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in the Francis A.Countway

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 :

THE LIVER
AND ITS DISEASES,

BOTH FUNCTIONAL AND ORGANIC.

THEIE HISTOEY, ANATOMY, CHEMISTRY, PATHOLOGY,

PHYSIOLOGY, AND TEEATMENT.

WILLIAM MOEGAN, M.D.,

Member ofthe Royal College of Surgeons, England ; Member of the British
Homeopathic Society ; Physician to the Brighton Homoaopathic Dispensary,
Formerly Bhysician to the North London Somceopathic Dispensary,
Accoucheur to the West End Maternity Institute, and one of
the Medical Officers to the London Somceopathic
Hospital, ^c, ^c.

FIRST EDITION.

LONDON
THE HOMGEOPATHIC PUBLISHING COMPANY,
2, FiNSBTJiiY Circus, E.C.
BOERICKE AND TAFEL,
HOMOEOPATHIC PHARMACIES,
NEW YORK AND PHILADELPHIA.
1877.
 WORKS BY THE SAME AUTHOR.
Sixth Edition, price 2s. &d.,

THE HOMCEOPATHIC TREATMENT OF INDIGESTION,

CONSTIPATION, H^MOEEHOIDS, HYPOCHONDRIASIS, &c.

First Edition, price 3s. 6^.

DIABETES MELLITUS:
Its History, Chemistry, Anatomy, Pathology, Physiology, and
Treatment.

First Edition, price 36. Q>d.

SYPHILIS AND SYPHILOIDAL DISEASES:

heir History, Anatomy, Pathology, Etiology, and Treatment. Witli
Comments on the " Contagious Diseases Act."

First Edition, price 25,

THE SIGNS AND CONCOMITANT DERANGEMENTS OF

PREGNANCY:
The Selection of a Nurse, and the Management of the
Lying-in Chamber.

Third Edition, price Is. ; cloth, Is. 6<f.,

THE PHILOSOPHY OF HOMCEOPATHY.

See opinions of the press.

First Edition, price \s.,

CHOLERA : its Pathology and Treatment,

pxicels.,
FirsiJEdition.

DIPHTHE;^ :QtsPatKoW^^^reatmento

.
UL 2 1918
W^-;

4?:BRAB:i
 PREFACE,

A PORTION of the materials of which this volume is

composed has appeared from time to time in the pages

of the " Homoeopathic World," and from the flattering

communications which I have received from some of

of my colleagues in England, as well as in the United

States of Americ% relative to the practical hearing of

the subject on which it treats, has induced me to pub-

lish it in the form now presented to the reader.

In undertaking this task I have kept prominently in

view that familiar phrase " brevity is the soul of wit,"
consequently I have endeavoured to concentrate into
the smallest possible compass, compatible with the scope
and usefulness of the work, —the history, anatomy,
chemistry, pathology, physiology, and treatment, both
allopathic and homoeopathic, of each disease.

The sections referring to allopathy, or the so-called

" orthodox doctrine of medicine," are simply introduced

by way of contrast, from which it is hoped the general

reader may derive food for thought, and weapons for fair

arguments and well balanced comparisons.

vi PREFACE.

For a knowledge of the early history and advanced

pathology of many of the more obscure diseases of the

liver, I am indebted to the researches of Frerichs and

Eokitanski; for practical experiments to Sanders; for
tropical and pysemic abscesses to Annesley and Ward ;

and for valuable clinical observations to Budd and

others.

This little work does not aim at being a complete or

exhaustive exposition of the subject upon which it

treats; it, however, embraces a large section of the

most important of " liver complaints," and the author

anticipates for it- with all its shortcomings, a useful

career.

Old Steine, Bkighton,

April I6th, 1877.
 ;

HOMCEOPATHIC MEDICINES,
THEIR MODE OF PREPARATION; THEIR CURATIVE SELEC-
TION; THE DOSE OR POTENCY, AND THE MANNER OF
THEIR ADMINISTRATION, BRIEFLY EXPLAINED.

Hommo'pailiiG Medicines.

The homceopathic " Materia Medica " contains at the

present time from 260 to 270 medicinal preparations
number of these have been faithfully proved
the greater
on man, woman, and child, while in a state of health,
in order to ascertain the pathogenetic and specific pro-
perties of each drug, others have been but partially
proved, and hold a place in its pages on empirical
grounds.
Homoeopathic medicines are prepared and kept in the
form of Tinctures, Triturations, Pilules, and Globules a ;

few in ether and glycerine, such as the snake poisons.

The tinctures are chiefly derived from the vegetable
and animal kingdoms known as expressed juice, mother
;

tincture, or matrix tincture, the symbol of which is the

Greek 0.
From these tinctures the various dilutions or potencies
are prepared and the higher we ascend in the scale of
;

dilution the further we depart from the crude substance,

which accounts for the non-poisonous, and consequently
non-injurious properties of homoeopathically prepared
medicines; but they nevertheless retain medicinal
 — —
Vlll HOMCEOPATHIC MEDICINES.

properties of marvellous efficacy, which are potent against

the disease ; and inert against the constitution, when
homoeopathically or specifically selected. Triturations,
on the contrary, are chiefly prepared from substances
derived from the mineral kingdom. Among these may
be enumerated sulphur, mercury, arsenic, zinc, tin,

baryta, gold, silver, iron, lime, copper, alum, tellurium,

and many more. The mode of preparing the various
potencies from the matrix triturations is similar to those
prepared from the tinctures for the manipulation of
;

which the reader is referred to the pages of the Homoeo-

pathic Pharmacopoeia, recently published under the
auspices of the British Homoeopathic Society.

Pilules and Globules,

These which have afforded our allopathic

little pellets,

brethren no scanty field for amusement and ridicule,

are not in reality homoeopathic medicines at all : they
are simply elegant and ingenious little vehicles for the
administration of the various remedies when reduced
to the liquidform (tincture), and used on the same prin-
ciple as Doctor Dosewell, selects honey, syrup, jam, or
jelly for his nauseous compound of grey powder, rhu-
barb, senna, or Dover's powder: in quovis vehisculo crasso
— in some convenient vehicle or as once facetiously
:

translated by a candidate for the licence of the Apothe-

caries' Company —
in some stout Hackney coach.

On the Selection of Remedies.

The fundamental principle of homoeopathic practice

the law of cure — as discovered, demonstrated, an
 —
HOMCEOPATHIC MEDICINES. IX

promulgated by Halinemann, is simply and forcibly

expressed in tbe following maxim : — Similia similibus
curantur, which simply means that diseases are cured
most quickly, safely, and effectually, by medicines which
are capable of producing symptoms similae to those
existing in the patient, and which characterize his
disease for in accordance with the therapeutic law of
;

similarity, medicines cure affections similar, or like

unto those they produce. The immortal bard of Aron
has well expressed this law in the following lines.

" Tut, man one fire burns out another's burning

!

One pain is lessened by another's anguish.

Turn giddy, and be holp by backward turning ;

One desperate grief cures with another's languish :

Take thou some new infection to the eye,

And the rank poison of the old will die."

Homoeopathy, then, proceeds upon the great incontro

vertible truth, that as thephenomena of chemistry
depend upon positive —
laws as the movements and
instincts of the brute creation are regulated in the most
orderly manner —as the physiological functions of the
human organism constitute an harmonious play of beauti-
fully co-ordinate forces, — so nature has ordained a
definite relation between remedial agents and diseasef.

In the discoveries of such relationship, extending over a

field co-extensive with ]N"ature herself, ever fresh, ever

increasing in interest, consists the study of homoeo-

pathy in its application as well as its practice. The
treatment of disease henceforth must rest on positive and
unerring laws, it cannot possibly depend on chance, but
must be regulated in a manner commensurate with the
unchanging principles of nature and philosophy.
a 2
X HOMOEOPATHIC MEDICINES.

While the differences of sexes in. all living beings

beneficently binds them together in prolific union, the
crude matters of inorganic nature are impelled by like
instincts. Even in the darkness of chaos, matter was
accumulated or separated accordingly, as af&nity or
antagonistic matter attracted or repelled its various parts.
The celestial fire follows the metals, the magnet, the iron ;

a mber when rubbed attracts light bodies earth blends

;

with earth ; salt separates from the waters of the sea

and joins its like. Everything in inanimate nature
hastens to associate itself with its like.

The beauteous aspect of the world, the order of the

celestial bodies, the revolution of the sun, the moon, and
all the stars, indicate sufficiently at one glance, that all
this is not the work of chance.

Potencies.

Homceopathic medicines have been used by physi-

cians at various dilutions —
from the mother tinctures
:

CO the two-thousandth attenuation for ordinary pur-

;

poses, however, I would advise my readers to confine

their selections from the mother tincture ^ to the
3rdx, or 6x dilution, as being the most useful and efSca-
cious, and is moreover in accordance with the views of
the majority and more advanced sections of homoeo-
pathic practitioners in this country and America. They
constitute the ordinary potencies prescribed by the
writer for many years, and have proved eminently suc-
cessful in his hands.

Mode of Administration.
We have observed that there are four modes of pre-
 HOMOEOPATHIC MEDICINES. XI

paring the medicin es :

— viz., Tinctures, Triturations,
medicated Pilules and Globules ; there is also more than
one mode of administering these remedies.
1. Tinctures. —The dose of these preparations is as
a rule, one drop administered at stated intervals.
In acute and in those severe and dangerous
diseases,
complaints which rapidly run their headlong course
to a fatal termination, as for instance, croup, cholera,
acute atrophy of the liver, &c. — it may be. necessary
at the commencement of the treatment, to repeat the
dose at intervals of every ten, twenty, or thirty
minutes, until a favourable impression is made on the
symptoms, when the interval between the doses should
be lengthened as the patient improves. For this pur-
pose itwere well to mix thoroughly twelve drops of
the selected tincture in twelve table-spoonfuls of water,
and administered accordingly.
In chronic diseases, there should be an interval be-
tween the repetition of the dose of from twelve to
twenty-four hours ; and according to the strict rules of
Hahnemann, to as many days or weeks. This pro-
longed action of one dose of a medicine has been much
doubted: I have but little faith in it myself, and gene-
rally advise that the medicine should be repeated once
a day or night and morning.
Triturations. —These preparations may be taken dry
on the tongue, or in solution one grain, or as much as
;

will stand on the point of a pen-knife, is about equal to

one drop of the tincture : one pilule, or six globules.
If the solution be preferred, twelve grains should be
dissolved in twelve table-spoonfuls of water, well stirred
and taken according to the circumstances of the case.
Xll HOMOEOPATHIC MEDICINES.

Pilules and Globules. —These elegant and Lilipiitian

medicaments may also be taken either dry on the tongue
or in solution. If the former, one pilule or six globules
may be considered a fair adult dose ; if the latter, one
pilule or six globnles dissolved in a table-spoonful of
water may be considered equivalent to one drop of the
tincture in the same quantity of water.
Medicines as a rule, should be taken on an empty
stomach, or about two hours after a meal.
The water used for mixing the medicine should be
distilled, filtered, or cold-boiled.

The solution should be made in a clean tumbler,

closely covered with half a sheet of note-paper ; or in a
bottle well corked and kept from dust and light.

Did.

All articles of diet and drinks which contain medi-

cinal properties should be strictly avoided whilst taking
homoeopathic medicines ; such as coffee, green tea, and
herb teas of every description ;
ginger, pepper, vinegar,
mustard, allspice, cinnamon, cloves, and spices of all

kinds; and every variety of vegetable food of an

aromatic or medicinal character; as onions, garlic,

radishes, celery, or parsnips ; and every variety of animal

food strong-scented or diflicult of digestion, as old
smoked meat, roof beef, bacon, fat pork, sausages, rancid
butter, strong cheese, &c.
In acute diseases the diet should consist of the most
light and nutritious kinds of food such as toast-water,
;

barley-water, rice-water, panada, arrowroot gruel, and

mutton broth. When the more violent symptoms of
the disease have subsided, and the patient is fairly con-
 HOMCEOPATHIC MEDICINES. Xlii

valescent, more substantial food may be allowed in

moderate quantities such as beef tea or chicken tea
;

thickened with pearl barley, arrowroot, or sago, boiled

rice, boiled chicken, or a sweetbread; toast, rice, and

bread pudding, and if there exists no derangement of

the stomach or bowels, a few grapes, strawberries, o
peaches may be taken. In chronic diseases, almost
every variety of wholesome, nutritious, and easily
digested food may be allowed, providing it does not
answer the description of such kinds of aliments as are
above prohibited.
As an ordinary beverage pure water should be allowed
in all cases, toast-water, apple-water, barley-water, or
rice-water, withan occasional glass of sound Burgundy,
Carlowitz, or Somlau.
 111
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 —

CONTENTS.

PAGE
Preface v
Medicines: —their mode of preparation, their curative selection ;

the dose or potency; and the manner of their administration,

briefly explained vii
Homoeopathic medicines — their number — their form —selection of
remedies —Potencies—mode of administration— diet vii
Table of medicines :
—their official names, abbreviations, English
names, and potencies usually prescribed by the author xiv

INTRODUCTION
Importance of a scientific study of — Confidence of
medicine
patient — Early history of medicine —Primitive period— Sacred
period—Philosophic period —Anatomical period — Greek period
Erudite period —Eeform period— Conflicting opinions of medi-
cine as a science — As an art progressive , 1

CHAPTER I.

History of the liver — Plato's views, Galen's — Asselli's discoveries

— Prequet's, Magendie, Tiedmann, Bernard, Lehmann, and
Schmidt —Anatomy of liver — structures —Physiology of Bile,
uses of, relative weight and size of liver in health and disease
Bartholin's views — Haller, Cruveilheir, Hiiscke, and Frerichs
—Age, sex, digestion, effect of, on size and disease — Normal and
abnormal conditions of liver — Causes : age, temperament,
climate, diet, regimen, type 4
 ——

xviii CONTENTS.

CHAPTER II.
PAGE
Functional disorders of the liver — 1. Diminislied secretion of
bile— Causes — Symptoms — Treatment —Allopathic — Homoeo-
pathic — 2.Increased secretion of bile — Causes — Symptoms
Treatment — Allopathic— Homoeopathic — Secretion of morbid
3.

or altered bile — Causes — Symptoms — Treatment —Allopathic

Homoeopathic 15

CHAPTER III.

Neuralgia of liver (Tic douloureux)—History Anatomy of,

Physiology— Clinical description—Nosology — Age — Sex — Symp-

toms — Diagnosis, cases illustrative of—Treatment 24

CHAPTER IV.

Jaundice, synonyms of—National names — History — Definitions

— Theories — Distinguishing characteristics — Symptoms — Causes
— Duration—Modes of termination — Diagnosis— Causes — Treat-
ment— Epidemic forms of— Spurious forms^— Infantile jaundice
Pregnant Jaundice — Malignant, history of—Morbid anatomy of
— Causes — Diversity of opinions — Treatment—Allopathic
Empirical—Homoeopathic—Hygienic — Mineral Waters 33

CHAPTER V.

Acute inflammation of the liver—Synonyms—National names —His-

tory —Forms — Causes — Symptoms —Treatment
of inflammation 68

CHAPTER VI.

Acute or yellow atrophy of the liver— Synonyms—History

Symptoms, Chemistry of Leucine, Tyrosine— Constituents
Physiology— Pathology—Anatomy, nature of— Etiology-
Causes— Diagnosis— Treatment—Allopathic Homoeopathic — 73
 —

CONTENTS. XIX

CHAPTER YII.

PAGE
Diffuse inflammation of the —Chronic form
liver (Cirrhosis)
Synonyms, history of—Anatomy— Symptoms (first stage)
Pathology — Symptoms (second stage), Hypertrophy of — Symp-
toms — Causes —Etiology — Fatty liver —Hyperaemic liver
Pyle-Phlebitic liver — Chronic atrophy,
— Peri-hepatic atrophy
red— Treatment—Allopathic — Homoeopathic — Diet — Hygiene
—Treatment of complications 97

CHAPTER VIII.
Tropical abscess and pysemic abscess of liver —Inflammatory forms
of — Terminations — Pysemic abscess, — Causes
diagnosis of
Tropical abscess, diagnosis of — Statistics — Symptoms—Pus,
quantity of— Authorities— Cases illustrative of— Post-mortems
— Treatment—Allopathic—Homoeopathic— Surgery of 122

CHAPTER IX.

Enlargement of the —Hypertrophy—Painless and Painful

liver
enlargement— History —Anatomy of — Waxy — Causes liver

—Etiology— — Symptoms —Duration and progress

Statistics
Diagnosis—Treatment 142

CHAPTER X.

Eatty liver —Anatomy— Causes— Symptoms—Complications 150

CHAPTER XI.

Treatment — Simple enlargement (Hypertrophy) — Symptoms

Causes — Treatment 15a

CHAPTER XII.
Hydatids—Description of— Synopyms —IS'ational names—History
of—Authorities —Anatomy —Echinococcus—Anatomy of— Size
— Direction — — Duration disease—Modes of Ter-
Statistics of
mination— Symptoms— Diagnosis — Treatment— Prophylactic
Therapeutic — Surgical 158
 —

XX CONTENTS.

CHAPTER XIII.
PACK
Cancer of tlie liver —History — Great affinity for liver — Anatomy
—
of— Varieties of Cancer, viz., Medullary Encephaloid— Car-
cinoma —
Fungus hsematodes —
Melanotic —Cystic Colloid —
Etiology of —
Age, influence of —
Statistics Sex Causes — —
Duration— Symptoms — Complications— Diagnosis — Prognosis
Diagnosis — Diseases confounded —Treatment—Allopathic
witli

Homoeopathic 175

CHAPTER XIV.
Gall-stones — Age, tendency to —
Biliary acids Bile pig- —
ments — Biliary colic —
Budd, authority on Sex Causes —
— Character of gall-stones— Chemical constituents of gall-
of
— Cholesterine —Cholepyrrhin — Cholepyrrhin and lime
stones
— Choleohlorin— Cholate of lime— Glycocholate of lime— Gall-
stones, their situation— Diet— Diathesis— History of gall-
stones — Hepatic colic — —
Inorganic metallic matters Gall-stones,
number found by Hoffmann— Frerichs —Morgagni— Author
Pathology of gall-stones — Authorities — Boerhaavc — Hoffmann
—Morgagni— Galeatti—Walter— Sex, tendency to— Symptoms
—when in substances of liver—when in gall-bladder— when in
cystic duct— when in common duct— Treatment—Allopathic
Homoeopathic l^*^

Mineral Waters ..- 216

 v
\ UL 2 1918

THE LIVEE.
Introduction.

In order to study and carry out the practice of

medicine in an accurate and scientific manner, it is
essential that we should be deeply impressed with its
importance ; and to be so impressed, we must be-
lieve in it, and worship it as our god. These words,
or something very similar, were uttered by a continental
physician* of great learning, classical and philosophic
lore, whose life and writings breathe a sincere philan-

thropy, contain a deep sense, and constitute, according

to my humble opinion, the foundation and moral status
of all medical practice. It is evident, indeed, that the
practitioner who has no faith in the compass that guides
cannot devote himself to
him, or the eflicacy of his art,

the study and practice of it with that zeal, perse-

verance, and pleasure he otherwise would have done.
Moreover, it will not suffice for the physician only to be
convinced of the utility and efficacy of the remedies he
prescribes ; it is of the greatest import to the success of
such treatment, that the patient share his confidence in
them as well. It is, therefore, important to all of us to
form early a reasonable opinion on the degree of efficacy

* Cabaniso, " Du Degre de certitude de la Medicine."

B
Z INTEODUCTION.

and certainty tliat may be attained in medicine. The

practice of medicine, or the " Art of Healing," is not of
recent birth, but stands coeval with the world's history.
The question is, Did it spring from the natural wants
"

of man ?
" or as some ancient and modern philosophers
will have it, " an evidence of the degeneration of the
human species?" It belongs to history alone to solve
these questions ; for, it appears from the most un-
doubted traditions, that there does not exist, and never
has existed a people, whether savage or civilized, who
had not some crude and primitive knowledge of medi-
cine. We are therefore compelled to conclude from this
fact, that the art of medicine is destined to satisfy an
Irresistible, Imperious, and a N'atural want.
The art of medicine may be said to be a Science
which aims at the preservation of health, the cure of
disease, and the physical perfection of man. In the early
ages this art of healing consisted only in a succinct
description of diseases which had been observed, and
the indication of the remedies employed to combat them.
These two parts correspond to what at this day are
named ^NTosology, and Therapeutics they relate to :

man in a state of disease only.

Subsequently, those who devoted themselves to the
practice of medicine enlarged gradually the field of their
observation: Nosological became more
descriptions
extended, and therapeutical medications more accurate
and precise. They became convinced, that to under
stand diseases well, it was necessary to study man in a
state of health. Thus Anatomy, or a knowledge of the
structure of the human body and Physiology, or the ;

knowledge of the organic functions, became important

 ;

INTEODUCTION. 3

branches of medical science. Experience also taught

those ancient physicians that it is always more important,
and often easier, to prevent the development of certain
diseases, than to arrest their progress when once deve-
loped. Consequently physicians turned their attention
towards this object. They traced the rules for the
preservation of health, and the collection of these rules
constitutes a new branch of the art called Hygiene.
As a profession, medicine was first practised primi-
tively by the chiefs of families, of tribes, and of nations

and by generals and legislators. This epoch may be set

down as the " Peimitive Period," or that of instinct
ending with the fall of Troy, about twelve centuries
before the Christian era.
Secondly, —
merged into what is called the Mystic
It
or Sacked period, which extended from the dissolution
of the " Pythagorean Society " to about the year 500 A.c.
Thirdly, —The Philosophic Period, which ended at
the foundation of the Alexandrian Library, 320 A. c.
Fourthly, —The Anatomic, or Galenic which period,
extended the
to age— 200th year of the Christian
first

Era.
Fifthly,—The Greek Period, which closed the at
destruction of the Alexandrian Library, 640. a.d.
Sixthly, — The Arabic Period, which closed with the
fourteenth century.
Seventhly, —The Erudite Period, comprising the
fifteenthand sixteenth century.
Finally,—The Eeform Period, embracing the seven-
teenth and eighteenth century.
As a science— so far as regard theories —medicine
offers the picture of a great republic, delivered up to
4 V HISTOKY OF LIVER.

many rival which dominate by turns, without

factions,
ever obtaining lasting power. The various theories
propounded, age after age, are so many arenas for
—
interminable discussions a real Tower of Babel it is, ;

in fact, the apple of discord among physicians.

As an art, that is to say, in regard to the rules which
have been established at divers epochs for the cure
of diseases and the preservation of health —medicine
appears to me to have followed a constantly progressive
march, from its origin in the mystic ages down to the
death of Galen, a.d. 200. Then it remained stationary,
or even retrograded, at least in Europe, until the end
of the fourteenth century of the Christian era. But
from epoch the healing art took a new and vigorous
this
bound, and acquired from generation to generation
remarkable perfection. Those who deny the progress
of medicine have never seriously studied its history.
With these preliminary remarks, let us now to the
more special object in view, — "The Liver AND ITS
DERANGEMENTS."

CHAPTEE I.

Historically. — It
an exceedingly interesting study
is

to trace the views which medical men at various

periods, and all ages, have formed relative to the func-
tions of individual organs of the body, and the diseases
to which these organs are liable and there is no organ ;

wherein history attests a greater change of views, than

in the case of the liver.
By the divine Plato, 430 B.C., the liver was regarded
as the central organ of vegetable life ; by Galen,
 HISTOEY OF LIVER. D

A.D. 200, as the focus of animal heat, and as the organ

intended for the formation of blood, and for the origin
of the veins. These views of the great Eoman physician
underwent scarcely any modification by his able
followers the Arabian physicians, and remained as such
until the middle of the seventeenth century. In the
pathology of the ancients, particularly of Galen, the
liverand the portal system served as the starting-point
of manifold disturbances. There were described, not
only a host of anatomical and functional lesions of the
organ itself; such as inflammation, abscess, obstruction
of the ducts, and the different conditions resulting from
intemperance ; but a large proportion of constitutional
diseases were at the same time referred to the same source.
A further cause was found in the
of general diseases
—
products of the secretion of that organ the yellow, and
—
the black bile which, under a humoral pathology, had
a mighty importance as elementary constituents of the
organism.
The yellow bile, for instance, was thought would induce
acute diseases, running a rapid course and accompanied
by a high degree of temperature, such as erysipelas, &c.;
while the black bile was believed to give rise to chronic
diseases, such as mental disorders, apoplexy, and con-
vulsions. Throughout the pathological works which
appeared from the time of Galen down to the middle of
the seventeenth century, this organ was looked upon
as the seat of the soul itself.

The discovery of the lacteal vessels by Aselli, in

1622; the thoracic duct by Prequet, in 1647; and the
circulation of the blood by our own Harvey, in 1628,
gave a severe shock to the views of Galen and his
6 ANATOMICAL STKUCTURE OF LIVER.

followers ; it was, however, reserved for such men as

Magendie, Tiedemann, Claude Bernard, Lehmann, and
C. Schmidt, to extend the boundaries of our knowledge,
and reproduce in a more exact form, the natural func-
tions of this remarkable gland, reference to which will
be made further on.
—
Anatomically. The liver may be described as a
secreting and excreting gland, of prodigious size, occupy-
ing a considerable space in the upper part of the abdo-
minal cavity it is irregular in form, measuring through
;

its longest diameter about twelve inches ; in weight,

from four to five pounds, and having on its under
surface a pear-shaped reservoir for the reception of the
bile —the gall-bladder.bounded above by the
It is
vault of the diaphragm anteriorly and laterally by the
;

arch of the ribs posteriorly by the spinal column and

;
;

below by the stomach and intestines.

In Steucture, the liver is divided externally into
five lobes, viz., the right, left, quadrangular, lobe of
Spigelius, and the caudated lobe. The outlines of these
lobes are marked by an equal number of fissures, viz.,
the longitudinal, the venous duct, the transverse, the
gall-bladder, and the fissure for the vena cava. It is
held in position by an equal number of bands, or liga-
ments, four of which are reflections of the serous
membrane of the intestines
— " the peritoneum," yiz.,

the longitudinal, two lateral, the coronary, and the

fifth, or round ligament : formed upon the obliteration of
the umbilical veins of the foetus, whose place it occupies.
The blood-vessels and lymphatics are likewise five in

—
number namely, the hepatic artery, portal veins,
hepatic veins, hepatic ducts, and lymphatics.
 PHYSIOLOGY OF LIVER, 7

The nerves entering the liver are derived from the

systems both of animal and of organic life ; the former
spring from the right phrenic and pneumogastric
nerves, the latter from the hepatic plexus of the great
sympathetic track.
The Minute Steucture of this wonderful laboratory
is composed of a vast number of bodies, called lobules,
which do not exceed in size a millet seed, or a " homoeo-
each lobule contains
pathic globule;" nevertheless all

the elementary parts of which the entire organ is

constructed —namely, branches of the hepatic artery

and veins, branches of the portal veins, branches of the
hepatic ducts and secreting cells.

The portal veins, hepatic artery, and hepatic duct

are enclosed in a sheath of fibro-cellular tissue, called
;
" Glisson's capsule " they enter the liver together at
its transverse fissure, and ramify throughout the whole
substance of the organ.
Physiologically. — The portal vein distributes its

branches through portal canals, which are channelled

throughout every portion of the organ, however minute ;
it conveys the returning blood from the chylo-poietic
viscera it likewise collects the venous blood from the
;

extreme ramifications of the hepatic artery in the sub-

stance of the liver itself. It gives off branches in

the canals, called vaginal, and form venous vaginal

plexuses ; these give off inter-lobular branches, and the

latter enter the lobules and form lobular venous ijlexuscs.

from the blood circulating in which the bile is secreted.
The bile so secreted in these lohular ;pUxuses is now
received by a network of minute ducts, the lobular
biliary ^plexuses, and conveyed from the lobule into the
 —

8 PHYSIOLOGY OF LIVER.

inter-lobular ducts; from thence poured into the

it is
biliary vaginal plexuses of the portal canal; thence into
the excreting ducts, by which it is carried to the gall-
bladder, and from thence into the duodenum, or the first
stage of the small intestines; where it comes in contact
with the pancreatic juice, and the chyme from the
stomach, which compound converts the latter into chyle.
The hepatic artery distributes branches through
every portal canal, and gives off what is termed vaginal
branches, which form a vaginal hepatic 'plexus, from
which the inter-lobular branches arise ; and these latter
terminate ultimately in the lobular venous plexuses of
the portal vein. The artery ramifies abundantly in the
coats of the hepatic ducts, enabling them to provide
their mucous secretions, and supplies the nutrient
vessels of the whole organ as well.
The hepatic veins commence in the centre of each
lobule by minute radicles, which collect the impure
blood from the lobular venous plexus, and convey it into
the intra-lobular veins ; these open into the sub-lobular
veins, and the sub-lobular veins unite to form the large
hepatic trunks by which the impure blood of the liver
is conveyed into the vena cava as it passes through the

organ. Such is a brief outline of the structure and

minute anatomy of the liver, as recorded by that eminent
anatomist and physiologist, the late Mr. Kiernan.
The knowledge we at present possess of the physio-
logical functions of the liver, as drawn from the fore-
going anatomical arrangement, coupled with the brilliant
experiments of Bernard, Sharpey, Harley, and others,
enables us to arrive at the following conclusions, viz.,

1. That the bile is secreted wholly from venous

 ;

USE OF BILIARY SECRETION. ^

blood, such blood being collected from the chylo-poietic

viscera.
That the hepatic artery carries pure (oxygenated)
2.

blood into the liver to supply nourishment to its various

structures.
That the hepatic ducts collect the bile and carry
3.

it into larger canals, and from thence into the main

—
resewoir the gall-bladder from thence into the cystic
;

duct, from this into the common duct, and from

thence into the intestines, where it enters into the
process of chylification.
4. That the liver participates directly in the genera-
tion of the elementary principles of the blood, and that
it moreover assists in purifying the blood by excreting
carbon and hydrogen, which being subsequently re-
absorbed, combine with oxygen, and thus assist to keep
up animal heat.
5. That the liver is a large manufacturer of sugar

which, according to C. Bernard, is burnt off in the

lungs, and goes to sustain animal heat but according
;

to Chauveau and Harley, plays an important part in

the process of nutrition. This appears to be a far more
feasible idea than the former, as it is a well-known fact,
that while bees have the power of transforming sugar
into wax, man and other animals change it into adipose
tissue. IS'egroes are said to become fat and lazy during
the sugar harvest, from sucking the fresh cane. Babies
fatten on sugar quicker than anything else and for a
;

like object I have known molasses and coarse sugar

given to pigs.
Lastly. The liver, as we have already observed, secretes
bile, which, when blended with the juice from the pan-
10 SIZE OF LIVER —NORMAL AND ABNORMAL.

creas, converts the chyme into chyle. It also performs an-

other important office, namely, it acts asan aperient,
''
Nature's own black draught ;
" for whenever there is
a scanty secretion, or excretion of bile, constipation in-
variably follows ; as clearly indicated in torpor of the
liver, biliary and jaundice.
congestion, Eestore the
natural functions of the liver, and you obtain a healthy
and regular supply of bile a train of morbid symptoms ;

will disappear and natural evacuations will invariably

;

follow.

Eelative Weight and Size of the Liver in Health

AND Disease and its Diagnostic Value in its
;

Normal and Abnormal Conditions.

In order to be able to form a correct diagnosis of

diseases of the liver, it is essential that we should be able
—in a forensic, pathological, and clinical point of view,
— draw a
to line between the Normal and Abnormal
conditions of that organ ; it should at the same time,
however, be observed, that the absolute weight of the
liver usually increases and decreases in proportion to
the weight of the body so that the term absolute can
:

only be employed in a comparative sense.

The relative weight of the liver in proportion to that
of the body, has occupied the attention of many eminent
authorities.
Bartholin, for instance, gives it as 1 to 36 ; Haller as
1 to 25 and the average weight of the gland, according
;

to the last-named authority, was calculated at 45 oz., or

3-7 pounds by Cruveilheir at 3 pounds by Huschke
; ;
 SIZE OF LIVER —NORMAL AND ABNORMAL. 11

at 4 to 6 pounds ; and by Frericlis at 4' 6 pounds avoir-

dupois.
The statistics from which these calculations were
gleaned, were made upon individuals who had died
suddenly —from accidents, without the loss of any blood ;

and whose livers, on careful examination, presented a

perfectly healthy appearance.
Age. —Frerichs states " that it is during the first stages
of infantile development, that the liver is largest, in
proportion to the size of the body." Portal and Mekel
have calculated that the liver in newly-born children
ought to be one-fourth heavier than in children from
eight to ten months old. As age advances the organ be-
comes smaller, and much in advance of that of the body.
In old age, therefore, the liver presents a marked contrast
to the muscular tissue of the heart; as there is as a
rule, atrophy of the former, and hypertrophy of the latter.

Sex. —With regard to sex, Francis Glisson in 1750

maintained that the liver is heavier in men than in
women Dumas ; maintained the very reverse. Frerichs
however, has been unable to detect any marked differ-

ences dependent upon sex, beyond the fact that in

" scrofulous women " he found it larger, and attributes
abundant deposit of fatty matter.
this to the
—
Digestion of Food. The process of digestion exer-
cises a marked influence over the size of the liver,
particularly during its second stage (chylification) ; this

is partly owing to the state of congestion which then

takes place; and partly to the abundant deposit of
granular and amorphous materials in the interior of the
hepatic cells. Still more striking is the influence of a
diet rich in fat, and too bulky, with at the same time
12 INFLUENCE OF AGE, SEX, AND FOOD ON LIVER.

an impaired power of digestion. In sncli cases the

deposit of fat, in the substance of the gland, induces an
undue proportion in its size. Bidder and Schmidt found
the relative weight in such cases to be as 1 to 16 ;
and
another observer, Lereboullet, ascertained that in geese
the relative weight of the liver varied from 1 in 26
to 1 in 18, after feeding for two weeks upon maize;
and that after four weeks it rose to 1 in 12-8. Such
statistics are exceedingly interesting, and of great value
to the physician, in a clinical and hygienic point of
view, as they point out to him the absolute necessity of
selecting a diet devoid of those aliments which go to
form adipose tissue.
Normal and Abnormal Conditions of the Liver. —
In the diagnosis of diseases of this gland, an accurate
knowledge of the size and form of the organ is one of
the first points for consideration. The size and normal
position of the liver have already been referred to and ;

its boundaries, after some experience, can be defined by

percussion, —palpation, —
mensuration, —
sometimes by
auscultation — and careful manipulation. Its abnorma-
lities present features of considerable interest, and such

as are found in no other organ of the body some of ;

these malformations are congenital, which on a cursory

examination at the bedside, may easily lead to a wrong
diagnosis. Thus, some livers of this type are found to be
quadrangular others have a prolonged left lobe, bearing
;

a strong similarity to a leg of mutton laid across the

hyponchondriac region and others, where adhesions
;

take place between the extremity of the left lobe and

spleen. To these congenital deformities may be added a
more numerous class of what may be called acquired
 CAUSES OF DISEASES OF LIVER. 13

malformations ; these arise partly from deformities of the

thorax, from disease of the hepatic tissue, from tumours,
cancer, abscesses, hydatids, and from tight lacing. The
liver may also be entirely dislodged or dislocated from
its natural position. The most frequent cause of this is
undoubtedly tight lacing, which forces the gland down-
wards even as far as the pubis. Lateral dislocations
likewise take place from pulmonary emphysema, from
effusions into the right or left pleural cavity, from peri-
cardial effusions, and from eccentric hypertrophies of
the heart.

Causes of Diseases of the Liver.

In order to avoid unnecessary repetition, whilst con-
sidering the divers forms of hepatic derangements, we
shall here glance at the most prominent Causes, which
the experience of many observers have found to occasion
them. These causes may produce various effects, or
allied effects, according to the Temperament, Constitu-
tion, and mode of living of the individuals prone to
such disorders.
Age. —As regards age, it has been found that diseases
of the liver seldom occur until after puberty, unless it

be in the children of Europeans residing in the East

Indies, or other inter-tropical climate.
—
Temperament. The sanguine, sanguino-melancholic,
the irritable, and those of a scrofulous diathesis, are
more frequently attacked with liver diseases than others.
In the young, and the middle-aged, the diseases are
acute and inflammatory at more advanced periods,
;

they are most frequently congestive and structural.

14 CAUSES OF DISEASES OF LIVER.

Climate. —The climacteric causes may be set down

as —high ranges of atmospheric temperature, and the
circumstances connected with them, such as a sudden
change from a dry to a humid air ; exposure to the sun's
rays ; malaria, &c.
Diet and Eegimen. — JSText to climabe and tempera-
ture, may be set down an irregular mode of living ; such
as partaking largely and frequently of animal, rich,
highly seasoned, incongruous dishes, sauces, spices, low-
class wines and spirituous liquors, unwholesome food,
and impure water. Mercurial preparations are likewise
known to exert an undoubted influence in producing
disease of the liver, either of an inflammatory, or of an
obstructive character to these may be added the
;

absorption of morbid or fsecal matters from the alimen-

tary canal, indolent and sedentary occupations, mental
emotions, dysentery and chronic diarrhoea. The sup-
pression of habitual discharges, such as haemorrhoids,
the catamenia, leucorrhoea, the disappearance or drying
up of eruptions and ulcers, the closing of fistulas, sinuses,
and the operation for piles, &c., have been no uncommon
causes of disease of the liver.
Type. —Finally, of the several races of mankind, the
white or fair races are the most prone to hepatic disorders.
The immunity of the dark races, particularly the negro,
from diseases of the liver, is very remarkable, even in
climates where these diseases may be considered as
endemic.
 — ;

15

CHAPTEE II.

Functional Disoeders of the Livee.

Under the head of functional disorders may be em-

bodied aU those conditions of the biliary secretions
which differ more from the healthy state, and
or less
terminate, sooner or later, in further and more serious
mischief.
The chief derangements which fall nnder this head
are
1. Diminished secretion of bile ;

2. Increased secretion of bile ; and

3. Secretion of morbid or altered bile.
1. Diminished Secretion of Bile, better known as
" torpor of the liver," and more familiarly so as a

" bilious attack," may be briefly defined as an irregu- —

lar or costive condition of the bowels, the stools being
insufficiently charged with bile ; a sallow or muddy ap-
pearance of the countenance ; dejection of spirits

flatulency ; and various other symptoms of a dyspeptic

character.
Causes. —The chief causes which lead an impaired to
action of the are — sedentary occupations, indolent
liver
indulgences, neglect of exercise, exposure to cold, humi-
dity, or malaria, after fatigue or excessive perspirations ;

habitual over-excitement of the stomach and liver, from

eating and drinking rich and heating articles; a neg-
IG THE LIVER.

lected condition of the bowels, or accumnlations of

secretions, and faecal matters, in the intestinal canal.
The symptoms (says Copland) of impaired action of
the liver are not always very manifest ; and it is often
very difficult, or even impossible to determine, even
when these symptons are well marked, whether or no
they depend merely npon diminished energy, or upon
change of the structure of the organ and of its appen-
dages, unless we obtain a correct history of the patient's
habits, and the nature of his former ailments. For in-
stance, when such a patient complains — after having
enjoyed good health, or without having experienced, on
former occasions, either acute or chronic affections of the
liver or stomach — of dyspeptic symptoms, with a costive
or irregular state of the bowels, the stools pale or clayey,
the urine dark or high-coloured; want of appetite, low-
ness of spirits, a foul a,nd coated tongue, a bitter or nasty
taste of the mouth, a dark, sallow, or dingy appearance
of the countenance, with fulness or tenderness in the he-
patic region, it may be fairly inferred that the functions of
the liver are only simply deranged. Should, however,
the above train of symptoms occur in a patient who has
for years lived intemperately, both in eating and drink-
ing, or who has resided for years in a hot climate, or
who has from repeated attacks of the same dis-
suffered
order; the inferences are, that such impaired functions
may be associated with congestion, inflammation, or some
deep-seated organic lesion of the substance of the
liver.

Treatment. — Allopathically, — Torpor of the liver is

usually treated by the various mercurial preparations,

saline and deobstruent aperients and taraxicum ; failing
 FUNCTIONAL DISORDERS OF THE LIVER. 17

this, by potass., soda, aloes, and saline or bitter stomachic

aperients; failing this, by emetics, blisters, nitro-

muriatic acid, plasters, iodide of potassium, and inspis-

sated ox -gall.
Homo&opathically. — Simple torpor of the liver will
yield kindly enough to such remedies as the Podo-
phyllum Peltatum, Leptanclra Virginica, and an occa-
sional or alternating dose of JSFux Vomica, to correct
stomachic derangements. The two'former maybe taken
in four, live, or six drop doses of the tinctures, in the
matrix form, two or three times a day, the latter in the
first or second decimal dilution.
In the more obstinate and aggravated form of torpor
of the liver, when there exists a sick bilious headache,
which is further characterized by a violent aching pain
in the whole head, with a feeling as if the brain were
sore,accompanied by a copious flow of water from the
mouth, nausea, vomiting of green and yellow bile, and a
muddy or sallow hue of the countenance, Merc. Sol. in

the first or second trituration will not fail to relieve the

sufferer and in the still more obstinate form, or when
;

it assumes a chronic character, indicated by a recur-

rence of the attacks from time to time a sallow icter- ;

oidal tint of the face, a coated tongue, a clammy mouth,

fulness and tension in the right hepatic region, disten-
sion and hardness of the abdomen constipation, which ;

at times alternates with green, dark brown, reddish, or

slate-coloured loose stools, at times tinged with blood
and slimy mucus ; I have found great benefit, and often
a radical cure, to follow a repetition of Merc. Sol., followed
by Leptandra, Taraxacum, and Acid; anNiiro-mitriatic
occasional Turkish bath, with a prolonged shampooing
c
18 THE LIVER.

over the repjion of the liver ; a cold compress, worn both

night and day ;and gymnastic exercise
horse, running, ;

early rising, followed by a cold sitz bath, and a resort

to some of the deobstruent and aperient mineral waters,
such as the Seidchutz and Pulna, in Germany Chel- ;

tenham, in Gloucestershire Leamington, in Warwick-

;

shire ; and the celebrated Sulpho-Saline of Llandrin-

dod, in Eadnorshire.
Increased or Excessive Secretion of Bile.—
2.

This is the very opposite of the foregoing morbid con-

dition, and may be defined as copious fluid faecal evacua-
tions, highly charged with which is sometimes
bile,
green, at other times slate-coloured and often preceded ;

by griping, tormina and nausea, and sometimes by vomit-

ing, and an accelerated pulse.
An inordinate secretion of bile more frequently is

inferred from circumstances, than proved by unequivocal

evidence accumulations of bile may form in the
: for
gall bladder and hepatic ducts, and when suddenly dis-
charged into the alimentary canal, give rise to the same
group of symptoms which characterize an increased
secretion when in fact only an increased flow of
;

previously obstructed or accumulated bile has taken

place. In this country, particularly during the sum-
mer and autumnal months, this form of biliary de-
rangement is of frequent occurrence, and known as bilious
diarrhoea —
bilious or English cholera and merely form —
minor grades, as it were, of the same pathological con-
ditions often met with in warm and Eastern climates. The
further symptomological phases of this form of biliary
derangement is recognized by the evacuations being at
first feculent, and commonly of a green, or greenish
 FUNCTIONAL DISOEDEES OF THE LIVEE. 19

yellow, or even a bright yellow colour ; they afterwards

become more fluid and watery, vary in colour, and
mixed with thin feculent matter. If the diarrhoea con-
tinues, it frequently contains yellowish or greenish
yellow mucus, either in large thick masses, or in thin,
glairy, or gelatinous pieces, which fall to the bottom of
the pan, and admit of being drawn into long filaments ;

or it consists chiefly of a serous fluid, coloured by the

bile, and presenting either a glairy mucus or albuminous
flocculi. This form of bilious diarrhcBa may terminate
in an inflammatory condition of some part of the
alimentary canal, or in dysentery.
Teeatment. — Allopatliically. — and fal-
If congestion
ness of the liver exist, this form of hepatic derangement
is first treated by general bleeding, cupping, or leeches
applied to the region of that organ. Next to bleeding
comes in rotation the administration of demulcents,
lubricating infusions, or diluents, combined with nitre,
sub-carbonate of soda, antimony, and camphor followed ;

by blue pill, grey powder, castor oil, and other purga-

tives and if the diarrhoea becomes obstinate, by opium
;

and various astringents {Copland).

Homoeopathically. —Increased secretion of bile, with its
attendant symptoms, is successfully treated by such
well-proved remedies as Aconite, Aloes, Arg. Nitratis,
Ghelid. MaJ., Cham., Merc. Sol, Ipec, Nux Tom., and
Rheum. In the selection of these medicines, due regard
should be paid to their pathogeneses and a correct ;

estimate formed of their similitude to the group of

symptoms presented to our view.
Aconite undoubtedly stands foremost as a curative
ao-ent in bilious diarrhoea, when connected with conges-
20 THE LIVER.

tion of the liver, or engorgement of the portal capillaries

in the bowels, resulting in the accumulation of bile as a
foreign agent, Avhich manifests an irritating influence
upon the mucous membrane followed by
intestinal ;

frequent and painful discharges of mucus and fsecal

matter, mixed with green bile.
Aloes is well indicated when the stools have a peculiar
putrid smell, the w^iole body feeling hot during an
evacuation, with an uncomfortable feeling in the region
of the liver.
Arg. Nit. —When there exists a sense of fulness and
stitches in the liver, coupled with organic diseases of
the organ. Green, bilious, mucous diarrhoea, preceded
by violent colicky pains.
ChelidoniumMojus. —The group of symptoms
which to
this remedy may be considered as homoeopathic, " and
vrhich may be described as a diarrhoea of a gastric bilious
character," consists of pain with a feeling of fulness in
the region of the liver, stomach, and spleen, with hard-
ness and pain on pressure. The motions are slimy, greyish
yellow, papescent, or watery; the complexion is sallow, the
tongue coated, and no appetite; the urine is turbid, and of a
deep yellow colour, with general chilliness and lassitude.
Chamomilla. — In
the bilious diarrhoea of children,
when the discharges have a sour smell, are watery, slimy,
green, or yellow, and. preceded by pinching or cutting
pains in the bowels, with sub-acute congestion of the
liver, indicated by pain on pressure, with a fretful,

peevish, and feverish condition of the little patient,

Chamomilla sometimes act as a curative agent in
will
the second or third dilution. Although Chamomilla is
very commonly administered for this affection, and forms
 -

FUNCTIONAL DISORDERS OF THE LIVER. 21

the leading remedy in most " Domestic treatises," yet I

infinitely prefer, and find I derive more satisfactory results

from Aconite in the second or third dilution.

Merc. Sol. JSah.—ln bilious diarrhoea, attended by

bilious colic and flatulent colic, Mercury will be found
one of our leading and most effectual remedies. The
pathogenetic effects of Mercury on the body in health
are remarkably striking, and produce as correct a picture
of the disease under consideration as anyone can well
imagine. This metallic compound not only increases
the frequency of the alvine discharges, but it alters their
colour and smell as well : thus we have as symptoms, —
" bloody mucous discharges, green excoriating discharges,
bright yellow, reddish or dark brown discharges, which
may be watery or papescent, with slight or very offensive
smell in addition, we meet with distension and hard-
;

ness of the abdomen ; dull aching pains in the liver ;

cutting pinching pains in the bowels the hands become

;

cold, the pulse feeble and accelerated; with tenesmus

and a frequent desire to go to stool."
lyecacuanha is a very useful remedy in certain forms

of bilious diarrhoea, and may be given alone .or in alter-

nation with the foregoing medicines, particularly when

the following symptoms are present, which indicate in a

marked deoree the selection of this drug: —nausea,

qualmishness in the stomach and bowels ; a flow of water
from the mouth, loss of appetite, and a white-coated
tongue; bloody, liquid, green, foul-smelling and fer-
mented evacuations, with pinching, cutting, neuralgic
pains in the abdomen. I generally vary the potency
from the third to the sixth.
Nux Vomica is another auxiliary remedy of great
22 THE LIVER.

value, and well indicated when there exists, in addition

to a bilious diarrhoea, considerable gastric derangement,

such as pain, tension, crampy pains, frequent eructation
and flatulence. The most useful form in which I have
found this remedy to act is the first and second decimal
dilution, one or two drops in a tablespoonful of water,
and repeated at short intervals till relieved.
Rheum, in the third dilution, has done good service
in a few cases of bilious diarrhoea of children, when the
stools were papescent, with tenesmus, prostration, dis-
tension of the bowels, and scanty, smarting urine.
3. Secretion of Morbid or Altered Bile. There —
is every reason to suppose that the bile, when first

secreted, is not, as a rule, possessed of any vitiated pro-

perties, but that it acquires such properties after having
passed into the hile ducts Siiid gall bladder, and that
during its accumulation and retardation in those cavities,

such properties are created, eitherby the reaction of its

different elements on each other, or by the removal by
absorption of its more watery constituents. That, how-
ever, the bilious secretion is at other times wonderfully
altered in character and appearance, is fully borne out
by post-mortem appearances, and its close connection
with structural lesions of the liver, and malignant or
pestilential maladies. In the former the bile is found
to be pale, watery, and albuminous in the latter, dark ;

green, greenish brown, or tar-like in consistency and

colour, with far more acridity than is ever found in its
normal condition ; so much so, indeed, as to produce
marked irritation of the various tissues it comes in
contact with.
It is, however, most probable (at all events in the
 FUNCTIONAL DISOEDEES OF THE LIVEE. 23

majority of cases) that the biliary secretions become

vitiated, either in the hepatic ducts or gall hladcUr, and
that the acrid properties there acquires act as an
it

irritant,and promote its own discharge into the duo-

denum, and from thence along the whole course of the
alimentary canal, setting up at times an obstinate and
aggravated form of bilious or choleraic diarrhoea.
In the treatment of " a vitiated secretion of bile," much
will depend upon the various phenomena attending it
Allopathically. —
It is treated by diluents, demulcents,
warm baths, ipecacuanha, alkalines, anodynes, and
aperients,
HomoeopatTiically. —Looking as I do upon the vitiated
bile thrown out from the gall-bladder into the alimen-
tary canal as a poison, or foreign body, and which cannot
be antidoted by any homoeopathically selected drug, I
treat this vicarious secretion as a poison, and so com-
mence my
treatment by ejecting the offending matter
from the alimentary canal, by the administration of a
mild oleaginous laxative, such as castor oil; this I
follow up by demulcent beverages, such as barley-water,
gum- water, or linseed tea ; and the administration of
Mercurius Soluiilis, Ipecacucmha, or Arse7iicum, if con-
siderable prostrationand gastric derangement exist. The
majority of such cases which have come under my notice
have yielded kindly enough to this mode of treatment,
care being taken that the diet should for the first few
days be bland, easy of digestion, and nourishing in its
properties.
 24

CHAPTER III.

