COMPOUND PANCREATIC TABLETS. 
(FAIRCHILD.) 
Especially useful in Intestinal Indigestion. 
W.e have been led to offer this combination, which has 
been for some time employed with good results in extempora- 
neous prescriptions, because it seems to be a well-advised asso- 
ciation of remedies. 
The pure Extractum Pancreatis is here combined with 
Bismuth—highly valued as a,sedative in allaying the irritabil- 
ity of the alimentary tract frequently associated with dyspep- 
sia, and with Ipecac, which, in small doses, is the mo.-t admir- 
able stimulant of the digestive functions. 
Each tablet contains : 
Extractum Pancreatis, - - - gr. 2. 
Bismuth Subnitrate, Squibb’s, - gr. 2. 
Powd. Ipecac, gr. 1-10. 
One or two tablets for a dose, an hour or so after eating. 
FAIRCHILD BROS. & FOSTER, 
MAKERS OF ORIGINAL AND RELIABLE 
Preparations of Digestive Ferments, 
- AND 
FINE PHARMACEUTICAL PRODUCTS, 
82 & Si, PULTON STREET, 
NEW YOEE. THE MODERN TREATMENT 
OF 
Diseases of the Liver, 
PROF. DUJARDIN-BEAUMETZ, 
-BY- 
Member of the Academy of Medicine and of the Council of Hygiene 
and Salubrity of the Seine: Editor of the Bulletin General 
de Therafieutique, Paris, France. 
translated from the fifth french edition by 
E. P. HURD, M. D., 
Newhuryport, Mass. 
1888. 
GEORGE S. DAVIS. 
DETROIT, MICH. Copyrighted by 
GEORGE S. DAVIS, 
1888 AUTHOR’S PREFACE. 
Dr. Hurd, who in making known my works in the United 
States, has displayed a zeal and activity which I cannot too 
much praise, in this volume presents to the medical profession 
of the American Republic that part of the second volume of my 
Lecons de Clinique Therapeutique which pertains to the treat- 
ment of diseases of the liver. 
The hepatic diseases constitute an important chapter of 
internal pathology, and one which I have here endeavored 
succinctly to treat, epitomizing to my best ability the existing 
knowledge respecdng this subject. I am aware that I have 
not given to this chapter all the extension and development 
which it deserves, and this is my reason: Utility being my 
main object, I have taken up only those diseases of the hepatic 
gland which we observe in our country, leaving one side all 
that important group of liver diseases which are so prevalent 
in tropical countries, and which the reader will find described 
at great length in leading text-books devoted to this subject. 
I may venture to hope that physicians in the United 
States will accord to this volume the same welcome and the 
same indulgence which have been extended to my previous 
publications. 
In concluding, I have to thank Mr. George S. Davis for 
the pains which he has taken in the typographical execution of 
these little volumes (for with the present I include the two 
volumes of last year’s series on Diseases of the Heart), and I 
have especially to acknowledge my obligations to my friend 
and correspondent, Dr. Hurd, for the fidelity with which he 
has reproduced my lectures, preserving their original form, 
and making no more changes than the English idiom 
demands. 
August i, 1888. 
Dujardin- Beaumetz. TRANSLATOR’S PREFACE. 
The works of Dr. Dajardin-Beaumetz, which have now 
appeared in English are the following, given in the order of 
their publication ; 
x. Clinical Therapeutics (1885) (from the press of G. 
S. Davis, Detroit). An octavo of about 500 pages, compre- 
hending the treatment of Nervous Diseases, General Diseases 
and Fevers. This is Vol. 11l of the Lesons de Clinique Ther- 
apeutique. 
2. On Bacteria (1885). This treatise, of about 100 pages, 
was published as an appendix to “ Diseases of the Lungs of a 
Specific Character,” by Germain See, and issued by Wm. 
Wood & Co., as the November number of the Library Series 
for 1885. 
3. Diseases of the Stomach and Intestines. This 
work, which is the second part of Vol. I, of the the Lemons de 
Clinique The'rapeutique, is an octavo of about 400 pages, and 
constitutes the May number of Wood’s Library Series for 1886. 
4. New Medications. This is a volume of 320 pages, 
and is a part of Davis’ Leisure Library Series for 1886. 
5. Alimentary Hygiene. A treatise on the Dietetic 
Treatment of Disease. The various chapters of this work may 
be found in files of the Boston Medical and Surgical Journal, 
Medical News and Therapeutic Gazette (the latter principally) 
for the years 1886-1887. 
6. The Modern Treatment of Diseases of the Heart. 
7. The Modern Treatment of Diseases of the Aorta. 
These two volumes comprise the remainder of Vol. I of the 
Lemons de Clinique Therapeutique, and constitute Nos. 2 and 4 
of the Leisure Library Series for 1887. 8. Hygienic Therapeutics. This work, which treats of 
Massage, Exercise, Hydrotherapy, Aerotherapy and Climato- 
therapy, has been published in its entirety in the columns of 
the Therapeutic Gazette, 1887-1888. 
VIII 
From the above statement, it will be seen that all of the 
Lemons de Clinique Therapeutique, a work which has had no 
little popularity and success in France, has now been rendered 
into English, except Vol. 11, which is devoted to the treatment 
of Diseases of the Liver Kidneys and Lungs. 
The present volume comprises Diseases of the Liver, and 
the succeeding volume on Diseases of the Kidneys, will leave 
only about half of Vol. II of the Leqons untranslated. 
I hardly need to apologize for the omission of many 
pages of the bibliographical indications. Some abridgement 
was deemed necessary, and it seemed that these references, 
pertaining, for the most part, to works in foreign languages, 
might better be spared than any other part 
It is unnecessary that I should call attention to the practical 
character of this work, and the wealth of research which it em- 
bodies, or allude to the prominent position which Dujardin- 
Beaumetz now occupies in the estimation of his colleagues in 
the medical profession everywhere, as a leader in therapeutics. 
Translator. 
Newburyport, Mass., July Ist, 1888. TABLE OF CONTENTS. 
Page. 
Author’s Preface .... v 
Translator’s Preface vi 
CHAPTER I. 
The Liver from a Therapeutic Standpoint. 
Summary.—General Considerations on the Liver—An- 
atomy of the Liver—The Hepatic Lobule—The Inter- 
lobular Spaces—The Physiology of the Liver—The 
Liver as a Glycogenic Organ—The Liver as a Producer 
of Urea—Accumulation of Medicinal Substances— 
Destruction of Alkaloids by the Liver—Difference of 
Action of Medicines according as Introduced by the 
Mouth or the Skin—Accumulation of Doses—The 
Liver as the Organ of the Biliary Secretion Cholesterine 
—Bile Pigment—The Biliary Salts—Secretion of Bile 
—Action of the Nervous System on this Secretion.... I 
CHAPTER 11. 
Cholagogues. 
Summary;—Cholagogue Medicaments—Physiological Ex- 
periments on Cholagogues—Process of Rohrig—Pro- 
cess of Rutherford and Vignal—Cholagogue Purga- 
tives—Cholagogue Action of Calomel—New Chola- 
gogues of Vegetable Origin Euonymin Iridin— X 
Page. 
Baptisin—Hydrastin—Juglandin—Sanguinarin-Phyto- 
laccin—Choiagogues of Mineral Origin—On the Action 
of Alkalies as Choiagogues 22 
CHAPTER 111. 
Treatment of Biliary Lithiasis. 
Summary.—Anatomy and Physiology of the Bile Ducts 
—-Hepatic, Cystic, Choledic Ducts—The Gall Bladder 
—Structure of the Bile Ducts—The Muscular Layer— 
Biliary Calculi, Their Composition—Chemical Causes 
of the Production of Calculi—lndividual Causes—In- 
fluence of Sex, of Regimen, of Exercise, of Diatheses 
—Pathological Physiology of Hepatic Colic—Spasm 
of the Bile Ducts—Indications and Treatment of 
Biliary Lithiasis—Treatment of Hepatic Colic—Sub- 
cutaneous Injections of Morphine—Chloral and Chloro- 
form Adjuvant Means Lithontriptics Durande's 
Remedy—Action of Alkaline Mineral Waters—Chola- 
gogue Medication Hygienic Treatment of Biliary 
Lithiasis 46 
CHAPTER IV. 
Treatment of Jaundice. 
Summary.—Symptoms of Jaundice, Causes—Jaundice by 
Obstruction—Spasmodic Jaundice—Pathological Phy- 
siology of Jaundice by Obstruction—Treatment of 
Catarrhal Jaundice—Hygienic Treatment—Medical 
Treatment—Symptoms of Acholia—Jaundice without 
Obstruction Pathological Physiology of Jaundice XI 
without Obstruction—Therapeutic Indications—Grave 
Jaundice—Pathological Physiology of Grave Jaundice 
Page, 
—Therapeutic Indications 87 
CHAPTER V. 
Treatment of Engorgements of the Liver. 
Summary.—Engorgements of the Liver—Division of En- 
gorgements—Degenerations of the Liver—Amyloid 
Degeneration, its Treatment—Fatty Degeneration, its 
Treatment—Cancerous Degeneration, its Treatment 
—Engorgements by Circulatory Troubles—Congestion 
of the Liver—Causes of Hepatic Congestion—Active 
and Passive Congestion—Treatment of Congestion of 
the Liver 115 
CHAPTER VI. 
Treatment of Inflammations of the Liver. 
Summary.—The Inflammations of the Liver—Acute and 
Chronic Inflammations—Hepatitis of Warm Countries 
—Abscess of the Liver—Pathogeny—Therapeutic In- 
dications—Aspiration—Opening of the Abscess—Slow 
Processes—Rapid Processes—Accidents Consecutive 
to the Opening of Abscesses of the Liver—Chronic In- 
flammation of the Liver—Interstitial Hepatitis or Cir- 
rhosis—Its Nature—Its Frequency—Symptoms of Cir- 
rhosis— Treatment of Cirrhosis Paracentesis for 
Ascites in Cirrhosis—Indications and Contra-Indi- 
cations 139 XII 
CHAPTER VII. 
Page. 
Treatment of Hydatid Cysts of the Liver. 
Summary.—Taenia Echinoccus—Development of Hydatid 
Cysts—Prophylactic Treatment—Frequency of Hy- 
datid Cysts in Iceland—Diagnosis of Hydatid Cysts— 
Medical Treatment—lodide of Potassium—Electro- 
Puncture—Capillary Punctures—Aspiration—Results 
Given—Free Opening of the Sac—Methods of Begin, 
Recamierand Jobert—Resume of Treatment—Lavages 
of the Sac x6i CHAPTER I. 
THE LIVER FROM A THERAPEUTIC STANDPOINT, 
Summary.—General Considerations on the Liver—Anatomy of 
the Liver—The Hepatic Lobule—The Interlobular Spaces 
The Physiology of the Liver—The Liver as a Glycogenic 
Organ—The Liver as a Producer of Urea—Accumulation 
of Medicinal Substances—Destruction of Alkaloids by the 
Liver—Difference of Action of Medicines according as 
introduced by the Mouth or the Skin—Accumulation of 
Doses—The Liver as the Organ of the Biliary Secretion 
Cholesterine—Bile Pigment—The Biliary Salts—Secre- 
tion of Bile—Action of the Nervous System on this 
Secretion. 
Gentlemen:—I intend to devote the present 
course of lectures to the therapeutics of diseases of 
the liver and kidneys, diseases which are frequent 
and often demand active treatment. I will begin 
with the study of affections of the liver, but before 
entering upon the main part of my subject, I desire 
to set forth in this lecture certain general considera- 
tions on the liver from a therapeutic point of view. 
You know the importance which I place on an 
exact knowledge of the anatomy and physiology of 
the organ whose diseased condition claims your in- 
tervention; such knowledge is the indispensable 
basis of a rational and scientific treatment; I will 
therefore sum up briefly what we know respecting 
this organ. I shall be brief on the anatomy of the liver, as you 
are already familiar with this subject through the works 
of Kiernan, Hering, and especially of Prof. Charcot. 
You know the ordinary description of the hepatic 
lobule, which Kiernan has compared to an oak-leaf, 
whose petiole and mid rib represent the interlobular 
vein, while the lateral branches, formed by vessels 
and cellular tissue, constitute a frame work in which 
are lodged the hepatic cells discovered by Purkinje 
and Henle.* You also know the regular, almost 
geometric, disposition of the hepatic cells, and the con- 
stitution of these cells, which contain pigmentary 
granulations, and nuclei with roundish nucleoli. 
* The hepatic lobule is constituted by a group of cells 
around which are blood vessels, bile ducts, lymphatic lacunae, 
and connective tissue fibrillse. Grouped together, these cells 
form little five or six faced prismatic masses, whose base rests 
on branches of the hepatic vein (sub-lobular vein). In the 
centre of the lobule is seen a small vein (intra-lobular vein); 
each lobule is enveloped by a sheath from the capsule of Glis- 
son which supports the ramifications of the vena portae (inter- 
lobular veins), which, according to Hering’s comparison, unite 
in the interlobular spaces after the manner of a tree which 
plunges its roots into the interstices of a rocky soil; these veins 
are accompanied by arterioles from the hepatic artery, bile 
ducts and lymphatics. 
The hepatic cell has an average diameter of from i - 
19 /J. (Kolliker), (Henle and Kolliker); it has one or more nuclei 
of 9[l in diameter, which are provided with a nucleolus. Some 
of the cells have even as many as from three to five nuclei 
(Henle). The contents of the cells consist, Ist, of pigmentary 3 
The web which contains the cells is constituted 
by a connective tissue framework, which, when affected 
by hyperplasia, gives rise to true cirrhosis; then by 
blood vessels, lymphatics and bile ducts, forming a 
multiple capillary net-work surrounding each of the 
cells. 
I must call your attention to the interlobular 
spaces, upon which Kiernan has rightly placed so 
much stress, and which Sabourin, in his researches 
on the constitution of the hepatic gland, has consid- 
ered as the biliary lobule.* 
These spaces are, in fact, the seat and starting 
point of abscesses, of tubercles, of syphilomata and of 
lymphomata of the liver. Alcoholic cirrhosis, a dis- 
ease which you see so frequently in our wards, and to 
granulations; 2d, of granules with pale borders, which have 
not the reaction of fat and which mostly fill the cell; 3d, gran- 
ules with dark borders, shiny, giving with ether and osmic acid 
the reaction of fat. Charcot, to whom we are indebted for 
these notions respecting the cell, remarks that these fat gran- 
ules are to a certain extent found in the animal and in man in 
a multitude of physicial conditions, such as lactation and di- 
gestion. 
* The interlobular spaces are formed by the polygonal 
space which several lobules leave between them; they contain 
branches of the portal vein and hepatic artery, bile ducts, and 
lymphatics; all send ramifications between the neighboring 
lobules, and all the elements are surrounded by Glisson’s cap- 
sule. This is according to Kiernan’s description. 
Sabourin has since modified slightly the anatomical and. which 1 shall return when the subject of its treatment 
comes up, has for origin these same spaces, being due 
to a perivascular inflammation affecting the ramifica- 
tions of the vena portse, as has been well shown by the 
researches of Solowief and Charcot. 
4 
If the anatomy of the liver has made manifest 
progress the past few years, and seems to-day almost 
complete, it is necessary to bear in mind that the 
knowledge of the physiology of this organ has not 
kept pace with that of the anatomy, and there are still 
certain functions of the liver concerning which physi- 
ologists are not completely agreed. 
Nothing, perhaps, in the history of medicine is 
more interesting than a general survey of the en- 
deavors which have been made to find out the func- 
tions of the liver. 
For centuries the world accepted with unques- 
tioning faith the doctrine of Galen, who taught that 
the hepatic gland was the centre of animal heat and 
the organ which presided over sanguification. Then 
came the discovery of the bile in the 17th century, and 
so to speak, classical conception of the liver. He considers 
the hepatic gland as constituted by tubular elements. He 
takes, as the centre of the biliary lobule, the portal interspace, 
into which abut the pyramidal segments formed by the hepatic 
lobules just as they have been heretofore described. This ag- 
gregate constitutes a glandular territory, perfectly limited, to 
which he gives the name of biliary lobule. (Sabourin, Soc. de 
Biol., 17 December, 1881). 5 
all the old doctrines were lost sight of, and the liver was 
reduced to the simple office of an emunctory, designed 
to separate from the economy an excrementitious 
liquid, the bile. But modern experimental physiology 
was destined to restore to the organ the high functions 
which were assigned to it by Galen and his school. 
In fact, it is, as you know, in the liver, in the hepatic 
cell itself, that Claude Bernard places the glycogenic 
function. The same organ also, according to Mur- 
chison, Brouardel, and Charcot, is the seat of that 
physiological process which is the most manifest 
expression of the combustions of the economy, 
namely, the production of urea. Lastly, a great num- 
ber of physiologists are of accord in affirming the 
haematopoietic functions of this gland. 
As you see, the liver has regained in our day its 
former high importance. 
From a therapeutic point of view, the study of 
the functions of the liver is, it must be admitted, 
much more limited ; we have really observed only the 
action of certain substances on the biliary secretion, 
and are ignorant of the action of medicaments on the 
liver as a glycogenic organ. 
As for the liver considered as a producer of urea, 
physiologists are far from being fully agreed. To the 
labors of Murchison and of Brouardel have been op- 
posed other experiments and other researches, and in 
particular those of De Sinety and Martin, which go to 
show that perhaps too much has been affirmed as to the relation of the liver to urea-formation, and that 
this excrementitious principle has not for its exclusive 
seat of production the hepatic gland, but that it is 
formed in all the glands and all the tissues of the 
economy. 
6 
De Sinety has observed that in frogs, which survive for 
some time the total ablation of the liver, the urine continues to 
contain urea. 
This doctrine of the formation of urea in the liver is one 
of the most contested in physiology; two orders of proofs have 
been alleged in substantiation, physiological and pathological. 
(a),' Meissner, Kuhn, Lehmann, have shown that while 
the muscles contain no urea, the liver contains notable quanti- 
ties. 
Cyon has shown, moreover, that in too cubic centimeters 
of blood which has not yet passed through the liver, there 
exists 0.09 of urea, while there is present 0.14 of urea in the 
same blood after haviug traversed that organ. 
Gathgens and Hensius have maintained that albumin- 
ous matters in the liver break up into glycogen and urea. 
(b). From a pathological point of view, Murchison, 
Charcot, Brouardel have seen that in diseases of the liver, 
which destroy more or less completely this organ, the quantity 
of urea notably diminishes. Hence Brouardel has concluded 
that the quantity of urea formed and eliminated in the 24 hours 
is dependent on two principal influences: 
1. The state of integrity or alteration of the hepatic cells; 
2. The greater or less activity of the hepatic circulation. 
Murchison has gone even farther, and maintained that 
the liver even fabricates uric acid. But to these facts have 
been objected other experiments and other analyses, and in 
particular those of De Sinety and Martin before alluded to, 
which tend to invalidate this teaching. Physiologists have 7 
laid stress upon the preponderant role of alimentation, as the 
quantity of urea varies according to the food ingested; and the 
more probable view would seem to be that urea is not formed 
exclusively in the liver, but throughout the entire organism. 
But there is one point in this study which ought 
to detain us longer: I allude to the passage of medi- 
cinal substances through the liver after having been 
introduced by the digestive tube, and their more or 
less prolonged sojourn in this gland. This is one of 
the most interesting subjects connected with the 
physiology of the liver, and you will see that by virtue 
of the experiments of Lussana, Heger, Schiff and 
Jacques, we may derive therefrom fruitful therapeutic 
results. 
You are aware that for a long time physiologists 
have known the possibility of the accumulation of cer- 
tain toxic substances in the liver, and it is a rule in 
legal medicine in cases of poisoning to analyze the 
liver, in order to find there traces of arsenic, copper, 
lead and other substances which have been suspected 
of determining symptoms of poisoning. 
Paganuzzi, of Padua, was the first to show the 
difference which exists in the mode of elimination 
when certain salts of iron are introduced by the veins 
of the general circulation, and when they are intro- 
duced by the mesenteric veins; in the first case the 
salt is eliminated by the kidneys, in the second by the 
bile.* 
* Annuschat has made some interesting experiments on 
the elimination of lead by the bile in lead poisoning. He has 8 
Lussana, basing himself on some previous experi- 
ments of Schiff, since verified by Rosenkranz, re- 
searches which have shown that the bile secreted in 
the intestine returns to the liver to be eliminated anew, 
verified the experiment of Paganuzzi, and affirmed as 
the result thereof that the reconstituent and haemato- 
poietic effects of ferruginous preparations are due to 
the intimate action on the hepatic cells of the salts of 
iron, which, when introduced by the digestive tube into 
the liver, are then eliminated by the bile and pass back 
again into the liver by the entero-hepatic circulation 
described by Schiff. 
In 1873, Hegar, of Brussels, applying to the elu- 
cidation of this question Ludwig’s ingenious method 
of artificial circulations effected in isolated organs, 
discovered that when blood containing a large dose of 
nicotine is made to pass through the hepatic gland, 
this alkaloid disappears completely in the liver, so that 
you no longer find any trace of it in the hepatic veins. 
In 1877, Schiff discovered that not only does 
nicotine in passing through the liver lose its toxic pro- 
perties, but that other alkaloids are almost as com- 
pletely destroyed by this gland, and he mentions 
among the latter hyoscyamin. 
Lastly, in 1880, Victor Jacques, a Belgian physi- 
cian, completed these researches by showing that a 
shown that in animals the greater the ingestion of lead the 
more abundant its elimination by the bile, and that the lead in 
he intestine comes in large part from the biliary secretion. 9 
certain number of alkaloids introduced by the diges- 
tive passage sojourn a while in the liver, and that 
some are in part destroyed in the hepatic gland, and 
that others may be eliminated after a limited time, 
whether by the bile or lymphatics. 
What is the intimate action of these substances 
on the hepatic cell ? Are more or less stable com- 
binations formed with these alkaloids, which either 
destroy the properties of the latter, or which, being 
slowly dissociated by an excess of albumen, are 
thereupon eliminated anew? We do not know, but it 
is none the less certain that these researches enable 
us to explain facts heretofore very obscure. 
Among these facts is the marked difference which 
exists between the effects of medicaments, and in par- 
ticular of alkaloids, when introduced by the mouth 
and when administered by the hypodermic method. 
The prompt and energetic action of subcutaneous in- 
jections finds an easy explanation. The medicine 
passes immediately into the general circulation, and 
brings its therapeutic or toxic action to bear upon 
different parts of the economy. When introduced by 
the mouth, however, the alkaloid passes into the liver, 
and there it is in part destroyed or tardily eliminated 
by the hepatic gland, hence we see the superior ad- 
vantage of hypodermic injections, which render every 
day such marked service; and we can never be too 
grateful to Wood, of England, and to my very regretted 
Master, Behier, for having introduced and popularized 
this method. This complete destruction or tardy elimination of 
alkaloids by the hepatic gland gives ns a physiologi- 
cal explanation of two other orders of facts: (i) the 
innocuousness of certain poisons introduced by the 
mouth, such as curare, of which Claude Bernard has 
shown the absolute inefficacy when absorbed by the 
alimentary canal, and (2) phenomenon so frequent- 
ly observed when certain alkaloids are given by 
the mouth, and in particular the alkaloids of the 
solanacege—l refer to the tardy effect of these alka- 
loids, and what Gubler has described under the 
name of “accumulation of doses.” 
You are acquainted with all these facts; you know 
that when we give atropine or duboisin in very minute 
doses, and for several days in succession, we are in 
danger of seeing symptoms of poisoning set in, 
although the daily dose remains the same. To-day, 
by virtue of the experiments which I have just men- 
tioned, we have a clear and scientific explanation of 
these facts. The alkaloid is absorbed by the digestive 
tube and fixes itself in the liver. Then, at a variable 
time, it is eliminated into the intestine with the bile, 
or passes into the circulation with the lymphatics, and 
its presence goes to augment the portion which is 
absorbed into the general circulation of the daily 
doses which you have administered. 
Permit me to add a word: I have just told you 
that medicaments introduced under the skin and pass- 
ing directly into the general circulation are eliminated by the kidneys. I shall show you, as we go on, that 
if this elimination is wanting, the therapeutic effects 
of the alkaloid cease, and give place to toxic symp- 
toms. 
It would be important to study, as opportunity 
may occur, the influence of diseases of the liver, and 
in particular of those which completely destroy the 
hepatic cell such as cirrhosis, on the action of alka- 
loids introduced by the mouth. Here there is an im- 
portant series of researches to be made, to which I 
invite your attention. 
But this action of the hepatic gland does not per- 
tain exclusively to the vegetable alkaloids, but also, 
and equally, to the toxic alkaloids which we have seen 
to be incessantly produced in the economy. 
In my work on Diseases of the Stomach and In- 
testines, I showed you the important part which these 
ptomaines or leucomaines play in the economy, and I 
dwelt on their, elimination by the different emunc- 
tories. 
The liver has an important function in the elim- 
ination and destruction of these toxic products. 
Hence, when its parenchyma is altered, you can under- 
stand how these toxic substances may accumulate in 
the blood and produce their deleterious effects, effects 
which play a preponderant role in the symptoms 
which accompany destruction of the hepatic gland. 
This discovery of the morbid poisons which the 
economy produces during life, and the important part  12 
which the liver plays in such cases, justifies somewhat 
the view set forth by Lautenbach* several years ago. 
The liver is the organ that secretes the bile, and 
from this point of view it possesses for us a great 
therapeutic interest, for there are numerous substances 
which modify the biliary secretion; these are called 
cholagogues. But before setting forth the physio- 
logical experiments which demonstrate this action, I 
shall make a few remarks concerning the bile and its 
secretion in the normal state. 
Considered in the most general manner, bile is 
constituted of three elements, cholesterine, bile pig- 
ment, biliary acids and salts, f 
Cholesterine, which the researches of Berthelot 
* Lautenbach basing himself on the experiments of Schiff, 
maintained that the liver not only destroys poisons intro- 
duced into the economy but that the organism in the physio- 
logical stage produces a poison which is destroyed by the liver 
as fast as it is generated. (Phil’a Med. Times, May 20, 1887.) 
f According to Charles Robin the composition of the bile 
is as follows: 
Water, 915.90—819.90 
Chloride of Sodium, 2.77 to 3.50 
Phosphate of Lime, i.ooto 2.50 
“ “ Potassium, 0.75 to 1.50 
“ Lime, 0.50 to 1.35 
“ “ Magnesia, 0.45 to 0.80 
Salts of Iron, 0.15 to 0.30 
“ Magnesia, traces to 0.12 
Silica, 0.30 to 0.66 
Taurocholate of Sodium, 56.50 to 
106.60 
Glycocholate or Chplate of Sodium, 
traces. 
Leucin, Tyrosin, Urea, traces. 
Cholesterine, 1.60 to 2.66 
Lecithin, 1 
Margarin, Olein and 3,20 to 31.00 
traces of Fat, 
Biliverdin, 14.00 to 30.00 
Mucosin, traces. have caused to be classed among the monatomic al- 
cohols, is a fatty substance which presents itself to the 
microscope under the form of rhomboidal tablets. 
You know also that these crystals have a characteristic 
reaction which consists in the red coloration which 
they assume in contact with sulphuric acid. To-day 
everyone is agreed in adopting the theory of Flint as 
to the origin of this substance, and Vulpian in his re- 
markable “ Lessons on the Bile ” has accepted this 
view which regards cholesterine as a product of dis- 
assimilation of the nervous substance. Feltz and 
Ritter have shown, on the other hand, that this sub- 
stance when it accumulates in the blood does not pro- 
duce any grave toxic symptoms.* 
Trefanowski has attained similar results, finding in a 
thousand parts of bile from the gall bladder of a human sub- 
ject, 908.70 of water, 91.22 of fixed matters, of which 28.56 
were glycocholates and taurocholates. 
* Cholesterine (C26H44 G-|-H2 O)discovered by Poullet 
and De la Salle in biliary calculi then by Fourcroy in a 
desiccated liver, was studied by Chevreul in 1824, who gave it 
the name which it bears to-day. It is a non-saponifiable fat, 
white, crystallizable, insoluble in water, soluble in soap and 
water, ether, wood spirit, boiling alcohol, glacial acetic acid, 
and in solutions of taurocholic acid and taurocholates; it con- 
tains almost eighty-four per cent, of carbon and twelve per 
cent, of hydrogen; the crystals present themselves under the 
form of rhomboidal plates, which are thin and brilliant and 
fuse at 140° C. 
Cholesterine is met in divers regions of the organism. As for the bile pigment, bilirubin, it is an azotized 
non-albuminous principle derived from the decompo- 
sition of the coloring matters of the globules, whose 
properties Tarchanoff and Vossius have thoroughly 
studied; in fact, from a chemical point of view, there 
is a great similarity between haematin and bilirubin, 
and you will see when we come to take up the subject 
of jaundice that the possible transformation of the 
former into the latter has given a name to a special 
form of jaundice, hsematogenous jaundice (icterus 
sanguinis). We shall see, also, that bilirubin has a 
characteristic reaction, and that the most important 
and best known is that determined by nitrous nitric 
acid, which in contact with bilirubin gives a play of 
colors; red, green, blue, yellow and brown.* 
and in the blood; it is very abundant in the nervous centres, 
existing in greatest quantity in the white substance. 
Since the researches of Austin Flint, 1868 (“ Experimental 
Researches on a New Function of the Liver ”), the majority of 
physiologists have regarded cholesterine as a product of dis- 
assimiiation eliminated by the liver and passing into the 
intestine with the bile. Beneke stands alone in regarding it as 
a product of the hepatic secretion contributing to the resorp- 
tion of the fats in the intestine. 
*Bilirubin, an azotized non-albuminous principle, pre- 
sents itself under the form of a red amorphous powder, or of 
needle-shaped crystals; it is held in solution by the biliary 
acids. 
There are two tests in common use: Gmelin’s and 
Schwanda’s. Gmelin’s test, which is also the common test for But the truly essential part of the bile consists in 
the biliary salts, glycocholates and taurocholates of 
sodium. You know that these two acids easily break 
up, the one into cholic and cholalic acids, the other 
into taurin and glycocol. Pettenkoffer has given a 
means of readily detecting these acids. If you sub- 
ject them to contact with a mixture of sulphuric acid 
and sugar, you see them take on a beautiful violet 
purple color. 
These acids give their principal character to the 
hzematoidin, is the nitrous nitric acid, which, instilled drop by 
drop into a solution containing bilirubin, gives a play of colors; 
green, blue, violet, red and brown. When hsematoidin pre- 
dominates, the violet color is the most pronounced, while the 
green color is the most marked when bilirubin predominates. 
Schwanda’s test is acetic acid, which when heated with biliru- 
bin, gives a green color. 
Bilirubin and hsematoidin are very much alike; they differ 
principally in this respect, that in hsematoidin an atom of iron 
replaces the two atoms of hydrogen which exist in the mole- 
cule of bilirubin. There are other biliary pigments which seem 
to be derivatives of bilirubin, such as biliverdin, bilifulvin, bili- 
fuscin, biliprasin and bilihomin. Studeler has given to bili- 
rubin the formula; Cl 6 HlB N03. He regards biliverdin as 
bilirubin plus water and oxygen. 
Vossius has made some recent experiments on the biliary 
secretion, and on the quantity of coloring matters secreted in 
24 hours. He has shown that in a dog weighing 25 kilo- 
grammes, the quantity of bile varies from 60 to 150 cubic cent- 
imetres in 12 hours, and that the coloring matter of the bile 
varies between 0.0487 and 0.056; the average furnished by biliary secretion, and in fact, while we have seen that 
cholesterine originates in processes of disassimilation 
of the cerebro-spinal axis, and the coloring matter of 
the bile has for its origin the hsematin of the blood 
globules, the biliary salts are formed solely in the 
liver, and are a product of the secretion of this gland. 
This is, you must remember, a fact of capital import- 
ance, which clearly differentiates the kidney from the 
liver, and while the one does nothing but separate 
from the economy substances which have accumulated 
in the blood, the other produces from elements in the 
blood special substances which are characteristic of 
eight experiments’was 0.056. This richness in coloring mat- 
ters is little modified by food; it nevertheless augments when 
the animal is subjected to a regimen exclusively hydro-carbon- 
aceous. When considerable quantities of haemoglobin are in- 
jected into the blood, the coloring matter of the bile is not aug- 
mented. On the other hand, when you inject distilled water 
into the veins, or a 5 per cent, solution of sodium chloride, 
you augment in a notable manner the coloring matter, and the 
same thing takes place when you introduce coloring matter into 
the blood. This shows, as Tarchanoff has pointed out, that 
the liver has the property of separating from the blood the col- 
oring matter of the bile, to incorporate it with its proper 
secretion. 
To test the coloring matter in the urine, Rosenbach pro- 
poses the following process; The urine is passed through 
white filtering paper, and when the filter is dry, a drop of nitric 
acid is let fall upon it, and then several concentric zones show 
themselves; green, blue, violet and yellow. 
The glycocholates and taurocholates of soda are obtained its secretion. The experiments of Muller, Lehmann, 
Kund, and especially the beautiful experiment of 
Molesschott, who performed ablation of the liver in 
frogs, and did not find the biliary acids to accumulate 
in the blood, are absolutely demonstrative on this 
point. 
Where is the bile elaborated? Must we admit, 
as Charles Robin suggests, that it is in the glands of 
under a crystalline form. They form from 55 to 61 per cent, 
of the solid residue of the bile. 
Their acids are glycocholic or cholic acid discovered in 
1825 by Tiedmann and Gmelin, and taurocholic or cholalic 
acid. 
