&■ %&\-m' -'\& "& ■tr ■•V Wlg$V ^VuflMUV'V -'— " >., po^^oncyvot)^ ODQtK1' kOootxD'O-^g I Surgeon General's Office Erection, No. / \J J L< J>iioao -£* k CLINICAL LECTURES DISEASES OF THE LIVER, JAUNDICE AND ABDOMINAL DKOPSY. CHAELES MUECHISON, M.D. F.E.S. Fellow of the Royal College of Physicians; Physician to the Middlesex Hospital ; Lecturer on the Practice of Medicine at the Middlesex Hospital Medical College; and formerly On the Medical Staff of H. M.'s Indian Army in Bengal and Burmah. ,^cca Gen/'3 . ;■ LIBSAEY. * Kington D.°v NEW YOliK: WILLIAM WOOD AND CO., PUBLISHERS, 61 WALKER STREET. 1868. wlc [A313c I6C8 TO JAMES SYME, ESQ., RRS.fi IX ADMIRATION OF THAT SYSTEM OF CLINICAL TEACHING \YH1CH HAS CONTRIBUTED SO MUCH TO THE RENOWN OF THE EDINBURGH UNIVERSITY AS A SCHOOL OF MEDICINE, (L^est; %ztttxxi& nxz Qthitnttb BY HIS FRIEND AND GRATEFUL PUPIL THE AUTHOR. PREFACE. These Lectuees were originally delivered to the students of the Middlesex Hospital, and the first four have already, in part, appeared in the pages of the ' Lancet.' It is hoped that their publication in the present form may be useful not merely to those for whom they were originally intended, but likewise to other members of the Medical Profession. It is not their object to set forth a complete account of the diseases of which they treat, but rather to put prominently forward the leading characters on which the diagnosis of these diseases mainly depends, and, in particular, to determine the diagnostic import of those signs and symptoms—such as enlargement of the liver, jaundice, dropsy, and pain—which are com- mon to many different hepatic disorders, but the precise cause of which is too often unrecognized. The original descriptions have in many instances been elucidated by the introduction of diagrammatic representations of physical diagnosis. With the third Lecture has been incorporated a portion of the matter viii PREFACE. contained in an essay on ' The Dangers, Diagnosis, and Treatment of Hydatid Tumours of the Liver,' which was published in the 'Edinburgh Medical Journal' for December 1865 ; and to the last lecture have been added the results of an inquiry into the pathological consequences of gall-stones commenced many years ago, and part of which appeared in a memoir on abdominal fistulse, published in the' Edin- burgh Medical Journal' for July and August 1857. To all of the lectures has been appended a history not only of those cases on which each lecture was ori- ginally founded, but of others which have occurred subsequently and been the subject of clinical remarks in the wards. These histories have been condensed from notes taken at my dictation by my clinical clerks, whose kind and ready assistance I take this opportunity of acknowledging. The records of these cases will, it is believed, be useful to the medical practitioner who meets with others of a like nature. ' Nulla est alia pro certo noscendi via, nisi quam- plurimas et morborum et dissectionum historias, turn aliorum, turn proprias, collectas habere, et inter se comparare.'—Morgagni ' De Sed. et Causis Morbor.' Lib. IV. Prooemium. 79 Wimpole Street, Cavendish Square: June 1868. CONTENTS. LECTURE I. ENLARGEMENTS OF THE LIVER. I'AC.K Introductory Remarks—Normal Dimensions and Boundaries of the Liver—Circumstances under which Enlargement of the Ltver is simulated and the means of distinguishing such spurious Enlargements : 1. Congenital Malforma- tions ; 2. Early Life ; 3. Rickets ; 4. Tight-Lacing ; 5. Certain Diseases of the Chest; 6. Tumour between the Liver and the Diaphragm ; 7. Abnormal Conditions of the Abdominal Viscera ; 8. Abnormal Conditions of the Abdominal Parietes ......•• 1 LECTURE II. ENLARGEMENTS OF THE LIVER. True Enlargements of the Liver : Subdivision into painless and painful : I. The Waxy, Lardaceous, or Amyloid Liver : II. The Fatty Liver ; III. Simple Hypertrophy . . 2'2 LECTURE III. ENLARGEMENTS OF THE LIVER. IV. Hydatid Tumour........ . 54 LECTURE IV. ENLARGEMENTS OF THE LIVER. V. Congestion. VI. Inflammation of the Bile-Ducts. VII. Obstruction of Common Duct . . . . . .119 X CONTENTS. LECTURE V. ENLARGEMENTS OF THE LIVER VIII. Pyemic Abscesses. IX. Tropical Abscess LECTURE VI. ENLARGEMENTS OF THE LIVER. X. Cancer—Rarer Forms of Enlargement: 1. Tubercular. 2. Lymphatic. 3. Multilocular Hydatids. 4. Enlarge- ments of Gall-Bladder . . . . . - .167 LECTURE VII. CONTRACTIONS OF THE LIVER. I. Simple Atrophy; II. Acute or Yellow Atrophy; III. Chronic Atrophy (Cirrhosis—Simple Induration—Red Atrophy, &c.) ......... 21o LECTURE VIII. J A UNDICE. Definition—Importance of recognizing Causes—Spurious Jaundice; 1. Chlorosis; 2. Cancerous Cachexia; 3. Malaria and Poisons ; 4. Sub-Conjunctival Fat ; 5. Icterus Neona- torum ; 6. Addison's Disease; 7- Exposure to Sun; 8. Pigments in Urine; 9. Feigned Jaundice. Phenomena of Jaundice:—1. Localities; 2. Secretions; 3. Bitter Taste; 4. Derangements of Digestion ; o. Itchiness ; 6. Cutaneous Eruptions; 7. Temperature; 8. Pulse; 9. Hemorrhages: 10. General Debility; 11. Yellow Vision; 12. Cerebral Symptoms—Theory of Jaundice......279 LECTURE IX. JAUNDICE. Classification of Causes of Jaundice—Jaundice from Obstrix- tion of the Btle-Duct . . . . . . . . 31-j PAGE 147 CONTENTS. XI LECTURE X. JAUNDICE. PAG 3 Jaundice independent of Obstruction of the Bile-Duct— Diagnosis of the Causes of Jaundice . . . . 37o LECTURE XL FLUID IN THE PERITONEUM. Its Signs—The Conditions which simulate it, and how to distinguish them: 1. Ovarian Cyst; 2. Hydatid Cyst; 3. Renal Cyst ; 4. Distended Urinary Bladder ; 5. Pregnant Uterus—Causes of Fluid in Peritoneum : I. Acute Peri- tonitis ; II. Chronic Peritonitis ; III. Cancer ; IV. Colloid ; V. Simple Dropsy—1. From Disease of Kidneys; 2. From Disease of Heart or Lungs; 3. From Portal Obstruction 432 LECTURE XII. A. HEPATIC PAIN. Simulated by: 1. Pleurodynia; 2. Intercostal Neuralgia; 3. Pleurisy; 4. Gastric Dyspepsia; 5. Intestinal Colic; 6. Renal Colic—The Varieties and Causes of genuine Hepatic Pain.........491 B. GALL-STONES. Their various Consequences, Symptoms, and Treatment . 499 c. enlargements of gall-bladder. Their Causes, Clinical Characters, and Treatment . . 536 INDEX 547 Errata. Pages 75 to 92, and page 179, line 27, for canula read cannula. „ 185, line 15, for liver read lung. „ 216, line 9, for autero-posterior, read antero-posterior. LIST OF WOOD-ENGRAVINGS. 1. Natural position of the Liver, as seen after removal of the Anterior Wall of the Chest and Abdomen 3 2. Natural position of the Liver, as seen after the removal of the Vertebra? and the Posterior Wall of the Chest and Abdomen .... I 3. Normal area of Hepatic Dulness, viewed anteriorly 5 4. Normal area of Hepatic Dulness, viewed from right side ......•• b' 5. Normal area of Hepatic Dulness, viewed posteriorly 6 6. Apparent enlargement of the Liver resulting from Tight-lacing . . . • • • .12 7. Area of dulness caused by effusion into the Right Pleura, depressing the Liver . . . .14 8. Displacement of the Liver downwards by extensive effusion into the Pericardium . . . .15 9. Increased area of Hepatic and of Splenic Dulness from Waxy Disease : anterior view . . .25 10. Increased area of Hepatic Dulness from Waxy Disease . . . • • • • .25 11. Area of Hepatic Dulness in a case of Hydatid Tumour of the Liver ..... 84 12. Area of Hepatic Dulness in a case of Hydatid Tumour of the Liver . . • .80 13. Area of Hepatic Dulness in a case of Enlargement of the Liver, and Distension of the Gall-Bladder from obstruction of the Common Bile-duct . 145 xiv LIST OF WOOD-ENGRAVINGS. FIG. PAGE 14. Area of Hepatic Dulness in a case of Tropical Abscess of the Liver . • • • .181 15. Area of Hepatic Dulness in a case of Cancer of the Liver ........ 189 16. Microscopic appearances in a case of Fungating Cancerous Tumour of the Liver, showing transi- tional forms between the Glandular Epithelium and'Cancer Cells'......205 17. Area of Hepatic Dulness in a case of Acute Atrophy of the Liver.......226 18. Microscopic needle-shaped Crystals of Tyrosine adhering in bundles and in stellate groups . 230 19. Microscopic globular Masses composed of acicular crystals of Tyrosine . . . . . .230 20. Microscopic, laminated, crystalline masses of Leucine ........ 231 21. Shows the Hepatic and Ascitic Dulness in a case of Cirrhosis of the Liver ..... 245 22. Microscopic crystalline masses of Carbonate of Lime from the Gall-Bladder.....277 23. Microscopic appearances of the Blood in a case of Chronic Atrophy of the Liver with Leukaemia . 277 24. Percussion-sounds over the Abdomen in a case of Ascites from Cirrhosis of the Liver . . .436 25. Percussion-sounds over the Abdomen in a case of Tumour of the Left Ovary .... 437 LIST OF CASES. CASE PAG 3 I. Caries of the Hip-joint—Waxy Liver weighing nearly one-seventh of • the entire body—Waxy Spleen—Fatty Kidneys.....35 H. Constitutional Syphilis, followed by Symptoms of Waxy Disease of the Liver, Spleen, and Kidneys. 37 IH. Syphilitic Necrosis of Lower Jaw—Albuminuria— Pleurisy and Pericarditis—Waxy Liver and Kid- neys . . .......41 IV. Waxy Liver enlarged and nodulated, simulating Cancer........42 V. Acute Phthisis—Fatty Liver.....52 VI. Hydatid Tumour of the Liver—Paracentesis—Re- covery ........ 83 VII. Hydatid Tumour of the Liver threatening to burst —Paracentesis—Recovery ..... 85 VIII. Hydatid Tumour of the Liver—Paracentesis—Re- covery.........89 IX. Hydatid Tumour of Liver opening into the common Bile-duct—Jaundice and Suppuration of the Cyst —Puncture with a large Trocar, and permanent opening—Pneumonia—Death .... 90 X. Hydatid Tumour of the Liver bursting into the Bile- duct—Jaundice—Discharge of innumerable Hy- datid Cysts per anum — Recovery—Attacks of Biliary Colic from passage of Cysts remaining in the Liver through the Bile-duct—Rupture of old Adhesions during the act of Vomiting—Peritoni- tis—Death ........94 a xvi LIST OF CASES. CASE PAGE XL Hydatid Cyst of Liver—Entrance of Bile—In- flammation—Paracentesis—Death ... 97 XII. Suppurating Hydatid Tumour of Liver—Pyaemia with Secondary Deposits of Pus ... 99 XIII. Suppurating Hydatid—Pyaemia, with Secondary Gangrenous Abscesses in the Liver . . . 100 XIV. Enormous Hydatid Cyst of the Liver, passing down through the Foramen of Winslow, and filling almost the whole of the Abdominal Cavity —Paracentesis—Pleurisy—Tubercle of Lungs- Death from Exhaustion.....102 XV. Hydatid Tumour of the Liver, bursting into the Right Pleura—Empyema—Death . . . 104 XVI. Hydatid Tumour of the Liver, opening into the Right Pleura—Empyema—Pericarditis—Death 105 XVH. Old Hydatid Tumour of the Liver, communicating with Base of Right Lung—Lobular Pneumonia and Gangrene of the Lung .... 106 XVIII. Hydatid Tumour of the Liver—Pyelitis—Pus in the Urine—Sudden Death.....107 XLX. Hydatid Tumours of the Liver and Peritoneum compressing the Ureters, and causing Degenera- tion of the Kidneys......109 XX. Hydatid Cysts of the Liver and Peritoneum— Ascites and Anasarca of lower Extremities— Albuminuria—Death......110 XXI. Hydatid Tumour of the Liver—Secondary Hy- datid Tumours in the Spinal Canal — Para- plegia ....... . Ill XXII. Large Hydatid Tumour of the Liver full of Col- lapsed Secondary Cysts, but containing no fluid.........112 XXIII. Enormous Cystic Tumour communicating with the Pelvis of the Right Kidney, existing for eight years, and simulating Hydatid Tumour of the Liver .......115 XXIV. Mitial Constriction—Dropsy and Congestion of the Liver—Death.......128 XXV. Indigestion from habitual Surfeit—Residence in Tropics—Exposure to Chill—Congestion of Liver 130 LIST OF CASES. xvu CASH PAGE XXVI. Congestion of the Liver.....131 XXVII. Painful Enlargement of the Liver, with Jaun- dice, due to Inflammation of the Bile-ducts . 135 XXVIII. Gouty Dyspepsia—Jaundice and Enlargement of the Liver from Inflammation of the Bile- ducts ........136 XXIX. Inflammation of the Biliary Passages, excited by Gall-stones—Gangrene of Foot—Diseased Kidneys—Death by Uraemia . . . 137 XXX. General Tuberculosis — Enlargement of the Liver from Tubercular Deposit—Jaundice from Inflammation of the Bile-ducts—Em- bolism of the Spleen.....140 XXXI. Enlargement of Liver and Dilatation of Gall- bladder from Obstruction of Common Duct by a Calculus.......145 XXXn. Injury of Cranium, followed by Pyaemia and multiple Abscesses in the Liver . . . 154 XXX1H. Multiple Abscesses in the Liver Secondary to Simple Ulcer of the Stomach . . . 155 XXXTV. Multiple Abscesses in the Liver secondary to Cancerous Ulcer of the Stomach . . . 157 XXXV. Attacks of Biliary Colic followed by Pyaemic Abscesses in the Liver ..... 158 XXXVL Multiple Abscesses of the Liver—Softening Tubercle in Mediastinal Glands . . . 160 XXXVII. Tropical Abscess of the Liver—No dysenteric Ulceration of the Bowel .... 180 XXXVin. Large Abscess of the Liver opening into the Ascending Colon......183 XXXTX. Abscess of the Liver opening upwards through Diaphragm—Secondary Abscess of Lung . 185 XL. Tropical Abscess of the Liver—Puncture with a large Trocar—Recovery .... 186 XLI. Cancer of the Liver and Ovary—Jaundice, but no Ascites.......196 XLII. Cancer of Uterus and Liver—Ascites, but no Jaundice..... 198 XLIH. Cancer of the Liver, Lungs, and Cervical Glands—Jaundice and Ascites . . . 200 a2 xvm LIST OF CASES. CASE PAGB XLIV. Primary Cancer of the Liver—Death from Hae- morrhage into the Peritoneum . . . 202 XLV. Cancerous Tumour (Fungus Haematodes), pro- jecting from upper surface of Liver—Haemor- rhage into Peritonenm.....204 XLVI. Cancer of Vertebrae, Supra-renal Capsule, Liver and Lung—No Symptoms of Disease of Liver 206 XLVII. Melanotic Cancer of the Penis, Lymphatic Glands, Liver, Pleura, &c.......208 XLVIII. Coexistence of Cancerous Stricture of the Oeso- phagus, with recent Tubercle in the Lungs— Simple Atrophy of the Liver .... 222 XLIX. Acute Atrophy of the Liver—Acute Peritonitis— Leucine and Tyrosine in the Liver and Kidneys, but none detected in the Urine . . . 236 L. History of Spirit-drinking and Symptoms of portal Obstruction—Dense, fibrous, granular Liver—True Cirrhosis......260 LI. History of Spirit-drinking—Cirrhosis of the Liver—Nephritis — Epileptiform Convulsions and Death by Uraemia.....263 LII. History of Spirit-drinking—Contracted Liver— Copious Haematemasis—Delirium Tremens . 266 LIII. Chronic Atrophy of the Liver—Ascites—Haema- temasis and Bloody Stools .... 267 LIV. No history of Spirit-drinking—Symptoms of portal Obstruction—Soft, atrophied, granular Liver—Spurious Cirrhosis .... 271 LV. Chronic Atrophy of the Liver, from Peri-hepati- tis—Simple Ulcers of the Stomach . . . 273 LVI. Bronchitis and Dilated Bronchi—Disease of the Aortic Valves—Contracted Liver—Great As- cites ........274 LVII. Chronic Atrophy of the Liver and Ascites—Para- centesis—No Accumulation after fourth Tap- ping—Enlarged Spleen and Leukaemia—Death from Ulceration of the Mouth and Pharynx, and Necrosis of the Jaw and Vertebrae . . 275 LVIII. Jaundice from Obstruction of the Bile-duct by Gall-stones.......360 LIST OF CASES. CASE PAGK LIX. Jaundice from temporary Obstruction of the Bile-duct by Gall-stones .... 361 LX. Jaundice from Congenital Closure of the Bile- duct ........363 LXI. Jaundice from Obstruction of the Common Bile- duct by the Cicatrix of a Duodenal Ulcer— Dilatation of the Bile-duct and Atrophy of the Liver.......365 LXII. Jaundice from Obstruction of the common Bile- duct by a Cancerous Growth from its lining Membrane—Dilatation of the Bile-ducts and Enlargement of the Gall-bladder—Cancerous Growth in the Pancreas.....367 LXIII. Cancer of the Pancreas and of the Gall-bladder— Jaundice from Obstruction of the Bile-duct . 369 * LXIV. Permanent Jaundice from Closure of the Bile- duct ........371 LXV. Typhus Fever complicated with Jaundice—Death by Coma—Leucine and Tyrosine, but scarcely any Urea, in Urine—Leucine and Tyrosine in Liver and Kidneys ...... 408 LXVI. Typhus Fever complicated with Jaundice . . 409 LXVII. Typhus Fever — Double Pleuro-pneumonia — Jaundice—Tyrosine in Urine .... 410 LXVIII. Typhus Fever followed by Phlegmasia Dolens, Jaundice, and Death . . . . .411 LXIX. Enteric Fever followed by a Relapse with Jaun- dice . . . . . . . .413 LXX. Enteric Fever complicated with Jaundice . .414 LXXI. Enteric Fever complicated with Jaundice and 'Phlebitis'.......415 LXXII. Scarlatina—Jaundice—Death by Coma . . 415 LXXIII. Scarlatina—Jaundice—Sudden Death . . 41(3 LXXIV. Scarlatina—Jaundice—Recovery . . .417 LXXV. Scarlatina—Jaundice—Recovery . . .418 LXXVL Acute Necrosis of Cervical Vertebrae—Pyaemia —Jaundice .......418 LXXVII. Acute Pleuro-pneumonia complicated with Jaundice.......420 LXXVIII. Jaundice from Congestion of the Liver . . 421 XX LISr OF CASES. CASE . PAGE LXXIX. Cystic Tumour of the Ovary opening into the Rectum—Entrance of Air into the Ovarian CyBt—Atrophy of Right Lobe of Liver and complementary Hypertrophy of Left Lobe.......466 LXXX. Enlargement of the Abdomen from a dis- tended Urinary Bladder mistaken for an Hydatid Tumour of the Liver—480 ounces of Urine drawn off by Paracentesis Ab- dominis ....... 468 LXXXI. Fluid in Peritoneum from Acute Peritonitis due to a Kick over a Congenital Hernia . 471 LXXXII. Fluid in Peritoneum'from Chronic Peritoni- tis—Chronic Atrophy of Liver with Fibroid Nodules in its interior, apparently indepen- dent of Syphilis.....473 LXXXIII. Primary Cancer of the Peritoneum, causing a large Effusion of Fluid .... 475 LXXXIV. Tubercular Peritonitis—Signs of a circum- scribed collection of Fluid in Peritoneum 477 LXXXV. Symptoms of Colic followed by signs of Fluid in the Peritoneum .... 480 LXXXVI. Fluid in the Peritoneum from Disease of the Kidney—Albuminuria and General Anasarca—Pericarditis and Pleurisy— Death by Uraemia—Great Hypertrophy of Left Kidney and Atrophy of Right . . 481 LXXXVH. Historyof Spirit-Drinking—Cirrhosis of Liver —Enlarged Spleen—Ascites—Gastroen- teritis—Removal of Ascites by Diuretics . 484 LXXXVni. Constriction of Mitral Valve—Chronic Atro- phy of Liver—Ascites and Jaundice . . 486 LXXXIX. Great Ascites and Diarrhoea—Enlargement of the Spleen and Liver and Albuminuria . 488 XC. Hepatic Neuralgia.....497 XC1. Gall-stones in a Sacculus of the common Bile- duct and in the Gall-bladder—Ulceration and Perforation of the Gall-bladder—Fatal Peritonitis .... 527 LIST OF CASES. xxi XCII. Fistulous Opening between the Gall-bladder and the Duodenum—Fatal Obstruction of the Small Intestine by a large Biliary Calculus . . 529 XCHI. Closure of the Cystic Duct—Abscess of the Gall- bladder—Discharge of Gall-stones through a Fistulous Opening in the Abdominal Parietes . 531 XCIV. Fistula in the Abdominal Parietes, opening into a circumscribed Cavity which communicated with the Colon and the Duodenum, and also with the Gall-Bladder.......534 XCV. Cancer of the Rectum, Secondary Cancer of the Liver and Gall-bladder obliterating the Cystic Duct—Enlargement of the Gall-bladder . . 543 XCVI. Destruction by Cancerous Ulceration of the Gall- bladder, and communication of the resulting Cavity with the Transverse Colon—Cancer of the Liver...... 543 CLINICAL LECTUEES ON DISEASES OF THE LIVEE AND JAUNDICE, LECTUEE I. ENLARGEMENTS OF THE LIVER. INTRODUCTORY REMARKS--NORMAX DIMENSIONS AND BOUNDARIES OF THE LIVER--CIRCUMSTANCES UNDER WHICH ENLARGEMENT OF THE LIVER IS SIMULATED, AND THE MEANS OF DISTINGUISHING SUCH SPURIOUS enlargements: 1. congenital malformations; 2. early life; 3. rickets; 4. tight-lacing; 5. certain diseases of the chest; 6. tumour between the liver and draphragm ; 7. abnormal conditions of the abdominal viscera ; 8. abnormal conditions of the abdominal parietes. Gentlemen,—In systematic lectures on Medicine, it is the custom to describe in detail the numerous symptoms which characterise different disorders. It requires, however, little experience to discover that there are symptoms and signs which are common to many diseases, and that no small difficulty is often encountered in determining to which of its many sources a particular symptom ought to be referred. Yet this determination must always be your first object in practice. You must never rest satisfied with treating merely a symptom without endeavouring to acquire some definite notion of the local or general B 9 ENLARGEMENTS OF THE LIVER, [lect. i. disease on which it depends. In all cases of dis- ease presenting some prominent symptom, you ought to ask yourselves two questions: 1. What are the different causes which may give rise to the symptom in question ? and 2. Which is the most probable cause in the individual case before you? Not until you have given a satisfactory reply to these enquiries will you be in a position to speak with any confidence as to prognosis, or to adopt a rational method of treatment. To no class of maladies are these remarks more applicable than to diseases of the liver. There are few diseases more difficult to discriminate, and perhaps none in which an erroneous diagnosis is oftener made ; while symptoms depending upon dis- ease of the stomach, the intestines, or the kidneys, or even the heart, the lungs, or the brain, are constantly ascribed to derangements of the liver. It will be my object in these lectures to point out to you the chief signs and symptoms resulting from hepatic dis- ease, the different morbid conditions from which each of them may arise, the rules by which you must be mainly guided in determining the precise disease in each case, and the conclusions to which you ought in this way to be led respecting prognosis and treatment. We shall commence, for instance, by discussing the different causes of Enlargement of the Liver ; and in subsequent lectures, the causes of Atrophy of the Liver, of Jaundice, Hepatic Pain, Hepatic Dropsy, &c, will be duly considered. lect. i.] NORMAL DIMENSIONS AND BOUNDARIES. 3 ENLARGEMENTS OF THE LIVER. Before proceeding to consider the various causes of true enlargement of the liver, it is necessary to have an accurate knowledge of its normal dimensions and boundaries, and also to keep in view certain condi- tions which during life may simulate enlargement. Normal situation and dimensions of the liver.—The liver is situated in the right hypochondrium, the convexity of the right lobe corresponding to the con- cavity at the base of the right lung with the dia- Fig. 1. Natural Position of the Liver, as seen after removal of the anterior wall of the chest and abdomen. Modified from Sibson's Med. Anat. A Liver, b, Ascending colon, c, Transverse colon, d, Descending colon. E, Small intestines. F, Stomach. G, Heart, h, Eight lung, i, Left lung. B 2 4 ENLARGEMENTS OF THE LIVER, [lect. i. phragm interposed, and the under surface being opposed to the stomach and large intestine, the right Fig. 2. Natural Position of the Liver, as seen after the removal of the vertebrae and the posterior wall of the chest and abdomen. Modified from Sibson's Med. Anatomy. The liver is covered by the diaphragm, beneath which, on the left side (b) there is also the spleen and a portion of the stomach, a, Right lobe of liver, c, Ascend- ing colon, d, Descending colon. lect. i.] NORMAL DIMENSIONS AND BOUNDARIES. 5 kidney and supra-renal capsule. The convex upper surface projects up into the right side of the chest, and a great part of it is in immediate juxtaposition with the ribs, but the uppermost portion (in a vertical direction) is separated from the wall of the chest by the thin lower margin of the right lung. (See fig. 1.) Accordingly, in percussion during life, the upper Fig. 3. Area of Hepatic Dulness, viewed anteriorly. a-b, Right mammary line, e-d, Median line, e, Splenic dulness. /, Cardiac dulness. margin of hepatic dulness may be said to be twofold, one boundary limiting the region where the organ is in close approximation to the walls of the chest, and where the dulness is absolute, the other correspond- ing to the extreme height of the liver, and including the space where it is overlapped by the thin layer of lung, and where the sound on percussion constitutes 6 ENLARGEMENTS OF THE LIVER. [lect. i. a transition from the hepatic dulness to the pulmo- nary resonance. It is the latter which is usually regarded as the true upper margin of the liver (fig. 3). There is a peculiarity in the upper margin of hepatic dulness which is of some practical importance Fig. 4. Area of Hepatic Dul- Fig. 5. Area of Hepatic Dulness, viewed ness, viewed from right side. posteriorly. a-b, Right axillary line. a-b, Right dorsal line, c, Splenic dulness, d, Left kidney, e, Right kidney. /, De- scending colon, g, Ascending colon. —namely, that it is not horizontal, but arched. Commencing posteriorly about the tenth or eleventh dorsal vertebra, it ascends gradually towards the axilla and the nipple, and then again descends slightly lbct. i.] NORMAL DIMENSIONS AND BOUNDARIES. 7 towards the median line in front. The arched cha- racter of the upper surface of the liver is shown in the annexed diagrams (figs. 3, 4, 5). In determining the upper margin of hepatic dul- ness we must trust to percussion alone. In ordinary cases it is sufficient to note the upper limit in what is called the right mammary line, or a line descending perpendicularly from the right nipple (fig. 3). Here, in a healthy adult, the true upper margin of the liver is situated in the fifth intercostal space, or in rare cases behind the fifth rib or in the fourth space. In this line, the liver is overlapped by lung to the extent of about one inch. But in all cases of suspected hepatic disease, the upper margin of hepatic dulness ought to be determined in its entire course. In the median line in front, it usually corresponds to the base of the ensiform cartilage, or rises slightly above this. To the left of the median line it is difficult or impossible to define the upper limit of hepatic dulness from the lower boundary of the heart, the two being in apposition, but a line drawn from the upper margin of hepatic dulness in the median line to the apex of the heart will usually correspond to the line of separation. In the right axillary line (fig. 4), or a line falling perpendicularly from the centre of the axilla, the upper margin of hepatic dulness corre- sponds to the seventh intercostal space, or more rarely, to the seventh rib. In the right dorsal line, or a line falling perpendicularly from the lower angle 8 ENLARGEMENTS OF THE LIVER, [lect. i. of the scapula (when the arm is dependent), it corre- sponds to the ninth intercostal space, or the ninth rib (fig. 5). The lower margin of hepatic dulness may be de- termined by percussion, and often also by means of palpation. It is, however, as a rule, less easily defined than the upper margin, being often obscured by a distended condition of the stomach or intestines. Hence it is always most satisfactorily examined when the stomach is empty, and after the bowels have been freely moved. In the right mammary line, it usually corresponds with the margin of the costal arch, or is half an inch above or below this; in the right axillary line, it corresponds to the tenth inter- costal space; and in the right dorsal line, to the twelfth rib, although here it is usually difficult to define it from the dulness of the kidney. In the epi- gastrium, the lower margin of the right and left lobes usually descends two or three inches below the angle of junction of the last costal cartilage with the sternum. The ordinary extent of hepatic dulness, in an adult of average size, is 4 inches in the right mam- mary line, 41 or 5 inches in the right axillary line, 4 inches in the right dorsal line, and, 3 or 4 inches in the median line anteriorly. But it must not be forgotten that, even in the same individual, the liver is constantly liable to slight alterations in its position consistently with health. During the act of inspiration the whole oro-an is lect. i.] SPURIOUS ENLARGEMENTS. * 9 slightly lowered—about half an inch—and its upper surface is somewhat flattened, whereas during expi- ration the organ ascends. Again, in the erect posi- tion, the lower margin will extend somewhat lower than when the patient is recumbent. If in the mam- mary line it correspond to the lower margin of the costal arch in the latter position, it may be a quarter of an inch lower in the former. These variations however are slight, and are not likely to embarrass the diagnosis. But difficulties in diagnosis may sometimes arise from the boundaries of the liver, as above defined, being greatly exceeded without any real enlargement of the organ. In all cases of suspected enlargement of the liver it is important to keep in view the possi- bility of its being of this spurious character. CIRCUMSTANCES UNDER WHICH ENLARGEMENT OP THE LIVER IS SIMULATED DURING LIFE. The chief of these conditions are the following:— I. Congenital malformations, &c.—In rare cases, in consequence of congenital malformation, the liver is more square or globular than natural, and a larger portion of it is in apposition to the abdominal and thoracic wall. In other cases the left lobe is propor- tionately large, as in the foetus. In cases of still greater rarity the liver is protruded into the right side of the chest through an opening in the dia- phragm, which may be congenital, or the result of accident. Not long ago a case of this sort came 10* ENLARGEMENTS OF THE LIVER, [lect. i. under my notice, where the greater portion of the right lobe of the liver was lodged in the right pleura, and where the hepatic dulness in consequence ascended as high as the third rib. The particulars of the case will be found in the last volume of the Pathological Society's ' Transactions,' vol. xvii. p. 164. The diagnosis of such conditions during life must of course always be difficult, and will rest mainly on the following conditions :— 1. The absence of any symptom indicative of dis- ease of the liver. 2. The absence of other circumstances likely to produce spurious enlargement. 3. The fact of the increased hepatic dulness per- sisting from early life (except in diaphragmatic hernia resulting from accident). II. Early life.—The liver is proportionally much larger in infancy and adolescence than in adult life. The organ does not grow in proportion to the rest of the body. In the adult the average weight of the liver is one-fortieth of that of the entire body, whereas previous to puberty it may be as much as one-thirtieth, or even one-twentieth. The dimen- sions vary accordingly, so that the upper margin of hepatic dulness is often higher in the child than in the adult, and the lower margin descends below the costal arch in the right mammary line. It follows, therefore, that an extent of hepatic dulness which in the adult would be abnormal, may be perfectly normal in the child. In the wards of the hospital I lect. i.] SPURIOUS ENLARGExMENTS. 11 have had frequent opportunities of pointing out to you this peculiarity of the liver in early life. III. Rickets, causing lateral distortion of the spine, and the deformity known as the ' pigeon breast,' may lead to apparent enlargement of the liver, owing to the organ being depressed and elongated in its ver- tical diameter from lateral compression. The resem- blance to hepatic enlargement may be further increased by there being a disproportionate recession of the ribs immediately above the margin of the liver, as the result of which there is an apparent bulging of the hepatic region. Hence, in lateral distortion of the spine and in the ' pigeon breast,' care must be taken not to arrive at any hasty conclusion as to enlargement of the liver. IV. The practice of tight-lacing may cause displace- ments and malformations of the liver, which may simulate enlargement, and which are of considerable importance in diagnosis. Tight-lacing may act on the liver in three ways, according to the situation, the tightness, and the duration of the constricting cause. a. The liver may be displaced upwards or down- wards, according as the pressure is applied below or above. The precise situation where the pressure is applied will vary with the prevailing fashion of dress; but most commonly in this country the displacement is downwards, and this may be to such an extent that the lower margin reaches the ilium, and the liver appears to fill up the whole of the right side and front of the abdomen (fig. 6). 12 ENLARGEMENTS OF THE LIVER. [lect. i. b. In consequence of lateral compression, the liver may be elongated in its vertical diameter, so that a larger portion of it is brought into apposition with Fig. 6. Apparent enlargement of the Liver resulting from Tight-lacing. Modified from Frerichs. The Liver is depressed, and its vertical diameter elongated. A deep transverse furrow corresponds to the site of constriction. the abdominal and thoracic walls. This is a very common result of tight-lacing (fig. 6). c. When the pressure is exerted by a tight cord, it may produce deep fissures in the substance of the lect. I.] SPURIOUS ENLARGEMENTS. 13 liver, as the result of which portions of the organ may be more or less detached, and may even be felt as movable tumours through the abdominal parietes. Apparent enlargements of the liver from tight- lacing are far more common than is generally be- lieved. You cannot pay many visits to the post- mortem room without observing examples of this malformation. Moreover, these acquired malforma- tions of the liver, although most common in females, are occasionally observed in the male sex. I show you here the liver of a man with a deep furrow, from indentation of the ribs, which resulted apparently from the practice of wearing a very tight belt. I may also call your attention to the case of a man, aged 23, lately under your observation in the hospital, with a firm movable tumour in the epigastrium, which there was every reason to believe was a portion of the liver partially detached from a similar cause. Apparent enlargements of the liver from tight- lacing may usually be recognised by the following characters :— 1. Evident signs of tight-lacing in the walls of the chest and abdomen. 2. Occasionally the existence of a distinct trans- verse furrow in the substance of the liver, appreciable through the abdominal parietes on palpation. 3. The absence of symptoms of structural disease of the liver itself, or of serious disease in the chest or abdomen. V. Certain diseases in the chest may cause great 14 ENLARGEMENTS OF THE LIVER, [lect. I. depression of the liver into the abdominal cavity, and lead to the idea that the organ is enlarged. This remark applies particularly to extensive effusion into the right pleural cavity, or to pneumo-thorax on the right side. In these affections the natural con- vexity of the diaphragm may be reversed, and the Fig. 7. Effusion into the Right Pleura depressing the Liver. a, Hepatic dullness. 6, Dulness from pleuritic effusion causing bulging of the right side of chest, and displacing the heart to the left; its upper margin horizontal. c, Cardiac dulness. d, Splenic dulness. lower margin of the liver may descend to the um- bilicus (fig. 7). Depression to a less extent may re- sult from intra-thoracic tumours, effusion into the left pleura or into the pericardium (fig. 8) ; and even in pulmonary emphysema and acute pneumonia * the * See a case of acute pneumonia of the right lung, referred to by Dr. Stokes in his work on ' Diseases of the Heart and Aorta,' p. 453. lect. i.] SPURIOUS ENLARGEMENTS. 15 liver may be lowered to the extent of an inch or more. In all cases, however, where the liver is depressed Fig. 8. Displacement of the Liver downwards by extensive Effusion into the Pericardium: after Sibson. A, Liver. B, Pericardium greatly distended with fluid. ' So great was the enlargement of the lung that the diaphragm and liver were pushed far down into the abdominal cavity.' Dr. Bright speaks of displacement of the liver downwards by pneumonic consolidation as a frequent occurrence (Abdom. Tumours, Syd. Soc. ed., p. 255); but Stokes regards it as exceptional, and this also is the result of my own observa- tion. In extensive pneumonia, however, the liver is usually more or less congested, and enlarged accordingly. 16 ENLARGEMENTS OF THE LIVER, [lect. I. in consequence of disease in the chest, the descent of its lower margin is probably due to a combination of causes; for when there is disease in the chest suf- ficient to depress the diaphragm, there is usually also congestion with slight enlargement of the liver. Apparent enlargements of the liver from the causes now referred to have the following distinguishing fea- tures :— 1. A previous history of pleurisy, pericarditis, bronchitis and emphysema, pneumonia, or phthisis ending in pneumothorax. At the same time it is well to remember that extensive effusion sometimes takes place? into the pleura in a very latent manner. 2. A degree of dyspnoea far greater than would be accounted for by the amount of enlargement of the liver, even if real. 3. The physical signs of the various thoracic diseases above referred to. In the case of emphy- sema and pneumothorax, there is no difficulty in defining the upper margin of the liver, and in ascer- taining that the extent of hepatic dulness is not increased, so that percussion will at once reveal the nature of the case. But in pleurisy it may be impossible to say where the dulness of the pleuritic effusion ends and the hepatic dulness begins, and here, as in some forms of true hepatic enlargement, there may be bulging of the ribs and obliteration of the intercostal spaces. Under such circumstances, there are several characters of considerable impor- tance in diagnosis—viz.: lect. i.] SPURIOUS ENLARGEMENTS. 17 a. The bulging of the side of the chest is more uniform in pleurisy, and not abruptly limited to the lower part, as in diseases of the liver. b. In pleuritic effusion, the upper margin of the dull space is horizontal (fig. 7), instead of arched as in enlargements of the liver. c. In pleuritic effusion, the upper level of the dull space will often be found to vary with the position of the patient. In enlargement of the liver, it is the same in all positions. d. In pleuritic effusion, the lower margin of the liver is not depressed upon deep inspiration, which is the case in enlargements of the liver, unless there be firm adhesions to the diaphragm. e. Eversion of the lower right costal cartilages would indicate hepatic enlargement, and not pleuri- tic effusion. /. When there is sufficient effusion into the pleura to cause downward bulging of the diaphragm, a depression may be sometimes observed between the lower margin of the ribs and the upper surface of the liver, which is not met with in hypertrophy of the liver. Effusion into the pericardium will be recognised by the outline of the area of dulness on percussion. It is the left lobe of the liver that is mainly displaced by it. In arriving at a diagnosis, it must not be forgot- ten that inflammation of the pleura or of the base of the right lung may coexist with enlargement of c 18 ENLARGEMENTS OF THE LIVER, [lect. i. the liver. This is a not uncommon occurrence in hydatid tumours or abscesses of the liver, and often precedes their bursting upwards through the dia- phragm. So also after an hydatid tumour of the liver has burst into the pleura, extensive empyema may coexist with great enlargement of the liver. I shall hereafter have an opportunity of bringing under your notice the particulars of cases in which this oc- curred. VI. A tumour or collection of fluid between the upper surface of the liver and the diaphragm may also cause great depression of the liver, and apparent enlarge- ment of the organ. The upper margin of hepatic dulness will be arched, and it will probably be im- possible during life to distinguish the case from one of real enlargement of the liver. You will find a case recorded by the late Dr. Bright, where a large abscess situated between the diaphragm and the liver produced apparent enlargement of the liver ; * and more than once I have known enlargement of the liver simulated by an encysted collection of peritoneal fluid between the liver and the diaphragm, when the organ was in reality atrophied. Such cases, however, are rare. VII. Various abnormal conditions of the abdominal viscera may displace the liver upwards, so that it en- croaches upon the cavity of the chest, and appears enlarged. This happens not unfrequently in cases of ascites, and in ovarian and uterine tumours, in * Clinical Memoirs on Abdominal Tumours. Syd. Soc. ed. p. 257. lect. i.] SPURIOUS ENLARGEMENTS. 