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DISEASES OF THE LIVER.
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ON
DISEASES OF THE LIVER.
BY
GEORGE BUDD, M.D. F.R.S.,
PROFESSOR OF MEDICINE IN KINO’9 COLLEGE, LONDON; AND FELLOW OF CATUS COLLEGE.
CAMBRIDGE.
LONDON:
JOHN CHURCHILL, PRINCES STREET, SOHO
MDCCCXLV.
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^61^05 KCOHQ 6^0
LONDON :
PRINTED BY «. J. PALMER, SAVOY-STREET, STRAND,
PREFACE.
The materials of which the present volume is composed accu- mulated gradually during eight years in which I have been engaged in hospital practice. For the first three of those years. I was the visiting Physician to the Seamen’s Hospital, Dread- nought, 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 Gulstonian Lectures, which I had the honour to deliver at the College 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 sur- geon of the Dreadnought, who was not only ever ready to give me his most valuable aid when we were acting together, hut who has ever since continued to call my attention to all cases of es- pecial 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 appreciate the singular disinterestedness with which it was given.
IV
PREFACE.
I am also much indebted to my friend, Mr. Bowman, for microscopic 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 occa- sions aided me by his intimate knowledge of structure.
To Dr. Inman, of Liverpool, and to Dr. James Russel, of Bir- mingham, my former pupils, I am likewise indebted for some va- luable 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 disappointment, 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 ab- sorbed in the business of teaching. It is hoped, however, that with all its imperfections, of which no one can be more sensible than myself, the work will contribute to render the diagnosis of dis- eases of the liver more certain, and their treatment, therefore, more rational and satisfactory.
Dover Street, June, 1845.
CONTENTS.
Introduction.
Page
Vagueness of our knowledge of Liver diseases — Structure of the liver — Cause of the variations in its form, size, and colour — Physical qualities and composition of the bile — Sources and uses of the bile — Cholagogue medicines . . . . . .1
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 — Portal-venous congestion. . . . . .38
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 ........ 46
Section II. Gangrenous inflammation — Appearances sometimes mis- taken for gangrene— Circumstances in which gangrene of the liver really occurs ..... . . 96
Section III. Adhesive inflammation of the capsule and of the sub- stance of the liver — Cirrhosis — Other forms of inflammation of the substance of the liver . . . . , .105
CONTENTS.
viii
Page
Section IV. Inflammation of the veins of the liver— Suppurative inflammation of the portal vein— Adhesive inflammation of branches of the portal vein— Inflammation of branches of the hepatic vein . 136 Section V. Inflammation of the gall-bladder and ducts — Catarrhal and suppurative inflammation— Croupal, or plastic, inflammation — Ulcer- ative inflammation — Effects of inflammation of the gall-bladder and ducts — Fatty degeneration of the coats of the gall-bladder . .149
CHAPTER III.
ON DISEASES WHICH RESULT FROM FAULTY NUTRITION OF THE LTVER, OR FAULTY SECRETION.
Section I. Softening of the liver — Destruction of the hepatic cells — Suppressed secretion of bile — Fatal jaundice .... 196
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 ........ 227
Section III. Scrofulous enlargement of the liver, and other kindred states ........ 246
Section IV. Excessive and defective secretion of bile — Unhealthy states of the bile ....... 256
Section V. Gall-stones ...... 272
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 ....... 299
Section II. Hydatid tumors of the liver .... 336
CHAPTER V.
On Jaundice.
. 372
Appendix.
1 lie 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 ...... 38Q
'■>
FLATS 1 .
EXPLANATION OF THE PLATES.
PLATE I. — Gall-stones.
The drawings for these plates were all taken from preparations in the museum of King’s College; to which reference is made.
Fig. 1 — Represents small, irregular gall-stones, compost. i of inspissated and altered bile, cemented by mucus. From a dry preparation, (No. 263,) which exhibits 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 colouring 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
b
X
EXPLANATION OF THE PLATES
li\ er, 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.)
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 cholesterine. 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.)
D? vreotmacott. del
H Adlard. ir
ON
DISEASES OE THE LIVER.
INTRODUCTION.
Vagueness of our knowledge of Liver Diseases. — Structure of the Liver — Cause of the variations in its form, size, and colour. — Physical qualities and composition of the bile. — Source and uses of the bile. — Cholagogue medicines.
In writing a book on Diseases of the Liver, I shall hardly he accused of haring undertaken a needless task. There are no other diseases of such frequent occurrence, which it is so diffi- cult to discriminate, 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.' medical 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 organisation and habits, and in the obvious relation of its secretion to the process of digestion, sufficient evidence of its great impor- tance in the animal economy, and of the serious consequences that must result from derangement of its functions.
This evidence has been enhanced and extended by the more explicit results of modern inquiry. Guided by the comparatively recent discovery, that a gland may be regarded as consisting essentially of a net-work of capillaries investing a secretory duct, anatomists have found a liver, in the form of ccecal tubes
B
2
INTRODUCTION.
opening into tlie intestinal canal, in almost the lowest animals, and have thus furnished the surest testimony that can be given to the importance of an organ ; namely, its all hut universal presence in the animal kingdom.
Notwithstanding this, while the press has been teeming with works on the diseases of the Nervous System, of the Chest, of the Kidney, of the Skin, comparatively few have appeared of late years, on diseases of the Liver. This, assuredly, is not owing to any falling off in our sense of their importance, hut to the vague and unsatisfactory state of our knowledge respecting them.
The scientific precision lately given to our knowledge of many other diseases by the employment of new methods of investiga- tion, has created a demand for more exact information, in every branch of medical inquiry, than pathologists have been able to communicate on diseases of the liver.
The unsatisfactory state of our knowledge of these diseases will scarcely be wondered at, if we reflect that many causes have conspired to render the study of them peculiarly difficult.
One of the most influential, perhaps, is, that the colour and tex- ture of the liver are such as to make it difficult, 'with the imperfect means of research hitherto employed, to detect and define, in the dead body, the various effects of disease, unless where this has gone on to disorganisation, 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 leam to connect them with the symp- toms observed during life ; but in organs naturally solid, and also nearly of the colour of blood, as the liver and the kidney, these chtinges, 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 minute inspection.
In the case of the kidney, the impediment which these condi- tions offer to the morbid anatomist is well illustrated by the fact, that a disease so common and so fatal as granular dege- neration 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
INTRODUCTION.
3
seventeen years, and tlie attention given to it by the best anato- mists of this and other countries, the real nature of the morbid change in which it essentially consists, is a matter of doubt.
Another circumstance unfavourable 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 contain 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 outline and estimate the strength of its ventricles, but, by the same sense, 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, 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, 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 analysed during the life of the patient ; indeed, until lately, they could scarcely be analysed at all, as the most celebrated chemists were not even agreed as to what are the normal consti- tuents of bile.
Thus, to detect and distinguish the diseases of the liver, practitioners had little more than the signs of functional dis- turbance ; — signs, in all cases of doubtful import, and here, if we except that of jaundice, more than commonly obscure and equivocal. We cannot, then, feel surprised that our knowledge of these diseases should be more imperfect, our diagnosis of them less sure, and our treatment, consequently, more tentative and cm-
b 2
4
INTRODUCTION.
piricftl, than of the diseases of any other organ of equal impor- tance.
Very recently, two of the impediments to the study of diseases of the liver have been in some degree removed. By the re- searches of chemists we have obtained more precise knowledge of the composition and uses of bile ; and by the labours of Kiernan and Bowman in this country, and of Muller 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 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.
2nd. A small particle taken from the lobular substance of a fresh liver in which the blood-vessels 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 woodcut (fig. i.) has been made from a por- tion of the liver of a frog, which I selected from the 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 ca- pillaries. 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 capillaries springing directly from them on every side and forming a close and continuous network.
By conceiving similar views of the branches of the two veins and their intermediate capillaries, obtained by slicing the liver in various directions, we shall perceive that the entire organ, abstracting the canals in which the trunk and branches of those veins run, is ocoupied by a close network of capillary blood-vessels, con-
DISTRIBUTION OF VESSELS. Fig. 1.
a a, twigs of the portal vein ; d, twig of the hepatic vein ; b, intermediate
capillaries.
tinuous in every direction throughout its substance. The capil- lary vessels of this network immediately minister to the secretion of hile. 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 sometimes nearly twice as wide, and their coats, which have no areolar tissue about them, appear very thin and delicate.*
But although the capillaries form a continuous network through- out the substance of the liver, no part of the portal blood tra- verses the entire network. The whole mass of capillaries is divided by the minute branches and twigs of the portal vein into small, tolerably defined masses ; and is likewise partitioned in a similar way, by the minute branches and twigs of the hepatic
* 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.
6
INTRODUCTION.
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 capillaries, having performed its part in secretion and been drained of the principles of bile, passes out of the liver through an intermediate 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, we see 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 terminat- ing 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 pentangular, spaces, having the outline, 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. The injected preparations of Mr. Bowman show, I think, clearly, that this opinion is erroneous — that the lobules are not distinct, isolated bodies, but merely small masses tolerably defined by the ultimate twigs of the portal vein and the injected or uninjected capillaries im- mediately 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 network. The lo- bules 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 annexed woodcut, (fig. 2,) for which I am indebted to the kind- ness of Mr. Bowman. It represents on a magnified scale six lobules of the liver, and was made from a drawing under the microscope, of a section of the liver of a cat, partially injected through the portal vein, and also through the hepatic vein ; a a. a
LOBULES.
7
Fig. 2.
represent minute twigs of tlie portal vein injected; b b b, capil- laries, likewise injected, immediately springing from them, and serving with them to mark the outline of the lobules ; d d d, ca- pillaries in the centre 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 interme- diate capillaries are coloured and conspicuous ; l l, centres of lobules into which the injection has not passed through the he- patic vein.
Since the capillary network of the liver has nearly the same re- lation to the minute branches and twigs of the hepatic vein, as to the minute branches and twigs of the portal vein, we might have anticipated that a similar appearance of lobules might be formed ; the circumference of each being marked by twigs of the hepatic vein and the capillaries immediately surrounding them, and the centre by a twig of the portal vein. This appearance is seen in what has been called, by Mr. Kicrnan, the second stage of hepatic venous congestion.
8
INTRODUCTION.
When the portal vessels are empty, and only the hepatic twigs and the capillaries immediately contiguous to them are filled with blood, there is an appearance of lobules, having a pale outline formed by the terminal twigs of the portal vein. The centres of the lobules appear as small, isolated, red spots.
If the injection extend from the twigs of the hepatic vein into the capillaries, but be not continued quite far enough to reach the twigs of the portal vein, all the capillaries of the lobular substance will be injected, except those immediately springing from the portal twigs, and a section of the liver will present small, isolated, pale spots, where the uninjected twigs of the vena porta are divided. These spots being surrounded by a red band continuous throughout the liver, gives rise to an appearance of lobules just like those formed by injecting the twigs and capillaries of the vena porta, so as not to fill those of the hepatic vein.
It has been stated that the capillaries have the same relation to the small branches and twigs of the hepatic vein, as to those of the portal vein. This statement, however, requires some qualification. The branches of the portal vein are each accompanied to their
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; b, orifices of ultimate twigs of the vein, springing immediately from it.
p
Fig. 3
\ D
PORTAL AND HEPATIC VEINS.
9
smallest twigs by a branch of tbe hepatic artery, and one of the hepatic duct. These vessels, which are very much smaller than the corresponding portal vein, run up (as seen in fig. 3#) on one side of it, and of course on that side the capillaries cannot spring so immediately from the venous trunk ; in other words, the lo- bules are not in such immediate contact with the vein. The capil- laries terminate in twigs which go to the vein through the space which the presence of the artery and duct necessarily interposes between the lobules and the vein.
The artery and duct are also liable to changes in volume, which is permitted by some areolar tissue being placed in the portal canals, surrounding the artery and duct, and continued in a thin
Fig. 4.