^tTEURALGIA OR " TlC-DoULOUREUX " OF THE LiVER.

Hyperj^isthesia, or exalted sensibility and irritability

of nerve fibre-, is met with in every section and organ of
the body.
The chief forms of "visceral neuralgia " which present
themselves to our notice in practice, are — Gastrodynia,
or Gastralgia, and its various complications ; Colic and
ilius, more especially lead colic ; Splenalgia, or neuralgia
of the spleen ; I^fephralgia of the kidneys ; Hysteralgia
of the wombMastodynia of the breast
; and the one ;

we are now more particularly interested in, viz., Hepa-

talgia —
liver pains, or neuralgia in fact, a form of " tic
douloureux;" for I see no just reason "taking the
;

—
'*
Mstoryandpathology of the disorder into consideration
— why such an expression should not be applied to
neuralgic affections invading other parts of the body, in
addition to the face ;
provided, of course, the form of
neuralgia be of that particular type which is character-
istic of true " tic douloureux." ^

Historically. — Severe pains of the liver were first

noticed by Avicenna of Bockhara, a.d, 980 afterwards ;

by Eolfink and Bartholin and more recently, by Gross-

;

man, Andral, and Stokes of Dublin.

—
Anatomically. It has already been observed that
the nerves, which convey normal and abnormal sensa-
tions to the liver, are derived from the systems, both of
 NEUKALGIA OR " TIC-DOULOUREUX " OF THE LIVER. 26

animal, and of organic life one from the brain, the other
;

from the spinal cord, or ganglionic system.

Physiologically speaking, the activity of the centri-
petal nerve is manifested by the aid of the sensorium, as
a conscious sensation ; and by the intervention of the
spinal cord, or ganglionic system, as, reflex action ; this,

when excessive, is called " hypersesthesia ;

" and when
below the average, " anaesthesia."
The character which these neuralgic affections have
in common, is exalted irritability, and increased
irritation of the sensitive or centripetal nerves. The
expression of such irritation is either mental, one of
consciousness, a sensation, — motor a reflex move-
or ;

—
ment or both may occur at the same time.
The sensation differs according to the peculiar activity
of the nerve of sensation the same difference presents
;

itself in the neuroses of sensibility. Whether a cuta-

neous nerve, or a nerve of sensation supplying a muscle
or an organ of sense, be affected, each retains the
peculiar sphere of sensibility in disease with which it is

endowed in health.
Clinically, it is of the first importance to be able
to diagnose as whether the seat of disease be
to
central or ^erii^heral ; and in making such distinc-
tions it is further necessary that the term peripheral
be correctly interpreted, and not, as is too often the
case, confined to the ultimate ramifications of the nerves.
A nerve can only be considered as central when it is

imbedded within the substance of the brain, the spinal

cord, or the ganglia where its fibres are surrounded by
;

ganglionic corpuscles, and submerged in them the terra ;

peripheral should only be applied to a nerve, from the

 — —— —

26 THE LIVER.

point where it quits, "as it were," the central organ, to

its extreme distribution and what is usually called the
;

root of the nerve, or, more correctly, its point of inser-

tion, is but a portion of the peripheral distribution. By
taking this view of the subject, the doctrine of hyper ces-
thesia and ancesthesia obtains a more exetnsive significa-
tion ; as, the mere casual and superticial examination of
the cutaneous nerves cannot, as it has hitherto done,
suffice to a correct diagnosis, and a successful treatment of
the many obscure forms of neuralgic diseases. It there-
fore becomes the more imperative to examine carefully
the various fibres traversing the osseous canals, or pass-
ing over the brain and spinal cord, as distinct characters
indicate, to the close observer, the seat of disease in dif-
ferent divisions of the peripheral tract. It is likewise
necessary to base the doctrine of the neuroses of sensi-
bility upon the physiological laws governing the nerves
of sensation. These are :

First, The laiu That nerve-

of isolated conduction.
fibre only presents exalted or depressing action which is
affected by the irritating or depressing cause and the ;

adjoining fibre, though ever so closely approximated, is

not implicated.
Secondly, The law of sympathy, or irradiation of sen-
sations. Here the irritation is propagated from the fibre
originally excited to other centripetal nerves.
Thirdly, The law of eccentric phenomena. Every sen-
sation, as it becomes perceptible to consciousness, is
referred to the periphery of the sensitive fibre, the entire
tract of which, from its commencement to its terminal
point, is susceptible of the impression. Sensation varies
according to the peculiar sphere of the affected nerve.
 NEUEALGIA OR "TIC DOULOUREUX" OF THE LIVER. 27

Hypersestliesia of the cutaneous nerves, for instance, is

manifested by pain in its various modifications ; that of
the nerves of special sense by phantasms. The sphere
taken by the brain, as the grand centre of the nervous
system, in sensations, is not only receptive, but reactive as
well. For if the imagination dwells upon the sensation,
the latter becomes more intense, and more defined ; and
the influence or power of imagination may create varied
sensations, as is often proved by the feeling of nausea,
prurigo, and that morbid condition termed " hypochon-
driasis!' Another manifestation of exalted irritability
of the centripetal nerve takes place by reflect action
upon the motor apparatus, in which sensation may be
absent, or it may continue. In the former case, the
absence of accompanying sensation increases the diffi-
culty of forming a correct judgment but we may satisfy
;

ourselves of the real character of the affection, by observ-

ing that the gentlest irritation of centripetal nerves,
which in ordinary conditions would produce no effect, at
once rouses reaction amounting to violent spasmodic
action this is well illustrated in cases of poisoning by
;

strychnine, in tetanus, and in hydrophobia. The com-

bination of sensation and reflex action is often exhibited
in neuralgia of the cerebro-spinal nerves, and more par-
ticularly in the sympathetic. In ciliary neuralgia, for
instance, or photophobia, the eyelids are closed by reflex
action, communicated by the sensitive fibres of the
trigeminus to the motor fibres of the facial nerve. In
prosopalgia, with neuralgia of the tongue, reflex action
is communicated and in consequence
to the hypogiossus,
of this, the tongue becomes tremulous, painful, and
thrown out.
28 THE LIVER.

That reflex action is a frequent source of some of the

most aggravated forms of neuralgia, there cannot be a
doubt ; one of the most obstinate and terrible forms of
" tic-douloureux " of the facial nerveswhich has ever
come under my notice, and which was sent me some
ten years ago by Dr. Shaw, of Battersea, was clearly
traced to organic disease of the kidneys and bladder, in
a male 60 years old. Other cases of a similar kind
have come under my notice, arising from disease of the
uterus, rectum, and spleen.
Passing from the physiological to the nosological
features of hypersesthesia, we find the following rules
applicable to the whole class.
1. Periodicity —the alternation of paroxysms and
intermissions.
2. Uniformity and persistence of the symptoms, how-
ever long the duration of the disease.
3. Absence of danger to life.
4. Freedom of early life from the disease, except in
rare cases.
Age. — As regards age, the middle period of life presents
the greatest predisposition to neuralgia ; old age very
little, and childhood still less.

Sex. — As regards sex, each has a separate proclivity

to certain forms of hypersesthesia ; in the male, it assumes
the form of hyponchondriasis ; in the female, hemicrania,
splenalgia, intercostal neuralgia, hysteralgia, mastodynia
neuralgia, and hepatalgia.
—
Symptomatology. Neuralgia, or tic-douloureux of the
liver, presents itself in the form of acute pain in the

region of that organ, more or less 'constant, but subject

to occasional and violent exacerbations, which at times
 NEURALGIA OR " TiC-DOULOUREUX " OF THE LIVER. 29

assume an intermittent form. These exacerbations,

or return of the pains, are frequently traced to inordinate
mental emotions, derangement of the stomach or bowels,
fatigue, irregularity of the catamenia, painful or other-
wise. The character of these pains, their severity, the
suddenness and rapidity of their
of their succession
disappearance, their intermissions, and the general good
state of health durino- the intervals of such attacks, all

lead to the belief that they are the result of some morbid
sensibility, manifested in the nervous filaments, or plex-
uses of the liver, supplied by the great sympathetic, or
the pneumogastric nerve.
DiAGNOSTiCALLY, —It is of the first importance that we
should be able clearly to define the symptoms of neu-
ralgia, in contradistinction to those of inflammation of
the liver ; an error, however, which many a physician of
experience has committed, as recorded in the literature
of the subject. Dr. W. Stokes, of Dublin, in his treatise,
mentions the case of a lady, of luxurious habits and
nervous temperament, who was attacked, while in India,
with pain in the region of the which was attributed
liver,

to inflammation for which she was largely bled and

;

mercurialized, wdth no relief from the pain. On her

passage to England she was again bled several times,
and twice mercurialized. After her arrival, she w^as
again bled, leeched, blistered, and mercurialized. These
bloodthirsty means afforded temporary relief, but the
complaint very shortly afterwards returned with in-
creased severity ; her constitution now became shattered ;

hysterical paroxysms were frequent and violent, and the

stomach irritable. Finding there was no fever, the right
hypochondrium supple, the lower part of the chest
30 THE LIVER.

soundini^ clear, the tongue clean, and the complexion

normal a repetition of the same reckless treatment was
;

omitted, and a generous diet, change of air, and full

doses of Iron were prescribed, which in a few weeks
perfectly restored her to health. Another lady was
treated for inflammation. A physician was consulted who
could detect no evidence of structural disease beyond the
pain she also was now treated by the carbonate of iron,
;

with complete success. Copland records an interesting case

of a similar kind, which occurred in his own practice. It
was that of a lady who had resided in India, and had
experienced hepatic disease, for which she also had been
bled, leeched, blistered, and mercurialized. On her return
to this country, she consultedan eminent accoucheur,
on account of a leucorrhcea and some uterine disorder.
She was hysterical, and much weakened and in this ;

condition suffered from a severe attack of pain in the

liver,which was mistaken for inflammation, and treated
—
secundem artem with marked aggravation of the pain.
Copland was now consulted, who viewed the case as
purely neuralgic, and a treatment in accordance with
such a view soon restored her to health.
Five cases of " tic-douloureux " of the liver have come
under my notice since 1857 four were females, and
;

one a male all had resided in India for many years

;
;

all were supposed to have suffered from inflammation of

the liver for which three were bled, blistered, and

;

mercurialized, and sent home to England as shattered

wrecks the remaining two were treated by mild mer-
;

curials. Now, whether all these did really suffer from

hepatitis I am not prepared to say ; but they all

showed unmistakable symptoms of hepatalgia when

 ;

NEUEALGIA OK " TIC-DOULOUREUX " OF THE LIVER. 31

they consulted me ; three were radically cured, and two

wonderfully relieved. In the treatment of hepatalgia
we must be guided in the selection of our remedies by
the whole circumstances of the case, and search to its

very foundations its exact cause ; without which a

random shot will avail but little. The causes of
hyperesthesia are numerous; some are prominent,
others very obscure. We have, however, been able to
trace it to atmospheric changes, and to soil. It is
nurtured, and carried on the wings of the wind, it
nestles in the storm, plays with the thunder and light-
ning, continued heat, or continued cold ; all these are
known to be its exciting causes. Acute forms of
neuralgia, with a clear and definite type, have been
repeatedly observed to assume an epidemic form. If
we turn to the vegetable and mineral kingdom, we find
that certain substances have a specific effect in producing
exalted sensibility of nerve fibre : lead for instance causes
neuralgia ; spurred rye and veratrine, formication
morphia, pruritus ; and the inhalation of protoxide of
nitrogen, optical hypersesthesia. An abnormal condi-
tion of the blood also plays an important part in the
causation field of neuralgia ; for we find that plethora
as well as anaemia are followed by vertigo, optical and
acoustic hypersesthesia and it seems here, as if pain
;

were the prayer of the nerve for healthy blood the :

—
plaintive voice of nature appealing in supplicating tones
to the physician for help. If we penetrate into the
domain of pathology, there also do we find divers causes
for neuralgic affections ; such as — obstruction, or cessa-
tion of habitual discharges, especially of haemorrhoids,
and the catamenia ; the suppression of herpes, and im-
32 THE LIVER.

petiginous affections ; scrofula, the secondary and tertiary

forms of syphilis ; swellings of osseons and cartilaginous
tissues, through which nerves of sensation take their
course. And, what are those stabbing, darting, piercing
pains which attend schirrus of the breast, and which form
so prominent a symptom of that fell disease, but an
exalted sensibility of nerve fibre ?

In the treatment of neuralgia of the liver, Aconite, Bell.

Bryon., and Nux Yom. have proved in many cases
eminently successful with a careful and well-regulated
;

diet, change of air, and a resort to some of the thermal

springs, as Bath, or Buxton.

 33

CHAPTEE IV.

JAUNDICE.

Synonymously. — Jaundice is recognized and known as

— the Icterus of Pliny the elder and Cselius Aurelianus

— the Morbus Eegius of Celsus and Pliny the younger
— —
the Morbus Arcuatus of Columella the Aurigo of
Plautus and Varro — the Cachexia Icterica of Hoffmann
—the Icterus of Boerhaave and Linnaeus —the Chole-
lithiaIcterus of Young — and the suffusio vel
Pellis
Obstructio of Cullen,
—
Nationally. The Jaunisse Ictere of the French the ;

Die Gelbsucht of the Germans and the Iterizia Citri-

;

nezza of the Italians.

Historically. —Jaundice was well known and clearly
defined at a very early period of the world's history, as
the works of Hippocrates, Cselius Aurelianus, ''
the great
African physician," who flourished in the second cen-
tury B.C., Galen, Celsus, and many more, teem with
scattered allusions to Jaundice as a complication of
other disorders. Hippocrates, in describing the symp-
toms of the autumnal remittent fever of ancient Greece
— see Book I. on Epidemics says, —
" Some were —
attacked with Jaundice on the sixth day, but these
were benefited either by a urinary purgation, or a dis-
order of the bowels, or a copious haemorrhage, as in the
case of Heraclides, who was lodged with Aristocydes."
D
34 THE LIVER.

In his third book on the same subject is to be found

^another case of considerable interest. Hermocrates,
says that immortal author, who lived by the ''NEW
WALL," was seized with fever. He began to have pain
in the head and loins an empty distension of the
;

hypochondrium the tongue at first was parched deaf-

;
;

ness at the commencement there was no sleep not ; ;

very thirsty ; urine thick and red ; when allowed to

stand it did not subside ; alvine discharges very dry,

and not scanty. On the fifth day, urine thin, and sub-
stances floating in which did not fall to the bottom
it ;

at night he was delirious on the sixth day he had ;

Jaundice. In the forty-second ''Aphorism," by the

same author, a work so celebrated that Suidas, " who
lived more than seventeen centuries after the time of
the writer, and who no doubt spoke the established
opinion of his age," does not hesitate to pronounce
it to be a performance surpassing the genius of man,

we find the following :

— " In cases of Jaundice
it is a bad symptom when the becomes indu- liver

rated." It may be here remarked, as a well-known

pathological fact, that Jaundice attended with Cirrhosis
or Scirrhus of the liver is necessarily all but hopeless,
and this doubtless was the form of induration referred to

by the sage philosopher of Cos. 450 years B.C.

In the sixty-second " Aphorism " we find the follow-

ing .
— « When Jaundice supervenes in fevers before the
seventh day it is a bad symptom, unless there be w^atery

discharges from the bowels." All the Greek authorities

confirmed the truth of this prognostic, but the Arabian
physicians called it in question.
Galen, a.d. 200, in his Commentaries, refers to the
 -

JAUNDICE. 35

complications of the antumnal remittent fevers with

Jaundice, and further remarks that '' when nature is un-
able to evacuate the bile it is collected in the skin, and
occasions Jaundice."
Definitions of Jaundice. — Copland Jaun-
defines
dice as a yellowness of the skin and eyes, sometimes
passing to a yellowish-green hue, or even to a greenish
brown ; the urine of a saffron or deep colour ; the stools
generally pale, and the course of the bile obstructed.
Murchison defines Jaundice as a yellowness of the
integuments and conjunctiva, and of the tissues and
secretions generally, from impregnation with bile-
pigment.
Budd defines Jaundice as a yellow colour of the con-
junctiva and skin, arising from the presence of the
colouring matter of the bile in the blood and tissues.
'*
It may further be observed that the term " Jaundice
is derived from the French jaune, yellow ; and the term
" Icterus*"
from the Greek, signifying the golden thrush,
a bird with yellow plumage, the sight of which by a
jaundiced person was believed by the ancients to be
death to the bird, but recovery to the patient.
—
Theoretically. Passing over the history and defini-
tions of this subject, we encounter two leading theories
relative to the different forms of Jaundice, each having
a host of supporters.
One theory is, that the seat of the disease is to be
looked for in a disturbance of the functions of the liver ;

that arises from abnormalities in the secretion or

it

excretion of bile; and that thus it exhibits symptoms'

indicative of derans^ement of the liver.
The other theory is that, under certain morbid con-
 ;

36 THE LIVER.

ditions of the system, substances are formed in the

blood, without the co-operation of the liver, which in
colour and other properties resemble the ingredients of
bile, if they are not identical with them, but which
only assume a pathological importance from their
quantity being in excess. But, whichever theory be the
correct one, this however we do know, that most,
although perhaps not all, cases of Jaundice do arise
from the reabsorption of the bile already secreted.
As a general rule it is not a very difficult matter to
point out the anatomical nature of the mechanical
obstruction to the natural excretion of bile; as the
experiments of Saunders in 1792, followed by those of
Tiedemann, Gmelin, and others, go to prove that by
applying a ligature to the ductus communis choledochus,
"the common bile duct," Jaundice results from such
and the passage of the secretion into the
obstruction,
lymphatics and veins follows. From these and other
experimental investigations, coupled with tlfe obser-
vations of many able men. Jaundice from reabsorption
forms a fair starting-point for further pathological study
and in all cases and forms of this affection our chief
object will be to search for all kinds of mechanical
obstructions which tend to prevent the escape of the
bile, or for other causes, which promote the passage of
this fluid into the blood. Before, however, we proceed
to investigate this pathological study, it may be as well
to point out certain groups of symptoms, connected
with other diseases, which may, to a casual observer,
be mistaken for Jaundice.
Firstly, —
There is that anaemic condition of young
women, known as Chlorosis, or the green sickness, easily
 JAUNDICE. 37

distinguished, however, from Jaundice by a glance at

the following tabular arrangement :
—
In CHLOROSIS, the In JAUNDICE, the

Skin. Is of a dusky yellowish, '

Skin varies in colour from a pale
hue, or the coilntenance, lips, and sulphur or lemoi yellow through a
tongue are deadly pale a liyid — citron yellow to a deep olive or
areola encircHng the eyes. bronzed hue.

Eyes. A pearly whiteness of Conjunctivae uniformly yellow,

the conjunctivse. and in some cases all white objects
appear yellow.

Chest. Breathing hurried by No particular derangement save

slightest exertion, pulse small, fre- the heart's action, which is con-
quent, and quick systolic bellows-
;
—
siderably retarded pulse falling to
murmur at base of heart, without 50, 40, and even 20 strokes to the
any other indication of heart dis- minute.
ease, or of leukaemia hysteria,
;

amenorrhoea, and divers other

forms of uterine and nervous de-
rangements.

Digestion. Flatulency, acidity, Taste sometimes bitter, denoting

and a singularly depraved appe- the presence of taurocholic acid in
tite, chalk, Hme, and other ab- the blood, flatulence, appetite varies
sorbents being greedily partaken of, — sometimes normal with a clean
and all accustomed food rejected. tongue, sometimes morbidly in-
creased, with a craving for shell-
fish. &c.

Feet. Frequently affected with Never, except Arhen connected

cedematous swellings. with organic disease of liver or
heart.

Urine. Pale and limpid, with no Urine of a dark brown or saffron

traces of bile-pigment. colour, tinging the Linen of the
same colour.

Alvine Secretions. Costiveness, Pale coloured, of a clayey con-

sometimes alternating with diar- sistence, and offensive,
rhoea.

Cutaneoios Surface. Normal. Frequently covered with urti-

caria, Uchen, carbuncles, and vitili-
goidea, and a distressing form of
pruritus.

Secondly, —There is that peculiar greyish-yellow

 —

38 THE LIVER.

waxen tint of skin, characteristic of organic visceral

disease — and more particularly that hitherto considered
incurable complaint — cancer. This, however, is easily
distinguished from Jaundice
By the absence of any yellow tint of the conjunc-
tivae;
By the absence of bile-pigment from the urine;
and
By the presence of marked symptoms of visceral
disease; and, in the case of Cancer, of the cancerous
cachexia.
Thirdly, —^We sometimes encounter a dusky yellowish
colour of the skin in persons who have suffered long, or
often,from malarious fevers, and sometimes also in those
whose systems have been poisoned by lead. This con-
dition is likewise easily distinguished from Jaundice
by the
Absence of the yellow tint of the conjunctivae,
Absence of the bile-pigment from the urine,
And the historic fact of the patient having suffered
from malarious fevers; and of having lived in a
malarious district or malarious country.
Fourthly, —In a large number of cases of the so-
called Jaundice new-born infants, ''the Icterus
of
Neonatorum," or Yellow Gum. The yellow colour which
appears on the third or fourth day after birth is not (as
many a sage monthly nurse will have it) due to
Jaundice at all but is simply the result of changes
;

in the blood in the over-congested skin —the vivid

redness of the new-born babe fading away, as bruises
fade, through shades of yellow, into the genuine flesh
colour.
 — ; ;

JAUNDICE. 39'

Infants, however, aresometimes prone to attacks of

real Jaundice, the symptoms and causes of which shall
receive due consideration in their proper place.
The spurious form of Jaundice already referred to is
easily distinguished from a genuine attack by
The conjunctivae being of the natural colour,
The urine being free from bile-pigment.
The gradual fading of the yellow colour of the skin
after a few days and by the infant appearing quite
;

well, the bowels acting regularly, and the secretions

being of a normal colour.
Fifthly, — to the close observer ; that peculiar bronzing
of the skin from disease of the Supra-Eenal
arising
Capsules, known as Addison's disease or that form of ;

cutaneous disorder known as leucoderma, is not very

likely to be mistaken for an attack of Jaundice it ;

differs materially in the browner or more dusky nature

of the discolouration
It being darker in some parts of body than others,
such as the face, neck, hands, areola of the nipples,
axillae, penis,and scrotum
In the extreme ansemia and frequent vomiting
In the whiteness of the conjunctivae and ;

In the absence of bile-pigment from the urine.

Finally — There is a spurious form of Jaundice which
has occasionally been successfully feigned by soldiers
and sailors desirous of deserting the flag of their country,
which it would be well for those who may be called upon
to give an opinion to bear in mind.
In such cases the yellow colour of skin has been
simulated by painting it with infusion of saffron,
turmeric, rhubarb, broom-flowers, or soot; >vhilst the
 — ; —

40 THE LIVER.

colour of the urine has been heightened by taking

rhubarb or santonine, as pointed out by Gavin in his
treatise on " Feigned and Fictitious Diseases."
As a counterpoise to such a fraud, it will be found by
close inspection
That the conjunctivae are white
That no bile-pigment can be detected in the urine by
the usual test ;
*

That soap and water, or better still a weak solution of

chloride of lime, will at once remove the yellow colour
from the skin and that if the urine be coloured by the
;

use of Santonine or Ehubarb, it will be rendered blood-

red by the Caustic Alkalies or their Carbonates.
Symptomatology. — In proceeding to describe the
divers symptoms of Jaundice we may in limine observe
that the bile-pigment permeates most of the organs and
tissues of the body. It first accumulates in the blood,
and from thence is carried into every part of the body
circulated by that fluid even the brain, bones, chambers
;

of the eyes, and the foetus in its mother's womb. The

intensity of Jaundice varies more or less in different
organs and tissues of the body. When Jaundice depends
on simple obstruction of the bile duct ductus communis
cJioledocTius —
the liver is the organ most deeply coloured,
which often presents a deep olive colour. I^ext to the
liver is the skin and next to the skin is the urine.
; In

* Bile-pigment can always be recognized by the so tainted urine

staining tbe linen of a yellow or saffron hue, or by applying the Nitric
Acid test, as follows :• — Pour a small quantity of urine containing bile
on a white plate, or on a sheet of writing paper, and carefully allow a
drop or two of Nitric Acid to fall upon it an immediate play of —
colours will be produced around the spot where the acid falls, passing
from, brown through green, blue, violet, and red, into a dirty yellow.
 JAUNDICE. 41'

proceeding then to enumerate the various phenomena

connected with Jaundice, we shall select as the basis of
our description that variety which owes its origin to a
mechanical impediment to the excretion of bile, such as
an obstruction in the common bile duct, as being the
most simple form, and being less apt to be interfered
with by disturbances of an extraneous nature. When
such an obstruction takes place, the bile first shows
itself after two or three days, by a yellow colour of the
conjunctiva?; by a saffron-yellow, reddish-brown, dark-
brown, greenish-brown, or brownish-black colour of the
urine ; by yellowness of the skin ; by the exudation of
bile-pigment through the sweat glands —particularly
those in the axillae — which tinge the linen of a yellow
colour ; by a peculiar itchiness of the skin which is

especially troublesome in the night-time; by the eruption

of urticaria, lichen, boils, and sometimes carbuncles by ;

derangement of the general sensations, with great exhaus-

tion and debility, dejection of spirits, peevishness of
temper, headache, and giddiness ; sometimes by a bitter
taste with a clean tongue by a peculiar delusion of the
;

sense of light, called Xanthopsy or yellow light all —

objects seen by the patient are of a yellow colour by a ;

retardation of the heart's action, which in its contraction

falls to a greater or less extent below the normal
standard, in the majority of cases to 50 or 40 beats, and
now and then to still fewer. Frerichs records two cases,
in one the beats were only 28, in the other as low as 21.
The writer has met with three cases where the beats did
not exceed 33 per minute. This is particularly noticed
when the patient is in the recumbent posture. The
cause of this slowness of pulse is supposed by some to
42 THE LIVER.

arise from the presence in the blood of unchanged biliary

acid which exercise a specific paralyzing action
salts,

upon the heart, and retard its action similar to that of —

Digitalis.
A slow pulse, however, is not a constant symptom of
Jaundice, as many which the normal
cases occur in
standard is maintained throuQ^hout the whole course of
the disease.
The digestive derangements are peculiar and note-
worthy : the functions of the stomach in many persons
afflicted with Jaundice are unaffected the patient may ;

have a clean tongue, and may enjoy an appetite which

leaves nothing to be desired ; but there is at the same
time an abnormal condition of the functions of disfestion
going on, and sometimes the appetite becomes depraved,
or morbidly increased, or there may be a craving for pe-
culiar articles of food, such as lobsters, crabs, mussels, or
limpets. The want of bile does not influence in any marked
degree the digestion of albuminous and carbonaceous
aliments ; but according to the experiments of practical
inquirers, such as Professor Staedeler, JSTeukomm, and
I'rerichs, the absorption of fat is considerably restricted.
Persons afflicted with Jaundice have, as a rule, a great
aversion to fat in any form or quality, and after par-
taking of such a large proportion of it appears unchanged
in the evacuations. The loss in nutrition which results
from this cause is sufficiently great to become observable
in the course of time hence the general emaciation of
;

the body in prolonged and chronic cases of Icterus.

Another result of this abnormality, " but perhaps of
less importance," is, the loss of the antiseptic influence
of the bile, which permits of unnatural and unhealthy
 JAUNDICE. 43

transformatiou of the contents of the alimentary canal,

and the development of large quantities of gas ; hence
flatulence is a common symptom in Jaundice, more par-
ticularly if preference be given to animal food when the
faecal matters emit a putrid odour. When, however, the
food consists principally of vegetables and amylaceous
substances, the evacuations yield no remarkable odour
and are an acid nature, because a part of the carbo-
of
naceous food undergoes acid fermentation in its course
through the alimentary canal.
Of much greater importance, however, in a diagnostic
point of view, and which should not be overlooked, are
the peculiar changes which take place in the colour which
the faeces are wont to exhibit in Jaundice, because it is
from the character of that excretion that we can most
easily draw our conclusions as to the more or less
complete exclusion of bile from the intestine. When
the obstruction of the bile-ducts is complete, every trace
of bile-pigment disappears from the evacuations ; they
assume an ash or clay colour, which only varies accord-
ing to the nature of the food; their consistence is

increased, they become hard and firm, and the bowels

become sluggish. This tendency to constipation is so
very frequent in Jaundice that the assumption appears
completely justified that it is owing to the absence of
bile in the bowels. Whether the bile favours evacuation,
by stimulating the peristaltic action of the intestines,
or by increasing the natural secretion of the intestinal
glands, or, again, by liquefying the ingesta, are questions
which hitherto have not been satisfactorily cleared up.
To my mind, however, the chief ofi&ce of the bile appears
to be, to act as an aperient; in fact, "Nature's own
 —

44 THE LIVER.

black draught." It may, however, be observed that

the character of the fseces are not always the same as
just described, as the colour will vary more or less in
accordance with the complete or incomplete obstruction
to the escape of the biliary fluid into the duodenum.
Amongst the partial or incomplete causes to the flow of
bile may be enumerated
1. A compression of a portion of the biliary ducts,
as happens in cases of cirrhosis, or the so-called gin-
drinker's liver, where the extreme ramifications of the
biliary ducts are partially obliterated by the compression
of the newly-developed areolar tissues; likewise in
carcinoma, and tumours, which are wont to encroach
upon certain of the large. branches only.
2. Partial constriction of the principal duct, which
impedes, but does not entirely arrest, the flow of the
bile.

Catarrh of the ductus communis clioledochus^ and

3.

hepatic duct, in which there is tumefaction of the

mucous membrane.
Angular concretions
4. which cannot completely
block up the canal.
Occasionally we find persons suffering from Jaundice
passing stools of a normal colour, or of a pitchy hue.
Two reasons have been assigned for this. Either the
cause of the biliary obstruction has been suddenly
removed, and the bile passes into the bowel, whilst the
colour of the skin remains unchanged, as often happens
in the case of Calculi, and other rapidly-disappearing
causes of obstruction ; or there is a sudden cessation of
an excessive absorption of bile, known as Polvcholia.
DuKATiON OF Jaundice. —The duration of Jaundice
 JAUNDICE. 45

is very various, and may fluctuate between a few days

and several years.
The determination of the longer or shorter duration of
the disease depends principally upon its primary causes,
the persistency of which may vary, and which may of
themselves help to bring about a fatal termination,
speedily or slowly.
In the Dublin Hospital Eeports, vol. v., page 103, there
are two cases recorded by Drs. Graves and Stokes in ;

one the Jaundice lasted eleven months, and in the other

two years, before nutrition became impaired. Budd met
with a case of Jaundice in a man which lasted four
years, with complete obstruction of bile, whose system
continued well nourished. Deway describes a case of
seven years' duration, and Yan Swieten one of eleven
years in a female, who was cured by "solvent medicines."
Modes of Termination of Jaundice. — Jaundice
does not disappear completely until some time after the
removal of the causes which have occasioned the accumu-
lation of colouring matter in the blood. When the
cause of Jaundice consists in an obstruction to the pas-
sage of bile into the intestines, the recovery announced
is

by a return of colour to the stools ; the colour becomes

darker by degrees when the disappearance of the ob-
struction is gradual, as in catarrh of the bile-ducts ; or
they become rapidly overcharged with bile, when, from
the sudden removal of the obstruction, the pent-up
secretion of the gall-bladder at once finds its way into
the intestinal canal, as in the case of ''
calcareous ob-
struction " (stones), or spasm.
Not unfrequently Jaundice terminates in death, which
may be brought about by divers causes sometimes by
:
46 THE LIVER.

exhaustion, sometimes by blood-poisoning, sometimes

from the so-called cholsemic intoxication, and sometimes
by perforation, followed by peritonitis, or suppurative
inflammation of the substance of the liver.

Diagnosis. —The diagnosis of Jaundice on the

is

whole not a very difficult task, as its outward mani-

festations present so many features which are indicative
of the complaint ; such as the yellow tint of the con-
junctivae and skin the pale clayey faeces and saffron-
;

coloured urine, which stains the linen of the same colour ;

the slow pulse and itchiness of the skin. Moreover, the

urine may easily be examined by the usual tests, so as to
detect with certainty any bile-pigment which may be
present. But the real difficulties in diagnosing this disease
— ''
if it may be so called" — commences when we come to
determine the cause, and apply, a suitable mode of treat-
ment to each particular case. Moreover, it is incum-
bent on the physician to be very guarded in his
prognosis of this complaint, as it depends principally
upon its causes. The natural course and modes of ter-

mination of the primary disease, and the greater or less

probability there is of interfering with effect in the way
of treatment, constitute the chief considerations which
alone will enable us to predict the result. A correct
knowledge of each particular case furnishes us with
o-rounds for a correct " prognosis " at once,
and only
where this is impossible do we want to remain in doubt
as to the result. It must, however, be borne in mind
that there are cases of apparently simple Jaundice,
without any perceptible organic disease of the liver,
where symptoms of blood-poisoning sometimes make
their appearance suddenly and quite unexpectedly;
 JAUNDICE. 47

death, as a general rule, invariably supervenes in such

cases. Under these circumstances, the physician cannot
be too guarded as to how he gives an opinion even in
apparently trivial cases.
About six years ago I attended a gentleman who
had resided for some years on the southern slopes of the
South American continent. He returned to England
invalided. He had, previous to my seeing him, consulted
several medical men in London of the homoeopathic
school, who treated him for dyspepsia. I diagnosed
abscess of the liver, which was confirmed by my friend,
Dr. Vaughan Hughes. Shortly after this, alarming symp-
toms set in the relatives suggested another opinion,
;

and one of the city magnates was selected. We met in

consultation, and to my utter astonishment he repudiated
all idea of hepatic abscess, and gave a favourable

prognosis in three more days my patient was a corpse.

;

A post-mortem, however, revealed an enormous abscess

in the right lobe of the liver, having one communication
with the stomach, and another with the right thoracic
cavity of recent origin. This case will be fully recorded
when I come to treat on the more serious and malignant
diseases of the liver.
Causes and Treatment of Jaundice. In the treat- —
ment of Jaundice the first and most important point to
be considered is the various causes which have led to
the accumulation of bile-pigment in the blood the ;

removal of these necessitates no further treatment against

the Jaundice itself, for let it be clearly understood that
Jaundice _2:>cr se is not a disease, but merely a symptom
of such; remove the cause, the icteroidal phenomena
disappear.
 ; —

48 THE LIVER.

As might naturally be expected, the means employed

for accomplishing these indications for treatment vary
considerably, according to the nature of the primary
causes of the disease — the " fons et origo mcdi." These
will occupy our attention when we come to treat of the
individual forms of Jaundice, and of the corresponding
and bile-ducts.
affections of the liver, calcareous deposits,
There are certain cases, however, where the cause of
Jaundice cannot be influenced by any special mode of
treatment under such circumstances, all we have to do
;

is to counteract in a suitable manner the injurious

influenceswhich the abnormal distribution of bile may
exercise upon the entire system.
For this purpose there are several leading points
which should always be kept prominently in view,
viz. :

The regulation of the functions of the bowels which

have become deranged by the stoppage to the flow of
bile
The purifying of the blood from the mass of bile-pig-
ment which has accumulated in it and ;

The consideration of the further consequences which

may befall the entire organism from the presence and
effects of the above abnormal conditions, and more
especially from the changes in the tissue of the liver
resulting from the stoppage to the normal flow of the
bile ; such results as general ansemia, dropsy, and
cholsemia, etc.
The deranged functions of the bowels, which manifest
themselves chiefly in the form of obstinate constipation
and flatulence, may be considerably relieved by restrict-
in o- the patient to easily-digested lean meat and vegetable
 ;

JAUNDICE. 49

food, and by avoiding all fatty articles, or such as liave

a tendency to create flatulence ; and by tbe administra-
tion of Alumin, Lycopa., Lept.^ Nux Vom., Podoph.y or
Sulphur, the sitz bath, etc.

As regards the second indication for treatment, the

renal organs contribute perhaps more than any other
to purify the blood from extraneous matter and next ;

to them come the glands of the skin surface. The

secretion of urine —
which in the later stages of the
more intense forms of Jaundice is not unfrequently
suppressed to a very serious and alarming extent, in
consequence of the deposit of colouring matter in the
minute structures of the kidneys must be combatted —
from time to time by means of Aeon., Canth., Nux Vom.,
Terebinth, and particularly lemon juice, which I have
found eminently ef&cacious as a diuretic in three cases
of chronic Jaundice, with very scanty secretion of urine
to these may
be added diluent drinks, such as barley-
water, linseed tea, seltzer and other mineral waters of a
similar kind, tepid sitz, baths and cold compresses over
the lumbar region. The functions of the skin —which
is a great helper to the excretion of all kinds of effete

matter — should be stimulated by means of tepid baths

to which some ounces of soda may be added or better ;

still, a series of Turkish baths, wLich should be taken

every second or third day, and continued for a con-

siderable length of time : these are particularly suitable
for the removal of the deposit of bile-pigment in the
epidermal layer of the skin, particularly when it remains
long after the removal of the obstruction in the bile-ducts.
It is, however, when we come to consider those forms
of Jaundice which arise as a sequence to organic disease
E
 ;

50 THE LIVER.

of the liver, such as atrophy, the destruction of numerous

branches of the portal vein by the pressure of the en-
larged bile-ducfcs, and from the disintegration of the
hepatic cells, that our difficulties arise in a therapeutic
point of view. Here we may have to encounter a general
cachectic and anaemic condition of the system, general
dropsy, and other symptoms indicative of a break-up of
the constitution. Much, however, may be done by regu-
lating the functions of the skin, bowels, and kidneys
by a and by the administration
carefully-selected diet ;

of Ars., Chin., the Bromide or Iodide of Potassium, and

the waters of Schwalbach or Pyrmont.
The Varieties, Special Causes, and Treatment of
Jaundice. —Jaundice, as I have already observed, is

rather a symptom of disease than a disease itself ; conse-

quently it may spring from a variety of causes, a know-
ledge of which is of great importance to a successful
treatment of the same.
There are few diseases which require so much dis-

crimination as to the indications and means of cure as

Jaundice. It proceeds in diff'erent cases from so many
different pathological states, and sometimes from so
many combinations of them, that the utmost attention
and practical acumen are necessary to ascertain the
morbid conditions and peculiarities of each case, and
to determine what is most efficacious in removing them.
1. Jaundice may take place in consequence of a con-
stricted condition of the ductus communis choledocus
and hepatic duct, the result of catarrh of their lining
" icterus catarrhalis," and most
mucous membrane, the
common form of Jaundice.

It is ushered^^-^rrij^^h^fy^^^tsti^ of catarrh of the

 —

JAUNDICE. 51 /

stomach and bowels, whicli last for some days before

the yellow colour of the eyes and skin can be distin-
guished. The region of the liver is painful on pressure,
and the dimensions increased. The urine assumes a
brownish colour, the and totally devoid
faeces are pale
of bile-pigment, the pulse is slow, and there is a general
itchiness of the skin. This form of Jaundice will
generally yield to Aconite, followed by Poclo]jhyllum, a
cold compress over the region of the liver, and a spare,
non-stimulatin£j diet.
2. Jaundice may result from the impactment of gall-
stones in the common biliary duct, thus preventing the
escape of bile into the intestine and its consequent re-
absorption into the system. This form of Jaundice is

generally of short duration, and disappears so soon as

the calculi have passed through the canal. But it some-
times, however, happens that a gall-stone becomes per-
manently fixed in the duct, or closure of the canal may
take place from adhesive inflammation, each of which
may terminate in Jaundice of a permanent character.
The temporary form of this type is best treated by warm
baths, friction, the application of hot compresses over the
affected region, and the administration of Bell., Cede -C,^
or Lycop. ; and in the more protracted and aggravated
forms by the inhalation of chloroform, which should be
repeated from time to time as circumstances may require.
3. Jaundice may take place as the result of violent

mental emotions, such as vexation, anger, or fright.

Physicians, in all ages, have recognized this form of
Jaundice, and so far as our present knowledge extends,
derangementsof the nervous system may lead to accumu-
lations of bile in the blood- in' two ways :

.r
 — —

52 THE LIVER.

Firstly, —By interruptions to the circulation of blood

through the liver, arising from the influence exerted by
the nerves over the caliber of the branches of the portal
vein, and
Secondly, —by interruptions to the heart's actions,
the respiratory movements, and the renal secretion.
Ib violent mental emotions, induced either by vexa-
tion, anger, or fright, the epigastrium becomes suddenly
compressed, and there is difficulty of breathing, a feeling
of suffocation, and sometimes vomiting. The skin first
becomes pale, and is soon followed by a jaundiced
colour, whilst large quantities of urine are secreted,
still devoid of colour. In such cases the Jaundice
makes its appearance in a few hours, and sometimes
according to well-authenticated records —in a still

shorter space of time. Villerme, in his "Dictionary of

Medical Science," records a case in which two young
men quarrelled, and drew their swords one of them ;

became suddenly yellow, and the other, terrified at this

change of colour, dropped his weapon. Another case is
that of an abbe, who became suddenly yellow, on a
mad dog rushing against him.
This form of Jaundice soon passes off, in the gene-
rality of cases. But to this there are exceptions, " as
we find in every rule." Cases of this kind are met
with in which the disease takes on a malignant character,
and in which death ensues after a few days, amid severe
nervous symptoms, such as delirium and convulsions.
Cases of the kind are recorded in the works of Morgagni
and Yillerme. The milder form of this kind of Jaun-
dice soon disappears under the administration of Aeon.,
Cham., Ign., Nux Vom., followed by Sul2)h.
 JAUNDICE, 53

4 In close alliance with. Jaundice from mental

emotion, we sometimes find tliat an icteroidal tint of
the skin will follow the administration of ether and
chloroform. It is also worthy of note that in such
cases sugar has been observed to pass off by the urine.
5. It is recorded that Jaundice of a very sudden
and severe form may follow the bite of venomous rep-
tiles this was observed by Galen, as far back as a.d.
:

200, who records the case of a slave who became in-

tensely jaundiced from the bite of a viper; this was
confirmed by Dr. Mead, an eminent English physician,
who flourished in the early part of the seventeenth cen-
tury. Eesults similar to those supervening upon the bite
of a viper have been observed after the bites of rattle-
snakes, as recorded by Moseley and of scorpions and
;

mad animals, as recorded by Bartholin and others.

The ancient physicians attributed the cause of this
form of Jaundice to a spasm of the bile-ducts ; or, as
Pontana, in 1780, did, to a liquefaction of the bile,

resulting from putrid decomposition.

It is more than probable, however, that the sudden
shock (fright) given to the nervous system, producing,
as in Jaundice from mental emotions, spasm and occlu-
was the chief cause of that
sion of the biliary ducts,
form of Jaundice observed by those illustrious physi-
cians of another age, consequently Cham.j Ign., JShix
Vom., and perhaps LycopocUum, would prove the most
appropriate remedies.
It is a striking feature in these forms of Jaundice
that no perceptible obstruction to the flow of bile exists ;

this is proved by the bilious character of the evacua-

tions, both by vomiting and by stool. It is also worthy
54 THE LIVER.

of note that the excretion of sugar in the urine gene-

rally follows.
Does the cause of the accumulation of bile in the
blood depend upon metamorphosis of a morbid character
in the blood itself ? or on a deranged innervation acting
upon the circulation and respiration as already referred
to ? or does it arise from congestion of the liver, fol-
lowed by the mal~assimilation of sugar ? If so, then I
maintain that a preparation of the Curari may prove a
potent remedy in Jaundice of this type, as Claude
Bernard has very clearly pointed out, that one of the
pathogenetic effects of this poison on the system is to
give rise to congestion of the liver, and to the
excretion of sugar in the urine. I venture to direct the
attention of my colleagues to this fact, and shall be
glad to receive any hints on the subject, as I am about
to institute a series of experiments with "Curari" in
hepatic derangements, particularly congestion, a form
by no means uncommon in fenny districts.
6. Jaundice may take place from pysemic infection
of the blood. Marechal, in 1828, was about the first to
observe that individuals, in whose bowels pus existed,
the skin, conjunctivae, and other tissues of the body,
exhibited a more or less jaundiced appearance. This
has since been noticed by many other observers. A^^se-
nicum, and perhaps Lachesis, or Curari, would prove
potent remedies, combined with a series of pack, or
Turkish baths.
7. Jaundice is no uncommon symptom of divers
forms of eruptive and other fevers. We find it in close
alliance with typhus, particularly the petechial or epi-
demic form. We encounter it running side by side with
 JAUNDICE. 55

the intermittent and remittent fevers of marshy dis-

tricts; and so common is it in Algeria that it forms
a prominent symptom in seven-tenths of the cases of
intermittent fever of that country. We likewise meet
with it as a symptom of the recurrent or relapsing fever
of the British Isles. This is the same fever which gave
rise to the great epidemics which have prevailed in
Scotland, Ireland, and England, particularly in London
and other large towns, since 1843. It is seen hand in
hand with the enteric, pythogenic, or typhoid fever,
which weU-nigh rohbed us of the heir-apparent to the
British throne. I have met with well-marked cases of
Jaundice, accompanying some severe cases of scarlatina,
and in one case of a severe form of rubeola.
Jaundice forms a prominent symptom of that
8.

deadly fever so prevalent in the West India Isles, and

that portion of the great continent of America which
extends from the mouth of the Mississippi to the Rio
de la Plata, and known as the typhus icterodes of
Cullen, —the febris flava of the present nomenclature
of the College of Physicians, — ^the fievre jaune of the
French,—the gelbes the Germans, — the vomito
fieber of
nigro the Spaniards, —the
of hsemagastrica
pestilentia
of Copland, —the synochus Young, —the
icterodes of
Americanorum
febris flava Frank, — the febbre
of J. gialla

of the —the yellow

Italians, of the generality
fever of
Englishmen, — and the Yellow Jack the British of tar.

It may be defined as a malignant epidemic fever, usually

continued, but sometimes assuming a paroxysmal type
characterized by yellowness and accom-
of the skin,
panied, in the severest cases, by haemorrhage from the
—
stomach, mouth, and nares more familiarly known as
the black vomit.
56 THE LIVER.

9. Jaundice has at various epochs assumed an epi-

demic form, more particularly in France and Germany.
In 1772 it broke out at the market town of Essen, in
Westphalia attacked principally children
; assumed ;

an intermittent form, and destroyed a great number of

them.
In 1790 it broke out in Llidenscheid; there children
were all but exempt. It, however, attacked both men
and women and many of the latter, who were preg-
;

nant, aborted, and died in a few days of general coma

and delirium.
In 1807-8, it appeared in the same form at Greifswald^
and soon afterwards at Chasselay.
In 1826, it prevailed along a large portion of the
coast of the north-west of Germany and of Holland.
Accompanying the generality of these epidemic visita-
tions of Jaundice, were observed bilious, intermittent,
and remittent which usually presented the double
fever,
tertian, or remittent typeand the anatomical lesions
;

found were considerable enlargement and softening of

the spleen, together with congestion of the liver ; in ad-
was found an abundant
dition to this congestion, there
accumulation of black pigment in the spleen, liver, and
blood. Delirium, coma, and convulsions were frequently
found during life.

In the epidemics of Ludenscheid and Chasselay,

however, which ran their course without fever, it was
found that they commenced with catarrh of the stomach
and bowels, and were accompanied by light-coloured
stools in fact, they were fair samples of simple catarrhal
;

Jaundice frequently met with in this country at certain

periods of the year.
 —

JAUNDICE. 57

10, In a considerably large number of newly-born

children, the skin and conjunctiva are tinged yellow,
and the urinary secretion contains the brown colouring-
matter of bile, which here, as elsewhere, indicates the
existence of true Jaundice, and distinguishes it from all
other yellow discolourations, and that laid down at page
39, which I have termed the spurious form of infantile
Jaundice. This is the icterus infantum — icterus neona-
torum —yellow gum, or true infantile Jaundice. As a
general rule, the origin of this icteroidal appearance is

connected with changes which the function and the

circulation of the liver undergo during birth, and has
been attributed to various pathological conditions or
causes, viz.
To catarrh of the bile-ducts ; occlusion of the ducts by
thickened bile or by concretions, as noticed and recorded
;

by Cruveilhier, Portal, and others.