19 aneurism of the abdominal aorta,* &c.; and hence elevation of the liver above its usual height must not, under such circumstances, be regarded as a sign of enlargement. Greater difficulty, however, in diag- nosis may result from tumours in the omentum or in the right kidney, being in the immediate proximity of the liver, and appearing to be tumours of the liver itself. The difficulty will be increased if such tu- mours compress the common bile-duct, so as to oc- casion jaundice. The diagnosis of an omental tumour under such circumstances must mainly depend on the want of all uniformity in the apparent hepatic en- largement, the dimensions of the liver in every other direction being normal; while in tumours of the kid- ney the urine usually presents important changes, and at the same time, when the patient lies on his back, the finger can usually be inserted between the ribs and the upper part of the tumour. Accumulations of faeces in the transverse colon also constitute a condition which it is often most difficult to distinguish from enlargement of the liver. Such cases are constantly occurring in practice, and it is important to bear in mind that, if you are to rely on the patient's statements, these accumulations are far from being necessarily associated with constipation. The resemblance to hepatic disease in these cases may be further increased by the hardened scybala imparting to the tumour a nodulated character like that of cancer, and by the development of such sym- * Stokes. Op. cit. p. 617. c2 20 ENLARGEMENTS OF THE LIVER, [lect. i. ptoms as jaundice, vomiting, and hiccup. The diag- nosis of these cases from true enlargement of the liver must rest mainly on— 1. The occurrence of spasmodic pains like those resulting from obstructed bowels, &c. 2. The disappearance of the tumour, and the ame- lioration of the symptons under such treatment as poultices and fomentations, purgatives, enemata, and belladonna. Lastly. VIII. Abnormal conditions of the abdominal parietes may simulate enlargements of the liver. Firm contraction of the bellies of the recti muscules, owing either to inflammation of the subjacent peri- toneum or stomach, or, in cases of increased muscular irritability, to the mere application of the hand, is frequently mistaken by inexperienced observers for hepatic enlargement. It is distinguished by :— 1. The situation, size, and form of the apparent tumour corresponding to those of the recti. 2. The sound on percussion being usually more clear and tympanitic than it would be over a solid tumour. The diagnosis may also be considerably embarrassed by an inflammatory swelling in the abdominal parietes over the liver. This has often been mistaken for an abscess of the liver itself. Not long since a remark- able instance of this sort came under my notice in a patient recovering from typhus fever with parotid buboes. For some days the diagnosis was very lect. i.] SPURIOUS ENLARGEMENTS. 21 doubtful. The following characters usually suffice to distinguish this condition from hepatic disease :— 1. The margin of inflammation and of dulness on percussion is ill-defined, and does not correspond to the boundary of an enlarged liver. 2. There is a greater amount of hardness and tightness of the superimposed integuments. 3. The constitutional symptoms are comparatively slight, and there are no indications of hepatic de- rangement. Keeping in view these sources of fallacy, we may now proceed to consider the various causes of true enlargement of the liver. 22 ENLARGEMENTS OF THE LIVER, [lect. ii. LECTUEE II. ENLARGEMENTS OF THE LIVER. TRUE ENLARGEMENTS OF THE LIVER: SUBDIVISION INTO PAINLESS AND PAINFUL: l.THE WAXY, LARDACEOTJS, OR AMYLOID LIVER J 2. THE FATTY LIVER ; 3. SIMPLE HYPERTROPHY. Bearing in mind the various circumstances under which I have told you that hypertrophy of the liver may be simulated during life, we are now prepared for considering those cases in which an increased area of hepatic dulness is due to real enlargement of the organ. And first of all it may be observed that enlargement is a character common to many different diseases of the liver, so that some classification will be a material aid in diagnosis. The late Dr. Bright, whose researches on diseases of the abdomen are scarcely less valuable than those on diseases of the kidney, with which his name will for ever be associated, divided enlargements of the liver into two classes, according as their form was smooth, or irregular.* But this subdivision is, in my opinion, objectionable, inasmuch as in certain diseases (e. g. waxy liver) an enlargement which is usually regular and smooth, may assume a lobular or nodulated character, whereas in * Abdominal Tumours. Syd. Soc. ed. p. 242. LECT. II.] WAXY LIVER. 23 others (e. g. cancer) an enlargement which is for the most part nodulated, may occasionally be perfectly smooth. A subdivision which appears to me to be, on the whole, preferable, is that into painless and painful enlargements. Painless enlargements are further characterised by an absence of jaundice, and a very chronic course; but in painful enlargements jaundice is a very common symptom, and the pro- gress is more rapid. Among painless enlargements we have the so-called amyloid liver, the fatty liver, hydatid tumour of the liver, and simple hypertrophy. Among enlargements in which pain is a prominent symptom we have congestion, catarrh of the bile- ducts, obstruction of the common duct and retention of bile, pysemic abscesses, tropical abscess, and cancer. There are probably other enlargements of the liver besides those now mentioned, the anatomical and clinical characters of which are still unknown; but the distinguishing characters of the several forms of enlargement with which we are acquainted may now be considered in detail. I. THE WAXY, LARDACEOUS, OR AMYLOID LIVER. The liver undergoes greater enlargement from the so-called waxy, or amyloid deposit, than from any other disease, excepting, perhaps, cancer. I have known the liver of an adult affected with this disease weigh upwards of 180, instead of 50 or 60 ounces, and the liver, of which I show you here a portion, 24 ENLARGEMENTS OF THE LIVER, [lect. ii. weighed one-seventh, instead of a twenty-fifth, of the entire body of the child from whom it was taken. Enlargement of the liver due to waxy or amyloid deposit may be recognised during life by the following characters:— 1. The enlargement is often great, so that the liver fills up a large portion of the abdominal cavity. 2. It is uniform in every direction, so that the form of the organ is not essentially altered. The area of hepatic dulness on percussion is increased in the median, dorsal, and axillary lines, as well as in the right mammary. The increase is greater in front than behind, because in the former situation there is greater room for growth (figs. 9 and 10). It is in- creased in an upward as well as in a downward direction, although mainly in the latter, the lower margin often reaching the umbilicus, or even the right groin; but nowhere is there any outgrowth from the normal contour. The abdomen is enlarged, and often there is a visible tumour below the right costal arch and in the epigastrium, but rarely, if ever, is there any bulging of the ribs themselves. Waxy enlargement of the liver moulds itself over adjacent organs, and has little tendency to cause displacement of the ribs by excentric pressure. 3. On palpation, the portion of liver which extends below the margin of the ribs is very dense, firm, and resistant. There is no elasticity, and still less any feeling of fluctuation. 4. The outer surface is smooth, and the lower mar- LECT. II.] WAXY LIVER. 25 gin is more rounded than natural, regular, and free from all indentation. In this respect, however, rare exceptions occur, an ignorance of which may lead to Fig. 9 shows the increased area of hepatic and of splenic dulness in the case of Henry D----: anterior view. Between the two is a space yielding the clear tympanitic sound of the stomach; and above the liver is the normal area of cardiac dulness. Compare this with fig. 3, which shows the normal bound- aries of the liver and spleen. Fig. 10 shows the increased area of hepatic dulness in Henry D----: view on right side. The upper border is arched, and gradually falls to- wards the spine. errors in diagnosis. In rare cases waxy deposit in the liver coexists with cirrhosis, or with what are 26 ENLARGEMENTS OF THE LIVER, [lect. ii. known as syphilitic cicatrices, and then the surface of the organ may be nodulated, or even broken up into irregular lobes, separated by deep fissures, the exist- ence of which may lead to the suspicion that the enlargement is due to cancer. In cases also of extreme enlargement there may be an exaggeration, so to speak, of the lobes into which the liver is natu- rally divided, deep fissures corresponding to the attachment of the ligaments. Some of you had an opportunity of observing a case of this sort under the care of my colleague Dr. Grreenhow, the particulars of which I shall relate to you presently. Cases have also been recorded by Professor Frerichs of Berlin, in which a waxy liver has presented a more or less lobu- lated form. 5. Waxy deposit in the liver has but little tendency to obstruct the portal circulation, and consequently ascites and enlargement of the subcutaneous veins of the abdominal wall are not common phenomena in its clinical history. When such indications of portal obstruction do occur, they are often due to pressure exerted on the trunk of the portal vein by lymphatic glands in the fissure of the liver enlarged from waxy deposit. Occasionally, also, fluid is effused into the peritoneum as the result of secondary peritonitis. 6. Jaundice is a rare symptom in waxy disease of the liver ; and when it occurs, it is due, for the most part, to the pressure on the bile-ducts of enlarged lymphatic glands, or to the co-existence of catarrh of the bile-ducts. lect. n.] WAXY LIVER. 27 7. Pain and tenderness are never prominent symp- toms. The liver can be manipulated with impunity, and the patient complains only of a feeling of weight or tightness in the right hypochondrium, or of un- easiness from the pressure to which the stomach and intestines are subjected. But occasionally, and par- ticularly where there is a syphilitic history, there is an attack of acute pain from intercurrent peri-hepa- titis. In a case now under your notice, the enlarge- ment commenced in India, with severe pain in the right side, for which numerous leeches were applied ; but the enlarged liver now exhibits its usual painless character. Frerichs also records a case where the disease supervened on protracted ague, and where ' the first symptom was persistent cutting pains in the side.'* 8. The growth of the tumour is slow and impercep- tible. It usually extends over several years. 9. Constitutionally, the symptoms are chiefly those of anaemia. There is no pyrexia; but the counte- nance is pale and sallow, the patient suffers from general debility, and the proportion of white cor- puscles in the blood is slightly increased. Other characters of no small moment in diagnosis, are derived from the spleen, the kidneys, the stomach, or the intestines being the seat of a similar morbid deposit to that producing the hepatic enlargement. 10. The spleen in most cases is enlarged, and often greatly, as well as the liver. * Diseases of the Liver, Syd. Soc. Transl. vol. ii. p. 200. 28 ENLARGEMENTS OF THE LIVER, [lect. ii. 11. Waxy disease of the kidneys has peculiar characters of its own, the presence of which in any case of hepatic enlargement would alone make it very probable that this enlargement was due to waxy deposit. These characters are :— a. An increased quantity of urine. Not uncom- monly the patient voids three or five pints of urine in the twenty-four hours. This is the rule throughout the greater part of the course of the disease. Towards the termination only is the quantity diminished. * b. The urine is pale, of moderately low specific gravity (about 1012), free from any smokiness, and contains a considerable amount of albumen. c. Casts of the renal tubes are often absent. When present, they may be of an epithelial or hyaline cha- racter, usually the latter, and most of them, from their size, appear to have come from tubes not denu- ded of their epithelium. These hyaline casts, so far as my observation goes, never yield the so-called amyloid reaction with iodine and sulphuric acid ; but, in exceptional cases, this reaction may be observed in some of the cast-off renal cells. d. During the greater part of the disease, when the urine is increased in quantity, there is rarely a mate- rial diminution in the excretion of urea, and conse- quently the tendency to uraemia is much less than in other forms of kidney disease. * To Dr. Grainger Stewart, of Edinburgh, we are mainly indebted for pointing out the characters of the urine in waxy disease of the kidneys. My own observations coincide with his in every essential point. lect. II.] WAXY LIVER. 29 The persistent secretion of a large quantity of urine containing much albumen by a person who has never had general anasarca, will of itself warrant the pre- sumption that the individual is suffering from waxy disease of the kidneys. In the contracted or gouty kidney there may also be no dropsy, and the quantity of urine may be increased; but then the specific gravity is remarkably low (often not exceeding 1002 or 1005), and albumen is present as a mere trace, or may be entirely absent. 12. The implication of the stomach and intestines in the waxy disease induces a tendency to vomiting and to obstinate diarrhoea from slight causes. Occa- sionally this diarrhoea is accompanied by tenesmus, and the patient may be thought to labour under dysentery; but post-mortem examination reveals no evidence of inflammation of the bowel. The diarrhoea appears to result from deficient absorption rather than from increased exhalation. 13. Here, as in many other maladies, the circum- stances under which the disease usually makes its appearance are of considerable importance in diag- nosis. Now there are certain conditions of the system which pre-eminently favour the advent of waxy disease. Among them may be mentioned the following:— a. Long-standing purulent discharge, such as is particularly apt to happen in connection with diseased bone or joints, and after surgical operations when the wound does not readily heal. 30 ENLARGEMENTS OF THE LIVER, [lect. ii. b. Constitutional syphilis. In a large number of cases of waxy disease the patients have been the sub- jects of constitutional syphilis, which appears to act as a predisposing cause quite independently of its inducing disease of the bones or protracted dis- charges. c. Tubercle of the lungs and of other organs must be regarded as a predisposing cause of waxy degene- ration, although the enlargement of the liver common under such circumstances is oftener fatty than waxy. Of 52 cases of persons dying from tubercle, and whose autopsies I have recorded, the liver was fatty in 20, and waxy in 6, and in 3 of the 6 there was likewise caries of the bones. Still, of the 52 cases, 14 had waxy disease of either the kidneys, the liver, or the spleen, or 1 in 3^. The proportion of tubercular males in whom waxy disease was found was more than double that of females. Thus, of 33 tubercular males, there was waxy disease in 11, or 1 in 3; whereas of 19 tubercular females, only 3, or 1 in 6^, had waxy disease. d. Many chronic diseases that seriously impair the general nutrition probably predispose to waxy degeneration, which has thus been met with as an occasional sequel of protracted ague,* dysentery, cancer, &c. Treatment.—The following rules comprise those measures which experience has shown to be most useful in the treatment of waxy disease of the liver. * See Lecture IV. lect. il] WAXY LIVER. 31 In many cases, unfortunately, when the disease is already in an advanced stage, and when the kidneys and intestines are involved in the waxy degeneration, all treatment is of little avail, and the patient dies of exhaustion, which may be often ascribed to the co- pious drain of albumen in the urine or to the occur- rence of profuse diarrhoea (as in Case III.). But, on the other hand, in not a few cases, the progress of the disease appears to be arrested by appropriate treatment, and in some, as in Case I., there is good reason for believing that the waxy deposit may be in great measure removed. 1. Prevention.—The prevention of diseases in general has not yet received from the practical physician the attention which it deserves. The more we study the causes of disease, the more apparent it is that we possess a power in this direction which has hitherto been too much neglected. Bearing in mind the causes which we have found to lead to waxy enlargement of the liver, the means for its prevention will at once suggest themselves. First and foremost, it is always advisable to arrest as early as possible copious sup- puration from any part of the body, and in particular from diseased bone, and, if necessary, to have recourse to surgical interference for this purpose. It may in- deed be a question whether some of those operations which what is called ' conservative surgery' has of late years substituted for amputation, from en- tailing protracted suppuration, have not sacrificed the life of the patient to the endeavour to save his 32 ENLARGEMENTS OF THE LIVER, [lect. ii. limb. The death of the patient is ascribed to a bad constitution, which may, however, possibly be the result of internal disease engendered by the opera- tion. In cases where the disease of the liver comes on in the course of phthisis, our treatment must be di- rected to the primary disease, and every means should be employed to arrest the purulent discharge from the lungs, the diarrhoea, and the exhausting sweats. Again, the symptoms of constitutional syphilis must always be met by appropriate treatment; and mea- sures must be taken to prevent the condition of general cachexia, which is apt to supervene on such enervating disease as ague and dysentery. Lastly, it may be mentioned that in cases where there is a copious suppurative drain from the system, alkalies have been proposed as a means of preventing the waxy deposit. Chemistry is said to have shown that the waxy material is dealkalised fibrine; and it is argued that as a large quantity of alkali passes off with the pus, the waxy deposit may be prevented by restoring this alkali to the system.* Experience has yet to decide on the practical utility of this recom- mendation, which certainly deserves a trial. I have had no opportunity of watching its effects, but most of you must have noticed in the wards a marked im- provement in cases of waxy disease, under the use of the mineral acids. When waxy disease is already present, we must combat it by such measures as the following : — * Dr. Dickinson, Med.-Chir. Trans, vol. 1. p. 55. lect. n.] WAXY LIVER. 33 2. The diet ought to be of as nutritious a character as is compatible with the digestive powers of the individual. A moderate allowance of alcoholic stimu- lants is generally useful. Considering the anaemic condition of the liver, alcohol is less likely to be injurious than in most other enlargements of the organ. When the disease is not too far advanced, and when the means of the patient permit, removal to a mild and equable climate is generally advisable. 3. Tonics.—Most patients suffering from waxy disease derive benefit from the use of tonics, and particularly of the various preparations of iron, such as the perchloride and the iodide. In more than one case I have met with marked improvement under the continued use of nitric acid, in combination with such vegetable bitters as gentian or quinine. The external use of mtro-muriatic acid in the way to be described to you in a future lecture (Lect. IY.) also deserves a trial. Cod-liver oil is of questionable util- ity ; Frerichs states that he has known cases where waxy liver was developed under its continuous use. 4. Iodine and its preparations are of undoubted utility in the treatment of waxy disease. No pre- paration, I believe, is superior in this respect to the tincture of iodine of the British Pharmacopoeia, which may be given in doses of 10 or 15 minims, diluted, three or four times a day. You will remember the marked improvement, not only in the general symp- toms, but in the size of the liver, which took place under its use in the case of H. D. (Case II.). The D 34 ENLARGEMENTS OF THE LIVER, [lect. ii. preparations of iodine will probably be found most useful in those cases where there is a syphilitic history. 5. Budd * has recorded cases where a marked im- provement with diminution in the size of the liver has occurred under the use of the salts of ammonia, such as the muriate and the carbonate. In one case where the muriate of ammonia was given in doses of from 5 to 10 grains three times a day. a great enlarge- ment of the liver, which had existed for nine months, and was accompanied by emaciation, pallor, and irri- tative fever, and where mercury, iodine, taraxacum, and nitro-muriatic acid had been tried in turn without success, was entirely reduced. 6. In all cases of waxy liver, you must be on the look-out for complications, and meet them when they arise. Those which you have chiefly to expect are diarrhoea, vomiting, albuminuria, dropsy, and uraemia. The diarrhoea must be met by mineral and vegetable astringents with opium, and counter-irritation to the abdomen. Even in cases where the kidneys are in- volved, opium is less to be dreaded than in other forms of kidney disease. But not unfrequently the diarrhoea resists all treatment and cuts off the patient. Persistent vomiting also is a serious complication, and is unaffected by treatment. Ice, bismuth, hydro- cyanic acid, and counter-irritation to the epigastrium are the most useful remedies. The albuminuria re- quires no special treatment apart from that of the diseased liver. Dropsy must be met by diaphoretics and diuretics, the liquor ammoniae acetatis with warm * Dis. of Liver, 3rd ed. p. 335. lect. n.] WAXY LIVER. 35 baths, and the bitartrate or acetate of potash with digitalis. With these remedies it will be well to combine the salts of iron, such as the perchloride with the liquor ammon. acetat., or the acetate of iron with the acetate of potash. Drastic purgatives must always be given with caution in this form of dropsy, for fear of inducing uncontrollable diarrhoea. Lastly, in those rare cases where uraemia occurs towards the close of the disease, the remedies indicated are diapho- retics, diuretics, the vapour-bath, and, if necessary, a brisk purgative. In illustration of the remarks now made I show you in the first place a portion of a liver which I removed from the body of a patient who died in this hospital some years ago, and in whom the clinical his- tory and post-mortem appearances were as follows :— Case I.—Caries of the Hip-joint—Waxy Liver weigh- ing nearly one-seventh of the entire body—Waxy Spleen—Fatty Kidneys. H. L----, aged 7, was admitted into the Middlesex Hospital under the care of Mr. Shaw, on November 30, 1858, having suffered from disease in the left hip-joint for about nine months. He was emaciated and of marked scrofulous habit, the head and joints being large in proportion to the rest of the body. There was considerable pain in the left hip, increased on movement, so that he walked with difficulty. Soon after admission, abscesses opened in the neighbourhood of the left hip, and sinuses continued to dis- charge until his death on January 27,1861. During life there was great tumidity of the abdomen, obviously due to enlargement of the liver, the lower margin of which extended to below the um- bilicus, and the surface of which was dense, smooth, and painless. The splenic dulness was also increased, and the boy passed urine containing much albumen, but he had no dropsy. He was also r>2 36 ENLARGEMENTS OF THE LIVER, [lect. ii. liable to intercurrent attacks of diarrhoea, and the tongue was preternaturally clean, red, and glazed. Po$t-morte?n examination.—The body was extremely emaciated, the joints being large in proportion to the limbs. The total weight of the body was only 31 lb. 3 oz., or 499 oz. avoird.; the length of the body was 3J ft. The abdomen was remarkably tumid and hard, particularly in the right hypochondrium. There was much swelling about the left hip-joint, with numerous sinuses passing into the bone. The left thigh was flexed forwards and immovable. The entire head of the left femur was absent, and the end of the bone was carious. The acetabulum was likewise diseased, the bone being exposed and carious, and at one part deficient, so that there was an opening into the pelvic cavity. The head was remarkably large, its circumference being 2l£ in. The brain weighed 55^ oz.; its structure was normal. Each of the lateral ventricles contained three drachms of serum, and at the base were two fluid ounces. The membranes were normal. The heart and lungs were normal. The river was enormously enlarged and very dense. Its weight was 69 oz. avoird., or nearly one-seventh of the weight of the whole body, the normal ratio for a child nine years of age being only about 1 to 25. It reached as far as the umbilicus, and moulded itself over the different organs in its vicinity. Its tissue was very firm, so that the organ retained its form when laid with its convex surface on the table. Its external surface was perfectly smooth and free from all adhesions, but exhibited impressions of the adjacent organs. Its cut surface was of a greyish-pink colour and translucent, and presented a network of opaque yellowish streaks composed of fibrous tissue, apparently corresponding to the outline of the enlarged lobules, and enclosing the firm trans- lucent material in its meshes. Iodine and sulphuric acid developed the so-called amyloid reaction in a marked degree. On micro- scopic examination, the hepatic cells appeared to be coherent into fiat scales, and could not be isolated. The nuclei were distinct but the outlines of the cell-walls were scarcely appreciable at many places, the nuclei appearing interspersed through a trans- lucent homogeneous mass: at some places even the nuclei could not be distinguished. Towards the circumference of the lobules the cells were more distinct, and at some places contained an un- usual amount of oil. The spleen weighed llf oz., and presented a dense, glistening LECT. II.] WAXY LIVER. 37 surface on section, which became deeply tinged when treated with iodine and sulphuric acid. The kidneys were large, the right weighing 5 oz., and the left 5|- oz. They were not at all dense, but, on the contrary, very flabby. Their capsules were non-adherent, and their surfaces were perfectly smooth and pale yellow, with a beautiful network of in- jected veins. The cortical substance was hypertrophied, pale yellow, opaque, and soft. The renal epithelium throughout the kidneys was loaded with fine molecules and oil-globules, and at many places the uriniferous tubes appeared blocked up with oil. Iodine and sulphuric acid produced a decided tinging of the minute arteries and the Malpighian bodies in the cortex. The mesenteric and Peyerian glands were slightly enlarged, and the application of iodine to the mucous membrane of the bowel produced numerous brownish-red puncta, corresponding to the villi. The co-existence of fatty kidneys with waxy disease of the liver and spleen, in this case, is worthy of notice. It is to be observed, however, that even in the kidneys the minute vessels yielded the so-called amyloid reaction. You have all had an opportunity of examining the patient whose case I am now about to relate, and who is still (April 1867) under my care in Cambridge Ward. Case II.—Constitutional Syphilis, followed by Symp- toms of Waxy Disease of the Liver, Spleen, and Kidneys. H. D----, aged 28, was admitted December 27, 1866. As a young man, he appears to have enjoyed good health, and to have been temperate. But six years ago he contracted syphilis, followed by buboes, which were opened, and the scars are still visible in the groins. The wound soon healed up, discharging only for about two weeks. He does not remember having had sore-throat or pains in the bones. In 1858 he joined a cavalry regiment in India. With the exception of one or two slight attacks of diarrhoea, his health still kept good until about November 1864, when he was seized with pain in the right hypochondrium, which confined him to bed for six weeks. The pain was increased on taking a long 38 ENLARGEMENTS OF THE LIVER, [lect. ii. inspiration ; and he had leeches and blisters applied. At the end of six weeks he returned to his duty ; but his liver enlarging and his strength failing, he was discharged from the service, and arrived in England again in June 1865. Since his return to England he has been able to earn his living as a labourer; but he has suffered each winter from a cough, and expectoration occasionally slightly streaked with blood. Eight weeks before admission he lost his appetite and strength and was sent as a case of 'fever' to the London Fever Hospital, where he took mercury and iodide of potassium, with the object of reducing the size of the liver. On leaving the Fever Hospital, he came here. He does not remember having had any form of fever in India, and at no time of his life has he had dropsy in any part of his body. On admission, the patient was thin and anaemic, and had a decided sallowness of the countenance, without any jaundiced tint of the conjunctivae. Over the back were numerous small scars and copper-coloured discolorations. But what was most remark- able was the enlargement of the liver, the upper margin of which rose as high as the fourth intercostal space, while the lower mar- gin reached as low as the lower edge of the umbilicus (see fig. 9, p. 25). The organ appeared large in every direction, its dimensions being as follows : In median line, 8| in.; in right mammary line, 9| in.; in right axillary, 6^ in.; in right dorsal, 5£ in. The upper margin of the hepatic dulness was arched (fig. 10), that in the axillary line being an inch lower than that in the right mammary; in the right dorsal line it rose to the eighth intercostal space, and from this it gradually fell towards the spine. There was no bulg- ing of the ribs, and the portion of liver below the margin of the costal arch was very firm and resistant, not at all tender, and per- fectly smooth. The only appreciable inequality was a transverse furrow situated three inches and a-half above the umbilicus, and apparently due to the pressure of some article of clothing. The lower margin of the liver was considerably depressed when the patient took a long breath, so that the surface of the organ was probably not adherent, or only slightly so. The dimensions of the spleen were likewise increased (see fig. 9) ; it did not project be- yond the margin of the costal arch, but the dimensions of the splenic dulness were—vertically, 5k in., and transversely, 6^ in., instead of 2 in. vertically and 4 in. transversely, as in the normal state. There was no evidence of ascites or of anasarca. The patient's appetite was bad; his tongue was coated with a lect. il] WAXY LIVER. 39 white fur, and for some weeks after his admission there was a tendency to vomiting and diarrhoea, there being from three to four relaxed motions daily. The patient did not complain of pain in the abdomen, except of occasional transient attacks, which ap- peared to be due to flatulence. His chief complaint was of weak- ness in his limbs. Since admission, the blood and urine have been carefully ex- amined. The blood was found to contain a slight but decided in- crease in the proportion of white corpuscles, while many of the red corpuscles were of irregular outline and had a tendency to tail. The quantity of urine voided daily has been ascertained for several weeks, and has been always considerably above the healthy standard: the average quantity has been from three to four pints, and occasionally there has been more than four pints. Its specific gravity has varied from 1010 to 1015; it has always contained a considerable quantity of albumen, but has been per- fectly clear, of an amber colour, and without any palpable deposit. Microscopic examination for casts of the uriniferous tubes has for the most part yielded negative results; on one occasion a few small hyaline casts were detected. For the first five days after the patient's admission there was slight febrile disturbance. The pulse ranged from 110 to 120; the temperature rose to 102o>4; and moist and dry bronchial rales could be heard over the back of both lungs. The patient had also sleepless nights, but without any rigors or perspirations. Since then the pulse and temperature have been normal, and the patient has slept weU; but a little coarse crepitus can generally be heard at the bases of the lungs. There is no evidence of heart disease. The treatment up to March 13, 1867, consisted in mineral acids, bitter tonics, and a generous diet. At first, sulphuric acid and small doses of laudanum were prescribed, with the object of checking the diarrhoea. On January 9, nitric acid was substituted for the sulphuric, and was given with small doses of laudanum in the compound infusion of gentian. On February 8 the opium was omitted, and a grain of quinine substituted for the compound in- fusion of gentian. The diarrhoea, which had quite ceased, at once returned, but was again held in check by the restoration of laudanum to the mixture on February 13. Under this treatment the patient steadily and greatly improved. He had a good appetite, and was much stronger. His weight on admission was only 7 st. 10£ lb.; but on March 13 he had gained 16 lb. 40 ENLARGEMENTS OF THE LIVER, [lect. ii. April 3, 1867.—On March 13 the nitric acid was discontinued, and fifteen minims of compound tincture of iodine substituted. Since then the patient has continued to improve. He has now gained 20 lb. since admission. There has been no diarrhoea, and the quantity of urine has diminished almost to the natural stand- dard. There is no material change, however, in the size of the liver. April 29.—The patient was discharged from the hospital to-day, greatly improved in strength and appearance. There was no diarrhoea, and the urine was of the normal quantity, with only i albumen. The size of the liver had also greatly diminished, as will be obvious from the following dimensions. In median line, 6 in.; in right mammary line, 1\ in.; in right axillary, 6£ in. The vertical splenic dulness was only 4£ in. The circumstance of the enlargement of the liver, in this case, commencing in the tropics with acute pain, might be thought to indicate abscess; but opposed to abscess are, the duration of the enlarge- ment, its uniform character, its great density, the absence of fluctuation, and the fact of the patient having been able to work as a labourer for more than twelve months prior to his admission into the Fever Hospital. On the other hand, the physical characters of the hepatic swelling, the enlargement of the spleen, the excretion of a large quantity of very albuminous urine without any history of dropsy, the tendency to diarrhoea, the condition of the blood, and the syphi- litic history, all point to waxy disease as the cause of the enlargement. As regards the pain, also, it may be stated that Frerichs records a case of waxy disease of the liver, in which 'the first symptom was per- sistent cutting pains in the side, and soon his strength diminished to such an extent that he felt it necessary LECT. II.] WAXY LIVER. 41 to give up his work. Almost at the same time he observed a swelling in the right hypochondrium and epigastrium.' Case III.—Syphilitic Necrosis of Lower Jaw—Albu- minuria—Pleurisy and Pericarditis—Waxy Liver and Kidneys. John R----, aged 38, was admitted under' my care on December 17, 1867. Six or seven years before he had contracted syphilis, and four years before he had been confined to bed for three months with a painful affection in the joints, which he believed to have been rheumatism, and ever since he had been liable to pains in the bones and joints. Twelve months before he had been a patient in this hospital with albuminuria and slight oedema of the legs, and at that time the alveolar process of the right side of the lower jaw exfoliated. Ten weeks before admission, he had been seized with cough, dyspnoea, and pain in the right side of the chest. On admission, the patient had an anaemic, chlorotic countenance, with slight general anasarca. The urine contained a very large quantity of albumen—about one-half—but no tube-casts; it was passed in considerable quantity, and had a specific gravity of 1015. There was absolute dulness over the whole of the right lung, with all the signs of pleuritic effusion. The cardiac dulness was also increased, but could not be isolated from that of the right lung; the sounds of the heart were feeble, but no abnormal murmur could be detected. Pulse 96. The tongue was clean and red; the breath was extremely offensive; there was no appetite, and frequent vomiting. The hepatic dulness extended downwards uniformly, about two inches below the normal boundary; above it could not be well defined from the dulness over the right lung. The portion of liver projecting below the right ribs was smooth and free from tenderness. Splenic dulness not increased. Patient suffered much from want of sleep. Treatment proved of no avail in relieving the patient's condi- tion. On January 2, profuse diarrhoea, with watery, very offensive motions, came on. This continued until the patient's death oc- curred, on January 7, by exhaustion rather than by coma. On examining the body, there was great thickening with firm 42 ENLARGEMENTS OF THE LIVER, [lect. ii. adhesions of the right pleura in front; posteriorly the right lung was separated from the chest-wall by about thirty ounces of turbid fluid. The right lung was extremely dense from fibroid change. The pericardium contained about twelve ounces of turbid serum, and the surface of the heart was coated with a thick rough layer of rather firmly adherent lymph. The liver, spleen, and base of right lung were all firmly adherent to the diaphragm. The liver weighed 66 oz. It was extremely dense, and presented to the naked eye the appearances and chemical reaction of waxy deposit. The spleen was of natural size and rather soft. The kidneys were of about the normal size, their surfaces were slightly granular, the cortices were extremely dense and pale, and the straight vessels and Mal- pighian bodies exhibited in a characteristic manner the so-called 'amyloid reaction.' The mucous membrane of the small intestine was intensely injected, but exhibited no ' amyloid reaction.' In the following case, which occurred not long ago in this hospital, the diagnosis was rendered difficult by the irregular, nodulated form of the enlarged liver. The case was under the care of Dr. Greenhow, and is recorded in the ' Pathological Transactions,' vol. xvi. p. 147. Case IY.—Waxy Liver enlarged and nodulated, simu- lating Cancer. The patient was a baker, aged 33, at the time of his death, on October 12, 1864. No cause could be assigned for the disease, but a scar of doubtful nature was noticed in the right groin. He first came under observation about four months before his death, and although the liver was then about as large as when he died, it had never been the seat of pain or discomfort, and indeed the patient was unaware of the existence of any tumour in the abdomen until it was discovered during his examination at the hospital. The tumour extended from the right to the left side, so as to occupy both hypochondria. There was absolute dulness on percussion from the fourth right rib to an inch above the level of the umbilicus. The tumour was not in the slightest decree tender, and its general surface was perfectly smooth. A smooth LECT. II.] FATTY LIVER. 