H, longitudinal section of an hepatic vein, a, a, portions of the canal, from which the vein has been removed ; b, b, orifices of ultimate twigs of the vein, formed hy the capillaries of single lobules.
* This figure and the two following ones, 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 blood-vessels in the liver, and of many other points of its structure.
10
INTRODUCTION.
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.
The hepatic veins are not accompanied by any other vessels, and are not surrounded by areolar tissue, and, in consequence, are everywhere in immediate contact with lobules. 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 figure 4, copied on a smaller scale from one by Mr. Kiernan.
To complete our view of the blood-vessels of the liver, we must 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 ducts, the liga- ments of the liver, its capsule, and the coats of the portal and 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 ministers to the secretion of bile, like blood re- turned from the other abdominal viscera.* These veins, which originate in the liver, and feed the porta with the blood brought by the hepatic artery, constitute what Mr. Kiernan 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 injected arteries, whilst in the coats of the vein, no vessels will be detected without the aid of the magnifying glass.” The blood of the hepatic artery, not only nourishes the coats of the excretory ‘portion of the ducts, but furnishes the materials of their proper secretion.
* It appeal's from some injections by Mr. Bowman, that some of the arte- » ial capillaries of the capsule return their blood, not into a branch of the portal vein, but immediately into the adjacent capillary plexus of the portal vein.
NUCLEATED CELLS.
11
the arteries in the
Fig.
The ducts, as we have seen, accompany portal canals. Each portal vein, however small, has an artery and a duct running along it. The coats of the duct are supplied with blood entirely through the hepatic artery, which forms a close network over the mucous membrane.
In the large ducts, and in the gall- bladder, the mucous membrane is thrown into folds. The inner surface of the ducts presents besides a great number of follicles, which in the large ducts are distributed irregularly, but in the small ones are ranged in two lines on oppo- site sides of the canal.
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, all we see under the microscope is a mass
Section of a small gall-duct, showing the follicles.
Fig. 0.
of nucleated cells, with, here and there, a fibre from one of the torn vessels.
The cells are flattened, irregular in form, but somewhat spheroidal, and have each a nucleus, which again contains a central pellucid spot, the nucleolus.
Some cells have two nuclei.
The cells are of various sizes. The largest are usually about the one-thou- sandth 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 co- lour and transparency depend on the colour and quantity of the matter they contain, which vary very much in different cases. They arc usually of a light brown and
Nucleated cells of the li- ver ; a, the nucleus ; b, the nucleolus; c, fat-globules; d, cells of small size, de- tached.
12
INTRODUCTION.
almost transparent, but in some subjects 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 coloured size, and thus rendered conspicuous, we shall per- ceive, that the whole liver, excluding the canals in which the portal and hepatic veins run, is a solid plexus of capillary blood- vessels, the meshes of which are filled with nucleated cells.
The mucous membrane of the gall-bladder and ducts, like the excreting ducts of other glands, in fact, like all mucous mem- branes and the skin itself, 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 oells, by their apposition and union, form a kind of pavement on the transparent membrane, which, serving as their basis of support, has for this reason been named by Mr. Bowman the base7nent-mQmbmn.e. The blood- vessels, lymphatics, and nerves ramify on the opposite, deep, or inner surface of the basement-membrane.*
But although mucous membranes are alike in structure, they being all composed of a basement-membrane, paved, if we may so express it, with nucleated cells, yet the cells differ much in form and appearance, in different situations.
In the tubuli of the human kidney, the cells, like those of the substance of the liver, are spheroidal. In the gall-bladder and
Fig. 7.
Nucleated cells of the gall-bladder, as seen under a high power; a, pave- ment formed by the union and apposition of the cells ; b, side-view of four cells ; c, the basement-membrane ; d, a detached cell.
* For ample details on this point I may refer the reader to the article Mucous Membrane, in Todd’s Cyclopaedia.
OFFICE OF THE CELLS.
13
ducts, as on the villi of the small intestine, the cells have the form of prisms.
If the gall-bladder he bruised a little, a portion of the bile taken from it exhibits under the microscope hundreds of these prismatic cells. The opaque mucus we sometimes find in an in- flamed gall- duct is almost made up of similar cells, which in the small ducts are very long and tapering.
There can be no doubt that the cells lining the gall ducts are continuous with the nucleated cells in the meshes of the capillary network of the fiver, but the basement-membrane has not been traced beyond the ducts ; and, at present, we do not know how the ducts terminate. They cannot be traced into the lobules of the fiver. Mr. Kiernan has indeed given a figure of what he calls the lobular biliary plexus, in which the bile-duct is continued into the lobule, forming there a plexus which interlaces with the plexus of capillary vessels. But he means the figure to he a diagram only. He confesses that no such view of the ducts can he obtained. All that has been actually observed of the arrangement of the cells within the lobule, is what has been observed by Mr. Bowman, that the cells have in some measure a radiating arrangement from the central axis towards the circumference, or towards certain parts of the circumference ; so that, when a lobule is torn up for examination under the microscope the cells are apt to form a linear series.*
The researches of Purkinje, Henle, Bowman, and Goodsir, leave no doubt that the nucleated cells are the immediate agents of secretion.
It is not in the fiver only that the cells perform this office, for it seems established as a general law, and it is certainly one of the highest and most interesting which the study of minute structure has yet disclosed — that all true secretion, whether in animals or in plants, is effected by the agency of cells ; that, “ however
* Professor Weber and Dr. Krukenberg, in two papers recently published in Muller’s “Archiv.,” maintain the opinion advanced by Mr. Kiernan, that the bile-duct is continued into the lobule, forming there a plexus interwoven with the plexus of capillary blood-vessels. They state that this lobular biliary plexus has been seen by them in the injected liver of the frog. Both these anatomists assent to the opinion advanced by Mr. Bowman, and maintained in this chapter, that the lobules of the liver are not isolated from each other, as was formerly supposed, by an investment of areolar tissue.
14
INTRODUCTION.
complex the structure of tlio secreting organ, these nucleated 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 un- known mode, discharge them through the excreting ducts.
The evidence of this is, perhaps, as clear in the liver as in any of the glands.
On examining the nucleated cells of the liver under the micro- scope, we see that most of them inclose small spheroidal globules, which are recognised by their dark outline, or high refractive power, to he globules of oil or fat.
In ordinary livers these oil or fat globules are small, and few in number ; hut in the fatty condition of the liver, 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.*
Fig. 8.
Nucleated cells, from a liver in a state of fatty degeneration : a, nucleus ; b, nucleolus ; c, c, c, fatty globules. (Bowman.)
From the high refracting power of oil globules we have, then, ocular proof that fatty matters taken into the system in too great quantity pass from the blood into the nucleated cells of the liver. There can be no doubt that they pass, either bodily or more or less changed, from these cells into the excreting ducts.
Most of the peculiar principles of bile are allied to fat, in con- taining a large proportion of hydrogen and carbon, and are, no doubt, eliminated in this way ; namely, by passing from the blood into the nucleated cells, and on the bursting or breaking down of * See Lancet, January, 1842.
LYMPHATIC VESSELS AND NERVES.
15
these, becoming discharged through the excreting ducts, so as to form the matter of secretion.
Direct ocular proof may also be often obtained that the co- louring matters of the bile are contained in the nucleated cells- Henle, in his recent edition of Soemmering, describes the nu- cleated cells of the liver as appearing yellowish or yellowish-brown in direct light, and as probably containing the colouring matter of bile ; but Mr. Gulliver was, I believe, the first who distinctly ob- served the colouring matter of bile in the nucleated cells.
In the livers of two persons who died jaundiced, he found an unusual quantity of this biliary colouring matter, which was col- lected chiefly round the nuclei, but was also scattered throughout the cells. In some cells it was in such quantity as to render them nearly opaque.*
I have repeatedly observed the same thing. Indeed the colour- ing matter of the bile can always be seen in the. cells taken from the roundish yellow masses in Cirrhosis, or from any portion of a liver which has a well-marked yellow or green tint. The colour- ing matter in the cells presents exactly the same appearance under the microscope as the colouring matter in the bile.
Mr. Goodsir has given a long list of animals, in which he ob- served 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 examined, but in each having nearly the colour of the bile.
We can hardly have more convincing proof that, in the liver, these cells are the real agents of secretion.
Mr. Goodsir supposes that the secretion is effected by the outer cell membrane, and that the nucleus is the reproductive organ of the cell.
I have already alluded to the areolar tissue of the liver. This, 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 com-
* This statement, and the quotation above, are taken from an admirable essay “ On the Origin and Functions of Cells,” by Dr. W. Carpenter, pub- lished in the twenty-eighth number of the British and Foreign Medical Review.
1G
INTRODUCTION.
pletely invests the branches — at least all the considerable branches — of the vein. It cannot he traced further than the ultimate twigs of the artery and duct, and seems not to enter the capillary network.
To make up the rest of the organ there remain the lymphatic vessels and the nerves.
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 he removed without injuring them ; or the peritoneal coat may he first removed, and the ab- sorbents afterwards injected.
They are spread over the whole surface of the liver. Those on the convex surface unite to form branches, some of which run to the lymphatic glands around the inferior cava; others pass through the diaphragm to the posterior or anterior mediastinal glands. The lymphatics on the concave surface of the liver also take different courses : those on the right lobe run to the lumbar glands ; 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 this kind accompany the hepatic veins. They seem to be very closely connected with the ducts. If the ducts he 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 the glands in the right border of the lesser omentum ; those from the portal canals to the glands situated in the course of the hepatic artery and along the lesser curve of the stomach.
The nerves (derived from the hepatic plexus) likewise accom- pany the arteries and ducts in the portal canals, but little is known of their distribution.
A knowledge of the structure of the liver enables us to explain the variations so often met with in the size, and form, and texture, of the liver, as well as the various shades of colour of which it is susceptible, and which have so taxed the descriptive powers of morbid anatomists.
The mass ol the liver is, as we have seen, made up of a plexus * Wilson. Anatomist’s Vade-Mecum, p. 361.
SIZE AND COLOUR OF THE LIVER.
17
of capillary bloocl-vessels, the meshes of which are filled with nucleated cells containing the peculiar principles of the biliary secretion.
The size of the liver will, of course, vary in some measure with the degree of congestion or quantity of blood in the capillaries ; but it depends much more on the number and volume of the cells. If, as in the fatty degeneration of the liver, the cells are distended with oil-globules, the lobules of the liver are large and unusually distinct, and the liver much increased in size and thickened. If, on the contrary, the cells be fews and small, the lobules will be small, and the lobular structure distinguished with difficulty, un- less different portions of the lobules be differently coloured by partial injection of the capillaries ; and the whole liver will be small and thin, or, as it were, flattened.
The size of the fiver may also be increased by the interstitial deposit 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 fiver may be much altered in form by external pressure. By tight lacing, for instance, the length of the fiver from above down- wards is often mucfi increased, and its lower portion flattened. The portion of fiver above an aneurysmal 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 outward form. *
The firmness of the fiver varies, not only witfi the firmness of the capillary vessels, the quantity of blood they contain, and the proportion of fibrine in the blood, but also in some measure with the state of the cells. When the cells are distended with oil, the liver is unusually soft, unless it contain newly-formed fibrous tissue, the result of interstitial deposit of coagulable lymph. When the fiver is unnaturally firm and dense, it is generally from the presence of new fibrous tissue formed in this way.
* A short time ago, I met with a remarkable instance of this in a man who died after having been paraphlegic many months, in consequence of disease of the dorsal vertebrae. The large intestine, which had been greatly dis- tended with gas from the commencement of the paraphlegia, 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.
C
18
INTRODUCTION.
The colour of the liver depends on the quantity of blood in the capillary vessels, and on the quantity of oil and of biliary colour- ing 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 biliary colouring matter they contain. The actual tint of the liver is the combined effect of the tints due to the vessels and the cells singly.
