, or where, as in the instances related by Dr. Griffin and Dr. Hanlon, 296 SUPPRESSED SECRETION OF BILE. it occurs with peculiar characters in several members of a family, or in several persons living together, in succession, it may confi- dently be assumed that the jaundice results from suppressed secre- tion. In other cases, when the circumstances under which the disease occurs are less insignificant, it is often difficult to pronounce a positive judgment. But when jaundice presents the characters it had in many of the cases related above—when it occurs in a young person, who has lately been leading a dissolute life, or been ex- posed to depressing influences; when the liver, instead of being enlarged, as it is from many conditions that produce jaundice, ap- pears to be within its natural limits ; when, during the jaundice, the matters brought up by vomiting, or discharged by stool, are occa- sionally bilious, showing that the common bile-duct is not stopped; when the jaundice is attended with depression, and not with in- flammatory symptoms — the probability is very great that the jaundice results from suppressed secretion. When hemorrhage from the stomach or bowels occurs soon after the accession of the jaundice, or when delirium, or coma, or con- vulsions, supervene, we may be almost sure that the jaundice is thus produced, because these events seldom occur in jaundice that results from mere obstruction of the ducts. Another circumstance that may help to distinguish the two forms of disease, is itching of the skin, which is generally much complained of in jaundice that results from mechanical closure of the gall-ducts, but not in that which results from suppressed secre- tion. The presence or absence of pain does not give us much infor- mation, for there is generally some degree of pain or tenderness in jaundice from suppressed secretion, as well as in that which results from closure of the gall-ducts; but in inflammation of the gall- ducts, the tenderness is probably less diffused, and felt more ex- clusively in the situation of the common duct, which is open to pressure. One of the surest signs of the existence of this kind of jaundice would be the diminution in the size of the liver, if it could be satisfactorily made out; but it is much more difficult to estimate diminution of the liver than enlargement. When the liver grows large, it extends below the false ribs and across the epigastrium, and can generally be felt through the yielding walls of the belly; TREATMENT. 297 but when the liver shrinks from its natural size, its lower edge rises under the ribs, and changes in the bulk of the organ are diffi- cult to detect. It is probable that the surest means of distinguish- ing this kind of jaundice will by and by be found in some peculiar condition of the urine. I have long suspected that the presence of oxalate of lime in the urine will turn out to be an important indi- cation of it. In many cases of jaundice which I have supposed to be of this kind, the urine contained oxalate of lime, which disap- peared from it as the jaundice went off. In more than one case of the kind, I have found in the urine, with the oxalate of lime, casts of the secreting tubules, or evidence of the rapid shedding of the epithelium of the secreting tubules of the kidney. But none of these cases have proved fatal, so that the real nature of the jaun- dice is, in some degree, doubtful. Jaundice from suppressed secretion, even when unattended with fever, or with weakening disorder of the stomach or bowels, very soon induces a state of great anemia ; and it seems to me to be much more common in summer than in winter, probably from the de- pressing influence of summer heat, or because noxious effluvia are then most rife. Until more is known of the causes of this form of disease, and until its different varieties can be distinguished with more cer- tainty, we cannot expect to have very satisfactory proof of the good or ill effects of particular plans of treatment. A consideration of the foregoing cases leads, however, to the important and gratifying inference that in two or three of them the terrible head symptoms were prevented or removed, and the life of the patient saved, by active purging. If this inference be true, there can be little doubt that purgatives will generally be produc- tive of benefit in milder cases of the same kind. The medicine which has seemed to be the most generally useful of any that I have tried, in cases of jaundice which I have supposed to result from suppressed secretion, is from 3ss to 3j of sulphate of magnesia, in conjunction with gr. xv of carbonate of magnesia, and 3ss of aromatic spirits of ammonia, given three times a day, an hour before food—the sulphate of magnesia to keep up free ac- tion of the bowels; the carbonate of magnesia to neutralize any ex- cess of acid in the stomach or bowels; and the aromatic spirit of am- monia to support the nervous system and to promote the action of 29S SUPPRESSED SECRETION OF BILE. the skin. The ammonia may act, not only through the general nervous system, but also as a direct stimulant to the nerves of the liver itself. In many instances in which there was absence of fever and the urine contained crystals of oxalate of lime, I have given, apparently with much advantage, the nitro-muriatic acid. The circumstance that jaundice of this kind often results from depressing emotions, and that it is always attended with depression, suggests the propriety of encouraging the patient with the hope of speedy recovery, and thus removing the mental distress which the mere existence of jaundice sometimes occasions. Where the patient is still able to walk about, he should carefully avoid fatigue, which is very soon induced, and has great influence in checking the secretion of the liver. When the disorder results from anxiety or mental shock, it is of course very important that the nervous system should be restored by sound sleep, and all expedients that tend to promote this, and that do not act injuriously on the liver or on the system at large, must be beneficial. I believe that in jaundice from suppressed secretion much harm is often done by the use of mercury, and that the remedies recom- mended above—aromatic spirits of ammonia, in conjunction with sulphate and carbonate of magnesia, and the invigorating stimulus of hope—will, if had recourse to in time, almost always prevent the occurrence of the fatal head symptoms, except when the sup- pressed secretion of bile results from the action of some terrible poison. 299 Sect. II.—Fatty degeneration of the liver—Partial deposit of fat in the liver—Waxy liver—Appearances caused by deficiency of fat in the liver. It has been before remarked that the size, and color, and firm- ness of the liver may be much altered without the agency of in- flammation, and without destruction of the cells or impaired nutri- tion of its other tissues, simply from matter being secreted or appropriated by the cells, which, instead of passing off freely in the bile, is retained in the substance of the liver. The most common disease of this class is what has been called the fatly liver, or fatty degeneration of the liver. The outward characters of this disease have been long familiar to pathologists, and have been rightly ascribed to the interstitial deposit of uncombined fatty matter in the substance of the liver; but it was not known precisely in what state, or where, the fat was deposited, till 1841,1 when Mr. Bowman discovered, in a specimen of very fatty liver which I requested him to examine with this in- tent, that it existed in the form of oil-globules in the hepatic cells. In every human liver there is some uncombined oil or fat, which, in healthy grown-up persons, amounts, perhaps, on an average, to three or four per cent, of the whole mass. In the spring of 1851, Dr. L. S. Beale was kind enough to make at my request an analysis of two livers presumed to be healthy. The first was that of a gentleman, 31 years of age, well formed and muscular, and above the middle stature, who had led a temperate life, and who, while in perfect health, was killed by falling from a second-floor window; the second was that of a schoolmistress, 40 years of age, who had lived well, but very temperately, and had enjoyed good health until an attack of cerebral hemorrhage, of which she died. 1 See Lancet, January 22, 1842. 300 FATTY DEGENERATION OF THE LIVER. The following are the results of the analysis :— i. Water........68-58 Fatty matter1.......3.82 Extractive, soluble in water and in alcohol . . ) Extractive, soluble in water only, and albumen ) 10.07 Alkaline and earthy salts • . . • 1.50 Matter insoluble in water, alcohol, and ether . 16.03 100.00 100.00 Von Bibra, who has made an elaborate examination of the liver fats, has published the analyses of two livers presumed to be healthy: the first taken from a healthy young man, killed sud- denly by a blow; the second taken from an itinerant, the nature of whose illness was unknown. The quantity of fatty matter they contained in 100 parts was 2.50 and 3.65 respectively. The fatty matter of the liver, when separated by alcohol and ether, has always a brown color, and, according to Von Bibra, con- tains from one and a half to three per cent, of phosphorus. It consists chiefly of olein, which dissolves the more solid fatty princi- ples ; so that it has all the form of globules of oil. In consequence of this its presence is most readily detected by the microscope, through which it may be seen in the hepatic cells in the form of very small globules, having a dark outline. These globules are of various sizes, and are placed irregularly in the cells. Their usual appearance in the healthy liver is represented in Fig. 6 (p. 27). In the fatty liver the quantity of fatty matter is enormously in- creased. The hepatic cells are gorged with large globules, which greatly distend them (see Fig. 8, p. 30); and usually a great num- ber of oil-globules of various sizes, not contained in cells and pro- bably set free by the rupture of cells, are likewise seen under the microscope. In many of the cells thus gorged with oil the nuclei have disap- peared or are rendered invisible by the oil globules. The quantity of oil in a liver in this state may equal in weight, and more than equal in bulk, all the other elements of the liver put together. M. Vauquelin obtained from a portion of fatty liver, 1 The figures denoting fatty matter in these analyses were obtained by evapo- rating a portion of the liver over a water bath, then treating the dry powdered residue with successive portions of boiling ether, until nothing further was ex- tracted, and, finally, weighing the matter left on evaporation of the ether. ii. 72.05 4.28 10.40 1.19 12.08 FATTY DEGENERATION OF THE LIVER. 301 by boiling, as much as 45 parts of oil in 100 of liver. Nearly half the liver, in weight, consisted of uncombined oil. A liver still more remarkable for the large amount of fat it con- tained fell under my observation in King's College Hospital, in the spring of 1850. It was taken from a drunkard, and was in a state of cirrhosis, as well as of fatty degeneration, and in consequence presented a very remarkable "hob-nailed" appearance, from the nodules of cirrhosis being enlarged by the accumulation of oil. A portion of it blazed when thrown into the fire, and a particle from the lobular substance had under the microscope almost the appear- ance of ordinary fatty tissue, from the number and size of the oil- globules it contained. Dr. L. S. Beale made an analysis of a portion of it for me, and found that 65 parts in 100—about six-sevenths of all the solid matter in the liver—consisted of fat.1 The following are the particulars of the analysis :— Water........24.930 Solid matter.......75.070 Fatty matter, with a trace of extractive matter and salts ...... 65.190 Fixed salts ....... .395 Animal matter and extractive . . . 9.485 100.000 The fatty matter consisted of saponifiable fats, the greater part of which was oily fat. The man had ascites and slight jaundice, but was reported to have died without medical attendance, after two days' illness. A coroner's inquest was in consequence held, and the body was carefully examined by the physician's assistant at the hospital. No tubercles existed in the lungs, and no organ 1 The result of this analysis is so extraordinary, that I subjoin, in Dr. Beale's words, a statement of the method employed in making it :— "A portion of the liver was evaporated to dryness, and then treated with a mix- ture of alcohol and ether. The solution thus obtained was evaporated to dryness, and the dry matter, which consisted of fat, with a little extractive matter and salts, was weighed. The residue, insoluble in alcohol and ether, was dried and weighed. It was attempted to separate the extractive matter and salts from the fat, by treat- ing the mass with water, but, in consequence of the large quantity of fat, this pro- ceeding was found not practicable. After the fats had remained for two or three davs on the surface of the water, they separated into two portions : the lighter, yellow, oily, and perfectly fluid at the ordinary temperature ; the heavier, white, granular, opaque, and crystalline-the crystals forming dense, radiating, striated, globular masses." 302 FATTY DEGENERATION OF THE LIVER. was found notably diseased except; the liver. The kidneys ap- peared to be healthy. A liver that has undergone the fatty degeneration is larger, paler, softer, and more greasy than natural. These changes in its sensible qualities depend chiefly, if not solely, on the interstitial deposit of the oil-globules, and their degree may give us some estimate of the quantity of oil the liver contains. When this is very large, the liver is large in proportion, sometimes twice its natural size, and is somewhat altered in shape, being thicker than natural, and having its edges blunter or more rounded. The capsule of the liver is stretched and smooth, and, when divided, its edges recede. The tissue of the liver is pale, and, generally, throughout of a soft buff color, dotted with brown or red. The brown or red dots mark the centres of the lobules, which are unusually large and distinct, and are buff-colored near their margins. The liver is very soft, and greases the hands or the scalpel like common fat. When the quantity of oil is less, the liver is not so large nor so soft, and is less uniformly pale. The cells near the margins of the lobules contain, as was, I believe, first observed by Mr. Gulliver, a much larger quantity of oil than those near the centres; and, as the blood almost always collects after death in the central parts of the lobules especially, there is a striking contrast between the pale buff-colored margins of the lobules and the red or brownish central portions. Sometimes more of the vessels forming the capillary net- work of the lobules are filled with blood, so that the red portion, instead of being in isolated spots, forms a continuous band con- necting contiguous lobules (see Fig. 10, p. 37), and a section of the liver presents the appearance described as the nutmeg-liver. The liver may not feel greasy, but an unusual quantity of fat may be at once detected by placing a thin slice of the liver on a piece of paper and exposing it to the action of heat. Some of the oil or fat exudes, and greases the paper. The best way, however, of ascertaining the quantity of fatty matter is by examining a small particle of the lobular substance of the liver through the micro- scope. The oil-globules are objects of sight, and from their form and their dark outline are at once distinguished. When the fatty degeneration occurs in a liver previously healthy, the different parts of the organ are commonly affected in pretty equal degree; but the existence of previous disease of the liver CHARACTERS. 303 sometimes prevents the even distribution of the fat. When, indeed, an accumulation of fat takes place in what is termed the "scrofulous liver," where the lobules are infiltrated with a soft albuminous sub- stance, the fatty matter is deposited very unevenly. The greatest quantity usually exists in the parts of the liver which are subject to the least pressure—namely, the left lobe, and towards the lower edge of the right; and in those parts the fat is deposited especially in the marginal portion of the superficial lobules, and in the lobules lining the portal canals, sometimes giving a distinct whitish or yellowish rim to the superficial lobules, and forming whitish lines along the portal canals; while in the upper part of the right lobe, which is compressed by the ribs, the liver may contain but little fat, and have the compact texture and the u niformity of aspect that characterize the scrofulous liver. Few observations have been made on the bile secreted by tlie human fatty liver. That found in the gall-bladder after death is sometimes unusually pale, and, it is said, less bitter than natural (Andral, Clin. Med., iv. p. 212; and Meckel, Anatomie, t. iii. p. 470); but it has generally the greenish or olive color proper to cystic bile. Not unfrequently, indeed, in persons dead of phthisis, with fatty liver (which is very apt to occur in this disease), the bile is unusually dark-colored and thick;1 but this is doubtless owing to its having remained long in the gall-bladder and become concen- trated, in consequence of the repugnance to food, and the empty state of the stomach and intestines, so common in the advanced state of phthisis. An.accumulation of fatty matter in the lobular substance of the liver, notwithstanding it so changes the appearance and other sensible qualities of the liver, causes no obvious derangement of health. There is no jaundice as the result of this condition, and the discharges from the bowels may be properly stained; there is no congestion of the veins that feed the vena porta?—no obstruction, therefore, to the circulation through the liver; no pain, or even tenderness. The absence of jaundice while the discharges from the bowels are properly stained, shows that the coloring matter of the bile is secreted, and passes off, as usual.2 The absence of other 1 See Louis, Recherches sur la Phthisie, 2ieme edition, p. 122. ' In the fatty state of the liver artificially induced in ducks and geese, the pro- portion of sugar contained in the liver-tissue appears to be not diminished. Bernard 304 FATTY DEGENERATION OF THE LIVER. symptoms seems to depend on the softness of the oil-globules, and the readiness with which they change their form and yield to pres- sure; on their being deposited gradually and evenly, so as not to cause sudden stretching of the capsule of the liver; and on their having no tendency to excite inflammation of the capsule, or of the veins. This fatty condition of the liver is not always, however, without manifest ill effects. When it exists in high degree, the liver, from its mere bulk, causes distension of the belly, and a sense of weight and fulness on turning in bed from the right side to the left; and sometimes, by compressing the pyloric end of the stomach or the upper part of the duodenum, it prevents the stomach from com- pletely emptying itself, and thus causes vomiting and other gastric disorder, and leads to the enlargement of the stomach, which is so common in phthisis. The liver becomes fatty in very different states of the body. 1st.—It is often fatty in persons who lead indolent lives, and are at the same time gross feeders—eating largely of fatty sub- stances, and drinking freely of porter and other heavy malt liquors; and in such persons there is generally with the fatty liver an ex- cess of fat under the skin, and in other parts of the body in which fat is usually deposited. It is sometimes, as in an instance mentioned above, extremely fatty in men who take little exercise, and drink immoderately of ardent spirits. The fattening effect of food depends much on climate, but in man, still more on individual peculiarities of constitution. Some persons can take no fatty substances without being disordered by them; others take them with apparent impunity, but still remain lean—the fat is not digested, or not assimilated; others, again, take them freely, and grow fat in consequence.1 In our domestic ani- found that the fatty liver of a duck contained 1.4 per cent, of sugar, while that of another duck in the ordinary state contained 1.27 per cent.—(Lemons de Physi- ologic Experimental, 1855, p. 126. 1 Prout, Stomach and Urinary Diseases, 3d edition, p. 242. Some important re- marks on these points, and valuable hints for fufure inquirers, will be found, in the chapter here referred to, in Dr. Prout's work; to which we are so deeply in- debted for our knowledge of the various effects of faulty digestion and assimila- tion. CAUSES. 305 mals the fattening influence of fatty substances taken as food is far more constant. It was well exhibited in some experiments per- formed by Majendie, for the purpose of ascertaining the nutritive powers of different kinds of food. In one of these experiments, a dog was kept entirely on fresh butter, which it continued to eat, though not regularly, for sixty-eight days. " It then died of inan- ition, although remarkably fat. All the while the experiment lasted, the animal smelled strongly of butyric acid, its hair was greasy, and its skin covered with a layer of fat. On dissection, all the organs and tissues were found infiltrated with fat. The liver, to use the common phrase, was fatty; and, on analysis, it was found to contain a very large quantity of stearine, but little or no oleine. It had acted as a kind of filter for the butter." Many other experiments of the same kind were made with hog's- lard and other fatty substances, and with a like result. The dogs became loaded with fat, but their muscles wasted; in many the cornea sloughed; and, at length, they died of inanition. In all of them the liver was fatty. Greasiness of the skin and the smell of butyric acid, which were remarked by Majendie in his dogs, may be likewise noticed in men who, from gross feeding and indolent lives, have their livers and other tissues loaded with fat. It has been rightly remarked by Eokitansky that the fatty condition of the liver in these men is attended with sallowness of the skin and with a greasy sweat of peculiar odor. The fatty matter passes off by the skin, as well as by the liver, and in precisely the same way—through the agency of the secret- ing cells. In a state of health, the secreting cells of the sebaceous glands, like those of the lobules of the liver, contain small globules of oil. There can be no doubt thac where the body is loaded with fat, the quantity of oil in the former cells, as well as in the latter, is enormously increased. This observation is important, because it gives optical proof that some of the matters eliminated by the liver may also be eliminated through the skin, and because it tends to impress on us the importance of attending to the skin in all cases in which the functions of the liver are deranged. In the cases under consideration, it is clear that the liver is not primarily in fault, any more than the skin. Both of them are ful- filling their proper office in getting rid of an excess of fatty matter in the blood. 20 306 FATTY DEGENERATION OF THE LIVER. 2d.—But the liver is often found fatty in persons dead of phthisis, who, instead of being loaded with fat are generally much wasted. The frequency with which the liver undergoes this change in phthisis was, I believe, first pointed out by M. Louis, in his cele- brated work on Phthisis, published in 1825. M. Louis there states that he had detected the fatty degeneration, by the altered look and feel of the liver, in 40 cases of phthisis out of 120—or, in one-third of the subjects he had examined. It appears from his researches that this change in the liver, in pul- monary consumption, is irrespective of age, and equally frequent whether the consumption is rapid or lingering. The only condition which he ascertained to have a marked relation to its frequency is sex. It was nearly four times as frequent in the women he had examined as in the men. From his subsequent experience he was led to rate still higher the difference between the sexes in this respect. In the second edition of his work, published in 1843, he states that in twenty-four fatal cases of phthisis in men, which had come under his observation at the hospital La Charite since the publication of the first edition, the liver was not fatty once, while in thirty fatal cases in women it was fatty thirteen times. These results have been confirmed by observations made in other countries. Dr. Home, out of sixty-five persons who died of phthisis in the Edinburgh Infirmary, found the liver fatty in ten, and waxy in five others. These fifteen instances, with one exception, occurred in women.1 In twenty-three of these sixty-five cases the liver presented different forms of the early stage of cirrhosis. This condition, which is not noticed by Louis in his account of the morbid appear- ances in phthisis, is, no doubt, more common in Edinburgh than in Paris, in consequence of the habit of whiskey-drinking which pre- vails among the lower classes in Scotland. But it is probable that in some of the cases Dr. Home mistook the nutmeg appearance of the liver caused by the deposit of fat in moderate quantity for the early stage of cirrhosis. Making a trifling allowance for an error of this kind, it would appear that a fatty condition of the liver is just as frequent in persons dead of phthisis in Edinburgh as in Paris. Its relative frequency in different countries probably de- 1 Lib. of Med., iv. 163. CAUSES. 307 pends in some degree on climate, national habits, and race; but no evidence has yet been collected showing the influence of these con- ditions. Fatty degeneration of the liver in a high degree is not only frequent in phthisis, but, setting aside the persons in whom the liver is loaded with fat in common with the areolar tissue and other parts of the body in which fat is liable to be deposited, is almost peculiar to this disease. Frequently, indeed, in subjects dead of various diseases, an unusual quantity of fat is found in the liver, which is at once discovered by the microscope, and which may be detected by a practised eye, by merely looking at the liver, but the quantity of fat is seldom so great as to cause a very striking change in the appearance of the organ, except in persons dead of phthisis. M. Louis states that, in the course of three years, he met with forty-nine instances of fatty liver, and in forty-seven of these the patients were phthisical. In speculating on the cause of this peculiar tendency to accu- mulation of fat in the liver in phthisis, it is important to remark that it does not depend on tuberculous disease of the liver itself. M. Louis states that there were no tubercles in the liver in any of the cases in which he found it fatty ; and that in two cases in which there were tubercles in the liver, the liver was not fatty. He even infers that the one state may preclude the other, and cites in sup- port of this opinion a remark made by M. Eeynaud, in his essay on Phthisis in Monkeys—that although in the monkeys he dissected the liver very frequently contained tubercles, it was in no instance fatty. My own observation tends, in some degree, to confirm this remark. The natives of the South Sea Islands, when they come to this country, like the monkeys brought to Paris and London, are extremely liable to phthisis, and to the deposit of tubercles in many organs besides the lungs. I have found the liver and various organs studded with tubercles in several of these men who died in the Seamen's Hospital of phthisis; but in none of these instances did I remark that the liver was fatty. It has been imagined that fatty matter accumulates in the liver in phthisis, in consequence merely of the office of the lungs being greatly and gradually interfered with—that hydro-carbonaceous matters, passing off in less quantity than natural through the lungs, are, in consequence, eliminated in larger quantity by the liver. 803 FATTY DEGENERATION OF THE LITER. This opinion is rendered very improbable by the circumstance, that in organic diseases of the heart, and in asthma, where the office of the lungs is not unfrequently as much interfered with as in phthisis, the liver does not undergo this change. Still stronger refutation of it is afforded by the fact, noticed by Eokitansky, that fatty de- generation of the liver is found in conjunction with tuberculous disease of other organs—the mesentery, the serous membranes, the bones—when no tubercles exist in the lungs. These facts show that we must seek the explanation of the fatty degeneration of the liver in phthisis in some other conditions than mere diminished function of the lungs. It has been already remarked that the fatty condition of the liver, independent of excess of fat in other organs, is seldom met with in such degree as to cause a very striking change in the appearance of the liver, except in persons dead of phthisis. Now and then, however, the liver is just as fatty after other diseases, and we may naturally expect to find the conditions on wrhich the accumulation of fat in the liver really depends in some points of resemblance which these exceptional cases bear to cases of phthisis. These ex- ceptional cases demand, then, great attention in our present in- quiry. . The most fatty liver that has fallen under my own observation for several years was that of a man who died in King's College Hospital, in April, 1844, at the age of thirty-six, of extensive can- cerous ulceration of the groins. He was a chimney-sweep, and had good health till about nine years before, when he noticed a pimple on the left side of the scro- tum, which gradually grew larger. The pimple was cut out, and the wound healed. He then gave up chimney-sweeping, and be- came a coal-porter, and from this time enjoyed good health till Fe- bruary, 1843, when another pimple, like that which had been cut out, appeared on the opposite side of the scrotum. He was admitted into St. Bartholomew's Hospital, where this tumor also was re- moved. The wound healed, as after the former operation. About a month after this the glands in the right groin enlarged and be- came painful, and shortly afterwards suppurated and burst, leaving a ragged deep ulcer in the course of Poupart's ligament. A gland- ular swelling soon appeared in the left groin, and burst, leaving a similar ulcer, but less extensive. In this state he was admitted into King's College Hospital, under Mr. Partridge, on the 14th of CAUSES. 309 September, 1843. He was then much emaciated, and his liver was felt to be enlarged. His complexion was somewhat dusky, but not sallow. He had no cough or difficulty of breathing. His appetite was very good, and he was free from thirst. He was ordered full diet, with a pint of porter; and a watery solution of opium was applied to the ulcers. The ulcers gradually spread till they were of frightful extent; but even then his appetite continued tolerably good. He gradually sank, and died on the 8th of April. Sweat- ing is not mentioned in the notes that were taken of his case. The liver was very large and very thick, and throughout of a pale buff color, from extreme fatty degeneration. It greased the scalpel, and under the microscope the hepatic cells were found gorged with oil-globules. The bile also contained a great number of oil-globules, visible under the microscope, together with distinct particles of greenish coloring matter. The capsule of the liver pre- sented no trace of inflammation. Except this change in the liver, there was no disease but the frightful ulceration of the groins. There were no cancerous tumors in any of the viscera. The lungs were congested, but otherwise perfectly healthy. A case, in some respects similar, is recorded by Cruveilhier, in which a high degree of fatty degeneration was found in conjunction with disseminated melanotic cancer, and with a large psoas abscess that resulted from caries of the lumbar vertebrae. Case.—The patient, a woman thirty years of age, was brought into the Hotel Dieu, in a state of extreme exhaustion, and died the next day. Cruveilhier has given a plate representing the front of the body, which was thickly studded with melanotic tubercles in or under the skin. There were also a great number of gray melanotic tumors in the lungs and in the mesentery ; many adhering to the kidney, and in the areolar tissue about it; many along the iliac and hypogastric arteries and veins. There was likewise an enormous medullary tumor, growing from the sacrum, which filled the cavity of the true pelvis, but all the organs of the pelvis were sound. In the upper, or expanded portion of the pelvic cavity there was a very large abscess, under the iliac fascia. The matter of this abscess came from the last lumbar vertebrae, which were carious. It ex- tended in the sheath of the psoas muscle as low as the little trochanter. The liver was yellow, and had undergone complete fatty degeneration {avait passi completement au gras), but contained no cancerous tumors. (Liv. xxxii. pi. 3.) This case presents many striking points of resemblance with the cases of phthisis in. which the liver is fatty. The patient was a 310 FATTY DEGENERATION OF THE LIVER. woman, and much emaciated. From this last circumstance, and from the wide dissemination of cancerous tumors, it may safely be inferred that she was in a state of cancerous cachexy, and probably subject to the profuse sweating common in this state. Lastly, the liver was completely fatty, but, what is very unusual when cancer is so widely disseminated, contained no cancerous tumors. In the following case, which I have copied from Dr. Bright's Hospital Eeports, fatty degeneration of the liver was found in con- junction with chronic dysentery, which had led to the perforation of the lower part of the large intestine, and the consequent formation of a large abscess behind it:— Case.—A. B., a young man about twenty-eight years of age, originally stout, vigorous, and active, who had been regular in his diet and very temperate in the use of wine and other fermented drinks, but had fre- quently been the subject of syphilis. Some years before his death he labored under a dysenteric affection, on the subsidence of which his bowels became habitually constipated. This state appeared to be in part attri- butable to a stricture of the rectum, which was felt at no great distance from the anus; a bougie was passed, and a considerable dilatation of the stricture was effected. His health continually declined, and symptoms of stricture higher up in the intestine became evident. An abscess was formed just above the crista of the ileum posteriorly, which, on its open- ing, proved to have communication with the intestine. Pain was felt in the upper part of the left iliac region. Leeches were applied, and their bites produced sinuous ulcers. He had no cough, or obvious chest affec- tion ; latterly, he had some diarrhoea, and wasted rapidly. The head was not opened. There was some old pleuritic adhesion on the left side, but none on the right. The lungs and heart were quite healthy. In the left iliac region the intestines were glued together by peritoneal adhesions, and firmly bound down on the iliacus internus * muscle. The cellular membrane below the peritoneum was very firm and much thickened. The mucous membrane of the stomach was free from rugae, rather firm, and not easily separated from the subjacent coat; towards the cardia it was of a diffused dusky livid color; that of the duodenum was pale, but its mucous glands were enlarged ; that of the rest of the small intestines was tolerably healthy. The same was the case with the first part of the large intestines; but in the sigmoid flexure of the colon, and more particularly in the lower part of it, there were numerous traces of old ulcerations ; these were of a lightish leaden color, of an uneven surface ; and the structure of the intestine at this part was thickened and condensed, and its calibre greatly contracted; there were three or four small perforations through the intestine at this part. Inside, the last part of the colon and the whole of the rectum appeared healthy; but a little above the anus there was a decided thickening with induration. This evidently depended on an old ulcer, which had occupied about half an inch of the intestine. Like those of the colon, it exhibited a leaden CAUSES. 311 hue, an uneven surface, an apparent deficiency of the mucous coat, and thickening of the subjacent structure. The liver was remarkably enlarged, and of a yellowish-brown color ; it was very exsanguine, and had uni- versally undergone the fatty degeneration. It felt soft and plastic under the fingers, soiled the clean blade of a scalpel which was thrust into it, and yielded an oily fluid on the application of heat. The gall-bladder was small and contained no bile, but a little dirty-colored somewhat puriform mucus. The patient, however, had some bilious vomiting but a few days before his death. The spleen was of moderate size and firm, and the kidneys were healthy. {BrighVs Reports, vol. i. p. 117.) In the spring of 1844 Mr. Busk sent me a portion of liver ex- tremely fatty, taken from a lad aged seventeen, who died of chronic dysentery. The lad was much emaciated, but had no disease of the lung, other than recent bronchitis. He died a few days after he was brought to the hospital, and, while under treatment there, had no sweating. In the autumn of 1843 I found a very fatty liver in a woman who died in King's College Hospital of gray hepatization of the left lung. Her illness lasted a month, and towards the end she had much hectic and sweating. There were no tubercles. It is stated by MM. Biett and Eayer, that a fatty condition of the liver is very common in persons with chronic pemphigus— persons almost invariably very low in condition. It would seem from these instances that the fatty condition of the liver so common in phthisis does not result from the office of the lung being interfered with, or from the presence of tuberculous matter in any particular organ, but rather that it is connected in some way with the general constitutional disturbance—the abund- ant suppuration, the wasting, the hectic—so common in advanced stages of phthisis. The opinion was many years ago advanced by the late Baron Larrey, that the fatty condition of the liver in these cases results from solution of the fat previously laid up in the body. He con- sidered this opinion strongly supported by the method then em- » ployed in France to make the livers of geese fatty, and of which he gives the following account: " To procure the large livers of geese for the making of patties, fatted birds are confined in close cages, and then exposed to a graduated heat, being kept at the same time entirely without food, even without water. They become feverish, the fat undergoes a kind of fusion, and the liver grows enormously 312 FATTY DEGENERATION OF THE LIVER. large. The liver is considered to be in the desired state when the animal is extremely wasted, and the fever increases."1 It is quite clear that if the liver be rendered fatty in this way, the fat which accumulates in it is derived from that previously laid up in the body. It is extremely probable that the same thing happens in phthisis, and in the other wasting diseases in which fatty degeneration of the liver occurs in man: that, in the process of wasting, the fat stored up in the body is largely taken up by the veins, so that it comes to be in excess in the blood, and is then laid hold of by the hepatic cells, which have a natural affinity for it. If this opinion be correct, it follows that in this class of cases, as in those before spoken of, the liver is not primarily in fault, any more than the kidneys are in fault in saccharine diabetes. In cer- tain states of the system the liver eliminates an unusual quantity of fat, just as in certain other states the kidneys eliminate sugar. But the fat in the liver, being in the form of large oil-globules, which are perhaps only slowly dissolved in the bile, is long pent up in the close meshes of the capillary network of the liver, and of course adds to the size of the liver, and alters its texture—while sugar, from its solubility and from the large quantity of water secreted with it, is at once carried out of the system, and may leave the kidneys unaltered. When oil has accumulated in the liver beyond a certain amount, it probably impedes the proper action of the liver and lessens the secretion of bile ; but in cases of phthisis, when the liver is fatty— if we may judge from the usual clearness of complexion, and from the appearance of the intestinal discharges, and from the fact that the bile found in the gall-bladder after death is often dark green or olive-colored—bile continues to be secreted in considerable quan- tity, and the oil in the liver offers no impediment to its escape 1 Baron Larrey was a native of the South of France, and the account cited above was probably derived from personal observation: but at present, as far as I can learn, there is in the fattening of ducks and geese in France only one method em- ployed—which consists in keeping the birds in a dark place, with little space to move in, and in cramming them with a paste of maize or some other farinaceous food, allowing them water to drink at will. Under this treatment there is at first a general increase of fat in the body: but when the fat stored up throughout the body has reached a certain amount, the further increment of fat appears to be de- posited chiefly in the liver, which soon passes into the fatty state that is so much prized. The color of the fat in any particular bird varies with the color of the maize on which it was fattened. CAUSES. 313 through the ducts. The liver seems, at least at first, not to be in fault, but to be merely performing its allotted task in withdrawing an excess of fatty matter from the blood. The question then comes to be, Why is the fat taken up by the blood in such quantity in phthisis as to be present in great excess in that fluid ? If it be to serve as fuel for respiration, why is not the liver fatty in all chro- nic diseases which prove fatal by slow emaciation ? Why does the liver become fatty so much more frequently in women affected with phthisis than in men ? As yet no satisfactory answers have been given to these questions.1 But although in the class of cases already considered the liver may not be primarily in fault, it is probable that fat may also accumulate in the liver, as in other organs, from local causes— causes affecting directly the nutrition of the part. It now and then happens that a very small portion of the liver —the size, it may be, of a walnut—is completely fatty, while the rest of the organ is quite sound. In the year 1843, when my atten- tion was directed to this subject, I met with three instances of this. One was in a portion of liver sent me by Mr. Busk, taken from a man who died in the Seamen's Hospital with enormous cavities in the lungs, which were probably tuberculous. The only morbid appearance on the surface of the portion of liver sent me was a pale drab-colored spot, the size of a shilling. When this was sliced across, a portion of the liver immediately beneath, as large as a walnut, with an irregular outline, was found to be of the same pale color, contrasting strongly with the color of the rest of the liver, and completely fatty. The appearance of this portion was precisely like that of extreme fatty liver in phthisis; and under the micro- scope the hepatic cells were seen to be filled to bursting with oil, while the cells in the rest of the liver had scarcely more oil than natural. There was another spot in the same state and about the same size in a different part of the liver. The second instance was in the liver of a woman who died in' King's College Hospital of diseased heart. She was reported to have drunk freely of spirits. At the surface of the left lobe, near the suspensory ligament, was an irregular portion, the size of a 1 The greater frequency of fatty liver in women may be partly accounted for by the circumstance that women are, in general, fatter than men. 314 FATTY DEGENERATION OF THE LIVER. small walnut, soft, and of a pale yellow color, in strong contrast with the color of the other portions. The cells in this pale portion were gorged with oil-globules; in the rest of the liver they were healthy. In another portion of the left lobe there was some atrophy, and the surface was slightly puckered, from obliterated branches of the portal vein. The third instance was in a girl, aged 20, who died also in King's College Hospital, of chorea. The capsule of the liver was united to the diaphragm and the abdominal parietes by threads of old false membrane. On the surface of the liver were two or three pale spots, like those before described, of about the same size, and having the same irregular outline. Under the microscope, the hepatic tissue forming these spots exhibited a few cells gorged with oil-globules, and an immense number of free oil-globules. Through- out, the liver contained more oil than natural. In these two last cases, there was no tuberculous disease of the lung. From the fat being deposited so partially, and from the presence of marks of former inflammation of the liver, we are perhaps justified in infer- ring that the complete fatty degeneration resulted here, not so much from general or constitutional causes as from some local cause affecting the nutrition of the parts in which it occurred. In other parts of the body, in persons even much emaciated, accumulations of fat are often found in wasted parts, especially where a certain form must be preserved for the due exercise of their functions. This is especially the case with the heart.1 Fat is almost always found about the heart in persons above the age of infancy, gradually increasing in quantity as the two sides of the heart become more unequal in bulk. This fat, as Mr. Paget has shown, serves a mechanical purpose, and allows the different cavi- ties to assume readily the changes of volume and position, which the entrance of the blood -and its forcible expulsion require. In phthisis, where the muscles of the heart, like other muscles, waste, and where the fat of most parts of the body disappears, an unusual quan- tity of fat is sometimes deposited about the heart ;2 in obedience, it would seem, to the law which determines the deposit of fat about 1 For an account of the manner in which fat is deposited about the heart, see an elaborate paper by M. Bizot, in the first volume of Memoires de la Societe Med- icale d'Observation. 2 For an account of the fatty state of the heart in phthisis, See Louis sur la Phthisie, second edition, pp. 61 and 63. CAUSES. 315 the heart in health, as, by the progress of age, the inequality of the two sides of the heart increases. Accumulation of fat about the heart, in phthisis, is associated with accumulation of it in the liver. Like the latter, it is almost exclusively met with in women, and is seldom found in persons who die of other wasting diseases. In phthisis, as in the process before described, that was formerly employed to make the livers of geese fatty, the fat previously laid up in the body seems to be absorbed by the vessels in greater quantity than is requisite to combine with the oxygen inhaled. The excess of fatty matter thus present in the blood is, in part, eliminated by the glands destined to excrete fat; in part, deposited about the heart, where, from the wasting of other tissues, an additional quantity of it seems to be required to serve an important mechanical purpose, and where forces have been placed which strongly favor its accumulation to the extent requisite for that purpose. The difficulty that before presented itself meets us again here. Why does the fat laid up in the body become absorbed, so as to be in excess in the blood, in phthisis, and not also in other chronic diseases equally wasting? The bones of persons very advanced in life always contain a large quantity of oil, which accumulates in them (as the vascular part of their structure shrinks), it would seem, for no other end than to occupy space. Another situation in which fat accumulates, and apparently for the same end—to occupy space—is under the integument of the belly in women who have had many children. In a woman who died in King's College Hospital, in the autumn of 1842, of stric- ture of the pylorus, although the body generally was extremely emaciated, there was a layer of fat, an inch thick, on the abdominal muscles. Andral, from the observation of similar facts, was led to imagine that the fatty state of the liver in phthisis might result from atrophy of its proper tissues. {Clin. Med., iv. p. 174.) There is, at present, no evidence to support this opinion.1 The liver be- comes fatty without any previous diminution of size; and the ac- cumulation of fat, so far from being intended merely to fill up a void, may go on till the natural volume of the liver is doubled. 1 This opinion is likewise advanced by Dr. Thompson, in an excellent article on Diseases of the Liver, published in the Library of Medicine. {Lib. of Med., vol. iv. p. 190.) 316 FATTY DEGENERATION OF THE LIVER. It is probable, however, that in some of the cases in which fat is found in less quantity, or in parts only of the liver, the fat may merely take the place of other tissues. But occasionally fat is deposited in great quantity in particular parts from causes that affect their nutrition without previous wast- ing of their proper structure, and where no beneficial mechanical purpose seems to be answered by it. This frequently happens in the neighborhood of cancer. Cancerous tumors of the breast, and cancerous glands in the axilla, are often surrounded by a large quantity of fat. The frequent accumulation of fat about cancer has been particularly noticed by Cruveilhier, who has given a strik- ing instance of it in a case of colloid cancer of the stomach with cancerous tubercles in the mesentery. (Liv. 27, PI. 3, p. 1.) In examining the bodies of sailors who have died much reduced by chronic dysentery, I have been often much struck with the large quantity of fat in the appendices epiploicce, and elsewhere in the neighborhood of the diseased intestine. In the dissections of persons dead of chronic dysentery, related by Annesley, in his work on the diseases of India, a fatty condition of the omentum is also frequently noticed. An unusual quantity of fat is sometimes found about a diseased joint; but this perhaps results, in part, from wasting of the adjacent muscles. Fat is sometimes deposited in the liver, in the same partial man- ner, about other disease, especially cancer. The hepatic tissue just round a cancerous tumor has often a nutmeg appearance from con- taining an unusual quantity of fat, and not unfrequently is for a short distance, completely fatty, when, in other parts of the liver, fat does not exist in sufficient quantity to produce any striking changes. In all the cases in which I have yet ascribed fatty degeneration of the liver to local causes affecting the nutrition of the part, the accumulation of fat has been partial. It may be, however, that the entire organ may be damaged by some acute disease, or in other ways, and may become fatty in consequence. I strongly sus- pect that this happens in yellow fever and in the severe bilious re- 'rnittents of tropical climates. These fevers greatly disturb the secreting function of the liver, and without leaving any permanent CAUSES. 317 marks of inflammation, and apparently without exciting inflamma- tion at all, may permanently alter its condition. It often happens that the office of the liver is not adequately performed for the future, and that years after, when the person dies, perhaps from some disease quite independent of this, the liver is found unusually pale. The pale color of the liver depends, I imagine, on fat, which is not present, however, in such quantity as to increase the size of the liver and to cause the striking appearance of the extreme fatty liver in phthisis. It is not unlikely that long courses of mercury, and other medicines that directly affect the nutrition of the liver, may, now and then, have a similar result. Hitherto we have considered merely the ordinary form of fatty liver, in which the fatty matter consists chiefly of olein. Various forms of fatty matter—olein, margarin, cholesterine—have been found in human bile; and it might have been expected, therefore, that the deposit in the liver would occasionally consist mainly of the more solid forms of fat. It has been proved that in some ani- mals kept exclusively on fatty substances, the fatter matter may be deposited in the form of stearin. In the dog that Majendie kept exclusively on fresh butter for sixty-eight days, the liver was found, on analysis, to contain a large quantity of stearin, but little or no olein. But no analogous observations have been made on man. The relative proportions of the different kinds of fat in the liver are difficult to ascertain by chemical analysis, and cannot be dis- covered, even approximately, by the microscope, because the solid fats, though microscopic objects, and readily distinguishable when separate, are soluble in olein, so that all the fat in the liver appears as globules of oil. In examining fatty livers under the microscope, I have, however, occasionally seen within some of the oil-globules a crystallized mass, like a small star, which probably consisted of margarin ;x but have never observed a scale of cholesterine, and am not aware that an interstitial deposit of cholesterine has ever been seen in the substance of the liver. This is the more remark- able, as cholesterine, which seems to be a normal constituent of bile, forms a very definite microscopic object, and is often found in large quantity in the gall-bladder in the form of gall-stones, or in glis- tening scales floating in the cystic bile. 1 In most animal fats, stearin and margarin exist together; but human fat con- tains no stearin. 318 DEFICIENCY OF FAT IN THE LIVER. In the fatty degeneration of the gall-bladder, considered in a former chapter, cholesterine is generally secreted in very large quantity by the diseased coats of the bladder. Now and then a liver is enormously enlarged and thickened, and its lower edge is rounded, as in the common fatty liver, evi- dently from the interstitial deposit of some foreign matter; but its substance is more compact than that of the common fatty liver, and does not feel greasy, and the cut surface is somewhat glisten- ing, and occasionally has a rich yellow color from the retention of bile. These characters are well expressed by the epithet " waxy," which has been applied by many pathologists to livers in this state. This condition of the liver, like the common fatty degene- ration, comes on gradually, often without pain or other striking symptom of hepatic disease, and the liver presents no marks of inflammation on its capsule. All these points of resemblance between the " waxy" liver and the " fatty" liver have led Laennec,1 and many pathologists since his time, to consider the former to be a mere variety of fatty liver, caused by the deposit of the more solid forms of fat. Such may, in some instances, be the case; but in the most striking examples of "waxy" liver which I have met with, the foreign matter in the liver was albuminous, and not fatty. They were examples, not of fatty degeneration, but of what may be termed, from the most common cause of the condition, the scrofulous enlargement—a condition which forms the subject of the next chapter. Our knowledge of the frequency of fatty degeneration of the liver in phthisis enables us often to discover it during the life of the patient. In a woman laboring under phthisis, considerable en- largement of the liver, without jaundice or ascites, or much pain or tenderness, is evidence enough, especially when she has been of temperate habits, that the liver is fatty. But as this condition of the liver usually causes but little inconvenience in itself, and as the disease with which it is associated is generally fatal, it is not an object of treatment. When the liver becomes fatty from gross feeding and indolent habits, the excess' of fat will, doubtless, disappear from it, as from other parts, on the person adopting an opposite mode of life. If he will rise early, take active exercise, live chiefly on lean meat, ' See Traite de l'Auscultation, torn. ii. p. 36. EFFECTS. 319 with plenty of salt, and drink water, and will abstain from butter, bacon, oil, beer and other fermented drinks, and not eat too largely of sugar and starch,1 he will not only get rid of much of his fat, but generally his muscles will be better nourished, and his strength be increased. There are some states of the system in which the quantity of fat in the liver, instead of rising above the standard of health, falls much below it. One of these states is diabetes. In advanced stages of diabetes, scarcely a particle of true fat can be found in the limbs, in the cavity of the belly, or even about the heart.2 The brain, too, is generally somewhat shrunk, probably from de- ficient supply of fatty matter to repair its waste; and the oil- globules in the liver are few and small. As excess of fatty matter renders the liver large, and pale, and soft, and the individual lobules large and distinct, a deficiency of it must tend to produce contrary effects. Where the cells contain but little oil, and are small, or fewer in number than they should be, the lobules of the liver, unless they are distended by some other foreign matter, are usually small and indistinct, and a cut surface of the liver is smooth and uniformly red. The whole liver is, of course, small in proportion to the small size of the individual lobules, and its lower edge is thin and sharp. In the scrofulous disease of the liver, to be noticed in the next chapter, the liver likewise contains an un- usually small quantity of fat; but in this disease, as has been before observed, the liver attains a very large size, and its lower edge is rounded, as in the common fatty liver, from the interstitial deposit of foreign matter of a different kind. 1 Starch and its chemical equivalents contribute directly to the formation of fat, and furnish besides a material for respiration soluble in the blood, and more readily acted on by oxygen than the insoluble fat, which is thus protected, and laid up in the system. Alcohol has a still stronger protecting power, for similar reasons. 2 See Observations by Dr. Percy, in the Medical Gazette, April 7, 1S43. 320 Sect. III.—Scrofulous enlargement of the liver, and other kin- dred states. A condition, resembling the fatty liver in many respects, but differing from it in the character of the matter deposited in the liver, is sometimes met with in persons who have long suffered from scrofulous disease, especially of the bones, and may be described as the scrofulous enlargement of the liver. In the spring of 1844, I had an opportunity of examining a very striking specimen of this disease obtained from a boy who was a patient of my brother, Dr. William Budd, of Bristol, from whom I procured the following brief notes of the boy's illness :— Case 1.