43 globular prominence in the epigastrium, however, simulated some- what a deeply-seated hydatid tumour, while a nodulated border and ascites subsequently gave rise to the suspicion of cancer. Still, the absence of pain or of the usual phenomena of the cancerous cachexia negatived the supposition of cancer; while the density of the epigastric tumour, the enlargement of the spleen, and the condition of the urine were in favour of waxy disease rather than of hydatid. A fortnight before the patient was first seen, his feet began to swell, and the anasarca gradually extended up to the thighs and scrotum. About two months before death fluid began to collect in the peritoneum, but the dropsy never invaded the arms or upper part of the body. The urine was copious, about three pints, and contained much albumen, but rarely any casts. At no time was there jaundice. Towards the last the patient became greatly emaciated, and he finally died exhausted. The liver weighed 184^ oz., and was in an advanced stage ot albuminous or waxy disease, yielding a most characteristic reaction with iodine. The spleen and kidneys, and the lymphatic glands in the portal fissure, were also greatly enlarged, and had undergone a similar change. Both lobes of the liver were equally enlarged, but they were prolonged upwards and backwards, so as to leave a fissure five inches in depth at the posterior margin, corresponding to the attachment of the suspensory ligament. The anterior border was much thickened, and was also indented by two deep fissures, corresponding to the notches for the suspensory ligament and the gall-bladder, which imparted to it a lobulated character. On the upper surface, also, corresponding to the epigastrium, there was a semi-globular elevation three inches in diameter. The under surface was marked by deep depressions, corresponding to the right kidney and the spleen. The surface of the liver gene- rally was smooth, but the capsule was much thickened, and supe- riorly adherent to the diaphragm. The stomach, intestines, and heart were normal. II. THE FATTY LIVEE. The second form of painless enlargement of the liver is that which is due to the accumulation of oil, 44 ENLARGEMENTS OF THE LIVER, [lect. ii. or 'the fatty liver.' This form of hepatic enlargement has the following clinical characters :— 1. The enlargement may be considerable, but is rarely so great as that often attained by the waxy liver. It is not often that the anterior or lower border reaches down beyond the umbilicus, or even so far. Occasionally, however, the vertical hepatic dulness is increased out of proportion to the actual amount of enlargement, in consequence of the organ being so soft and flabby that it folds upon itself, so that the anterior margin is depressed, and a larger portion of the organ is brought into apposition with the abdominal parietes. 2. As in waxy disease, the enlargement is tolerably uniform in every direction and there are no circum- scribed bulgings, so that the natural form of the liver is but little altered. There is no expansion or bulging of the lower ribs. 3. The enlarged liver is less resistant to pressure and of softer consistence than in the waxy disease. Owing to its flabbiness, it is easily pushed aside by the finger, and when the abdominal parietes are thin, its soft, doughy consistence may be readily ap- preciated. 4. The outer surface is smooth, and the lower margin rounded. Although fatty degeneration may coexist with cirrhosis, the liver under such circum- stances is reduced in size, and the irregular surface is rarely appreciable during life. A lobulated en- larged fatty liver is rarely, if ever, met with. lect. n.] FATTY LIVER. 45 | 5. There is no ascites or enlargement of the super- ficial veius of the abdomen. A large accumulation of oil in the liver interferes with the circulation so far as to lead to an ansemic condition of the liver itself, but not to such an extent as to cause ascites. 6. Even in extreme cases bile continues to be secreted, and its secretion is not arrested or impeded. Jaundice, therefore, is not a symptom of the fatty liver. 7. The same remark applies to pain. Fatty en- largement of the liver is painless from first to last. The organ can be freely manipulated with impunity, although in extreme cases the patient may complain of a feeling of weight or distension in the abdomen, increased by turning on the left side. 8. From the absence of symptoms, few opportuni- ties are afforded of watching the growth of fatty enlargement of the liver, but this is always slow and imperceptible, 9. The constitutional symptoms of fatty liver are few and not characteristic, and those which have been noted are often due for the most part to co- existing fatty degeneration of other organs, and more especially of the heart. General debility and want of tone in the nervous and vascular systems are amongst the most prominent symptoms. The patient is easily tired, and bears depletion or the inroads of acute disease badly. The late Dr. Addison described a condition of the integuments which he believed to be pathognomonic of fatty degeneration of the liver. ' To the eye,' he says, ' the skin presents a bloodless, 46 ENLARGEMENTS OF THE LIVER, [lect. ii. almost semi-transparent, and waxy appearance. When this is associated with mere pallor it is not very unlike fine polished ivory, but when combined with a more sallow tinge, as is now and then the case, it more resembles a common wax model. To the touch, the general integuments, for the most part, feel smooth, loose, and often flabby; whilst in some well- marked cases all its natural asperities would appear to be obliterated, and it becomes so exquisitely smooth and soft as to convey a sensation resembling that experienced on handling a piece of the softest satin.' * These appearances are chiefly met with in females, and although they are far from being invariably present, yet in most cases the countenance and general integuments are more or less pasty and anaemic, and sometimes the skin appears greasy from increased action of the sebaceous follicles. Patients with fatty liver also suffer often from dyspeptic symptoms, such as flatulence, hypochondriasis, irre- gular action of the bowels—usually constipation, but not unfrequently profuse diarrhoea from slight causes. 10. Enlargement of the spleen is rarely present. The portal circulation is not obstructed to such an extent as to lead to enlargement of this organ from stasis of blood; and the spleen is not liable, as in waxy disease, to a deposit of the same material as that which causes the liver to enlarge. There are, however, certain other organs which are apt to undergo fatty degeneration as well as the liver, and the disease in each of these organs has * Guy's Hospital Reports First Series, vol. i. 1836, p. 479. lect. ii.] FATTY LIVER. 47 symptoms of its own, which, when present, will throw light on the nature of the hepatic enlarge- ment. Thus— 11. When there is fatty degeneration of the heart, in addition to the signs already enumerated, there are often— a. A very feeble, or even inappreciable, cardiac impulse. b. Very faint, or even inaudible, cardiac sounds. c. A very slow, or a quick, feeble, and irregular radial pulse. d. Attacks of vertigo, syncope, or pseudo-apoplexy. e. Dyspnoea on slight exertion, and a feeling of sinking at the epigastrium. 12. When there is fatty degeneration of the kid- neys, in addition to the signs already enumerated, there will usually be— a. Urine below the normal standard in quantity, oftener turbid than clear, containing much albumen, and depositing numerous oil-casts. b. A tendency to general anasarca. c. Extreme pallor and pastiness of countenance. 13. As in waxy disease of the liver, the diagnosis will often be materially aided by attending to the circumstances under which the enlargement occurs. Many different conditions of the system may give rise to fatty enlargement of the liver, but most of them may be referred to one of the following heads :— a. Large accumulations of fat beneath the skin throughout the body, in persons who for the most part are large feeders and lead indolent lives. It 48 ENLARGEMENTS OF THE LIVER, [lect. n. is in this condition that the heart is most likely to participate in the fatty change, and that you will expect to discover the symptoms of fatty heart already referred to. It is patients in this state who are most prone to die of rupture of the heart. In the ' Pathological Transactions' you will find several cases recorded in which patients died of rupture of the heart, and where not only was the heart found in a state of fatty degeneration, but the liver was enormously enlarged from fatty deposit, and there was a large accumulation of fat throughout the body.* b. Alcoholism.—Persons who drink immoderately of ardent spirits, particularly if they take little exer- cise, are very subject to fatty liver. Of thirteen persons who died of delirium tremens, Frerichs found the liver very fatty in six. Of two fatal cases of delirium tremens in which an autopsy was made by me in this hospital some years ago, there was con- siderable fatty enlargement of the liver in both : in one the organ weighed eighty-three ounces ; in the other ninety-six ounces. It is under these circum- stances that the kidneys often participate in the fatty degeneration. c. Phthisis.—The great frequency of fatty enlarge- ment of the liver in persons suffering from pulmonary consumption has been already referred to under the head of the waxy liver (p. 30). In consumptive females it is much more common than in males. In this * See particularly case by Dr. Quain, vol. iii. p. 262 ; and case by Mr. Pollock, vol. xv. p. 84. lect. II.] FATTY LIVER. 49 disease, it is not a little remarkable that, while fat disappears rapidly from almost every tissue in the body, it should accumulate in such large quantities in the liver. d. Other wasting diseases besides phthisis—such, for instance, as cancer,* simple ulcer of the sto- mach,! and chronic dysentery J—are likewise often attended by fatty enlargement of the liver. It appears, then, that fatty liver is met with under two opposite conditions: one, in which there is an increased supply of material capable of being con- verted into oil, and where fat often accumulates in all the tissues of the body; the other, in which there is a rapid absorption of fat from all the tissues, with consequent emaciation. Its mode of production in the former case is sufficiently obvious; in the latter, the blood becomes loaded with oily matters derived from the patient's own tissues, and this oily matter is sepa- rated from the blood in its passage through the liver. The impaired absorption of oxygen in phthisis, inter- fering with the proper metamorphosis of the oil, ac- counts for fatty liver being more common in pulmo- nary than in other wasting diseases ; and the greater frequency of fatty liver in women may be accounted * See case of cancer of the larynx, by Mr. C. Heath, Pathological 'ransactions, vol. xiii. p. 28; and case of extensive cancerous ulcera- ion of groin, by Dr. Budd, Diseases of Liver, p. 299. t Case by Mr. R. Robinson, Path. Trans, vol. iv. p. 133 ; and by vlr. H. Thompson, id. vol. vi. p. 186. \ Case by Dr. Bright, in Hospital Reports, vol. i. p. 117. E 50 ENLARGEMENTS OF THE LIVER, [lect. n. for by women having in general a larger quantity of fat to be absorbed. Treatment—-It is not often that fatty enlargement of the liver causes such a derangement of functions as in itself to call for treatment. As a rule, treatment must be directed against the conditions in which the enlargement in question is known to occur. 1. When the disease is developed in persons who are large feeders and of indolent habits, the fat will usually disappear from the liver, as well as from the rest of the body, on the individual adopting an op- posite mode of life. He must rise early and take active exercise in the open air, and live principally on lean meat, fish, and green vegetables, with light claret, hock, or plain water to drink, and avoid butter, fat, oil, fermented drinks, strong wines, and all substances rich in starch or sugar. Under such a regimen, the fat will not only disappear, but the nutrition of the muscles will be improved, and the patient's strength increased. In cases, however, where there is reason to suspect the existence of fatty degeneration of the muscular tissue of the heart, the change of regimen here recommended must not be too sudden, and its effects must be carefully watched, while caution must be exercised in withdrawing the accustomed allowance of alcoholic stimulant. 2. When fatty liver is the result of alcoholism, a simple withdrawal of the cause will usually be suffi- cient to effect a diminution in the size of the liver. 3. Alkalies, alkaline carbonates, or compounds of lect. ii.] FATTY LIVER. 51 the alkalies with the vegetable acids, in combination with some vegetable bitter, such as taraxacum or gen- tian, have generally been found useful for correcting the digestive derangements resulting from fatty liver; and if the bowels be constipated, recourse may also be had to occasional doses of the compound rhubarb, or colocynth pills of the Pharmacopoeia, in combination with blue pill and extract of henbane. Eating large quantities of common salt with the food has some- times appeared useful; and, when circumstances per- mit, it may be advisable to recommend a trial of the alkaline or saline mineral waters of Carlsbad, Marien- bad, Kissingen, Ems, or Vichy. 4. The preparations of iron are often of great ser- vice in cases where there is marked anaemia, and those which are best suited are the ferrum redactum, the ferri et quinise citras, the ferri et ammonise citras, and the mistura ferri aromatica. The chalybeate mineral waters of Tonbridge or Moffat, or of Spa, Pyrmont, or Schwalbach, on the Continent, are also useful for the same object. 5. Lastly, when the disease appears in the course of phthisis, it rarely calls for any special treatment, but its presence is a contra-indication to the use of cod-liver oil, or other oleaginous remedies. In the following case, I had several opportunities of demonstrating to you in the wards the clinical characters of the fatty liver. The absence of albu- minuria or of enlargement of the spleen made it E 2 52 ENLARGEMENTS OF THE LIVER, [lect. n. improbable that the enlargement was due to waxy deposit. Case V.—Acute Phthisis—Fatty Liver. Charles C----, aged 57, was admitted into the Middlesex Hos- pital, under my care, on June 11, 1867. He had enjoyed good health until about two months before, when he began to suffer from frequent cough, emaciation, and night sweats, and subse- quently from diarrhoea. On admission he was very thin and pro- strate, he had a frequent cough, with purulent expectoration ; there was marked dulness for several inches below the right clavicle, and coarse moist rales audible over the whole of both lungs. The bowels were very relaxed. The liver was much enlarged; the hepatic dulness in the right mammary line measuring 7 in., and reaching fully 3 in. below the margin of the ribs. The enlarge- ment was uniform ; its outer surface was smooth, but much, softer and less resistant than that of the waxy liver, and it was devoid of all pain or tenderness. There was no jaundice, albuminuria, or enlargement of the spleen. The patient rapidly sank, and died on June 16. On examination of the body, both lungs were found infiltrated throughout with yellow tubercle, breaking down at the apices into small cavities. At the right apex the pulmonary tissue had en- tirely disappeared. Numerous small ulcers, without tubercular deposit in large intestine. Kidneys and spleen healthy. Liver much enlarged, weighed seventy-eight ounces, was smooth, pale yellow, opaque, and extremely friable; the secreting cells through- out were loaded with oil. III. SIMPLE HYPERTROPHY. By ' simple hypertrophy' is understood an enlarge- ment of the liver, due to an increased size of the lobules and an increased size or number of secreting cells, without any alteration of structure. The en- largement of the liver is uniform and rarely great; and, as might be expected, it is not attended with lect. n.] SIMPLE HYPERTROPHY. 53 any prominent symptom. The condition is compara- tively rare, and has still to be studied. It has chiefly been observed in a. Leuksemia; and in b. Exceptional cases of saccharine diabetes.* Hence, when the liver is found enlarged in either of these maladies without any obvious derangement of its functions, simple hypertrophy may be suspected. It has been suggested that the enlargement of the liver arising from protracted residence in hot climates may be of this nature; but in most cases this is probably due to chronic hypersemia or to waxy disease (see Lecture TV.). * See Prerichs' Diseases of Liver, Syd. Soc. Transl. vol. ii. p. 210. According to Budd, the liver in diabetes is often unusually small, and the lobules shrunken, from the quantity of oil being below the normal standard (Diseases of Liver, 3rd ed. p. 310). 54 ENLARGEMENTS OF THE LIVER, [lect. hi. LECTUKE III. ENLARGEMENTS OF THE LIVER. IV. HYDATID TUMOUR. The fourth and last form of painless enlargement of the liver is that which is due to the presence of hydatid tumour. This is known during life by the following characters:— 1. The enlargement maybe very great, so as to fill the greater part of the abdominal cavity, or reach upwards to near the clavicle, but in its earlier stages the hydatid may form a perceptible tumour at one part of the liver, not larger than an orange. 2. Unlike any of the enlargements already consi- dered, it is not uniform in every direction, but usually it follows one direction in particular; so that the natural form of the liver is greatly altered (figs. 11 and 12, pp. 84, 86). If it grow upwards, the natural arched outline of the upper boundary of hepatic dul- ness will be exaggerated ; if it grow downwards, the lower boundary of hepatic dulness will be found to be natural at some places, while at others there is an abrupt protuberance or tumour (see fig. 11). Not unfrequently, it takes a lateral direction, and causes more or less bulging of the ribs; and then the disease lect. m.] HYDATID TUMOUR. 55 is apt to be mistaken for empyema, which is readily distinguished by the characters already enumerated (see page 17). 3. It is neither dense nor doughy, but elastic, or even fluctuating. If the hydatid be deeply seated, with much hepatic tissue separating it from the outer surface, the tumour will be only elastic; but if it approach near to the surface there will be distinct fluctuation, with a thrill as from fluid, on palpation. Occasionally there is the sign known as 'hydatid vibration.' This is a peculiar trembling sensation, experienced when three fingers of the left hand are laid flat on the tumour, and the back of the left middle finger is struck abruptly with the point of the middle finger of the right hand. This sign is not due to the presence of secondary cysts in the interior of the parent, nor is it peculiar to hydatid tumours. It is elicited when any large cyst, with thin tense walls and watery contents, is treated in the manner above described. But, inasmuch as the only tumours in the liver answering to these characters are hyda- tids, the sign referred to, when present, is of consi- derable value in the diagnosis of hydatids in the liver. Unfortunately, in a large proportion—probably the majority—of cases of hydatid tumours of the liver, it is altogether wanting. 4. The surface of the tumour is smooth, and free from irregularities of every sort. In rare cases, when there are several distinct cysts projecting from the surface of the liver, this organ may appear through 56 ENLARGEMENTS OF THE LIVER, [lect. in. the abdominal parietes to have somewhat of a lobu- lated character, which may occasion considerable embarrassment in diagnosis. The possibility of this source of fallacy arising must be kept in view. 5. Ascites, oedema of the lower extremities, enlarge- ment of the superficial veins of the abdomen, and haemorrhoids are not distinguishing characters of hydatid enlargement of the liver. Their occurrence in rare cases must be regarded as in some measure accidental, and due to compression by the tumour of the trunk of the portal vein, or of the inferior vena cava. Care must be taken not to mistake for ascites an enormous hydatid tumour projecting down from the liver and filling the fore-part of the abdominal cavity. This is distinguished by a history of growth from above downwards, and by the portions of the abdomen yielding tympanitic percussion not being the most elevated in any position of the patient. For instance, when the patient lies on his back, there may be dulness on percussion and unmistakable evidence of fluid in the most elevated part of the abdomen, while in both flanks the percussion is tympanitic (see Case XIV.). When hydatid tumour of the liver coexists with ascites, and no opportunity has been afforded of examining the patient prior to the ascites, the diagnosis will be extremely difficult, if not im- possible. 6. Enlargement of the spleen is not a common con- sequence of hydatid enlargement of the liver, but may occur under conditions similar to those which occa- lect. in.] HYDATID TUMOUR. 57 sion ascites. In very rare cases, also, the spleen may be enlarged from the presence of secondary hydatid tumours. 7. Jaundice is also an exceptional, and, so to speak, accidental symptom of hydatid enlargement of the liver. When present, it is due to pressure by the tu- mour on the common bile-duct, to catarrh of the bile- ducts, or to the bursting of the tumour into the ducts, which become obstructed by its contents. I show yon here a specimen taken from the body of a gentleman under my care, in whom jaundice was due to the last of these causes (Case X.), and you have recently had an opportunity of studying the symptoms in a similar case, which proved fatal in the hospital (Case IX.). 8. Enlargement of the liver from hydatid tumour rarely interferes with the functions of the kidneys, and hence we do not meet with those alterations in the urine so common in waxy and of frequent occurrence in fatty enlargements. In rare case s, however, the kid- neys also may be the seat of hydatids, or pyelitis may be induced by the pressure of a large hydatid tumour of the liver on the ureter. Under these circumstances the urine may contain large quantities of pus, as happened in a patient who was under my care in this hospital a few years ago, and the particulars of whose case I shall narrate to you presently (Case XVIII.). 9. The growth of an hydatid tumour is slow and imperceptible, and, when the tumour is large, it has usually existed for years before the patient has recourse 58 ENLARGEMENTS OF THE LIVER, [lect. hi. to medical advice. Dr. Budd mentions the case of a lady who died at the age of seventy-three, and in whose body two hydatid tumours of the liver were found, which there was reason to believe had existed since she was eight years old.* 10. The latent character of hydatid enlargement of the liver is one of its chief characteristics. It often attains a great size without causing any pain or un- easiness, and often indeed without the patient being aware of its existence. The first local indications of its presence are those resulting from pressure on ad- joining parts, a feeling of weight or distension, or embarrassment of the breathing. Then, and not till then, it may become the seat of occasional attacks of acute pain and tenderness, in consequence of inflam- mation of the superimposed peritoneum ; but, on the whole, even these attacks are rare. 11. There is, in like manner, an absence of all constitutional symptoms. Even when of large size, the tumour does not interfere with the functions of the liver. There is no pyrexia or impairment of the general health, and the chief symptoms are those due to pressure on adjoining organs, and interference with their functions. Some years ago a patient came to me complaining of cough and shortness of breath, and fearing that she was consumptive. On examining the chest, I found an enormous hydatid tumour of the liver compressing the right lung, and causing great bulging outwards of the ribs, as well as a prominent * Diseases of Liver, 3rd ed. p. 433. lect. in.] HYDATID TUMOUR. 59 tumour in the abdomen. The patient had suffered nothing except the cough and dyspnoea, and was not aware of the existence of any tumour (Case XVIII.). Instances also are not uncommon of patients who have died from acute inflammation excited by the bursting of a large hydatid tumour of the liver, who, previous to the attack of fatal inflammation, have been thought to be in perfect health (Case XV.). 12. The diseases which are most readily con- founded with hydatid of the liver are abscess, dis- tended gall-bladder, effusion into the right pleura, aneurism, cancer, and cystic tumour of the kidney (see page 19 and also Case XXIII.). a. The absence of symptoms, both constitutional and local, and the slow growth, of hydatid tumour, form a marked distinction between it and abscess, which, so far as its physical characters are concerned, is the form of hepatic enlargement most closely re- sembling hydatid. There is one source of fallacy, however, which must be kept in view, although an accurate diagnosis under the circumstances would not materially modify the prognosis or the treatment. An hydatid tumour of the liver occasionally inflames and suppurates, and then it presents all the constitu- tional and local phenomena of abscess. The diagnosis of this condition must depend entirely on the patient's previous history—the fact of a painless tumour having long preceded the symptoms of abscess, and the ab- sence of exposure to the ordinary causes of tropical abscess. 60 ENLARGEMENTS OF THE LIVER, [lect. hi. b. A distended gall-bladder may closely resemble a pendulous hydatid of the liver, and may also be free from pain. It is recognized by its shape and position, by its development being usually accompanied by attacks of biliary colic, and by the fact that in most cases there is jaundice, owing to there being ob- struction of the common duct. c. Extensive effusion into the right pleura, with bulging of the ribs, and obliteration of the intercostal spaces, may closely simulate a large hydatid tumour; but, on the whole, an hydatid tumour of the liver is more likely to be regarded as an example of pleuritic effusion, than pleuritic effusion mistaken for hydatid. The hydatid is mainly distinguished by its insidious growth, and by the absence of constitutional sym- ptoms. The chief physical distinction is derived from the upper boundary of the dull space. In pleuritic effusion this is horizontal (page 14); in hydatid tumour it is arched, being at a higher level in the infra-axillary space than it is close to the spine or near the sternum. The possibility of an hydatid tumour of the liver co-existing with pleuritic effusion must not be lost sight of (see Cases XV. and XVI.). d. An aneurism of the abdominal aorta, or of the hepatic artery, may present a smooth, globular tu- mour, very like that of an hydatid. Its main dis- tinctive characters are pulsation, bellows-murmur, and the fact that it is usually the seat of acute neuralgic pains, owing to pressure on the branches of the solar, or of the hepatic, plexus. An aneurism of lect. m.] HYDATID TUMOUR. 61 the hepatic artery is further distinguished by its being invariably accompanied by jaundice from compression of the bile-ducts. e. Cancer of the liver is mainly distinguished by its irregular surface, tenderness and hardness, and by the absence of elasticity or feeling of fluctuation. The diagnosis may be embarrassed by the circumstance that several hydatid tumours projecting from the surface of the liver may impart to it an uneven surface, or that the nodules of medullary cancer may exhibit a degree of elasticity approaching to fluctuation. Under such circumstances, the diagnosis of hydatid must mainly depend on its slower growth and on the absence of constitutional cachexia. If there be any doubts as to the nature of the case, they may at once be removed by an exploratory puncture. The fluid which escapes from an hydatid, even if it contain no echinococci or shreds of striated hydatid membrane, will reveal its nature with ab- solute certainty. If the sac be not inflamed, it is limpid, when running in a stream, with a slight opalescence when viewed in bulk; it is alkaline, and has a specific gravity of 1007 or 1009 ; it contains neither albumen nor urea, but throws down a copious white precipitate with nitrate of silver, owing to its strong impregnation with common salt. These characters apply to no other fluid in the body, whether healthy or morbid.* Even if the case should turn out to be * The contrast between the fluid in the hydatid-cysts described in Case XX., and the surrounding peritoneal fluid, in which they were floating, is worthy of notice. 62 ENLARGEMENTS OF THE LIVER, [lect. in. an aneurism or a cancer, no harm is likely to result from an exploratory puncture. Modes of Termination of Hydatid Tumours of the Liver.—It may be thought that a tumour which causes so little inconvenience that even when of large size the patient himself may be ignorant of its exist- ence, requires little interference in the way of medical treatment. In reference to practice it is therefore important to have a correct knowledge of the natural modes of termination of hydatid tumours of the liver. The chief of these are as follows :— Spontaneous Cure.—In the first place, there can be no doubt that some of these tumours undergo a spon- taneous cure. The parasite may die from calcification of the parent cyst preventing further growth, from inflammatory action lighted up by the entrance of bile or by some other cause, or from the secondary vesicles increasing out of all proportion to the fluid in which they float (Case XXII.) ; the parent cyst slowly shrivels up, and in place of the hydatid we find a putty-like material, the real nature of which is dis- closed by its containing shreds of the striated hydatid membranes or hooklets of echinococci. But, unfor- tunately, this favourable result is confined for the most part to tumours of so small a size that they are not recognized during life. When the tumour is sufficiently large to give rise to symptoms and be diagnosed, such an event is so rare that it cannot be calculated on. The tumour then continues to increase in size. Its growth may be slow; it may extend over years; but almost as surely as the lect. in.] HYDATID TUMOUR. 63 tumour grows will it one day burst or lead to an equally certain, though less sudden, death. The directions in which an hydatid tumour of the liver may burst are very various, and the danger will vary accordingly. 1. Into the Pleural Cavity or Pulmonary Tissue.— This direction is more common than any other. It is almost always the right lung and pleura that are invaded. When the contents of the hydatid are dis- charged through an opening in the diaphragm into the pleura, acute and almost invariably fatal pleurisy is the result.* If adhesiohs form between the diaphragm and the base of the right lung prior to the bursting of the hydatid, the contents of the latter may escape by the bronchial tubes, and the patient may recover; f but even here, in most cases, fatal inflammation or gan- grene is set up in the lung, J or the patient dies from exhaustion, owing to the profuse discharge from a large cavity, or from many small cavities, excavated in the lung.§ Eatal pleurisy may result from an hydatid tumour of the liver, without any perforation of the diaphragm. || Erom Case XVTL, also, it will * See Cases XV. and XVI.; also Frerichs, Dis. of Liver (Syd. Soc. Ed.), ii. 235 ; Ogle, Path. Trans, xi. 299; Bristowe, Path. Trans, iii. 341; H. Davies, Path. Trans, i. 278 ; Davaine, Traite des Entozooaires, p. 437. f For examples, see Bright, Abdom. Turn. (Syd. Soc. Ed.), p. 49; Todd, Med. Times and Gazette, Jan. 5, 1854; Path. Trans, iv. 44; v. 303 ; viii. 92 ; ix. 28; Davaine, op. cit. p. 449. t See cases by Peacock, Path. Trans, ii. 72; Pollock, id. xvi. 155. § Frerichs, op. cit. ii. 264; Peacock, Path. Trans, vol. xv. p. 247; Davaine, op. cit. p. 443. || See Murehison, Ed. Med. Joum. Dec. 1865, Case XL, and case by Dr. Pollock, Path. Trans, v. 301. 64 ENLARGEMENTS OF THE LIVER, [lect. m. be seen that an obsolete hydatid cyst of the liver may inflame, and, after establishing a communication with the bronchial tubes, may give rise to all the phenomena of gangrene of the lung. 2. Into the Pericardium.—This is, fortunately, a very rare direction, as the cases in which it has been no- ticed have been always fatal, either instantaneously by embarrassment of the heart's action, or within a few hours by acute pericarditis.* 3. Into the Peritoneum.—The tumour collapses, and violent and almost always fatal peritonitis is at once excited. This accident must not be confounded with the attacks of partial peritonitis, which are so common before the tumour bursts in any direction. The rup- ture of the sac is often caused by external violence, in the form of a blow, fall, or strain. In the museum of St. Mary's Hospital is the calcified cyst of an hy- datid taken from the body of a man who dropped down dead after receiving a slight blow on the epigastrium from a comrade with whom he was sparring. The blow ruptured the cyst; the contents of the cyst escaped into the peritoneum, and the man died from shock. Three cases of fatal rupture in consequence of a fall are recorded by Mr. Csesar Hawkins.f Three similar cases are mentioned by Frerichs ; in two the rupture was caused by a fall, and in the third it was * Two cases of rupture into the pericardium will be found in Davaine's work (p. 408); a third is recorded by Wunderlich (Med. Times and Gaz., Nov. 12, 1859, p. 488). t Med.-Chir. Trans, vol. xviii. p. 124. lect. rn.] HYDATID TUMOUR. 65 due to a strain; in one of the cases, death occurred within a quarter of an hour of the rupture. Eight additional cases have been collected by Davaine, in which death ensued within a few hours or days of the rupture of an hydatid tumour of the liver into the peritoneum. In several of the cases the rupture was caused by a fall or strain, and in one it occurred while the patient was wrestling with a comrade.* Rupture into the peritoneum was probably the cause of the fatal event in Case XX. On the other hand, Bright records a case where what appeared to be a large hydatid tumour of the liver burst into the abdomen, without being followed by a fatal result, f Ogle also mentions the case of a patient who re- covered after the symptoms of peritonitis resulting from the rupture of an hydatid cyst in the omentum.^ 4. Through the Abdominal Parietes or Lower Inter- costal Spaces.—This is not a common mode of termi- nation, although several cases are on record. The contents of the hydatid may be discharged by an opening at the umbilicus or in some other part of the abdominal parietes, or in one of the lower intercostal spaces, and the patient may get well. Even here, however, the cyst is apt to take on suppuration, and the patient may die from exhaustion or from perito- nitis ; or fatal haemorrhage may occur from the interior of the sac, as in a case recorded by Dr. Bright. Of ten * Davaine, op. cit. p. 493. t Abdom. Tumours, Syd. Soc. Ed. p. 47. \ Path. Trans, xi. p. 295. F 66 ENLARGEMENTS OF THE LIVER, [lect. hi. cases where a spontaneous opening occurred, and of which I have collected notes, five terminated fatally.* 5. Into the Stomach or Intestine.—This is the most favourable direction in which the tumour can burst, although death sometimes results from the peritonitis which is set up around the opening, or from secondary abscesses of the liver,t and unfortunately it is not a common mode of termination. According as the tumour opens into the stomach or the intestine, the hydatids are vomited or evacuated per anum;% some- times they escape in both directions. The opening is usually small, so that the hydatids are discharged slowly. Davaine has collected eleven cases where an hydatid tumour of the liver appeared to open into the stomach, of which six were fatal; and fifteen cases where there was reason to believe that it had opened into the intes- tine, of which only one was fatal. In one of Davaine's cases the tumour opened through the abdominal parietes, as well as into the stomach. In a case of large hydatid tumour of the liver which occurred in this hospital nine years ago, under the care of my friend Dr. A. P. Stewart, where the liquid contents were drawn off by a trocar, the tumour subsequently * Budd, Dis. of Liver, 3rd ed. p. 437; Frerichs, op. cit. ii. p. 237; Hawkins, Med.-Chir. Trans, xviii. pp. 153, 158 ; Bright, op. cit. p. 50; Griffiths, Lond. Med. Gaz. 1844, vol. xxxiv. p. 585; Davaine, op. cit. p. 384, Obs. V. f See a case under Dr. Owen Rees, Med. Times and Gaz. June 20, 1857. \ For examples, see Frerichs, op. cit. ii. p. 237 ; Budd, op. cit. p. 452; Bright, op. cit. p. 49 ; Davaine, op. cit. p. 496. lect. hi.] HYDATID TUMOUR. 67 burst into the bowel, discharging numerous cysts per anum, and the patient made a good recovery. In the 'Gazette des Hopitaux' for 1850, a remarkable case is recorded where three hydatid cysts of the liver opened spontaneously: the first, in 1833, into the bronchi; the second, in 1845, into the stomach; and the third, in 1848, into the intestine: the patient recovered. Although hydatid tumours of the pelvis occasionally open into the urinary passages, I am not acquainted with any case where this has happened when the primary tumour has been in the liver. 6. Into the Biliary Passages.—It is not uncommon for a communication to be established between an hydatid tumour of the liver and one of the bile-ducts. In several cases where this has occurred, I have found the secondary cysts ruptured, empty, and more or less stained with bile. The entrance of bile, as was long ago stated by Cruveilhier, appears to be fatal to the life of the parasite, and in many cases probably con- stitutes the commencement of a spontaneous cure, while in other cases it lights up severe and even fatal inflammatory action in the cyst. (Cases IX. and XI.) Not only does bile enter the cyst, but occasionally the contents of the cyst pass into the bile-ducts and gall- bladder, causing obstruction of these passages, with persistent and often fatal jaundice. You have lately had an opportunity of watching a case of this sort F 2 68 ENLARGEMENTS OF THE LIVER, [lect. m. (Case IX.), and several others will be found in Davaine's work.* In the case which has been under your notice, the jaundice almost disappeared, although the stools remained colourless, in consequence of the bile draining away through the external opening. Mr. Hawkins has recorded a case where the common bile-duct was obstructed by hydatids, without jaun- dice, owing to the bile escaping by a fistulous open- ing into a bronchus.f But now and then the bili- ary passages become sufficiently dilated to permit the evacuation of the contents of the cyst through them into the bowel. This is an extremely rare occur- rence, and most of the cases where it has been noticed have been fatal. A remarkable case is re- corded by Dr. Hillier, where the contents of an hydatid tumour were discharged through the bile- duct into the bowel, but where the patient died in consequence of haemorrhage from the wall of the cyst, the blood (derived apparently from branches of the hepatic artery) passing along the duct into the stomach and intestines. J Two cases are recorded by Dr. Wilks, where an hydatid cyst opened into a bile- duct, but where death was caused by peritonitis or by ' inflammation about the liver and ducts ;' in one * Op. cit. p. 462. In rare instances an hydatid tumour appears to be developed in the bile-duct, although the possibility of such an occurrence is denied by Davaine. Dr. Dickinson has recorded the case of an hydatid developed in the right hepatic duct, where obstruction of the common duct was caused by a portion of the cyst together with inspissated bile (Path. Trans, xiii. 104). t Med.-Chir. Trans, xviii. p. 148. I Path. Trans, vii. p. 222. lect. in.] HYDATID TUMOUR. 69 of the cases hydatid cysts had been vomited and passed from the bowel before the occurrence of in- flammation.'55' Frerichs mentions a case where most of the contents of an hydatid had escaped by the bile-duct, but where the common duct ultimately became obstructed, and fatal rupture of the gall- bladder was the result.f Case X. is a very rare example of recovery after the discharge of the con- tents of a large hydatid cyst through the bile-duct into the bowel; but although the recovery appeared to be complete, several months afterwards the passage of some of the remaining contents of the tumour along the duct gave rise to severe pain and vomiting, and the muscular efforts in vomiting tore across some of the old adhesions: the result was fatal peri- tonitis. The only other case of recovery, under like circum- stances, which I have met with, is one referred to by Davaine, where there was reason to believe that an hydatid tumour of the liver had ruptured into the gall-bladder, and where the patient recovered after a severe attack of biliary colic and jaundice, accom- panied by the passage per anum of both hydatid cysts and gall-stones. J 7. Into the Vena Cava Inferior.—In exceptional cases, an hydatid tumour of the liver bursts into the inferior vena cava, and its contents, reaching the right side of the heart, become impacted in the * Path. Trans, xi. p. 128. f Op. cit. ii. p. 231. \ Op. cit. p. 477. 70 ENLARGEMENTS OF THE LIVER, [lect. m. pulmonary artery and cause instant death. Three cases of this sort are mentioned by Frerichs.'55' But, independently of rupture, there are various ways in which an hydatid tumour may destroy life. 1. By Marasmus and Exhaustion.