To congenital obliteration of the bile-ducts.
To thickening of Glisson's capsule.
To congenital cirrhosis of the liver.
To a stagnant and altered condition of blood, contained
in the umbilical vein, changing the state or colour of the
serum.
To obstruction of the opening of the ducts from viscid
meconium, or mucous sordes.
To a spasmodic condition of the excretory ducts.
To an inordinate quantity of the biliary secretion.
To obstruction, or a paralyzed condition of the secret-
ing structure of the liver.

These and many more may be set down as causes of

infantile Jaundice;but the mode of production of
" icterus neonatorum," in ordinary cases, must be sought
 ;

58 THE LIVER.

for in the diminished tension of the capillaries in the

which takes place upon the stoppage
tissues of the liver,
of influx of blood from the umbilical vein, and which
gives rise to an increased transfusion of bile into the
blood. In strong, fully-developed infants the equilibrium
of pressure is soon restored, but in infants prematurely
born, where the respiration is a long time in becoming
established, and where the foetal vessels remain long
open, a more or less intense degree of Jaundice is apt to
make its appearance ; hence it is that we find that infants
prematurely born are more liable to Jaundice than those
born at full time.

The symptoms of infantile Jaundice usually appear

soon after birth, sometimes even within a few hours, or
the colour becomes most distinct about the third day,
and then, as a general rule, lasts one or two weeks. It is

generally attended with languor, drowsiness, and debility;

the skin and eyes present a more or less jaundiced tint
the urine of a deep yellow ; there is constipation ; the
stools are pale in colour, but afterwards resume their
normal tint.
11. There are two which
distinct forms of Jaundice
affect woman during her pregnancy, which in their
symptoms and results present very different features.
One of these is of little importance, and easily removed
by a very simple mode of treatment but the other, how- ;

ever, is of very serious import, as we find it generally

associated with serious organic lesion of the hepatic
tissue, and almost invariably terminates fatally. The
first of these forms makes its appearance during the

later months of pregnancy, and is produced by the

distension of the womb, or by the accumulation of fsecal
 — ;

JAUNDICE. 59

matter in the transverse portion of the large intestines,

acting as a foreign body, and pressing against the bile-
ducts with sufficient force to impede the further flow of
bile. The same form of Jaundice may likewise take
place during the early months of pregnancy, which can
generally be traced to sudden emotions of the mind, as
grief, which we sometimes
vexation, or that kind of anger
find associated with those domestic broils which will
occasionally take place in the best-regulated families
this form, however, is quickly removed by such remedies
as Ignatia or Nux Vomica; the former, by the lady
reclining, as a rule, on her left side, either in the recum-
bent or half-sitting posture; and when caused by
constipation, by the administration of such remedies as
—
Alum., Bry., Nux-Vom., Sejpia, or Sulph. These failing,
resort should be had to the administration of an enema
of tepid soap-and-water (soapsuds), or weak gruel, to
which may be added a dessert or tablespoonful of salad
or castor oil.

The second form is distinguished by serious derange-

ments of the nervous system, and, so far as cases of it
have as yet been examined, depends upon acute wasting
of the liver, the result of inflammation of the spongy
substance (parenchyma) of the organ ; the kidneys also,
as a rule, are affected at the same time.
12. Finally, there is another kind of Jaundice which
I am unwillino[ to omit in this brief sketch, a reference
to which I have been unable to find in the voluminous
works of Frerichs, the fascinating lectures of Murchison,
or the practical treatises of Budd, Saunders, and others
namely, the green or black Jaundice. Synonymously:
The MiXaiva vovaoQ of the Greeks ; the Icteritia nigra of
 —;

60 THE LIVER.

Forestus tlie Icterus viridis, melas Icterus, vel melan-

;

cliolus ofFennel and Var. Auct. the Icterus melsena of

;

Good and the green or black Jaundice of Baillie.

;

Pathologically, however, this is merely the extreme

grade of the disease in its milder and more tractable
form.
—
Aretseus, the Cappadocian, and sup-
Historically.
posed contemporary of Galen, A. D. 200, was the first to
give us a description of this form of Jaundice. In his
work on chronic diseases, article Icterus, he says :

" It is superfluous in me to tell you whence the name

is derived, further than that it is derived from certain
four-footedand terrestrial animals called tKri§£c*(ictides)
whose eyes are of this colour."
—
He then goes on to say: "There are two species of
this affection, for the colour of the whitish-green species
either turns to yellow and saffron, or to livid and bla,ck
and the cause of these is the same as the cause of
the two kinds of bile. In cases therefore, of black
Icterus, the patients are of a dark-green colour ; are
subject to rigors, become faintish, inactive, and spiritless ;

emit a fcetid smell, have a bitter taste, breathe with

difficulty, are pinched in the bowels ; alvine evacuations
like leeks, darkish, dry, passed with difficulty ; urine
deeply tinged with black ; without digestion, without
appetite; restless, spiritless, and melancholic. It is

more familar to adolescents."

Since the era of Aretaeus, no very important contribu-
tions have been given on this subject, till down to the time
of the late Dr. Baillie, who contributed an able article

* A species of ferret ; either the Mustela Erminea, or the Mustek Furo.

 :

JAUNDICE. 61

on the subject in the Transactions of the College of

Physicians, vol. v. p. 143, entitled '' Observations on
:

Green Jaundice" The symptoms are briefly these

The colour of the skin varies in depth from a yellowish-
green to a deep green or olive colour. The temperature
of the surface is not increased, but burning heat is felt

in the palms of the hands and soles of the feet. The

evacuations are often pale ; but sometimes they are
dark-coloured —pitchy—with grumous cofPee or cho-
colate-like matter, and The urine is
slight diarrhoea.

occasionally clear, but oftener very dark and loaded,

imparting to the linen a dark, tawny hue. The patient
is greatly depressed, physically and morally complains
;

of anxiety at the epigastrium, and of tenderness either

in that situation or in one or both hypochondria. A
sensible enlargement of the liver is often felt, and some-
times also of the spleen. The pulse is usually natural —
or slow — vertigo, sickness, and vomiting of a green acid
coUuvies, occasionally are present. In the intervals,
the appetite is either capricious or but little affected.
This form of Jaundice seldom affects young persons.
It is commonly met with in the aged, and is much
more frequent in males than females, particularly in
those who have lived long in unhealthy inter-tropical
countries, or who, with great anxiety and fatigue, have
been tried by frequent changes of climate. It is gene-
rally connected with the most chronic and profound
organic lesions of the liver, especially those which in-
volve, or destroy, its secreting structures, and obliterate
the minuter ramifications of the ducts through the
organ. It seldom admits of more than a partial re-
moval, but usually terminates in either a fatal exhaustion.
62 THE LIVER.
#

or with coma, apoplexy, epilepsy, or palsy. Abdominal

dropsy frequently takes place in its progress. Its course,
in its slightest grades, is generally slow —sometimes
continuing, with various fluctuations, for seven or eight
years but, when the colour becomes very deep,
; it often
terminates rapidly, in one of the above ways.
When this form of Jaundice is attended with pitchy,
or dark grumous evacuations, there is generally either
congestion of the spleen and of the portal system of
vessels, with the secretion of a dark-green unhealthy
bile, a portion of which is absorbed and deposited in
the structure, particularly in the rete mucosum; or a
congested and hasmorrhagic state of the mucous mem-
brane of the stomach, duodenum, and upper part of the
intestines, owing to the obstructed circulation through
the liver; but both pathological conditions may be
present, giving rise to an exhalation of venous blood
from this membrane, and thereby to the dark and
grumous motions. The mucous membrane in these
situations is usually found, on dissection, dark-coloured,
mottled, softened, ecchymosed, or its venous capillaries
loaded.
The morbid anatomy accompanying this and other
profound cases of Jaundice, present features of grave
import and considerable interest.
THE BODY is generally emaciated.
THE SKIN presents a deep-yellow or bronzed
colour; the serum in the oedematous limbs —when
anasarca exists— the cellular, adipose, and serous
tissues, the internal surface of the blood-vessels, the
muscles, cartilages, tendons, periosteum, and bones,
partake of the same colour.
 JAUNDICE. 63

THE LIVER has been found to present all those

lesions which follow every form of inflammatory action ;

sometimes it is considerably enlarged, its blood-vessels

congested, its ducts engorged, and its structure softened,
inflamed, deeply tinged or suffused with bile, and con-
taining, in its substance, one or more abscesses, or the
remains of such ; at other times we find the organ
considerably diminished in size, hardened, scirrhous, or
tuberculated, and apparently devoid of blood and biliary
secretion. In some cases, it is changed to a white par-
boiled condition ; in others, into fatty steatomatous,
tallowy, or adipocerous substance. Occasionally, the
ducts are loaded with green inspissated bile, or ob-
structed by concretions of cholesterine, or resinous
matter. Sometimes we find the surfaces of the liver
adhering to the adjoining organs. In other cases, one
or more abscesses.
THE GALL-BLADDER is found to contain one or
more calculi if solitary, it becomes, after a time, of
;

considerable size, blocks up that viscus, distends its

walls, and ulcerates its surface.

THE BILIARY DUCTS are frequently obstructed,

either by by the pressure of tumours in
gall-stones, or
the pancreas, mesentery, pylorus, or duodenum and ;

the common duct by scirrhous and other tumours.

The stomach is another organ which becomes seri-
ously implicated in aggravated cases of Jaundice,
particularly when the disease has been occasioned by
intemperance, and more especially by the abuse of
ardent spirits.

The pyloric extremity is found thickened, cartila-

ginous, and constricted, and its mucous membrane is
64 THE LIVER.

studded with, patches of erosion. Next to this, is

the
Duodenum, which is often found inflamed, thickened,
softened, indurated, or ulcerated, and in some cases
apparently scirrhous. Tumours also, of various kinds,
have been found imbedded in its coats at the place
where the biliary ducts empty themselves, which either
entirely obliterate these apertures, or very greatly
diminish them.
Finally, the pancreas, spleen, and right kidney are
in some cases found considerably enlarged, and are the
seat of Scirrhus and many other abnormalities.
There are few diseases," says Copland, " the nature
"

and morbid relations of which have occasioned greater

diversity of opinions than Jaundice and there are ;it —
may safely be averred —few diseases the treatment of
which has created greater conflicts of opinion among
physicians. On these grounds it may in truth be stated
that there are few diseases which require more discrimi-
nation as to the indications, the selection of the remedy,
and other means of cure than Jaundice. It proceeds,
as we have already pointed out, in different cases, from
so many different pathological states, and sometimes from
so many combinations of them, that the closest attention
and practical acumen are necessary to ascertain and dis-
tinguish the morbid conditions and peculiarities of each
individual case, and to select the specific drug for their
removal. merely to guard against
It is requisite not
vascular excitement on the one hand, and vital depres-
sion on the other, but in many cases, also, to prevent
or to remove both, as being the more immediate causes
of the obstructed secretion or excretion of bile. In all
 JAUNDICE. 65

cases the states of general and local vascular fulness or

action, must claim our particular attention, and in many
cases it will be found requisite to aid the former, whilst
we diminish the latter.

Allo^atliimlly. — becomes a matter of considerable

It
difficulty to ascertain, what are the effects of medicines
upon the circulation and functions of the ]iver for much ;

of what has hitherto been said and written upon the

subject, has been characterized by dogmatism rather than
—
by truth by vague assertions unsupported by facts.
Some of the medicines which have been supposed to
excite the liver to action most probably operate by
removincj slicfht obstructions from the mouth of the
common duct by reducing vascular turgescence in the
duodenum, and carrying off mucous collections among ;

these may be mentioned the preparations of mercury,

particularly calomeland blue pill, as the provings and
experiments of Bennet of Edinburgh prove beyond
doubt that no af&nity exists between mercury and the
liver.

Empirically. —Divers remedies have beenrecommended

" for the treatment of Jaundice," from the far-off epoch
of Hippocrates to the present time. Foremost among
these have been antiphlogistics, general blood-letting,
emetics, laxatives, purgatives, diaphoretics and sudorifics ;

anodyne and stimulating antispasmodics, etc.

Hoinmopailiically and Hygienically. — Jaundice in its

various forms and phases is fairly amenable to treat-
ment. In the first form —the " Icterus Catarrhalis
"

— a larger number of cases have in my hands yielded

quickly to a dose or two of Aconite, followed
by PodoioTiyllum ; a compress over the region of
F
66 THE LIVER.

the liver and stomach, with a spare non-stimulating

diet. In the second form — to warm baths, friction, the
application of hot compresses over the seat of pain,
or, what is still better, the application of a liniment con-
and chloroform the sub-
sisting of Tr. Bell. J Tr. Aeon, ;

cutaneous injection of morphia, and the administration

of Bell, Calc.-C, or Lye. ; and in the more protracted
and aggravated cases, the inhalation of chloroform,
which should be repeated from time to time according
to the severity of the symptoms. In the third form to —
Aeon., Cham., Ign., JVux Vom., and Sulph ; and in the more
severe and aggravated form to Laeh. or CuraH, and a
series of Turkish baths. In the fourth form to Ign. —
and Turkish baths, which will suffice in the majority of
cases. —
In the fifth form to Lack., Curari, and Turkish
baths, and perhaps Cham., Ign., Nux Vom., and Lye.
—
In the sixth form to Ars., Laeh., and Currai, combined
with a series of pack, and Turkish baths. In the
—
seventh form to Aeon., Bry., Mere., andXac^., pack, and
—
Turkish baths. In the eighth form chiefly to Laeh.
—
and Curari. In the ninth form to Aeon., Mere.-Sol.,
and Fodolph. In the tenth form, when it arises from
catarrh of the bile-ducts — to Cham., Dig., Mere.-Sol, or
Podoph., and the sudden application of cold water to
the hepatic region by means of a small douche, a jug, or
flowering-pot. Many cases of this kind have in my
hands quickly yielded to this mode of treatment.
When from congenital obliteration of the bile-ducts,
thickening of Glisson's capsule, or congenital cirrhosis,
the treatment can only be palliative.
In the eleventh form there are two types the simple —
and maligant ; the first has already been discussed. The
 JAUNDICE. €7

second form is distinguished by serious derangements of

the nervous system, coupled with acute wasting of the
which will demand prompt and energetic treatment.
liver,

This should consist of Aeon., to subdue inflammatory

action Bell., Cham., Coff., Hyos., or Nux Vom., to cope
;

with the exalted sensibility of the nervous system.

Curari and Laeh. are also worthy of trial.
In the twelfth and which
one of the most
last form, is

terrible and obstinate types of Jaundice we have to

contend with, being generally connected with the most
chronic, and profound organic lesions of the liver and
other adjacent viscera, no radical cure can be looked for ;

but much may be done by properly-chosen medicines,

a carefully- selected diet, a series of pack, compresses,
and Turkish baths, change of air and scene, and a resort
to some of the mineral waters adapted to that class of
complaints ; such as the waters of Karlsbad, Marienbad,
Kissengen, Homburg, Vals, Yichy, Ems, Cheltenham
or Llandrindod in Eadnorshire. Independently of the
effects of the water itself, which, when taken in large
quantity, finds its way through the walls of the portal
vein, and gives rise to an abundant secretion of thin bile
—these mineral waters are chiefly indebted for their
action to the soda and neutral salts which they
contain.
They are with difficulty replaced by any other reme-
dies, in cases where the Jaundice owes its origin to
chronic congestions of the liver, with obstinate catarrh
of the bile-ducts and mucous membrane of the stomach
and duodenum, to gall-stones, etc.
Their selection must, however, always be determined
by the nature of the fundamental affection of the liver.
68 INFLAMMATION OF THE LIVER.

and by the constitution of the individual patient. It

should also be borne in mind, that the constant use of
these waters is prejudicial in the case of new growths,

such as cancer, or in more profound degenerations of

the organ, such as cirrhosis. They are not, there-

fore, to be resorted to when there is any uncertainty in

the diagnosis, or when the indication to be fulfilled in
each individual case is not perfectly clear.

CHAPTEE V.

INFLAMMATION OF THE LIVER.

Synonymously. —
Inflammation of the Liver is re-
cognized and known as the Hepatitis of Galen the —
—
Morbus jecinoris of Celsus the Inflammatio hepatis of
—
Sennertus Hepatalgia apostematosa of Sauvages the —
Cauma Hepatitis of Young — and the Empresema He-
patitis of Good.
N'ationally. —Hepatite, vel Inflammation du foie, of
the French; Entziindung der Leber, of the Germans;
Inflammazion de fegato, Epatite, of the Italians ; In-
flammation of the Liver, or Hepatic Inflammation, of
the English tongue.
Historically. — Inflammation of the Liver, terminat-
ing in the formation of abscess, was well defined by
Hippocrates as far back as 450 B.C., afterwards by his able
follower Galen, a.d. 200 (see his "De Locis Affectis,''
lib. v., cap. 7). It was not, however, until the beginning

of the seventeenth century, when anatomy

pathological
began to be studied, that a firm foundation was esta-
blished for the clinical observation of these obscure
 ;

INFLMAMATION OF THE LIVER. 69

affections. Among the valuable collections of tlie post-

mortem observations of this era we recognize those of

Thomas Partholin, Nicholas Tuepins, D. Panaroli, J. I,

Webfer, F. Euysch, J. C. Peyer, and Theophilus Bonet,

and the masterly researches of the immortal Morgagm,
whose work appeared in 1762. From that period to
the end of the eighteenth century a great number of
physicians occupied themselves with anatomico-patho-
logical investigations, and added new and valuable ob-
known. Among these may be
servations to those already
more particularly mentioned T. Walter, Sandifert, Portal,
Lieutund, John Hunter, and more especially Bichat,
who, uniting to a genius eminently generalizing an ad-
mirable talent for analysis and observation, shed, not
only on pathological anatomy, but on the whole of
pathology, a clear light, whose rays have directed the
assiduous labours of many a brilliant successor. For
the study of "true suppurating Inflammation of the
Liver," however, a disease which is onlyfound prevalent
in tropical countries, particularly in the East Indies, we
owe more to the researches of our own countrymen
far
than to any of the Continental physicians, as recorded
in the able works of Annesley, published in 1841
Charles Morehead, 1856 W. Saunders, 1809 Griffiths,
; ;

and others.
True suppurating Inflammation of the Liver is a
rarity in our own climate, as well as in other countries
in the temperate zone, although numerous cases have
been designated as such, when the symptoms present
were only due to " hypersemia " of the gland, a catarrh
of the bile-ducts, or to an inflammatory condition of the
serous covering, or of the hepatic vessels. We do,
 •

70 INFLAMMATION OF THE LIVER.

however, enco-unter iu this country two forms of In-

flammation of the Liver of considerable frequency, and
of far more importance than " suppurative hepatitis."
Of these, one terminates in simple or granular indura-
tion, known as cirrhosis, interstitial hepatitis, hob-
nailed liver, the nutmeg liver, but more familiarly
known at the London hospitals as the Gin-Drinker's
liver ; the other in softening and acute wasting of the
whole gland, whilst its history coincides, for the most
part, with that of malignant typhoid jaundice, slightly
referred to in the articles on those symptoms of hepatic
derangement. Inflammation of the Liver is a protean
disease, which is sometimes diflicult to diagnose, and
sometimes difficult to treat, owing to the fact that the
individual parts only of that complex organ may be
affected, whilst the process itself may vary greatly in
intensity, extent, and result. Thus we may have —
1. Inflammation in the fibrous covering of the gland

(which is a reflection of the peritoneum), or in the

sheath of the vessels, in **
Glisson's capsule," or in the
bile-ducts, the glandular parenchyma, or the blood-
vessels (the portal or hepatic veins).
2. The inflammation may invade the substance of the
organ as diffused hepatitis.
3. As chronic inflammation, which is an insidious
form, ultimately terminating in cirrhosis, or the Gin-
Drinker's liver.

4. The inflammation may restrict itself to a certain

radius, followed by abscess. This is the circumscribed
inflammation, terminating in abscess — or the tropical
" hepatitis abscess ''
of some writers — which shall receive
special notice in another chapter of this work.
 CAUSES. 71

Let us briefly examine these in the order as set down.

1. Inflammation of the capsule of the liver, and of
Glisson's capsule. The Peri-hepatitis vel Peritonitis
Hepatica of some writers.
Causes. — Inflammation of the covering of the liver
may arise from many causes. We sometimes meet with
it as a part of general peritonitis ; at other times the
result of exterDal violence directed against the hepatic
region, as once occured in my own practice, from the
kick of a horse. The result was fatal, while a post-
Tnortem examination revealed not only inflammation of
the capsule, bat rupture of the liver as well.In other
cases the inflammatory process is found to spread from
neighbouring structures, and morbid deposits such as, in ;

pleurisy of the right side, the serous coverings of the

diaphragm, ulceration, and cancer of the stomach. But
diseases of the liver itself, such as abscess and chronic
induration (cirrhosis), are the most prolific causes ; as
in such cases Necropsy invariably reveals the capsule
thickened, and united by numerous bands of cellular
tissue, which extend to the neighbouring peritoneum, the
surface of the ribs, or to the adjacent portion of intestines.
Peri-hepatitis in its more ordinary forms is not as a
rule a very serious disease, but may become so when
implicated with thickening of '
Glisson's capsule,' the
portal vein, artery, or vena cava. Hence the im-
portance of paying strict attention to all the symptoms

which indicate its presence.

—
Symptomatology. The leading characteristics which
attend Peri-hepatitis are, a certain amount of tenderness
of the region of the liver, which is increased upon
pressure, motion, and upon deeply inspiring ; there is
72 TKEATMENT.

also a certain amount of febrile excitement, coupled

with occasional signs of jaundice, which, as a rule, are

but slight and of short duration. In addition to these

symptoms, we must not omit to recount the various
phenomena which accompany the divers complica-
tions sometimes accompanying Peri-hepatitis, such as
pleurisy of the right side simple ulcer, and cancer of
;

the stomach with its train of cachectic symptoms and

: ;

when the portal vein, the hepatic veins, or the bile-

ducts become involved, the symptoms of disease of the
liver, or of chronic wasting, or of obstruction of bile,

become daily more and more manifest.

Teeatment. —
Allojpathically. —
Peri - hepatitis is
treated bv the local abstraction of blood, either with
leeches or the cupping instrument, by warm cataplasms,
Calomel, and the neutral salts.
Hom(Eopatliically. — This form of inflammation will
yield kindly enough to Aconite and Bryonia in alterna-
tion, followed as circumstances may require by
Belladonna or Nux Vomica ; to warm cataplasms, com-
presses or fomentations, coupled with a carefully-
selected and rigid diet, perfect rest, together with a due
regard to the indications for treatment derived from the
primary disease.
If fromulcer,^r^.-iV'?;^. and Merc.-Corr. ovMerc.-Sol. will
befound valuable remedies, together with the blandest diet.
If from the cancer, Ars.^ Nux Vom., Baryta, Carh.,
Phosphorus, or Verat-Alb,, with the same form of diet,

and nourishing enemas and, ;

If from pleurisy. Aeon, and Bry., followed, when

effusion has taken place, by Merc-Sol, Iodide of Potass.,
and Sulphur.
 73

CHAPTEE VI.

ACUTE OE YELLOAV ATEOPHY OF THE LIVEE.

Synonymously. — The Atrophia hepatis ilava sive

acuta, Hepatitis diffusa, or Diffuse Inflammation of the
Liver.
HiSTOEiCALLY. — Morgagni, in his work entitled, " De
sedibus et causis Morborum," gives us the first authentic
records of acute wasting of the liver. Long before this,
however, cases of the same kind were noticed by various
authors, Jacob Vercelloni in 1660 gives a clear
as
account of the disease from which his brother suffered.
Being hardly pressed by his creditors one night, he
became suddenly jaundiced from fright, and soon fell
into a restless delirium, with an irregular pulse and
panting respiration, and died on the third day. Paibeus,
about the same time, gives an analogous case. Baillou
records the case of a boy, only fourteen, who, on the
fifteenth day of an apparently slight attack of jaundice,
with clay-coloured stools, suddenly fell into delirium
and convulsions, gave utterance to loud articulate
sounds, and suddenly died. In the works of Morgagni
we find other cases recorded, and in addition two inter-
esting ones from the practice of Valsalva, in both of
which the jaundice was the result of violent mental
emotions. Both patients were young, and died, one in
two days, the other in twenty-four hours after the com-
74 SYMPTOMS OF

mencement of the jaundice. For a more accurate

description of the anatomical character of Acute
Atrophy of the Liver we are deeply indebted to the
indefatigable labours of more recent pathologists, par-
ticularly Eokitansky of Vienna, and Budd.

—
SYMPTOMATOLOGY. Acute Atrophy of the Liver pre-
sents symptoms of grave import, which ought not to
escape the notice of the practitioner. It is some-
times preceded by a preliminary stage ; at other
times it manifests itself without the slightest warning.
The incipient symptoms present nothing very character-
istic usually they resemble the symptoms of an acute
;

gastro-enteric catarrh. A patient so affected gets out

of sorts, and simply complains of dulness and head-
ache the tongue is coated the bowels irregular, some-
; ;

times relaxed and sometimes costive the abdomen is ;

tender, particularly that portion which appertains to

the region of the liver and the pulse is accelerated.
:

Sooner or later, sometimes not until after the lapse of

several weeks, a slight jaundiced tint supervenes upon
these derangements. This jaundice may exist in the
simple form for from eight to fourteen days, or even
longer, before the local changes take place in the liver
and spleen, haemorrhages, and the very serious nervous
derangements which so prominently characterise this
disease become apparent.
Acute Atrophy of the Liver runs a more or less
violent career, and in severe cases death closes the
scene at the end of twelve or twenty-four hours in ;

other cases after two or five days, and is scarcely ever

prolonged to a week or ten days.
In the severe types of the disease the premonitory
 ACUTE, OK YELLOW ATEOPHY OF THE LIVER. 75

symptoms are usually ushered in with vomiting, by

means of wliicli there is first thrown up the ordinary
contents of the stomach, then is followed grey mucus,
and lastly blood, in the form of a dirty brown or black
coffee-ground substance. There is severe pain in the
head, which soon lapses into delirium. In the gene-
rality of cases this delirium is noisy the sufferers scream
;

out, beat themselves, endeavour to leave their beds, and

are with difficulty restrained. In other cases they are
quieter, lay in a comatose condition, and are only roused
by loud shouting. The delirium is sometimes succeeded
by convulsions, which extend over most of the voluntary
muscles, or are confined to certain localities, such as the
muscles of the face and neck ; occasionally they appear
in the form of trismus or lock-jaw; and in other cases
one half of the body is implicated to a greater extent
than the other. After a time the patient becomes by
degrees more and more tranquil, the state of excitement
gradually passing into a stupor, and finally into a deep
coma ; there is a vacant stare, the pupils
become large,
and the respiration becomes
react but slowly to the light,
sighing, intermittent, and stertorous. The pulse, which
at first is slow, continues so as long as the Jaundice
remains simple but as the nervous system becomes
;

more exalted, it increases in frequency, and gradually

rises to 110 or 120, and even more at the same time;

it presents variations in frequency and volume which

are very remarkable, as sometimes, when the patients

are roused, the pulse rises from 70 or 80 to 120 or 130,
which soon lapses again into its normal standard, or
even below it. These variations in the frequency of the v

pulse cease when the disease draws towards a close

 —;

76 CHEMICAL CONSTITUENTS OF ABNORMAL SECRETIONS.

the pulse then increases in frequency, diminislies in

calibre, and becomes smaller, smaller, and smaller,
until it can no longer be felt, and the mirror, when
placed to the mouth, is no longer tarnished.
The tongue and teeth are covered, at an early stage
of the disease, with a sooty crust ; the abdomen is

tender, particularly in the right hypochondriac region ;

and even when the patient is in a dreamy, comatose

condition, the application and pressure of the hand over
that region is responded to by hippocratic distortion of
the features, and loud muttering complaints. The
boundaries of the normal dimeusions of the liver
become less and less as the disease advances; whilst
that of the spleen is increased. The bowels are, as
a rule, confined, and the stools are firm, dry, pasty,
clay-like, and deficient in bile, and at a later period are
of a dark tarry colour, indicating the presence of
grumous blood. The secretion from the kidneys and
bladder is normal as to quantity, always of an acid
reaction ; its specific gravity varies from 1012 to 1024,
and holds in solution albumen, amorphous mucus,
epithelium, urinary casts, and a brown colouring matter,
which yields bile-pigment to the usual chemical tests
but the most important constituents found in the urine
of those suffering from acute, as well as chronic Atrophy
of the Liver, and which may be considered as pathog-
—
nomonic of the complaints conditions, likewise, which
hitherto have not been found in any other diseases
are large quantities of Leucine and Tyrosine, coupled
with the gradual disappearance of the urea and phos-
phate of lime.
Chemically. —Leucine is, when pure, a white, non-
 —

CHEMICAL CONSTITUENTS OF ABNORMAL SECRETIONS. 77

crystallizable, and tasteless organic

odourless, fatty-
looking substance, composed in 100 parts of
Carbon .
54-96 .

Oxygen . .
24-44
Mtrogen . . 10-68
Hydrogen . ,
9*92

100.00
And although looking something like fatty matter,
yet it is quite different from it in its chemical reactions ;

for it is very soluble in water, strong acids, and alka-

lies, sparingly soluble in alcohol, and quite insoluble
in ether.
In searching for Leucine, about half an ounce of
urine should be slowly evaporated to the consistency of
a syrup, set aside to cool, and afterwards examined
under the field of the microscope, when circular, oily-
looking discs, occasionally laminated like the granules
of potato starch, will be revealed to sight. The best
chemical test hitherto discovered is that proposed by
Scherer, and confirmed by Frerichs and Harley
namely, to put a small quantity of the urine on a
platinum spatula, add nitric acid, evaporate to dryness^
and then treat the residue with caustic soda, which
dissolves it. When the solution thus obtained is con-
centrated, an oily-looking drop is formed, which can be
readily rolled on the spatula.
Physiologically. —Leucine has for some years been
known to scientific men
normal product of some of
as a
the organs of the body and according to the researches
;

of Liebig, Scherer, Frerichs, Neukomm, and Harley, it

may now be said to be one of the normal constituents
78 CHEMICAL CONSTITUENTS OF ABNORMAL SECRETIONS.

of the spleen, liver, pancreas, lungs, brain, thymus, and

thyroid glands ; but whether it exists in the healthy
living body as such, or is only a morbid product of de-
composition, is not yet a settled question. Be that as
it may, one thing is quite clear — viz., that its quantity
is vastly increased during disease, and that its appear-
ance in some of the excretions is a diagnostic sign of
considerable importance and of great value.
Secondly, Tyrosine belongs to the same class of sub-
stances as Leucine. It differs, however, from the latter
by its being crystallizable, and when pure it crystallizes
in fine white, glistening, stellate groups of small prisms ;

or very thickly-set stellate groups of fine needles or

spiculated balls, not unlike a rolled-up hedgehog, with
the bristles sticking out in all directions.
Chemically, it is similar to Leucine, one hundred
parts yielding
Carbon .... 52*67
Oxygen
Nitrogen
Hydrogen
....
. .

.
.

,
.

.
26"52
7-73
6 '08

100-00
Tyrosine is an odourless, tasteless substance, but
when burned gives off an unpleasant. smelling vapour.
It is soluble in acids, alkalies, and boiling water ; it is

insoluble in cold water, ether, and alcohol.

The most simple test for the detection of Tyrosine is
—
that proposed by Scherer namely, to moisten a few
crystals with strong nitric acid on a spatula, and slowly
evaporate to dryness. The residue, which is of a fine
rich yellow colour, when moistened with hydrochloric
 ;

CHEMICAL CONSTITUENTS OF ABNORMAL SECRETIONS. 79

acid becomes red. If the mixture be again evaporated

to dryness, it yields a blackish residue ; reactions which
are thought to be quite characteristic of Tyrosine.
met with in urine, is generally
Tyrosine, however, as
so mixed up with Leucine and other abnormal matters,
that, before applying the test, it is necessary to purify it.

This may be done by precipitating all the colouring

matter by means of a solution of basic acetate of lead
filter, and then free the liquid from the excess of lead
by means of a current of sulphuretted hydrogen again ;

filter, and evaporate the clear liquid to nearly dryness,

when the Tyrosine will crystallize in the white stellate

groups of small prisms, or thickly-set groups of needles
or spiculated balls already described.
Another mode of testing for impure tyrosine is that
recommended by Hoffman — namely, add to the sus-
pected solution a little nitrate of the protoxide of
mercury, which will throw down a red precipitate, and
turn the supernatant liquid rose-coloured if Tyrosine be
present.
Frerichs gives the following : The suspected substance
is put into a watch-glass along with sulphuric acid,
and after standing half an hour the mixture is diluted
with distilled water. It is next neutralized with carbo-
nate of soda, filtered, and to the clear filtrate a few drops
of perchloride of iron, devoid of acid, is added, when the
presence of Tyrosine is recognzied by the formation of a
dark purple colour.
Should these tests, however, fail in yielding sufficient
evidence of the presence of either Leucine or Tyrosine,
we must then resort to the use of the microscope, which
fortunately is amply sufficient for all practical purposes.
80 PATHOLOGY OF ACUTE ATROPHY.

Physiologically. — Tyrosine may be obtained from

almost all the organs in which Leucine is to be found.
It can scarcely, however, be said to be a normal con-
stituent of the human frame, but rather appears to be
one of the artificial products of the decomposition of
highly nitrogenized matters. It also proves that it can
be artificially obtained in large quantities by acting
upon horn, hair, or feathers with sulphuric acid.
Pathologically. —These remarkable and peculiar pro-
perties of the urine indicate the existence of grave and
deeply important, although long unrecognized, abnormal
conditions of the metamorphosis of matter; and they fur-
nish no small insight into the transformations which take
place in the albuminous principles, in cases where the
functions of the liver are arrested. They likewise
furnish prominent landmarks to the anxious physician,
which enables him to give due warning that the appear-
ance of Leucine and Tyrosine in the urine of his patients
is an almost certain sign of a rapidly approaching fatal
termination. As a pathological product, Tyrosine is

occasionally met with in the kidneys, in the urine, and

in the liver in a free state.
In acute yellow atrophy, it
may be almost said to be constantly present in all
of these situations, as Ererichs, Neukomm, Scherer,
Staedeler, Harley, and others, have met in all cases
brought under their notice, well-formed crystals of tyro-
sine in the tissues of the atrophied liver, kidneys, and in
the urine, without subjecting the one or the other to
any chemical manipulation, but merely placing the
morbid product under the field of the microscope.
Tyrosine has also been detected in the urine of those
suffering from severe smaU-pox, from typhus compli-
 PATHOLOGY OF ACUTE ATROrHY. 81

cated with jaundice, and from chronic atrophy of the

liver, supervening on obstructed gall-duct. The pecu-
liarity of the urine of most value in a clinical point of
view is the deposit, upon exposure to the cold, of a
greenish yellow precipitate, which, even with the naked
eye, and still more readily upon microscopical examina-
tion, can be recognized as differing from all other
deposits.
This has been amply confirmed by the observations
and researches of Trerichs, Murchison, Harley, and
others. Harley, in his excellent work on the " Urine
and its Derangements," puts the following leading and
practical question :
— " Where does the tyrosine met with
in disease come from ?
" " The results," says that author,
" of my experiments on animals to which jaundice had
been artificially given led me to the belief that tyrosine
and leucine stand in the same relation to each other in
disease as the two bile-acids, glycocholic and tauro-
cholic, do in health. Glycocholic acid is crystallizable,
taurocholic is not.

"The urine of some of the dogs to which I gave

artificial jaundice by the subcutaneous injection of bile,

contained both leucine and tyrosine, and even in one of

these cases crystals of tyrosine spontaneously formed in
the bile taken from the animal's gall-bladder immediately
after death, and merely allowed slowly to evaporate. In
another case, again, free crystals of tyrosine were
encountered in the tissue of the liver itself, all of which
facts led me to the conclusion that tyrosine and leucine
are the products either of the arrested or of the retro-
grade metamorphosis of glycocholic and taurocholic
acid."
G
82 ANATOMY OF ACUTE ATROPHY.

Anatomically. — Acute Atrophy of the Liver presents,

on post-'}norte'm examinations, structural changes and
lesions and
of grave diverse kinds
the only constant ;

one, however, is a marked diminution in the size of the

liver and an enlarged condition of the spleen hence ;

we must regard the liver as the grand centre of mischief

from whence the varied derangements in the functions
of the other organs take their rise. Taking the liver
in its normal condition as weighing about 4 lb.
avoirdupois, and its relative weight to that of the entire
body as 1 to 25 or 30, and taking the statistics, as
recorded by our own Bright, and Budd, and Frerichs
of Vienna, of 31 cases of acute wasting of that
organ, it was found that the diminution in volume
was estimated at one-third, one-half, or even two-
thirds of its normal size. saw the weight
Bright
reduced to 2 lb., to 23 and even to 19 oz.
oz.,

Frerichs, in two cases, found the liver to weigh only

1 lb. 13 oz. avoirdupois, the relative weight in these
instances to the whole body being
and 1 as 1 to 68*5
to 54*2, which clearly indicated a wasting of more
than one-half of the organ. Buhl found the liver
reduced to 22 and I have met with three cases of
oz.,

a like kind; one weighed 23, one 22J, and the third

19 J oz. respectively. In the majority of cases the size

of the gland is diminished in every direction, more
especially in its thickness ; the capsule is puckered,
and the parenchyma flabby and shrivelled ; a
section of the organ presents the colour of yellow ochre
or rhubarb, the blood-vessels are empty, and the out-
lines of the lobules are no longer visible. The gall-
bladder in many cases is found empty, or contains only
 ;

o
NATURE OF ACUTE ATROPHY. 8

a small quantity of grey mucus, or a turbid, pale

yellow, rarely brown or greenish, fluid. The stomach
and intestines presentno important alteration of struc-
ture beyond here and there patches of ecchymosis
and the contents of the intestines consist either of pale,
dry faeces, or black tarry matter. The muscular tissue
of the heart is flabby and shrivelled, and its lining
membrane is of a jaundiced colour. The blood pre-
sents divers characters : sometimes it is dark violet and
incompletely coagulated ; at other times hard firm
coagulaj of fibrin separate from and the number of
it,

white corpuscles are increased, more particularly in the

blood found in the right ventricle. Extravasations of
blood are frequently found in the mucous membrane of
the stomach and bowels, beneath the serous coat of the
intestines, and between the folds of the mesentery and
omentum, in the retro-peritoneal areolar tissues, and
beneath the pleura and pericardium. The kidneys and
brain also are seriously involved in the destructive
inroads made on the general constitution by Acute
Atrophy of the Liver ; in the former is found deposited
bile pigment, fatty degeneration and granules, with a
flabby and shrivelled condition of its tissues ; in the
urine the almost total disappearance of urea, and the
appearance of that substance in the blood ; the occur-
rence of albuminuria and those remarkable products,
leucine and tyrosine. In the latter the brain is found
softened with an inordinate quantity of serum in the
ventricles.
Nature of the Disease. —Acute
Wasting of the
Liver is related to those obscure and, to many, un-
fathomable processes, as to the nature of which various
 ;

84 NATURE OF ACUTE ATROPHY.

opinions have been advanced. The simple fact of the

disappearance in a few days, or may be in a few hours,
of one-half or one-third of a large organ of the body,
abounding as it does in blood, without the slightest al-
teration in the blood-channels leading to it, is one of
those extraordinary phenomena which has no analogy
in any other known disease.
Rokitansky, of Vienna, in 1852, was about the first

pathologist to give us an accurate description of the

anatomy of this affection, who regards the process as
one of bilious liquefaction, caused by the excess of the
elements of formed in the blood of the portal vein,
bile,

which, becoming separated, permeates the whole vascu-

lar apparatus of the liver, and causes the destruction of
the glandular substances by liquefaction.
Henoch assumes it to be a case of true polycholia, in
consequence of which all the excretory ducts become
distended with secretion, and compress the blood-vessels
hence arises a considerable impairment in the nutrition
of the hepatic cells, which ultimately leads to their dis-
integration by fatty degeneration.
Von Dusch maintains that the disease proceeds from
paralysis of the bile-ducts and lymphatic which
vessels,
gives rise to an infiltration of the organ with bile, and
through this to a solution of the cells.

Buhl regards the disease as analogous to typhus, and

the disintegration of the hepatic cells he attributes to
the same cause as the concomitant hsemorrhage, namely,
to the marked weakening and to
of the heart's action,
the rapid decrease of the peripheric metamorphosis of
matter and the changes which the liver undergoes in
;

typhus, pysemia, and other blood-poisoning diseases, are

 ETIOLOGY OF ACUTE ATROPHY. 85

considered by him as the incipient stage of Acute

Atrophy.
Bright attributed the disease to a diffuse inflammation
of the gland. Under the appellation of Hepatitis, these
views have since been enunciated by Engel, Wedl, and
Bambergen, who have accounted for the destruction of
the cells by a fatty degeneration, arising from an acute
exudative process.
Trerichs coincides, to a great extent, with the. views
propounded by Bright and his followers and although ;

not quite agreeing with their theory as to the destruc-

tion of the hepatic cells by fatty degeneration, yet he is
quite of opinion that an exudative process constitutes
the starting-point of the disease.
Etiologically.* —We are still very much in the dark
as and precise mode of origin of Acute
to the real
Atrophy of the Liver. We can, therefore, in the meantime
only enumerate the various circumstances under which
so terrible and fatal a disorder makes its appearance. It

is, however, a well-established fact that females are

more prone to it than males as, out of 31 cases col-
;

lected by Bright and others, there were 9 men and 22

women, so that the number of the latter more than
doubled that of the former. Of the 22 females one-haK
were attacked during pregnancy, consequently we are
justified in setting down sex and pregnancy as predis-
posing causes of no small import. Nevertheless Acute
Atrophy of the Liver not by any means a disease of
is

daily occurrence even among pregnant women, as out of

33,000 cases recorded by Spaeth, he only found this

* Atrta, cause, and \oyog, a discourse.

 —

SQ CAUSES OF ACUTE ATROPHY.

complication in two instances. Acute Wasting of the

liver in pregnant women may be recognized by the fact
that it is almost invariably accompanied by fatty de-
generation of the kidneys.
As regards age, the majority of those attacked with
the disease are under the middle epoch of life. Of 31
cases collected by Frerichs there were
6 between 10 and 20 years of age.
20 „ 20 „ 30
3 „ 30 „ 40
2 „ 40 „ 60
Causes. —The circumstances under which Acute
Atrophy of the Liver occurs, constitute a very interest-
ing part of its clinical history; these causes, however,
still require further investigation, as many are, as set

down by various authors, of an obscure nature. The

most prominent, however, hitherto known are nervous
influences, such as a severe fright or a sudden outburst
of passion. Sir Thomas Watson, in his classic lectures
on the practice of medicine, states that scores of in-
stances are on record where jaundice has suddenly
appeared under such circumstances and that such cases
;

are often fatal, with head symptoms, convulsions, deli-

rium or coma, &c., supervening upon such jaundice.
Similar cases have likewise been recorded by much
older writers, namely, Vercelloni, Morgagni, Ballonius,
and That a sudden " outburst of passion " may
others.
"
act as an exciting cause of " Acute Atrophy of the Liver
the writer has no moral doubt whatever, as a case of
the kind occurred in his own practice about six years
ago. The patient was a short, thin, wiry-looking
woman, about thirty-five years old, and the mother of
 CAUSES OF ACUTE ATEOPHY. 87

several children.She had a very active brain, which

was endowed with remarkably keen perceptive faculties,
coupled with a highly nei^vous and excitable tempera-
ment the greater portion of her face was covered with
;

the Pannus hepaticus, or liver spots and take her all in all,
;

she was indeed a fair specimen of a " veritable Xantippe."

Her husband, on the contrary, was a man of " fair pro-
portions," manly in form^ gentlemanly in manner, and
amiable in disposition, and submitted with stoical
philosophy to his wife's frequent outbursts of ill

temper. In the month of July, 1865, after an un-

usually violent and outrageous paroxysm of passion,
she became suddenly jaundiced, followed by headache
and despondency, which alternated with irritability
and great restlessness. She occasionally vomited
mucus, bile, and the iDgesta the tongue became furred,
;

the mouth dry, the appetite failed, the bowels irregular,

and there was considerable pain (on pressure) over the
epigastric and hypochondriac region. She continued in
this condition for two days, when she aborted. After
this the symptoms became more alarming, and were
succeeded by low, muttering delirium, tremors, twitch-
ing, and rigidity of the muscles ; the urine was scanty,
the bowels irregular, and the faeces of a dark, grumous
character; the tongue became brown and dry, and the
teeth and lips covered with sordes ; the pulse was
small, quick, and jerking, varying from 120 to 130
strokes to the minute. Percussion revealed consider-
able diminution in the hepatic area, with an increase
over the region of the spleen ; the abdomen was tym-
panitic. In this condition she continued for another
twelve hours, when she became more tranquil and passed
88 CAUSES OF ACUTE ATROPHY.

into a state of stupor; the pupils became large, and

reacted but slowly to the light ; the respiration became
sighing, intermittent, and stertorous, when she shortly
afterwards ceased to breathe. A post-mortem exami-
nation, twenty-four hours after death, revealed consider-
able diminution in the normal condition of the liver, which
appeared flabby and shrivelled. The spleen was con-
siderably enlarged, and the heart flabby and shrivelled.
The urine, a portionwhich was obtained before
of
death, was of a dark colour, specific gravity 1020, and
of an acid reaction ; it yielded traces of albumen, but
no traces of bile, urea, or uric acid ; it was also very
scanty in chlorides, sulphates, and earthy phosphates,
but yielded bountifully of leucine and tyrosine.
2. ISText in frequency comes pregnancy for of twenty- ;

two by
patients referred to wereFrerichs, one-half
attacked while pregnant and from the third to the
;

sixth month is the most common period of pregnancy

at which the disease shows itself.
3. Dissipation, including drunkenness, venereal ex-
cesses, and constitutional syphilis, appears in some cases
to be a predisposing cause, particularly the latter, as
many writers on syphilis have observed the frequent
occurrence of jaundice about the commencement of
what is known as the " secondary stage " of that disease,
and in some of these cases Acute Atrophy of the
Liver has been found to follow the icteroidal symp-
toms.
4. Malaria. — Budd, Graves, and others have pointed
out that malarious districts, with their poisonous emana-
tions, are prolific sources from whence Acute Atrophy
of the Liver may spring, as instances are recorded where
 ;

CAUSES OF ACUTE ATROPHY. 89

several cases of what appeared to have been undoubtedly

this disease occurred in thesame house.
5. The blood-poisons of typhus fever, the yellow
fever of the West Indies, and allied diseases have been
known to give rise to Acute Atrophy of the Liver.
" Jaundice," says Murchison, " is a very rare complication
more than one instance
of typhus, or scarlet fever, but in
where it has occurred, crystals of leucine and tyrosine
have been found in the tissues of the liver and kidney by
me." Most writers on the" Typhus Icterodes," or yellow
fever of the tropics, have described fatty degeneration
of the liver as one of its most characteristic lesions
but hitherto none have pointed out the presence of
leucine or tyrosine, which, as Frerichs says, is
"pathognomonic " only of acute wasting of that organ.
In 1842, whilst in charge of 450 Portuguese emigrants^
which were transported from the charming island of
Madeira to British Guiana, I had ample opportunities,
whilst stopping at the latter place, of confirming the
views set forth by writers on diseases of the tropics, that
fatty degeneration of the liver is commonly found in
those who have died of yellow fever. In addition to
the privilege of inspecting the public hospital of that
dependency, which was situated in one of the outskirts
of George Town, and surrounded by fine cocoa-nut^
banana, and other tropical fruit trees, and watching for

some days about thirty cases of yellow fever in its

various gradations, from the remission of the mild, or

common biliary, to the low typhoid state, and its black
vomit, I devoted some hours in carefully inspecting the
various " morbid specimens " deposited in the museum
attached to that institution, which were courteously
 —

90 CAUSES OF ACUTE ATROPHY.

shown me by the late Dr. Edward Bascome, who was

at the time one of the leading physicians in that once
flourishing colony, and who, a few years afterwards,
succeeded me as medical superintendent to the Sussex
House Asylum, under the proprietorship of the late
Dr. Forbes Winslow.
6. Lastly, Dr. Budd has ventured to suggest that a
special poison engendered in the body by some
itself

faulty digestion or assimilation may cause Acute

Atrophy of the Liver. It may be that the nervous in-
fluences already referred to may have something to do
in developing such a poison.
DiAGNOSTiCALLY. —Acute Wasting of the Liver is not at
all times easy of recognition, as there are other diseases

which, " symptomologically speaking," bear certain re-

semblances to that and which may, in the
affection,

hands of an incautious practitioner, be mistaken. The

most prominent of these are
1. Typhus, complicated with jaundice.
2. and remittent fevers of various kinds.
Bilious
3. Pyaemia: and among the local diseases may be

mentioned meningitis, paeumonia, and peritonitis.

{a) In contradistinction to the symptoms of Acute
Atrophy of the Liver, typhus may be recognized by its
rose-coloured eruption, its bronchial catarrh, its diarrhoea,

and the wandering character of its delirium.