—The boy had suffered many years from scrofulous disease of the hip, and pieces of bone had come away through permanent fistulous open- ings. About six months before his death he became dropsical. There was general anasarca, but dropsy of the belly predominated, and, on account of this, he was tapped three times. After tapping, the ascites returned very rapidly to the same degree as before. There never was any jaundice. There was great emaciation at last, but it came on very slowly. Through- out the illness very little fever had existed; and the appetite continued good up to a late period. The urine was of low sp. gr., and much loaded with albumen. The boy had been always sickly, and in consequence much indulged by his parents; having been allowed, among other things, to drink, for a child, large quantities of beer. The liver was immensely enlarged, its edges were rounded, and its peritoneal coat was remarkably smooth and tense, from stretching. "When the liver was sliced, the cut surface was smooth, presenting no appear- ance of lobules. It was of a very pale red, mottled by white lines and spots. The pale red portions were of close uniform texture, and semi- transparent, having much the look of bacon-rind ; the white lines and spots were opaque. The opaque white matter consisted almost entirely of fat. Under the microscope, it exhibited a mass of large oil-globules— some free, others in hepatic cells. In the interior of the liver the fatty matter was deposited chiefly along the small twigs of the portal and the hepatic veins, forming very distinct white lines. Near the surface it was in greater quantity ; and in this portion of the liver some lobules were completely fatty, and large and very distinct to the eye, as in ordinary fatty degeneration. In the pale semi-transparent portions the hepatic SCROFULOUS ENLARGEMENT OF THE LIVER. 321 cells were distinct, and contained no oil-globules at all. No other objects were visible. The fat was not in sufficient quantity to cause the great increase in the size of the liver, and the liver contained hardly any blood. It was clear that the increased size of the liver and the semi-transpa- rency resulted from some peculiar matter deposited in the lobules—in the cells or between them. After the fat was dissolved out with ether, the tissue of the liver had still a very peculiar appearance—in many parts the compact, uniform aspect of bacon. On the surface of the peritoneum covering the intestines there was a deposit of granular lymph, having much the appearance of the semi-trans- parent granulation of tubercle, the result probably of inflammation of the peritoneum set up by the "tappings." Several of the bronchial glands were tuberculous, and there was one encysted tubercle in the left pleura; but there were no tubercles in the substance of the lungs. The kidneys were in a state of granular degeneration. Here the liver was immensely enlarged, and its capsule stretched, from an accumulation, not of oil, but of some other matter, which rendered the organ pale, almost effaced the appearance of lobules, and gave to great part of its substance the close uniform texture and the semi-transparency of bacon-rind. Notwithstanding these remark- able changes, there was very little fever, the appetite continued good, and there was no jaundice. The scrofulous disease of the hip had existed many years, but there is no evidence to show when the disease of the liver came on. The circumstance that there was very little fever and no jaundice, and the immense size of the liver, tend, however, to show that the enlargement was very gradual; and the predominance of ascites over other dropsy, six months before death, would alone render it probable that disease of the liver then existed. Other cases of the same kind, to be presently related, leave little doubt that it existed long before that time. It will be remarked that the kidneys were diseased as well as the liver; and, from the occurrence of general dropsy, there can be little doubt that they were diseased at least six months before death. All that was noted respecting them is, that they were in a state of granular degeneration; but a more minute examination of the kidneys made in one or two of the subsequent cases renders it probable that the foreign matter choking the gland was like that in the liver, and somewhat peculiar in kind. In November, 1844, I had an opportunity of examining a more remarkable specimen of the disease, taken from a woman who died 21 322 SCROFULOUS ENLARGEMENT OF THE LIVER. in St. Peter's Hospital, Bristol, under the care of my brother, Dr. Wm. Budd. The following are notes of the case:— Case 2.—The patient was a single woman, rather above thirty, who at the time of her death had been about twelve months in St. Peter's Hospi- tal for scrofulous caries of the metatarsal bones of both feet, and of one ankle-joint. She had several scrofulous sores besides, but there was no enlargement of the glands of the neck or groin. At the time of her ad- mission to the hospital, it was discovered that her liver nearly filled the belly. All that was recorded of her former history is, that she had been living for several years in London—it was believed on the town, though she would not confess as much; that she had been intemperate there; and that it was there her health broke down. Throughout her illness there was no ascites or other dropsy; and she appeared to die, at length, from the mechanical effects of the enormous enlargement of the liver. For the last fortnight of her life she could re- tain nothing on her stomach. The liver, which was nine pounds in weight, occupied the whole belly, and a great part of the chest, especially on the right side, where it rose to the third rib. In consequence of this, the right lung, which was universally adherent, was compressed into a space not much bigger than one's hand; the heart was displaced, and lying quite across the chest; and the greater part of the stomach was in the pelvis. On the right lobe there was a large space which had been formerly the seat of peritonitis; and the gall-bladder was distended with rather thick, dark olive-colored bile. The substance of the liver did not burn or grease paper, and was com- pact and tough, having much the appearance of yellow wax. On microscopic examination, the cells were found to be for the most part imperfect, their outline being more or less irregular, and to contain oil-globules and a much more coarsely granular matter than is contained in normal cells. Beside the cells was seen a granular matter (the granules being of very irregular form and size), and a quantity of oil. From the "waxy" appearance of the liver, I thought that it probably contained some solid form of fatty matter, and requested Professor Miller to analyze a portion of it for me. He found that a small proportion of yellow oily fat could be extracted by digesting thin slices of the liver in ether; but that the foreign matter to which the liver owed its large size was not fatty, but albuminous. The albumen was not in a soluble form, as cold water merely took up a portion of albumen, such as might have been expected from the serum contained in the gland. The spleen was of an enormous size, and there were extensive adhesions between it and the diaphragm. The kidneys were in an early stage of granular degeneration. The greater part of the stomach, as has been already observed, was in the pelvis. Its cardiac end was singularly drawn out into a tube, nearly as narrow as the oesophagus. The intestine, and especially the colon, was very much contracted. ■ In the summit of each lung there was a tuberculous deposit, about the size of a walnut, not yet broken down, and having no active disease about it. EFFECTS. 323 The heart was somewhat enlarged, but had no valvular disease. There were no tubercles in the mesentery or intestines. In this case, as in the last, the patient had long suffered from scrofulous caries; and the liver was enormously enlarged by the accumulation of an albuminous matter in its substance. The history of the case, incomplete as it is, and the enormous size of the liver, make it certain that the enlargement had been coming on for a long time. It is remarkable that, notwithstanding the liver was so changed, in size and texture, no pain in the side was noted, there was no ascites, and bile was secreted to the last. After death, indeed, the gallbladder was found distended by thick olive-colored bile. Great enlargement of the liver was known to have existed for at least twelve months, but it was only when the body was examined that it was discovered that the kidneys were likewise diseased. The appearance of the kidneys, which was taken for the early stage of granular degeneration, and the absence of dropsy, render it probable that the kidneys became diseased only a short time before death. In November, 1848, I witnessed a striking instance of the same disease in a young man who died in King's College Hospital, under the care of Mr. Partridge, with scrofulous disease of the bones, and tubercles in the left lung. The following particulars of the case were recorded:— Case 3.—John Shaw was admitted into King's College Hospital, under Mr. Partridge, in 1846, with numerous small abscesses in the left arm— the result, he imagined, of a fall he had not long before. He was a na- tive of London, had never had very good health, and was then nineteen years of age. Portions of the radius were removed by Mr. Partridge, and Shaw left the hospital. The discharge from fistulous openings in the arm con- tinued, and two years afterwards, on the 28th of June, 1848, he again came into the hospital under Mr. Partridge. At that time, in addition to the disease of the arm, there was a small circular wound in the left side of the chest, and an abscess on the side of the great toe of the left foot. After staying in the hospital a few days, he was sent to the Margate Infirmary. On the 19th of November, not having received any benefit from his visit to Margate, he was taken again into the hospital ; and it was then 324 SCROFULOUS ENLARGEMENT OF THE LIVER. observed that he had marked symptoms of phthisis, and that his liver filled the whole abdomen. On the 25th of November he died. There had been no jaundice. At the time of death the left leg was puffy, but there was no ascites or dropsy of other parts of the body. The liver was enormously enlarged, extending down to the crest of the ilium, over all the viscera of the abdomen, and was much thickened. There was no contraction of the surface, and no mark of inflammation on the capsule. The substance was paler than usual, and contained very little blood. It was not indurated, as in cirrhosis, and a considerable quantity of serous fluid could be squeezed out of it, which coagulated on the application of heat and nitric acid. The cut surface presented only faint traces of lobules, and had a uniform " waxy " appearance. On microscopic examination, it appeared that the liver owed its large size and its "waxy" appearance to the deposit of a whitish matter throughout its substance. This matter, which seemed to have taken the place of the secreting cells, and to have no organization, had, under the microscope, a peculiar white glistening appearance, very like semi-fluid size. In parts of the liver where the deposit was" less abundant, the secreting cells were visible, and contained about the usual amount of oil. Mr. L. S. Beale was kind enough to make for me an analysis of the liver, and found that in 100 parts it contained— Water . 80.600 Solid matter in water only 19.400 Animal extractive, soluble 1.391 Animal extractive, soluble in water and alcohol . .885 Albumen (soluble) . . . . . 1.933 Alkaline salts • .850 Earthy salts • . . . .120 Fatty matter 1.119 Animal matter . . 13.100 A small piece of the liver, when boiled in water or submitted to the action of dilute nitric acid, became quite white, almost like white of egg. The kidneys were of the natural size, but presented in some parts an irregular, puckered appearance, as if from the contraction of a white de- posit like that found in the liver. On microscopic examination, in making which I had the valuable as- sistance of my friend and colleague, Dr. George Johnson, it was found that the greater number of the tubes in each kidney, with their epithelial lining, were quite healthy, but that some of them were filled with a material having the same appearance as that in the liver. The tubes thus filled contained no epithelial cells. It seemed as if the unorganized product had exuded from the basement membrane, and had taken the place of the normal secreting cells. The radius of the left arm was found to be extensively carious for about three-fourths of its extent, and two pieces of dead bone, each about EFFECTS. 325 an inch in length, lay loose in its substance. The ulna was quite sound. The joints of the arm were unaffected, except that the bone was a little softened. The phalanges of the great toe, and half of the metatarsal bone of the left foot, were also carious, and the metatarso-phalangeal joint was ex- tremely diseased. The seventh rib on the left side was carious for about two inches over the pericardium. On opening the chest, a great quantity of yellowish serum was found in the sac of the pericardium, and a large quantity of lymph was spread on the heart. The inflammation of the pericardium, of which these were traces, most probably resulted from the disease of the rib immediately above. • The upper part of the left lung was filled with tubercles. The lower and posterior part was carnified, apparently from the pressure of the fluid in the pericardium. The right lung and pleura were quite healthy. The state of other organs was not noted. The main facts of this case are very like those of the case imme- diately preceding. Extensive scrofulous caries had existed for a long time; a deposit of tuberculous matter, not very extensive, had taken place in the lung; and the liver was enormously en- larged, and much thickened, not by an accumulation of oil, as so often happens in cases of simple tuberculous disease of the lung, but by the presence of a large quantity of foreign albuminous matter, diffused pretty evenly throughout its substance. The pre- sence of all this foreign matter in the liver did not very much im- pede the passage of blood through it, for there was no ascites; and it probably did not prevent the secretion and escape of bile, for the discharges from the bowels were not remarked to be white, and there was no jaundice. Here, as in the former cases, the kidneys were diseased; and a microscopic examination showed that some of their secreting tubes were filled by a foreign matter, which had much the same appear- ance as that in the liver. The disease of the kidneys was, however, in this case only par- tial, and, to judge from the puckering at certain parts of the gland, must have occurred some time before death. In 1850, another very remarkable instance of the same kind fell more immediately under my own observation, and for some time before death the progress of the disease was carefully watched. The following were the main facts recorded:— 326 SCROFULOUS ENLARGEMENT OF THE LIVER. Case 4.—Frederick Woodman, a fair-haired lad, fifteen years of age, small in stature and crippled by scrofulous disease of the right hip, but very intelligent, applied to me as an out-patient of King's College Hos- pital, in June, 1850. He was an orphan, and had spent all his life in London. Four years before this time he came under the care of Mr. Fergnsson, on account of disease of the right hip-joint, with abscesses in the upper part of the thigh. The abscesses broke or were opened, leaving fistulous openings, which continued to discharge matter up to the time of his death. Some time in the course of the first year after he became afflicted with disease of the hip, his belly began to grow large. He noticed nothing further respecting it till about two years before I saw him, when he ob- served a definite swelling, the result of a large liver, in the epigastric and right hypochondriac regions. When he first applied to me, his belly was greatly distended, obviously in consequence of enormous enlargement of the liver and spleen, the lower edges of which could very readily be traced. In the upper part of the right thigh there were two fistulous openings, which discharged freely. He was pale, but not at all jaundiced, and not much wasted in flesh. There seemed to me little doubt that the large size of the liver was owing to that peculiar change in its texture which existed in the fore- going cases, and I prescribed, in succession, the oil of almonds, as a sub- stitute for cod-liver oil, nitro-muriatic acid, and muriate of ammonia. These medicines gave him uo marked relief, and on the 30th of October he came into the hospital. At that time he was very pallid, but not particularly thin. The belly was enormously distended, and large veins were seen on its surface, passing up from the flanks. There was evidently a small quan- tity of liquid in the peritoneal sac ; but the large size of the belly was owing to the liver and the spleen, the lower edges of which could still be very readily traced. His appetite was tolerably good, and his tongue clean, and he slept pretty well; but his skin was dry, his pulse was above 100, and he com- plained constantly of thirst. For a few days he had been troubled with diarrhoea, which, he said, had made him feel weak. There had never been any jaundice, but there was now a faint sallow tinge in the con- junctiva. The urine was acid, and contained a large quantity of albumen, being rendered almost solid by nitric acid. When it was examined under the microscope, a few transparent and slightly granular casts of the tubules of the kidney, without any oil-globules, were seen. It was now plain that the kidneys were likewise diseased, and there could be little doubt that they had undergone much the same change as the liver. For more than a month after he entered the hospital no striking change in his condition occurred. He had occasionally a feeling of nausea, and frequently complained of thirst; but his appetite remained tolerably good, and his tongue clean, and he generally slept well. The pulse was always rapid; never under 100, and sometimes as high as 120. The diarrhavi he had on his admission to the hospital soon ceased, but more than once afterwards it recurred and lasted a few days. / EFFECTS. 327 He now and then complained of slight pain at particular parts of the liver, which were then also slightly tender on pressure. The urine was throughout in good quantity, of sp. gr. about 1008, and contained a considerable quantity of albumen. At times it contained, also, a large quantity of lithic acid. About the middle of December the urine began to diminish greatly in quantity. The following are the quantities noted as passed on the succes- sive days, reckoning from 7 P. M. of one day to 7 P. M. of the next:— Dec. 6 " 7 Ounces. 54 Dec. 10 42 " 11 45 " 12 54 " 13 Ounces. 48 47 44 44 During this time, then, the quantity did not vary much. The real varia- tion was doubtless less than it appears to be from this table; for, whenever the quantity of urine is thus measured on successive days, it almost neces- sarily happens that what belongs to one day gets now and then placed to the account of the next, and there is an apparent variation, even though none may really exist. After the 13th of December, the following quantities were noted:— Ounces. Dec. 14 . . 54 Dec. 19 " 15 . . 42 " 20 " 16 . . 36 " 21 " 17 . . 36 " 22 " 18 . . 40 Ounces. . 30 22 '. 17 . 12 During these nine days, therefore, there was a rapid and progressive diminution in the quantity of urine, which at length became reduced to one-fourth of its former amount. The kidneys seemed to be rapidly block- ing up. As the quantity of urine diminished from fifty-four ounces to twelve, its specific gravity rose from 1010 to 1015. During the latter part of this time Woodman's appetite failed, and he was much purged, and frequently vomited. He complained also, at times, of headache. ' He gradually sank, and died, apparently from exhaustion, on the 29th of December. The liver was enormously enlarged, weighing eight pounds and a half avoirdupois, and reaching in the body as low as the pubis. It had no unnatural adhesions, and there were no false membranes upon it; but its convex surface presented a few short linear fissures, which resulted, I be- lieve, from the obliteration of small twigs of the portal vein, near the sur- face of the liver, and the consequent atrophy of the portions of the liver which those twigs supplied. The gall-bladder was filled with bile, which was viscid and of an olive color, as bile usually is which has become concentrated in the gall-bladder. It was not analyzed, but there was nothing unusual in its appearance. The large gall-ducts were apparently healthy, as were the large branches of the portal and hepatic veins. The morbid changes were confined to the substance of the liver, wnicn was of a pale yellowish color, and pitted when pressed by the finger. 328 SCROFULOUS ENLARGEMENT OF THE LIVER. In all its upper broad and thick portion, the liver presented no appear- ance of lobules, and seemed composed of a uniform, grayish, compact, and in some degree transparent substance; its cut surface looking not unlike that of firm bacon. In some parts, however, near the edges of the liver, the lobules were very conspicuous. They were enlarged, as in the fatty liver, and had yel- low opaque margins, contrasting strongly with the central portions, which were grayish and compact, and somewhat transparent, as the entire sub- stance of the liver was in its upper portion. On examination under the microscope, the gray compact substance ex- hibited a few gland-cells, which contained a good deal of granular matter, and were in consequence somewhat opaque, but were not enlarged. The opaque yellow matter composing the margin of the lobules was more readily torn up for microscopic examination than the gray substance, and exhibited under the microscope a greater number of detached cells, and more oil-globules, both in the cells and out of them. A portion of the liver was analyzed for me by Mr. Beale, as in the case of Shaw, before related, and the following is the result:— In 100 parts there were— Water..........80.150 Animal matter, with much albumen .... 16.098 Extractive matter, soluble in water .... 1.986 Fatty matter.........575 Alkaline salts.........784 Earthy salts.........407 100.000 So that there was little more than half a grain of fatty matter in 100 grains of the liver. The kidneys were slightly nodulated on the surface, and their texture was changed, like that of the liver. They were of a yellowish white color, and the capsular surface pre- sented very little appearance of vascularity, or of lobular structure. They were not, however, much increased in size ; the two, together, weighing ten ounces. In making a microscopic examination of them, I had the assistance of Dr. Johnson. Some of the tubes were filled with a material like that in the liver; and this, in some places, being squeezed out, formed large casts, which, like those observed in the urine during life, had somewhat the appearance of "wax." The tubes which contained this waxy-looking material had no epithelial lining. In some of the other tubes, not thus blocked up, the epithelium was opaque and granular, having undergone a change like that of the liver cells. Microscopic examination confirmed, then, the opinion which the first sight of the two organs suggested—that the liver and the kidneys had undergone the same kind of change. In some of the medullary cones of the kidneys, near their apices, were opaque white lines, plainly seen by the naked eye. Under the microscope, this opaque white matter was found to consist of crystals of a square pris- EFFECTS. 329 matic form. I could not tell by their shape what they were composed of, and sought the aid of Mr. Beale, to make out this point by chemical ana- lysis. The result of this analysis is, that the matter was— Insoluble in boiling acetic acid, and in alcohol, and in potash. Insoluble in cold water, but soluble to a great extent in boiling water. Soluble in strong nitric acid, with effervescence. When this solution was evaporated to dryness, the dry residue, treated with ammonia, gave the purple color of murexide. After incineration, it left no appreciable residue. The inference from all this is, that the salt was some "lithate." It will be recollected that during life the urine often contained abundance of lithic acid. The spleen was very large and very firm, and weighed one pound and a half. It had no unnatual adhesions. As had been inferred during life, there was a small quantity of serous fluid in the peritoneal sac. The head of the right thigh-bone was completely destroyed by caries. All that remained of it were two fragments that were lying loose in the socket of the acetabulum. There was not much else found amiss in the body. The right lung was everywhere united to the pleura costalis by adhe- sions, which were readily broken through. The left lung was free from adhesions. The lungs themselves, and the heart, were sound. The stomach and intestines were small and contracted, but presented no marks of disease; and the mesenteric glands were little, if at all, en- larged. In this case, the patient died after scrofulous disease of the hip had lasted four years, and the following striking changes were found:— 1st. The liver was enormously enlarged, as in the preceding cases, by the interstitial deposit of a whitish and glistening matter. 2d. The kidneys, though not much enlarged, had undergone an analogous change. Their secreting substance presented the same general appearance as that of the liver, and many of the secreting tubes were blocked up by a foreign matter, looking like that in the liver. 3d. The spleen was greatly enlarged and very firm. The disease of the liver seems to have come on in the course of the first year after the occurrence of the disease of the hip; for it was then remarked that the belly was growing large. There are no means of fixing the date of the disease of the kidney. It certainly existed on the 30th of October, two months before death, for the urine then contained a large quantity of al- 330 SCROFULOUS ENLARGEMENT OF THE LIVER. bumen. It is probable, however, that it had not then long existed, in any great degree, for there had been no dropsy, and the daily examination of the urine which was made subsequently, showed that the kidneys were rapidly blocking up in the last fortnight of life. The enlargement of the spleen was detected six months be- fore death. There is no evidence to show how long it had existed. It will be seen that in all the four cases related, this peculiar change in the liver was found in conjunction with protracted canes, and that in all of them, at the time of death, the kidneys were dis- eased as well as the liver. In the last two cases, simple inspection of the kidneys, as well as the more minute examination by the microscope, showed that the disease of the kidneys was analogous to that of the liver— that the secreting part of the gland was blocked up by a foreign matter having the same general appearances as the matter in the liver. There can be little doubt that the disease of the kidneys was of the same kind in the former cases in which they were not so carefully examined. In every instance, the disease of the kidney appeared to be much more recent than that of the liver. It seems probable, therefore, that in such cases the liver becomes generally blocked up first, and then the kidneys. The disease of the kidney is, however, much more fatal than that of the liver, so that it is possible that it may sometimes come on first, and may destroy life before the liver is so much enlarged and changed in texture as to excite attention. The patient may die of what may be termed granular disease of the kidney, and the condition of the liver be unnoticed. In this scrofulous disease, the liver increases in size in much greater degree than the kidney. In the case of Woodman, last related, where, by the progress of the disease, the kidneys had almost ceased to perform their office, the liver reached to the pubis, and almost filled the belly, while the kidneys were not very much larger than they should be. The same thing happens in the " fatty degeneration " of these organs: the liver enlarges in much greater degree than the kidneys, and contains a very much larger proportion of fatty matter. But although the foreign matter is relatively in much smaller amount in the kidney, it does, apparently, much more mischief. EFFECTS. 331 To take merely the case of Woodman. Notwithstanding the large size of the liver in him, there was no decided jaundice; and after death, the gall-bladder was found filled with dark-colored, viscid bile, as it usually is in persons who have taken no food for some time before death. Bile, then, of the usual appearance, con- tinued to be secreted to the last, and its passage through the ducts was not sufficiently impeded to cause serious disorder of health. There was, indeed, some obstruction to the passage of the blood through the liver; but it was not sufficient to cause much ascites. The disease of the liver most probaby induced an impoverished state of the blood, but there is reason to believe that if it had existed alone, Woodman might have continued to live for a long time. It was the disease of the kidneys that brought his life to a close. This disease of the kidneys caused a constant drain of albumen, and thus gradually exhausted the strength; and, in the end, destroyed life quickly, by preventing the proper excretion of urine. A similar difference is observed in the effects of the fatty degene- ration of these two organs. The liver, from fatty degeneration, may be doubled in weight, and more than doubled in bulk, but may still perform its office tolerably well; the blood, at least, may pass freely through it; there may be no jaundice; and, after death, the bile found in the gall- bladder may present no unusual appearances. Fatty degeneration of the kidney, however, although the organ is increased in bulk in much less degree, and the fatty matter forms a much smaller proportion of the entire weight, leads to albuminous urine and dropsy, and destroys life. It will be seen that in two of the four cases, without any history of ague, the spleen was very large and very firm. No minute exa- mination of it was made; but it is probable that it had undergone a change analogous to that of the liver and the kidney, and that its increase of size was due to the interstitial deposit of a foreign albuminous matter. The details of the preceding cases show the changes which the liver undergoes in this disease. 1st. It becomes enormously enlarged, and, as happens in the fatty degeneration, in which the foreign matter is likewise retained in 332 SCROFULOUS ENLARGEMENT OF THE LIVER. the lobules, it becomes at the same time much thickened, and its lower edge much rounded. 2d. Like a liver that is much enlarged by fatty degeneration, and probably from the same mechanical condition, it contains after death but a small quantity of blood, and is consequently pale. 3d. When the disease is far advanced, the lobules can scarcely be distinguished, especially in the centre and in the upper broad part of the liver, where they are most compressed; and the hepatic substance is uniform and compact, and at the same time somewhat glistening or semi-transparent, so that the cut surface looks very much like that of compact bacon. It is very tough, so as not to be readily broken down, and is generally whitish; but, now and then (as in Case 4), from the retention of bile, has a yellowish cast. Livers in this state have been often described as " waxy" livers, and their peculiar appearances have been wrongly attributed to the interstitial deposit of one of the solid forms of fat. 4th. The foreign matter, to which the liver owes its large size, is albuminous, and, when not stained by bile, is whitish and some- what glistening. It does not become hard, and, unlike the lymph that is poured out in ordinary inflammation, it seems to have no tendency to contract; so that after the disease has lasted for years, the liver pits on pressure, and its surface is smooth. These circum- stances explain the fact, that the foreign matter, though large in amount, does not much impede either the passage of the blood through the liver or the escape of the bile through the ducts. 5th. The foreign matter is situated within the lobules, and from one of the cases (Case 4), it would seem that it is deposited first in the central portions of the lobules. In the parts of the liver which are most diseased, the secreting cells are few in number, and they are not enlarged. The foreign matter is not within the cells, but between them, and, in advanced stages of the disease, seems, in some parts of the liver, completely to take their place, filling up the interstices of the capillary vessels that form the lobular network. In some of the cases the cells were observed to contain much granular matter, and to be in consequence more opaque than na- tural ; but it must be remembered that this was after the occur- rence of disease of the kidney, which might in some degree have changed the secreted product of the liver-cells. The absence of decided jaundice, the natural appearance of the EFFEOTS. 333 bile found in the gall-bladder in two of the cases, notwithstanding the disease of the liver had lasted so long, and the fact that the cells contained nearly their natural quantity of oil, tend to show that the cells performed their office tolerably well. 6th. Chemical analysis showed that in two of the cases the liver contained a small proportional quantity of fat. In one of them (Case 3), it contained rather more than a grain of fatty matter, and, in the other (Case 4), little more than half a grain in 100 grains of liver: whereas, it would appear, from cases related in the preceding chapter, that the normal quantity of oil in the liver is three or four parts in 100. It must be borne in mind, however, that the liver was doubled in weight by the interstitial deposit of a foreign albuminous mat- ter ; so that the total quantity of oil in the liver was only half as much below the natural standard as the figures above would at first seem to denote. It is probable, also, that by the long presence of the foreign matter the cells had become much less numerous than in a healthy liver; and we have thus an explanation of the fact, that while the liver contained a very small relative amount of oil, the quantity of oil seen by the microscope in the cells did not seem to be much smaller than natural. 7th. All the cases related above were striking examples of the disease. The same changes, in less degree, not unfrequently occur among such of the poor in our large cities as are scrofulous or cachectic, and, at the same time, intemperate—causing more or less enlargement of the liver, and giving it a somewhat " waxy" appear- ance, but without otherwise attracting particular notice. 8th. This peculiar condition of the liver, in its highest degree, is most frequently found in young persons who have long suffered from scrofulous caries. There is some circumstance connected with caries—most probably the protracted suppuration resulting from it, or the continual loss of earthy matter—that disposes to this peculiar form of disease. In the following case it occurred in a man of middle age, who exhibited no marks of the scrofulous habit, and was not afflicted with caries, but who had long suffered from disease of the left kid- ney, attended with constant suppuration. Case 5.__Henry Warner, a printer, aged thirty-seven, who had always lived in London, was admitted into King's College Hospital on the 26th of August, 1849, suffering severe pain in the left loin, passing pus with his urine, and having other symptoms indicating the existence of suppura- 334 SCROFULOUS ENLARGEMENT OF THE LIVER. tion in the left kidney. He was rather short in stature, but well-formed and muscular, and presented no marks of the scrofulous habit. He con- fessed that of late years he had drunk gin rather freely ; but stated that his health had been good until the accession of the illness he then had, of which he gave the following account:— About four years before he was taken with severe pain in the left loin, extending to the pubis and scrotum ; attended with difficulty in passing his water, which was red and turbid. The pain subsided after a time, but the water continued to be more or less turbid. Between two and three years after this illness, in the summer of 1848, he received a severe blow in the back by a trap-door falling on him while he was in the act of stooping. On account of this accident he was taken to St. Bartholomew's Hospital, where he remained a fortnight. About a month after this he had severe pain in the left loin, with rigors and vomit- ing, and applied as an out-patient at King's College Hospital. He was there under treatment, as an out-patient, for four months, during which time there was constantly pus in his urine In August, 1849, soon after he was admitted into King's College Hos- pital, it was discovered that there was an abscess in the left loin, making its way to the surface. The abscess was opened, and a great quantity of pus escaped. From that time, with the exception of a few weeks during which the opening in the back was closed, there was constantly a discharge of pus through a fistulous opening in the loin. He was a patient at the hospital, off and on, for several months, constantly suffering pain in the loin, and having a constant discharge of pus in the urine, and also through the fistulous opening in the loin. In this state he at length resumed his work, and I lost sight of him. No enlargement of the liver had been then noticed. On the 15th of October, 1851, he was again brought into the hospital, considerably reduced in flesh, and suffering much in the same way as be- fore, with pus still escaping with his urine, and through the loin. The liver was now found to be enormously enlarged, reaching below the um- bilicus and into the right iliac region, and greatly distending the belly. The superficial veins of the belly were enlarged, and there seemed to be a small quantity of fluid in the peritoneal sac. The liver was slightly ten- der, and he occasionally felt pain in it when lying on the right side. Its lower edge was felt to be rounded. He stated that the belly had been growing gradually larger for twelve months. He remained in the hospital till the 28th of November, when he left at his own request. During the last fortnight of his stay there the urine, which was constantly acid, ranged in quantity from two to three pints a day, and in sp. gr. from 1017 to 1010. It always contained a small quantity of pus. On the 19th of January, 1852, he came into the hospital again—more emaciated than before. His complexion was now slightly sallow; there was distinct ascites; and the legs and scrotum were slightly cedematous. Pus still escaped in the urine, and through the loin. The pulse was fre- quent ; the tongue brown ; and he had frequent vomiting. The urine now averaged little more than a pint daily, and its sp. gr. was about 1016. He died in the hospital on the 29th of January. EFFECTS. 335 The body was examined thirty-two hours after death. It was much emaciated, and the skin had a faint yellow tinge. The peritoneum contained a large quantity of straw-colored fluid of sp. gr. 1017 ; and the legs and scrotum were slightly dropsical. The liver, which had no unnatural adhesions, was enormously enlarged, and weighed eight pounds and three-quarters. Its surface was smooth, except near the lower edge, where it was slightly nodulous, as in cirrhosis. It was tough, and pitted on pressure, and when cut into presented the compactness and the same uniform glistening ap- pearance as in the preceding cases. In its upper part there seemed to be but little fat, and the lobules could nowhere be distinguished. Towards the lower edge fat was deposited in greater quantity, and formed a distinct yellowish rim round many of the lobules. A portion of the liver from the upper part, and a portion from near the lower edge, were analyzed for me by Mr. Beale, and were found to contain in 100 parts 2.1 parts and 4.7 parts of fatty matter respectively. The gall-bladder contained a pale orange-colored bile, which reddened litmus paper. The left kidney, which was imbedded in a dense mass of fat and adven- titious tissue, was distended into pouches filled up by irregular calculi of phosphate of lime. Its interior communicated with the fistulous opening in the back. The right kidney was enlarged, and presented changes of structure like those noticed in some of the preceding cases. All the secreting tubules were more or less diseased ; in some the epithelium was only slightly granular; in others it was entirely disintegrated; in others, again, it was replaced by cells in size and appearance like pus-globules. In a few tubules the epithelium contained pretty numerous but minute oil-globules. There was no disease worthy of note in other parts of the body. In this case, the change in the liver was of precisely the same kind as in the preceding cases, but the circumstances under which it occurred were different. The patient, instead of being young and affected with scrofulous caries, was of middle age, and his primary disease was abscess of the left kidney, which seems to have nothing in common with scrofulous caries, excepting protracted suppuration. By the nature of the matter choking the liver, the disease we are considering is closely allied to cirrhosis, and in the instance just related the patient was known to have drunk spirits to excess. It seems probable, therefore, that in this instance spirit-drinking con- tributed to produce the disease; and it is not unlikely, although no evidence is adduced to this effect, that in some of the former cases ardent spirits were taken, according to the custom which prevails among the poor in this city, with the view of supporting the strength under the protracted suppuration, and that in them, too, it may have contributed to induce the disease. It will be seen that in the case just related, as in many of the 336 SCROFULOUS ENLARGEMENT OF THE LIVER. preceding cases, there was disease of the secreting tubules of the kidney. The disease of the liver, indeed, in such cases, almost necessarily leads, in the end, to disease of the kidney. In conse- quence of the primary chronic disease, and the unhealthy constitu- tion, and, it may be, the faulty habits of life, the blood becomes charged with impurities, which, as they can no longer be retained in the liver, or cast off through it, are thrown upon the kidneys. An attempt is made by the kidneys to eliminate them, in addition to the ordinary principles of the urine, and the result is disease of the secreting tubules. In most of the preceding cases it was noted that the patient, even when not much wasted in flesh, was in a state of anemia. The state of anemia in these cases may have resulted, in part, from the loss of albumen, in consequence of the disease of the kidney; but this disease of the liver itself, as does every disease of the liver that causes much atrophy of its secreting element, induces after a time a state of anemia, most probably by lessening the amount of those changes which the blood naturally undergoes in its passage through the liver, and which, doubtless, contribute in some way or other to the reproduction of its colored corpuscles. It seems strange that, notwithstanding the striking change in the size and texture of the liver, which must often be attended with great diminution in the number of its secreting cells, there should be no jaundice in this disease, and after death, often no tinge of bile in the liver itself. The circumstance may, like the state of anemia, be owing in some measure to diminution in the amount of those changes which the blood naturally undergoes in its passage through the liver, which diminution probably lessens the quantity of biliary coloring matter that has to be cast off. The absence of jaundice affords, therefore, a strong argument in favor of the opinion that much of the coloring matter of the bile is formed in the liver itself, as a result of the changes which there take place in the blood. The bile found in the gall-bladder after death presents, as in cir- rhosis, different appearances in different cases. In some cases (as in Case 4) it is viscid and of a dark olive color, like healthy bile that has been concentrated; in others, on the contrary (as in Case 5), it is thin and unusually pale. It might be expected that it would occasionally contain albumen; but no observations, that I EFFECTS. 337 am aware of, have been made showing that it has any peculiar or constant characters. The scrofulous enlargement of the liver may sometimes be dis- tinguished when the patient is living. It occurs in its highest degree in scrofulous persons suffering from caries, and, like the enlargement from accumulation of fat, it comes on insidiously, without much pain or even much tenderness—a circumstance ac- counted for by the gradual and even manner in which the foreign matter accumulates, and by its having no tendency to cause inflam- mation of the capsule of the liver. As happens with the fatty degeneration, the first evidence that the liver is diseased is gene- rally furnished by its large size. The belly is observed to be large, and, on examination, the liver is found to extend much below its natural limits. The intestines are seldom much distend- ed with gas, and, if the walls of the belly be thin, the surface of the liver may be felt to be smooth, and its lower edge to be rounded. The effects are, so far, like those of the fatty degenera- tion ; but in the scrofulous enlargement, the passage of the blood through the liver is more impeded than in the fatty degeneration— probably from the foreign matter being firmer and less yielding than oil-globules—and the escape of bile from the liver is also somewhat more impeded, so that, after a time (as happened in Case 4), the superficial veins of the belly sometimes grow large, a small quantity of fluid collects in the peritoneal sac, and there is a slight tinge of yellow in the conjunctiva and the skin. The effects of this disease at this stage are intermediate between the effects of the fatty liver and those of cirrhosis. If, in a young person, who has long suffered from scrofulous disease of the bones, there is great enlargement of the liver, with a small quantity of liquid in the peritoneal sac, and very slight sallowness of the conjunctiva, and if the surface of the liver be smooth, and its lower edge rounded, and it be occasionally slightly tender at certain spots—there can be little doubt that the liver does not owe its large size to an accumulation of fatty matter, but to the peculiar disease we are considering. If, after a time, the urine becomes albuminous, and if, when the urine is examined under the microscope, waxy-looking casts of the secreting tubules are seen, there can be no doubt of the existence 22 338 SCROFULOUS ENLARGEMENT OF THE LIVER. of this peculiar change in the liver, and of corresponding disease in the kidney. The cases related above furnish no satisfactory evidence on the subject of treatment. In the last but one of the series (Case 4), the patient was under treatment for many months after the nature of the disease of the liver was known; and almond oil, nitro- muriatic acid, and the muriate of ammonia, were given for some time in succession, without lessening the size of the liver, or doing any essential good. From the failure of these medicines, in this instance, we should not, however, be warranted in inferring their complete inefficacy to remedy or prevent this disease in all other cases. It must he borne in mind that the scrofulous disease of the hip, which was, seemingly, the primary cause of the changes in the liver and the kidney, was not remedied; and it can hardly be ex- pected that any such changes will be arrested while their cause continues in active operation. If the diseased limb could have been removed, or the caries of the bone stopped, before the kidneys became seriously damaged, it is not impossible that the effect of some of those medicines might have been more satisfactory. I have more than once known a large liver, which I supposed to have undergone the change we have been considering, diminish very much in size under the pro- longed use of muriate of ammonia. Enlargement of the liver, which seems to be identical with the scrofulous enlargement, sometimes occurs in persons whose health is broken from the combined effects of mercury and syphilis. The fact that enlargement of the liver is apt to occur in such persons, was, I believe, first distinctly noticed by Dr. Graves, who gives the following account of a case of it: " About two years since, I was consulted by an English gentleman, who had been ill for a con- siderable time. The history of his case from the commencement was this: Three years previously, he had venereal — used and abused mercury—was exposed to cold, and got periostitis. He now got into a bad state of health, used mercury a second time; obtained some relief, and then relapsed again; finally, after having used mercury three or four times, he was attacked with mercurial cachexy, became weak and emaciated; the periostitis degenerated into ostitis, producing superficial caries and nodes of a bad charac- ter ; he had exfoliation of the bones of the cranium, and rupia, and * EFFECTS., 339 was reduced to a most miserable state. Under our care, the symp- toms gradually disappeared; he recovered to all appearances, and even got fat. He then caught cold, and relapsed again. At last, his liver became engaged; he was attacked with hypertrophy of the liver, ascites, and jaundice, and died soon afterwards." " While this gentleman's liver was enlarging, there was no tenderness of the right hypochondrium on pressure." " What is equally remarkable, he had no fever, and the tongue was perfectly clean and moist during the whole course of the hepatic affection." Dr. Graves says that he has since witnessed a similar train of phenomena—syphilis, abuse of mercury, periostitis, enlargement of the liver—twice in private practice, and once in hospital prac- tice. In not one of these cases was the liver tender on pressure. This account alone would render it extremely probable that the change which the liver undergoes in such cases is very like that which occurs in scrofula. Mere fatty degeneration of the liver does not cause ascites, which occurred in the case of which Dr. Graves has given the details. My own experience furnishes more positive evidence on this point. Some time ago I had an opportunity of minutely examin- ing a liver, which had all the characters of the scrofulous enlarge- ment in a striking degree, and which was taken from a man of middle age, who had long had syphilitic caries of the bones of the skull. Severe and protracted syphilitic disease of the bones, like scrofulous disease, often leads after a time to fatal disease of the kidney, which, like the enlargement of the liver, comes on gradu- ally without pain or any active inflammatory symptoms. Sus- picion is excited by the gradually increasing paleness, and an examination of the urine leads to the discovery that it is highly charged with albumen. I could cite from my own experience many examples of this sequence of events. It has been truly remarked by Dr. Graves, that the mercurial and syphilitic cachexy very closely resembles scrofulous cachexy. There is the same impaired nutrition, irritability and feverishness; and the skin, the glands, and the bones, which principally suffer in the one, suffer also, and in much the same way, in the other. I believe, however, that when arising from syphilis, as when arising from scrofula, the highest degree of this peculiar change in the liver will be generally found associated with caries,.or with some other disease of the bones. 340 SCROFULOUS ENLARGEMENT OF THE LIVER. It is stated by Eokitansky, that enlargement of the liver, with the same anatomical characters, is sometimes produced by pro- longed attacks of ague. I have met with one instance in which severe and long-continued ague in a boy was followed by scrofu- lous disease of the glands of the neck and of the bones, and subse- quently, by great enlargement of the liver, and ascites. But here, the enlargement of the liver was attributable to the scrofula, and could not be considered the immediate effect of the ague. The liver very seldom gets much enlarged from ague. I have ex- amined, in the Seamen's Hospital, a great number of bodies in which the spleen was enormously enlarged from ague, caught in China, in the West Indies, or on the west coast of Africa; but in none of those cases did I remark the liver to be much enlarged. After remittent or yellow fever, the liver remains for a long time of a pale slate color, but it is not generally enlarged. Enlargement of the liver presenting the characters of the scrofu- lous enlargement now and then occurs, without our being able to trace it to any of the circumstances specified. The diseases we have been considering were at one time re- garded as simple hypertrophy of the liver; the term hypertrophy meaning, as when applied to muscles, mere increase of bulk, with- out change of structure. But, as we have seen, this is an errone- ous view. The increased size of the liver, in the fatty liver, in the scrofulous liver, and in other kindred states, depends on the pre- sence of some peculiar matter which, instead of passing off in the bile, is retained in the substance of the organ. The pathologists, who looked upon the enlargement of the liver in these cases as due to simple hypertrophy, were at times much perplexed to account for the symptoms attending it. Andral, in his remarks on a case of great enlargement of the liver, consequent on syphilis and the use of mercury, which he has given as an instance of simple hyper- trophy of this organ, expresses much surprise that there was not a corresponding increase in the quantity of bile secreted. He says: " One would have thought, a priori, that when the nutrition of the liver was increased in so extraordinary a degree, the secretion of bile would have been more abundant in proportion. Such, how- ever was not the case. During life but little bile was discharged, and after death the gall-bladder held only a small quantity, and TREATMENT. 341 this containing, seemingly, more water and albumen than usual, as if, while the nutrition of the liver became more active, its force of secretion diminished. The case to be next related will serve, perhaps, to confirm this conjecture. It furnishes, in fact, an in- stance of jaundice, without other change in the liver than simple hypertrophy." {Clin. Med., iv. 305.) The thin and pale bile in one of the cases related by Andral, and the complete suspension of secretion, as evinced by the complete jaundice in the other, lead to the conclusion, that the malady was not simple hypertrophy, in the sense usually given to that term. The liver, if it be called on to do for a long time somewhat more than its ordinary work, may perhaps become somewhat enlarged from simple hypertrophy—that is, from increase in the number of the secreting cells, and a corresponding increased development of the other tissues of which the liver is made up ; parts of the liver may doubtless undergo this kind of hypertrophy when other parts are wasted; but in such cases the functional power of the organ will be increased in proportion to its increased bulk, and the hyper- trophy will not be disease. The treatment in the class of cases considered in this chapter should in some degree be directed by reference to the primary disease, or the peculiar cachexy, on which the enlargement of the liver depends. When the enlargement of the liver is consequent on scrofura, our chief reliance must be on warm clothing; sea air and sea-bathing; a light nourishing diet, comprising a liberal allowance of animal food; cod-liver oil; the muriate of ammonia ; the preparations of iodine and iron, separate or combined; and if the enlargement of the liver should be associated with caries, those surgical or other means which tend to arrest the disease of the bone. When the health has been broken by the combined effects of syphilis and mercury, warm clothing, a tonic regimen, iodide of potassium, iron, nitric acid, hot sulphur baths, sarsaparilla, and guaiacum, are the appropriate remedies. In either case, when the liver is thus oppressed, the patient should entirely abstain from ardent spirits, and be very sparing in the use of the less injurious fermented drinks. Reasons have, indeed been already given for thinking that spirit-drinking is often, if not generally, instrumental in producing the disease. However the disease may originate, it must be important, with 342 SCROFULOUS ENLARGEMENT OF THE LIVER. the view of relieving the oppressed liver and of preventing the similar, but more serious disease of the kidney, that the bowels should be rightly regulated; that the action of the skin should be kept up; and that the patient should breathe the fresh air. There is great reason to hope, that, if we can cure the original malady before the enlargement of the liver has attained a very great degree and before the kidneys have become likewise diseased, we shall be able, in many cases, if not in all, to remedy, in great measure, the unnatural condition of the liver and other secondary ailments. The matter deposited in the liver does not become or- ganized, like the lymph poured out in common inflammation ; and if the general health should mend, it may, in time, all pass off with the bile, or be removed by absorption. I have met with more than one instance of considerable chronic enlargement of the liver, with impairment of health, in which, after a time, the liver returned to its natural size, and the health was restored. In July, 1846, I was consulted by a lady, forty-four years of age, on account of considerable enlargement of the liver, which had been detected by her former medical attendant in the March pre- ceding. She had been much out of health more than six months, and had lost flesh, and had a craving appetite, and a constant sense of weight and fulness in the right side; but there was no jaundice. She remained under my care for three months, at the end of which time, contrary to my anticipation, her health was re-established, and the liver had returned nearly, if not quite, to its natural size. The amendment seemed to result from properly regulated diet and the prolonged use of the sesquicarbonate of ammonia, in doses of five grains twice a day. This was ordered, at first, without direct reference to the liver, and persevered in, from the fact that her health continued to improve under its use. In December, 1847, a young lady, twenty-six years of age, was placed under my care, with great enlargement both of the liver and the spleen. The enlargement of the liver had been detected nine months before. She had lost flesh much, and was pallid and slightly sallow, and had a good deal of irritative fever. Mercury to salivation, iodine, taraxacum, and nitro-muriatic acid, had been tried in turn, without success. Her health greatly improved under strict diet, with abstinence from all stimulants, and the muriate of ammonia, in doses from five to ten grains, three times a day. In TREATMENT. 