In persons who have died from hemorrhage from the stomach or intestines, or from chronic dysentery, or in great general anemia, as in the advanced stage of granular kidney, the liver is always found very anemic, and its colour depends almost entirely on the state of the cells. In portions of liver of an orange or green tint, the colour- ing matter on which this tint depends, may always he seen in the cells.
In effect of partial injection of the capillaries, the liver, after death, generally presents two colours— a yellowish colour 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. Iviernan, was held by all anato- mists, that there are two substances in the liver, a yellow sub- stance and a red, which were supposed to constitute the medullary and cortical part of each lobule. It was Mr. Kiernan who first showed conclusively, that the mottled appearance so frequently observed in the fiver, is owing to part only of its blood-vessels being full of blood ; and that in the great majority of cases in which it presents this appearance, the hepatic veins and the capil- laries that terminate in them are the full vessels; the portal veius and the capillaries that spring from them, the empty ones.
Having examined the structure of the fiver, we may next con- sider the composition and uses of the bile.
We have seen that the nucleated cells in the lobules of the fiver withdraw from the blood the principles of then’ secretion, which they probably elaborate in some degree, and then discharge into the ducts. In its passage through the ducts the matter secreted 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 he considerable in
PHYSICAL PROPERTIES OF THE BILE.
19
quantity. 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 re- mainder passes down the cystic duct into the gall-bladder.
During digestion, on the contrary, the gall-bladder contracts, and pai’t of the bile accumulated in it, together with all that brought by the hepatic duct, is poured into the duodenum. *
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 this cavity. After death, if it be not soon removed 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 pass in the opposite direction through the coats of the vessels and in- testines and gall-bladder, and become mixed with the bile.
The bile in the gall-bladder is of a greenish-yellow colour, 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 colour is yellowish, but if concentrated 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 odour, somewhat like that of melted fat, but the odour of healthy human bile, when fresh and not mixed with in- testinal 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 great analogy with soaps. It combines readily with water in any proportion, mixes freely with oil or fat, and foams, when stirred, like soapy water; and is, indeed, in com- mon use in the same way for cleaning articles of dress, and espe- cially for taking out grease. It will be seen, hereafter, that these properties are probably closely related to one of the physiological uses of the bile. When evaporated, it leaves inspissated mucus,
* Bouisson — De la bile et de ses varietes physiologiques, et de ses altera- tions morbides. Paris. 1843.
20
INTRODUCTION.
and a variable proportion of a yellowish-green matter, which is very bitter, and which dissolves almost completely in water and 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 T02G and T030. Cystic bile has been generally sup- posed to have an alkaline reaction, but M. Bouisson and Dr. Kemp, who have lately made observations on tins point, state that when fresh and perfectly healthy, it is neutral. The effects of bile on test-papers are difficult to appreciate on account of the yel- low stain it gives them.
Under the microscope, bile, if diluted, gives a yellow stain to the glass, but presents no definite objects. If, on the contrary, it be dark coloured and concentrated, it shows amorphous particles of yellowish-green matter, which is usually collected into small roundish masses, and is the matter obtained by evaporating the bile.* In addition to this, a few prismatic cells from the mucous membrane of the gall-bladder may be seen.
Perfectly healthy bile presents, perhaps, no other objects, but, now and then, some oil- globules, or small plates of cholesterine, are seen besides. The oil-globules are, probably, usually derived from the lobules of the fiver. The plates of cholesterine are, it would seem, generally, if not always, formed in chief part in the gall-bladder, in consequence of disease of its coats. 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 structure, the bile in the gall-bladder generally contains visible scales of 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-coloured. Under the microscope, it gives a fight 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 colour, 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- coloured.
There are probably more important differences between cystic * See Bouisson, op. cit., p. 16.
COMPOSITION OF THE BILE.
21
and hepatic bile than those which result from different degrees of concentration, hut little is known on this point. It is very diffi- cult to collect bile from the hepatic ducts in quantity enough for a 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 more readily got in a healthy state, and can he obtained in larger quantity 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 the degree of its concen- tration. In the often-quoted analysis of bile from the gall- bladder of the ox, by Berzelius, the water amounts to 904'4 parts in 1,000. The quantity of water may be readily ascertained by evaporation.
Bile also contains mucus, derived from the gall-bladder and ducts, the quantity of which, like that of the water, varies very much in different specimens. In the ox-bile analyzed byBerzelius, the mucus amounted to 3 parts in 1,000. In human cystic bile, the average proportion of mucus is probably very much larger than this. It may be obtained by adding to bile a sufficient quantity of alcohol, which precipitates the mucus in flakes, while it dissolves the other princi- ples. The mucus may also he precipitated by acetic acid. It is chiefly to this ingredient 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 certain organic constituents, to which last it owes its colour and bitterness. The organic constituents are very readily decom- posed, and enter into new combinations with the substances em- ployed to separate them. In consequence of this, different che- mists, by employing 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.
The principles to which bile owes its colour may be sepa- rated from those to which it owes its bitterness. They are en- tirely removed by filtering bile through animal charcoal, and are also thrown down from solution by precipitates of barytes and other earthy salts. The green colouring matter in the bile of the ox seems closely to resemble, if it be not identical with, the
22
INTRODUCTION.
green- colouring matter of plants. (See Graham's Elements of Chemistry.) *
Most chemists have inferred that the organic constituents of bile are combined in some way with the soda.
M. Demarcay has lately advanced the opinion that these essen- tial principles of bile, abstracting the colouring matters, are in the form of a resinous acid, (called by Liebig choleic acicl,) which is combined with the soda, forming a substance analogous to soaps. This view of the composition of bile brings us hack to the doctrine which, before the elaborate analyses of Thenard and others, was generally held, that the bile is an animal soap, whose base is soda. This doctrine seemed sanctioned by the physical qualities of bile — 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 contains fatty matter and an alkali.
In addition to these constituents, bile contains a small quantity of chloride of sodium, and most of the other salts found in the blood.
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 0T1
lOO'OO
* Many considerations vender it probable that the colouring matter of bile is derived from that of the blood. A relation between the two has been long remarked.
Saunders says, “ Green and bitter bile being in common to all animals with red blood, and found only in such, renders it probable that there is some relative connexion between this fluid and the coloui-ing matter of the blood, by the red particles contributing more especially to its formation.”
Quite recently, Professor Schultz has revived this notion, and dressed it op with much fanciful speculation. He is of opinion that in the liver
SOURCE OF THE BILE.
23
In some later researches, Berzelius lias separated from his biliary matter a green and a yellow colouring matter, and has giveu the name of bilin to the peculiar principle of bile. Bilin is a soft substance of a light yellow colour, without smell, and having a hitter and at the same time a sweetish taste. It is soluble in water and in alcohol, and when obtained by evaporation from alcohol, reddens litmus paper. It is readily metamorphosed by various agents, and especially by heat and acids.
In the analyses of Demargay and Liebig, the bilin of Ber- zelius is represented by choleic acid, which, like those matters, enters very readily into new combinations.
Choleic acid is a compound of nitrogen, and, according to De- ni argay, its ultimate composition is as follows : *
Carbon 63'707
Hydrogen 8'82l
Nitrogen 3 ‘25 5
Oxygen 24'217
100-000
Most chemists have obtained from bile a small quantity of cholesterine. 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 bile, in man, has been supposed to he ultimately derived from two sources. It is clear enough that, in most circumstances, a large proportion of the proper principles of bile are derived from the waste of the body, and are a product of the metamorphosis of
the blood sheds the colouring 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’oeuf de poule, le jaune fixe au feuillet muqueux acquiert une coloration verdatre, en sorte qu’il reste demontre qu’il y a coincidence entre ia sanguification et la separation d’une matiere verte.”
* In a late No. of Muller’s “Archiv.,” is a communication from Dr. Platner, of Heidelberg, stating that he has succeeded in obtaining the electro- negative body, which is supposed to be the essential constituent of bile, in a state of crystallization, both pure and in combination with soda. (Muller’s “Archiv.” Heft. ii. 1844.)
24
INTRODUCTION.
the tissues and of materials stored away in the system. In the carnivora, in the hybernating animal in its winter sleep, and in the foetus, these materials must he its only source. And under cer- tain conditions, the same must be the case in man also. In pro- tracted abstinence, for example, bile continues to be formed, and often in large quantities. 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 hydrogen and carbon. But while the liver and lungs have thus much in common, there is this important difference between them ; that in the lungs, the hydrogen and carbon pass off burnt — that is, in combination with oxygen, as water and carbonic acid, — while, in the liver, they escape uncombined with oxygen, and still combustible. From which it would appear, that the larger the amount of these ele- ments discharged by the lungs as water and carbonic acid, the less, ceeteris paribus, must remain unburnt to form constituents of bile. So that here, we already meet with a fundamental and im- portant relation between the secretion of bile and the great function of respiration. I shall not, however, dilate upon this topic now, as in endeavouring to follow the bile to its final des- tination, we shall again have to consider relations of a similar kind.
To return from this digression, it appears, then, sufficiently clear, that the proper principles of bile are in great part derived, like those of the urine, from the waste of the tissues. But it seems probable, that in man, and in all animals which live on a mixed diet, those articles of food which are devoid of nitrogen, also contribute to the elements of bile. Liebig, indeed, imagines that, as regards the horse and ox, he has fully established this by means of quantitative analysis, — showing that the bile these animals secrete in a day, contains more carbon than all the albu- men, 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, aud by those con- stituents of it, such as starch and sugar, which contain no
QUANTITY OF BILE SECRETED.
25
nitrogen. If this he 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, too, the same part.
But the calculations of Liebig are open to very serious, if not fatal, oh j ections. 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 con- sumes in the form of vegetable albumen, fibrine, and casein, only about four ounces and a half of nitrogen, which, reckoning from the known composition of these substances, would give not quite sixteen 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. This 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. Con- sidering the size of the gall-bladder of the ox, thirty-seven pounds seems an enormous quantity of bile to he secreted in a day, and if the daily secretion should turn out to he only quarter the amount, and few physiologists, we imagine, would rate it nearly so high even as this, the argument falls to the ground.*
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 he one of the starting points in any such inquiry. Many attempts have been made to estimate the quantity of bile
* 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 neutralise 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 inference, 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 Physiologie, t. vii. p. 439.)
26
INTRODUCTION.
daily secreted by a man in a state of health, hut, as might have been expected, the conclusions come to are wide apart, and little confidence can he placed in the greater number of them. Some physiologists, 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 esti- mated 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 twenty-four ounces.
It is clear that the amount of the proper principles of bile secreted in a day must, like that of urinary ingredients, vary widely in different persons, and in the same person under different circumstances. Thus, from what has already been said, it must vary with the activity of respiration, and with the quantity and quality of the food. Probably, too, with the amount of perspi- ration, or with the quantity of matter thrown off by the skin.
In some circumstances, a quantity of bile, as large as the estimate of Burdach or Haller, may certainly be secreted for a considerable time together. A very interesting case showing this was read to the Medico- Chirurgical Society during the spring of the present year, by Mr. W. K. Barlow, of Writtle, Essex.
A strong, healthy man, a thatcher, fifty-four years of age, injured him- self hy lifting a heavy ladder, on the 28th of August, 1843. When seen hy 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 faint, in a cold sweat, and the pulse could scarcely he 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 fol- lowing 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 repeated at different times, and a blister was applied over the right hypochondrium. 1 he same medicine was continued till the 15th of Sept., when a swelling, the size of a walnut, was observed over the region of the liver. This gradually inci eased, and on the 9th of October, was so large and caused so much
QUANTITY OF BILE SECRETED.
27
pain from distension, that it was thought proper to tap it. Seven quarts of fluid were drawn off, which from its colour 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 analysed by Dr. Pereira, Dr. G. O. Rees, and Mr. Taylor, and found to be composed in great part of bile. Dr. Rees guessed the pro- portion of bile in tbe 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 be 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 on the former operation, 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 coloured. On the 3rd of December, the motions were of proper colour, containing plenty of bile. The swelling 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 Society, appeared to be in good health.*
It appears here that in twelve days, from the 9tli of Oetoher 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 of a pint a day. The quantity of fluid discharged at the two subsequent tappings was still larger in proportion to the time, hut of this fluid no analysis seems to have. been made.