Glychocolic acid (Cl 6 His NOg) is but little soluble in 
water and ether, more soluble in alcohol. It is obtained under 
the form of fine needles. Under the influence of hydrochloric 
acid it breaks up into cholalic acid and gly cocol (sugar of 
gelatin). 
Cholalic acid, obtained for the first time by Demarquay, 
presents itself in the amorphous state or in four-sided prisms 
with bevelled edges. By the action of prolonged heat it is 
converted into dyslysin. Moreover, dilute sulphuric or hydro- 
chloric acid transform it at first into choloidic acid, then into 
dyslysin. 
Taurocholic acid (C 36 H45 N04 S.) has not yet been ob 
tained in a crystalline stale. Under the influence of heat and 
of caustic alkalies, it breaks up into cholalic acid and into 
taurin. 
Taurin, discovered by Gmelin, crystallizes in 4 or 6 sided 
prisms, terminated by pyramids with four facets. It contains 
sulphur in considerable proportions. Like glycocholic acid, 
taurocholic acid exercises a right handed polarization. the bile ducts that the secretion of the biliary acids 
takes place, while to the hepatic cell is reserved the 
glycogenic function? Must we locate in the hepatic 
cell itself this secretion? This is a question which the 
researches of Kolliker seem to have solved, for he 
found the biliary acids in the hepatic cells. It is, 
then, in the cell that the secretion of bile takes place, 
and it remains for us to study what are the influences 
which cause this secretion to vary. 
In the physiological state, the bile, as Colin has 
shown, flows continuously into the intestine, but this 
flow is subject to intermittences; for example, during 
the period of digestion, and under the influences of 
certain emotions, the secretion is much augmented. 
We shall study more at length the various modifica- 
tions in the biliary secretion in a future lecture devoted 
to biliary lithiasis. 
The quantity of bile secreted in twenty-four hours in a 
dog weighing ten kilogrammes is 150 grammes (Nasse and 
Plater). In the cat, according to Stackman, the quantity 
secreted per kilogramme of the weight of the animal is sixteen 
grammes in the twenty-four hours. 
This proportion is the same as that found by Scott & 
Ritter; thus a man of average weight, say 150 pounds, will 
secrete one kilogramme, or about two pounds of bile in twenty- 
four hours. 
This figure is, however, higher than that furnished by 
direct experiments on patients with biliary fistulae. 
De Witch and Westphalen, in two cases of the kind, the 
one a man, the other a woman, noted that the quantity of bile 
secreted in twenty-four hours was about 500 grammes. You know that when we tie the hepatic artery, we 
do not cause the secretion of bile to cease. It is the 
same when the ligature embraces the portal vein, 
leaving the artery intact. What do such experiments 
show ? They prove this, that owing to the numerous 
anastomoses, it suffices that the hepatic shall be sup- 
plied with blood, it matters not from what source, in 
order to accomplish its function of secretion. 
This is so true, that when you bleed animals, you 
see the secretion of bile notably diminish; on the other 
hand, if you make an intra-venous injection of water, 
the biliary secretion is augmented. 
But there is a physiological process which notably 
augments this secretion, viz.; digestion, or, more 
strictly speaking, the irritation produced by food or 
chyme on the intestinal mucosa. There is in these 
cases a double action: first, an augmentation in the 
production of bile, then augmentation of the excretion 
caused by increase of the contractile movements, of 
which the gall bladder and its ducts are the seat. 
In this regard, there is a fact noticed by Rohrig 
and Vulpian which presents a great interest, viz.: that 
when you inject water into the intestine of animals 
under experimentation, you see the secretion of the 
bile augment.* 
* Numerous experimenters have investigated the mode of 
secretion of bile. Malpighi, Schiff, and others, found that 
after ligature of the hepatic artery, the biliary secretion still 
went on. Ore, of Bordeaux, by numerous experiments on As for the influence of the nervous system on this 
secretion, it is not at all doubtful; at the same time, 
experiments in this direction are not very decisive. 
Certainly, the vaso-motor nerves—vaso-constrictors 
and vaso-dilators—undergo there, as everywhere else, 
modifications from reflex influence, but, as I have said 
before, we need more light on this subject. 
20 
Such, gentlemen, are the brief considerations 
which I wished to present respecting the liver and its 
cats and dogs, also noticed that the secretion continued after 
obliteration of the vena portae, on condition, however, that the 
obliteration was not made suddenly. Schiff undertook several 
series of researches. In a first series he tied the branches of 
the coeliac axis and the inferior diaphragmatic artery. In a 
second series of experiments, he tied the portal vein and the 
small branches going to the liver; he separated the hepatic 
artery and tied in one mass the hepatico-duodenal ligament 
and the common bile duct; the animals died in convulsions an 
hour and a half after the operation. Finally, in his third series 
of experiments Schiff gradually interrupted the circulation of 
the portal vein, and observed that the biliary secretion per- 
sisted. 
To explain this fact, Schiff says that the secretion con- 
tinues by reason of persistence of the portal circulation, due to 
the accessory para-umbilical portal veins. 
With regard to the influence of the nervous system on the 
biliary secretion, numerous experiments have been made by 
Heidenhain, Rohrig, Munk and others. 
Heidenhain in operating on dogs, has shown that 
electrization of the spinal cord produces, first, an augmenta- 
tion then retardation, in the secretion of bile. He thinks that 
the retardation of the flow of bile is a consequence of the con- functions. Now that we know the general particulars 
of its anatomy and physiology, and the conditions 
which preside over the secretion of the bile, we can 
study the action of certain substances on this secre- 
tion, and pass in review that important group of 
medicaments which have so important a part in the 
treatment of diseases of the liver; I refer to chola- 
gogues, which will be the subiect of my next lecture. 
21 
striction of the vessels and diminution of the blood pressure in 
the interior of the liver. The acceleration of the flow of bile, 
on the contrary, is to be attributed to contraction of the bile 
ducts. Munk has arrived at the same conclusions as Heiden- 
hain. As for Rohrig, he has also observed the augmentation 
of the biliary secretion under electrization of the cord. But 
electrization of the central end of the sciatic nerve does not, he 
says, produce this augmentation of the secretion, as Heiden- 
hain and Monk have affirmed. 
Vulpian, moreover, remarked that section of the pneumo- 
gastrics and experimental lesions of the floor of the fourth 
ventricle produce a congestion of the liver with increased ac- 
tivity of the biliary secretion. These facts have, he thinks, a 
high importance. They explain the mechanism of the jaundice 
resulting from strong mental emotions, such as fear, anger, etc. CHAPTER 11. 
CHOLAGOGUES, 
Summary;—Cholagogue Medicaments—Physiological Experi- 
ments on Cholagogues—Process of Rohrig—Process of 
Rutherford and Vignal—Cholagogue Purgatives—Chola- 
gogue Action of Calomel—New Cholagogues of Vege- 
table Origin—Euonymin—lridin—Baptisin—Hydrastin 
Juglandin—Sanguinarin—Phytolaccin—Cholagogues of 
Mineral Origin—On the Action of Alkalies as Chola- 
gogues. 
Gentlemen:—When I was lecturing on purga- 
tives, I told you that there were certain of them which 
act by augmenting the secretion of bile. It is to this 
group that the name of cholagogues has been given. 
I told you, also, that I was intending to study more at 
length this class of purgatives when I came to dis- 
eases of the liver, and the subject properly comes up 
for consideration to day. But before enumerating the 
different substances which enter into this group, I will 
first examine upon what experimental bases the study 
of cholagogues rests. 
Formerly it was by examination of the stools that 
physicians were enabled to classify these medicaments, 
and according as the stools were more or less bilious, 
the medicine was considered as having a greater or 
less action on the liver and was reckoned cholagogue. 
This method, which was not a very scientific one, has 
given place to more precise researches, for which we are principally indebted to certain foreign physi- 
cians.* 
In 1863 Hanfield Jones was the first to enter on 
this experimental method. He gave certain medicinal 
substances to animals which he afterwards killed, and 
he then examined the state of the liver and intestines; 
according as he found the hepatic gland more or less 
congested, he concluded that the medicament had a 
more or less energetic action on the biliary secretion. 
This it must be admitted, was a somewhat rude and 
primitive process, which had been nevertheless put in 
usage by previous experimenters and in particular by 
Pecholierf in studying the action of calomel. 
In 1867 and ’6B, the British Association, which 
has done so much to elucidate important problems in 
therapeutics, and in particular, that of the action of 
alexipharmic medicines and of antagonism in thera- 
peutics, submitted the question of cholagogues for 
discussion, and appointed a commission consisting of 
Arthur Gamgee and Hughes Bennett to undertake a 
series of experiments to ascertain the action of the so- 
called cholagogues. 
This commission made an important report, based 
* Arthur Gamger, Rutherford, Hughes Bennett, Rohrig, 
etc. 
f Pechc lier (“ Indications for the Employment of Calomel 
in the Treatment of Dysentery”) noticed in 1865 that in hares 
to which he had administered calomel, the liver was very 
much congested. on numerous experiments performed upon dogs, 
which were all put on the same diet and subjected to 
the action of certain medicaments whose influence on 
the biliary secretion was then studied by careful anal- 
ysis. 
In 1873, Rohrig, in Germany, completed and per- 
fected this mode of research. 
He curarized dogs and subjected them to artificial 
respiration. Then, after taking care to empty the gall 
bladder and tie the cystic duct, he introduced into 
the extremity of the common bile duct a tube ending 
in a tapering point, like a dropping tube; then, by the 
aid of a metronome beating seconds, he counted the 
number of drops of bile flowing in a given time by the 
tube, and thus studied the action of different sub- 
stances introduced into the stomach or digestive tube 
of animals under experimentation. 
You see that quite an improvement was effected 
in the way of scientific definiteness, as indicated by the 
distance which separtes the method of Jones from 
that of Rohrig; but progress did not stop here. 
Rutherford and Yignal, in 1875, repeated and 
improved the processes of Rohrig; they proceeded at 
first as did the latter experimenter, that is to say, they 
curarized the animal, emptied the gall bladder, and 
applied a ligature to the cystic duct but instead of intro- 
ducing into the common bile duct a simple tapering 
tube, they employed a glass pipette adapted to a rubber 
tube, terminated at its distal extremity by another glass tube dipping into a graduated test measure; 
then they calculated the quantity of bile secreted in a 
given space of time. 
In some preliminary researches, these experi- 
ments proved first of all that curare has no action on 
the biliary secretion, and that during the entire dura- 
tion of the experiment the bile kept its composition 
almost unchanged; then they showed that in the nor- 
mal state in the dog the quantity of bile secreted is 
about 20 cu. c. m. per kilogramme of the weight of 
the body and per hour, and it is by relying on this 
latter figure that they established the coefficient of 
cholagogue medicaments. This word coefficient, then, 
indicates the quantity of bile secreted in an hour 
and corresponding to i kilogramme of the weight of 
the animal; the more that figure exceeds the sum of 
20 cu. c. m., the greater the action of the medicament 
on the biliary secretion. Note in this connection that 
the substance under experimentation was not intro- 
duced by the mouth, but inserted into the duodenum; 
it is in this way that Rutherford and Vignal have 
arrived at the following table which I here place be- 
fore you:  26 
COEFFICIENTS EXPRESSING THE ABSOLUTE QUANTITY OF BILE 
OBTAINED IN EACH EXPERIMENT DURING ONE HOUR 
PER KILOGRAMME OF THE WEIGHT OF THE 
ANIMAL. 
Podophyllin (with addi- 
tion of bile) o. 01 
Aloes 0.93 
Salicylate of sodium ... 0.89 
Corrosive sublimate... . 0.85 
Extract of physostigma, 0.75 
Corrosive sublimate. ... 0.72 
Aloes (without bile) 0.69 
Salicylate of sodium. ... 0.66 
Benzoate of sodium .... 0.64 
Iridin 0.63 
Salicylate of sodium. ... 0.56 
Corrosive sublimate.... 0.55 
Ipecacuanha 0.55 
Benzoate of ammonia.. . 0,54 
Podophyllin(without bile) 0.47 
Euonymin (with bile). .. 0.47 
Corrosive sublimate. ... 0.47 
Phytolaccin 0.47 
Sulphate of potassium.. 0.47 
Sanguinarin 0.46 
Euonymin 0.46 
Colocynth 0.45 
Colchicum 0.45 
Phosphate of sodium. . . 0.44 
Sanguinarin 0.40 
Nitro-hydrochioric acid, 0.39 
Baptism 0.39 
Ipecac 0.38 
Hydrastin 0.38 
Sulphate of sodium 0.38 
Extract of physostigma, 0.36 
Jalap 0.35 
Rochelle salt 0.33 
Rhubarb 0.32 
Hydrastin 0.32 
Juglandine 0.32 
Leptandrin 0.31 
Sanguinarin 0.30 
Jalap 0,29 
Baptisin 0.29 
Phytolaccin 0.29 
Hydrastin 0.28 
Colocynth 0.27 
Leptandrin o 27 
Sulphate of sodium 0.25 
Colchicum 0.20 
You will notice, first of all, the change which has 
been effected by these experimental researches in the 
old group of cholagogues, constituted by podophyllin, aloes, rhubarb and senna. This group has in great 
part well stood the test of experimentation; podo- 
phyllin still holds in the tables of some of the experi- 
menters the very first place among the cholagogues.* 
But the action of podophyllin is characterized by 
this curious fact, to which I shall again allude, viz., 
that its maximum effect, as far as the activity of the 
biliary secretion is concerned, does not take place 
with large, but with moderate doses. Aloes and 
rhubarb remain still good cholagogues, while the 
drastics properly so-called, colocynth, scammony and 
croton oil are very moderate cholagogues. 
Thus far, you see, experimentation has done com- 
plete justice to the medicaments called cholagogues, 
but this is not the case when we take up the study of 
calomel, and we have here, it must be confessed, one 
* The experiments of Rohrig, on the one hand, and of 
Rutherford and Vienal on the other, do not agree respecting 
the action of these cholagogues on the biliary secretion, as may 
be seen by the following classification: 
CHOLAGOGUES IN THEIR ORDER 
OF EXCELLENCE. 
According to Rohrig: 
Colocynth, 
Jalap, 
Aloes, 
Senna, 
Rhubarb. 
CHOLAGOGUES IN THEIR ORDER 
OF EXCELLENCE. 
According to Rutherford and 
Vignal: 
Podophyllin. 
Rhubarb, 
Aloes, 
Colchicum, 
Senna. of the most delicate and difficult points connected 
with the question, and one which shows how difficult 
it often is to bring into harmony physiological experi- 
menters and clinicians. 
From the time of Paracelsus and Von Helmont 
down to our days, physicians have vaunted the action 
of calomel on the liver; the green stools produced by 
this medicament were considered an undoubted sign 
of the elective action of calomel on the hepatic gland; 
and whatever Stille may have said to the contrary, 
who affirmed that the color of the stools produced by 
calomel were due to a subsulphuret of mercury, it is 
to-day demonstrated by the experiments of Golding 
Bird and Simon, and especially by the researches of 
Michea, that this coloration is due to a biliary pigment. 
If clinical experience is unanimous in affirming 
the cholagogue action of calomel, quite as decided 
agreement and unanimity exist among experimental 
physiologists in denying this action. Consult the ex- 
periments of Scott, Hosier, Kolliker, Midler, of Ben- 
net, of Rohrig and of Rutherford, and all will tell you 
that calomel does not augment the secretion of bile in 
the dog but that it diminishes it. 
How are we going to reconcile results so contra- 
dictory. Some authorities, and in particular Fraser, 
have attempted an explanation; the experimenters, 
they say, put themselves in special conditions which 
were different from what one observes in the man 
whether well or sick. Between the curarized dog living by artificial respiration and the man, there is a 
great difference. But this argument seems to me to 
miss the point, and for this reason: if it were sound 
we ought to reject in toto all the experiments on 
cholagogues. for the same objection applies to all the 
experiments, which would thereby be hopelessly viti- 
ated. But this none of the authorities are willing to 
grant, and there is general agreement that the re- 
sults of the experiments as far as most of the medica- 
ments are concerned are trustworthy, and valid. 
Murchison seems nearer the truth when he 
says that mercury augments the biliary excretion 
without augmenting the secretion; i. e. by exciting 
the contractions of the bile ducts, by diminishing 
the catarrhal congestion of these ducts, by modify- 
ing perhaps the bile itself, calomel causes a greater 
quantity of bile to flow into the intestine without, 
however, augmenting the secretion of this liquid. 
I am inclined to take the same view of the case 
as Murchison, and, while giving the precedence to 
clinical experience over physiological experimentation, 
I persist in regarding calomel as one of the best 
cholagogues; but I would associate with it another 
mercurial preparation, which some have supposed to 
be void of cholagogue properties, namely, corrosive 
sublimate. In fact, while the mild chloride of mer- 
cury, when administered experimentally, diminishes 
rather than augments the biliary secretion, the cor- 
rosive chloride, on the contrary, according to Ruther- ford, augments this secretion; therefore, I advise you, 
when you wish to obtain the full benefit of the salts of 
mercury in the treatment of hepatic affections, to com- 
bine calomel with corrosive sublimate, and to prescribe 
pills containing ten centigrams of calomel and two 
milligrams of the sublimate. These pills, in the dose 
of one or two at bedtime, have a marked cholagogue 
effect. 
As you see, the group of cholagogues, with the 
exception of calomel, passes, as it were, intact through 
the hands of the experimenters. To this group should 
be joined ipecac, whose particular action on the liver 
you have already learned theoretically. For you can- 
not have forgotten what I said while on the treatment 
of dysentery, when I endeavored to explain the heroic 
curative action of this medicament by the excitation 
which it produces on the biliary secretion. This view 
is confirmed by experimentation, and you see by the 
work of Rutherford that ipecac deserves a place 
among the best cholagogues. 
But the researches of the English experimenters 
have not had merely for result to confirm what tradi- 
tion had taught us concerning the cholagogues, but 
also to call attention to a new group of medicaments 
of whose action on the biliary secretion we were abso- 
lutely ignorant. These are certain new medicaments 
which I am going to pass in review, and which I shall 
classify under two heads; those derived from the 
vegetable kingdom and those from the mineral. The first of these groups, by far the most im- 
portant, is composed of a series of substances called 
by the English writers baptism, euonymin, hydrastin, 
iridin, juglandin, leptandrin, phytolaccin. These are 
aqueous or hydro-alcoholic extracts of uncertain chem- 
ical composition, and which, if they are to take a place 
in therapeutics, need to be studied anew. Their very 
name, even, cannot be accepted in France, at least 
where their very termination is suggestive of alkaloids 
or glucosides, and it will not do again to commit the 
mistake which Bonjean has perpetuated, to the con- 
fusion of therapeutic nomenclature, by giving to the 
hydro-alcoholic extract of ergot the name of ergotin. 
I propose, however, on this occasion to employ the 
terms in ordinary use, as, in fact, is done in the case 
of podophyllin, and to say baptisin, euonymin, etc. 
This terminology, moreover, is adhered to despite the 
fact that chemists have already described under the 
names of juglandin, euonymin, iridin, hydrastin, cer- 
tain substances which are veritable alkaloids. One of 
my pupils, Dr. Daret, has made a careful study of 
these new cholagogues, the first, in fact, that has been 
undertaken in France.* 
I here place before you samples of several com- 
paratively new pharmaceutical products which I have 
obtained in England, and of which I am enabled to 
*G. Daret on Certain New Cholagogues of Vegetable 
Origin (These de Paris, 1880). give you a summary description, owing to the kind- 
ness of my excellent interne in pharmacy, M. Jaillet, 
who has examined them. 
Here is a sample of euonymin. It is, as you see, 
a greenish powder, of strong, rank odor, insoluble in 
water, slightly soluble in alcohol and ether, and which 
is obtained from a species of wahoo, the euonymus 
atro-purpureus, much prized in our gardens by reason 
of the beautiful color of its leaves. It is an oleo-resin, 
which burns readily, and which must not be con- 
founded with the euonymirie, a species of mannite, 
studied by Kubel, Roedei'er, and Grunner. The latter 
is a crystalline substance, obtained from the enonymus 
Europseus. 
In France euonymin is often found under the 
form of a brown powder; the difference in color is 
owing to the part of the plant from which the resin 
has been extracted. In England the leaves and stalk 
are utilized; in France the root. 
This substance, which, according to experimenters 
is one of our best cholagogues, and which has 
received honorable mention in the U. S. Dispensatory, 
is given in the dose of ten to twenty centigrammes 
(two to four grains). You do not obtain from it a 
very decided purgative action, but its cholagogue 
effect is quite marked. I have myself prescribed it 
with success in cases of catarrhal icterus, and in dys- 
entery. Moreover, in France Henri Gueneau de 
Mussy, who was the first to introduce these medica- merits, has derived good effects from it, and Dr. 
Blondeau has reported a case of pseudo-membranous 
enteritis in which euonymin produced excellent 
results. 
The euonymus is chiefly known in the U. S. under the 
name of wahoo, a name given it by the Indians. 
The plant has also been named spindle tree and burning 
bush. It is a tall, erect shrub, with small dark-purple flowers, 
in cymes, in axillary peduncles. The wahoo is indigenous in 
the northern and western states. Euonymin in this country 
is obtained from the dried bark by reducing it to powder, 
agitating with chloroform a tincture made with dilute alcohol, 
separating the chloroformic solution, and allowing it to evap- 
orate, and by a further process of purification; the euonymin 
thus obtained is uncrystallizable, and intensely bitter. Dr. 
Geo. B. Wood speaks of it as tonic, hydragogue, cathartic, 
antiperiodic and cholagogue, although he regards its action as 
somewhat uncertain. 
A fluid extract is much used; dose, a dessert to a tablespoon- 
ful. The euonymus is a favorite with the eclectics.—[Trans.] 
This blackish powder with shiny particles is 
iridin, an oleo-resin extracted from iris versicolor. 
Wood and Bache mention it, and Rutherford ranks it 
along with euonymin among the very best chola- 
gogues. It has given me the same results as euony- 
min, and from a therapeutic view I regard it as of 
about equal merit. 
Iris versicolor (blue flag) is found in all parts of the U. S. in 
low wet places and on the borders of swamps, which it adorns 
by its large and beautiful flowers. The root is the medicinal 
part. Blue flag possesses cathartic, emetic, diuretic and chola- gogue properties. It is, however, little used by the profession 
at large. 
The dose of the dried root is from ten to twelve grains. 
“ Under the unscientific name of iridin or irisin, which should 
be reserved for the active principle when discovered, the 
eclectics have obtained an oleoresin, got by precipitating the 
tincture of the root with water and mixing the result with some 
absorbent powder, such as licorice root. This may be given 
in the form of a pill in the dose of three or four grains. It is 
thought to unite cholagogue and diuretic with aperient proper- 
ties.”—[Wood and Bache.] 
This yellowish powder, which I now show you, 
with strong and rank odor resembling podophylihn, is 
baptism, which is extracted from the wild indigo, Bap- 
tisia tinctoria; it is a medicament similar to the pre- 
ceding, and the dose, according to Wood and Bache, 
is 2 grains at bed time. 
The Baptisia tinctoria is an indigenous plant found all 
over the United States, abounding in woods and uplands. The 
whole plant becomes black when dried, and has been used for 
dyeing purposes, known by the name of “dyers’ weed.” The 
root, which is the medicinal part most in use, has a nauseous, 
bitter and somewhat acrid taste. Baptisin, which is an impure 
extract, is emetic and cathartic in large doses, laxative in small 
doses. 
Rutherford has experimented with it in dogs in the dose 
of six or seven grains: it produces considerable congestion of 
the stomach and intestines. 
I here show you a specimen of hydrastin, the 
alcoholic extract of Hydrastis Canadensis, which you 
must not confound with the crystallized hydrastin, 
which is a real alkaloid, discovered by Durand, and studied by Perrins and Mahla. It is a decided 
cholagogue, and more of a purgative than the pre- 
ceding preparation. This, by the way, is one of the 
most curious facts connected with the experiment of 
Rutherford, i. e., the discovery of these non-purgative 
cholagogues which augment the biliary secretion with- 
out increasing the number of stools, and in the em- 
ployment of which it is necessary to add a true purga- 
tive, such as sulphate of soda, for instance. 
Hydrastin is a resinous alcoholic extract of the root of 
hydrastis Canadensis. It presents itself under the form of a 
brown powder, of bitter and astringent taste. It is soluble 
in alcohol and in ether, little soluble in water, soluble in 
chloroform. This gum-resin readily burns, and gives all the 
characters of a resin. It is probable that the alkaloid dis- 
covered in 1861 in the same plant by Durand is contained in 
this gum-resin. Durand’s hydrastin (hydrastia W. and B.) 
which has been studied by Perrin and Mahla, crystallizes in 
white spiny prisms and melts at 1350 C. (2750 F.) Heated on 
platinum foil, it burns with a sooty flame. It is insoluble in 
water, soluble in alcohol, ether, and dilute mineral acids. 
Hydrastin is associated with berberine in the roots of the 
hydrastis Canadensis. 
This specimen of juglandin which I here place 
before you under the form of a black powder has a 
special oily odor resembling that of decayed nuts; as 
its name indicates, it is an extract of the Juglans 
cinerea and belongs to the group above mentioned, 
being a cholagogue medicament without being a 
purgative. A propos of this substance, I must remind 
you that Tanret has found in the butternut an alka- loid which he has called juglandin, and that Luton has 
recommended in the treatment of tuberculous menin- 
gitis an alcoholic extract of the juglans under the 
name of extract of Granval.* 
[Podophyllum peltatum (described in “ Diseases 
of the Stomach and Intestines) is a perennial plant of 
the Berberidaceas family, growing in North America. 
The parts employed are the rhizomes and roots, from 
which a resin is extracted called podophyllin, which 
presents itself under the aspect of a brilliant powder 
of yellowish brown color, and acrid, bitter taste. 
According to Mayer, besides this resin, podophyl- 
lin contains berberine, a colorless alkaloid, a special 
acid, an odorous matter and saponine. The resin 
is soluble in alcohol, ether, the essential oils, bisulph- 
ide of carbon, and in part in the alkalies. In the dose 
of from }i to i grain, podophyllin provokes regular 
stools ten to twelve hours after its administration. 
Large doses (i to 2 grains) are likely to produce 
nausea and vomiting as well as colic.] 
This powder with shiny particles which I here 
place before you is leptandrin, an impure resinoid 
extract of the Leptandria veronica. Reeb, of Phals- 
bourg has recommended it along with podophyllin in 
*Tanret’s juglandin is in the form of long needles; this sub- 
stance exists in the leaves of the butternut combined with tan- 
nin. The juglandin of commerce is an alcoholic extract of the 
butternut, and comes in the form of little lumps of a brownish 
color; dose, 2 to 5 grains. the treatment of dysentery, and Lloyd has made a 
special study of this resin.* 
Here is a sample of sanguinarin, an impure ex- 
tract from the Sanguinaria Canadensis. We are al- 
ready acquainted with an alkaloid derived from this 
same plant, Sanguinarine. The product now before 
you is a cholagogue with but slight purgative proper- 
ties. According to Rutherford, it excites the secretion 
of the liver, giving rise to a flow of watery bile; the 
dose is from one-half grain to a grain. 
Lastly, this powder, of a dirty grey, earthy color 
and saltish taste, is phytolaccin, a resin which is ob- 
tained from a plant which grows in abundance in 
North America, the Phytolacca decandra. It will not 
do to confound this product with the phytolaccine 
studied by Claassen, which is a glucoside; the pre- 
* Lloyd, American Journal of Pharmacy, 1880. 
Leptandrin is of rank nauseous odor, bitter somewhat 
sweetish but nauseous taste. According to Lloyd, Mayne and 
Mayer, the resin precipitated from the alcoholic extract of the 
Leptandria, does not contain the active principle of this plant 
to this must be added the precipitate thrown down by 
sulphuric acid from the liquid which has furnished the resin; 
this precipitate contains an impure glucocide. 
Reeb, a pharmacist of Phalsbourg, made a study of 
leptandrin in 1875. According to him, this substance has 
feeble laxative properties, in large doses producing frequent 
evacuations. He has employed it in conjunction with pod- 
ophyllin in epidemic dysentery; it may also be given, he 
says, in this disease associated with camphor and quinine. paration before you, in large doses, is both purgative 
and emetic, while in smaller doses (one to three grains) 
it is both cholagogue and purgative. 
What is the true value of these substances with 
which Rutherford, according to the expression of 
Gueneau de Mussy, has enriched the armamentarium 
of the physician ? What is to be their future ? The 
first trials which I have made in Cochin hospital with 
these substances, obtained directly from Edinburgh, 
have shown that, with the exception of euonymin, hy- 
drastin, and perhaps iridin and phytolaccin, there is 
little to expect from these novelties, and that they are 
largely impure, ill-defined substances, demanding both 
from a chemical and pharmaceutical point of view, a 
more complete investigation. 
To these complex products, these oleo resins, I 
would join two well-defined medicinal agents which 
seem to possess great activity as cholagogues: Col- 
chicine, which, according to Garrod, has a marked 
action on the liver, and aconitine, which, also as 
Laborde and Gelle have shown, also acts powerfully 
on the biliary secretion. 
Colchicine is an extract of the colchicum autumnaie, it 
is crystalline, inodorous, with sharp bitter taste, soluble in 
water, alcohol and ether. 
There is also an amorphous colchicine, which is neutral 
and uncrystallizable, not forming definite salts, and breaking 
up, under the influence of acids, into colchiceine and a resin- 
ous substance. Tannate of colchicine has been extolled as 
remedial in gout. Garrod employs only the amorphous colchicine. The 
dose would be two to four milligrammes in water or in some 
aromatic infusion. 
As for the cholagogues of mineral origin, I shall 
rapidly pass in review the new facts brought to light 
by the experiments of Rutherford. These experi- 
ments have taught us that salicylate of sodium is a 
powerful excitant of the biliary secretion, and it occu- 
pies the third rank in the scale of cholagogues. 
According to Rutherford, the action of sodium salicylate 
on the intestine is very feeble, hence, when given with chola- 
gogue intent, the dose should be administered at bedtime, and, 
followed the next morning by a dose of Glauber’s salts. 
The phosphate and especially the sulphate of 
sodium are also excellent cholagogues, and thus is 
explained the favorable action of certain sodic sul- 
phate mineral waters, and especially of Carlsbad, on 
hepatic affections. The double tartrate of potassium 
and sodium, Rochelle salts (sal de Seignette), is also 
a good cholagogue. 
But while the salts of sodium augment the biliary 
secretion, those of magnesium on the contrary, and 
especially the sulphate of magnesia, diminish this 
secretion, according to the experiments of Rutherford. 
We ought then, if we accept this experimental datum, 
to substitute as a purgative in affections of the liver 
sulphate of sodium for sulphate of magnesium. 
We have already seen the contradictions which 
exist between clinical and physiological experimenta- 
tion in reference to the action of calomel; there is the same want of agreement relative to the action of the 
alkaline carbonates on the biliary secretion. 
Clinical experimentation in almost numberless in- 
stances says that the alkaline carbonates, and in particu- 
lar the sodic carbonate waters, such as Vichy, have a 
curative action in affections of the liver, and physio- 
logical experimentation replies that instead of increas- 
ing the secretion of bile, they diminish it. We admit 
the claims of the experimental physiologist without 
discarding the results of the clinic. Doubtless the 
secretion of bile is not augmented, but the alkalies, in 
modifying the functions of nutrition, in regulating the 
digestive functions, in calming all inflammatory states 
of the disordered mucosa, in acting on the circulation 
of the liver and modifying the bile, have certainly a 
manifest action on the excretion of the bile, and on 
the hepatic gland. 
Moreover, if experimentation shows us that the 
alkalies have no action on the liver as the organ of the 
biliary secretion, recent experimental researches con- 
ducted by Martin Damourette and Hyades* have put 
in clear light the undoubted action of alkalies on the 
augmentation of the figure of urea secreted in the 
twenty-four hours, and for this reason their beneficial 
effect on the liver considered as the principal organ of 
urea formation, f 
*Acad. des Sciences, March, 1880. “On the Nutritive 
Effects of Alkalies in Large Doses.” 
f Martin Damourette and Hyades have shown the As you see, from the point of view of the treat- 
ment of diseases of the liver, it is not sufficient that 
experimentation shall have pronounced more or less 
definitely on a medicament, to warrant the medical 
profession in at once adopting these conclusions as a 
datum of practice; it is necessary that clinical experi- 
ence shall confirm the results of experimentation, and 
I cannot point you to a more striking proof of this 
than the facts which I have just stated relative to 
cholagogues. 
How are we to explain the cholagogue action of 
the substances which we have just examined ? We 
may suppose it to be due to the irritation determined 
by these substances on the duodenum, and thus com- 
pare what takes place in the liver with what takes 
place in the salivary glands when you irritate the buc- 
cal cavity. At the same time this explanation does 
not seem sufficient, and for this reason: we have seen 
undoubted effects of alkalies, and in particular of the natural 
alkaline waters, on nutrition. According to them, these alka- 
lies are trophic agents in quantities equal to a bottle of 
Vichy water per day. They energize nutrition in helping 
the entire series of acts which constitute it, and they notably 
increase the figure of the blood globules and favor disas- 
similation, as is proved by the augmentation of urea and 
diminution of uric acid in the urine. Alkalies are then pro- 
moters of disassimilation (nutritifs dbperditeurs) after the 
manner of muscular exercise, hydrotherapy and inhalations 
of oxygen. that there are substances which are cholagogue with- 
out being purgative, and vice versa. 
Rutherford, on the other hand, has shown that 
the more a substance is purgative the less it is chola- 
gogue; thus it is that purgatives which are the highest 
in the scale, drastics for instance, are medicines which 
diminish rather than increase the biliary secretion. 