343 1850, the spleen was still large, but the liver had returned to its normal size; and, though still looking very delicate, she considered herself well. The salts of ammonia probably relieve the liver, and do good in such cases by promoting the action of the skin and the kidneys. Dr. Graves has given very strong testimony to the fact that con- siderable enlargement of the liver, having the characters of the fatty or the scrofulous enlargement, may after a time disappear. He says:— "In persons below thirty, the liver may become enlarged to a very considerable extent, and yet return again to its natural size under proper treatment. I could point out several persons, in Dub- lin, in whom the liver had been so much enlarged that I thought their cases hopeless, and yet they have recovered, and are at pre- sent in the enjoyment of good health. The process by which the organ returns to its natural state and dimensions is generally slow; in two or three cases it occupied a space of time varying from one to two years. I attended a gentleman some time ago, with Mr. Carmichael, and, from the history of the case, as well as from the symptoms present, we were induced to look upon it as incurable, and yet the patient has completely recovered. The late Mr. Mac- namara and I attended a lady who had a very remarkable enlarge- ment of the liver, but, in the course of a year, the viscus diminished so much in size as to be very little above the normal dimensions. Within the last year (1842), Dr. Stokes and I have treated success- fully an old gentleman, between seventy and eighty years of age, who had an enormously enlarged liver and ascites. We agreed to try a combination of blue pill and hydriodate of potash. This he took for nearly six months, and its use was attended by visible, almost daily, decrease in the size of the liver, and his general health gradu- ally improved. He took the pills for a couple of months before his mouth got a little sore; but full salivation was not produced. He called on us, a few weeks ago, to thank us for our successful treatment, and took no small pleasure in directing attention to his altered appearance and renovated health. This is a matter of no common interest, for cases of this description have been generally looked upon as beyond the reach of medical aid. You should, therefore, be very careful in your prognosis of such cases, and not give them up at once as incurable." {Clinical Medicine, p. 568.) A paper has recently been published by Yirchow {Archiv. f. Pa- 344 SCROFULOUS ENLARGEMENT OF THE LIVER. tholog. Anatomie und Physiologie, Bd. viii. p. 364), and transferred to the pages of the Microscopical Journal {Quarterly Journal of Microscopical Science, No. 14, for January, 1856), in which he announces that the matter infiltrating the liver, in what I have called "the scrofulous enlargement," gives, with a solution of iodine, the chemical reaction of starch, like the so-called amyloid bodies, occasionally found in the brain; that, when treated with a solution of iodine, it acquires, like starch, an intense reddish-yellow color, turning, on the addition of sulphuric acid, to a beautiful violet and blue, and he, therefore, proposes to call this condition of the liver the amyloid degeneration. Virchow observes that, as I have before stated, the peculiar matter in the liver is deposited first in the cen- tres of the lobules, and that the liver, spleen, and kidney, undergo, in succession, the same change. He likewise confirms the remark that this peculiar change is in some way or other connected with disease of the bones, especially with caries. If the announcement —that the matter which infiltrates the liver is starch—should turn out to be true, this disease of the liver may be cited to show how unexpected are the changes and relations sometimes disclosed, as medicine advances, and how imperfect and transitional our know- ledge of most subjects of pathology still is. 345 SECT. IY.—Excessive and defective secretion of bile—Unhealthy states of the bile. From the diseases just considered, we pass, naturally, to a very important class of disorders—namely, those functional disorders in which too much, or too little, bile is secreted, or the bile secreted is not healthy. It has been shown by Bernard (see p. 56) that two distinct pro- cesses of the nature of secretions go on in the liver—the secretion of bile, and the formation of sugar. The bile flows through the gall-ducts into the bowel; the sugar is absorbed by the veins and lymphatics in the liver, and thus passes directly into the blood which is about to traverse the lung. Both these secretions are no doubt connected with the reparative and other changes which the blood undergoes in its passage through the liver. The manner in which the functions of the liver are performed may, therefore, be investigated with reference to three points— 1st. To the changes effected in the blood. 2d. To the formation of sugar. 3d. To the secretion of bile. In living human beings we have no means of ascertaining the degree in which the regeneration of the blood in the liver is affected by various morbid conditions; but the facts related in the preced- ing pages show clearly-enough that any great destruction of the lobular substance of the liver, or any condition that arrests the secretion of bile, causes a state of anemia—that is, lessens the pro- portion of the red corpuscles in the blood. Our knowledge of the formation of sugar in the liver, and of the various conditions that lessen or increase it, is entirely due to the researches of Bernard. The sugar formed in the liver, except it be in excessive amount so as to cause the diabetic state, is all trans- formed in the blood, and does not appear in any secretion open to 346 FUNCTIONAL DISORDERS OF THE LIVER. our inspection, so that its relative amount at different times in ordinary cases cannot be determined, even approximately, by mere clinical observation. It has been ascertained by Bernard that, in the animals that were the subjects of his experiments, the production of sugar is lessened by subjecting them to extreme heat or extreme cold; that it is lessened by prolonged fasting, by severe pain, and, generally, by acute diseases attended with fever ; so that, in persons who die of disease, the liver after death seldom contains sugar; and that it is completely arrested by division of the pneumogastric nerves in the neck, and by cutting across the spinal marrow just below the brachial enlargement. The secretion may be increased, so as to cause for a time the diabetic state, by lacerating the floor of the fourth ventricle, be- tween the origins of the pneumogastric and the auditory nerves; and it is somewhat increased by the apoplectic state, whether this result from disease or physical injury of the brain, or from the action of some narcotic poison upon it. The increased formation of sugar in the apoplectic state is, ac- cording to Bernard, but a particular exemplification of the general law, that, " when the voluntary movements and sensation are ex- tinguished, all internal organs—the liver, intestines, glands—all the viscera, in short, which are not subjected to the influence of the will, present a greater activity than in the normal state. The vital energy, which has ceased for all the actions of animal life, seems to concentrate itself upon the acts that are purely organic." The most striking and suggestive circumstance disclosed in these remarkable researches, is the controlling and governing power over the secretion of sugar which the nervous system exerts. It appears, from Bernard's experiments, that although these two secretions—the secretion of sugar and the secretion of bile—go on together in the liver, the variations in the one do not correspond in time or degree with the variations in the other. The secretion of bile may be disordered from organic disease of the liver, which renders it incapable of adequately performing its functions; or, without this, when the portal blood, from which the materials of the bile are drawn, is rendered unhealthy by medicines, by unwholesome food, by faulty digestion or assimilation, or by defective action of some other excreting organ. It may be dis- FUNCTIONAL DISORDERS OF THE LIVER. 347 Ordered, too, by the direct influence of anxiety or strong mental emotion. In any case, the disordered secretion of bile is the effect of some other disease, or of some condition that deranges other organs as well as the liver. But the bile has a long course before it passes out of the body, and serves an important office in the intestinal canal; and on these accounts, if it be in undue quantity, or unhealthy, however the change in its quantity or quality may have been brought about, it may cause various secondary disorders. In the first place, it may inflame or irritate the gall-ducts, or the parts of the intestine with which it is brought into contact. There is reason to believe that most of the diseases of the gall-bladder and gall-ducts are produced by irritating bile; and there can be no doubt that disorders of the bowels sometimes arise from the bile being in improper quantity or unhealthy. But besides these mere loeal effects, a faulty state of the bile may render digestion imperfect, and in this way may impair nutrition; and the noxious products of imperfect digestion may be absorbed into the blood, and from this, again, many se- condary evils may spring. Unhealthy states of the bile are analogous to unhealthy states of the urine, and may result in the same way, either from fault of the secreting organ, or from an unhealthy state of the blood. Un- healthy states of the urine have excited more interest, because, from our being able to collect and analyze the urine, we can distinguish them, and trace them to the disease of the kidney, or to the faulty digestion and assimilation, on which they depend. They are some of them, as albuminous urine and saccharine urine, almost pathog- nomonic of certain fatal diseases which we might not otherwise de- tect. Unhealthy states of the bile have less importance in this sense, because we cannot distinguish them, and thus trace them to their source; but in another sense they are more important, from the bile serving an important office, and not being merely excre- mentitious, like the urine. From our not being able to collect the bile during the life of the patient, and from the difficulty of analyzing what may be found in the gall-bladder after death, we have little knowledge of unhealthy states of this fluid. It is often easy to say, from the symptoms, that too much bile, or too little bile, is secreted, and something is known of the effects of this redundant or deficient secretion; but we have 348 EXCESSIVE SECRETION OF BILE. little knowledge of changes in the composition of bile, except what is derived from mere inspection. We may therefore first consider excessive secretion of bile, and deficient secretion of bile. Excessive secretion of bile.—The quantity of bile secreted, like the quantity of urine, no doubt varies very much, without disorder of health, according to climate, season, and habits of life. In certain circumstances, pointed out in a former part of this work, an un- usually large secretion of bile is necessary for the maintenance of health. It can only be considered morbid, when, from the abund- ance of the bile, and perhaps from its being at the same time altered in quality, secondary disorders arise. This frequently happens to persons on their first going to a hot climate. It is of very common occurrence among Europeans in India, and has been well described by Annesley, under the head, Excessive Secretion of Bile. In the slighter degrees of this bilious disorder the patient has purging of bilious matter, which soon produces scalding of the rec- tum, with slight sickness, a bitter taste in the mouth, and a foul tongue, but without much fever, or the pulse being much quickened. These symptoms rapidly subside, when the redundant bile has been got rid of by an emetic and by purgatives. In a more severe form of the disease, together with purging of bilious matter, and vomiting, and foul tongue, there is a good deal of fever, with pain and tenderness in the region of the liver; and the complexion is bilious, or dusky. The illness resembles a slight form of bilious fever, and is attended with much congestion of the liver, and, it would seem, with inflammation of the gall-ducts, caused by the bile, which, while it is increased in quantity, is doubt- less also altered in quality, and irritating to the lining membrane of the ducts as well as to that of the bowel. In such cases, Annesley recommends bleeding from the arm, or cupping over the liver, calomel and saline purgatives, and copious draughts of hot water to dilute the irritating bile. Under this treatment, the patient in most cases soon regains his former health.1 1 Diluents must have a most beneficial action in such cases, because water is readily excreted by the liver, and thus tends to dilute the bile at its source. It has been shown by Lehmann that the blood of the portal vein contains much more water than the blood of the hepatic vein, especially after drinking. (Lehmann's Physiological Chemistry, vol. ii. p. 99.) TREATMENT. 349 In this country a similar form of illness is often seen, especially among men of middle age who have long been in the habit of liv- ing freely. Such persons go on for some time without apparent indigestion or other inconvenience, but, at length, get what is called a bilious attack. This is marked by sickness and bilious diarrhoea, a certain degree of fever, with a feeling of general disorder, often with headache, and by a foul tongue and turbid urine. In some instances there is likewise a sense of fulness, or uneasiness, in the region of the liver, and the complexion is bilious. These com- plaints are, in most cases, readily removed by brisk purging with calomel and salts, and the patient enjoys again, for some time, his former health. If he returns to his former habits, he, by-and-by, gets a similar attack, which perhaps is removed as before. In this way, he may go on for years, his general good health being only interrupted by an occasional bilious attack of this kind, which, like a fit of gout, seems to clear the system for a time. As was re- marked by Dr. Prout, the acid and unassimilated matters seem to accumulate in the system, and to be thrown off periodically. The readiness with which these attacks are removed, often makes people regard them lightly; but they are not unimportant, as evi- dence of disorders, which, aggravated by time and by continuance in the habits under which they have arisen, may end in some or- ganic disease, or in the total failure of those assimilating processes on which nutrition depends. During the attacks, signal relief is produced by a dose of calomel, or blue pill, followed by saline pur- gatives. If there should be pain or tenderness in the region of the liver, and the patient can well bear it, blood may be taken by leeches, or by cupping. These measures are generally sufficient for the time, but they do not strike at the root of the evil. Exemption from future attacks, and from the manifold and greater evils to which these disorders may lead as age advances, can only be pro- cured by a change of habits. One of our objects in directing this should be to increase the amount of oxygen inspired, and thus to consume in respiration, or burn off, materials that would otherwise be left for the liver to excrete. The means most efficacious for this purpose are sea-voyages, riding, or other exercise in the open air, well-ventilated rooms, early rising, the cold or shower bath, &c. Too much indulgence in sleep, which so much reduces the activity of both respiration and circulation, must be especially injurious, 350 EXCESSIVE SECRETION OF BILE. more particularly in rooms that are ill ventilated, as most bedrooms are. Another object, of equal or still greater importance, should be to limit in the food the supply of those materials—such as spirituous liquors, butter, cream, fat—which, in persons in the condition we are considering, embarrass the secreting function of the liver, and, at the same time, if they do not contribute directly to form bile, tend, by serving as fuel for respiration, to increase the quantity of matter which the liver is called on to excrete. Plainly enough, it must be especially injurious for persons who suffer from this class of disorders, to indulge in sleep immediately after a full meal. To lessen by sleep the activity of respiration at the very time when the materials consumed in this process are being poured in large quantity into the blood, must lead, in a twofold way, to an accumulation of excrementitious matters in the system, and favor the occurrence of a bilious attack. Iu this way may be ex- plained the ill effects of suppers in disorders of this class, and the well known fact that a single indulgence of this kind may bring on a bilious attack in a person predisposed to it. The medicines that are most efficacious are such as tend to pro- mote digestion, and to keep up a regular action of the bowels. A few grains of rhubarb, alone, or in conjunction with a grain of ipe- cacuanha, taken habitually at dinner, or, if the patient be plethoric, occasional small doses of saline purgatives, taken in the morning, are often of service. Fluids taken in large quantity, in the form of mineral waters, or pure water, have also often much efficacy in these disorders. But our most effective resources are those hygienic regulations, before pointed out, which have relation to the great conditions of air, exercise, and temperature, on the one hand, and to the quantity and quality of the food, on the other. In the degree of confidence he places in these resources, and in the preponderance he gives them over mere drugging in the treatment of disorders of this class, the practitioner will give the best evidence of his real insight into their nature, and of practical skill founded upon it. It adds not a little to the value and importance of these means that they are so free from hazard, and that they act in a way in which no others can act, and therefore have no perfect substitute in any direct medication. By appropriate purgatives, we may temporarily drain the liver and intestines of redundant bile ; but by the means here pointed out, DEFICIENT SECRETION OF BILE. 851 we attack the evil at its source, and prevent the occurrence of the bilious state. Deficient secretion of bile.—But disorder may likewise result from the bile being secreted in too small quantity. In secreting bile the liver serves two purposes—it purifies the blood by freeing it from the excrementitious principles of the bile and from other excrementitious substances that are eliminated with it; and, by means of the bile, it aids the work of intestinal digestion. The secretion of bile may therefore be deficient in two respects. Too little bile may be secreted to purify the blood, or without this, too little may be secreted to perform the necessary part in digestion. The simplest form of disorder arising from deficient secretion of bile is where, while the blood is not tinged with the biliary pig- ment, and the complexion remains clear, too little bile is secreted for the purposes of digestion. ' In such cases, digestion is usually slow and imperfect; the bowels are irregular, and generally con- fined ; the contents of the large intestine often become too acid, or otherwise irritating, and produce headache, or depression of spirits, or occasional diarrhoea. Disorder of this kind is sometimes the effect of the spare diet to which weakly and nervous persons are often condemned by pain- ful digestion or uneasiness in the stomach after meals. Many of the evils of this state may be lessened by supplying the place of the bile, as a purgative, by aloes or colocynth; but the disorder will not be removed until the patient is enabled to live more freely. Another form of disorder, attended with a very scanty flow of bile into the intestine, if not with diminished secretion of bile, and of which I have met with several well-marked examples, is this: a young person, delicate, and easily upset by any imprudence in diet, has three or four times a year an attack of diarrhoea, which lasts three or four days, or, it may be, a week, and which, during that time, no sedatives or vegetable astringents will stop. The diarrhoea is attended by smarting at the anus, and by great languor and debi- lity, but not by sickness; and while it lasts the intestinal discharges are not at all colored by bile. As soon as the bile flows the diar- rhoea immediately stops of itself. In these cases, the diarrhoea and the general disorder cannot be ascribed merely to defective secre- tion of bile, or to the bile's not flowing into the intestine. It 352 DEFICIENT SECRETION OF BILE. is probable that the illness begins in disordered digestion, and that acid and irritating matters produced by this check the secretion of bile, or stop the flow of bile into the intestine by causing sptfsm or inflammation of the mouth of the common gall-duct, at the same time that they cause diarrhoea. While the disorder lasts, the con- tents of the bowels seem to be unnaturally acid, and the most effectual remedies are, magnesia, bismuth, and chalk. Dr. Prout has ascribed a variety of similar disorders to excess of acid in some part of the intestinal canal, especially the caecum. He says : " Excessive acidity of the caecum is generally accom- panied by a deficient secretion of bile; and sometimes by a com- plete temporary suppression of the bilious discharge, apparently from spasmodic constriction of the common gall-duct; or, it may be, of the biliary ducts themselves. In this state of things all in- dividuals feel more or less of uneasiness; but the point we wish to mention is, that certain individuals under these circumstances experience what is called nervous headache. This species of head- ache is frequently accompanied by nausea; is confined to the fore- head ; and, when severe, produces complete intolerance of light and sounds, and a state of mind bordering on delirium. After a greater or less period the pain ceases, sometimes quite suddenly ; and the remarkable circumstances to be mentioned here are, that this sud- den termination is preceded by a peculiar sensation (sometimes accompanied by an audible clicking noise) in the region of the gall- ducts ; that immediately afterwards a gurgling sensation is felt in the upper bowels, as if a fluid was passing through them ; and that in a few seconds, when this fluid, which we suppose to be bile, has reached the caecum, the headache at once vanishes like a dream. One of the greatest martyrs to this species of headache I have ever seen, invariably experiences the train of symptoms above described : and I have witnessed it in a greater or less degree in many instances; indeed, I have experienced it in my own person." {Stomach and Urinary Disorders, 3d ed. p. 75.) During attacks of this kind, our object should be to neutralize the excess of acid, and to carry off this and other offending matters by a mild but effectual purgative. Dr. Prout recommends the compound decoction of aloes, with magnesia, as well adapted to fulfil these ob- jects. He says: "Drastic purgatives, in general, should be avoided; for, though they sometimes give immediate relief, they usually leave the patient more inveterately disposed to the disease."—{Id., DEFICIENT SECRETION OF BILE. 353 p. 88.) I have lately had striking proof of the truth of this remark. A healthy-looking man, near fifty, who has habitually difficult digestion, and costive bowels, with occasional heartburn, has had for a great number of years frequent attacks of headache, like those described in the passage just cited from Dr. Prout. The headache generally comes on at night, and is confined to the forehead. It is extremely severe, and while it lasts the brow feels hot, the eyes water, and the urine is turbid. If let alone, its always lasts two or three days; but for many years he was in the habit of getting rid of it by Morrison's Pills. In the evening, as soon as the head- ache came on, he took sixteen of Morrison's Pills. In the course of three hours these purged him violently, and the headache was relieved at once. He continued to treat himself in this way for several years, but gave the plan up at last, from the headaches be- coming more severe and more frequent. Under a restricted diet, and by taking daily at dinner a few grains of rhubarb, with a grain of ipecacuanha, and, now and then, a little magnesia or potash, to correct acidity, the headaches have become again much less frequent. In all diseases of this class, resulting from faulty digestion or assimilation—which manifest themselves now and then in a bilious attack, or a severe headache, or a fit of gout— our object must be, not merely to remedy the present disorder, but to change those habits of life by which recurrence of the disorder is favored. Another class of disorders is where the secretion of bile is defi- cient, not with reference to digestion merely, but as regards the blood—where the blood is not sufficiently freed from the excre- mentitious principles which it is the business of the liver to excrete. This may even happen where a large quantity of bile is secreted. The bile may be in excess as regards the intestines, and cause the bilious diarrhoea before described, and yet may be eliminated in too small quantity to purify the blood, and the complexion be bilious or sallow. Disorder of this kind is, in general, of short duration. A dose of calomel and a few brisk purgatives carry off the redund- ant bile; and if no mischief have been done to the gall-ducts, all is soon well. The malady depends, not on defective power in the liver, but on heat of climate, or too rich living, or indolent habits, which render necessary a more than commonly abundant secretion of bile. 23 351 DEFICIENT SECRETION OF BILE. But it often happens that, in consequence of some structural change in the liver, too little bile is habitually secreted both to purify the blood and to forward digestion, even when the habits of life, and other circumstances, are most favorable to health. Where there has been adhesive inflammation of branches of the portal vein, or where adhesive inflammation in the areolar tissue about the vein has obliterated many of its small twigs, and the parts of the liver which those branches or those twigs supplied are atrophied; or where, from the more interstitial deposit of lymph, in cirrhosis, the original substance of the liver is divided into small masses of lobules, which, by the subsequent contraction of the effused lymph, get more or less atrophied; or where by a different agency, and, it may be, without inflammation at all, the number and power of the secreting cells have been permanently lessened— the liver may be inadequate duly to perform its office, and the health be permanently impaired in consequence. The various forms of adhesive inflammation which lead to indu- ration and atrophy of parts of the liver are brought on, in almost all cases, by spirit-drinking. The more direct injury to the secreting element of the liver is more commonly the effect of mental anxiety, of some form of protracted indigestion, or of long residence in a hot climate and of the various bilious disorders incident to it. Habitual defective secretion of bile is therefore met with most commonly in persons who have been hard drinkers, and in persons who have been subject to the other influences injurious to the liver that have been just named. The condition of the liver in these two classes of persons differs in this, that in the former class there is an impediment to the passage of blood through the liver, in con- sequence of a deposit of lymph about the vessels, and its subse- quent contraction; while in the latter class no such impediment exists. But the condition of the liver is so far alike in the two classes, that the secreting element has been damaged in both, and what is left of it does not suffice for the purposes of health. In effect of the injury done to the secreting element of the liver, and the consequent inadequate secretion of bile, digestion is slow, and imperfectly performed; the bowels are habitually costive; the blood contains less than its natural proportion of globules; there is a falling-off in flesh and strength; and usually the skin is more or less sallow and dry. In this state a person may go on for years, ■with very little effective liver left. When a state of great anemia TREATMENT. 355 is induced, comparatively little liver, as well as comparatively little lung, is required to maintain the blood at the diminished standard. In the advanced stage of consumption, the blood is sometimes per- fectly arterialized, and, while the patient is at rest, there is no dis- tress of breathing, when not more than one-third or one-fourth of the lungs is left in an effective state. The reason of this is, that the muscular tissue and the quantity of blood in the body are almost as much diminished as the respiratory power. So it is with the liver. Many of the persons who return from India with dry wrinkled skins and greenish complexions, who, if we consider the liver merely as a secreting organ, have truly, to use the common phrase, very little liver left, may yet, with proper care, enjoy moderate comfort for years. In the advanced stages of cirrhosis, too, a person may still live on, when but a comparatively small portion of the original secreting structure of the liver remains; and here there is an additional cause of wasting, in the impediment to the passage of the portal blood. But, in all such cases, where, from some damage done to its secreting element, the liver is perma- nently very inadequate to its office, though life may continue, digestion and nutrition are imperfect, a state of anemia exists, the person grows gradually thinner, and at length dies, much wasted. In disorders of this class, which result from organic disease, the health cannot be perfectly re-established; but it may be very much mended, and life may be much prolonged. Nothing contributes to this so much as strict attention to diet. A sufficiency of light . nourishing food should, of course, be taken; but all rich dishes should be avoided, and, as much as possible, fermented drinks, as they tend to induce a bilious state of the system, and thus to render the liver still more inadequate to its office. The bowels should be regulated by some mild, but effectual, purgative. A pill of aloes, or of aloes and rhubarb, taken habitually at dinner, answers the purpose well. The patient should have the advantage, when possi- ble, of a pure, moderate cool air, which has great efficacy in bilious states of the system. When the weather permits, airing in an open carriage, or, if it can be borne, riding on horseback, short of fatigue, will be productive of good. These simple hygienic measures- regulation of diet, and provision for free respiration—are the more important, because, as has been before remarked, there is no sub- stitute for them. A medicine that is often of much efficacy in cases in which there 356 DEFICIENT SECRETION OF BILE. is deficient secretion of bile from injury to the secreting structure of the liver, is the so-called nitro-muriatic acid, which has long been extensively used in India in the treatment of chronic hepatic derano-ements. AVhen it acts favorably, it increases the secretion of bile, and at the same time strengthens digestion, promotes the action of the bowels, and has a tonic influence on the system at large. From eight to fifteen minims of each of the dilute acids in a wineglass of water may be given twice a day, half an hour or three-quarters of an hour before the principal meals; or, as is a common practice in India, the nitro-muriatic acid may be applied externally in the various forms of bath and lotion. The most con- venient forms for general use are foot-baths, and fomentations or lotions to the side.1 Of medicines that have a special action on the liver to increase the flow of bile, or, as they have been termed, cholagogues, the most energetic is mercur}^. In the occasional bilious disorders of persons who have no organic disease of the liver, a dose of calomel or blue pills, followed by a brisk saline purgative, produces more speedy relief than anything else, and is more likely, therefore, to prevent inflammation or ulceration of the gall-ducts, which seem generally to result from the irritation of unhealthy bile. Occasionally, and under these circumstances, and especially in persons of full habit, mercury may be given with great advantage. But its frequent use, in any case, may lead to much mischief. When the liver has been accustomed to the stimulus of mercury, no other medicine will sufficiently excite its action. The person is thus led to the habitual use of this medicine, and, after a time, the constitution is seriously injured by it. In the class of cases we have just been considering, where, from organic disease, the liver is inadequate to its office, and nutrition has suffered much in consequence, mercury, although even here it may relieve for the moment, almost invariably does harm. It increases the activity of the liver at first, but seems 1 Annesley directs f§iv of nitric acid, and f^iv of muriatic acid, of the strength of the London Pharmacopoeia, to be added to f^viij of pure water, and the mixture to be labelled, "the nitro-muriatic solution." From fgj to fgij of this solution to a pint of water is the strength used for lotions and foot-baths. For a foot-bath, the water should be nearly the temperature of the blood, and the feet should be kept immersed in it for twenty minutes or half an hour, every night, at bedtime. When used as a wash, it should be of an agreeable temperature, and should be applied assiduously to the trunk and insides of the thighs for a quarter of an hour daily. UNHEALTHY STATES OF THE BILE. 357 to leave it weaker than before; and if frequently resorted to, the nutrition of the patient, impaired by the original disease, is still further impaired by the drug. In all such cases we should be con- tent with milder medicines, which promote the secretion of bile without having any permanent deleterious effect on the system. One of the best medicines of this class is taraxacum, which may be given alone, or in conjunction with the nitro-muriatic acid. Chola- gogue medicines, especially mercury and soda, are, like diuretics, uncertain in their action; and if given in too large doses when the secreting organ has been damaged, or when any extraneous condi- tion exists interfering with its action, they sometimes lessen or even altogether arrest secretion instead of increasing it. In all organic diseases of the liver, where the secretion of bile is habitually deficient, and nutrition is impaired in consequence, the person should be warmly clad, and should avoid all avoidable causes of exhaustion. Fatigue, and lowering remedies, exhaust the strength, and draw, as it were, upon the capital of the patient, when this is very difficult to recruit. The disease destroys its victim, not by sudden illness, but by gradually wasting the strength. The more, therefore, this is economized, the longer will life be preserved. The bile altered in quality.—The bile found in the gall-bladder after death varies much in color and consistence in different cases. In some it is of a light yellow, and thin, or watery; in others, it has a reddish cast; in others, again, it is of a dark olive, and thick, and viscid—but little is known of the changes in its che- mical composition that correspond to these changes in its outward characters. Few analyses have been made even of healthy human bile. The attempts of chemists to ascertain the composition of bile have most of them been made on ox-bile, which can be more readily obtained fresh, and can be obtained in larger quantity than human bile. It cannot, therefore, excite surprise that little is yet known by chemical analysis of the changes produced by disease in human bile. The chief morbid states of bile ascertained in this way consist in the presence of a free acid, in the presence of urea, in the presence of some medicines that pass off in the bile, and in an excess or a deficiency of the water, biliary matter, or mucus of the bile. The presence of a free acid in bile found in the human gall- 358 UNHEALTHY STATES OF THE BILE. bladder after death is not a very uncommon occurrence. Instances have been related above in which it occurred:— 1st. In a woman who died, in the month of July, of jaundice from suppressed secretion, with symptoms of cerebral poisoning. (See page 273.) Eapid decomposition of the body took place, and when it was examined thirty-six hours after death, the gall-bladder contained about a drachm of chocolate-colored bile, which, to judge by the reaction of blue litmus-paper, was intensely acid. Litmus- paper placed in contact with the liver itself was immediately changed to a bright red. 2d. In a man (p. 245) who died in January, 1852, in a state of great exhaustion, from scrofulous enlargement of the liver and chronic abscess of the left kidney. The bile in the gall-bladder was of a pale orange color, and had a distinct acid reaction. The body, which was examined thirty-two hours after death, presented no striking marks of decomposition. In the first edition of this work, reference was made to the case of a woman who died in the autumn of 1843, in King's College Hospital, of cancerous ulceration of the rectum and granular kid- ney, in which this condition was observed. The bile reddened litmus-paper distinctly, and from its being of a pale amber color, no doubt could exist that the change of color in the paper was owing to the action of an acid. In the autumn of 1849 I met with very pale-colored bile, dis- tinctly acid, together with three gall-stones, in the gall-bladder of a man who died in King's College Hospital of chronic granular dis- ease of the kidney, with recent inflammation of the pericardium and pleura. The bile in this instance presented other unnatural appearances, containing numerous flaky masses which were found to consist of epithelium, and many amorphous masses which seemed to consist chiefly of biliary coloring matter. I have met with several other instances in which the bile, and the liver itself, had a very distinct acid reaction; and in most of them the bile, as in the instances noticed above, was unnaturally pale. Deficiency of the proper biliary coloring matter seems to promote the occurrence of an acid condition in the bile. The immediate cause of this acid condition of the bile is most probably decomposition of the bile, or of the mucus it contains.1 1 Since the preceding observations were published in the second edition of this work, the third volume of Lehmann's elaborate work on Physiological Chemistry UNHEALTHY STATES OF THE BILE. 359 When ox-bile is allowed to decompose exposed to the air, it be- comes after some days distinctly acid; and if it be then neutralized, it becomes, on further standing, acid again. It is a curious cir- cumstance, tending to show the complementary relation that exists between the bile and the urine, that decomposition, which renders the urine alkaline, renders the bile acid. The decomposition of the bile takes place, of course, more rapidly in hot weather, and is much promoted by the mucus it contains, which acts as a ferment. There can be little doubt that in the bodies of persons who die of disease, a process of decomposition goes on constantly in the liver after death, although for some time it may produce no striking change. In animals that were killed, M. Bernard constantly found sugar in the liver, when the liver was analyzed immediately after death; but if some hours only were allowed to elapse before the analysis was made, no sugar was found. In this short time the sugar had been changed into some other substance. AVe may expect then most frequently to find the bile acid when it is unnaturally pale, or contains a large proportion of unhealthy mucus, and is thus unnaturally prone to decomposition; when death occurs from exhaustion, and rapid decomposition of the body ensues; and when the body is examined a considerable time after death, in hot weather. We may expect, also, sometimes to find it acid in those cases of jaundice from suppressed secretion, in which the unexpected occur- rence of fatal head symptoms, the softened state of the liver after death, and the early putrefaction of the body* evince the existence of some noxious agent which seems (see page 273) to be developed in the system by decomposition of the broken-up hepatic cells, or of the retained elements of the bile. In some instances the bile may be rendered acid, as Gorup- Besanez has suggested, by the presence of pus, generating lactic acid. It is possible, however, that under certain circumstances, bile may be acid when first secreted. Dr. Prout seems to have imagined that in consequence of great development of lactic acid, either in the stomach from imperfect has appeared, in which it is stated that the juices of the liver, spleen, thymus, supra-renal capsules, and the smooth muscles, all contain free acid.—(Lehmann's Physiological Chemistry, translation of the Sydenham Society, vol. iii. p. 223.) 360 UNHEALTHY STATES OF THE BILE. digestion, or in the blood from constitutional diseases, especially those produced by malaria—the portal blood might become black and acid; and that this unnatural blood passing through the liver might disorder its secretion, and the bile might thus be deprived of its neutralizing properties, "if not actually rendered acid."1 I am not aware that any attempts have been made, by chemical analysis, to settle this important point. Urea has been found in the bile, only, I believe, in persons dead of cholera. It was first detected by Dr. O'Shaughnessey, in bile which he analyzed at the request of Dr. Koupell, and which was taken from a person who died of cholera, after having made very little urine for eight days. The bile did not differ in appearance from ordinary bile, but contained in one thousand parts, six of salts, and three of urea. {Roupell on Cholera, p. 84.) Various medicines have been found in the bile, but our list of those which pass off in this way is, doubtless, very imperfect. It is probable that most of the medicines which increase the secretion of bile pass off, in part, either bodily or more or less changed, through this channel. The observations made by chemical analysis on the altered qualities of the natural constituents of bile are very few and of little value. They are sufficient to show that some of the natural constituents of bile become changed in disease—which might have been anticipated from the readiness with which the principles of bile enter into new combinations—but they do not tell us in what these changes consist.' The difficulty of analyzing bile, and the circumstance that human bile can only be obtained in small quantity and many hours after death, when the bile in the gall-bladder is probably already changed by decomposition, sufficiently account for the observations of this kind yet made being so few and so little to be relied on. The most valuable observations that have been made on altered qualities of the bile—and these are few and imperfect—relate to changes that can be at once recognized by the senses. In some cases, the coloring matter is deficient, the bile, found even in the gall-bladder, is pale and thin, and has not its usual bitterness, and the lining membrane of the gall-bladder and gall- 1 See Prout on Stomach and Urinary Diseases. 3d edition. Introduction, p. 45. UNHEALTHY STATES OF THE BILE. 361 ducts is hardly stained by it. This condition of the bile is fre- quently found in those diseases which change the structure of the whole liver. It is not uncommon in cirrhosis, and is now and then remarked where the liver is much enlarged from the inter- stitial deposit of fat, or other morbid products. But occasionally the bile has these characters when there is no apparent disease of the liver itself, and when the unnatural quality of the bile results from an unhealthy state of the blood. I have found bile of this kind several times in persons dead of granular kidney, and twice in cases of suppurative phlebitis, with scattered abscesses in the lungs and other parts of the. body, without there being any abscess or other marks of inflammation in the liver. The elaborate researches of M. Louis have shown that in persons dead of typhoid fever, the bile in the gall-bladder is often (in more than one-half the cases) more thin and watery than healthy bile, and often has a reddish or rust color, instead of the yellow or greenish tints proper to bile. It has been remarked in a former chapter that, in typhoid fever, suppurative inflammation of the gall-bladder sometimes comes on, doubtless in consequence of the retention, and it may be the decomposition, of unhealthy and irri- tating bile. The observations of M. Louis, on the condition of the cystic bile in persons dead of typhoid fever, have been confirmed by the late researches of Gorup-Besanez, who states that he analyzed many specimens of bile taken from the gall-bladders of persons who died of this disease, and found that not one of them contained more than half the usual quantity of solid matter. In persons dead of inflammation of the lungs, according to Gorup-Besanez, the bile in the gall-bladder has often the outward characters so common in typhoid fever, and contains an unnaturally small proportion of solid matter. The same thing happens not unfrequently in dysentery.1 But in none of these cases do the color and consistence, and the relative proportion of the solid constituents, of the bile in the gall-bladder afford very trustworthy evidence respecting the characters of the bile when first secreted, because the bile undergoes concentration in the gall-bladder, and consequently its color and consistence depend very much on the time it had been in the bladder when death occurred. 1 See Parkes on Dysentery, &c, p. 46. 362 UNHEALTHY STATES OF THE BILE. In other cases, and sometimes even in the diseases referred to above, the bile, instead of being pale and thin, is unusually dark- colored and thick. This may be from mere long retention in the gall-bladder. If the bile remain long in the bladder, much of its water is absorbed, and it becomes very dark-colored and viscid. This is usually found to be the case in healthy persons who die from some accident after long fasting. In persons who die during the cold stage of malignant cholera, where the whole body is drained of its water, the bile in the gall-bladder is always of a dark olive and viscid. In persons who die of phthisis, the bile in the gall-bladder, even when the liver is fatty, is often very dark- colored and viscid, most probably from remaining there long, and becoming concentrated, by reason of the repugnance to food, and the consequent emptiness of the stomach and intestines, that is common in the advanced stages of phthisis. But the bile may be secreted unusually viscid, and unusually dark-colored, and may present these characters in the hepatic ducts when the passage of the ducts is free. This is, perhaps, most common in hot climates, where the essential principles of the bile are formed in large quantity in the system. Annesley states that very commonly in India, in persons who die of diseases of the liver, or of other organs, the gall-bladder is found distended with thick, acrid bile, and the hepatic ducts are completely gorged with bile of this character, without any apparent organic change suffi- cient to account for the circumstance, and without other impedi- ment to the escape of the bile than that which arises from its own viscidity. Where the secretion of bile is very abundant, a partial obstruction of short continuance may cause great accumulation of it in the gall-bladder and in the liver itself. Annesley believes that in India this accumulation of bile occurs, not only in the course of other disorders, but as an ailment of itself, the disturb- ance in the system resulting solely from the retention of bile in the liver, and the subsequent irruption of the long retained bile into the intestinal canal. He says: " The earliest symptoms of which the patient generally complains, when he attends to his sen- sations and state of health, are, clamminess and foulness of the mouth, fauces, and tongue, with a bitter taste, particularly in the morning; a sense of distension and weight at the epigastric region, and at the precordia, frequently with a sense of coldness and sinking in the same situations; slight anxiety; acid and acrid UNHEALTHY STATES OF THE BILE. 363 eructations -about three or four hours after a full meal, with painful fulness at the epigastrium, and difficult digestion. The patient often complains of headache, pain in the back or loins, uneasiness under the shoulder-blades, fulness and pain in the region of the liver, particularly when pressure is made at the time of his taking a full inspiration, and of aching in his knees, shoulders, and limbs, his countenance being pale, sallow, or muddy, and the conjunctivae more or less tinged of a yellowish hue. The state of the pulse is different in different cases. It is often slow and full, and some- times it is irregular in frequency and strength; occasionally it in- termits, and not unfrequently becomes quick, but oppressed upon the least motion or exertion. The urine is generally high-colored, and deposits a brownish sediment. The stools are often costive, spmetimes light or clay-colored, and frequently tenacious. AVhen the accumulated bile is discharged into the alimentary canal, much constitutional disturbance generally arises, according to the qua- lities which this fluid may have acquired from its retention. The pulse now becomes quick, and often irregular; vomiting and purg- ing, with griping pain and anxiety, often supervene, sometimes with spasms. Thirst becomes urgent, and the tongue, -which was before foul, is now excited, often dry, and its papillae large, distinct, and erect." (Vol. i. p. 329.) " It sometimes occurs that the inordinate flow of morbid bile into the duodenum, particularly when it has been long retained, and during close, warm, and moist states of the air, occasions faint- ness, the most alarming state of sinking, and prostration of the vital energies." (Id. p. 331.) In this country, a bilious disorder attended with symptoms very like those described by Annesley, is now and then met with, and is probably occasioned, as Annesley, supposes, by temporary reten- tion of viscid or unhealthy bile. But the retention of thick and unhealthy bile may lead to other mischief. When healthy bile even is much concentrated, it throws down irregular, solid, green or yellow particles—consisting of biliary pigment in combination with bases—which may be dis- tinctly seen under the microscope, and which, if the concentration be carried far enough, render the bile gritty, or even form a com- plete magma. If the bile be unusually dark-colored and thick, and otherwise unhealthy, when first secreted, and especially if it remain long in the gall-bladder, such a precipitate may take place in the bladder, and lead to the formation of gall-stones. 364 UNHEALTHY STATES OF THE BILE. In man, gall-stones have almost always a dark nucleus of con- crete biliary matter, which is surrounded by cholesterine, mixed with variable proportions of the coloring matter of bile; and they are almost always found in the gall-bladder or in the cystic or common ducts, obviously because the bile, during its stay in the gall-bladder, becomes concentrated, and perhaps decomposed, and is, in consequence, more apt to be precipitated in solid form there than in the hepatic ducts.1 Another morbid state of bile, of great importance from its con- tributing largely to the formation of gall-stones, is where the bile contains sparkling scales of cholesterine. I have never found this in the hepatic ducts. Cholesterine seems in most cases to be formed ' in the gall-bladder, or at least to be there deposited in crystals, and its presence in visible scales in the bile is generally associated with disease of the gall-bladder. AVhen the coats of the gall-bladder have undergone the fatty degeneration before spoken of, the cystic bile always abounds in crystals of this substance. But crystals of cholesterine are now and then formed when the coats of the gall- bladder seem healthy.2 These considerations lead us to gall-stones, which, from their pal- pable form, their frequency, and the distressing symptoms they often occasion, have excited more attention than any other result of un- healthy bile. 1 In stall-fed oxen, whose bile, from the nature of their food, is perhaps rioher in coloring matter, gall-stones, composed entirely of the coloring matters and the resinous principles of bile, are frequently found in the hepatic ducts. z Cholesterine may doubtless be secreted by any part of the mucous lining of the biliary passages. The " knotty tumors" described in the next chapter prove an abundant secretion of it from the hepatic ducts under certain circumstances. 365 Sect. V.— Gall-stones. Gall-stones, as already remarked, are usually formed in the gall-bladder, where the bile becomes concentrated from absorption of part of its water, and often otherwise altered by unhealthy se- cretions from the coats of the bladder, and where it is longer stag- nant than in the ducts. But it now and then happens that gall- stones form in the substance of the liver, in branches of the hepatic duct. These hepatic gall-stones are always very small, of irregular, tuberculated form, and of a dark olive color, approaching to black. They probably originate, in most cases, in inflammation of the he- patic ducts. In consequence of this, a duct becomes closed at some point. The bile then accumulates in the portion beyond, and after being some time stagnant, is inspissated by the absorption of part of its water, and some of its constituents are precipitated, forming solid dark-coloured granules. These granules and the inspissated bile that remains are cemented by mucus secreted by the coats of the duct, so as to form a small calculus. The way in which gall-stones in the substance of the liver are formed explains the circumstance, remarked by Cruveilhier and others, that they are often encysted. The cyst, like some other va- rieties of cyst occasionally found in the liver, is formed of the coats of the gall-duct. The duct is distended into a pouch by the foreign matter, and, being closed on each side of this by inflammation, forms, if the foreign body be not absorbed, a permanent cyst. Gall-stones of the same kind are now and then found in the gall- bladder. They are usually small, and are at once distinguished from ordinary gall-stones by their irregular, tuberculated form, and their almost black color—circumstances which have led to their be- ing compared, and not unaptly, to black pepper. They are heavier than ordinary gall-stones, and do not burn so readily, and, when burnt, sometimes leave a considerable quantity of carbonate and 366 GALL-STONES. phosphate of lime.1 They are composed chiefly of biliary coloring matter, some salts of lime, and mucus. The bile-pigment forms in- soluble compounds with the alkaline earths, and the pigment and lime are consequently precipitated together, forming minute dark- colored nodules, which become cemented by mucus. Little is known of the circumstances which lead to the formation of this kind of gall-stone. Dr. Prout has hinted that they are asso- ciated with a tendency to the formation of oxalic acid, and to that of malignant disease, more especially of the liver. I have met with gall-stones of this kind in two cases, of which I have kept notes. The first was that of a sailor, fifty-four years of age, who died of fever, in the Seamen's Hospital, in July, 1827, and who for seven months previously had been employed on the Thames. The liver appeared healthy, and no marks of disease were noticed in the gall-bladder. There were some small serous cysts in the cortical substance of each kidney; and at the back part of the upper lobe of the left lung, the surface, for the breadth of a half crown, was puckered, and the pulmonary tissue beneath indurated, the consequence of a cavity which had formed there at some former period, and which was not quite closed. There were no tubercles, or other marks of former disease, and the only recent changes of structure were ulcers in the lower part of the ileum, the result of the fever. The gall-bladder contained a great number of very dark mulberry-looking calculi, all of them about the size of small peas. When dried, they were very friable, and were found to be composed of solid black grains, cemented by a greenish matter, which consisted of mucus and inspissated bile. The second case was that of a man, aged sixty-two, who died in the summer of 1838, also of fever. The gall-bladder contained three irregular black calculi, apparently composed of biliary matter and mucus, the smallest of the size of a cherry-stone. There was a calculus of the same kind in one of the hepatic ducts. The mu- cous membrane of the gall-bladder was somewhat thickened, but was not ulcerated. Besides the calculi, there was in the bladder a small quantity of yellow gritty bile. In the Museum of King's College is a dry preparation, left to the College by the late Dr. Hooper, showing a great number of 1 Prout on Stomach and Urinary Diseases. Third edition. Introduction, p. 65 ; and Lehmann's Physiological Chemistry. VARIETIES. 