Is 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. The fluid was not analysed, 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
* The Medico-Chirurgical Transactions, vol. xxvii. p. 378.
28
INTRODUCTION.
circumstances ; or at any rate, in drawing from such an estimate any important physiological inference not warranted by other reasons.
In secreting bile, the liver serves unquestionably very important purposes. The large size of the organ, and its existence in all animals, down almost to the lowest in the animal scale, leave no doubt on this point. But when we come to details, our knowledge of the whole matter is found to be much wanting in precision.
One of the purposes served by the liver in secreting bile, per- haps one of the most important purposes, is to purify the blood by separating from it noxious and effete principles. There has been much debate among physiologists, whether the principles of bile are formed in the liver, or are not rather merely separated by this organ from the blood, in which, under this supposition, they are supposed to exist, ready-made for secretion. Data are yet want- ing for the complete solution of this question. But it is quite clear that the colouring matters of the bile exist in the blood, since if they be not separated from it by tbe liver, as sometimes happens when the secretion of bile is suppressed, the person is speedily jaundiced.
The liver tends in another way 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 neces- sarily 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, ab- sorption is constantly going on, and various matters must, there- fore, enter the portal vessels, not fit by their nature to form blood, or to serve any other purpose in the body. Many of these sub- stances are removed from the blood in its passage through the fiver. The discharge of such matters through the fiver, when they are in unusual quantity, or of a particular kind, is, no doubt, tbe primary condition of many biliary disorders.
But the bile is far from being a merely excrementitious fluid. Arrived in the intestine, it has important offices to serve, as in- deed might already be surmised from its being poured into this canal so near its upper end. These offices are related to the func-
USES OF THE BILE.
29
tion of digestion on the one hand, and (according to Liehig) to that of respiration on the other.
It was formerly supposed that the one great use of the bile was 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, indeed, an important relation to digestion, is evident from the presence in man and other animals that feed at intervals by large meals, of a gall-bladder, which allows bile to accumulate when the stomach and duodenum are empty, so as to be poured into the digestive canal in greater quantity when they are full. But there can be no doubt that the part which bile plays in diges- tion has been over-rated. The recent investigations of chemists have much simplified our views of this process. Since the im- portant discovery, that the greater part of the staminal principles of our food, whether animal or vegetable, are identical with the constituents of blood, all that appears necessary to digestion, as far as mere chemical changes are concerned, is to effect their solu- tion. Now experiments of conclusive kind have shown that the gastric juice is sufficient for this object. Starch, sugar, and their equivalents, are soluble, of themselves, in the fluids found in the stomach and intestines. Fat, however, is not altered by the gastric juice, and is not soluble in the fluids found in the intesti- nal canal, and must require, therefore, 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. There are many reasons for believing that the fatty matters we take as food undergo the needful modification in mixing with bile.
The experiments first performed by Brodie, and repeated by several physiologists, show that if the flow of bile into the duodenum be prevented by tying the ductus communis in a living animal, and the animal be killed some time after, the chyle in the thoracic duct will generally be found thin and serous, containing much less than the usual proportion of fatty matter. The fact too, long noticed by physicians, that when the common duct is obstructed by a gall-stone, or otherwise, the patient rapidly loses his fat, sanctions the inference. The soda of the bile, in its passage through the intestines, is absorbed, together with the fatty matter, by the lacteals. It is not found in the excrement, but exists in abundance in the chyle.
30
INTRODUCTION.
Another effect commonly attributed to bile is that of neutra- lizing the acid that passes from the stomach into the intestines, after having performed its part in digestion. The chyme is acid as it enters the duodenum, hut gradually loses its acidity in its passage through the small intestine, after it has been mixed with the bile. It is no valid objection to this doctrine that healthy bile is neutral, since the bile might he decomposed in its passage through the bowels. But 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. The quantity of soda in the bile seems, moreover, to he too small, even if it were all employed for this purpose, to neutralize the acid of the chyme.* The chyme is most probably neutralized, at least in part, by the secretions of the intestinal canal. The bile may contribute to it also indirectly, by stimulating the coats of the canal, and rendering their secretion more active.
Whether, by virtue of its bitter quality, bile prevents, as some suppose, the fermentation of the chyme, and the putrefaction of the residue of digestion, is open to question. From the readiness with which bile itself undergoes decomposition, such an office would seem improbable. Nevertheless, it is well known, that one of the first effects of jaundice is, that the stools become unusually fetid, and the bowels very flatulent.
Collaterally, the bile forwards in various ways the great busi- ness 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 he used, — bile is the natural pur- gative. If poured into the intestine in too large quantity, it causes diarrhoea, and if by a gall-stone, or otherwise, its flow he stopped, constipation generally follows. Eberle further ob- served that in animals, which he made the subject 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 was tbe 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 371bs. of bile.
USES OF THE BILE.
31
It seems clear that, in man, under ordinary circumstances, the bile which is evacuated hy the bowel, can he but a small propor- tion of the whole amount secreted. For the quantity thus voided is very trifling, and consists chiefly of its colouring matter. The remainder, and larger part, must, therefore, he re-absorbed. Liebig states, that, in the carnivora, the whole of the bile is re- absorbed. 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 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 im- portance 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 examined.
Liebig adopts the estimates of Haller and Burdach, that a man in health secretes daily from 1 7 to 24 ounces of bile ; and he assumes that this bile contains 90 per cent, of water, which gives from 816 to 1152 grains of dried bile.*
Now Berzelius found in 1,000 parts of fresh human faeces, only 9 parts of a substance similar to bile. Reckoning from this pro- portion, the daily faeces of a man, which do not, on an average, weigh more than 5^ 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 he detected in the matters discharged from the alimentary canal in at least the pro- portion of 816 to 24, or 34 to 1 .
The chief part of the bile is, therefore, re- absorbed, and as (Liebig argues) no traces of it are found in the other excretions, the hydrogen and carbon it contains must evidently be discharged through the lungs in union with oxygen, as carbonic acid and water. Whatever intermediate purposes it may serve, this must he 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.
* See “ Liebig’s Organic Chemistry, in its Application to Physiology and Pathology” — pp. 64, 5.
32
INTRODUCTION.
But tlie 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 famished from this source. Even at tins esti- mate, the carbon furnished by the bile would he hut a small proportion of that given out in respiration. It has been com- puted that in a grown-up person, taking moderate exercise, 13_^. oz. of carbon escape daily through the skin and lungs as carbonic acid. (Liebig, a. c., p. 14.) 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 li oz.# These considerations tend to show that it can hardly he 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 re-absorbed, 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.
Many physiologists, however, still hold to the old opinion that the bile is mainly excrementitious, and is voided by the intestine. In their view, the great office of the liver is 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 lung in union with oxygen. These organs are thus considered to be directly and strictly vicarious in their office, and in support of this view it is alleged that, throughout the animal scale, whenever the lungs are large and active, the liver is small, and vice versa. Thus, it is re- marked, that in all cold-blooded animals — creatures in which re- spiration is very feeble — the liver is very large and excessively developed when compared with the lungs. But it is a very formid- able objection to this vicarious theory, that in serpents, whose re- spiration 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 he excreted, that would not disprove Liebig’s theory of the use of bile in man and the higher
* Liebig has made a calculation of this kind with reference to the ox, and concludes that in that animal the bile daily secreted contains 40 ounces of carbon, hut he starts with the extravagant estimate of 371bs. (as concentrated as that in the gall-bladder) for the amount of bile daily secreted.
USES OF THE BILE.
33
animals, since this professes to rest on entirely independent evi- dence. The same may be said with regard to the instances of animals in which the bile is poured into the rectum, and is, therefore, pro bably voided by the intestine.
Thus it appears, on any supposition, that the relation of bile to respiration is direct and fundamental. Fortunately, the activity and effects of the respiratory process are largely under our control. In the vast power we have of modifying these by appropriate re- gulations, 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 re- gulations is by far the most fruitful source.
Thus, for example, may he explained many of the bilious dis- orders of hot climates. If, in such climates, the food he 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 — are the consequence.
Hence, also, the general repugnance to rich meats, and the greater tendency which these and spirits unquestionably have to produce disease of the liver, in hot seasons and in tropical climates.
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 hut 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.
These, however, are not the only conditions that influence the secretion of bile, and its tendency to accumulate in the system. This must also depend on the state of the liver itself, and espe- cially on the number and activity of the cells in its lobular sub- stance.
u
34
INTRODUCTION.
Not unfrequently, in bodies examined in our hospitals, consider- able portions of the liver are found atrophied, from adhesive in- flammation in or about branches of the portal vein. In conse- quence of the obstruction of those vessels, the portions of liver to which they carried blood, waste, and if those portions be near the surface, the capsule is drawn iu, and the surface appears puckered, or fissured, according to the size and direction of the obstructed veins. Again, hydatid and other tumours 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 be- come less active, without sensible derangement of health. They have more liver, as they have more lung, than is absolutely neces- sary. In others, on the contrary, the liver, from natural con- formation, seems only just capable of purifying the blood from the principles of bile, in favourable circumstances. They are born with a tendency to bilious derangements. This innate defect of power in the liver has its counterpart in the deficient respiratory power in persons with vesicular emphysema of the lungs, and like this latter defect, and most other peculiarities of physical structure, is no doubt frequently inherited. People who in- herit this feebleness of the liver, if we may so term it, or in whom, in consequence of disease, a portion of liver has atrophied, or the secreting element of the fiver has been da- maged, may suffer little inconvenience as long as they are placed in favourable 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 secretion of bile is requisite to purify the blood, the
CHOLAGOGUE MEDICINES.
35
liver is inadequate to its office, and they become bilious and sallow. In the management of such cases, we have two objects to fulfil — 1st, to enjoin those conditions and rules of life, that render a plentiful secretion of bile less needful ; and 2nd, to en- deavour 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. Acids have been supposed to act in the same way, and have been much in repute as a remedy in liver disorders, particu- larly in India, where, from the circumstances mentioned, a remedy having this mode of action is especially required.
Various medicines seem to fulfil to a certain extent the 2nd object, that of rendering the liver more active, and increasing in this way the secretion of bile. Mercury, iodine, muriate of am- monia, and taraxacum, 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 distinguishing the various diseases of the liver, and the consequent indiscriminate 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 debility, which the prolonged use of the mercury but too often increased. Of late, these evils have much abated, but still, before the diagnosis is rightly made, 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, perhaps justly, to render the liver more active, and increase the secretion of bile. The great relish with which they are eaten by our coun- trymen in the East and West Indies, gives considerable sanction to this opinion.
Most purgatives, but especially rhubarb, have perhaps an effect of the same kind, and may fitly be styled in the language of our fatheis, cholayogues. Many persons have succeeded in warding
D 2
3G
INTRODUCTION.
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 pro- bably 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 medicines, probably excite the secretion of the liver chiefly, if not solely, by becoming absorbed into the blood, and passing out of the system with the bile.
We have, indeed, little positive evidence in favour of this theory, by regarding the liver merely, because not many analyses of any kind have been made of human bile ; and very few at- tempts have been made to discover different medicines in it.
Authenrieth and Zeller * state that they found mercury in the bile of animals treated by mercurial frictions. Bouissonf states, that the colouring principles of madder and some other sub- stances pass off in the bile ; a fact which, if established, would lead us to expect that some principles of rhubarb and taraxa- cum might pass off in it likewise. Iodine, I believe, has not been found in human bile, but from its escaping so readily as it does in most other secretions, and from its being found in con- siderable quantity in the liver of the cod and other fish, we may expect to find it in the bile of persons who die while taking it.