Can we affirm that it is by acting on the circula- 
tion of the liver that the special effect of these medi- 
caments is produced, and that every medicament 
which has for its property to congest this organ should 
be ranked in the group of cholagogues? This explana- 
tion hardly meets the requirement, for we have seen 
that certain cholagogues really lessen the circulation 
in the liver. We are, in fact, reduced to the supposi- 
tion that it is by acting directly on the hepatic cells, 
or on the secretory nerves which preside over the 
function of the organ, that the substances act which 
we have just passed in review. 
In order that you may better remember what I 
have just said, I here place before you a couple of 
tables which I have borrowed from Gueneau de Mussy, 
tables in which are grouped the different medicaments 
according to their cholagogue power. The figure 
which accompanies each substance is its biliary co- 
efficient, i. e., the quantity of bile obtained per hour 
and per kilogramme of the animal weight. ACTIVITY OF THE BILIARY SECRETION BEFORE AND AFTER THE 
INTRODUCTION INTO- THE DUODENUM OF THE SUB- 
STANCES UNDER EXPERIMENTATION. 
Before. 
After. 
Difference 
Aloes (average of the differences, 
i 0.26 
0.61) .! 
0 93 
67 
! O.34 
0.69 
35 
Podophyllin, average, 0.46 \ 
1 O.52 
1.01 
49 
! 0.04 
0.47 
43 
Salicylate of sodium, average, 0.455. - 
\ 0.32 
0.89 
57 
( 
! 0.26 
0.66 
40 
Extract of physostigma, average, 
0.455 
i 0.13 
0-75 
62 - 
| 0.09 
0.36 
27 
Benzoate of Sodium, Single experi- 
ment, 0.42 
0.22 
0.64 
42 
( 
: 0.07 
0.48 
39 
Sanguinaria, average, 0.404 h 
0.16 
0.40 
24 
( 
' 0.12 
0.30 
18 
Iridin, average, 0.36 j 
1 0.16 
0.63 
47 
1 0.23 
0 53 
3i 
Bichloride of mercury, average, j 
0.32 -1 
r 0.22 
0.20 
0.85 
o.55 
€>3 
35 
0.17 
0.47 
32 
L O.48 
0.72 
24 
Euonymin, average, 0.30 \ 
1 0.07 
0.46 
39 
' O.25 
0.47 
22 
Benzoate of ammonia, single experi- 
ment, 0.30 
O.24 
0-54 
30 
Nitro-muriatic acid, single experi- 
28 
ment 
O.II 
0-39 
Ipecac, average, 0.255 j 
i O.24 
1 O.lS 
0-55 
0.38 
3i 
20 
Juglandin, single experiment, 0.22.. 
O. IO 
0.32 
22 
Colchicura, average, 0.21 j 
1 O.I3 
[ O.IO 
0-45 
0.20 
32 
10 
( 
j O.IO 
0.32 
38 
Hydrastin, average, 0.186 ■< 
0. to 
0.28 
18 
1 
: 0.23 
0.38 
15 ACTIVITY OF THE BILIARY SECRETION BEFORE AND AFTER THE 
INTRODUCTION INTO THE DUODENUM OF THE SUB- 
STANCES UNDER EXPERIMENTATION. 
Before 
After. 
Difference 
Phosphate of sodium, single experi- 
ment, 0.17 
0.20 
0.44 
17 
Baptism, average, 0.165 
j 0.12 
I O.23 
0.28 
o-39 
I? 
6 
Leptandrin, average, 0.155 
j O.IQ 
] 0.08 
0.27 
0.21 
8 
23 
Jalap, average, 0.155 
j 0.17 
( 0.16 
O O 
tO (-O 
■O cn 
18 
13 
Rhubarb, single experiment, 0.15... 
0.17 
0.32 
IS 
Sulphate of potassium, single experi- 
ment. 0.15 
0.32 
0 47 
15 
Colocynth, average, 0.135 
j 0.29 
( 0.16 
0.45 
0.27 
16 
11 
Sulphate of sodium, average, 0.14. . 
j 0.25 
( O.IO 
0.38 
0.25 
13 
15 
Rochelle salt, single experiment, 
O.IO 
I have largely drawn from Rutherford’s ■ import- 
ant physiological work, but I repeat, with certain re- 
servations which I desire again to emphasize in fin- 
ishing this lecture. These reservations pertain to 
the therapeutic value of these different substances. 
You have seen that with respect to the sodic-bicarbon- 
ate waters, as well as to calomel we have had to give 
the precedence to the clinic, over experimentation; 
this precedence ought always to be insisted upon, and 
before adopting certain cholagogues, as yet unknown 
to medical practice, it will be best to wait till, by 
numerous clinical observations, such new medicaments have merited the dignity of a place in the materia 
medica, and in the physician’s drug case. 
These data having been settled, we will now enter 
on the study of the therapeutics of diseases of the 
liver, and begin with the treatment of biliary lithiasis, 
which will be the subject of the next lecture.* 
GIVEN TO THE SECRETION OF BILE BY DIFFERENT SUB- 
STANCES ACCORDING TO THE EXPERIMENTS OF RUTHERFORD. 
Figures expressing the excess of secretion excited by 
these substances; 
Aloes 0.67 
Bichloride of mercury . . 0.63 
Physostigma 0.62 
Salicylate of soda 0.57 
Iridin 0.47 
Podophyllin 0.43 
Benzoate of soda 0.42 
Salicylate of soda 0.40 
Euonymin 0 39 
Sanguinarin 0.39 
Aloes 0.39 
Corrosive sublimate.... 0.35 
Colchicum 0.32 
Ipecac 0.31 
Colocynth 0.15 
Sulphate of potassium.. 0.15 
Hydrastin 0.15 
Rhubarb 0.15 
Phytolaccine 0.15 
Phytolaccine 0.14 
Corrosive Sublimate.... 0.30 
Benzoate of ammonia .. 0.30 
Nitro-muriatic acid 0.28 
Physostigma 0.27 
Sanguinaria 0.26 
Hydrastin 0.23 
Leptandrin 0.23 
Juglandin 0.22 
Euonymin 0.22 
Ipecac 0.20 
Jalap 0.18 
Hydrastin 0.18 
Sanguinaria 0.18 
Phosphate of sodium... 0.17 
Baptisin 0.17 
Baptisin 0.16 
Sulphate of sodium 0.13 
Jalap 0.13 
Colocynth o. u 
Colchicum 0.10 
Leptandrin 0.08 
Rochelle salt 0.10 CHAPTER 111. 
TREATMENT OF BILIARY LITHIASIS. 
Summary.—Anatomy and the Physiology of the Bile Ducts— 
Hepatic, Cystic, Choledic Ducts—The Gall Bladder— 
Structure of the Bile Ducts—The Muscular Layer—Biliary 
Calculi, Their Composition—Chemical Causes of the Pro- 
duction of Calculi—lndividual Causes—lnfluence of Sex, 
of Regimen, of Exercise, of Diatheses Pathological 
Physiology of Hepatic Colic—Spasm of the Bile Ducts— 
Indications and Treatment of Biliary Lithiasis—Treat- 
ment of Hepatic Colic—Subcutaneous Injections of Mor- 
phine—Chloral and Chloroform—Adjuvant Means—Lith- 
ontriptics—Durande’s Remedy—Action of Alkaline Min- 
eral Waters—Cholagogue Medication—Hygienic Treat- 
ment of Biliary Lithiasis. 
Gentlemen:—Biliary lithiasis is a frequent affec- 
tion which gives rise, as you know, to certain acute 
symptoms known under the name of hepatic colic, for 
which a prompt and energetic treatment is demanded; 
therefore I shall make this subject a part of my present 
course, and dwell at some length upon it. But, in 
order that you may well understand the value and 
utility of the therapeutic agents recommended in such 
cases, I must enter somewhat into anatomical and 
physiological details concerning the bile ducts and 
the biliary calculi which pass through them. 
I shall be brief in my description of the bile ducts. 
You remember the course of the hepatic duct, which takes its origin in the liver by that network of biliary 
canaliculi, which, as we have seen in one of the pre- 
ceding lectures, surrounds the hepatic cells. After a 
short transit, this duct meets the cystic duct from the 
gall bladder, and both unite into one duct, the ductus 
choledochus, and empty into the duodenum by the 
ampulla of Vater. I shall say little concerning the 
bile duct, with whose anatomy you are sufficiently 
familiar; but there is one point to which I desire 
especially to call your attention, viz: the intimate 
structure of these bile ducts. 
As for the mucous membrane, there is general 
agreement among anatomists; it presents little valves 
or folds, especially in the neighborhood of the cystic 
duct, which are called valves of Heister; moreover, 
this mucosa has glands in greater or less abundauce. 
There is not the same agreement respecting the fibro- 
muscular structure of these ducts, and in some experi- 
ments undertaken about fifteen years ago, I was led 
to make an attentive study of this question.* 
I had been impressed by the disagreements of 
histologists on this point. In fact, while certain an- 
atomists, as Sappey, assign to these excretory bile 
ducts a muscular coating rich in unstriped fibres, and 
Fort even describes as pertaining to this coat three 
layers with variable directions, others, on the contrary, 
* Dujardin-Beaumetz, “A Study of Spasm of the Bile 
Ducts.”—(Bull de Therap., 1873.) as Kolliker, Leydig, Frey, and Virchow, affirm that 
there is not any muscular layer properly so-called in 
these ducts; they scarcely even admit that any exist 
even in the gall bladder. 
In order to decide this contention, I prevailed 
upon two histologists whom I have the honor to have 
had for pupils, Prof. Renaut, of Lyons, and Prof. 
Grancher, to study anew this question. The results of 
their labors were decisive; both show that there un- 
doubtedly exist smooth muscular fibres in the bile 
ducts, and that these muscular fibres are disseminated 
throughout the fasciculi of connective and elastic 
tissue constituting the fibrous coat of these ducts; 
moreover, they put in clear light this fact, already long 
known, that inflammation taking place in the duct 
augments this muscular layer; Bouisson, Herard, De- 
ville, and Broca, have, in fact, shown that in patholo- 
gical cases this stratum may become hypertrophied.* 
* Below the epithelium you find a very thin layer with a 
small number of oval nuclei scattered throughout its substance, 
a layer, essentially of connective tissue fibres, and very adher- 
ent to the subjacent tissue; this tissue,which forms the limiting 
membrane of the ductus choledochus, is remarkable for its rich- 
ness in fine elastic fibres thickly set in a connective tissue very 
poor in cells. In proportion as your dissection embraces the 
deeper tissues of the choledochus, the elastic connective tissue 
changes, and the reciprocal disposition of these elements is 
modified; we find bundles of true connective tissue and inter- 
laced undulating elastic fibres resembling the same elements 
existing in the subcutaneous connective tissue. It is probable that it is with one of these patho- 
logical cases that Martin had to do in his examination 
of the choledic duct, when he claims to have found 
two planes of muscular fibres, the one internal, 
longitudinal, the other external, of circular fibres. So 
then, it is well settled that the excretory bile ducts are 
fibro-muscular tubes which are the seat of more or less 
energetic contractions, as has been shown by the re- 
searches of Audige, of Laborde and myself. You 
will see later the capital importance of these facts. 
Laborde has shown that tinder the influence of induc- 
tion currents the gall-bladder and even the bile ducts, 
hepatic, cystic, and choledic, undergo a slow but very mani- 
fest contraction. 
Let us now examine the calculi which sometimes 
pass through these ducts. They offer a variable 
volume, and their number is variable also. In the 
vast majority of cases they are constituted by choles- 
terine or bile pigment, forming stratified layers of dif- 
It is by an insensible transition that this difference of 
appearance between the elastic fibres and simple connective- 
tissue fibres presents itself as you dissect away from the 
cavity of the duct. 
We may then divide the wall proper of the choledochus 
into three coats which are insensibly blended; an internal con- 
nective and sub-epithelial coat, a middle coat of very close 
elastic fibres, and an external coat of connective tissue 
bundles and undulating elastic fibres. It is in this last coat 
that we find here and there a few scattered elements of smooth 
muscular fibres. ferent colors, according as they are more or less tinted 
by bilirubin. 
The number of calculi is very variable. Ordinarily from 
five to twenty are found in the gall bladder. In other cases 
they are single; in other cases a considerable number are met 
with. In a woman, 61 years of age, Frerichs counted 1950. 
Morgagni has counted 3000, Hoffman 3606, and in the collec- 
tion of Osto there is a gall bladder containing 7802 calculi. 
All the calculi contained in the gall bladder, whatever the 
number, are of the same chemical composition, color and 
structure. Their size is variable, from a grain of millet seed 
to a hen’s egg. Fauconneau-Dufresne has divided gall stones 
into three classes: 
1. Those of small size from a grain of sand to a 
small pea. 
2. Middle size, from a small pea up to a filbert. 
3. Large size, from a filbert up to a hen’s egg. 
The calculi may be olivary, pisiform, lenticular, poly- 
hedric, cylindric, cubic, finger shaped, have the form of dice, 
of coins, of pyramids, etc. They may be smooth, hollow 
and striated, etc. But the ordinary typical form is the olive- 
shaped. The solitary calculi are roundish or ovoid. Multiple 
calculi ordinarily present facets, which appear to be due to the 
massing together of the calculi, and not to the friction of one 
upon another, for you do not often find, on examining gall 
stones, any interruption in the lamellae which constitute 
them, which would be apt to take place if the facet was the re- 
sult of friction. 
Nevertheless, in 1851, Barth found in the gall bladder of 
a woman of 63 years, a dozen irregular calculi, with rough sur- 
faces; he remarked that certain of these calculi had been broken 
and a little worn by friction. Other observers have recorded 
similar facts. Some have found in the gall bladder, not 
stones properly so called, but a thick pasty whitish mass com- posed almost entirely of cholesterine (Besnier), or even a bili- 
ary sediment of the consistence of mud (Durand-Fardel). 
Ordinarily, however, the biliary concretions are quite con- 
sistent, although they are marked easily by the finger nail; the 
hardest calculi are those of cholesterine. 
The structure of the calculi is variable, and has been well 
studied by numerous authorities, who have differently divided 
these biliary concretions. Walter’s classification is; ist. The 
striated calculi, transparent or opaque, which may be either 
smooth or anfractuous; 2nd. The lamellated calculi, whose 
substance is disposed in layers around a nucleus; 3rd. Calculi 
enveloped by a cortex.—Hein’s classification is “ simple cal- 
culi;” 2, “ composite calculi.” 
Frerichs divides calculi into: 1. Simple homogenous 
calculi, whose structure is uniform, whose fracture presents 
an earthy, soapy, or crystalline surface, and which have 
neither nucleus nor cortex. 2. Composite calculi presenting 
a central nucleus surrounded by a zone more or less thick, and 
covered by a cortex. The nucleus, brown or black, is com- 
posed of colepyrrhine and lime, cholate of lime, or of choles- 
terine. 
The nucleus, ordinarily single and central, is sometimes 
excentric. There may even be in a calculus several nuclei. 
In a dry state these nuclei may undergo a sort of retraction, 
become split or even fragmented. The smaller the calculus, as 
a rule, the larger the nucleus. 
Cases have been mentioned in which the nucleus was 
constituted by a foreign body, such as a lumbricus or blood 
clot. The middle layer, immediately surrounding the nucleus, 
is generally striated, and constituted by crystals of cholesterine, 
pure or mingled with pigment. 
Concentric zones are also generally observed, indicating 
the growth of the calculus by successive strata. 
The cortex is generally more or less thick, sometimes smooth and sometimes mammillated, but it is clearly distin- 
guished from the middle layer by its color, its stratified appear- 
ance and its consistence. It is formed either of cholesterine, 
of bile pigment or of lime. 
Biliary calculi are formed at the expense of the elements 
of the bile; rarely they are composed of a single substance, 
they are ordinarily mixed. Cholesterine is generally the basis 
of these stones; next in the order of frequency come bile pig- 
ment and lime salts. 
Charles Robin divides calculi into calculi of cholesterine 
and calculi of coloring matter. Those of cholesterine pure are 
colorless or pearly white. Subjected on platinum foil to a lamp 
flame, they first melt, then burn like a fatty substance, giving 
off a sooty light. If the calculus is composed of pure choles- 
terine, there remains no residue on the platinum foil. Insolu- 
ble in caustic potash and soda, they are very soluble in boiling 
alcohol and in ether. A drop of this ethereal solution under 
the microscope gives colorless rhomboidal plates by evapora- 
tion. 
Concentrated H2 So4 colors these calculi yellow, and 
boiling nitric acid transforms them into cholesteric acid. 
The calculi of the coloring matter of the bile (biliverdine 
and cholepyrrhinc) are brown, black or dark, deep green or 
greenish, according to the quantity of coloring matter. They 
do not melt when heated, they burn without flame, and leave a 
sooty residue. They are insoluble in ether and alkaline 
liquids. Treated by nitric acid, they pass successively through 
different shades of colors; green, blue, violet, red and yellow. 
To ascertain the composition of the calculi, Luton, of Rheims, 
has proposed a very simple method of analysis, which consists 
in subjecting a portion of the calculus to the action of solvents, 
hot alcohol, for instance, then allowing it to become cold; 
crystallization takes place and the microscope enables you to 
recognize the principal constituent elements of the calculus; rhomboidal plates of cholesterine, needles and bacillary 
crystals of cholate of lime, etc., etc. The following is a recent 
analysis of a biliary calculus of a woman thirty-four years of 
age (Bettmann): 
Cholesterine 79.00 
Fatty matters 0.80 
Water 7.41 
Mineral elements 3.23 
Glycocholate and taurocholate of soda 5.28 
Mucus and coloring matters 2.69 
Loss o-73 
Under the name of biliary gravel, Fauconneau-Dufresne 
classes only such concretions as are under the size of the 
smallest lentil, and which present no appearance of structure. 
He gives three varieties: cholesteric gravel, pigmentary gravel, 
and melanic or carbonaceous gravel. 
I have said that the size is variable; in fact from 
the calculus which is as large as a hen’s egg and fills 
the gall bladder, down to the little grains of sand 
constituting what Fauconneau-Dufresne calls hepatic 
gravel, you will find gall stones of all dimensions. 
You may also find calcareous concretions in the 
ducts; but this is a matter which it is not a part of our 
present plan to treat of, for this calcareous hthiasis 
never takes place except when, from some cause, the 
gall bladder becomes obliterated. These calculi, 
then, play no part in the production of hepatic colic, 
which is our present subject. What it is of import- 
ance for us to know is the pathology of these calculi, 
for if we understand the first cause of their produc- 
tion, we shall be able, from a therapeutic standpoint, 
to oppose their formation. I have said that the calculi are constituted by de- 
posits of cholesterine; what are the circumstances 
which lead to the precipitation of cholesterine ? We 
have to study the two following causes: either the 
cholesterine is precipitated because it is in excess in 
the bile, or the proportion of cholesterine remains 
normal, but the other elements of the bile undergo 
modification and lead to precipitation of the latter. 
Let us take up the cases where cholesterine is in 
excess, and here you must recall to mind what you 
know concerning its origin. Physiologists, as I have 
told you, are agreed in accepting Flint’s conclusions, 
deduced from his careful experiments, and in con- 
sidering this substance as a product of disassimilation 
of the nervous system. This experimental datum 
seems to be confirmed, in a certain measure, by clini- 
cal experience, for it is principally in women with 
highly developed nervous systems that you observe 
biliary lithiasis; and for my part, the more my atten- 
tion has been directed to this explanation, the more 
firm is my conviction as to its truth. 
It is chiefly young women, nervous and impres- 
sible, who are the subjects of hepatic colic. It is 
probable that in these cases the too active exercise 
of the cerebro-spinal axis explains the excessive pro- 
duction of cholesterine and its precipitation in conse- 
quence of over-production, and I am convinced that 
this circumstance has not been sufficiently taken ac- 
count of by the different authorities who have con- 
sidered this question. The second cause of the precipitation of choles- 
terine, i. e., the modifications of its vehicle, the quan- 
tity of this substance remaining the same, has been 
studied by Thenard, who has indicated, as a factor 
which may bring about this precipitation, the diminu- 
tion of the salts of sodium. Moreover, Bramson has 
shown that the appearance of lime in the bile may 
cause the precipitation of the coloring matter. Lastly, 
the bile which in the normal state is alkaline may be- 
come acid, and this is especially likely to take place 
under the influence of animal diet; and acid bile 
favors the precipitation of cholesterine. 
Moreover, as we frequently find a nucleus of 
mucus in these calculi, we must assign an important 
role to the inflammations of the bile ducts; these in- 
flammations cause a hyper-secretion of mucus which 
may give rise to a nucleus, around which the choles- 
terine deposits itself. 
Such are the physical and chemical causes which 
favor the production of calculi. Let us now inquire 
what are the individual causes. 
Women, as you know, are the most frequent sub- 
jects of biliary lithiasis, for statistics show that twice 
as many women as men suffer from this disease. 
(Durand-Fardel’s statistics (1868) show that out of 230 
cases, 142 were women, and 88 were men. Senac’s 
statistics, out of a total of 311 individuals, give 227 
women). With reference to individual causes, an im- 
portant part has been assigned to diet; it has been maintained that a too fatty regimen is one of the most 
prolific causes of biliary calculi. I believe this state- 
ment to be somewhat overdrawn. It has not, in fact, 
been proved, either by experimental or chemical ob- 
servations, that a diet exclusively of fatty food predis- 
poses more than any other to biliary lithiasis, and the 
observations which have been made among people 
living on oleaginous food, as the people of the far 
north, the Norwegians, the Esquimaux, etc., do not 
prove that they are more subject to hepatic colic than 
other nations which consume less of fatty substances. 
But if the influence of these fatty aliments is not 
demonstrated, there is another factor which in my 
opinion plays an important part in pathogeny, namely, 
allowing too long an interval to elapse between meals. 
Physiology in fact teaches that during digestion the 
bile flows in great abundance into the duodenum, and 
that the gall bladder nearly or quite empties itself at 
this time. We know also that one of the predominant 
causes of the precipitation of cholesterine in the bile 
is the prolonged sojourn of that liquid in the gall 
bladder. When the meals are too far apart, or when, 
as is the practice of some persons, only one meal a 
day is eaten, the gall bladder is placed in a favorable 
condition for the precipitation of cholesterine. 
There is another factor which also aids the flow 
of bile, viz., the respiratory movements, wTich by the 
pressure which they effect upon the gall bladder and 
the intestinal mass through the intermediation of the diaphragm tend to empty the gall bladder. Hence 
the influence of want of exercise on the production of 
these calculi is apparent, and it is in fact, sedentary 
persons whom we find to be the most subject to biliary 
lithiasis. Add that active respiratory movements 
favor the combustion of fatty matters, and you easily 
understand why we assign the first place to exercise 
in the hygiene of lithiasis.* 
The diatheses have a notable influence on the 
production of biliary lithiasis, and despite the opposi- 
tion of Durand-Fardel to the doctrine of Willemin 
who maintains that biliary lithiasis, like urinary 
lithiasis, depends on the uric diathesis, it is none the 
less true that we find more cases of biliary calculi 
among the arthritic than among any other class of 
people. 
Heredity seems also to play a prominent part in biliary 
lithiasis. Petit and Willemin cite examples, as also do Budd 
and Fauconneau-Dufresne. 
Senac, in studying the family health and constitution of 
patients who have consulted him, has so often met with differ- 
ent manifestations of the arthritic diathesis, that he believes 
this diathesis to be an important factor in biliary lithiasis. 
To the support of this view, he brings forward a certain 
* Consult the following authorities: Budd on Diseases 
of the Liver, London, 1857; Frerich's, on Diseases of the Liver, 
Wm. Wood & Co., 1879; Fauconneau-Dufresne, Treatise on 
Calculous Affections of the Liver; Willemin, on the Treatment 
of Hepatic Colic by Vichy Water, Beneke in Deutsch. Archiv. 
f. Klin. Med., 1876, etc., etc. number of observations which seem to place the matter beyond 
all doubt. 
According to Senac, individuals smitten with hepatic 
colic are not attacked in a state of health; the hepatic disease 
either succeeds existing pathological states or adds itself to 
states that have previously existed. Migraine, uric lithiasis, 
diathetic coryzas, hemorrhoids with or without hemorrhage, 
acute or chronic arthrites of rheumatic or gouty nature, urti- 
caria, eczema, acne rosacea, etc.; pregnancy, accouchement, 
menstruation, the menopause, suppression of a bloody flux or 
an habitual discharge, forced rest, the depressing moral emo- 
tions, affections of the liver, in fact all causes capable of modi- 
fying the hepatic circulation, may, it is said, determine the 
outbreak of hepatic colic. 
Beneke has also set forth the relation which exists 
between atheromatous degeneration of the arteries and 
biliary lithiasis. He has found that in three-fourths 
of his cases (350 autopsies made by him at Marbourg) 
there was atheromatous degeneration of the arteries 
along with biliary lithiasis.* To sum up, all the facts 
go to prove, as Bouchard has well shown, that the 
cause of biliary calculi resides essentially and primarily 
in a general disturbance of nutritionf. 
* Beneke, Gallensteintildung Atheromatose Arterienen- 
tartung und Fettsbildung (Arch. f. Klin. Med., 1876). 
f This is the way Bouchard expresses himself: “ Biliary 
lithiasis manifests itself only in individuals whose nutrition is 
retarded; in those affected with that nutritive vice of which 
one of the consequences is to prevent the destruction of acids, 
and to cause their accumulation in the organism, to diminish 
the alkalinity of the humors, to take lime from the anatomical 
elements, and with it impregnate the liquids of excretion.” 
(Maladies par Ralentissement de la Nutrition, p. 85), We know now the causes which are operative in 
the formation of calculi, and we have studied the an- 
atomy of the bile ducts. Let us now consider the 
mode of passage of gall stones in the different ducts, 
and the accidents which may result from their presence. 
In the immense majority of cases, calculi form in the 
gall bladder; this is where the major part of the bile 
accumulates and sojourns; nevertheless, in certain 
circumstances true biliary gravel has been known to 
be deposited in the hepatic bile ducts and to manifest 
its presence in the radicles of the hepatic duct and in 
the hepatic duct itself. But such facts are exceptional; 
ordinarily the calculus, when formed in the gall blad- 
der, may increase in size and remain there a long time 
without determining any symptom, and this is so true 
that at the autopsies of the aged women at the Sal- 
petriere, it may be said that it is the rule to find in the 
gall bladder calculi more or less voluminous, without 
any disturbance having been noted during life there- 
from. But at other times, calculi of little size pass 
with the bile into the cystic duct and thence into the 
ductus choledochus, and are voided by the intestine. 
These calculi may make their journey from the gall 
bladder to the intestine without causing any attack of 
colic, and in my own practice I observed several years 
ago, a very curious instance in one of my patients 
who had been passing by stool a considerable quantity 
of biliary gravel without ever feeling any colicky pains. 
At the same time, there generally ensues an aggregate of painful symptoms described under the name of 
hepatic colic. 
In 1873, I made with Dr. Audige (a) numerous 
experiments in order to obtain a clearer understand- 
ing of the way these gall stones pass through the 
biliary passages. We first of all discovered in animals 
that the bile ducts when irritated are the seat of a real 
spasm, which is, moreover, easily explained, if you re- 
call to mind the anatomical structure of these ducts. 
Then we artificially reproduced the attack of hepatic 
colic, for after having introduced into the common 
bile duct of dogs by the intestinal opening certain 
foreign bodies, we observed the extreme sensibility of 
these conduits in these animals and the mode of pass- 
age of the calculi, which by reason of the spasmodic 
movement of which the ducts are the seat, either travel 
towards the intestine or gall bladder.* 
This is a fact of capital importance, which even 
justifies the affirmation that when, in persons affected 
with biliary colic, you do not find the offending body 
(a) Dujardin-Reaumetz, Etude sur le spasme des voies 
biliaires, k propos du traitement de la colique hepatique (Bull, 
de therap., 1873, t. LXXXV, p. 305).—Audige, Researches ex- 
perimentales sur le spasme des voies biliaires, a propos du 
traitement de la colique hepatique. These de Paris, 1874. 
* These are the conclusions of the thesis of Audige: 
(1). The treatment of hepatic colic should consist in 
diminishing the contraction of the bile ducts and the pain 
therefrom resulting: (2). Anaesthetics and morphine em- 
ployed subcutaneously fulfill this end.” —the corps du delit—in the stools, you should not at 
once conclude that the calculus does not exist, and 
make the diagnosis of hepatalgia. It may happen, in 
fact, that the calculus, after having traversed the duc- 
tus choledochus a part of the way towards its intes- 
tinal opening, shall return to its starting point and fall 
back into the gall bladder. 
These experimental researches, which have since 
been confirmed by Laborde, demonstrate that in hep- 
atic colic there is a veritable painful spasm of the 
bile ducts.* 
I. The bile ducts are endowed with contractility, and 
may consequently enter into a state of spasm under the influ- 
ence of an excitation direct or indirect; this contractility is of 
the same kind as that pertaining to the smooth muscular 
flbresof organic life, and the existence of these fibres in the 
bile ducts is demonstrated both by histological examination 
and experimental physiology. 
* These are the conclusions of the work of M. Laborde: 
2. The mucous membrane of these ducts is endowed 
with a very high sensibility, which shows itself, under the ac- 
tion of excitants more or less intense, by pain and its expres- 
sion, and by certain reflex symptoms whose immediate manifes- 
tation is spasm of the ducts. 
3. These phenomena are especially determined by the 
presence and contact of foreign bodies (biliary calculi) whose 
spontaneous migration is, for that reason, rendered very diffi- 
cult, and is not effected till after a variable time; and there is this 
peculiarity attending this migration, that these bodies may re- 
turn to the gall bladder instead of passing downward to the 
intestine. 
4. Anaesthetics and antispasmodics are best adapted to  62 
Trousseau’s penetrating mind understood this 
spasmodic action of the bile ducts. In the very faith- 
ful description which he has given in his Clinical 
Medicine* of hepatic colic, he speaks of the ejacula- 
tion of bile into the intestine, and assigns a consider- 
able role to the muscular layer of these ducts. Senac, 
however, the author of a remarkable study on the 
treatment of hepatic colic published in 1870, has most 
clearly shown the importance of these spasms. Hence, 
from the point of view of general pathology, there is good 
warrant for placing the acute accidents determined by 
the passage of gall stones through the excretory ducts 
of the liver in the great group of colics, which, as 
the treatment of this morbid state, of which it is easy to realize 
experimentally the mechanical conditions. 
5. These medicaments, notably morphine, chloroform, 
hydrate of chloral, act by exercising an immediate anaesthetic 
and paralyzing influence, whence result the cessation of the 
spasmodic state, distention of the ducts, and the accumulation 
of bile, which acts upon the foreign body after the manner of a 
vis h tergo and forces it towards the intestine. 
6. The association of hydrochlorate of morphine with 
chloroform or hydrate of chloral (i. e., the simultaneous ad- 
ministration of these medicinal agents) constitutes the most 
powerful means for obtaining the results indicated, viz: anaes- 
thesia of the bile ducts and consequent cessation of pain, and 
a favorable influence on the migration and rapid expulsion of 
the foreign bodies. (Laborde, Experimental Study on the Con- 
tractility, Spasm and Sensibility of the Bile Ducts. Bull, de 
Therap., 1873-74. 
*Trousseau, Clirique Medicale de 1 Hotel Dieu de Paris. you know, are properly defined as the painful con- 
tractions of mucous tubes which have a muscular 
layer. 
Pardon me for dwelling so long upon these points, 
but you will see that from a therapeutic standpoint 
the recognition of the spasmodic element in hepatic 
colic is of the utmost importance. 
When a gall stone is formed, either it produces 
no marked symptoms, as I have before said, or it gives 
rise to two orders of phenomena, viz; the acute pain- 
ful symptoms of hepatic colic, or, as is sometimes the 
case, a train of obscure symptoms with slow evolution 
and often of difficult diagnosis. 
I can not here give you a lengthy description of 
hepatic colic, and must refer you therefor to your 
text books. I must however remind you that this af- 
fection, so rarely fatal, may be complicated with grave 
accompaniments. Sometimes there is an inflamma- 
tion of the bile ducts and gall bladder sufficiently in- 
tense to give rise to peritonitis of a more or less 
spreading character; in other cases less well known 
(and it is for this reason that I mention them), the 
pain is so sever as to produce lipothymia and fatal 
syncope.* 
* Hepatic colic may be preceded by prodromes: vague 
pains, cramps of the stomach, weight in the hepatic region; 
but often it begins suddenly by a pain which appears with or 
without appreciable cause, several hours after a meal. This 
pain rapidly attains its maximum. It is atrocious, paroxysmal; If hepatic colic in its ordinary form is quite 
easy of diagnosis, there are masked forms sufficiently 
common which often pass unperceived, and which at 
the same time by their symptoms indicate to the prac- 
ticed eye the presence of biliary lithiasis. We have 
it compels the patient to cry out. According to Durand-Fardel, 
the maximum of this pain is in the right hypochondriac region; 
according to Senac, on the contrary, it is in the epigastrium, 
and it is from this region that the pain radiates to the sides 
and posterior part of the body, to the vertebral column, to one 
or both shoulders, etc. 
The patients are taken with extreme restlessness, they do 
not find any comfortable position in bed. There is one posi- 
tion to which Durand-Fardel cells attention, which they seem 
to prefer, viz; the sitting posture with the body bent forwards, 
the head resting on the knees. 