(b) Bilious and other fevers by their more or less dis-
tinctly marked remittent types, and by repeated returns
of rigors.
(c.) Pyaemia by repeated shiverings, and the presence
of the deposit of pus.
Those local diseases referred to — viz., inflaiamation
 ;

TEEATMENT —ALLOPATHIC. 91

of the membrane and peritoneal

of the brain, the lungs,
covering, which, when associated with jaundice and
delirium, present a train of phenomena very similar to
Acute Hepatitis, but which, however, can be easily
distinguished by a careful examination of the individual
organs.
The morbid phenomena exhibited in the liver itself
are of greater importance in diagnosis, "not so much,
however, in the tenderness of the organ, which in some
cases is more or less absent, or but slightly felt,' but in
the marvellous rapidity by which the organ is dimin-
ished in volume until all dulness on percussion entirely
disappears. Of equal diagnostic value are the changes
—
which take place in the urine viz., the almost total
disappearance of urea and uric acid, and the deposition
of sediments of tyrosine and leucine, and the vomiting
of blood, which have invariably been met with as
prominent symptoms of Acute Atrophy of the Liver.
— —
Teeatment. Allopathic ally. The mode of treat-
ment adopted by those physicians who have hitherto
encountered Acute Atrophy of the Liver has been any-
thing but satisfactory. Still there are a few well
authenticated cases on record, where patients have
recovered even after falling into a condition bordering
on coma. "In Acute Atrophy of the Liver," says
Murchison, " all treatment has hitherto proved unsatis-
factory." " The results of treatment hitherto recorded,"
says Frerichs, " are of a hopeless character ; hence no
approved empirical method exists." According to
Corrigan, of Dublin, the progress of the disease is
arrested by emetics ; according to Griffin, of Limerick,
and Hanlon, of Portarlington, by drastic purgatives
 ;

92 TREATMENT —HOMCEOPATHIC.
according to Trericlis, of Braslau, who has only seen
one case, it yielded favourably to purgatives and mineral
acids ; and, according to Budd, even coma n:ay probably
1)6prevented, or removed, and the life of the patient
saved by active purgatives. Leeches, blisters, and the
cupping instrument have been applied to the head, and
liver; senna,
aloes, colocynth, and the sulphate of
magnesia have been administered as purgatives; the
subnitrate of Bismuth, combined with the aqueous
extract oWux
Fbm. has been prescribed to stop vomiting
and ice, both externally and internally, with alum,
gallic acid and similar astringents, to check hsemorrhages
from the stomach and ether, camphor, and musk to
;

rouse nervous depression.

HommopatUcally. — Little, I fear, can be said, in a
practical point of view, on the Hahnemannian mode of
combating that terrible, and too fatal disease as I have ;

been unable to meet with any well-authenticated cases

in the now extensive literature {little, Jiowever, of real
practical value) of our doctrine, beyond the case recorded
by me, which unfortunately proved fatal. Much, however,
I am persuaded, may be accomplished by Homoeopathy,
provided a clear and unmistakable diagnosis be made
out, coupled with judiciously-selected remedies and the
aid of hydropathic appliances and hygienic measures.
It is, however, in the early stage of the malady, and
before delirium, coma and other cerebral symptoms
manifest themselves, that most advantage may be
expected from this, or any other mode of treatment,
however fortified and bolstered up it may be by the halo
of antiquity and the so-called orthodoxy.
To grapple with a disease so little known in the wide
 TREATMENT. 93

arena of medicine, the first onslaught and invasion of

which is so sudden, its causes so obscure, its symptoms
and effects so rapid, and its results so disastrously
fatal, requires more than ordinary experience and
acumen to distinguish at one glance its peculiar and
mysterious characteristics, and apply its appropriate
remedies.
In the homoeopathic Armamentarium we possess many
remedies of undoubted value. Among these may firstly
be mentioned those brilliant American medicines, the
Iris Versicolor, Leptandra Virginica, and Podoijhyllum
Peltatum ; secondly, Aeon., Bell., Grotalas, Horridiis
Merc-Sol., Nux Vom., Strychnine, and Chamomilla,
with Bo^yonia, Lachesis, Chin., and Sidphitr as in-
termediate auxiliaries. With these much may be
done to prove that a specifically selected drug, and
specifically selected hygienic measures, may go far to
diminish much of the terrors and heavy mortality,
which now environ " Acute Atrophy of the Hepatic
Organ." In the first stage of the disease, which I am
disposed to look upon as "a paralj^sis of the gland,"
caused by the invasion of some subtle poison, whether
It be fright, or a miasma, through the nervous system, our

primary object will be to rouse its lost f auctions, and

restore it to its normal standard. And how is this to

be done ? We possess in the Mandrake and Culver's

Root such remedies : they rouse to vigorous action the
functions of the liver, they stimulate the kidneys, they
augment the functions of the whole glandular system,
and cleanse the intestinal canal of all foreign and
irritating matter. Either of these remedies should be
administered in potent doses, and repeated at frequent
94 TREATMENT.

intervals, or until bilious motions appear. Should there

exist at the same time tenderness over the region of the
liver, a well-adjusted compress should be applied, or a
powerful cold douche should be directed to the surface
of the hypochondria from a distance, and kept playing
for some minutes here, also, Aconite would be expected
;

to play an important part as a curative agent. The

provings and toxicological records show most conclu-
sively that that drug exercises a specific action upon
the functions and tissues of the liver. Aconite causes
Jaundice, which is one of the pathognomonic signs of
Hepatitis ; it likewise causes bilious vomiting, a foul
bilious coating upon the tongue, painful feeling of
swelling in the pit of the stomach, violent constriction,
and weight in the hypochon-
tightness, pressure, fulness,
driac region tensive, painful swelling under the ribs
; ;

shocks and pressure in the region of the liver, with

oppression and arrest of breathing pricking in the liver
;

and bowels, and a constrictive pain in the region of the

gall-bladder, arresting the breathing. The first or second
decimal dilution of this medicine should be selected,
and administered at frequent intervals, or in alternation
with one of the foregoing medicines every one or two
hours.
This mode of treatment should be unflaggingly perse-
vered in, coupled with cheering society, the holding out
hopes of recovery, change of scene, careful attention to
the condition of the stomach and bowels, and the pro-
duction of calm, sound sleep, by means of Coffea, Bell.,

Hyos., Aeon., Gelseminium, or Glonoine. Should the

disease, however, refuse to yield to those remedies, and
pursue its onward course of destruction, by invading the
 — — ;;

TEEATMENT. 95

brain, which we generally encounter in the form of

Delirium, Coma, and Convulsions, all known measures
calculated to promote the elimination of those poisonous
properties, Urea and Uric Acid, from the system, —
should be called into action.
It is in this way, perhaps, that the purgatives, as
prescribed by
and Hanlon the laxatives by
Grifiin ;

Budd and the purgatives and mineral acids by Ererichs,

;

have done some good. We have, however, in our own

Le'ptandra and Podophyllum, potent aids Medicines
which not only penetrate into the inmost recesses of
the liver, but act as purgatives as well ; consequently,
the action of these drugs should be assiduously kept up
the skin also should be submitted to the influence of
warm baths, and more particularly the " Turkish bath."
In would not hesitate to keep my patient in the
fact, I

latter for from two to three hours at a time, followed by

the cold douche, which should be played up and down
the spine, and over the whole of the hepatic region, for
three or four minutes each time, and even longer. The
Kidneys, which have not hitherto received that attention
they deserve, ought not to be forgotten in the treatment
of Acute Atrophy of the Liver, as microscopic examina-
tions have revealed in these organs the deposit of bile-
pigment ; the glandular epithelium iniiltrated with
granules ; and in most cases in a state of fatty degenera-
tion ; and the tissue itself flabby and shrivelled. The
urine also undergoes important changes ; as we have the
almost total disappearance of the Chlorides, Sulphates
Earthy Phospates, Uric Acid, and Urea from that fluid
and the accumulation of the latter in large quantities
in the blood ; the temporary occurrence of albuminuria
95 TREATMENT.

also ; all of which point to an important implication of

the kidneys *
In the treatment of the kidneys, as a complication of
Acute Atrophy of the Liver, we must be guided by the
totality of the symptoms which present themselves to
view.
In the congestive stage no better remedy can be
selected than TerehinthincB 3x.
In the inflammatory stage Aeon., Gels., or Bell., with
an occasional dose of Canth. or Cannabis Sativa.
When the symptoms of blood-poisoning, haemorrhage,
sickness, &c., make their appearance, such symptoms
should be met by their appropriate remedies.
Haemorrhages from the stomach and bowels, by ice
externally and internally, Terebinth, Ham., Ipec., Mille-
folium, or Arsenicum.
To check vomiting Ipec., Nux Yom., or : Kreasote.
To remove coma Opium, Bell., Hyos., or
: Hell,, and, if

possible, the Turkish bath.

To remove convulsions and wild muttering delirium :

Crotalus or Lachesis, and more particularly the Turkish

bath.
And when symptoms of nervous depression,
there are
alternating with convulsions^ Camphor or Moschus.

* Ursemic poisoning is a subject of grave importance to the medical

man, as it may occur in the course of any disease. Trae ursemia de-
pends on the arrested elimination of the poisonous material by the
kidneys, and its reabsorption into the circulation. There can be no
doubt that urea is a powerful irritant poison, and when injected into
the veins of animals it rapidly induces fatal convulsions, and to remove
such poison from the system, quicMy and effectually, I know of no
more powerful eliminator than the Turkish or Eoman bath.
 —

97

CHAPTER VII.

Diffuse Infla^imation of the Liver — the Chkonic

Form.

{Hepatitis Dijfusa Chronica Adhcesiva.)

—
Synonymously. The chronic form of Diffused Inflam-
mation of the Liver is known as the Hepatitis Diffusa
Chronica Adhaesiva, of Aritseus —the Marasmus Hepatis
of Bianchi, —the Hepar Durum Tuberculosa of Morgagni,
—the simple Granular Induration of Matthew Baillie,—
the Interstitial Hepatitis of —the simple
Abercrombie,
Granular Induration of — the
some French writers,
Hepar Duram Vitellarium* —the Hob-nailed
of Clossy,
Liver ofHoecker,— the Laennec, —the simple
Cirrhosis of
Atrophy Cars well andKiernan,— and the Gin-drinker's
of
Liver of English practitioners.
Historically. — the Cappadocian, and con-
Aritaeus,
temporary of Galen, a.d. 131, was about the first to
describe " Induration of the Liver " as a consequence of
inflammation,
"Verum si a phlegmone hepar non suppuratur, nemini
dubium fuerit, tumorem durum subsidentum in scirrhum
mutari ac Stabiliri." —Book I., chap. 13.

* From its resemblance to the Vitellarium of a laying hen.

H
98 CIRRHOSIS OF LIVER.

" But if, after the inflammation, the liver does not
suppurate, the pain does not go off, its swelling, changing
to a hard state, settles down into scirrhus." In which
case, indeed, the pain is not continuous, and when pre-
sent is dull, and the heat is slight ; there is loss of
appetite, delight in bitter tastes, and dislike of sweets ;

they have rigors ; are somewhat pale, green, swollen

about the loins and feet, forehead wrinkled, belly dried
up, or the discharges frequent. The cap of all these bad
symptoms is dropsy!'
"
In the dropsy, provided there is a copious discharge
of thick urine, having much re-crementitious sediment,
there is hope that the dropsical swelling may run off;
but if the urine be thin, without sediment, and scanty,
it conspires with the dropsy. The chief causes alluded
"
to by and eminent author are primarily
this ancient
Intemperance, a proof that teetotalism was not in the
ascendency at that remote epoch and protracted ;

diseases especially from dysentery and colliquative

wasting, and it was customary to call such persons tabid,
who died emaciated from ulcers and atrophy of the
liver.

Hippocrates, who flourished 450 makes mention

B.C.,

of something similar, for in the 42nd Aphorism of his

masterly work we find the following :
— " In cases of
jaundice and dropsy they are bad symptoms when the
liver becomes indurated." What form of induration,
however, he does not say but it is a well-known patho-
;

logical fact that jaundice or dropsy, attended with

scirrhus, or cirrhosis of the liver, is necessarily all but
hopeless.
Yesalius, a celebrated Belgian anatomist of the fifteenth
 HISTORY OF THE LIVEE. 99

century, records the case of a lawyer who, after having

suffered for a long time from symptoms of " obstruction
of the liver," died suddenly while sitting at table. A
post-mortem revealed the trunk of the portal vein torn,
the abdominal cavity filled with blood, and the liver
HARD and ATROPHIED.
Mcolas Tulph, of Amsterdam, another eminent
physician and patriot, at about the same era, found
on opening the body of a man, who had suffered from
Ascites, and Tympanitis, and who had passed blood
upwards and downwards, the spleen enlarged, and the
liver HARD and shrivelled.
John Baptist Morgagni, an Italian physician of
great renown in his period —
the " sixteenth century," re-

cords several cases of the same kind, partly from his

own observations, and partly from the works of Posth,
Wepfer, and Euysch.
With rec^ard to the nature and character of the
disease, various conflicting opinions have been ad-
vanced by different authors. Morgagni looked upon
the external nodulated surface of the organ as the
formation of a new deposit —tubercles ; Matthew Baillie

and Meckel fell into the same error. Lawrence, who

was the first to give it the name of Cirrhosis —
—
from the Greek (kirros Yellow) also enunciates the
—
same view that the nodules were new formations,
which might be developed in other organs as well,
and which, like other new formations, might undergo
softening.
In 1826, BouiUaud endeavoured to prove that no new
formation existed, and that the yellow granulations
consisted in the disorganization of the glandular paren-
100 , CIRRHOSIS OF LIVER.

chyma, from diseases of the vascular connecting

tissues. Andral in the main supported this theory
except that he bestowed greater prominence upon the
distinctions between the red vascular portion and the
yellow secreting tissues of the gland and looked upon ;

those abnormal granulations as hypertrophy of the

latter, accompanied by atrophy of the red vascular
portion, which in many cases appeared to be converted
into fibrous tissues. Cruveilheir steps forward and
disputes the existence of two different substances in
the liver, and considers the disease under discussion
to be the result of atrophy of one portion of the gland,
with hypertrophy of the other portion. Becquerel
constructed a new theory and maintained,
altogether,
that the so-called yellow substance was the peculiar
seat of the disease, and further thought that it became
infiltrated with an albuminous substance which was
followed by hypertrophy that the red vascular portion
;

was compressed by it, and became atrophied, and that

at a more advanced stage the yellow substance itself
became likewise atrophied.
That eminent pathological anatomist, Carl Eokitansky,
distinguishes two different modes of origin of Cirrhosis
of the liver, the one proceeding from a morbid develop-
ment of the capillary blood-vessels, owing to an
excessive secretion of bile the other due to a chronic
;

inflammation of the hepatic parenchyma.

Oppolzer attributes the disease mainly to partial
impermeability of the finest ramifications of the portal
vein, resulting from inflammation and obliteration, or
from lateral compression by the bile ducts, which are
enlarged, or, loaded with fat.
 ANATOMY OF CIRKHOSIS. 101

More recent writers, such as Gubler, Budd, Heiiocb,

Bamberger, and others refer cirrhosis to a chronic inflam-
mation of the liver.
The French pathologists already referred to arrived
at no clear or definite results, because they all proceeded
upon anatomy and
indistinct views of the microscopical
structure of the hepatic organ and it was left to the
;

brilliant investigations of our own Carswell, and more

particularly to the late Dr. Kiernan to point out to the
present and future generations the true nature of cir-

rhosis,and designated by them " Atrophy of the liver/'

—
Anatomically. The cirrhosis of Laennec is one of the
most important forms of atrophy of the liver which
comes under the notice of the physicians. In it we find
the organ is diminished to one-half, or even to one-third
of its normal bulk and how are we able to account for
:

all this ? Let us see. One seldom has an opportunity of

tracing the development of induration of the liver
during life, or of examining anatomically the early
stages of the various morbid tissues for as a rule the
;

disease only comes under notice when it is more or less

developed, and when the consecutive disorders draw
attention to the organ primarily affected. Hence in the
majority of cases the gin-dkinker's liver can only be
inferred during life by tracing backwards the clinical

history of such cases, where these morbid changes are

found after death.
The liver, "as we have already pointed out in
another part of this Essay," is constructed of certain
blood-vessels, lymphatics, nerves, lobules, and bile-

ducts, which are supported and welded together by

a framework of connective (areolar) tissue, which per-
 ;

102 SYMPTOMS OF CIRRHOSIS.

vades the whole organ, both internally as well as exter-

nally. Beneath the peritoneal covering there is a
capsule of connective tissues containing a large number
which envelop the outer surface of the
of elastic fibres
organ. In addition to this there is another fibrous
tissue composed of the same elements, and known as
"Glisson's capsule;" this penetrates the liver at its

fissure and accompanies the various vessels, nerves,

absorbents, and bile-ducts as far as their very finest
ramifications. In addition to all this there is a still
finer structure, an "alveolar matrix" in the " gossamer-
like" meshes of which lie nestling the hepatic cells and
the extreme ramifications of the capillary system.
The progress of the " gin-drinker's " liver is slow, very
so, and insidious; its history extends over many years,
and for clinical purposes may be conveniently divided
into two distinct stages, each having its respective anato-
mical, pathological, and symptomalogical, characteristics.
—
Symptomatology. The early symptoms of cirrhosis
are obscure, and may be chiefly referred to a disordered
digestion there is a capricious and defective appetite
;

there is a furred and loaded tongue —

particularly in the
morning; there is frequent nausea and qualmishness,
with an occasional tendency to reject the contents of
the stomach there is at times a slight degree of fever
;
;

there is a sense of weight with a dull, aching, or obtuse

pain in the right hypochondrium, which shoots up under
the right shoulder-blade, increased by pressure or by
lying on the left side. The region corresponding to the
liver is tense and distended, and the size of that organ is
increased in size, which may, on careful palpation, be
felt cropping out below the margin of the floating ribs.
 PATHOLOGY OF CIEEHOSIS. 103

The countenance becomes sallow; there is general languor

and depression of spirits, flatulence, an irregular action
of the bowels, sometimes costive, sometimes relaxed,
sometimes pale and clayey, sometimes dark, with a faint
jaundiced tint of the skin and conjunctivse. After a
longer or shorter duration these symptoms may abate,
although the disorganizing process may still go on in
the liver, and gradually undermine the constitution;
consequently, these symptoms, however trivial they may
appear to a casual observer, ought not to be treated
lightly, especially when present in a patient known to
be fond of his drams, one of the most prolific causes
of cirrhosis of the liver.
Not unfrequently the disease may set
symp- in with
toms of a more severe and prominent character, and
which commence with vomiting and purging, and other
symptoms of intense " gastric catarrh." At other times
we encounter all the phenomena of acute congestion
of the liver, viz., fever coupled with pain, tenderness,
and enlargement of the organ, with nausea, vomiting
jaundice, and high-coloured urine, containing bile-
pigment and a heavy deposit of lithates. Such is a
brief outline of the leading symptoms generally encoun-
tered in the first or early stages of cirrhosis.
Anatomo-pathologically. —We find in this stage the
liver enlarged and increased in consistency, caused by a
congested or hypertrophied condition of the areolar
framework, (Glisson's capsule). The surface of the
organ is covered by a smooth, opaque, thickened capsule,
studded with flattened projections, which vary in size
from a pin's head, a homoeopathic globule, to a small pea :

similar nodules are also found in the interior of the

104 SYMPTOMS OF SECOND STAGE OF CIRRHOSIS.

structures, which are separated from each other by

narrow strips of grey, or more or less vascular " areolar
tissues ;" in some cases the colour is dark from the pres-
ence of bile-pigment in other cases pale, from the deposit
;

of fatty matter.
In the second stage, symptomatologically speaking, the
patients still complain of feeble digestion, which is
easily disordered by articles of diet that formerly could
be taken with impunity. The appetite falls off. There
is distention and tenderness of the epigastrium along .

with flatulence and obstinate constipation after a time ;

these symptoms abate, but return from time to time from

any slight and trivial cause. By degrees such patients lose
flesh and strength the colour of the skin becomes either
;

pale, earth-coloured, or a dirty yellow, whilst the skin

itself is dry, and rough. The abdomen now
scaly,
becomes distended, and fluctuates, the prominent out-
lines of the liver are no longer felt by either percussion
or palpation, but a close examination reveals atrophy
of this organ, and considerable enlargement of the
spleen.
Onward now is the course of destruction of cirrhosis,
a general condition of emaciation and debility sets in.
The watery portion of the blood is effused into the abdo-
men (ascites),producing distention of that cavity, and, as
a consequence, urgent and distressing dyspnoea. Haemor-
rhages take place from the stomach and intestines, the
nose and mouth; the urine, at first tolerably abundant,
now becomes more and more scanty as the flood of
dropsy advances, and, at the same time, puts on a deep-
red hue, often turbid, and deposits a brick-red sediment.
The dyspnoea becomes more urgent day by day, and in
 PATHOLOGY OF SECOND STAGE OF CIEEHOSIS. 105

most cases a diarrhoea now sets in, wliicli sooner or later,

terminates farther suffering by death.
In other cases the fatal termination is induced by
inflammation or congestion, and sedema of the lungs ; at
other times it occurs under symptoms of acholia ;* when
the sufferer becomes deeply jaundiced, the skin studded
with purple spots or bruises, delirium, convulsions and ;

finally, a deep coma closes the scene.

Such is a general outline of the chief symptoms which
characterize the second stage, and closing scene of
cirrhosis.
Anato - PATHOLOGICALLY. —In this the second stage
the disease differs in many important respects. The
liver now is reduced in size, particularly the left lobe,
which is often found shrivelled up into a small mem-
branous appendage. Semi-globular knobs of unequal
size and form are thickly scattered over its

surface. The serous envelope is thickened and

tough ; numerous bands of connective tissue pass from
it to the neighbouring organs, such as the diaphragm,
colon, stomach, and spleen. Upon making a section of
a cirrhotic liver, the surface presents a cartilaginous
hardness and leathery tenacity. The knife grates, " as it

were," in cutting through Broad and narrow lines of

it.

connective tissue surround the granulations, and send

streak-like processes into their interior. These granu-
lations are in most cases dark, or of a pale yellow. A
large portion of the hepatic'cells are destroyed, and their
remains are found in the form of small masses of
" brownish pigment " scattered through the filaments of

the newly formed connective " areolar tissue." Other

• Bile-poisoning.
106 PATHOLOGY OF SECOND STAGE OF CIRRHOSIS.

portions constitute the substance of the granulations,

and may remain for a certain period intact but in the ;

further and more advanced progress of the disease these

cells likewise undergo great changes, which materially

interferes with their healthy and normal functions, from

the deposit of fatty substances, and various kinds of
pigments, the result of a deranged nutrition of the liver,

produced by a slow and latent inflammation. The

deposit of pigment, from which the term cirrhosis
(yellow) is derived, is but seldom absent. This is

caused by the hypertrophied connective tissue pressing

against the extreme radicles of the bile-ducts, and thus
giving rise to a retention of the secretion, followed by
an icteroidal condition of the liver. This colouring
matter accumulates in the form of a fine orange, or
sulphur yellow-granules. Besides this there is another
colour to be met with in a cirrhotic liver, which is of a
dirty red-brown or black pigment, the result of decom-
position of the red globules of the blood. There is an
increase in the amount of connective (areolar) tissue.
This increase is first met with in the prolongations of
" Glisson's capsule," which accompany the finer sub-

divisions of the vessels in the remotest parts of the

interior of the liver ; from this it gradually proceeds
to invade the substance of the " lobules," and by
degrees increases so in breadth as finally to destroy the
whole secreting portion of the organ. The vascular
apparatus also does not escape the ravages of chronic
atrophy of the liver. The trunk and large branches of
the portal vein have b^en found considerably enlarged,
and filled with clots of blood the smaller branches nar-
;

rowed or totally destroyed to an extent proportionate to

PATHOLOGY OF SECOND STAGE OF CIRRHOSIS CASES. 107

the disappearance of the glandular substance of the

organ. The trunk of the hepatic artery is generally
dilated, and its capillary network far more extensive
than in its normal condition. The bile-ducts at the
periphery of the globules are in a great measure oblite-
rated by the pressure of the newly formed connective
tissues. The walls of the gall-bladder are thickened,
and adhering and its
to the neighbouring structures,
contents are in most cases scanty and liquid and of
a pale orange or yellow colour. In extreme cases of
cirrhosis, when the secreting and circulating functions
are almost or entirely destroyed, nature makes a grand
and munificent effort to prolong life by establishing a
collateral circulation.
The late Dr. Kiernan, who was the first to discover
the true nature of cirrhosis, has on record several
left

interesting cases of the kind. In one where the liver

had diminished to more than one-half its normal size,
he discovered on injecting it that a collateral venous
circulation had been established by way of the dia-
phragm.
In another case, that of a woman who had been
tapped "ninety times," he found upon injecting the
liver that the same kind of collateral circulation had
been established. The circulation throuoh the liver had
been impeded by the development and deposit of dense
" areolar tissue " —
every floodgate, in fact, was blocked up
and hermetically sealed, and the greater part of the blood
of the portal vein had found a new channel through dilated
vessels upon the surface of the organ and through the
diaphragm, and from thence into the general circulation.
In this case there were numerous bands of adhesion
 —

108 COMPLICATION OF CIRRHOSIS.

between the and the diaphragm, and between the

liver
intestines and the walls of the abdomen, and these also
were traversed by large veins conveying blood from the
portal vein into the general venous circulation.
Complications. — Irrespective of the diseases of the
liver, we often encounter affections of other organs of the
body which are sometimes independent of the hepatic
disorder, but at other times are closely or remotely con-
nected with it. To the former belong the deposit of
tubercles, and emphysema of the lungs ; diseases of the
heart, carcinoma., delirium tremens, a lardaceous spleen,
syphilitic affection of the bones, lardaceous deposit in
the kidneys, and the morbus Brighti of drunkards.
To the latter belong pneumonia, pleurisy, peritonitis,
dysentery, hsemorrhage from almost every part of the
body, ascites, and anasarca.
M. Hanot, in his thesis (December, 1875), states that
he has made out, by careful investigations at the Hopital
Cochin, in Paris, a peculiar kind of hypertrophic
cirrhosis of the liver, presenting the following characters
extra-lobular and extensive cirrhosis without any ten-
dency to retraction of the conjunctive tissue of new
formation; and sometimes intra-lobular cirrhosis
abnormal development and chronic catarrh of the biliary
ducts.
—
Symptomatically. It is characterized by chronic
jaundice depending on the obliterations of the biliary
canaliculi, and by a considerable hypertrophy of the
liver without ascites, or the abnormal enlargement of the
subcutaneous veins of the abdomen which is observed
in ordinary cases of cirrhosis. The affection may last a

long time, but sometimes ends in the acute malady called

 a

CAUSES OF CIRRHOSIS. 109

" severe icterus." No particular etiology has been made

out, nor is there anything reliable respecting treatment.
— {Lancet, August, 1876.)
Causes. —There are perhaps various conditions capa-
ble of producing, or" at all events may help to produce,
the different forms of adhesive inflammation of the sub-
stance of the liver now under consideration ; but the
most common, and indeed the most powerful cause in
this country is the habitual indulgence in " ardent
spirits." These forms of disease are in consequence
most frequently seen in London and other large towns
chiefly among the poorer classes, many of whom spend
the greater portion of their earnings in, and when that
fails even sell or pledge their bed for the purchase of

gin, and for this reason the granular or hob-nailed liver

known to the French as cirrhosis, has been familiarly
termed in this country the " gin-drinker's " liver —
disease commonly met with at the various London
hospitals. The influence of spirit drinking in causing
this disease has lil^ewise been observed in France and in ;

the many cases published by the eminent Andral, all

are traced to spirit-drinking. He imagined that the
spirit produced irritation of the mucus membrane of the
stomach and duodenum, and spread through continuity
of tissue to the gall-ducts, and from thence into the
substance of the . liver, or, that the achohol being
absorbed into the veins may act directly on the liver.
The latter exposition is undoubtedly the correct one ;

as the spirit when absorbed by the blood-vessels, is

carried at once to the liver,and there exerts an imme-

diate and deleterious action on its tissues. In proof of
this observation some interesting experiments on the
 ;

110 ETIOLOGY OF CIRRHOSIS.

poisonous effects of alcohol were, a few years ago, per-

formed by Dr. Percy, of Birminghara, who found that
in dogs poisoned by alcohol, he could recover that spirit
from the blood, the brain, the spleen, and other organs,
but in far the greatest quantity from the liver. The
inflammation of the "areolar tissue" in the portal
canal. " Glisson's capsule " is
most probably owing to
the diffusion of alcohol through it from the portal veins
and bearing in mind the volatile principle of alcohol,
we can readily conceive how quickly and effectually
it permeates animal membranes and tissues. These
remarkable properties of alcohol also explain the fact

observed by the generality of pathologists, that in cirr-

hosis, or the gin-drinker's liver, the whole of the liver is

uniformly changed in structure ; but if globules of mer-
cury or globules of pus find their way into the veins
that feed the vena porta they become arrested at some
particular points in the lobules of the liver, and excite at

each of such points circumscribed irritation, followed by

inflammation, and ultimately by abscess, while the whole
of the remaining liver continues healthy, but it is quite
different with alcohol,which being of a volatile nature^
mixing freely with water, becomes equally diffused
throughout the whole mass of the portal blood flowing
through the liver, and the inflammation it excites, "slow
though it may be," involves, as a consequence, the entire
orfyan, and its ultimate destruction.
Etiolo GIG ALLY. —The
form of degeneration of the
liver herein described has been pretty generally attri-
buted to a " chronic inflammation of the gland," and the
chief cause to the abuse of " ardent spirits," hence the —
English term " gin-drinker's liver." There can, however,
 — ;

hypeetEmic liver characteristics. Ill

be no doubt that a granulated condition of the liver

may arise in other ways, and from divers other causes
but anato-pathologically there is only a superficial re-
semblance between such granulations and those of true
cirrhosis. Clinically granulations of this type are to
be met with under the five following circumstances :

1. The Patty Liver. — In this disease, segments of

the gland in which the cells are greatly distended with
fat, form of yellow rounded granulations,
project in the
the size of a globule, or a pin's head. In all cases
of this kind examined by Ererichs and others, the
prominences were formed by the portal zones of the
lobules, and after injection, twigs of the portal vein and
hepatic artery might be seen on the top of the granulations
whilst the hepatic vein lay in the depressions. In true
cirrhosis, however, it will be observed that the relation
of the parts is precisely the reverse. The hypertrophy
of the connective areolar tissue ; the development of
new vascular channels; and the great firmness and
tenacity of the whole gland, which is never absent in a
case of genuine cirrhosis, are invariably absent in an
adiposed and which is also exempt from any
liver,

prominent derangements of the circulation.

2. —
The Hyper^aiic Liver. This form of hepatic
derangement arises from an obstructed circulation in
heart and lung affections. In the first stage there is
considerable enlargement of the gland (hypertrophy),
arising from a redundancy of blood (hyperaemia), but
after a time this enlargement is followed by an opposite
condition — atrophy. Here also the liver becomes firm,
leathery, and finely ''granular," which has led many
able practitioners to confound it with true cirrhosis.
 112 PEKI-HEPATITIC ATROPHY CHARACTERISTICS.

These granulations, however, are formed in quite a

different manner — viz., the roots of the hepatic veins
are enlarged as far as their capillary origin, and cause the
surrounding cells to disappear. In this way the parts
corresponding to the hepatic veins sink down, whilst
those occupied by the portal vein project in tine granu-
lations. At first the wasting of the organ is confined to
the circumference of the enlarged capillaries, but, after a
time it extends to the large branches, and as a conse-
quence produces extensive depressions, and new con-
nective tissue is developed around the vessels, imparting
to the organ a certain amount of firmness. This form of
atrophy of the liver is frequently traced to hypertrophy
and valvular disease of the heart.
8. Pyle-phlebitic Atrophy. —A wasting of the liver
. will sometimes follow an obliteration of the fine branches
of the portal vein —the result of " adhesive phlebitis.'"'
On tracing the branches of the portal vein into the
interior of the gland, we arrive at blind extremities,
which are surrounded by a firm shrivelled tissue, the
remaining portion of parenchyma being left unchanged,
depressions are thus formed, which give to the liver a
lobulated, and at other times a coarse granulated appear-
ance not unlike that of cirrhosis. This condition however
differs materially from the latter disease — viz., by its

greater size, its less regular form, the flatter character of

its projections, by the total absence of the bands of
connective tissue in its interior, and by there being no
history of spirit drinking.
4. Peri-hepatitic Atrophy. —There is a form of
wasting of the liver which follows repeated attacks of
inflammation or its capsule (peri-hepatitis). In such
 CHRONIC ATROPHY OF FRERICHS. Il3

cases the capsule becomes thickened, and is often con-

nected to surrounding organs by firm bands of fibrous
tissue ; similar bands also pass into the interior of the
organ, which on pressure presents a dense, smooth, uniform
surface, with the outlines of the "lobules" more or less
obliterated. This condition of liver is recognised by
some writers as " simple induration," and is not unfre-
quently met with in patients suffering from the secondary
—
and tertiary forms of typhilis valvular disease of the heart
of long standing, inflammation of the pleura, ulceration of
the stomach and duodenum, and various derangements of
the secreting tissues of the liver itself In such cases
the inflammation is sent to the capsule of the liver
through the diaphragm, along the coronary ligament,
or from the subjacent glandular structures. When the
disease has a syphilitic origin the surface of the con-
tracted liver marked by cicatrices, or deep and irregular
is

fissures. Under other circumstances the surface is

smooth, and totally devoid of those granulations or
hobnailed protuberances which, so characteristically
mark true cirrhosis.
5. The chronic atrophy of Frerichs — or the red
atrophy of Eokitansky. — This form of atrophy is
distinguished from all others by its dark-brown or
bluish red colour: the substance of the organ is

gorged with blood, and presents a spongy, elastic con-

sistence there is an absence of granulation, and a
;

section gives an appearance of a perfectly homo-

geneous texture : the secreting cells are smaller than
natural, and loaded with brown pigment granules.
The atrophy of the organ is general, though its thick-
ness preponderates over the dimensions. The other
I
 114 TREATMENT OF CHRONIC ATROPHY CIRRHOSIS.

most important anatomical phase connected with this

form is the destruction of the ramifications of the
portal vein, the branches of which terminate in blind,
club-shaped extremities.
The disease is and is invariably accom-
chronic,
panied by general torpor of the abdominal ganglia, and
venous plethora of the abdominal viscera; cancerous
ulcerations of the stomach and intestines and by the ;

formation of brownish black or greenish black tarry

bile, and faeces of a similar composition. By itself this

form of atrophy rarely proves fatal, though death may

ensue from the general marasmus brought on by the
prolonged congestion of the portal system, or from
repeated attacks of intermittent or remittent fever.

TREATMENT.

The leading indications for the treatment of this,

the chronicform of inflammation of the liver
(cirrhosis) must vary according to the state of the
disease, and the consequences to which it gives rise.
But from the difficulty of its early recognition, or from
the patient not seeking early the advice of his medical
adviser, an opportunity is not often afforded of treating
the complaint in its incipient stage ; and from what has
been already said of the nature of cirrhosis, it is quite
clear that it is only in the early stage that
we can successfully grapple with the complaint,
and so benefit the patient. During this, "the
early stage," while the inflammation is active, and
the effused lymph in a liquid condition, our Materia
Medica undoubtedly contains remedies which possess
the power of checking the further effusion of lymph,
 ALLOPATHIC TREATMENT. 115

preventing its and promoting its removal

organization,
by absorption. Much, of course, will depend upon the
patient himself: he must, with a fixed determination
and stoical bravery, resist, " once for all," the fascina-
tions of his daily dram he must place implicit
;

confidence in his doctor, and carry out with religious

exactitude his medical, dietetic, and hygienic rules.
But when that treacherous element the fibrine has — —
been thrown out, and when it has become organized
and becomes a part .and parcel of the living body,
incapable of removal, and is already by its puckering
and contracting causing impediment to the natural flow
of the portal blood, and materially impeding the
natural secretion of bile, then the curative power ;

of drugs will avail him not ; the medical treatment

henceforth can only be palliative. It therefore becomes
of the greatest possible importance that the disease be,
if possible, detected in its very earliest stage, in order
to counteract such grave and irremediable effects. But,
as we have clearly seen, this is not without serious diffi-

culties, as the symptoms then are but few and often ob-
scure, and it is only by considering the previous habits of
the patient that we are led to see in them the early tokens
of an organic, and but too often intractable disease. In
the person of a regular spirit-drinker, who has a coated
tongue, loathes his food, has nausea, with occasional
rejection of his meals ; and who complains of slight
fever, with pain and tenderness in the region of the
liver,— such a case, it " need hardly be said," should com-
mand the immediate attention and the most judicious
and skilful treatment of the physician,
—
Allopathically. At the commencement of the
116 CIRRHOSIS.

disease cupping, leeching, bleeding from the arm, blister-

ing and saline purgatives constitute the chief treatment
as laid down by Budd. When the feverish symptoms
have subsided, and the liver continues large then ;

mercury, both internally and by inunction, followed by

the iodide of potassium internally, and the iodine oint-
ment rubbed into the side. When dropsy sets in, Hydra-
gogues, says the same author, have but little power in
reducing the ascites, and may do more harm than good.
Ererichs lays down a more elaborate code of treatment,
but whether successfully carried out or not I am unable
to say. In the inflammatory stage he advises leeches to
be applied to the hepatic region, and to the anus, mer-
curial ointment to be rubbed in, and warm fomentations.
Internally saline laxatives in decoction of tamarinds, or
grass-root, the " Triticum repens," which contains sugar
and free oxalic acid, calomel, rhubarb, saline and solvent
extracts. As stomachics he recommends the tinctures
of rhubarb, orange peel, wormwood, quassia, and the
Calamus aromaticus; for nausea and vomiting hydrocyanic
acid, Belladonna, Morphia, and Bismuth; for ha^mor-
rhac^e from the stomach, tannin, acetate of lead, and
nitrate of silver; for constipation, rhubarb, aloes, and
ox-(yall ; for diarrhoea, calumba, cascarilla, logwood, Nux
Yom. and tannin acd ; for ascites, digitalis, squills, juni-

per. Ononis spinosa and levisticum, and saline diuretics.

—
HoMCEOPATHiCALLY. Having now disposed of the
history, anatomy, symptoms, pathology, causes (its
allied disorders), and its allopathic treatment, we now
come to the homoeopathic and hygienic treatment, and
there is but little doubt that much may be done with
these curative and palliative agents in the different
 HOMCEOPATHIC TREATMENT. 117

stages of the disease. As a preliminary to such, treat-

ment, the entire disuse of all " alcoholic drinks, coffee,

curry, pepper, mustard, highly seasoned dishes, and all

other condiments of a like kind, which tend to irritate

the liver," must be strictly enforced. The pain, tender-
ness, and swelling of the be combated by
liver should
Aconite, either alone or in alternation with the Bryonia
alba, and continued some days,
for or until a marked
amelioration in the symptoms takes place. The region
of the liver should be covered with linseed meal poultices,
over the surface of which may be sprinkled the tincture
of Aconite or Belladonna ; or, better still, a wet compress,
sufficiently large to cover both the right and left lobes
of the liver,and kept on for some days, till pain, sensi-
tiveness, and swelling disappear, or until a thick
eruption of pustules crop out on the surface of the skin.
A Turkish bath should be taken at least three times
a week, and strict injunctions should be given that the
whole of the hypochondriac, splenic, and epigastric
regions be well shampooed. The functions of the stomach
should be regulated by Nux vomica, the Ignatia or Pulsa-
tilla. I, however, know of no medicine which more
quickly cleanses a coated tongue, or corrects a dis-
ordered stomach, than the stryclmos nux vomica, adminis-
tered according to the following formula :
— Tinct. Nux
Vom. 12 drops ; distilled water a tumbler full : well mix.
A table- spoonful to be taken every one or two hours.
The functions of the bowels should be regulated, and
indeed, even kept slightly relaxed, by means of the
'podophyllum peltatum, nux vomica, and the saline waters
of Cheltenham, Leamington, or the Llandrindod in Ead-
norshire; or, when circumstances may permit, the
118 CIRRHOSIS.

waters of Eger, Karlsbad, Vichy, or Yals. If there

exists during this stage nausea, with occasionally
vomiting and slight jaundice, an occasional interme-
diate dose of ipecacuanha will generally suffice to remove
such symptoms. In cases of cirrhosis, where all pain
and uneasiness have subsided, but there still remains
enlargement of the organ, the mercurius solubilis will
prove a useful remedy. We do sometimes meet with
cases where constitutional syphilis appears to be the
primary cause of cirrhosis for su.ch a cause the pre-
;

parations of mercury and iodine should be selected,

namely, the mere, sol., mere, vivus, mere, corr., mere,
proto-iodide, the mere, biniodide, the iodide of potas-
sium, or the iodide of iron, with the occasional inunction
of the two latter medicines, and the use of the waters
of Kreuznach, Carlsbad, or Friedrichshall.
The dietmust consist of mild, simple articles of
nourishment, which in strong persons, with a tendency to
plethora, should be mainly of a vegetable nature, such
as fruits, lightly boiled eggs, milk, light pulse, and suit-
able farinaceous substances, in the form of puddings or
porridge ; but in the debilitated a careful selection should
be made of the most easily digested and least stimu-
lating animal and vegetable foods, such as tripe and
pig's feet (soused), lamb, mutton, and boiled fowl, with
plain boiled rice, a sago or tapioca pudding, with no
more stimulating beverages than a glass of spring, seltzer,
or the Apollinaris water.
Hygie:j^ically. —There must be total rest from all

mental and bodily labour, with daily walks, and plenty

of fresh air.

In the second stage, we have to encounter a far more

 ;

HYGIENIC TREATMENT. 119

formidable and irremediable group of symptoms ; in this

stage the degeneration of the hepatic cells is far advanced
the secreting and excreting functions of the organ are in a
great measure destroyed the floodgates are closed, the
;

canals blocked up, and the current of the circulation is

diverted through other and new channels, followed by

ascitesand anasarca, hsemorrhage from the nose, stomach,
—
and bowels, and general emaciation a group of symp-
toms as painful and harassing to the patient, as they are
unyielding to the action of medicine, and the best efforts
of the anxious physician. It is at this stage, unfortunately
for the patient, that the physician is but too often consulted
for the first time when a radical cure is in the majority of
casesbeyond the confines of medicine, and the power of
man, for there does not exist a drug in the materia medica
of any nation whose records extend back to nearly two
thousand years, which is capable of removing the morbid
deposit of an organized tissue, or restoring the lost
functions of a cirrhotic liver ; we do, however, possess
remedies of great value, capable of checking the peri-
hepatitis which supervenes from time to time of remov- ;

ing the dropsical effusions, of checking the haemorrhages,

prolonging life, and making that life bearable and when
;

the final crisis comes, of smoothing the rugged path of

life gently and softly into the grave.
The Mineeal Acids. —The nitro-hydrochloric and
nitric acid are both valuable remedies in this stage of
the disease ; they should be administered both internally,
and externally in the form of baths, and continued for
some weeks, with an occasional dose of Aconite, when
any feverish symptoms crop up, and I^ux Vomica to
correct stomach derangement and constipation; and
120 CIRRHOSIS.

Pepsine to promote digestion. Should the bowels not

yield kindly to the action of JSTuxVom, and the patient
complain of stitches in the liver, costiveness, with fre-
quent straining, and the expulsion of hard balWike
fasces, with tympanitic distention of the abdomen,
colocynth may prove of great advantage, or sulphur.
Bleeding from the nose is frequently checked by
either Aeon., Bell., Arnica, I'pec, Rhus, or Sabina.
Bleeding from the stomach, by Aeon., Arnica, Ferr,,
Gallic Acid; cold drinks, ice, and a bladder of ice
to the abdomen.
Bleeding from the bowels, by Hamamelis, the injection
of Gallic or Tannic Acid, or Sulphur, which in some
cases is a potent remedy.
Ascites and anasarca, which are constant symptoms in
the last stage of cirrhosis, will often yield for a time to
Ars., China, Copaiba, Digitalis, or Elaterium ; and more
particularly to a compound of my own, the Ferri ammo,
citratis c. Strychnice, c. Digitalis. In a case of extensive
hypertrophy of the liver, with hypertrophy and dilatation
of the right ventricle of the heart, dilatation of the auriculo
ventricular openings, coupled with ascites, hydrothorax,
and anasarca of the upper and lower extremities this ;

motley group of symptoms were entirely dispersed on

three consecutive occasions; the contour of the liver
became considerably diminished, the heart's action
considerably subdued, its size lessened, and life prolonged
for nearly twelve months, by this preparation alone. This
case is well known Mr. Spencer Wells, and Dr.
to
William Bell, late of Mayfair, and now of Eastbourne.
As the disease advances, the chief indications for
treatment are always to assist, as far as possible, the
nutrition of the body and the formation of blood, and
 — ;

HOMCEOPATHIC TREATMENT. 121

to remove every cause of exhaustion. A diet carefully

selected in reference to its digestibility and nutritious
qualities is the first requisite. Fresh milk, if easily

digested, forms a valuable item in this respect ; concen-

trated beef tea, made of equal parts of beef, mutton, and
veal (which I have designated the "triple alliance"),
thickened with the finest Scotch oatmeal or Indian
corn, both of which are rich in nitrogenous matter and
fat, forms another well-made cocoa diluted with half
;

its weight of fresh milk; stewed venison; stewed oysters

stewed rump -steak, or a loin chop ; eels stewed in milk,
to which may be added a little cream stewed chicken ;

and rice macaroni boiled in milk rice, arrowroot, or

; ;

vermicelli blancmange and ''nourishing soups," all of

;

which are very nourishing, non-stimulating, and digest-

ible little dishes. To make nourishing soup " stew two :

ounces of the best well-washed pearl sago in a pint of

water till it is quite tender and very thick, then mix it
with half a pint of good boiling cream, and the yolks of
two or three fresh eggs. Blend the whole carefully with
one quart of essence of beef, or the "triple alliance."
The essence must first be heated separately, and mixed
while both mixtures are hot. A
little of this may be

warmed up when required. be absolutely necessary

If it

at this stage to prescribe stimulants, they should be

selected from the purest and mildest kinds, and in very
moderate quantity, with a glass of sound Burgundy, Hock,
or the Hungarian Somlau, or Edsenburgh.
The acute gastro-enteric catarrh, which is generally
accompanied by low typhoid symptoms, a frequent
phase of the disease in its last stage, should be treated
by the mineral acids, China, Zincicni, and Arsenicum, and
all other complications by their appropriate remedies.
 ;

122 HEPATIC ABSCESS.

CHAPTER YIIL
Inflammation of the Liver terminating in Tyjfmig
AND Tropical Abscess.

Definition. — Inflammation of the liver may be de-

fined as pain, tenderness, and fulness in the region of
the liver or stomach, the pain often extending to the
right shoulder-blade and adjacent Inflammatory
parts.
fever, a furred tongue, frequent cough, and bilious vomit-
ing ; a costive or irregular condition of the bowels
scanty and high-coloured urine, with a heavy deposit of
lithates ; slight and sometimes confirmed jaundice.
Inflammation of the liver, in this country, generally
comes on insidiously in some one of the functional dis-
orders just mentioned. In the tropics the premonitory
sj^mptoms are more prominent, and are frequently pre-
ceded by increased secretion of bile, fever, diarrhoea,
which often
or slight dysentery, attracts the chief notice
and misleads the physician.
Inflammation of the liver may be limited to the
following regions of the organ, viz.
1. To its superior convex surface.
2. To its inferior concave surface.
3. To its internal structure.
4. To its right or to its left lobe.
Let US briefly review the symptoms of each in the
order given.
A. The symptoms appertaining to the convex surface
 HEPATITIS OF DIFFERENT PARTS OF THE LIVER. 123

bear a strong resemblance to pleurisy and pneumonia.

There is cough, oppression, dyspnoea, pain in course of
the diaphragm, much increased on inspiration; the pulse
is quick and hard; the tongue is dry; and there is thirst,

heat and dryness of the skin. The stools are disordered,

at first scanty, dry, and infrequent, at other times relaxed
and more or less tinged and the urine is
with bile,

scanty, high-coloured and charged with lithates.