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 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 system through it, but conversely, that nearly everything foreign
* Bouisson, p. 14, who takes this fact from ReiPs. Archiv. fur die Physio- logic, vol. viii. p. 252 ; 1807, 1S08.
t Id. p. 303.
10
CHOLAGOGUE MEDICINES.
37
to its own secretion, that drains off' through a gland or mucous membrane, excites its secreting function. #
Medicines that pass off in this way through a gland, not only increase the flow from it, but may also alter the qualities of the secretion, and act directly, on the surfaces over which the secre- tion passes ; and when the secretion is unhealthy or these sur- faces 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 knowledge of the effects of different medicines on the qualities of the bile, and on the mucous membrane of the gall-bladder and 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 quautity of the bile, there are others, whose chief merit consists in their altering its quality. Alkalies, — especially soda, — ether, and turpen- 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 favour, because, from being always able to collect and analyse the urine, we have better opportunities of fixing their value.
* On the same principle, undoubtedly, various abnormal matters that find their way into the portal blood, cause sudden and copious fluxes of bile. — Cruveilhier has some good remarks on this in his “ Anatomie Pathologique.”
CHAPTER T.
CONGESTION OF THE LIVER.
Congestion of the liver from impediment to the flow of blood through the lungs or heart — Effects of tins — Congestion from other causes — Portal-venous congestion.
The liver, from being occupied by a close plexus of capillary vessels, which is supplied with blood, already retarded by passing through a capillary system, is peculiarly liable to congestion, — that is, to an accumulation of blood in its vessels, — when, from organic disease of the heart, or acute disease of the lung, the course of the blood through the chest is impeded.
The liver presents different appearances, according to the degree of congestion.
In slight degrees, the twigs of the hepatic vein and the capillaries that terminate in them, are found, after death, turgid with blood, while the portal twigs, and the capillaries that immediately spring from them, are empty. A section of the liver presents, in consequence, a mottled appearance. The central portions of the lobules, where the vessels are congested, form isolated red spots, while the margins of the lobules, where the vessels are empty, have a colour which varies from yellowish-white to greenish, according to the quantity of oil-globules and of colouring matter which the cells contain. This appearance has been termed by Mr. Kiernan, the first stage of hepatic-venous congestion. When the course of the blood through the heart or lungs is impeded, the hepatic veins and the capillaries that open into them are naturally the first to become turgid.
In a further degree of congestion, more of the vessels forming
APPEARANCES PBODUCED BY CONGESTION.
39
Fig. 9.
Rounded lobules on the surface of the liver, in the first stage of hepatic- venous congestion. A, centres of the lobules, red from congestion of the hepatic twigs and adjacent capillaries ; C, margins of the lobules, pale, from the capillaries there not being congested ; B, spaces between the lobules, occupied by twigs of the portal vein. (After Kiernan )
die capillary network are filled, of course in a direction backward, towards the portal vessels. The congestion extends from lobule to lobule, at those points where the adjacent lobules are connected by their capillaries ; and when the congestion 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 injected, except- ing those immediately surrounding the portal twigs. A section of the liver will still present a mottled appearance, but now the pale portion will be in spots, where the uninjected twigs of the portal vein are divided, and the red portion will form a band continuous through- out the liver. This appearance is what Mr. Kiernan has called the second stage of hepatic-venous congestion.
A liver congested to this degree is enlarged from the large quantity of blood it contains ; and, as Mr. Kiernan has remarked, it is fre- quently at the same time in a state of biliary congestion. The biliary congestion is an accumulation of biliary matter in the lo- bules of the liver, giving the uninjected portions of the lobules a deeper yellow or greenish tint than is natural to them. It seems to be a consequence of the congestion of blood, and is produced perhaps in great measure by impediment to the free escape of the bile through the small ducts, from the pressure exerted on them by the distended vessels.
40
CONGESTION OF THE LIVER.
Fig. 10.
c.
Lobules on the surface of the liver, in the second stage of hepatic-venous congestion. A, centres of the lobules, red from congestion of the hepatic twigs and adjacent capillaries ; C, places where capillaries uniting contiguous lobules are congested ; B, pale spots, where the capillaries springing from the portal twigs are uninjected. (After Kiernan.)
In a still higher degree of congestion, the portal vessels like- wise are found filled after death, and the whole liver is red, hut, as was observed by Mr. Kiernan, the central portions of the lohules are of a deeper hue than the marginal portions.
It is only when the vessels are so turgid, that the liver is en- larged, or the secretion and discharge of hile are somewhat impeded, that the congestion can be considered morbid.
Simple congestion, perhaps, renders the liver more friable, but this change of consistence is not very appreciable. The chief anatomical characters of congestion, are the deep colour of the liver and its increased size.
Enlargement of the liver must take place in some degree in all cases where the vessels are turgid, but the degree of enlargement will depend on the time the congestion has lasted, and on the previous condition of the liver. The longer the vessels are kept distended, and the more yielding the other 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, the liver will necessarily enlarge much more for a given force of dis- tension, than in persons in opposite circumstances. When the liver has become unnaturally firm and tough by the interstitial
EFFECTS OF PASSIVE CONGESTION.
41
deposit of new fibrous tissue, an impediment to the free passage of blood from it towards th& heart, unless it be long-continued, will produce but little increase of its size ; but it will exert 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 most frequent opportunities we have of observing the effects of simple congestion of the liver, are in persons labouring under organic disease of the heart. It often happens, that in such persons, when the circulation is more than commonly impeded, the liver grows larger. 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 volume. This enlargement of the liver from congestion, often takes place, and again subsides, very rapidly, according to the varying condi- tions of the general circulation.
In estimating the bulk of the liver, iu congestion and other diseases, we must bear in mind, that its natural limits vary with posture and many other circumstances. It descends an inch or two lower when the person under examination is standing or sitting, than when he is lying down ; it is lower after in- spiration, than after expiration ; and it may be pushed down by fluid in the cavity of the pleura, or by bloated, emphysematous lung.#
Enlargement of the liver from congestion is, in general, un- attended with pain, and the only complaint the patient makes is of a sense of weight, or fulness, in the right hypochondrium. Occasionally, these symptoms are succeeded by a slight tint of jaundice. As the blood, when its passage through the lungs is impeded, is imperfectly decarbonized, and gives a purplish colour to the face, — so, when its course through the liver is im- peded, the blood is not completely freed from the principles of bile, and the countenance acquires a slightly jaundiced, or sallow tint. When both organs are congested at once, as happens when the flow of blood through the left side of the heart is obstructed, both effects sometimes follow, — the complexion becomes purplish, and, at the same time, sallow. This hue of the complexion, in cases of obstructed circulation, has been distinctly noticed by Dr. Bright. He says : “ Wbcn obstruction takes place to the circu- * Andral’s “Clinique Mcdicale,” t. iv. p. 108.
42
CONGESTION OF TIIE LIVER.
lation through the chest, but more particularly when the heart becomes over- distended with blood, we observe the countenance gradually assume a dingy aspect, in which the purple suffusion of carbonized blood is mingled with the yellow tint of slight jaun- dice : the conjunctiva is more decidedly tinged ; and, if the dis- ease continue long, sometimes completely prevails over the purple tint.”
This jaundiced tint of the complexion, co-exists with a jaun- diced condition of the liver itself, or, as Mr. Kiernan expresses it, with biliary congestion, which has been already noticed as some- times consequent on sanguineous congestion.
If the biliary congestion he long kept up, the function of the cells in the congested lobules is arrested, or rendered less active, and the cells become perhaps impaired in their vitality and powers of reproduction.' The liver is permanently injured in its se- creting element, as it is when the common duct has been long obstructed.
Andral and most other writers have remarked that congestion of the liver from a mechanical cause, when long continued, often leads to organic disease of the liver ; and they have explained in this way 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 dis- tension of the capillary blood-vessels, and in accumulation of biliary matter in the lobules, — in consequence, probably, of im- pediment to its escape through the small ducts. If this im- pediment 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 ; hut whenever the cells are long pre- vented from discharging their contents, they seem to lose their fertility, and, consequently, diminish in number. Further on, cases will be related, where, from the flow of bile having been long obstructed by closure of the common duct, the liver had entirely lost its lobular appearance, and contained no nucleated cells; 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.
Most writers have stated that disease of the heart produces cirrhosis of the liver ; meaning, by this term, the hardened and granular state of the liver so frequently found in drunkards,
OTHER KINDS OF CONGESTION.
43
which is produced by the interstitial deposit of librine from ad- hesive inflammation, and which often produces accumulation of biliary matter in the lobules, — probably by preventing, like con- gestion of the liver, its escape through the small ducts. But disease of the heart does not, it would seem, 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 rheumatism, we seldom find the liver tough and granular, from newly formed fibrous tissue, except in such of them as have drunk spirits to excess. But although disease of the heart may not directly lead to inflammation of the liver, it may yet, by causing a stagnation of blood in the vessels of the liver, give greater effect to spirits, or any other deleterious agent absorbed from the intestinal canal, and thus mixed with the portal blood. This point will be again noticed in a subsequent chapter on Ad- hesive Inflammation of the Liver.
There is little to be said on the treatment of mechanical con- gestion of the liver. The congestion is the consequence of an- other disease, and the treatment which relieves the latter, will diminish the congestion. When the congestion depends on ob- stacle to the circulation through the heart, the proper remedies are those, — such as bleeding, purgatives, diuretics, rest, — which most effectually relieve the heart. When the liver cannot free the blood from the principles of bile, or the skin becomes sallow, the patient should carefully abstain from rich meats and fermented drinks, which would render the liver still more inadequate to its office, and increase the bilious disorder.
Hitherto, we have considered only congestion of the liver pro- duced by mechanical impediment to the return of blood from it, — or, as most writers express it, passive congestion. But the liver may be congested from other causes. Thus, in the hot stage of ague, there seems to be, in some instances, in the liver, as well as in the spleen, an accumulation of blood, which is not attended with effusion of any matter characteristic of inflammation, and which subsides when the fit of ague is past. We are ignorant of the exact cause of these temporary accumulations of blood.
Congestion of the liver may also result from a faulty state of the blood, quite independently of any mechanical impediment to its course through the lungs or heart. In a person dead of purpura hremorrhagica, I have found the liver and spleen very
44
CONGESTION OF THE LIVER.
large, and. of the dark colour of a morello cherry, from the great quantity of blood they contained. From the late researches of M. Anclral, it seems that a great diminution in the proportion of hbrine is the change in the blood that most disposes to such congestions.
The congestions of the liver in ague and from faulty states of the blood, have to the congestion produced by a mechanical im- pediment to the flow of blood through the lungs or heart, merely the outward resemblance caused by distension of the vessels. They differ from it in their causes, and are not removed or lessened by the same means. We have a clear conception of the way in which congestion from disease of the heart is produced, and also of the way in which it impedes the function of the liver, and ultimately leads to permanent change of structure — hut of the mechanism and remote effects of these other kinds of congestion, we know very little.
In congestion of the liver from disease of the heart and lungs, the hepatic veins, being nearer the seat of obstruction, in the course of the circulation, than the portal veins, are naturally the vessels first distended ; — and when the congestion is partial, the hepatic twigs, and the capillaries that immediately surround them,
Lobules on the surface of the liver, in a state of portal-venous congestion.
A, twigs of the hepatic vein in the centres of the lobules, surrounded 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. (After Kiernan.)
Fig. 11.
PORTAL-VENOUS CONGESTION.
45
are found after death, to be the full vessels ; the portal twigs, and the capillaries that immediately spring from them, the empty ones.
But, now and then, the portal veins, and the capillaries imme- diately springing from them, are found alone congested. The margins of the lobules, and the interlobular spaces are then of a red colour — forming a continuous red band — while the centres of the lobules appear as isolated pale spots.
Mr. Kiernan has applied to this congestion of the portal veins only, the term portal-venous congestion. From the pale unin- jected portion being in isolated spots, it looks very like the second stage of hepatic-venous congestion. It is remarked by Mr. Kieman, that the injected substance never has the deep red colour that it has in hepatic-venous congestion.