At the beginning of the paroxysms, you sometimes ob- 
serve a severe chill, epigastric distress, with vertigo, nausea, 
and vomiting, first of food then of bile; sometimes, also the 
patients may have convulsions, hysterical attacks, etc. Coinci- 
dently with the first attack, jaundice may appear; it is how- 
ever sometimes wanting, especially in mild cases; it is variable 
both in intensity and extent, may remain limited to the sclero- 
tics, to the circumference of the nose, or mouth, or may in- 
vade the whole body. During the entire attack, you observe 
little or no change in the pulse and temperature. Pressure 
over the liver is painful, and it is with difficulty that by palpa- 
tion and percussion you can detect congestion of the organ. 
After the attack, the patients suffer from general lassitude, 
which is in ratio of the intensity of the attack; there is often, 
also, want of appetite, nausea and vomiting; the bowels are al- 
ways constipated; the urine is of a deep wine color, and con- 
tains the coloring matter of the bile. cases where gastric symptoms predominate, and Senac 
has also done well in insisting upon this point; in fact 
the majority of patients affected with gall stones 
(sixty-five per cent.) suffer from painful cramps in 
the stomach. This variety of dyspepsia called hepatic 
dyspepsia, which I mentioned while on the treatment 
of affections of the stomach, has been studied by Cor- 
nillon, who has called attention to its frequency.* 
* Fauconneau-Dufresne says also that we must refer to 
the accompaniments of lithiasis, many of the pains called 
cramps of the stomach, or regarded as spasmodic, neuralgic or 
rheumatic affections. 
Willemin also indicates a prodromic period, constituted 
by dyspepsia, or gastric troubles recurring more or less often. 
Senac has also noticed similar cases among persons sent 
to Vichy to be treated for “gastralgia” or “cramps of the 
stomach.” 
In some patients you have only these attacks of gastric 
cramp as a guide to diagnosis; in others, after the attack, you 
will notice that the urine is of a wine tint more or less marked;: 
sometimes there is a jaundiced hue of the skin, which suffices 
to clear up the diagnosis. 
Out of one hundred observations, Senac found sixty five 
in which the only symptoms were of a gastric order: 
Cramps of the stomach 26 ) , 
Gastralgias 20 \ 
Dyspepsia 19 
Pain in the epigastric region and in the back, 3 
Pain in the stomach and liver 3 
Hepatic pains 7 
Sudden onset of the affection by well marked hepatic tolic, 15 
Cases where the existence or absence of prodromes was 
not mentioned 7 
100 To these gastralgic phenomena we may add an- 
other symptom quite as characteristic, namely, the ap- 
pearance of remittent febrile attacks. Senac, who is 
so excellent authority on these subjects,* has shown 
that these intermittent attacks appear between four 
o’clock and six o’clock in the afternoon. They are 
accessions of little intensity, but in some cases, as 
Charcot has pointed out, they may take on the char- 
acter of real pernicious paroxysms like those seen in 
the worst forms of malaria. We have here something 
very similar to what takes place in connection with 
states of the urinary passages when you catheterize 
certain individuals. You well know that febrile at- 
tacks of an intermittent character are often thereby 
provoked. It is the same with the bile ducts, where 
the presence of foreign bodies is the occasion of simi- 
lar reflex symptoms. 
I can affirm the reality of these facts; so whenever 
you have a patient with the symptoms of painful dys- 
pepsia, in whom you observe a slight febrile move- 
ment coming on between four and five o’clock in the 
afternoon, especially if you notice a slight jaundiced 
hue which may be scarcely appreciable; moreover, if 
you find the region of the gall bladder sensitive and 
pain produced on pressure, you are warranted in 
affirming the presence of gall stones. 
As you see, I have dwelt at some length on the 
pathogeny and symptoms of biliary lithiasis. I have 
*Senac, Treatment of Hepatic Colic; 1870. deemed it necessary to do so, because, before under- 
taking the treatment, you should have mastered well 
the first causes of the lithiasis and its accompaniments, 
in order the more certainly and methodically to meet 
them. 
The treatment of biliary lithiasis should fulfil the 
three following indications; To meet and allay the 
symptoms determined by the presence of the calculus; 
to attempt the solution of the latter, if this be possible; 
lastly, to prevent their formation. Let us consider 
the first indication, viz.: to combat the pain. This, 
as before said, ordinarily takes the form of colic. 
I shall not concern myself with those rare cases 
which belong rather to the domain of surgery, and 
which are connected with ulceration of the gall 
bladder by the calculi and the passage of the latter 
through the abdominal walls, and shall restrict myself 
to the treatment of the colic itself. 
But before proceeding any farther, we must settle 
the question, Ought we to treat the colic at all ? I 
have told you, in fact, that the reflex and painful 
symptoms which characterize the colic are determined 
by the passage of calculi through the bile ducts; this 
passage is necessary; it is the only natural means of 
getting rid of the trouble. 
The attack of colic is then, as Durand-Fardel has 
said, a necessary evil, and we ought not, properly 
speaking, to treat the colic, if by the word treat we 
are to understand to oppose the passage of the calculus and its movements toward the intestine, which ought 
to be favored rather than hindered. 
But we ought to render this transit as easy and 
painless as possible; and our duty is to relieve the suf- 
fering of the patient. To attain this result, there are 
four great therapeutic agents which we may employ: 
morphine,* chloral, chloroform and antipyrine. 
Do not forget that one of the modes of introduc- 
tion of medicaments, namely by the primce vice, is 
often denied us by reason of the continual vomiting 
of the patient, and that we are obliged, in order that 
our medicines may be absorbed and do good, to in- 
troduce them by the skin, the rectum, or the respira- 
tory passages. Of these three channels the sub- 
cutaneous is the preferable one, and I recommend you 
to employ a combination of morphine and atropine, of 
which the following is a useful formula: 
IJ Morphinae hydrochloratis, 10 centigrams. 
Atropinse sulph., i centigram. 
Cherry laurel water, 20 grammes. 
M. 
Otie cubic c. m. of this solution, or a hypodermic 
syringeful, contains Yz c. g. of morphine and Y* m. g. 
of atropine. 
*A useful combination for hepatic colic is that known as 
chlorodyne or chloranodyne (P., D. & Co.), which contains 
chloroform and morphine. Dose, fifteen drops.—Tr. This treatment is to-day very generally adopted, 
but there are those who object to it. Senac has shown 
himself one of the most determined opponents of these 
injections, and from what follows you will understand 
the grounds of his opposition. 
In my experimental researches on spasm of the 
bile ducts, I had shown the reality of this spasm, and 
also explained the true mechanism of the colic; 
Laborde had confirmed these experiments, and our 
conclusion was a natural one, that morphine associated 
with atropine was the best remedial agent in our pos- 
session, as these alkaloids moderate the contraction of 
the smooth muscular fibres. But Senac, who had also 
taken up this idea of spasm, and was one of the first 
to put it in clear light, replied: “ The contraction is 
necessary to the transit of the gall stone, and by your 
morphine injections you hinder the passage of the cal- 
culus into the intestine and thus you retard the cure 
of your patient.” 
Who is to be judge in this dispute? Clinical ex- 
perience must decide. Never (and I emphasize 
the word never) in innumberable cases of hepatic 
colic have morphine injections appeared to pro- 
long colic, and always practitioners have obtained 
from these injections relief of pain. The explanation 
seems simple enough. We recognize the fact that 
morphine, like atropine, opposes to a certain extent 
spasm of the unstriped fibres, but who will say that 
when this spasm exceeds certain limits, instead of favoring the passage of the calculus, it does not arrest 
it in its course by excess of contraction ? However 
this may be, Senac has relaxed somewhat of his rigor, 
and to-day, like the greater number of physicians, he 
resorts to morphine injections in the most painful 
cases. 
Before having recourse to injections of morphine, 
which are to be reserved for cases of great severity, in 
hepatic colic of medium intensity you may employ- 
anodyne suppositories, of which the following is a 
good formula: 
5 Ext. belladonnae, I centigramme. 
Ext. opii, 2 centigrammes. 
Olei theobrom., 3 grammes. 
Cerse albse, q. s. 
M.—For one Suppository. 
Chloral is also an excellent medicament when 
given in lavement according to the method which I 
advise, and which consists in dissolving two or three 
grammes in a cup of milk, in which the yolk of an egg 
has been beaten up, Unfortunately, chloral cannot 
render us great service, for, generally, patients under 
the tyranny of their colic cannot retain these injec- 
tions. 
Lastly, there is another means which I advise you 
to employ whenever, after injections of morphine, the 
pain still keeps its intensity. I cannot describe the 
agony of some typical cases of hepatic colic; you 
must be present yourself and witness this suffering, the incessant cries of the patient, the almost 
delirous agitation which nervous patients man- 
ifest. In these cases you may use chloroform by in- 
halation, following the method which obstetricians 
have popularized, and which has been called obstetrical 
ancesthesia. Administer the chloroform delicately, i.e., 
pour ten, twenty or thirty drops upon a handkerchief, 
and let the patient inhale the anaesthetic; these inhala- 
tions you can repeat till you have obtained abatement 
of the pain with conservation of the intelligence. 
This, as you are aware, is Simpson’s obstetric method; 
which has been also defended by Campbell. (*) 
I have not spoken of the internal administration 
of chloroform, which Corlieu, a long time ago, ex- 
because administration by the stomach is very 
difficult, and because it is proved that this method is 
less efficacious than by the respiratory passages. I may 
say the same of the chloroform ointments in which 
some seem to have faith, but which hardly seem to me 
to have the merit of placebos. 
However, as saturated chloroform water has been 
vaunted by some authorities, notably Lesegue and 
Regnauld, you may employ this chloroform water 
for the intense pains in the stomach which individuals 
often suffer from who are victims of biliary lithiasis. 
Chloroform water is made by agitating a little chloro- 
*Gaz. des Hop. 1856. 
tUnion Medicale, 1847. form in pure water and allowing it to settle. The 
supernatant liquid which is decanted off contains a 
minute quantity of chloroform. If you administer 
chloroform water, you can prescribe it in the follow- 
ing way: 
1J Saturated chloroform water, 60 grams (2 f|) 
Orange flower water, 30 grams (1 f § ). 
Syrup of poppy, 30 grams (1 f § ). 
Sig.—A tablespoonful every quarter of an hour till the 
pains cease. 
The analgesic properties of antipyrine have been 
applied by Germain See to the treatment of biliary 
lithiasis, and the professor has shown us the benefits 
which may be derived from it. I have myself often 
had recourse to antipyrine in bilious colic, and in 
certain cases I have obtained real service therefrom. 
You can employ the hypodermic or the rectal method. 
The hypodermic injections may be thus formulated: 
Antipyrine, grams v. 
Water, grams xx. 
As these solutions are often painful, I prefer sup- 
positories of antipyrine, or small rectal injections con- 
taining a gram of the medicament. 
M. Sig. Inject a whole syringeful of this solution. 
To these principal means you may add iced 
drinks and especially iced milk, warm baths, cata- 
plasms over the hepatic region, and even the applica- 
tion of ice to the region of the liver. So much for the treatment of hepatic colic. The 
attack yields at the end of several hours or of several 
days, according to circumstances, then disappears al- 
most suddenly, and the patient finds the offending 
body in the stools. The diagnosis is settled; you 
know beyond doubt that the patient is affected with 
biliary lithiasis, and it is probable that he will again 
be afflicted in the same way. 
Do we possess any means of preventing these re- 
currences, i. e., is it possible to effect solution of those 
calculi which remain in the gall bladder ? In other 
words, is there a lithontriptic treatment of biliary 
calculus ? I believe we may reply categorically in 
the negative to this question, and at the same time, 
there is a certain number of remedies which are said 
to possess this property. 
The most noted certainly is Durande’s Solvent 
which consists of turpentine and sulphuric ether. 
Jean Francois Durande who died in 1704 was physician 
and professor of Botany in this city (Paris). His formula for 
the solution of gall stones was as follows: 
B Olei Terebinthinse, 3ij (8 grams), 
Sulph. ether, 3 iij (12 grams. 
M. Sig.—Half a teaspoonful to a teaspoonful in the 
morning, or night and morning. 
This remedy is to be given in the morning along with 
glycerine or syrup, and washed down with a little whey or 
broth. The same dose may be repeated in the evening. 
Durande recommended to continue the usage of his specific till the patient had taken 500 grams (or about a pint); the medicine 
to be suspended, if irritation of the stomach should follow. 
At the same time that he gave this preparation, Durandc 
subjected his patient to a severe regimen with emollients and 
sometimes even practised blood letting. 
Various modifications of Durande’s formula have been 
proposed, thus, the proportion of turpentine has been aug- 
mented (2 parts turpentine to one of ether) or the proportion 
of ether has been augmented (2 parts ether to one of turpen- 
tine). 
Turpentine is a very disagreeable remedy to take, 
and it is for this reason that its administration in cap- 
sules as Trousseau recommends, is preferable to the 
administration in emulsion: Trousseau’s method was 
to give one capsule of turpentine and two of ether 
several times during the day. 
Some have explained the action of the turpentine 
and ether mixture on the principle that gall stones in 
a capsule dissolve in such a menstruum. This chem- 
ical solution, however, is not as complete as you would 
suppose, but even admitting the chemical fact as true, 
it can not explain the results of the remedy when 
given internally. It is not to be supposed that these 
two substances when taken by mouth pass without 
transformation through the stomach and duodenum to 
reach the gall bladder by traversing the bile ducts, 
and there produce their solvent action. The explana- 
tion is then erroneous, and yet it must be admitted that 
this remedy has possessed and still possesses a great 
reputation based upon its clinical results, for there 
exist very many observations in which the employ- ment of this means has attenuated and distanced the 
attacks of colic. 
I do not believe that these favorable results imply 
the possibility of solution of the calculi, but they are 
doubtless due to the antispasmodic and calmative 
action of the ether and turpentine mixture, and 
not to any lithontriptic action. But however this 
may be, as the remedy easily fatigues the stomach, 
and as its antispasmodic properties are inferior to 
those of the other medicaments of which I have 
spoken, I think it is better to discard it altogether. 
What I have said of Durande’s “specific,” I 
would apply also to the terebinthinate soap proposed 
by Franck (a mixture of sweet almond oil, turpentine, 
and caustic soda), to chloroform, counselled as a solv- 
ent by Corlieu, Rouchut and Gobley, and I say the 
same of the choleate of sodium recommended by 
Schiff, of the succinate of iron, the effects of which 
Buckler has vaunted, and, in general, of all those sub- 
stances which have been considered as solvents of 
biliary calculi.* 
* Corlieu was the first to counsel the employment of 
chloroform as a solvent of calculi. His formula is as follows: 
9 Chloroform, grams ij. 
Alcohol, grams xvj. 
Water, grams ccc. 
M. 
Gobley has shown that cholesterine dissolves more rapid- 
ly in chloroform than in ether. Cholagogues have also a considerable part in the 
treatment of biliary lithiasis; by favoring the flow of 
bile they oppose one of the frequent causes of the de- 
position of cholesterine, and as podophyllin is one of 
the most powerful cholagogues known, you will not 
be surprised that it has been recommended in these 
cases, As for myself, I much prefer euonymin, and to 
all my patients affected with biliary lithiasis, I order- 
two of the following pills on going to bed: 
Schiff considers that the precipitation of cholesterine is 
due to want of cholate of soda and potash in the bile. He 
therefore counsels the administration of two or three grains of 
choleate of soda thrice a day; the medicine to be continued 
until the economy is thoroughly under its influence, as is 
shown by irregularity of the pulse, which becomes very slow 
by rest, and markedly accelerated by the movements of the 
patient. 
Buckler, of Baltimore, has advised chloroform, five drops 
every four hours, and the succinate of iron in the dose of a tea- 
spoonful after each meal. He affirms that the succinate of iron 
has the power to dissolve cholesterine even in the blood, by 
setting free a considerable quantity of nascent oxygen. Buck- 
ler has affirmed that by this process he has rapidly obtained 
the solution of all the calculi that he has been called upon to 
treat. 
Lothromp declares that for eighteen years he has treated 
with success more than twenty cases of biliary lithiasis with the 
succinate of iron alone. 
Dabney (Am. Jour. Med. Sc., 1876,) also vaunts the em- 
ployment of choleate of soda as a preventive of the formation 
of gall stones. He gives five grains twice a day. Enonymin, 
Castile soap, aa 3 grammes (gr. xlv). 
F. S. A. pil, No. xxx. 
The really curative treatment of biliary lithiasis 
is the thermal treatment, i. e., by the natural alkaline 
waters, and there are two spas especially whose 
waters are efficacious in these cases; I refer to Vichy 
and Carlsbad. 
You remember that while speaking of chola- 
gogues, I mentioned the want of agreement which 
exists on this point between clinicians and physio- 
logists, and I have shown you how we must explain 
the undoubted curative action of these waters. Surely, 
it is not by dissolving the calculus that these waters 
act, but by ameliorating the digestive functions, by 
regulating nutrition, by diminishing the hepatic con- 
gestion which almost always accompanies the presence 
of calculi, lastly, by modifying the bile itself. 
What differences exist between the waters of 
Carlsbad and Vichy, these two rival stations which 
possess an equal reputation acquired by innumer- 
able cures ? It is chiefly owing to their richness in 
sodium bicarbonate that the waters of Vichy are 
efficacious. And it is chiefly to sodium sulphate that 
we are to look for the curative element in Carlsbad.* 
*The Vichy Springs belong to Allier, a province in 
Central France. They are strongly alkaline; their temperature 
varies between 44° and 14° C.; their richness in sodium bicar- 
bonate is aoout 5 grammes per litre. There are 11 of these Of the various Vichy waters, the Hopital spring 
is the best for biliary lithiasis; the patient may drink 
a tumbler full four times a day. Of the Carlsbad 
waters, Sprudel is to be preferred. Add, that at this 
latter station the alimentary regimen is very severe, 
and at all the hotels patients are subjected to a 
uniform diet, which plays a considerable role in the 
treatment at these stations.* 
springs, of which 4 are cold springs, the waters of which are 
fit for transportation. 
We have no alkaline springs in this country comparable 
with these Vichy waters unless we except the Congress 
Springs, of California, which contain 2 grammes per litre of 
sodic bicarbonate; the Soda Springs of Wilhorts, Oregon, are 
also strongly alkaline. The Hathorn, Congress, High Rock, 
Vichy and other of the chloride of sodium waters of Saratoga, 
the St. Leon (Canada) are often prescribed for biliary lithiasis, 
and have proved useful in very many cases. 
The Carlsbad waters (Carlsbad, Bohemia), are the type 
of sodic sulphate waters. There are 10 principal springs, of 
which the most important is Sprudel. There are in every litre 
over 2 grammes sulphate of sodium, and 3 of carbonates of 
sodium, magnesium and potassium. The taste of the Sprudel 
water is salty, brackish and strongly alkaline. From two to 
three glasses are usually drank per day. These Carlsbad waters 
are alterative and laxative, and have a great reputation in 
Europe for biliary lithiasis.—Trans. 
*The Sprudel water gives a sensation of comfort and even 
of hilarity after drinking it. When taken in quantities not ex- 
ceeding half a tumblerful, it has little effect, but it becomes 
purgative after drinking from three to six glasses. This water 
also produces nervous disturbances of a very curious nature, Whether they act by the bicarbonate or sulphate 
of sodium which they contain, the waters of Vichy 
and Carlsbad produce essentially the same effect; i. e., 
patients experience almost always during the employ 
of these waters, or, as is most frequently the case, one 
or two months afterward, new attacks of colic, due to 
the passing of the calculi. But this is a necessary 
evil, as I have before shown you, and it is essential 
that for a period of years the patient shall periodically 
resort to these waters in order to get completely rid of 
the biliary lithiasis which causes the calculi. 
Other thermal stations have also been recom- 
mended, but they occupy a second rank in the treat- 
ment of biliary lithiasis. I refer to Vittel, Contrexi- 
ville, Niederbronn, and Capvern. The sodium sul- 
phate waters ought all to enter into this group of 
lithontriptic waters, and we must place at the head of 
these waters, not the Hunyadi Janos, which contains 
sulphate of magnesia, a salt which is but slightly 
cholagogue, but the Rubinat water, which contains 
sulphate of sodium in larger proportion than almost 
any other mineral water. 
After the employment of mineral waters, we must 
which may be compared to drunkenness; vertigo, dazzling 
sensations, loss of memory, etc. 
By evaporating Sprudei water, a salt is obtained very 
much in use in Germany as a purgative, and known as Carls- 
bad salt; the composition is almost exclusively sodium sulphate. 
Sprudei water contains 2.27 grammes of this salt per litre. assign the first importance to hygiene in the means at 
our disposal for the cure of lithiasis. The hygienic 
regimen should be absolutely based on the different 
physiological circumstances which, as I showed you at 
the beginning of this lecture, modify the excretion of 
bile. Cholesterine, as I have told you, is a product of 
the disassimilation of the nervous system; urge your 
patients then to avoid too intense mental emotions 
and everything that can cause undue exercise of the 
cerebro-spinal axis. 
We must, as I have before said, guard against 
stasis of the bile in the gall bladder. Recommend 
then exercise, active respiratory movements, which 
have for their effect both to oxidize fatty matters and 
hydrocarbons, and to exert pressure on the gall blad- 
der. Catarrh of the bile ducts, through the mucus 
which it engenders, may be the commencement of 
biliary calculi; counsel, then, avoidance of all the pro- 
ducing causes of catarrh and, and for this end forbid 
too highly seasoned foods, too generous wines, and 
too abundant meals. 
Lastly, from the point of view of diet, without 
absolutely forbidding fatty foods, I would advise a 
very moderate use of fats, and urge you above all to 
insist upon a vegetable rather than an animal diet, for 
it seems to be demonstrated that it is the acidity of 
the bile which most favors the precipitation of choles- 
terine. and this acidity may be produced by a diet 
largely nitrogenous; but you should be very chary in the permission of starches and sugars, and ever keep 
before you the excellent precepts given by that master 
in dietetics, Prof. Bouchardat, as well as the therapeu- 
tic indications which have so recently been formulated 
by Prof. Bouchard. 
Bouchardat’s alimentary regimen for biliary lithiasis is as 
follows: 
Eat moderately, abstain from soups containing sorrel, 
tomatoes, etc., and from strong liquors; regulate the employ- 
ment of tea and coffee according to their effects. One egg and 
never more during the day, or entire abstinence from eggs. 
Meats of all kinds (butcher’s meat, fowl, game) may be per- 
mitted, but must be used with moderation. 
It is necessary to be still more reserved in respect to fish, 
lobsters, cray fishes and crabs, shrimps, and other shell fishes, 
as well as old cheese. Milk and fresh cheese are unobjection- 
able. The vegetables and legumes of the season are almost all 
indicated, and should be a part of every day’s fare. I would 
particularize spinach, lettuce, chiccory, artichokes, cucumbers, 
carrots, parsnips, sweet potatoes, asparagus, green beans and 
peas in moderate quantity. 
Potatoes are useful and should in part replace bread at 
meals; bread, in fact, ought to be eaten moderately, and the 
crust is preferable to the rest of the loaf. Common radishes 
and black radishes may be eaten freely, also cabbages, cauli- 
flowers, Brussels cabbage, mushrooms, truffles, chestnuts and 
other nuts; beans and lentils in moderate quantity are per- 
mitted. 
The daily use of water cresses or of salads, lettuce, en- 
dives, chiccory, Indian cresses, dandelion, corn-salad, viper’s 
grass, etc., is allowable. 
All the fruits may be freely eaten (raspberries, peaches, 
bananas, strawberries, prunes, figs, etc.) The “grape cure” 
is often beneficial. Olives, almonds, pistachio nuts, etc., in moderate quantity. Little or no beer; the only alcoholic 
beverage, red or white wine with twice or three times as much 
water. The sparkling wines are contra-indicated, as well as 
the effervescing waters. 
For constipation, Bouchardat recommends to be taken 
in the morning in sweetened lemonade, a tablespoonful of a 
mixture of equal parts of Rochelle salts and Glauber salts. 
The healthy function of the skin should be promoted by a 
sponge bath in the morning, followed by a brisk rub-down 
with a dry towel or flesh brush, or the naked hand, oiled with 
a little sweet oil. Once or twice a week, a hygienic alkaline 
bath (three ounces carbonated potash, half a drachm of essence 
of lavender, a drachm and a half of compound tincture of 
benzoin to the water of the bath). These baths to be followed 
by prolonged rubbing and massage. 
Lastly, to prevent the formation of calculi, take for the 
first ten days of the month, morning and evening before meals, 
a pill containing a grain and a half of tartrate of potassa and 
lithia; each pill to be washed down with a tumbler of water. 
For the ten following days, morning and evening, a table- 
spoonful of a mixture containing the syrup of five roots with a 
little acetate of potassium. [May be replaced in American 
practice by the syrup of buckthorn, or the cascara cordial to 
which acetate of potassium may be added.] For the ten suc- 
ceeding days of the month, a quart of water every day con- 
taining in solution a couple drachms of Rochelle salts. 
In the spring, the patient may take to advantage every 
morning on rising, four ounces of the juice of herbs (lettuce, 
ehiccory, dandelion), with 75 grains of acetate of potash. This 
to be followed up for a month. 
According to Bouchard, the pathogenetic conditions of 
tfie production of gall stones are as follows: 1, Excess of 
cholesterine; 2, Lack of fatty acids; 3, Lack of biliary acids; 4, 
Lack of alkaline bases; 5, Excess of acids in the organism; 6, 
Lime in solution in the organism. These unfavorable conditions may depend on the diet, 
on digestion, on the hepatic function, on general nutrition, and 
on respiration. 
In respect to diet, we should exclude brains, blood pud- 
dings, and the yolk of egg. The ternary aliments should be 
used with extreme moderation, and fats should be preferred to 
sweets and starches; farinaceous substances should enter as a 
very small part into the diet, as well as leguminous substances, 
being too rich in starch and in lime. Green vegetables and 
fruits may be sparingly indulged in, notwithstanding the lime 
and vegetable acids which they contain, sweet effervescent 
drinks, and especially the sparkling wines, beer, cider, etc., 
are to be interdicted, but red wine and coffee may be permitted. 
Hard drinking waters are to be avoided; in fact, the purer the 
drinking water the better. 
To favor the biliary secretion, the sodic chloride or sodic 
sulphate or magnesia sulphate waters are to be recommended 
(Blue Lick, Lansing, St. Leon, Saratoga and Ballston waters, 
Freidrichshall, Hombourg, Kissingen, Marienbad, Brides, 
Pullna, etc.). It is a good plan to send patients to the warm 
springs of Vichy, or, better still, to Carlsbad. 
To promote the general nutrition, you should have re- 
course to all the great stimulants of the nervous system which 
energize the metamorphoses of the economy. Recommend 
frictions of the skin, cold affusions, warm salt baths, cold sea 
baths, exercise in the open air, sea air, mountain air, corporal 
exercise to be taken fasting and several hours after meals. 
(Bouchardat on the Hygienic Treatment of Biliary Lithiasis, 
(Bull, de Th6rap., t. xcix, p. 145). Bouchard, Maladies par 
ralentissement de la nutrition, Paris, 1882, p. 102). 
Along with the purely medical treatment I must 
allude to the surgical treatment of biliary lithiasis. 
Emboldened by the success attained by antiseptic methods in operations practiced upon the peritoneum, 
certain physicians have proposed to open the gall 
bladder for biliary obstruction. When the gall blad- 
der is distended by large calculi, and the outflow of 
bile is thereby hindered, these surgeons, following the 
lead of Godefroy Muller who performed cholecysto- 
tomy about the middle of the last century, have ad- 
vised to cut into the gall bladder, and remove stones 
contained in this sac. 
Cholecystotomy has been performed by Lawson 
Tait, of England, by Bernays, of St. Louis, by Parkes, 
of Chicago, by Langenbrich, of Berlin, by Musser 
and Keen, of Philadelphia, etc. 
Some have gone even farther in this direction, 
and have proposed completely to extirpate the gall 
bladder and to substitute cholecystectomy for chol- 
ecystotomy. 
The future must decide as to the practicability 
and safety of such surgical interference. It must 
however be admitted that a great number of surg- 
eons of our country are becoming every day more 
strenuous advocates of cholecystotomy. 
Cholecystotomy was practiced about the middle of the 
last century by Godefroy Muller, who opened up a biliary 
fistula, and following it to the gall bladder, broke up a cal- 
culus and removed it by piecemeal. Afterwards the opera- 
tion went into oblivion. Since the progress of the antiseptic 
method, there has been a revival of interest in cholecysto- 
tomy, and recently Drs. Musser and W. W. Keen, of Phila- 
delphia, have compiled thirty-five cases in which this opera- tion has been performed, in twenty-five of which it was suc- 
cessful. 
In cases of biliary lithiasis with perceptible swelling of 
the gall bladder, two kinds of operations have been proposed; 
the incision of the gall bladder and removal of the calculus, or 
complete extirpation of the gall bladder. Before proceeding 
to either of these operations, it is necessary to confirm the 
diagnosis by suitable exploratory methods. 
Aspiration is often innocuous, but it may give rise to 
accidents such as haemorrhages or local peritonitis. Through 
the aspirating needle it is possible to pass a fine probe by 
which to percuss the calculi. But, according to Keen, the 
most certain result is furnished by acupunctures. With small 
steel needles, you may perforate the gall bladder with safety, 
and determine the presence or absence of calculi. 
Lastly, the exploratory incision, ordinarily harmless 
when it is practised with antiseptic precautions, is the best 
means of detecting calculi in the gall bladder, while enabling 
you to complete the operation at the same sitting, if the gall 
bladder be found to contain stones. 
The different stages of the operation have been carefully 
mapped out. 
The incision is made over the centre of the tumor hori- 
zontally with the lower border of the ribs. It must be large 
enough to enable the operator to explore the deep parts. The 
knife should be carried to either side as far as may be neces- 
sary. All oozing of blood must be stopped before opening the 
peritoneum. The latter having been penetrated by an opening 
large enough to admit the finger and even the hand if neces- 
sary, the exploration of the gall bladder, of the cystic duct, 
and of the neighboring parts is made with care. If impacted 
gall stones are found, the gall bladder is opened, emptied of its 
calculi, and a biliary fistula is established by attaching the 
opening in the bladder to the lips of the abdominal wound. 
The fistula gets well in a few days. The gall bladder has also been removed, but the dissec- 
tion is difficult, gives rise to haemorrhage, and is much the 
more dangerous operation.* 
Pardon me, gentlemen, for having so long dwelt 
on the treatment of biliary lithiasis, but this is a disease 
of the liver very common in our climate and one 
which you will often be called upon to treat, and I 
trust I have givep you hints which will be of use to 
you in your practice. 
’Articles by Drs. Keen and Musser in the American Journal of 
Medical Sciences, October, 1884, and Braithwaite’s Retrospect, Part 91, 
page 249. See also Medical Record, Vol. xxvii, page 499, and Vol. xxviii, 
page 716. Brun has summed up the'observations down to the date of his 
writing in an article in the Archives G&idrales de M&tecine, January, 1885. CHAPTER IV. 
TREATMENT OF JAUNDICE. 
Summary.—Symptoms of Jaundice, Causes—Jaundice by Ob- 
struction—Spasmodic Jaundice—Pathological Physiology 
of Jaundice by Obstruction—Treatment of Catarrhal 
Jaundice—Hygienic Treatment Medical Treatment— 
Symptoms of Acholia—Jaundice without Obstruction— 
Pathological Physiology of Jaundice without Obstruction 
—Therapeutic Indications—Grave Jaundice—Pathologi- 
cal Physiology of Grave Jaundice—Therapeutic Indica- 
tions. 
Gentlemen;—ln the previous lecture I alluded 
to a symptom which almost always accompanies biliary 
lithiasis, viz.: jaundice. I have reserved the consid- 
eration of this symptom, so common in affections of 
the liver, for the present lecture, and shall now study 
the subject at some length, with the therapeutic indica- 
tions pertaining thereto. 
You know that jaundice is characterized by the 
passage of bilirubin in the blood and in the different 
humors of the economy; you know also that besides 
the yellowish color of the integument and conjunctivse, 
which is the result of the impregnation of the blood 
by this principle, you find in the urine a sure and pre- 
cise means of diagnosis by detecting there the pres- 
ence of bilirubin. One of the most certain tests is the 
action of nitrous nitric acid, and the multiplicity of 
colors which it causes; another is the emerald green tint obtained by tincture of iodine, or the azotite 
(nitrite) of potash.* 
When you take a general survey of the pathogeny 
of icterus considered as a symptom of hepatic affec- 
tions, you find that this symptom sometimes accom- 
panies obstacles to the excretion of the bile; some- 
times, on the contrary, these obstacles do not exist, 
and the bile flows freely into the intestine, but jaundice 
none the less ensues; lastly, sometimes the jaundice is 
* Jaundiced urine is of a more or less deep greenish- 
yellow color, and stains linen. As a test for bilirubin, the 
nitrous nitric acid test is the best. Filter a little of the urine, 
and from a pipette, let fall a few drops of this acid (nitric, with 
a little nitrous) on a small quantity of the filtered urine in a 
test-tube. You observe a play of colors: green, blue, violet, 
red and yellow. 
In doubtful cases, you can employ the following means; 
Agitate a little of the urine with hot chloroform, which dis- 
solves bilirubin, then pour off the chloroform, filter and drop in 
a little nitric acid which floats upon the chloroform; the play of 
colors is produced if there be bilirubin present. 
The tincture of iodine test is applied in this manner: 
Filter a little of the urine and add a few drops of tincture of 
iodine. A beautiful emerald green color is produced. 
Heller proposes this test for doubtful cases; He adds a 
little albumen to the urine, then drops in the HNOs which 
gives to the albumen the play of colors previously described. 