367 gall-stones of this kind in the bladder in which they were found. (See Plate I., Fig. 1, in which some of these gall-stones are repre- sented.) The coats of the bladder seem to have been healthy. A healthy state of the gall-bladder seems to be requisite in order that stones of this kind may continue to exist for any considerable time in it. When its coats are much diseased, cholesterine is usu- ally formed, or at least takes the solid form, in large quantity in the gall-bladder, and if there be a small mass of inspissated bile, to serve as a nucleus, cholesterine collects around it, and produces the more common kind of gall-stone. Gall stones composed for the most part of precipitated biliary pigment are seldom found in the human gall-bladder, and when found there, are usually very small, on account of the great tend- ency to the formation of cholesterine; but in the gall-bladder of the ox, cholesterine seems less apt to be formed, and gall-stones, composed almost entirely of the coloring matters of bile, are not unfrequently met with. The gall-stones found in the bladder of the ox have been long esteemed as a pigment. (Prout.) Gall-stones from the human gall-bladder are almost always com- posed in great part of cholesterine, mixed with a certain quantity of the coloring matters of bile. They have all a nucleus, which is generally of a dark olive or black, and which, like the small, irregu- lar, dark-colored gall-stones, described above, is in most cases com- posed chiefly of biliary coloring matter and lime, cemented by mu- cus. Late researches have shown that dark-colored gall-stones often contain also an appreciable quantity of copper. The shape, and size, and appearance of gall-stones vary very much, according to the circumstances under which they are formed. When there is only one gall-stone in the bladder, it may grow to the size of a hen's egg, but is seldom found so large. While it remains small, and can move freely in the bladder, it is generally spherical; but when it becomes so large that it is girthed by the bladder, or can no longer roll freely in it, it grows most at the ends which are not subject to pressure, and so becomes somewhat egg- shaped. Large solitary gall-stones, with the exception of their nuclei, are composed almost entirely of cholesterine, and are, consequently, whitish and crystalline. They have a soapy feel, and when placed in the flame of a candle, readily melt, and burn with a bright flame. 368 GALL-STONES. Sometimes the cholesterine is deposited after closure of the cystic duct, and when all the bile previously in the gall-bladder has been absorbed, and the stone is then quite white, like a ball of camphor, or of white marble. The surface is generally a little rough and dull, but it readily takes a fine polish. When these round or oval stones are sawn through the centre, they are seen to be crystallized in rays, which converge towards the nucleus. (See Plate I., Fig. 2, which represents the section of a gall-stone of this kind.) It sometimes happens that two round or oval gall-stones are found in the bladder, when, by some constriction at its middle, the bladder is divided into two distinct pouches. When the cystic duct has been closed, and the coats of the gall- bladder are healthy, the stone is sometimes closely embraced by the bladder and marked by its rugae, so that it has its surface tubercular, like the mulberry. But it is much more common to find many gall-stones in the bladder than a single one; and occasionally they are found in almost incredible numbers. As many as three thousand have been counted in a single bladder. When there are many gall-stones in the bladder, they differ in form and appearance from solitary gall-stones. Instead of being round or oval, they have, usually, plane, polished faces—the effect of the mutual attrition of the stones, which polish each other the more from the presence of the minute crystals of cholesterine con- tained in the bile. AVhen the stones are few in number, and can shift their relative positions in the bladder, they may attain a considerable size, and sometimes become very irregular in form, often, as remarked by Haller, very much resembling the bones of the wrist. In other instances, their forms are strikingly regular. In the spring of 1837 I found in the gall-bladder of a man, who died of scurvy, at the age of sixty, eight gall-stones, little larger than peas, all of them very regular tetrahedrons. It is difficult to imagine how forms so regular are produced. Gall-stones which have smooth, flat faces, generally contain more of the coloring matters of bile than large solitary gall-stones, and are usually of a variegated greenish and brownish color. When sawn through the centre, they are found to be laminated, and to have a nucleus, which generally contains traces of mucus and earthy phosphates, but consists principally of a combination of the • VARIETIES. 369 bile-pigment with lime.1 The successive laminae are sometimes very fine; but, even then, when the face is polished, they are gene- rally distinctly visible from being of different shades of brown and green. When a section is made through the centre, and its surface polished, together with the concentric laminae, rays may still be seen converging towards the centre, as in the white oval calculi of cho- lesterine. (See Plate I., Fig. 3.) In both varieties of calculi the cholesterine is deposited in the same way, but in the pure choles- terine calculi the appearance of concentric laminae is not produced, because the successive layers are not tinged of different colors by the bile. Gall-stones, which appear distinctly laminated, have sometimes a crust of pure cholesterine, which was formed after the entrance of bile into the bladder had been prevented by one of them becoming impacted in the cystic duct. (See Plate II., Fig. 2.) Now and then, but rarely, for obvious reasons, this order is re- versed. A gall-stone almost of pure cholesterine, and therefore uniformly white, has a crust, of which the successive layers are differently colored by bile, and which therefore appears laminated. The different gall-stones found in the same bladder have almost always the same characters. They are laminated alike; their nuclei have the same appearance; and if one of them have a crust of pure cholesterine, they all have it. From this it is probable that they are generally formed at the same time, and not in succes- sion. A circumstance that seems almost necessary to the formation of gall-stones, is the presence of a small mass of biliary gravel, or inspissated bile cemented by mucus, or some other substance about which the cholesterine may collect. An excess of cholesterine is not, of itself, sufficient for the formation of gall-stones. In a case related in a former part of this work, the mouth of the cystic duct seemed to have been long blocked up by a gall-stone, and the gall- bladder, whose coats had undergone the fatty degeneration, was filled with viscid mucus sparkling with scales of cholesterine, yet no other gall-stones had formed in the bladder. Another specimen, precisely of the same kind, was sent to King's College Museum, in 1 The nucleus sometimes contains copper, and probably other metals, which, in the state of oxide, combine, like the alkaline and ea'rthy bases, with the coloring matter of bile. Occasionally uric acid has been found in gall-stones. (See Leh- mann's Physiological Chemistry. Translation by Dr. Day, vol. ii. pp. 74-5.) 24 370 GALL-STONES. the summer of 1843, by Mr. Lingen, of Hereford. (King's College Aluseum, Prep. 268.) Gall-stones are formed in numbers in the gall-bladder, only when the bile can flow into it through the cystic duct. But the presence of bile, even of dark-colored bile, and a plentiful formation of cholesterine, are no,t alone sufficient. On more than one occasion I have found in the gall-bladder very dark- colored viscid bile, sparkling with scales of cholesterine, when there were no gall-stones. It seems necessary for the formation of a gall-stone, that there should be a nucleus of some other substance, about which the cholesterine may crystallize. It would appear, from some of the published descriptions of gall-stones, that a par- ticle of cholesterine may of itself serve as a nucleus of a solitary gall-stone, but this happens very seldom. In almost all cases the nucleus is of a dark color, and consists chiefly of biliary coloring matter, lime, and mucus. The nucleus presents different appear- ances in different gall-stones. In some it is round and compact, even when the gall-stone has been long kept, and is perfectly dry; in others, in which it is composed in great part of mucus, it is of irregular outline, and, in drying, contracts, so as to leave a hollow in the centre of the stone. (Plate I., Fig. 4.) In some, the nucleus is a mere point; in others, of the size of a small pea. But, as before remarked, when there are many gall-stones in the same bladder, their nuclei have, usually, all the same characters. If one nucleus is small, all are small; if one is compact, all are compact; if one stone have a hollow in the centre, all have it. A few instances have been recorded in which some other sub- stance than those mentioned above formed the nucleus of a gall- stone. Bouisson states that he has a small solitary gall-stone, whose nucleus seemed to be formed of blood (Bouisson, p. 243); and one the size of an almond, which he found in the hepatic duct of an ox, in which the nucleus is a fragment of a fluke. He cites an instance, represented by Lobstein in his plates of morbid anatomy, where a large gall-stone had formed about a dried lumbric worm. The gall-stone was found in the common duct of a woman, sixty-eight years of age, who died of colliquative diarrhoea, in a hospital at Strasburg. There were one hundred and eighty-five worms of this kind in the stomach, and thirty in the branches of the gall-ducts, which were very much dilated. He cites another instance where a gall-stone had formed about VARIETIES. 371 a pin in the gall-bladder; and another, where the nucleus of a gall-stone is said to have contained globules of mercury. This last gall-stone, which was of the size of a prune, and composed chiefly of cholesterine, was taken from a person to whom mer- cury had been given for syphilis. The nucleus of the stone, when melted by heat, is said to have presented many globules of mercury. Gall-stones are very light considering their size. When fresh from the gall-bladder, they usually sink if placed in water; but when they have been kept long, and are quite dry, most of them float, until they have imbibed a certain quantity of the water, when they sink slowly. Their specific gravity depends chiefly on the relative proportion of cholesterine and coloring matter. Cholester- ine is lighter than water; the bile-pigment and its compound with lime are heavier. The lightest gall-stones are therefore usually those which contain the largest proportion of cholesterine. The weight of gall-stones, especially when dry, will, of course, vary also with the character of their nuclei. Mr. Taylor has lately described a calculus, which he found among the calculi in the Museum of the College of Surgeons, and which he supposes to be biliary, composed chiefly of stearate of lime. It was oval, slightly flattened, an inch and a half in length, rather more than an inch in thickness, and about an inch and a quarter in breadth. Its surface was of a dirty white, and it had the greasy feel of cholesterine calculi. It floated in water, and when applied to the tongue left an impression of bitterness. It yielded readily to the knife, and the cut surface had a polished ap- pearance. It was composed of white and reddish yellow concen- tric layers, alternating with each other, and easily separable. At its centre there was a small hollow. AVhen heated before the blow- pipe it readily fused, and then caught fire, burning with a clear flame, and giving out the smell of animal matter, but nothing of a urinous character. " From cholesterine calculi it is readily distin- guished by the absence of any crystalline structure when broken, which, unless the quantity of coloring matter be very large, is always more or less apparent in that variety; also by its insolu- bility in alcohol and ether, and by readily dissolving in these men- strua, and in a cold solution of caustic potass, after it has been 372 GALL-STONES. acted upon by an acid. {London and Edinburgh Phil. }faga::ine, 1840.) There is no account of the source from which this calculus was derived; and it is doubtful, therefore, whether it was taken from man or from one of the lower animals. Now and then, chalky concretions, composed chiefly of phosphate of lime, or of carbonate of lime, are found in the gall-bladder or in the ducts, or, apparently isolated from the ducts, in the substance of the liver. Andral relates the case of a man who died at the age of fifty, in whose gall-bladder were three small calculi of phosphate of lime. The cystic duct was obliterated, and, with the exception of these calculi, the gall-bladder contained nothing but a little ropy mucus. The liver was united to all the adjacent parts by old false membranes, and its substance was remarkably tough and granular. The disease seems to have commenced ten years before death, when the patient had jaundice, which was soon followed by ascites. {Clin. Med., iv. p. 511.) M. Bouisson states that he once found a calculus, of the size of a pea, composed of carbonate of lime, projecting from the surface of the liver. {Bouisson, p. 197.) I have more than once found a small gall-stone of biliary matter surrounded by a layer of phosphate and carbonate of lime, in a pouch formed by partial dilatation of the cystic duct. These chalky concretions are not formed from ftie bile, but origi- nate in disease of the mucous membrane of the gall-bladder or gall- ducts. In sheep that have been infested with flukes, some of the gall-ducts not unfrequently become almost converted in this way into bony cylinders; and, now and then, in the liver of one of these animals a small chalky concretion may be found, apparently isolated from the ducts. These chalky bodies are surrounded by a cyst, which is formed, like so many other varieties of hepatic cyst, from a small portion of a gall-duct, which becomes dilated by the foreign matter, and isolated, by inflammation, from the rest of the duct. Ordinary gall-stones are composed, as we have seen, of choles- terine, which, with variable proportions of coloring matter, is de- posited about a nucleus, which generally consists of biliary coloring matter, some salts of lime, and mucus. The cholesterine crystal- lizes so as to form rays converging from all points of the circum- ference of the stone to its centre; but when it is mixed with, or CAUSES. 373 stained by, the coloring matters of bile, which, as is usual, are in different proportions in layers successively deposited, the stone, while it still exhibits the converging rays, appears made up of dis- tinct concentric laminae. Two circumstances seem, then, generally to concur in the forma- tion of these cholesterine calculi: the presence of a small mass of concrete biliary matter, lime, or mucus, to serve as a nucleus, and the presence of cholesterine in crystals, to make up the body of the stone. The first step is the formation of the nucleus, which pro- bably results in most cases, especially when many gall-stones are formed together, from an unhealthy state of the bile, or from its decomposition, or undue concentration in the gall-bladder, leading to precipitation of some of the essential principles of the bile, or of some salt of lime, in solid form.1 The second step is the forma- tion of crystals of cholesterine. This may likewise result from an unnatural state of the bile, especially from a relative deficiency of tauro-cholic acid, or tauro-cholate of soda, which seems to be the chief solvent of the cholesterine in the bile; but it is frequently associated with, and apparently dependent upon, fatty degeneration of the coats of the gall-bladder. In every case the presence of gall-stones is evidence of an unna- tural state of the bile at the time of their formation. The question then arises—What conditions of life, or what other influences, tend to bring about those unnatural states of the bile on which the formation of gall-stones depends ? The first circumstance to be noticed is, that gall-stones can sel- dom be traced to structural disease in the substance of the liver itself. Some diseases of the liVer seem, indeed, to be almost in- compatible with gall-stones. Dr. Prout has made a remark, which ' The formation of gall-stones is illustrated by the fact noticed by Dr. Beale, that when ox-bile undergoes spontaneous decomposition exposed to the air, it has usually, at the end of three or four days, a tolerably abundant sediment, consist ing of white nodular granules, which seem to be composed of lime in conjunction with a biliary or fatty acid. At a further stage of decomposition, it contains nume- rous crystals of oxalate of lime. The nuclei of gall-stones taken from the gall- bladder usually contain lime, and occasionally, according to Lehmann, a minute quantity of oxalate of lime : a substance which, from want of oxidizing influences, is much less likely to form when bile undergoes decomposition in the gall-bladder than when it does so exposed to the air. The absence of the peculiar biliary acids in the nuclei of gall-stones may be partly attributable to the readiness with which these substances undergo decomposition, when in contact with organic matter. 374 GALL-STONES. my own experience tends to confirm, that gall-stones of cholesterine are seldom found in conjunction with the granular disease of the liver produced by spirit-drinking. They are also, I believe, very seldom met with in the diseases of the liver that occur in hot cli- mates. Among the numbers of bodies that I examined in the Seamen's Hospital, of men who returned from India with abscess or other disease of the liver, very few, indeed hardly any, had gall- stones ; but these men, it must be remembered, were sailors, and had probably great immunity from gall-stones on account of their seafaring life. There is, however, one disease of the liver in which gall-stones are of very frequent occurrence—namely, cancer: but gall-stones are also frequently found in conjunction with cancer of other parts, and seem connected with the cancerous diathesis rather than with cancer of the liver itself, which probably gives no additional tend- ency to them, except when it involves the gall-bladder, or causes the bile to stagnate in it by narrowing the cystic or the common duct. The tendency to the formation of gall-stones is much influenced by age. Gall-stones of cholesterine, like the fatty degeneration of the coats of the gall-bladder with which they are frequently asso- ciated, are seldom found in persons under the age of 30. Bouisson, calculating from the numerous observations collected by Walter {Museum Anatomicum, torn, iii., in 4to., Berolini, 1805), found that among 91 persons who had gall-stones, 1 was 20 years of age, 27 were between 30 and 40, 14 between 40 and 50, 19 between 50 and 60, 8 between 60 and 70, 13 between 70 and 80; while one was 80, and another 90. The ages of the remaining 7 are not mentioned. The youngest persons in whom I have found a gall-stone com- posed chiefly of cholesterine were of the ages of 24 and 18. The first was a woman, aged twenty-four, who died in King's College Hospital, in the summer of 1844, of phthisis, with extremely fatty liver, whose gall-bladder contained a single round calculus, of the size of a small marble, composed almost entirely of cholesterine; the second, a girl, aged eighteen, whose case has been related above (p. 206), who died of fever, and in whose gall-bladder six small angular gall-stones, composed chiefly of cholesterine, were found. Gall-stones are, in this country, much more frequent in women CAUSES. 375 than in men; but in what exact proportion in the different classes of society we have as yet no statistics to determine. Hoffman, Haller, and Soemmering, found gall-stones more common in women than in men; but the rule does not seem to be universal. Bouis- son states that, of the 91 instances of gall-stones collected by Wal- ter, before referred to, 44 occurred in women, 47 in men. Mor- gagni states that, among the numerous cases of gall-stones he had observed himself, or had collected from others, the number of men was nearly equal to that of women. The greater liability of women to gall-stones depends, probably, not so much on the peculiar constitution of the sex as on their habits of life, which are different in the different classes of society and in different countries. Among the conditions of life that dispose to gall-stones, seden- tary occupations and confinement seem to have the greatest influ- ence. Gall-stones have been observed to be especially frequent among literary men, and prisoners, and people long bed-ridden; while, on the contrary, they are, like urinary calculi, very rare among sailors, who lead an active and roaming life, and are con- stantly exposed to a current of fresh air. The sedentary habits of women in this country perhaps sufficiently account for their being so much more liable to gall-stones than men. The influence of confinement in bringing on gall-stones might almost have been inferred from the circumstance that cholesterine, which is their chief constituent, is a fatty substance, into the com- position of which oxygen enters but in very small proportion. Another condition that seems to me to have great influence in the production of gall-stones, or at least of biliary gravel, is mental anxiety or trouble. Particular modes of living, which directly alter the qualities of the bile, have, without doubt, great influence in producing gall- stones ; but our knowledge on this point is very vague. Gall. stones are most frequent in fat persons, and in those who live richly and lead indolent lives; but they are not unfrequently found in persons advanced in life, especially women, who are lean and have always been extremely temperate. It has been stated that they are especially frequent in districts where the water drunk is rich in lime. There can be no doubt, also, that a liability to gall-stones often depends on peculiarity of constitution, which, like the tendency to 376 GALL-STONES. gout or urinary gravel, may be inherited as well as acquired. In- stances are not unfrequently met with of several members of a family becoming affected with gall-stones, without any marked peculiarity in their habits of life. At present little is known of the characters, or of the other effects, of this diathesis. It probably conduces to fatty degeneration of the coats of the gall-bladder, which is so frequently associated with gall-stones, and to the fatty degeneration of the arteries, so common in advanced life. Dr. Prout has remarked that a tendency to the formation of gall-stones of cholesterine is frequently associated with a tendency to lithic- acid deposits in the urine. It is probable that in London the habit of drinking porter, which frequently leads to lithic-acid deposits and to the most inveterate forms of gout in persons who inherit no disposition to them, may also frequently lead to the formation of gall-stones. When, from any cause, the bile is prone to form deposits, various circumstances that favor its stagnation in the gall-bladder—such as the habit of sleeping long, long fasting, some obstruction in the cystic or the common duct—that otherwise would be without effect, may lead to the formation of gall-stones. Inflammation or ulcera- tion, of the gall-bladder, by altering the quality of the mucus, or by leading to the effusion of a small clot of blood or a flake of lymph, may also cause their formation. When gall-stones have formed in the gall bladder, they may produce various effects upon the bladder and ducts. One of the most common of these is closure of the cystic duct. A gall-stone too large to pass through the duct floats with the current of bile to its mouth, and becomes firmly lodged there. This prevents the flow of bile into the gall-bladder, and not unfrequently, by exciting inflammation, leads to' permanent closure of the duct beyond the stone. We have already considered the effect which this closure of the cystic duct has on the gall-bladder. The bile in the gall- bladder gets absorbed, and its place occupied by the secretions of the bladder itself, which consist of a mucous, glairy fluid, in which are suspended glistening scales of cholesterine. Perhaps the clo- sure of the duct may lead to the formation of another gall-stone around an unusually large scale of cholesterine, or a flake of lymph that may be retained in the bladder, or some concrete biliary mat- ter that may be left when the more watery parts of the bile are absorbed. But it never happens that many gall-stones are formed EFFECTS. 377 in the bladder after the cystic duct is closed. That many gall- stones may be formed, it is requisite that the bile should flow into the bladder, and that some of its constituents should be deposited in solid masses, to serve as nuclei about which the cholesterine may collect. Closure of the cystic duct of course destroys the office of the gall-bladder, and by so doing more or less deranges digestion; but when gall-stones have formed, the evils resulting from this are per- haps more than compensated by its preventing for the future the passage of the stones along the ducts, which is the. cause of most of the suffering and of many of the other evils which gall-stones occasion. If a gall-stone pass through the cystic duct, it generally passes also through the common duct, which is larger and straighter than the cystic duct. If it pass slowly, and be large enough completely to block up the duct and prevent the flow of bile into the intestine, it soon causes jaundice and dilatation of the gall-ducts behind and of the gall-bladder. The distension of the gall-bladder may be so rapid and so great, that, on some trifling effort, as that of coughing or vomiting, it may burst, especially if its coats were previously diseased, and its contents be poured into the cavity of the perito- neum. Several instances of this kind have been recorded. The gall-stone may also become fastened in the common duct, and may lead to permanent closure of the duct below it, by adhesion, and, consequently, to permanent jaundice and all the other evils which obliteration of the common duct occasions. Sometimes a large gall-stone gets permanently lodged in the lower end of the common duct, without completely closing it. That part of the duct which embraces the stone participates in the dilatation of the ducts be- hind, and bile still passes round the stone into'the intestine. This, however, can scarcely happen without much impeding the flow of this fluid, and leading to occasional jaundice, and, in the end, to great dilatation of the hepatic gall-ducts and more or less destruc- tion of the secreting element of the liver. But, as before remarked, a gall-stone does not often rest long in the common duct. After a time, which seldom extends beyond a few days, it passes into the intestine. One is occasionally surprised, considering the natural size of the common duct, at the large size of a gall-stone which has passed through the ducts, without ulceration, into the intestine. A stone, as large as an almond, or larger, may escape in this way. 378 GALL-STONES. • The circumstance shows to what an extent the ducts may be dilated by a constant, and gradually increasing, fluid pressure. AVhen the ducts have been much dilated, they return to their natural size very slowly. The common duct has been found as large as the finger, or even larger, a considerable time after the passage of the stone by which its dilatation was caused. But gall-stones, while lodged in the gall-bladder, may, by me- chanical irritation, excite inflammation of its coats, and perhaps hasten the progress of fatty degeneration and ossification of them. The frequent association of gall-stones with fatty degeneration of the coats of the gall-bladder has been already noticed. It is pro- bable that this change in the gall-bladder is generally the effect of that derangement of the animal chemistry which leads to the forma- tion of gall-stones, and that it is often one of the immediate causes of the gall-stones, by rendering the secretions of the gall-bladder unhealthy and causing them to be loaded with scales of cholesterine; but it is probable also that gall-stones, once formed, may, by me- chanical irritation, bring about degeneration of the coats of the gall- bladder, or may, in their turn, hasten that degeneration of the gall- bladder to which in part they owe their origin. I have more than once found fatty degeneration and ossification of the gall-bladder which contained gall-stones far more advanced than elsewhere at its under and free surface, near the broad end, where gall-stones must be most apt to rest. Another occasional and very serious effect of gall-stones is ulcera- tion of the gall-bladder, or of the cystic or common duct. The relation of gall-stones to ulceration of the bladder and ducts has already been considered. Gall-stones are frequently associated with ulceration of the bladder; but it must not be inferred in all such cases, that the ulcers were caused by the stones. Ulcers of the gall-bladder and gall-ducts may be produced by unhealthy bile, and are sometimes found where there are no gall-stones. It is fair, therefore, to infer, that in some cases where gall-stones and ulcers are found together, and where from the very existence of the gall- stones, we know that the bile has been unhealthy, the ulcers, like the gall-stones, are the immediate effect of unhealthy trile. Small, scattered, round ulcers, found in connection with a few small gall- stones, which do not rest on the ulcers and can readily change their place, are probably always produced in this way. But there can EFFECTS. 379 be no doubt that a large gall-stone, lodged in the bladder, or in some part of the cystic or common duct, may cause ulceration and sloughing, or may fret a small ulcer produced by unhealthy bile into a large and deep one. The effects of this vary, according to the situation of the ulcer and other circumstances. An ulcer in the gall-bladder or in the cystic or the common duct may eat through the different coats, till the peritoneal coat is laid bare. The contact of the bile then causes this to slough, and the contents of the blad- der or ducts escape at once into the cavity of the peritoneum, causing inflammation of the whole surface of that membrane, rapid collapse, and death. If, however, the cystic duct has been pre- viously closed, and the bile that was in the bladder absorbed, the contents of the bladder may escape into the peritoneum by oozing, and suppurative inflammation may set up, which is limited to the neighborhood of the gall-bladder by adhesions, thus forming a cir- cumscribed abscess in the cavity of the peritoneum. But either of these events is very rare. In the great majority of cases in which an ulcer in the gall-bladder or ducts is formed, or fretted, by a gall-stone, adhesive inflammation of the peritoneum covering the ulcer is set up before all the coats are eaten through, and lymph is poured out, which glues that part of the gall-bladder or duct in which the ulcer is situated to the part with which it happens to be in contact. When the ulcer is in the common duct, this is gene- rally the duodenum ; when in the gall-bladder, the duodenum or the colon. After these adhesions have formed, the process of ulcera- tion may still go on till the coats of the bowel are eaten through as well, and the gall stone escapes into the intestinal canal. It has been already remarked that, in such cases, the process of ulceration is slow, and that the adhesive inflammation of the peritoneum which it sets up is of small extent, so that there are seldom severe or alarm- ing symptoms, and, now and then, the first clear intimation that anything serious has been going on, is the discharge of a large gall-stone from the bowel. A large gall-stone escaping into the bowel in this way, may cause much less suffering than by passing along the ducts. AVhen an unnatural communication is thus made between the gall-bladder, or duct, and the intestine, the continued passage of the bile may prevent it from being closed, and a per- manent biliary fistula be formed. Now and then, the gall-stone passes by ulceration from the gall-bladder into the stomach; or the gall-bladder becomes adherent to the abdominal parietes, and the 380 GALL-STONES. stone escapes, by ulceration, through them.1 In either case, un- less the cystic duct be closed so as to prevent the' bile from flowing into the bladder, a permanent fistula will be formed. It would also seem, from cases before referred to, that gall-stones, by causing, or by keeping up, ulceration of the gall-bladder or ducts, may lead to abscesses in the substance of the liver: either by setting up suppurative inflammation of a small vein in the neigh- borhood of the ulcer, or through absorption of ichorous matter from it. Such a result is, however, very rare. In these several ways, and by their passage through the ducts, gall-stones are, in this country, the cause of a large proportion of the severe and recurring ailments attributable to the liver in persons, more especially in women of the middle and upper classes, who have led sedentary lives and have reached the middle period of life. Gall-stones may exist in the gall-bladder a long time without giving rise to any symptoms that are noticed. They are not un- frequently found, and sometimes in great numbers, in persons who during life had no ailments referable to the liver that could lead to the suspicion even of their presence. AVhile stationary in the bladder they seldom give rise to striking symptoms, unless they are so large or so numerous as to distend it, or unless there be at the same time ulceration or inflammation of its coats. In such cases they cause a sense of weight or uneasiness often felt in the region of the gall-bladder, or pain, with more or less tenderness, in that part. Not unfrequently they cause also pain in the back, about the angle of the right scapula, which is very significant of irritation of the gall-bladder or gall-ducts, and which sometimes extends even to the right arm. The pain or uneasiness in the site of the gall-bladder is increased by distension of the stomach, by a deep breath, or by certain movements of the body.2 The fact that gall-stones often exist without causing much pain, is explained by the circumstance, that the gall-bladder does not contract on the stones, and is perhaps seldom completely emptied, 1 Andral, Precis d'Anat. Path., i. pp. 187 and 241. Since the first edition of this book was published, three instances have been brought under my own notice, in which a gall-stone had thus worked its way through the walls of the belly. 2 In describing the symptoms produced by gall-stones, I have freely availed myself of the admirable account that has been given of them by Dr. Prout, in the third edition of his work on Stomach and Urinary Diseases. SYMPTOMS. 381 and that gall-stones are so light that they are suspended in bile, and in consequence exert no pressure on the coats of the bladder by reason of their weight. It may also be owing in part to the little sensibility to pain which the gall-bladder has when not in- flamed. A gall-stone may also remain long impacted in the cystic duct, without causing pain or having other ill effect than those obscure disorders of disgestion which result from loss of the natural reser- voir of the bile. Some instances of this kind have been related in a former chapter. A gall-stone fastened in the common duct must cause jaundice by impeding the flow of bile, but unless it occasion sloughing or ulceration of the duct, it may cause no other pain than that which results from the mere stoppage of the bile. The passage of gall-stones through the ducts is generally produc- tive of great pain, but, unless tnere be ulceration or inflammation, it is seldom that much pain results from their mere presence, either in the bladder or in the ducts. The symptoms of the passing of gall-stones generally come on suddenly and unexpectedly, two or three hours after eating, with severe pain, and what is described, and no doubt rightly described, as spasm in the region of the gall-bladder. The pain is not equable, but subsides and again recurs in paroxysms, which are often so excruciating that the patient bends himself double or rolls about the floor, at the same time pressing his hands against the pit of the stomach, which sometimes eases the pain. The severe paroxysms produce great exhaustion; the pulse becomes slow or weak, the face pallid, and the whole body covered with a cold sweat. The pain in the region of the gall-bladder is often attended with pain referred to the angle of the right scapula, and with a sense of constriction round the lower part of the chest, as if a cord were tied tightly round it—a sensation not peculiar to gall-stones, but very distinct- ive of sudden stoppage of the common gall-duct. Together with these symptoms there is sympathetic disorder of the stomach, which varies in degree, according to the intensity of the original irritation and the nervous susceptibility of the patient, from mere flatulent distension of the stomach to frequent and distressing vomiting. In some of the severer cases, only the mechanical act of the vomiting is excited, and the stomach is emptied of its ordinary contents; in others, the irritation in the gall-duct excites the secreting function 382 GALL-STONES. of the stomach, and great quantities of gastric acid are brought up by the repeated efforts of vomiting. This sympathetic disorder of the stomach, like that arising from other sources of irritation, is, as a general rule, much greater in women than in men. A gall-stone in the common duct of course impedes the flow of the bile, so that, if the stone do not quickly pass into the bowel, the symptoms above mentioned are usually followed by jaundice. When the obstruction of the duct is complete from the first, the" jaundice appears very soon—it may be, within a few hours of the first seizure. When the obstruction is partial, a week or more may elapse before the occurrence of jaundice. The severity of the symptoms, and the time they last, are of course very variable, depending on the number, and the form, and the size, of the stones that are passing, and on the previous state of the ducts. In some cases, the symptoms cease after an hour or two, or a still shorter time, and in most instances, suddenly, as the stone escapes into the duodenum, the obstruction of the duct is not complete or does not last long enough for the production of jaundice, and the disorder may be taken for mere hepatic colic. In other cases, where the stone is larger, or the passage less free, or where many stones pass in succession, the paroxysms of pain and spasm may continue to recur, with intervals of comparative ease—and jaundice, with varying degrees of intensity, may persist—for many weeks. The passage of gall-stones does not produce, at first, either ten- derness of the side or fever. On the contrary, the pain is generally somewhat eased by firm pressure; and, during the severe parox- ysms of pain, the skin is cold and the pulse slow or weak. If, however, the stone be long in passing, some degree of fever is set up, the epigastrium becomes tender, and the tongue foul. These symptoms are probably owing to inflammation of the ducts, caused by the mechanical irritation of the stone. Besides tenderness at the epigastrium, there is general soreness of the belly, from the repeated efforts of vomiting, and from the spasmodic action of the muscles during the paroxysms of pain. When the stone is long in passing, the sensibility of the nerves about the gall-ducts is heightened, and, in addition to the functional disorder of the stomach before described, the patient now and then has hiccough, or a peculiar catch in the region of the gall-duct on drawing breath, and sometimes feels as if there were a knot there SYMPTOMS. 383 in the constricting cord. The liver grows larger from retention of the bile within it; there is often a manifest fulness of the right hypochondrium from distension of the gall-bladder; sometimes a throbbing is felt there; and the thin edge of the liver may be traced much below its natural limits. Another common symptom in severe and protracted cases is a shivering fit which recurs generally at irregular intervals, but some- times almost with the regularity of ague. The rigors probably depend on distension of the bladder or ducts. Kigors of the same kind not unfrequently occur from distension of the urinary bladder in consequence of stricture, or from the introduction of a catheter, and now and then from distension of the large intestine by feces. The passage of a gall-stone through the ducts, though productive of alarming symptoms, is attended with little immediate danger to life. It can only prove fatal when the stone gets long fastened in the common duct, but, as before remarked, the common duct is larger and straighter than the cystic duct, so that a stone which has passed through the cystic duct, generally passes through the com- mon duct as well. The stone, after having caused the most agon- izing pain (continued, perhaps, with short intervals of comparative ease, for several days, or, it may be, for several weeks), and great exhaustion, and juandice, passes into the intestine, and the alarm- ing symptoms at once cease. It does, however, now and then happen, that a person dies from the pain and vomiting, and the great depression of the heart's action, that are caused by the pas- sage of a gall-stone through the common duct. An instance of this is recorded by Abercrombie {Diseases of the Stomach, &c, 2d edit., p. 389); and several other instances of the same kind have been published. Instances are also recorded where a gall-stone in the common duct has proved speedily 'fatal, by causing bursting of the gall- bladder, or of the duct behind, in consequence of their great and rapid distension. But such events are extremely rare. AArhen a gall-stone in the common duct proves fatal, it is generally by caus- ing permanent closure of the duct, and lasting jaundice. A fatal issue, in any way, is, however, of comparatively rare occurrence. In the great majority of instances the stone passes into the intestine, and the chief danger is over. If the time of its passing has been short, the patient is then well, or suffers merely from the exhaustion consequent on the 384 GALL-STONES. severe pain and the repeated efforts of vomiting, and from the irritation and obstruction which the stone may afterwards occa- sion in its passage through the bowel. But if the stone have been long in passing, and have produced jaundice, the patient, after it escapes into the duodenum, has the tenderness and the fever consequent on the injury done to the. ducts, and the addi- tional disorder caused by long pent-up and irritating bile flowing suddenly into the intestine. Gall-stones in their passage through the intestine frequently pro- duce slight colic and tenesmus, but seldom other evils unless they are very large. When this is the case they may obstruct the bowel and cause constipation, or even fatal ileus. Many instances of this kind are recorded ;l but in most of them, I believe, the gall- stone was too large to pass through the gall-duct, and had escaped by ulceration, from the gall-bladder or the common duct, into the in- testine. A small gall-stone, like any other small hard body, may, in its passage through the intestine, get lodged in the vermiform appen- dix, and may cause ulceration or sloughing, and perforation of the appendix; and, as a consequence of this, a circumscribed abscess in the cavity of the peritoneum, or general peritonitis that proves rapidly fatal—according as the contents of the intestine ooze into the cavity of the peritoneum or are poured into it at once. Several instances of this kind have been recorded, and one has fallen under my own notice. Such an event is, however, very rare, and in general the passage of a gall-stone through the in- testine causes no other inconvenience than a little colic and tenesmus. The symptoms hitherto mentioned result merely from the mechanical effects of the stones in the gall-bladder, or in their passage through the gall-ducts and the bowel. But persons who have gall-stones have frequently other ailments which result from the faulty assimilation that led to the gall-stones, and per- haps in part from the irritation of the stones, even when they do not cause the severer symptoms that mark their passage. These ailments are usually of a very vague and uncertain charac- 1 A case of this kind has been published by Abercrombie (2d ed., p. 133), and one by Cruveilhier (liv. xii., pi. 4, p. 3) ; and two others referred to in an elaborate paper on gall-stones, by M. Fauconneau Dufresne, published in the first volume of the Revue Medicate, for 1841 (p. 194). SYMPTOMS. 385 ter. In one person they are principally nervous, and consist in hypochondriasis, or depression of spirits, or other nervous disorder; in another, they are chiefly disorders of digestion that are com- plained of; in a third, the urine is unhealthy, and frequently deposits lithic gravel, and the chief complaint is of irritation of the kidneys or bladder. Persons of middle age, or older, who have urinary calculus, have not unfrequently gall-stones as well. Nu- merous examples of this were collected by Morgagni, who inferred from them that gall-stones and urinary calculus are often caused by the same conditions; and that the presence of a urinary calcu- lus in a person who has reached middle age, should strengthen any suspicions of the existence of gall-stones which other symptoms may awaken. (Epist. xxxvii., art. 43.) Many of the various ailments that are found associated with gall- stones are, no doubt, mainly owing to the faulty assimilation in which these originate; but it would seem that in some cases they are attributable in great part to the mere irritation kept up by the gall-stones themselves. The mechanical irritation of the stones, even when contained in the bladder, sometimes greatly disturbs the stomach, causing not only vomiting, but also an abundant and unseasonable secretion of gastric acid; and the irritation is now and then reflected upon the kidneys. I have been informed by a person who has several times passed small angular gall-stones that the illness attending their passage always began with pain in the loins and the passing of a large quantity of urine. It seemed that the irritation of the stone in some part of its course through the ducts-probably in the cystic duct-was in this instance, reflected upon the kidneys so as to excite an 'abundant secretion of urine. Disease or irritation of other parts seems occasionally to excite through the same nervous agency the action of the kidneys. A person who has once suffered from the passing of a gall-stone is very liable to suffer in the same way again. AVhere there are many gall-stones in the bladder, a few only, or even a single one, may pass at a time; or after all that were in the bladder have come away others may form in their place. Now and then, a person, after having suffered from the passing of gall-stones at irregular intervals for years, has freedom from such suffering for the^rest_ of his life. This may happen from the cystic duct becoming blocked 25 386 GALL-STONES. up by a stone—an event which allows no others to form, or, at any rate, to pass; or it may happen from all the stones in the bladder being at length discharged, and no others forming in their place. It has been already remarked, that when there are many gall-stones in a bladder, they have usually the same characters, and appear to have been formed at the same time. The immediate cause of their formation is probably the deposit of some of the principles of the bile in solid form, in consequence of some passing fault of the bile, or of unusual retention, which may not again occur. From the account that has been given of the symptoms produced by gall-stones, it will appear that, before any have passed, while they are still lodged in the bladder, or when one has become im- pacted in the cystic duct, it is impossible to detect them. They then give rise to no symptoms, or merely to some pain or uneasiness in the region of the gall-bladder, with certain obscure derangements of health, which may equally result from ulceration of the gall- bladder, from organic disease of the liver itself, from disorder of the stomach or of the large intestine, and from various other causes. No constant or peculiar constitutional symptoms, indica- tive of gall-stones, have been yet noticed, and our knowledge of the circumstances under which gall-stones occur is too meagre to give meaning to symptoms otherwise vague. AVhen gall stones are passing, the symptoms are more significant, but even then may not be so peculiar as to give assurance of the fact, unless the person have had former attacks of the same kind, and have ascertained that they resulted from gall-stones. Some- times, indeed, the passing of gall-stones causes but a few severe paroxysms of pain, or a few sharp twinges, which, unless it be known that the person has passed gall-stones before, may be attri- buted to various other conditions. Now and then, similar attacks of pain in the region of the liver, more severe in paroxysms and unattended by fever, are brought on in highly sensitive persons by what seem to be very trivial causes of disturbance. They are of the kind we are in the habit of calling nervous—that is, they owe their chief severity to the peculiar state of the nervous system, and are most common in unmarried or hysterical women. In such persons they may generally be dis- tinguished from the paroxysms of pain produced by the passing of gall-stones by the circumstances under which they occur, and DIAGNOSIS. 387 by the general condition of the patient. They have been preceded by hysterical pain, or spasm, in other parts of the body; or the paroxysms are brought on by emotion, or fatigue; and, as in other painful hysterical disorders, there is exquisite and widely-diffused tenderness. In persons of feeble digestion, a solid mass of undigested food, which cannot readily pass through the pyloric orifice of the stomach, may cause pain and spasm, and great depression of the heart's ac- tion; and may thus excite the suspicion that gall-stones are passing. If the disorder continue a day or two, as sometimes happens, the secretion of bile may be checked so as to produce slight jaundice, and the train of symptoms may be still more like that which results from gall-stones. Such attacks, moreover, like those produced by gall-stones, are very liable to recur. Several cases have been re- ferred to me, in which a disorder of this kind, brought on by some indiscretion in diet, has been wrongly attributed to gall-stones. Where, without there having been any particular indiscretion in diet, the illness begins suddenly with pain starting from the region of the gall-bladder, accompanied by a sense of spasm and by a feel- ing of constriction round the lower part of the chest; where the pain recurs in excruciating paroxysms, attended with vomiting, but at first without tenderness of the side and without fever, and where these symptoms are followed, at the end of a day or two, by jaun- dice: where, moreover, the patient is of sedentary habits, and of middle age, or older—the condition of life and the age in which gall-stones are common—there can be but little doubt that the ill- ness is owing to the passage of gall-stones. The presumption that such is the case is still stronger if similar attacks have occurred before, and if in these the violent symptoms have ceased, as they began, suddenly. Such a succession of events is proof of an inter- mitting stoppage of the common gall-duct, and almost proof of the passage of gall-stones, or, at least, of the passage of gritty and irri- tating bile. It may, indeed, be caused, as we have seen above (p. 292),°by a wart-like body growing from the mucous membrane of the common duct, but such disease is very rare in comparison with gall-stones. The symptom which, more than any other, is significant of me- chanical stoppage of the common gall-duct, is the feeling of con- striction round the lower part of the chest, which varies in definite- ness according to the degree of obstruction and the nervous 383 GALL-STONES. susceptibility of the patient. When the obstruction is incomplete, a sense of tightness only is usually felt, which, as the obstruction increases, sometimes goes on to a distinct sense of constriction, as if a cord were tied tightly round the waist. Extension of the pain to the back about the angle of the right scapula is another circum- stance that affords strong presumption that the disorder originates in irritation of the gall-ducts. It frequently happens, however, that the symptoms are of more doubtful character. The stoppage of the duct may not be sufficiently complete or may not last long enough for the production of jaundice: or the stone pass into the bowel by ulceration, or even through the ducts, without any very severe paroxysms of pain: and in a first attack the evidence fur- nished by the mere repetition of similar attacks is of course want- ing. On all these accounts it often happens that we can only guess that gall-stones are passing. In all cases where the illness is suspected to result from gall- stones, the matters discharged from the bowels should be examined, with the view to discover the stones. It is always satisfactory to see the stones; and we may besides draw important inferences from their size and form. If only one stone is discovered, and this is of considerable size, and round, or oval, we may infer that there are no others in the bladder, and that if the patient change his mode of life he may not suffer in the same way again. If the stone be of considerable size, but, instead of being round or oval, have smooth or polished faces, we may be sure that there were others, but pro- bably not many, in the bladder with it, and which perhaps are still there. If the stone be small and angular, with polished faces, or even if many such stones are found, the probability is still greater that others are yet left in the bladder which will pass out, and the patient may expect at uncertain intervals a recurrence of similar attacks. It often happens, however, that when search is made no gall-stones are found, even when the train of symptoms has been precisely such as the passage of gall-stones occasions. The failure to find the offending bodies is no doubt owing in many cases to the incompleteness of the search ; but in some cases it is attributable to the fact, that severe paroxysms of pain and spasm are sometimes caused by a mere gritty state of the bile, or by what may be more properly called biliary gravel than gall stones—and that in the dis- charges from the bowels the particles tha.t have caused so much irri- tation are difficult to detect. Dr. Prout recommended that, when TREATMENT. 389 the passage of gall-stones is suspected, directions should be given to mix the feces with water, on the surface of which, he says, the stones, if present, will be found floating. But this certainly will not always be the case. Most gall-stones, when fresh from the bladder, are heavier than water. They become, indeed, lighter than water by drying, and will then float in water until they have imbibed a certain quantity of it, when they sink slowly to the bot- tom. Dr. AVatson has also recommended the adoption of this me- thod of finding the stones, but he adds—" I never but once suc- ceeded in thus catching a concretion in the evacuations of a patient, whose symptoms had led me to search for it." {Lectures on the Practice of Physic, vol. ii. p. 527.) In the treatment of gall-stones three distinct objects have been proposed: 1st. To calm the pain and spasm while the stone is passing; 2d. To dissolve any stones that may remain in the blad- der; 3d. To prevent fresh stones from forming. AVhile a gall-stone is passing nothing calms pain and spasm, and prevents, therefore, the exhaustion it occasions, so much as opium. This should be given in large doses, and is generally best given in a pill; for, from the irritability of the stomach, liquids are usually almost immediately rejected. Occasionally opium may be given with advantage in effervescing draughts, which allay the irritability of the stomach, and for a time enable the patient to retain the opium. In some cases much relief is obtained from sulphuric ether or chloric ether, in conjunction with opium. But, as was stated by Dr. Prout, more immediate relief is often afforded by large draughts of hot water, containing bicarbonate of soda in solu- tion (in the proportion of from one to two drachms of the bicarbon- ate to a pint of water), than by any other means yet recommended. " The alkali counteracts the distressing symptoms produced by the acidity of the stomach; while the hot water acts like a fomentation to the seat of the pain. The first portions of water are commonly rejected almost immediately; but others may be repeatedly taken; and after some time it will be usually found that the pain will become less, and the water be retained. Another advantage of this plan of treatment is, that the water abates the severity of the retching, which is usually most severe and dangerous where there is nothing present on which the stomach can react. This plan does not supersede the use of opium, which may be given in any way 390 GALL-STONES. deemed most desirable; and in some instances a few drops of lauda- num may be advantageously conjoined with the alkaline solution, after it has been once or twice rejected." (Third ed., p. 263.) The hot bath, fomentations with hot water, alone or with opium or decoction of poppies, or other appliances of like effect, but more especially the hot bath, should be had recourse to at the same time, and will often much alleviate the patient's sufferings. If these means fail, trial may be made of very cold applications—as a blad- der of pounded ice—which have been much recommended by several writers, and, it would appear, have often been productive of benefit. These means not only mitigate the pain and spasm, but in so doing doubtless promote the escape of the stone, and thus lessen the danger of ulceration or permanent obstruction of the duct. It seems to have been formerly a common practice to give emetics or strong purgatives, to quicken the passage of the stone; but this practice has been justly reprobated, on the ground that it increases the pain before the ducts are sufficiently dilated to allow the stone to pass. A certain time is requisite for the necessary dilatation of the ducts; and when the stone is in the common duct it is suffi- ciently urged forward by the constant and gradually increasing pressure of the accumulated bile behind. AVhen the symptoms lead to the inference that the stone has passed into the duodenum, purgatives and copious injections of warm water should be given to hasten its discharge from the bowel, and with it the discharge of the accumulated and irritating bile. If any tenderness and fever should come on during the passage of the stone, leeches should be applied at once to the tender part. These symptoms show that inflammation of the ducts has been set up, which may produce ill effects of various kinds. AVe have con- sidered in a former chapter the nature of these effects, and the great importance of the early employment of local remedies—leeches and blisters—when the symptoms lead to the inference that inflamma- tion either of the gall-bladder or of the gall-duct exists. In the present instance, the tenderness and the fever, from the peculiar symptoms that precede them, are unusually significant of inflamma- tion of the ducts, and of inflammation excited by a local cause, and, therefore, to be chiefly relieved by local remedies. The second object proposed in the treatment of gall-stones, is to TREATMENT. 