—This was the mode of death in Case XIV., where an hydatid tumour of the liver became so large that the entire abdomen was enormously distended by it, and re- spiration was seriously embarrassed. This case was further remarkable from the circumstance that there were dulness and fluctuation over the greater part of the front of the distended abdomen, while the epigas- trium and both flanks were tympanitic on percussion. 2. By Pressure upon important Organs and Inter- ference with their Functions.—An hydatid tumour of the liver may compress the vena cava so as to cause anasarca and varices of the lower extremities,! or the portal vein, so as to induce ascites, and necessi- tate recourse to paracentesis.;]: By pressure upwards also it may embarrass the respiration and the action of the heart. 3. By Suppuration or Gangrene of the Cyst, or Suppu- ration external to the Cyst, with or without Pycemia, and Secondary Purulent Deposits.—Cases IX. XI. XII. * Op. cit. ii. p. 238. Two of these cases are related at greater length by Davaine (op. cit. p. 405). f A case of this sort is recorded by Dr. Habershon, in Guy's Hos- pital Reports, 3rd ser. vol. vi. p. 182. J See cases by Dr. Barker, Path. Trans, vol. vii. p. 225, and by Dr. Budd, Dis. of Liver, p. 451, and Hawkins in Med.-Chir. Trans, xviii. p. 149. mil] HYDATID TUMOUR. 71 and XIII. afford illustrations of these modes of termi- nation, and many similar cases are on record.* Bris- towe has recorded a case where the secondary ab- scesses appeared due to obstruction of one of the ducts, t hut in several of the cases pus has been found in the vein in the neighbourhood of the suppurating hydatid. 4. By the Formation of Secondary Hydatid Tumours. —Secondary hydatid tumours may form in the liver or mesentery; % and, if they be large or numerous, they may interfere with the patient's nutrition, and cause death by exhaustion, by peritonitis, or by urae- mia from compression of the ureters, as in Case XIX. Not uncommonly they form in the lung, and destroy life by inducing pneumonia. Case XXI. is an in- stance of a secondary hydatid tumour compressing the spinal cord, and causing paraplegia. § Dr. Barker relates the particulars of a case where death was due to the formation of a secondary hydatid tumour in the brain. || An interesting case is recorded by Dr. Wilks, of a girl, aged nineteen, who died suddenly, having previously been in good health. An hydatid tumour was found in the liver, and another at the apex of the left ventricle of the heart. The latter had burst, * For examples, see Bright, op. cit. p. 37; Budd, op. cit. p. 444 ; and Frerichs, op. cit. ii. p. 245. f Path. Trans, vol. ix. p. 290. + See cases recorded by Bright, op. cit. pp. 13, 23, and 30; Jones, Path. Trans, v. 298; Peacock, id. xv. 247; Gibb, id. xvi. 157. § Another case of an hydatid tumour of the spinal column pressing on the cord is recorded by Dr. Ogle, Path. Trans, p. xi. 299. || Path. Trans, x. p. 6. 72 ENLARGEMENTS OF THE LIVER, [lect. in. and discharged a loose hydatid into the cavity of the left ventricle. * The treatment of hydatid tumours of the liver may be considered under the following heads. 1. Their prophylaxis is based on a knowledge of their cause. Hydatid tumours in man are developed from the eggs of a tape-worm which enter the body from without. This tape-worm, the Tarnia echi- nococcus, the entire length of which does not exceed a quarter of an inch, inhabits the intestine of the dog and wolf, and is in no way connected with the pig, as is commonly believed to be the case. It has only four joints, and the ova are contained in the last, or proglottis, are voided with the faeces of the dog, and subsequently find their way into the human body with the food or drink. Arrived in the intestines, they are developed into embryos, which penetrate into the liver or other parts, in a way not yet satisfactorily ex- plained, and are there developed into hydatid tumours. But the ova of the Taenia echinococcus develop hy- datids in other animals than man, and especially in the sheep. The hydatids of human beings, as Dr. Thu- dichumf observes, most frequently accompany them * Path. Trans, xi. p. 71. See also Path. Trans, xv.p. 247. Cases of hydatid tumours of the heart, without any implication of the liver, are recorded by Habershon (Path. Trans, vi. p. 108), Budd (Path. Trans, x. p. 80), and Davaine, op. cit. p. 396. In Budd's case, an hydatid tumour at the apex of the heart had burst, and loose hydatids were found in the right ventricle and in the pulmonary artery. t Report on Parasitic Diseases in Quadrupeds used as Food, in Seventh Report of Med. Off. of Privy Council, London, 1865. uscT.ni. J HYDATID TUMOUR. 73 to their graves, or, at all events, they are not permitted to continue their dangerous existence, but the echino- cocci of sheep are again set free in the process of slaughtering, and are devoured by dogs, to be again developed into tape-worms. While then, man does not contribute to the multiplication and propagation of echinococci, his constant liability to the disease is kept up by the cycle of infection which subsists between dogs and sheep. It follows, therefore, that for the prophylaxis of hydatid tumours in man it is necessary:— a. To prevent dogs feeding on the offal of sheep, and other animals infested with hydatids. Dogs ought to be rigidly excluded from all slaughter- houses or knackeries, and ' dogs' meat' ought al- ways to be thoroughly boiled. b. To destroy, as far as possible, the tape-worms generated in the dog, for which purpose it would be well that all dogs were periodically physicked, and their excreta buried in the ground or burnt. These are measures which are of national importance in such countries as Iceland, where the sheep-dog, during the long nights of winter, occupies the crowded dwelling of his master, and where hydatids are the cause of one-seventh of the human mortality, and which merit attention even in our own country. 2. Medicines.—It must be confessed that little or no dependence can be placed on any medicinal agent for effecting a change in the size or in the structure of an hydatid tumour. Among the many remedies 74 ENLARGEMENTS OF THE LIVER, [lect. hi. that have been proposed, common salt and iodide of potassium are the two which have been most relied on for destroying-.the life of the hydatid, but there is no evidence that either the one or the other is en- dowed with such a property. It is difficult to con- ceive how chloride of sodium can be unfavourable to the growth of an hydatid, when it is remembered how large a quantity of this salt is contained in the fluid contents of the cyst, and that, therefore, it must be compatible with, if not necessary to, the healthy ex- istence of the parasite. And with regard to the preparations of iodine, there is not only no proof of their power to destroy the life of the parasite,* but there is positive evidence that the iodine does not reach it. Frerichs was unable to discover a trace of iodine in the fluid of an hydatid cyst, removed from a woman who had taken iodide of potassium for many weeks, and similar observations were made in Cases VI. VTI. and VIII. 3. Evacuation of the Fluid Contents of the Cyst by a * The following are references to instances in which iodide of potas- sium was thought to have effected the cure of an hydatid cyst:—Med. Times and Gaz. April 7, I860, p. 344, and Feb. 17, 1855; Lancet, Oct. 16, 1858. In one, at least, of the cases, the disappearance of the tumour appeared to be due to its having burst. The others may be viewed in connection with a case related by Dr. P. McGillivray, where an hydatid tumour, which it was intended to tap, disappeared spon- taneously, a few days after the patient's admission into hospital (Austral. Med. Journ. Aug. 1865). As Dr. M. remarks: 'If the patient had been getting iodide of potassium, common salt, or any other reputed specific, the medicine would, no doubt, have got the credit of the cure.' Certain it is that, in hundreds of cases, iodide of potassium has been taken in large quantities without producing the slightest change in the tumour. lect. in.] HYDATID TUMOUR. 75 fine Trocar and Canula, and Closure of the Opening.— Although medicines be of little or no avail, there is, happily, one expedient which holds out a fair chance of effecting a permanent cure, and that is puncture of the cyst and removal of its contents. It is now many years since hydatid tumours of the liver were tapped by Sir Benjamin Brodie, and the patients made a good recovery.* Successful cases were afterwards pub- lished by Dr. Bright,f and by many other observers. It is only of late years, however, that the operation has been often resorted to, and even still it is very doubtful if most practitioners would not prefer leaving the patient to the very uncertain chances of a spontaneous cure, or would limit the operation to cases where the tumour is of a size rarely attained. The fears expressed are not unnatural, for in not a few cases the operation has been followed by dan- gerous symptoms or even death. The dangers of the operation are mainly two; viz. 1. Acute peritonitis, owing to the escape of a portion of the hydatid fluid into the peritoneal sac; and, 2. Suppuration of the cyst, owing, in some degree, to the admission of air. These dangers have mainly arisen in cases where an opening has been made with a scalpel or a large trocar, on the mistaken supposition that it was neces- sary to remove the secondary cysts as well as the liquid, or because the tumour was thought to be an abscess. But the dangers in question may be in a great * Med.-Chir. Trans, vol. xviii. p. 119. + Op. cit. p. 42. 76 ENLARGEMENTS OF THE LIVER, [lect. hi. measure avoided by employing a very fine trocar. Experience has shown that the removal of the liquid, which is as thin and limpid as water, suffices to destroy both the parent hydatid and its offspring, and accordingly this is all that is necessary to be done. The administration of chloroform before the operation is not advisable, as the pain is but moment- ary, and the vomiting sometimes induced by the chlo- roform interferes with that perfect rest of the parts which ought always to be insisted on for forty-eight hours after the puncture; but if the patient be young or nervous, it may be well to induce local anaesthesia by the ether-spray. The point selected for puncture ought to be that where the hydatid fluid appears to approach nearest to the surface. The injection, after removal of the fluid, of such substances as alcohol, iodine, oil of male fern, or bile, is unneces- sary, and may be injurious, by exciting excessive inflammatory action. Care ought to be taken to prevent even the entrance of air, and for this purpose it is well to remove the canula before the whole of the fluid has been drawn off, or as soon as the fluid ceases to flow in a full stream, first passing a wire through the canula to ascertain whether the stoppage be due to the closure of its orifice by an hydatid vesicle. Dr. G. Budd * has further recommended, for the same object, that the fluid be drawn off by means of an exhausting syringe, adapted to the canula; but on one occasion (Case VI.) when I employed Dr. Budd's * Med. Times and Gaz. May 19, I860, p. 494, lect. in.] HYDATID TUMOUR. 77 apparatus, the patient experienced so much pain from the suction action of the syringe that I have pre- ferred the simpler precaution abave mentioned. After removal of the canula, the opening should be covered with a piece of lint steeped in collodion, over which a compress and bandage are applied, and for forty- eight hours the patient ought to be kept in the recumbent posture, and every movement of the body be strictly prohibited: it may be well also to give an opiate at once, and, if there be the slightest pain, this may be repeated after a few hours. One advantage of using a fine instrument is that it it unnecessary to wait for the formation of adhesions between the tumour and the abdominal wall, or to endeavour to induce them, before puncturing. The walls of the cyst are so elastic that the small opening closes immediately that the instrument is withdrawn, and prevents all subsequent oozing from the interior. If there be no adhesions, however, one precaution ought never to be neglected, viz. during the removal of the canula to press the punctured portion of the abdominal wall against the cyst. By neglecting to do this the abdominal wall will be pulled away from the cyst in the extraction of the canula, and the fluid in the canula may drop into the peritoneum. The patient often experiences immediate relief from the sensation of tension and other unpleasant symptoms, from which he may previously have suf- fered, and within three or four days he is up and walking about. Sometimes the operation is followed 78 ENLARGEItiENTS OF THE LIVER, [lect. hi. by a feeling of uneasiness in the tumour, or by con- siderable pain and constitutional disturbance; but if the above rules be attended to, these symptoms soon pass off, and the patient makes a good recovery. It not unfrequently happens, however, that about a week or ten days after the operation the tumour ap- pears again to enlarge. This enlargement is not due to a reaccumulation of the hydatid fluid, but to in- flammatory products thrown out, probably between the collapsed parasite and the surrounding hepatic tissue, which are slowly reabsorbed. Under these circumstances it is well not to be hastily tempted to have recourse a second time to paracentesis. A cer- tain degree of fulness may remain for many months, or even longer, in the site of the tumour, the existence of which has been cited as a proof that the operation has been unsuccessful. Tet inasmuch as the opera- tion does not profess to remove the parent and se- condary cysts, but only to kill the hydatid, and thereby avert those dangers which have been shown to result from its prolonged vitality, and induce that slow process of atrophy which sometimes occurs in- dependently of an operation, the fulness referred to is only what might be expected. If by the operation we can prevent the dangers likely to arise from an hydatid tumour, nothing more is necessary. The safety and efficiency of the operation now re- commended may be regarded as established. You have had many opportunities of satisfying yourselves on this matter in the cases under my care and that lect. in.] HYDATID TUMOUR. 79 of my colleagues, in this hospital, during the last few years. In addition to the three cases which I have now brought under your notice (Cases YI. VII. and Yin.), I would particularly direct your attention to two others which were under the care of Dr. Greenhow, and which are reported in the eighteenth volume of the ' Pathological Transactions,' p. 127 ; in one of these the quantity of fluid drawn off amounted to 110, and in the other to 148 fluid ounces; fifteen months after the operation in the former case, the patient was free from all signs or symptoms of the tumour. These and other similar cases which might be quoted afford the best answer to the objection that the operation is only effectual where the tumour is of small capacity. It is true that the operation, in killing the parasite, occasionally excites a certain amount of inflammation between it and the cavity of the liver in which it is embedded which may favour the supposition that the sac is refilling, but in most cases this, after a short time, spontaneously subsides, and it is only in exceptional cases that a second operation for the evacuation of pus becomes necessary. I have collected the par- ticulars of forty-six reported cases in which the operation was performed (see Table at page 118). In thirty-five of the cases the operation appears to have been perfectly successful: in ten cases it was followed by suppuration, necessitating a free opening; eight of these ten cases recovered, and two died, but in one of the fatal cases death is said to have resulted 80 ENLARGEMENTS OF THE LIVER, [lect. hi. 'not so much from the suppuration of the tapped cyst, as from the general prostration consequent upon the arrest of function of surrounding organs ' by the liver, which contained three other cysts, each holding a pint of fluid; and in the other it was occasioned by the bursting of the tumour into the lung after the establishment of a free external opening. In one case the patient died of peritonitis within twenty-four hours of the operation, but he was in a state of ex- treme prostration and emaciation before it was per- formed, and the propriety of having recourse to any operative procedure under the circumstances may be doubted. In estimating the results of the operation, those cases only of course ought to be taken into the calculation where it was resorted to as a curative measure, and those ought to be excluded where it was performed merely as a palliative, and where death was already inevitable. I have therefore ex- cluded from the Table (appended to this lecture) several such cases, and others where the operation was per- formed with a large trocar, where caustic was em- ployed to procure adhesions before puncturing, or where some irritating substance was injected after the withdrawal of the fluid, and also those where the hydatid had suppurated or been contaminated with bile before the operation. The operation here re- commended is only adapted for those cases where the fluid retains its natural limpid character, and the results of other operative procedures ought certainly not to be confounded with it. lect. hi.] HYDATID TUxMOUR. 81 A careful consideration, then, of the whole matter —of the dangers of the disease when left alone, and of the inutility of medicines on the one hand, and of the success hitherto obtained from the operation on the other, leads to the practical conclusion that, in all cases where an hydatid tumour is large enough to be recognized during life and is increasing in size, it is advisable to puncture it at once. If the tumour appear to be diminishing in size, it may be well to wait, but it is unnecessary to wait for the formation of adhesions, or to endeavour to induce them. An hydatid tumour is not prone to form adhesions over its outer surface, like an abscess. By the time that adhesions form hi the natural way, the tumour has attained a large size, and is probably eating its way into some of the adjoining cavities; the chances are increased of its becoming inflamed and converted into an abscess; its walls also are much less elastic than at an earlier stage, and a puncture through them will close up less readily, so that there is a greater risk of fluid escaping into the peritoneum after re- moval of the canula, if the adhesions be not sufficient to prevent it. While the walls are still elastic, the opening made by a fine trocar may be expected to close immediately that the instrument is withdrawn, and the existence of adhesions is therefore unnecessary. 4. Evacuation of the Contents of the Cyst by a large Permanent Opening.—In the case of Mrs. C. (Case IX.) you have had an opportunity of studying the dangers to which a person must be subjected who has a large G P2 ENLARGEMENTS OF THE LIVER, [lect. hi. suppurating or perhaps gangrenous hydatid of the liver communicating by a free opening with the ex- ternal atmosphere, and I have already pointed out to you that one-half of the cases where an external opening forms spontaneously are fatal. The dangers are mainly four : viz. a. Exhaustion from the pro- tracted discharge; b. Pyaemia and secondary inflam- mations ; c. Haemorrhage from the cavity in the liver ; d. Peritonitis. Of 62 cases of which I have collected the particulars, where an opening of this sort occurred spontaneously, or was made by caustic, by a large trocar, or by incision, 24 were fatal, and deducting those cases where the tumour had been previously punctured but had again closed, there remain 21 deaths to 22 recoveries. Many of those patients also, who ultimately recovered, endured a protracted and exhausting illness. When, however, the symptoms, or an exploratory puncture, show that the sac has undergone suppura- tion, a large permanent opening is the only justifiable mode of operating. The opening should be made with a large trocar, and a silver canula or india-rubber tube secured in the wound until the whole of the hydatid contents have come away. The cavity ought also to be washed out two or three times a day with an aqueous solution of carbolic acid (2 per cent.). Before operating in this way, it will always be necessary to ascertain the existence of adhesions, and, if necessary, to produce them by an incision over the tumour, plugged with lint, or by the application of lect. hi.] HYDATID TUMOUR. 83 caustic potash; or an opening may be made by suc- cessive applications of caustic potash, in the manner recommended by Recamier in cases of abscess.* The records of the following cases may serve to impress upon you more forcibly the symptoms and the dangers of hydatid tumours of the Hver, and their appropriate treatment. Case YI.—Hydatid Tumour of the Liver—Para- centesis—Recovery. You have had an opportunity of studying the clinical characters of hydatid tumour of the liver, which have now been described, in the case of John N----, aged 28, who wa9 admitted under my care on December 3, 1866. He was a clerk, and had been in the Crimea for fourteen months, in 1855 and 1856. His previous health had always been good. In September 1864 he had sore-throat and slight aching pain in his right side, and it was then discovered by Mr. Churton, of Erith, that he had a tumour in the epigastrium, which was almost as large then as when he came under your notice. After that he suffered no uneasiness in the tumour until February 1866, when it became the seat of occasional darting pains, and on this account he was a patient in this hospital, under my care, from March 31 to April 18, 1866. Excepting these pains, which were very transient, and unaccompanied by any ten- derness, the patient's general health was good, and he had not the slightest fever. On April 7, an attempt was made to empty the cyst by means of a small trocar and canula and an exhausting syringe, the puncture being made to the left of the middle line, where the tumour was most prominent. The action of the syringe, however, caused much pain in the back and faintness, and the opera- tion was abandoned after obtaining only four or five ounces of fluid, a quantity evidently much less than the tumour contained. Excepting an attack of urticaria, the operation was followed by no bad symptom. The patient was readmitted on December 3, partly on account of * Frerichs, Dis. of Liver, Syd. Soc. Ed. ii. p. 148. g2 84 ENLARGEMENTS OF THE LIVER, [lect. in. a return of the slight pain from which he had previously suffered, but mainly with the object of having what was probably a second cyst emptied. At the time of his readmission, the following note was taken of bis state :—' Patient has a healthy appearance, and his only complaint is of a prominent tumour in the epigastrium, extending into both hypochondria, and evidently connected with the liver. It fills up the space between the sternum and the umbilicus, and causes a slight bulging of the ribs on both sides, particularly on the right. Its lower margin is about one inch above the umbilicus. It measures about 6 inches transversely, and 5 inches from above downwards. The hepatic dulness is Fig. 11. Outline of Hepatic Duiness in the case of John N----, at the time of his admission into hospital, on December 3, 1866. a. hepatic dulness; b. tumour; c. spleen; d. heart. 6 inches in the mesial line, and 5 inches in the right mammary line; in the right axillary and dorsal lines it is normal. These dimensions exactly correspond with those noted when the patient left the hospital last April. The' upper margin of hepatic dulness is not more arched than natural. The tumour is globular, per- fectly smooth, and not at all tender. It is very elastic, distinctly fluctuates, and presents the character known as "hydatid vibration " in a marked degree. It does not appear to be adherent, as its lect. m.] HYDATID TUMOUR. 85 position varies with the respiratory movements. There is no jaundice, no ascites, no enlargement of the spleen, and no albumen in the urine. Tongue clean; bowels regular ; no vomiting or pain after food ; pulse 72.' On December 7, Mr. Moore introduced a fine trocar into the most prominent part of the tumour, to the right of the middle line, and drew off by the canula, without any syringe, twenty fluid ounces of fluid. This fluid was opalescent, colourless, and alkaline, with a specific gravity of 1009; it contained no albumen, but yielded a copious white precipitate with nitrate of silver; numerous booklets and several entire echinococci were discovered with the microscope. It is worthy of notice that, although the patient had been taking large doses of iodide of potassium for several days before both operations, on neither occasion did the fluid contain a trace of iodine. The operation was not followed by the slightest febrile excite- ment or unfavourable symptom of any sort. On December 12, the patient got up, and on the 18th he left the hospital apparently well, the tumour showing no tendency to enlarge, and the hepatic dulness in the right mammary line being only 3f inches. On March 18, 1867,1 again saw John N----, who informed me that four days after leaving he was attacked with typhus fever, which he had probably contracted in the hospital, and with which he was dangerously ill. At the commencement of the fever the tumour appeared to enlarge, but by the time of his convalescence the swelling had quite subsided again, and now not the slightest trace of it can be discovered, the vertical hepatic dulness in the median line being only three inches. March 9, 1868.—The patient presented himself at the hospital, and was examined by Dr. Thompson, Dr. Greenhow, Mr. Moore, and a large number of students, but no trace of a tumour could be discovered. Case YTI.—Hydatid Tumour of the Liver, threatening to burst—Paracentesis—Recovery. On August 3, 1864, Hannah S----, a very nervous woman, aged 31, consulted me about a tumour in the region of the liver. She was a cook in a medical man's family. In the summer of 1863 she had been laid up for three weeks with a pain across the stomach; but, with this exception, she had never suffered from any symptom of 86 ENLARGEMENTS OF THE LIVER, [lect. hi. abdominal disease until about nine weeks before she came to me. She was then seized suddenly with acute pain in the 'region of the liver, which lasted for about two hours. For several days she vomited after everything she ate, and she had great pain in her side when she attempted to cough or to turn in bed. She kept her bed for a week, and did not resume her work until after three weeks. The liver was then first observed to be enlarged and prominent, but the patient was unable to say whether this enlarge- ment had existed before the attack of pain or not. On examina- tion, there was found to be a slight bulging in the right hypochon- drium below the ribs, this bulging being apparently continuous above with the liver, extending to half an inch below the umbilicus, Fig. 12 represents the outline of Hepatic Dulness in the case of Hannah S----, in August 1864. «. tumour; b. spleen; c. heart. and, transversely, from one inch to the left of the mesial line to about 3£ inches to the right. The vertical hepatic dulness two inches within the right nipple was 7 inches, A\ inches of the dull space being below the edge of the ribs. The tumour was tense, but elastic and almost fluctuating. It was slightly tender on deep pressure. It did not appear to be adherent to the abdominal wall. Posteriorly, the hepatic dulness did not extend higher than usual lect. in.] HYDATID TUMOUR. 87 and its upper margin was horizontal. The respiratory sounds at the right base were normal. The patient was slightly sallow, but had no decided jaundice. The tongue was clean, the appetite good, and the bowels regular. There was no ascites and no anasarca; the urine contained neither albumen nor bile-pigment. Pulse 84. On August 7, the patient had a return of pain in the tumour, accompanied by vomiting and purging, lasting for two or three clays. For several days after this attack the tumour was tender, and over its surface coarse friction could be both heard and felt during the respiratory movements. On August 19, Hannah S----was admitted, under my care, into Middlesex Hospital, and placed on iodide of potassium, five grains three times a day. On August 24, the tumour was noted as more tense and tender. On the night of September 2, the patient had an attack of acute pain in right side, greatly increased by pressure, movement, or a long inspiration, and accompanied by much nausea, but by no vomiting or rigors. Pulse 96. Under the use of opium, poultices, and rest, these symptoms gradually subsided, but the tumour continued tender, the friction was again distinguishable for several days, and the pulse did not fall below 96. On September 9, the patient had another similar attack of pain, but more severe; the pulse rose to 116, and the friction returned. On September 14, the pain was less, but the tumour was observed to extend more to the right side, and was less rounded. On September 17, there was another severe attack of pain ; and indeed, since August 24, the tumour had never been free from tenderness, while the patient felt herself gradually getting weaker, the pulse being rarely below 108. Although there was no evidence of firm adhesions over the tumour, it was now determined to puncture it. From the first, the tumour had been diagnosed as an hydatid, and indeed the object of the patient's admission into hospital was to have it punctured. All who examined it were agreed that it contained fluid, and the only other affections at all likely to produce the appearances observed were a distended gall-bladder and an abscess of the liver. The tumour did not occupy quite the situation, and latterly did not- present the shape of a distended gall-bladder, and there had never been jaundice. The persistent pain and tenderness noted for several weeks pointed rather to abscess, but there had been no rigors or perspirations, and, moreover, the tumour had not increased 88 ENLARGEMENTS OF THE LIVER, [lect. hi. much in size since it had been first observed. Supposing the tumour to be hydatid, there was reason to fear that it was about to burst. On September 20, my colleague, Mr. Hulke, tapped the tumour with a fine trocar, the canula of which was scarcely so large as a No. 1 catheter, and drew off about twelve fluid ounces of clear limpid fluid, the specific gravity of which was 1009. No echino- cocci or hooklets could be discovered in it, but it was found to contain a large amount of chloride of spdium and no albumen. It did not contain a trace of any salt of iodine, although iodide of potassium had been taken almost continuously for several weeks. In removing the canula, the abdominal parietes were pressed down against the tumour, and the puncture was afterwards covered with collodion and a pad. The patient was kept on her back for forty-eight hours, and not permitted to move. Twenty drops of laudanum were administered immediately after the operation, and for two days an opiate was given about once in four or six hours. The night after the operation, the patient slept well. On the following day, the urine was retained, and was drawn off by catheter; and on September 22, the abdomen was distended and tympanitic, the skin hot and dry (temperature 101°), the pulse 120, and there was much thirst. Still there was much less pain and tenderness over the tumour than before the operation. The bowels had not been open for two days. An enema of turpentine and confection of rue brought away a large quantity of flatus, and the patient at once began to improve. On September 26, the pulse was 96, the tongue clean and moist, and the appetite was returning. For the first time for several weeks, the patient could tolerate free manipulation of the tumour, the dimensions of which were much reduced. On September 27, pulse 84; the collodion was removed from the wound, from which not a drop of discharge had escaped. On September 30, the patient was able to get up. Convalescence was retarded by an attack of facial rheumatism and other trifling ailments; but, on November 22, the patient was able to leave the hospital. The dimensions of the tumour were gradually diminish- ing, so that the dulness from the upper margin of the liver to the lower margin of the tumour did not exceed 5f inches. The tumour also was quite soft and free from tension, and could be manipulated without causing pain. The tongue was clean and moist; the appe- tite and digestion good. Pulse 100. lect. in.] HYDATID TUMOUR. 89 June 1867.—Nearly three years have now elapsed since the operation, and during the most of that time the patient has been able to follow her occupation as a cook, subject only to flatulence and other symptoms of dyspepsia and hysteria. Only a slight fulness is now perceptible in the epigastrium. March 1868.—The patient writes that she is quite well, and is about to be married. Case VIII.—Hydatid Tumour of Liver—Puncture with fine Trocar—Recovery. Elizabeth C----, aged 6, was admitted into the Middlesex Hospital under my care on December 3, 1867. With the exception of hooping-cough at the age of 3, she had always enjoyed excellent health ; but her mother, almost since she was an infant, had noticed that she was larger about the waist than natural. Three months before, the girl had been seen by Miss Garrett, L.S. A., who diagnosed an hydatid tumour of the liver. Since then the mother thinks that the tumour has been increasing, but the only uneasiness the child has experienced has been an occasional feeling of sickness, a morning cough, and slight pain in the region of the liver. On admission, the patient was a robust, healthy-looking child, who seemed to have nothing amiss with her, with the exception of a swelling in the epigastrium, extending vertically from the lower end of the sternum to the umbilicus, and 2^ inches laterally to either side of the median line. The tumour was globular, smooth, painless on manipulation, and with distinct fluctuation, and 'hydatid vibration.' It was quite movable over the subjacent parts, and did not appear to be adherent to the abdominal parietes, as it descended readily with inspiration. Although evidently connected with the liver, the area of hepatic dulness was not generally increased, its extent in the right mammary line measur- ing only 2£ inches. The girth of the abdomen over the tumour was as follows:— Dec. 3 243 Dec. 20 23-3 Jan.16 24-5 Jan. 24 22-75 March 9 22-5 24-5 235 235 23-75 23-5 At umbilicus At ensiform cartilage Half-way between um-' bilicus and ensiform cartilage The patient's tongue was clean, her appetite good, and her bowels regular. There was neither ascites nor jaundice. Pulse 96. 25-75 24-66 25-25 24 22*5 90 ENLARGEMENTS OF THE LIVER, [lect. hi. She was ordered a draught containing two grains of iodide of potassium three times a day. On December 10, Mr. Hulke punctured the tumour with a fine trocar, and drew off fourteen fluid ounces of fluid. This was colourless, slightly opalescent, with a specific gravity of ^010, and contained no albumen, but a large quantity of chlorides; neither echinococci, nor hooklets, nor any trace of iodine could be detected in it. Two hours after the operation the patient was sitting up in bed laughing and talking as if nothing had happened. During the following night, however, she had several attacks of vomiting (which was, perhaps, the effect of the chloroform that had been administered), and for two days the pulse rose to 140, and the temperature was as high as 100o-8, but there was no tenderness of the abdomen, nor thoraic breathing. On December 13, the temperature and pulse were again normal, and after this the patient had no bad symptom, except that from December 20 till January 14 the tumour appeared to increase again slowly in size, so that the question of performing paracentesis a second time was entertained. This, however, was abandoned, as the tumour began to diminish spontaneously, as will appear from the table of measurements. On March 9, there was no perceptible bulging, and scarcely any tumour to be felt. In the following case, which you must all have watched with much interest, we were enabled to diagnose during the patient's life that a communica- tion had been established between the tumour and the common bile-duct. The fact that the tumour had undergone suppuration contraindicated the ordi- nary operation, and compelled us to substitute a large permanent opening. Case IX.—Hydatid Tumour of Liver, opening into the common Bile-duct.—Jaundice and Suppura- tion of the Cyst—Puncture with a large Trocar, and Permanent Opening—Pneumonia—Death. On February 4, 1868, I was requested by Mr. Ayling, of Great Portland Street, to see Mrs. C----, aged 30, who was suffering lect. hi.] HYDATID TUMOUR. 91 from jaundice and enlargement of the liver. Her mother stated, that ever since she had been fourteen there had been a fulntss in the epigastrium and left hypochondrium, but that, with the excep- tion of occasional pain after food and other symptoms of indiges- tion, she had enjoyed good health until her present illness. She had been married for eleven years, and during that period the catamenia had been regular, and she had had no children or mis- carriages. Eighteen days before I saw her, she had been suddenly seized with severe pain in the back and upper part of the abdo- men, which almost bent her double. This was relieved by warm poultices, &c, but was soon followed by pyrexia, and four days later by jaundice, which soon became intense, with dark porter- coloured urine, and a complete absence of bile from the motions. The fever continued; the swelling in the epigastrium and left hypochondrium was observed to increase, and the patient was so prostrate, that some days before I saw her she was thought to be sinking; but she had no vomiting, rigors, or night-sweats. I found the patient much emaciated, and with deep jaundice of the conjunct! vse and whole surface of the body. There was a distinct tumour in the epigastrium, extending apparently into both hypochondria. It projected forwards fully 1| inch beyond the natural level, and pushed forward the lower end of the sternum, and the lower ribs on both sides, but particularly on the left. When the patient lay on her back, the lower margin of the tumour was 1 inch above the umbilicus. The tumour was evi- dently connected with the liver, the dulness of which in the mesial line was 9 inches, in the right mammary line 5 inches, and in the left 6 inches. Posteriorly and laterally the hepatic dulness did not rise higher than natural on the right side, but on the left, pos- teriorly, it was fully 2 inches higher than on the right, and the dul- ness in the left axillary line was 9 inches. The tumour, where it presented itself at the epigastrium, was rounded, smooth, and slightly tender. Distinct fluctuation could be felt in it, and a thrill, as from fluid, could be made out in the epigastrium when percussion was made over the dull part at the back of the left side of the chest. The tongue was very red and clean, with enlarged papilla? at the tip, and the centre smooth and deeply fissured. The motions were clay-coloured, without a trace of bile-pigment. Pulse 108. Apex of heart elevated by tumour to between fourth and fifth ribs. Respirations 28, and slightly embarrassed, but pulmonary signs normal. Temperature 100°-6. Urine 1027, 92 ENLARGEMENTS OF THE LIVER, [lect. hi. containing both bile-pigment and bile-acids (Harley's test), but no albumen. The fact that the tumour contained fluid, and had probably existed for years without giving rise to symptoms, indicated hy- datid ; the acute pain, followed by jaundice, with disappearance of bile from the stools, made it probable that this hydatid had com- municated with and obstructed the main bile-duct; while the enlargement of the tumour, with fever and great prostration, was accounted for by inflammation of the tumour, consequent on the entrance of bile. This was the diagnosis. On the following day the patient was admitted, under my care, into the Middlesex Hospital, and as her condition became daily more critical, it was determined to have recourse to puncture of the tumour, as holding out the only chance of safety. Accord- ingly, on February 7, a fine trocar was introduced by Hulke in the left side of the epigastrium, and about six ounces of fluid drawn off. This was deeply tinged with bile and very fetid, and contained numerous pus corpuscles and scales of cholesterine, but no hooklets or echinococci. On ascertaining the nature of the fluid, the small canula was withdrawn, and a full-sized trocar substituted. Several hydatid vesicles escaped through the larger tube, but only about eight ounces more of fluid, although a probe could be passed in 6 or 8 inches. It appeared, therefore, that the contents of the cyst consisted mainly of hydatid vesicles. A solution of carbolic acid (2 per cent.) was injected into the cavity, and a large tube was tied into the wound. During the ten days that followed the operation, several pints of the carbolic acid solution were injected three times a day through an elastic catheter passed into the cavity, and on each occasion large numbers of hydatid vesicles (with hooklets and echinococci in some) came away, with a fetid, purulent fluid, containing a large quantity of green bile. While this was going on, the abdomen returned to almost its normal dimensions, and the jaundice in a great measure disappeared from the integuments and urine, but the motions remained as light as before. The patient had repeated doses of morphia after the operation, and for four days the pulse was about 108, the temperature was normal, and there was no very bad symptom, except the develop- ment on the tongue, and inside of the mouth of numerous aphthous ulcers on a raised base, which caused excruciating pain whenever she took food or drinks; but both the pain and the ulcers almost lect. in.] HYDATID TUMOUR. 