Pettenkofer’s test for the bile acids is the addition of a 
little strong H2 S04, drop by drop to a small quantity of the 
urine to which sugar has been added (one part sugar to four 
parts urine). The mixture is stirred with a glass rod, and first 
takes on a violet then a purple-red color. attended with severe and speedily fatal symptoms and 
constitutes, both by its own violence and the compli- 
cations which it determines, a disease of the utmost 
gravity. 
Hence we have three great divisions of jaundice, 
each of which demands different treatment; icterus 
without obstruction, icterus with obstruction, and 
grave icterus. 
But, do you ask me now, from a clinical point of 
view, how can we recognize these three varieties 
of jaundice? Nothing is more simple. In patients 
affected with jaundice, the faecal matters either contain 
bile and are colored, or they contain no bile and are 
colorless. 
In the latter case you have to do with icterus with 
obstruction, and in the former with icterus without 
obstruction. Does a case of jaundice present itself 
with a train of symptoms bespeaking a state of general 
constitutional infection ? i. e., with nervous, febrile or 
grave adynamic disturbances? You have before you, 
either a case of grave primary icterus, or a case of 
“ aggravated ” icterus, a variety of grave icterus be- 
longing properly to the terminal period of several 
attacks of hepatitis. Hence, as you see, nothing is 
easier than this diagnosis when once you have detected 
the passage of bilirubin into the blood and urine. It 
suffices to examine the stools and general symptoms 
to determine the kind of jaundice. 
Let us then examine the first of these groups, i. e., icterus by obstruction: the causes are subdivided into 
three groups. In the first group, the cause resides 
within the bile ducts themselves, as in biliary lithiasis, 
where the calculi obstruct more or less completely 
the excretory conduits, and determine an icterus which 
may be temporary or persistent. 
Besides biliary calculi, authors have also admitted an 
icterus caused by obstruction of the ducts, due to thickened 
bile (Murchison and Frerichs); to foreign bodies (Saunders); 
to lumbrici, to hydatids, to distomata. 
Jaundice may also be caused by a congenital absence or 
obliteration of the duct (fatal icterus of new born children); by 
a swelling of the bile ducts, due to perihepatitis; by an oblitera- 
tion of the orifice of the choledochus by reason ol an ulcer of 
the duodenum (Murchison); by cicatrices resulting from ulcers 
caused by presence of calculi, etc. Tumors within the bile 
duct may also cause obstruction, but ordinarily the compres- 
sion comes from tumors in the vicinity—tumors of the liver, 
cancers, hydatids, hypertrophied lymphatic glands, tumors of 
the stomach, of the pancreas, of the kidneys, etc., aneurisms, 
(Frerichs), the gravid uterus compressing the common bile 
duct, and ovarian or uterine tumors. 
In the second group, the cause of the icterus is in 
the walls of the bile ducts, as in catarrhal icterus, where 
the jaundice is determined by inflammation of the 
ductus choledochus, which produces swelling of the 
mucosa and the formation of mucus plugs which op- 
pose the passage of the bile. 
It is in the same group that authorities would 
place the so-called spasmodic icterus, i. e., icterus 
determined by contraction of the muscular tunic of the bile ducts, said to be at times sufficiently intense 
to prevent the excretion of the bile. But I utterly 
deny the existence of this spasmodic icterus, and al- 
though I fully believe in the possibility of spasm of 
the choledochus duct, my experiments have shown 
that this spasmodic action is never intense enough or 
persistent enough to be the cause of anything like 
prolonged arrest of the passage of the bile. 
Lastly, in the third group of jaundice by obstruc- 
tion the cause of the jaundice resides outside of the 
bile ducts. We have, in fact, to do with all kinds of 
tumors compressing these ducts and thus opposing the 
outflow of bile. 
I have just stated that whenever, from any cause, 
the bile does not flow into the intestine, jaundice ap- 
pears. 
There are several explanations of this fact. Some 
believe that the biliary secretion is suppressed by 
virtue of the obstruction. The liver, they say, simply 
separates the bile from the blood, and when this sep- 
aration does not take place, the bile accumulates in 
the blood and causes symptoms of jaundice. This 
theory, which is called the functional theory, is similar 
to that which is invoked in explanation of the uraemia 
which supervenes when the ureters are tied in an 
animal. But this interpretation which is quite ap- 
plicable to the kidney, is not applicable to the liver, 
because, as I have already told you in the previous 
lecture, the hepatic gland does not simply separate the materials of the bile from the blood, but forms de novo 
from that fluid the principal elements of this secretion. 
The second explanation is more physiological. 
It affirms that the bile when it accumulates in the ex- 
cretory ducts is absorbed and passes back into the 
blood. The experiments of Heidenhain, and especially 
of Picard, of Lyons, have in fact shown that very ac- 
tive absorption goes on in the mucous membrane of 
the bile ducts. I believe, then, that this latter theory, 
called theory of resorption, is the only one which ex- 
plains the facts now before us. 
But with what rapidity does this absorption of 
bile take place. The experiments which Audige and 
myself have undertaken have convinced us that the 
passage of bilirubin into the circulation is more rapid 
than is generally supposed. 
We have, in fact, shown that when you tie the 
common bile duct in a dog, and examine the urine, 
it is four hours after the ligature before the first traces 
of bilirubin appear in that excretion. 
This was the view which Saunders defended in 
1795, but which has been in our time combated by 
Frerichs, who affirms that the passage of bile into the 
urine does not take place until at the end of from 18 
to 30 hours.* 
* Frerichs, Treatise on Diseases of the Liver; Saunders, 
Treatise on the Liver; Dujardin-Beaumetz and Audige, loc. cit. 
Wickham Legg has made some experiments on cats in 
which he practised ligature of the bile ducts. He affirms What are the therapeutic indications in icterus 
by obstruction ? 
First, remove the obstacle if it be possible, and 
favor the flow of bile, then combat the symptoms 
which are due to this obstruction. To fulfil the first 
indication, we have already seen what must be done 
when the obstacle is a gall stone. 
What now should be the treatment when the 
obstacle is a mucous plug. In other words, what is 
the treatment of that most common form of jaundice, 
catarrhal jaundice ? This jaundice, bear in mind, is 
the result of an inflammation of the bile ducts, an in- 
flammation which is generally secondary, and the con- 
sequence of an irritation of the upper part of the in- 
testine (the duodenum). This mucous plug which 
obliterates the biliary conduits and thus explains the 
catarrhal jaundice, is not a matter of theory, a mere 
assumption, and Vulpian has demonstrated its un- 
doubted existence in animals. How will you treat 
that in this animal the icteric hue of the conjunctiva ap- 
pears but tardily. Most of the animals died in from two to 
twenty-nine days after ligature of the ducts. Two of the sur- 
viving animals were killed from twenty-seven to twenty-nine 
days after the operation, but in these cases the ducts were 
found not to be absolutely impervious, some bile still filter- 
ing through into the duodenum despite the ligature. In all 
these observations there was a notable augmentation of the 
connective tissue of the liver, although the hepatic cells seemed 
to be intact.* 
*Wickham Legg, on “ The Changes in the Liver which follow 
Ligature of the Bile Ducts,” St. Bartholomew’s Hospital Reports, 1873, 
page 161. this cholecystitis ? By hygienic means, on the one 
hand, and therapeutic means on the other. 
The hygienic means pertain principally to the 
dietary, and especially to milk diet. In fact, this 
gastro-duodenitis, which has brought about by con- 
tiguity and continuity of morbid action the chole- 
cystitis, is generally the result of a too excitant or too 
abundant diet. 
Our duty in these cases is to let the organ rest, 
but as this means if fully carried out is incompatible 
with life, you should advise the kind of food which is 
the least irritating. Recommend, then, to your patients 
to employ a milk diet exclusively. You may add 
alkalies and alkaline waters, which regulate the func- 
tions of nutrition, calm irritation of the primse viae, 
and favorably modify the hepatic circulation. 
Then, again, you should stimulate the biliary 
secretion, in order to endeavor to overcome the ob- 
stacle causing the jaundice. You may give podophyl- 
lin, euonymin, or calomel, drawing largely from the 
group of cholagogues of which. I gave you a descrip- 
tion in a former lecture. You will especially employ 
those which have a manifest purgative action, and for 
this reason, that the intestinal acholia, which is the 
result of the obliteration of the bile ducts, always en- 
tails more or less obstinate constipation. 
Make use, then, of the saline purgatives with a 
sodium sulphate basis, or the mineral waters, such as 
Carlsbad and Rubinat, which owe their activity prin- cipally to this salt. Employ also an excellent method 
prescribed by Krull, i. <?., give to your patient twice a 
day a large enema of cold water. You know that 
Vulpian has shown that in animals these irrigations of 
cold water have a powerful cholagogue action.* 
Such are the most common and useful therapeutic 
measures in this affection; by their use the catarrhal 
jaundice may disappear quite promptly, but in other 
cases it is more persistent and may last for months. 
It will be necessary then to have recourse to other 
means which fulfil the second indication mentioned, 
viz.; to combat the symptoms caused by the passage 
of bilirubin into the blood. This therapeutic indica- 
tion is especially applicable to persistent and chronic 
icterus, which manifests itself constantly by such 
symptoms as these: there is obstinate constipation, 
but this is not all—the intestinal acholia also prevents 
regular absorption from the surface of the intestine. 
Recall to mind what 1 told you, when lecturing on dis- 
eases of the intestines, respecting the utility of bile 
from a digestive point of view. Bile excites the peri- 
staltic movements and clears the bowel, neutralizes 
the acidity of substances peptonized by the stomach, 
* Krull recommends to slowly inject, by the Davidson’s 
®r fountain syringe, from one to two quarts of water, tempera- 
ture about 50° F. The patient should keep up the injection as 
long as possible. (Krull On the treatment of catarrhal jaun- 
dice by rectal injections of cold water, Bull, de Therap., t. 
XC, iii, p. 212). and, to a certain extent, opposes the fermentation of 
matters contained in the intestine, and perhaps favors 
the digestion of fatty substances. Hence the phe- 
nomena which have been noticed in jaundice by ob- 
struction: retardation in the functions of nutrition, 
bleaching of the fecal matters, which often have a 
horribly foetid odor. Such are the symptoms pro- 
duced by acholia. 
We must endeavor, as far as possible, to antagon- 
ize these bad effects. We must give purgatives, we 
must administer food in little quantity and such as 
demands but little work on the part of the intestine, 
we must also take care that what the patient eats shall 
not give rise to too active a fermentation in the in- 
testine; and the most of these indications, it must be 
admitted, are met by an aliment whose utility I cannot 
too much extol, viz; milk. 
You want especially to combat here the symptoms 
arising from intestinal putridity, which result from 
absence of bile in the intestine; bile being, as I have 
told you, an antiseptic agent of the first order. For 
my part, I am persuaded that in explaining the nerv- 
ous symptoms which ensue in prolonged cases of 
jaundice, we should make much account of the pene- 
tration into the economy of putrid substances and of 
ptomaines absorbed from the surface of the intestine. 
Many means have been advised. Some have pro- 
posed wood charcoal, others iodoform, others, as 
Bouchard, naphthalin or naphthol; for my part, I recommend you to employ sulphide of carbon water, 
of which I have often spoken to you before, and whose 
formula is as follows: 
5 Pure sulphide of carbon, 25 grams. 
Water, 500 grams. 
Essence of peppermint, 30 gtt. 
M.—Place in a flask capable of holding 700 cubic centi- 
metres. Shake the mixture and allow it to settle. Decant 
off the clear solution when needed. Renew the water as fast 
as it is poured off from the flask. You may give every day five 
or six tablespoonfuls of this carbon bisulphide water, taking 
care to dilute each dose in half a tumbler of milk. 
In employing this simple remedy, you will see the 
foetidity of the stools rapidly disappear in the most 
intense cases of jaundice by retention. 
Bilirubin produces very painful cutaneous itch- 
ing. I have known patients in whom this symptom 
became a veritable torture, and you must expect to 
witness this pruritus at advanced periods of icterus. 
What succeeds best in these cases is massage and 
vapor baths, which temporarily allay this annoying 
pruritus. 
Lastly, bilirubin, in being absorbed into the blood, 
determines phenomena very similar to those caused by 
digitalis, i. e. it slows the pulse and circulation. 
Icterus even modifies the state of the heart muscle, 
and gives rise to a cardiac murmur which has been 
studied especially by Potin, Gangolphe, Morel, Fabre, 
Tessier, of Lyons, etc. Moreover, it alters the blood crasis and gives rise to hemorrhages, of which Mon- 
neret has treated at length. It produces also in the 
mental functions a very peculiar modification to which 
alienists have called attention, which manifests itself 
principally by hypochondriasis and profound gloom.* 
*Frerichs, in the case of icterus has seen the pulse fall 
28 or more beats. Besides the slowing of the pulse a dis- 
turbance of the heart rhythm has been noted, and this disturb- 
ance has been known to last for several weeks. This slowing 
of the pulse had been before noted by Bouchard. Rohrig, 
Feltz, and Ritter have shown that the injection of bile and in 
particular of the biliary acids, into the blood immediately pro- 
duces slowing of the pulse and heart. 
The study of the alterations of the heart produced under 
the influence of icterus is of quite recent date. These alterations 
manifest themselves by a bruit de souffle whose origin is not yet 
well known. * * * This peculiar mitral murmur is accom- 
panied by a presystolic bruit de galofi. According to Fabre, 
there are three kinds of cardiac troubles in icterus; troubles in 
the innervation of the heart, troubles in the nutrition of the 
left ventricle, and dilatation of the right ventricle. 
As for the intimate mechanism of this cardiac change, it is 
very obscure. Morel, of Lyons, maintains that these disorders 
depend on an elevation of tension in the cardio-pulmonary 
system, whose mediate cause is an excitation of the sympathetic 
filaments of the abdominal viscera, an excitation first con- 
veyed to the bulbus, then reflected upon the cardio-pulmonary 
organs, (a) 
(a) Louis Gangolphe, On the mitral bruit de souffle in Icterus, 
Thfese de Paris, 1875; Morel, Experimental Researches on the Pathology 
of Lesions of the Right Heart consecutive to certain principal diseases of 
the Liver and Intestines, These de Paris, 1880; Laurent, Modifications of 
the Heart-sounds in Cirrhosis of the Liver, Thfese de Paris, 1880; Fabre, 
Fragments of Clinical Medicine, 1881, p. 194. How are you to treat these symptoms ? Princip- 
ally by favoring as far as possible the elimination of 
bilirubin from the blood, and in seeking to accomplish 
this you will have to avail yourself of the two great 
emunctories the kidneys and lungs. 
Respiration has an important office in the com- 
bustion of the coloring matter of the bile, which be- 
longs to the group of carbon compounds, and Frerichs 
has rightly insisted on the utility of compelling the 
patient to live out of doors, take long walks and in- 
dulge in gymnastic exercises. 
The kidneys play an important part in the elimin- 
ation of bilirubin, and we find constantly in the urine 
of jaundiced patients a considerable quantity of this 
coloring principle. You must, then, promote the 
elimination of this substance, and you will see, when I 
come to speak of grave icterus, that if, for any reason, 
this emunctory becomes obliterated in the icteric, 
accidents of high gravity supervene. Therefore, lam 
fully of the opinion of Decaudin * respecting the 
functions of the kidneys in jaundice, and ascribe to 
that organ an important role in the production of 
malign icterus. You ought then, in chronic icterus, 
The alterations of the kidneys in jaundice have been but 
recently studied. Vogel, Kolliker and Leyden, have shown 
how variable is the quantity of urine excreted in 24 hours by 
the icteric. Wickham Legg affirms that ligature of the bile 
ducts is accompanied with polyluria; Feltz and Buckler have 
* These de Paris, 1878. to administer diuretics and especially milk, that ad- 
mirable medicament, which, fulfilling special indica- 
tions pertaining to digestion, also assists the elimina- 
tion of bilirubin by the urine. 
Support also the forces of the patient, do what 
you can to prevent hemorrhages; oppose the evils 
resulting from retardation of the circulation, by sub- 
jecting your patient to a tonic treatment of which 
quinine shall be an important element. Prescribe 
journeyings and change of scene; you will thus divert 
your patient’s mind from constant brooding over 
his disease, and thus antagonize the gloom and depres- 
sion of spirits so common to icteric patients. 
Under the influence of persistent obliteration of 
the bile ducts, there is produced, at first, an abnormal 
dilatation of the biliary net work and of the gall blad- 
der, then, secondary alterations of the liver, veritable 
scleroses, well described by Prof. Charcot, which we 
shall study more fully when we come to the subject of 
hypertrophic sclerosis. Two therapeutic means have 
been proposed for this dilatation of the biliary pas- 
sages and gall bladder—aspiration or paracentesis of 
shown that the injection of bilirubin into the blood has the 
same effect. 
When the icterus is prolonged, there sometimes takes 
place in the renal ducts a deposition of pigment which alters 
the epithelium, and gives rise to pigment cylinders in the urine, 
which have been observed by Budd, Johnson, Virchow, Noth- 
nagel and Gubler. the gall bladder, and electrization, according to the 
method of Gerhardt, of Wurzbourg.* 
Such are the therapeutics of icterus with obstruc- 
tion, and although this treatment seems simple, pre- 
cise, and adapted to the different indications which re- 
* The alterations of structure consecutive to ligature of the 
common bile duct have been studied by Wickham-Legg, Charcot, 
Gombault and Chambard. They are characterized by the fol- 
lowing signs: the perilobular ducts begin first to dilate, then 
there is an inflammation around these canaliculi, and this 
peri-angiocholuis leads to the production of connective tissue 
fibres constituting a veritable experimental sclerosis, which 
Charcot describes under the name of insular and uni-lobular 
sclerosis. 
Ducastel pointed out this kind of peri angio-cholitis in a 
case of biliary calculus which was lodged in the ductus chole- 
dochus. (W. Legg, in St. Bartholomew’s Hospital Report vol. 
xii, p. 23: Charcot and Gombault in Arch, de Phys., 1876, etc.) 
In a patient of his affected with obliteration of the 
common bile duct, Dixon (Practitioner, April, 1876,) aspirated 
the gall bladder and drew off on five separate occasions a few 
grammes of bile; each aspiration was attended with great re- 
relief. 
As for electrization of the gall bladder in catarrhal jaun- 
ice, Gerhardt’s method is of the simplest kind. He employs a 
strong faradic current. One pole is applied as accurately as 
possible with some pressure (the place being determined by 
palpation and percussion) over the region of the gall-bladder. 
The other pole is placed on the region of the back opposite, 
and now and then both poles are moved to and fro. Gerhardt 
claims remarkable results (even the overcoming of mucous ob- 
struction and reduction of the gall bladder) from this Faradic 
treatment. (Gerhardt, in Berlin Klin. Woch., 1873, No. 47.)  102 
suit from suppression of the biliary secretion, do not 
forget that icteric patients are difficult patients to 
treat. This yellow discoloration of the integument 
frightens the patient and his family; so when the affec- 
tion lasts for some time, you will need to resort to all 
the means which I have pointed out, in order to vary 
the treatment and allay the impatience of the patient. 
The precision of therapeutic indications which 
characterizes the kind of jaundice just described is 
wanting when we come to the study of icterus with- 
out obstruction, and the difficulty here results chiefly 
from the uncertainty in which we find ourselves re- 
garding the pathogeny of these kinds of jaundice. 
This very fact, gentlemen, shows us that our thera- 
peutic system should always be based on solid physio- 
logical and clinical data, for when these bases are 
wanting, as in icterus without obstruction, our thera- 
peutic indications become hesitating. 
Jaundice without obstruction supervenes despite 
the excretion of bile, and often even when the bile is 
secreted too abundantly. 
According to Murchison, jaundice without obstruction 
may be referred to one of the causes enumerated below: 
I. Presence in the blood of poisons which oppose the 
normal metamorphoses of the bile. 
2. Enfeeblement or disorder of the innervation control- 
ing these metamorphoses. 
3. Insufficient oxygenation of the blood, which has the 
same result. 4. Hypersecretion of the bile, more being absorbed 
than can be transformed in the normal state. 
5. Abnormal retention of bile in the bile ducts and in- 
testines by reason of habitual or prolonged constipation. 
I shall endeavor as far as possible to bring into 
agreement clinical experience and the different theories 
which have been broached to explain this icterus. 
Writers have hypothecated modifications of the blood 
in explanation of this kind of jaundice, or have assumed 
troubles in the biliary secretion, and others still, per- 
turbations taking place in the functions of the liver. 
Those who have ascribed icterus without obstruc- 
tion to alterations in the blood, support one of two 
theories, the one advocated by Frerichs, the other by 
Kuhne. 
According to the teachings of Frerichs, the bile 
which flows into the intestine passes in the normal state 
back into the blood, where the biliary acids are trans- 
formed into the coloring matter of the bile; then this 
coloring matter is burned and destroyed as fast as 
produced. But let any circumstance oppose this oxi- 
dation, and the bilirubin, being no longer burned, 
passes into the blood and the different humors of the 
economy. 
According to this theory, the failure of oxidation 
is the cause of this hseraatogenous icterus, which it 
will not do to confound with hgemaphseic icterus, and 
you understand why it is that Murchison has made of this a special group under the name of icterus by in- 
sufficient oxygenation of the blood.* 
According to Kuhne, whose explanation starts 
from similar data, the bile which passes into the intes- 
tine under normal conditions is reabsorbed into the 
blood, where the biliary acids (as seems demonstrated 
by experimentation) destroy the globules and set at 
liberty the haemoglobin which is transformed into 
bilirubin. When the transformation is too active, na- 
turally the bilirubin would accumulate in the blood 
and produce jaundice. 
Other physiologists regard this jaundice as simply 
and solely due to resorption of bile from the surface 
of the intestine. I have already shown you that Lus- 
sana and Schiff ascribe a great importance to this 
“ entero-hepatic circulation,” which they say goes on 
between the intestine and the liver. The bile poured 
into the intestine is reabsorbed by the portal circula- 
tion, and returns to the liver, to be anew excreted into 
the intestine. It is easy to understand that when the 
biliary secretion is too abundant, a certain quantity of 
bile and coloring matter may pass into the blood and 
produce jaundice. Vulpianf has, in fact, shown, in 
contradiction to the experiments of Feltz and Ritter, 
* The icterus of the newly-born, according to Murchison, 
comes under this category, so also many cases of icterus in 
acute pneumonia. 
f Vulpian, Course of Lectures on the Liver, Ecole de 
Medicine. that when bile is injected into the veins of animals 
jaundice is produced. 
Lastly, other physiologists have maintained that it 
is in the liver itself that we are to look for the cause 
of jaundice without obstruction, and in certain patho- 
logical circumstances the bile which is secreted in the 
hepatic cells may pass, not into the radicles of the bile 
ducts which surround them, but directly into the net- 
work of blood-vessels with which the liver is so richly 
endowed. 
Which of these theories shall we adopt ? Is there 
any one which responds better than the others to the 
different facts which clinical experience furnishes? 
No, all the theories which I have enumerated may 
find their application in individual cases belonging to 
the large group of icterus without obstruction. 
Jaundice with polycholia, in which congestion 
of the liver entails a more abundant secretion of bile 
and the production of icterus, we would explain by the 
resorption of bile fron the surface of the intestine. In 
other circumstances, the icterus results manifestly from 
an alteration of the blood. Thus it is that certain 
animal poisons and certain miasms may be the cause 
of this affection. In such cases we get most light from 
the theories of Frerichs and of Kuhn, which find the 
cause of the jaundice in primary alterations of the 
blood. 
Among the animal poisons which may provoke icterus, 
we may mention, besides the virus of venomous serpents, the special microbes of pyaemia resulting from traumatism, the 
puerperal state, or external causes. 
The mineral poisons may also give rise to jaundice. 
Jaundice is often seen in acute poisoning from phosphorus, 
sometimes in poisoning from mercury, copper and antimony. 
Chloroform and ether sometimes produce jaundice. 
Jaundice is often seen in different fevers; yellow fever of 
the tropics, marsh fevers of India and Algiers, typhoid fever, 
relapsing fever (observed chiefly in London, in Scotland, and 
in Ireland), bilious typhoid fever (Griesinger). Epidemics of 
icterus, of undoubted malarial origin are on record; and Quin- 
quaud relates the history of an epidemic of forty-six cases of 
benign icterus observed in 1869 in the service of Lorain. 
As for those cases of icterus called nervous icterus, 
which are occasioned by strong emotions, anger, fright, 
etc., and which we cannot explain either by spasm or 
paralysis of the bile ducts, we are obliged to hypothe- 
cate disturbances of the cerebro-spinal axis and par- 
ticularly of the bulbus, which determine direct modifi- 
cations in the circulation of the bile in the hepatic 
cells—it would seem that the bile, instead of passing 
from the hepatic cell into the bile ducts, finds its way 
into the capillary net-work. 
According to Frerichs, in icterus from mental emotions 
the troubles of innervation may conduce in two ways to the 
accumulation of bile in the blood: 
1. By modifications in the hepatic circulation, due to the 
influence which the nerves exercise on the calibre of the branches 
of the vena portze. 
2. By perturbations in the action of the heart or in the 
respiratory movements, as well as in the renal secretion. 
What are the therapeutic indications for the treat- ment of jaundice without obstruction, based on the 
data which I have just given ? We can really effect 
little. In combating these kinds of jaundice, we can 
only attack the primary cause which has occasioned the 
jaundice. Oppose the alteration of the blood in cases 
of haematogenous icterus, re-establish the functions of 
the liver in those which are due to excess-of the 
biliary secretion, calm nervous perturbations in jaun- 
dice resulting from strong emotion—snch are the 
principal indications to fulfil in the treatment of jaun- 
dice without obstruction. 
It only remains for me to speak of the third 
variety of icterus, namely, grave icterus. I shall en- 
deavor to do this as briefly as possible. 
Grave icterus (acute, pernicious, typhoid, hemorrhagic, 
essential, fatal icterus), which Monneret defines: “a bilious, 
icteric, remittent, hemorrhagic and adynamic fever whose 
almost constant termination is death,” may be observed at 
all ages, but it presents its maximum of fiequency between the 
ages of 18 and 30 years. Pregnancy seems to be a predispos- 
ing cause (Charcot, Frerichs, Laborde and others). Out of 31 
cases. Frerichs found 9 in the male and 22 in the female; one- 
half of the latter were connected with pregnancy. Lebert’s 
statistics give 40 men and only 20 women. Syphilis is said to 
be a predisposing cause, also excessive labor, malaria, drunk- 
enness, etc. The disease has prevailed epidemically within 
narrow areas (barracks, prisons, ships). 
Grave icterus may be grave from the onset; oftener per- 
nicious symptoms set in during the course of an attack of 
jaundice. In the great majority of cases softening or destruc- 
tion of the liver has been found in connection with it (acute 
yellow atrophy. 
The onset is often insidious. If sometimes the disease 
begins suddenly by a chill, headache, vomiting, generally the 
first symptom is a simple digestive disorder. The patient com- 
plains of fatigue, is in bad trim, without appetite, with a little headache, fulness at the epigastrium or over the liver. These 
symptoms go on increasing, the patient gets weaker and 
weaker. The jaundice first appears limited to the conjunctivae, 
and extends to the rest of the body. Coincidently there are 
often hemorrhages of variable magnitude, from the bloody ooz- 
ing of the gums, sanguinolent expectoration, cutaneous extra- 
vasations, to copious bleeding from stomach, nose and in- 
testines. 
The fever, which was nil or intermittent at first, be- 
comes ordinarily remittent about the eighth day, with nocturnal 
exacerbation and agitation. 
The debility augments, and yet there is sometimes on the 
part of the patient a gaiety and an indifference which contrasts 
singularly with the gravity of the general condition. 
The intelligence remains intact; it is not till the last stages 
of the disease that the patient is delirious or is convulsed in 
the trunk and limbs; a persistent hiccough sometimes compli- 
cates the suffering of the patient. 
The heart sometimes presents a murmur, due, according 
to Potain, to a temporary tricuspid insufficiency. 
The urine shows nothing characteristic at the outset, but 
soon becomes of high color and may be bloody, either from 
passage of the coloring matter of the blood or blood itself into 
the renal secretion. The urea seems to augment at first, then 
diminishes, and may fall as low as 50 c. g. in the twenty-four 
hours. 
Leucin, tyrosin, xanthin and hypoxanthin, sometimes al- 
bumin, are found in the urine. The microscope reveals casts 
and blood globules. 
In cases that terminate favorably, amelioration is ushered 
in by a copious diuresis. 
The progress of grave icterus is rapid: death sometimes 
supervenes the fifth or sixth day, generally from the seventh to 
the twelfth day. The patients succumb in a state of som- 
nolence, coma, algidity, or in convulsions. 
Although the termination is generally fatal, yet quite a 
number of cases of recovery have been reported. 
From the above description you see that occasion- 
ally in jaundice symptoms of the greatest gravity 
appear. Hemorrhages from the mucous membranes 
supervene; cerebral disorders manifest themselves; the patient falls into profound adynamia and succumbs 
more or less rapidly. To explain these accidents, 
some have referred to the post mortem alterations 
noticed in patients that have succumbed to grave ic- 
terus. This is the anatomo-pathological theory main- 
tained by Rokitansky. Others as Monneret, Ozanam, 
Genouville, basing themselves on the fact that the an- 
atomo-pathological lesions may be wanting in certain 
cases of grave icterus, have held that the affection is a 
general disease of typhic nature, and that the hepatic 
lesions are secondary. Lastly, there is an intermediate 
theory which has had for supporters, Bright, Budd, 
Trousseau, and Vulpian, which considers malignant 
jaundice as the product of a general blood poisoning 
which smites indeed the whole economy, but more 
particularly the hepatic functions. Does experimental 
physiology throw any light on the one or the other of 
these theories ? 
Researches made in this direction have shown us, 
first, that bile as such, passing into the blood, never 
produces the symptoms of grave icterus, and that, in a 
word, the choletoxaemia which Lebert had invoked 
as the point of departure of all the symptoms 
supervening in malignant icterus, has not been demon- 
strated experimentally. Flint has incriminated but 
one element of the bile as the cause of the toxaemia, 
viz: cholesterine, and to the choletoxczmia of Lebert, 
he opposes his cholesteramia as the chief factor in the 
toxic accidents observed. Here, also, experimenta- tion has given a negative answer, for when you inject 
cholesterine into the blood you do not determine any 
very deleterious effect. 
Moreover, destruction of the liver, which has 
been hypothecated as the cause of grave icterus, be- 
cause favoring the accumulation or the passage of bile 
or of certain of its elements into the blood, cannot be 
accepted as the true cause, if we may rely on experi- 
mentation. 
Decaudin * has alleged another cause, and has 
referred us to the resemblance between the symptoms 
of grave icterus and those of uraemia, showing that 
suppression of the functions of the kidney may be a 
consequence of the passage of the coloring matter of 
the bile through those emunctories. 
While recognizing the importance of Decaudin’s 
facts, it must be admitted that they do not apply to 
all cases of grave icterus. Perhaps we should, also, in 
* Decaudin, Concomitance of Diseases of the Liver and 
Kidneys, and in particular of the Kidneys in Jaundice. (These 
de Paris, 1878.; 
He has shown that in grave icterus the kidney is often af- 
fected with pigmentary infiltration and fatty degeneration. 
He recommends us to examine the urine minutely, and to 
look for albumen and tube casts; he recommends also to take 
note of the quantity of the urea, and the presence of leucin 
and of tyrosin. In grave icterus the appearance of polyuria, 
and the augmentation of the figure of urea indicate an ap- 
proaching recovery. 
In certain cases of icterus the liver may be little affect- 
ed, and the kidney gravely diseased. Decaudin calls this 
grave icterus with renal form. explaining the grave symptoms of this kind of jaun- 
dice, give due weight to the passage into the blood of 
the alkaloids of putrefaction which are incessantly ab- 
sorbed from the surface of the intestine, and which it 
is one of the functions of the liver to destroy, in part; 
when the parenchyma of this gland is destroyed, it 
is easy to understand that there may result from the 
retention of these unchanged alkaloids in the system, 
symptoms of the greatest gravity. This is an hypo- 
thesis which applies to a great number of cases, but it 
is not supported by sufficiently solid scientific proofs 
to warrant us in adopting it in its application to all 
cases. 
We must confess, then, that the primary cause of 
the toxic phenomena is wanting, and that in indi- 
viduals affected with icterus there supervene, under 
the influence of a special poisoning which generally, 
but not constantly, produces grave lesions on the part 
of the liver, pernicious symptoms such as are char- 
acteristic of the icterus which we have just been 
studying. 
This uncertainty in the pathogeny of grave icterus 
entails an equally profound uncertainty in the treat- 
ment. Ignorant of the primary cause of this icterus, 
we are ignorant of the proper therapeutic means to 
combat these affections, and we can only direct our 
treatment to certain of the symptoms of this grave 
malady. One of the most manifest is the adynamia, 
hence the necessity of a supporting treatment is insist- Ed upon by all authorities. You will then employ 
Peruvian bark and even quinine, by reason of the 
intimate relations which connect these grave hepatic 
troubles with certain affections of malarial nature. 
Give also alcoholic and other stimulants, and endeavor 
to combat the hemorrhages which are so prone to ap- 
pear from the nasal, pulmonary and gastric mucous 
membranes. 
There is yet another form of grave icterus which 
you will have to treat. I refer to that icterus 
which succeeds poisoning by phosphorus; this form, 
in fact, is peculiar in that it has a chronic course, al- 
most without fever. You ought to prevent such un- 
toward results by treating the symptoms of poisoning 
when they occur by such remedies as preparations of 
turpentine, but when the icterus is once declared, you 
have still the progressive enfeeblement of the patient 
as the capital symptom, and it is to this that you 
should address all your therapeutic efforts. 