All that we know of this form of partial congestion, is con- tained in the few observations of Mr. Kiernan, who says, that it is very rare, and that he has met with it in children only.
46
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 iu practice, because the terms are applied, not with reference to the kind of inflammation, or the rapidity with which it works its effects, hut 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 hut few and obscure local symptoms, and would consequently he styled chronic during the life of the patient ; while inflammation, involving the surface of the liver, even of such kind as causes the slow effusion of coagulahle lymph only, will he attended with well-marked local symptoms, — with great pain and tenderness, — and would be termed acute.
We shall never have faithful descriptions of inflammatory diseases, or unerring rules for their treatment, until we arrange them, not according to their mere outward characters, or the pro- minence of particular symptoms, but according to the nature of their causes ; for it is a truth that cannot he too strongly en- forced, that it is the nature of the cause of an inflammatory dis- ease, that mainly determines its course and character, and the influence of remedies over it.
To take, for example, the inflammatory diseases of the knee- joint
GENERAL REMARKS.
47
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 tbe presence of pus in the blood, it is attended with very little effusion and swelling; but, as in tbe former case, it leads to tbe 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 in- flammation iu 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 effusion; but tbe 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 greater effusion ; but the fluid effused here dif- fers 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, aud in the areolar tissue about the joint. These, perhaps by mechanical irritation, occasion fresh attacks 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 effusion, which distends the synovial capsule, and causes great swelling. 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 remedy, 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 that suffer 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
48
SUPPURATIVE INFLAMMATION OF TFIE LIVER.
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.
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 clearly the result of an inflammatory disease, or foretel 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 cha- racters 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 in- flammatory diseases of the liver with reference solely to their causes ; hut, 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 classing 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 suppura- tion and abscess ;
2nd. Gangrenous inflammation;
3rd. Adhesive inflammation, or inflammation that causes effusion of coagulable lymph ;
4tli. Inflammation of the veins of the liver ;
5th. Inflammation of the gall-bladder and 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 inflammation of the liver that leads to suppuration 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 cases in which one or more abscesses were found in the liver after death. Fifteen of these cases
CAUSES.
49
occurred in my own practice at the Dreadnought, in sailors, most of whom had been in the East; sixteen are published in the works of Andral* and Louis, h and were most of them collected m the hospitals 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 he made to these cases.
The most obvious cause of abscess of the liver, and which may therefore be fitly placed first, is —
1 st. A blow, or other mechanical injury. But this is by no means a frequent cause. In the sixty 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. tom. iv. ohs. xxviii.), there were two large abscesses 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 fiver, when of its natural size, is shielded by the libs.
2nd. A second, and far more frequent cause of abscess of the fiver, is suppurative inflammation of some vein, and the conse- quent contamination of the blood by pus.
\ ery soon after morbid anatomy began to be studied, it was noticed that in persons who die some days after a severe injury or suigical 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 symptoms ; 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 found in the lungs and liver in such cases, have, in con- sequence, been very generally spoken of, as deposits of pus.
* Clinique Medicale, t- iv. .
1 Memoires ou Recherches Anatomico-pathologiques sur diverses maladies.
50
SUPPURATIVE INFLAMMATION OF THE LIVER.
An examination of pus through the microscope is sufficient to show, that it cannot he deposited in the way supposed. Pus- globules are larger than blood-globules — according to some anato- mists, twice as large — they could not then escape bodily from the vessels, without the blood-globules escaping as well. This circum- stance is perhaps, of itself, sufficient proof that the pus of those 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 furnished by the researches of M. M. Dance and Cruveilhier. They have shown that although in most of such cases we find in the lungs fully-formed abscesses immediately surrounded by pul- monary tissue perfectly healthy — yet in other cases, in which death happens earlier, instead of abscesses, we find small circum- scribed, indurated, or liepatised masses. In some instances, the abscesses are formed in succession, so that in the same lung we may find all intermediate stages between commencing induration, or hepatisation, 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.* And his sa- gacity led him from this very near to what at present seems to be the true mode of formation of these abscesses, +
He inferred that pus earned to the viscera from distant parts, is
* 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 referenda. Quid ? si asgro moriente, necdum ulla essent qua; pus habere inciperent.” (Epist. li. art. 23.)
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 nonullas ejus partieulas cum sanguine permistas, et prorsus disjunctas, in augustiis quibusdam, fortasse glandularum lymph aticarum, hserere, easque, ut in venereorum bubonum productione fit, obstruendo, aut irritando, eoque humores praeterituros reti- nendo distendere, et multo copiosoris quam quod advectum est, puris gene- ration!, a rigoribus illis, et horroribus significatse, causam praebere. Qua ratione illud quoque intelligitur, quomodo multo plus puris in visceribus, et caveis corporis ssepe deprehendatur, quam modicum vulnus dare potuisset.”
CAUSES.
51
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. Saun- ders, and related by him in his admirable work on the structure and diseases of the liver. He injected 5ij. 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 puru- lent phlebitis, became arrested in the capillary vessels of the lungs, and each globule, acting perhaps by mere mechanical irritation, excited circumscribed inflammation and abscess. The inflamma- tion 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 purulent phlebitis consequent 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 circum- stance 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 net-work ; 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 consequence, it would seem, of the anatomical fact noticed by
j; 2
52
SUPPURATIVE INFLAMMATION OF THE LIVER.
Mr. Bowman, that the lobules of the liver are not distinct bodies, separated from each other by a layer of areolar tissue, but that their capillaries 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 opera- tions are formed in the way here supposed, that in many such cases no inflamed vein can he detected after death.
This objection was much weakened by the important observa- tion made by Mr. Arnott, that the effects of purulent phlebitis are not in relation to the size of the vein, or to the extent of the por- tion inflamed — and that even in cases rapidly fatal, the portion of vein inflamed is often very small. Mr. Amott 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 hone. 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 hones is more apt to cause them, than in- flammation of the veins of other textures.
He accounts for this by the circumstance 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 globule was the centre of a small liepatized 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,
CAUSES.
53
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 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 main- tained 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 their being more con- spicuous from the stronger contrast between the colour of pus and the natural colour 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 he the source of abscesses in those 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 can- cerous 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 he 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 in- flammation of a vein, and the consequent contamination of the blood by pus. The globules of pus, mingled with the blood, are
54
SUPPURATIVE INFLAMMATION OF THE LIVER.
conveyed to the capillary vessels of the lungs, and, it would seem, by becoming mechanically arrested there, excite each circum- scribed inflammation 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 becom- ing arrested in the 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 operations 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 suppura- tive phlebitis set up in any other way. I have met with two in- stances in which scattered abscesses in various organs seemed to result from a collection of pus that had formed, from some cause which I could not discover, between the periosteum and hone of the upper arm ; another instance, in which their source was pro- bably a large tuberculous 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 inflamma- tions 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 anatomical seat occupied are also the same as in the case of in- jected mercury and secondary cancer, — are conclusive in showing that the agent arrives by the blood, and almost conclusive 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 fre- quency 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 he small. In the cases published by Annesley, there is not one that we can, from his de- scription, place in this category.
CAUSES.
55
In the fifteen cases that fell under my own observation at the Dreadnought, there is only one that clearly belongs to this head. In this 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.
In the 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, Ohs. 1 ;) a third, (Andral, Obs. 23,) where with abscesses of the liver, there was lobular pneumonia of the left lung, grey hepa- tisation of the right, and pus between the vertebral column and pharynx ; a fourth, (Andral, Obs. 26,) in which there was grey hepatisation of the lower lobe of the left lung, and pus in the me- diastinum.
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 must pass through the capillaries of the lungs before it can be sent to other organs. In such cases, abscesses are sometimes found in the lungs only, and are usually more numerous in them than in other organs. But if one of the veins that go to form the vena portae be inflamed, the pus will be carried to the liver first, and abscesses will be found solely, or in greatest number, in that organ. Cruveilhier found, that if mercury be injected into one of the veins that feed the vena portae, it will all be stopped in its course through the liver, and will cause circumscribed 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 colour, 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 umbilical omental hernia, he injected mercury into one of the small veins of the omentum. The dog was killed about ten weeks after, and
56
SUPPURATIVE INFLAMMATION OF THE LIVER.
tlie liver found studded with a countless number of, wlmt Cruvcil- hier calls, tubercles, in the centre of each of which was a globule of mercury.
Some of these tubercles had two distinct layers : the outer, al- buminous or tuberculous ; the inner, puxiform.
In these two experiments the different stages of suppurative inflammation are seen. At first, there is a spot of a deep red colour ; — this passes to suppuration and abscess ; and the matter of this abscess, acting as a source of irritation, excites around it inflammation of a different kind, which leads to effusion of albu- men or fibrin, and thus forms a cyst for the matter.
The veins that feed the vena portae, are little exposed to acci- dental injury, hut 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 immediately consequent on repeated attempts to return a pro- lapsed 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 assistance 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 prostration, 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 colour and softened. (Cruv. liv. xvi.)
Dance mentions a case in which abscesses formed rapidly in the liver after an operation for cancer of the rectum, where cau- terization was practised ; another, in which they were consequent on a simple operation for fistula ; two others, in which they followed the operation for strangulated hernia, where a portion of
CAUSES.
57
irreducible omentum suppurated externally. (Archiv. Geuerales, t. xix. p. 172.)
There can be little doubt tlmt in all these cases, 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 do Cruveilhier or Dance speak of abscesses in other organs. It would seem that all the pus furnished by the inflamed veins, was stopped in its passage through the liver ; and that abscesses formed in the liver only.*
3rd. — The consideration of these cases leads us naturally to a third cause — 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 ducts; parts, which return their hlood to the portal vein, to be thence transmitted through the capillaries of the liver.
A connexion between abscess of the liver and dysentery has long been noticed, but the two diseases are associated far more frequently 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 in- testine 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 Dreadnought, the state of the intestines was not noticed in two. In eight of the remaining thirteen cases, there were ulcers in the large 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.
In the sixteen cases collected by Andral and Louis, who seem not to have suspected any connexion between abscess of the
* In some instances, perhaps, the pus passes through, or the abscesses of the liver cause inflammation of the hepatic vein, and thence disease of the lung. In Ohs. 3, ofM. Louis, there were ulcerated intestines, abscess of the liver, double pleuro-pneumonia.
58 SUPPURATIVE INFLAMMATION OF THE LIVER.
liver and ulcerated intestine, ulcers are noticed in the large intes- tine and in the lower end of the ileum, in two cases ;* in the lower end of the ileum only, in one case ;+ in the stomach, in four cases in the gall-bladder, in one case.§
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 extensive 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 in 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 winch the abscesses were not the consequence of a blow or of general phlebitis, there was ulceration of the stomach, the small or large intestines, 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 ob- viously consequent on chronic disease of the stomach, and after death, the lining membrane of the stomach was found in some parts so softened 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 followed by disseminated cancerous tumors in the liver, and in no other organ. In a subsequent chapter I shall refer to nu- merous instances of this kind from those storehouses of patho- logy— the Clinique Medicale of Andral, and the Anatomie Putholoc/ique of Cruveilbier. 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.
* Andral, Obs. 25 ; Louis, Obs. 3. I Andral, Obs. 24.
X Andral, Obs. 27, 30, and 31 ; Louis, Obs 4. § Louis, Obs. 5.
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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 ; bnt that in two cases, he found abscesses in its substance. (Dub- lin 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.* It is remarkable that Dr. Abercrombie should have considered the asso- ciation of the two diseases accidental. He says, “ Dysentery is often accompanied by diseases of neighbouring organs, especially the liver, in which are found in some cases abscesses, and in the protracted cases chronic induration. These are to he regarded as accidental combinations, though they may considerably modify the symptoms.” (Diseases of the Stomach, &c., 2nd 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 this. He sup- poses that, in some cases, the abscess is consequent on the dysen- tery ; 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 large 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 he extremely difficult to discover the relation between the two diseases, on account of the 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 Dreadnought, 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 con- clusion, that the abscess of the liver was not only consequent on the dysentery, hut caused by it.