93 entirely disappeared from repeatedly washing out the mouth with Condy's ' ozonized water.' During the night of February 11, the patient suffered from repeated rigors, and after this the pulse rose to 132 or 140, the respirations became quick, and the tongue dry ; there was occasional vomiting, and the prostration rapidly in- creased. On the morning of the 18th delirium set in, and at 6 P.M. she died. On opening the abdomen, the peritoneum contained no fluid, and there was no sign of recent peritonitis, but there were firm adhesions between the tumour and diaphragm and the abdo- minal parietes in front. The left lobe of the liver had disappeared, and its place was occupied by an enormous hydatid cyst. This cyst contained about two pints of very fetid thick green fluid, with large fragments of the parent hydatid cyst lying loose in the cavity. It opened externally through the wound in the abdominal wall, while internally it communicated with the common bile-duct by an opening large enough to admit a full-sized catheter. On slitting open the duodenum, the orifice of the duct was found sufficiently dilated to admit a goose quill, but obstructed by a large hydatid cyst, partially protruded into the duodenum. Be- tween this and the opening into the cyst, the duct was distended with hydatid vesicles. The bile-ducts throughout the liver were greatly dilated and the liver itself was very fatty and intensely jaundiced, with a tight-lace prolongation downwards of the right lobe. There was no trace of bile-pigment in the intestinal con- tents. The spleen was adherent to the tumour, but otherwise normal; kidneys healthy. There was recent pneumonia, at some places passing into the condition of grey hepatization, of the back of the lower lobe of both lungs and of the upper lobe of the right. The following case resembles in some respects that last recorded. It is remarkable no less for the fact that the patient recovered after discharging the contents of a large hydatid of the liver through the bile-duct into the bowel, than for the extraordinary manner in which death ultimately occurred (see page 69). 04 ENLARGEMENTS OF THE LIVER, [lect. in. Case X.—Hydatid Tumour of the Liver, bursting into the Bile-duct—Jaundice—Discharge of innumerable Hydatid Membranes per Anum—Recovery—Attacks of Biliary Colic from passage of Cysts remaining in Liver through the Bile-duct—Rupture of old Ad- hesions of Liver during act of Vomiting—Peritonitis —Death. On October 29,1861,1 was consulted by Mr. G. W----, a solicitor, aged 53. For some weeks he had been suffering from flatulence and a feeling of tightness and oppression after meals, and three days before he had been attacked with severe pains in the abdomen, resembling colic. The countenance was somewhat sallow; the motions were pale, but contained bile : there was no bile in the urine, which was scanty and dark, having a specific gravity of 1027, and depositing much lithic acid. The vertical hepatic dulness in the right mammary line extended about an inch below the edge of the ribs, and all along the right hypochondrium there was slight tenderness on pressure. Pulse 64. His digestion had always been good, except once, about seven years before, when he had several attacks of colicky pain in the abdomen, similar to those from which he had recently suffered. The medicines prescribed by myself, and afterwards by Sir Thomas Watson, who met me in consultation, failed to give any relief. On November 24, the patient had an attack of vomiting, followed by an aggravation of the dyspeptic symptoms, and by increased tenderness in the right hypochondrium. On December 6, he was much worse. The tenderness in the right side had increased greatly, and there was also constant pain there, which became veiy acute when he took a long breath or coughed. The tongue was furred and moist. The bowels were very costive, and there was considerable tympanitic distension of the abdomen and increased sallowness, but no sickness. The pulse had risen to 88, and the respirations were 30, and thoracic. Fifteen leeches were applied to the seat of pain ; twelve more on December 8, and eight more on December 10, with poultices in the intervals, and the bowels were kept open by castor-oil and turpentine enemata. On December 12, the pain was much less, but there was still lect. m.] HYDATID TUMOUR. 95 considerable tenderness and a stitch in the right side on taking a breath or coughing. The countenance was very sallow, but there was no decided yellowness of the conjunctivae, and the motions, though pale, contained bile. The vertical hepatic dulness in the right mammary line was 5 inches. Nothing like a .defined tumour could be felt, and there was no bulging of the ribs. The breathing at the base of the right lung was normal. Pulse 88.* On December 16 and 17, the patient passed, for the first time, several hydatid cysts in a bilious motion. On December 18, he was much worse. There was decided jaundice of the integuments; the urine was loaded with bile- pigment, and there was not a trace of bile or of hydatid membranes in the motions. There was a constant pain in the right side, in addition to occasional paroxysms, like colic; lips parched ; tongue furred; much perspiration in the night, and great prostration. Pulse 100. The treatment consisted in the constant application of poultices to the side, and in the administration of quinine, and of blue pill and opium. December 19.—Is much easier. Has passed innumerable hydatid vesicles, from a pin's head to an orange in size, per anum. Skin and urine still jaundiced, and no bile in stools. 20.—Fasces to-day are tinged with bile, and still contain numerous hydatid cysts. 21.—Jaundice almost gone. Motions still contain hydatids and abundance of bile. Below and to the left of the right nipple, there is tympanitic percussion over a space the size of a crown- piece. Both above and below this there is hepatic dulness. Pulse 88 ; pain much less; tongue cleaning. The patient continued to pass a few hydatid vesicles with each motion up to December 31, and the tympanitic percussion sound above noted remained a few days later than this. He had occa- sional sharp but temporary attacks of pain in the abdomen, re- sembling colic. On January 6, 1862, he was quite convalescent. Pulse 72. The tympanitic sound noted above could no longer be distinguished, and the upper border of hepatic dulness was an inch lower than before. At the end of January, Mr. W----was able to drive out; and on February 19, he went to Ventnor for change of air, returning to London on March 11. * From this date until January 25, I attended Mr. W----in conjunc- tion with Mr. E. Lavies, of Upper Gower Street. 96 ENLARGEMENTS OF THE LIVER, [lect. in. Once, while at Ventnor, he had a severe attack of colicky pain, lasting for an hour and a half, and ' bending him up double.' He had a similar attack, but less severe, a few days after his return to London. Both attacks were unaccompanied by vomiting. Every day he gained strength, and on his return to town he was able to resume his business. On April 2, he went down to Essex on business. He walked about the country several miles every day, feeling none the worse, and returned to town on April 6. On April 8, he went to his business as usual, and walked several miles. Shortly after dinner, about 7 p.m., he was suddenly seized with severe pain in the abdomen, which returned in paroxysms, and this time was accompanied by vomiting. There was slight tenderness at the epigastrium, but no jaundice. The pulse was only 84. Repeated doses of opium and chloric ether were pre- scribed, and poultices were kept constantly applied over the ab- domen. On the following day, the paroxysms of pain had ceased, but there was more tenderness at the epigastrium and in the right hypochondrium, and considerable pain when he coughed or moved. The vomiting had not quite ceased. There was slight sallowness, but the stools contained bile. Pulse 86. Ten leeches were ordered to be applied to the side, and the poultices and opiates were to be continued. The patient did not apply the leeches, as he felt better. In the afternoon, he had two severe attacks of rigors, after which he felt so much better and free from pain that he thought it unnecessary to send for me. On the morning of April 10, he said that he felt so much better that he had eaten a good breakfast, and wished to get up and go down stairs; but he was in a state of extreme prostration, and evidently sinking. The pulse was 120 at the elbows, and im- perceptible at the wrists. The sickness had ceased, but the features were pinched, and the skin was cold and covered with clammy sweat. He gradually sank, and died at 8 p.m. Autopsy.—The abdomeu only was examined. On opening this cavity the intestines appeared healthy, but distended with gas. There was no exudation or increased vascularity in the general cavity of the peritoneum. The large intestines contained a quantity of pulpy material of the colour of cream, and without any tinge of bile. The small intestines contained bile. The left lobe of the liver was healthy and non-adherent. Both lect. in.] HYDATID TUMOUR. 97 the upper and under surfaces of the right lobe were connected to the adjoining parts by firm adhesions. Near the right edge of the liver a few of the bands of adhesion fastening it to the ribs appeared to be ruptured, and at this point there was a patch of recent lymph not larger than a square inch, with slightly increased vascularity round about. In the substance of the right lobe was an irregularly-shaped, collapsed cavity, the size of a large orange. The walls of this cavity were partly formed by the ribs and the surrounding adhesions. The inner surface of the cavity consisted of indurated hepatic tissue, presenting a shreddy appearance, and was not lined by any hydatid membrane. The cavity was almost empty; but it contained four or five collapsed hydatid vesicles about the size of a shilling. Communicating with it was a greatly dilated bile-duct, passing directly on to the common duct. The entire duct, from the cavity to the orifice in the duodenum, was large enough to admit the tip of the little finger. Further back in the right lobe, and quite distinct from the cavity now described, was another, about the size of a plum, which was lined by an obsolete and cribriform hydatid cyst, presenting a tough, opaque yellow appearance. The contents of this cavity had escaped during the hurried division of the liver. (This tumour was probably the source of the symptoms from which the patient had suffered seven years before his death.) Case XI. appeared to be an example of an hydatid tumour of the liver, which had suppurated and be- come converted into an abscess in consequence of the entrance of bile. Considering the patient's con- dition before the operation, it is not probable that this contributed in any way to the fatal result. Case XI.—Hydatid Cyst of Liver—Entrance of Bile- Inflammation—Paracentesis—Death. This patient was under the care of Mr. Moreton, of Tarvin, an- Dr. Dobie, of Chester, by whom the fluid removed from the cys; was sent to me for examination. Joseph B----, aged 58, a publican and huckster, had led rather an intemperate life. For three years he had often suffered from H 98 ENLARGEMENTS OF THE LIVER, [lect. hi. attacks of vomiting and pain in the stomach, but he never had jaundice. On October 29, 1864, he was seized suddenly with severe pain in the stomach, greatly increased at intervals, and accompanied by tenderness on pressure, and incessant vomiting of glairy mucus. Calomel and opium were given in full doses, and warm fomentations applied. Next day the symptoms were much relieved, and for a fortnight the patient seemed to be improving. At the end of this time, the pain and tenderness of the abdomen had almost left him, and the vomiting had quite ceased ; but the tongue remained coated, the appetite was bad, and the motions unnatural. On November 14, hiccup set in, which gradually became incessant, and about the same time the left lobe of the liver was noticed to become gradually enlarged. Ten days later there was unmistakable fluctuation over a space three inches in diameter, situated in the median line, two inches above the um- bilicus. The man's condition became worse; incessant vomiting was substituted for the hiccup, and aphthae formed on the tongue and cheeks, but there was no jaundice, and the motions always contained bile. On November 23, he had some shivering sensa- tions, but at no time distinct rigors. On December 1, a small trocar was introduced in the median line, two inches above the umbilicus, and about 1| pint of fluid was drawn off; and on December 6, a still larger quantity was removed. The patient, however, experienced no relief. He gra- dually sank, and died on December 10. The fluid removed on December 1, after standing, consisted of (1) a clear, slightly yellowish, supernatant liquid, containing a mere trace of albumen, but a large quantity of chloride of sodium ; and (2) of a copious yellowish-brown sediment, containing choles- terine and bile-pigment, but no pus. The fluid removed on December 6 was of the consistence of thin pus, and of the colour of turmeric; and it contained -numerous pus-corpuscles. No deposit or change occurred on standing. No echinococci or hooklets could be discovered in either specimen. No post-mortem examination of the body was permitted; but notwithstanding the absence of echinococci, the characters of the fluid removed on December 1 left little doubt in my mind that the tumour was an hydatid, which had become inflamed from the entrance of bile. lect. in.] HYDATID TUMOUR. 99 In Case XII. the hydatid tumour not only sup- purated, but induced pyaemia, with secondary deposits of pus throughout the liver. Case XII.—Suppurating Hydatid Tumour of Liver— Pywmia, with Secondary Deposits of Pus. Thomas B----, aged 35, was admitted into the London Fever Hospital on January 20, 1866. He had lived for twenty years in Tasmania ; but for the last four years in England. His previous health had always been good. His illness commenced five weeks before admission with severe pain in the right side, followed three weeks later by jaundice and diarrhoea. When seized with the pain, he first noticed a swelling in the right side; but this was as large then as at the time of admission. The patient was emaciated and jaundiced, and the liver was much enlarged, the vertical dulness in the right mammary line being eight inches. The por- tion of the hver projecting below the right ribs was smooth, painless, elastic, and almost fluctuating, but yielded nothing like ' hydatid vibration.' There was a moderate amount of ascites. Pulse 96 ; tongue moist and red; no appetite ; six or seven liquid stools daily, containing little or no bile. Considerable sweating at night. Three or four days after admission, irregular attacks of rigors set in; the diarrhoea continued; the emaciation and per- spirations increased; the tongue became dry and brown; and on February 22, the patient died. On two occasions (January 31 and February 7) an exploratory puncture was made into the tumour. On the first occasion nothing came away, owing to the trocar being too short; on the second occasion about six ounces of- thin purulent bilious fluid was drawn off, which, unfortunately, was not sub- mitted to microscopic examination. No bad consequence appeared to follow either operation. At the autopsy an hydatid cyst, as large as a child's head, and full of pus and secondary hydatids, was found projecting from the under surface of the liver, and compressing the portal vein and bile-ducts. The liver was studded with numerous small abscesses, and its outer surface was coated with recent lymph. Traces of the punctures were discovered with difficulty, and there was no evidence of increased inflammatory action in their neighbourhood. h2 100 ENLARGEMENTS OF THE LIVER, [lect. hi. In the following case the suppuration of an hydatid appears to have induced pyaemia, with secondary gangrenous abscesses in the liver. The anatomical characters of the liver agreed with those of ' Gangrene of the Liver' as described by Bokitansky.* The dis- ease, however, is so rare that experienced observers have denied its occurrence, and Frerichs makes no mention of it. Even Eokitansky had met with only one example, and there it was associated with pul- monary gangrene. Budd reports one case, and quotes another from Andral.f Considering the rarity of such cases, the remarkably fetid odour observed during life is of considerable clinical interest. Case XIII.—Suppurating Hydatid—Pyaemia, with Secondary Gangrenous Abscesses in the Liver. A man, aged 27, was admitted into the London Fever Hospital under my care on February 23,1867. He was so prostrate that he could give little account of himself, and all that could be ascer- tained was that he had been a soldier in the West Indies for about seven years, but that his health had been good until about a month before admission, when he was seized with pain in the epi- gastrium and right hypochondrium, with nausea and vomiting, and about the same time he first noticed a tumour below the right ribs, the pain in which made it difficult for him to button his tunic over it. On admission he lay on his back, with his legs drawn up; the abdomen was full and tender all over; friction could be heard distinctly over the liver, which appeared large, extending down- wards to the crest of the ilium, and upwards to the lower border of the third rib. The tongue was dry and brown, and there was frequent vomiting; but there was no jaundice, and the bowels were stated to be regular. The splenic dulness was increased; the pulse * Path. Anat. Syd. Soc. Trans, vol. ii. p. 136. f Budd, Op. cit. 3rd ed. p. 129. lect. hi.] HYDATID TUMOUR. 101 was 132 and feeble; the heart's sounds were normal; the respira- tions were quick and thoracic; there was dulness on percussion over the back of the right lung, and moist sounds were heard over the greater part of both lungs. The skin was hot, the face pale, and the features pinched. On the following morning the prostration had increased, and, in addition, there was noted slight jaundice of the conjunctivae, and a peculiar, very fetid odour—sui generis, which appeared to proceed from the entire body, and not from the breath in particular. This was noted in the case-book before the patient's death, which took place on the same day. On post-mortem examination, which was made on the day after death, there was found to be considerable evidence of recent perito- nitis, particularly in the neighbourhood of the liver. Projecting from the under surface of the right lobe of the liver, and but slightly embedded in it, was an hydatid cyst, larger than a cocoa-nut. The wall of the parasite was opaque, tough, and cribriform, from the presence of numerous large openings, and its interior was filled with dirty brown purulent fluid, having a very offensive odour. The entire liver was studded with numerous softened masses from the size of a nut up to that of a small orange, in which the hepatic tissue was softened, and consisted of a spongy material, corre- sponding to the fibrous stroma and vessels, saturated with a greenish, extremely fetid pulpy fluid. Embedded in the substance of the liver, near the anterior edge of the right lobe, was a healthy hydatid cyst, about the size of a chestnut, containing clear fluid and echinococci. The lungs were congested, but were nowhere in- flamed or gangrenous. In the following case the hydatid tumour was so large as to almost fill the abdominal cavity, and bile had entered the cyst. The real nature of the case was not recognized during the patient's life, and paracentesis was resorted to merely as a palliative to relieve the patient's extreme distress, and with no idea of effecting a cure. 102 ENLARGEMENTS OF THE LIVER, [lect. hi. Case XIV.—Enormous Hydatid Cyst of the Liver, passing down through the Foramen of Winslow, and filling almost the whole of the Abdominal Cavity— Paracentesis—Pleurisy—Turbercle of Lungs—Death from Exhaustion. Elizabeth C----, aged 15, was admitted into the Middlesex Hospital, under Dr. Greenhow, August 26, 1862. She had been a very healthy infant, but at the age of 3 she had a severe fall on her right side, and since then she had never been well. For nine or ten years a swelling had been observed in the right side of the abdomen. Three years before she had been a patient in a London Hospital, but she had left on account of some operation having been proposed. The tumour increased gradually in size without causing pain, while at the same time the patient herself became thin and weak. Four weeks before admission she had been attacked with scarlatina, and during convalescence or for the last few days before admission, a very rapid increase had taken place in the size of the tumour, and there had been occasional pains in the abdomen. At the time of admission, the face and extremities were greatly emaciated ; the countenance had a haggard, anxious expression, and the conjunctivae were slightly tinged with yellow. The whole abdomen was enormously enlarged, and yielded distinct fluctuation ; but the remarkable fact was that there was resonance on percussion in both flanks, as well as in the epigastric and both hypochondriac regions. The patient suffered from attacks of dyspnoea and of severe pain in the abdomen. Pulse 100, and feeble; no abnormal sound with heart; respirations hurried and thoracic ; appetite good; bowels regular; urine very scanty and loaded with bile. On September 3, the abdominal pain and dyspnoea had become so distressing that the operation of paracentesis abdominis was per- formed as a palliative measure, and 248 ounces of a dirty brownish fluid were drawn off. The fluid was, unfortunately, not submitted to the microscope or to chemical reagents. The immediate effect of the operation was great relief to the pain and dyspnoea; but within three days the swelling was observed to be rapidly increasing, and on September 26 its dimensions were larger than before the operation, although the dyspnoea was not nearly so urgent. On the following day, the patient died from exhaustion. Autopsy.—On dividing the abdominal parietes, about fourteen lect. in.] HYDATID TUMOUR. 103 pints of straw-coloured serum escaped. The g-reater part of the abdominal cavity, as far down as the pubes, was lined with a closely adherent gelatinous membrane, forming part of an enormous hydatid cyst, by which the stomach and intestines were pressed up closely against the under surface of the diaphragm and liver, where they were matted together, their peritoneal surface being considerably injected. Floating in the fluid, in the large abdominal cyst, was a secondary cyst containing about a pint of fluid and what appeared to be the dehris of other cysts. Several cysts of smaller size were likewise found in the cavity of the large sac. On tracing the large primary cyst, it was seen to be continuous with a cyst about the size of a child's head projecting from, and attached to, the under surface of the liver. The two cavities, in fact, con- stituted one cyst, with an hour-glass constriction, the channel of commimication being large enough to admit three fingers, and apparently corresponding to the foramen of Winslow. The gall- bladder was compressed, empty, and atrophied. Attached to the anterior border of the left lobe of the hver, by a thin fibrous peduncle, was another tumour about the size of a goose's egg, which, on being opened, was found to contain a crumpled-up hydatid cyst, filled with a putty-like material, in which were numerous hooklets of echinococci. A third tumour was found attached to the upper surface of the right lobe of the liver, and firmly adherent to the under surface of the diaphragm, which was pressed up into the cavity of the right pleura. This tumour was lined with a cyst, containing about a pint of straw-coloured serum, and the inner surface of which was studded with echinococci. The right pleural cavity contained about a pint of semi-purulent fluid, and the opposed surfaces of the pleura, at the base of the right lung, were coated with a deposit of recent semi-organized lymph. Both pleural cavities were much diminished in calibre by the elevation of the diaphragm, and both lungs contained a considerable amount of scattered miliary tubercles. The heart was small, but, in other respects, normal. The spleen was pale and shrunken. The kidneys were large and congested. In the next three cases an hydatid of the liver proved fatal by opening into the pleura or lung. The first case, which occurred while I was patho- logist to the hospital, illustrates the absence of all 104 ENLARGEMENTS OF THE LIVER, [lect. hi. symptoms in a large hydatid tumour of the liver prior to its bursting into the pleura, and also the difficulty in diagnosis likely to arise from the co- existence of empyema with hydatid enlargement of the liver. Case XV.—Hydatid Tumour of the Liver, bursting into the Right Pleura—Empyena—Death. Louisa R----, aged 17, was admitted into the Middlesex Hos- pital, under Dr. H. Thompson, March 23, 1861. She was a servant, and until a fortnight before she had continued at her work, enjoy- ing good health, and not suffering any pain or uneasiness. She was then suddenly seized with acute pain in the upper part of the abdomen and on both sides of the chest, which was increased by inspiration, and was accompanied by cough, dyspnoea, febrile symptoms, and great prostration. On admission, pulse 112, small and weak. Slight cough. Dulness and absence of breathing over whole of right side of chest, except in infra-clavicular space. There was likewise dulness, with feeble breathing, at the base of the left lung. The hepatic dulness in the right mammary line extended nearly four inches below the margin of the ribs. There was no jaundice and no ascites, but the urine contained albumen. Hectic fever, with great prostration, set in, and death occurred on April 8, one month after the first symptom of illness. Autopsy.—The heart was normal. The left lung was firmly and universally adherent: its lower lobe was hyperaemic, and near the base its tissue sank in water; but it was not granular on section, and it was unusually firm and tenacious. The right pleural cavity was filled with pus, floating in which were innumerable hydatid vesicles, from the size of a pin's head to that of an orange. The right lung was completely collapsed and carnified, except at the apex, which contained a little air. The liver was much depressed, its lower margin reaching to more than half-way between the umbilicus and the pubes. Projecting from the posterior margin of the right lobe was a cyst, as large as a child's head, which was firmly connected to the diaphragm; the liver was not adherent at any other part of its surface. At the upper part of the cyst there was a rupture through the diaphragm, measuring one inch and a- lect. hi.] HYDATID TUMOUR. 105 half in diameter, by which the cyst communicated with the right pleura. The interior of the cyst was lined with an hydatid mem- brane ; its cavity was filled with pus and vesicles. A large num- ber of the vesicles were examined with the microscope, but no echinococcus or hooklet could be discovered. There was no other hydatid tumour either in the liver or in any organ of the body. The pelvis and calices of the right kidney and the upper part of the right ureter were dilated, apparently owing to the pressure below of the displaced liver; the secreting tissue of the right kidney was much atrophied ; the left kidney was normal. Case XVI.—Hydatid Tumour of the Liver, opening into the Right Pleura—Empyema—Pericarditis. George K----, aged 54, a gardener, of sober habits, was admitted into the Middlesex Hospital, under Dr. F. Hawkins, April 25, 1854. He had always enjoyed good health until four months before admission, when he was suddenly seized with pain all over the abdomen, but particularly in the right hypochondrium, and extending thence to the right shoulder. About the same time, he became slightly jaundiced. The pain and jaundice continued; and at the time the patient came under observation, he was very weak and emaciated, and suffered from incessant cough. The liver was much enlarged, extending down to the umbilicus. There was con- siderable bulging of the right side of the chest, which was univer- sally dull on percussion, and devoid of respiratory murmur, except at the upper and back part close to the spine. The patient gradu- ally sank, and died on May 10. Autopsy.—On removing the sternum, the right pleural cavity was found to be filled with a yellowish, turbid, semi-purulent fluid, containing masses of a gelatinous substance, which proved to be hydatid cysts. The right lung was compressed and flattened against the vertebral column, and at its base was firmly bound by adhesions to the diaphragm. It did not crepitate in the least; it sank in water, and was completely carnified. The liver was enor- mously enlarged, extending downwards as far as the umbilicus, and weighing 90 ounces. It was firmly adherent to the diaphragm. In the posterior part of the right lobe was a cavity as large as a swan's egg, lined with an hydatid cyst, and containing similar cysts in its interior. The upper wall of this cavity was formed by 106 ENLARGEMENTS OF THE LIVER, [lect. hi. the diaphragm, and here there was a large opening by which the cavity in the liver communicated with the right pleura. The liver was much congested. The pericardium was glued to the heart by recent soft adhesions. The left lung, spleen, and kidneys were healthy. Case XVII.—Old Hydatid (?)—Tumour of the Liver, communicating with Base of Right Lung—Lobular Pneumonia and Gangrene of the Lung. Robert J----, aged 72, was sent to the London Fever Hospital, August 21, 1864, as a case of ' fever.' On examination, he was found not to be suffering from any form of idiopathic fever. The man stated that he had had a bad cough for two months, and had kept his bed for two days. His breath had a most decidedly gangrenous odour. His sputa were of a dirty greenish muco- purulent character, and extremely fetid. Dry bronchial rales were audible over the chest, and at the right base there was slight dulness, with increased vocal resonance, and large moist rales, but nothing approaching to cavernous breathing. Pulse 96; respi- rations 36. No change took place in the physical signs of the chest; but the tongue became dry and brown, diarrhoea supervened, and the patient gradually lost flesh and strength until death on September 11. On post-mortem examination, there was found to be lobular pneumonia of the lower lobe of the right lung, and quite at the base there was a gangrenous portion about the size of an orange. The lung was here firmly adherent to the diaphragm, and the diaphragm to the liver, and the broken-down tissue of the gan- grenous lung communicated by several openings with a cavity in the upper part of the right lobe of the liver, measuring about three inches in diameter. This cavity contained much calcareous matter, and a quantity of a dirty greyish, very fetid, pultaceous substance. On careful examination, no hooklets of echinococci could be discovered. The rest of the liver and the intestines were healthy. The absence of hooklets may be thought to negative the opinion that the tumour of the liver was originally an hydatid. But though these hooklets resist the changes which occur in the interior of the body for an indefinite period, they do not resist the putrefactive changes resulting from exposure to atmospheric air, lect. in.] HYDATID TUMOUR. 107 and such exposure must have existed here for many weeks before death. An obsolete abscess is the only other lesion that could have produced the appearances described, but the man had never suffered from the symptoms of abscess of the liver. In the two following cases (and also in Case XV.) the tumour appeared to compress the ureters. Case XVIII.—Hydatid Tumour of the Liver—Pye- litis—Pus in the Urine—Sudden Death. Ellen C----, aged 21, came under my care as an out-patient at the Middlesex Hospital, in April 1861. She stated that for about eighteen months she had been getting very weak and losing flesh, and that latterly she had suffered from dyspnoea. She had no cough, but her father had died of consumption. She had also suffered from irregular menstruation and leucorrhoea. On ex- amining the chest, there was found to be a bulging of the right side, commencing at the upper border of the fifth rib, attaining its maximum at the false ribs, and then as gradually declining. The hepatic dulness in the right mammary line extended for 3 inches below the margin of the ribs, and its total length was 6^ inches. The bulging below the ribs occupied the right hypochondrium and epigastrium, and extended over to the left hypochondrium. It was slightly tender, and presented an elastic, almost fluctuating con- sistence, and on percussion communicated to the finger the pecu- liar sensation known as 'hydatid vibration.' These characters were most marked in the epigastrium. The superficial veins about the epigastrium and hypochondrium were much enlarged. The movements of respiration were mainly confined to the left side of the chest. On the right side, the respiratory murmur could not be heard below the fourth rib in front, or below the lower angle of the scapula posteriorly. Above this the breathing was harsh, and the expiration was prolonged. On the left side there were also dulness and absence of respiration up to within half an inch of the lower angle of the scapula. The patient could give no information as to the length of time the tumour had existed. In fact, she was quite ignorant of the existence of any unusual swelling until it was pointed out to her. Her complexion was slightly sallow, but she had never suffered from jaundice or vomiting, and her bowels 108 ENLARGEMENTS OF THE LIVER, [lect. hi. were regular; her appetite was very bad. In addition to the tumour on the right side, a painful swelling, apparently an exten- sion of the left lobe of the liver, could be felt in the left lumbar region in the situation of the kidney, and there was a copious dis- charge of pus in the urine. The patient remained under my observation for nearly twelve months. The dimensions of the tumour did not alter much, but, on the whole, they became slightly larger. From time to time she suffered severe pain in the swelling in the left lumbar region. At these times the urine was clear, or almost so, and relief was always attended with a sensation of bursting and a return of the pus in large quantity. The urine was repeatedly examined with the microscope, but no pus-casts or trace of echinococci could be discovered. The treatment—which consisted in the administration of tonics and iodide of potassium, and the external application of iodine— failing to give relief, the patient was admitted into the hospital on January 14, 1862, with the object of having a puncture made into the tumour in the right hypochondrium. After remaining in the hospital for six weeks she refused to give her consent, and was discharged at her own request. I did not see the patient after this: but I have ascertained that, on November 6, 1863, she was admitted into University College Hospital, under the care of Dr. Hare, to whom I am indebted for the particulars noted while she was under his observation. To- wards the end of 1862, she had first suffered from pain in the region of the tumour in the right hypochondrium. The pain was intermittent in its character, ceasing after a few days. For this she had been treated at the Female Hospital in Soho Square. The dimensions of the tumour noted in University College Hospital showed that it had increased considerably. Although the right costal angle was still greater than the left, there was bulging of the ribs on both sides as high as the nipple, and dulness on per- cussion up to the third rib on the right side, and up to the third intercostal space on the left side. The heart was displaced up- wards, its apex beating in the third left intercostal space. The vertical hepatic dulness in a line with right nipple was 11£ in.; in the median line, 9^ in.; and in a line with left nipple, 9| in. Distinct fluctuation could be felt in the epigastrium over a space measuring 4£ in. transversely, and 2£ in. vertically; but there was now no hydatid fremitus. There was no oedema of the lejrs. The lect. in.] HYDATID TUMOUR. 109 patient was sallow; her urine contained no bile-pigment, but was still loaded with pus. She still suffered from the attacks of pain in the region of the left kidney, which were always relieved by a sensation of bursting and a copious discharge of pus in the urine. On admission, there was a considerable amount of pain and tender- ness in the region of the tumour near the umbilicus. This pain recurred from time to time, but was always relieved by leeches, poultices, and morphia. The patient also had an attack of pain and stiffness in the left groin and knee, accompanied by enlarge- ment of the lymphatic glands in the groin, and slight oedema in the upper part of the thigh. On January 26, 1864, it was noted that she was free from pain, but that she had lost flesh and strength. On February 9, she was discharged for unruly conduct. The patient was confined to bed after leaving the hospital, and died rather suddenly and unexpectedly at the end of ten days. An hour before death she seemed tolerably well, and the pro- bability is that the fatal event was due to the burstin°- of an hydatid cyst. Case XIX.—Hydatid Tumours of the Liver and Peri- toneum, compressing the Ureters, and causing Degene- ration of the Kidneys. Mary Ann W---, aged 45, was admitted into the Middlesex Hospital, December 15, 1864, under the care of Dr. H. Thompson, and died January 15, 1865. For a year before death she had suffered from headache and impairment of the mental faculties, and seven weeks before death she had a fit of unconsciousness, followed by right hemiplegia, involuntary evacuations, and bed- sores. There were no symptoms referable to liver. The arteries at the base of the brain were atheromatous, and there was an apoplectic cyst, with a patch of white softenino- in the left corpus striatum. The liver, spleen, and diaphragm were adherent by fibrous bands. In the adhesions between the spleen and liver was a cyst the size of a walnut, filled with soft putty- like matter, and lined by portions of a gelatinous echinococcus membrane. In the right lobe of the liver was another cyst, the size of a small cocoa-nut, partly embedded in its substance, and partly projecting from its upper surface, where it was firmly ad- 110 ENLARGEMENTS OF THE LIVER, [lect. hi. herent to the diaphragm. Its outer wall was partly calcified, and its anterior was full of fragments of secondary gelatinous cysts, and soft, putty-like matter. The secreting tissue of the liver was healthy. In the folds of the mesentery of the small intestine were three partly calcified cysts, varying in size from a hazel-nut to a walnut, and containing putty-like matter and secondary cysts. The greater part of the pelvis was occupied by another large cyst, situated behind and above the uterus, which was forced down, so as to appear at the vulva. This cyst contained a clear fluid and innumerable small cysts, varying in size from a pea to a walnut, all of them gelatinous and filled with a clear fluid. There was another cyst, not so large, in the right side of the pelvis. The ureters were compressed by these cysts, and the pelves of the kidneys were somewhat dilated. The kidneys were small and granular, and the cortices were wasted and hardly distinguishable from the cones. All of the cysts in the abdomen contained numerous teeth of echinococci. In the following case secondary hydatid cysts were formed in the omentum and peritoneal cavity. Case XX.