As you see, our ignorance is great respecting the 
special treatment of the forms of grave icterus; it is 
to be hoped that coincidently with future progress in 
experimental physiology and clinical medicine, we 
shall attain to a better knowledge of these affections 
and thereby of their treatment. 
Thus far I have spoken to you in this lecture of 
only three kinds of icterus. It remains to me in con- 
clusion to allude to two kinds of false jaundice, the 
jaundice of the newly born, and hsemaphseic jaundice. The first of these affections has been well studied of 
late years by Porak* who has shown us that we are to 
distinguish two species of jaundice in infancy, the 
jaundice of the newly bornf and jaundice in the newly 
born. The first is a simple hsemaphseic icterus, while 
icterus in the newly born is always biliphaeic, i. e. a 
true icterus. As for hsemaphseic icterus, I need not 
remind you of the important researches which Gubler 
on the Icterus of the Newly Born. 
These de Paris, 1878. 
fThe icterus of the newly-born is a very frequent affec- 
tion, it is observed, according to Porak, in eighty per cent, of 
births. 
It is almost always a haemaphaeic icterus; sometimes, 
however, it seems to have a biliary origin, hence the distinc- 
tion between the icterus of the newly-born and icterus in the 
newly born. The icterus of the newly-born is, as before said, 
almost always hsemaphseic, and presents itself as a benign 
affection of short duration. 
The icterus of the newly-born may however be biliph(Eicr 
and then it is due to congenital lesions of the biliary passages;: 
it is always grave. As for icterus in the newly-born, it is- 
always symptomatic of an affection of the liver, i. e., it is a 
true 'icterus. (Porak, on Icterus of the Newly-born, Paris, 
1878.) 
Gubler was the first to describe hsemiphseic icterus 
(1858) in connection wiih the icterus of lead-poisoning. This 
is his theory of haemaphaeic icterus: There is a great likeness 
between bile pigment and the coloring matter of the blood. 
The transformation of haemoglobin into bile pigment takes 
place in the blood, and this pigment is then eliminated by the has made on this subject; but if this affection has 
given rise to labors fraught with interest from a clinical 
and pathogenic point of view, it must be admitted 
that as therapeutists we are still as much in the dark 
as before. Therefore I can only mention these forms 
and pass on to the study of engorgements of the liver, 
to which I propose to devote the following lectures. 
bile; but let the functions ot the liver be suppressed, or let 
there be an excessive breaking up of the blood globules, the 
haemaphaein accumulates in the blood and produces a yellow 
coloration of the integuments. We find, then, this icterus in 
diseases which have a double origin; exaggerated deglobuliza- 
tion (haemaphaeism of bilious fevers, haematuria of warm coun- 
tries, icterus from certain poisons), and functional alterations 
of the liver—hepatic congestion, nervous perturbations of the 
liver, etc. (Gubler, Haemaphaeic Icterus in Lead-poisoning, 
1857; also Article Albuminuria in Diction. Encylop, etc.) CHAPTER V. 
TREATMENT OF ENGORGEMENTS OF THE 
LIVER. 
Summary.—Engorgements of the Liver—Division of Engorge- 
ments—Degenerations of theLiver—Amyloid Degeneration, 
its Treatment—Fatty Degeneration, its Treatment—Can- 
cerous Degeneration, its Treatment—Engorgements by 
Circulatory Troubles—Congestion of the Liver—Causes 
of Hepatic Congestion—Active and Passive Congestion— 
Treatment of Congestion of the Liver. 
In taking up the treatment of engorgements of 
the liver I do not under-estimate the difficulties of 
such a task, difficulties which result especially from 
the multiplicity of conditions connoted by this term 
engorgement. This word, in fact, comprehends a great 
number of dissimilar affections which have only one 
point in common, that they are all accompanied by 
augmentation in the size of the liver. 
I might have taken up in their proper order the 
various diseases of the hepatic gland, and stated in 
connection with each one the kind of treatment ap- 
propriate. But it has seemed to me preferable, from the 
point of view of the general considerations into which 
I desire to enter, to retain that old word—now gone 
out of fashion—engorgement of the liver, but which still 
possesses a real clinical value; hence I shall endeavor to pursue this difficult study with as much method as 
possible. 
We may in a general manner group the engorge- 
ments of the liver in five special classes. In the first 
we may place the true degenerations of the liver, and 
in this group we shall study the amyloid, fatty, and 
cancerous degenerations of this gland. 
To the second division we may assign that aug- 
mentation of volume which results from disturbances 
in the circulation of the organ, and hepatic congestion 
is the type of this group. In the third group we 
have enlargements produced, not by troubles in the 
circulation, but in the biliary excretion; hypertrophic 
cirrhosis with icterus, enters into this group. Inflam- 
mation of the liver, acute or chronic, accompanied or 
not with abscess, constitutes the fourth group; we 
shall here study the hepatites, and in particular, chronic 
interstitial hepatitis, described under the name of cir- 
rhosis. Lastly, the fifth class comprehends the aug- 
mentation of volume of the liver produced by cysts, 
and I shall devote an entire lecture to the treatment 
of hydatid cysts of the liver. 
You will see, gentlemen, that if the progress of 
clinical medicine and of pathological anatomy has 
greatly extended our knowledge of hepatic engorge- 
ments, therapeutics, unfortunately, has lagged behind, 
and there will be numerous instances in which I shall 
have occasion to point out the little advance which has been made in the knowledge of how to treat these 
diseases of the liver. 
Let us take up the first group which includes the 
degenerations of the liver, amyloid, fatty, and cancer- 
ous. Without entering here into anatomo-pathological 
details which are quite outside of my subject, I shall 
mention the symptoms which will enable you to re- 
cognize these different alterations. 
Amyloid or waxy degeneration of the liver deter- 
mines the greatest engorgement of the organ; the liver 
becomes enormous, and sometimes fills the whole ab- 
dominal cavity. This augmentation affects uniformly 
the whole hepatic gland; you detect no nodules, and the 
liver whose lower border you can often feel through 
the abdominal walls, presents a hardness and a con- 
sistency like leather. This enormous engorgement of 
the liver is never accompanied with pain, with ascites, 
or with icterus, and this is a sign of the utmost im- 
portance.* 
You will find this waxy degeneration chiefly in 
prolonged suppurations; sometimes syphilis or inter- 
mittent fever may be the starting point, but it is 
especially to suppurations of long standing, both in 
the case of the liver and of the kidney, that we are to 
*Murchison has seen the liver of an adult affected with 
amyloid degeneration weighing 5500 grammes instead of 1500 
to 1800 grammes the normal. attribute the chief influence in the production of amy- 
loid degenerations.* 
What is the treatment of amyloid degeneration 
of the liver ? Unhappily, we can do but little. We 
have, first of all, the prophylactic means which oppose 
amyloid degeneration, that is to say, in individuals af- 
fected with prolonged suppurations, with white swell- 
*Hepatic syphilis presents itself under two aspects, that 
of interstitial hepatitis or infiltrated syphilis, and that of gumma- 
tous hepatitis or nodular syphilis. The first is characterized 
by special cicatricial-like depressions which modify the form of 
the organ. Fatty or amyloid degeneration is often also 
noticed. In the second species, the liver presents numerous 
gummata, varying in aspect, according to the period of their 
evolution. 
As for the symptomatology of hepatic syphilis, it is very 
obscure. Cornil and Ranvier teach that interstitial hepatitis 
belongs to the second period, while the gummy form belongs to 
the tertiary period of syphilis. 
Jaundice may appear in the course of syphilis, and may 
depend on acute gastric catarrh. Lacombe has noticed a case 
of grave syphilitic icterus. 
Hepatic syphilis, mentioned in old medical works, was first 
described by Dietrich in 1849; it was afterwards treated of by 
Gubler (1852), Quelet (1856), Lecontour (1858), Virchow (1858), 
and still later by Leudet, Frerichs and Lancereaux, all of 
whom have made a complete study of the subject. (Virchow, 
Treatise on Tumors; Frerichs, Diseases of the Liver; Lan- 
cereaux, Historical and Practical Treatise on Syphilis; Cornil 
and Ranvier, Pathological Histology; Gubler, Gaz. Medicale, 
1852; Lacombe, A Study on the Hepatic Accidents of Syphilis 
in the Adult, These de Paris, 1874.) ing, for instance, the physician should interfere early 
to remedy these suppurations. From the point of 
view of amyloid degeneration of organs, conservative 
surgery, in endeavoring to save limbs in spite of the 
grave disorders with which they may be affected, is 
attended with a certain danger, and it is to this fact 
that the advocates of resections of the joints have ap- 
pealed in justification of early surgical intervention. 
As special medicaments for amyloid degenera- 
tion, I shall mention only iodine and the iodides, on 
the one hand, and the ammoniacal salts on the other. 
Murchison vaunts the tincture of iodine of the 
B. Ph., which he gives in the dose of ten to fifteen 
drops. You can also use iodide of potassium in the 
dose of 15 to 30 grains.* 
We are indebted to the English physicians for the 
principal clinical data respecting the ammoniacal salts 
in the treatment of hepatic affections, and particularly 
*Murichison says that he has sometimes witnessed 
amelioration after the prolonged employment of nitric acid as- 
sociated with certain vegetable bitters (gentian or quinine). 
He also speaks well of the external usage of nitro- 
muriatic acid; two fluidounces of nitro-muriatic acid to nine 
litres of water, heated to 350 or 36° C. 
The feet are immersed in this bath, the legs and thighs 
are sponged with it, and it is freely applied over the region of 
the liver, while the abdomen is swathed with a flannel cloth 
wrung out of this solution. 
This bath should be continued half an hour, and be re- 
peated morning and evening.  120 
of amyloid degeneration. You may employ the chlor- 
ide or carbonate of ammonium, but it is especially the 
ammonium chloride which is recommended, and this 
salt it to be given in the dose of from five to ten grains 
three times a day. Budd and Washburton Begbie 
have vaunted the effects of this medicine. But as you 
may imagine, these are remedies which are very un- 
certain, and which oftener have no well-marked results 
on the amyloid degeneration.* 
Steatosis of the liver determines a less increase of 
size than amyloid degeneration; the gland is less hard, 
and, as is the case with amyloid liver, there is never 
any pain, icterus, or ascites. 
You will meet with fatty degeneration under these 
conditions: sometimes in individuals with polysarcia, 
in whom you have not only fatty liver, but also fatty 
heart and fatty kidneys; sometimes in phthisis, and in 
chloride (sal ammoniac, muriate of am- 
monia, hydrochlorate of ammonia) is a salt in common use, 
of disagreeable taste, whose pungency may be partly over- 
come by combining it with extract of licorice. Thus by rub- 
bine up equal parts of the extract of licorice and ammonium 
chloride, you have a preparation which can without difficulty be 
taken by the patient in doses of a scruple in water ter die. 
Has been recommended in bronchitis (acute or chronic), in 
catarrhal affections generally, in acute rheumatism (Dujardin- 
Beaumetz). According to Murchison, sal ammoniac in scruple 
doses bis vel ter die causes diaphoresis, augments the urinary 
secretion, diminishes congestions of the portal system, and 
relieves pains which have their seat in the liver.—Tr. fact it is oftenest met with in this disease, and we may 
truly say that in the autopsies of tuberculous patients 
fatty degeneration is the rule. Lastly, in deaths 
from chronic alcoholism you find this degeneration, 
and I recall to your mind the autopsy of a patient 
where many of you were present; this man ended his 
career of drunkenness by imbibing a quantity of 
brandy in the lees, and the liver presented a fine 
specimen of fatty disease.* 
As fatty degeneration of the liver is not accom- 
panied by any very characteristic symptoms, and plays 
but a secondary part in the diseases which I have just 
mentioned so that the attention of the physician is 
rarely called to this engorgement, it results that but 
little has been done for the therapeutics of this affec- 
tion. 
What we know, is that we ought, as far as possible, 
* Besides alcoholism and pulmonary tuberculosis, other 
diseases may be accompanied with fatty engorgement of the 
liver; such are cancer and ulceration of the stomach, chronic 
dysentery and consumptive affections. An inappropriate diet, 
or diet rich with fatty matters, over-eating, life in a warm, 
damp and marshy climate, may bring about this steatosis. 
Frerichs’ tables, which give the results of a multitude of post- 
mortem and microscopical examinations of persons who had 
died at the hospital Allerheiligen, at Breslau, show that fatty 
liver is met with at its maximum in pulmonary tuberculosis, 
then in pyaemia, then in cirrhosis of the liver, and, lastly, now 
and then in certain diseases, as pleurisy, Bright’s disease, and 
typhus.  122 
by a proper hygienic treatment, to get rid of the fat 
which tends to accumulate in the various tissues; 
gymnastics, rhythmical movements and daily exercise 
are then to be counselled. We ought also to endeavor 
to promote respiration, in order to consume these fatty 
matters, and we should prevent their introduction into 
the economy by the food. This fact has a certain 
importance when, in phthisical patients for instance, 
you have detected fatty degeneration of the liver; here 
you should prohibit cod-liver oil. As medicines, we 
can do no better than prescribe alkalies under all their 
forms, and particularly the sodic bicarbonate waters 
Vichy, Vais, etc. 
I shall be brief, and for good practical reasons, 
concerning cancer of the liver. At the same time, as 
this affection may be confounded with other hepatic 
engorgements, you will have occasion to treat it; and 
in this connection I recall to mind a patient who was 
sent to me by my pupil and confrere Dr. Doumanges, 
of Forges. 
This patient was suffering from chronic icterus, 
which had brought about such a cachectic state that 
one could almost affirm the existence of cancer from 
his very appearance; nevertheless it was nothing of 
the kind, for he got well under the influence of a treat- 
ment long continued, consisting in the employment of 
calomel, of milk diet, and of alkalies. 
Ordinarily in cancer of the liver you find this organ very 
much increased in size, and stuffed with cancerous nodules which give it a characteristic form. These nodules are of 
variable size and consistency according as they have undergone 
development and regression; some are hard and resistant, 
others are of soft and almost liquid character. 
Several varieties of cancer have been found in the liver; 
scirrhus, which is by no means rare, the encephaloid which is 
much the most common, and which may be accompanied by a 
considerable development of the blood-vessels (carcinoma 
hsematodesj. Lastly, in exceptional cases, you observe 
melanotic cancers. 
To explain the frequency of cancer of the liver as a 
secondary affection, authorities have assumed the passage of 
cancerous elements by the portal vein from the diseased organ 
to the liver. It very frequently occurs in connection with 
cancer of the stomach. According to Murchison, women are 
oftener the subjects of hepatic cancer than men. 
What then are the characters which enable you to 
distinguish cancerous from other degenerations of the 
liver ? In cancerous degeneration there is certainly 
augmentation of volume of the organ, but this aug- 
mentation does not affect the whole gland, it occurs 
only in places, and for this very reason markedly 
alters the normal form of the gland. In certain cases 
you can feel through the abdominal walls the hard 
nodosities or lumps, as large as a chestnut or larger; 
these are characteristic of cancer. There is in all 
cases more or less pain, sometimes intense and per- 
sistent icterus, and in half the cases there is ascites.* 
Add, moreover, that from a clinical point of view, 
*The liver may take on a great increase of size in a very 
short time. Budd cites a case in which the liver, having be- 
come cancerous, weighed seven times the ordinary weight. 
He has also seen a cancerous mass weighing five pounds form 
in the course of five months; while Farre reports the case of  124 
cancer of the liver in the majority of cases is second- 
ary to cancer elsewhere; out of 91 cases Frerichs 
found but 22 in which the liver was primarily affected, 
and 35 were consecutive to cancer of the stomach. 
It results from this that you will almost always observe 
in patients affected with cancer of this organ, disorders 
indicating a degeneration of the same nature in an- 
other part of the abdominal cavity. Here you will 
employ for treatment hypodermics of morphine to 
allay the pain; you will prescribe milk diet; you will 
combat the icterus by the appropriate means already 
mentioned; you will support the forces of the patient. 
You must be persevering in your treatment, and not- 
withstanding the certainty of your diagnosis, you can 
always hope that possibly you have made a mistake, 
and that you may yet triumph over the disease which 
you have before you. 
I now proceed to take up a disease of the liver 
which is extremely frequent, and on which therapeut- 
ics has a real influence; I refer to the engorgement 
determined by the troubles in the circulation of the 
liver. 
an hepatic cancer which increased in weight by five pounds in 
ten days. 
The pain in cancer of the liver is more or less acute, es- 
pecially on pressure over the organ. It radiates into the 
shoulders, the back and the loins; it is sometimes paroxysmal, 
and lancinating; is rarely absent, especially in cases that grow 
rapidly. (Budd, Diseases of the Liver, 1855; Farre, Morbid 
Anatomy of the Liver, 1812), Whenever, from any cause, the blood accumulates 
in the liver, this accumulation produces an increase 
in the size of the organ. Monneret, who has made a 
careful study of hepatic congestion, has shown that 
the liver, which in the normal state weighs about 
i,600 grams may acquire, when forcibly injected with 
blood, a weight of more than 2,500 grams. This aug- 
mentation of weight manifests itself by an augmenta- 
tion of volume, and one of the first symptoms of con- 
gestive engorgement is the marked increase of size of 
organ. These congestions present themselves under 
two aspects : sometimes they are active, sometimes 
passive. Let us see under what circumstances they 
are produced. 
The congestion is passive, when, for instance, it is 
linked to a cardio-pulmonary trouble. Recall to mind 
what I told you while speaking of the treatment of 
mitral lesions, and you will remember that always, at 
an advanced period of their course, these affections are 
accompanied by a passive and chronic congestion of 
the liver.* I have dwelt at some length on these con- 
gestions and their treatment, and I have endeavored 
to make clear the difference which exists between 
cardiac cirrhosis and true cirrhosis. The circulatory 
disorders of the lungs, tumors of the mediastinum, 
and, in general, all causes which hinder the emptying 
of the inferior vena cava, have the same result. 
* See Diseases of the Heart, Vol. I, page 131 (G. S. 
Davis’ Library Ed.).  126 
As for active congestions, they are due to a 
variety of causes; in a great number of cases their 
origin is gastro-intestinal. You readily understand 
the influence of diet on congestions of this gland, as 
the liver receives from the portal vein all the liquid 
substances introduced into the digestive tube; so when 
the food is of too exciting a nature, and, especially, 
when too prolonged usage has been made of alcoholic 
drinks, such intemperance entails as a certain conse- 
quence a congestion of this organ; the inflammations 
of the digestive tube have the same effect, and are 
propagated to the liver; hence we see hepatic stases 
accompany or follow any phlegmasia of the stomach 
or intestines. 
There is another affection of the digestive tube 
which is always attended with congestion of the liver; 
I refer to dilatation of the stomach. Bouchard was the 
first to call our attention to this point, and it is proba- 
able that this congestion is caused by the passage into 
the liver of toxic substances occasioned by impairment 
of the gastric digestion. 
Sometimes also the hypersemia is linked to a gen- 
eral diathetic state, and you will see in arthritic 
patients congestion of the liver more or less severe. 
Gout and even rheumatism may have the same effect, 
and you know that clinical medicine has recognized a 
particular form of icterus having such origin: rheu- 
matic icterus. 
Lastly, in certain circumstances, hypersemia of the liver takes the place of the physiological congestion of 
certain organs ; and when in females there occurs an 
abrupt suppression of the menses, or in men the sud- 
den cessation of a hemorrhoidal flux, there sometimes 
supervenes in these cases a hepatic congestion which 
is vicarious or supplementary. 
This rapid pathogenetic description of congestion 
of the liver would be incomplete if I did not point out 
in connection therewith the influence of the atmos- 
phere on hepatic stasis. It is, in fact, in certain 
zones, and under the influence of certain climates that 
these hypersemias of the liver are almost sure to occur, 
and it may be affirmed that there is hardly a European 
living in the torrid zone who has not suffered more or 
less from congestions of this organ. 
Malaria very often adds its influence to that of 
climate in modifying the hepatic functions, and in 
marshy countries you will notice at some stage more 
or less advanced of intermittent fever, a congestion of 
the hepatic gland. 
These hypersemias of the liver are either acute or 
chronic. In our climate, and apart from traumatism, 
we see but little of the acute congestions of the liver; 
it is generally the chronic forms that we have to treat. 
Whether they be active or passive,* the congestions of 
*Baillon, Portal and Andral have observed congestion of 
the liver in scurvy. Hyperaemia of the liver has also been 
noticed in poisoning by lead, by phosphorous and by curare.  128 
the liver manifest themselves by the following train of 
symptoms: 
There is first of all an increase in the size of the 
liver, an augmentation which affects the whole organ; 
then there is pain, which is never wanting. This pain 
is seated in the hepatic region; it often encircles the 
base of the thorax like a girdle, and radiates into’ 
neighboring parts and particularly the shoulder of the 
right side; almost always there is a slight jaundice, 
characterized by a sub-icteric tent of the conjunctivae 
and skin. 
Monneret, who has carefully studied hypersemia of the 
liver and its causes, gives the following etiological division; 
A. Hypenrmia by disease of the organs: i, Diseases of 
the circulatory organs (according to Monneret, the hepatic 
circulation is the first partial circulation disturbed in dis- 
eases of the heart); 2, Cancerous and tuberculous diseases 
of the liver. 
B. Hypersemia by alteration of the blood: 1, by 
plethora (Monneret affirms that these sorts of hepatic conges- 
tions are disputable); 2, by dissolution of the blood (typhus, 
yellow fever, diphtheria, puerperal fever); 3, by diminution of 
albumen; 4, by presence of pus in the blood; 5, by virulent dis- 
eases (syphilis, glanders); 6, by diathetic diseases (scrofula and 
rheumatism); 7, by malarial poisoning. 
C. Dynamic hypersemia: 1, by secretory hypersemia 
(Monneret includes in this group the congestion which accom- 
panies icterus called essential or spasmodic); 2, hypersemia 
vicarious of another flux (suppression of menses and of hemor- 
rhoids); 3, physiological hypersemia (Monneret includes in this 
group the congestion which follows the digestion of certain 
aliments (Monneret, Pathologic Interne, 1861-1863).  129 
These congestions are accompanied by a fever, 
which Monneret has well studied, a fever with parox- 
ysms which come on between four and five o’clock in 
the afternoon. Lastly, patients affected with intense 
congestion of the liver complain of respiratory diffi- 
culty, a veritable dyspnoea, which is to be referred to 
the cardiac troubles consecutive to the hepatic affec- 
tions of which we have just spoken. Such are, in 
brief, the principal symptoms determined by hyper- 
aemia of the liver. 
The treatment varies according tb the cause which 
has determined the afflux of blood; and that of active 
... 
hypersemia of the liver is widely different from the 
treatment which is suited to the congestion determined 
by mechanical troubles in the cardio-pulraonary cir- 
culation. This latter congestion, you know, depends 
generally on a mitral affection, and already under 
diseases of the heart I have set forth the treatment 
proper for these passive congestions.* Our remedies, 
in fact, are not directed primarily to the liver, but to 
the heart, and you have at this moment in one of our 
wards a good example of these hepatic and cardiac 
congestions. I refer to a patient whom I have before 
pointed out to you in Ward St. Lazare, who is suffer- 
ing from mitral lesions with enormous congestion of 
the liver, and in whom, by the use of digitalis alone, we 
*See Diseases of the Heart, vol. I, (Library Ed. G. S. 
Davis.) have succeeded in diminishing by one half, the volume 
of the hepatic gland. 
As for chronic or subacute hyperaemia-originating 
under the influence of a general diathesis or of modi- 
fications effected in the gastro-intestinal tube, you can 
place most reliance on the following means: 
ist. The revulsive method: large fly blisters have 
a marked resolvent action on hyperaemia of the liver, 
and I have always derived from them excellent re- 
sults. Monneret places great importance on the re- 
vulsive method, and I have been surprised not to see 
mention made of this powerful curative agent in the 
excellent article of Murchison on the treatment of 
hepatic congestion. 
Local blood lettings have also been advised for 
congestions of the liver, especially for those which 
have an acute course and a phlegmasic character; you 
apply over the hepatic region where the pain is most 
severe, from six to ten wet cups or a dozen leeches; 
you may also apply the leeches, not over the liver, but 
to the anus; this practice, which has been much 
vaunted by my colleague Rendu, causes disappear- 
ance of the hepatic pains. But I advise you to reserve 
this spoliative method for plethoric persons and those 
in whom the hepatic congestion manifests itself by 
very intense symptoms, for in general I am not a 
strenuous advocate of blood lettings in diseases of the 
liver; these withdrawals of blood almost always entail 
perturbations which manifest themselves by hemor- 
rhages, so frequently observed in hepatic affections. You should always employ internally medicaments 
which act as cholagogues, and it is in these cases that 
calomel gives marvellous results; thus in arthritic pa- 
tients, for example, who have a tendency to hepatic 
congestion, you will see the symptoms determined by 
this hypersemia rapidly disappear under the usage of 
calomel in small doses, two grains a day, for instance. 
You can add to this treatment enonymin and the other 
cholagogues; chloride of ammonium has also been 
employed, especially in India, in the treatment of 
hepatic congestion. Lastly, do not forget that cold 
lavements, which I have already recommended in the 
treatment of catarrhal jaundice, may here appropriate- 
ly find their place. 
It is also in these congestions that a certain 
remedy is said to do good which has a great reputa- 
tion in South America, and especially in Chili, namely 
boldo. 
I have studied this medicament with Claude 
Verne, and have shown that the tincture of boldo, and 
especially the essence, has an action not only on the 
liver but also on the kidneys, and it is probably by 
the enhanced diuresis that it acts indirectly on the 
hepatic diseases.* 
*ln Chili boldo is considered as having stomachic, car- 
minative, and diaphoretic properties. Claude Gay affirms 
that it is a popular remedy for diseases of the liver. 
Boldo (Peumus boldus) is a tree which grows chiefly in 
Chili. The leaves are the medicinal part. Analyzed, they give But of all the curative means employed in 
chronic hyperaemia of the liver, the most 
certainly, is the thermal treatment. Here we wit- 
ness the triumph of Vichy and of Carlsbad; it is 
probable that Vichy bears the palm over its rival, and 
one can truly say that there is hardly a patient in this 
country affected with chronic hepatic congestion who 
has not been to these spas for relief. 
By the side of these waters we should also place 
a heroic remedy, hydrotherapy. In the active con- 
gestions determined generally by alimentary excesses 
an essential oil, a bitter principle boldine, citric acid, lime, 
sugar, gum, and tannin. The most important product of the 
plant is the essence which is contained in great quantity in 
the leaves. The bitter principle boldine has, according to 
Bourgoin and Verne, all the characters of an alkaloid. Dif- 
ferent preparations are made with boldo; there is a tincture, 
made by macerating one part of the bruised leaves with five 
parts of alcohol at 6o°. The wine is made thus; macerate for 
twenty-four hours one part of the bruised leaves with two 
parts of alcohol and add parts of Madeira wine; macerate 
eight days, express and filter. There is also a syrup and an 
elixir; the latter is made by displacing 200 grammes of bruised 
leaves with alcohol at 6o°. In some experiments made on man 
and animals, Dujardin-Beaumetz has shown that the essence of 
boldo, in passing out by the kidneys, provokes an abundant 
diuresis, and that the urine has a marked odor of essence of 
boldo. In man, the tincture of boldo produces a sense of heat 
and of general stimulation. These experiments show that 
boldo ought to be classed among the excitant medicaments. 
By its tincture boldo belongs to the class of aromatic plants, or by malarial poisoning, Fleury has shown the benefit 
which may be derived from the employment of the 
cold douche. 
How ought this douche to be administered ? 
Permit me here to interpose a word of caution. It is 
not enough that you should simply prescribe hydro- 
therapy, you should also indicate the temperature of 
the water, the duration of the douche and the man- 
ner of administering it. 
The ignorance, unfortunately too prevalent, con- 
cerning the rules for the practice of hydrotherapy, of- 
ten results in the attending physician finding his 
directions misunderstood, either by the physician in 
charge of the thermal establishment, or by the assist- 
ant to whom is intrusted the care of giving the douche. 
How then will you order the administration of 
hydrotherapy in these cases ? You will see that a 
and like the latter it is a general diffusible stimulant and a 
promoter of the digestive functions; by its essence it resembles 
the gums and resins, and like these, it has a stimulating 
action on the urinary functions. Dujardin-Beaumetz has em- 
ployed the tincture and the wine in cases of anaemia and 
dyspepsia; he gives one to two grams of the tincture (15 to 
30 drops), and sixty grams (two ounces) of the wine per 
day. He has administered the essence of boldo in capsules 
in the dose of five or six grains a day in cases of catarrh of the 
bladder, whether acute or chronic. This dose should be 
given at meal time. (Bourgoin and Verne on Boldo, Jour, de 
Pbarmacie, May, 1872; Dujardin-Beaumetz and Claude Verne, 
A Study of Boldo, Bull, de Therap., t. Ixxxiv, p. 165.) cold jet douche is given over the liver; in order that 
the action may be more local, you will place the sub- 
ject in such a manner that with the right arm slightly 
raised, the thigh of the same side half bent, he may 
receive over the hepatic region, the jet of cold water. 
The duration of the douche should be very short. I 
can not too much insist on this point. I sometimes see 
practitioners order douches of from four to five 
minutes duration; this is a great mistake. In the 
great majority of cases, the douche should not exceed 
thirty seconds duration, and generally fifteen seconds 
suffice. 
Beni Barde counsels in these cases of congestion 
of the liver the Scotch or alternating douche i. e., the 
douche in which, in the space of a minute, the cold 
douche and the warm douche are given alternately. 
Lastly, when the patient manifests too great ner- 
vous irritability, when, instead of ameliorating the 
state of the liver, these douches augment the volume 
of the organ, you may begin by the employment of the 
swan’s neck douche. This name is given to a douche 
administered with an instrument which resembles the 
swan’s neck, and which projects along the vertebral 
column a considerable volume of water, but at low 
pressure. 
Next to thermal medication and hydrotherapy, 
but almost on the same level as a therapeutic agency, 
comes the dietetic treatment. As in a great number 
of cases, the active congestions of the liver have for their cause a too abundant and too stimulating diet, 
you readily understand that milk, which gives such 
good results in the treatment of the other hepatic af- 
fections, is also particularly indicated in the treatment 
of hepatic hypergemias. You ought then, not only to 
regulate minutely the alimentary regimen of pa- 
tients, but to prohibit all substances which may bring 
about a congestion of the liver. 
But before ordering a milk diet, you must ascer- 
tain whether there exists or not any dilatation of the 
stomach; in cases where the stomach is dilated, you 
should prohibit an exclusive milk diet, and subject the 
patient to the alimentary regimen proper to gastro- 
ectasis. It is because different authorities have not 
sufficiently made account of this distinction, that milk 
diet in the treatment of congestion of the liver has 
been considered by some as favorable, by others as 
injurious. 
Such are the principal therapeutic indications to 
be fulfilled in the treatment of hepatic congestions. 
These indications will be complete if you add to them 
such as spring from the indicatio causalis, but this im- 
plies a treatment which is variable and into the study 
of which I cannot enter, but must refer you to what I 
have said respecting the etiology of hepatic conges- 
tions, and I pass now to another group of hepatic en- 
gorgements. 
At the beginning of this lecture I mentioned 
among the causes of engorgements of the liver, dis- turbances in the excretion of the bile. I now come to 
the study of these engorgements. In my experimental 
researches with Audige on spasm of the bile ducts, I 
noticed that when in a dog we tied the common bile 
duct, we determined a considerable dilatation of all 
the biliary passages intra and extra hepatic, which 
causes a considerable increase in the size of the liver. 
I have, moreover, shown you, when speaking of the 
obstructions of the ductus choledochus, the alterations 
of the hepatic parenchyma therefrom resulting, and 
which amount to a veritable cirrhosis taking its origin 
in the bile ducts; but this cirrhosis of biliary origin 
may also come about spontaneously; it is this form 
which Hayem, Cornil and Harnot have described 
under the name of hypertrophic cirrhosis with icterus. 
This cirrhosis, which is a true generalized angio- 
cholitis, producing a secondary sclerosis around the 
distended canaliculi, presents the following symptoms: 
the liver is uniformly hypertrophied, there is a sharp 
pain on pressure over the region of the liver; lastly, 
jaundice always accompanies this affection, But this 
icterus presents this particular character that it varies 
in intensity from one day to another during the course 
of the disease. There is not, ordinarily, any ascites 
in this form of cirrhosis. 
This affection generally resists all means of treat- 
ment, and notwithstanding the very precise notions 
furnished by pathological anatomy respecting the 
special processes of this cirrhosis, we know of no curative treatment. Cholagogues, revulsives, and tonics 
have been all tried, but tried in vain.* 
It remains for me in concluding the subject of 
engorgements of the liver to study such as are pro- 
* The history of hypertrophic cirrhosis is of quite recent 
date. It was Olivier, of Rouens, who, in 1871, first separated 
this affection from ordinary cirrhosis, then the researches of 
Hayem and Cornil, in 1875, showed the alterations of the bile 
ducts, while Harnot, in 1876, gave a complete description of 
this affection. 
When you examine the anatomo-pathological lesions of 
hypertrophic cirrhosis, you observe that it is characterized by 
an alteration effecting essentially the intra and extra lobular 
biliary canaliculi. These ducts are dilated and often obliterated 
by an infiltration of pigmentary granules. 
This idiopathic angiocholitis determines an increase in 
the connective tissue frame-work, a veritable sclerosis, which 
Charcot has described under the name of insular sclerosis, 
which is generally circumscribed to a single lobule, and sys- 
tematically invades the periphery of this lobule. 