391 endeavor by medicines to dissolve any stones that may yet remain in the bladder. Various medicines have at different times had the credit of doing this. The alkaline carbonates were long held in repute as solvents of gall-stones, and a plausible reason of their having such virtues has been assigned in the great solubility of the cholesterates of potash and soda. Soda is a natural constituent of bile. It is probable, therefore, that salts of soda, given as medi- cine, may be in part excreted in the bile, and may tend to form a soluble compound of cholesterine. But the medicine that has been most celebrated as a solvent for gall-stones is a combination of sulphuric ether and turpentine. This was at one time much relied on in France, where it was brought into great vogue by Durande, a physician of Dijon, who published the details of many cases for the sake of establishing its efficacy. Durande's remedy, which consisted of a mixture of three parts of ether with two of essence of turpentine, became in conse- quence very famous. It has never been much employed in this country, and latterly has lost much of the credit it at one time had in France. It is clear that it must be extremely difficult to obtain satisfactory evidence in favor of such virtue for any medicine. Before gall- stones have passed we can never be sure of their existence; and after a person has once passed gall-stones, he may go on for years, or even for the rest of his life, without passing others. All the stones in the bladder may have come away at once, and no others may form; or those which remain in the bladder may be too large to pass out; or one may have permanently blocked up the cystic duct: or, if the person continue to pass gall-stones, he may suffer much less in the subsequent attacks than at first, on account of the dilatation of the ducts which was then effected, or the smaller size of the stones. AVhen, therefore, a person who has once passed gall- stones, passes no more for the future, or if he have other attacks, suffers less in them than in the first, we must be very cautious in assuming that this happy circumstance is the effect of our remedies. Medicines whose efficacy is so difficult to establish, however real their efficacy may be, almost inevitably fall after a time into com- parative disrepute. This has happened for taraxacum, and for most other medicines that have been supposed to increase the quantity and to alter the qualities of the bile. Few practitioners have the same faith in the reputed virtues of cholagogues and alteratives of 392 GALL-STONES. the bile, as they have in medicines which increase the quantity or alter the qualities of the urine, because, although analogy leads us to conclude that some medicines have such virtues, there is not equal proof that the virtues actually belong to the particular medi- cines to which they have been ascribed. The natural tendency, therefore, seems to be, to estimate too low the value of such medi- cines, and perhaps of late the notion has been too much discarded, that gall-stones once formed in the bladder may be again dissolved. Combinations of ether and turpentine, if they do not dissolve gall-stones, seem occasionally to have done good—probably by re- lieving the pain and spasm which the irritation of gall-stones occa- sions. The third object of treatment is, when gall-stones have been formed and passed, to prevent others from forming in future. For this, chief reliance must be placed on free exposure to the fresh air, on exercise, and on proper diet. The chemical composition of gall- stones and the facts well established by observation, that they are most common in persons of sedentary habits, and that they very rarely occur at the time of life when respiration is most active, tend alike to show that free exposure to the air must have great influence in preventing their formation. The patient should there- fore be much in the open air, and sleep in an airy bedroom; he should rise early, and take plenty of exercise; should abstain as much as possible from fat or gross meats and heavy malt liquors; and, with the view of preventing undue concentration of the bile in the gall-bladder, should take diluents rather freely, and not make the intervals between meals too long. The bowels should be duly regulated, if need be, by the habitual use of rhubarb, or rhubarb and aloes; or by mild saline purgatives, as the Piilna water ; and the action of the skin should be kept up by an occasional warm bath. In addition to these means, we may endeavor to render the bile more healthy by some of those medicines which are supposed to alter its quality. In some persons who suffer from gall-stones and other disorders that arise from an unhealthy state of the bile, no medicine does such signal good as mercury, in small doses, con- tinued for some time. It seems to increase the quantity of the bile, and at the same time to render it more healthy, and certainly often improves in a striking manner the general health. The best pre- paration of mercury for this purpose is the blue pill. It may be TREATMENT. 393 given most safely, and with best chance of benefit, to persons of full habit who have lived freely, and in whom there is no reason to suspect organic disease. Where the patient is thin, or has lived badly, or where there is reason to fear organic disease of the. liver, or of some other organ, it is safer and wiser to abstain from mercury, and to be content with taraxacum, or muriate of ammonia, or the alkaline carbonates, or other mild medicines that are supposed to alter the qualities of the bile. Where the secretion of bile has been long disordered, and the health is much broken, great benefit sometimes results from a mild course of the natural alkaline or saline waters. The alkaline waters of Vichy and Ems, and the waters of Carlsbad, on the Con- tinent ; and in this country, the saline waters of Cheltenham and Leamington, and the sulphurous waters of Harrowgate, are those whose efficacy in such cases is best established. The waters of Vichy, in particular, are very highly thought of by French physi- cians, and probably with sufficient reason. 394 CHAPTER IV. DISEASES WHICH RESULT FROM SOME GROWTH FOREIGN TO THE NATURAL STRUCTURE. Sect. I.— Cancer of the liver—Origin of cancerous tumors of the liver —their growth, dissemination, and effects—Encysted, knotty tubera of the liver. Having considered the inflammatory diseases of the liver, and the diseases which result from impaired nutrition of its tissues, and from faulty secretion, there remain for us to consider those which consist in some growth foreign to the natural structure. The most important member of this class is Cancer, which is more frequent in the liver than in any other organ. Indeed, no serious organic disease of the substance of the liver is, in this country—at least among people who have never drunk hard—so frequent as cancer. In some instances, the liver is the only organ infected with can- cer, or is the organ in which the cancer originates; but far oftener the formation of cancerous tumors in it is consequent on cancer of some other part, especially the stomach and the breast. In the Anatomie Pathologique of Cruveilhier, the Clinique Midi- cale of Andral, and the little work by Dr. Farre on the Morbid Anatomy of the Liver, twenty-nine cases are recorded in which can- cerous tumors were found in the liver. In three only of these cases was the disease confined to the liver. {Cruv., liv. xii. pi. 2, p. 8; Clin. Med., iv. p. 445 ; Farre, Case 2.) In another case {Cruv., liv. xxxvii. pi. 4, p. 3), the lungs and the liver were the only organs in which cancerous tumors were noticed; in another {Clin. Med., iv. 433) the liver and the gastro-hepatic omentum. In all these cases it is, perhaps, fair to conclude that the disease originated in the liver. CANCER OF THE LIVER. 305 In the remaining twenty-four cases, other parts of the body were affected with cancer, as well as the liver. In thirteen of them there was cancer of the stomach; in five, cancer of the breast. Some particulars of these cases will be presently mentioned, which leave little doubt that in most of them, if not in all, the disease was pro- pagated to the liver from the stomach and the breast respectively. Many circumstances conspire to render the liver, more frequently than any other organ, the seat of both disseminated abscesses and disseminated cancer. One of these is the great vascularity of the liver, and the slow- ness with which the blood, already retarded by passing through a system of capillary vessels, traverses the dense plexus of vessels that goes to form its lobular substance. But a circumstance much more influential, is that the liver is the organ through which the blood, returning from the intestinal canal, first passes. AVhen the stomach or intestines are ulcerated, the blood that flows to the liver from these parts is liable to be contaminated by pus and other noxious matters, which cause inflammation that rapidly leads to abscess. When the stomach is the seat of cancer, the portal blood is liable to be contaminated by cancer-germs, which, being stopped in their passage through the liver, are there developed into cancer- ous tumors. In such cases, the abscesses and the secondary can- cerous tumors are usually found only in the liver, which seems to detain all the pus-globules and cancer-germs that are brought to it by the portal blood. It rarely happens that any of these seeds of mischief pass through to cause abscesses or cancerous tumors in the lungs and other organs. It is seldom that a single cancerous growth is found in the liver. There are usually scattered through its substance a great number, often hundreds, of round tumors, some of them so small as to be distinguished with difficulty, others of the size of a bean, of a wal- nut, or of an orange. Sometimes, indeed, cancerous tumors in the liver grow still larger, especially when there are but few of them; for, as Cruveilhier has justly remarked, their size is usually inversely as their number. AVhen they are numerous, it is generally plain, from their differ- ence of size and texture, that they are of different ages: so that in the same liver they are often seen in various stages of growth. The first token of the deposit of cancerous matter, discoverable by the naked eye, is a change of color, which is limited to two or 396 CANCER OF THE LIVER. three contiguous lobules, or even to a single lobule. The tainted lobules, instead of being of their natural tint, are whitish or black, according to the variety of cancer, and their consistence is altered, but they remain unchanged in size and form; thus showing that the disease originates in the lobules, and not in the areolar tissue in the small portal canals. Not unfrequently, in a small cancerous tumor, throughout, and near the circumference in large tumors, when they are cut across, a mottled appearance is seen, like that of the lobular structure of the liver, and clearly resulting from this structure having been involved in the cancerous growth. A cancerous tumor in the liver grows larger by infiltration of the cancerous matter into the contiguous liver-substance, which becomes gradually converted into cancer. In this way, a great portion of the proper liver-substance may be entirely replaced by the new structure. I have more than once known the left lobe of the liver undergo this transformation in its entire thickness, so that, as in a case related further on, when a vertical slice was made a little to the left of the suspensory ligament, the cut surface, from front to back, exhibited nothing but white cancer. The cancerous tumor grows, also, by addition to its own proper mass, and may thus come to project above the surface of the liver, and in the sub- stance of the liver may, to a certain extent, push aside and com- press adjacent tissues. One effect of the pressure, not unfrequently observed when the cancerous tumors are thickly studded, is partial biliary congestion. Portions of the hepatic substance between the tumors are of a dark green, or an olive color, in consequence of compression of the small gall-ducts. The cancer may afterwards invade these portions, and the corresponding parts of the cancerous growth will be deeply colored with bile. I have more than once found parts, near the circumference, of large cancerous tumors, and small cancerous tumors throughout, tinged of a deep green, evidently from the can- cer having invaded portions of the hepatic substance already gorged with bile. The hepatic substance immediately surrounding a cancerous tumor not unfrequently, however, exhibits a change which cannot, perhaps, be attributed to pressure. It is pale and fatty, while other portions are not so. As before remarked, such a partial deposit of VARIETIES. 397 fat round a cancerous tumor is not peculiar to the liver, but is often found also in cancer of the omentum and of other parts. Those cancerous tumors which originate near the surface of the liver, in growing project above it, so as to render it knotty or un- even. AVhen the projecting tumors are large, the centre of the projecting portion is often somewhat depressed or cupped; an effect, it would seem, of strangulation of the central part of the tumor. The tumor is more freely supplied with blood, and grows faster, round the edge. This cupped form is not peculiar to cancerous tumors of the liver, but is sometimes observed also, though much less frequently, in cancerous tumors of the lung, when these are large and project above the general surface of the pleura. Cancerous tumors in the liver, as in other parts, differ much in firmness, vascularity, and color, in different cases. Sometimes the tumors are white and fibrous, or, as it is termed, scirrhous ; but far more frequently, especially when numerous, they are soft, or me- dullary. Instances are now and then met with, in which, in the same liver, some tumors are hard, and others soft. Soft cancer presents the same varieties in the liver as in other organs. Most commonly the cancerous mass contains but few vessels, and is pulpy and whitish, or of a grayish-white—present- ing that striking resemblance to brain rather softened, which led Laennec to apply to it the term encephaloid. In other cases, the tumors are extremely vascular, presenting the appearance known as fungus hematodes. In others, again, they are melanotic. Indeed, every variety of cancer, excepting, perhaps, gelatiniform, or colloid cancer, has been met with in this organ. The color of melanotic tumors of the liver varies, according to the quantity of pigment-granules they contain. In the same liver tumors may sometimes be found of every shade from light brown to black. Melanosis, whatever be its primary seat, becomes disseminated sooner, and more widely, than any other variety of cancer. I am not aware that melanotic tumors have ever been found in the liver without being found, at the same time, in other organs; and when they exist in the liver, they are usually in very great number. Sometimes, indeed, the whole liver is thickly studded with small black grains, giving to a section of it an appearance compared by Cruveilhier to granite, or black mica. This appearance is repre- 398 CANCER OF THE LIVER. sented in Plate 4, which was made from a preparation in the Muse- um of King's College. (Prep. 324.) Large cancerous tumors, whether hard or soft, white or melan- otic, are usually slightly lobulated, from there having been greater impediment to their growth in some directions than in others; and they are united to the substance of the liver in which they are imbedded only by areolar tissue and vessels. It happens, however, now and then, though very seldom, that tumors of medullary cancer are surrounded by a well-defined cyst. The cyst, as was observed by Laennec, is a smooth membrane, about half a line in thickness, of fibrous texture, and silvery white color, imperfectly transparent, and easily separable from the mass it incloses. Encysted cancerous tumors are always very soft and fluctuating, having much the feel of an abscess. AVhen cut across and macer- ated, the pulpy matter is washed out, and a beautiful filamentous mass is left. AVe are ignorant of the circumstances which deter- mine the formation of the cyst. Melanotic tumors, as well as common encephaloid tumors, are sometimes encysted ; and some tumors in a liver may be encysted, while others are not. {Cruv., liv. xxiii. pi. 5, p. 5.) It may be, that the cyst is owing to the de- velopment of cancerous matter from the inner surface of a gall-duct. The cyst is very like that of the knotty tumors containing a cheese- like matter, which are sometimes found in the liver, and which (as will be seen towards the end of this chapter) appear to originate in inflammation of a small gall-duct. It now and then happens that cancer is found in the gall-bladder, as well as in the substance of the liver. Sometimes the cancer of the gall-bladder is distinct from the neighboring cancerous masses; in other cases it results from a cancerous tumor in the substance of the liver involving the gall-bladder in its growth. Not unfrequently, too, cancerous matter may be found in the veins of the liver, and, as happens for the gall-bladder, this may grow from their inner surface, and be distinct from the neighboring cancerous masses, or it may result from a cancerous tumor involv- ing, and penetrating, as it grows, the coats of the vein from without. When a liver contains numerous masses of cancer, it is generally much enlarged, extending far below the false ribs, and sometimes even to the brim of the pelvis. Its increased size is in most cases EFFECTS. 399 owing entirely to the presence of the cancerous tumors; and, in- deed, when these are removed, the hepatic substance is found to be diminished in volume. As before remarked, portions of the lobu- lar substance are involved in the tumors; and other portions, espe- cially between contiguous cancerous masses, are sometimes found pale and atrophied, and even converted into fibrous tissue, probably from their supply of blood being stopped by the pressure of the cancerous masses, or by cancerous matter within the veins, or by adhesive inflammation of the inner surface of the veins, which is very common in the neighborhood of cancer in some other parts. From the tumors thus invading the lobular substance of the liver in their growth, and from their causing atrophy of other portions, the organ may contain numerous masses of cancer, and yet be smaller than in health. But this happens very seldom. In almost all cases, the tumors more than compensate in bulk for any destruction or wasting of the lobular substance which they occasion; and sometimes the bulk of the organ, without the tumors, is much increased from the pre- sence of an unusual quantity of fatty matter, or other products of secretion, in the lobular substance. Even when the cancerous masses have grown rapidly, there are seldom any marks of inflammation in the hepatic tissue around them. The tumors owe their development, not to any process of inflammation, but to their own independent vitality; and the hepatic tissue in which they are lodged generally presents no other changes of structure than those produced by pressure and defective nutrition. But although cancerous growths do not cause inflammation of the surrounding hepatic tissue, they now and then, when superficial, cause inflammation of the peritoneum above them. But even this happens seldom. The liver is often found much enlarged from cancerous tumors, and much deformed by some of these tumors projecting above its surface, without any traces of inflammation of its capsule. AVhen inflammation occurs, it is probably caused by rupture of the peritoneal coat and escape of cancerous matter. The character of the peritoneal inflammation which is excited by cancer has been already noticed (p. 147). It is always adhesive, and is generally very partial, causing the effusion of only a very small quantity of lymph. The usual traces of it found after death are, 400 CANCER OF THE LIVER. opacity and apparent thickening of the peritoneum above the pro- jecting tumors, or very delicate, thread-like bands, uniting these tumors to the opposite surface of the diaphragm or abdominal walls. Sometimes, however, the inflammation is more extensive, and it may involve the entire surface of the liver, and even that of the peritoneum. But it is a property of cancer to invade and destroy all structures within its immediate reach; and in consequence of this, if a can- cerous mass be on the convex surface of the liver, it may eat through the diaphragm, and cause adhesive inflammation of the pleura. {Cruv., liv. xxxvii. pi. iv. p. 4.) Cancer of the liver may perhaps, also, like cancer of other parts, cause adhesive inflammation of contiguous veins. Inflammation of the adjacent veins is yery common in cancer of the uterus, and it is in such cases that the inflammation of veins which is produced by cancer has been most studied. The uterine, and often one or both of the iliac veins, are found blocked up with fibrin. Lower down in the veins, proceeding against the course of the circulation, there may be small collections of pus, bounded above and below by fibrin; and sometimes the veins of the leg for a great length are found filled with pus. I met with an instance of this, in the spring of 1843, in a poor woman who died under my care in King's Col- lege Hospital. She had cancer of the neck of the uterus, which had eaten into the bladder in front, and into the rectum behind, so that, for many weeks before her death, both the urine and the feces were continually passing through the vagina. She had constant severe pain in the lower part of the belly, and occasional pain in the region of the liver. Two or three weeks before her death she began to complain of severe pain in both legs, which became very much swelled. The intestines in the lower part of the abdomen were found matted to- gether, while those in the upper part were free and presented no traces of inflammation. On separating the adherent coils, two pouches of the peritoneum filled with pus were opened. The lumbar glands were cancerous, and the liver was studded with medullary tumors, of various sizes, of which many of those that were superficial were united to the opposite surface of the diaphragm, or ab- dominal walls, by thread-like bands of false membrane. In the lower lobe of the left lung was a small whitish mass, which was inferred to be can- cer. No cancerous tumors were discovered in other parts of the body. The internal iliac vein on each side was blocked up with fibrin, while the femoral and popliteal veins, and the veins of the legs as far as they were traced, were filled with pus. The left knee-joiut contained a large quantity of pus, but there was none in any other joint, nor were there any EFFECTS. 401 abscesses in other parts of the body. The fibrin that plugged the upper portion of the vein prevented the pus from contaminating the circulating blood. Cruveilhier has distinctly remarked that, while it is very com- mon, in cancer of the uterus, for small isolated collections of pus to form in the veins of the pelvis or of the legs, it very seldom happens that abscesses form in other parts of the body, or that the patient presents the general symptoms of contamination of the blood by pus. The pus is prevented from mixing with the cir- culating blood by adhesive inflammation of the upper portion of the vein. It would seem that adhesive inflammation is first set up in this portion, and that afterwards, suppurative inflammation is excited in the portion below. This sometimes happens in inflam- mation of veins from other causes; and it would almost seem that adhesive inflammation of the trunk of a vein may of itself lead to suppurative inflammation of the branches through which the flow of blood is thus prevented. In cancer of the liver, I have more than once found some veins of this organ blocked up with what I took for coagulated fibrin, but have never found any filled with pus. Inflammation of the contiguous veins is most common in cancer of the uterus and cancer of the breast, in consequence of the great frequency of ulceration in cancer of those parts. The ulceration produced by cancer, like that from other causes, is adequate, of itself, to cause inflammation of adjacent veins. It not unfrequently happens that, with cancer of the liver, a collection of serous fluid is found in the cavity of the peritoneum, even when this membrane presents, no trace of inflammation. The serum is probably effused in consequence of obstruction to the passage of blood through part of the liver from some of the veins being blocked up by cancerous matter, or by fibrin, or from their being simply compressed by the cancerous tumors.1 The quantity of fluid in the peritoneum in such cases is usually small, and is very seldom sufficient to cause that distension of the belly which is observed in cirrhosis, where the passage of blood through every part of the liver is impeded. A similar effect is frequently produced by cancerous masses in ' In a preparation in the Museum of King's College (No. 288), large branches the hepatic vein between contiguous masses of cancer are seen to be flattened. 402 CANCER OF THE LIVER. the lung. Serous fluid collects in the cavity of the pleura without any inflammation of the serous membrane, or, at any rate, without inflammation that leaves other permanent traces. But there may be impediment to the flow of blood and partial oedema in the cancerous matter itself. The centre of a large can- cerous tumor in the liver has not unfrequently a gelatinous appear- ance, and when this part is punctured, and the tumor pressed, a transparent, serous fluid escapes, very unlike the opaque, white fluid of cancer. This oedema is very common in the projecting tumors whose surface is cup-shaped. Another occasional event in the soft and vascular varieties of cancer of the liver is hemorrhage into the cancerous mass. This sometimes takes place to such an extent as to cause a rapid increase in the size of the liver, and almost to produce the alarm- ing symptoms of copious internal hemorrhage. Now and then, indeed, the capsule of the liver is ruptured, and the blood escapes in large quantity into the sac of the peritoneum. AVhen only a small quantity of blood is effused in the substance of the tumors, the serum and the coloring matter may be absorbed, and small masses of fibrin be left. But the most remarkable property of cancer—a property which often influences the condition of the patient more than any damage the disease does to the part in which it first appears—is its power of dissemination. This varies much in degree, according to the variety of cancer and the part of the body in which it originates. The laws which regulate the dissemination of cancer have not been fully made out, but there is clear proof that the dissemination may take place in two ways: 1st. By inoculation, or by the mere contact of a sound part with a part affected with cancer, without any direct vascular connection between them; 2d. By cancerous matter conveyed by lymphatics and veins to other parts of the body. In the belly, where the relative motion between the surfaces is great, we have now and then distinct evidence of inoculation, in finding cancer communicated from one surface to another by mere contact without adhesion. In a woman who lately died in King's College Hospital, of cancer of the liver, there were small cancer- ous tubercles on the under surface of the diaphragm corresponding to a projecting cancerous tumor of the liver, although there were DISSEMINATION OF CANCER. 403 no unnatural adhesions between the liver and the diaphragm, and no cancerous tubercles on other parts of the reflected peritoneum. In another woman who died of cancer, which involved all the organs in the pelvis, and led to secondary cancerous tubercles of the peritoneum covering the intestines, the under edge of the liver, which had touched the tainted parts, had its surface studded with cancerous tubercles, while the substance of the liver, and the upper part of its surface, which was shielded by the ribs, were free from them. It was impossible to doubt that the edge of the liver had been infected by contact with the cancerous mass below. In 1847, I met with another striking proof of the dissemination of cancer in this way in a woman who died in King's College Hos- pital of a cancerous cystic tumor of the ovary. The reflected layer of the peritoneum and the coils of intestine in contact with the tumor were studded with cancerous tubercles. There were only a few scattered tubercles on the coils of intestine above the umbili- cus, which were not in contact with the tumor; but the surface of the liver was adherent to the diaphragm, and between them there was a continuous layer of cancerous tubercles. There were no cancerous tumors in the substance of the liver or in the lung, and there could be no doubt that the cancerous tubercles on the surface of the liver originated from germs which were transferred to that part from the original tumor in the lower part of the belly. Cruveilhier mentions a case in which he found cancer of the left extremity of the pancreas with cancer of the upper part of the left kidney. (Liv. xii. pi. 2, p. 5.) It is chiefly in this way—namely, by inoculation—that gelahni- form cancer of the stomach or intestines becomes extended to other organs in the cavity of the belly. In this variety of cancer the cancer-cells are too large to be readily transmitted by the veins so as to infect distant parts. It would seem, indeed, that cells of gela- tiniform cancer, when detached from the outer surface of the stomach, may like the fibrin which is effused in inflammation, become ad- herent to any part of the serous membrane with which they are accidentally brought in contact, and may be nourished from the vessels of that part. But the widest dissemination of cancer is effected by the transfer of cancerous matter to distant parts of the body through the lym- phatics and veins. The dissemination effected in this way usually 404 CANCER OF THE LIVER. takes place in the direction of the current of blood, or lymph. This is well shown by contrasting the organs that become infected from cancer of the breast, a part from which the blood is returned immediately to the vena cava, with the organs that become infected from cancer of the stomach, a part from which blood is returned to the portal vein. To take merely the cases recorded by the writers before referred to—Cruveilhier, Andral, and Farre. In the Ana- tomie Pathologique of Cruveilhier, there are, as before remarked, five cases (liv. xxiii. pi. 5, p. 1; id., p. 2; id., p. 3; id., p. 4; liv. xxxi. pi. 2, p. 3) in which cancerous tumors of the liver were con- sequent on cancer of the breast. In all these cases, with the ex- ception of one (liv. xxiii. pi. 5, p. 1), in which the state of other organs is not mentioned, the lungs were infected as well as the liver. The cancer-cells had to pass through the lungs, before they could arrive at the liver. But although cancer of the breast seldom causes cancer of the liver, without also causing cancer of the lungs, it not unfrequently gives rise to cancerous tumors in the lungs, without giving rise to any in the liver. In the Anat. Path, of Cruveilhier, three cases of this kind are recorded. (Liv. xxvii. pi. 3, p. 1;' id., p. 5; liv. xxxi. pi. 2, p. 2.) Cruveilhier asks how it happens, that in some cases of cancer of the breast secondary cancerous tumors form chiefly in the lungs; while in other cases they form chiefly in the liver? The circumstance may be accounted for from the variable size of cancer-cells, which, in some cases, can pass readily, in others only with difficulty, through the capillary vessels of the lungs. When cancer originates in the stomach secondary cancerous tumors form in the liver before they form in the lungs; undoubtedly from the blood infected with the cancerous matter having to pass through the liver first. Indeed, it very seldom happens that the lungs become affected at all. As before remarked, all the cancerous matter brought in the portal blood is usually detained in the sub- stance of the liver, as are the globules of pus in purulent phlebitis, instead of passing through to contaminate other organs. In the works already referred to there are thirteen cases in which can- cerous tumors in the liver seemed to be secondary to cancer of the stomach. In nine of these cases the liver was the only organ, be- sides the stomach, in which cancerous tumors were found. In the remaining four cases there was cancerous disease of some part of DISSEMINATION OF CANCER. 405 the mesentery, or of the glands about the aorta, as well as of the liver. It is a striking fact, that in not one was any cancer remarked in the lungs. Cruveilhier relates seven other cases of cancer of the stomach. In four of these the disease was confined to the stomach; in the remaining three, all of them of gelatiniform cancer, there were likewise cancerous tubercles in the mesentery, but in no other organ. When cancer originating in the kidney becomes disseminated, the lungs are infected more frequently than the liver. It might have been imagined that the same law would hold for the uterus which, like the kidney, returns its blood immediately to the vena cava; but it sometimes happens, as in a case before related, that in consequence of cancer of the uterus, cancerous tumors form in the liver, without any forming in the lungs. This results from the primary cancer extending to the rectum, and involving the haemorrhoidal veins, which return their blood to the vena portae. All these instances are sufficient to establish the fact that cancer often becomes disseminated by means of cancerous matter which is conveyed onwards in the venous current. We have additional proof of it, in the points of resemblance, before noticed, between secondary cancerous tumors of the lungs and liver and the scat- tered abscesses which form in these organs in consequence of sup- purative phlebitis. It would seem, indeed, that cancer may even be propagated by inoculation, or by injection of cancerous matter into veins from one animal to another. Professor Langenbeck injected into the veins of a dog some pulp taken from a cancer which had just been removed from a living body. At the end of some weeks the dog began to waste rapidly. It was then killed, and several cancerous tumors were found in its lungs. Another instance to the same effect, taken from a German peri- odical, is related in the Provincial Medical Journal for September 23, 1843, in the following words : " Some cells were collected from a black liquid in the orbit of a mare affected with melanosis, and were inoculated into the conjunctiva and lachrymal gland of an old 406 CANCER OF THE LIVER. horse. These merely caused a black spot on the conjunctiva, which extended very slowly ; but about the sixteenth week after inocula- tion, melanosis of the lachrymal gland was very decided; it had invaded the whole organ, and pushed the globe of the eye forward. Some of the melanotic matter, taken from the same mare, was injected into the veins of the neck of a dog, who died suddenly whilst hunting, three weeks after the operation. There was found in the left lung a melanotic tumor, which was ruptured, and which contained a brown, coffee-colored fluid, abounding in cells." So many instances have occurred of cancer of the penis in men whose wives had cancer of the womb, that many physicians have been led to believe that the disease in. these instances was propa- gated by contagion. But the most obvious, if not the most common mode in which cancer becomes disseminated from the part in which it first appears, is by transmission of the cancerous matter through the lymphatics. It is through these vessels that cancer is so constantly propagated from the breast to the glands in the axilla. The small cancerous tubercles that are sometimes found surrounding a cancer of the breast of long standing are also, as was beautifully shown by Sir Astley Cooper, seated in the lymphatics. Cancer of the stomach may, as we have seen, give rise to dis- seminated cancer of the liver, or to cancerous tubercles in the mesentery. In some instances of the latter kind the presence of the tubercles in the mesentery may be best explained by supposing cancer-cells to have been detached from the outer surface of the stomach, and to have been transferred, mechanically, to other parts of the serous membrane; but in other instances, the secondary tumors are clearly under the peritoneum, and in the mesenteric glands, and the germs of the disease must have been transmitted by lymphatics and lacteals. AVhen cancer is disseminated from the liver, it is usually through the lymphatics, and not through the veins. The lymphatic glands along the common gall-duct and in the belly, to which the lympha- tics of the liver run, and some of the lymphatic glands in the mediastinum, usually become affected before cancerous tumors form in the lung. In the lymphatics cancer is propagated, not in the natural direc- DISSEMINATION OF CANCER. 407 tion of the current of lymph only; it is sometimes propagated backwards, as when, in cancer of the breast, cancerous tubercles are found under the skin, not in the direction of the axilla merely, but surrounding the breast. This propagation of the disease back- wards through the lymphatics probably depends chiefly on the onward course of the lymph being impeded. Cruveilhier has re- marked that cancer of the breast leads less frequently to cancer of internal organs when the disease is thus disseminated outwardly. It may be readily conceived that obstruction in the course of the lymphatics leading to the axilla, or in the axillary glands, or that adhesive inflammation of the veins, by blocking up the usual channels for the transmission of the cancerous matter, may favor the dissemination of this matter in the opposite direction, and thus lead to the formation of cancerous tubercles in the neighborhood of the primary disease. Admitting all these means for the propagation of cancer, there are still cases occasionally met with, which they do not enable us to explain satisfactorily, and which strongly favor the inference, that the cancerous tumors found in different parts of the body are not offsets from one primary cancer, but are the result of a peculiar disposition to the disease. There are, perhaps, few cases in which such a supposition is more needed than in cases of primary cancer of the liver. In these cases, as when cancerous tumors form in the liver in consequence of cancer of the stomach, the infection does not often pass much beyond the liver, but there are almost always a great number of cancerous tumors in the liver itself. We have at present no evidence that these are, in all cases, derived from a single parent tumor, but it seems probable that more careful observation will hereafter prove them to be so. It is clear, at least, that dissemination may take place within the liver in various ways ; through the lymphatics, and through the veins; and, as before explained, in a twofold direction in both. Cancerous tumors may form in the liver, as a consequence of cancer of some other part, at any period of life. They are in that case dependent on the primary cancer, and of course are most frequently found in conjunction with cancer of particular parts at the periods of life when those parts are most liable to the varieties of cancer which become readily disseminated. For the breast, this is, perhaps, the period comprised between the ages of thirty and fifty. Under 408 CANCER OF THE LIVER. the age of thirty, cancer of the breast, of any kind, is very rare; and beyond the age of fifty, the disease is frequently scirrhous, of slow growth, containing but few vessels, and, in virtue of these conditions, less apt to become disseminated than other varieties of cancer. Cancer of the stomach does not occur so early in life as cancer of the breast. It is very rare in persons under the age of forty. Twenty cases of cancer of the stomach, recorded in the works of Cruveilhier, Andral, and Farre, have been already referred to. In eighteen of these the age of the patient is noted, and in all of them it was above forty, with the exception of one, in which it was thirty-eight. In eight of the cases, or nearly one-half, the patient was sixty or upwards. Dissemination from cancer of the stomach is not much influenced by age, but it seems to be much favored by the occurrence of ulcera- tion. In the great majority of the cases just referred to, in which cancerous tumors were found in the liver, the cancer of the stomach was ulcerated. This may, however, be partly explained from the circumstance, that the soft varieties of cancer, which are most readily disseminated, are also the most prone to ulcerate. Cancer of the uterus follows nearly the same laws, with respect to age, as cancer of the breast; and cancer of the colon and rectum the same as cancer of the stomach. But cancer of the uterus, and of the large intestine, becomes disseminated much less frequently than cancer of the stomach or breast. The parts above specified are by far the most frequent seats of primary cancer; and since this disease occurs in them only in the middle and advanced periods of life, disseminated cancer of the liver is also most frequent at those periods. But cancerous tumors may form in the liver at any age, as a consequence of cancer of some other part. Dr. Farre has related the case of an infant, three months old, in which there was fungoid cancer of the left kidney, with fungoid tumors in the liver and lungs; another case in a boy, two years and a half old, in which numerous cancerous tumors of the liver, and a single cancerous tumor of the lung, were conse- quent on fungoid cancer of the testicle; and a third case in a boy of the same age, in which there was a melanotic tumor in the pel- vis, with cancer of the lumbar glands and cancerous tumors in the liver and lungs. Indeed, secondary cancerous tumors form much more frequently in the liver in children affected with cancer than , CAUSES. 409 in grown-up persons, because children are subject only to the soft and very vascular varieties of cancer, which, by reason of their soft- ness and vascularity, are the varieties which become soonest and most widely disseminated. But, although cancerous tumors may form in the liver, in conse- quence of cancer of a distant part, at any period of life, the disease seldom, if ever, originates in the liver until the age of 35. In the five cases before alluded to, in which cancerous tumors seemed to have formed primarily in the liver, one of the patients was 37 years of age, two were 39, and two were 45. The disease often occurs in persons much more advanced in life, and now and then in ex- treme old age. The period from 35 to 55, in which functional dis- order of the liver is most common, appears to be that in which cancer most frequently originates in this organ. Nothing more than this is known of the conditions that dispose to primary cancer of the liver. We have no evidence that it is more frequent in hot climates than in our own; or in persons who drink spirits to excess than in those who abstain from them. It has been found, with more perhaps than the average frequency, in conjunction with gout and gall-stones; so that it is probable that high living and indolent habits, which favor the production of these latter diseases, may also dispose the liver to become the primary seat of cancer. It seems, to judge by my own experience, to be more common in the middle classes than among the poor. In speculating on the cause of cancer, the question at once arises —Is the germ of the disease a true parasite, introduced from with- out; or is it generated within the body, and of the materials of the body, under the influence of certain agencies ? The strongest argument in favor of the first supposition, is, that cancer originates in various organs, and has, in all of them, inde- pendent vitality and powers of growth. This is shown in the con- tinued increase of the primary tumor, without any process allied to inflammation, whatever be the age of the patient; and still more strikingly by the fact, which seems fully established, that the mere lodgment of one or more germs from the original tumor in a distant part, is sufficient of itself, and independently of constitutional pre- disposition, to communicate the disease to that part. In cases in which the disease is propagated from one animal to another, by inoculation, or by injection of the cancerous matter into veins, it 410 CANCER OF THE LIVER. may, indeed, be considered parasitic, in the strictest sense of that word. But although cancer is capable of being thus directly implanted from one individual to another, it occurs in almost all cases in circumstances in which it is difficult to believe that any such in- oculation or infection has taken place; and not unfrequently it appears to originate in some direct injury, or in prolonged irrita- tion of the part. Thus cancer of the breast is frequently ascribed to a blow, and instances are now and then met with in which it is difficult to avoid the conclusion, that it really had this origin. Cruveilhier relates a case in which cancer of the breast in a man, which is a very rare disease, was consequent on a sabre-cut received there. Cancer of the lip is much more common in persons addicted to smoking, than in others; and probably originates in the irritation of the pipe, or tobacco-juice. It is hardly ever met with in woman; and almost invariably occurs in the lower lip. Cancer of the penis is found in undue proportion in men with congenital phimosis—an effect, probably, of irritation by long re- tained and acrid secretions. Cancer of the anus or rectum is said to be especially frequent in persons who have had syphilitic vegetations or piles-. {Cruv., liv. xxv. pi. 3, p. 2.) These instances go to bear out the old doctrine, that a disease, which is not primarily malignant, may become so—a doctrine which is in some degree at variance with the notion, that the germs of cancer are always introduced from without. Another instance to the same purport, more convincing than any of those yet adduced, is the cancer of chimney-sweeps, which ap- pears to originate in prolonged irritation of soot.1 Perhaps the facts that cancer does not occur in the mamma, or in the uterus, before puberty ; and that it originates in the liver chiefly in the middle period of life—give further support to the doctrine, that the disease results from depraved nutrition of one of the normal constituents of the part. 1 An interesting case in which cancer of the hand was produced by the hand- ling of soot, in a gardener, who had long been in the habit of spreading it over his beds as manure, is related by Mr. Travers, and is cited by my brother, Dr. William Budd, in a paper published in the Lancet, in 1843, in which the origin and propagation of cancer are fully considered, and from which some of the instances adduced in the text have been borrowed. SYMPTOMS. 411 The structure of cancer affords additional reasons for rejecting the notion, that the germs of the disease are always introduced from without. The essential elements of a cancer, as of other tissues, are nucleated cells and fibres. These cells multiply by throwing off the germs of fresh cells from their outer surface; and sometimes also, as in colloid cancer, from their inner surface. All these circumstances give powerful sanction to the opinion, that cancer originates in depraved nutrition of the original nucle- ated cells of the part in which it first appears. We are ignorant of the conditions which lead to this depraved nutrition, except in the comparatively few cases in which the disease can be traced to some direct injury, or to some palpable cause of irritation. Cancer seems to depend less on the general state of nutrition, and more on accidental conditions affecting the particular part, than some other diseases—for instance, consumption, and scrofula—which likewise result from faulty nutrition. It is not hereditary in the same degree, and it very seldom originates, as the last-named dis- eases do, at the same time, or nearly at the same time, in fellow- organs, on the two sides of the body. It occurs also in persons who are plethoric and seemingly robust. Symptoms.—Cancer of the liver comes on without marked con- stitutional disturbance, and its early symptoms are very obscure. When the disease originates in the liver, the patient usually com- plains, first, of uneasiness and of a sense of fulness and weight in the right hypochondrium, and of failing strength, attended very commonly with impaired appetite, flatulence, and other disorders of digestion. After these ailments have lasted some time, the medical attend- ant, or perhaps the patient himself, discovers that the liver is en- larged. The liver is felt extending across the epigastrium, or below the false ribs, sometimes reaching as low as the umbilicus, or lower, and not unfrequently an unevenness of its surface, caused by the cancerous tumors projecting above it, or even a palpable tumor, can be distinguished through the walls of the belly. The patient now, or even before this, suffers-more or less pain in the region of the liver, and the functions of the organ are often hindered. In one case the flow of bile through the large ducts is stopped and there is jaundice; in another, without this, the passage of the blood through the liver is impeded, and there is slight ascites: sometimes, both these events occur in succession. 412 CANCER OF THE LIVER. In addition to these local symptoms, there often exists some of the sympathetic disorders—vomiting, a short dry cough, rigidity of the abdominal muscles, pain in the right shoulder—which have already been noticed as frequently occurring in abscess of the liver. As the disease progresses, the patient falls away more and more in flesh and strength, and generally becomes very anemic; the spirits are depressed; and pains are felt in the back and loins, caused most probably by cancerous contamination of the abdominal glands to which the lymphatics of the liver run. The functions of the stomach are variously performed. In some cases the appetite is good, at times almost ravenous, and digestion is easy ; in other cases the appetite is much impaired, and there is frequent vomiting or retching, with other disorders of digestion. When the tumors grow rapidly, some degree of fever is set up: the pulse is habitually rather frequent; the skin of the hands is often hot; the tongue is red and furred; and the urine is high-colored, and throws down a lateritious sediment, which is not unfrequently pinkish. In advanced stages of the disease there is often, as in cancer of other parts, profuse sweating; the patient is much wasted and very anemic, has aphthae of the mouth, colliquative diarrhoea, and other tokens of defective nutrition, and at length dies of exhaustion. Such is the usual course of primary cancer of the liver, but the remark which was made in a former chapter on abscess of the liver, applies equally here—namely, that the local symptoms, on which we rely most in forming our diagnosis, are far from being uniform, or constantly present. The degree of enlargement of the liver, and of pain or tenderness, and the presence or absence of jaundice and of ascites, depend mainly on the number, and size, and situation, of the tumors, on their rate of growth, and on the inflammation which they happen to excite'in their neighborhood—circumstances which vary in every separate case. Enlargement of the liver, which is the most constant, and by far the most significant, of these local symptoms, in most cases varies in degree with the number and size of the cancerous tumors. If the tumors be few in number, and small, there may be no enlarge- ment of the organ that can be discovered while the patient is alive. But this very seldom happens. Almost always the liver is per- SYMPTOMS. 413 ceptibly enlarged, and in .some cases it attains a prodigious size. A case is related by Dr. Farre, in which the liver, which was thickly studded with cancerous tumors, was more than fifteen pounds in weight. The enlargement of the liver is constantly progressive, and in the soft and vascular varieties of cancer is so rapid, that, week after week, a further increase in the size of the organ may be noticed. An important circumstance that may serve in some degree to distinguish enlargement of the liver caused by the presence of can- cerous or other tumors within it from the fatty or scrofulous en- largement and the enlargement that takes place in cirrhosis, is, that the lower edge of the liver is not uniformly thick and blunt, as in the latter diseases, in which the enlargement is owing to a change that affects every part of the organ alike. The degree of pain and tenderness depends, perhaps, chiefly on the situation of the cancerous masses and on their rate of growth, and varies very much in different cases. In some cases, even when the liver is much enlarged, and deformed by cancerous tumors pro- jecting above it, there is very little distinct pain, and pressure may be made on the liver, or the tumors themselves may be freely handled, without exciting complaint. In other cases, with much less amount of disease, the pain and tenderness are great. The pain has not any particular or constant character that might serve to distinguish it as belonging to cancer. In some cases it is lancinating; in others, not. When the liver extends far below the false ribs, it may occa- sionally be remarked that the tenderness is greater at some points than at others. It is greatest at those points where tumors project and where circumscribed inflammation has been excited in the serous membrane above them. The presence or absence of jaundice depends, not so much on the number and size of the tumors and on their rate of growth, as on their being so situated as to prevent the flow of bile into the in- testine. The liver may be tripled in volume, and a considerable part of its proper substance be converted into cancer, without jaundice; and, on the other hand, there may be deep jaundice, without appreciable enlargement of the organ, and when the amount of disease is small. 414 CANCER OF THE LIVER. Jaundice is a frequent symptom in cancer of the liver; occurring probably, sooner or later, in the majority of cases. AVhen it has once come on, it continues till the death of the patient. It results, in most cases, from some of the gall-ducts being compressed by the cancerous tumors; but it may also result from the ducts being closed by the growth of cancerous matter within them. Ascites occurs much less frequently than jaundice. Its presence or absence, like that of the latter condition, seems to depend more on the situation of the tumors than on their number and size. Circumstances have already been mentioned which render it pro- bable that the ascites results from obstruction to the flow of blood through branches of the portal or of the hepatic vein, either from the pressure of neighboring cancerous tumors, or from the presence of cancerous matter, or of fibrinous coagula in the vein itself. The immediate cause of the ascites is clearly different from that of the jaundice. Ascites may exist without jaundice; and jaundice with- out ascites. The quantity of fluid effused is generally small. As before re- marked, it happens but seldom that the belly is distended by fluid, as it is in the advanced stages of cirrhosis. The ascites may come on without pain. In some cases, indeed, its occurrence relieves the pain which previously existed, by pre- venting the tender surface of the liver from rubbing so much against the walls of the belly. AVhen ascites has occurred, it is generally permanent—a circum- stance which tends further to show that it results from some mechanical impediment to the passage of the blood. Now and then, however, the ascites, after having existed for a time, disappears, to recur again at a future period. The degree of constitutional disturbance excited by cancer of the liver, when other organs are sound, depends chiefly on the rapidity with which the cancerous tumors grow and multiply. When the tumors are of slow growth, and multiply slowly, they may, from their situation, produce local, or special symptoms—pain, or jaun- dice, or ascites—but they cause little fever, or other disturbance of the system at large than what results from these several conditions. AVhen, on the contrary, they multiply and grow rapidly, there is usually an irritative fever, the pulse is habitually more frequent SYMPTOMS. 415 than natural, and the patient wastes rapidly, and becomes rapidly anemic. When the disease has existed a few months, the pallor is often very striking, if there be no jaundice to conceal it. The im- poverishment of the blood results partly from derangement of the functions of the liver and stomach, but more especially from the rapid growth of albuminous tumors, which must be formed ulti- mately from the albuminous constituents of the blood. The following case, and I have seen several like it, is an instance of extreme anemia brought on by the rapid growth of cancerous tumors, without much pain or other suffering:— John Clewer, a carpenter, forty years of age, was admitted into King's College Hospital on the 17 th of May, 1855. He came of a healthy stock— his father and mother were both living—his habits had always been tem- perate, he had never had severe troubles, and his health had been constantly good until his present illness, which commenced soon after Christmas with indigestion and occasional vomiting. Up to Christmas he was very strong and healthy, capable, as he assured us, of as much work as any man in his trade. The vomiting recurred for a time about once in two or three days, and he began to fall away in flesh and strength. About two months before his admission to the hospital, he discovered a globular tumor in the epi- gastric region. This went on increasing in size for about a month, and then, as he judged, ceased to enlarge further. It was at the beginning hard to the feej and painless, and so it continued. A week before his admission to the hospital his feet and ankles began to swell. On the 17th of May, when he entered the hospital, he was much emaciated, and strikingly pallid. The liver was found to be much enlarged, its edges reaching below the umbilicus. In the epigastric region there was a large and apparently somewhat globular tumor, evidently projecting from the surface of the liver, and so situated that a vertical line from the ensiform cartilage to the umbilicus would pass through its centre. The tumor felt hard, and could be freely pressed and examined without causing pain. In the right side of the belly, the edge of the liver could be felt not thickened. There was a conspicuous network of enlarged veins over the chest, especially over the left side of the chest, the enlargement of the veins seeming to begin at the epigastric tumor. There was not the slightest tint of jaundice, but there seemed to be some liquid in the peritoneal sac, and the feet and ankles were cedematous. He had pain or uneasiness in the stomach, when the stomach was dis- tended, and pain round the waist, with a sense of constriction when he lay on his right side. Otherwise he was free from pain. His pulse was lrijrh—generally about 100 a minute—but he slept well. His tongue was clean, and he had desire for food, but refrained from eating much, from fear of exciting pain in the stomach. The urine was 1015, acid, and free from albumen. He was put on milk diet, and ordered small doses of hydrocyanic acid and morphia. 