B. When the concave and posterior surface of the

liver is inflamed there are marked functional derange-

ments of stomach, nausea and vomiting, particularly
after food thirst, great anxiety with urgent pain in the
;

epigastrium and back, which often extends to the right

shoulder and neck. The pulse varies from an irritable,
quick, small, contracted, to a hard one. There is often
a sense of fluttering with heavy dragging pains in the
pit of the stomach great anxiety, frequent sighing, and,
;

in the advanced stage, hiccup. The usual posture of

the patient is on the back or right side.
The leading symptoms of inflammation of the
c.

substance of the liver are marked early by chills, rigors,

irregular diarrhoea, uneasiness, weight, and oppression
in the right hypochondrium and pit of the stomach,
extending to the ensiform cartilage and diaphragm to
the back and shoulder-blades, increased on pressure
made beneath the ribs and over the stomach, or a deep
inspiration. The pulse at this stage is hardly affected,
but as the inflammatory action progresses it becomes
quick, particularly towards night ; the pulse, however,
varies, as we sometimes find it slow, oppressed, irregular,
and even intermittent the countenance is pale, sallow,
;

and anxious the spirits depressed the tongue is white

; ;
124 TERMINATIONS OF INFLAMMATION OF LIVER.

or yellow, more or less coated with a slimy deposit, with

an unpleasant taste in the mouth. There is nausea, at
times vomiting and loss of appetite ; the bowels are
irregular, at times costive, at other times diarrhceic, the
urine is scanty, high-coloured, and heavily charged with
lithates ; there is more or less night fever and general
restlessness.
As the disease progresses, the pulse becomes quicker,
f dler, and more irritable as night approaches ; oppressed
and embarrassed during the morning and day. The
uneasiness in the liver becomes augmented complaints ;

are made of a heavy dragging pain in the organ, increased

on motion or turning in bed; there is a short suppressed
cough, great oppression, dyspnoea, and a catch on full
inspiration. Percussion reveals great tumefaction of
the organ as evinced by the area of dulness which
extends below the and high into the thorax. The
ribs,

stools become watery, frequent, and scanty the colour ;

is dark, sometimes charged with blood and attended

with a distressing tenesmus the urine becomes very

;

scanty, and thickly charged with a lateritious or pinky

sediment, which scalds the patient while passing it and ;

if the flow of bile is obstructed, there is found in the

urine a dark brown flocky sediment.
Such, then, are the ordinary steps taken by inflamma-
tion of the substance of the liver, as observed both in
cold and warm and which continue with certain
climates,
variations till removed by treatment, or glide into suppu-
ration, &c.
Termination. —Acute inflammation of the substance
of the liver may terminate in various ways.
1. It may terminate in a rapid and complete recovery,
 ;

TEEMINATIONS OF INFLAMMATION OF LIVEE. 125

which is marked by the subsidence of all pain, uneasi-

ness,and fever by the stools and urine assuming their
;

normal standard by the reduction in the size of the

;

liver by a healthy tone in the chest and stomach by free

; ;

perspirations ; a clean tongue, keen appetite, and by a

free escape of blood from the hsemorrhoidal vems; a
bilious diarrhoea, and a copious sediment in the urine.
2. It may terminate in chronic inflammation, which
by judicious treatment may return to its original normal
condition.
3. It may pass into the sub-acute state.
4. It may occasion enlargement and other organic
lesions.
5. It may implicate the biliary ducts, gall-bladder,
and cause permanent jaundice.
6. It may
give rise to various complications of neigh-
bouring organs; and
7. It may terminate in one or more abscesses.
There are two kinds of abscesses found in the liver,
the result of inflammation, —the metastatic or pysemic,
and the tropical abscess.
The pysemic abscesses are peculiar Europe the to ;

tropical abscess and other hot

to the East Indies
regions the pygemic abscesses are small and numerous
:

the tropical abscess stands alone. How comes this?

let us investigate their respective causes.
The diagnosis of pysemic abscesses will be greatly
by keeping in view the circumstances under
simplified
which the disease usually occurs. The mode of for-
mation of these abscesses is well illustrated by
experiments made more than half a century ago by
Dr. Sanderson, and described by him in his admirable
 — ;

126 CAUSES OF HEPATIC ABSCESS.

work on the structure and diseases of the liver. He

injected two drachms of quicksilver into the crural
vein of a dog at the end of twenty-four hours the animal
:

became feverish ; end of two or three days he

at the
had cough and which continued
difficulty in breathing,
till his death. On a post-mortem examiuation, per-
formed by the doctor, he found the lungs studded with
small hard tubercles and small circumscribed abscesses,
and in the centre of each was found a globule of the
quicksilver. Here the globules of mercury, like the
globules of pus in the diseases which I shall immedi-
ately refer to become arrested in the
as causes,
capillary vessels of the lungs, and often in the liver,
and each globule, acting by mere mechanical irritation,
excites inflammation and abscess.
The chief causes attributed to pysemic abscesses in
the liver have been traced
To ulceration of the stomachand intestines to ul- ;

ceration of the gall-bladder and biliary ducts to ;

dysentery, fissures in the anus, and internal fistulge

to operations for fistula in ano to inflammation of
;

the portal vein following cauterization of the rectum

for piles, fissures, or polypi ; to the operation for
strangulated hernia, and to capital operations of the
lower extremities. All these may be set down as
primary causes, from which it may be inferred that in
the progress of ulceration, phlebitis of the capillary
veins of the bowels occurs, and that the matter thus
formed in these veins passes with the blood into the
portal circulation,, where (like the quicksilver) it

irritates and inflames the minute ramifications of the

portal vessels and minute structure of the liver, giving

 PATHOLOGY OF TKOPICAL ABSCESS. 127

rise to purulent infiltration, and small abscesses in

various parts of the organ, similar to those of phlebitis
in other regions of the body ; but in this instance
always occurring in the and there only, because
liver,
the pus globules directly from their respective
j)ass

sources into the portal circulation, and wend their way

slowly throughout the whole of the minute structures
of that organ.
The same thing may occur between the secondary
abscesses from phlebitis, and secondary masses of cancer.
A cancer of the breast, for instance, may be the source of
cancerous tumours in the lungs or liver, just as an inflamed
vein in the arm may be the source of abscesses in those
parts : those abscesses and secondary cancerous masses
will be scattered in thesame manner, and immediately
surrounded by healthy lung or liver substance. The
liver and lungs are the organs in which secondary can-
cerous tumours, as well as the abscesses from phlebitis,
are most frequently met with, this is accounted for by
the quantity of blood which naturally flows through
these organs. The cancerous tumours and the abscesses
have in each organ the same form and locality and in ;

the lungs both have a great predilection for the surface.

Tropical Abscess.— The pathology of tropical abscess
of the liver, Murchison, has been a subject of
says
considerable discussion, and one on which opinions
are still divided. The frequent co-existence in the
tropics of abscess of the liver with dysentery, has
naturally led pathologists to connect these two lesions ;

Annesley and others maintaining that the dysentery is

the result of the hepatitis, and some that the hepatitis
is the result of dysentery ; while a third class, like
 —

128 STATISTICS OF CAUSES OF TROPICAL ABSCESS.

Dr. Abercrombie, maintain that the frequent occurrence

of the two maladies is merely the result of accident. The
doctrine, which is most generally accepted at the present
day is that propounded some twenty years ago by Dr.
—
George Budd, of London thathepaticinflammation is the
result of purulent absorption from the ulcerated colon
the result of dysentery ; in fact, the pathology of tropical
abscess appeared to him to be identical with the pysemic
abscesses so common in this country. Morehead, how-
ever, maintains —with whom Frerichs, of Berlin, agrees
that the general cachexia induced by a long residence
in the tropics is the chief cause of hepatic disease, and
attributes immediate exciting cause to a '' chill."
the
This view, says Frerichs, is more in harmony with the
facts in the case of those abscesses of the liver which
accompany tropical dysentery.
The following statistics, however, go far to prove that
dysenteryhas much to do with the tropical hepatic abscess.
Of 29 cases collected by Annesley in India, 21- had
dysenteric ulceration of the large intestine.
Of 25 cases collected by Haspel in Algeria, 13 were
similarly affected.
Of 17 cases collected by Budd, chiefly among sailors
on board the old Dreadnought Hospital, in the Thames,
10 had ulceration of the large intestine. To counter-
balance these statistics as regards the frequency of
dysentery in connection with tropical abscess, we find
that out of 300 cases collected by Waring in India,
dysentery preceded hepatitis in only 82 cases, or 27.3
per cent. The most conclusive cases, however, are
those in which the patients have died of hepatic abscess
and no sign of dysenteric ulceration found after death.
 HEPATIC ABSCESS. 129

Morehead records 17 cases of abscess without a single

sign of intestinal ulceration and out of 204 cases of
;

hepatic abscess collected by Waring, not a sign of

ulceration, cicatrices, or abrasions was found in the
intestines of 51 cases —being exactly one-fourth. It is,

therefore, clear from those statistics that we must look

for other causes than dysentery as productive of
tropical abscess.
Symptomatology. — It would be extremely difficult,
if not impossible, to lay down a clinical history of
hepatic abscess, which would act as an undeviating
guide in the diagnosis of all cases inasmuch as the ;

complex and ever- varying train of symptoms presents

so many changes, depending on the topographical area
of the inflammatory deposit and its concomitant morbid
processes. It is also worthy of note that medical
history records many cases of suppurative inflammation
in the liver, the existence of which was not known or
even suspected during life ; and yet post-mortems have
brought to light abscesses of a prodigious size. Budd
records the case of a Lascar, age 62, admitted into the
Breadnought, October 2, 1839, seemingly only suffer-
ing from catarrh and general emphysema, and only
complained of general weakness, night sweats, and hectic
fever he died on the 12th ]N"ovember following. A post-
:

mortem brought to light an abscess which contained over

a pint of pus, with traces of dysenteric ulcers in the
intestines. Andral gives the history of a young man,
who, after a long ride on horseback, fell ill with feverish
symptoms on the fourth day he had rigors, headache,
;

a white tongue, loss of appetite, and obstinate consti-

pation on the twelfth day he became delirious, and on
;

K
 —

130 LARGE HEPATIC ABSCESSES.

the seventeenth he died. A post-mortem found all the

organs apparently healthy ; but an accidental puncture
of the liver with the scalpel, laid open an abscess the size
of an orange, filled with yellowish white pus destitute of
odour. Inman, of Liverpool, gives us the case of a woman,
aged 45, who died in the Liverpool Infirmary, in whose
liver was found three abscesses containing about 20
ounces of matter. Frerichs gives two cases of large
abscesses in the liver, the existence of which was not
indicated during life by any local or constitutional
symptoms. One was that of a man set. 34, who had
been treated for chronic inflammation of the kidneys,
and exudation into the left pleural cavity. A post-
mortem brought to light an abscess in the right lobe of the
liver, 5^ inches in diameter. The second case occurred
in an aged man, whose autopsy revealed a cavity in the
light lobe of the liver the size of a goose's egg, filled
with greenish yellow pus.
Abscesses of the liver sometimes attain an extraordi-
nary In ore instance Budd estimated the quantity
size.

at two quarts. Annesly in one case found ninety

ounces Inman,
;
of Liverpool, another which contained
the enormous quantity of 13 pints. In September,
1870, I met with a very interesting case of abscess of
the liver, which, from its exact measurement, must
have contained at least two quarts of matter, and which
forms the subject of the following notes: — T. J., set. 44,
a tall, well-built man, of a somewhat swarthy com-
plexion, consulted me on September 6, 1870.
HiSTOKY. — He had resided on the southern slopes of
the South American continent for some years
Chili —
as manager to a copper ore mine. He was a free
 SYMPTOMS. ,
131

liverand large eater. On first landing in that country

he was smitten with yellow-fever. A few years after this
he had dysentery, which continued to harass him for
many months. He at last became unfitted for business,
and was ordered home invalided. On his arrival in London
he consulted one of the head physicians" to the ''London
*«

Homoeopathic Hospital," who treated him for Dyspejpsia.

Finding no relief he consulted me on the above date.
Here are the symptoms, as roughly sketched at the
time :
—
There is a darkish hue of the countenance he ;

complains of great debility, and is unable to walk any

distance ; there is considerable dyspnoea ; talking
fatigues him and there is a peculiar anxiety depicted in
;

the face. The tongue is thickly coated with a yellowish

brown slimy deposit he is much troubled with flatus
; ;

he eats but little at a time, as it creates nausea; the

pulse is quick, and jerks ; the bowels are tolerably
regular —in colour of a dark brown. The urine is scanty,
high-coloured, and deposits a heavy pinky sediment.
There are signs of anasarca round the ankles; he sweats
freely, and the sleep is restless and disturbed. A careful
examination of the chest and abdomen revealed the fol-
lowing :
—
The chest is well developed, and has no
abnormality beyond the dyspnoea, which was distressing.
The right hypochondriac region is greatly distended ; the
skin is tense and shining ;
percussion marks extensive
dulness, and pain which extends through to the inter-
scapular region and palpation yields distinct fluctua-
;

tion. To take Aeon, and Ars. at stated intervals.

Sei^temher 8. —
There is no change beyond an increased
pain over the surface of the liver, which I look upon as
peritoneal. To take Bryonia Q.ndiAco7iite in alternation.
 ;

132 PKOGRESS.

Septeniber 9. —He is not so well : there is increased

dyspnoea, and the pain now shoots through to the back
fluctuation is more perceptible. To have warm fomenta-
tions applied to the seat of pain and to take Ars. and
;

Bry. in alternation.
From this date to the 15th there has been no special
improvement ; the pain continues, the tumefaction and
dyspnoea increase ; the nights become more restless ;

he sleeps but little, and that by short snatches the ;

tongue remains coated. To continue the fomentations

and to take Nux Vom. and Ars.
September 16. — He feels better; there is less tension
in the hypochondria, and less dyspnoea ; the B. have been
moved and the U. copious and fairly normal.
copiously,
" All good or bad signs." To continue the Nux V. and Ars.
From the 17th to the 20th there has been a general
and continued relapse of most of the symptoms he is ;

more restless; the dyspnoea is more urgent; the region

of the liver is more distended the skin is tense and ;

glassy he looks haggard, anxious, and careworn the

; ;

stomach is irritable, and he rejects his food the tongue ;

continues coated, and the pulse is small and irritable. To

take Hep. S. and Ars.
On the following morning, at about 3 a.m., he felt some-
thing burst into the stomach, and he vomited nearly a pint
of pus, with marked relief to the more urgent and distress-
ing symptoms. From this date to the 26th he continued
toimprove more or less. All urgent symptoms have sub-
sided ; he sleeps tolerably well the tongue is getting ;

clean he takes his food with a fair relish his counte-

; ;

nence looks calm ; his B. are regular, his U. is copious,

and he expectorates pus more or less daily. To take Ars.
 ;

PROGKESS. 133

September 27. — Not so well; he has rigors; his

pulse is quick he has dyspnoea the anxious counte-
; ;

nance has returned the tongue is brown ; he is thirsty

;

and trembles. To take Bell, and Ars.

September 30. —He is not so well; his countenance
looks more anxious ; his features are pinched ; the pulse
runs; the expectoration is offensive, and tinged with
blood ; the dyspnoea is distressing ; the B. are relaxed,
and sleep restless. To take Ars. and Garbo Veg.
October 1 and 2. — About the same. To continue Ars.
and Carbo. Veg.
October 3 and 4. —There is a slight improvement ; the
expectoration is less offensive ; the pulse is softer
To cont. med.
October 5, morning. — Is not so well; passed a restless
night; had delirium ; the tongue is coated and dry;
dyspnoea is distressing ; the pulse is quick and jerking.
Cont. med.
Evening. —The dyspnoea continues ; has a distressing
cough ; the pulse is quick, and intermits is thirsty the ; ;

tongue is dry and brown ; the faeces are dark and scanty.
October 6 ; 10 a.m. —He passed a very restless night.
Was seen by Mr. Yeldham, who diagnosed pleurisy and
pneumonia, and gave a favourable prognosis. To give
Bry. and Ars.
October 7.-^ He passed a very restless night ; no sleep;
delirium, and distressing dyspncea B. moved freely ;

faeces dark and offensive cough troublesome. Ars. and ;

Garb. Veg.
October 8 ; 1 p.m. — Passed a very restless night ;

is propped up in bed ; is delirious ; death is at hand

his countenance is anxious ; has a supplicating look ; his
 —

134 POST-MOETEM APPEARANCES.

features are pinched; his eyes sink and look glassy ; his
tongue is brown and dry; the breathing is ojDpressed
with heaving gasps, the sputa is scanty and offensive ;

the pulse is thready, rapid, and intermittent; he swal-

lows with difficulty ; the lower jaw drops, and a cold
clammy sweat bedews his brow. In this condition he
was again seen by Mr. Yeldham at 10 a.m., who gave
the afflicted relatives hopes of recovery.
At 3 p.m. he was no more, and his spirit winged its
flight to another sphere.
A post-mortem examination which was performed in
the presence of, and with the assistance of Dr. Vaughan
Hughes, twenty-four hours after death, gave us the
following results :

The liver was considerably hypertrophied and mela-

notic ; in fact, it presented a black, charred, brittle mass,
which crumbled under the slightest pressure. In the
centre of the right lobe was found a cavity full six inches
long, and sufficiently capacious to hold a pint pot; at its
anterior extremity was a perforation about the cir-
cumference of a which opened into the oblique
shilling,
portion of the duodenum, bordering on the pyloric ex-
tremity of the stomach the completion of this canal was
;

announced on the morning of the 20th September by the

upheaving of nearly one pint of pus, which continued
more or less till three or four days before death. At
the posterior surface of the same cavity was another
opening, the circumference of sL crown piece, which
perforated the diaphragm and pleura, and broke down
the right lung into a thousand shreds, which were found
floating in about four or five pints of grumous fluid.

The spleen, like the liver, was an hypertrophied black,

 INFLAMMATORY ACTION. 135

carbonized mass, brittle and easily torn. The lieart

was liabby and in a state of hypertrophy the left lung ;

healthy. The stomach was of enormous size, and ex-

tended from the left to the right hypochondriac region.
The symptoms of hepatic abscess resolve themselves
under the two following heads, viz., those that indicate
inflammatory action, and those that indicate suppu-
ration.
The first group isby pain in the right
signalized
hypochondrium, increased by pressure, by a deep inspi-
ration, by coughing, or by lying on the left side there is ;

a dry hacking cough, difficulty of breathing, with shoot-

ing pains in the chest, somewhat resembling pleurisy,
and which extends to the shoulder of the affected side j

there is a yellow tinge of the conjunctiva, and some-

times jaundice ; the urine is high-coloured, scanty, and
throws down a copious sediment of lithates, or lithic
acid ; therederangement of the stomach, vomiting,
is

hiccup, costiveness, or diarrhoea, which is dysenteric, and

there is more or less fever, which assumes an intermittent
type. In some instances there is a deficiency of bile in
the intestines, in which case the faeces are of a clay
colour, in other instances there is a superabundance,
which is then rejected by vomiting and by stool. When
the inflammation glides into suppuration, which usually
occurs at the end of eight or twelve days, unless it

previously terminates in resolution, the symptoms are

characterized by
and distinct rigors, followed by
chills
well-marked hectic fever and stomach derangement; the
;

pain, which is dull or acute in the inflammatory stage,

is now changed to a distinct throbbing, which may be

considered as pathognomonic of abscess ; there is rigid-

 ;

136 SUPPURATION.

ity of theabdominal muscles of the right side, particularly

the rectus, which becomes tense and band-like; there is a
feeling of weight about the liver, emaciation, prostration
diarrhoea, or dysentery. The liver is more or less enlarged,
according to the quantity of matter contained in the sack
it isno longer uniform, the normal outline of the area of
hepatic dulness is altered, and it may bulge upwards,
downwards, forwards, or outwards, according to the
direction the abscess takes in each case. The contour of
this bulging tumour is tense, rounded, and smooth the ;

skin shines, and fluctuation can usually be detected in

the tumour, which will be more or less prominently felt
according to the distance of the abscess from the
surface.
Abscess of the liver is gregarious in its course of
exit from the organ it may burst into the stomach and
;

be emptied by vomiting. It may empty itself into the

duodenum, or colon, and pass offby the bowels it may ;

break through the walls of the abdomen, and escape

externally ; it may open into the right kidney, and pass
away with the urine ; itmay perforate the diaphragm,
and pleura, where it may excite suppurative pleurisy ;

or it may open into the lung, and discharge itself

through the] bronchial tubes, as confirmed by a well-
marked case of a lady who came to consult me from the
fenny little town of St. Ives, Huntingdonshire. When
this happens it is marked by symptoms of its own, viz.,
by a new set of stetheoscopic signs, and by the expec-
which comes
toration of a dirty red or brownish matter,
up easily sometimes in mouthfuls, without effort on the
part of the patient. In another case which I saw in
consultation with my friend Dr. G. Sheppard, at Clifton,
 —

ALLOPATHIC TEEATMENT. 137

similar symptoms presented themselves. In rare cases

the central aponeurosis of the diaphragm is perforated,
and the pus discharged by sinuses into the pericardium,
inducing pericarditisand in still rarer cases the hepatic
;

abscess discharges itself into the large blood-vessels,

the vena cava and vena porta3, as witnessed by Smith,
Graves, and Eokitanski.
A cure of the hepatic abscess is effected after the pus
has been discharged by one of the above-described
methods ; or it may result without this occurrence from
more or less complete absorption of the pus by the
cellulo-vascular membrane investing the sides of the
abscess, and the hepatic peritoneal lamina forms a
cicatrised, dense, shrivelled covering.

TREATMENT.

Allopathically. —The inflammatory stage is treated

by general and local bleeding and blisters ; Ant. Tart.,
Calomel, Iodide of Potassium, Colchicum and Digitalis,
Sulphate of Soda, Taraxacum, Aloes, Gentian, and Chloride
of Ammonium, Acid Tartrate of Potass, Salines, Opium,
Belladonna, or Morphia.
When abscess occurs, by bark and ammonia, mineral
acids, quinine and iron, opium and wine.
Homceopathically. — The Acute Stage. —When the
homoeopathic physician is fortunate enough to diagnose
inflammation of the liver in its early stage, he will find
in Aconite a potent remedy. The provings and toxicolo-
gical effects of this drug show most conclusively that it
exercises a specific action on the functions and tissues
of that organ, and causes a variety of symptoms which
point to inflammation. Among these we specially note
 ;

138 THE ACUTE STAGE.

A painful feeling of swelling in the pit of the

stomach, want of appetite, and paroxysms of dyspnoea-
Violent constriction, tightness, pressure, fulness, and
weight in the hypochondriac region.
Tensive, painful under the ribs, shocks,
swelling
and pressure in the region of the liver, with oppression,
and arrest of breathing.
Pricking pains in the liver and bowels.
Constrictive pains in the region of the gall, bladder,
arresting the breathing.
The abdomen is distended and swollen as in dropsy.
These indications might be increased by a number of
other symptoms from the urinary and alvine group, which
would fairly complete the picture of Hepatitis. This
medicine should be administered in the matrix form
3 or 4 drops dissolved in a tumblerful of water a ;

table-spoonful to be taken every hour, gradually in-

creasing the intervals to two or three hours. If the

peritoneum .becomes involved, which is known by

stinging, tensive, burning pains, increased on pressure
or inspiration, Bryonia,^ should be given in alternation
with the Aconite and great benefit will be derived from
;

the application of a hot compress to the hypochondriac

region, sprinkled over with the tincture of Aconite. These
medicines should be assiduously administered at regular
intervals for at least 30 to 36 hours, as well as the
outward application. When the hepatitis is accom-
panied by gastric catarrh, a coated tongue, nausea,
vomiting, distention, and tenderness of the epigas-
trium, Nux. Vom. in quarter-drop dose dissolved in
filtered or distilledwater will have a most beneficial
effect. When dysentery is known to have preceded
 :

HOMOEOPATHIC TEEATMENT. 139

the hepatitis, and is still persistent, we must endeavour

to remove by means of the Merc, Cor. 3 x a
this cause
dose three times a day or by Aloes if there is tenes-
;

mus, a burning, cutting pain in the bowels and rectum,

with a rush of blood to the head, symptoms which Aloes
cover remarkably well. For colicy pains which occasion-
ally supervene, and where Nux V. fails, Colocynth will
come to the rescue and for inordinate bleeding per ani
;

Hamamelis will generally suffice to check the discharge.

If, however, in defiance of the best means at hand,

and the most energetic treatment, the inflammation

glides into an abscess, every precaution should betaken
to counteract the exhaustion which invariably follows
Merc, Ars., China, Bell., or Quina, should be given, with
a nourishing, non- stimulating diet. When the abscess
is fairly formed our first object will be to endeavour to
promote its dispersion by resolving its component parts.

For this purpose, Ars., Bry., Hep. S., Lctchesis, or Silicia,

should be selected. When, however, we are unable to
effect this object, we must bide our time and carefully
watch the current of events, and help nature as far as
able in promoting its speedy outlet from the body
through which ever channel it may select. For this
purpose, Hep, S., Bell., Lack., Mere. S., and Silicia., are
potent remedies. Here also surgery may step in as a
useful handmaid.
When the pus makes its way into the lung, and symp-
toms of inflammation set in, the more urgent symptoms
are to be subdued by Aeon., Verat. Vir., Phos. Ac, and
Ars.; and when symptoms of gangrene mark its pro-
gress, Ars. Carlo. V., Chin., Sec. C, and Terehene may
prove useful, also Moschus in low triturations.
 —

140 OPERATION FOR HEPATIC ABSCESS.

"When tlie abscess opens into the abdominal cavity,

although death is almost inevitable, yet mnch may be
done by absolute rest in the recumbent posture warm
;

compresses or cataplasms, and the administration of

Ars., Merc. Corr., Bell, Bryon., with an occasional dose of
Aeon, or Verat. Vir., according to the prominence of
the symptoms. When the abscess takes an outward
direction there should be no delay in making an artificial
opening, as much danger to neighbouring structures may
be thus avoided. The most simple and satisfactory
operation is that recommended by Begin he places the
:

patient on his back, with the upper' part of the body

bent forward, and the thighs flexed on the abdomen after ;

having carefully ascertained the outline of the abscess,

which the thinning of the walls and fluctuation enable
us to do, an incision three inches Ions is made through
the skin, cellular, adipose, muscular, and aponeurotic
tissues. —
The peritoneum is then opened like hernia
by being slit up on a grooved director to the extent of
the first incision. The wound is now dressed with lint
or cotton wool. After three or four days the dressing is

removed, and the liver is found to have contracted firm

adhesions to the margins of the wound, so that the abscess
may be punctured without the slightest risk. This
operation is simple, safe, successful, and easily performed.
Graves, of Dublin, adopts the same plan. Budd found
it unsuccessful in two cases operated on, on board the
Dreadnought. Indian surgeons thrust up a long exploring
needle into the liver when the presence of an abscess is

suspected. Cures are uncertain.

Recamier and other surgeons apply to the most pro-
minent part of the swelling caustic potash, so as to
 ;

NOURISHING DIET REQUIRED. 141

produce a slough an inch and a half in circumference

after the separation of the slough a stick of caustic
potash is applied to the sore, and repeated as mauy times
as may be required to open the abscess. This mode is

a safe and certain one, but objections have been raised

to its tediousness and painful effects. Others make an
opening with a bistoury, or a trocar and canula, leaving
the canula in the wound for some days to allow the pus
to dribble away."When the abscesses are large the pus
should be allowed to run away by instalments, ex-
tending over many days, care being taken to exclude the
air.

The strength of the patient should be kept up by good

nourishing diet, and the stomach and excreting organs
should be carefully attended to.
 CHAPTEE IX.

Hypeetrophy (Enlargement) oe the Liver.

—
Hypertrophia Hepatic.e —
The various diseases of the liver have continued to
remain to the present day a subject of great difficulty,
in spite of the progress made the last few years, in the
anatomy of this viscus. As one of the chief organs
concerned in sanguification it affects the corporeal and
physical character of the individual in the most varied
and extensive manner within the range of physiological
bounds and on the other hand, many of its morbid
;

affections, which are beyond the reach of the scalpel,

become intelligible only by attending to the anomalies
presented in other organs.
These enlargements of the liver, are for Clinical
purposes, divided into the painful and painless.
Among the former is embodied hyperaemia, congestive
turgor, inflammation, inflammatory swelling, congestion
and statis in the capillary gall vessels, pyaemic abscesses,
tropical abscess, and cancer.
Among the latter, we have the so-called amyloid
liver; the nutmeg liver ; the waxy liver ; the fatty liver;
the lardaceous liver; the hydatid tumour; and the
pure and simple " hypertrophy of the liver."
 HYPERTEOPHY OF THE LIVER. 143

I.— THE WAXY, LARDACEOUS, OK AMYLOID LIVER.

Historically. — The ancient physicians had but an

obscure idea of this form of disease. Stahl and
Boerhaave, described this and other forms of enlarge-
ment — as infarctions, obstructions, and engorgements.
Portal sub-divided these engorgements into an albu-
minious, gelatinous, and a mucous variety. Andral,
as hypertrophy ; Budd, as scrofulous enlargement : it
was, however, left to that brilliant pathologist, Carl
Kokitanski, of Vienna, to give us a clear description of
the essential characters of this waxy or lardaceous
degeneration, and its pathogenetic relations to certain
cachectic conditions of the body.
Anatomically. —Waxy degeneration of the liver
commences in the glandular cells ; the organ is enlarged,
the increase of size taking place chiefly in a lateral
direction; it edges are flattened and swollen, the
peritoneal covering is smooth, shining, transparent, and
tense; the structure is soft, and pits on pressure; its
colour, internally and externally, is uniformly yellowish
red, or light yellow, resembling that of
"autumnal
foliage ;" the structure is pale and exsanguine, and
contains a large amount of fat, as evidenced by the
greasy deposit when cut with a dry warm knife, or as
proved by submitting the liver to a high temperature.
This disease then consists in a deposit of fat in the
substance of the liver, and to such
an extent as notonly
to replace the true glandular structure, but to penetrate
and permeate the entire organ, to the exclusion of the
vascular tissue. In the early stages of this affection the
various signs just alluded to are less marked.
 —
;

144 CAUSES OF FATTY LIVER.

Causes. —There are three main causes which favour

the production of a fatty liver.

1. It very commonly accompanies tubercular phthisis

(consumption), and according to the researches of Louis
and others, is found in two thirds of all cases of phthisis.
Andral has explained this occurrence on the ground of
impeded secretion of hydrogen by the lungs but the ;

more recent investigations of Eokitanski go to prove that

this is not the cause of the deposit but that it is an
;

essential constituent, or pathognomonic combination of

the "tubercular dyscrasia/' in fact a part and parcel of
the tubercular or consumptive diathesis, inasmuch as it
allies itself with tubercular affections of every kind^
viz., with tubercle of the intestinal mucous membrane
tubercle of the bronchial glands ; tubercle of the serous
membrane, and of the bones and brain, &c.

2. A fatty liver is often met with in persons who lead

an indolent life and a luxurious diet in children who ;

have been gorged with food ;

3. In persons who have accustomed themselves for

years to dram-drinking.
Etiologically. — Waxy or lardaceous degeneration of
the liver occurs more frequently in the male than in the
female. Of 68 cases collected by Frerichs, 53 occurred
in the male sex, and only 15 in the female ; and as
regards the age of these 68 cases, we find the following :

Under 10 years old 3 cases.

From 10 to 20 19 „
„ 20 to 30 19 „
„ 30 to 50 18 „
„ 50 to 70 _9 „

Total 68
 SYMPTOMS OF WAXY LIVER. 145

This tabular arrangement clearly shows that the waxy,

lardaceous, or amyloid degeneration of the liver, like
scrofulous and tubercular affections, is more frequently
developed during the age of adolescence, than at any other
stage of life ; and itmay further be observed, that with
few exceptions a waxy liver makes its appearance in
persons of broken-down constitutions, the result of other
morbid processes, and whose nutrition has been seriously
impaired by divers causes.
—
Symptomatology. The symptoms of a waxy liver are
not difficult of diagnosis. There is considerable enlarge-
ment of the organ, so large at times as to occupy a con-
siderable portion of the abdominal cavity, and extends
to the umbilicus or the groin the increase is uniform in
;

every direction the outer surface is smooth, and denser

;

than normal, and its lower margin is rounded, regular,

and free from all indentations.
Waxy deposit in the liver has but little tendency to
obstruct the portal circulation, consequently ascites and
enlargement of the veins of the abdominal wall, and
jaundice are but seldom present. Pain and tenderness
are never prominentsymptoms. The liver, as a rule,
can be manipulated with impunity, and the patient
complains only of a feeling of weight or tightness in
the right hypochondrium. The consequences which
follow waxy deposits in the liver are always of great im-
portance as regards the affected parts, because the organs
and tissues, so far as they are implicated in the disease,
lose their normal functions.
The hepatic cells cease to take part in the formation
of sugar, and the secretion of bile ; the blood-vessels
also, when implicated in the mischief, lose their capa-
L
146 ' SYMPTOMS OF WAXY LIVEK.

bility of transmitting fluids through their walls, and

cease to furnish the materials necessary for nutrition and
secretion. These injurious consequences become more
marked, the farther the degeneration has extended
throughout other organs which play an important part in
the elaboration of the blood, and the process of nutrition,
viz., the spleen, stomach, kidneys, intestinal canal, and
lymphatic glands, all of which are frequently found im-
pregnated with the same disorder. Hence we can clearly
see, how individuals suffering from a waxy liver present
a pale, sallow, cachetic appearance, general anaemia, and
debility. A waxy liver does not often obstruct the
portal circulation, hence jaundice is not a common
symptom; but enlargement of the spleen is very common:
The functions of the stomach become more or less de-
ranged; the appetite may cease, and vomiting with a clean
tongue may supervene from time to time. The bowels
are irregular ; are sometimes relaxed, sometimes costive,
sometimes pale, at other times dark or pitchy, with
troublesome tympanitis and tenesmus. The urine is pale,
and is voided in large quantity, as much as 3 to 5 pints
in the 24 hours specific gravity
; is about 1012, and holds
in solution a considerable amount of albumen : this
continues, and towards the termination of the disease
only is the quantity diminished.
Duration and Progress. —This disease is always a
lingering one, its duration, as a rule, extending over
many months, and its commencement obscure.
DiAGNOSTiCALLY the disease presents but few diffi-

culties. The uniform enlargement of the gland, its firm

consistence, its association with enlarged spleen, albu-
minous urine, and its succeeding to disease of the bones,
 TREATMENT. 147

and tuberculous affections, &c., are

scrofulous, syphilitic,
all indications which guide us with tolerable certainty.

—
Teeatment. Taking into consideration the various
causes which give rise to waxy degeneration of the
liver and kidneys, our general treatment and selec-
tion of medicines must vary accordingly.
1. Long-standing purulent discharges, such as we find
connected with diseased bones or joints, should be
treated with the Merc.-Prot-Iod,, Ars., Assaf., Phos. c.

Silecia, Hejpar. s., and Suljoh.

2. If able to trace the disease to constitutional sy-

philis, which appears to act as a predisposing cause,
independently of its capability of inducing disease of
the bones and protracted discharges, a cure is best
obtained by the various preparations of iodine, viz.,

the Iodide of Potassium, Iodine, Merc-Prot.-Iod., and the

Syrupus Ferri Iodide, and the waters of Aix-la-Chapelle,
Woodhall in Lincolnshire, or Purton in Wiltshire.
3. If the waxy liver is connected with well marked
symptoms of tubercles of the lungs and other organs of
the body, Gale. c. Chin., Potass, lod., Lycop., Phosphorous,
and Stannum should be selected.
4. There are other chronic diseases that tend seriously
to impair the general nutrition of the body, and which
may be set down as predisposing causes of waxy de-
generation of the liver, viz., the sequelae of intermittent
and remittent fever, dysentery and cancer ; for such a
condition China, Quina., Ars., Carho.-veg., and Sulph.
should be selected, also the Carbonate, Sulphate, and
Phosphate of Soda, and the Muriate of Ammonia. The
late Dr. Budd strongly recommended the latter medicine
in doses of from five to ten grains three times a day.
 —

148 COMPLICATIONS.

By means he succeeded in removing

of this medicine
an enlargement of the liver and spleen which had
existed for nine months, which was accompanied by-
emaciation, pallor, and irritative fever to these we must
:

add the mineral acids, which have proved very successful

in the hands of Murchison and myself, namely, the
Nitric, hydrochloric, and the compound Mtro-hydro-
chloric acids.
In all cases of waxy degeneration we must at all
times be on the look-out for complications, the chief
being
1. A sluggish condition of the bowels, to be counter-
acted by Aluminia, Bry., Cede, c, Zycop., Nux Vom.
Opium, or Sulph.
2. A harassing diarrhoea, wont to supervene
which is

in the latter stages of the malady, and which most pro-

bably arises from ulceration of the mucous membrane of
some part of the intestines must be checked by Ars.,
;

Arg. Nit., China, Merc. Corr., Ijpee., or Veratrum, Album

and Tannic Acid injections.
3. Vomiting, which is an important symptom in some

cases, and is usually accompanied by a clean tongue

and cessation of appetite, should be corrected by Ars.,
Cuprum, Nux Vom., Arg.-Nit, Ijpee., or the mineral,
acids, coupled with pepsine and ice.

4. —
Albuminuria. The urine must be carefully and
repeatedly examined, and the first trace of albumen met
with must be combated by warm baths, the vapour, or
the Turkish bath, and the nitric or hydrochloric acid.
5. Dropsy. —
Serous effusions into the peritoneum
and other organs and parts of the body must be removed
by Turkish baths or the lamp bath, Ars., Chin., Colchieum
 REMEDIES. 149

Dig., Copaiba, or the "Ferri Ammonia citratis cum

Strych. c. Dig."
6. Lastly, in those cases where " ursemia " * occurs

towards the close of the disease, the remedies best indi-

cated are a free action of the skin by Aeon., the vapour
or Turkish bath, Ars., Nnx Vom., and Podophyllum, to
act freely on the bowels, and Cantharides on the kidneys
and bladder.

* Blood-poisoning.
 150

CHAPTEE X.

Tatty Livee.

The second form of painless enlargement of the liver

is that which is due to the deposit of fatty or oily matter
in that organ. A certain portion of oily or fatty matter
is one of the chemical constituents of the liver ; but this
may be so greatly increased, and appearing in different
forms in the substance of the organ, as to constitute more
than one-half of its normal weight. M. Yanquelin once
analyzed a fatty liver, which furnished forty-five parts
of oil out of 100 parts of the organ.
Anatomically. —This lesion is characterized by ap-
pearances resembling those exhibited by the livers of
those fishes which furnish a large quantity of oil, the
cod to wit : the organ is of a cream, yellowish red, or
pale yellow colour, both internally as well as its outer
surfaces ; the liver is enlarged, the increase in size taking
place chiefly in a lateral direction ; its edges are flattened
and swollen, the peritoneal covering is smooth, shining,
transparent, and tense the organ is soft, and pits or
;

pressure its flabbiness is such that it enables us to push

;

it aside with the finger, and when the abdominal walls are

thin, its soft doughy consistence may be readily felt. The

fatty matter is generally distributed equally throughout
the whole structure, or infiltrated in the connecting cellu-
lar tissue. Sometimes, however, it is deposited in a mass.
 CAUSES OF FATTY LIVER. 151

or forms several collections in various parts of the organ.

This change is readily recognised by the greasy feeling
it occasions. A section of it appears like that of yellow
soap. The
vessels seem pressed upon, are scarcely
perceptible,and the greasy deposit is divided into
angular masses by a coarse and compressed cellular
tissue. The quantity of fat deposited in the organ is
sometimes very and
sometimes exists even in
great, it

a fluid (oily) state. Portal, in one case, found the liver

quite white, and softened almost to the fluidity of melted
fat, where no hepatic symptoms existed during life he ;

alsomet with a similar condition of the liver in a female

who had suffered from a severe form of syphilis.
Causes. — This condition of the liver is found most
frequently in persons who have died of scrofulous
tubercles in the lungs and of cancerous maladies. In-
dependently, however, of tubercle, a fatty liver is deve-
loped in consequence of a luxurious and indolent mode
of living ; in children who have been gorged with all
kinds of sweets and rich food and in those who have
;

for years indulged in dram drinking. In this case it is

accompanied by accumulations of fat in the omentum,
the mesentary, the pericardium, the heart, and the sub-
cutaneous cellular tissue ; by fatty degeneration of the
muscular fibres of the gall-bladder ; and even of the
muscular tissues of the heart and kidneys. The skin
puts on a leaden hue, the perspiration has a greasy
appearance and a peculiar odour, and the fat throughout
bears a strong resemblance to tallow or soap. The
WAXY liver already referred to is, in fact, a variety of the

FATTY liver ; it is, however, to be distinguished from the

latter by the colour, which resembles beeswax ; by its
 —;

152 SYMPTOMS.

greater consistence, dryness and brittleness, and these

qualities depend upon a peculiar modification of the
infiltrated fat, which, although accumulated to a con-
siderable amount, leaves but few traces on the scalpel.
When there is fatty degeneration of the heart in
addition to that of the liver, there is a feeble inappre-
ciable "cardiac impulse ;" very faint cardiac sounds ; a
very slow, feeble, or quick and irregular beat of the
pulse; with frequent attacks of giddiness, faintness,
difficulty of breathing on the slightest exertion ; and a
feeling of sinking at the pit of the stomach.
When the kidneys become implicated, the urine is

diminished in quantity, is generally turbid, deposits

numerous oil-casts, and holds a large amount of
albumen in solution; there is likewise a tendency to
general dropsy; extreme pallor and pastiness of the
countenance.
Symptomatology. —The constitutional symptoms of
a fatty liver are but few, and not very prominent
there is, however, general debility and want of tone in
the nervous and vascular system; the patient flags, is

easily tired, and bears depletion, active exertion, or the

invasion of acute disease badly.
"To the eye," says the late Dr. Addison, in describing
a condition of the integuments, which he believed to be
pathognomonic of fatty degeneration of the liver:
''
The skin presents a bloodless, almost semi-transparent,
and waxy appearance. To the touch, the general in-
teguments, for the most part, feel smooth, loose, and
often flabby ; whilst in many well-marked cases, all its
natural toughness would appear to be obliterated, and
it becomes so exquisitely smooth and soft as to convey
 TREATMENT. 153

a sensation resembling that experienced on handling a

piece of the softest satin. These appearances are chiefly
met with in females/' There is dyspepsia, flatulence,
and hypochondriasis, with an irregular action of the
bowels, which are sometimes costive, at other times
profusely relaxed from very slight causes. Enlarge-
ment of the spleen in the fatty Jiver is rarely present.
Teeatment. — It is not often, says Murchison, " that
fatty enlargement of the liver causes such a derange-
ment of functions as in itself to call for any special
treatment. As a rule, the treatment must be specially
directed against the conditions in which the enlarge-
ment in question is known to occur. When for
instance, the fatty degeneration is developed in persons
who are large and gross and of indolent habits,
feeders,
the fat will generally disappear from the liver, as well as
from all other parts of the body, if the individual adopts
an opposite mode of living. He should rise early, take
plenty of active exercise in the open air, lie should
take Turkish baths three or four times a week, drink
freely of cold water, seltzer or the Yals water, night
and morning, and on lean meat, fowl,
live principally
rabbit, and fish, —
green vegetables, with light claret,
hock, or water, mineral or plain ; no salmon, eels, or
herring. He should avoid butter, milk, cream, and all

fat meats, fermented liquors, strong and rich wines, and

all substances rich in starch or sugar. In fact, he must
adopt a regular system of *'
Under such
Bantingism."
a diet the fat will not only disappear, but the tone and
nutrition of the muscles will be much improved, and
the patient's general strength much increased.
When a fatty liver is the result of alcoholism, a simple
154 TREATMENT.

withdrawal of the cause will in most cases be sufficient

to effect a diminution in the size of the liver unless
the disease is too far advanced. The diet here also,
more particularly if the heart becomes similarly impli-
cated, must be selected with due regard to the condition
of each case.
If thestomach becomes deranged, a not uncommon
accompaniment of a fatty liver, it should be corrected
by NiLx Vom. or Pusatilla. If the bowels become
costive, they should be regulated by Nux V., Fodoph, or
Sulphur. Eating large quantities of table-salt with the
food has been recommended by some authors ; and
when circumstances permit, the patient should take the
saline waters of Cheltenham, Leamington, Llandrindod,
or Builth, inEngland; those of Carlsbad, Marienbad,
Kissengen, Ems, or Vichy, on the Continent.
When marked anaemia with general debility sets in,
the various preparations of iron often prove of very
great service : —the Eerri Am. Citras ; the Eerri et Quin.
Citras, and my own preparation, the Eerri Am. Citras,
cum. Strychnse, cum. Digitalis, and the chalybeate
mineral waters of Tunbridge Wells, Moffat in Scotland,
and the Spa, Pyrmont, or Schwalbach on the Continent.
 ;

155

CHAPTEE XL
Simple Hypertrophy of the Liver.

The third form of painless enlargement of the liver

is that known as "Simple Hypertrophy," by which
is meant a uniform enlargement of the organ, with
an increased size of the lobules and an increased
size of the secreting cells, without any alteration of
ctructure. The gland may attain two or three times its
normal size, without its form being essentially altered
it is hard, lacerable, and full of blood the acini are;

enlarged, and of the normal reddish brown colour.

The circumstances under which this increased growth
of liver takes place are somewhat obscure; but a per-
sistent (hypersemia) determination of blood appears
under certain circumstances to favour the development
of enlargement of the organ. Hypertrophy has been
observed in cases where a portion of the liver has been
destroyed by some exudative process, the result of
syphilitic hepatitis, or from obliteration of the branches
of the portal vein.
Hypertrophy has been found to exist with certain
forms of "diabetes mellitus." Frerichs, in 1849,
examined the liver of a man, set. 44, who had died of
" diabetes mellitus," tubercles in the lungs, and
pneumothorax. He found the liver considerably en-
larged, its form normal, and outer surface smooth ; its
156 SIMPLE HYPERTROPHY

substance was congested, dense and firm, and of a

uniform brownish red colour. In 1854, Frerichs exa-
mined another liver, that of a woman's, aged 37, who
had suffered from " diabetes mellitus," but who died
from caries of the petrous portion of the temporal bone,
and erysipelas of the face, which presented the same ab-
normal characters. Stockvis, in 1856 Claude Bernard,;

in 1855; Hiller, in 1843 ; Griesinger, in 1859, met with

similar cases.In 1870 a similar case came under my
own observation it was that of a near relative who came
;

to consult me from !N'orth Wales for diabetes mellitus.

The specific gravity of his urine was as high as 1050,
and held in solution a large quantity of sugar there was ;

considerable enlargement of the liver, which was uniform

all over ; a carefully selected diet, a Turkish bath
daily, Podo])hyllum, and Niix Vom, internally ; and a
compress sufficiently capacious to cover both hypo-
chondriac regions, (which brought out in ten days a
tremendous crop of pustules), sufficed to dispel every
vestige of sugar, and reduce the enlarged liver to its
normal standard within the brief period of six weeks.
"Hypertrophy" of the liver, in company with
"hypertrophy" of the spleen and lymphatic glands,
frequently attends that condition of the system, known
"LEUKCEMIA." Virchow, Bennett, Vogel, Freidreichs,
and others,have recorded a series of observations in
proof of the occurrence of an altered nutrition of the
liver, in conjunction with this abnormal condition of

the blood.
It has been noticed by physicians who have practised
in the tropics, that after some years' residence in those
countries the liver is wont to increase in size without
 OF THE LIVEE. 157

any actual structural disease. Similar observations may

be made with regard to malarious districts of the tem-
perate zone, as I have met v^ith five cases of enlarge-
ment of the liver and spleen in persons who came to
consult me from the fen districts below Cambridge, and
the Isle of Ely.
Treatment. —In the treatment of simple enlargement
of the liver, we must be guided by the circumstances
connected with each particular case, as enlargement may
take place from many different causes ; consequently,
each case will command a special mode of treatment,
which must be left to the judgment and discretion of
the practitioner.
 158

CHAPTEK XII.

HYDA.TIDS —ECHINOCOCCI OF THE LiVEK.

Synonymously.— Hydatids are known as the Hydatis of

Laennec, and derived from the Greek vdang, a vesicle,
from vdwp water; Acephalocystis,from a privative, KerpaXri
the head, and Kvrrrig a vesicle — simply a vesicle
without a head ; the Vessie sans adherence of Cruveil-
hier ; the Echinococcus Hominis of Eudolphi and
Bremser ; the Polycephalus Humanus of Zeder ; the
Eischiosoma of Brera.
Nationally.—The Hydatide of the Erench ; the
Wasserblasse, Blasenwtirm of the Germans ; the Idatide
of the Italians, and the Hydatid of the English.
HiSTOEiCALLY. —Physician s at a very remote period
were undoubtedly familiar with large cysts of the liver ^

hlled with an aqueous fluid, but were ignorant of their

real nature. Hippocrates, a.d. 450, in his 55th Aphorism
(section vii.), gives the following :
— " When the liver is

filled with water and bursts into the epiploon, in this

case the belly is filled with water and the patient dies.
Galen, some two centuries afterwards, understood this
case to refer to Hydatids of the liver, but finds difficulty
in explaining how they could burst into the epiploon
unless by ulceration. It would seem, says Galen, that
our author meant the cavity of the peritoneum.
Hartmann, in 1685, directed attention to their being of
an animalcular nature. Tyson, in 1691, endeavoured to
prove that they were a species of worms, or imperfect
 — —

•'HUMAN ECHINOCOCCUS.'' 159

animals. Pallas, in 1760, recognised them as parasites,

and showed their close connection to the tapeworm
a discovery which was confirmed and extended by
Goeze shortly afterwards. The first accurate description
however, of a "Human Echinococcus " was given by
Bremser in 1821, who traced the relationship of a
hydatid to the tapeworm and it is now recognised more
;

or less in all countries by those who have read the able

works of Von Siebold and Frerichs, that the echinococcus
is nothing more nor less than the " embryo " of a tape-

worm, which immigrates in that form into the liver, and

there assumes the form of tapeworm by gradual develop-
ment, and enters the intestinal canal as such.
—
Anatomically. The anatomy both microscopically
and otherwise of the hydatids and echinococci, are
marvellously interesting, and given with great minute-
ness both by Frerichs and Eokitanski, which are here
briefly embodied, in the following description :

1. Hydatid, or the Acephalocyste of Laennec. This

consists externally of a firm fibrous capsule, of a
whitish tint, intimately adherent to the surrounding
glandular and freely supplied with a shower of
tissue,

branches of the hepatic artery, and portal vein.