—Hydatid Cysts of the Liver and Peri- toneum—Ascites and Anasarca of Lower Extremi- ties—Albuminuria—Death. Catherine C----, a hawker, aged 45, was a patient in the Middle- sex Hospital, under Dr. Goodfellow, from January 10,18(55, until her death on June 21. With the exception of an attack of rheumatism, she had enjoyed good health until about a month before admis- sion, when she had been seized with violent pain in the abdomen and loins, and at the same time her legs and abdomen had begun to swell. While in hospital, she suffered from ascites and great anasarca of the lower extremities. The urine contained albumen. She was treated with diuretics and purgatives, and her legs were punctured. On examination of the body, the legs were observed to be very oedematous, and the abdomen was greatly distended. Both lungs were very oedematous, and the right lung was firmly adherent and carnified at its base. lect. hi.] HYDATID TUMOUR. Ill The peritoneal cavity contained upwards of a gallon of clear serum, floating about in which were six nearly transparent hydatid cysts, with tremulous gelatinous walls, the largest about the size of a hen's egg, and the smallest about that of a walnut. The fluid in the floating cysts had a specific gravity of 1010, and contained no albumen ; that in the peritoneal cavity had a specific gravity of 1020, and was highly albuminous. The left lobe of the liver was partly atrophied, and between it and the spleen, and firmly adherent to both and to the stomach was an hydatid cyst, the size of a foetal head, containing a little clear fluid and innumerable smaller cyst of various sizes pressed together. In the great omentum were three or four similar cysts the size of chestnuts, and attached to the right kidney was another cysts as big as an orange. Numerous echinococci were found in the larger cysts. Both kidneys were much enlarged and fatty. Case XXI.—Hydatid Tumour of the Liver—Second- ary Hydatid Tumours in the Spinal Canal—Para- plegia. Tbj2 preparation of this case is in the Museum of Middlesex Hospital (v. 15), and the following particulars are extracted from the Catalogue :— ' Vertebrae with spinal cord from dorsal region. The canal and dura-mater laid open. The pleura is separated from the ribs and the sides of the bodies of the vertebrae by two hydatid cysts, one on each side. The hydatids have been opened in sawing through the laminae of the vertebrae; but their walls remain, and the spinal cord is at this place considerably smaller than elsewhere. ' The patient was a women aged 40, who had been admitted into the hospital with paraplegia and retention of urine. She died with a large slough on the sacrum, and the bladder was found to be inflamed. There was also a large hydatid cyst in the liver.' In the following case a process of spontaneous cure appears to have commenced in the tumour, and the observation is interesting in connection with the manner in which a cure is probably effected in an 112 ENLARGEMENTS OF THE LIVER, [lect. hi. hydatid tumour, when the fluid contents are drawn off by means of a small trocar and canula (see pages 62 and 76). Case XXII.—Large Hydatid Tumour of the Liver, full of Secondary Cysts, but containing no Fluid. This liver was taken from the body of a man, aged 36, who was admitted into the Fever Hospital on December 2, 1866, with petechial small-pox, of which he died on December 5. He was too ill to give any particulars of his previous history. After death, an hydatid tumour, the size of a child's head, was found in the posterior part of the right lobe of the liver. The chief point of interest in the case was that this cyst was tightly packed with secondary cysts, but that it contained no fluid. The secondary cysts were collapsed; but still they exhibited their natural gelatinous appearance. They were "not at all opaque or mixed up with any putty-like material. The outer cyst, however, at several places presented an atheromatous calcified appearance. Note.__The practical conclusion to be deduced from the annexed Table (p. 118) is identical with that published by me in the ' Edin- burgh Medical Journal' for December 1865, but is opposed to*that arrived at from a similar enquiry by Dr. John Harley, and published in the 49th volume of the' Medico-Chirurgical Transactions' (1866). Dr. Harley, who advocates the treatment of hydatid tumours of the liver by a large and permanent opening, gives a Table of'34 cases which were treated by a single puncture, evacuation of a portion or of the whole of the fluid, and immediate closure of the wound,' and states that, ' there were 11 cures, 13 recoveries, i.e. cases which were relieved by the operation, but which, since the tumour was not wholly removed, or the result sufficiently certified, cannot be regarded as radical cures, and 10 deaths.' Inasmuch as the parent and secondary cysts can never be ' wholly removed' by the operation of simple puncture, it is difficult to understand how Dr. Harley can admit that there was a ' radical cure ' in any of the 34 cases. It is necessary, therefore, to explain that he seems to look upon the result as a recovei~y, and not a cure, if any trace of the tumour can be felt some time after the operation (as in my own case, No. 25 in his Table). The introduction of the 10 fatal cases into lect. hi.] HYDATID TUMOUR. 113 the Table, however, throws, in my opinion, an illegitimate discredit upon the operation in question, and it is, therefore, necessary to a dvert to them in detail. Case 4.—In this case the tumour filled up the whole abdomen, and the operation of paracentesis (with a large trocar) was resorted to, with the object of relieving the impending asphyxia, aud not as a curative measure. The patient, moreover, before the ope- ration, was in a state of extreme marasmus and prostration, and the immediate cause of death was miliary tubercles in the lungs, and empyema. See Greenhow, ' Lancet,' 1862, ii. p. 476, and Murchison, 'Ed. Med. Journ.' Dec. 1865. Case 8.—There is no evidence that this case was fatal. Dr. Harley quotes the case from Mr. Caesar Hawkins, and Mr. Hawkins from Dr. Thomas's 'Practice of Physic' Mr. Hawkins observes, ' The result is not mentioned, so that it may probably be concluded that the case ended fatally,' but Dr. Thomas savs nothing to warrant such a conclusion. ' Med.-Chir. Trans.' vol. xviii. p. 121. Case 9.—The operation was resorted to merely as a palliative mea- sure: 8 pints of fluid were withdrawn from one cyst, and a second cyst, containing 12 pints, was found after death between the liver and the diaphragm. Dr. Abercrombie adds, ' The two cysts had so much injured the patient's constitution, that, although he was relieved by the operation, his strength quickly failed him.' Aber- crombie, ' Dis. of Stomach,' p. 356. Case 10.—In this case the opening was evidently a large one, and it is not stated whether it was closed up or not. But what is more important, the hydatid had suppurated before the operation. Hawkins in 'Med.-Chir. Trans.' vol. xviii. p. 157. Case 11.—From the original account of this case in the ' Edin. Essays and Observ.' vol. ii. p. 29'..), it is clear that the boy was almost moribund at the time of the operation, and that, in addition to hydatids of the liver and spleen, he had ascites, general dropsy, and orthopncea. It seems probable also that the peritoneum, and not the hydatid, was tapped. Case 13.—In this case there was great constitutional disturbance, and the hydatid had suppurated before the operation. The patient also was pregnant and miscarried, and sank after this. Dr. Bright on 'Abdom. Tumours,' Syd. Soc. Ed. p. 41. Case 15.—In this case there were two hydatid tumours. Three pints of fluid were drawn from one. This cyst did not again become enlarged, and the patient fancied herself cured, when I 114 ENLARGEMENTS OF THE LIVER, [lect. in. death occurred from the rupture of the other cyst through the diaphragm into the lungs. Davaine, 'Traite des Entozoaires,' p. 447. Case 16.—In this case the patient was in a state of extreme pros- tration before the operation. He was seized with syncope within five minutes, and died at the end of eighteen hours. Traces of recent peritonitis were found after death. The fatal result was no doubt determined in this case by the operation, but a large opening left patent is not likely to have led to a more favourable termination. Archiv. Gen. de Med. ser. v. torn. xiii. p. 145. Case 19.—In this case the puncture was simply an exploratory one, preparatory to the application of caustic potash seven days afterwards. Death was due to tetanus twenty-five days after the puncture, and Recamier states, ' aucun accident n'a suivi la ponction.' Davaine, Op. cit. p. 590. Case 32.—In this case, according to Dr. Harley, no attempt was made to relieve the sac of its contents after the first puncture, and the hydatid fluid escaping into the peritoneum caused peritonitis and extension of the disease; but he omits to mention that the presence of a large and increasing amount of fluid in the perito- neum was diagnosed before the operation. Moreover, caustic potash was applied to the integuments before the cyst was tapped. Rogers in ' Brit. Med. Journ. 1862,' vol. i. p. 71. Since the above lecture was delivered the following case has come under my notice,* which is an illus- tration of another disease that may be confounded with hydatid tumour of the liver. The tumour during life was believed to be an hydatid, with which the history of an injury is in no way incompatible, for in many cases of hydatid the patients date their origin from an injury, which probably acts merely by at- tracting attention to a tumour already existing. I * Similar cases are recorded by Mr. Csesar Hawkins in the 18th volume of the Med.-Chir. Transactions, p. 175; by Mr. Stanley in the 27th volume, p. 1; and by Sir Henry Thompson in the 13th volume of the Path. Transactions, p. 128. lect. in.] HYDATID TUMOUR. 115 know no rule by which a similar mistake might be avoided in future, but in most cases of cystic tumours connected with the urinary passages and arising from injury there would probably be: 1. A history of heenia- turia or albuminuria, or some symptoms of urinary irritation, all of which were absent in this case; and 2. Urea would be found in the fluid drawn off by tapping. Unfortunately, the fluid drawn off in this case was not examined for urea, but none was found in that which remained in the sac after death. The operation was resorted to merely as a palliative, and contributed in no way to the fatal result; the inflammation of the sac and the secondary deposits in the lungs had com- menced previously. Case XXIII.—Enormous Cystic Tumour communi- cating with the Pelvis of the Right Kidney, existing for Eight Tears, and simulating Hydatid Tumour of the Liver. Joseph 0----, aged 16, was admitted into the Middlesex Hospital under my care on December 19, 1867. Eight years before he had been thrown with great force against a wall, injuring his back and right side. For a week he vomited every- thing he swallowed, and altogether he was laid up for two months, but he never was observed to pass blood in his urine, or to have urinary symptoms of any sort. He then went to school for a month, when he was seized with severe pain in his back and right side, for which leeches were applied. He was in bed for five months, and during this time he had frequent vomiting and nine fits of convulsions, the movements being limited to the left side of the body. Shortly after this his mother noticed that his right side had 'grown out,' and the swelling increasing she took him to the London Hospital, where he remained for four months, and where his general health i2 116 ENLARGEMENTS OF THE LIVER, [lect. hi. underwent great improvement. His health continued good, and he was able to go about, but the swelling went on slowly increasing, until about a week before admission, when, after getting thoroughly wet outside a cab, he was seized with severe pain in the back, cough, and febrile symptoms. On admission, the patient was anaemic and emaciated, and complained of cough and shortness of breath, and of great pain and tenderness in the lower part of the spine. Pulse 108; respirations 48 and thoracic ; bronchitic rales over whole of both lungs, with dulness and friction over lower fourth of left. Tongue clean; appetite bad; temperature 1010, 4. There was no ana- sarca, and the urine contained no albumen. But the most re- markable feature about the boy was the enormous size of the abdomen, which measured 33 J inches at the umbilicus, the bulging being greatest in the right flank. This enlargement was almost painless, and was evidently due to an encysted collection of thin fluid in the right side, extending from the liver down into the pelvis, and as far forwards as the middle line, but clearly shut off from the general cavity of the peritoneum, as the rest of the abdomen was tympanitic in whatever position the patient lay. The hepatic dulness ascended to the nipple in front, and to the lower angle of the scapula behind. After admission the tumour increased in size, and the dyspnoea became so urgent that, on December 23, it was resolved to tap the cyst, which was accordingly done by Mr. Hulke, midway between the ribs and the crest of the ilium, and 170 ounces of fluid drawn off. The fluid which first came away was clear, but of a brownish colour; its specific gravity was 1010, and it contained much chlorides, and about one-sixth of albumen. The last two pints contained much pus, forming on standing a creamy deposit, of about one-half of the entire bulk. No portion of the fluid contained either echinococci or hooklets. At first the operation was followed by great relief to the dyspnoea, and at no time afterwards had the patient either rigors, profuse perspirations, pain in the tumour, or albumen in the urine. The prostration, however, increased daily ; the tongue became dry ; the temperature varied from 100° to 103°-2; there was much restlessness with sleeplessness and occasional delirium, and the signs of pleurisy at the base of the left lung, noted before the operation, extended. He gradually sank, and died on January 2. 1868. lect. in.] HYDATID TUMOUR. 117 Autopsy.—There were no signs of recent peritonitis, but on the right side of the abdomen, lying behind the intestines, was a cyst, with thick fibrous walls, about the size of an adult human head, It was firmly attached by fibrous adhesions to the under surface of the liver, to the false ribs, and to the abdominal wall. It extended downwards to the brim of the pelvis, and slightly beyond the middle line to the left. The right kidney was expanded over its outer and posterior aspect, and the renal tissue was attenuated and wasted. On opening the sac, its contents amounted to 65 ounces of thin pus; its inner wall presented a fibrous puckered aspect, with no trace of hydatid structure, and it communicated by three open- ings, oblique and valvular, but large enough to admit a full-sized catheter, with the pelvis of the kidney.* The right ureter was rather small, but pervious throughout; it ran for some distance in the wall of the cyst immediately beneath its lining membrane, and then passed down to the bladder, which was quite normal. The upper part of the right kidney was converted into a cicatrix- like fibrous tissue, intimately incorporated with the cyst. The left kidney was double the normal size, but otherwise normal. The liver was fatty; the spleen was very large and soft. There was recent pleurisy over the lower lobe of the left lung, which contained a patch of red hepatization ; and in the lower lobe of the right lung were several small patches of lobular pneumonia, with yellow centres. There was no pus in the joints, and no sign of old fracture of the ribs, or of disease of the bodies of the vertebras. * It is remarkable that, notwithstanding these openings the urine, up to the day of death, never contained any pus or a trace of albumen. A similar observation was made in the case recorded by Mr. Caesar Haw- kins, and already referred to (p. 114, foot-note). In that case also, although the cyst communicated with the pelvis of the right kidney, no urea could be found in the contained fluid, which is also said to have been devoid of albumen, although it contained pus! Table of Cases of Hydatid Tumour of Liver treated by a Simple Puncture, and Closure of Opening after Evacuation of Fluid. No. Med. Attendant Quantity of Fluid Withdrawn Result Reference! and Remark) 1 Murchison 5 oz. and 20 oz. Cure Antea, Case VI. p. 83. 2 Do. 12 oz. Cure Antea, Case VII. p. 85. 3 Do. 14 oz. Cure Antea, Case VIII. p. 89. 4 Greenhow 21 and 110 oz. Cure Path. Trans., vol. xviii. p. 127. 5 Do. 148 oz. Cure lb. p. 130. 6 G. Budd 150 oz. Cure Med. Times and Gaz. May 19,1860. 7 Holthouse 100 oz. Cure lb. Jan. 6, 1855. 8 J. Hutchinson 30 oz. Cure Lancet, 1862, vol. ii. p. 389. 9 Sir B. Brodie 30 oz. Cure Med.-Chir. Trans, vol. xviii. p. 118. 10 Do. 60 oz. Cure lb. p. 119. 11 Dr. Thompson 60 oz. Cure lb. p. 121. 12 Recamier Small quantity Cure Rev. Med. Tom. i. p. 28. 13 Key 80 oz. Cure Bright on Abd. Tumrs. Syd. Soc. Ed. p. 42. j 14 Boinet 20 oz. Cure Traitement des Tumeurs hyd. dn Foie, Paris, 1859, p. 13. 15 Do. 4 oz. Cure lb. p. 14. 16 J. Hutchinson 40 oz. Cure Brit. Med. Jour. Feb. 20,1864. 17 Do. 60 oz. Cure lb. 18 Frerichs 120 oz. Cure Dis. of Liver, Syd. Soc. Ed. vol. ii. p. 268. 19 Langenbeck 1 Cure lb. 20 Do. ? Cure lb. 21 W. Budd 23 oz. Cure Brit. Med. Jour. 1859, p. 273. 22 Robert ? Cure Gaz. des Hopitaux, 1857, p. 147. ■>i Do. ? Cure Soc. de Chir., Mars 18, 1857. 24 BriDton 30 oz. Cure Lancet, 1862, vol. ii. p. 639. 25 Kiuhard 40 oz. Cure Bull. Gen. de Therap. 1855, p. 414. 26 Demarquay 20 oz. Cure Boinet, Op. cit. p. 30. 27 Boinet 20 and 15 oz. Cure lb. p. 18. 28 McGillivray 30 and 20 oz. Cure Austral. Med. Journ. Aug. 1865. Case iii. 29 Do. ? Cure lb. Case vii. 30 Do. 180 and 100 oz. Cure lb. Case xv. 1 3l Do. 114 oz. Cure lb. March 1867. Case xxiv. 32 Do. 20 oz. Cure lb. Case xxvi. Three distinct cysts were tapped, none of which refilled. 33 Do. 2 oz. Cure lb. Case xxxv. 34 Do. 18 oz. Cure lb. Case xxxvi. 35 Do. 70 oz. Cure lb. Case xxxviii. 36 Owen Rees 38 oz. Suppuration FreeExt.Opene Cure. Guy's Hosp. Reports, ser. ii. vol. vi. p. 17. 1 37 Garrod 4 oz. Do. do. do. Lancet, Sept. 1, 1860. 38 Boinet 40 oz. Do. do. do. Gaz. Hebdom. de Med. ser. ii. 1864, i. p. 80. j 39 Demarquay 160 oz. Do. do. do. Gaz. des Hop. Fev. 19, 1859, p. 82. 40 Babington and -Cock 10 and 80 oz. Do. do. do. Guy's Hosp. Rep. 3rd. ser. vi. p. 179. In this case the object of the operation was not to remove all the fluid at once, but by repeated punctures. 41 McGillivray 20 oz. Do. do. do. Austral. Med. Jour. Aug. 1865. Case xiv. 42 Do. 10 oz. Do. do. do. lb. March 1867. Case xix. The fluid was milky at first operation. 43 Do. Large quantity Do. do. do. lb. Case xxxiii. 44 Do. 60 oz. Do. do. death lb. Case xvi. Death was due to the burst-ing of the tumour into the lung after the large external opening was made. 45 Wiltshire Large quantity Do. do. death Lancet, Sept. 1,1860. The liver contained three other cysts, each containing about a pint of fluid, besides the one that was punctured. Death was mainly at-tributed to the pressure of the liver on neighbouring organs. 46 Moissenet 12 oz. Death Arch. Gen. de Med. Fev. 1859, p. 144. The patient was extremely prostrate before the operation, and died of peritonitis eighteen hours after. lect. iv.] CONGESTION. 119 LECTTJBE IV. ENLARGEMENTS OF THE LIVER. CONGESTION—INFLAMMATION OF BILE-DUCTS—OBSTRUC- TION OF COMMON DUCT. Gentlemen,—In the previous lectures I have called your attention to the distinguishing characters of the four enlargements of the liver which are for the most part unattended by pain. Those in which pain is a prominent symptom remain to be considered. Six diseases are included under this head; viz. 1, con- gestion of the liver; 2, inflammation of the bile-ducts ; 3, obstruction of the common duct and retention of bile; 4, pysemic abscesses; 5, tropical abscess; 6, can- cer. Speaking generally, it may be said that jaundice, which is a rare symptom in painless enlargements of the liver, is present to a greater or less extent in the class of enlargements now to be noticed. Tropical abscess is the one in which it is oftenest absent. First among the enlargements of the liver attended by pain comes— V. CONGESTION OF THE LIVEE. In the first place, it is necessary to bear in mind, in reference to the pathology and treatment of this 120 ENLARGEMENTS OF THE LIVER, [lect. iv. condition, that the quantity of blood in the liver varies greatly at different times consistently with health, and that even these healthy variations may influence to some extent the size of the organ. For instance, the amount of blood in the liver and its size are greatly influenced by diet, both being tem- porarily increased after a meal, and particularly when the food has been too large in quantity, or contained an excess of fatty, saccharine, or alcoholic ingredients. By morbid congestion of the liver, we mean some- thing more than this. The phrase ' congestion of the liver' is too often used very vaguely and applied to cases of indigestion, where there is probably little amiss with the liver. True congestion of the liver is distinguished by the following characters:— 1. There is enlargement of the liver which is uni- form in character—not greater in one direction than another—and which is rarely very great. The liver may project an inch or more below the margin of the ribs in the right mammary line. In the venous engorgement from mechanical obstruction of the cir- culation, the enlargement is usually greater than in active congestion, where the engorgement commences in the arteries. Another peculiarity of this enlargement is that it is rarely permanent, but that after a time it usually disappears. Even when the cause of the obstruction is most permanent, such as mechanical obstruction of the cardiac circulation from valvular disease of the heart, the primary enlargement of the liver from congestion gives place after a time to an LECT. IV.] CONGESTION. 121 opposite condition of contraction. The pressure ex- erted by the constantly distended hepatic veins causes atrophy of the central portions of the lobules, and induces a form of granular liver, very different from true cirrhosis, where the atrophy commences at the circumference of the lobules. In true cirrhosis of the liver most observers have noted a temporary enlarge- ment of the liver from congestion in the early stage of the malady ;* and although this has been doubted by the late Dr. Toddf and others, there can be little doubt that at the commencement of cirrhosis there is congestion, with more or less enlargement, due to the excessive amount of alcoholic ingesta on which cir- rhosis ordinarily depends. But here, as in other forms of congestion, the enlargement is of temporary dura- tion. 2. The surface of the portion of liver projecting below the ribs is perfectly smooth. 3. The patient complains of a feeling of tightness or painful distension in the region of the liver, and there is more or less—but rarely very acute—tender- ness on pressure below the margin of the right ribs. The pain and feeling of uneasiness may stretch up to the right shoulder, and are almost always increased after meals, or by lying on the left side. In the latter case, there is usually a sense of dragging or weight in the hepatic region. The patient consequently sleeps for the most part on his back, or on his right side. * Frerichs : Klinik derLeberkrankheiten. Syd. Soc. Ed. ii. pp. 37, 53, t Clinical Lectures on Urinary Diseases and Dropsies, 18o7, p. 113. 122 ENLARGEMENTS OF THE LIVER, [lect. iv. 4. Jaundice is present, in most cases, after two or three days, but is rarely intense, and it is not often that bile is altogether absent from the motions. When there is intense jaundice with absence of bile from the stools, catarrh of the ducts is probably present, as well as congestion of the hepatic tissue. 5. There is usually nausea, with loss of appetite, headache, furred tongue, flatulence, and other sym- ptoms of indigestion, and not unfrequently there is vomiting or diarrhoea, or both. The same cause that produces congestion of the liver may induce a similar condition of the stomach and intestines. Slight irri- tation then suffices to induce catarrhal inflammation of the mucous membrane of these parts, of which vomiting and diarrhoea are the prominent sym- ptoms. But when the hepatic congestion is independent of mechanical obstruction of the circulation, the bowels are oftener constipated than relaxed, and the patient's chief symptoms are loss of appetite, furred tongue, a bitter taste in the mouth, nausea, and flatulence, with general languor and debility, ansemia, emaciation, and hypochondriasis. 6. More or less dyspnoea is not uncommon, even in cases where the primary disease is not in the chest, and many patients are harassed by a frequent dry cough. 7. Signs of obstructed circulation are not un- common. In acute cases there may be tension in the left hypochondrium, and an increased area of lect. rv.] CONGESTION. 12:5 splenic dulness ; while in more protracted cases there may be haemorrhoids or ascites. 8. The urine is usually scanty and high coloured, and besides containing more or less bile pigment, often deposits a copious sediment of lithates or lithic acid. 9. As in other forms of enlargement of the liver, the circumstances under which the enlargement ap- pears constitute an important aid to the diagnosis of the real nature of the case. Hepatic congestion may be mechanical, active, or passive, and the chief con- ditions under which it occurs are the following :— A. Mechanical.—Among the most common causes of hepatic congestion in this country is mechanical obstruction of the circulation in the chest, and par- ticularly that consequent on disease of the mitral or tricuspid valves of the heart. In many cases of valvular disease of the heart, a time arrives when the chief symptoms are those of hepatic congestion, and the main treatment must be directed to their relief. B. Active.—Several causes contribute to the de- velopment of active congestion :— a. Irritating ingesta, in the form of alcohol, fer- mented liquors, spices, or food which errs in being habitually too rich in quality or in excessive quantity may cause congestion of the liver. The temporary increase of blood which the liver always contains after a meal may become morbid in degree and permanent, if the ingesta be habitually of an irrita- ting character. Congestion of the liver is more 124 ENLARGEMENTS OF THE LIVER, [lect. iv. likely to result from these causes in weakly persons who lead indolent and sedentary lives, than in persons of a robust constitution who take plenty of muscular exercise in the open air. b. A high temperature is usually reckoned among the causes of congestion of the liver, but probably rarely leads to such a result except in conjunction with irritating ingesta. It is to this combination of causes that must be attributed the frequency of active congestion of the liver among Europeans in warm climates. c. A sudden or protracted chill in warm climates may increase the congestion arising from the causes now mentioned, and may even induce inflammation and abscess. d. Malaria and Blood-Poisons.—Persons who suffer from malarious fevers, or live in malarious districts, are very prone to have congestion of the liver, which may persist long after the febrile symptoms have passed away. Officers and soldiers not uncommonly return from India with enlargement of the liver from this cause. But when great and permanent enlargement of the liver succeeds to ague or remittent fever, it is more probably the result of waxy deposit than of simple congestion.* There are other blood-poisons besides malaria, which may induce congestion of the liver, such as the yellow fever of the tropics, and the relapsing fever of our own country. * See page 30 and Case II., and also Morehead, Res. on Dis. in India, 1860, p. 428; and Six Ranald Martin, in Lancet, 1865, ii. n. 615. LECT. IV.] CONGESTION. 125 e. Active congestion of the liver may have a traumatic origin, and result from contusions, wounds, &c. C. Passive.—Passive congestion of the liver may be due to— a. Suppression of habitual discharges, as of the catamenia or of the bleeding from piles. b. Habitual constipation.* c. Torpor of the portal vascular system from paralysis of the sympathetic nerves or from any other cause. Treatment.—In the treatment of hepatic conges- tion, you must be guided by the following rules :— 1. In most cases of any severity advantage will be derived from the employment of local depletion in the form of leeches or cupping to the region of the liver, or, what is still better, the application of a few leeches around the anus. If depletion be deemed inexpe- dient, sinapisms may be applied over the liver. After the leeches or the sinapisms, their place ought to be supplied by linseed or bran poultices. Tepid baths are sometimes useful. 2. The diet should be of the least irritating cha- racter. Only small quantities of milk, beef-tea, or fari- naceous articles ought to be taken at a time. Alcohol, wine, fermented liquors, spices, fat, and all rich or indigestible articles ought to be rigidly interdicted. In modern practice much mischief is often done by * See Frerichs, Dis. of Liver, Syd. Soc. Transl. i. p. 376. 126 ENLARGEMENTS OF THE LIVER, [lect. iv. compelling patients with heart-disease and congestion of the liver to swallow large quantities of brandy. 3. Purgatives are in most cases of great utility, unless there be spontaneous diarrhoea, which ought not to be too speedily or completely checked. The best purgatives are those which increase the watery exhalation from the mucous membrane of the bowels, such as the sulphates of soda and magnesia, seidlitz powder, Pullna water, the citrate of magnesia, and the bitartrate of potash. The action of these purgatives is sometimes materially assisted by an occasional dose of calomel, blue pill, or podophyllin, which bring away copious bilious motions.* 4. When the congestion is traceable to irritating ingesta, an emetic in the early stage sometimes ap- pears to do good, by clearing out the stomach and duodenum. The pressure also to which the liver is subjected during the act of vomiting may squeeze out of it some of the superfluous blood. 5. During the persistence of the symptoms of con- gestion—enlargement and tenderness of the liver with jaundice—and especially in those cases where there is much gastric derangement, alkalies and their salts with the vegetable acids ought to be pre- scribed. They may be taken two or three times a * The increased biliary excretion after the calomel in these cases is not due to an increased secretion of bile by the liver, but probably to the mercury irritating the upper part of the small intestine, so that the bile is propelled onwards, instead of being re-absorbed (see Lect. VIII). If calomel acted by stimulating the liver to increased secretion, it would be injurious in cases of hepatic congestion. LECT. IV.] CONGESTION. 127 day on an empty stomach. The alkaline mineral waters, such as those of Vals, Vichy, and Ems, or the artificial effervescing Vichy salt, may often be advan- tageously substituted for the alkaline preparations of the Pharmacopoeia. 6. When the more urgent symptoms have passed off, and the patient chiefly suffers from debility and dyspepsia, with a slight increase of the hepatic dulness, with or without hypochondriasis, the treat- ment must be modified. The mineral acids and vege- table tonics are now most useful, such as the mineral acids with taraxacum or gentian, or small doses of quinine and iron. The latter remedies are particu- larly indicated in patients who have suffered from malarious fevers. The diet also ought to be more generous, although care must be taken to exclude from it every source of irritation. Fermented liquors ought still to be absolutely interdicted, and if wine be allowed at all, it should be given in small quantities and diluted. Dry sherry and claret are the best. Regular exercise in the open air ought to be enjoined ; if there be much debility, the advantages of exercise without fatigue may be derived from riding on horse- back. The bowels will still require attention, and great advantage will often be obtained from the use of mineral waters which combine chalybeate with purgative properties, such as the springs of Harro- gate, Cheltenham, and Leamington. 7. It is in the chronic condition last referred to that advantage is often derived from the use of the 128 ENLARGEMENTS OF THE LIVER, [lect. iv. nitro-muriatic acid bath, as recommended by Sir Ranald Martin.* The bath should consist of two ounces of strong hydrochloric, and one ounce of strong nitric acid to two gallons of water, at a temperature of 96° or 98°. Both feet are to be placed in the bath, while the inside of the legs and thighs, the right side over the liver, and the inside of both arms, are sponged alternately, or the abdomen may be swathed in flan- nel soaked in the fluid. The process is to be con- tinued for half an hour night and morning, f As an example of congestion of the liver resulting from mechanical obstruction of the circulation in the chest, I may recall your recollection to the following case:— Case X£IV. —Mitral Constriction—Dropsy and Congestion of the Liver—Death. Emma F---, aged 13, was admitted under my care on October 24, 1865, suffering from much cough, great dyspnoea, and considerable anasarca of the lower extremities. The cardiac dul- ness had double its normal area, and a prolonged bellows-murmur was audible over the left apex. There were all the signs of general * bronchitis; and, in addition, the conjunctivae and general surface had a slightly jaundiced tint; the hepatic dulness was much increased, measuring in the right mammary line, more than five inches, and extending down nearly to the umbilicus. The splenic dulness was also increased. There was considerable tenderness on * See Lancet, Dec. 9, 1865, p. 641. f The bath, as above prepared, may be kept in use for a few days, 1 drachm of hydrochloric, and half a drachm of nitric acid, with a pint of water, being added daily to make up for waste. About a fourth of the fluid is to be well heated in an earthen pipkin, so as to bring up the temperature of the whole to 96° or 98°. Glazed earthen or wooden vessels should be used, and the sponges and towels kept in cold water lest the acid corrode them. LECT. IV.] CONGESTION. 129 pressure below the right ribs. The tongue was furred. There was much nausea and occasional vomiting, and the boAvels were relaxed about four or five times a day. The motions were pale, though coloured with bile. The urine contained a small amount of bile-pigment, but no albumen. Five or six years before, this patient had an attack of scarlet fever, followed by articular rheu- matism and dropsy. Ever since, she had suffered from dyspnoea and palpitations, increased by any exertion. About ten days before admission she began to complain of cough, headache, and vomiting, and swelling appeared in her ankles, which gradually extended upwards. The treatment consisted in the administration of purgatives and diuretics, and particularly the bitartrate of potash and tincture of digitalis, while leeches and mustard and linseed poultices were applied over the right hypochondrium. At first there was a manifest improvement iu all the symptoms; but about a fortnight after admission the indications of obstructed cardiac circulation became aggravated: the dyspnoea and dropsy increased, and the lips and face were livid; the jaundice was more marked, the vomit- in°- more urgent, and the motions contained less bile. The pulse was very rapid, and on November 10 was scarcely perceptible. At eleven r-.M. of this day the girl died. On examination of the body, the heart was found much enlarged, weighing 13 ounces. The mitral valve was much thickened and its margins adherent, so that the orifice was contracted, and its circumference measured only fifteen lines. Both lungs were much congested, and presented the ordinary anatomical characters of bronchitis; but they were nowhere consolidated. The peri- toneum contained about a pint of clear serum. The liver was very large for the patient's age, weighing nearly 4 pounds. Its outer surface was smooth; and, on section, the branches of the hepatic vein were found gorged with dark blood, contrasting strongly with the intermediate pale-yellow hepatic tissue. On microscopic examination, the quantity of oil in the secreting cells did not seem increased. The spleen weighed 6£ ounces, and was firm and dark on section. The pyramids of the kidneys were much congested, but the renal tissue in other respects was healthy. The mucous membrane of the pyloric half of the stomach presented the ordinary characters of catarrhal inflammation. As an illustration of congestion of the liver arising K 130 ENLARGEMENTS OF THE LIVER, [lect. iv. from other causes, I may narrate to you the particu- lars of the following case :—■ Case XXV.—Indigestion from Habitual Surfeit— Residence in Tropics—Exposure to Chill—Congestion of Liver. Mr. C----, aged 30, a gentleman much addicted to the pleasures of the table, consulted me in June 1867, on his return from India. He had for several years suffered from constipation, flatulence, and a feeling of weight and oppression in the region of the liver. About six weeks before I saw him, he was attacked with pain in the region of the liver, followed by vomiting and jaundice, after sleeping on a verandah in the night air in India. He had leeches applied over the liver, and was ordered home at once. I found him still moderately jaundiced ; the liver enlarged, mea- suring 5 inches in the right mammary line, and slightly tender; no vomiting, but the bowels constipated; a bitter taste in the mouth, and nausea. The motions were light but contained bile. The urine was scanty, dark, contained bile-pigment, deposited much lithates, and became very dark on the addition of nitric acid after heating. He was treated with saline purgatives and occasional pills of the comp. colocynth mass (gr. vi.), podophyllin (gr. £), and extract of henbane (gr. ii.) ; an effervescing mixture of citrate of potash was ordered to be taken three times a day; a warm bath three times a week ; moderate exercise ; and a simple diet, from which alcohol in every form was excluded. At the end often days, the patient was much improved, the jaundice had almost gone, and the hepatic dulness diminished. A mixture with nitric acid and compound infusion of gentian was now sub- stituted, and in two or three weeks more the patient had regained his usual health. In the next case the patient's symptoms were pro- bably those of congestion of the liver, which, had it not been for the treatment adopted, would probably have been accompanied with catarrh of the ducts and jaundice as in her two previous attacks. lect. iv.] INFLAMMATION OF BILE-DUCTS. 131 Case XXVI.—Congestion of the Liver. Jemima S----, aged 35, a corpulent married woman of seden- tary habits, was admitted into the hospital under my care on November 14,1866. She had always suffered much from dyspepsia and flatulence, and on two occasions, when she was 21 and 28, she had been laid up for several weeks with vomiting, jaundice, and pain in the region of the liver. On Sunday evening, November 11, probably after some indiscretion in diet, she felt a weight in the stomach. She passed a restless night, and next morning she was seized with pain, rather severe, in the region of the liver, and constant retching; the retching ceased at the end of twenty-four hours, but the pain increased until the time of admission. Her symptoms then were as follows :—Pulse 120. Temp. 99°-2. Slight yellowish tint of conjunctivas. Hepatic dulness increased, mea- suring oh inches in the right mammary line. Complains of severe pain in the hepatic region, aggravated by pressure or inspiration, or by lying on the left side. Much nausea and flatulence. Urine presents no distinct reaction of bile-pigment, but becomes very dark on the addition of nitric acid after boiling. Six leeches were applied to the region of the liver, and a draught, containing one drachm of sulphate of magnesia in an ounce of peppermint water, was prescribed to be taken every six hours. By November 16, the patient had had frequent and copious bilious motions, and the symptoms had begun to subside. A mix- ture with nitro-muriatic acid and infusion of gentian was now ordered, and on November 30, she left the hospital, with a good ap- petite, free from pain, and with the hepatic dulness in the right mammary line less than 5 inches. The next form of painful enlargement of the liver is due to VI. INFLAMMATION OF THE BILIARY PASSAGES. This condition is usually associated with more or less congestion of the hepatic tissue, and accordingly its clinical characters are those of congestion, with K 2 132 ENLARGEMENTS OF THE LIVER, [lect. iv. those peculiar to catarrh of the bile-ducts and gall- bladder superadded. Thus Ave have— 1. Enlargement of the liver, which, like that from congestion, is uniform in every direction, and rarely very great; but which is sometimes accompanied by enlargement of the gall-bladder in the form of a more or less pyriform tumour projecting from the anterior margin (see fig. 13, page 145). 