On the 12th of March, 1838, four men, Brown, Flctt, Crere, and Davies, were brought into the Dreadnought, from the same * Diseases of Stomach, &c. ; 2nd edition; cases 93, & 130.
60
SUPPURATIVE INFLAMMATION OF THE LIVER.
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 hut 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 dysentery after leaving the Cape, but these new hands had good health until, between the western islands and the channel, when they had gotinto cold weather, they were attached, one after another, with dysentery of the most severe kind. Two of these men died soon after their admission to the Dreadnought, the others recovered sufficiently to leave the hospital.
In the two fatal cases, I found the state of the large intestine exactly the same. From the ileo-ccecal 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 fiver was only found in one of them, we must infer that it was se- condary, the consequence of the dysentery.
Among many cases of dysentery, there may he only one in which abscesses form in the fiver, 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 Dreadnought, the patient had dysentery at the Isle of France. The violent symptoms subsided after two months, and he continued his work for four years. At the end of this 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 Dreadnought. He died soon afterwards.
On examination, I found a superficial abscess on the convex surface of the right lobe of the fiver. The mucous membrane of the small intestine was quite healthy to within two inches of the ileo ■ccecal valve. Immediately above that valve, were three ulcers, (the largest about the breadth of half- a- crown,) in most part of
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Gl
which the muscular coat of the iutestine was laid bare. The edges of these ulcers were not raised or ragged. In their imme- diate vicinity were many other ulcers, about the size of small-pox marks, which had not eaten through the mucous membrane. The mucous membrane about these ulcers was not softened or unusually vascular. In the coecurn, 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 ccecum was much softened ; in the rest of the large intestine it was in all respects healthy. The mesenteric glands in the neighbourhood of the ccecum were enlarged and softened to a pulp of a pinkish colour. 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 intestine.
The sequence of events in this case seemed to he, dysentery, winch had left a few chronic ulcers in the ccecum and lower end of the small intestine ; at the end of four years, recurrence of dysenteric symptoms, inflammation and abscess of the liver. The abscess of the liver clearly dated from the recurrence of the dy- senteric symptoms, when the patient first felt pain referable to the liver. An abscess so superficial could not have existed without manifest symptoms.*
If the liver- disease had been the cause of the dysentery, it would, in all probability, have caused more extensive ulceration. Irritating bile might cause ulcers of the large intestine, and scattered ulcers, but it could hardly affect so exclusively, such a small portion of the gut.
I might adduce other instances, which I should perhaps weary the reader by relating, in which there could he 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 asso- ciated ?
Annesley thought not, from the circumstance, that, in India,
* Compare this case with Obs. 25 of Andral, where suppurative inflam- mation of the liver occurred in the course of chronic enteritis.
62
SUPPURATIVE INFLAMMATION OF THE LIVER.
the symptoms of liver-disease sometimes appear as soon as those of dysentery ; iu 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 uot 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, in- flammation of a vein may occur, pass on to suppuration, and con- taminate the system, in less than forty-eight hours. Supposing, then, the suppurative inflammation of the liver to be excited in the same way in dysentery, it might be expected, that its symp- toms would, in some cases, appear almost as soon as those of the primary complaint.
But, in India, it sometimes happens that the symptoms of liver- disease precede those of dysentery. Tliis, 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 Eng- lish 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 he readily mistaken for it. If, then, a person with any such de- rangement of the liver should he taken with dysentery, and have abscess of the liver in consequence, it is very natural that the dysentery should he ascribed to pre-existing suppurative inflam- mation of the liver.'*
If the explanation I have offered he 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
* Cases 71, 75, 77, of Annesley, are probably examples of this sequence
chronic disease of the liver, dysentery, abscess of the liver.
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63
marks of disease in the gall-ducts and the upper part of the small intestine — parts, with which the irritating secretion came first in contact; hut, instead of this, these parts are almost always perfectly healthy in cases in which abscess of the liver i s associated with the most destructive forms of dysentery. The whole of the large intestine may be a complete slough, while the gall-bladder and ducts and the small intestine almost down, or even quite down, to the ileo-coecal valve, are perfectly healthy, and the bile in the gall-bladder is of its natural consistence and colour. Annesley, indeed, makes a distinction between what he calls simple dysentery and hepatic dysentery ; and states that in simple dysentery, or dysentery unconnected with liver disease, the in- flammation of the large intestine generally stops abruptly at the ileo-coecal valve, while in hepatic dysentery, the lower part of the small intestine is often inflamed, as well as the large intestine. He believes that in the latter cases the small intestines become diseased from the irritating quality of the bile. Annesley is right in stating that in dysentery connected 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 Dreadnought, but it not unfrequendy 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-coecal 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 in- flamed as well as the large intestine.
The proper reading of these facts seems to me to be, tbat the disease 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, it causes abscess of the liver, in others, not.
In no cases, whether of simple or hepatic dysentery, is the upper part of the small intestine ulcerated. The ulcers of the small intestine, if any exist, are always near the ileo-coecal valve.
There can be no doubt that a copious flow of irritating bile 8
04 SUPPURATIVE INFLAMMATION OF THE LIVER.
may cause diarrhoea, and may prevent the ulcers of dysentery from healing ; it may perhaps cause ulceration of the howel ; hut it is very improbable that it causes the early and extensive ul- ceration and gangrene of the large intestine in Asiatic dysentery, which 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 dy- sentery, and then by abscess ; and consequently, that in all the cases, or most of the cases, in which abscess of the liver and dy- sentery are associated, the former disease is the consequence of the latter.
If irritating bile cause ulceration of the intestine, it may he the remote cause of abscess of the liver, through the disorder it first occasions in the intestine.
Admitting dysentery, or ulceration of the howel, to he a source of abscess of the liver, it is obvious that the liver does not be- come involved by spreading of the inflammation, hut by some contamination of the portal blood.
This may he either by pus, formed by suppurative inflammation of one of the small intestinal veins ; or by matter of other land resulting from softening of the tissues ; or by the fetid gaseous and liquid contents of the large intestine in dysentery, which must he 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 in- flammation, 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, cir- cumscribed 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.
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
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G5
abscess of the liver recorded by Andral and Louis, there are three in which the stomach was found ulcerated, without any ulceration being noticed 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 stomach. The liver was enlarged, and contained scattered through it, a great number of small, firm, red masses, the result, it was supposed, of partial inflammations; but which were more probably cancerous. 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 symp- toms of chronic gastritis— loss of appetite, vomiting, sour eructa- tions, 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, wlieu, 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 mem- brane was ulcerated ; and in place of the underlying coats, there was a uniform gristly substance of a dead white colour.
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.
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 appe- tite, occasional 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 hypo-
F
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SUPPURATIVE INFLAMMATION OF THE LIVER.
chondrium, 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 he fairly attributed to the disease of the stomach. There was likewise, indeed, disease of the gall-bladder and cystic duct ; hut 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 seemed consequent on softening of the mucous membrane of the stomach. The patient, a man aged 51, had symptoms of chronic gastritis for eighteen months, when he became jaundiced, and began to have a constant and troublesome pain in the right shoulder. Some time after the accession of these last symptoms — Andral does not say how long — ■ he was seized suddenly with symptoms of peritonitis, and died at the end of three days.
In the liver was an abscess, not encysted, which had opened into the cavity of the peritoneum on the under surface of the liver near the gall-bladder. The gall-bladder and the ducts were healthy. In the splenic extremity of the stomach, the mucous mem- brane was much softened ; in some parts so much as to re- semble liquid mucus on the subjacent tissue. In the pyloric extremity, on the contrary, the mucous membrane was hypertro- phied.
Here, symptoms of disease of the stomach had lasted eighteen months before the patient had any symptoms of disease of the
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07
liver. The circumstance that the abscess was not encysted goes to prove that it was of recent date.
In the Provincial Medical Journal for December 3, 1842, the case of a man is related who died at the age of 48, with ulcerated 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 circumscribed 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.
Ulceration of the gall-bladder or 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, 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 1st volume of Guy’s Hospital Reports (p. 030) : gall-stones, ulcera- tion 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 Dreadnought.
The patient, aged 33, was brought into the Hospital on the 2nd of December, immediately on his return from Quebec. At Quebec he had ague, and this was succeeded, three weeks before bis admission, by jaundice and pain below tbe ensiform cartilage. The jaundice continued, but he had gained strength, when, on the 2Gth of January, just eight weeks after he was brought into the hospital, he -was suddenly seized with symptoms of peritonitis, which carried him off in four days.
On the convex surface of the right lobe of tbe liver was a large irregular abscess, lined by a buff- coloured, and moderately firm, false membrane.
The gall-bladder was firmly adherent to the duodenum, audits
F 2
G8
SUPPURATIVE INFLAMMATION OF THE LIVER.
coats were thickened. Its cavity, which was no larger than a hazel- nut, was filled hy a yellow, friable gall-stone, having a firm dark- green nucleus. The cystic duct was much dilated, and contained 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 hepatic ducts were very large, and were readily traced a long way into the liver. There was no ulceration of the stomach, or of the intestines, with the exception of this ulcerated opening in the duodenum ; which, as well as the dilatation of the ducts behind and the jaundice, was caused, no doubt, by a gall-stone, which had stuck for some time in the common duct, and then passed, hy ulcera- tion, into the bowel.
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 hy 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 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 hy 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 hy a cartilaginous hand. The intestines, small and large, were quite sound.
In the third case (case 120), 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 hounded the abscess ; and the bile secreted by the liver was either retained in the abscess, or discharged hy the wound. (The abscess had been opened.) I here was no other appearance of disease in any of the viscera.
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Abercrombie, in bis work on diseases of the Stomach, Ac., 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 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 ducts, the gall-bladder, and tlie capsule of the liver, are nourished by the hepatic artery, and blood flows, not from the portal vein to them, but from them to the portal vein. This circumstance 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 in- volved. The suppurative inflammation is confined to those parts of the liver that receive blood from tbe 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 catalogue of abscesses of tbe 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 tbe spleen, and all that part of it which runs on the pancreas, were inflamed, and contained a puriform fluid, aud an rrre^rlar deposit of lymph.
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SUPPURATIVE INFLAMMATION OF THE LIVER.
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 colour, and very soft.
There were no ulcers in the intestines ; no abscesses anywhere hut in the liver.
The most probable supposition is, that the disease in this case originated in the spleen, that the splenic vein subsequently be- came 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 quantity to the portal vein, being all arrested in its passage through the liver.
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 he 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 ducts. When ulcers were found in the intestines, by which the occurrence of abscess in the liver could he 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 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 abscess of the liver noticed in conjunction with ulcerated intestine in 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 atten- tively 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
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were tubercles 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 in- testines, 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 iu 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.
The causes that have here been assigned for abscess of tbe 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 causes.
Yet various other conditions have been very confidently as- signed 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 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 duode- num 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 dis- ease is very rare in the duodenum.
2nd. — Another cause assigned for hepatitis, is spirit-drink- ing. But this produces adhesive inflammation and induration of the liver, not suppurative inflammation and abscess. Not-
72 SUPPURATIVE INFLAMMATION OF THE LIVER.
withstanding 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 has been received into King’s Col- lege Hospital since its establishment — a space now of five years.
3rd. — A third cause confidently assigned by Annesley and many other writers, is congestion of the liver. But this, assuredly, — that is, mechanical, congestion, produced by impediment to the flow of blood through the lungs or heart, — never produces sup- purative inflammation. Abscesses of the liver are never met with as a consequence of the congestion caused by the organic dis- eases 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. Of the other kinds of congestion, and the points in which they differ from states to which the term inflammation may properly be applied, we know but little — and their influence in causing abscess of the liver, will be comprehended in that of heat of climate, malaria, and the other circumstances by which such states of congestion are produced.