Within this fibrous sac or capsule is enclosed a soli-
tary, independent and thoroughly distended bladder, or
vesicle, containing a limpid serous fluid — the so-called
mother-sac of the echinococcus ; that is to say, in its
earliest stage or Embryonic form. Within this parent
sac are found floating about other and similar vesicles
of various sizes and numbers. In size they vary from
a poppy or millet seed, or homoeopathic globule, to
that of a goose's %gg, and sometimes even to a greater
160 HYDATIDS AND ECHINOCOCCI.

magnitude, and their number not unfrequently amounts to

several hundreds, or even thousands. Pemberton counted
560 hydatids in one and Allen 7,000 to 8,000-
cyst,
The larger vesicles sometimes contain smaller ones of a
third generation, and occasionally the latter in their turn
contain others of a fourth generation. From this remark-
able development and increase in numbers, it can readily
be understood how the size of the mother-sac must in-
crease, according to the number and size of the daughter
and granddaughter vesicles, and in proportion to the
quantity of contained fluid, which often attains to the
and even much larger. This growth
side of a man's head,
of the mother-sac may go on until it ruptures, and then
only a few shreds of it may be found lying among the
dausfhter and granddaughter cells. In their unim-
paired vegetation, however, these vesicles are filled to
repletion, are distended and elastic, and impart to pal-
pation a sense of tremulous fluctuation —the "hydatid
tremulousness " of Eokitanski.
2. Echinococcus. — On a close inspection of the inner
surface of these vesicles, we perceive in many of
them a whitish, opaque, gritty efflorescence, usually
aggregated in groups ; and if submitted to the field

of the microscope there is revealed to our anxious

gaze thousands of densely nestled animalcules, which
prove by the most varied changes of form that they
long continue to live on in the dead subject. Many of
them are likewise found free in the liquid found in
these vesicles. These are the scoloces —the embryo, in
fact, of the " Taenia echinococcus," in various gradations
of development. This entozoon is from the ^V ^o ^^^ J of
a line in length ; its head is similar to that of the taenia ;
 HYDATIDS. 161

it is furnished wifcli four suckers and a proboscis, and

encircled by a double festoon of hooks, the number of
which, according to Kuchenmeister, amounts to from
28 to 36 or from 46 to 52. The head of the animal is
separated from its body by a groove, and on its pos-
terior extremity is a transverse cleft or depression, in
which is inserted a cord-like appendage, by means of
which the creature maintains its seat upon the vesicle.
The body presents elongated strise, and between these
are seen oval lime-like corpuscles, resembling those
striae

found upon the cysticercus. In its developed condition

the creature appears in the above form ; but this is not
always the case, as other forms where
are observed,
the mother-sac contains no daughter-vesicles, and the
scolices only grow upon the inner surfaces of the pri-
mary sac. Other hydatids are met with which contain
no scolices at all; here the external capsules is lined
by a mother-sac composed of several layers in which no
scolex can be detected, either on its surface or in the
fluid within : in form they may assume the shape of a
heart, a pitcher, or a horseshoe.
Chemically, the fluid filling the vesicles is colour-
less, clear, or slightly opalescent, of low specific gravity,

from 1-008 to 1-015. It coagulates readily by heat or

viz.,

Mt. acid, and contains a very small amount of fat. A

thousand parts will yield fifteen parts of solid ingre-

dients, principally common salt, a trace of sulphate of

soda, phosphate of lime, and some albuminous extrac-
tive matter. The envelopes of the hydatids leave when
dried a brown residuum which dissolves with a deep
brown colour when boiled with hydrochloric acid.
Hydatids are formed in all parts of the liver ; in the
M
162 HYDATIDS.

right as well as in the left lobe, on its upper as well as

on its lower surfaces, down deep in the substance of the
gland, and cropping out from its surface or margins.
In the majority of cases there is but one cyst, but not
unfrequently there may be two or three, and in excep-
tional cases five or six may exist in the same organ.
Not unfrequently they occur in several organs simul-
taneously. Thus they will infest in vast numbers both
the peritoneum and the abdominal viscera, and some-
times the thoracic organs.
Hydatids vary much in size and the direction they
take in magnitude the sacs may attain or even exceed
;

the diameter of a foot or more they have been known

;

to fill the greater part of the abdominal cavity and the

right side of the chest. The more the cysts grow the
more is the glandular tissue compressed and reduced in
size. In the early stage the cysts may form a circum-
scribed tumour at one part of the liver, not larger than
a Seville orange or Spanish onion; the alterations in
the form of the liver are as various as the directions in
which the cysts develop themselves ; thetumour is
neither dense nor doughy, but is as a rule elastic, and
sometimes fluctuating (the hydatid tremulousness of
Eokitanski), particularly if the cyst be near the surface.
The echinococcus cysts (if not checked by proper treat-
ment) may become perilous through their great volume,
and when present in great numbers generally prove
fatal through exhaustion and great wasting, and in-
dependently of their injurious effects upon the glandular
tissue, interfere with the functions of the adjoining
organs, and ultimately burst and empty themselves
through various channels.
 ——

CASES OF ECHINOCOCCI. 163

The direction in whicli the perforation takes place

varies considerably. Davaine has collected a number
of cases scattered through the records of medicine, with
something like the following results, viz. :

The echinococci bulged into the thorax in 4 cases.

j> opened into the pleural

cavity 9 „
}j
opened into the base of
the lung, or into the
bronchi 21 „
y) communicating with the
bile-ducts ... 8 „
jj
bursting into the abdo-
minal cavity 8 ,,

jj
bursting into stomach
or intestine 22 „
}i
not extending beyond
the liver

166

Frerichs gives us the records of 23 cases which have

come under his immediate observation, viz.,

3 Extended into the right side of the chest.

1 Into the base of the right lung, where it gave rise
to a large abscess.
1 Opened into the bronchi.
1 „ „ intestinal canal.
2 „ „ abdominal cavity.
1 Opened externally through the umbilicus.
 — —

164 MODES OF TEKMINATION.

14 Eemained confined to the liver 11 of these show- —

ed no symptoms during life in 9, the echino- ;

cocci were dead and undergoing fatty degenera-

tion. One was calcified.
The writer has met with 10 cases of echinococci in
the course of his professional career ; of these
5 Burst into the abdominal cavity.
3 „ „ stomach.
2 „ „ base of right lung.

Duration of the Disease. — As the development of

the echinococci is slow, the duration of the disease is like-
wise slow, and may exist for many years before they
cause death, or terminate in recovery. Trerichs has met
with a case where the disease had existed for about
seven years. Barrier, in 1840, gives an analysis of 24
cases in reference to this subject :

In 3 cases the disease lasted about 2 years.

„ 8 „ ., „ 2 to 4 „

}} 4 „ „ „ 4 to 6 ,

And in single cases the affection had existed from 15,

18, 20, or even 30 years.
Modes of Termination. —The manner in which the
hydatids (like its duration) terminate, vary con-
siderably. The hydatids not unfrequently undergo a
—
spontaneous cure the animals die, as proved by post-
mortem examinations, without their existence having
been suspected during life. In some cases a cure
follows the expulsion of the cyst through the stomach,
intestine, and sometimes by a direct outlet
bronchi,
through the abdominal parietes. Moreover many cases
 — ; ; ;

SYMPTOMATOLOGY. 165

are brought about by medical and surgical treatment,

Notwithstanding the vis meclicatrix naturcE coupled
with the most approved and therapeutic,
surgical
treatment, a fatal termination is by no means an un-
common result, which may be brought about by a
variety of ways.
Death may take place from the bursting of the
hydatids
Into the peritoneal cavity ;

Into the pericardium

Into the pleural cavity
Into the lungs, by perforating the diaphragm.
Death may take place from sheer exhaustion, the
result of prolonged suppuration of the lungs.
Death may take place from inflammation of the
hepatic veins, and pysemia.
Death may take place from plugging of the pul-
monary artery from inflammation and suppuration of
;

the circumference of the sac ; or death may take place

from hsemorrhage into its interior; and in some cases
death takes place from general marasmus, caused by
the echinococcus in the course of its growth, gradually
compressing the greater portion of the hepatic
parenchyma, and interfering with the normal functions
of the adjacent organs.
Symptomatology. —The early symptoms of the appear-
ance of echinococci in the liver are exceedingly
obscure, particularly when small or deeply seated
and it frequently happens that echinococci exist in
the grow and degenerate, and are found after,
liver,

death without having exhibited any symptom of their

presence during life. This is no uncommon occurrence.
166 SYMPTOMATOLOGY.

" I have found," says Frericlis, " a '

hydatid ' ia the liver
as large as a man's which had occasioned no remark-
fist

able symptom, and whose presence had consequently not

been recognised during life." I have myself found an
ABSCESS in the liver sufficiently capacious "when
empty " to hold which some of my
a quart-pot,
confreres failed to discover, but which was diagnosed by
myself, and confirmed by Dr. Vaughan Hughes. In
the majority of cases, however, local changes take
place which will indicate beyond doubt the presence
of a " hydatid,"
or some other abnormality a ;

knowledge of which must be obtained by a thorough

investigation of the history of the case. In the gene-
rality of cases, however, particularly when the hydatids
are fairly developed, local changes take place, which
indicate, and that without little doubt, the existence of
hydatids. The liver increases in size, and may be traced
projecting into the chest or the abdominal cavity, or at
other times in both directions by so doing it naturally
;

loses its normal form. It may extend upwards as high as

the second rib it may extend downwards as low as the
;

pelvis and it may extend laterally either to the right or

;

to the left ; its boundaries in either case are to be deter-

mined by palpation and percussion, and in some cases
by the aid of the ear, and stethoscope. Bearing in mind
the normal position of the abdominal viscera, as laid bare
to us on the dissecting-room table, and taking into
consideration the history of the case in all its bear-
ings, we shall have, in the majority of cases, but little
difficulty in arriving at a correct diagnosis. It is next
to an impossibility to describe all the various modifi-
cations of form which echinococci of the liver may

/
 —

TREATMENT. i6*r

assume ; a correct knowledge of these can only be

acquired by a frequent and extended experience at the
post-mortem table. More frequently a rounded bulging
of the liver is felt in the right or left hypochondriac and
epigastric region. On palpation hydatids are felt as
smooth, globular, elastic tumours on percussion they ;

yield a peculiar vibration or trembling, which is felt

distinctly when the tumour is gently compressed by two
fingers of the left hand and struck abruptly with the
right hand. There is but little pain attending echino-
cocci of the liver ; the disease develops itself slowly
and insidiously, without any fever, stomach, or bowel
derangement, jaundice or ascites. But when the growth
of the tumour increases to such an extent as to act as a
mechanical pressure upon the adjoining viscera, then
we encounter a series of distressing symptoms ; there is

difficulty of breathing, there is a short dry cough, and

palpitation of the heart, there is frequent vomiting and
obstructed defsecation, and there are varicose veins and
general oedema of the lower extremities ; symptoms
which indicate consecutively the rising of the animals
into the thorax, the dislocation of the heart, compres-
sion of the stomach and bowels, and pressure on the
vena cava.

Treatment.

I propose to divide the treatment of " Hydatids " and

**
Echinococci " under the three following heads, viz.,

1. The Prophylactic,
2. The Therapeutic,
3. The Surgical.
1. Prophylactic. — Prerichs, in his elaborate work on
 —;

168 TREATMENT —PROPHYLACTIC.

the liver, says we are acquainted with no prophylactic
measures for preventing the entrance of the " Taenia
echinococcus " into the system, because the manner in
which this is effected has hitherto eluded all investiga-
tion. Hence medical treatment can only be directed
against the hydatids already developed." Let us see :

" Prevention," it is said, is better than cure. l!^ow I

have already pointed out that the essential cause of the

formation of the echinococci is the swallowing of the
ova or embryo of the " Tsenia echinococcus," which
pass from the stomach into the duodenum, and fro^i
thence into the liver. Accurate observation is, however,
wanting as to the manner in which this is accomplished

all we at present know is, that they are met with in

large numbers in the liver, as well as other parts of the
body. As a general proposition, ii is inferred that the
animal infested by cystic worms is usually the source
of food, or the prey, of that infested by tapeworms.
The host of the cystic worm is devoured by a carnivo-
rous predaceous animal, and by this means the cystic
worm arrives, together with his host, in the stomach of
the carnivorous animal. During the process of diges-
tion, the enveloping cysts in which the cystic worms
were enclosed are digested, or opened by the teeth of
their devourer, when the cystic worm escapes into the
cavity of the stomach, and thence to other organs
of the body, either by migration, or may be by absorp-
tion, via the lacteals and thoracic duct into the general
circulation. For our present purpose it is sufidcient to
know that the ova of the " Taenia echinococcus " develop
hydatids in many animals besides man namely, the —
sheep, dog, lamb, rabbit, rat, and mouse; and who
 TREATMENT —PROPHYLACTIC. 169

knows but what a " sleek little mouse," who invades

our larder by night, may not deposit the ova of the
echinococcus on our bread, butter, and cold meat, which
we innocently partake of at our first meal on the
morrow, and more particularly cheese. Again, the
animal may be conveyed to the inward man by means
of impure water, raw vegetables, fruit, and roots. Like
the embryos of other ''Tsenise," however, they are so
small as to escape the field of ordinary vision. Their
migration, however, is certainly performed like that of
by passing into the system,
the embryos of other Taeniae,
as I have ventured to suggest, either by absorption or
by perforating the intestines, and getting into the
abdominal cavity, where they prefer attaching them-
selves to the liver or the kidneys, or to the organs in the
cavity of the chest, or by migration along the " ductus
communis choledocus" into the liver, or to the outer
surface of that organ.
The hydatids of human beings, says "Thudicum,"
most frequently accompany them to their graves or ;

at all events, they are not permitted to continue their

dangerous existence ; but the echinococci of sheep or
lambs are again set free in the process of slaughtering,
and are in turn to be devoured by and it may
dogs, "
be " by cats, pigs, ducks, rats, and mice, whose favourite
haunt is the slaughterhouse, butchers' shambles, or
the knacker's yard, to be again developed into tape-
worms. It has not yet been clearly proved that the
animals herein mentioned, in addition to the dog, are
not infested by the ova of the echinococcus. While man,
then, does not contribute to the multiplication and
propagation of the worm, his constant liability to the
 — "

1 70 TREATMENT —THERAPEUTIC.
disease is kept up by the " cycle " of infection which
subsists between dogs and the animals I have men-
tioned, and sheep.
It follows, therefore, that for the prophylaxis of the
echinococcus in man, it will become absolutely
necessary
1. To prevent dogs, or any other pet or household
animals, from feeding on the offal of sheep, lamb, or
other animals infested, or supposed to be infested, by
" hydatids."

2. Dogs, and all other animals (as far as able), ought

to be rigidly excluded from slaughterhouses, butchers'
shops, and the knacker's yard.
3. Dog's meat and cat's meat " in any form ought
"

to be WELL BOILED; and no "tit-bit" of fresh meat,

particularly " liver," should be dropped into Carlo,
or Lilley's mouth when cook goes to pay the butcher's
weekly bill. Against this practice a " dead stand
should be made by every Lady Bountiful, unless de-
sirous of being invaded and overrun byth ese parasites.
A pet nightingale is to my knowledge daily fed on
raw meat the owner, a fine woman, is an invalid she
: ;

flags, and is out of sorts who knows but what she is

;

a victim to an echinococcus, which is gradually and

imperceptibly robbing the bloom from her cheeks,
innocently conveyed to the fair jailer by that match-
less warbler of the brake and forest? I know another
lady who has adopted a guinea-pig as her " darling
pet j" she coos and caresses him, takes him to bed, and
allows him to nestle on her bosom. She feeds him with
all sorts of food — raw meat, green food, and fruit of all
kinds. This lady is " embonpoint :
" she complains but
 TKEATMENT —HOMCEOPATHIC. 171

little yet, although there is depicted on her forehead signs

of liver complaint — who knows but what this guinea-
pig has not innocently transferred the germs of a
hydatid to her which ere long will burst forth
liver;
with all the symptoms of the disease in its worst
form ?

4. To destroy, as far as possible, the tape worm

generated in the dog — for this purpose — it would be
well that all dogs were periodically physicked with
gamboge, calomel, turpentine, or kousso, and their
excreta buried in the ground or destroyed by fire.

These are measures which are of national import-

ance —particularly in such countries as Iceland, where
the sheep-dog during the long winter nights occupies a
portion of the overcrowded dwelling of his master,
and where " hydatids " are the cause of one-seventh of
the human mortality, and which merits more than
ordinary attention in many parts of our own country.
Therapeutically, very little it is feared can be done
in the destruction of these animals by medicine. We
know full well that when the tapeworm infests the
alimentary canal, we have in the Areca nut, Filix mas,
Kamela, Kousso, Pomegranate, and Turpentine, potent
remedies, which undoubtedly do kill the animal; but
to treat the hydatid in the liver by the same means,
is quite another matter for. the attainment of this
:

object, however, certain therapeutic agents have been

employed, which are thought to pass from the blood
into the " cysts," and there kill the inhabitants in their
own fortresses. Baumes believed that calomel was
endowed with such properties Caesar Hawkins, iodine,
;

and the iodide of potassium, and Laennec the common

172 TKEATMENT — SURGICAL.
salt. The virtue of the latter is much relied on by
man}^ other French physicians, who recommend that a^
strong solution of it be applied either as a lotion or in
the form of a poultice over the tumour. It is worthy
of remark, that common salt is the chief ingredient
found in the fluid of hydatid tumours, and in many
instances the fluid from a hydatid cyst in the liver
has been found to be quite devoid of albumen, and to
be more than pure water holding in solution com-
little

mon salt. Such being the case, the question may well
be asked, has the sac of a hydatid tumour any special
affinity for salt ? and does the accumulation of this
substance beyond its normal quantity in the fluid within
the sac destroy the echinococcus, or arrest their further
increase or their growth ? These are, to my mind,
questions well worthy the close attention of every
physician.
HoMCEOPATHiCALLY. —There are several medicines set
down in books" and "Domestic Guides" as
"Text
applicable to the treatment of tape worm, namely,
Ambra Grisea Calc. carb. Arsenicum Mercurius
; ; ; ;

Graphitis Pusatilla Sabadilla; Stannum and Sulphur.

; ;

Each of these may be worth a trial, but to my mind

Arsenicum is eminently useful when resorted to in time,
with the application of a compress over the whole of
the hepatic region, saturated in a strong solution of
"common salt."

Arsenic am, cures anasara following fever, ague, or that

following the retrocession of some acute eruption.
Arsenicum removes the ascites resulting from
disease of the liver or kidney.
Arsenicum, cures hydrothorax and hydro-peri-
 TREATMENT — SUEGICAL. 173

cardium ; and Arsenicum has in my hands cured two

cases of the " Ascites saccatus/' or sacculated dropsy, in
other words, " hydatids," with the help of the salt water
compress.
Surgically. —We now come to the most important
section of the treatment of hydatids —the use of the knife,
with other surgical appliances, and electricity. Several
modes of operating have from time to time been adopted
with varying results, to these I shall now briefly refer.
1. The Simple Pimctitre. —This mode has been adopted
with both medium, and small-sized trocars. This
large,

plan has generally been found free from danger, provided

the adhesions are sufficiently complete to prevent any
of the fluid from escaping into the cavity of the chest,
or the peritoneum. It may be that one puncture may
suffice to effect a cure; but in other cases several
operations of a like kind may be required before the
" cyst," is completely destroyed.
2. The puncture of the hydatid, with subsequent
injection of water, a solution of iodine, port wine, or
bile.

Having first plunged the trocar into the cyst, the

trocar is withdrawn, and the canula is allowed to
remain in the cyst, through which pure water is first
injected to wash out the pus, and shreds of the hydatid
membrane, then diluted alcohol, a solution of iodine, or
even bile is injected into the cyst. Favourable results
generally follow either of these solutions.
Bile has been selected from the fact, that it kills the
echinococci; moreover it acts as an antiseptic, and so
iodine.
3. The opening of the hydatid, by means of caustic.
174 THEATMENT — SURGICAL.
or the Vienna paste it is, however, a clumsy and painful
;

operation, and but seldom adopted in the present day.

4. By incision into the sac. This mode is only per-
missible when the tumour threatens to burst externally,
and the integuments are red or when we are certain
;

that firm adhesions exist between the sac and adjacent

structures.
5. Another plan, is to make an two different
incision at

times, first down to the peritonaeum, and after the

wound has been dressed with lint or cotton wool for
some days, then the scalpel is carefully plunged into
the " cyst."
 ^

175

CHAPTER XIII.

Cancer of the Livee.

Having now disposed of tlie inflammatory and non-

inflammatory diseases of the liver; those which result
from mal- nutrition of its tissues : and those which arise
from faulty secretions there now remains for our con-
:

sideration those which consist of some growth which

becomes obnoxious to the normal structure of the organ
Foremost among the members of this class is cancer ;

which, according to the most carefuUy collected statistics^

is found more frequently in the liver than any other

organ in the body. Indeed, no serious disease of the
liver is, in this country particularly— and among that
class of the community who have not drunk hard — so
frequent as cancer.
In some instances the liver is the only organ impreg-
nated with the germs of cancer, but far oftener the
formation of cancerous tumours in it is consequent of
the deposit of cancer in some other part of the body,
more especially the stomach and the mammae.
—
Historically. Cancer of the liver was not clearly
defined from other tumours of that gland, till the early
part of the present century. It is, however, worthy of
note that cancer of the external organs, particularly the
mammae and scrotum, was clearly recognised as far
back as the era of Hippocrates. We have in the forty-
176 CANCER OF THE LIVER.

second aphorism of his great work the following striking

sentence :
—
In cases of jaundice it is a bad symptom
"

when the liver becomes indurated^ clearly proving the

marvellous diagnostic powers of that great man at that
remote period of " medical history." Similar observa-
tions are to be found in the writings of Galen, Aretseus
and other ancient authors. Under the term " scirrhus
hepatis/' however, every form of induration of the liver
was formerly included, whether its character was that of
the simple, the granular induration, or the true cancer.
Bianchi, in his " Historia Hepatica," Hoffmann, in his
"Dissertatio Medica de Hepatis Scirrhos," 1722 ; Boer-
haave,Van Swieten, Morgani, Euysch, StoU, and Matthew
Baillie, down to 1794, improved but little on the crude

pathology of cancer as viewed and described by the

physicians of a far more remote era; and it was not
tiU 1812 tha.t Bayle, of Paris, gave us the first accu-
rate description of cancer of the liver, and a clear
statistical demonstration of its frequent occurrence in
that organ. He it was who first pointed out that
those tumours of the liver, previously described as
steatoma, —white bodies, —nodes,— tubercles, —granular
bodies, — scirrhus, &c., were in reality '''
true cancer '*

—inasmuch as their anatomical structure was iden-

tical with that of cancer of the breast, and because
they underwent the same changes, — co-existed with
cancer in other organs, and finally produced the same
injurious consequences upon the general constitution.
Anatomically, many circumstances conspire to render
the more susceptible to the deposit both of
liver
abscesses and the dissemination of cancer than any
other organ in the body. We have in the first plape^
 CANCER GEEMS. 177

the great vascularity of tlie organ, the slowness with,

which the blood, already retarded by passing through
a complicated system of capillary vessels, traversing
the dense plexus of vessels that goes to form its lobular
substance —a cause unquestionably favourable to such
a result. Moreover we well know that the liver is the
grand sentinel or ''
which the
floodgate " through
whole blood returning from the lower extremities and
intestines must pass before it gets to the great centre
of circulation and purification —
the heart and lungs.
Bearing this in mind, we can readily perceive how,
when the stomach or intestines become ulcerated, the
blood that flows to and through the liver from these
parts is liable to be contaminated by pus, and other
noxious aliments, setting up inflammation which
quickly terminates in abscess. How ? When the
stomach is the seat of cancer the portal blood is liable
to be contaminated by cancer germs, which being
stopped in their passage through the liver, are there
deposited and developed into " cancerous tumours."
In such cases the abscesses and the secondary cancerous
tumours are usually found only in the liver, which
seems to detain all the pus globules and cancer germs
that are brought to it by the
and it rarely
portal blood ;

happens, under such circumstances, that any of these

germs of mischief pass through to cause abscesses or
cancerous tumours in the lungs or other organs of the
body. There are four varieties of cancer (carcinoma)
found in the liver, each having its peculiar character-
istics, which we now briefly examine in succession.
will
1. —
The Medullary Cancer. This is the most com-
mon form of cancer found in the liver. It occurs either
178 MEDULLARY CANCER.

in the shape of detached masses, or as an infiltration

in the liver structure. In size the medullary cancer
varies from that of a millet or hemp-seed —a homceo-
pathic globule, to an apple, a cricket-ball, to a child's
head. In most instances morbid growths of various
sizes are found in the same individual. In number
they vary, sometimes there may be only one, some-
times a few, at other times very numerous at other ;

times we meet with one as large as a man's fist, sur-

rounded by several small ones. The greater the number
of those occupying the circumference of the organ, the
more numerous will be the protuberances on the
surface and when the morbid growths are numerous
;

and large, two or more often coalesce.

In consistence we find two varieties, which by some
pathologists have been considered as differing in texture.
They do not, however, constitute any essential distinc-
tion, but are merely different degrees of development
of the same morbid growth. In the first stage the
cancer is of the consistence of bacon (the lardaceous of
Frerichs), and presents on section a smooth, homo-
geneous, shining surface of a dull white colour, and
without a trace of blood-vessels. On pressure, a small

quantity of a thick creamy fluid exudes from the

meshes of a dense fibrous structure, which is detached
from the adjoining hepatic tissues with considerable
difficulty, and has but a very faint cellular investment,

scarcely perceptible to the naked eye.

2. EucEPHALOiD Cancer. —The second variety pre-
sents all the characters of the true eucephaloid (brain-
like) disease ; its usual colour is milk-white ; it is, how-
ever, at times, more or less vascular, and conse-
 CAECINOMA AND FUNGUS H^MATODES. 179

quently in part grey, yellow, brownish red, or even

dark red ; it is spungy, and on pressure yields a large
quantity of a thin milky fluid, which is contained in the
meshes of a friable fibrous tissue. The tumours are
invested by a delicate eel lulo- vascular sheath, which
is easily detached from the substance of the liver.

When present with the first variety they generally

form the large morbid growths.
3. Carcinoma (literally a crab). —
This form of cancer
is not met with in the liver quite so often as the one

we have just disposed of; it is, however, sometimes

taken for the medullary, and the mistake is accounted
for from the fact that the two frequently co-exist. In
consistence it forms masses from the size of a filbert to
a man's fist, which are surrounded by an investment of
delicate cellular tissue, and although the surface is
uneven and lobulated, yet the general outline is round.
In texture it is firm and almost cartilaginous in colour ;

it is of a pale yellowish red, and almost of a glassy

transparency. These carcinomatous masses are com-

monly found in considerable numbers, and, like the
medullary form, they cause rounded protuberances of the
organ, and produce an increase in its weight and size.
4. Fungus —
H^matodes. This form of cancer is
characterized by the abundance of blood-vessels, which
are large, and furnished with thin walls, so that they
are easily torn, and give rise to the extravasation of
blood. This infiltrated medullary cancer is analogous
to the other infiltrations of the liver tissues already
referred to. It always contains obliterated and obsolete
blood-vessels and gall-ducts which are gradually absorbed.
The infiltration attacks larger or smaller sections of the
180 MELANOTIC CANCEK.

liver ; it does not present distinct boundaries, but in-

sensibly passes into the healthy structure. It is rarely
present without the nodulated form ; it is the seat of
haemorrhages, which are proportioned to the rapidity of
its growth, and the looseness of its texture. In some
cases it penetrates through the peritoneal covering of
the liver development then proceeds with great
; its

rapidity, while it indaces exhausting hsemorrhages. In

other cases it perforates the coats of the larger gall-
ducts and biliary passages, and grows into their cavities.
5. Melanotic Cancer. —A medullary carcinoma not
unfrequently occurs in the liver in the form of melanosis
(black cancer). In this case a number of small
nodules are disseminated through the liver, which are
partly pale and partly coloured with yellow, brown, or
black pigment, and which present an irregular form, and
in most cases an ill-defined outline. The liver, in conse-
quence, acquires the appearance of a piece of granite.
The pigment is deposited for the most part in the in-
terior of the cancer cells they are also found floating
free in the cancer juice. This form of cancer is marked
by rapid growth and extension. In addition to the fore-
going, Frerichs has pointed out two other but rare forms
of cancer found in the liver, namely the " cystic " and
" colloid." The first presents itself in the form of
rounded from the size of a pea to that of a
cavities
walnut, which is filled with a clear serous fluid, and
lined by a smooth serous-looking membrane. The
second contains cavities of a larger size, and filled with a
gelatinous fluid.
From the foregoing description of cancer of the liver
it will be observed that they differ as much in firmness.
 CAUSE OF CANCEE. 181

vascularity, and colour, as they do in other parts of the

body. Sometimes the tumours are white, firm, and
fibrous (scirrhous, hard) sometimes they are pulpy and
;

whitish, or greyish, presenting a strong resemblance to

BEAIN, and which Laennec to apply the term
led
Eucephaloid sometimes the tumours are extremely vas-
;

cular, and full of blood, which led Hey and Wardrop to

give it the name of Fungus Haematodes sometimes the ;

tumours are dark or sooty, which kd Laennec to give it

the name of Melanosis (black) ; sometimes the tumours
are filled with a gelatiniform or gluey substance, which
led Velpeau to designate it as Colloid — from the Greek
(koXXu glue).
Etiologically. —The immediate cause of the develop-
ment of cancer in the liver, like that of cancer in
general,is entirely unknown. We are only acquainted
with those external conditions which accompany the
development of this pest of humanity, and which it is
the custom to connect, although remotely, with the
disease. In speculating, however, on the cause of
germ of
cancer, the question immediately arises, is the
this baneful disease a true parasite, introduced from
without or is it generated within the body, and of the
;

materials of the body, under the influence of certain

morbid agencies ? The strongest plea in favour of the
first theory is this, that cancer originates in various
organs, and has in all ofthem independent vitality and
powers of growth. This is clearly shown in continued
increase in the primary tumour, however small it may
have been ;
besides, it is further and fully proved that
the transplanting of one or more germs from the primary
tumour to a distant part of the body, is sufficient of
 ;

182 STRUCTURE OF CANCER.

itself to communicate the disease to tliat part ; more-

over cancer can be conveyed from one animal to another,
both by inoculation and the injection of the cancerous
matter into the veins : a further proof of its parasitic
origin. But although cancer is capable of being thus
transplanted from one individual to another, it occurs
in almost all cases under circumstances in which it is

any such inoculation or infection

difficult to believe that

has taken place: the most common being from some

direct injury, or prolonged pressure and irritation of
some part of the body.
Thus cancer of the breast is frequently ascribed to a
blow cancer of the lip to the constant pressure of
;

a pipe cancer of the penis to congenital phymosis

;

cancer of the anus and rectum to piles or syphilitic

vegetations ; cancer of the scrotum, in sweeps, to the
irritation of soot, &c.
These few instances go to bear out the old doctrine,
that a disease not primarily malignant may become so,

—a doctrine which some degree at variance with

is in
the theory that the germs of cancer are always intro-
duced from without. The structure of cancer affords
additional reasons for rejecting the idea that the germs
of the disease are always introduced from without. The
essential elements of cancer, as of other tissues, are
nucleated cells and fibres. These cells multiply by
throwing off the germs of fresh cells from their outer
surface and sometimes also from their inner
; surface,
as in the colloid form of the disease.
All these circumstances go to prove that cancer
originates in a depraved nutrition of the original
nucleated cells of the part in which it first appears.
 ' — —

AGE OF PERSONS AFFECTED. 183

Age. — Cancer of the liver, say Frericlis, belongs

pre-eminently to the later periods of life, although Farr
mentions three cases where it appeared in early infancy,
one in an infant three months old and lungs), one (liver

in a boy, two and a half years old (testis), and another

of the same age (pelvis). Of 31 cases observed by that
author he gives the following results :

From 20 to 30 years old . . . . 2 cases

„ 30 to 40 a • • • . 4 »>

„ 40 to 60 3i • • • . 15 »
„ 60 to 70 >» • • • . 8 »>

Above 70 — J) • • • . 2 »

Total 31 „

Of 52 cases recorded by other observers we have :

From 20 30 ^ears old

to :
. . . . 5 cases.

„ 30 to 40 j>
, . . . 10 „
„ 40 to 60 ;> . . . . 26 „
„ 60 to 70 5> . . . . 11 .,

Above 70 — J» ^ . . . „

Total 52 „

Of 8,289 deaths from cancer in Paris as recorded by

Herrick and Popp,578 cases are ascribed to the liver alone.
Age appears to exercise but little influence in predis-
posing cancer of the liver, as both are fairly balanced.
Of the 31 cases observed were men and
by Frerichs, 10
21 women; of 60 other cases collected from various
sources 35 were men and 25 women and of the total ;

91 cases, 45 were males and 46 females. Of 31 cases

 ; '

184 CAUSE AND DURATION

recorded by Van der Byl 13 were males and 16 females;

whilst the mean age of the males was 41, females 50.
Walsh e states that he finds hepatic cancer more frequent
27 to 18,
in males than in females, in the proportion of
very rare before 35 or 40 years, most common between
the ages of 50 and 70, two-thirds of the total number of
deaths occurring within the latter periods.
Causes. — Of special causes of hepatic cancer, predis-
posing or otherwise, none have been discovered. The
disease is met with in the ansemic as well as in the
plethoric ; in the badly fed as well as in the well fed
in the peasant's hut, the cot of the mechanic ; the home-
stead of the farmer, the house of the well-to-do trades-
man, the baronial halls of our aristocracy, and the
palaces of royalty. Like its prototype, phthisis, it spares
neither young or old, male or female, the peasant, or the
prince. Spirituous liquors, which so easily derange and
even destroy the secreting functions and nutrition of the
liver, do not predispose to cancer of that organ. The
same may be said of climate, as we find it endemic in
both warm and cold countries.
—
Duration. It is impossible to determine accurately
the duration of cancer in the liver, as its premonitory
stage is in most cases so obscure as to elude the most
careful investigation. There are instances in which
the progress is slow and almost latent for many years
until the very highest grade of marasmus wasting is — —
attained and there are other instances where the dis-
;

ease runs a rapid course, and terminates fatally at the end

of seven or eight weeks. In such cases it is usually
attended with fever, tenderness in the hepatic region,
and jaundice. M. Andral relates a case in which death
 OF HEPATIC CANCER. 185

occurred within three weeks ; in that case there was

fever, tenderness, and jaundice, with perceptible enlarge-
ment tumours from day to day till death took
of the
place. As a rule the medullary form of cancer is cha-
racterized by a rapid course the scirrhotic form by a slow
:

course the termination in any case is always fatal, as

:

no one has yet succeeded in proving beyond doubt, a

single instance of a radical cure. Our prognosis, there-
fore, in all cases must be a gloomy one in the : soft cancer
it runs a rapid course to a fatal termination ; in those
hard cancers which grow slowly much may be done, by
appropriate means, to prolong life for some years, and
make that life bearable.
Symptomatology. —The clinical history of cancer
of the liver varies considerably ; there are in many cases
certain prominent "landmarks" which seldom fail us
in diagnosing the disease and there are on the other
;

hand, many cases so very obscure as to baffle the skill

0^ most acute observer. Cases of this kind are not
'^he

unfrequently met with where all signs of hepatic disease

are wanting, where symptoms of an undefined character
constitute its leading characteristics —namely, indiges-
tion, ilatulence, constipation, together with a disordered
condition of the nervous system —a group symptoms
of
often looked upon as simply *'
hypochondriasis ;" and it
is not till grave symptoms arise, terminating in death,
that we are able to discover the causewhich led to a
fatal issue. In other cases we have consecutive dis-
eases, such as chronic peritonitis, and pleurisy, ascites,
all of which may mask the fundamental disease.
Again, in other cases, there are derangements proceeding
from the primary diseases, to which the liver affection is
 — ;

186 SYMPTOMS OF

but secondary, which may engage the exclusive atten-

tion of the physician, and cause the disease going on in
the liver to be entirely overlooked. Still these are
exceptional cases, and in the main we encounter a group
of symptoms so clear and characteristic, as to lead us
without doubt or hesitation to a correct diagnosis. We
will review these symptoms under the following
heads :

1. Dyspepsia. —Many of the symptoms of cancer of

the stomach are observed in cancer of the The
liver.

reason of this is tolerably clear, as the stomach and

intestines are themselves very often implicated in the
mischief; and as a rule the gastric as well as the
intestinal functions are much deranged in cases of
hepatic cancer.
There is frequent eructation of air more or less foetid.

There an impaired appetite, followed by a sensation

is

of fulness and uneasiness in the epigastric and hepatic

region after each meal.
There is obstinate constipation, which sometimes
changes into a diarrhoea of a very offensive character
and in the advanced stage the stools evince a deficiency
of bile, are clay-coloured, and attended with a con-
siderable amount of flatus, at other times dysenteric
stools and bleeding piles.
There is vomiting of a glairy mucus, bloody matters,
or, the food.
There is a gradual emaciation of the whole frame,
with an equally gradual loss of strength.
There is excessive depression of spirits and morose-
ness of temper. There is a pale and earth-coloured
tint of the countenance, with a light straw-coloured
 ;

HEPATIC CANCER. 187

discoloration of the skin, whicli in advanced stage tlie

becomes of a citron-yellow, or olive-green, and dry

like parchment. The respiration becomes more or less
impeded, dependent on a participation of the dia-
phragm in the cancerous degeneration distention of
the abdomen, or pleurisy of the right side.

There may be jaundice, but this is not a constant

symptom, unless the position of the tumours are such
as to implicate the large bile-ducts. If the jaundice
attains a considerable degree of intensity, we may
fairly infer that a cancerous tumour has become
developed in the fissure of the liver between this and
the duodenum in such a way as to obstruct the flow
of bile. Thereone peculiarity in the jaundice
is

dependent upon hepatic cancer which is worthy of

—
note whether slight or severe it never disappears,
but continues to the close of the scene.
Ascites. — Cancer of the liver may give rise to
effusion of water into the peritoneal cavity in
various ways ; when slight in amount the accumula-
tion of fluid appears to result from chronic peritonitis
when abundant, from pressure of the large venous
trunks. The water sometimes accumulates to such an
extent as to demand tapping in order to relieve the
distressing breathing it incurs. As regards the
frequency of ascites, in the thirty-one cases recorded
by Frerichs, he found the peritoneum contained a large
quantity of water in 18 : five times it consisted of pure
serum — eight times serum and fibrinous flakes —four
times bloody fluid, and once pure blood. Of sixty
cases recorded by others, dropsy was present in
thirty, absent in nineteen, and no record of the
 — :

188 SYMPTOMS OF

remaining eleven. Towards the close of life there is

dropsy in the lower extremities as well as ascites ; the
progress of the accumulation varies considerably
occasionally the anasarca of the lower extremities and
the ascites increase equally and gradually ; at other
times the former proceeds more slowly than the latter,

and in others again the ascites arrives at its utmost

extent without much oedema of even the ankles. In
many cases there is much vacillation in the course of
each, the one increasing, the other diminishing, or
either or both experiencing a sudden aggravation, and
rapidly reaching its In dropsy from cancer of
acme.
the liver there is seldom any effusion into the serous
cavities of the chest or head. But as ascites reaches
the utmost, the breathing becomes and short, urgent,
and faintness on
distressing, palpitation of the heart,
the slightest exertion these symptoms arise owing to
:

the diaphragm being carried high up into the thorax

by the enlarged liver and accumulation of fluid.

During the last few days there is a distressing hiccup

profuse sweating, a slight or low delirium ; towards
night there is a rapid panting for breath, aphthse of the
mouth, a small and quick pulse, extreme weakness,
distressing nausea, or retchings, colliquative diarrhoea,
and the patient at last sinks into the bed and dies
from sheer exhaustion. Urine. From the careful re- —
rearches of MM. Becquerel and Walshe there
is nothing very peculiar to be found in the urine
of those suffering from cancer of the beyond
liver,

the fact, that where cancer is attended with symp-

toms of inflammation, the urine is high - coloured^
contains a deficient quantity of water, has an excess
 ;

APPEAEANCE OF CANCER OF THE LIVER. 189

of lithic acid and which are almost always

lithates
pinkish. When general cachexia has fully set in, and
the patient is exhausted by insufficent nourishment and
repeated loss of blood, the urine acquires the ancemic
character as described by M. Becquerel; and it has
been shown by the same observer that all serious organic
affections of the liver are attended by febrile urine
cancer of this organ only obeys the general law, whilst
the change does not become established till an advanced
period of the disease.
—
The Lwer. The last and most important group of
symptoms which I shall now have to refer to, are the
peculiar characters presented by the liver when invaded
by cancer. I have already said that the early symptoms
are obscure, and refer chiefly to signs which may easily
be confounded with indigestion, or a mild form of
hypochondriasis. After these ailments, however, have
lasted for some time, the medical attendant, or perhaps
the patient himself discovers that the region of the liver
is larger or fuller than usual, and that there is more
and tenderness on pressure.
or less pain
The surface and margins of this fulness, or swelling
are in exceptional cases smooth, but in by far the
majority of cases are covered with large or small
hard nodules. With these symptoms are not unfre-
quently associated jaundice, and a puffiness of
ascites,

the lower limbs, particularly round the ankles. These

symptoms from time to time undergo aggravation the ;

pains become more acute, and shoot up between the

shoulders the abdominal walls become tense.
; The
breathing is distressed, the skin is hot and dry, and the
pulse is quick. These symptoms, and a repetition of such,
 — —

190 PROGNOSIS.

indicate an increased and rapid growth of the cancerous

tumours. To sum up, cancer of the liver is marked by
1. All grades of enlargement of the organ, sometimes

so large as to fill up the greater portion of the

abdominal cavity.
2. The surface is studded with nodulated protuberances

which are easily felt by the hand and the bounderies

:

of the organ may be marked by palpation and percussion.

The enlargement of the organ is constantly pro-
3.

pressive and in the soft and vascular variety so rapid,

;

that an increase in size may be clearly distinguished

week by week.
4. It is attended by tenderness and more or less pain.
5. It is attended by jaundice,ascites, and more or less
oedema of the legs. And it is
6. Attended from the commencement, which con-

tinues through its whole course, by a train of dyspeptic

symptoms, irregularity of the bowels, a gradual wasting,
a gradual loss of energy, and a pale pasty, cadaverous
look.
Peognosis. —From the nature and character of cancer,
our prognosis, under the most favourable circumstances,
cannot be otherwise than of a very gloomy nature, and
it is only in the case of hard cancers, which grow
slowly, that we are able to give one ray of hope, that
by a carefully selected diet, a judiciously selected resi-
dence, and appropriate medical treatment, life may be
prolonged for some years.
—
Diagnosis. The recognition of cancer of the liver
may be extremely simple, or almost impossible. Where
great enlargement of the organ exists, and where this
enlargement may be felt to depend on the presence of
 — ;

HEPATIC CANCER. 191

nodular masses of various size, where there exist pain in

the hepatic region, jaundice, ascites, emaciation, and
great digestive disturbances, and where the individual is

of advanced age, there can scarcely be any doubt

entertained as to the presence of cancer in the liver.
On the other hand, where not one of these symptoms
exists, where the disease is almost latent, the existence
of cancer obviously may not be suspected, much less
substantiated.
Diseases which may be confounded with Cancee. —
There are several diseases incidental to the liver and
other organs of the body, which, to a casual observer,
maybe mistaken for cancer of that organ. Among these
may be set down
The Waxy Liver. —
Here there is the same increase
in but it
size, must be borne in mind that in cancer the
surface is studded with nodules, in the waxy liver it is
smooth, and attended with enlarged spleen, albumi-
nuria, caries, or necrosis.
The syphilitic liver ; the tight-laced liver ; hydatids
abscesses in the liver ; dilatation of the bile-ducts and
gall-bladder ; cancer of the omentum, stomach, and right
kidney ; and large accumulations of fseces in the trans-
verse colon.

TREATMENT.
Allopathically. — I now approach the most important
section of this paper —namely, the treatment of hepatic
cancer. Would that 1 could endorse the extravac^ant
pretensions, the dishonourable and dishonest asser-
tions made by a section of our profession ;
" who,
'
parasite-like,' cling to the aged tree, and from
 ;

192 ALLOPATHIC TREATMENT.

beneath its venerated branches, which now extend to

every quarter of the globe, palm upon the public their
worthless nostrums, and extort from the timid and
unwary fabulous sums of money." under the plea that
cancer is a curable disease, and as such is as amenable to
treatment as any common disorder. What glorious
news this would be humanity
to suffering ! But such is
not the case. Cancer has remained as the " opprobrium
medicorum " from the far-off epoch of Hippocrates to
the present time remedies innumerable have been
;

suggested, tried, and found wanting hospitals have ;

been established, and the wards of others have been

richly endowed for the special treatment of this dire
pest of mortality and fabulous sums have been offered
;

by many a victim to any man, who could discover a

remedy that would grapple successfully with this
hydra-headed monster. N'o talis manic wand has yet
revealed to man the grand specific it still nestles in the
:

mysterious womb of nature. The various honest authors

who have written on this subject dismiss it with but a
few passing remarks. The treatment of these organic
diseases of the liver, says Guy, is simply palliative
the treatment of cancer of the liver, says Walshe, should
be generally conducted as that of cancer of the stomach;
and it has appeared to that author that the progress of
the affection has been stayed by a liberal inunction of

the iodide of lead ointment over the hepatic region

and the internal administration of liquor potassae in
infusion of taraxacum. The treatment of malignant
diseases of the liver, says Budd, should be simply
palliative ;
have hoped to destroy can-
practitioners
cerous tumours by some powerful alterative, or at all
 HOMCEOPATHIC TEEATMENT. 193

events to check their growth ; for that purpose alkalies,

mercury, and iodine have been

arsenic, but tried

signally failed. The treatment of cancer of the liver,

says Murchison, must be entirely palliative. Mercury,
iodine, arsenic, and the sanguinaria canadensis, have
proved worse than useless. The attempts, says
Frerichs, which were formerly made, and continue
to be made at the present day, to cure cancer of the
liver by means of the preparations of iodine, mercury,
and and the waters of Karlsbad, are very
arsenic,
objectionable and hasten the advent of death by many
;

months, or even years. Conium was recommended

by Hahnemann belladonna, by Alberti the muriate
; ;

of baryta, by Hufeland aconite, by Greding digitalis,

; ;

by Mayer corrosive sublimate, by Euysch mezereon,

; ;

by Home the solanum nigrum, as far back as the

;

Arabian era of medicine, and the various preparations

of iron by Carmichael.
—
HoMCEOPATHiCALLY. Although we are unable to boast
of possessing any specific drug that will attack and destroy
the cancer germ, nevertheless we are able to do much,
to control symptoms, subdue pain, and prolong life.
Having ascertained the real nature of the case, every
measure of a debilitating nature should be strictly avoided.
The pains which attend the development of cancer
and when the peritoneal covering becomes implicated
should be met by Aconite, Bell., and B7y. warm fomen-:

and warm baths. To grapple with

tations, cataplasms,
the cancer germ, Ars., Merc, iod., and Phosph. are well
worthy of a fair and prolonged trial; and should the
stomach become implicated, the Arg. nit. and Nux.
vom. will prove valuable agents.
 ;

194 HOMCEOPATHIC TREATMENT.

In a case of cancer of the stomach, which I repeatedly

saw in consultation with my valued friend Dr. Tuckey,
late of Canterbury, Nux vom. invariably came to the
rescue, and gave more durable relief than any of the
remedies previously selected.
To moderate the derangements of digestion, and check
the nausea and vomiting which frequently accompany
such derangements, Ntix vom. here again will prove a
trusty friend, coupled with an occasional dose of I;pecax.

or Kreasote.
To correct acidity and eructation of fostid gas. Arnica,
Carbo mg., Acid, ac, Acid. n.,Acid. liydrocy,, and Pulsatilla
will give us material help, with a weak solution of Car-
bolic acid, or that innocent but effective disinfectant,
the Terebene. n

The functions of the bowels, when costive, are to be

regulated by Lycopod., Podoph. p., Lept., Nux. Yom., or
Sulphur ; and w^hen too relaxed, by Ars., Phos., Ac,
Verat. Alb. or Gallic acid.
Dropsical effusions are to be subdued, if not entirely
removed, by Ars., Acid, n., China, Copaiba, and Digitalis,
particularly if the heart becomes implicated, functionally,
or organically ; with a series of Turkish or vapour baths
and in cases of great emergency, by the ordinary surgical
mode of tapping.
The general debility and wasting (Cachexia), which
is wont to accompany the progress of hepatic cancer

from its early stage to its closing scene, is best opposed,

by means of a light, bland, nutritious diet animal food
:

both plain and in a concentrated form; milk and

cream, raw eggs, cocoa or chocolate ; oatmeal porridge,
to which may be added a teaspoonful of lentil powder
 —

HOMCEOPATHIC TREATMENT. 195

Vichy or soda-water ; "Wenham Lake ice ; filtered, dis-

tilled, or cold boiled water, with, a fair allowance of a
generous Burgundy, or the Ofner Auslese of Hungary.
The general anaemia and impoverished condition of
the blood must be enriched by the various preparations
of iron, —the Iodide, Lactate, Ammonio-citrate, Phos-
phate, and my own preparation, " the Ferr. Ammo-citrate
cum Strych. c. Quinae c. Dig.
;
" cod-liver oil when ;

this causes have prescribed

nausea,. I my compound
combined with cocoa-nut oil with very favourable
results, with pepsine or pancreatine, or Parrish's chemi-
cal food and a resort to the chalybeate waters of
;

Tunbridge Wells the bromo-iodated saline of Purton,

;

and those of Woodhall, in Lincolnshire ; or the chaly-

beate waters of Pyrmont and Pranzensbad, on the
Continent.
When haemorrhages threaten to prove exhausting
which we generally find in the latter stages of the
—
complaint we must endeavour to check them by means
of Gallic acid, Tannin, Alum, Hamamelis, or Sulphur,
the latter having proved eminently successful in three
cases of cancer with hsemorrhagic complications which
have come under my notice.
 196

CHAPTEE XIV.