2. The portion of liver projecting below the right ribs is smooth on palpation. 3. There is a feeling of tightness and distension in the right hypochondrium, with tenderness on pres- sure. This tenderness is usually particularly marked over the enlarged gall-bladder. 4. Inasmuch as the bile-ducts are obstructed from the tumefaction of the mucous membrane, as well as from the inflammatory products thrown off from its free surface, the jaundice, after a day or two, is much more intense than in simple congestion, and the motions contain no bile. 5. Here, again, the circumstances under which the attack occurs are of great assistance in diagnosis. a. In a large majority of cases the attack is pre- ceded by symptoms of catarrh of the stomach and duodenum. The inflammation, in fact, commences in the mucous membrane of the digestive canal, and extends thence to the common bile-duct. Accord- ingly there are to be noted, in the first place, a furred tongue, loss of appetite, flatulence, nausea or vomit- ing, pain and tenderness at the epigastrium, and lect. rv.] INFLAMMATION OF BILE-DUCTS. 133 sometimes diarrhoea, these symptoms being often accompanied by slight pyrexia. After a few days or longer, jaundice appears, and the fever, if present, may subside, although the dyspeptic symptoms re- main. Attacks of this sort are very common in children, as the result of eating indigestible food, or of a surfeit ; and, in that case, the jaundice and other symptoms usually subside at the end of ten days or three weeks. They are also not uncommon in persons of more advanced age of a gouty constitu- tion, and more than once I have met with cases of this sort where the frequent vomiting, the emacia- tion, and the jaundice, persisting for many weeks, have led to the suspicion of cancer, but have soon subsided under the use of purgatives with colchicum and alkalies. Lastly, inasmuch as catarrh of the stomach and duodenum appears sometimes to be in- duced by a chill, or other atmospheric influence, jaundice from catarrh of the bile-ducts occasionally prevails as an epidemic. b. Inflammation of the biliary passages may be secondary to congestion or other diseases of the liver, and then its symptoms may be persistent. It is probable that catarrh of the ducts may not only excite congestion of the hepatic tissue, but may result from it. In any case, where congestion of the liver is developed under the circumstances already mentioned, and where, in addition to the symptoms of simple congestion, there is intense jaundice, with an absence of bile from the motions, we may infer 134 ENLARGEMENTS OF THE LIVER, [lect. iv. that there is catarrh of the ducts as well as conges- tion. Other diseases of the liver, also, such as the waxy liver and the hydatid tumour, are occasionally complicated with catarrh of the ducts; and in this way jaundice may appear in the course of diseases of the liver in which it is usually absent. In Case XXX., which is an example of a very rare disease— enlargement of the liver from tubercular deposit— the jaundice was apparently due to inflammation of the common bile-duct. c. Inflammation of the bile-ducts or gall-blad- der may be due to the irritation of gall-stones or of other foreign bodies. Under these circumstances, it will usually be distinguished by a previous history of biliary colic, which, however, was notably absent in the case of one patient who lately died in the wards (Case XXIX.). d. Certain poisons, such as those of pyaemia and phosphorus, have been recently stated by Virchow to excite catarrh of the bile-ducts.* Treatment.—The rules already laid down for the treatment of congestion of the liver are also appli- cable to catarrh of the bile-ducts. Little more need be added, except that— 1. Leeches and cupping are on the whole less necessary. In most cases sinapisms and warm fo- mentation, with purgatives and alkalies, suffice for subduing the disease. The propriety of employing local depletion must be decided by the degree of pain and amount of congestion existing in each case. * Virchow's Arch. 1865, xxx. hft. 1. lect. iv.] INFLAMMATION OF BILE-DUCTS. 13f> 2. When there is reason to suspect that the affec- tion is of a gouty nature, great benefit will often be derived from the addition of colchicum to the alkalies. In these cases also it will be necessary to adopt such measures as are calculated to correct that disordered condition of the stomach and duodenum, which, if neglected, will before long lead to a recurrence of the hepatic attack. 3. The treatment must occasionally be modified by the presence of other diseases of the liver of which the cartarrh of the bile-ducts is merely a complication. Most of you have had an opportunity of watching the following case of painful enlargement of the liver accompanied with jaundice, apparently due to catarrh of the ducts. Case XXVII.—Painful Enlargement of the Liver, with Jaundice, due to Catarrh of the Bile-ducts. Elizabeth L----, aged 21, a maid-servant, was admitted under my care on December 7, 1866. For nine months she had been weakly and unable to take a place, and had also suffered from dyspeptic symptoms. Ten days before admission, at the cessation of the last catamenial period, which had its usual dura- tion, she had been seized with great nausea and vomiting, but she had no diarrhoea. Five days after this she began to complain of pain and tenderness in the region of the liver; but the pain was never very severe. About the same time jaundice made its appearance, which increased in intensity, and was accompanied by much itchiness of the skin. On admission, there was a deep jaundiced colour of the entire skin and conjunctivas; the urine was very dark, and gave the characteristic reaction of bile-pigment; the tongue was thickly coated, and there was no appetite, but the vomiting and pain in the side had much subsided; the lower margin of the liver was ascertained to project about an inch below the margin of the ribs 136 ENLARGEMENTS OF THE LIVER, [lect. iv. in the right mammary line, and here there was slight tenderness on pressure; the bowels had a tendency to be constipated, and the motions were clay-coloured, without a vestige of bile-pigment; the pulse was 100; the skin rather hot (temperature 100° F.) ; the respiration was slow and easy; and the physical signs of the heart and lungs were normal. The treatment consisted in the frequent administration of saline purgatives (sulphate of magnesia), and a blue pill occasionally at bed-time, together with the application of mustard and linseed poultices to the region of the liver. The bowels were freely purged, aDd on December 17 the symptoms had considerably improved ; the pulse had fallen to 08; the tongue was clean; there was neither nausea nor vomiting; the appetite was returning; and the urine contained less bile-pigment. No change, however, had taken place in the colour of the skin and conjunctivae, which were still deeply jaundiced. An alkaline mixture, containing bicarbonate of soda, chloric ether, and tincture of orange, was now substituted for the sulphate of magnesia; a purgative was still given occasionally, and the patient had a warm bath twice a week. On December 20 the jaundiced tint was first noticed to be giving way, and from this date it gradually faded until January 7, 1867, when it had quite disappeared. A tonic mixture with nitric acid and quinine was now ordered, and on January 22 the patient left the hospital in good health. The following case is cited as a good illustration of catarrh of the bile-ducts occurring in a gouty in- dividual. Case XXVIII. — Gouty Dyspepsia—Jaundice from Catarrh of the Bile-ducts. In the autumn of 18651 was consulted by Mr. C. D----, a gentle- man aged 30. His father had been a martyr to gout, and a younger brother had suffered from it early in life. He had never had well- marked gout himself, but he had long been liable to gastric derangements characterized by nausea and flatulence and transient pains in the small joints. About three weeks before I saw him he had been seized suddenly, about an hour after dinner, with a severe pain at the epigastrium, followed by vomiting and nausea. lect. iv.] INFLAMMATION OF BILE-DUCTS. 137 A few days later jaundice appeared, and gradually increased in intensity; the nausea continued without vomiting, and the patient became much emaciated. On examination I found the lower margin of the liver projecting more than half an inch beyond the edge of the ribs in the right mammary line, and slightly tender on pressure. There was intense jaundice of a deep olive tint, great itchiness of the skin, and complete absence of bile from the motions. The urine was dark like porter. Pulse 60. The patient had no appetite, and had nausea and flatulence after everything he swallowed; he was extremely weak and thin, and his appearance in an older man would certainly have suggested the existence of malignant disease of the stomach or liver. The treatment adopted consisted in the application of mustard and linseed poultices to the region of the liver, warm baths, blue pill with saline purgatives, a mixture with citrate of potash and vinum colchici and a diet restricted to milk, beef-tea, and fari- naceous articles. After two days the symptoms began to improve, and by the end of three weeks the j aundice had quite disappeared, and the patient was restored to his usual health. In the following case death was due to ureemia from diseased kidneys, but the hepatic symptoms appeared to result from inflammation of the gall- bladder and bile-ducts excited by gall-stones, which was subsiding before death. Case XXIX.—Inflammation of the Biliary Passages excited by Gall-stones—Gangrene of Foot—Diseased Kidneys—Death by Uraimia. Most of you will remember the patient, J. K----, aged 49, who was a patient in Cambridge Ward from October 27, 1866, until his death on November 21. His story was that he had enjoyed good health until the previous June, when he began to suffer from loss of appetite, lowness of spirits, and pain and flatulence after meals. About the same time he got a rusty nail into his left big toe. This resulted in an abscess, which burst, and continued discharging until a few days before admission. He had continued working, however, as a labourer, until within the last 138 ENLARGEMENTS OF THE LIVER, [lect. iv. three weeks. During his illness his weight had diminished from 12 st. to 11 st. 5 lbs. On October 20 he had a severe rigor, lasting for three hours, and followed by a rather severe, constant,' gnawing' pain, with tenderness in the region of the liver, vomiting of bitter green fluid, and headache. Two days later his skin became jaun- diced, and he suffered from itchiness of the skin and loss of sleep. About the same time that the jaundice appeared, the left big toe became black, and the ulceration extended. At no time of his life had he suffered from symptoms of biliary colic. On admission it was noted that the patient had rather deep jaundice of the skin and conjunctivae. He complained of general itchiness, and of dull pain in the region of the liver, which was uniformly enlarged, the dulness in the right mammary line being 5£ inches. There was also decided tenderness at a spot corre- sponding to the gall-bladder, which was also enlarged. The abdo- men was distended and tympanitic; the ingesta were constantly vomited within half an hour; the tongue was moist, jaundiced, and furred; the bowels were costive, and the motions stone- coloured. The urine was of the colour of porter, and contained a large quantity of bile-pigment and also of albumen, with granular and a few oil-casts. On the dorsum and sole of the left big toe were several large sloughy ulcers, the surrounding soft parts being much swollen and livid. The pulse was 72; the skin was cool; and there had been no rigors or perspirations. The patient was treated with blisters and mustard and linseed poultices to the region of the liver, while bismuth, chloric ether, purgatives, &c.,were given internally. For some time there appeared to be considerable improvement: the jaundice diminished, and bile reappeared in considerable quantity in the motions. But about November 12 the vomiting became more urgent, and the prostration increased. On November 19 the left foot was found to be much swollen, and livid lines marking the course of the lymphatics passed up the legs. On November 20 an abscess was opened above the left ankle, from which fetid pus and gas escaped. On the same day the man was seized with a fit of convulsions, followed by coma. These fits recurred in rapid succession, so that he had nearly thirty before his death at five p.m. on November 21. On examination of the body after death, the brain and its membranes were found to be normal, except that there was a con- siderable amount of fluid, which contained urea, at the base and lect. iv.] INFLAMMATION OF BILE-DUCTS. 139 in the lateral ventricles. The kidneys were considerably enlarged, arid there was much fatty and granular deposit in the secreting cells. The liver was large, and weighed 80 ounces; its secreting cells were loaded .with oil; the lobules were unusually distinct, giving a granular appearance to the organ on section. The gall- bladder contained a soft, black concretion, as large as a walnut, and many small, irregularly-shaped fragments of the same material. These were suspended in a small quantity of dark-green viscid fluid, which, on microscopic examination, was found to contain a large number of pus-corpuscles. The mucous surface of the gall- bladder had a stretched, white appearance, and at the fundus was deeply injected, granular, and excoriated. The bile-ducts contained a similar viscid fluid to that in the gall-bladder, with minute particles of black inspissated bile. This could be squeezed into the duodenum without much difficulty. The mucous membrane of the stomach and duodenum was minutely injected with numerous small ecchymoses, and the surface was coated with much viscid mucus. There was great oedema and congestion of both lungs. Fat was deposited in large quantity throughout the body, and all the soft tissues were deeply jaundiced. In the following case also the jaundice appears to have been due to inflammation of the biliary passages, which was subsiding before the patient's death. But the main interest of the case lay in the cause of enlargement; for although Rokitansky* speaks of hepatic tubercle occurring 'in the shape of semi- transparent, greyish, crude, miliary granulations, in which case it is more especially the product of acute tuberculosis,' tubercle has not usually been regarded as one of the causes of hepatic enlargement. Frerichs also mentions the occurrence of nodules of yellow tubercle in the liver, which may soften into vomicae; while other observers have noted contractions and * Path. Anat. Syd. Soc. Transl. vol. ii. p. 149. 140 ENLARGEMENTS OF THE LIVER, [lect. iv. dilatations of the fine bile-ducts from the deposit of tubercle in their walls.* Case XXX.—General Tuberculosis—Enlargement of the Liver from Tubercular Deposit—Jaundice from Catarrh of the Bile-ducts — Embolism of the Spleen. Mary C----, aged 40, was admitted into the Middlesex Hospital, under my care, on December 17, 1867. Her father and mother had both died at the age of 50, of some chest affection, and of eleven brothers and sisters all were dead but one, though the patient could not say of what they had died. The patient was extremely prostrate, and somewhat confused in her mind. So far as her history could be obtained, it was to the effect, that six months before she had lost her appetite, and vomited about half an hour after every meal. Two or three months after this she became jaundiced. She had not suffered from cough, haemoptysis, rigors, or night-sweats, but from the first she had lost flesh and strength. On admission there was jaundice of moderate intensity of the skin and conjunctivae, and the uriDe exhibited the renction of bile- pigment, and threw down a copious deposit of lithates, but con- tained no albumen. There was no itchiness of the skin ; tongue dry and brown, except at the edges, which were preternaturally red. The patient stated that up to the time of admission she had vomited almost everything within half an hour of swallowing it, but she did not vomit once after admission. A motion passed soon after admission was formed, and of a dark brown bilious colour. The hepatic dulness was increased, in the right mammary line measuring 5 inches, and extending fully an inch below the margin of the ribs. The portion below the ribs felt smooth and was slightly tender. Pulse 120, small and feeble; a faint systolic bellows' murmur at left apex of heart; temperature 100o,2. There was nothing to attract attention to the lungs, which in the patient's weak state were not examined. A large superficial bed- sore over sacrum. ' The patient was treated with bismuth, chloric ether, and stimu- lants, but she became rapidly more prostrate; low muttering de- * Frerichs' Dis. of Liv. Syd. Soc. Ed. ii. 220. lect. iv.] INFLAMMATION OF BILE-DUCTS. 141 lirium set in, the motions and urine were passed in bed, and death took place on December 23. Autopsy.—About a pint of clear serum was found in thg peri- toneum. The liver was very large and weighed 77 oz. Its capsule was not thickened or adherent. Its surface was generally smooth, but marked by numerous minute depressions and ele- vations. The glandular tissue was pale yellow and opaque, exactly like that of a fatty liver, from which it differed, however, in being remarkably firm and tough. On section, a little thin watery bile could be squeezed from the divided bile-ducts, many of which presented small dilatations. The gall-bladder contained a small quantity of a similar fluid, as well as numerous minute, black, gritty concretions. On microscopic examination it was ascertained by Dr. Cayley that the enlargement of the liver was mainly due to the presence of numerous miliary tubercles scattered through the glandular tissue between the lobules, and presenting all the structural characters of grey tubercle. The mucous membrane of the stomach was pale and normal, but immediately below the pylorus that of the duodenum, for about 8 inches, was intensely injected, tumid, and studded with numerous small granular punctated elevations, apparently enlarged solitary glands. The lining membrane of the common bile-duct was also very red, and the mucous membrane slightly swollen, but the passage was not obstructed. There were three small tubercular ulcers in the lower part of the ileum. Both lungs were studded with numerous grey miliary tubercles, and near both apices was a small patch of old grey tubercle. The edge of one of the flaps of the mitral valve was much thickened. There was no lymph at the base of the brain, and no tubercles in the pia-mater, but there was much serous fluid beneath the arachnoid and in the cerebral ventricles, and in the cavity of the arachnoid over both hemi- spheres was a thin film of extravasated blood. In the uterus there was a fibrous tumour as large as a cocoa-nut, and the position of the right ovary wa3 occupied by a tumour a3 large as an orange, partly solid, and partly breaking down into a soft cheesy material. The right Fallopian tube was as large as a finger, and filled with soft putty-like material; its lining membrane was rough and ulcerated, like that of the pelvis of the kidney in tubercular pyelitis. The spleen was large, and weighed 15^ oz.; it was very soft, and studded with numerous abscesses, from a pea to a hazel- nut in size, and containing thick yellow pus; there were also 142 ENLARGEMENTS OF THE LIVER, [lect. iv. several solid deposits in the spleen, having the character?, of recent embolism. The cortices of both kidneys were studded with minute yellow tubercular granules. The next form of enlargement of the liver, attended by pain and jaundice, to which I wish to direct your attention, is— VII. ENLARGEMENT FROM OBSTRUCTION OF THE COMMON BILE-DUCT BY CALCULI, TUMOURS, ETC. Obstruction of the common bile-duct may lead to enlargement of the liver in two ways. a. By causing dilatation of the biliary passages with accumulation of bile in them. But if the ob- struction be of long standing, the liver may ulti- mately contract to less than its natural size, its secreting tissue becoming atrophied from the pressure of the permanently distended bile-ducts. b. By inducing inflammation of the biliary pas- sages, associated with more or less congestion of the hepatic tissue. The distinguishing characters of the enlargement of the liver that occurs under such circumstances are as follows :— 1. The enlargement is rarely great, and, with one important exception, it is uniform in every direction. The exception referred to is due to the enlargement of the gall-bladder, which can often be felt as a pyriform tumour projecting from the lower margin of the liver. This enlargement is due, in the first place, to an accumulation of bile, but after a time not unfrequently to the admixture or substitution of lect. rv.] OBSTRUCTION OF BILE-DUCT. 143 inflammatory products. The late Dr. Bright has re- corded a case in which such an enlargement of the gall-bladder formed an oval tumour descending nearly to the crest of the ilium; and you have had an oppor- tunity of examining a similar though smaller tumour in the case of J. W----. (Case XXXI. and fig. 13.) 2. There is jaundice, which, if the cause of ob- struction be a gall-stone, like the pain about to be referred to, is often in the first instance paroxysmal, but by the time that the liver becomes enlarged is permanent and usually intense, and is accompanied by a total disappearance of bile-pigment from the motions. In cases of persistent jaundice, where from the colour of the motions it is clear that the flow of bile into the bowel has been cut off for many weeks, there can be little doubt that there is obstruc- tion of the common duct; and if the jaundice has been at first paroxysmal, the cause of that obstruction is probably an impacted gall-stone. But if there be no evidence of the jaundice having been paroxysmal, it may be difficult to say whether the obstruction be due to an organic obliteration of the duct at its duodenal opening from an ulcer or from a cancerous growth in the duodenum, or to a tumour in some other part of the course of the duct, or to pressure by a tumour on the duct from without. The rules for your guidance under these circumstances will be best considered when I come to describe the various forms of jaundice arising from obstruction of the common bile-duct. 144 ENLARGEMENTS OF THE LIVER, [lect. iv. 3. Pain and tenderness in the region of the liver, and particularly in the situation of the enlarged gall- bladder, are present in most cases. The pain is always greatest in those cases where there is catarrh of the biliary passages, or where the bile-duct is com- pressed by a tumour which at the same time com- presses and stretches the hepatic plexus of nerves. When the obstruction is due to the impaction in the duct of a gall-stone, there will usually be a his- tory of attacks of paroxysmal pain with the other phenomena of biliary colic. 4. The diagnosis will usually be assisted by the presence of those symptoms which mark the various morbid conditions producing obstruction of the bile- duct, and which will be considered hereafter under the head of Jaundice. The treatment of this form of enlargement of the liver, or rather of its various causes, will also be best considered under the head of Jaundice. In the meantime, I may recall to your recollection the following case, which has been under your observa- tion for some weeks, and which is a good illustration of enlargement of the liver and jaundice, apparently from gall-stones, except that the patient's age is considerably under that at which gall-stones are ordinarily met with. In this case also, the enlarge- ment of the gall-bladder and many of the other symptoms appeared to be due to catarrhal inflamma- tion of the bile-ducts and gall-bladder, excited by a gall-stone. lect. iv.] OBSTRUCTION OF BILE-DUCT. 145 Case XXXI.—Enlargement of Liver and Dilatation of Gall-bladder from Obstruction of Common Duct by a Calculus. John W----, aged 30, a stone-cutter, was admitted on Febru- ary 5, 1867. He had enjoyed good health until six months before he came to hospital, when he began to suffer from acute paroxysms of pain in the abdomen. For a week he would have several parox- ysms daily; then he would be free for a week, and during this in- Fig. 13 shows the enlargement of the Liver and the Tumour in the case of J. W.,on February 20. Compare this with Fig. 3, at p. 5. terval he would be able to resume his work. The attacks were not accompanied by vomiting, but the first was followed by jaundice, which has never left him. The paroxysms of pain continued to recur for six weeks, but subsequently to this he had none; he had suffered much, however, from flatulence and itchiness of the skin, and had lost flesh. On admission, there was universal jaundice of moderate intensity: the urine was loaded with bile-pigment, but the motions contained none. The hepatic dulness was mode- L 146 ENLARGEMENTS OF THE LIVER, [lect. iv. rately and uniformly increased, measuring five inches in the right mammary line. No tumour corresponding to the gall-bladder could be discovered, but possibly this was obscured by the flatu- lent distension of the bowels. There was no ascites. The tongue was moist, and but slightly furred. The patient's appetite was good, and he never vomited; but he was obliged to be very careful as to his diet, as he suffered much from flatulence and pain after eating. The pulse was 72. About a fortnight after the patient's admission he became much worse; and on February 20 it was noted that the jaundice was more intense, that the urine was darker, and that the hepatic dulness was increased, measuring fully 5| inches in the right mammary line. In addition, there was now in the situation of the gall- bladder a distinct tumour (see fig. 13), extending 1^ inch below the margin 'of the liver, and measuring 2| inches transversely. This was tender on pressure. The temperature had risen to 104°-2 F., and the pulse to 96. The tongue was somewhat dry, and the motions were perfectly devoid of bile. These symptoms continued, with occasional vomiting, for several days; but on February 25 the temperature had fallen to 990,2, and on the 27th to 97°. On March 1 the pulse was down to 72, and the tumour in the region of the gall-bladder had disappeared. On March 4 the motions contained abundance of bile, and the jaundice was fading. By the beginning of April the jaundice had almost disappeared ; and in May the patient was able to resume his employment. The motions were carefully searched for gall-stones for ten days subsequent to February 24, but none were found. Possibly a gall- stone may have either become disintegrated, or slipped back into the gall-bladder. During the acute stage the patient was treated with alkalies, ammonia, ether, belladonna, and opium. During convalescence, strychnia appeared to relieve the flatulence, and the disappearance of the jaundice was encouraged by warm baths and diaphoretics. lect. v.] PY.EMIC ABSCESSES. 147 LECTUEE V. ENLARGEMENTS OF THE LIVER. PYJEMIC ABSCESSES—TROPICAL ABSCESS. Gentlemen,—The first form of enlargement of the hver to which I desire to draw your attention to-day is that due to VIII. PTiEMIC ABSCESSES. The abscesses which are often developed in the liver in the course of pyaemia are for the most part many in number and small, and in these respects they differ from the tropical abscess, which is usually single, and often attains a large size, so as to form a distinct tumour. The clinical characters vary in ac- cordance with this anatomical difference, and with the different conditions under which the hepatic disease occurs. Those of the pysemic abscess are as follows :— 1. There is enlargement of the liver,' usually of moderate extent, but sometimes so great that the lower margin of the organ reaches to the umbilicus. 2. The enlargement is uniform in every direction, and does not produce any bulging of the ribs. In exceptional cases only, one of the abscesses enlarges L 2 148 ENLARGEMENTS OF THE LIVER, [lect. v. somewhat more than the others and forms a small bulging tumour at the epigastrium; and in cases of still rarer occurrence, the lower margin of the liver, as felt through the abdominal parietes, has a nodu- lated character, from the presence of several small abscesses or inflammatory deposits along its free margin. 3. No fluctuation can be felt in the enlarged liver. The abscesses are rarely large enough to admit of this. Only in those rare cases where one of the abscesses enlarges so as to form a bulging in the epigastrium, or where a small quantity of pus be- comes encysted between the liver and abdominal wall (Case XXXIV.), is anything approaching to fluctua- tion perceptible. 4. Pain and tenderness are always present. They are often among the first symptoms noted, and are usually acute in consequence of inflammatory action being propagated from certain of the abscesses to the superimposed peritoneum. The pain is often increased by coughing or by a long inspiration, so that in consequence the respirations are quick and short, and mainly thoracic. 5. Jaundice is present in the majority of cases—in fully four-fifths; but the possibility of its absence must be kept in view in diagnosis. The intensity of the jaundice varies. In most cases it appears to be due to the morbid condition of the blood to which the term pyaemia is applied, just as jaundice is known to result from many other blood-poisons, and then lect. v.] PYEMIC ABSCESSES. 149 it is usually slight, and the motions are still tinged with bile-pigment; but if the pyaemia arise from an ulcer of the biliary passages, excited by the pressure of an impacted gall-stone, the jaundice may be in- tense and the excrement devoid of bile-pigment. 6. Pysemic abscesses of the liver rarely interfere with the portal circulation. Accordingly there is no enlargement of the veins of the abdominal parietes, and only in exceptional cases (from implication of a large branch of the vein), ascites. The spleen, it is true, is usually enlarged, but this is due not so much to obstructed circulation as to the tendency of the spleen to enlarge in consequence of the morbid con- dition of the blood, as happens in the course of many diseases arising from a blood-poison. Occasionally fluid is thrown out into the peritoneum as the result of peritonitis. 7. The constitutional symptoms are important in diagnosis. They are mainly those of hectic fever, with increased temperature, emaciation, progressive prostration, and a tendency to vomiting, diarrhoea, and the ' typhoid state.' Eigors and profuse perspi- rations during sleep are common, and afford material assistance in diagnosis; but it is well to remember that they are not necessary symptoms. The rigors occasionally recur at such regular intervals that the attack simulates ague; errors in diagnosis are con- stantly committed from this fact not being remem- bered (Case XXXIII.). On the other hand, the possibility of rigors resulting from the mere passage 150 ENLARGEMENTS OF THE LIVER, [lect. v. of a gall-stone must not be lost sight of. As the disease advances, symptoms of blood-poisoning, such as a dry brown tongue and delirium, make their appearance. 8. The course of the disease is rapid, usually rang- ing from two or three weeks to three months. I have never known the latter limit exceeded. This rapid course may be of service in diagnosing cancer, in which the duration is more protracted, from pysemic abscess of the liver. 9. The diagnosis will also be assisted by keeping in view the circumstances under which the disease usually occurs. Among them the following hold a prominent place:— a. External injuries and surgical operations. When symptoms like those above described follow either of the causes now mentioned, there need be no difficulty about the diagnosis. The most of the cases, how- ever, which come under the care of the physician depend upon internal causes, and then the difficulty of diagnosing is increased. b. Ulceration of the stomach or intestine. I have repeatedly known pyaemic abscess of the liver super- vene on simple ulcer of the stomach, and shall relate to you immediately the particulars of a case where this occurred. The same condition of liver may follow simple ulceration of any portion of the intes- tine, or even cancerous ulceration of the stomach or bowel. Pyaemic deposits in the liver, however, only occur in exceptional cases of intestinal ulceration, lect. v.] PYEMIC ABSCESSES. 151 probably for the same reason that general pyaemia only occurs in exceptional cases of external injury (see pp. 162-3). c. Ulceration of the gall-bladder or of the bile- ducts may give rise to pyaemic abscesses of the liver, which in this way may be a sequel of gall-stones. I shall narrate to you presently a case where what appeared to be an ordinary attack of biliary colic was followed by fatal inflammation of the liver (Case XXXV.). When the common bile-duct also is ob- structed by a gall-stone or from any other cause, the ducts in the interior of the liver may become dilated into irregular cavities full of pus, and give rise to many of the symptoms of pyaemia. d. In a former lecture I brought before your notice two instances in which a suppurating hydatid cyst appeared to be the starting-point of pyaemic abscesses in the liver (see pp. 99 and 100). e. Lastly, any suppurating ulcer or cavity on or near the outer surface or in the interior of the body, espe- cially if in connection with diseased bone or commu- nicating with the external atmosphere, may induce pyaemia with secondary deposits in the liver. On more than one occasion, for instance, I have found these deposits in the liver resulting from a tubercular vomica in the lungs, ulcerative endocarditis, pyelitis, &c. When the signs and symptoms already enumerated supervene on those of any of the maladies now re- ferred to, the probability of pyaemic abscess of the liver ought at once to suggest itself. But occasionally 152 ENLARGEMENTS OF THE LIVER, [lect. v. the primary disease is latent, and the first symptoms are those of inflammation of the liver. Even then, however, the probability of pyaemic abscess ought to suggest itself in English practice, inasmuch as, with extremely rare exceptions, this is the only form of hepatic abscess met with in this country in persons who have never been abroad. Treatment.—In pyaemic abscess of the liver, medical art, it is to be feared, is powerless to avert the fatal result, and can only mitigate the patient's suffering. 1. By hygienic arrangements, by the local use of carbolic acid in open sores and wounds, and by evacu- ating decomposing pus pent up in any part of the body, much can be done in the way of preventing general pyaemia in surgical injuries; but, unfortu- nately, in a large number of cases of pyaemic abscess in the liver that come under the physician, the primary disease is inaccessible. 2. Depletion, both general and local, is contra- indicated ; but if the pain be very acute it will often be materially relieved by the application of a few leeches to the region of the liver. Mustard and linseed poultices are also useful for relieving the pain. 3. Professor Polli, of Milan, has of late years written strongly in favour of the sulphites of potash and soda as antidotes for the pyaemic poison. The power which these substances possess of arresting putrefaction or fermentation out of the body it is believed that they can exercise in the living blood. I have tried them repeatedly, and I regret to say lect. v.] PYEMIC ABSCESSES. 153 that in my practice they have signally failed. They may be given in doses of twenty or thirty grains every four hours. 4. Quinine and mineral acids have appeared to me to be the remedies most generally useful. They sup- port the patient's strength, keep the tongue moist, and tend to diminish the profuse sweating. 5. Opium or morphia in repeated doses will be necessary in most cases to relieve pain or procure sleep. If there be much retching, the subcutaneous injection of morphia will be preferable to administer- ing opiates by the mouth. 6. The treatment must often be modified in such a way as to counteract various distressing symptoms which are apt to arise, and more especially vomiting and diarrhoea. For the vomiting, the best remedies are ice, bismuth, effervescing alkaline draughts, and the application to the epigastrium of sinapisims or of a small blister, followed by the sprinkling of a quarter of a grain of morphia on the blistered surface. For the diarrhoea you must have recourse to vegetable and mineral astringents, and particularly the acetate of lead and morphia, and opiate enemata and suppo- sitories. 7. The diet must be of as nutritious a character as is compatible with the patient's digestive powers. It ought to consist of such articles as milk, beef-tea, and eggs, given frequently, but in small quantities at a time. In most cases it will be necessary to give small quantities of wine or brandy, which ought to be well diluted. 154 ENLARGEMENTS OF THE LIVER, [lect. v. I shall now proceed to relate to you the particulars of a few cases in illustration of the foregoing remarks. In the first case the hepatic disease was the result of an external injury. Case XXXII.—Injury of Cranium, followed by Pyosmia and Multiple Abscesses in the Liver. Thomas D----, aged 21, was admitted into one of the surgical wards on August 16, 1867, with lacerated wounds of the scalp, a fracture of the sixth left rib, and a bruise of the left shoulder- injuries which he had received from being run over by a cab. He had so far recovered that on September 3 he was able to be out in the garden; but on the same day he was seized with rigors, fol- lowed by febrile symptoms, headache, and loss of appetite. During the next two days he had several attacks of severe rigors, like those of ague, followed by moderate perspiration and frequent vomiting. When he first came under my care, on September 6, he had all the symptoms of blood-poisoning, but without any eruption on the skin. Pulse 120; respirations 36; temperature 103°. Alternate fits of chilliness and perspiration. Countenance heavy and de- pressed; great lassitude; throbbing headache, but mind quite clear; great prostration, and tendency to syncope on sitting up; frequent retching, with tenderness in the epigastrium and right hypochondrium. The tongue was moist, and but slightly furred. The bowels had been freely opened by medicine. The cardiac and respiratory signs were normal. The urine contained a small quantity of albumen, with blood-corpuscles and epithelial casts of the uriniferous tubes. A wound in the left temporal region of the scalp was found covered with a hard scab, from beneath which about a teaspoonful of dirty, not fetid, pus could be squeezed. Soon after the patient's admission he became very restless and delirious; there was no paralysis, but the hearing was preter- naturally acute. The tongue became dry and brown, and there was frequent vomiting with a tendency to diarrhoea. The tenderness in the epigastrium and right hypochondrium continued, and the hepatic dulness became much increased, extending down almost to the umbilicus. The surface of the organ felt smooth. The skin was sallow, but there was no decided jaundice. The patient was treated mainly according to the plan recom- lect. v.] PYEMIC ABSCESSES. 