416 CANCER'OF THE LIVER. From this time his appetite was very variable. On some days he had desire for animal food ; on others he could eat little of anything. The tongue remained clean, the bowels were regular, and the sleep was gene- rally good. The pulse gradually mounted from 100 to 120; he complained very little of pain, but grew daily weaker, and died on the 25th. On examination of the body, the liver was found to be greatly enlarged, and to weigh 9 lbs. 4 oz. The left lobe was almost entirely converted into cancer. When it was cut through by a vertical slice a little to the left of the suspensory ligament, nothing was seen in the cut surface, in the entire thickness of the liver at that part, but white cancer. The cancer diminished in amount in moving to the right, and the extreme right of the right lobe (about one-fifth of the original entire liver) was but little tainted—contained only a few small cancerous tubercles. The gall-bladder and larger gall-ducts were free from disease and unobstructed—a circum- stance which explains the absence of jaundice. Many of the deep mesen- teric glands—gastric and lumbar—were enlarged and cancerous. The coats of the stomach along the lesser curvature were somewhat thickened, and obviously infected with cancer. A series of enlarged cancerous glands were found in the posterior mediastinum, reaching as high up as the upper extremity of the sternum. The lower lobes of both lungs were thickly sprinkled with small bodies looking like tubercles, and many of the lymphatics of the lung were distended and of an opaque white, so that they were plainly seen by the naked eye under the pleura. Under the microscope the small masses in the lung and the matter distending the lymph-ducts presented the appearance of cancer. No other disease worthy of note was found in the body. In this case the patient died after an illness of only five months; and at the time of death the cancerous tumors in the liver and else- where, consisting for the most part of solid albuminous matter, must have weighed at least five pounds. Now the blood does not contain more than one-fifth of its weight in albuminous substances, so that in the growth of these tumors there must have been ex- pended, on a very moderate calculation, twenty pounds of blood. No wonder the patient became rapidly blanched. It is worthy of remark, that there was not the slightest tint of jaundice, although the cancer was so extensive that not more, it was estimated, than one-fifth of the original liver-substance remained. The absence of jaundice is attributable to the circumstance, that the large gall-ducts were free from disease and unobstructed. Instances have been before related of equal or even greater de- struction of the liver-substance from cirrhosis without any decided jaundice, and they strongly favor the opinion that the coloring matters of the bile are formed, for the most part, not in the blood, but in the tissues of the liver itself. SYMPTOMS. 417 The case is still further interesting from the evidence it affords in favor of the opinion I have before advanced, that extension of the disease from the liver takes place, not through the bloodvessels, but through the lymphatics. There was a series of enlarged cancer- ous glands in the posterior mediastinum, the lymph-vessels under the pleura were rendered white and conspicuous by cancerous matter within them, and small cancerous tubercles were scattered through the lower lobes of the lungs. It was impossible in this instance to resist the conviction that the lymph-ducts conveyed the cancerous matter to the lungs. In some instances cancer of the liver, without setting up any inflammatory process, causes great pain, and, as has been already remarked, the character of the illness may be further diversified by the occurrence of jaundice. AVe are ignorant of the conditions which dispose to primary cancer of the liver, or which immediately give rise to it, so that in the diagnosis of this disease we are little helped by knowing the previous habits of the patient, or the circumstances in which he has lately been placed. We know only that the disease does not occur before the age of thirty-five. In persons above this age it can only be discovered by the intrinsic import of the symptoms. But in the early stages of the disease, and while the liver is still shielded by the ribs, the symptoms are vague, and such only as are common to various derangements of this organ. They may justly excite our fears; but they cannot give us assurance that the liver is the seat of cancer. The most significant symptom is enlargement of the liver. When this comes on in the middle period of life, attended with gradual wastino- and such serious disorder of health as may justify the sus. picion of cancer, and especially when the enlargement is progressive, and when- other conditions that may equally give rise to it are wanting-when there is no obstacle to the circulation in the chest, when the patient is not consumptive and has no chronic disease of the bones, when his habits have not been such as to lead to the suspicion of cirrhosis, and when, from the absence of jaundice the enlargement of the liver cannot be ascribed to stoppage of the common gall-duct-it affords, of itself, strong presumption that the disease iscancer. The presumption is much strengthened if,_on a careful examination of the liver, any tumors are discovered m it, 27 418 CANCER OF THE LIVER. and if the lower edge of the liver is felt to be not thickened, as it is in the fatty and in the scrofulous enlargement and in the enlarge- ment that results from cirrhosis. AVhen, with the conditions mentioned above, the liver is of very great size and its surface can be felt to be nodulous or uneven, there is no longer much room for doubt. Another symptom, which is of very frequent occurrence, and which may help to distinguish this disease from some others in which the liver is likewise enlarged, is pain and tenderness of the liver itself, and pain, more widely diffused, in the back and loins, resulting, perhaps, from cancerous contamination of the glands to which the lymphatics of the liver run. A small, permanent collection of fluid in the cavity of the perito- neum, when there is no reason to believe it to be the result of cirrhosis, is another significant token of the presence of cancerous tumors in the liver. A large quantity of fluid in the peritoneum is less significant of itself, and it may even increase the difficulty of diagnosis, by preventing our feeling the large and nodulous liver. A circumstance to be especially attended to when cancer of the liver is suspected is the time the disease has lasted and the general condition of the patient with reference to it. Cancer of the liver generally grows and multiplies rapidly, and generally causes, there- fore, rapid wasting and anemia, when no other exhausting influences exist. Sometimes, as we have seen, the. growth of the cancer is so rapid, and so much blood is taken to feed it, that, after an illness of no more than five or six months, the patient dies greatly ema- ciated, and almost as much blanched as if death had been caused by an -issue of blood. In other cases, the progress of the disease is slower, and life may be protracted to a year and a half or two years, but the cancer always gradually reduces the strength and impoverishes the blood, and the patient dies at length wasted and anemic. If, therefore, a disease of the liver has existed a year or two, or if it has existed several months without causing much wasting and anemia, the presumption is strong that the disease is not cancer. Cases as difficult of diagnosis as any are those in which the can- cerous growth stops the common gall-duct and causes persisting jaundice before the liver has become much enlarged or any tumors can be detected in it, and before the patient is much wasted. In such cases the subsequent enlargement of the liver may be ascribed TREATMENT. 419 to accumulation of bile in it from closure of the duct and the sub- sequent wasting to the jaundice—and for some time it may be impossible to say that the jaundice and enlargement of the liver do not result from stoppage of the common duct by a gall-stone or by inflammatory thickening, or through simple enlargement of a con- tiguous lymphatic gland. When, however, the common duct is stopped by a cancerous tumor, other tumors soon form in the liver itself, the patient wastes more rapidly and the enlargement of the liver is more continuous than in the other diseases just referred to, and after a time, on a careful manipulation of the liver, some tumor or small projecting nodule can often be discovered in it. When cancer of the liver is consequent on cancer of some other part, its detection is much easier, because, from our knowledge of the frequent dissemination of cancer, symptoms, which are in other circumstances trivial, then acquire great significance. In a woman who has ulcerated cancer of the breast, with the general symptoms of the cancerous cachexy ; or in one who has cancer of the uterus, which has eaten into the intestine; or in a person who has presented for some time the symptoms of cancer of the stomach—pain and tenderness in the region of the liver, or a slight increase in its volume, with jaundice, or slight ascites, or even one of these symp- toms, is sufficient evidence that cancerous tumors have formed in this organ. The same symptoms, occurring soon after an injury to the head, or after amputation of the leg or arm, together with the constitutional symptoms of suppurative phlebitis, would scarcely leave a doubt that abscesses were forming in the liver. The diag- nosis is formed, not so much from the intrinsic value of the symp- toms, as from the significance which these derive from the circum- stances under which they occur. The treatment of malignant disease of the liver should be simply palliative. Practitioners have, indeed, hoped to destroy cancerous tumors by some powerful alterative, or, if not to destroy them, at least to retard their growth. Various powerful medicines—alkalies, mercury, arsenic, iodine—have been tried in turn with this view, and all—it is almost needless to remark—have signally failed. They have aggravated suffering and hastened death, by adding their own noxiousTffects to those of the malady; but there is no evidence that they have ever in the slightest degree retarded the growth or 420 CANCER OF THE LIVER. prevented the multiplication of the tumors. AVe can, indeed, hardly expect ever to effect this by medicines of any kind—seeing that cancer is not destroyed by any injury short of entire removal, and that it never loses its vitality by any change in the patient's con- stitution. The objects of rational treatment are, then, to mitigate the pain and any inflammation that may be caused by the cancerous tumors; to procure sleep; to remedy, as far as is possible, the various disorders of digestion; and in these and other ways to retard the emaciation and exhaustion that attend the disease. For the relief of the pain, which is often quite independent of inflammation, and to procure sleep, no means are available but narcotics, which are very useful for this end, more especially in advanced stages of the disease. The most efficient of these reme- dies are the extracts of belladonna and conium, and the different preparations of morphia. Any inflammation of the peritoneum that may be excited by cancer of the liver will be best relieved by the application of a few leeches, or a blister to the side. The diminution of tenderness from these means is often great, and before the strength of the patient is much reduced there are no countervailing evils which should deter us from their use. When the patient has become somewhat low in condition, we should, of course, be chary in taking away blood; and but little benefit can be expected from other active measures. Any good to be obtained from blisters, or other modes of counter-irritation, will seldom compensate for the torture and the weakness they occasion. In the advanced stages of the disease blisters are never advisable, since in the cachectic condition produced by cancer, and, indeed, in persons much reduced by any organic disease, they often cause severe pain and give rise to irritable ulcers of the skin. The strength of the patient should be supported by a light, nourishing diet; and we should carefully abstain from mercury, iodine, strong purgatives, and all other powerful and lowering medicines. The wisdom of the practitioner is best shown in his abstaining from all fruitless interference. In no cases, perhaps, has the specific influence which has been long attributed to mercury in the treatment of liver diseases done so much harm as in cases in which this organ has been the seat of cancer. In its early stages the disease is often set down vaguely as enlargement or obstruction of the liver, and mercury is given KNOTTY TUMORS OF THE LIVER. 421 in consequence. In this country, indeed, a few years ago, the patient was fortunate if he escaped salivation, even after the tubera could be plainly felt, or when the existence of cancer elsewhere should have left no doubt as to the nature of the disease of the liver. In eight out of ten cases which have been recorded by Dr. Farre, the patient was mercurialized. In some of these cases mercury was given, or its use was continued, after the tumors in the liver were felt. In three of the cases in which it was given the patients were young children. In cases such as these it is happy for the patient if the physician sees the true scope of his power, and is especially careful to do no harm where, confessedly, he can do but little good. Dr. Farre makes some judicious remarks on the error that was committed in the cases which he has recorded, in making ineffectual efforts to cure, where the treatment should have been simply palliative. As he well observes, " the perfection of medicine consists, not in vain attempts to do more than nature permits, but in promptly and effectually applying its healing powers to those diseases which are curable, and in soothing those which are incurable." Encysted Knotty Tumors of the Liver. In connection with cancerous tumors of the liver, it will not be altogether out of place to describe tumors which are now and then met with in this organ, and which, although essentially different from cancerous tumors, resemble them somewhat in appearance, and have been generally confounded with them. The tumors I allude to are the encysted tumors, containing a cheese-like matter, which have been cursorily noticed in a former chapter (p. 200). From their nodulous form in most of the specimens which have fallen under my notice, I have ventured to call them " knotty tumors of the liver." The first instance of this disease that I met with occurred in a man who had been a hard drinker, and who died under my care in the Seamen's Hospital, in 1838, at the age of 32. The liver presented marks of extensive adhesive inflammation. It was enlarged, its surface was uneven, its edges were rounded, and its conve°x surface was united to the diaphragm by tufts of old false membrane. It contained several solid tumors, the largest of them 422 KNOTTY TUMORS OF THE LIVER. about the size of a walnut, which were composed of a uniform firm, yellowish-white substance. The disease struck me at the time as being different from cancer, but no close examination of the tumors was made. There was no similar disease in any other part of the body. In the spring of 1844 I had an opportunity of closely examin- ing some tumors of the same kind in a liver which was sent to me by Mr. Busk, and which was taken from a man who died in the Seamen's Hospital of fever. The liver was of moderate size, and adhered to the diaphragm in patches. It contained about a dozen firm, white, fibrous-looking tumors, from the size of a large pea to that of a walnut. Most of these tumors were imbedded in the liver, but two or three of them reached its surface, and the liver was adherent to the diaphragm at those spots. One of the tumors projected above the surface, and the hepatic tissue around the others seemed to be compressed. The larger of the tumors were very nodulous, and all of them, large and small, were surrounded by a thin, but well-defined cyst. They appeared to be all situated in portal canals, and were composed of a compact substance, of a dead white color, to the eye not unlike firm white cheese. This substance was tough, like the coagulated fibrin of inflammatory blood, and adhered firmly to the cysts.1 Some of the tumors had at their centres a small cavity (about the size of a partridge-shot), filled with a greenish matter, which had the appearance of inspis- sated bile. The cheese-like substance of which the tumors were composed exhibited, under the microscope, a mass of irregular granules (which was not much altered by acetic acid), with some free oil- globules, and with here and there a plate of cholesterine. No fluid could be pressed out of it, and it presented no trace of organiza- tion, no fibres or cells. A slice of it digested for twenty-four hours in cold muriatic acid, gave a violet solution, showing that it was allied in composition to albumen or fibrin. The greenish matter which was found at the centres of some of the tumors presented, under the microscope, a great number of oil- globules, plates of cholesterine, and shapeless masses of an orange- yellow, of various sizes, mixed with irregular, transparent, color- 1 One of these tumors is preserved in the museum of King's College. (Prep. 327.) KNOTTY TUMORS OF THE LIVER. 423 less granules. On a drop of nitric acid being added to the specimen under the microscope, the orange yellow masses immediately became of a rich marine blue, but remained perfectly distinct. After the glass on which the specimen was placed had been heated, these objects were indistinct, but round purplish globular masses were here and there seen. The tumors seemed to be of long standing. There was no similar disease in any other part of the body, nor were there any marks of scrofula, and the person did not appear to be of scrofulous habit. The hepatic substance was in an early stage of cirrhosis; and the hepatic cells were unusually small, and contained but little oil. The bile in the gall-bladder was reported, by Mr. Clapp, who exa- mined the body, to be of natural appearance. A short time before this examination was made, I received from Dr. Inman, of Liverpool, some notes of a case in which tubera were found in the liver, which, from Dr. Inman's description, I inferred to be of the same kind as those which have just been described. At my request, Dr. Inman sent me one of the tumors, and my infer- ence proved to be correct. The case is further interesting as illus- trating the tendency, noticed in a former chapter, which gangrene of an external part has to produce gangrene of internal organs, and I shall therefore relate it at length in Dr. Inman's words:— (Jan. 31, 1844.) Maria Sprounds, aged thirty-one, a market woman, of loose habits, but not intemperate in drink, was admitted into the Lock, with deep slough- in«- of the vulva and perineum, which extended backwards over the whole sacrum. The day before her death, when I first saw her, the parts were black, and emitted a most disgusting smell. Her breathing was hur- ried, the inspirations being forty-four a minute, and she had cough, with expectoration of a thin serous fluid, not u^K+aPricot-Julc,efflr,i1lthetn°^ of gangrene from the vulva was so strong that it was very difficult to say whether the breath was fetid or not. The pulse was 120, and small. She lav on her right side, and did not complain of any pain. The following particulars I learned from her sister: She was always healthy till eighteen months ago, when she began to suffer pain in the region of the liver, which has continued, more or ess severe ever since Six months ago she had a venereal complaint, which soon got well. She was n0rcompelled to leave her habitual 7Pto7m«V!i;dliTrfe£ before her death. She then complained of pain and swelling of the nudenda the venereal origin of which she stoutly denied to her death. At firat there was simply swelling of the labia externa, which soon became wLk the skin then broke, and'the whole of the vulva began to slough; the -angrene spread rapidly over the sacrum, but not laterally towards 424 KNOTTY TUMORS OF THE LIVER. the nates. In this condition she was taken to the Lock, where she died a week after. The nymphte, the clitoris, and the vagina, were all included in the slough. The body was examined eighteen hours after death. In the right pleural cavity there was a large quantity of opaque serous fluid, and both the costal and the pulmonary pleurae were coated by a recently-formed false membrane. The lung was adherent to the side at a spot corresponding to a cavern, which existed immediately beneath the pulmonary pleura in the middle lobe. On the left side of the chest there was likewise a turbid serous fluid in the pleural cavity, and both the costal and the pulmonary pleura? were covered with false membrane, but the inflammation had not been so intense as on the right side. The right lung was carnified in great extent, and on its middle lobe being cut into, a gangrenous cavern was found, lined by a thin false mem- brane, and containing a diffluent substance, of repulsive smell, which, when subjected to a stream of water, left a rough, irregular mesh of partly mortified pulmonary substance. In the vicinity of this cavity, there were three others, which were smaller, but like it in other respects. There was also a small collection of pus in this lung. The left lung contained a great many small cavities, lined by a delicate cyst, and containing a thick yellowish matter, like concrete pus or softened fibrin, which was insoluble in water, but was easily washed away. These existed in all parts of the lung, but seemed to be most numerous near its surface and edges. This lung also- was carnified in great extent. No tubercles existed in either lung. There was some fluid in the pericardium, but the heart was healthy. The liver, which was of natural size, contained three yellowish-white bodies, which projected a little above its surface, and were attached to the walls of the belly by bands of false membrane, about three inches in length. The smallest of these tumors was about the size of a Spanish nut, and was situated at the acute margin of the left lobe. The largest of them was situated at the junction of the right and left lobes, and ap- peared to be made up of several smaller ones, each of them contained in a cyst. They do not appear to have had any influence on the hepatic substance, as that part of it which is in immediate contact with them does not seem to be denser than natural. The stomach, the intestines, the kidneys, the uterus, the mesentery, and the peritoneum lining the pelvis, were all healthy. The internal iliac veins were healthy, and contained no pus. A portion of the liver containing one of the tumors, which was sent me by Dr. Inman, is now in the museum of King's College (Prep. 326). This tumor, which is as large as a moderate sized potato (see Plate 3, Fig. 2), is widest at the surface of the liver, and projects slightly above it. It is round, but has an irregular sur- face, not unlike that of a mulberry calculus. The knotty projec- tions are not distinct tumors, as Dr. Inman supposed, but mere excrescences. They are all included in a common cyst, which, KNOTTY TUMORS OF THE LIVER. 425 although very thin, is readily distinguished from its being more transparent than the substance it contains. The tumor was evidently formed in a portal canal. A portal vein of considerable size can be traced into its capsule, round which it winds for some distance. The substance of the tumor is precisely of the same character as that of the tumors in the liver which was sent me by Mr. Busk. It is of a dead white, or rather faint yellowish-white, firm, smooth when cut, and apparently homo- geneous, not unlike firm white cheese. As happened in the tumors before described, it adhered firmly to the inner surface of the cyst. Under the microscope, it exhibits a granular matter, and some small free oil-globules, but no plates of cholesterine. The granular matter is rendered a little more transparent, but not much more so, by the addition of a drop of acetic acid. The substance of the tumor con- tains less oil than that of the tumors of the same kind which I had before examined. A particle picked out from the centre of the tumor showed small orange-colored masses, which seemed to be composed of the coloring matters of bile. The substance of the tumor exhibits no trace of organization—no fibres or cells. A small slice of it, weighing 4.6 grains, which was dried by my friend, Dr. Miller, at 200° F., left an ash amounting to 0.15 grain. In May, 1846, I met with several tumors of the same kind in a girl eighteen years of age, who was brought into King's College Hospital with dropsy from granular disease of the kidney, and died twenty-four-hours after her admission. On inquiry, I learnt that she was a prostitute, that she had drunk hard of spirits, and that she had long been an out-patient of the hospital on account of secondary syphilis. The tumors that reached the surface of the liver were all covered by false membrane. In the museum of King's College (Prep. 328), there is another preparation, showing a portion of liver which contains three tumors, evidently of the same kind as those just described. No history of the case is given. The tumors are about the size of hazel-nuts, and reach the surface of the liver, which, at those spots, is covered by a false membrane. The material composing them is more friable than in the former cases, and exhibits under the microscope irregular granules, with here and there an orange- yellow mass, apparently consisting of biliary matter, a few plates of cholesterine, and some round solid globules, which refract light stroncrlj and some of which exhibit faint rays proceeding from 426 KNOTTY TUMORS OF THE LIVER. the centre. These globules were most of them dissolved when a drop of ether was put on the glass under the microscope, and were probably composed of margarin. A fresh section was made of two of these tumors, and a small mass of concrete biliary matter was found in the centre of each, exactly as in the tumors which were sent to me by Mr. Busk. In this specimen there is a good deal of green biliary matter in the hepatic substance, and at a spot near the tumors a small biliary concretion. From the examination of these tumors, it would seem that they are analogous to the glairy cysts described in a former chapter, and that they result from dilatation of portions of the hepatic ducts by matter secreted by their mucous membrane. This explains their being encysted, and also another circumstance, which I noticed when examining them—namely, that the cyst is not thicker in the large tumors than in the small. It explains, too, the presence of biliary matter in the centres of all these tumors. The circum- stance that, in all the specimens, an old false membrane covered the tumors which reached the surface, but not other portions of the liver, showed that an inflammatory process attended their for- mation. It would appear, therefore, that the disease commences as in- flammation of the mucous membrane of the hepatic ducts—that, in consequence of this, a duct becomes closed at some particular point, and the portion behind distended into an irregular pouch by the matter subsequently secreted. This origin explains the absence of any trace of organization in these tubera. The matter which is poured out on the free surface of an inflamed mucous membrane is not susceptible of organization; but, if it be pent up in a closed cavity and do not contain much pus, it forms at length a cheese- like mass, as in these tubera. The cheese-like matter of a scrofulous gland originates in the same way—from inflammation of the mucous membrane of the gland. Encysted cheese-like masses of the same kind are occasionally found in the lung; and they may also form in the kidney. Small tumors containing a cheese-like matter are now and then found under the skin, especially on the inside of the upper arm, KNOTTY TUMORS OF THE LIVER. 427 and probably originate in circumscribed inflammation of the lym- phatic vessels. Tubera of this kind can only form in mucous tubes which are small, and which—as the lymphatics, the hepatic gall-ducts, and the small bronchial tubes—have, in fulfilling their natural office, but a feeble current through them. Abercrombie, in his work on the Stomach and Intestines, has given a short chapter on tumors of the kind under consideration, and has classed them with glairy cysts of the liver. The chapter is headed, "Tubera of the liver without other disease of its struc- ture." He says, "These tubera present externally a surface ele- vated into irregular knobs of a yellowish or ash color, and perhaps from two or three inches in diameter. Internally they exhibit a variety of texture—in some cases fibrous, in others tuberculous or cheesy, and frequently there are cysts containing a viscid fluid. It appears that they produce marked symptoms only when they are numerous, or accompanied by enlargement of the liver, or disease of its general structure; but that when the structure is otherwise healthy, they may exist without any symptoms calculated to give a suspicion of their presence. Of this I shall only give the following example." {Diseases of the Stomach, 2d edit. p. 367.) The example given by Abercrombie is the case of a gentleman, aged 80, who had enjoyed uninterrupted good health until a few weeks before his death, when he became one day suddenly inco- herent. This disorder of intellect was removed by purgatives, and he had not shown any other symptom of disease, when one morn- ing he was found dead in his bed. "No morbid appearance could be discovered to account for his sudden death, except that all the cavities of the heart, the aorta, and the vena cava were completely empty of blood. On the convex surface of the liver there was a tumor about three inches in diameter, elevated into numerous irre- gular knobs; on cutting into it a cavity was exposed capable of hold- ing about Iviij, and full of an opaque ash-colored fluid, which could be drawn put into strings. The liver in other respects was perfectly healthy." For a more particular account of these tubera, Abercrombie refers to the work on the Morbid Anatomy of the Liver, by Dr. Farre, in which, however, only cancerous tumors of the liver are described. 428 Sect. II.—Hydatid Tumors of the Liver. Hydatid tumors, like cancerous tumors, are more common in the liver than in any other organ. They consist of a sac, of peculiar character, which is closely lined by a thin membranous bladder, or cyst, and filled with a liquid, which is usually colorless and limpid as the purest water. In some cases, on a superficial examination, nothing more than this appears; but generally, in hydatid tumors in man, there are found floating in the liquid a variable number (sometimes many hundreds) of globular bladders or cysts, similar to that which lines the sac, but of various sizes, from that of a small pea to that of a walnut. To these bladders, Laennec gave the name Acephalocyst—from axim . be con. the character of a thoughtful and experienced pky- 4 BLANCHARD & LEA'S MEDICAL BUCKNILL (J. C), M. D., Medical Superintendent of the Devon County Lunatic Asylum ; and DANIEL H. TUKE, M. D., Visiting Medical Officer to the York Retreat. A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of INSANITY. With a Plate. In one handsome octavo volume, of 536 pages. $3 00. (Just Issued, 1858 ) The increase of mental disease in its various forms, and the difficult questions to which it is constantly giving rise, reader the subject one of daily enhanced interest, requ'ring on the pari of the physician a constantly greater familiarity with this, the most perplexing branch of his profes- sion. At the same time "there has been for some years no work accessible in this country, present- ing the results of recent investigations in the Diagnosis and Prognosis of Insanity, and the greatly improved methods of treatment which have done so much in alleviating the condition or restoring the health of the insane. To fill this vacancy the publishers present this volume, assured that the distinguished reputation and experience of the authors will entitle it at once to the confidence of both student and practitioner. Its scope may be gathered from the declaration of the authors that "their aim has been to supply a text book which may serve as a guide in the acquisition of such knowledge, sufficiently elementary to be adapted to the wants of the student, and sufficiently modern in its views and explicit in its teaching to suffice for the demands of the practitioner." , BENNETT (J. HUGHES), M.D., F. R. S. E., Professor of Clinical Medicine in the University of Edinburgh, &c. THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken for or associated with, Phthisis. One vol. 8vo.,extra cloth, with wood-cuts. pp. 130. $1 25. BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. New and much enlarged edition, preparing by the author for publication in 1859. BY THE SAME AUTHOR. A REVIEW OF THE PRESENT STATE OF UTERINE PATHOLOGY. 8vo., 75 pages, flexible cloth, 50 cents. BIRD (GOLDING), A. M., M. D., 8cc. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. Edited by Edmund Lloyd Birkett, M. D. A new American, from the fifth and enlarged London edition. With eighty illustrations on wood. In one handsome octavo volume, of about 400 pages, extra cloth. $2 00. (Now Ready, June, 1859.) The death of Dr. Bird has rendered it necessary to entrust the revision of the present edition to other hands, and in his performance of the duty thus devolving on him, Dr. Birkett has sedulously endeavored to carry out the author's plan by introducing such new matter and modifications of the text as the progress of science has called for. Notwithstanding the utmost care to keep the work within a reasonable compass, these additions have resulted in a considerable enlargement. It is, therefore, hoped that it will be found fully up to the present condition of the subject, and that the reputation of the volume as a clear, complete, and compendious manual, will be fully maintained. It can scarcely be necessary for us to say anything of the merits of this well-known Treatise, which so admirably brings into practical application the re- sults of those microscopical and chemical researches regarding the physiology and pathology of the uri- nary secretion, which have contributed so much to the increase of our diagnostic powers, and to the extension and satisfactory employment of our thera- peutic resources.— The British and Foreign Medico- Chirurgical Review. BOWMAN (JOHN E.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Second Ame- rican, from the third and revised English Edition. In one neat volume, royal 12mo., extra cloth, with numerous illustrations, pp. 288. $1 25. by the same author. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS. Second American, from the second and revised London edition. With numerous illus- trations. In one neat vol., royal 12mo., extra cloth, pp.350. $125. BEALE ON THE LAWS OF HEALTH IN RE- LATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one volume, royal 12mo., extra cloth, pp. 296. 80 cents. BUSHNAN'S PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE; a Popular Treatise on the Functions and Phenomena of Organic Life. In one handsome royal 12mo. volume, extra cloth, with over 100 illustrations, pp.234. 80 cents. BUCKLER ON THE ETIOLOGY, PATHOLOGY, AND TREATMENT OF Fl BRO-BRONCHI- TIS AND RHEUMATIC PNEUMONIA. In one 8vo. volume, extra cloth, pp. 150. $1 25. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp. 460. %l 25. BRODIE'S CLINICAL LECTURES ON SUR- GERY. lvol.8vo. cloth. 350 pp. «1 25. AND SCIENTIFIC PUBLICATIONS. 5 .BARCLAY (A. W.) M.D., Assistant Physician to St. George's Hospital, &c. A MANUAL OF MEDICAL DIAGNOSIS ; being an Analysis of the Sig and bymptoms of Disease. In one neat octavo volume, extra cloth, of 424 pages. 62 00. (A n. work, just issued.) ns (Anew L^r'Jj '"r™"^elyu devoted to this important ; deficiency, is the object of Dr. Barclay's Manual. tivelv 'but few andThi^f " cor"m;lnd- compare- The task 'of composing such a work is neither an Jh?nr«PnV™VS lif iT' ,n.th« Publication of easy nor a light one; but Dr. Barclay has performed l«»f£™H n»™h '*' Blanc5"d, & L«« have ! it in a manner which meets our most unqualified inJlTn r i,p,m US-- I?r- uBarclay- fr»m | approbation. He is no mere theorist; he knows his ?a.v!?£,OC,?!\H!?dJ... _.ar,1.onS. Perlod> ^e position of work thoroughly, and in attempting to perform it, has not exceeded his powers.—British Med. Journal, Medical Registrar at St. George's Hospital, pos- sessed advantages for correct observation and reli- able conclusions, as to the significance of symptoms. which have fallen to the lot of but few, either in his own or any other country. He has carefully systematized the results of his observation of over twelve thousand patients, and by his diligence and judicious classification, the profession has been presented with the most convenient and reliable work on the subject of Diagnosis that it has been our good fortune ever to examine; we can, there- fore, say of i)r. Barclay's work, that, from his sys- tematic manner of arrangement, his work is one of the best works " for reference" in the daily emer- gencies of the practitioner, with which we are ac- quainted ; but, at the same time, we would recom- mend our readers, especially the younger ones, to read thoroughly and study diligently the whole work, and the " emergencies" will not occur so often.— Southern Med. and Surg. Journ., March, 1858. To give this information, to supply this admitted Dec. 5, 1857. We venture to predict that the work will be de- servedly popular, and soon become, like Watson's Practice, an indispensable necessity to the practi- tioner.— N. A. Med. Journal, April, 1S5S. An inestimable work of reference for the young practitioner and student.—Nashville Med. Journal, May, 1858. We hope the volume will have an extensive cir- culation, not among students of medicine only, but practitioners also. They will never regret a faith- ful study of its pages.— Cincinnati Lancet, Mar. '58. This Manual of Medical Diagnosis is one of the most scientific, useful, and instructive works of its kind that we have ever read, and Dr. Barclay has done good service to medical science in collecting, arranging, and analyzing the signs and symptoms of so many diseases.—N. J. Med. and Surg. Re- porter, March, 1858. BARLOW (GEORGE H.), M. D. Physician to Guy's Hospital, London, careful attention of all surgeons who make addition to obstetrical lltera""f-. M Brown de- i female comp.aints a partof theirstudy and practice. S^eSt Z^fS^SX ^kiii, | -*™» «™terly Journal. 6 BLANCHARD & LEA'S MEDICAL CARPENTER (WILLIAM B.), M. D., F. R. S., &.C., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- tions, by Francis Gurney Smith, M. D., Professor of the Institute* of Medicine in the Pennsyl- vania Medical College, &c. In one very large and beautiful octavo volume, ol about nine hundred large pages, handsomely printed and strongly bound in leather, with raised bands. $4 25. In the preparation of this new edition, the author has spared no labor to render it, as heretofore, a complete and lucid exposition of the most advanced condition of its important subject. The amount of the additions required to effect this object thoroughly, joined to the former large size of tne volume, presenting objections arising from the unwieldy bulk of the work, he has omitted all those portions not bearing directly upon Human Physiology, designing to incorporate them in his forthcoming Treatise on General Physiology. As a full and accurate text-book on the Phy- siology of Man, the work in its present condition therefore presents even greater claims upon the student and physician than those which have heretofore won for it the very wide and distin- guished favor which it has so long enjoyed. The additions of Prof. Smith will be found to supply whatever may have been wanting to the American student, while the introduction of many new illustrations, and the most careful mechanical execution, render the volume one of the most at- tractive as yet issued. For upwards of thirteen years Dr. Carpenter's work has been considered by the profession gene- rally, both in this country and England, as the most valuable compendium on the subject of physiology in our language. This distinction it owes to the high attainments and unwearied industry of its accom- plished author. The present edition (which, like the last American one, was prepared by the author him- self), is the result of such extensive revision, that it may almost be considered a new work. We need hardly say, in concluding this brief notice, that while the work is indispensable to every student of medi- cine in this country, it will amply repay the practi- tioner for its perusal by the interest and value of its contents.—Boston Med. and Surg. Journal. This is a standard work—the text-book used by all medical students who read the English language. It has passed through several editions in order to keep pace with the rapidly growing science of Phy- siology. Nothing need be said in its praise, for its merits are universally known j we have nothing to say of its defects, for they only appear where the science of which it treats is incomplete.—Western Lancet. The most complete exposition of physiology which any language can at present give.—Brit, and For. Med.-Chirurg. Review. The greatest, the most reliable, and the best book oa the subject which we know of in the English language.—Stethoscope. | This book should not only be read but thoroughly studied by every member of the profession. None are too wise or old, to be benefited thereby. But especially to the younger class would we cordially commend it as best fitted of any work in the English language to qualify them for the reception and coin- prehension of those truths which are daily being de- veloped in physiology.—Medical Counsellor. Without pretending to it, it is an encyclopedia of the subject, accurate and complete in all respects__ a truthful reflection of the advanced state at which the science has now arrived.—Dublin Quarterly Journal of Medical Science. A truly magnificent work—in itself a perfect phy- siological study.—Ranking's Abstract. This work stands without its fellow. It is one few men in Europe could have undertaken; it is one To eulogize this great work would be superfluous We should observe, however, that in this edition the author has remodelled a large portion of the former, and the editor has added much matter of in- terest, especially in the form of illustrations. We may confidently recommend it as the most complete work on Human Physiology in our language.— Southern Med. and Surg. Journal. The most complete work on the science in our language.—Am. Med. Journal. The most complete work now extant in our lan- guage.—N. O. Med. Register. The best text-book in the language on this ex- tensive subject.—London Med. Times. A complete cyclopaedia of this branch of science. —JV. Y. Med. Times. The profession of this country, and perhaps also of Europe, have anxiously and for some time awaited the announcement of this new edition of Carpenter's Human Physiology. His former editions have for many years been almost the only text-book on Phy- siology in all our medical schools, and its circula- tion among the profession has been unsurpassed by any work in any department of medical science. It is quite unnecessary for us to speak of this work as its merits would justify. The mere an- nouncement of its appearance will afford the highest pleasure to every student of Physiology, while its perusal will be of infinite service in advancing physiological science.—Ohio Med. and Surg. Journ. no man, we believe, could have brought to so suc- cessful an issue as Dr. Carpenter, ft required for its production a physiologist at once deeply read in the labors of others, capable of taking a general, critical, and unprejudiced view of those labors, and of combining the varied, heterogeneous materials at his disposal, so as- to form an harmonious whole. We feel that this abstract can give the reader a very imperfect idea of the fulness of this work, and no idea of its unity, of the admirable manner in which material has been brought, from the most various sources, to conduce to its completeness, of the I ucid- ity of the reasoning it contains, or of the clearness of language in which the whole is clothed Not the profession only, but the scientific world at large, must feel deeply indebted to Dr. Carpenter for this great work. It must, indeed, add largely even to his high reputation.—Medical Times. BY THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations, pp.752. Extra cloth, f 4 80; leather, raised bands, $5 25, The delay which has existed in the appearance of this work has been caused by the very thorough revision and remodelling which it has undergone at the hands of the author, and the large number of new illustrations which have been prepared for it. It will, therefore, be found almost a new work, and fully up to the day in every department of the subject, rendering it a reliable text-book for all students engaged in this branch of science. Every effort has been made to render its typo- graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the mechanical arts of this country. AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM B.>, M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con taming the Applications of the Microscope to Clinical Medicine, &c. By F. G Smith M S" Illustrated by four hundred and thirty-four beautiful engravings on wood In one' l«?il ' i ' D' handsome octavo volume, of 724 pages, extra cloth, $4 00 ; ilatherT$4 50 S and very Dr. Carpenter's position as a microscopist and physiologist, and his jrrpnt „„„,;<,„„ eminently qualify him to produce what has long Wen ffi good texSok o„ ,h^ * ,6aCher,' use of the microscope In the presentvolunAs object has been as SSedfo hi feiace^ff' combine, within a moderate compass, that information with regard to the u«e of his «tnnlf' 'u ? is most essential to the working microscopist, with such an amount of the objects te°t fiuTn fh his study, as might qualify him to comprehend what he observes, and rai^tZfnli f°r benefit science, whilst expanding and refreshing hisownmind » That he has succeededIn .- l° phshing this, no one acquainted with his previous labors can doubt succeeded in accom- The great importance of the microscope as a means of diagnosis, and the number nf m,«^c pists who are also physicians, have induced the American pnbWStheS^'^T?' add an Appendix, carefully prepared by Professor Smith, on the tpplZatiot othe inTumln ' o clinical medicine, together with an account of American Microscopes, their mod fication,JS accessories. This portion of the work is illustrated with nearly one hundred woTcuts and it ia hoped, will adapt the volume more particularly to the use of the American student ' Every care has been taken in the mechanical execution of the work, which is 'confidently ore sented as m no respect interior to the choicest productions of the London pre*s co"naently Pre" JdtsTdtynoSof 'ST"*0' ^ ^^^ MS iUteati0nS ^ to gathered '*«* ^e following CONTENTS. [KTRODUCTION-History of the Microscope. Chap. I. Optical Principles of the Microscone Chap. II. Construction of the Microscope. Chap. III. Accessorv Annarnt,,* xv^croscoP?- Management of the Microscope Chap, f Preparation^^^85^ o^Ooie fession will soon regard it not only as a very good but as the vert best "Practical Treatise on the Diseases of Children."—American Medical Journal In the department of infantile therapeutics, the work of Dr. Condie is considered one ot the best wh;eh has been published in the English language. — The Stethoscope. We pronounced the first edition to be the beat work on the diseases of children in the English language, and, notwithstanding all that has been published, we still regard it in that light.—Medical Examiner. The value of-works by native authors on the dis- eases which the physician is called upon to combat, will be appreciated by all; anl the work of Dr. Con- die has gRined for itself the character of a safe guide (or students, and a useful work for consultation by those engaged in practice.—N. Y. Med. Times. This is the fourth edition of this deservedly popu- lar treatise. During the interval since the last edi- tion, it has been subjected to a thorough revision by the author; and all new observations in the pathology and therapeutics of children have been included in the present volume. As we said bifore, we do not know of a better book on diseases of chil- dren, and to a large part of its recommendations we yield an unhesitating concurrence.—Buffalo Med. Journal. Perhaps the most full and complete work now be- fore the profession of the United States; indeed, we may say in the English language. It is vastly supe- rior to most of its predecessors.—Transylvania Med. Journal. CHRISTISON (ROBERT), M. D., V. P. R. S. E., &c. A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the most important New Remedies. With copious Addi- tion^, and two hundred and thirteen large wood-engravings. By It. Eglesfeld Griffith, M. D. la one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. COOPER (BRANSBY B.), F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. in one very large octavo volume, extra cloth, of 750 pages. $3 00. COOPER ON DISLOCATIONS AND FRAC- TURES OF THE JOINTS —Edited by Bransb? B. Cooper, F. R. S., f the page, these very extensive additions have been accommodated without unduly increasing the size of the work. contribution for the illustration of its topics. The material thusderivedhasbeen used with consummate skill, and the result has been a work creditable alike to the author and his country.—N. A. Medico-Chir. Review, May, 1858. No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the a.lvanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.—Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this departmentof medical science. — N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for the frequent consultation of the young practitioner.— American Medical Journal. This work contains a vast amount of interesting matter, which is so well ananged and so curtly worded that the book may be regarded as an ency- clopaedia of information upon the subject of which it treats. It is certainly also a monument of Dr. Churchill's untiring industry, inasmuch as there is not a single work upon the diseases of children with which we are acquainted that is not fully referred to and quoted from in its pages, and scarcely a con- tribution of the least importance to any British or Foreign Medical Journal, for some years past, which is not duly noticed.—London Lancet, Feb. 20, 1858. Availing himself of every fresh source of informa- tion, Dr. Churchill endeavored, with his accustomed industry and perseverance, to bring his work up to the present state of medical knowledge in all the subjects of which it treats; and in this endeavor he has, we feel bound to say, been eminently success- ful Besides the addition of more than one hundred and thirty pages of matter, we observe that some entirely new and important chapters are introduced, viz: on paralysis, syphilis, phthisis, sclerema, &c. &c As the work now stands, it is, we believe, the most comprehensive in the English language upon the diseases incident to early life.—Dublin Quarterly Journal, Feb. 1858. It brings before the reader an amount of informa- tion not comprised in any similar production in the lanjruaire. The amount of labor consumed upon its production can only be conceived by those who have been similarly occupied, every work of note pub- lished within the last twenty-five years ,„ the dif- ferent languages of Europe having been laid under BY THE SAME AUTHOR. FSqAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- ?tttTAR TO WOMEN Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. After this meagre, and we know, very imperfect notice of Dr. Churchill's work, we shall conclude by saying, that it is one that cannot fail from its co- piousness, extensive research, and general accuracy, to exalt still higher the reputation of the author in this country. The American reader willbenarticu- larly pleased to find that Dr. Churchill has done full justice throughout his work to the various American authors on this subject. The names of Dewees, Eberle, Condie, and Stewart, occur on nearly every page, and these authors are constantly referred toby the author in terms of the highest praise, and with the most liberal courtesy.—The Medical Examiner. We recommend the work of Dr. Churchill most cordially, both to students and practitioners, as a valuable andjeliable guide in the treatment of the dis- eases of children.—Am. Journ.of the Med. Sciences. We know of no work on this department of Prac- tical Medicine which presents so candid and unpre- judiced a statement or posting up of our actual knowledge as this.—N. Y. Journal of Medicine. Its claims to merit both as a scientific and practi- cal work, are of the highest order. Whilst we would not elevate it above every other treatise on the same subject, we certainly believe that very few are equal to it, and none superior.—Southern Med. and Surgical Journal. 10 BLANCHARD & LEA'S MEDICAL1 CHURCHILL (FLEETWOOD), M. D., M. R. I. A., A.C. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condie, M. D., author of "A Practical Treatise on the Diseases of Children." With nume- rous illustrations. In one large and handsome octavo volume, leather, of 768 pages. $3 00. This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so thoroughly has he revised it in every portion. It will be found greatly enlarged, and thoroughly brought up to the most recent condition of the subject, while the very handsome series of illustra- tions introduced, representing such pathological conditions as can be accurately portrayed, present a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- peared desirable for the American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone, while the price has been kept at the former very moderate rate. It comprises, unquestionably, one of the most ex- act and comprehensive expositions of the present state of medical knowledge in respect to the diseases of women that has yet been published.—Am. Journ. Med. Sciences, July, 1857. We hail with much pleasure the volume before us, thoroughly revised, corrected, and brought up to the latest date, by Dr. Churchill himself, and rendered still more valuable by notes, from the ex- perienced and able pen of Dr. D.F. Condie.— South- ern Med. and Surg. Journal, Oct. 1857. This work is the most reliable which we possess on this subject; and is deservedly popular with the profession.—Charleston Med. Journal, July, 1857. Dr. Churchill's treatise on the Diseases of Women is, perhaps, the most popular of his works with the profession in this country. It has been very gene- rally received both as a text-book and manual of practice. The present edition has undergone the most elaborate revision, and additions of an import- ant character have been made, to render it a com- plete exponent of the present state of our knowledge of these diseases.—N. Y. Journ. of Med., Sept. 1857. We know of no author who deserves that appro- bation, on "the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and stu- dents as a masterpiece in its particular department. —Tht Western Journal of Medicine and Surgery. As a comprehensive manual for students, or a work of reference for practitioners, it surpasses any other that has ever issued on the same subject from the British press.—Dublin Quart. Journal. DICKSON (S. H.), M. D., Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and handsome octavo volume, of 750 pages, leather. $3 75. (Now Ready, June, 1859.) The steady demand which has so soon exhausted the first edition of this work, sufficiently shows that the author was not mistaken in supposing that a volume of this character was needed—an elementary manual of practice, which should present the leading principles of medicine with the practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail and fruitless speculations, it embodies what is most requisite for the student to learn, and at the same time what the active practitioner wants when obliged, in the daily calls of his profession, to refresh his memory on special points. The clear and attractive style of the author renders the whole easy of comprehension, while his long experience gives to his teachings an authority every- where acknowledged. Few physicians, indeed, have had wider opportunities for observation and experience, and few, perhaps, have used them to better purpose. As the result of a long life de- voted to study and practice, the present edition, revised and brought up to the date of publication, will doubtless maintain the reputation already acquired as a condensed and convenient American text-book on the Practice of Medicine. A few notices of the first edition are appended. Not professing to be a complete and comprehensive This book is eminently what it professes to be; a distinguished merit in these days. Designed for " Teachers and Students of Medicine," and admira- bly suited to their wants, we think it will be received, on its own merits, with a hearty welcome.—Boston Med. and Surg. Journal. Indited by one of the most accomplished writers of our country, as well as by one who has long held a high position among teachers and practitioners of medicine, this work is entitled to patronage and careful study. The learned author has endeavored to condense in this volume most of the practical matter contained in his former productions, so as to adapt it to the use of those who have not time to devote to more extensive works.—SouthernMed. and Surg. Journal. Prof. Dickson's work supplies, to a great extent, a desideratum long felt in American medicine.