As symptoms, hypertrophic cirrhosis is always accom- 
panied by a very considerable augmentation of the liver, with 
jaundice more or less pronounced, without ascites, and without 
augmentation of the collateral venous circulation. 
As for the prognosis, it is most grave, and thus far all 
cases have terminated by death. 
Latterly, Litten has combatte 1 the views of Charcot re- 
specting the pathogeny of hypertrophic cirrhosis; he does not 
believe, for instance, that this affection originates in stagnation 
of the bile. 
Repeating Charcot’s experiments on the effects of ligature 
of the choledochus, he notices that the lesions of insular cir- duced by inflammation. This is an important topic 
which merits your special attention, and to this I shall 
devote my next lecture. 
rhosis do not take place when antiseptic precautions are used; 
on the other hand, they are produced when you irritate power- 
fully, by means of croton oil, the mucous membrane of the bile 
passages. Litten concludes that it is not to biliary stasis, but 
to inflammation of the bile ducts, that the pathogeny of hyper- 
trophic cirrhosis should be ascribed. 
Lastly, from a clinical point of view, according to Litten, 
the diagnosis between the two varieties of cirrhosis, true cir- 
rhosis and hypertrophic cirrhosis is often impossible, although 
intense icterus belongs only to the hypertrophic form. 
According to Lancereaux, it will not do to confound hyper- 
trophic cirrhosis with the grave icterus which sometimes 
accompanies cirrhosis in the alcoholic. In these cases the bile 
ducts have neither undergone proliferation nor alteration, at 
the same time the sclerosis is insular and unilobular.flr) 
(a) Olivier, Memoire sur la cirrhose hypertroph. (Union medicale, 
1874, p. 361).—Hayem, Contribution k I’etude de I’hdpatite interstitielle 
chronique avec hypertrophic du foie (Arch, de phys., 1874, p. 126).—Cornil, 
Anatomic pathologique de la cirrhose (Arch, de phys., 1874, p. 365).—Hanot, 
Etude sur une forme de cirrhose hypertrophique du foie (Thfese de Paris, 
1876).—Charcot et Gombault. Sur les alterations du foie ala 
ligature du canal cholddoque, 1876, p. 272 et 453.—Litten, Ueber die biliare 
Form der Lebercirrhose u. den diagnostichen Werth der Icteriis (Charity 
Annalen de 1879, P- 152- Berlin, 1880).—Pierre Dupont, De inter- 
stitielle diffuse aigne. Th&se de Paris, 1878. CHAPTER VI. 
TREATMENT OF INFLAMMATIONS OF THE 
LIVER. 
Summary.—The Inflammations of the Liver—Acute and 
Chronic Inflammations—Hepatitis of Warm Countries 
—Abscess of the Liver—Pathogeny—Therapeutic Indi- 
cations— Aspiration Opening of the Abscess—Slow 
Processes—Rapid Processes—Accidents Consecutive to 
the Opening of Abscesses of the Liver—Chronic In- 
flammation of the Liver—Interstitial Hepatitis or Cir- 
rhosis—Its Nature—lts Frequency—Symptoms of Cir- 
rhosis—Treatment of Cirrhosis—Paracentesis for Ascites 
in Cirrhosis—lndications and Contra-Indications. 
Gentlemen.—ln the last lecture I included in- 
flammation of the liver in the group of engorgements 
of this organ. It is the treatment of these inflamma- 
tions which I intend to set forth to-day. As I desire 
to confine myself within the limits indicated by the 
title which I have given to this course (Clinical Thera- 
peutics), I shall occupy your time only with those af- 
fections which we meet in our wards, and with dis- 
eases of which you can watch the progress, and judge 
the effects of the treatment. Therefore I shall not 
attempt a complete study of hepatitis properly so- 
called, a disease which is not observed in our country, 
and to which has been given the name of the hepati- 
tis of warm climates. You will find, moreover, in the remarkable works of our confreres of the marine ser- 
vice, and in the writings of the English physicians who, 
practising in the colonies, and in particular in India, 
have very frequent opportunities for observing this 
kind of hepatitis, precepts and useful data on this sub- 
ject. What we find in our hospital service, under our 
climate, is the result of this, hepatitis contracted in the 
tropics, a suppurative hepatitis, which produces volum- 
inous abscesses of the liver, and at this moment, in 
this very hospital you can see in the wards of my col- 
league and friend, Perier, a fipe instance of these ab- 
scesses brought on by living in a hot climate. The 
hepatitis of warm countries, when it is not due to 
traumatism or to an alteration of the digestive pas- 
sages, may be determined by rapid chilling of the 
body while sweating, and sudden suppression of per- 
spiration by excessive drinking of cold water, etc. 
This disease, frequent in India and in the tropical 
countries generally, is not equally grave in the French col- 
onies; hence it is quite rare at Cayenne, while frequent and 
very fatal at Martinique and Senegal. 
As Dutrouleau remarks, the endemic hepatitis of hot 
climates passes through different stages which have their 
distinct characters; to the three anatomical characters, con- 
gestion, inflammation, suppuration, correspond certain 
symptoms which give to the disease a special physiognomy. 
To the form which is the most mild, has been some- 
times given the name of the dominant symptom “liver 
ache” (point de cote')-, the denominations acute and chronic 
hepatitis indicate the disease arrived at the stage of phlegm- 
asia Corresponding to these two forms; abscess of the liver 
indicates the disease gone on to suppuration. 
The pain in the side corresponds to active hyperaemia. 
Sometimes suddenly, after fatigues or excesses, the patient is taken with an excruciating pain in the right side, exasperated 
by pressure and strong inspirations. This pain by degrees 
becomes less, then disappears, to return alter the least 
fatigue or excess. Sometimes the disease is confined to this 
one symptom, and the patient gets well; if it continues its pro- 
gress, it soon goes on to the second and third stages. 
Habitually, the hepatitis begins by an accession of 
fever with a chill, heat, and sweats; then supervenes an ex- 
cruciating, lancinating pain, which obliges the patient to 
writhe and draw himself up in his bed; at the same time 
there is a considerable difficulty of breathing, which auscul- 
tation does not sufficiently explain. 
When the crisis is passed, the patient still experiences 
the pain, which is less intense, and which almost always 
corresponds to an inflamed point in the liver. Dutrouleau at- 
taches a great importance in diagnosis to a sympathetic pain 
which the patient sometimes experiences in the right 
shoulder, and which indicates an inflammation of the convex 
surface of the organ. 
If the patient is to get well, the pain little by little disap- 
pears, leaving only a little soreness behind. If the disease 
passes to the chronic stage, the pain becomes intermittent, 
lancinating, while the fever becomes high if the hepatitis goes 
on to suppuration. Jaundice does not always exist after the 
crisis; sometimes there is a straw-yellow color of the skin, a 
simple icteric pallor, with slight discoloration of the sclerotics; 
the urine is red and scanty, and does not contain the coloring 
matters of the bile, except when the icterus is intense. 
When the hepatitis goes on to suppuration, the liver be- 
comes tumefied and protuberant, and sometimes bulging is de- 
tected at the point where the abscess is seated. 
Abscesses of the liver are superficial or deep, are oftener 
seated in the right lobe than in the left (in 122 out of 136 cases). 
They differ from metastatic or pysemic abscesses, which have 
a brown color, are small, situated at the surface, and do not 
possess a pyogenic membrane. The abscesses of hepatitis are 
generally single. Out of 66 Dutrouleau found 41 in which 
there was but one; 16 in which there were 2; 5 in which there 
were 3. Lastly, out of these 66 cases there were 56 large ab- 
scesses, i. e., the size of an orange at least, and 10 small ones. 
The pus of recent abscesses is yellow, creamy, and in- 
odorous; that of old abscesses is brown, the color of wine  142 
dregs, sometimes contains blood or the debris of the organ; 
takes on an ammoniacal, sometimes putrid odor. 
When surgical interference is not resorted to, the abscess, 
if not too large, may get well by absorption; else it in- 
creases in size from day to day, and the patient, by reason ot 
the progress of the disease, falls into a profound adynamia, 
and dies of exhaustion. Under other circumstances, the pus 
dissects for itself a passage externally, or into the neighboring 
organs. If there are peritoneal adhesions, it may burrow its 
way through the abdominal walls; in other cases it bursts into 
the peritoneal cavity, and causes a rapidly fatal peritonitis. If 
the abscess opens into the pericardium, death does not long 
delay, but if it opens into the bronchi, the stomach, or the 
colon, recovery may sometimes take place. Murchison relates 
such a case of recovery in a physician whose abscess opened 
into the bronchi. 
But before taking up the treatment of hepatic ab- 
scesses, allow me a short digression concerning their 
origin. I have just told you that these purulent col- 
lections are the consequence of suppurative hepatitis; 
I thus touched upon an important question in their 
pathogeny. In fact, in the opinion of a great number 
of observers, abscesses of the liver do not result from 
hepatitis, but from dysentery; the ulcerations of the 
intestines determine the passage of septic matters into 
the portal circulation and the transference of these 
matters into the substance of the liver, causing ab- 
scesses more or less voluminous. I myself saw in 
this very city, while clinical chief under Behier, an ab- 
scess consecutive to dysentery. The fact then is settled; 
but must we therefrom conclude that all the hepatic 
abscesses of warm countries have this intestinal origin? 
By no means. Murchison maintains that generally 
these abscesses are the consequence of the inflamma- tion, and that if dysentery exists, it is only a coinci- 
dence, a coincidence by the way which is very fre- 
quent, as dysentery and hepatic inflammation are 
two affections which are endemic in the tropical 
zone. 
Whether they result from an hepatic inflammation 
or are due to dysentery, abscesses of the liver present 
themselves under the following form: they are fluctu- 
ating tumors, sometimes of enormous size, which un- 
equally augment the volume of the gland; these 
tumors are generally slow, are accompanied, like every 
suppurating swelling, with accessions of intermittent 
or remittent fever; sometimes, however, the fever is 
wanting. These abscesses, if left to themselves, may 
open externally into the intestine or into the perito- 
neum, or they may dissect for themselves a passage 
through the lungs and pleura. 
What treatment is advisable in such cases ? We 
find ourselves in the presence of opinions which are 
diametrically opposite. Budd maintains that it is best 
not to interfere; Murray, Murchison, Cameron, Martin 
and others urge the most prompt possible surgical 
interference.. This latter practice is the one which 
you should follow, for not to render surgical aid is to 
greatly increase the chances of death; and this is not, 
gentlemen, a haphazard assertion, but one based on 
trustworthy statistics, which show that out of 120 
cases of abscess of the liver left without operation, 
there is a mortality of 80 per cent., while by suitable surgical intervention this mortality is reduced to 32 
per cent.* 
Moreover, gentlemen, you know that all surgical 
operations on the liver are made at the present day 
with extreme facility, and with little or no danger. 
Thanks to the aspirators of Dieulafoi and Potain, we 
can now puncture the hepatic gland with safety, and 
if it happens for any reason that we do not hit the 
fluctuating sac, no harm results from the operation. 
Lavigerie has made experiments on animals to judge 
of the innocuousness of punctures of the liver. He practised 
in dogs fine exploratory punctures, and killed the animals 
three days after, and however numerous were these trocar 
punctures, he never found any lesion of the hepatic paren- 
chyma. 
The Medico Chirurgical Society of Alexandria has re- 
produced these experiments on cattle, horses and dogs, and 
has obtained similar results. 
If we may trust the reports of the English physi- 
cians who practise in India, and make almost daily 
use of the aspirator, as they are able to render assist- 
ance at the onset of the abscess, we cannot help be- 
lieving that these punctures always relieve the patient, 
*The Medico-Chirurgical Society of Alexandria in Egypt 
has given the most complete statistics concerning abscesses of 
the liver. Out of 123 cases of hepatic suppurations, 80 per 
cent, of those on whom no operation was performed died, 
while 32 per cent, that received surgical help got well. In 
cases of large abscesses, there was a mortality of 88 per cent, 
among those where there was no operation, to offset 68 per 
cent, of recoveries where surgical aid was early resorted to. 
(Bulletin de la Soc. Med.-chir. d ’Alexandrie, 1867.) even when they do not bring away pus, by producing a 
local letting of blood in the inflamed gland. 
However this may be, we ought always, before 
resorting to a more active kind of treatment, to prac- 
tise these aspiratory punctures. In the hepatic abscess 
of warm countries, this simple operation may suffice, 
but ordinarily this is not a curative method, and it is 
necessary to have recourse to other processes in order 
to give a free issue to the pus, and to wash out the sac 
by antiseptic syringings. 
These processes, which pertain to the domain of 
surgery, are some of them slow, others rapid; I will 
give you a more complete account of them when I 
come to the treatment of hydatid cysts, and will only 
briefly allude to them here. 
The slow processes are recommended principally 
by Graves and Recamier. Graves has advised an 
operation similar to that proposed by Begin in the 
treatment of hepatic cysts; i. e. he counsels to incise 
the abdominal walls down as far as the peritoneum, 
then to wait till nature makes the opening through 
that membrane. Recamier prefers the application of 
caustics, and the process is the same as that described 
for the opening of hydatid cysts. It is the process 
which Perier employed in the case of which I have be- 
fore spoken. 
Recamier places over the spot where the tumor points, 
from 3 to 5 grains of caustic potash; he thus obtains an eschar 
of 3or4c. m. in extent. Then, when this is detached, he puts in the wound a new piece of caustic potash, and repeats 
the operation till the abscess opens. 
Graves incises the soft parts to within 3 or 4 m. m. of the 
abscess, fills the wound with charpie, and waits till the suppur- 
ative inflammation has brought about the opening of the sac. 
Begin cuts down to the peritoneum and wails till by the 
progress of the inflammation the abscess bursts outwardly. 
But the rapid processes are preferred to-day, and 
authorities seem to attach less importance than 
formerly to the formation of adhesions, relying on the 
fact that in the abscesses of hot countries the hepatitis 
will have determined at the very outset of the affection 
the adhesions which are sought for, therefore the 
method of Cambray seems to have prevailed, who ad- 
vises to enter the sac at once and by direct incision. 
This is also the practice of Dutrouleau, who first 
makes an aspiratory puncture into the sac, then by 
means of the canula left in place and used as a 
grooved director, he incises the tissues and at one 
sweep makes a large opening into the abscess. 
This practice has since been perfected, and with 
antiseptic precautions and Lister’s dressings, the cus- 
tom is now to open these abscesses altogether with the 
bistoury. This is the mode of treatment successfully 
employed and heralded by a physician at Shang-Hai, 
Louis Stromeyer Little.* 
success under rigid antisepsis has been complete. 
The operation is done under the spray, with a long bistoury. 
To facilitate the issue of pus, a pair of dressing case forceps With regard to a choice between the methods, 
this must depend upon circumstances. When you 
have to do with an immense abscess causing a marked 
bulging of the hepatic region, and by its very size 
producing profound disorders, you will employ the 
rapid process, that of Cambay, or of Dutrouleau, 
modified by Little. When, on the other hand, the 
abscess is of small size, and the operation less urgent, 
you may have recourse to the method of Recamier, a 
process which is not so long as one would think, as 
with repeated applications of caustics it is possible for 
you in two days easily to reach the liver. You can 
act even more promptly by resorting, not to the 
caustics, but to the Paquelin cautery. You will thus 
be renewing the practice which, from time immemorial, 
the negro empirics have followed in the treatment of 
abscesses of the liver in their countrymen. 
They pass back and forth over a point of the hepatic 
region a red-hot iron, then at the end of several days they 
make a free opening with the knife. 
Accorking to Bordier, the Negro operators of Senegal 
base their procedure on the fact which they have observed (and 
which is, moreover, perfectly exact), that a burn made on a 
point of the abdominal wall determines an adhesive inflamma- 
tion of the peritoneum which corresponds to this point.* 
is introduced and the blades forcibly separated; then 
the abscess is washed out with a carbolic solution, and 
a large drainage tube inserted. The whole is covered with 
Lister’s dressing (Bull, de Therap., txcix, p. 408). 
* Bordier, Treatment of Abscess of the Liver in SenegalCJour.de 
TMrap., 1880). Now that surgeons, thanks to the antiseptic treat- 
ment, boldly enter the abdominal cavity, the rapid 
processes are coming more and more into vogue, and 
have pretty generally superseded the slow methods. 
An abscess of the liver is considered just like a collec- 
tion of pus elsewhere, to be freely opened, at whatever 
depth it exists. 
Whether you have recourse to the slow or to the 
rapid processes, when once the sac is open, care must 
be taken to make antiseptic lavages with solutions of 
chloral, or of boric or phenic acids. 
After the operation, there are two untoward 
accidents which you may have to meet; first, hemor- 
rhages, and you can understand the reason of this 
when you think of the active circulation in the liver; 
then biliary fistula. The hemorrhages are generally 
venous, and cold injections of perchloride of iron will 
be likely to control them. The other accident, the 
creation of a biliary fistula, is not so amenable to treat- 
ment, and sometimes patients will carry all their life- 
long a fistulous tract which gives issue to a more or 
less free flow of bile. 
Thus far I have given exclusive attention to 
the treatment of hepatitis, and have shown you 
how rare this affection is in our climate; this is, 
unfortunately, not the case with another form of 
inflammation of the hepatic gland, interstitial he- 
patitis which you will frequently observe in our wards, and which is known under the name of cirr- 
hosis.* 
To any one who should deny the important ad- 
vances which histology has made in the study of dis- 
eases, I know of no more-convincing instance of such 
progress than this subject of cirrhosis. At the com- 
mencement of my studies, thirty years ago, we were 
taught with reference to cirrhosis the doctrine of 
Laennec, i. e.y the existence of two substances in the 
liver, a yellow substance and a red substance; the pre- 
dominance of the first over the second constituting 
cirrhosis. 
Since then, thanks to the progress of histology, 
we have learned that there are varieties of cirrhosis, 
* Laennec was the first to describe cirrhosis as a special 
disease; he gave it the name of cirrhus (red), and considered 
the granulations seen on sections of the liver as productions of 
a parasitic nature similar to tubercules, and called these granu- 
lations cirrhoses. Andral taught the existence of two substances 
in the liver, and while the one, the red vascular substance, 
undergoes atrophy, the yellow glandular substance hypertro- 
phies. Becquerel, in 1840, defended from an anatomo-path- 
ological point of view the correctness of this division of the 
liver into two substances. Gubler, in 1853, called attention to 
the researches made by Kiernan in England, and Hallmann in 
Prussia, and was the first to point out the true nature of cir- 
rhosis. 
Lastly, we are especially indebted to Gharcot, who in 
these latter years has insisted on the importance of periphle- 
bitis as the point of departure of interstitial hepatitis. which are all characterized by a chronic inflammation 
having for its origin the different constituent elements 
of the liver. First, we have the common cirrhosis, 
dependent on inflammation and hyperplasia of the 
capsule of Glisson which surrounds the veins, and this 
is the only kind of which I shall speak here. Then 
we have a chronic inflammation having for origin the 
biliary canaliculi, the hypertrophic cirrhosis of which 
I spoke in my last lecture. The lymphatics, as 
Hayem, has shown, may also be the point of departure 
of a chronic inflammation which is observed in indi- 
viduals affected with syphilis. This is syphilitic cir- 
rhosis; lastly, according to Talamon the arterial system 
may, in its turn, be the origin of this chronic inflam- 
mation, and certain forms of hepatic cirrhosis may be 
attributed to that arterio-sclerosis of which interstitial 
nephritis, as we shall see later, is one of the most com- 
mon symptoms. 
As you see, gentlemen, sclerous inflammation of 
the liver may have for its origin the veins, the lymp- 
hatics, and the bile ducts, and to each one of these 
kinds corresponds a special cirrhosis; if I add that 
these lesions may be combined, and constitute mixed 
forms, you will agree with me that a great deal has 
been accomplished the last fifty years in elucidating 
the pathology of the cirrhoses. 
Common cirrhosis, which is still called atrophic 
cirrhosis, is constituted, as I just told you, by hyper- 
plasia of the connective tissue frame work of the liver, which chokes the hepatic cells and compresses the 
capillary venous net work; we know also that this in- 
terstitial inflammation has for its starting point the 
ramifications of the portal vein, and it is in the 
cellular tissue which surrounds these veins, i. e. in 
Kiernan’s interlobular spaces, that the inflammatory 
processes begin. 
This is of great importance from the point of 
view of the pathogeny of cirrhosis: it explains the well 
known action of the alcohols on the development of 
this affection, a cause which is so frequent, that in 
England the name of “ gin drinkers’ liver ” is given to 
this disease. The alcohol, absorbed from the surface 
of the digestive tube by the venous system, passes to 
the liver, but its presence in the ramifications of the 
portal vein determines a periphlebitis of special nature, 
which propagates itself in the connective tissue bind- 
web of the liver, and determines there that particular 
hyperplasia which characterizes cirrhosis. Inasmuch as 
drinking habits have been for several years on the in- 
crease (and here in Paris as well as in other parts of the 
world)—moreover, as in consequence of the high price 
of wine and the ravages of the phylloxera the alcohols 
of vinous origin are becoming so rare that only the rich 
can afford them, so that the fiery liquors are chiefly in 
demand and the poorer qualities of distilled spirits 
sold in the dram shops are consumed by the masses, 
it is easy to understand the reason of the constantly 
increasing number of cases of alcoholic cirrhosis. These two conditions, the growing abuse of al- 
coholic stimulants and the use of impure spirits, suffi- 
ciently explain the increasing frequency of cirrhosis, 
and we have always in our wards one or two typical 
cases of this affection. 
However, in the experiments which I undertook 
with Audige on swine, which we subjected to slow 
poisoning by daily doses of different kinds of alcohols, 
we did not succeed after three years of experimenta- 
tion in engendering interstitial hepatitis. It will not 
do to conclude from the negative result of these ex- 
periments that alcohol is not influential in the pro- 
duction of cirrhosis, for the anatomical arrangement of 
the liver in swine explains the absence of cirrhosis in 
the particular cases referred to, the liver in hogs being 
extraordinarily supplied with connective tissue reti- 
culum, which keeps the lobules apart and prevents 
their compression.* 
You all know the train of symptoms which 
cirrhotic patients present when they enter the hospital: 
* In our experimental researches on chronic alcoholism 
practised for three years on a number of hogs, we noted the 
following symptoms: During life some of the animals under 
experimentation presented a yellowish coloration of the con- 
junctivse, and their urine became icteric. This icterus always 
showed itself when we exceeded the quantity of two grams per 
kilogram of the animal’s weight, and the symptoms were more 
marked with alcohols of bad quality (the higher atomic alco- 
hols) than with ethylic alcohol. At the autopsy we found ascites more or less developed, abundant serous diar- 
rhoea, hemorrhoids, enlargement of the abdominal 
veins, advanced cachexia, profound emaciation, high- 
colored urine, liver generally reduced in size, spleen, 
however, somewhat tumefied. Such are the morbid 
phenomena observed in such cases, all resulting from 
the mechanical disturbance in the circulation of the 
portal vein. It is this mechanical disturbance, having 
its origin in the intra-hepatic reticulum, which has for 
its consequence stasis of blood in the portal vein and 
mesenteric veins, this stasis entailing effusion of serum 
into the abdominal cavity, preventing absorption from 
the surface of the intestinal mucosa, and thus giving 
rise to serous diarrhoea and hemorrhoids. It is to 
overcome this obstacle that the spleen augments in 
size, and it is to establish a supplementary circulation 
that the subcutaneous abdominal circulation under- 
goes increased development. 
But what we have just been considering is but 
the ultimate stage of the disease; there is another 
nothing but congestion of the liver; in certain cases the hepatic 
parenchyma was friable, but there was neither interstitial 
hepatitis nor ascites. 
Prof, Cornil, who made the histological examination of 
the liver in the poisoned animals, indeed noticed an extraordin- 
ary amount of connective tissue substance, but this is, he says, 
a normal condition in the hog. (See Beaumetz and Audige, 
“ Experiments in Chronic Alcohol-Poisoning,” (translation of 
E. P. Hurd), in Therapeutic Gazette for July and August, 1884). stage which precedes the organization of the connec- 
tive web-work, a congestive period during which the 
patient does not demand medical help. He, in fact, 
does not present himself at the hospital till his disease 
has produced ascites, and only applies for treatment 
when it is too late for anything but palliation. 
In these sclerous, interstitial inflammations, we 
can only influence the congestive element which pre- 
cedes the connective tissue hyperplasia. What I say 
to you of the liver, I may also say of interstitial 
nephritis, of sclerous myelitis, of which the inflamma- 
tory process is the same. When once the prolifera- 
tion of connective tissue cells is a settled fact, we can 
not by any therapeutic means destroy these organized 
products, or hope to restore the hepatic cells when 
we have to do with the liver, the malphigian bodies, 
when we have to do with the kidney, or the nerve 
tubes when it is a case of interstitial myelitis. 
We can then hope to render efficacious service 
only in the first period of the disease, characterized by 
congestive symptoms; hence, in the case of every per- 
son addicted to alcoholic abuses, you should give your 
attention to even the minor symptoms referable to the 
liver, and combat them by the best means available 
for diminishing hypersemia of the liver, i.e., revulsives, 
cholagogues, milk diet, and absolute abstinence from 
alcoholic beverages. By these means you will some- 
times obtain really marvellous results, and one of the 
most curious cases which I have ever witnessed was that of a patient who was sent to me by Dr. Touran- 
gin, and who presented all the symptoms of advanced 
cirrhosis; he is to-day quite well, and has been so for 
more than two years.* 
You will place, then, at the head of your treat- 
ment, milk diet which is capable of itself of bringing 
about an amelioration equivalent to a cure; and you 
may have seen by recent discussions at the Medical 
Society of the Hospitals that such cases are not as 
rare as one would think. 
You may add a therapeutic agent which I have 
tried, and which has given me good results; I refer to 
the hippurate of lime, which you may prescribe ac- 
cording to the following formula: 
5 Pure hippuric acid, 25 grams, 
Milk of lime, (to neutralize) q. s., 
Syrup, 500, grams, 
Essence of anise (to flavor) q. s. 
M. Sig.—Four to six spoonfuls a day. 
* The following are the notes of this case: M. R., watch- 
maker, aged 44 years, of somewhat intemperate habits, which 
he had contracted during the siege of Paris. 
This man was in an advanced slate of cachexia, the liver 
was voluminous and irregular, urine small in quantity and 
high colored; he had diarrhoea and was emaciating so rapidly 
that we at first thought it a case of cancer of the liver making 
rapid progress. 
This patient was subjected to milk diet, and blisters were 
applied over the hepatic region. After six months of treat- 
ment he got completely well, and has kept well ever since. But it will not do to place more than a moderate 
confidence in this medicament, and you will be often 
fated to see your patients improve in health only to 
resume their alcoholic excesses, and to succumb to 
the progress of their cirrhosis. 
Do you ask whether, when cirrhosis has attained 
its complete development, there is nothing to be done ? 
There will certainly be a demand for medical help, 
and there is much that you can do in the way of 
combating the mechanical troubles effected in the 
portal circulation, and in particular the ascites which 
results therefrom. 
Is it then possible by diuretics or purgatives to 
cause the ascites to disappear ? 
This is the opinion of some authorities, who be- 
lieve that they find in cirrhosis an indication for the 
anti-hydropical (evacuant) medication of which I spoke 
while on diseases of the heart.* I do not hold this 
view, and I maintain that in the majority of cases, 
diuretics, and especially purgatives, have no effect in 
removing the abdominal effusion, and when you con- 
tinue these medicines too long, for reasons obvious 
enough, you injure rather than improve the state of 
your patient. I think, then, that after a few moder- 
ate trials it is better to discontinue diuretics and 
drastics. 
of the Heart, Vol. I, p. 83, (Ed. of G. S. Davis, 
Detroit). Is it desirable to resort to tapping ? 
Here, also, there is much dispute. In most cases, 
and I have only to call your attention to what takes 
place before your own eyes in our wards, you will see 
that tapping, in the true cirrhotic, instead of prolong- 
ing life, only hastens the end; hence I remain gen- 
erally deaf to the entreaties of my patients, and put 
off this operation as long as possible, and only per- 
form it in the last stages, when the patients are be- 
coming asphyxiated by reason of the enormous de- 
velopment of the abdomen. This custom, gentlemen, 
is not peculiar to myself, but quite as much character- 
izes the practice of a great number of my colleagues. 
The annals of medicine, however, contain some 
curious cases in which patients have been known to 
hold out for months, even for years, owing to tappings 
frequently repeated, and even recoveries have been 
reported by this means. 
The number of recoveries is greater than one 
would think. In the discussion which took place in 
1885 on this subject at the Medical Society of the 
Hospitals, a large number of our colleagues related 
facts of this kind, and Lancereaux, in a communica- 
tion made in 1886, cited still other examples. 
I have myself published an interesting observa- 
tion of a patient affected with alcoholic cirrhosis, who 
was tapped and got well, continuing so for three 
months, till, by an imprudence, he contracted pneu- monia and died. The autopsy enabled us to confirm 
our diagnosis, interstitial hepatitis being found.* 
There is, then, a question of opportuneness, which 
must first be settled. In certain cases, in fact, the 
cirrhosis affects only a limited portion of the hepatic 
gland, and if the patient, by an intelligent hygiene, by 
absolute abstinence from alcoholic drinks, succeeds in 
arresting the invading march of the hepatic sclerosis, 
it is easy to understand that, by the fact of the oozing 
of liquid from the veins being slow and in small 
quantity, or even arrested altogether (owing to a suffi- 
cient supplementary venous circulation), paracentesis 
practiced in due time may free the abdomen, favor 
the portal circulation, and put the patient in a better 
situation. 
On the other hand, when the cirrhosis is complete, 
tapping can be only palliative, and the obstruc- 
tion to the circulation remaining, the abdomen 
speedily fills again with the liquid effusion, and thus 
the blood is drained of a large quantity of its serum; 
it stands to reason, then, that this abundant serous 
blood-letting will enfeeble, if it does not quickly kill 
your patient already cachectic. 
How are you to judge of the opportuneness of 
paracentesis? If you have to do with a young, vigor- 
ous patient, if the digestive functions are performed 
* Dujardin-Beaumetz on “The Treatment of Cirrhosis” 
(Soc. Med. des Hop., 1886). with sufficient regularity, if the nutrition is not too 
profoundly disturbed, your duty is to tap, and to 
watch and see if there is more or less speedy repro- 
duction of the liquid. If the abdomen speedily refills 
after three or four days, recovering its former disten- 
tion, it will not do to repeat the tapping. If, on the 
contrary, the patient has derived benefit for a fort- 
night, three weeks, or a month, from the paracentesis, 
you may repeat the operation. 
But when the cirrhotic patient is very cachectic, 
when his emaciation is considerable, when assimilation 
is nil, or almost so, I believe that if you desire to pro- 
long the life of your patient, you should not perform 
tapping. 
The economy becomes habituated, in a certain 
measure, to the often enormous accumulation of liquid 
in the abdomen, till little by little the patient becomes 
enfeebled and succumbs to the cachexia. 
As for the rules which should govern you in the 
performance of paracentesis abdominalis, I will not 
take up this subject, for it is, as you know, one of the 
most simple and easy of operations; at the same time 
I will call your attention to two points: First of all, 
you should be careful as to the place where you make 
your trocar-puncture, in order to avoid wounding the 
enlarged and distended veins, which in the cirrhotic 
ramify so abundantly upon the abdominal wall. Then, 
when the tapping is terminated, you should see that 
the patient lies on the side opposite to that where the puncture was made, and that he keeps this position 
for some time, in order to enable the wound which 
you have made to cicatrize. You thus avoid those 
fistulas which often remain behind, and which are ex- 
ceedingly disagreeable, for they soil the patient’s linen 
and produce cutaneous inflammation. 
Apart from this interesting question of paracen- 
tesis, are there any other indications for the treatment 
of cirrhosis ? I know of none that are very clear, with 
the exception of milk diet, whereby, in fact, you may 
be able to augment the quantity of urine, support the 
patient, and prolong his life. This is indeed very 
little, but, I repeat, this very paucity of therapeutic 
resources results from the profound disorders effected 
in the hepatic gland, disorders which are always be- 
yond the reach of any medicinal treatment. I shall 
finish what pertains to the treatment of diseases of 
the liver by devoting a lecture to hydatid cysts of this 
organ. CHAPTER VII. 
TREATMENT OF HYDATID CYSTS OF THE 
LIVER. 
Summary:—Taenia Echinococcus—Development of Hydatid 
Cysts—Prophylactic Treatment—Frequency of Hydatid 
Cysts in Iceland—Diagnosis of Hydatid Cysts—Medical 
Treatment—lodide of Potassium—Electro-Puncture— 
Capillary Punctures—Aspiration—Results Given—Free 
Opening of the Sac—Methods of Begin, Recamier and 
Jobert—Resume of Treatment—Lavages of the Sac. 
Hydatid cysts may develop in all the tissues of 
the economy, and if I here occupy your time with the 
treatment of these cysts, it is because it is in the liver 
that they are most frequently observed. But before 
touching upon the therapeutics of hydatid tumors, it 
is necessary that I should state as briefly as possible 
their pathogeny. When, in my “ Diseases of the 
Stomach and Intestines ”* I traced the history of the 
taeniae, I mentioned that these cestoids, before reach- 
ing the stage of tape worm, pass through an inter- 
mediate vesicular stage—that of cysticercus. These 
are facts long known in respect to animals; we may 
add that man may be the bearer of these vesicular 
worms, and without dwelling upon the cysticerci of 
the taenia, which have been known to develop in 
Wm. Wood & Co., N. Y., Chap, xxv p. 360. the muscles of man,* and which render him measly, 
(a condition once supposed to be peculiar to the 
hog), I wish to call your attention to another verminous 
affection, unhappily more frequent, and which is also 
one of the phases of the life of a taenia, I refer to 
the echinococcus cyst. 