GALL-STONES.

Gall-stones are usnally formed in the gall-bladder,

where the bile becomes concentrated from the absorp-
tion of the watery portion of the fluid but it some-;

time happens that gall-stones form in the substance

of the liver, and in branches of the hepatic duct. These
hepatic stones are very small, irregular in form, of a
dark olive or black colour, and chiefly composed of
solid biliary matter.
Historically. —There is no correct account extant of
gall-stones having been observed anterior to the fifteenth
century ,when they were first noticed by Johann Kentmann,
of Dresden, who communicated his discovery to Gressner,
who made use of them to adorn his work on fossils.
About the same time a similar discovery was made by
Vesalius, Fallopius, Fernl, and Glisson, who contri-
buted valuable additions to the history of these con-
cretions.
As regards the early pathology, diagnosis, and treat-
ment of gall-stones, we owe much to the researches of
Hoffmann, Morgagni, Boerhaave, and Sydenham. For
the first chemical examination of gall-stones we are
indebted to Galeatti, 1748; and for the first accurate
description of the structure of gall-stones to F. A.
Walter, 1796.
 —

CHEMISTEY OF GALL-STONES. 197

Chemically. —The number of substances entering

into the formation of gall-stones are numerous. The
most important are as follows :

1. Cholesterine. —This
substance is but seldom
absent, and forms the principal constituent of biliary-
concretions. It is found in a crystalline form, and
mixed with fatty and saponaceous substances. It is
estimated that gall-stones contain from 70 to 80 per
cent, of this substance, which in this respect bears a
similar relation to these stones as uric acid does to
stones found in the bladder.
2. Bile Pigment, which is found more or less in all
gall-stones.
3. —
Cholepyrrhin. This substance is either found in
a pure state or combined with lime it goes to form the
;

nuclei, the shell, and outer crust of the gall-stones. When

treated with chloroform the cholepyrrhin dissolves, and
separates, and on evaporation crystallizes in the form of
needles, prisms, and lamine, of a yellowish brown or
garnet-red colour.
4. —
Cholepyrrhin and lime. This compound is found
in most gall-stones in colour it is yellowish red, and
;

deposited in the form of layers of granules, or scales,

between the lamine of the stones.
5. Cholechlorin. — This is a green pigment —found
but sparingly in gall-stones —when separated from the
other substances, and submitted to alchohol, it presents
a beautiful grass-green colour.
6. Biliary acids and calcareous salts.

7. Bile pigments.
8. Glycocholate of lime, found in the ox as weU as
man.
198 COMPOSITION OF GALL-STONES.

9. Chelate of lime, found in the gall-stones of many

ruminants, as well as man.
10. Free fatty acids, a compound of fatty acids and
lime, mucus, epithelium, and uric acid.
11. Inorganic Metallic Matters. — Iron, manganese,
copper, and earthy matters, such as the carbonates,
phosphates, potass, and soda have been found in varied
quantities in the human gall-stone.
Ordinary gall-stones are composed, as we have seen,
of cholesterine, which, with variable proportions of
colouring matter, is deposited around a nucleus which
generally consists of biliary matter, more or less altered
with other properties. The cholesterine crystallizes so
as to form rays converging from all points of the
circumference of the stone to its centre ; but when
it is mixed with, or stained by, the colouring matters
of bile, which, as usual, are in different proportioned
layers successively deposited, the stone, while it still

exhibits the converging rays, appears to be made up of

distinct concentric laminae. Two circumstances then seem
generally to concur in the formation of these choles-
terine stones : — the presence of a small mass of concrete
biliary matter, or of some other substance, to serve as a
nucleus and the presence of cholesterine in crystals to
;

make up the body of the stones. The first step then,

is the formation of the nucleus, which probably results

in most cases, especially when many gall-stones are

formed together, from the peculiar principles of the bile
being in an abnormal condition, and more than un-
usually insoluble. The second step is the formation of
crystals of cholesterine, which, like the former, results
from faulty assimilation, and which is frequently asso-
 CHARACTER OF GALL-STONES. 199

ciated with fatty degeneration of the coats of the gall-

bladder, if not indeed immediately dependent upon
it. It may, therefore, be set down as a rule that the
presence of a gall-stone is direct evidence of an un-
natural condition of the bile; and the question now
arises, what condition of life, or what other influences;,
tend to bring about those unhealthy conditions of the
bile on which the formation of gall-stones so clearly
depends ? There are some structural diseases of the
liver, where gall-stones are seldom or never found, namely,

the cirrhosis, or gin-drinker's liver, and those affected

with tropical abscess. The disease of the liver in
which gall-stones are most frequent is cancer and con-
sumption. Gall-stones are also frequently found in
conjunction with cancer of other organs of the body.
Characters of Gall-stones. —A solitary stone is bub
seldom found in the gall-bladder ; in most cases they
occur in large numbers, varying from 5 or 10 to 1,000,
or more. I once found in the gall-bladder of a young
man of twenty-two, who died of consumption, 31stones
ofmany forms, which, when put together formed a very
elegant pyramid these were exhibited at a meet-
little ;

ing of the B. H. S. some few years since.

Morgagni mentions a case where 3,000 stones were
found in the gall-bladder Hoffmann counted 3,646 in
;

another and Otto counted 7,802 stones which are pre-

;

served in his pathological museum in Berlin. Frerichs,

found in the gall-bladder of a woman aged sixty, who
died under his care at Breslau, 1,950 calculi. In size gall-
stones vary from a millet seed to a hen's egg, or even
larger ; in form they are primarily globular, but when
many congregate together they become altered in form.
 —

200 INFLUENCE OF AGE.

Dr. J. V. Shoemaker, in the Philadelphia Medical Times,

relates the particulars of a case of gall-stones in which
1,940 stones were found impacted in the gall-bladder
after death.
Age. —The tendency to the formation of gall-stones is
influenced considerably by age. In youth they appear
but seldom : Bouisson, however, found in the gall-
bladder of a newly-born infant three stones ; Cruveilheir
several in children during the first year of life ; Frerichs
in a girl of seven years, who died of waxy degeneration
of the liver, spleen and kidneys consequent on disease
of the hip joint. The tendency, however, to gall-stones
increases with the advance of life, for of 395 cases
collected by Hein, there were only fifteen persons under
twenty-five and three under twenty.
; Of ninety-one
cases collected by Walter, we have the following :

At 20 years of age there was 1 case

From 30 to 40 27 „
„ 40 to 50 14 „
„ 50 to 60 l!> .,

„ 60 to 70 8 „
„ 70 to 80 l:^ „
„ 80 ... 1 „
„ 90 ... » . • 1 „

The ages of the remaining 7 are not mentioned.

Sex. — It is calculated that women are more prone to
gall-stones than men. Budd andProut maintain that they
are as 4 or 5 to 1 this, to a great extent, has been con-
;

firmed by others. Out of 620 cases collected by Hein,

he ascertained that 377 were females and 243 were males,
making a difference of nearly 3 to 2. The greater
 ;

CAUSES OF GALL-STONES. 201

liability of women to gall-stones depends, perhaps not so

much on the constitution of the sex, as on their mode of
life which varies considerably in different countries.
Causes, —There and
are certain changes in the liver
biliary passages which, interfering with the normal
excretion of bile, may favour the development of gall-
stones. Under this head may be mentioned cancer of
the liver, or gall-bladder ; adhesions of the gall-bladder
to adjacent parts; repeated attacks of catarrh of the
mucus membrane of the gall-bladder ;
general torpidity
of the liver, with a deficiency in the peristaltic action
of the gall-bladder ; a sacculated condition of the gall-
bladder, whereby a portion of the bile is retained for an
indefinite period, when it becomes altered in character
and reduced to that consistency capable of acting as a
nucleus for the deposit of the cholesterine. The
sedentary habits of women in this country, and the
sedentary habits of many men, undoubtedly tend to
retard the normal excretion of bile. Hence Tissot
ranks gall-stones among the diseases of men of letters
Sommering among incarcerated prisoners ; the same
cause holds good in animals, as Glisson observed that
cows are more liable to from gall-stones when
suffer
tied up during the winter months than when at pasture
during the summer. For the same reason, they are
not unfrequently developed after protracted confine-
ment to bed from illness.

Diet. —A particular mode of living, which directly

alters the properties of the biliary fluid, exercises con-
siderable influence in developing gall-stones. Hence,
calculi are more frequently met with in persons of full
habit, who eat largely of animal food, rich dishes, and
202 DIATHESIS.

lead indolent lives, than those who lead an active life

and live sparingly.

Diathesis. — Differences of opinion exist as to
whether there is any peculiar idiosyncrasy of consti-
tution necessary for the development of gall-stones.
Frerichs says :
" No calculous diathesis, arising from
abnormal states of the metamorphosis of matter, such
as lead to the formation of urinary calculi, can be
discovered in the case of gall-stones. They are met
with in the most different constitutions, and are more
dependent upon local than upon general derangements."
Budd says, " there can be no doubt that a liability to
gall-stones often depends on peculiarity of consti-
tution, which, like the tendency to gout, or gravel,
may be inherited as well as acquired." At present little

is known of the characters, or of the other effects, of

this diathesis. It, however, most probably leads to
fatty degeneration of the coats of the gall-bladder, which
is so often associated with gall stones ; and, perhaps,
also to fatty degeneration of the arteries, so common
in advanced life. Prout noticed that a tendency to the
formation of gall-stones of cholesterine is frequently
alliedwith a tendency to lithic-acid deposits in the
urine and it is more than probable that, in London
;

and other large towns, the habit of drinking heavy

malt liquor, which frequently leads to lithic-acid
deposits, and
most inveterate forms of gout and
to the
rheumatism, in persons who inherit no disposition to
them, may also frequently lead to the formation of
gall-stones.
" Situation of Gall-stones, and their Patho-
logical Consequences." — Gall-stones are formed and
 SITUATION OF GALL-STONES. 203

found in any part of the liver where bile is secreted ;

they are consequently erratic in their movements, in

their endeavour, so to speak, to take their departure
from the body.
1. Gall-stones may form in the radicles of the
hepatic duct, in the interior of the liver ; they are here
very small and numerous, and constitute what has been
generally called " biliary gravel." Chopart met with a
case where the liver contained so many concretions,
that it could not be cut with a scalpel. These con-
crecions sometimes cause ulceration of the ducts : a
series of small abscesses, obliteration, and dilatation of
the bile-ducts.
2. Gall-stones may become arrested in the hepatic
duct. When this takes place, the immediate conse-
quence an obstruction to the flow of
is bile, extending
over the whole of the ducts within the liver, followed
by enlargement of the liver, jaundice, vomiting, colic
and other symptoms indicative of obstruction of the
common duct. Wolf records a case of this kind, which
gave rise to violent colic and rupture of the hepatic
duct, terminating in death.
3. Gall-stones are found most frequently, of a larger
size, and in greater numbers in the gall-bladder, than
in any other portion of the biliary passages. This organ
seems to be the central depot for the manufacture of
these concretions, from whence the various derangements
they give rise to usually proceed. Gall-stones may exist
in the bladder for a considerable length of time without
giving rise to any marked symptoms. I once found over
thirty stones (some of them as large as small marbles) in
the gall-bladder of a young man who died of consumption,
204 SITUATION OF GALL-STONES.

which gave him no inconvenience during While life.

stationary in the bladder they give rise to no marked

symptoms uuless they are so large and numerous as to
distend the viscus, when they give rise to a sense of
weight, uneasiness, tension, or a dragging pain in the
region of the gall-bladder, which extends through to the
right shoulder blade, and even to the right arm. The pain
is usually worse after meals, violent muscular exertion,
riding or driving over rough roads. Gall-stones, when
located in the some time, give rise
bladder for
to considerable irritation of the mucous membrane,
followed by ulceration which may terminate in perfo-
ration. Moreover diphtheritic exudations, purulent
fluid, hypertrophy, adhesions between the bladder and

pylorus, duodenum, colon and abdominal walls some-

times result from concretions in the gall-bladder.
When the gall-bladder is occupied by a solitary stone,
it is usually large, oval, and smooth, the mucous
membrane is likewise smooth, and not ulcerated.
4. become arrested in the neck of the
Gall-stones
cystic duct, and in the ductus communis choledochus.
When a stone passes from the gall-bladder into the neck
of the cystic duct, it usually gives rise to vomiting, and
colic, and as long as it does not advance beyond that spot,

there is no jaundice. Sometimes the stone will roll

back into the bladder, when all unpleasant and painful
symptoms disappear at other times it becomes firmly
;

fixed in the duct, where it sets up inflammation and

suppuration, followed by gangrene of the coats of the
gall-bladder, with an escape of bile into the abdominal
cavity.
6. GaU-stones may become arrested in the common

/
 PATHOLOGICAL CONSEQUENCES. 205

duct, this in fact is one of their most common situations.

The passage of a stone through the cystic duct gives rise
to vomiting and severe colic only but when it enters;

the common duct, we have jaundice when it passes ;

along the common duct the severity of the pain abates ;

"but returns again with great severity while passing

through the narrow opening into the duodenum, when
the pain immediately ceases, as if by enchantment.
ISTow and then the common duct is found to be the
number of calculi. Cruveilhier and
receptacle for a large
Morgagni record some cases where the gall-bladder was
dilated to the size of the stomachs, which were found
filled with calculi. Frerichs also has met with similar
cases.
There are various other channels through which gall-
stones may make their exit from the liver and its ap-
pendages ; they are, however, artificial, consequently re-
vulsive to nature's laws. To obtain this object, however,
fistular openings are manufactured by the stones, by a
process of irritation, inflammation, adhesion, ulceration
and finally perforation. By this mode gall-stones find
their way and duodenum, into the
into the stomach
transvers colon, into the peritoneum; and outwards
through the skin, into the abdominal cavity, into the
urinary passages, into the vagina, and into the portal
vein. The majority of gall-stones which pass into the
intestines through the ordinary channels make their
way along the small and large intestines and are expelled
with the fseces without creating any unpleasant symp-
toms ; but it sometimes happens that a stone becomes
firmly impacted in some portion of the small intestine :

when this accident occurs the intestine above the

 —

206 SYMPTOMATOLOGY.

obstruction is greatly distended, and below empty. There

is obstinate constipation and vomiting first of food, then
of bile, and afterwards of stercoraceous matter ; there is

pain and tenderness of the abdomen, and other promi-

nent symptoms of peritonitis, which continues till death,
or until the stone makes its exit into the large intestine.
—
Symptomatology. In considering the symptoms
arising from the presence of gall-stones in the liver, I
shall review them under the following heads :

1. Those which arise from the presence of concretions

in the substance of the liver, and in the radicles of the

hepatic duct.
2. Those which arise from the presence of stones in the
gall-bladder.
3. Those which arise from the presence of stones in
the cystic duct.
4. And those which arise from the presence of stones
in the —
common duct the ductus communis choledochus.
The symptoms appertaining to the first are as a
{a)

rule of an obscure and indefinite character the smallness

;

of the concretions, and the depth of the substance wherein

found, accounts for this obscurity in a great measure.
They consist of dull pains in the liver, which some-
times extend upwards to the shoulder-blade and down-
wards lumber region, and over the greater portion
to the
of the abdominal region ; there is more or, less stomach
derangement, easily aggravated by slight errors in diet,
which give rise to nausea, retching, and vomiting, with
pains in the right hypochondrium. At other times
severe attacks of rigors set in, followed by heat and
perspiration. These, in the absence of jaundice and
other hepatic symptoms have led many to view the
 ;

SYMPTOMATOLOGY. 207

case as one of intermittent fever ; indeed, the eminent

Frerichs himself frankly acknowledges having fallen
by treating a case of this kind for some
into this error
months with Quinine, whilst a '-'post-mortem" revealed
numerous calculi about the size of a bean lying in the
hepatic duct.
(b) IN'umerous calculi may be present in the gall-
bladder for a length of time without producing any
morbid derangements, particularly if the concretions be
small and smooth on the surface. If the concretions
are large and numerous, they tend to set up a catarrhal
or plastic inflammation, with pains of a dull or pinch-
ing character about the epigastrium, which extend to
the right shoulder, lumber region, and hip. The gall-
bladder becomes distended, is easily mapped out by
palpation, and, if the concretions are large, they may be
clearly recognised both by manipulation, the naked ear,
or the stethoscope, when a grating or rattling noise may
be distinctly heard. The appetite becomes impaired,
there is indigestion and constipation, but there is no
jaundice. These symptoms are not always present
there may be a total cessation of all signs, but they are
particularly apt to supervene after great exertion, riding,
driving over rough roads, and excesses in diet. They
however disappear to a very great extent under the
influence of rest in the recumbent posture.
(c) When stones of any size leave the gall-bladder
and enter the cystic duct, they cause a group of
well-marked and severe symptoms, known as Hepatic,
Biliary, Gallstone Colic.
or These symptoms
usually commence about two or three hours after
a meal, or about the time that the contents of the gall-
 ;

208 SYMPTOMATOLOGY.

bladder are poured into the duodenum, simultaneously

with the entrance of the chyle from the stomach, where
the second process of digestion takes place. It is more
than probable that many a small stone has at this
moment been carried by the rush of bile through the
cystic duct into the common
and from thence into
duct,
the duodenum, without causing any marked pain or
inconvenience. With larger stones the case is different,

for as soon as a calculus is forced into the cystic duct,

pains are complained of at the margin of the liver and
epigastrium, accompanied by nausea, retching, and
vomiting, with constipation and flatulence. These pains
are very severe —indeed excruciating —and have been
described to me — as, first, aching, then bruising, then
boring, then burning, then sharp piercing, ulcerating,
and tearing, with a pitiable expression that something
were being torn to shreds in the stomach. In irritable
persons there is great restlessness, cramps, and convul-
sions ; in the weakly, they become faint and delirious.
The severity and duration of the colic varies according
to the size, hardness and roughness of the concretions ;

itmay pass off in a few hours, or it may continue for

many days. In the latter case it comes off and on in
paroxysms, and is attended with rigors, heats, and sweats
this continues till the duct is sufficiently dilated to
allow of the passage of the stone. A calculus, after
entering the cystic duct, may return into the bladder ; it

may back like the small pebbles with the receding

roll

wave on the sea-shore at other times it becomes firmly

;

impacted, and hermetically seals the neck of the bladder,

which is often followed by serious mischief, jaundice,
and even death.
 — ;

ALLOPATHIC TREATMENT. 209

{d)The entrance of a calculus into the common duct

is marked by symptoms of a milder character than those
produced in the cystic duct. This is accounted for by
The pain however, is very
the larger size of the canal.
severe when the concretion reaches and passes through
the abdominal opening. If the common duct be long
occluded, jaundice appears ; if the obstruction continues,
or becomes permanent, jaundice increases, the liver en-
larges, the gall-bladder becomes distended, and sooner
or later death ensues, unless the stone passes into the
bowel, or forms for itself one of those fistular openings
I have already described, and makes its escape either
into the intestinal canal, or through the walls of the
abdominal cavity.

Treatment.

Allopathic. —For the relief of biliary colic, opium,

morphia, Indian hemp. Belladonna, and
chloroform,
ether, with copious draughts of hot water containing
bicarbonate of soda, haveby various authors been re-
commended as internal remedies. The external re-
medies consist of fomentations of poppy heads and
chamomile flowers linseed meal poultices
; opium and ;

Belladonna poultices; hot water, vapour, or hot air

baths opium and tobacco enemata the sucking of
; ;

ice, and bags of ice to the seat of pain. For the ex-
pulsion of the calculus from the alimentary canal,
castor oil, seidlitz powders, phosphate of soda and aloes,
colocynth and hyoscyamus, sulphate and phosphate of
soda, infusion of senna with calomel and scammony
such is the formidable armamentaria of allopathy.
P
210 HOMOEOPATHIC TREATMENT.

Homoeopathic. —In the treatment of gall-stones there

are two main points to be observed.
The first is to calm as far as able the excruciating
pain and spasm while the stone is forcing its way-
through the canal.
The second is to disperse the concretions still remain-
ing in the biliary passages, and to prevent as far as
possible the manufacture of fresh stones and their re-
accumulation in the liver.

The first object will be best attained by placing our

patient in a warm bath, where he should remain till he
borders on syncope ; the administration of Aconite 3x
every half-hour, and a hot compress, sprinkled over with
the Tincture of Aconite in the matrix form, should be
applied, and kept on over the seat of pain for some hours,
or until relief follows. Belladonna is another remedy
which covers many of the symptoms of biliary colic ; it

calms the spasmodic tension, the cramp-like constrictive

pain, and the griping, tearing pain, which mark its
most prominent symptoms, Nux Vom. is another
remedy which has afforded me valuable help in the
treatment of gall-stones. The venerable Hempel, in
describing the properties of this drug as a remedy in
biliary colic, says " a philosophical view of the nature
of the case will assist us in making up our minds as to
what will be an adequate dose in the case before us.
The irritation caused by the friction of the calculus
against the side of the duct induces spasmodic con-
strictions, which resist the passage of the concretion, and
render the irritation so much more excruciatingly painful.
It is this spasm that we have to relieve. How much
medicine does it take to accomplish this ? Any more
 HOMCEOPATHIC TREATMENT. 211

than is spasm in strangulated

required to relax the
hernia ? We relieve this spasm by means of the 3rd,
6th, or even higher potencies then why not spasm of
;

the gall-ducts ? Irrespective of the homoeopathicity of

NuxVom. to biliary colic, it corrects dyspeptic symptoms,
it cleanses the foul tongue, disperses flatulence, subdues
nausea, dispels vomiting, and acts as a potent aperient.
There should be no hesitation about the dose, no
coquetting with the 30th or 100th dilution, but it
should be administered in one, two, or even three drops
of the tincture, and repeated at short intervals. Dr.
Drury has recommended Calcarea Carbonica in the 30th
dilution as a gall-stone expeller ; I have tested that
preparation in two cases, and signally failed to produce
any effect whatever; the Lycopodium Clavatum, however,
came to the rescue, and gave me very valuable assist-
ance. It was delightful to watch the soothing influence
which the club-moss or wolf s-claw exercised over the
spasmodic paroxysms which affected my patients.
Lycopodium has been used with marked success in
spasmodic stricture of the urethra ; in the strangury of
children during dentition, and in the spasmodic stricture
of grown-up people, depending upon the presence of
gravel or pus in the urinary passages. It is the potent
effect which this drug exercises over spasm of the urinary
passages that first induced me to test it in spasmodic
stricture of the cystic and common biliary ducts. When
the calculus or calculi have been kicked out of the
common duct into the intestines, they should be compelled
without delay to move on ; this is effectually accomplished
by a dose of castor oil, or one or two seidlitz powders,
followed by a breakfast-cupful or two of warm tea.
212 REMEDIES.

After the removal of the calculi, the alleviation of pain,

and restoration of the functions of the stomach and
bowels, are best accomplished by Nux Vom. and China,
combined with plenty of out-door exercise, a bland but
gCDerous diet, and the use of the Friedrichshall, the
Seidschutz, or the Pulna waters, we must at the same
time proceed to grapple with the second object in view,
viz., to rid the system of the remaining concretions,
and prevent the manufacture of fresh ones.
Allopathic Treatment.— Eemedies for dissolving
gall-stones have in all ages been suggested and sought
after. Hoffmann believed he had discovered the
"specific" in the "fixed alkalies;" Bianchi and Van
Swieten condemned them as useless. Durandi extolled
the compound sulphuric ether and oil of turpentine;
Sommering, ether with the yolk of egg and Duparcque,
;

ether with castor oil. These remedies have in turn been

condemned by Thenard, FrerichSj, Murchison, and Tanner
as worthless. Trerichs thinks that a very alkaline
solution of BILE may and the
dissolve the cholesterine,
compound of cholepyrrhinand lime, which are the most
important constituents of gall-stones, and which may
lead to their mechanical destruction and pulverization.
—
HoMCEOPATHic TREATMENT. The materia medica of
homoeopathy contains many medicines which undoubt-
edly do act specifically on the secreting functions of the
liver, and which tend to prevent that tendency to the

manufacture of calculi we are so anxious to avoid.

Among these remedies maybe prominently mentioned the
Podophyllum Peltatum, Leptandra Virginica, Iris Ver-
sicolor, Euonymus Atropurpureus, Apocynum Androsse-
mifolium. Taraxacum, Mercurius Solubilis, Nux Vomica,
 ;

EXERCISE. 213

Acidum Mtricum, Acidum Hydrochloricum, both in-

ternally and externally, and compresses.

as baths
Professor Kutherford and M. Viqual, in the Jowncd

of Anatomy and Physiology, give the results of a

series of experiments made on the cholagogue action of
the Euonymns Atropurpurens, or Wahoo ; San-
guinarin, Iridin, Leptandrin ;
Ipecacuanha, Coloeynth,
and Jalap. The first four named drugs are rarely or
ever prescribed in this country amongst allopaths ; but
it may be observed that they all stimulate the liver
the first THREE powerfully; the last, however, only
feebly. The animals experimented upon were dogs.
Ipecacuanha powerfully stimulates the liver ; so does
Coloeynth ; so does Jalap.*
Much however, must be done by the patients them-
selves ; for it were futile to lay down a code of rules
unless faithfully carried out with unflinching and stoical
determination.
The indolent and high liver should take active exer-
cise, either in boating, tennis, or a daily ride on a rough
trotting cob, and moderate his sumptuous repasts; he
should dig in his garden, or imitate Gladstone, by
becoming a woodman and a feller of timber.
The wealthy merchant who daily drives in to his
City ofiice from his suburban retreat, or takes his seat
on the downy couch of a Pulman's drawing-room car>
and in the hurry-skurry anxiety of business, too often
neglects mid-day chop, not however, the City
his
banquets, where, with an empty stomach, and a jaded
brain, he partakes of all sorts of indigestible dishes and
adulterated wines, which derange the stomach, congests
* "Action of Drugs on the Biliary Secretion," Lancet, Feb. 10, 1876.
214 DIET.

the liver, paralyses its secreting and excreting functions,

and lays the foundation for biliary concretions, to —
such I would suggest a morning trot on the bay
cob round his domain. No Cambridge sausages, grilled
kidneys, Melton Mowbray porkpies, devilled turkey
and pates de foie gras, for breakfast but a basin ;

of fresh milk, oatmeal porridge, and well-made brown

bread, with a dash of lentil in it. And for a change,

a mutton chop, with claret diluted with soda, seltzer,

Vichy, or the ApoUinaris water. The hours for meals
should be as regular and as strictly observed as the
hours for business. At 12 a.m. he should partake of
a well grilled chop, rump steak, or the leg of a fowl with
a fair quantity of green vegetables —which cannot be too
green, — spinach, turnip tops, young nettle tops, cabbage

or Brussels sprouts, with a glass of burgundy, sauterne,

or somlau. All malt liquors should be avoided. The
dinner should be light, plain, and easy of digestion, with
farinaceous puddings and stewed fruit. To promote the
regular action of the liver and the uniform expulsion of
bile, he should take a dose of Podophyllum, or Leptandra,
two or three times a week a ; tumbler-full of cold water
night and morning, or the ApoUinaris or Vichy water. A
cold water compress should be applied over the hypochon-
driac and epigastric region, and renewed night and morn-
ing, for a week or ten days, or until there exists consider-
able irritation, or the appearance of a crop of pustules on
the surface of the skin. The bowels should be regulated
by Nux Vom., Podoph., or Lept., and the waters of
Carlsbad, Fried richshall, or Pullna, and the skin by a
morning sitz bath, and an occasional Turkish or vapour
bath. In addition great benefit will often be derived from
 DIET. 215

drinking the waters of Karlsbad, Ems, Marianbad, Vichy,

or Eger. In choosing these waters Karlsbad and Vichy
stand pre-eminent as the most efficacious. Ems is best
suited to irritable and debilitated persons suffering from
a tendency to diarrhoea ; Marianbad is best suited for
the plethoric with a tendency to congestion.
 216

MINEEAL WATEES.
Their special use in the different forms of diseases of
the Liver.

Mineral Waters have been used in medical practice

since the days when ^sculapius was worshipped
thronghout Ancient Greece.
It is recorded that in olden times the practice of
medicine was conducted in temples dedicated to that
purpose.
Fifty years after the destruction of the kingdom of
Priam, there was elevated at Titanus, a city of Pelopon-
nesus, the first temple in honour of ^sculapius. Very
soon the worship of this god was spread throughout
Greece, whence it passed into Asia, Africa, and Italy.
Among a multitude of temples which were consecrated
to him, those at Epidaurus, in the Peloponnesus, at
Pergamus, in Asia, on the island of Cos, now Cnidus,
and at Gyrene, a city of Lybia, are particularly remark-
able. In the temple of Epidaurus there was a statue of
colossal size, representing the god of medicine,
under the figure of an old man seated on a throne,
holding in one hand a sceptre, and resting the other on
the head of an enormous serpent a dog, an emblem of
;

vigilance, reposed at his feet. This statue, made of

gold and ivory, was the work of Trasymedus. Socrates,
in his last discourse with his friends, requested them to
offer a cock as a sacrifice for him to ^sculapius,
 MINERAL WATERS. 217

whence we infer that this bird was sacredgod to the

of medicine. The temples of the god of medicine —
—
grand and imposing edifices were generally very
salubriously situated, sometimes on the summit of a
hill, or the declivity of a mountain; sometimes skirting

the sea-shore, and sometimes near to thermal springs,

or a fountain of living water. Groves of trees refreshed
the sight of the sick, and afforded to them cool and
solitary retreats in their beautiful and spacious avenues.
The people came from all quarters on pilgrimages to
these sanatoriums, or temples of health, sacred to the
god of medicine. The sick and the convalescent found
there both agreeable and healthful diversions. The
wholesome regimen to which they were subjected, the
pure and temperate air they breathed, the faith and
hope by which some of them were animated, the mirac-
ulous cures that were testified to, as recorded on the
tablets which hung on the walls of the temples, all
united to affect their minds agreeably, and exercise a
happy influence on their constitution.
Beside these hygienic means, the disciples of ^scula-
pius (Asclepiadse, as they were called) prescribed
gymnastic exercise, walking, riding, sea bathing, and
"Mineral Waters," which were selected in accord-
ance to the nature and character of the disease. In
fact, the hydropathic establishments, the various spas

in France, Germany, England, and other parts of the

world at the present time are but small and very humble
representatives indeed of the grand and colossal
temples of ancient Eome and Greece, which were dedi-
cated to the god of health.
The mineral waters best suited for the various dis-
218 MINERAL WATERS.

eases of the liver may for convenieace, be arranged

under the following heads :—
1. Those which are best adapted for functional dis-
orders.
2. Those which are best adapted for chronic disorders,
organic diseases, and the deposit of foreign matter in
its substance.
For a torpid condition of the with a diminished
liver,

secretion of bile, a resort should be had to the saline

waters of Cheltenham, Leamington, or Llandrindod, in
England ; the Seidschutz, Pulna, or Friedrichshall on
the Continent.
For the secretion of morbid or altered bile, the waters
of the royal spa Cheltenham, Llandrindod, or Karlsbad.
For neuralgia of the liver, the waters of Bath or
Buxton.
For jaundice, the waters of Schwalbach, Pyrmont,
Karlsbad, Marienbad, Kissingen, Homburg, Vals,
Vichy, Ems, Cheltenham, or Llandrindod. All these
waters are saline, are very similar in their chemical
constituents, and when taken in proper quantities they
find their way through the walls of the portal vein, per-
meate the remotest parts of the liver, and give rise to an
abundant secretion of thin healthy bile. They are with
difficulty replaced by any other remedies, in those cases
of jaundice, which owe their origin to chronic congestion
of the liver, a torpid and inactive condition of the organ,
with obstinate catarrh of the bile ducts, and mucous
membrane of the stomach and duodenum, to gall-stones,
&c., Their selection however, must at all times be
determined by the nature of the cause of the complaint,
and by the temperament of each individual patient. It
 MINERAL WATERS. 219

should also be borne in mind that the continuous use

of these waters is prejudicial in the case of new
growths, as the different forms of cancer, cirrhosis, and
other profound degenerations of the gland.
Eor chronic atrophy of the liver (cirrhosis), the waters
of Cheltenham, Leamington, Llandrindod, Eger, Karls-
bad, Vichy, or Vals and when complicated with
;

syphilis, the waters of Kreuznach, Carlsbad, and Fried-

richshall.
For waxy liver, the waters of Woodhall, in Lincoln-
shire,and Purton, in Wiltshire, and Aix-la-Chapelle.
For fatty liver, the waters of Builth, Cheltenham,
Llandrindod and Leamington, and Carslbad, Marienbad,
Kissingen, Ems, and Vichy.
For hypertrophy of the liver and general obesity,
the waters of Builth, Llandrindod, or Pulna.
For gall-stones, after the calculi have passed and the
pain has been alleviated, the Bitter wassers of Fried-
richshall, Seidschutz, Pulna and Llandrindod.
For marked anoemia arising from prolonged organic
disease of the liver, the chalybeate waters of Tunbridge
Wells, Moffat, Spa, Pyrmont, and Schwalbach,
 220

GLOSSARIAL INDEX.

;A

Abdomen (from abdo, abdere, to hide), the belly.

Abscess (from abscedo, to escape), a cavity containing pus matter.
Albuminuria (from albumen, and oipsio, to void urine, an albuminous
condition of the urine.
Allopathy (from dXXoc, another, and TraObg, affection or suffering),
the removal of a diseased action by inducing an opposite action,
the so-called orthodox system of the present day.
Anaemia (from a, gr. priv., and aifia, blood), exsanguinity, or a state
of bloodlessness.
Antiseptic (from avri, against, and (jrjTTb), to putrefy), to prevent and
destroy putrefaction.
Abnormal (ab, from, and norma, a rule), irregular ; that which de-
viates from the usual order ; disease of any organ of the body
constitutes an abnormal condition of that structure.
Ascites (from d(TKdg, a sack), dropsy of the belly.
Atrophy (a, gr. priv, and Tpo(pTi, nourishment), wasting of the body,
emaciation.
Anatomy {avareixv<i),]to cut up), the science whose object is the examina-
tion of the organs or machinery of life.
Amyloid.
Auscultation (from ausculto, to listen).
Analogous (from ava, according to, and -yoyoQ, a word corresponding
with another ; analogous expressions.
Apoplexia (from d'7ro7TXr)Gxcj), lo strike down.

Cardialgia, heartburn, or spasm of the stomach.

Cachectic (from KaKog, bad, and e^ig, a habit), a depraved state of
the body.
Chyle, a milk-like fluid, absorbed by the lacteal vessels of the intes-
tines, which is carried into the circulation.
Chylo-poietic, a term applied to the viscera and vessels connected with
the formation of bile.
Cirrhosis, a granular and diminished size of the liver, the result of
spirit-drinking.
Constipation, a torpid and inactive state of the bowels.
 GLOSSAEIAL INDEX. 221

Clinical (kKivt)), a bed to recline ; in a general sense pertaining to a

bed ; short practical lectures at the bedside of a patient.
Convalescence (from convalesce), to grow strong or well.
Coryza (from Kapa, the head, and ^soj), to void. A
limpid, ropy,
mucous defluxion from the nostrils.
Catarrh (from Kara, down, psw, to flow), a cold and inordinate dis-
charge from a mucous membrane, as the nose, bronchi, &c.
Comatose (Kw/xa, a deep sleep), a drowsy, sleepy condition.
Chlorosis (from x^^P^Q> green), gi^een-sickness, peculiar to young
ladies, from prolonged suppression of the natural periods.
Conjunctiva, the mucous membrane which covers the eyeball and
lines the eyelids (from con, together, axidjungo, to join), the white
of the eye.
Coma (from KoJixa, drowsiness), lethargic sleep.
Carcinoma, hard cancer.

D
Deglutition (deglutio, to swallow), the act of swallowing or bolting
food.
Diabetes (from dia, through, (Baivu), to pass or flow), a term given to a
disease whose chief characteristic is an inordinate passage of
sugary urine.
Dropsy (from hydrops, water), an effusion of water into the cellular
tissue or, into some of the cavities of the body.
under the skin,
Digestion (from digero, to change), in Physiology, the change of the
food into chyme by the secretions from the mouth and stomach.
Dyspnoea (from Svg, difficult, and ttj/sw, to breathe), difliculty in
breathing, as from asthma.
Diagnosis (from yevwfTKw, to discern), the distinction of diseases, the
faculty of reading diseases.
Ductus communis choledochus, the common bile-duct leading from
the gall-bladder to the intestines.
Dysentery, inflammation and ulceration of the mucous membrane of
the colon, with loose bloody stools, peculiar to warm climates.
Dyspepsia, bad digestion.

E
Etiology (from airia, cause, and \oyog, a discourse), an account of the
causes of disease..
Empirical, versed in experiments.
Encephaloid cancer, cerebriform, or brain-like.
Epidemic, prevalent (from swl, among, and dfjixog, a people).
Enteralgia, nervous pain in the bowels, "tic."

F
Fungus hasmatodes, bleeding cancer. ^
222 GLOSSARIAL INDEX.

G
Gastralgia, pain or spasms of the stomach.

H
Hygiene (from vyiaivu), to be well), health, the preservation of health.
Hepatic (from hepar, the a term applied to any part belong-
liver),
ing to the liver.
History, matter of record.
Homoeopathy (from o^uo to f, like, and 7ra0oc, disease), like cured by like.
Hypertrophy (from vwep, over, Tpotprj, nourishment), an excess of nutri-
tion, as applied to organs or tissues.
Hysteralgia, pain situated in the womb.
Hepatalgia, pain situated in the liver (from rjirap, the liver, and aXvoQy
pain).
Hypochondriasis, lowness of spirits.

Icterus (from tKrrf|00f, the golden thrush), jaundice, a yellow condition

of the skin from the presence of bile in the blood.
Idiopathic (icftog, peculiar, and rraQoq, affection), primary disease, op-
posed to sympathetic, or symptomatic.
Icterus catarrhales.
Icterus neonatorum, infant jaundice.

Leucine, a peculiar substance found in the urine of those suffering from

cirrhosis.
Lardaceous, like the grease of swine.

M
Mastodynia, pains in the breast.
Malaria, literally bad air.
Medullary cancer, brain-like cancer.
Melanotic cancer, black cancer.
Metastasis (from ixtQurrrjiii, to transpose), the transportation of a
disease from one part of the body to another.

N
Nosology (from voaoQ, disease, and Xoyoc, a discourse), a description
and arrangement of diseases according to their classes, orders, or
genera.
 GLOSSAEIAL INDEX. 223

Neuralgia (fromvevpov, a nerve, and aXyog, pain), nerve-ache, or pain

in a nerve.
Normal, healthy condition.
Nephralgia, pain of the kidneys.

O
CEdema (from olSeto, to swell), a swelling from the effusion of the
serous fluid of the blood into the tissue beneath the skin.

Pannus hepaticus, liver spots, a jaundiced tint of skin, in spots or

patches.
Pathognomonic, a term applied to symptoms which are characteristic
of and peculiar to a disease.
Prophylactic (from rrpo, beforehand, and (pvkaaao), to guard, caution),
preservation of health or prevention of disease.
Pyaemia, blood-poisoning with pus.
Physiology, the science of the different functions of which life is the
manifestation, or the doctrine of vital phenomena.
Pathology, that part of medicine which explains the nature of diseases,
their causes and symptoms.
Peri-hepatitis, inflammation of the covering of the liver.
Paroxysm (from Trapo^vvu), to aggravate), an evident increase of
symptoms.
Phlebitis (from (p\s4>, a vein), inflammation of a vein.
Potency, the strength of a medicine.
Pathology, the science of investigating the nature of diseases.
Portal system, a subordinate course of venous circulation, of which the
liver is the head-quarters.
Pilules, small pills, composed of starch and sugar of milk, used as
vehicles for the administration of homoeopathic medicines.

Splenalgia, pain in the spleen.

Symptomatology, the doctrine of symptoms.
Synonymously.
Syphilis, a foul, malignant, and contagious disease.
Similia similibus curantur, like by likes are cured.

Therapeutics, that part of medicine which relates to the composition,

the application, and the modes of operation of the remedies for
disease.
224 GLOSSARIAL INDEX.

Typhus, a malignant fever.

Typhus icterodes, the yellow fever of the West Indies.
Type, to prefigure, to represent by a model.
Tyrosine, a peculiar principle found in cirrhotic urine.
Tic-douloureux, painful affection of the nerves of the face, without any
particular inflammatory action.
Triturations, medicinal preparations made by the process of rubbing or
pounding.

U
Uraemia, blood-poisoning with urea.

V
Vis medicatrix naturae, the healing or preserving power of nature.

W
Waxy liver, appertaining to wax.

X
Xantippe, the wife of Socrates, a brawling, turbulent woman.
 225

INDEX.
PAGE
Abscess pysemic 126
tropical ... ... ... ... ... ._ ^ 127
various sizes of ... ... ... ... ... ... i-^o
Abercrombie's, Dr. , views on liver j28
Acute atrophy of liver .. . ... ... ... ... ... ... y^
Age of persons suffering from gall-stones ... ... 200
Allopathy ... ... ... ... ... ... ... ,.. a

Amyloid liver ... ,., ... ... ... ... ... ._ j^^
Anatomy, history of ... ... ... ... ... ... ... t

morbid ...
'.
-y

Angular calcareous concretions ... ... ... ... .. ig8

Andral's views of acute atrophy of liver ... ... ... ... 100
Anato-pathology 105
Annesley's statistics of liver diseases ... ... ... ... 128
Arabian period of medicine ... ... ... ... ... ... ?

Ascites ... ... ... ... ... ... ... ... ... 120
Atrophy, chronic, of liver ... ... ... ... ... ... u^

Baillie, Dr 60
Bell, Dr., case of ... 120
Begin's mode of operating for abscess ... ... ... ... 140
Bernard, G., on physiology of liver ... ... ... ... ... 8
Bile, diminished secretion of . . . ... ... ... ... ... i
^
increased secretion of ... ... ... ... ... ... 18
morbid secretion of 22
Biliary ducts ... ... 6"/

acids in gall-stones ... ... ;.. ... ... ... 197

colic in gall-stones ... ... ... ... ... ... 207
pigments in gall-stones 197
Bilious fevers ... ... ... ... ... ... ... ... 90
Bianchi's views on chronic atrophy i.. ... 97
Q
 226 INDEX.