—N. O. Med. and Surg. Journal. treatise, it will not be found full in detail, nor filled with discussions of theories and opinions, but em- bracing all that is essential in theory and practice, it is admirably adapted to the wants of the American student. Avoiding all that is uncertain, it presents more clearly to the mind of the reader that which is established and verified by experience. The varied and extensive reading of the author is conspicuously apparent, and all the recent improvements and dis- coveries in therapeutics and pathology are chroni- cled in its pages.—Charleston Med. Journal. In the first part of the work the subject of gene- ral pathology is presented in outline, giving a btau- tiful picture of its distinguishing features, and throughout the succeeding chapters we find that he has kept scrupulously within the bounds of sound reasoning and legitimate deduction. Dr. Dickson merits a place in the first rank of American writers. —Western Lancet. DRUITT (ROBERT), M.R. C.S., &c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. Edited by F. W. Sargent, M. D., author of " Minor Surgery," &c. Illustrated with one hundred and ninety-three wood-engravings. In one very handsomely printed octavo volume, leather, of 576 large pages. $3 00. Dr. Druitt's researches into the literature of his subject have been not only extensive, but well di- rected ; the most discordant authors are fairly and impartially quoted, and, while due credit is given to each, their respective merits are weighed with an unprejudiced hand. The grain of wheat is pre- served, and the chaff is unmercifully stripped off. The arrangement is simple and philosophical, and the style, though clear and interesting, is so precise, that the book contains more information condensed into a few words than any other surgical work with which we are acquainted.—London Medical Times und Gazette. No work, in our opinion, equals it in presenting so much valuable surgical matter in so small a compass.—St. Louis Med. and Surgical Journal. AND SCIENTIFIC PUBLICATIONS. 11 DALTON, JR. (J. C), M. D. Professor of Physiology in the College of Physicians, New York. A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students and Practitioners of Medicine. With two hundred and fifty-four illustrations on wood. In de" very beautiful octavo volume, of over 600 pages, extra cloth, $4 00; leather, raised bands S4 25 (Now ready, 1859.) The object of the author has been to present a condensed view of the present condition of his subject, divested of mere theoretical views and hypothetical reasonings, but comprehending all important details which may be received as definitely settled. His long experience as an invest- gator and as a teacher has given him peculiar advantages in this, and he has endeavored wherever practicable to show the means by which results have been reached, so as to afford the student the means of pursuing original research, as well as a text-book of the science in its most advanced con- dition. Of the numerous illustrations, all are original with the exception of eleven, so that the whole possesses a completeness and authority not otherwise attainable, and in the mechanical execution every care has been taken to present one of the handsomest volumes as yet produced by the American press. Throughout the entire work, the definitions are clear and precise, the arrangement admirable, the argument briefly and well stated, and the style nervous, simple, and concise. Section third, treat- ing of Reproduction, is a monograph of unar>- proached excellence, upon this subject, in the Eng- lish tongue. For precision, elegance and force of style, exhaustive method and extent of treatment, fulness of illustration and weight of personal re- search, we know of no American contribution to medical science which surpasses it, and the day is far distant when its claims to the respectful atten- tion of even the best informed scholars will not be cheerfully conceded by all acquainted with its range ano depth.—Charleston Med. Journal, May, 1659. A new elementary work on Human Physiology lifting up its voice in the presence of late and sturdy editions of Kirke's, Carpenter's, Todd and Bow- man's, to say nothing of Duiglison's and Draper's, should have something superior in the matter or the manner of its utterance in order to win for itself deserved attention and a name. That marter and that manner, after a candid perusal, we think dis- tinguish this work, and we are proud to welcome it not merely for its nativity's Bake, but for its own intrinsic excellence. Its language we find to be plain, direct, unambitious, and falling with a just conciseness on hypothetical or unsettled questions, and yet with sufficient fulness on those living topics already understood, or the path to whose solution is definitely marked out. It does not speak exhaust- i/ely upon every subject that it notices, but it does cdumrys press, n is uy mu uuumi wm/, ^.>/u5.. , speak suggestively, experimentally, and to their young, is considerably famous for physiological re- "main utilities. Into the subject of Reproduction The work before us, however, in our humble judg- ment, is precisely what it purports to be, and will answer admirably the purpose for which it is in- tended. It is par excellence, a text-book; and the best text-book in this department that we have ever seen. We have carefully read the book, and speak of its merits from a more than cursory perusal. Looking back upon the work we have just finished, we must say a word concerning the excellence of its illustrations. No department is so dependent upon good illustrations, and those which keep pace with our knowledge of the subject, as that of physiology. The wood-cuts in the work before us are the best we have ever seen, and, being original, serve to illustrate precisely what is desired.—Buffalo Med. Journal, March, 1859. A book of genuine merit like this deserves hearty praise before subjecting it t J any minute criticism. We are not prepared to find any fault with itB design until we have had more time to appreciate its merits as a manual for daily consultation, and to weigh its statements and conclusions more deliberately. Its excellences we are sure of; its defects we have yet to discover. It is a work highly honorable to its author; to his talents, his industry, his training ; to the institution with which he is connected, and to American science.—Boston Med. and Surgical Journal, Feb. 24, 1859. A new book and a first rate one; an original book, and one which cannot be too highly appreciated, and which we are proud to see emanating from our country's press. It is by an author who, though search, and who in this work has erected for him self an enduring monument, a token at once of his labor and his success.—Nashville Medical Journal, March, 1659. our author plunges with a kind of loving spirit. Throughout this interesting and obscure department he is a clear and admirable teacher, sometimes a brilliant leader.—Am. Med. Monthly, May, 1859. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands, f 12 00. *±* This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine | titioner This estimate of it has not been formed inc iiium wnujin. .. ________ D../F-I/, frnm n hastv examination, hut after nn infimnto no. extant; or, at least, in our language.—Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner.— Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.—Medical Examiner. We rejoice that this work is to be placed within the reach of the profession in this country, it being unquestionably one of very great value to the prac- from a hasty examination, but after an intimate ac- quaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many of the most eminen professors and teachers of London, Edinburgh, Dub- lin, and Glasgow. It is, indeed, the great merit of this work that the principal articles have been fur- nished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them, and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority.—American Medical Journ. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many Engravings. Twelfth edition with the |u?hor's1astgimpr1fvements and «£«£>»-■ £ one octavo volume, extra cloth, of 600 pages. $3M. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD- REN. The last edition. In one volume, octavo, extra cloth, 518 pages. $2 80 DEWEES'S TREATISE 0> THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo extra cloth, 532 pages, with plates. 83 00. 12 BLANCHARD & LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. NEW AND ENLARGED EDITION. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, &c. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations, &c. With French and other Synonymes. Fifteenth edition, revised and very greatly enlarged. In one very large and handsome octavo volume, of 992 double-columned pages, in small type; strongly bound in leather, with raised bands. Price $4 00. Especial care has been devoted in the preparation of this edition to render it in every respect worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by the profession as the standard authority. Stimulated by this fact, the author has endeavored in the present revision to introduce whatever might be necessary " to make it a satisfactory and desira- ble—if not indispensable—lexicon, in which the student may search without disappointment for every term that has been legitimated in the nomenclature of the science." To accomplish this, large additions have been found requisite, and the extent of the author's labors may be estimated from the fact that about Six Thousand subjects and Wins have been introduced throughout, ren- dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size of the page. The medical press, both in this country and in England, has pronounced the work in- dispensable to all medical students and practitioners, and the present improved edition will not lose that enviable reputation. The publishers have endeavored to render the mechanical execution worthy of a volume of such universal use in daily reference. The greatest care has been exercised to obtain the typographical accuracy so necessary in a work ot the kind. By the small but exceedingly clear type employed, an immense amount of matter is condensed in its thousand ample pages, while the binding will be found strong and durable. With all these improvements and enlargements, the price has been kept at the former very moderate rate, placing it within the reach of all. This work, the appearance of the fifteenth edition of which, it has become our duty and pleasure to announce, is perhaps the most stupendous monument of labor and erudition in medical literature. One would hardly suppose after constant use of the pre- ceding editions, where we have never failed to find a sufficiently full explanation of ever} medical term, that in this edition " about six thousand subjects and terms have been added," with a careful revision and correction of the entire work. It is only neces- sary to announce the advent of this edition to make it occupy the place of the preceding one on the table of every medical man, as it is withoutdoubt the best and most comprehensive work of the kind which has ever appeared.—Buffalo Med. Journ., Jan. 1858. The work is a monument of patient research, skilful judgment, and vast physical labor, that will perpetuate the name of the author more effectually than any possible device of stone or metal. Dr. Dunglison deserves the thanks not only of the Ame- rican profession, but of the whole medical world.— North Am. Medico-Chir. Review, Jan. 1858. A Medical Dictionary better adapted for the wants of the profession than any other With which we are acquainted, and of a character which places it far above comparison and competition.—Am. Journ. Med. Sciences, Jan. 1858. We need only say, that the addition of 6,000 new terms, with their accompanying definitions, ma; be said to constitute a new work, by itself. We have examined the Dictionary attentively, and are most happy to pronounce it unrivalled of its kind. The erudition displayed, and the extraordinary industry which must have been demanded, in its preparation and perfection, redound to the lasting credit of its author, and have furnished us with a volume indis- pensable at the present day, to all who would find themselves au niveau with the highest standards of medical information.—Boston Medical and Surgical Journal, Dec. 31, 1857. Good lexicons and encyclopedic works generally, are the most labor-saving contrivances which lite- rary men enjoy; and the labor which is required to produce them in the perfect manner of this example is something appalling to contemplate. The author j tells us in his preface that he has added about six thousand terms and subjects to this edition, which, before, was considered universally as the best work of the kind in any language.—Silliman's Journal, March, 1858. He has razed his gigantic structure to the founda- tions, and remodelled and reconstructed the entire pile. No less than six thousand additional subjects and terms are illustrated and analyzed in this new edition, swelling the grand aggregate to beyond sixty thousand ! Thus is placed before the profes- sion a complete and thorough exponent of medical terminology, without rival or possibility of rivalry. —Nashville Journ. of Med. and Surg., Jan. 1858. It is universally acknowledged, we believe, that this work is incomparably the best and most com- plete Medical Lexicon in the English language. The amount of labor which the distinguished author has bestowed upon it is truly wonderful, and the learning and research displayed in its preparation are equally remarkable. Comment and commenda- tion are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary than this.—St. Louis Med. and Surg. Journ., Jan. 1858. It is the foundation stone of a good medical libra- ry, and should always be included in the first list of books purchased by the medical student.—Am. Med. Monthly, Jan. 1858. A very perfect work of the kind, undoubtedly the most perfect in the English language.—Med. and Surg. Reporter, Jan. 1808. It is now emphatically the Medical Dictionary of the English language, and for it there is no substi- tute.— N. H. Med. Journ., Jan. 1858. It is scarcely necessary to remark that any medi- cal library wanting a copy of Dunglison's Lexicon must be imperfect.—Cin. Lancet, Jan. 1858. We have ever considered it the best authority pub- lished, and the present edition we may safely say has no equal in the world.—Peninsular Med. Journal, Jan. 1858. The most complete authority on the subject to he found in any language.— Va.Mtd. Journal, Feb. '58. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and Tho- rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $6 25. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine la the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, leather, of about 1500 pages. $7 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled ; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated and the work in every respect has been brought up to a level with the present state of the subject! The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. We believe that it can truly be said, no more com- plete repertory of facts upon the subject treated, can anywhere be found. The author has, moreover, that enviable tact at description and that facility and ease of expression which render him peculiarly acceptable to the casual, or the studious reader. Tins faculty, so requisite in setting forth many graver and less attractive subjects, lends additional charms to one always fascinating.—Boston Med. and Surg. Journal, Sept. 1856. The most complete and satisfactory system of Physiology in the English language.—Amer. Med. Journal. The best work of the kind in the English lan- guage.—Silliman's Journal. The present edition the author has made a perfect mirror of the science as it is at the present hour. As a work upon physiology proper, the science of the functions performed by the body, the student will find it all he wishes.—Nashville Journ. of Med. Sept. 1856. That he has succeeded, most admirably succeeded in his purpose, is apparent from the appearance of an eighth edition. It is now the erreat encyclopaedia on the subject, and worthy of a place in every phy- sician's library.— Western Lancet, Sept. 1656. BY THE SAME author. (A new edition.) QENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. From the Author's Preface. " Another edition of this work being called for, the author has subjected it to a thorough and careful revision. It has been gratifying to him that it has been found so extensively useful by those for whom it was especially intended, as to require that a sixth edition should be issued in so short a time after the publication of a fifth. Grateful for the favorable reception of the work by the profession, he has bestowed on the preparation of the present edition all those cares which were demanded by the former editions, and has spared no pains to render it a faithful epitome of General Therapeutics and Materia Medica. The copious Indexes of Remedies and of Diseases and their Remedies can- not fail, the author conceives, to add materially to the value of the work." This work is too widely and too favorably known to require more than the assurance that the author has revised it with his customary industry, introducing whatever has been found necessary to bring it on a level with the most advanced condition of the subject. The number of illustrations has been somewhat enlarged, and the mechanical execution of the volumes will be found to have undergone a decided improvement. The work will, we have little doubt, be bought and read by the majority of medical students: iis size, arrangement, and reliability recommend it to all; no one, we venture to predict, will study it without profit, and there are few to whom it will not be in some measure useful us a work of refer- ence. The young practitioner, more especially, will find the copious indexes append*d to this edition of great assistance in the selection and pieparation of suitable formulae.—Charleston Med. Journ. and Re- view, Jan. 185b. In announcing a new edition of Dr. Dunglison's General Therapeutics and Materia Medica, we have no words of commendation to bestow upon a work whose merits have been heretofore so often aud so justly extolled. It must not be supposed, however, that the present is a mere reprint of the previous edition: the character of the author for laborious research, judicious analysis, and clearness of ex- pression, is fully sustained by the numerous addi- tions he hns made to the work, and the careful re- vision to which he has subjected the whole.—AT. A. Medico-Chir. Review, Jan. 1858. ' BY THE same author. (A new Edition.) NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. $3 75. Another edition of the "New Remedies" having been called for, the author has endeavored to add everything of moment that has appeared since the publication of the last edition. The articles treated of in the former editions will be found to have undergone considerable ex- pansion in this, in order that the author might be enabled to introduce, as far as practicable, the results of the subsequent experience of others, as well as of his own observation and reflection; and to make the work still more deserving of the extended circulation with which the preceding editions have been favored by the profession. By an enlargement of the page, the numerous addi- tions have been incorporated without greatly increasing the bulk of the volume.—Preface. The great learning of the author, and his remark- able industry in pushing his researches into every source whence informs tion is derivable,have enabled One of the most useful of the author's works.- Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physicians, it is unsurpassed by any other work ii existence, and the double index for diseases and for remedies, will be foundgreatly to enhance its value.—New York Med. Gazette. him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire t» examine the original papers.—The American Journal of Pharmacy. 14 BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, &c. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries, Diseases, and Operations. New and improved American, from the second enlarged and carefully revised London edition. Illustrated with over four hundred engravings on wood. In one large and handsome octavo volume, cf one thousand closely printed pages, leather, raised bands. $4 50. (Now Ready, January, 1859.) The very distinguished favor with which this work has been received on both sides of the Atlan- tic has stimulated the author to render it even more worthy of the position which it has so rapidly attained as a standard authority. Every portion has been carefully revised, numerous additions have been made, and the most watchful care has been exercised to render it a complete exponent of the most advanced condition of surgical science. In this manner the work has been enlarged by about a hundred pages, while the series of engravings has been increased by more than a hundred, rendering it one of the most thoroughly illustrated volumes before the profession. The additions of the author having rendered unnecessary most of the notes of the former American editor, but little has been added in this country; some "few notes and occasional illustrations have, however, been introduced to elucidate American modes of practice. It is, in our humble judgment, decidedly the best I step of the operation, and_ not deserting him until the book of the kind in the English language. Strange that just such books are notoftener produced by pub- lic teachers of surgery in this country and Great Britain Indeed, it is a matter of great astonishment. but no less true than astonishing, that of the many works on surgery republished in this country within the last fifteen or twenty years as text-books foT medical students, this is the only one that even ap- proximates to ihe fulfilment of the peculiar wants of youngmen just entering upon the study of this branch of the profession.— Western Jour .of Med. and Surgery. Its value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering his novitiate of practice, we regard it the most serviceable guide which he can consult. He will find a fulnessof detail leading him through every final issue of the case is decided —Seihoscope. Embracing, as will be perceived, the whole surgi- cal domain, and each division of itself almost com- plete and perfect, each chapter full and explicit, each subject faithfully exhibited, we can only express oui estimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the best single volume now extant on the subject, and with great pleasure we add it to our text-books.— Nashville Journal of Medicine and Surgery. Prof. Erichsen's work, for its size, has not been surpassed; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes ; and will prove a reliable resource for information, both to physician and surgeon, in the hour of peril.—N. 0. Med. and Surg. Journal. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one neat octavo volume, extra cloth, of 296 pages. $1 75. FOWNES (GEORGE), PH. D., &.C A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. From the seventh revised and corrected London edition. With one hundred and ninety-seven illustrations. Edited by Robert Bridges, M. D. In one large roval 12mo. volume, of BOO pages. In leather, $1 65; extra cloth, $1 50. (Now Ready, July, 1859.) The death of the author having placed the editorial care of this work in the practiced hands of Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience could suggest to keep it on a level with the rapid advance of chemical science. The additions requisite to thi« purpose have necessitated an enlargement of the page, notwithstanding which the work has been increased by about fifty pages. At the same time every care has been u-ed to maintain its distinctive character as a condensed manual for the student, divested of all unnecessary detail or mere theoretical speculation. The additions have, of course, been mainly in the depart- ment of Organic Chemistry, which has made such rapid progress within the last few years, but yet equal attention has been bestowed on the other branches of the subject—Chemical Physics and inorganic Chemistry—to present all investigations and discoveries of importance, and to keep up ihe reputation of the volume as a complete manual of the whole science, admirably adapted for the learner. By the use of a small but exceedingly clear type tbe matter of a large octavo is compressed within the convenient and portable limits of a moderate sized duodecimo, and at the very low price affixed, it is offered as one of the cheapest volumes before the profession. A few notices of former editions are appended. We know of no better text-book, especially in the difficult department of organic chemistry, upon which it is particularly full and satisfactory. We would recommend it to preceptors as a capital •' office book" for their students who are beginners in Chemistry. It is copiously illustrated with ex- cellent wood-cuts, and altogether admirably "got up."—N. J. Medical Reporter. A standard manual^ which has long enjoyed the reputation of embodying much knowledge in a small space. The author has achieved the difficult task of condensation with masterly tact. His book is con- cise without being dry, and brief without being too dogmatical or general.—Virginia Med. and Surgical Journal. The work of Dr. Fownes has long been before the public, and its merits have been fully appreci- ated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.—Lon- don Journal of Medicine. A work well adapted to the wants of the student It is an excellent exposition of the chief doctrines and facts of modern chemistry. The size of the work, and still more the condensed yet perspicuous style in which it is written, absolve it from the charges very properly urged against most manuals termed popular.—Edinburgh Journal of Medical Science. FISKE FUND PRIZE ESSAYS —THE EF- FECTS OF CLIMATE ON TUBERCULOUS DISEASE. By Edwin Lee, M.R. C.S , London, nnd THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TUBERCLES. By Edward Warren, M. D., of Edenton, N. C. To. gether in one neat 8vo volume, extra cloth. PI 00. FRICK ON RENAL AFFECTIONS; their Diag- nosis and Pathology. With illustrations. One volume, royal 12mo., extra cloth. 75 cents. AND SCIENTIFIC PUBLICATIONS. 15 FERGUSSON (WILLIAM), F. R. S.f Professor of Surgery in King's College, London, &c. A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third and enlarged Loiidon edition. In one large and beautifully printed octavo volume, of about 700 pages, with 393 handsome illustrations, leather. $3 00. FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, &c. PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. $3 00. We can only state our general impression of the high value of this work, and cordially recommend it to all. We regard it, in point both of arrangement and of the marked ability of its treatment of the sub- jects, as destined to take the first rank in works of this class. So far asour information extends, it has at present no equal. To the practitioner, as well as the Btudent, it will be invaluable in clearing up the diagnosis of doubtful cases, and in shedding light upon difficult phenomena.—Buffalo Med. Journal. This is the most elaborate work devoted exclu- sively to the physical exploration of diseases of the BY THE SAME author. (In Press.) A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, of about 500 pages. An authoritative practical work on this important class of affections has for some time been a desideratum. The ample opportunities of the author, his long experience, and his ability both as a teacher and a writer, are sufficient guarantee that the present volume will supply the want. It is now passing rapidly through the press, and may be confidently expected for publication early in the autumn. lungs, with which we are acquainted in the English language.—Boston Med. and Surg. Journal. A work of original observation of the highest merit. We recommend the treatise to every one who wishes to become a correct auscultator. Based to a very large extent upon cases numerically examined, it carries the evidtnce of careful study and discrimina- tion upon every page. It does credit to the autnor, and, through him, to the profession in this country. It is, what we cannot call every book upon auscul- tation, a readable book.—Am. Jour. Med. Sciences. GRAHAM (THOMAS), F. R. S., THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applica- tions of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert Bridges, M. D. Complete in one large and handsome octavo volume, of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. $4 00. **# Part II., completing the work from p. 431 to end, with Index, Title Matter, &c, may be had separate, cloth backs and paper sides. Price $2 50. Gentlemen desirous of completing their copies of the work are requested to apply for Part 11. without delay. It will be sent by mail, prepaid, on receipt of the amount, $2 50. It is a very acceptable addition to the library of standard books of every chemical student. No reader of English works on this science can afford to be without this edition of Prof. Graham's Elements.— Silliman's Journal, March, 1658. From Prof. J. L. Crawcour, New Orleans School of Medicine, May 9, 1858. It is beyond all question the best systematic work on Chemistry in the English language, and I am gratified to find that an American edition at a mo- derate price has been issued, so as to place it within the means of students. It will be the only text-book I shall now recommend to my class. From Prof. Wolco't Gibbs, N. Y. Free Academy, May 25, 1858. The work is an admirable one in all respects, and its republication here cannot fiil to exert a positive influence upon the progress of science in this country. From Prof. E. N. Horsford. Harvard College, April 27, 1853. It has, in its earlier and less perfect editions, been famil'ar to me, and the excellence of its plan and the clearness and completeness of its discussions, have long been my admiration. GRIFFITH (ROBERT EJ, M. D., &c. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- tists Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas. M fi Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume, extra cloth, of 650 pages, double columns. $3 00; or in sheep, $3 25. It was a work requiring much Perseverance, and when published was looked upon as by far the be»l work of its kind that had issued, frorn the American Dress Prof Thomas has certainly "improved," as well as added to this Formulary, and has rendered i. ceutisis and physicians.-^- Journal of Pharmacy We are happy to announce a new and improved ne are nappy valuable and useful edition of this, one oi mc "■"= \mt.T\oan nen r^u,ldh£Wr^ It would aocreo i , ■ j s of medicine it is I Sd^ptin,Mrppr-S2«. *« *• d'sPensal°- t[es-Southern Med. and Surg. Journal. This i« a work of six hundred and finy one^pages rrusis aworii u preparing and adm ■ Jil u'nn'^d?"«..that «nb°e desired by the phys. clan an3 pharmaceutist.- Western Lancet. It is one of the most useful books a country practi- tioner can possibly have in his possession.—Medical Chronicle. The amount of useful, every-day matter.for a prac- ticing physician, is really immense.—Boston Med. and Surg. Journal. This edition of Dr. Griffith's work has been greatly improved by the revision and ample additions of Dr. Thomas, and is now, we believe, one of the most complete works of its kind in any language. The additions amount to about seventy pages, and no effort has been spared to include in them all the re- cent improvements which have been published in medical journals, and systematic treatises. A work of this kind appears to us iudispeu-able lo the physi- cian, and ih^reis none -.ve can more cordially recom- mend.—^. 1". Journaluf Medicine. 16 BLANCHARD & LEA'S MEDICAL GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. Now Ready, August, 1859. A SYSTEM OF SURGERY : Pathological, Diagnostic, Therapeutic, and Opera- tive. Illustrated by Nine Hundred and Thirty-six Engravings. In two large and beaulifully prinled octavo volumes, of nearly twenty-four hundred pages; strongly bound in leather, with raised bands. Price $12. From the Author's Preface. " The object of this work is to furnish a systematic and comprehensive treatise on the science and practice of surgery, considered in the broadest sense; one that shall serve the practitioner as a faithful and available guide in his daily routine of duty. It has been too much the custom of mod- ern writers on this department of the healing art to omit certain topics altogether, and to speak of others at undue length, evidently assuming that their readers could readily supply the deficiencies from other sources, or that what has been thus slighted is of no particular practical value. My aim has been to embrace the whole domain of surgery, and to allot to every subject its legitimate claim to notice in the great family of external diseases and accidents. How far this object has been accom- plished, it is not for me to determine. It may safely be affirmed, however, that there is no topic. properly appertaining to surgery, that will not be found to be discussed, to a greater or less extent. in these volumes. If a larger space than is customary has been devoted to the consideration of inflammation and its results, or the great principles of surgery, it is because of the conviction, grounded upon long and close observation, that there are no subjects so little understood by the general practitioner. Special attention has also been bestowed upon the discrimination of diseases; and an elaborate chapter has been introduced on general diagnosis." That these intentions have been carried out in the fullest and most elaborate manner is sufficiently shown by the great extent of the work, and the length of time during which the author has betii concentrating on the task his studies and his experience, guided by the knowledge which twenty years of lecturing on surgical topics have given him of the wants of students. In view of the magnitude and importance of the work, the publishers have spared neither labor nor expense to carry out fully the designs of the author, and to render its external appearance in every respect unexceptionable. The series of illustrations is fuller and more complete than has hitherto been attempted in any work of the kind, and while wood-cuts have been unsparingly se- lected from every authoritative and accessible source, a very large number of original drawings have been prepared, where the material already existing was unsatisfactory or insufficient. Printed in the handsomest manner, with new and clear type, on fine paper, these volumes are therefore oflered to the profession with the hope that they will fully meet the views of the most exacting and fastidious; and that no practitioner, however well supplied his library may be, will consider it com- plete without them; while the student may feel, in procuring them, that he does not merely possess a guide for his preliminary studies, but a copious book of reference, to be preserved for consultation during his whole professional career. BY THE SAME AUTHOR. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo volume, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings. Price in extra cloth, $4 75; leather, raised bands, $5 25. (Lately Published.) The very rapid advances in the Science of Pathological Anatomy during the last few years-have rendered essential a thorough modification of this work, with a view of making it a correct expo- nent of the present state of the subject. The very careful manner in which this task has been executed, and the amount of alteration which it has undergone, have enabled the author to say that " with the many changes and improvements now introduced, the work may be regarded almost as a new treatise," while the efforts of the author have been seconded as regards the mechanical execution of the volume, rendering it one of the handsomest productions of the American press. We most sincerely congratulate the author on the We have been favorably impressed with the gene- successful manner in which he has accomplished his proposed object. His book is most admirably cal- culated to fill up a blank which has long been felt to exist in this department of medical literature, and as such must become very widely circulated amongst all classes of the profession. — Dublin Quarterly Journ. of Med. Science, Nov. 1857. ral manner in which Dr. Gross has executed his task of affording a comprehensive digest of the present state of the literature of Pathological Anatomy, and have much pleasure in recommending his work to our readers, as we believe one well deserving ol diligent perusal and careful study.—Montreal Med. Chron., Sept. 1857. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- four illustrations. In one large and very handsome octavo volume, of over nine hundred pages. Tn leather, raised bands, $5 25; extra cloth, $4 75. agree with us, that there is no work in the English Philosophical in 'ts design, methodical in its ar- rangement, ample and sound in its practical details, it may in truth be said to leave scarcely anything to be desired on so important a subject.—Boston Med. and Surg Journal. Whoever will peruse the vast amount of valuable practical information it contains, will, we think, language which can make any just pretensions to be its equal.—N. Y. Journal of Medicine. A volume replete with truths and principles of the utmost value in the investigation of these diseases.— American Medical Journal. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. $2 75. AND SCIENTIFIC PUBLICATIONS. 17 GRAY (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London, &c. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly by the Author and Dr. Carter. In one magnificent imperial octavo volume, of nearly 800 pages, with 363 large and elaborate engravings on wood. Price in extra cloth, $6 25; leather raised bands, $7 00. (Ready this month.) The author has endeavored in this work to cover a more extended range of subjects than is customary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The engravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student id obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Some delay has arisen from the fact that the English edition was found to contain various typo- graphical errors, which, though of minor importance in themselves, might yet prove annoying to the student. Arrangements were therefore made with a competent professional man to revise the work thoroughly, and the necessary correctness, it is hoped, has been thereby secured. While no additions have been found necessary, some alterations of arrangement have been introduced, among which may be mentioned the Index, the plan of which is much more convenient than that of the original work. The completeness of the whole volume may, indeed be judged by the fulness of this Index, which occupies one hundred columns, and contains over seven thousand references. In every detail of mechanical execution, the publishers feel justified in presenting this volume as one of the handsomest that has yet been offered to the American public. For this truly admirable work the profession is indebted to the distinguished author of " Gray on the Spleen." The vacancy it fills has been long felt to exist in this country. Mr. Gray writes through- out with both branches of his subject in view. His description of each particular part is followed by a notice of its relations to ttie parts with which it is connected, and this, too, sufficiently ample for all the purposes of the operative surgeon. After de- scribing the bones and muscles, he gives a concise statement of the fractures to which the bones of the extremities are most liable, together with the amount and direction of the displacement to which the fragments are subjected by muscular action. The section on arteries is remarkably full and ac- curate. Not only is the surgical anatomy given to evsry important vessel, with directions for its liga- tion, but at the end of the description of each arte- rial trunk we have a useful summary of the irregu- larities which may occur in its origin, course, and termination.—N. A. Med. Chir. Review, Mar. 1859. Mr. Gray's book, in excellency of arrangement and comoleteness of execution, exceeds any work on anatomy hitherto published in the English lan- guage, affording a complete view of the structure of the human bodv, with especial reference to practical surgery. Thus the volume constitutes a perfect book of reference for the practitioner, demanding a place in even the most limited library of the physician or surgeon, and a work of necessity for the student to fix in his mind what he has learned by the dissecting knife from the book of nature.—The Dublin Quar- terly Journal of Med. Sciences, Nov. 1858. In our judgment, the mode of illustration adopted in the present volume cannot but present many ad- vantages to the student of anatomy. To the zealous disciple of Vesalius, earnestly desirous of real im- provement, the book will certainly be of immense value; but, at the same time, we must also confess that to those simplv desirous of "cramming" it will be an undoubted godsend. The peculiar value of Mr. Gray's mode of illustration is nowhere more markedly evident than in the chapter on osteology, and especially in those portions which treat of the bones of the head and of thair development. The study of these parts is thus made one of comparative ease, if not of positive pleasure; and those bugbears of the student, the temporal and sphenoid bones, are shorn of half their terrors. It is, in our estimation, an admirable and complete text-book for the student, and a useful work of reference for the practitioner; its pictorial character forming a novel element, to which we have already sufficiently alluded.—Am. Journ. Med. Sci., July, 1859. GIBSON (WILLIAM), M. D., Lnte Professor of Surgery in the University of Pennsylvania, &c. INSTITUTES AND PRACTICE OF SURGERY; being Outlines of a Course of Lectures. Eighth edition, improved and altered. With thirty-four plates. In two handsome octavo volumes, containing about 1000 pages, leather, raised bands. $6 50. GLUGE (GOTTLIEB), M. D., Professor of Physiology and Pathological Anatomy in the University of Brussels, &c. AN ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva- nia. In one volume, very large imperial quarto, extra cloth, with 320 figures, plam and colored, on twelve copperplates. * $5 00. GARDNER'S MEDICAL CHEMISTRY, for the use of Students and the Profession. In one royal 12mo. vol., ex. cloth, pp. 396, with illustrations. $1 00. HUGHES' CLINICAL INTRODUCTION TO THE PRACTICE OF AUSCULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS, IN DISEASES OF THE LUNGS AND HEART. Second American, from the second London editior. 1 vol. royal 12mo., ex. cloth, pp. 304. $1 00. PA' OF THE ^LIMENTAE'- TTNES With illustrations on wood. In one handsome octavo volume. i\ early Ready. (Pub- lishing in the Medical News and Library for 1858 and 185^.) 18 BLANCHARD & LEA'S MEDICAL HAMILTON (FRANK H.), M. D., ofessor of Surgery, in Buffalo Medical College, & lege, &c. A COMPLETE TREATISE ON FRACTURES AND DISLOCATIONS. In one handsome octavo volume, with several hundred illustrations. (In press.) This long promised work has been delayed by the desire of the author to render it a complete and authoritative treatise, reflecting on every point the latest results, both as regards the principles involved and the practical details of procedure. In no department, perhaps, has the ready and inventive genius of the American profession produced so many improvements as in Ihe processes and appliances devoted to these classes of injuries. An American treatise on the subject is there- fore peculiarly appropriate, while the attention bestowed on it by Professor Hamilton for many years, and his numerous contiibutions to its literature, point him out as specially fitted to undertake the task. In view of the large portion which such cases form in the practice of every surgeon, the necessity for prompt action and ready knowledge, and the frequency with which ihey give rise to harassing lawsuits, a work like the present becomes a necessity to every practitioner. Its appear- ance may be expected early in the autumn of 1859. HOBLYN (RICHARD D.), M. D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. A new American edition. Revised, with numerous Additions, by Isaac Hays, M. D., editor of the " American Journal of the Medical Sciences." In one large royal 12mo. volume, leather, of over 500 double columned pages. $1 50. To both practitioner and student, we recommend this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for ordinary consultation.—Charleston Med. Journ. Hoblyn has always been a favorite dictionary, and in its present enlarged and improved form will give greater satisfaction thanever. The American editor, Dr. Hays, has made many very valuable additions. —N.J. Med. Reporter. We know of no dictionary better arranged and adapted, ltisnotencumbered with the obsolete terms of a bygone age, but it contains all that are now in use ; embracing every department of medical science down to the very latest date.—Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best bookvof definitions we have, and ought always to be upon the student's table.— Southern Med. and Surg. Journal. HOLLAND (SIR HENRY), BART., M.D..F.R.S., Physician in Ordinary to the Queen of England, &c. MEDICAL NOTES AND REFLECTIONS. From the third London edition. In one handsome octavo volume, extra cloth, $3 00. HUNTER (JOHN). (See "Ricord," page 26, for Ricord's edition of Hunter on Venereal.) HORNER (WILLIAM E.), M. D., Professor of Anatomy in the University of Pennsylvania. SPECIAL ANATOMY AND HISTOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, extra cloth, of more than one thousand pages, handsomely printed, with over three hundred illustrations. $6 00. JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, &c. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and ten illustrations. Second American from the second and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills' Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. $1 50. The work sustains, in every point, the already high reputation of the author as an ophthalmic surgeon as well as a physiologist and pathologist. The book is evidently the result of much labor and re- search, and has been written with the greatest care and attention; it possesses that best quality which a general work, like a system or nwnual can show, viz : the quality of having ill the materials whence- soever derived, so thoroughly wrought up, and di- gested in the author's mind, as to come forth with the freshness and impressiveness of an original pro- duction. We entertain little doubt that this book will become what its author hoped it might become, a manual for daily reference and consultation by the student and the general practitioner. The work is marked by that correctness, clearness, and precision of style which distinguish all the productions of the learned author.—British and For. Med. Review. JONES (C. HANDFIELD), F. R. S., &. EDWARD H. SI EV EKING, M.D. Assistant Physicians and Lecturers in St. Mary's Hospital, London. A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, Revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautiful octavo volume of nearly 750 pages, leather. $3 75. In offering the above titled work to the public, the As a concise text-book, containing, in a condensed form, a compleie outline of what is known in the domain of Pathological Anatomy, it is perhaps the best work in the English language. Its great merit consists in its completeness and brevity, and in this respect it supplies a great desideratum in our lite- rature. Heretofore the student of pathology was obliged to glean from a great number of monographs, and the field was so extensive that but few cultivated it with any degree of success. As a simple work of reference, therefore, it is of great value to the Btudent of pathological anatomy, and should be in every physician's library.—Western Lancet. authors have not attempted to intrude new views on their professional brethren, but simply to lay before them, what has long been wanted, an outline of the present condition of pathological anatomy. In this they have been completely successful. The work is one of the best compilations which we have ever perused.—Charleston Medical Journal and Review. We urge upon our readers and the profession gene- rally the importance of informing themselves in re- gard to modern views of pathology, and recommend to them to procure the work before us as the best means of obtaining this information.—Stethoscope. AND SCIENTIFIC PUBLICATIONS. 19 KIRKES (WILLIAM SENHOUSE), M.D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. A MANUAL OF PHYSIOLOGY. A new American, from the third and improved London edition. With two hundred illustrations. In one large and handsome royal 12mo. volume, leather, pp. 586. $2 00. (Lately Published.) In again passing this work through his hands, the author has endeavored to render it a correct exposition of the present condition of the science, making such alterations and additions as have been dictated by further experience, or as the progress of investigation has rendered desirable. In every point of mechanical execution the publishers have sought to make it superior to former edi- tions, and at the very low price at which it is offered, it will be found one of the handsomest and cheapest volumes before the profession. This is a new and very much improved edition of Dr. Kirkes' well-known Handbook of Physiology. Originallyconstructed on the basis of the admirable treatise of Muller, it has in successive editions de- veloped itself into an almost original work, though no change has been made in the plan or arrangement. It combines conciseness with completeness, and is, therefore, admirably adapted for consultation by the busy practitioner.—Dublin Quarterly Journal. Its excellence is in its compactness, its clearness, and its carefully cited authorities. It is the most convenient of text-books. These gentlemen, Messrs Kirkes and Paget, have really an immense talent for silence, which is not so common or so cheap as prat- ing people fancy. They have the gift of telling us what we vv;:nt to know, without thinking it neces- sary to tell us all they know.—Boston Med. and Surg. Journal. One of the very best handbooks of Physiology we possess—presenting just such an outline of the sci- ence, comprising an account of its leading facts and generally admitted principles, as the student requires during his attendance upon a course of lectures, or for reference whilst preparing for examination.— Am. Medical Journal. We need only say, that, without entering into dis- cussions of unsettled questions, it contains all the recent improvements in this department of medical science. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know, without special details, which are read with interest only by those who would make a specialty, or desire to possess a criti- cal knowledge of the subject.—Charleston Medical Journal. KNAPP'S TECHNOLOGY ; or, Chemistry applied to the Arts and to Manufactures. Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson. First American edition, with Notes and Additions, by Prof. VValtkr R. Johnson. In two handsome octavo volumes, extra cloth, with about 500 wood- engravings. $6 00. LAYCOCK'S LECTURES ON THE PRINCI- PLES AND METHODS OF MEDICAL OB- SERVATION AND RESEARCH. For the Use of Advanced Students and Junior Praetitionf rs. In one very neat royal 12mo. volume, extra cloth. Price SI. LUDLOW (J. L.), M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Designed for Students of Medicine throughout the United States. Third edition, thoroughly revised and greatly extended and enlarged. With three hundred and seventy illustrations. In one large and handsome royal 12mo. volume, leather, of over 800 closely printed pages (Lately Published.) $2 50. The great popularity of this volume, and the numerous demands for it during the two years in which it has been out of print, have induced the author in its revision to spare no pains to render it a correct and accurate digest of the most recent condition of all ihe branches of medical science. In many respects it may, therefore, be regarded rather as a new book than a new edition, an entire section on Physiology having been added, as also one on Organic Chemistry, and many portions having been rewritten. A very complete series of illustrations has been introduced, and every care has been taken in the mechanical execution to render it a convenient and satisfactory book for study or reference. The arrangement of the volume in the form of question and answer renders it especially suited for the office examination of students and for those preparing for graduation. We know of no better companion for the student I crammed into his head by the various professors to during the hours spent in the lecture room, or to re- whom he is compelled to listen.—Western Lancet, fresh, at a glance, his memory of the various topics | May, 1857. LAWRENCE (W.), F. R. S., Sec. A TREATISE ON DISEASES OF THE EYE. A new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather with raised bands. $5 00. This admirable treatise-the safest guide and most comprehensive work of reference, which is within the reach of the profession.—Stethoscope. This standard text-book on the department of Which it treats, has not been superseded, by any or likely that this great work will cease to merit the confidence and preference of students or practition- ers. Its ample extent—nearly one thousand large octavo pages—has enabled both author and editor to do justice to all the details of this subject, and con- dense in this single volume the present state of our le ^numerous publications on the'sub'ject j knowledge of the whole science in this department, heretofore issued. Nor with the multiplied improve- ■ whereby its practical value cannot be excelled.—AT. ments of Dr. Hays, the American editor, is it at all 1 Y. Med. Gaz. LALLEMAND AND WILSON. A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SI'EHMATORRHGEA. By M. Lali.emand. Translated and edited by Hfnry J McDougall. Third American edition. To which is added-----ON DISEASES OF THE VESICULATE SEMINALES; and their associated organs. Wiih special refer- ence to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Markis Wilson M. D. In one neat octavo volume, of about 400 pp., extra cloth. $2 00. (Just Issued.) 20 BLANCHARD & LEA'S MEDICAL LA ROCHE (R.), M. D., &c. YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination of the connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. From Professor S. H. Dickson, Charleston, S. C, September 18, 1855. A monument of intelligent and well applied re- search, almost without example. It is, indeed, in itself, a large library, and is destined to constitute the special resort as a book of reference, in the subject of which it treats, to all future time. We have not time at present, engaged as we are, by d;i.y and by night, in the work of combating this very disease, now prevailing in out city, to do more than give this cursory notice of what we consider as undoubtedly the most able and erudite medical publication our country has yet produced But in view of the startling fact, that this, the most malig- nant and unmanageable disease of modern times, has for several years been prevailing in our country to a greater extent than ever before; that it is no longer confined to either large or small cities, but penetrates country villages, plantations, and farm- houses; that it is treated with scarcely better suc- cess now than thirty or forty years ago; that there is vast mischief done by ignorant pretenders to know- ledge in regard to the disease, and in view of the pro- bability that a majority of southern physicians will be called upon to treat the disease, we trust that this able and comprehensive treatise will he very gene- rally read in the south.—Memphis Med. Recorder. This is decidedly the great American medical work of the day—a full, complete, and systematic treatise, unequalled by any other upon the all-important sub- ject of Yellow Fever. The laborious, indefatigable, and learned author has devoted to it many years of BY THE SAME AUTHOR. PNEUMONIA; its Supposed Connection, Pathological and Etiological, with Au- tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. $3 00. arduous research and careful study, and the result is such as will reflect the highest honor upon the author and our country.—Southern Med. and Surg. Journal. The genius and scholarship of thisgreatphysicinn could not have been better employed than in the erection of this towering monument to his own fame, and to the glory of the medical literature of his own country. It is destined to remain the great autho- rity upon the subject of Yellow Fever. The student and physician will find in these volumes a rtsumi of the sum total of the knowledge of the world upon the awful scourge which they soelaborately discuss. The style is so soft and so pure as to refresh and in- vigorate the mind while absorbing the thoughts of the gifted author, while the publishers have suc- ceeded in bringing the externals into a most felicitous harmony with the inspiration that dwells within. Take it all in all, it is a book we have often dreamed of, but dreamed not that it would ever meet our waking eye as a tangible reality.—Nashville Journal of Medicine. We deem it fortunate that the splendid work of Dr. La Roche Bhould have been issued from the press at this particular time. The want of a reliable di- gest of all that is known in relation to this frightful malady has long been felt—a want very satisfactorily met in the work before us. We deem it but faint praise to say that Dr. La Roche has succeeded in presenting the profession with an able and complete monograph, one which will find its way into every well ordered library.— Va. Stethoscope. LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- trations. $6 00. This great work, universally acknowledged as the most complete and authoritative exposition of the principles and details of Zoochemistry, in its passage through the press, has received from Professor Rogers such care as was necessary to present it in a correct and reliable form. The work is, therefore, presented as in every way worthy the attention of all who desire to be familiar with the modern facts and doctrines of Physiological Science. it treats.—Edinburgh Monthly Journal of Medical Science. Already well known and appreciated by the scien- tific world, Professor Lehmann's great work re- quires no laudatory sentences, as, under a new garb, it is now presented to us. The little space at our command would ill suffice to set forth even a small portion of its excellences.