4th. — In India, great influence is attributed to the heat of the climate 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 cause suppurative inflammation of the substance 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 originated from 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 in the trade to the west coast of Africa are exposed to heat, perhaps 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
8
CAUSES.
73
their health suffers in consequence, yet we never find them coming1 into our hospitals with abscess of the liver.
5th. — Another cause brought forward to explain the frequency of abscess of the liver in India, is remittent or intermittent fever, or, mere 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 re- mittent fever, it is much and permanently damaged in its secret- ing 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 physician to the Dreadnought, 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 colour from anemia, but without any marks of inflammation.
Annesley, indeed, notices abscesses in the liver, among the morbid appearances of the remittent fever of India, but he also notices ulceration of the intestine (Annesley, vol. ii. p. 45G). Sir G. Blane, 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 malaria, favoured perhaps by the heat of the climate, produces abscess of the fiver 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 different 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
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SUPPURATIVE INFLAMMATION OF THE LIVER.
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 structure to which it leads.
The earliest perceptible changes in the appearance and texture of the liver from suppurative inflammation involving its sub- stance, 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 was found strewed through the liver, and the hepatic tissue around each globule of a deep red colour, and softened. In the human subject, in most cases of abscess of the liver, when speedily fatal, the hepatic tissue about the abscess is of a bright red and softened.
This preliminary stage, is, however, of very short duration. The inflammation soon passes, in some cases i'n a few days only, to suppuration and abscess. Dr. Stokes has noticed a stage, be- tween red softening and abscess, in which the pus is disseminated through the lobules of the liver, the form of which can still he distinguished, and the inflamed substance is yellowish, and of course still very soft.
I have never found this change in the liver without abscess, nor does Dr. Stokes seem to have done so, hut in several instances I have observed it extending a distance of two or three lines about a recently formed abscess.
This state of yellow softening, or purulent infiltration, is, there- fore, very transitory ; and we may, consequently, consider red softening and abscess, as the anatomical characters of suppurative inflammation of the substance of the liver.
The inflammation we are considering, commences in the lobular substance of the liver, and is often confined to it; the capsule of the liver, tne trunks of the vessels and of the ducts, being per- fectly healthy. But if the inflamed part reach the surface of the liver, adhesive inflammation is generally set up in the portion of the capsule immediately above it, and coagulable lymph is poured out, which causes permanent adhesion between that portion
CHANGES OF STRUCTURE.
75
of the liver and the parts with which it is in contact. This adhe- sive inflammation is usually of small extent, being confined to the portion of the capsule immediately above the abscess. It some- times happens, too, when the portion of liver inflamed reaches a trunk of the hepatic vein, that inflammation is set up within the vein. In two instances in which abscesses had formed in the liver after amputation of the leg, I found one or two branches of the hepatic vein blocked up by soft fibrine ; and in each I ascer- tained that an abscess reached the vein where it ceased to be ob- structed by the fibrine. 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 tbe effused fibrine, 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 very interesting 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 contigu- ous 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 An- nesley, 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 an hepatic abscess is usually white or yellowish ; and is free from odour, unless when is close proximity to the lung, where it sometimes becomes decomposed and fetid, from the admission of air.
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SUPPURATIVE INFLAMMATION OF THE LIVER.
Many of the old writers describe the pus of abscess of the liver as being red or claret-coloured, but this is incorrect. In all the abscesses of the liver that I have examined, tlie pus was white or yellowish, just like that of a phlegmon. The error of those who have described it as being reddish, resulted, perhaps, 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 described the matter expectorated, and not the matter con- tained 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 was a dirty-red, or brownish, pus. The reddish colour was acquired in its passage through the lung. The matter in the abscess was yellowish or white.
Kokitansky 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 Dread- nought; 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 hounded by a dense grey substance, 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 effect of pressure.
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 inflam- matory action which leads to the effusion of fibrine. The fibrine, becoming organized, forms the cartilaginous-like layer described.
M' lion 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
CHANGES OF STRUCTURE.
77
time without further change ; but in most cases, after being, per- haps, some time stationary, it grows larger, apparently through secretion of fresh matter from the inner surface of the now organised cyst. By the pressure exerted on it by the distcndiug force, the cyst may become ulcerated, and in this way, as well as by mere distension, tbe 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 be 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, the large gall- ducts about the abscess break down by the spreading of the sup- puration, 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 subsequent growth, reaches the surface of the liver, it may have various issues. The abscess may burst into the cavity of the peritoneum, 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, adhesive inflammation is set up in the portion of peri- toneum immediately 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 cavity of the peritoneum, but outwards, or into the lung or pleura, or the different portions of the intestinal canal just specified.
Livers containing abscesses are found of all shades of colour that can be produced by different degrees of congestion, and by differences in the quantity and colour of the biliary matter retained in the cells ; but they are seldom indurated from inter- stitial deposit of fibrine. The inflammation which terminates in abscess, and that which leads to effusion of fibrine and in- duration, or cirrhosis, are not different in degree merely, but in kind also. 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 induration of the liver in persons who return from India with abscess of this organ.
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SUPPURATIVE INFLAMMATION OF THE LIVER.
We may now consider the symptoms of suppurative inflamma- tion 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 ; hut in actual practice, it is far otherwise. The physicians who have had most experience in this disease, confess their inability, in many cases, to distinguish 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 arises. This knowledge will make us observant of symptoms which would otherwise escape our notice, and will enable us to interpret 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 done to the convex surface of the liver, and the local symptoms are well marked. There is pain and tenderness in the region of the liver, and a sense of fulness and resistance under the false ribs, from increased size of the organ. The liver becomes en- larged, and if the abdomen be flaccid, and the intestines empty, its edge can he felt some inches below its natural limit. The se- cretion of bile may he suppressed, or deficient, and the patient jaundiced.
In addition to these symptoms, which may he 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 aud yellowish ; appetite is alto- gether absent or much diminished. The patient is thirsty, and there is occasionally vomiting of bilious matter, while the urine is scanty, high coloured, 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, are perhaps, in the absence of evidence of disease of the lung or pleura, sufficient to characterise 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
SYMPTOMS.
79
much more frequently after injuries clone 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 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 a 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 connexion between the two diseases enables us to attach due im- portance to these symptoms and ascribe them to their actual cause. Pain and tenderness in the region of the liver, slight in- crease in its volume, and jaundice, which, in other circumstances, might excite little alarm, and be attributed to their most frequent cause, — inflammation and obstruction of the gall-ducts, — when they occur in the course of dysentery, will lead us to dread sup- purative inflammation and abscess.
But these special symptoms are far indeed from being all pre- sent in every case ; and in some cases they are entirely wanting.
On the 2nd of October, 1830, a Lascar, 02 years of age, was admitted into the Dreadnought, 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. ITe grew weaker, and died of the catarrh, on the 12th of November. While in the hospital, he made no com- plaint of pain or tenderness in the right hypochondrium, had no
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SUPPURATIVE INFLAMMATION OF THE LIVER.
vomiting, no diarrhoea, no jaundice, — not a symptom to lead me to suspect that his liver was diseased. On examination, an abscess, containing more than a pint of matter, was found in the substance of the liver. The abscess was hounded 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 presented no marks of having been inflamed. The stomach and small in- testines were healthy. 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.
My friend and former pupil, Dr. Inman, of Liverpool, has sent me notes of an interesting case, in which abscesses of the fiver occurred, in consequence it would seem of dysentery, without any symptom immediately referable to the fiver. The patient, a woman 45 years of age, was admitted into theLiverpool Infirmary, on the 21st of June, 1843, in a state of extreme weakness, from bad living and from constant diarrhoea, which had then lasted nine or ten weeks. The diarrhoea came on without urgent symp- toms, and was unattended by griping or tenesmus. The stoctls were occasionally 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 ile'o- coecal valve to the rectum. The stomach, the small intestines, the kidneys, and the spleen, were healthy. The fiver 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 fiver. The lungs were cedematous ; other- wise 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 fiver. The abscesses were discovered by acci- dent, in the examination of the body.”
Andral, Abercrombie, and indeed all writers who have pub- lished a series of cases of suppurative inflammation of the fiver, have noticed the same fact, — that, occasionally, in this disease, the patient has no symptoms immediately referable to the fiver.
Anncsley says, “ The supervention of abscess of the fiver ”
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(in dysentery) “ is often not manifested by symptoms of a de- cided nature.” “ The formation of matter may commence and terminate without the appearance of any of those signs on which the inexperienced are taught to rely.” In another place, he says, “When the disorders of both viscera are nearly coeval, the inex- perienced observer may not detect the presence of biliary de- rangement, 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 compli- cation is overlooked.”
The presence or absence of the symptoms directly referrible to the liver depends chiefly on the situation, and extent, of the part of the liver inflamed. These symptoms are, as before remarked, fulness of the right hypochondrium, from enlargement of the liver; pain or tenderness ; and jaundice.
The degree of enlargement must evidently depend in some measure on the extent of the part inflamed. If only a small portion of the liver be inflamed, the inflammation, though at- tended with considerable 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 of 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 ge- nerally 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 of the principles of bile.
The presence, or absence, of 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,
82 SUPPURATIVE INFLAMMATION OF THE LIVER.
and is not sufficiently extensive, nor attended with sufficient con- gestion 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 inflammation of these 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 generally 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, provided 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, con- sulting surgeon to the Dreadnought, 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 abscess be large, the health is usually much broken. Even when there is neither pain or tenderness, there is yet some degree of fever ; the pulse is frequent ; there are night sweats ; and the pa- tient does not recover strength ; and, not uufrequently, 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
SYMPTOMS.
83
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 belongs to disease of the liver. He conjec- tures, that, when present, it 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 Dreadnought, 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 convex 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 our 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 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 —
g 2
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SUPPURATIVE INFLAMMATION OF 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 si- tuated on the convex surface of the right lobe. There was no recent inflammation 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, aud adhesions had formed between the peritoneum covering this abscess, and the layer of peritoneum 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 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. * 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 great propor- tion 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 frequently 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 it may even be produced by a tumor compressing
* 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.
85
the liver. It was complained of by a man who was admitted into King’s College Hospital, under my care, in April, 1 843, with aneu- rysm of the abdominal aorta. The man died suddenly from burst- ing of the aneurism, between four and five weeks after his admission. The aneurysm, which sprung from the side of the artery oppo site the origin of the caeliac axis, formed a tumor as large as a man’s head immediately behind the liver. It had partially de- stroyed 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 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, hut has advanced similar opinions respecting the vomiting and cough. The vomit- ing he supposes to arise from inflammation of the mucous mem- brane of the stomach ; and the cough, to he 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 have 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 Dreadnought, immediately on his arrival from Calcutta. 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, hut there was no tenderness on pressure. He was somewhat thirsty, hut afraid to drink, on ac- count of the vomiting it immediately excited. My impression was that his disease was gastritis, and I prescribed for him ac- cordingly. The symptoms increased, and at the end of a fortnight he could he got to take little besides toast and water, which he sipped rather than drank. He died about a month after his ad-
10
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SUPPURATIVE INFLAMMATION OF THE LIVER.
mission to the Dreadnought. The stomach was found apparently sound, hut the liver was the seat of a large abscess, the presence of which was not 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 symptom 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 some other surgeons 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 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, and which is cited at length in a subsequent 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 can- not be explained by the condition of the lung — when the vomiting occurs, immediately after food or drink has been taken ; which is a general character of sympathetic vomiting — when, in fact, these symptoms 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.
SYMPTOMS.
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Rut when the abscess is large and near the surface, it may, ac- cording to its situation, discharge itself in various ways. If situated on the outer surface of the liver, it may either hurst into the cavity of the peritoneum, or, by means of adhesion, make its way through the abdominal parietes ; if it he situated on the upper part of the liver, in contact with the diaphragm, it may perforate the diaphragm and burst into the cavity of the pleura, or adhesions may form between