PAGE
Bleeding from the nose ... ... ... ... ... ... 1 20
bowels ... ... ... ... ... ... ... 120
stomach ... ... ... ... ... ... ... 120
Bouillaud, views on chronic atrophy ... ... ... ... 99
Bockhara, Avicenna, native of ... ... ... 24
Book on epidemics ... ... ... ... ... ... ... 33
Budd, views on gall-stones ... ... ... ... 200
jamidice ... ... ... ... ... ... ... 35
statistics ... ... ... ... ... ... ... 128
Bouisson, views on gall-stones ... ... ... ... ... 200
Causes of diseases of the liver, general ,
13
jaundice ... ... ... ... ... ... ... 47
of jaundice, special ... ... ... ... ... ... 50
— —— inflammation of the liver ... ... ... ... ... 71
acute atrophy ... ... ... ... ... ... ... 86
of enlarged liver ... ... ... ... ... ... 144
gall-stones ... ... ... ... ... ... ... 201
Cancer, distinguished from jaundice ... ... ^8
Calculi, a complication of jaundice ... ... ... ... ... 44
Carlsbad waters ... ... ..., ... ... ... ... 118
Catarrh of bile-ducts 44
Cheltenham waters 18
Chemistry of leucine ... ... ... 76
tyrosine 78
Chelidonium, action of 20
Chauveau's views on functions of liver 9
Chyme, use of ... 10
Chyle, use of 10
Climate, case of liver complaints 14
Clinical views on enlarged liver ... ... ... 143
Cirrhosis of liver ... ... ... ... 97
Clinical views of cirrhosis ... Ill
Chronic atrophy of Frerichs 113
Constitutional causes of liver complaints 13
Chlorosis distinguished from jaundice 36
Clinical history of neuralgia 25
Copland's definition of jaundice 36
Corrigan's treatment of cirrhosis, acute 91
Convulsions, treatment in cirrhosis, acute 95
Coma, treatment in cirrhosis, acute 95
 —

INDEX. 227
PAGE
Character of gall-stones ... ... ... ... ... ... 199
Chemical constituents of gall-stones ... ... ... ... ... 197
cholechlorine... ... ... ... ... ... ... 197
cholate of lime ... ... ... ... ... ... 197
cholepyrrhin... ... ... ... ... ... ... 197
cholepyrrhin and lime ... ... ... ... ... 197
cholesterine ... ... ... ... ... ... ... 197
Culver's root, properties of ... ... ... ... ... ...
93
Cullen's views of jaundice ...
55
Curari, medicinal properties of ... 54

Derangements of the liver ... ... ... ... ... ... 4

Definitions of jaundice ... ... 35
Budd 35
Copland ... ... ... ... ... ... ... 35
•— Murchison... ... ... ... ... ... ... 35
Definition of inflammation of liver ... ... ... ... ... 97
Diagonistic value of liver ... ... ... ... ... ... 10
— normal ... ... ... ... ... ... ... 10
abnormal ... ... .. ... ... ... ... 10
Digestion, influence of, on liver ... ... ... ... ... ii
Digestive derangements in jaundice ... ... ... ... ... 42
Diagnosis of jaundice ... ... 46
acute atrophy ... 90
Diffuse inflammation of liver (chronic form) ... ... ... 97
Diathesis of gall-stones... ... ... ... ... ... ... 202
Diet, cause of gall-stones 201
Diseases of liver, causes of ... ... ... ... ... ... 13
Diet, influence on 14
Delirium in jaundice ... ... ... ... ... ... ... 56
Diagnosis of tic -douloureux ... 29
Dreadnought Hospital ... 140
Dr. Mead on cause of jaundice 53
Dublin Hospital Reports 45
Duodenum, condition of, in jaundice ... 64
Ductus communis, experiments on ... ... ... ... ... 36
Duration of jaundice ... ... ... ... ... ... ... 44
Diminished secretion of bile ... ... ... ... ... ... 15
causes ... ... - ... ... ... ... ... 15
symptoms... ... ... ... ... ... ... 16
treatment ... ... ... ... ... ... ... 19
 1

228 INDEX.

PAGE
Erudite period of medicine ... ... 3
Excessive secretion of bile ... ... ... ... ... ... 65
Empirical medicine ... ... ... ... ... ... ... 85
Etiology of acute atrophy of the liver ... ... ... ... no

Fatty liver, pathology of ... ... ... ... ... ... ill
Five cases of "tic" of liver 30
French pathologists ... lOl
Frerichs views of the liver ... ... ... ... ... ... 1

gall-stones 200
test for tryosine ... ... ... ... 79
leucine ... ... ... ... ... ... 79
acute atrophy ... ... ... ... ... 82
statistics ... ... ... ... ... 86

Greek period of medicine ... ... ... ... ... ... 3

Galen's doctrine of medicine ... 5
Glisson's capsule ... ... ... ... ... ... ... 7
German epidemic of jaundice ... ... ... ... ... ... $6
Gall-bladder, diseases of, in jaundice ... ... ... ... 63
Glisson's capsule, thickening of, in jaundice ... 66
Gin-drinker's liver ... 70
Graves' views of acute atrophy of the liver 88
on hepatic abscess ... ... ... ... .. 140
gall-stones ... ... ... ... ... ... 140
Gall-stones ' 200
— age, influence of ... ... ... ... ... ... 200
Bouisson ... ... ... ... ... ... ... 200
.
Cruveilheir ... ... ... ... ... ... ... 200
Frerichs ... ... ... ... ... ... ... 200
.
Hein 200
Walter 200
biliary acids ... ... ... ... ... ... ... 197
biliary colic ... ... ... ... ... ... ... 207
pigments
biliary ... ... ... ... ... ... 197
Budd, authority, or influence of sex 1... 200
_ causes of gall-stones 201
characters of gall-stones 199
chemical constituents of gall-stones 197
cholesterine ... 197
 INDEX. 229
PAGE
Gall-stones, cholepyrrhin ... 197
cholepyrrhin and lime ... ... ... ... ... 197
cholechlorine ... ... ... ... ... ... 197
cholate of lime ... ... "... ... ... ...,198
diet, influence of .. . ... ... ... ... ... 201
diathesis ... ... ... ... ... ... ... 202
glycocholate of lime ... 197
their place of abode ... ... ... ... ... 202
liver, substance of ... ... ... ... ... 203
hepatic duct, radicles of . . . ... ... ... ... 203
common duct ... ... ... ... ... ... 203
bladder ... ... ... ... ... ... ... 203
cystic duct... ... ... ... ... ... ... 204
by stomach
pass out ... ... ... ... ... 205
duodenum ... ... ... ... ... ... 205
colon 205
skin ... ... ... ... ... ... ... 205
abdomen ... ... ... 205
urinary passages ... ... ... ... ... ... 205
vagina ... ... ... ... ... ... ... 205
portal vein ... ... ... ... 205
history of ... 196
Boerhaave... ... ... ... ... ... ... 196
Hoffmann ... ... ... 196
Morgagni ... ... ... ... ... ... ... 196
Sydenham... ... ... ... ... ... ... 196
inorganic metallic matters ... ... ... ... 1 98
ordinary, composed of ... ... ... ... ... 198
Pulman's car ... ... ... 213
sex, influence of ... ... ... ... ... ... 200
symptoms... ... ... ... ... ... ... 206
from concretions in substance of liver .. ... ... 206
bladder, stones in ... ... ... ... ... ... 206
cystic duct... ... ... ... ... ,„ ... 206
common duct ... ... ... ... ... ... 206
" stones ... ... ... ... ... ... ... 197
Granular induration of the liver ... 79
Griflin's treatment of acute atrophy of the liver ... ... ... 95
Gall-stones, number found by author ... ... ... ... 199
—— Frerichs ... ... ... ... ... 199
 . :

230 INDEX.

PAGE
Gall-stones, Hoffmann 199
Morgagni ... ... ... ... ... 199
globules ... ... ... ... ... ... ... 199
Treatment — Allopathic, opium, morphia, chloroform, Indian
hemp, belladonna, ether, hot water and soda fomentations, linseed
poultices, tobacco, ice, castor oil, seidlitz, phospate of soda,
aloes, colocynth, hyoscyamus, sulphate of soda, senna, calomel,
scammony, &c. For dissolving gall-stones, alkalies, sulphuric
ether and turpentine, ether and yolk of egg, ether and castor
oil, solution of bile ... ... ... ... ... ... ... 209
Homoeopathic —To relieve spasm, colic, and excruciating pain,
on passage of stone, Aeon., Bell., or Nux vom., hot compress,
saturated with Tr. Aeon, or Bell., Lycopodium valuable, Calc.
c. useless, to hasten departure of calculi from alimentary canal,
castor oil, seidlitz, and warm tea. To alleviate " after pains,"
and restore functions of stomach, Nux vom.. Chin., Friedrich-
shall, Seidchutz, or Pulna waters. To remove tendency to fresh
•
calculi, Podoph. p. , Lept. v. : Iris. v. : Ennoy. Atr. Apocy. :

And. : Tarax. : Merc, sol., Nux vom. : Acid n. Acid hyd. :

Acid hyd. and nit. : externally, as lotion and sponge baths, to take
active exercise, plain, non- stimulating food, void highly seasoned
dishes, light beverages, and saline waters 2io— 215
on size of the liver
Haller's, statistics ... ... ... ... 10
Henoch's views of acute wasting of the liver 84
Hepatitis diffusa chronica ... ... ... ... ... ... 97
History of hepatic abscess ... ... ... ... ... ... 130
jaundice ... ... ... ... ... ... ... 33
malignant ... ... ... ... ... ... ... 60
gall-stones ... ... ... ... ... ... ... 196
acute inflammation of the liver ... ... ... ... 68
chronic ... ... ... ... ... ... ... 73
liver ... ... ... ... ... ... ... ... 4
Homoeopathic medicines, &c. ... ... ... ... ... 3
treatment of acute wasting of liver ... ... ... 92
Hippocrates' views ... ... ... ... ... ... ... 98
Hygienic treatment of cirrhosis ... ... ... ... ... 118
Hypersemia of the liver ... ... ... ... ... ...iii
Hypertrophy of the liver ... ... ... ... ... ... 143
Homoeopathic treatment of hepatic abscess .. ... ... ... 130
 —

INDEX. 281
PAGE
Hein, views on gall-stones ... ... ... ... ... .•• 200

Introduction ... ... ... ... ... ... ... ... i

Increased secretion of bile .... 119

Icterus, synonym of jaundice 33
Icterusneonatorum ... ... ... ... ... ... •• 57
Inflammation of liver ... ... ... ... ... ... ... 68
peritoneal covering ... ... ... -•• --• ^o
substance of liver ... ... ... ... • • • 7^
abscess of liver ... ... ... 122

Jaundice, causes of ... ... ... ... ... ... ••• 44

definition ... 35
— diagnosis ... ... ... ... ... ••• 4^
— digestive complications ... ... ... • • • • • • 42
distinguishing characteristics from chlorosis ... •••37
— duration of ... ... ... ... ... .•• ••• 44
faeces, colour of .... ... ... ... ... • • • 43
history of ... ... ... ... ... ••• ••• 33
authorities ... ... ... ... ... ••• ••• 33
'

national names ... ... ... ... ••. ••• 33

—~ pulse, condition of . . . ... ... ... • • • • • • 42
symptoms ... ... ... ... ... •• ••• 40
synonyms ... ... ... ... ... ••• ••• 33
authorities ••• ••• 33
theory of ... ... ... ... ••• ••• ••• 35
treatment, according to causes •
. . -
47
—— to ward off attacks, alum, ly cop., Nux vom 48
Podoph., Sulphur, and sitz bath 49
•
varieties, special causes,and treatment ... 50
from catarrh of bile-ducts. Aeon, and Podoph 51
impactment of gall-stones, warm baths, friction, hot
compresses, and Bell., Calc. c., and Lycop 51
fright, Aeon., Cham., Ignas, Nux vom., Sulph... ... 52
from inhaling ether and chloroform 53
from bite of the viper, Cham Ignas, Nux vom., Lycopod. 53
from pyaemic infection of the blood 54
Ars., Lach., and Curari 54
from eruptive fevers 54
from congestion of liver, curari 54
232 INDEX.

PAGB
Jaundice, epidemic ... 56
— infantile ... ... ... ... ... ... ... 57
causes ... ... ... ... ... ... ... 57
treatment, Cham., Merc, sol., Digitalis 58
from pregnancy, Ignas, Nux vom.. Alum, Bryon., Sepia,
Svxlphur ... ... ... 58-59
malignant ...
59
anatomy of . . . ... ... ... ... ... ... 62
causes ... ... ... ... ... ... ... ...51
history ... ... ... ... ... ... ... 60
authorities ... ... ... ... ... ... ... 60
symptoms ... ... ... ... ... ... ... 61
pathology ... ... ... ... ... ... ... 62
body ... ... ... ... ... ... ... ... 62
skin ..'. ... ... ... ... ... ... .... 62
liver ... ... ... ... ... ... ... ... 6^
gall-bladder ... ... ... ... ... ... . ... 63
biliary ducts ... ... ... ... ... ... ... 63
duodenum ... ... ... ... ... ... ... 64
treatment ... ... ... ... 65
allopathic ... ... ... ... ... ... ... 65
empirical ... ... ... ... ... ... ... 6e
homoeopathic ... ... ... ... ... ... 65
hygienic ... ... ... ... ... ... ... 67
nationally ... ... ... 33
John B. Morgagni ... .,. 99

Kiernan ... ... ... ... ... ... ... ... ... 97
Kreuznach waters ... 219

Lacteals, discovered by A selli ... ... 5

Leamington waters ... ... ... ... ... ... ... 18
Leptandra, a liver medicine ,
95
Liver, abnormalities of 12
age, influence on ** 11
anatomy of... ... ... '" ... ... ... ... 6
Aselli, discoverer of lacteals ...
5
bile, nature's aperient 8
blood-vessels of ... 7
causes of various diseases of ... ... ... .., ... 13
 INDEX. 233
PAGE
Liver, climate, influence on ... ... ... ... ... ... 14
construction of ... ... ... ... ... ... loi
digestion, influence on... ... ... ... ... ... 11
diet 14
form of the ... ... ... ... ... ... ... 10
functional disorders of 15
bile,diminished secretion of 15
causes ... ... ... ... ... ... ... ... 15
— symptoms ... 16
treatment ... ... ... 16
Allopathy —mercury, salines, taraxacum : potass, soda, aloes,
aperients, emetics, blisters, nitromur. ac, plasters, iod. potass... 17
oxgall 17
—
Homoeopathy Podophyllum, Leptandra, Nuxvom., Merc, sol.,
Taraxacum nit., Mur. Ac, Turkish baths, sitz bath, horse
exercise, gymnastics, Seidchutz, Pulna, Leamington, and Llan-
drindod saline waters ... ... ... 17-18
-bile, excessive secretion of iS
symptoms ... ... ... ... 18
causes ... 18
treatment ... ... ... ... ... ... 19
Allopathy —bleeding, cupping, leeches : Nitr. soda : Ant. tart,

camphor, blue pill, grey powder, castor oil, purgatives, opium.

—
Homoeopathy Aconite: Aloes Argent. Nit. : : Chelidon. maj.,
Cham., Merc, sol., Ipec, Nux vom., Rhei 20—22
bile, morbid secretion of ... ... ... ... 22
causes ... ... ... ... ... ... ... 22
— symptoms ... ... ... ... ... ... 22
treatment ... ... ... ... ... ... 23
Allopathy — diluents, demulcents, warm baths, Ipecac, alkalies,
anodynes and aperients ... ... ... ... ... ... 23
Homoeopathy —Mer. sol., Ipecac, Arsen. ... ... ... 23
Liver, history of ... ... ... ... ... ... ... 4
Galen's views ... ... ... ... ... ... ... 4
Plato's 4
list of medicines ... ... ... ... ... ... 3
Linnaeus's view of ... ... ... ... ... ... 33
Liidenscheid, Dr., epidemic of jaundice ... ... ... 56
manufacturer of sugar. . . ... ... ... ... ... 9
normal size of ... ... ... ... ... ... 12
234 INDEX.

Liver, nerves of the ... ... ... ... ... ... ... 6
neuralgia of the ... ... ... ... ... ... 24
Plato's views ... ... ... ... ... ... ... 4
physiology of the ... ... ... ... ... ... 7
regimen ... ... ... ... ... ... ... 14
structure of the ... ... ... ... ... ... 6
temperament ... ... ... ... ... ... ... 13
type of mankind ... 14
weight of ... ... ... ... ... 10
relative weight of ... ... ... ... ... ... 10
secretion of bile ... ... ... ... 8
sugar ... ... ... ... ... ... ... ... 9
neuralgia of, see tic-douloureux 24
age ... ... ... ... ... ... ... ... 28
anatomy of ... ... ... ... ... ... ... 24
^^

anaesthesia ... ... ... ... ... ... ... 26

authors of ... ... ... ... ... ... ... 24
Avicenna ... ... ... ... ... ... ... 24
Andral 24
Bartholin 24
— Rolfink 24
Stokes -
24
chief viscera ... ... ... ... ... ... ... 24
diagnosis ... ... ... ... ... ... ... 29
character of pain ... ... ... ... ... ... 25
clinical remarks ... ... ... ... ... ... 25
•
freedom of early life ... ... ... ... ... ... 28
hypersesthesia of ... ... ... ... ... ... 26
hypersesthesia, manifestations of ... ... ... ... 27
law of isolated conduction ... 26
law of sympathy 26
law of eccentric phenomena ... ... ... ... 26
law of irradiation ... ... ... ... ... ... 26
law of sensation ... ... ... ... ... ... 26
nature of pain .:. ... ... ... ... ... ... 29
nosology of ... ... ... ... ••• ... .•• 28
•
physiology of ... ... ... ... ... ••. ••• 26
periodicity ... ... ... .•. .-. ... ••• 28
reflex action of nerve ... ... ... .•• ••• ••• 28
symptoms ... •
28
 INDEX. 235
PAGE
Liver, sex ... _
28
sensation of pain .., ... ._ __ ^^^ __ 2";
uniformity of pain 28
treatment — Aconite, Belladonna, Bryonia, Nux vom.,
Aconite, and Bell., externally
32
=
acute inflammation of ...

authorities 58
causes
71
different forms of
70
fibrous covering yo
cirrhosis
70
abscess
70
national names 68
symptoms 71
sjmonyms 68
treatment 72
allopathic ... ...
72
homoeopathic .. ... ... ... ... ... ... 72
Aeon., Bry., Bell., Nux v. ; from ulcer: Arg. nit., Merc.
cor. Merc. sol. ... ... ... ... ... ... ... 72
from cancer : Ars. Nux v., Bart, c, Phosph., Verat. a. ... 72
from pleurisy, Aeon., Bryon., Merc, sol., lod. potass.. Sulphur 72
inflammation of, terminating in tropical and pyemic abscess 72
Andral's views of ... ... ... ... ... ... 129
Annesley i^o
abscess, mode of exit ... ... ... ... ... ... i^r
size 136
allopathic treatment ... ... ... ... ... ... 137
Budd, cases ... ... 130
causes ... ... ... ... ... ... ... ... 126
definition ... ... ... ... ... ... ... ... 122
** Dreadnought," cases on board of ... ... ... ... 129
etiology 130
Frerichs, cases by ... ... ... ... ... ... j-jq
histoiy of remarkable cases ... ... ... ... ... j-^q
inflammation, forms of ... ... ... ... ... ... J22
convex surface ... ... ... ... ... ... ... 122
•
concave ... ... ... ... ... ... ... ... 122
internal structure ... ... ... ... ... ... 122
right lobe •
122
236 INDEX.

PAGE
Liver, left lobe 122
medical opinions of ... ... ... ... ... 127-8
Morehead's cases ... ... ... ... ... ... ... 129
•
pysemic abscess ... ... ... ... ... ... ... 125
diagnosis ... ... ... ... ... ... ... ... 125
statistics ... ... ... ... ... ... ... ... 128
symptoms of each form of inflammation ... ... ... 123
abscess ... ... ... ... ... ... ... 129 — 135
termination ... ... ... ... ... ... 134-5
— —
^
tropical abscess ... ... ... ... ... ... ... 122
causes of ... ... ... ... ... ... ... ... 125
symptoms ... ... ... ... ... ... ... 129
treatment ... .., ... ... ... ... ... ... 137
Allopathic —bleeding, blisters. Ant. tart., colomel, lod. potass
Colchicum ... ... ... ... ... ... ... 137
Dig. Sod., Sulph., Taraxacum : Aloes : Gentian : chloride
ammonium: Acid, tart, of potass., salines: opium: Bella-
donna morphia.
: Homoeopathic, acute stage — Aeon., Bryon,
Merc, sol., Aloes, Nux v., Colocynth, Hamamelis ... ... 137
for dysentery, Merc, cor., Aloes ... ... ... ... 139
exhaustion following abscess, Ars. Chin., Quina ... ... 139
abscess, to disperse, Ars., Bry., Hep. s., Lach., Sil. ... ... 139
to promote. Hep. S., Bell., Lach., Merc. Sil., ... ... 139
into lung. Aeon., Ars., Phos., Ac, Verat v. ... .. ... 139
gangrene of lung, Ars., Carbo. r., Chin., Sec, Cor., Tere-
bene, Mosh. ... ... ... ... ... ... ... 139
into abdominal cavity, compress., cataplasms, Ars., Merc.
Cor., Bell., Aeon., Verat v., surgery ... ... ... ... 140
acute wasting of (yellow atrophy) ... ... ...

anatomy of .. ... ... ... ... ... ... 82

allopathic treatment of ... ... ... ... ... ... 91
abnormal size of ... ... ... ... ... ... ... 82
age ... ... 86
Bright's views ... ... ... ,., ... ,.. ... 82
Budd's 82
Buhl's ... 84
bilious fevers ... ... ... ... ... ... ... 90
blood poisons ... ... ... ... ... ... ... 89
causes ... , 86
chemistry... ... ... ... ... ... ... ^.^^ 75
 INDEX. 237

Liver, characteristics ... ... ... ... ... ... ... 90

Corrigan ... ... ... ... ... ... ... ...* 91
dissipation ... ... ... ... ... ... ... 88
diagnosis ... ... ... ... ... ... 90
diseases similar to ... ... ... ... ... ... 90
etiology ... ... ... ... ... ... ... ... 85
Frerichs ... 82
female's ... ... 85
Harley 81
: Henoch ... ... ... ... ... ... ... ... 84
history :. ... 73
— — leucine chemistry
^

77
malaria ... ... ... ... ... ... ... ... 88
male's ... ... ... ... ... ... ... ... 85
red atrophy ... ... ... ... ... ... ... 113
synonyms ... ... ... ... ... ... ... ... 97
symptoms, first stage ... ... ... ... ... ... 102
second stage ... ... ... ... ... ... ... 104
syphilis, cause of . . . ... ... ... ... ... ...113
Tulph ...
99
treatment ... ... ... ... ... ... ... ... 1 14
allopathic — cupping, bleeding, leeches, blisters, purga-
tives hydragogues, &c. .. . ... ... ... ... ... 116
homoeopathic —Aeon., Bell., Bryon, Inflam. stage, Nux. vom.
Ignas., Pidsat., Podoph. , saline waters, second stage ... 117
Hygienic 118
complications ... ... ... ... ... ... ...

bleeding from nose. Aeon. Bell., Arnica, Ipec, Rhus,

Sabina ... ... ... ... ... ... ... ,.. 120
stomach, Aeon., Arnica, Ferr., Gallic ac. ... ... ... 120
cold drinks, ice, and to stomach ... ... ... ... 120
from bowels, Ham., Gallic, tannic acid, sulphur ... ... 120
Ascites and anasarca, Ars., China, Copaib., Digitalis and
Elaterium, Ferri, Annn., Cit. c, Strych. c, Dig 120
Gastric catarrh, China, Zinc, Ars. ... ... ... ...121
diet 121
wines ... ... ... ... ... ... ... ... 121
Murchison... ... ... ... ... ... ... ... 81
nature of ... ... ... ... ... ... ... ... 83
normal size of ... ... ... ... ... ... ... 82
238 INDEX.

PAGE
Liver, nervous excitement g5
.pregnancy gg
pathology go
physiology... ... ... ... ... ... ... ._ 77
pulse, condition of ... ... ... ... _^ _ yc
pyasmia ... ... ... ... ... ... ... _. qq
relative frequency
g5
rage g6
Rokitanski... g^
special poison ... ... ... ... ... ... ... go
symptoms ... ... ... ... ... ... ... ... 74
synonyms ... ... ... ... ... ... ... ... y-y

statistics ... .... ... ... ... ... ... ... g2

treatment ... ... ... or
yx
allopathic oi
homoeopathic 02
tyrosine ... ... ... ... ... ... ... ... yg
detected in various organs ...... ... ... ... gi
typhus 8g
complicated with jaundice ..... 00
Von Dusch. ... ... ... ... ... .._ .. g^^
yellow fever ... ... ...

Treatment—AllopathicEmetics, purgatives, leeches, blisters, senna.

Aloes, Colocynth, Bismuth, Nux vom., astringents 91
Homoeopathic— First stage. Iris, v., Lept., Podoph. 92-3
second stage—Aeon., Bell., Crotal, H., Merc, sol.,
Nux vom., Strychnine, Cham., Bry., Lach., Chin,,
Sulph.,
g^
for sleep, Coff., Bell. , Hyos., Aeon. , Gelsem. Glonoine
,
94
congestion of kindneys, Terebinthina 3X 96
inflammatory stage—Aeon. , Gels. , Bell. , Canth. , and
Cannabis S. ... 06
Haemorrhage from stomach — Terebinth., Ham ,

Ipec, Mill, and Ars 96

for vomiting, Ipec, Nux v., and Kreas., 96
to remove coma, Op., Bell., Hyos., Hell., Turkish
baths q5
convulsions, Crot., Lach., and Turkish bath ... 96
nervous depression — Camph., Mosch. 96
chronic inflammation of
96
anatomy of .. joi
 INDEX. 239
PAGE
Liver, Aretaeus ... ... ... ... ... ... ... ... 97
Bouillaud gg
causes ... ... ... ... ... ... ... ... 109
complications ... ... ... ... ... ... ... 108
diet 118
etiology 118
fatty Ill
gin 109
Hippocrates ... ... ... ... ... ... ... q8
history
97
homceopathic treatment ... ... ... ... ... 116
•'
hypersemia ... ... ... ... ... ... ...in
hypertrophic cirrhosis ... ... ... ... ... ... 108
inflammation, cause of . . . ... ... ... ... ...112
Morgagni 99
•
nomenclature ... ... ... ... ... ... ... loi
pathology — first stage... ... ... ... ... ... 103
second stage ... ... ... ... ... ... ... 105
pyle-phlebitic atrophy ... ... ... ... ... ... 112
peri-hepatic ... ... ... ... ... ... ... 112
Rokitanski, ... ... ... ... ... ... ... 100
Treatment— From Syphilis. lod., Pot., Iodine, Merc, Prot. lod. ... 147
Syr. Ferr. lod. Aix-la-Chapelle waters... ... ... ... 147
from tubercular deposit, Calc. c, Chin., lod.. Pot., Lycop.,
Phosph., Stannum... ... ... ... ... ... ... 147
from Intermittent fever. Chin., Quin., Ars. Carb. v., Sulph.,
Nit. Ac, Mur. Ac. 147
for constipation, Alum, Bryon. , Calc. c, Lycop., Nux v. ... 148
Opium, Sulph 148
—— for Diarrhoea or dysentery, Arg- Nit., Merc. Cor., Chin.
—
Ipec, Verat. Al. Tannic Acid Injections ... 148
for vomiting, Ars., Cupr. M., Nux v., Arg. Nit., Ipec. ... 148
for Albuminuria— Turkish baths. Acid. Nit., Acid. Mur. ... 149
Dropsy, Turkish baths, spirit lamp, Ars., Chin., Colch.,
Dig., Copaiba, Ferr. Ammo., Cit., Strych,, Dig. ... ... 149
for Uraemia, Turkish bath, Ars., Nux v., Canth., Podoph. ... 149
Fatty liver, anatomy ... ... ... ... ... ... ...150
causes ... ... ... ,.» ... ... ... 151
—— ^
symptoms ,, ... 152
 .

240 INDEX.

Fatty Liver, treatment...

'

enlargements of, hypertrophy ...

— amyloid
anatomy
authorities ...

Andral, views
Louis
•
Rokitanski
Boerhaave...
Budd
— causes
fatty
etiology
•
history of ...

lardaceous ...

•
nutmeg
painful
•
painless
statistics

waxy, anatomy of. .

diagnosis ... ... ... ...

duration
symptoms ...

causes
Treatment — if from Necrosis, Merc, Pro., lod. Ars., Assafset.
Phos. Ac, Sil., Hep. S., Sulphur
Liver, hydatids of the ...

•
anatomy of
minute ...

authorities
chemistry of fluid
death, causes of
diagnosis
•
duration of
direction they take
•
hydatids form in all parts of
•
vary in size

mode of communication
mode of termination ...

palpation
 INDEX. 241

PAGE
Fatty Liver, percussion 167
prevention 16/
prophylactic 16
remedies for killins: I7i
symptoms i6e
statistics ... ... ... ... ... ... 163
author's experience, ... ... ... ... ... 164
Treatment for killing, Calomel, Iodine, lod. potass., Salt ... 171
Ambra grisea, Ars., Calc. c, Merc, sol., Graph., Puis., Sabadilla,
Stannum, Sulphur 172
surgery ...
173
different modes of 173
mjections ... ... ... ... ... ... ,_ 173
caustics
174
cancer of 175
— anatomy of ... 176
— age, influence of 183
— ascites, 187
— allopathic treatment ... .. ... ... ... igi
— Aretsus ... ... ... ... ... ... ... 175
— Baillie ... ... ... ... ... ,,, ^_ 175
•
causes 184
carcinoma 179
coUoid 181
complications 186
constipation ... ... 186
characteristics 190
cystic 180
diagnosis ,, ... 190
diarrhoea 186
diseases, confounded with 191
dyspepsia 186
etiology 181
fungus hasmatodes 179
emaciation 186
encepbaloid 178
Galen... ... ... ... ... ... 176
history ... ... ... ... ... ... ... 17c
Hippocrates 176
jaimdice 187
R
 .. ,

242 INDEX.

PAGE
Fatty liver, appearance of . 189
melanotic ... . 180
medullary ... . 177
sex, influence of ... . 183
soot, influence of . . . 182
symptoms ... . 185
urine . 180
Van S wieten . 176
treatment ... ... - . 191
allopathic . 191
homoeopathic 193—95

Malaria, cause of acute atrophy ... S8

Medical Science, Dictionary of • 52
Medicines, list of • 3
Mercurius sol., liver medicine . 21
Mineral acids . 119
Minute structure of liver • 7
Morehead, views on the liver . . . 6q
statistics of tropical abscess . 129
Modes of termination of jaundice • 45
Morbus arcuatus • 33
Medicine, history of 2
anatomic period ... • 3
Arabic period
erudite period • 3
Greek period • 3
philosophic period) • 3
primitive period ... • 3
progress, continual, of ... • 4
refoian period ... ... • 3

Normal condition of liver . 12

Neuralgia of liver .
24
Neukomm, views on jaundice . 42
National names of inflammation of liver . 68
Nosology 2

Oppolzer, views of cirrhosis . ICX)

Frequet's discovery of thoracic duct .

. 5
 INDEX. 243

Physiology of the liver 7

Professor Staedeler, views on jaundice ... ... ... ... 42
Physiology of leucine ... ... ... ... ... ... 77
Pathology of acute atrophy of the liver ... ... ... ... go
•
cirrhosis
jaundice ... ... ... ... ... ... eg
acute inflammation of the liver ... ... ... 122
gall-stones ... ... ... ... ... ... 201
hypertrophy of the liver 143
- — — cancer
•
... ... ... ... ... ... ... 171-
amyloid liver ... ... ... ... ... ... ja^
waxy liver ... ... ... ... ... ... 144
hydatids ... ... ... .. ... ... jcg
echinococcus irg
Peri-hepatic atrophy ... ,,. ... ... ... ... ... 112
Preface ...
2
Pilules viii
Podophyllum, a liver medicine ... ... ... ... ...117
Potency of medicine ... ... ... ... ... ... ... ^
Pyaemia mistaken for acute atrophy go

Reform period ... ... ... .,. ... ... ... -?

Relative weight of liver in health and disease ... ... ... 10

Rhuem in diarrhoea of children ... ... ... ... ..-. 22
Radnorshire mineral waters ... ... ... ... ... ... 57
Rokitansky on acute atrophy of the liver ...
g4

Sex, influence of, on li^-er ... ... ... ... ... ... n
neuralgia of the liver ... ... ... ... ... ... 2g
Secretion of morbid bile ... ... ... ... ... ... ir
Saunders' experiments on the bile ... ... ... ... ... og
Size of the liver in health and disease ... ... ... ... 10
Staedeler's views of acute atrophy of the liver ... ... ... go
Symptoms of inflammation of the liver ... ... ... ... 71
acute atrophy of the liver ... ... ... ... 74
neuralgia of the liver ... ... ... ... ... 2g
jaundice 40
tropical abscess ... ... ... ... ... 129
Synonyms of chronic atrophy of the liver ... ... ... ... 07
acute atrophy of the liver ... ... ... ... 7^
 244 INDEX.

PAGE
Synonyms of inflammation of the liver ... ... ... ••• 68
jaundice... ... ... ... .r. ... ••• 33
Structure of the liver 9

Theory of jaundice ... ... ... ... ••• ••• ••• 35

Termination of jaundice, mode of ... ... ... .-• ••• 45
Treatment of jaundice ... ... ... ... ... ... ••• 47
acute atrophy of liver .. . ... ... -•• •• 9'
chronic atrophy of liver ... ... ... ... 97
inflammation of liver ... ^.. ... ... 68
hypertrophy of liver ... ... ... ... ••• '43
amyloid liver ... ... ... ... ... ... I43
•

waxy liver ... ... ... ... ... .•• 147

•
fatty liver ... I47
gall-stones 209
torpor of the liver 16
cancer of the liver 191
hydatids of the liver ... 167
— echinococcus of the liver 167
'
increased secretion of bile ... ... ... ... 16
secretion of morbid bile ... ... ... ... 16
Termination of acute inflammation of liver ... ... ... ... 124
Tic-douloureux of the liver ../ ... ... ... ... .•• 24
Tiedemann's experiments on the bile ... ... ... •.• 36
Tinctures, mode of administration ... ... ... ... .•• vii

Triturations, mode of administration .. . ... ... ... ... x

Tyrosine, chemical properties of ... ... •• 7^

Uniformity of symptoms ... " 28

Varieties of jaundice ... ... ... ••• ••• ••• ••• 4^

gall-stones 196

Walter, on gall-stones 200

Works by the author ... iv

Yellow atrophy of the liver ... 73

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By the late Dr. HAERIS EUDDOCK.
Corrected and Eevised by E. B. SHULDHAM, M.D., M.E.C.S., M.A. Oxon.

RECENT REVIEWS.
"In homcEopathic literature diet has hitherto been considered solely as among the causes of disease,
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mere list of ai-ticles of diet likely to be prejudicial to sick persons, or such as would blunt the
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to particular diseases, oreven as a means of cure in itself. This book supplies that want, and gives
us in a [handy form the essentials, as it professes, in these particulars. We cannot say that the
theoretical views are quite up to the day, for they savour too much of the chemical theories ot
physiology, but this is of little importance, as we think the, practical directions are extremely well
chosen, and, in the main, in accordance with the best authonties on the subject. In fact, this book
supplies what, as regards diet, we would be disposed to put into the third section ot the therapeutic
part (k the Hahnemaam Society's Repertory, if that much-wanted work ever comes to completion. We
cannot give it greater praise, and cordially recommend it in the mesintimey— The British Journal of
^om^op-aihy. ,. . ,
" 0ne last work from the pen of the late Dr. Ruddock, lately published under the editorial care of
©r. Shuldham, will not be found the least useful of the books prepared by that prolific author. It is
•entitled 'Essentials of Diet; or, Hints on Food in Health and Disease.' The subject has been
^treated somewhat abundantly of late years, and there is little excuse now for any well-read person
ito torment his stomach with food not suitable for it. The danger is, that a course ot this kind of
literature may lead one to torment his imagination with distorted pictures ot the frightful eflects of
almost any meal he may happen to take; and we are inclined to think that dyspepsia is almost as
closely dependent on the imagination as on the stomach. Dr. Ruddock's small treatise, hke all his
works, is simple and practical. It gives no elaborate chemical tables of analyses, nor does the author
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genous, carbonaceous, and mineral foods which they are to take in each twenty-four hours. Halt the
book is devoted to a consideration of the qualities of the various kinds of foods, and the rest is occupied
with chapters on the diet most desii-able in the various disorders resulting from dyspepsia, and under
special circumstances. A series of useful recipes is added, which tell how to prepare in the best way
any of the ordinary household forms of diet, suitable especially to the sick-voom." — Chemist and
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" Some serviceable hints ou the regulation of diet are followed by a tew pages pointing out the
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" Brief notes on the special properties of the many varieties of animal and vegetable food occupy
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some of the more prominent morbid conditions. The seventh and concluding chapter enters into
details respecting the best methods of preparing food. A large amount of really useful information
is contained in Dr. Ruddock's last contribution to popular medical hterature, and we feel sure that
our readers will find its perusal of service to them in the many dietetic difficulties which surround
efficient nursing. Dr. Shuldham has, as we can see, carefully revised the MSS., and done all that
could be done to i-ender the book pleasant and easy readrng." —Homceopathic Revieio.
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DOCTOE LOWE'S SACEIEICE;

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ment, it is nevertheless a most excellent story, most ingeniously worked out, and full of very amusing
and interesting \x\cidenis." —Southport News.

HOMCEOPATHIC PUBLISHING COMPANY, 2, Finsbury Circus, London, B.C.

And all Somoeopathic Chemists and Booksellers.
 — ,

HOMCEOPATHIC PUBLICATIONS.

NOW READY.
TENTH EDITION (130.000 CopiVs), price, lettered, good binding, toned paper,
with a CLINICAL DIRECTORY, price Is. 6d. ; ditto, elegant binding, gilt
edged, for Presents, Ss. 6d.; Cheap Edition, without Clinical Directory, etc., 1b.

TEE STEPPIIfG-STOM TO HOKEOPATHI

AND HEALTH.
Opinions of the Press on previous Editions.
"The present issue is both an enlargement of, and an improvement upon, its predecessor.
Its use is not intended to supersede the attendance of the properly qualified practitioner, but only
as a guide to the treatment of trifling but painful ailments, or the prevention of more dangerous ones
by prescribing precautionary treatment." - PiibUc Opinion.
" Contains all that is essential to a domestic work, in an easily accessible form, and in more
explicit and satisfactory language to the non-professional than many a larger and more pretentious
work.''— United States Medical and iSurgical Journal.
" He who has never opened the book before is able to find the remedy he wants.'.- —
Honiceopatliic Record.

Sixth Edition, 26th Thousand, thoroughly revised and improved, with new
Sections, toned paper, handsomely bound in patent morocco, bevelled boards
burnished edges, price 5s. Cheap edition, in cloth, 3s. 6d.
By E. H. RUDDOCK, M.D., L.R.C.P., M.R.C.S., L.M. (Lond. and Edin,), etc.

THE LADY'S MAIUAL

Of HonKBopatMc Treatment ia the various Derangements incident to her Sex.
" Written in clear language. .. . Women's diseases are here treated as clearly as the most
exacting student could require."— CAemisi and Dmggist.
" The work of Dr. Kuddock is precisely what every woman needs, and contains infor-
mation for the want of which she often sufters permanent loss of health. The whole range
of functions and diseases incident to women is treated with care and precision." New England
Medical Gazette.
" We do not hesitate to say that 'The Lady's Homoeopathic Manual is the best book of its kind we
'

ever examined. The author knows what to say, how to say it, and how to stop when it is said."—
United tUtates Medical and Surgical Journal.
" The Lady's Manual is a work which should be in the hands of every lady in the land. The
'
'

remedies pi escribed are mainly homoeopathic and hydropathic, and are extremely judicious. We
never examined a medical work which pleased us so well. — Westei'n Rural.
'

"The fact that this is the * Sixth Edition shows the estimate placed upon it by the public, and the
'

estimate is a just one, for the work is in every respect meritorious. As a book to be placed in the hands
of married women it stands unrivalled, and yet it is full of just such information as the general
P) actitioner should possess, and will here find easily and quickly. We have seen nothing of the
kind that pleases us so -vieW..''— Cincinnati Medical Advance.

7th Thousand, 12mo., pp. 228, 3s. 6d.

^
THE DISEASES OE IIEAITS AID CHILDEEI,
and their Homoeopatliic and (jeneral Treatment.
By E. H. RUDDOCK, M.D. L.R.C.P., M.R.C.S., L.M. (Lond. and Edin.), etc.
" A very valuable contribution to the pathology and therapy of the diseases of children. It contains
for physicians much interesting matter, and also not a little that is new."— Ailgemeine Homceop.
Zfituna. . .
' Admiiable hints on the general management of children, hygienic and medical prescriptions being
intended for preventive as well as fur curatiye treatment." -Piib/ic Opinion.
"The Doctor traverses the entire domain of therapeutics."— Z>ai/i' Review.
"It is a work worthy of commendation, for while written in plain language, so that" all may
understand its teachings, it preserves a sound pathology and diagnosis throughout, and its treatment,
which embraces the new remedies' as well as the old, is in accord witti the experience of most
'

practitioners, and is thoroughly safe.

" This volume is in keeping with the handsome style in which other volumes by the same prolific
author have been presented."— Ha/ineman7iian Monthlti.

HOMCEOPATHIC PUBLISHING COMPANY, 2, Finsbury Circus, London. E.G.

And all JEomoeopatliic Chemists and Booksellers.
 — — —— — —

HOMOEOPATHIC PUBLICATIONS.

Crown 8vo., handsomely bound in half-calf, pp. 840, price ISs.

THE VETBEIMUT VADE MECUM,

A Manual, on the Horse, Cow, Dog, and Sheep; their Diseases, Homoeopathic
Treatment and General Management.
Edited by K. P. G. LORD, M.R.C.7.S.L. ; also by J. RUSH and W. RUSH,
Veterinary Surgeons.

REVIEWS.
" There are so many valuable publications on this subject that it seems invidious
to
draw attention to one particular work, but we can safely say that the work under review is one
that every breeder and others having cattle will find of great service. Homoeopathy has
worked a radical change in the system of treatment of the human body, and in a like maimer
—
has a different method of treatment for the animal a system, we venture to s ty more in.
accord with our humanitarian ideas than the former one. Looking at the subject in an
economic point of view, we find homoeopathy claims advantages worth recording. Thus the
author, Mr. W. C
Lord, veterinary surgeon of the cavalry depot, Canterbury, "when stating
his reasons for preferring homoeopathy to the old system, says that the remedies act quicker
safer, and better in many ways, particularly in not reducing the strength of an animal after
drugging, as is frequently the case under the old system. In reference to colic or gripes, he
says :
—
The average time it takes to cure colic homoeopathically (as taken from sixty-four
'

consecutive cases in my ofiicial record of treatment) is 77 min., but some cases I have cured in
from 10 min. to 14 min. with ten drops of the appropriate remedy. The longest of my cases
under treatment was 65 hours, the shortest 5 minutes.' " Melbourne Weekly Times.
"Lucidly arranged and well treated, sufficient for the guidance of non-medical readers
and not overloaded with technical information we cordially recommend the book." British
;

Journal of Homoeopathy-
"Those who desire to treat the diseases of the horse, cow, dog, and sheep on homoeopathic
principles cannot have a better manual for their purposes than The Veterinary Vade Mecum '
'

and even those who are inclined to abide by the older fashioned and more generally practised
'
heroic treatment of diseases will find much valuable information in the work. The editors
'

are veterinary surgeons of large experience in the army as well as in country practice and
evidently know their business thoroughly." Irish Farmers' Gazette-
" The section devoted to the consideration of horse ailments appears to have been done with
much care. . . Taken as a whole, this book will be found useful alike in the stable, the
.

kennel, and the eow-shed.'" Homoeopathic Review.

" The authors know their business thoroughly. They treat the various diseases concisely,
but completely. We know of no book where we could turn so readily for an exact statement of
the symptoms in the several anmials which indicate the complaint and as far as hygienic ;

treatment is concerned we admit also the usefulness of this volume.'' Chemist and Druqgitt.
The law of similars, similia similibus curantur, having been found beneficial to mankind
"
is to be extended to the diseases of the lower animals. The dumb creation has suffered much
in times gone by at the hands of ignorant cow-leeches and farriers, and though the veteri-
'
'

nary surgeon is now no longer a brutal, ignorant practitioner, yet, at times, his treatment la
far too heroic. If homoeopathy can provide simpler but not less effective means of cure than
animals have hitherto been subjected to, we cordially wish it success in the experiment. The
present volume describes in a simple manner modern scientific methods of detecting disease
and observing symptoms, also the best modes of treating animals in sickness. Special attention
has been paid to the disorders of the horse, very full descriptions of their causes, pathology,
and symptoms being given, together with the remedies which extensive experience has proved
to be most applicable. The administration of remedies is based upon homoeopathic principles,
and is indicated not only by an acquaintance with those principles, but also by divei-sified ex-
perience in ihe use of the remedies. The instructions on feediing, and housing, and the best
course of treatment to aid in restoration to health, are very useful, and hence farmers and
others who keep animals may refer to the work with profit." Public Opinion.

HOM(EOPATHIG PUBLISHING COMPANY, 2, Finsbury Circus, London, E.G.

And all J3.omoeopathic Chemists and Booksellers.
 —

ITOMCEOPATHIC PUBLICATIONS.

New Series.— Enlarged and Improved.

THE A HOMCEOPATHIC WORLD:

Popular Journal of Medical, Social, and Sanitary Science.
Edited by E. B. SHULDHAM,
Trinity College, Dublin ; M.R.C.S., M.A. Oxon.
M.A.,
Elegantly Bound, Bevelled Edges, Gilt Lettered, price 7s. 6d., post free.
HOMCEOPATHIC WORLD VOLUME FOR 187 6.
Specially presentation Libraries, Reading
suitable for to Rooms, E tc.
Monthly Parts, 6d. by Post, 7d. or prepaid 6s. per annum, post free Monthly.
; ;

An idea of the Contents may be gathered from the Index in the December part. Each Volume
furnishes profitable reading, and will be found very usetul for reference.
The YEARLY VOLUMES from 1866 to 1874, inclusive, well bound in cloth, gilt lettered, price 5s.
each, post free.
Covers for binding for 1873 and 1874 and previous years, price Is. each. Covers for 1375 and 1876,
Is. 6d. each.
" A welcome addition to ordinary redding ." —Public Opinion.
" We can commend this Journal as the best our School ever published."— A^ew England
Medical Gazette.
" Fills a void in homoeopathic hterature. .
. The cheapest journal published. .
.

Filled with well-written articles."— Soe/'icA;e and Tafel's Quarterly Bulletin.

"Ranks much higher ithan any other popular homoeopathic journal.'' —.American fi'ojwajojsa/Atc
Observer.

MATERIA MEDICA AKD SPECIAL THERAPEUTICS

By
OF THE
Dr. E.
REMEDIES.
M. Hale.
MW
Fotirth Edition, revised and enlarged. In two Yols.,
half-bound, 55s.
From a personal interview with Dr. E. M. Hale, when on a visit to England, we learn [that the
fourth edition of bis New Remedies diliers from previous editions in this, namely :—
" Vol. I. contains the characteristic and [special symptoms of all the American remedies
mentioned in the first, second, and third editions, together with many other new drugs from the
mineral kingdom.
" Vol. II. is made up of matter nearly new, being mainly Dr. Hale's lectures on the Materia
Medica and Therapeutics of New Remedies, delivered before the class of Hahnemann Medical
College, Chicago, during the last four years. This volume gives, therefore, his latest and
ripest experience with those medicines which he was so instrumental in bringing before the
homoeopathic profession.— Homceopathic World, November, 1876.

Second Edition, enlarged, fcap. 8vo., price Is. 6d.

01 coiSDMPTioisr im tuberculosis
OE THE LUIGS.
Their Dignosis, Causes, Prevention, and General Treatment, embodying the
Modern Views on these Diseases, with cases treated by the Author.
" Treated fully and intelligently. We gladly wish Dr. Ruddock's work a wide circulation, and
we trust it may prove useful in enabling 'delicate' persons to ward off Consumption." Homoeo-
pathic Review.
"We admire the precision and clearness with which the Author unfolds the questions and matters
of which his book treats, and the depth of knowledge he displays within such naiTOw limits,
in order to place before the public the preventive and curative measures in cases in which
they are possible. This work may be consulted with advantage by the i&cxxlty."— El. Criteno
Medico.
" We are surprised at'the amount and clearness of the information given in so small a work
It should be on sale in every city ; and those who thoughtlessly place themselves in the wav
of this remorseless malady should take warning flrom its lucid pages.' —.^'eM; England
Medical Gazette.

HOMCEOPATHIC PUBLISHING COMPANY, 2, Finsbury Circus. London, EX.

And all Somoeopathic Chemists and Booksellers,
 —

HOMffiOPATHIC PUBLICATIONS.

HOMEOPATHIC MISSIONAEY TRACTATES.

Fifth Edition, much improved.
1. Fallacies and Claims.Being a word to the world on Homoeopathy.
" It is the clearest and most comprehensive little treatise we have in our litera-
ture." Dr. Sering.
Fourth Edition, revised and enlarged.
2. Ministers and Medicine. An Appeal to Christian Ministers on the
subject of Homoeopathy. By Rev. Thomas Sims, M.A. (late Eector
of St. Swithin's-upon-Kiagsgate, Winchester), Author of " Letters on
the Sacred Writings," &c.
3. Principles, Practice, and Progress of Homoeopathy. (Fourth
Edition.)
4. The
Practical Test of Homoeopathy; or, Cases of Cure by Homoeo-
pathic remedies, in the practice of various physicians. (Second Edition.)
5. Measles; its Complications and Fatality prevented by Homoeo-
pathy. Being contributions from more than twenty medical men.
(Second Edition.)
6. Homoeopathy Explained; a Word to the Medical Profession.
By Dr. John Wilde.
7. Constipation its origin and Homoeopathic Treatment, and the
;

use of Enemeta. By Dr. John Wilde.

8. Scarlet Fever being an attempt to point out how the ravages of this
;

very fatal disease may be limited. By Dr. John Maefey.

The above Tracts are published at One Penny each, or for enclosure in
letters, &c., post free, 25 copies for 15 stamps, 50 for 26 stamps, 100 for 48
stamps.
Catalogues of Homoeopathic Publications post free on Application.

A SYSTEM or SDE&ERT.
By WILLIAM TOD HELMUTH, M.D., Professor of Surgery in the New York
Homoeapathie Medical College. Illustrated with 571 Engravings on wood.
Price 40s. ; superior binding, 45s.
"
The author is no mere theoriser, but is well known as a bold, skilful, and successful surgeon
who has made a high mark amongst the best surgeons of thecounti-y; and into this book'
hs has put the experience he has gathered within the past twenty years. We are able to assert,
from a very careful examination of the work, that as a text-book of surgery, or as a work especially
adapted to the requirements of a homoeopathic practitioner, it has no superioi-."— i/^a/jne/waw/tjo/i
Motit/di/.
"Perhaps no surgeon's success has reflected more credit upon Homceopathy than that of
Prof. Helmuth. Nearly twenty years ago he had felt the want to which we have alluded, and
he had barely entered his profession before he made this a subject of special study, and
compiled a work on surgery of 650 pages, which was published in 1855. Eighteen yeai-s'have
added greatly alike to his experience, hia reputation, and his ability for such a task and now ;

we have this splendid volume of 1,228 pages from his pen, carefully illustrated in all essential
points. The advent of such a volume is indeed an epoch both in surgery and in oui- school.
He has collected, summarized, and condensed the experience of the homoeopathic school for
—
more than half a century from Hahnemann to the present time. In this he has left little to
be desired and has written what no homcEopathic physician can afford to be without." iWw
England Medical Gazette.

All British and American Homoeopathic Medical Books.

Price Lists on Application. Special terms to Shippers and large buyers.
For further particulars address THE HOMCEOPATHIC PUBLISHING COMPANY,
2, FlM-SBDBY CiCUS, LONDON, E.C.
 ADVERTISEMENTS.

PRIZE MEDAL,

PARIS MARITIME EXHIBITIONjyS,

INFANTS FROM INDIA.

The following letter has been receive el

ifrom a Colonel in the Madras Army :—

To Messrs. N'eave & Co.,

10, Claeence BtriLDisfGs, Wetmofth:.

^^^P'^ 29th Nov., 1875.

"Gentlemen,— Having proved the efficacy of your 'Farinaceous Food for Infants,'' Ifsubjoin
a case vphich may induce others to adopt it. An emaciated infant about twelve months old was
brought home from the East Indies ; when I first saw the child, I thought there was but very
little hope that the child would be spared to us, but, without consultmg any medical man, or
giving the child any medicine at all, I tried ' Neave's Farinaceous Food for Infants.' In an
incredibly short space of time the appearance of the child quite altered, she digested her food
perfectly {she had no other food.) In a fortnight or three weeks she got good firm fieshfon her
bones, and is now as healthy a baby as any would wish to see. I have only used it for about
two months, but I think it due to you to express my perfect satisfaction with the result of my
ti'ial of your manufacture.— I am. Gentlemen, yours faitMully. • * •
" Colonel, Madras Army.
"P.S.— You are at liberty to make any use you please of this testimonial, omitting my name.
I enclose my card for your own satisfaction."

The Committee of the House of Commons on Food.

Dr. Bai-tlett, who gave such valuable evidence before the above Committee, June 8, 1871, as to the
isuitableness of Corn Flour (or Starch) for Infants' Food, has written the following report of
unsuitab
NEAVE'S FOOD FOR INFANTS, viz..
•'
Laboratory, 7, South Square, W.C.
" Messrs. J^ R. Nf.ave & Co. "June 29th, 187J.
" Geptletnen,— My analysis of your 'Farinaceous Food' has proved very satisfactory ; it
contained :—
Moisture
Proteinaceous flesh-forming matters 147
Starch, gum, «Scc 75"5
Cellulose 3'5
Mineral salts contairing phosphates I'2
The flesh and bone-forming constituents are far above the average of the best Farinaceous Foods, and
the dryness shows the most careful preparation of the highest class of flours. Such a result must
cause your Food to be valued as sound substantive nutriment, upon which the gi-eatest dependence
'
'

may be placed. During and after dentition the quantity administered may be gi-adually increased in
infants' food, and invalids may rely upon it whenever a diet of this class is required.— (Signed) H.
C. BARTLETT, Ph.D., F.C.S."

J. R. NEAVE & Co., Manufacturers, FORDINGBRIDGE.

Orders received by the HOMCEOPATHIC FUBLISRING COMPANY, 2, Finshury
Circus, London, JE.C.
Agent for the United States:— Mr. J. O. NOXON, 444,
Fulton Street, BROOKLYN, NEW YORK.

&
^*^
COUNT WAY LIBRARY OF MEDICINE
•"^
RX
i^ 333
-^ :
M82

RARE BOOKS DEPARTMENT