It is in the dog or the wolf that we find the 
tsenia echinococcus. This worm is very different from 
those I have described; it is extremely small, scarcely 
appreciable to the naked eye, and is composed of 
a head furnished with four suckers, a double crown 
of hooks, and a body formed of three rings, of which 
the last only is provided with genital organs. This 
taenia produces eggs in abundance which are found 
in the faecal matters of these animals. 
Suppose now that these excrementitious matters 
are washed by the rain and carried to a brook or 
spring, and an individual drinks this water: the ova 
will be absorbed, will penetrate the intestinal walls 
into the abdominal venous system, and will thus enter 
the general circulation. They will then engender in 
various organs, but particularly in the liver, through 
which filters all the blood of the portal vein, liquid 
tumors more or less voluminous, which have been 
described under the name of hydatid cysts. You all 
are familiar with these vesicles of variable size, having 
the aspect of a trembling jelly, and containing a 
* Delpech, Lancereaux, Davaine, Boyron. transparent non-albuminous saline liquid; these are 
the acephalocysts described by Laennec. 
If you examine carefully the walls of these cysts, 
you will find them composed of a series of structure- 
less layers imbricating each other, the most internal 
of which presents a granular aspect, concerning which 
Prof. Charles Robin has given a long description. It 
is, in fact, the germinal membrane, and if you observe 
it with care, you will find sticking to its surfaces, or 
floating in the liquid, little white grains, which micros- 
copical examination will enable you to recognize as 
constituted by a body formed of a roundish vesicle 
containing granules of carbonate and phosphate of 
lime. These vesicles, the anterior part of which is 
constituted by a head absolutely identical with that of 
the taenia echinococcus, i. e., presenting a double 
crown of hooks and four suckers, are the scolices of 
this taenia, and if by accident these echinococci are 
swallowed by a wolf or dog, they engender in this ani- 
mal the taeniae of which I have just spoken. 
Von Siebold in 1853 gave to twelve young dogs and to a 
fox some echinococci from the lungs of an ox and a sheep, and 
he found in the small intestine a great number of little tape 
worms. Von Beneden made similar experiments, and obtained 
like results. These experiments were successfully repeated in 
1863 by Finsen and Krabb. 
Pardon me, gentlemen, for having dwelt so long 
on the development of these hydatids, but I have seen 
so many mistakes committed in this connection, and 
witnessed such confusion of opinion on this subject, that I deem it necessary to state briefly and clearly 
what is known relative to this matter of pathogeny. 
Moreover, as you will see, important conclusions from 
the point of view of the prophylactic treatment of 
hydatid cysts result from the knowledge of the facts 
which I have stated. But before going further, I wish 
to say a few words concerning the ultimate course of 
these hydatid cysts, which may present themselves in 
all parts of the economy; but as their seat of predilec- 
tion is assuredly the liver, I intend to confine my 
remarks to the hydatid cysts of this organ. 
Enclosed in a firm resisting fibrous envelope—a 
true adventitious cyst—these hydatids tend gradually 
to increase in size, and this increase ultimately pro- 
duces rupture of the cyst into the neighboring organs. 
If into the peritoneum, death is the consequence; if 
into the veins, into the vena cava for instance, a fatal 
embolism is the result; if the cyst bursts into the pleura 
and lungs, you readily understand the grave conse- 
quences of such perforation. 
The most favorable cases are those in which the 
sac ruptures into the stomach or intestine, and this is 
one of the modes of cure. 
I have just said that the bursting of the cyst into 
the peritoneum is fatal. This does not always hold 
true, and several cases are on record of hydatid cysts 
which have opened into the peritoneum, and in which 
recovery took place after a sharp attack of peritonitis. 
The best instance of the kind to which I can refer is that of a young girl, five months pregnant, who 
entered our wards; she presented a fine example of 
hydatid cyst of the liver. We tapped her and drew 
off 1,500 grams of liquid; two months after she fell 
upon the sidewalk and ruptured the cyst; there was, 
as she told us at the time, the sensation of a liquid 
effused into the abdominal cavity. A frightful peri- 
tonitis ensued, a miscarriage took place, and in the 
end she recovered. 
These cysts may, however, disappear without 
bursting into the neighboring organs; the hydatids 
die, the liquid is reabsorbed, leaving behind nothing 
but a mass of fatty debris representing the regressive 
metamorphoses that the sac has undergone, and at 
the autopsy these remains will be found. 
In other circumstances, the sac suppurates without 
undergoing rupture, and the patient succumbs to the 
progress of the putrid infection determined by the 
suppuration. Lastly, in some cases, without bursting 
into neighboring organs, without suppurating, these 
cysts may cause death by the cachectic state to which 
the patients are reduced by reason of disturbances in 
the functions of the digestive tube effected by pressure 
of the tumor. 
Hence, then, the rarity of spontaneous recovery, 
the possibility of the cyst bursting into neighboring 
organs with either death or recovery, frequent sup- 
puration of the sac, profound disorders of nutrition— 
all this goes to show that hydatid cyst of the liver is a grave affection, necessitating active and energetic in- 
terference. 
I will first consider the prophylactic treatment. 
Our knowledge of the mode of evolution of the tsenia 
itself suggests what this should be, and I can not too 
much impress upon you the danger, when in the coun- 
try, of drinking directly from brooks or springs, as 
these water-sources are so apt to be contaminated by 
the ova of the taenia voided by animals and carried 
there by the rain. It is important, then, for the 
soldier as well as for the laboring man, for the peas- 
ant as well as for the traveller, never to drink water 
from springs or pools without having first filtered it 
(through a charcoal filter, for instance) or boiled it, 
for when once the disease is contracted, it becomes a 
serious matter to get rid of it. 
There is one country where these precautions 
ought to be rigorously carried out, viz.; in Iceland, 
where hydatid cysts are extremely frequent. Accord- 
ing to Dr. Hyatalin, one-tenth of the population of 
this island are affected with hydatid cysts; but this 
figure is too high, if we may rely on the statistics of 
Finsen and Jonassen, which show'that of the 
population (viz.: about 2,300) are victims of echino- 
coccus.* 
*lceland is, moreover, the true country of the vesicular 
helminthi or cestoid worms. The sheep have almost all stag- 
gers, produced by the taenia coenurus, and out of 100 dogs This sad condition results from the following cir- 
cumstances: First, in Iceland the dogs are very num- 
erous; 20,000 dogs to 70,000 inhabitants; then a great 
many of the animals that graze are affected with 
hydatid cysts. When these beasts are slaughtered, it 
is the custom to throw their entrails to the dogs, the 
dogs thereby contract taenia, and as they live in terms 
of close intimacy with the inhabitants, and deposit 
their excrements on the snow near the farms or boers, 
it results that when the snow melts, animals as well as 
man that consume a great deal of lichen, devour the 
eggs of the taenia which have been deposited thereon, 
and thus contract hydatid cysts. So, in order to com- 
bat this vicious circle, which brings this result that the 
frequency of taenia in the dog entails frequency of 
hydatid cysts in men and other animals, and vice versa, 
Murchison thinks that this sanitary regulation should 
be enforced, viz.: the dogs should be absolutely pre- 
vented from eating the entrails or debris of animals 
near the slaughter houses; then they should be fed 
only with cooked food, and frequently purged to rid 
them of their tape worms. Galliot proposes also an 
energetic remedy: to kill all the dogs, and replace 
Krabbe found 93 infected with different taeniae, in the follow- 
ing proportions; tcenia marginata, 75 per cent.; tcenia coenurus, 
18 per cent.; tcenia echinococus, 28 per cent.; tcenia cumarina, 
57 per cent.; tcenia lagopodis (of the blue fox). 21 per cent.; 
bothriocephalus cuscus, 5 per cent.; ascaris marginata, 2 per cent. them by others of a different race, which shall be pre- 
vented from eating the debris of diseased animals. 
But, to return to our subject, supposing that you 
have a patient affected with cysts of the liver, what 
are you going to do ? The diagnosis, save in excep- 
tional cases, is generally easy, but you must not count 
too much on a characteristic sign of cyst, the hydatid 
thrill. This is a rare symptom; the Icelandic physi- 
cians, who see so many cases, have never remarked 
this symptom. 
The gradual development of the tumor, its round- 
ed form, and, it may be, the aspiratory puncture, gen- 
erally make the diagnosis sufficiently certain. But 
before coming to the subject of tapping, I wish to say 
a few words concerning the medical treatment. 
Certain medicines have been vaunted in the treat- 
ment of hydatid cysts. Laennec advised chloride of 
sodium; Hyatalin, kamala (in tincture, 30-drop dose, 
for adults). Guerault claims that cold applied ex- 
ternally gives good results; Hawkins vaunted potas- 
sium iodide, and Jaccoud speaks well of this remedy. 
If, however, we can rely on the authority of Frerichs, 
this treatment is of no value, for he has never found 
iodine in the hydatid liquid of individuals taking 
iodide of potassium. This view, however, has been 
combated by Semmola, of Naples, who has shown 
that in certain cases where potassium iodide is given, 
the iodine may pass into the interior of the cystic 
pouch. This is his mode of procedure: he subjects the 
patient to an iodide treatment, then, at the end of 
several days, he aspirates the sac and ascertains if 
iodine appears in the liquid; if it be found there, he 
continues to give iodide of potash, and claims that he 
obtains a very considerable diminution in the sac 
and its reduction to a solid mass; in negative cases, 
(/.«?., where iodine is not found in the water of the sac) 
he has recourse to other modes of treatment. 
Before resorting to puncture, you may employ a 
therapeutic means which I believe is destined to be 
very successful; I refer to electrolysis. 
In a previous course of lectures * I showed you the 
good results of electro-punctures in the treatment of 
aneurisms. The same method is applicable in the 
treatment of hydated cysts. You enter the cyst with 
your acupuncture needles, then you connect them with 
the poles of a galvanic battery. Here the kind of 
current is not of the same importance as in the case 
of the aneurismal tumor. You may employ indiffer- 
ently the positive or negative current, or even both at 
once. Hilton Fagge and Cooper Foster, who have 
published eight cases with satisfactory results, employ 
only the negative current. 
I have practiced electrolysis in three cases, and 
this is my mode of procedure: I place over the cyst, 
* Diseases of the Heart, Part II (G. S. Davis, Detroit 
Series for 1887). according to the method of Apostoli, a cake of moist 
clay connected with the negative pole, which termin- 
ates in a circular disc resting upon the clay. This 
clay cake does not touch the needles, two or three of 
which I introduce into the tumor. These needles are 
the same as those of which I make use in the electro- 
lysis of aneurisms of the aorta. They are covered 
with a protective insulating varnish, and the two ex- 
tremities alone are free. The penetration and extrac- 
tion of these needles is performed with the same 
instruments as in aneurismal electro-puncture.* I 
keep the intensity of the current between 40 and 45 
milliamperes, and the duration for each needle aver- 
ages ten minutes. I have not obtained complete cure 
by this means, but like Semmola and Gallozi, I have 
observed marked diminutions in the size of the sac, 
and have not noticed any untoward results whatever. 
Therefore I believe that this method can be an 
eminently advantageous one. First, of itself it may 
bring about destruction of the hydatids and their slow 
resorption, and if it does not produce this effect, it 
will always tend to produce adhesions between the 
sac and the abdominal walls, adhesions which, as you 
know, are conditions of success in these mechanical 
evacuations of hydatid cysts. This operation, prac- 
tised with success in England and in Italy, deserves 
henceforth to be adopted in our country. 
* See Diseases of the Heart, Part II (Ed. of G. S. Davis), 
page 285. We come now to the treatment of hydatid cysts 
by puncture, an operation which may serve not only 
as a means of diagnosis, but also as a therapeutic 
agency, for it may of itself bring about a complete 
cure in some cases. These punctures are practised 
with capillary trocars which may be attached to the 
aspirator. Although Murchison rejects aspiration, 
and uses only the capillary trocars, it must be admit- 
ted that Dieulafoy has rendered to medical practice in 
general, and to the treatment of hydatid cysts in par- 
ticular, a great service in making easy and handy the 
method of aspiration. It is in fact the only method 
which we ought now to put in usage; but before re- 
sorting to aspiration, you should remember that these 
capillary punctures are not always absolutely safe, as 
the fatal cases of Moisenett, Pidoux, and Damaschino 
go to show. 
With aspiration, such disasters are however very 
rare; but in order to avoid all accidents and to obtain 
from the operation all the success desirable, the follow- 
ing precautions should be taken: 
First, to withdraw all liquid from the sac, and to 
make the aspiration as complete as possible. This is 
a practice on which Gosselin, Jaccoud, Dieulafoy, 
Moutard-Martin, and Desnos have rightly insisted, 
and which is in vogue among the Icelandic physicians. 
* Murchison, Diseases of the Liver, Dieulafoy, On the 
Diagnosis and Treatment of Hydatid Cysts. (Traite de Ins- 
piration.) Then, you should not employ the aspirator needles, 
but always use a trocar of small diameter; in as- 
pirating the sac you may, in fact, with the needle 
wound certain parts of the sac or the hepatic paren- 
chyma, and determine a hemorrhage or a lesion which 
shall compromise the result of the operation; this 
does not happen with the trocar, of which the sharp 
extremity is withdrawn. 
Moreover, it is a good plan to perform aspiration 
according to the rules of the antiseptic method, i. e., 
to have the instruments scrupulously clean, and the 
needles rendered aseptic by subjecting them to strong 
phenic acid before being used. 
Lastly, when the aspiration is completed, you 
should keep the patient in bed at absolute rest for 
three or four days, and if any inflammatory symptoms 
should present themselves, ice bags should be placed 
over the tumors, as Jaccoud recommends. 
These capillary aspiratory punctures have been 
known to result in a radical cure, and without accept- 
ing fully Dieulafoy’s statement that this result may be 
attained seven times out of ten, I can affirm that the 
number of cases of cysts cured by one or more capil- 
lary punctures is very large. Look over the reports of 
the Bulletin of the Medical Society of the Hospitals, 
consult the work of Davaine, you will see that 
Moutard-Martin, Gerin-Roze, Dieulafoy, Constantin 
Paul, Delens, Archambault, Hayem, Laveran, Lan- 
ceraux, Charles Bussard, Massart, etc., have recorded cases of this kind. Gosselin, Jaccoud, Desnos, vaunt 
the curative action of these capillary punctures, and 
I have myself observed two cases in which a simple 
aspiratory puncture brought about a cure.* 
One of these was the case of a patient on whom 
I operated at the Hotel Dieuforan abdominal hydatid 
cyst; the other was that of a child whom I here show 
you to-day, and who two years ago underwent a single 
puncture operation for hydatid cyst of the liver, and 
the child is to-day perfectly well. 
The following notes of these cases may be of 
interest: 
HYDATID CYST OF THE ABDOMEN. 
Aspiration—Recovery.—Madam R., aged 30 years had in 
the right iliac fossa a tumor as large as a child’s head, regular 
and ovoid. Aspiration was performed Feb., 25, 1872, with the 
No. 2 trocar of the Dieulafoy apparatus. Nearly a quart (900 
grammes) of liquid clear as water, without a trace of albumen 
was removed. Five days later the patient left the hospital, 
cured. Since this period, till 1879, there was no return of the 
malady. 
The other case is given from the notes of Dr. Paul Bon- 
cour. 
Paul V., aged 11 years, was admitted to St. Antoine 
Hospital, during the year 1877. In the epigastric region there 
was a roundish tumor connected with the liver, and making a 
perceptible bulging at this point; the digestive functions were 
a little disturbed by the presence of this tumor; the other func- 
tions were normal. 
This tumor continued to grow for three months, till Nov. 
22, 1877, when Dujardin-Beauraetz performed aspiration and 
*Dujardin Beaumetz “ On the Value of Aspiration in the 
Treatment and Diagnosis of Hydatid Cysts,” Bull. de. 
Therap., Feb. 15, 1873, etc. withdrew 200 grams (or not quite ]/% pint) of a clear limpid 
liquid containing no albumen. No untoward results followed, 
and the tumor completely disappeared. The child was brought 
to the hospital in Nov. 1879 and was presented to the class on 
the occasion of this lecture; the tumor had not been repro- 
duced. 
But it may be asked, when is this operation likely 
to result in perfect cure. One important element of 
prognosis is the quality of the cyst liquid, and to this 
the Icelandic physicians attach a great importance. 
When the liquid is clear, limpid, containing neither 
albumen nor pus, one puncture may result in cure, if 
it is turbid and albuminous, a cure from a single 
puncture is more doubtful; if it is purulent, cure is 
next to impossible by this means.* 
I myself hold this view, and in a memoir published 
in 1873 in the Bulletin de Therapeutique, I urged the 
absolute necessity of resorting to methods which shall 
permit a complete washing out of the sac when the 
cyst has suppurated, for the capillary puncture is in- 
sufficient to prevent putrid resorption. It is necessary, 
* Jonassen gives the following indications from the state 
of tbe cyst liquid. 
{a) Liquid clear as spring water, without any opales- 
cence if heated, containing therefore no albumen, but some 
chloride of sodium. Liquid of this character indicates that the 
cyst is still in the state of development, not having under- 
gone any degeneration or inflammation. The vesicles are 
living vesicles. 
(b) Liquid turbid, becoming opalescent if heated. The 
opalescence indicates the death of the echinococci, whose then, to interfere energetically; the presence, even, of 
albumen in the cystic liquid necessitates, according to 
certain medical authorities, and in particular those of 
Iceland, a free opening of the sac. 
How should you make this opening ? Several 
methods have been proposed; that of Begin consists 
in incising, layer by layer, the abdominal walls down 
to the peritoneum, then after having stuffed charpie 
into the wound, the surgeon waits several days to ob- 
tain adhesion between the sac and abdominal wall, 
after which he incises the tumor. This method is 
now abandoned; possibly as a result of the progress 
of antiseptic dressings, it may be again tried with 
reference to seeing if there may not be thereby ob- 
tained sufficient adhesions. 
The method of Recamier is still in usage; it con- 
sists in opening the sac by caustics. You make 
successive applications of caustic down to the sac, 
cadavers, dissolved in the liquid of the cyst, have rendered it 
albuminous. 
(c) Liquid with purulent aspect, but not generally con- 
taining real pus. This indicates the presence of fatty granules, 
due to regression of the cadavers of the echinococci. You find 
in this liquid little albumen, considerable chloride of sodium, 
and the booklets of the echinococci, the chitine of which has 
resisted all the causes of destruction. These two last signs 
when discovered, indicate without any possible doubt, the 
presence of a hydatid cyst. / 
The free opening of the sac, with frequent cleansing 
lavages, is indicated in the two latter cases. employing Vienna paste or chloride of zinc; Richet 
prefers the latter. Then, when you have reached a 
sufficient depth, you plunge in your trocar or your 
bistoury, and open the cyst. In these cases, the slough 
formed by the caustic ought, as Demarquay has 
shown, to be quite extensive; you want a large open- 
ing in order to make sufficient and complete lavages 
of the sac, and give issue to the numerous hydatids 
and their membranes. If you employ the trocar, 
select the largest size. My colleague, Ernest Besnier, 
has had' made at the Maison de Sante an enormous 
trocar, of which I make use, and I confess that it was 
not without considerable trepidation that I first dared 
to plunge this trocar into the cystic tumor. But large 
openings have great advantages, and I cannot too 
much recommend you to bear this in mind, and not 
err on the side of timidity. 
Jobert, Dolbeau, and Gallard, in order to obtain 
the adhesions so much desired between the abdominal 
wall and the sac, have counselled a method which 
seems to me to be excellent; it is to leave the trocar- 
canula in place for one or two days. The canula pre- 
vents the passage of liquid into the abdomen, favors 
adhesion, and its presence permits lavage of the sac. 
Surgical interference has been much oftener re- 
sorted to the last few years in the treatment of hydatid 
cysts, owing to the progress of antiseptic methods. 
Hence, the processes of Begin and Recamier, which 
are confessedly slow and insufficient, have been abandoned in favor of immediate and free opening of 
the sac by means of the bistoury. The results ob- 
tained by this method have been very satisfactory. 
The large opening gives easy exit to all hydatids, and 
enables one to empty and wash out the sac. The 
brilliant success obtained by Lawson Tait in the case 
of one of our most noted faculty professors by this 
method has tended to make this operation popular in 
our country. 
Hence, to sum up, I would say: If you have to 
do with a hydatid cyst, make an aspiratory puncture 
and empty completely the sac with the trocar. If the 
liquid is limpid and the sac is single, you may hope 
for a cure, though you may have to repeat the punc- 
ture. If the liquid is turbid and albuminous or puru- 
lent, you may have to resort to some other operation. 
You may then have recourse to the surgical procedure 
which I have mentioned, i. e., free opening of the sac 
with the knife, or to some of the ancient methods by 
caustics, following the rules which Davaine has laid 
down.* If you resort to the caustic, when the eschar 
has attained a sufficient depth, plunge in a large 
trocar, then withdraw it, leaving the canula in place 
for two or three days; then, for the canula, you may 
substitute a rubber drainage tube, and perform fre- 
quent washings of the sac. 
*Davaine, Traitement des Entozoaires, 2d. Ed., 1878, 
p. 662. These lavages are very necessary, and ought to 
be made with antiseptic liquids, such as solutions of 
phenic acid, boric acid or alcohol. Boinet recom- 
mends iodine; Ludet, Cadet-de-Gassicourt, and Dol- 
beau highly recommend the employment of bile, bas- 
ing themselves on cases of spontaneous cure of the 
cyst by the opening of a bile duct into it. Pavy has 
counselled injections of ethereal extract of male fern; 
and I cannot too much urge the use of a solution of 
chloral, 1 to 200, and the washing out of the sac with 
it morning and evening. You can also use all the 
other antiseptic solutions, boric acid, thymic acid, 
phenol, etc. 
Do not forget, at the same time, that the walls of 
the sac may absorb the medicinal solutions with ex- 
treme rapidity, and I have often seen carbolic solu- 
tions injected into the sac cause a blackening of the 
urine and real toxic symptoms. This is why you 
ought not to think of using solutions of red iodide or 
bichloride of mercury, which are powerfully antiseptic, 
but which are dangerous by becoming toxic if absorb- 
ed in too great quantity. 
There are several ways of introducing these anti- 
septic solutions into the sac. Revelliod, of Geneva, 
suggests employing in these cases the syphon. He 
introduces into the sac a long rubber tube communi- 
cating with a basin, which the patient may raise or 
lower at will, and which, according to the position which he takes, enables the liquid to flow into the 
cyst or flow out from it. 
I have tried this method of syphoning, and con- 
fess that I have not derived the same advantages 
therefrom as my confrere of Geneva claims, since, for 
various reasons, the syphon does not always work to 
your satisfaction. In order to inject my antiseptic so- 
lutions, I employ either a common syringe or, what is 
better, one of those handy apparatuses which are ap- 
plied to bottles; by simply compressing a rubber ball 
injector, you can aspirate the liquid contained in the 
bottle, and a rubber tube furnished with a canula en- 
ables you to direct the current upon any point or into 
any cavity that you desire. 
But it must be admitted that the difficulty of an- 
tiseptic cleansings in the treatment of hydatid cysts of 
the liver is due, in the majority of cases, to the ob- 
stacles in the way of the discharge of the echinococci 
by the abdominal opening, and you have seen a recent 
case in our female wards illustrative of this fact, where, 
despite the large extent which we gave to this open- 
ing, the exit of the hydatid sacs was rendered extreme- 
ly difficult.* You must then take the utmost pains to 
keep this opening as wide and free as possible, and if 
it contracts, you should not hesitate an instant to 
dilate and enlarge it by means of a sea tangle tent. 
* A large trocar was used, but it kept getting clogged. 
By phenic acid lavages the debris were finally cleared, and the 
patient got well. Do not forget, moreover, after each dressing to 
withdraw the sound which you have introduced by the 
opening. Often the orifice of the sound is clogged 
by the cyst membranes, which easily obliterate the 
bore of the tube, and if you withdraw the canula, you 
see a gush of putrid matters issuing by your fistulous 
opening. 
The sac retracts little by little, and you find your- 
selves able to get less and less of liquid into it by your 
syringe; you take a smaller tube, and after a while no 
more liquid can be made to enter. You take out the 
tube, and the patient is cured. Recovery is not always 
the rule. Often the patient succumbs to the suppura- 
tion, or, as in a case that I saw with Dr. Herard, when 
in a lobe of the liver one sac has disappeared, an- 
other develops in another lobe. But whatever may 
happen, you should do everything, try everything— 
when once the cyst has been opened—to avoid the 
causes of septicaemia, and to support the strength of 
the patient by an appropriate treatment. 
As you see, the treatment of hydatid cysts of the 
liver demands surgical knowledge and skill. But it be- 
longs to you, as practitioners of medicine,to be ready for 
the emergency and to employ the needed surgical 
means, and no less responsibility belongs to the after- 
care of the case, which demands constant watchfulness 
and attention, so that it may be said that the treatment 
of this affection is as much the province of the physi- 
cian as of the surgeon. INDEX. 
Page. 
Abscess (hepatic) 141 
Acholia • 96 
Alcohol, Influence of, in Cirrhosis 151 
Alkalies in Biliary Lithiasis 40 
Ammonium Chloride in Amyloid Liver 120 
Antiseptics in Jaundice g6 
Antipyrine in Hepatic Colic 68-72 
Aspiration in Hydatid Cysts of Liver 169 
Hepatic Abscess 144 
Baptisia 34 
Bilirubin 14 
Tests for 88 
Blood Letting in Hepatic Congestion 129 
Boldo in Hepatic Congestion 130 
Bouchard on Pathogeny of Calculi 82 
Bouchardat, his Alimentary Regimen in Biliary Lithiasis. 81 
Buckler, his Specific for Gall Stones 75 
Calomel 28-94 
Calculi Biliary 50 
of Cholesterine 54 
Cancer of the Liver 122 
Carbon Sulphide in Jaundice 97 
Carlsbad Water in Lithiasis 78 
Charcoal in Jaundice 96 
Charcot 2, 66, too, 101, 107, 137, 149 
Chloroform as a Biliary Solvent 75 
in Hepatic Colic 62-72 
Chloral in Hepatic Colic .62, 70 Cholesterine 12 
Choleate of Sodium 75, 76 
Cholagogues 22 
in Treatment of Biliary Calculi 76 
Physiological Experiments 0n... 23 
Calomel 28, 94 
New Cholagogues of Vegetable Origin 31 
Alkalies as 40 
Cholecystotomy 84 
Cirrhosis, Hypertrophic 136 
Atrophic 149 
Colic, Hepatic 61 
Pathogeny of 62 
Treatment of 67 
Colchicine 38 
Congestions of Liver t25 
Passive 125 
Active 126 
Malarial 127 
Corrosive Sublimate 30 
Cramps in Hepatic Colic 65 
Cysts Hydatid of Liver 161 
Page. 
Degenerations of the Liver „ 117 
Amyloid 117 
Fatty 120 
Cancerous 122 
Diet in Lithiasis 80 
Dujardin-Beaumetz, Experiments on Alcohol Poisoning.. 152 
Durand-Fardel 67 
Durande, his Specific for Gall Stones 73 
Electrolysis in Hydatids of Liver 169 
Electricity in Treatment of Jaundice 101 
Enemata Cold in Catarrhal Jaundice 95 Page. 
Engorgements of Liver 115 
Ether as a Solvent for Gall Stones 73 
Euonymin 32, 72, 94 
Fauconneau-Dufresne 65 
Fever in Hepatic Colic 66 
Frerichs on Jaundice without Obstruction 103 
Gall Stones 50 
Pathogeny of 53 
Gastralgia in Hepatic Colic 65 
Glychocholates of Sodium 15 
Haller, Tests for Bile in Urine 88 
Hemorrhages in Jaundice 98 
Hepatitis 140 
Hippurate of Lime in Cirrhosis 155 
Hunyadi Janos 79, 94 
Hydatids of the Liver 161 
Hydrastin 35 
Hydrotherapy in Hepatic Congestion 132 
Hygiene in Prophylaxis and Treatment of Biliary Lithiasis, 80 
Icterus (see Jaundice) 87 
from Mental Emotion 106 
by Animal Poison 105 
Inflammation of Liver 137 
lodine in Amyloid Liver irg 
lodoform in jaundice g6 
Ipecac as a Cholagogue 30 
Iridin ... 33 
Jaundice 87 
Symptoms of 87 
Causes 88 Page. 
Jaundice by Obstruction 89 
by Spasm 90 
without Obstruction 102 
Grave 107 
Juglandin 35 
Kuhne on Jaundice Without Obstruction 103 
Kamala in Hydatid Cysts of the Liver 168 
Lavage in Hydatid Cysts 178 
Leptandrin 36 
Lithiasis Biliary 46 
Treatment 67 
Lithontriptics 73 
Liver, Anatomy of . . 2 
Physiology of 4 
Glycogenic Function of 5 
Organ of Urea Formation 6 
Passage of Medicinal Substances Through 7 
Effect on Medicines and Poisons 10 
Biliary Secretion of 12 
Malaria, Influence of in Hyperaemia of the Liver 127 
Milk Diet in Cirrhosis 155 
in Hepatic Congestion 135 
Catarrhal Jaundice 94, 100 
Mineral Water in the Treatment of Biliary Calculi 77 
Monneret on Etiological Divisions of Hyperaemia of the 
Liver 128 
Morphine in Hepatic Colic 62- 68 
Murchison on Jaundice Without Obstruction 102 
Naphthalin in Jaundice 96 
Paracentesis in Cirrhosis 156 Petenkoffer, His Test for Bile 88 
Phytollaccin 37 
Podophyllin 27, 36 
Potassium lodide in Amyloid Liver 119 
in Hydatid Cysts of the Liver 168 
Pruritus in Jaundice 97 
Punctures in Treatment of Hydatid Cysts of the Liver.... 169 
Page. 
Quinine in Jaundice . 112 
Revulsions in Hepatic Congestion 129 
Rubinat Water 79, 94 
Sanguinarin 37 
Sodium Salicylate 39 
Sulphate 39 
Phosphate 39 
Sulphate-waters as Lithontriptics 79 
in Catarrhal Jaundice 94 
Steatosis of the Liver 120 
Succinate of Iron 75, 76 
Syphilis of the Liver IxB 
Taurine and Taurocholates 15 
Turpentine as a Solvent for Gall-stones 73 
Vichy-water in Lithiasis 78 PARKE, DAYIS & CO. ask the attention of physicians to 
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Podophyllin, 1-2 gr. Blue Mass, 1-4 gr. 
Ext. Henbane, 1-8 gr. Ext. Nux vomica, 1-16 gr. 
Oleores. Capsicum, 1-8 gr. 
Cathartic Comp., Granules, 3-4 gr. 
Jalapin, 1-16 gr. Powd. Gamboge, 1-32 gr. 
Leptandrin, 1-16 gr. Powd. Capsicum, 1-64 gr. 
Aloin, 1-8 gr. Ext. Henbane, 1-8 gr. 
Podophyllin, 1-4 gr. Oil Peppermint, 1-128 gr. 
Cathartic Comp., Improved, 3 gr. 
Ext. Coloc. Co., 1 gr. Leptandrin, 1-4 gr. 
Ext. Jalap, 1-2 gr. Ext. Henbane, 1-4 gr. 
Podophyllin, 1-4 gr. Oil Peppermint, q. s. 
Ext. Gentian, 1-2 gr. 
Cathartic Comp., Mild, 3 gr. 
Ext. Coloc. Co., 1 gr. Gamboge, 1-4 gr. 
Jalap res., 1-2 gr. Ext. Henbane, 1-2 gr. 
Calomel, 1-2 gr. Oil Peppermint, q. s. 
Cathartic Comp., Modified, 3 1-2 gr. 
Ext. Coloc. Co., 1 gr. Powd. Gamboge, 1-6 gr. 
Ext Jalap, 3-4 gr. Powd. Rhubarb, 1-2 gr. 
Calomel, 3-4 gr. Powd. Jam. Ginger, 1-4 gr. 
Cathartic Comp., U. S. P., 3 1-2 gr. 
Ext. Coloc. Co., 1 3-10 gr. Calomel, 1 gr. 
Ext. Jalap, 1 gr. Powd. Gamboge, 1-4 gr. 
Cathartic Comp., Vegetable, 2 1-2 gr. 
Ext. Coloc., 1-3 gr. Powd. resin Scammony, 1-3 gr. 
Podophyllin, 1-4 gr. Powd. Cardamom, 1 -8 gr. 
Powd. Soap, 1-8 gr. Purified Aloes, 11-4 gr. 
Liver, Improved, 2 3-4 gr. 
Purified Aloes, 1 gr. Calomel, 1-8 gr. 
Powd. Jalap, 1 gr. Oil Capsicum, 1-48 gr. 
Powd. Gamboge, 1-8 gr. Tinct. Verat. viride, 1-4 gr. 
Leptandrin, 1-8 gr. 
Liver, Improved, Vegetable, 2 3-4 gr. 
Purified Aloes, 1 gr. Podophyllin, 1-8 gr. 
Powd. Jalap, 1 gr. Oil Capsicum, 1-48 gr. 
Powd. Gamboge, 1-8 gr. Tinct. Yerat. viride, 1-4 gr. 
Leptandrin, 1-8 gr. 
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$5.00 PER SET, 
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Antiseptic Midwifery. 
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