—Boston Med. and Surg. Journal, Dec. 1855. The most important contribution as yet made to Physiological Chemistry.—Am. Journal Med. Sci- ences, Jan. 1S56. The present volumes belong to the small class of medical literature which comprises elaborate works of the highest order of merit.—Montreal Med. Chron- icle, Jan. 1856. The work of Lehmann stands unrivalled as the most comprehensive book of reference and informa- tion extant on every branch of the subject on which by the same author. (Lately Published.) MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Noies and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsylvania. With illus- trations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. Prom Prof. Jac&son's Introductory Essay. In adopting the handbook of Dr. Lehmann as a manual of Organic Chemistry for the use of the students of the University, and in recommending his original work of Physiological Chemistry for their mote mature studies, the high value of his researches, and the great weight of his autho- rity in that important department of medical science are fully recognized. MAVNE'S DISPENSATORY AND THERA- PEUTICAL REMEMBRANCER. Comprising the entire lists of Materia Medica, with every Practical Formula contained in the three British Pharmacopoeias. Edited, with the addition of the Formulae of the U. S. Pharmacopoeia, by R. E. GriiiitHjM.D. 112mo. vol. ex. cl.,300 pp. 75 c. MALGAIGNE'S OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French by Frederick Brittan, A.B.,M.D. Withnumerous illustrations on wood. In one handsome octavo volume, extra cloth, cf nearly six hundred pages. $2 25. AND SCIENTIFIC PUBLICATIONS. 21 MEIGS (CHARLES D.), M.D., Professor of Obstetrics, &c. in the JefTerson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Third edition, revised and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. $3 75. The rapid demand for another edition of this work is a sufficient expression of the favorable verdict of the profession. In thus preparing it a third time for the press, the author has endeavored to render it in every respect worthy of the favor which it has received. To accomplish this he has thoroughly revised it in every part. Some portions have been rewritten, others added, new illustrations have been in many instances substituted for such as were not deemed satisfactory, while, by an alteration in the typographical arrangement, the size of the work has not been increased, and the price remains unaltered. In its present improved form, it is, therefore, hoped that the,work will continue to meet the wants of the American profession as a sound, practical, and extended System of Midwifery. Though the work has received only five pages of enlargement, its chapters throughout wear the im- pressof careful revision. Expunging and rewriting, remodelling its sentences, with occasional new ma- terial, all evince a lively desire that it shall deserve to be regarded as improved in manner as well as matter. In the matter, every stroke of the pen has increased the value of the book, both in expungings and additions —Western Lancet, Jan. 1857. BY THE SAME AUTHOR. The best American work on Midwifery that is accessible to the student and practitioner—N. W. Med. and Surg. Journal, Jan. 1857. This is a standard work by a great American Ob- stetrician. It is the third and last edition, and, in the language of the preface, the author has "brought the subject up to the latest dates of real improve- ment in our art and Science."—Nashville Journ. of Med. and Surg., May, 1857. (Now Ready, June, 1859.) WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lec- tures to his Class. Fourth and Improved edition. In one large and beautifully printed octavo volume, leather, of over 700 pages. $3 60. The gratifying appreciation of his labors, as evinced by the exhaustion of three large impressions of this work has not been lost upon the author, who has endeavored in every way to render it worthy of the favor with which it has been received. The opportunity thus afforded for another revision has been improved, and the work is now presented as in every way superior to its pre- decessors, additions and alterations having been made whenever the advance ol science has ren- dered them desirable. The typographical execution of the work will also be found to have under- gone a similar improvement, and the volume, it is hoped, will be found in all respects worthy to maintain its position as the standard American text-book on the Diseases of Females. A few notices of the previous editions are appended. In other respects, in our estimation, too much can- not be siid in praise of this work. It abounds with beautiful passages, and for conciseness, for origin- ality, and for all that is commendable in a work on the diseases of females, it is not excelled, and pro- b ibly not equalled in the English language. On the whole, we know of no wortc on the diseases of wo- men which we can so cordially commend to the student snd practitioner as the one before us.—Ohio Med. and Surg. Journal. The body of the book is worthy of attentive con- sideration, and is evidently the production of a clever, thoughtful, and sagacious physician. Dr. Meigs's letters on the diseases of the external or- gans, contain many interesting and rare cases, and many instructive observations. We take our leave of Dr. Meigs, with a high opinion of his talents and originality.— The British and Foreign Medico-Chi- rurgical Review. Every chapter is replete with practical instruc- tion, and bears the impress of being the composition of anacute and experienced mind. There is a terse- ness, and at the same time an accuracy in his de- scription of symptoms, and in the rules for diagnosis, which cannot fail to recommend the volume to the attention of the reader.—Ranking's Abstract. It contains a vast amount of practical knowledge, bv one who has accurately observed and retained Full of important matter, conveyed in a ready and agreeable manner.— St.Louis Med. and Surg. Jour. There is an off-hand fervor, a glow, and a warm- heartedness infecting the effort of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in such bold relief, as to produce distinct impression* upon the mind and memory of the reader. — Th* Charleston Med. Journal. Professor Meigs has enlarged and amended this <*reat work, for such it unquestionably is, having passed the ordeal of criticism at home and abroad, but been improved thereby ; for in this new edition the author has introduced real improvements, and increased the value and utility of the book im- measurably. It presents so many novel, bright, and sparkling thoughts; such an exuberance of new ideas on almost every page, that we confess out- selves to have become enamored with the book and its author; and cannot withhold our congratu- lations from our Philadelphia confreres, that such a teacher is in their service.—N. Y. Med. Gazette. the experience of many years, and who tells the re suit in a free, familiar, and pleasant manner.—Dub lin Quarterly Journal. ' BY THE SAME AUTHOR. r>tt TTTF NATURE SIGNS, AND TREATMENT OF CHILDBED FEVER In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. $2 50. The instructive and, interesting author of thu - ous labors in the department of us. It is a delectable book. * * * This treatise upon child-bed fevers will have an extensive sale, being destined, as it deserves, to find a place in the library of every practitioner who scorns to lag in the rear.—Nashville Journal of Medicine and Surgery. tresh ana Vlg ^ ^ ^^ AUTHOR J WITH COLORED PLATES. * mT^TTW ON ACUTE AND CHRONIC DISEASES OF THE NECK nK THE UTERUS With numerous plates, drawn and colored from nature in the highest "vie o7St I? one handsome octavo volume, extra cloth. $4 50. 22 BLANCHARD flz LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto. With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. $11 00. %* The size of this work prevents its transmission through the post-office as a whole, but those who desire to have copies forwarded by mail, can receive them in five parts, done up in stout wrappers. Price $9 00. One of the greatest artistic triumphs of the age in Surgical Anatomy.—British American Medical Journal. Too much cannot be said in its praise; indeed, we have not language to do it justice.—Ohio Medi- cal and Surgical Journal. The most admirable surgical atlas we have seen. To the practitioner deprived of demonstrative dis- sections upon the human subject, it is an invaluable companion.—N. J. Medical Reporter. The most accurately engraved and beautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.—Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, and so useful a work, is offered at so moderate a price.—Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond the reach of competition.—Medi- cal Examiner. A work which has no parallel in point of accu- racy and cheapness in the English language.—N. Y. Journal of Medicine. Country practitioners will find these plates of im- mense value.—N. Y. Medical Gazette. We are extremely gratified to announce to tha profession the completion of this truly magnificent work, which, as a whole, certainly stands unri- valled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand.—The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. We know of no other work that would justify a stu- dent, in any degree, for neglect of actual dissec- tion. In those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, awork of this kind keeps the details of the dissecting-room perpetually fresh in the memory.—The Western Journal of Medi- cine and Surgery. MILLER (HENRY), M. D., Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PRINCIPLES AND PRACTICE OF OBSTETRICS, &c. ; including the Treat- ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent cause of Abortion. With about one hundred illustrations on wood. In one very handsome oc- tavo volume, of over 600 pages. (Lately Published.) $3 75. The reputation of Dr. Miller as an obstetrician is too widely spread to require the attention of the profession to be specially called to a volume containing the experience of his long and extensive practice. The very favorable reception accorded to his " Treatise on Human Parturition," issued some years since, is an earnest that the present work will fulfil the author's intention of providing within a moderate compass a complete and trustworthy text-book for the student, and book of re- ference for the practitioner. We congratulate the author that the task is done. We congratulate him that he has given to the medi- cal public a work which will secure for him a high and permanent position among the standard autho- rities on the principles and practice of obstetrics. Congratulations are not less due to the medical pro- fession of this country, on the acquisition of a trea- tise embodying the results of the studies, reflections, and experience of Prof. Miller. Few men, if any, in this country, are more competent than he to write on this department of medicine. Engaged for thirty- five years in an extended practice of obstetrics, for many years a teacher of this branch of instruction in one of the largest of our institutions, a diligent student as well as a careful observer, an original and independent thinker, wedded to no hobbies, ever ready to consider without prejudice new views, and to adopt innovations if they are really improvements, and withal a clear, agreeable writer, a practical treatise from his pen could not fail to possess great value.—Buffalo Med Journal, Mar. 1858. In fact, this volume must take its place among the standard systematic treatises on obstetrics; a posi- tion to which its merits justly entitle it. The style is such that the descriptions are clear, and each sub- ject is discussed and elucidated with due regard to its practical bearings, which cannot fail to make it acceptable and valuable to both students and prac- titioners. We cannot, however, close this brief notice without congratulating the author and the profession on the production of such an excellent treatise. The author is a western man of whom we feel proud, and we cannot but think that his book will find many readers and warm admirers wherever obstetrics is taught and studied as a science and an art.—The Cincinnati Lancet and Observer, Feb. 1858. A most respectable and valuable addition to our home medical literature, and one reflecting credit alike on the author and the institution to which he is attached. The student will find in this work a most useful guide to his studies; the country prac- titioner, rusty in his reading, can obtain from its pages a fair resume of the modern literature of the science; and we hope toEee this American produc- tion generally consulted by the profession.— Va. Med. Journal, Feb. 1858. MACKENZIE (W.), M.D., Surgeon Oculist in Scotland in ordinary to Her Majesty, A,c. &c. A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, &c. &c. In one very large and handsome octavo volume, leather, raised bands, with plates and numerous wood-cuts. $5 25. The treatise of Dr. Mackenzie indisputably holds the first place, and forms, in respect of learning and research, an Encyclopaedia unequalled in extent by any other work of the kind, either English or foreign. —Dixon on Diseases of the Eye. Few modern books on any department of medicine or surgery have met with such extended circulation, or have procured for their authors a like amount of European celebrity. The immense research which it displayed, the thorough acquaintance with the subject, practically as well as theoretically, and the able manner in which the author's stores of learning and experience were rendered available for general use, at once procured for the first edition, as well on the continent as in this country, that high position as a standard work which each successive edition has more firmly established. We consider it the duty of every one who has the love of hie profession and the welfare of his patient at heart, to make him- self familiar with this the most complete work in the English language upon the diseases of the eye. —Med. Times and Gazette. AND SCIENTIFIC PUBLICATIONS. 23 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, See. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume, leather, of 700 pages, with two hundred and forty illustrations on wood. $3 75. The work of Mr. Miller is too well and too favor- ably known among us, as one of our best text-books, to render any further notice of it necessary than the announcement of a new edition, the fourth in our country, a proof of its extensive circulation among us. As a concise and reliable exposition of the sci- ence of modern surgery, it stands deservedly high— we know not its superior.—Boston Med. and Surg. Journal. The work takes rank with Watson's Practice of Physic; it certainly does not fall behind that great work in soundness of principle or depth of reason- ing and research. No physician who values his re- putation, or seeks the interests of his clients, can acquit himself before his God and the world without making himself familiar with the sound and philo- sophical views developed in the foregoing book.— New Orleans Med. and Surg. Journal. BY THE same author. (Just Issued.) THE PRACTICE OF SURGERY. Fourth American from the last Edin- burgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume, leather, of nearly 700 pages. No encomium of ours could add to the popularity of Miller's Surgery. Its reputation in this country is unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to to which no conscientious surgeon would be willing practice his art.— Southern Med. and Surg. Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the "Principles" and the "Practice" of Surgery by Mr. Miller—or so richly merited the reputation they have acquired. The author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it.—Kentucky Medical Recorder. By the almost unanimous voice of the profession, $3 75. his works, both on the principles and practice of surgery have been assigned the highest rank. If we were limited to but one work on surgery, that one should be Miller's, as we regard it as superior to all others.—St. Louis Med. and Surg. Journal. The author has in this and his " Principles," pre- sented to the profession one of the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding the attention. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recom- mended.—Southern Journal of Med. and Physical Sciences. MORLAND (W. W.), M. D. Fellow of the Massachusetts Medical Society, &c DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, Pathology, and Treatment. With illustrations about 600 pages, extra cloth. (Just Issued.) Taken as a whole, we can recommend Dr. Mor- land's compendium as a very desirable addition to the library of every medical or surgical practi- tioner.—Brit, and For. Med.-Chir. Rev., April, 1859. Every medical practitioner whose attention has been to any extent'attracted towards the class of diseases to which this treatise relates, must have often and sorely experienced the want of some full, yet concise recent compendium to which he could refer. This desideratum has been supplied by Dr. Morland, and it has been ably done. He has placed before us a full, judicious, and reliable digest. Each subject is treated with sufficient minuteness, In one large and handsome octavo volume, of !3 50. yet in a succinct, narrational style, such as to render the work one of great interest, and one which will prove in the highest degree useful to the general practitioner. To the members of the profession in the country it will be peculiarly valuable, on account of the characteristics which we have mentioned, and the one broad aim of practical utility which is kept in view, and which shines out upon every page, together with the skill which is evinced in the com- bination of this grand requisite with the utmost brevity which a just treatment of the subjects would admit.—N. Y. Journ. of Medicine, Nov. 1858. MONTGOMERY -o- STANLEY'S TREATISE ON DISEASES OF THE BONES. In one volume, octavo, extra cloth, 280 pages. SI 50. 2S BLANCHARD & LEA'S MEDICAL SHARPEY (WILLIAM), M. D., JONES QUAIN, M. D., AND RICHARD QUAIN, F. R. S., &.c. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidt, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, leather, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. $6 00. SARGENT (F. W.), M. D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. Second edition, enlarged. One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood- cuts. Extra cloth, $1 40; leather, $1 50. Sargent's Minor Surgery has always been popular, and deservedly so. It furnishes that knowledge of the most frequently requisite performances of surgical art which cannot be entirely understood by attend- ing clinical lectures. The art of bandaging, which is regularly taught in Europe, is very frequently overlooked by teachers in this country; the student and junior practitioner, therefore, may often require that knowledge which this little volume so tersely and happilv supplies —Charleston Med. Journ. and Review, March, 1856. A w/>rk that has been so long and favorably known to the profession as Dr. Sargent's Minor Surgery, needs no commendation from us. AVe would remark, however, in this connection, that minor surgery sel- dom gets that attention in our schools that its im- portance deserves. Our larger works arealro very defective in their teaching on these small practical points. This little book will supply the void which all must feel who have not studied its pages.— West- ern Lancet, March, 1856. OF SMITH (W. TYLER), M.D., Physician Accoucheur to St. Mary's Hospital, &c. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $125. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT OF LEUCORRHCEA. With numerous illustrations. In one very handsome octavo volume, extra cloth, of about 250 pages. $1 50. SOLLY ON THE HUMAN BRAIN; its Structure, Physiology, and Diseases. From the Second and much enlarged London edition, in one octave volume, extra cloth, of 500 pages, with 120 wood- cuts. $2 00. SIMON'S GENERAL PATHOLOGY, as conduc- ive to the Establishment of Rational Principles for the prevention and Cure of Disease. In one neat octavo volume, extra cloth, of 212 pages. $1 25. TANNER (T. H.), M. D., Physician to the Hospital for Women, &c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. To which is added The Code of Ethics of the American Medical Association. Second American Edition. In one neat volume, small 12mo., extra cloth, 87| cents. The work is an honor to its writer, and must ob- I tioners, it has only to be seen, to win fer itself a tain a wide circulation by its intrinsic merit alone, place upon the shelves of every medical library. Suited alike to the wants of students and practi- \ —Boston Med and Surg. Journal. TODD (ROBERT BENTLEY), M. D., F. R. S., Professor of Physiology in King's College, London; and WILLIAM BOWMAN, F. R. S., Demonstrator of Anatomy in King's College, London. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume, of 950 pages, leather. Price $4 50. 13T Gentlemen who have received portions of this work, as published in the " Medical News and Library," can now complete their copies, if immediate application be made. It will be fur- nished as follows, free by mail, in paper covers, with cloth backs. Parts I., II., III. (pp. 25 to 552), $2 50. Part IV. (pp. 553 to end, with Title, Preface, Contents, &c), $2 00. Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c), $1 25. A magnificent contribution to British medicine, and the American physician who shall fail to peruse it, will have failed to read one of the most instruc- tive books of the nineteenth ctntury.—N. O. Med and Surg. Journal, Sept. 1857. 11 is more concise than Carpenter's Principles, and more modern than the accessible edition of Mailer's Elements; its details are brief, but sufficient; its descriptions vivid ; its illustrations exact and copi- ous ; and its language terse and perspicuous.— Charleston Med. Journal, July, 1857. We know of no work on the subject of physiology so well adapted to the wants of the medical student. Its completion has been thus long delayed, that the authors might secure accuracy by personal observa- tion.—St. Louis Med. and Surg. Journal, Sept. '57. Our notice, though it conveys but a very feeble and imperfect idea of the magnitude and importance of the work now under consideration, alre.-idy tran- scends our limits ; and, with the indulgence of our readers, and the hope that they will peruse the book for themselves, as we feel we can with confidence recommend it, we leave it in their hands for them to judge of its merits.—The Northwestern Med. and Surg. Journal, Oct. 1857. TODD (R. 6.), M. D., F. R. S., &.c. CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY ORGANS AND ON DROPSIES. In one octavo volume. (Just Issued, 1857.) $ 1 50. BY the same author. (In Press.) CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat octavo volume, to match the above. AND SCIENTIFIC PUBLICATIONS. 29 TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Fourth American Eaition. With Notes and References to American Decisions, by Edward Hartshorne, M. D. In one large octavo volume, leather, of over seven hundred pages. $3 00. This standard work has lately received a very thorough revision at the hands of the author, who has introduced whatever was necessary to render it complete and satisfactory in carrying out the objects in view. The editor has likewise used every exertion to make it equally thorough with regard to all matters relating to the practice of this country. In doing this, he has carefully ex- amined all that has appeared on the subject since the publication of the last edition, and has incorpo- rated all the new information thus presented. The work has thus been considerably increased in size, notwithstanding which, it has been kept at its former very moderate price, and in every respect it will be found worthy of a continuance of the remarkable favor which has carried it through so many editions on both sides of the Atlantic. A few notices of the former editions are appended. we do not hesitate to affirm that after having once commenced its perusal, few could be prevailed upon to desist before completing it. In the last London edition, all the newly observed and accurately re- corded facts have been inserted, including much that is recent of Chemical, Microscopical, and Patholo- gical research, besides papers on numerous subjects never before published .-Charleston Medical Journal and Review. It is not excess of praise to say that the volume before us is the very best treatise extant on Medical Jurisprudence. In saying this, we do not wish to be understood as detracting from the merits of the excellent works of Beck, Ryan, Traill, Guy, and others; but in interest and value we think it must be conceded that Taylor is superior to anything that has preceded it.—N. W. Medical and Surg. Journal. We know of no work on Medical Jurisprudence which contains in the same space anything like the same amount of valuablematter.—N. Y. Journal of Medicine. No work upon the subject can be put into the hands of students either of law or medicine which will engage them more closely or profitably; and none could be offered to the busy practitioner of either calling, for the purpose of casual or hasty reference, that would be more likely to afford the aid desired. We therefore recommend it as the best and safest manual for daily use.—American Journal of Medical Sciences. This work of Dr. Taylor's is generally acknow- ledged to be one of the ablest extant on the subject of medical jurisprudence. It is certainly one of the most attractive books that we have met with ; sup- plying so much both to interest and instruct, that by the same author. (New Edition, now ready.) ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Second American, from a second and revised London edition, in one large octavo volume, of 755 pages, leather. $3 50. The length of time which has elapsed since the first appearance of this work, has wrought so great a change in the subject, as to require a very thorough revision to adapt the volume to the present wants of the profession. The rapid advance of Chemistry has introduced into u-e many new substances which may become fatal through accident, carelessness, or design—while at the same\itne it has likewise designated new and more exact modes of counteracting or detecting those previously treated of. Mr. Taylor's position as the leading medical jurist of England, has during this period conferred on him extraordinary advantages in acquiring experience in all that relates to this department, nearly all cases of moment being referred to him for examination, as an expert whose testimony is generally accepted as final. The results of his labors, therefore, as gathered together in this volume, carefully weighed and sifted, and presented in the clear and intelligible stvle for which he is noted, may be received as an acknowledged authority, and as a guide to be followed with implicit confidence. In his Preface the author says:— < f h subject lhaI in reproducing it no additions has brought it so completely up to «£ pre-eru.^ ^ ^^ ^ hereiof.ore met ^^ th&l jh? im_ have been found necessary, j. * nre«ent form it will be found eminently worthv a continu- portance has been appreciated, mid in "^ «{£ longest claims to the attention of ihe medical ance of the same favor, Pf°**Yhe "admirable manner in which the various inquiries in the different student and practitioner, irou , combined and generalized by an experienced practical phy- branches of P^fy^toUielnves'tigation and treatment of disease. sician, anddirecuy w . matter and recommend it for a text-book, guide, and constant We find that the deepiy-inrCI Sj that we CJmpanion to every practitioner and every student style of this book have so la^'<*°'-. es not too who wishes to extricate himself from the well-worn have unconsciously hung upt n fonger' than re- ruts of empiricism, and to base his practice of medi- long, indeed, for our own PjV"^,^ yve leave the cine upon principles.—London Lancet. viewers can ^f P^^udentand practitioner Our text-book to which no other in our language is uUgrn^t o? thewo^ has already be sufficiently comparable._c W^o„ Mtaical Journal Upressed. It is u ^8™"'°' ,ntroversial. but of No work has ever achieved or maintained a more praise. The work is not ot a com. . und deserved reputation —Ko. Med. and Surg. Journal. I didactic character; and as sucn wc , 30 BLANCHARD & LEA'S MEDICAL New and much enlarged edition—(Now Ready.) , WATSON (THOMAS), M. D., &.C. *?K Late Physician to the Middlesex Hospital, Sec. tlVQTPP^'' LECTURES ON THE PRINCIPLES AND PRACTICE OF Kargej^ Delivered at King's College, London. A new American, from the last revised &n ■ Treatise1"1"^ English edition, with Additions, by D. Francis Condie, M. D., author of " A Practical jQ' o«r on the Diseases of Children," &c. With one hundred and eighty.five illustrations.on J 's iU|W one very large and handsome volume, imperial octavo, of over 1200 closely printed p S yp small type; the whole strongly bound in leather, with raised bands. Price $4 25. (.;» The publishers feel that they are rendering a service to the American profession in PreS^.,jje°for<:!'['i so very moderate a price this vast body of sound practical information. Whether asa.° non kv^'! the student entering on a course of instruction, or as a book of reference for daily con . n(jness^ the practitioner, " Watson's Practice" has long been regarded as second to none,- lne sou ^..up8*1 and fulness of its teachings, the breadth and liberality of its views, and the easy and l'°*,in^-, f?"1 in which it is written having won for it the position of a general favorite. That this high r p - ^i tion might be fully maintained, the author has subjected it to a thorough revision; every por o has been examined with the aid of the most recent researches in paihology, and the results ol modern investigations in both theoretical and practical subjects have been carefully weighed ana embodied throughout its pages. The watchful scrutiny of the editor has likewise introduced whatever possesses immediate importance to the American physician in relation to diseases inci- dent to our climate which are little known in England, as well as those points in which.experience here has led to different modes of practice ; and he has also added largely to the series of i"Ll^ra' tions, believing that in this manner valuable assistance may be conveyed to the student in elucidat- ing the text. The work will, therefore, be found thoroughly on a level with the most advancea state of medical science on both sides of the Atlantic. The additions which the work has received are shown by the fact that notwithstanding an en- largement in the size of the page, more than two hundred additional pages have been necessary to accommodate the two large volumes of the London edition (which sells at ten dollars), within the compass of a single volume, and in its present form it contains the matter of at least three ordinary octavos. Believing it to be a work which should lie on the table of every physician, and be in the hands of every student, the publishers have put it at aprice within the reach of all, making it one of the cheapest books as yet presented to the American profession, while at the same time the beauty of its mechanical execution renders it an exceedingly attractive volume. It would appear almost superfluous to adduce commendatory notices of a work which has so long been established in the position of a standard authority as "Watson's Practice." A few ex- tracts are, however, subjoined from reviews of the new and improved edition. The fourth edition now appears, so carefully re- vised, as to add considerably to the value of a book already acknowledged, wherever the English lan- guage is read, to be beyond all comparison the best The lecturer's skill, his wisdom, his learning, are equalled by the ease of his graceful diction, his elo- quence, and the far higher qualities of candor, of courtesy, of modesty, and of generous appreciation systematic work on the Principles and Practice of of merit in others. May he long remain to instruct Physic in the whole range of medical literature Every lecture contains proof of the extreme anxiety of the author to keep pace with ihe advancing know- ledge of the day, and to bring the results of the labors, not only of physicians, but of chemists and histologists, before his readers, wherever they can be turned to useful account. And this is done with such a cordial appreciation of the merit due to the industrious observer, such a generous desire to en- courage younger and rising men, and such a candid acknowledgment of his own obligations to them, that one scarcely Knows whether to admire most the pure, simple, forcible English—the vast amount of useful practical information condensed into the Lectures—or the manly, kind-hearted, unassuming character of Ihe lecturer shining through his work. —London Med. Times and Gazette, Oct. 31, 1857. Thus these admirable volumes come before the profession in their fourth edition, abounding in those distinguished attributes of moderation, judgment, erudite cultivation, clearness, and eloquence, with which they were from the first invested, but yet richer than before in the results of more prolonged observation, and in the able appreciation of the latest advances in pathology and medicine by one of the most profound medical thinkers of the day.— London Lancet, Nov. 14, 1857. us, and to enjoy, in the glorious sunset of his de- clining years, the honors, the confidence and love gained during his useful life.—N. A. Med.-Chir. Review, July, 1858. Watson's unrivalled, perhaps unapproachable work on Practice—the copious additions made to which (the fourth "dition) have given it all the no- velty and much of the interest of a new book.— Charleston Med. Journal, July, 1858. Lecturers, practitioners, and students of medicine will equally hail the reappearance of the work of Dr. Watson in the form of a new—a fourth—edition. We merely do justice to our own feelings, and, we are sure, of the whole profession, if we thank him for having, in the trouble and turmoil of a large practice, made leisure to supply the hialus caused by the exhaustion of the publisher's stock of the third edilion, which has been severely felt for the last three years. For Or. Watson has not merely caused the lectures to be reprinted, but scattered through the whole work wr find additions or altera- tions which prove that the author has in every way sought to bring up his teaching to the level of the most recent acquisitions in science.—Brit, and For. Medico-Chir. Review, Jan. 1858. WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, extra cloth, of 476 pages, Wi,u illustrations. $2 80. ' Wiia WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES Published under the authority of the London Society for Medical Observation. A new American' from the second and revised Londou edition. In one very handsome volume, royal 12mo„ ev "' cioth. $1 00. Xlra To the observer who prefers accuracy to blunders I One of the finest aids to a young practitioner ■» and precision to carelessness, this little book is :u- have ever seen__Peninsular Journal of MediCin valuable.—iV. H. Journal of Medicine. \ **• AND SCIENTIFIC PUBLICATIONS 31 New and much enlarged edition—(Now Ready.) WILSON (ERASMUS), F. R. S., V SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- I( vised American, from the last and enlarged Engli.-h Edition. Edited by W. H. Gobrecht, M. D. •f. Professor of Anatomy in the Philadelphia Medical College, &c. Illustrated with three hundred ilj and ninety-seven engravings on wood. In one large and exquisitely printed octavo volume of > over 600 large pages; leather. $3 25. 6. The publishers trust that the well earned reputation so long enjoyed by this work will be more .nan maintained by the present edition. Besides a very thorough revision by the author, it has been frriost carefully examined by the editor, and the efforts of both have been directed to introducing Everything which increa'ed experience in its use has suggested as desirable to render it a compleie ]text-book for those seeking to obtain or to renew an acquaintance with Human Anatomy. The ^amount of additions which it has thus received may be estimated from the fact that the present [edition contains over one-fourth more matter than Ihe last, rendering a smaller type and an enlarged jipage requisite to keep the volume within a convenient size. The author has not only thus added [largely to the work, but he has also made alterations throughout, wherever there appeared the , opportunity of improving the arrangement or style, so as to present every fact in its most appro- priate manner, and to render the whole as clear and intelligible as possible. The editor has I exercised the utmost caution to obtain entire accuracy in the text, and has largely increased ihe , number of illustrations, of which there are about one hundred and fifty more in this edition than »in I he last, thus bringing distinctly before the eye of the student everything of interest or importance. > The publishers have felt that neither care nor expense should be spared to render the external , finish of the volume worthy of the universal favor with which it has been received by the American i profession, and they have endeavored consequently to produce in its mechanical execution an im- provement corresponding with that which the text has enjoyed. It will therefore be found one of the handsomest specimens of typography as yet produced in this country, and in all respects suiied j to the office table of the practitioner, notwithstanding the exceedingly low price at which it has been placed. A few notices of former editions are subjoined. This is probably the prettiest medical book ever published, iind we believe that its intrinsic merits are in keeping with its exterior advantages, having examined it sufficiently to satisfy us that it may be recommended to the student as no less distinguished by its accuracy and clearness of description than by its typographical elegance. The wood-cuts are ex- quisite.—British and Foreign Medical Review. An elegant edition of one of the most useful and accurate systems of anatomical science which has been issued from the press. The illustrations are really beautiful. In its style the work is extremely concise and intelligible. No one can possibly take u(> this volume without being struck with the great beauty of its mechanical execution, and the clear- ness of the descriptions which it contains is equally evident. Let students, by all means examine the claims of this work on their notice, before they pur- chase a text-book of the vitally important science which this volume so fully and easily unfolds.__ Lancet. In every respect, this work, as an anatomical guide for the student who seeks to obtain know- ledge which he has not yet acquired, and for the practitioner who wishes to keep up that which he findi gradually fading from his mind, merits our warmest and most decided praise.—Med. Gazelle. We regard it as the best system now extant for students.—Western Lancet. It therefore receives our highest commendation.__ Southern Med. and Surg. Journal. BY the same author. (Just Issued.) ON DISEASES OF THE SKIN. Fourth and enlarged American, from the last and improved London edition. In one large octavo volume, of 650 pages, extra cloth, 52 75. The writings of W'ilson, upon diseases of the skin, are by far the most scientific and practical that have ever been presented to the medical world on this subject. The present edition is a great improve- ment on all its predecessors. To dwell upon all the great merits and high claims of the work before us. seriatim, would indeed be an agreeable service; it would t>e a mental homage which we could freely offer, but we should thus occupy an undue amount ot space in this Journal. We will, howtver. look at some of the more salient points with which it abounds, and which make it incomparaoiy superior in excellence to all other treatises on the subject ot der- matology. IS o mere speculative views are allowed a place in this volume, which, without a doubt, will, for a very long period, be acknowledged as the chief standard work on dermatology. The principles of an enlightened and rational therapeia are introduced on every appropriate occasion. The general prac- titioner and surgeon who, peradventure, may have for years regarded cutaneous maladies as scarcely worthy- their attention, because, forsooth, they are not fatal in their tendency; or who, if they have attempted their cure, have followed the blind guid- ance of empiricism, will almost assuredly be roused to a new and becoming interest in this department of practice, through the inspiring agency ol tnis book.—Am. Jour. Med. Science, Oct. 1657. ALSO, NOW READY, A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF THE wTvIN ' consisting of nineteen beautifully executed plates, of which twelve are exquisitely colored presenting the Normal Anatomy and Pathology of the rjkm, and containing accurate re- presentations of about one hundred varieties of disease, most of them the size of nature. Price in cloth $4 25. „,.,_,.„,,., these plates will be found equal to In beauty of drawing and accuracy and finish of coloring ivthing of the kind as yet issued in this country. One of the best specimens of colored lithographic illustrations that have ever been published in this country The representations of diseases of the E even to the most minute shade of coloringare remarkably accurate, giving ^V*" ?h,Mu«v- tioner a very correct idea ot the disease he is •tutlv - „g We know of no work so well adapted tc.he wants of the general practitioner us Wil«»'». ™J the accompanying plates. — Med. and Surg. Re porter, May, 185S. We have already expressed our high appreciation of Mr. Wilson's treatise on Diseases of the ^kin. The plates are comprised in a separate volume, which we counsel alt those who possess the text to purchase. It is a beautiful specimen of color print- ing, and the repiesentations of the various forms of skin disease are as faithful as is possible in plates of the size.—Boston Med. and Surg. Journal, April {?. 1:-.j3. 30 BLANCHARD & LEA'S MEDICAL New and much enlarged edition—(Now Ready.) WATSON (THOMAS), M. D., &c. Late Physician to the Middlesex Hospital, &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the last revised and enlarged English edition, with Additions, by D. Francis Condie, M. D., author of "A Practical Ireatise on the Diseases of Children," &c. With one hundred and eighty.five illustrations on wood. In one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in small type; the whole strongly bound in leather, with raised bands. Price $4 25. The publishers feel that they are rendering a service to the'American profession in presenting at so very moderate a price this vast body of sound practical information. Whether as a guide for the student entering on a course of instruction, or as a book of reference for daily consultation by the practitioner, " Watson's Practice" has long been regarded as second to none; the soundness and fulness of its teachings, the breadth and liberality of its views, and the easy and flowing style in which it is written having won for it the position of a general favorite. That this high reputa- tion might be fully maintained, the author has subjected it to a thorough revision; every portion has been examined with the aid of the most recent researches in pathology, and the results of modern investigations in both theoretical and practical subjects have been carefully weighed and embodied throughout its pages. The watchful scrutiny of the editor has likewise introduced whatever possesses immediate importance to the American physician in relation to diseases inci- dent to our climate which are little known in England, as well as those points in which experience here has led to different modes of practice; and he has also added largely to the series of illustra- tions, believing that in this manner valuable assistance may be conveyed to the student in elucidat- ing the text. The work will, therefore, be found thoroughly on a level with the most advanced slate of medical science on both sides of the Atlantic. The additions which the work has received are shown by the fact that notwithstanding an en- largement in the size of the page, more than two hundred additional pages have been necessary to accommodate the two large volumes of the London edition (which sells at ten dollars), within the compass of a single volume, and in its present form it contains the matter of at least three ordinary octavos. Believing it to be a work which should lie on the table of every physician, and be in the hands of every student, the publishers have put it at a price within the reach of all, making ii one of the cheapest books as yet presented to the American profession, while at the same time the beauty of its mechanical execution renders it an exceedingly attractive volume. It would appear almost superfluous to adduce commendatory notices of a work which has so long been established in the position of a standard authority as "Watson's Practice." A few ex- tracts are, however, subjoined from reviews of the new and improved edition. The fourth edition now appears, so carefully re- vised, as to add considerably to the value of a book already acknowledged, wherever the English lan- guage is read, to be beyond all comparison the best systematic work on the Principles and Practice of Physic in the whole range of medical literature. Every lecture contains proof of the extreme anxiety of the author to keep pace with ihe advancing know- ledge of the day, and to bring the results of the labors, not only of physicians, but of chemists and histologists, before his readers, wherever they can be turned to useful account. And this is done with such a cordial appreciation of the merit due to the industrious observer, such a generous desire to en- courage younger and rising men, and such a candid acknowledgment of his own obligations to them, that one scarcely Knows whether to admire most the pure, simple, forcible English—the vast amount of useful practical information condensed into the Lectures—or the manly, kind-hearted, unassuming character of Ihe lecturer shining through his work. __London Med. Times and Gazette, Oct. 31, 1857. Thus these admirable volumes come before the profession in their fourth edition, abounding in those distinguished attributes of moderation, judgment, erudite cultivation, clearness, and eloquence, with which they were from the first invested, but yet richer than before in the results of more prolonged observation, and in the able appreciation of the latest advances in pathology and medicine by one of the most profound medical thinkers of the day.— j Medico-Chtr. Review, Jan. 1858. London Lancet, Nov. 14, 1857. WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, extra cloth, of 476 pages, with illustrations. $2 80. The lecturer's skill, his wisdom,his learning,are equalled by the ease of his graceful diction, his elo- quence, and the far higher qualities of candor, of courtesy, of modesty, and of generous appreciation of merit in others. May he long remain to instruct us, and to enjoy, in the glorious sunset of his de- clining years, the honors, the confidence and love gained during his useful life.—N. A. Med.-Chh. Review, July, 1858. Watson's unrivalled, perhaps unapproachable work on Practice—the copious addiiions made to which (the fourth »dition) have given it all the no- velty and much of the interest of a new book.— Charleston Med. Journal, July, 1858. Lecturers, practitioners, and students of medicine will equally hail the reappearance of the work of Dr. Watson in the form of a new—afourth—edition. We merely do justice to our own feelings, and, we are sure, of the whole profession, if we thank him for having, in the trouble and turmoil of a large practice, made leisure to supply the hiatus caused by the exhaustion of the publisher's stock of the third edition, which has been severely felt for ihe last three years. For Dr. Watson has not merely caused the lectures to be reprinted, but scattered through the whole work wr find additions or altera- tions which prove that the author has in every way sought to bring up his teaching to the level of the most recent acquisitions in science.—Brit, and For. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority of the London Society for Medical Observation. A new American, from the second and revised London edition. In one very handsome volume, royal 12mo., extra cioth. SI 00. To the observer who prefers accuracy to blunders I One of the finest aids to a young practitioner w« and precision to carelessness, this little book is :n- have ever seen.—Peninsular Journal of Medicine. valuable.—N. H. Journal of Medicine. I AND SCIENTIFIC PUBLICATIONS 31 New and much enlarged edition—(Now Ready.) __Tri WILSON (ERASMUS), F. R. S., A SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- vised American, from the last and enlarged English Edition. Edited by W. H. Gobrecht, M. D., Professor of Anatomy in the Philadelphia Medical College, &c. Illustrated with three hundred and ninety-seven engravings on wood. In one large and exquisitely printed octavo volume, of over 600 large pages; leather. $3 25. The publishers trust that the well earned reputation so long enjoyed bv this work will be more than maintained bythe present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to introducing everything which increased experience in its use has sugsresied as desirable to render it a compleie text-book for those seeking to obtain or to renew an acquaintance with Human Anatomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appro- priate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. The publishers have felt that neither care nor expense should be spared to render the external finish of the volume worthy of the universal favor wiih which it has been received by the American profession, and they have endeavored consequently to produce in its mechanical execution an im- provement corresponding with that which the text has enjoyed, it will therefore be found one of the handsomest specimens of typography as yet produced in this country, and in all respects suiied to the office table of the practitioner, notwithstanding the exceedingly low price at which it has been placed. A few notices of former editions are subjoined. This is probably the prettiest medical book ever published, and we believe that its intrinsic merits are in keeping with its exterior advantages, having examined it sufficiently to satisfy us that it may be recommended to the student as no less distinguished by its accuracy and clearness of description than by its typographical elegance. The wood-cuts are ex- quisite.—British and Foreign Medical Review. An elegant edition of one of the most useful and accurate systems of anatomical science which has been issued from the press. The illustrations are really beautiful. In its style the work is extremely concise and intelligible. No one can possibly take ui> this volume without being struck with the great beauty of its mechanical execution, and the clear- ness of the descriptions which it contains is equally BY the same author. (Just Issued.) ON DISEASES OF THE SKIN. Fourth and enlarged American, from the last and improved London edition. In one large octavo volume, of 650 pages, extra cloth, $2 75. The writings of Wilson, upon diseases of the skin, a place in this volume, which, without a doubt. are by far the most scientific and practical that have ever been presented to the medical world on this subject. The present edition is a great improve- ment on all its predecessors. To dwell upon all the great merits and high claims of the work before us, seriatim, would indeed be an agreeable Bervice; it would be a mental homage which we could freely offer, but we should thus occupy an undue amount ot space in this Journal. We will, however, look at some of the more salient points with which it abounds,and which make itincompatauiy superiorin excellence to all other treatises on the subject of der- matology. No mere speculative views are allowed ALSO, NOW READY, A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF THF °KIN • consi*tin°- of nineteen beautifully executed plates, of which twelve are exquisitely oJwH oresentin^ the Normal Anatomy and Pathology of the Skin, and containing accurate re- presentations of about one hundred varieties of disease, most of them the size of nature. Price T h antv of drawing and accuracy and finish of coloring these plates will be found equal to anything of the kind as°yet issued in this country. t , j One of the best specimens of colored lithographic the accompanying plates. — Mea. ana o s porter, May, 1858. evident. Let students, by all means examine the claims of this work on their notice, before they pur- chase a text-book of the vitally important science which this volume so fully and easily unfolds.— Lancet. In every respect, this work, as an anatomical guide for the student who seeks to obtain know- ledge which he has not yet acquired, and for the practitioner who wishes to keep up that which he findi gradually fading from his mind, merits our warmest and most decided praise.—Med. Gazette. We regard it as the best system now extant for students.—Western Lancet. It therefore receives our highest commendation.— Soutlteni Med. and Surg. Journal. on every appropriate occasion. The general prac- titioner and surgeon who, peradventure, may have for years regarded cutaneous maladies as scarcely worthy- their attention, because, forsooth, they are not fatal in their tendency; or who, if they have attempted their cure, have followed the blind guid- ance of empiricism, will almost assuredly be roused to a new and becoming interest in this department of practice, through the inspiring agency ol tins book.—Am. Jour. Med. Science, Oct. 1857. We have already expressed our high appreciation of Mr. Wilson's ireatise on Diseases of the Skin. The plates are comprised in a separate volume, which we counsel all those who possess the text to purchase. It is a beautiful specimen of color print- ing, and the repiesentations of the various forms of skin disease are as faithful as is possible in plates of the size.—Boston Med. and Surg. Journal, April P, 1K)S. 32 BLANCHARD & LEA'S MEDICAL PUBLICATIONS. ¥ WILSON (ERASMUS), M. D., F. R. S. Lecturer on Anatomy, London. THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third American, from the last revised and enlarged English edition. Modified and rearranged, by William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, leather, of 582 pages, with 154 illustrations. $2 00. The modifications and additions which this work has received in passing recently through the author's hands, are sufficiently indicated by the fact that it is enlarged by more than one hundred pages, notwithstanding that it is printed in smaller type, and with a greatly enlarged page. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. $2 25. BY THE SAME AUTHOR. HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat volume, royal 12mo.: extra cloth, of about 300 pages, with numerous illustrations. $1 00; paper cover, 75 cents. (Now Complete.) WEST (CHARLES), M. D., Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for Sick Children, &c. LECTURES ON THE DISEASES OF WOMEN. Now complete in one hand- some octavo volume, extra cloth, of about 500 pages ; price $2 50. Also, for sale separate, Part II, being pp. 309 to end, with Index, Title matter, &c, 8vo., cloth, price $ 1. pf" Copies of Part II, done up in paper covers, for mailing, will be sent, free of postage, to any ad- dress within'the United States on receipt of One Dollar in current funds or postage stamps. Sub- scribers to the "Medical News and Library" who received the first portion of this work as published in 1856 and 1857, should lose no time in securing the completion. painstaking, practical physician isapparent on every page.—N. Y. Journal of Medicine, March, lt5a. We know of no treatise of the kind so complete and yet so compact.—Chicago Med. Journal, Janu- ary, 1S53. A fairer, more honest, more earnest, and more re- liable investigator of the many diseases of women and children is not to be found in any country.— Southern Med. and Surg. Journal, January 1858. We gladly recommend his Lectures as in the high- est degree instructive to all who are interested in obstetric practice.—London Lancet. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language ; and that it stamps Dr. West as the facile princeps of British obstetric authors.—Edinb. Med. Journ. As a writer, Dr. West stands, in our opinion, se condonly to Watson, the" Macaulay of Medicine;" he possesses that happy faculty of clothing instruc- tion in easy garments; combining pleasure with profit, he leads his pupils, in spite of the ancient proverb, along a royal road to learning His work is one which will not satisfy the extreme on either side, but it is one that will please the great ma- jority who are seeking truth, und one that will con- vince the student that he has committed himself to a candid, safe, and valuable guide. We anticipate with pleasure the appearance of the second part of the work, which, if it equals this part, will com- plete one of our very best volumes upon diseases of females.—N. A. Med.-Chirurg. Review, July, 1S58. We must now conclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal. The conscientious, BY THE SAME AUTHOR. LECTURES ON THE DISEASES OP INFANCY AND CHILDHOOD. Second American, from the Second and Enlarged London edition. In one volume, octavo, extra cloth, ol nearly five hundred pages. $2 00. We take leave of Dr. West with great respect for his attainments, a due appreciation of his acute powers of observation, and a deep sense of obliga- tion for this valuable contribution to our profes- sional literature. His book is undoubtedly in many respects the best we possess on diseases of children. Dublin Quarterly Journal of Medical Science. Dr. West has placed the profession under deep ob- BY THE SAME AUTHOR. AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. ligation by this able, thorough, and finished work upon a subject which almost daily taxes to the ut- most the skill of the general practitioner. He has with singular felicity threaded his way through all the tortuous labyrinths of the difficult subjecthe has undertaken to elucidate, and has in many of the darkest corners left a light, which will never be extinguished.—Nashville Medical Journal. WILSON (MARRIS), M. D. ON DISEASES OF THE VESICULiE SEMINALES. See "Lallemand," page 19. WHITEHEAD ON THE CAUSES AND TREAT- I Second American Edition. In one volume, octa- JIENT OF ABORTION AND STERILITY. | vo, extra cloth, pp. 308. «1 75. YOUATT (WILLIAM), V. S. THE DOG. Edited by h. J. Lewis, M. D. With numerous and beautify illustrations In one very handsome volume, crown 8vo., crimson cloth, gilt. $ 1 2S. v. \t',i mv I