155 mended for pysemia by Professor Polli, of Milan, with large doses of sulphites. Sulphite of soda was given in doses of fifteen grains every four hours. No improvement, however, was observed; and the symptoms above noted continued almost till death, at 9-45 p.m. on September 9. On examination of the body after death about a square inch of bone, corresponding to the wound in the scalp, was bare and dis- coloured. The bone appeared scratched on the surface. It was not fractured; but between its under surface and the corresponding dura-mater there was about a drachm of pus. The veins leading from this to the longitudinal sinus contained pale, soft, non- adherent coagula. The liver was very large, extending down to the umbilicus, and weighing 104 ounces. Its tissue was dark and intensely injected, and riddled with innumerable pyaemic deposits breaking down into pus, from the size of a pin's head up to that of a walnut. The spleen was large, weighed 10J ounces, and was dark and firm, but contained no infarctions. Both kidneys were much enlarged, weighing together 18£ ounces. Their surfaces were smooth, and the capsules non-adherent. The cortical sub- stance was greatly hypertrophied and deeply injected, but was free from pyaemic deposits. The sixth left rib was fractured at about two inches from the cartilage. The edges overlapped, and were enveloped in callus; but there was no trace of laceration of the lung, or of pleurisy—old or recent—in the neighbourhood. There were slight traces of recent pericarditis, and numerous minute ecchymoses beneath the pericardium. In the second case the hepatic inflammation fol- lowed a simple ulcer of the stomach. Case XXXIII.—Multiple Abscesses in the Liver Secon- dary to Simple Ulcer of Stomach.* John P----, aged 51, was admitted into the London Fever Hospital on October 6, 1865. For six weeks he had been suffering from pain, tenderness, and flatulence in the abdomen after food, followed occasionally by vomiting. He had suffered from similar symptoms on former occasions, but had always recovered. The * A second case of a similar nature is recorded by me in the Path. Trans, vol. xvii. p. 146. 156 ENLARGEMENTS OF THE LIVER, [lect. v. hepatic dulness was A\ inches in the right mammary line. There was no jaundice. Pulse 84. Bismuth and a milk diet were pre- scribed. Three days after admission it was noticed that the patient had a daily febrile accession about one p.m. ; and it was ascertained that twenty-two years before (but never since then) he had suffered from ague in Kent. Quinine was accordingly administered in large doses. It had no effect, however, on the paroxysms. On the contrary, they became more severe, came on at irregular intervals, and were followed by profuse perspirations and great prostration. The tongue also became dry and brown, the pain and tenderness at the epigastrium were greatly increased, and the bowels became very loose. On October 16 it was noted that he was much lower and greatly emaciated, and that the skin and conjunctivae had a decidedly jaundiced tint, although the motions contained plenty of bile. The hepatic dulness in the right mammary line was now 5^ inches; but the enlargement was uniform, and free from nodu- lation. There was considerable tenderness on pressure below the lower margin of the right ribs. The splenic dulness was increased. Pulse 96; temperature 101°. The symptoms above narrated became gradually aggravated. He still had irregular paroxysms of rigors, followed by fever and sweating. On October 21 the jaundice was noted as deep, although bile was still present in the motions. The mind was slightly confused, and he had occasional low delirium. He gradually sank, and died on October 24. On post-mortem examination, near the pyloric end of the stomach, on its lower and posterior surface, was a circular ulcer the size of a crown-piece, with its edges slightly elevated and indurated, but containing none of the microscopic elements of cancer. From the base of this ulcer a small fistulous channel passed into an abscess, almost the size of a walnut, in the head of the pancreas. The liver generally was enlarged, and weighed 81 ounces; the posterior half of the right lobe was studded with minute abscesses, from the size of a pin's head up to that of a pea, containing thick yellow pus. The intervening hepatic tissue was very hyperaemic. There was no peritoneal inflammation over the surface of the liver. The spleen was large, dark, and firm. The other organs were healthy. In the next case a cancerous ulcer of the stomach appeared to be the exciting cause of the disease in lect. v.] PYEMIC ABSCESSES. 157 the liver. The case has additional interest from the fact that there was a small fluctuating tumour at the epigastrium caused by a circumscribed collection of pus between the liver and abdominal parietes. Case XXXTV.—Cancerous Ulcers of the Stomach followed by Pyemic Abscesses of the Liver. In June 1867 I was requested by Dr. Rogers, of Dean Street, to see a patient under his care. He was a man, aged 45, whose father and sister were said to have died of cancer. For several months he had been losing flesh, and had suffered pain after food, and other symptoms of indigestion, but not vomiting. About May 19 his symptoms became worse, and he first consulted Dr. Rogers. He then began to suffer from a constant pain in the right side, febrile symptoms, dyspnoea, and a frequent dry cough, and on May 23 and again on the 28th he had severe attacks of vomiting. About June 2 a slight swelling was first noticed in the epigastrium, and he became slightly jaundiced, and when I saw him on June 8 with Drs. Anstie and Rogers, there was considerable jaundice, with great emaciation and prostration. The pulse was quick and feeble, and there was a tendency to nocturnal perspiration, but no rigors. The tongue was moist, clean, and red; there was no vomiting or diarrhoea, and the motions contained bile. The liver was much enlarged, and in the epigastrium there was a very painful promi- nent tumour, about the size of half an orange, extremely elastic, and indeed apparently fluctuating. An exploratory puncture was made into this tumour, but only a few drops of blood came away. The patient became daily more emaciated and prostrate; the tongue became dry and brown, and the jaundice increased; although the stools still contained bile-pigment. On June 24 he died from ex- haustion. Throughout there had been no rigors, and only slight perspiration during sleep. On examining the body the liver was found of almost twice the normal size; there were signs of recent peritonitis over its outer surface; the glandular tissue was extremely congested, and was studded with inflammatory (not cancerous) deposits up to the size of a walnut, which were pale yellow, granular, and very friable, but which had not yet softened into pus. Between the left lobe and the abdominal wall there was about an ounce of pus circum- 158 ENLARGEMENTS OF THE LIVER [lect. v. scribed by firm adhesions. This accounted for the fluctuating tumour felt during life; the fine trocar had probably passed through the abscess into the liver, and thus no pus had been obtained by the puncture. On opening the stomach an ulcer was found about 2 inches from the pylorus; the edges and base of this ulcer were indurated from what the microscope showed to be cancerous tissue, and the surface of the ulcer was ragged and sloughy. The next case which I shall refer to is that of a lady, 23 years of age, whom I saw in consultation with the late Mr. Young, of Sackville Street, in No- vember and December 1861. It affords an illus- tration of pyaemic abscesses of the liver supervening on gall-stones. Case XXXV.—Attacks of Biliary Colic followed by Pywmic Abscesses in the Liver. On November 30, 1861, I was called to see Mrs.----, aged 23 who had been married only four or five months. Two years before she had suffered for several weeks from jaundice, with severe attacks of biliary colic. Ten days before I saw her the jaundice had re- turned, and during the same period she had been suffering from severe paroxysms of pain in the right hypochondrium, often accom- panied by vomiting. Although, notwithstanding the patient's age, her history was clearly one of. gall-stones, yet, after making allow- ance for her hysterical temperament, the symptoms led to the sus- picion that there was something more. The pulse was 100, and there was an unusual amount of tenderness in the region of the liver and particularly in the situation of the gall-bladder. The hepatic dulness was increased; there was also great increase of the splenic dulness. The jaundice was of moderate intensity; and the motions, though very pale, were not entirely devoid of bile-pigment! Leeches, followed by warm fomentations, were applied to the right hypochondrium, and repeated doses of opium were prescribed. During the first week in December the patient had frequent attacks of vomiting, and on the 4th she miscarried, at the third month. After this she became much worse. She had repeated attacks of rigors, lasting for half an hour or more, and often lect. v.] PYEMIC ABSCESSES. 159 followed by the involuntary discharge of light-yellow fluid from the bowels. She had also frequent and severe paroxysms of retching, and the pain in the right side became so intense that she could not take a long inspiration without crying out. The patient was never free from pain and tenderness in the region of the duo- denum, but the intense pain was decidedly paroxysmal; sometimes, but not always, the paroxysms seemed to be induced by the patient moving or taking a long inspiration. The pulse varied from 100 to 120; the cheeks were flushed, but there were no perspirations; the patient suffered much from thirst, but even fluids were at once rejected from the stomach. The jaundice diminished; the motions always contained bile, and at last were almost natural in appear- ance. All treatment failed to give relief; she became rapidly emaciated, and was occasionally delirious during the night; and towards the end the tongue was dry and brown, and sordes col- lected on the lips and teeth. Death took place on December 23. On post-mortem examination the liver was found to be large, and the entire substance of both lobes studded with an immense number of circumscribed abscesses, varying in size from a pea to a small orange, and filled with yellow flaky pus. The outer surface was glued by recent lymph to the diaphragm and adjoining organs. The hepatic and common ducts were pervious, and contained bile. The gall-bladder was collapsed, its cavity being scarcely larger than a hazel-nut, and its coats much thickened. A gall-stone, somewhat larger than a pea, was found impacted at the com- mencement of the cystic duct, and the mucous membrane in contact with the concretion was ulcerated, and partly converted into a blackish slough. Beyond this the cystic duct was oblite- rated. The gall-bladder contained about a dozen calculi of smaller size, but no bile. The fundus of the bladder was firmly adherent to the duodenum, and between these two viscera was a closed cavity containing gall-stones equalling in size and number those found in the gall-bladder itself. The corresponding mucous surfaces of the duodenum and of the gall-bladder were marked by an extensive cicatrix. These appearances were probably the result of a direct passage of gall-stones through the fundus of the gall- bladder into the bowel in the attack two years before death. The mucous membrane of the first three inches of the duodenum was intensely injected, but not ulcerated. The inner surface of the stomach and intestines presented nothing abnormal. The spleen was four times its normal size. In addition to the coating 160 ENLARGEMENTS OF THE LIVER, [lect. v. of recent lymph, the capsule of the liver at several places presented old thickening and firm adhesions. The right lung and pleura were normal. Case XXXVI. was remarkable for the large size attained by the liver, and for the absence of any cause of the hepatic inflammation, excepting the softening tubercle in the mediastinal glands. Case XXXVI.—Multiple Abscesses of the Liver—Soft- ening Tubercle in Mediastinal Glands. Ann C----, aged 57, a cook, was admitted into the Middlesex Hospital under my care on January 13,1868. Her father and mother had both lived to upwards of 80, and, with the exception of an um- bilical hernia and a great tendency to vertigo, she herself had always enjoyed good health until her present illness, which commenced a week before Christmas with acute pain in the region of the liver, stretching round the back to the left side. This pain was accom- panied by febrile symptoms, loss of appetite and sleep, and by a swelling and tightness in the upper part of the abdomen, which increased daily. On January 5, her face and eyes had been noticed to be slightly yellow. On admission the patient was an extremely corpulent woman, whose skin and conjunctivae presented a slightly jaundiced tint, and who was so weak as to move her great bulk with difficulty in bed. The abdomen was enormously enlarged, measuring 53 inches at the umbilicus. There was moderate oedema of both lower extremities; but no distinct thrill of fluid could be detected in the abdomen, and percussion yielded a clear sound in both flanks. The great size of the abdomen appeared due partly to an enormous subcutaneous deposit of fat, and partly to enlargement of the liver, which measured 9 inches in the right mammary line, and which reached fully 5 inches below the margin of the right ribs. So far as an examination could be made through the thickened abdominal parietes, the enlargement of the organ appeared to be uniform in every direction, and its surface was hard and smooth. On pressure over it there was decided tenderness, and a pain shooting from the point of pressure to the back. The tongue was dry and red down the centre ; much thirst; no vomiting, and bowels regular. Pulse lect. v.] PYEMIC ABSCESSES. 161 108. Heart's sound very feeble, but no bellows-murmur. Re- spirations embarrassed and thoracic; sonorous rales at bases of both lungs. Urine of a dark amber colour, with a copious deposit of lithates, but containing no albumen. Mind clear. Tempe- rature 98° Fahr. The patient was ordered the day after admission a draught containing a drachm of sulphate of magnesia three times a day, but on January 15, after three doses, the bowels were so purged that a mixture of nitro-hydrochloric acid and gentian was substi- tuted. The diarrhoea, however, persisted, the motions being watery and dark-brown ; the tongue continued dry, the tempera- ture rose to 101o,4; on the nights of January 17 and 18, the patient had much low delirium; and in the afternoon of January 19, she died suddenly by syncope while attempting to get out of bed. Autopsy.—The layer of fat at some parts of the abdominal parietes measured fully 4 inches in thickness. The peritoneum contained about three pints of turbid serum, with small flakes of lymph. The liver was enormously enlarged, its lower margin pro- jecting about 5 inches beyond that of the right ribs. It weighed 256 ounces, and was studded throughout with innumerable minute abscesses, the projection of which from the outer surface gave to this a coarsely granular aspect. The portions of hepatic tissue which remained were in an advanced stage of fatty degeneration, but there was scarcely a quarter of an inch of the organ free from gurulent deposit. The gall-bladder was much distended with innumerable black polygonal concretions, from the size of a small cherry to that of a grain of sand. The majority were small, and re- sembled the grains of coarse gunpowder. The larger ones were found on section to be white internally, and to be composed of cholesterine. The common bile-duct was patent, and after careful examination, no ulceration could be discovered in the lining membrane of the gall-bladder or of any of the ducts, nor in the mucous membrane of the stomach or intestines. There was no pus in the portal vein or embolism of the hepatic artery. The spleen was large and soft. The kidneys were rather large and pale, but appeared normal. The right Fallopian tube was dilated into a cyst the size of an orange, containing a dark thin fluid, and with several small vege- tations attached to its lining membrane. There was a fibrous tumour the size of a walnut in the walls of the uterus. At the apices of both lungs there were old tubercular cicatrices, but no M 162 ENLARGEMENTS OF THE LIVER. [lect. v. cavities, and in the anterior mediastinum were two or three collections of pus, formed by suppuration of tubercular lymphatic glands. The heart was pale, flabby, and friable, and in an advanced stage of fatty degeneration. IX. TROPICAL HEPATITIS AND ABSCESS OF THE LIVEE. The pathology of tropical abscess of the liver has been a subject of much discussion, and one on which opinions are still divided. The frequent coexistence in the tropics of abscess of the liver with dysentery has naturally led pathologists to connect the two lesions, some, like Annesley, maintaining that the dysentery is the result of the hepatitis, others that the hepatitis is the result of the dysentery, while a third class, like Dr. Abercrombie, have suggested that the frequent concurrence of the two maladies is merely the result of accident. The doctrine which is now most generally accepted is that propounded more than twenty years ago by Dr. G-. Budd, viz. that the hepatic inflammation is the result of puru- lent absorption from the ulcerated colon, or in fact that the pathology of tropical abscess is identical with that of the pyaemic abscess of this country.* Considering how frequently in this country abscess of the liver is secondary to ulcers of the stomach or bowels, or other sources of purulent absorption, it would indeed be extraordinary if dysenteric ulceration of the colon never led to a like result, as some have contended. The fact that fatal dysentery with ulce- * Dig. of Liver, 3rd ed. p. 82. lect. v.] TROPICAL ABSCESS. 163 ration uncombined with hepatic abscess is a common occurrence in India is no argument against hepatic abscess occasionally resulting from dysentery, any more than that, in Europe, pyaemic abscess only occurs in exceptional cases of intestinal ulceration, or of the other sources of purulent absorption already enumerated. Something more than an open sore is necessary for the formation of pyaemic deposits. The discharges from the sore must be in a peculiar state of decomposition. The causes of this decomposition may vary, but where there is no such decomposition there is no pyaemia. But a large number of the abscesses of the liver met with in tropical countries cannot be ascribed to dysentery, or to a pyaemic origin, or to mechanical injury. Fourteen years ago, I stated that this was the result of my observations on the diseases of Burmah,* and the facts, which have since been pub- lished by Morehead,f Bristowe,J Frerichs, § and others, appear to me to be perfectly conclusive on the matter. These facts are of a threefold nature. 1. Cases are not uncommon in tropical countries where there has been abscess of the liver, and where the patient has recovered without any symptoms of dysentery before, during, or after the hepatic malady. * Observ. on the Climate and^Diseases of Burmah. Edin. Med. and Surg. Journ. 1854, pp. 245-7. f Eesearches on Diseases in India, 1856, ii. p. 10. % Path. Trans. 1858, ix. p. 250. § Frerichs, Treatise on Dis. of Liver, Eng. Ed. ii. p. 116. m 2 164 ENLARGEMENTS OF THE LIVER. [lect. v. I shall give you the particulars of such a case imme- diately (Case XL.). 2. In not a few cases where there has been a con- currence of hepatic abscess and dysentery, the sym- ptoms of the former malady have preceded those of the latter. A case of this sort was recorded by me in the eighth volume of the ' Pathological Transac- tions' (p. 237), and similar cases are referred to by Morehead, Waring, and Bristowe. It may perchance be argued that in the cases in- cluded under these two heads dysenteric ulceration was really present, but that its symptoms were latent. Dr. Dickinson, for instance, has recorded a case where extensive dysenteric ulceration and a large abscess of the liver were found after death without any symptoms during life to lead to a suspicion of either malady.* But although such an explanation may apply in a few exceptional cases it is obviously inap- plicable to such results as those obtained by Mr. Waring, who states that of 300 cases of hepatic abscess proving fatal in India, in only 82 cases, or 27*3 per cent., was the hepatitis preceded by symptoms of dysentery, f 3. The most conclusive cases, however, are those in which the patient has died of hepatic abscess, and no sign of dysenteric ulceration has been found after death. I shall give you immediately the details of a case of this sort, in which, it is important to add, * Path. Trans. 1862, vol. xiii. p. 120. t An Enquiry into the Statistics and Pathology of Abscess of the Liver. Trevandrum, 1854. lect. v.] TROPICAL ABSCESS. 165 there had been a considerable amount of diarrhoea during life (Case XXXVII.). Morehead has de- tailed ' 17 cases in which there was abscess of the liver without intestinal ulceration,' * while in 204 cases of abscess of the liver collected by Waring there were no ulcerations, cicatrices, or abrasions in 51, or in exactly one-fourth, t It is clear, therefore, that although dysenteric ulceration of the bowel may occasionally lead to pyaemic deposits in the liver similar to those met with in this country, many cases of tropical abscess are independent of such an origin. It appears to me that the etiology of hepatic abscess may receive further elucidation from an anatomical point of view. The abscesses of the liver which are met with in this country, and which are the result of purulent absorption, are usually, if not always, small, but numerous. On the other hand, in most cases where abscess of the liver is met with in the tropics, there is but one abscess which attains to large di- mensions, or in exceptional cases there may be two or three. Abscesses of the liver, answering to this description, are almost unknown in this climate or in temperate climates generally, except in persons who have sustained some local injury of the liver, or who have at one time resided in the tropics—an extraor- dinary fact, if its cause be the same as that of multiple abscesses. Accordingly I have proposed to designate this, the Tropical Abscess, to distinguish it from the * Op. cit. ii. p. 12. t Op. cit. 1G6 ENLARGEMENTS OF THE LIVER. [lect. v. Pyemic Abscess, which is the common form in this country. The experience, however, of Indian practitioners shows that multiple abscesses of the liver are not unknown in the tropics; but, so far as I have been able to ascertain, this form is never met with except in connection with dysentery, or some other source of purulent absorption. The true tropical abscess may also coexist with dysentery, but from the large number of cases in which both dysentery and hepatic abscess are independent of each other, it follows that when they coexist, they are either the effects of a common cause, which in certain persons will produce either of the diseases separately, or of a concurrence of causes which individually will cause only one of the diseases. Supposing, for example, what is pro- bably the truth, that dysentery is the result of ma- laria or of contaminated water, and that hepatitis may be caused by a chill in a person whose liver has been congested by residence in a hot climate, aided by irritating ingesta and exposure to malaria (see p. 124), it is readily conceivable that in a country like India where these causes so often operate simul- taneously, attacks of dysentery and hepatitis—com- bined as well as separate—should not be uncommon. The distinction drawn above between pyaemic and tropical abscess is far from being one merely of pa- thological curiosity; it has a most important bearing both on prognosis and treatment. The pyaemic abscess is much the more serious and fatal malady of the lect. v.] TROPICAL ABSCESS. 167 two ; recovery from it, rarely, if ever, occurs. The tropical abscess again is not unfrequently recovered from, and it may burst into the pleura, the lung, the peritoneum, the stomach, the bowel, or externally— accidents to which the pyaemic abscesses are not liable ; and lastly, one of these natural modes of ter- mination of the tropical abscess may be occasionally advantageously imitated by the surgeon, who evacu- ates the abscess by an external opening—a procedure which would obviously be worse than useless in the pyaemic abscess. It follows therefore that it is of considerable practical importance to be able to dis- tinguish during life between the pyaemic and the form of tropical abscess. The characters of the former have been already detailed; those of the latter remain to be considered. They are as follows:— A. In the early stage of the disease, the main cli- nical features are those of hepatic congestion already described (see p. 120). There is pyrexia ushered in with chilliness, often of a remittent character, and accompanied by pain and tenderness, or a feeling of weight and uneasiness in the region of the liver, and occasionally by pain in the right shoulder, defective respiratory movement of the right ribs, a uniformly augmented area of hepatic dulness, and slight jaundice. The enlargement, however, is on the whole less, and the jaundice of rarer occurrence, than in the congestion of the liver resulting from disease of the heart or lungs. This is due to the circumstance that the branches of the portal vein, 168 ENLARGEMENTS OF THE LIVER. [lect. v. which are gorged in the latter case, are much larger than those of the hepatic artery, which are the main seat of the congestion that precedes the formation of abscess. B. When the inflammation goes on to suppuration, which, unless it terminate previously by resolution, usually occurs at the end of a week or twelve days, the characters are as follows :— 1. There is enlargement of the liver, which is no longer uniform. The natural outline of the area of hepatic dulness is altered, and will bulge upwards, downwards, forwards, or outwards, according to the direction which the abscess takes in each case (see fig. 14, page 181). Not unfrequently there is a bulg- ing of the ribs, with obliteration of the intercostal spaces, or there is a prominence in the epigastrium, or in the right hypochondrium, such as occurs in hydatid tumours. 2. This bulging or tumour is tense, rounded, smooth, and free from any inequalities. In the advanced stage, however, of exceptional cases, the margin of the enlarged liver may be nodulated from the de- velopment in it of small secondary pyaemic abscesses. 3. Fluctuation can usually be detected in the tu- mour, which will be more or less distinct according to the distance of the abscess from the surface. The feeling of vibration, however, which can often be appreciated on tapping with the finger over an hydatid tumour (page 55), cannot be elicited in an abscess, owing to the greater thickness of its con- lect. v.] TROPICAL ABSCESS. 169 tents. Another distinctive character of abscess is, that the fluctuation is usually surrounded by a mass of inflammatory hardness. 4. Pain and tenderness are present in most cases. The pain, however, is dull and heavy, and is rarely of that acute character, in the first instance, at all events, so common in the pyaemic abscess. This is because the abscess is usually at first in the interior of the liver. The pain only becomes acute, and the tenderness great, when the matter approaches the surface and excites peri-hepatitis, or stretches the integuments. Some cases are remarkably latent, as far as pain is concerned, throughout their whole course, while in others pain is only produced when the patient takes a long breath, and at the same time pressure is made below the margin of the ribs. A sympathetic pain in the right shoulder is not un- common, when the abscess is situated on the convex surface of the right lobe; but in the majority of cases it is absent. The presence of pain in the shoulder will undoubtedly increase, although its ab- sence will not diminish, the importance of other symptoms. 5. Ascites, oedema of the lower extremities, en- largement of the superficial veins of the abdomen, and haemorrhoids are not distinguishing characters of tropical abscess, any more than of hydatid of the hver. Their occurrence in rare cases is accidental, and due to compression by the tumour of the trunk of the portal vein or of the inferior vena cava. Oc- 170 ENLARGEMENTS OF THE LIVER. [lect. v. casionally fluid is thrown out into the peritoneum as the result of peritonitis. 6. Enlargement of the spleen is rarely present in tropical abscess. 7. Jaundice is a much rarer symptom in the tropical than in the pyaemic abscess. Its occurrence, in fact, if we except a slight icteric tint during the primary stage of congestion, is quite exceptional. Morehead has noted it in only five out of upwards of 120 cases.* When it occurs, it has mostly a mechanical origin, and is due to the concurrence of catarrh of the bile- ducts, or to the direct compression of the large ducts by the abscess. 8. The constitutional symptoms are important, as serving to distinguish the tropical abscess from hy- datid tumour. After the occurrence of suppuration, they are mainly progressive emaciation and fever of the hectic type. Rigors and night-sweats, however, are less prominent than in the pyaemic abscess. The tongue in many cases is preternaturally red, and more or less coated with aphthae; diarrhoea is not uncommon; the urine is high-coloured, and throws down a copious sediment of lithates or lithic acid; and often there is a short dry cough. 9. The duration of tropical abscess of the liver is a matter of some importance in diagnosis. Whether fatal or not, it rarely lasts more than six months after the occurrence of obvious swelling, yet on the whole the course of the disease is less rapid than that of the pyaemic abscess. Cases, too, have been known * Res. on Dis. in India, 1860, p. 373. lect. v.] TROPICAL ABSCESS. 171 where a small tropical abscess with organized walls has existed for months, or even perhaps for years, in a quiescent form,"and has then undergone enlarge- ment and burst. Some of the cases met with in this country, where a large abscess forms in the livers of persons years after their return from India, admit perhaps of this explanation. 10. The circumstances under which ' tropical ab- scess' occurs, its frequency in the tropics, and its extreme rarity in temperate climates, except in per- sons who have visited the tropics, may sometimes be of material assistance in its diagnosis. 11. The diseases most likely to be confounded with tropical abscess are hydatid tumour, inflammatory enlargement of the gall-bladder, pyaemic abscesses, and abscess of the abdominal parietes (see p. 20). a. An hydatid of the liver is the enlargement most likely to be mistaken for abscess. In both there is an unequal enlargement, presenting fluctuation and occasionally causing bulging of the ribs or a semi- globular tumour in the epigastrium. Tropical abscess is mainly to be distinguished from hydatid by the presence of pain, by its much more rapid course, and by its constitutional symptoms. The possibility, how- ever, already referred to, of an hydatid tumour sup- purating, or becoming converted into an abscess, must not be lost sight of. An error in diagnosis from this cause is all the more likely to arise if the patient, as often happens, has been ignorant of the existence of the hydatid tumour prior to the occurrence of the 172 ENLARGEMENTS OF THE LIVER. [lect. v. acute symptoms due to its taking on inflammatory action. b. The circumstances under which enlargement of the gall-bladder may simulate hepatic abscess and its distinguishing characters will be considered in a subsequent lecture. c. The constitutional symptoms of tropical and pyaemic abscesses may be identical. For distin- guishing them, we must rely mainly on the form of the enlargement and the circumstances under which it occurs (see pp. 150 and 171). Treatment.—A. Before suppuration has occurred, the rules for treatment will differ but little from those already laid down for congestion of the hver. But acute congestion in tropical climates is often benefited by more active measures than would be justifiable in the forms of congestion which are more common in this country. 1. When the disease sets in suddenly, and when the pulse is full and firm and the temperature high, a full bleeding from the arm, by diminishing the force of the heart and the total amount of blood, will sometimes appear to check the advance of the disease to suppuration. This remark applies espe- cially to Europeans who have not resided long in the tropics, and who have not suffered from the injurious effects of malaria, intemperance, &c. 2. Local depletion by means of leeches may be had recourse to after general bleeding, or independently, in those cases where general bleeding is unsuitable. lect. v.] TROPICAL ABSCESS. 173 3. Poultices and warm fomentations to the region of the liver often give great relief, and should be employed in all cases, whether depletion be practised or not. 4. In those cases where the symptoms of con- gestion pass into a chronic state, but at the same time there is no evidence of suppuration, a small blister often appears to do good. 5. Saline purgatives, with occasional doses of calo- mel or blue pill, alkalies, diaphoretics and diuretics, must be employed according to the rules already laid down (see p. 126). 6. The diet must be of that bland and restricted character which I have already told you is essential to the proper treatment of ordinary congestion (see p. 125). B. In tropical abscess of the liver, not only may we hope to prevent suppuration by appropriate treat- ment, but even after it has occurred, the case is far from being, as in the pyaemic abscess, necessarily fatal. The treatment, however, for the stage ante- cedent to suppuration is no longer suitable. 1. Warm fomentations and poultices are still to be applied to the region of the liver; and in the event of acute pain supervening, a few leeches will often give relief. 2. The patient's strength must be supported by mineral acids and vegetable tonics, and in particular by the sulphuric or nitric acid with quinine. 3. Opium is in most cases necessary to relieve 174 ENLARGEMENTS OF THE LIVER. [lect. v. pain, to procure sleep, or to allay the harassing cough. 4. Purgatives are no longer called for. If the bowels be constipated, a mild laxative may be given from time to time, but more commonly there is diar- rhoea or dysentery, necessitating the use of vegetable and mineral astringents, with opiate enemata or suppositories. Mercury in this stage is worse than useless, and is now almost universally discarded. 5. The diet must be of a much more generous nature than that which is permissible in the stage of congestion ; and when the circulation is weak, small quantities of wine or brandy will be necessary. 6. In multiple abscesses it is clear that no advan- tage is to be derived from operative interference, but when there is a single large abscess, the propriety of evacuating the pus may fairly be entertained. It is no doubt true that a large abscess of the liver may become encysted and shrivel up, and in this way undergo what may be called a spontaneous cure, in- dependently of rupture, but this is an event so rare that it cannot be calculated on. Recovery also takes place occasionally in consequence of the abscess emptying itself through a bronchial tube, into the bowel, or externally through the abdominal parietes ; but the process is tedious, and even when it occurs many patients die of exhaustion from fever, pneumo- nia or diarrhoea, to say nothing of their liability to destruction at any moment from the abscess bursting into the pericardium, the pleura, or the peritoneum. lect. v.] TROPICAL ABSCESS. 175 In a large proportion of cases, however, the patient dies while the abscess is still confined to the liver.* Under these circumstances the expediency of hasten- ing the evacuation of the matter naturally suggests itself. You will find nevertheless that professional opinion is divided on this important question. Dr. Budd, in his standard work on ' Diseases of the Liver,' con- siders the dangers of operating so many and so great that it is better to let matters alone and allow the abscess to open of itself; f and more recently a similar opinion has been strongly expressed by Professor Maclean, of the Army Medical School at Netley.J Some authorities, again, such as Frerichs § and Morehead,|| advocate opening the abscess in selected cases; while others, like Dr. Murray, formerly Inspec- tor-General of Hospitals in Bengal, Dr. Cameron,^! and Sir Ranald Martin,** maintain that ' when we have just grounds for believing that abscess of the liver exists, we ought not to lose a day in evacuating * Of 300 fatal cases of hepatic abscess collected by Mr. Waring, the abscess, at the time of death, had not extended beyond the boundaries of the liver in 169 ; in 48 it had been opened by operation ; in 42 it had opened spontaneously into the right lung or thoracic cavity ; in 15, into the peritoneum; in 8, into the stomach or colon ; in 3, into the hepatic vein, &c. (An Enquiry into the Statistics and Pathology of some points connected with Abscess in the Liver, as met with in the East Indies. Trevandrum, 1854.) t Op. cit. 3rd ed. 1857, p. 124. J Lancet, July 18, 1863. § Dis. of Liver, Syd. Soc. Ed. ii. p. 147. || Pes. on Dis. in India, 2nd ed. 1860, p. 410. f Lancet, June 6 and 13, August 8, 1863. ** Lancet, August 20 and 27, 1864. 176 ENLARGEMENTS OF THE LIVER. [lect. v. it by puncture, and that we are both justified and safe in endeavouring to hit upon it with a trocar when deep-seated, avoiding the gall-bladder and large veins.'* Dr. Cameron, in fact, goes so far as to re- commend exploring the liver with a trocar, in cases where the existence of an abscess is suspected though not certain, and has published cases where no pus was found, and yet the patient's symptoms subsided instead of being aggravated subsequently to the ex- ploration. Amid such conflicting opinions we may be aided in forming a just judgment by considering, on the one hand, the dangers of the operation, and, on the other, the dangers of non-interference. The main objections raised against the operation are as follows :— a. That pus is apt to escape into the peritoneum and excite fatal peritonitis. In most cases, however, when the abscess is near the surface, there would be adhesions which would prevent the entrance of pus into the peritoneum. Morehead speaks of the absence of adhesions as quite exceptional (in only 3 of 76 fatal cases). Moreover, if desirable, it is always pos- sible to produce adhesions. b. That air will enter the abscess and excite fresh inflammation. This is an undoubted source of dan- ger ; but it is as (if not more) likely to be incurred if the abscess opens spontaneously into the bowel, a bronchial tube, or externally. c. That the mechanical injury of the puncture is * Cameron. Lancet, June 6, 1863, p. 631. lect. v.] TROPICAL ABSCESS. 177 apt to produce haemorrhage and fresh inflammation in the hepatic tissue. So far as I have been able to ascertain, this is an objection founded on theoretical considerations, rather than on actual observation. I have had several opportunities of confirming Dr. Cameron's statement to the effect that a fine trocar can be plunged into the liver without any ill result except a little local pain, and without, in fact, any trace of the puncture being discernible when death occurs shortly afterwards. d. That the fatal event may be hastened by gan- grene of the tissues around the wound.* This acci- dent has been chiefly observed when the opening has been made in an intercostal space, and then, as More- head has shown, it occurs alike when a spontaneous rupture takes place, and when a puncture is made.f The gangrene is most probably connected with the caries or necrosis of the ribs, which is almost always present in these cases, and which would probably not occur were the abscess opened before the ribs became implicated. The chief dangers of non-interference are these :— a. The abscess becomes daily larger, more and more of the hepatic tissue is destroyed, and ultimately the gland may be reduced to a mere sac containing pus, while adjacent organs are compressed and the ribs are eroded. * Maclean. Lancet, July 18, 1863. f Op. cit. p. 410. N 178 ENLARGEMENTS OF! THE LIVER, [lect. v. b. The patient may die suddenly from the abscess bursting in various directions. c. The great majority of patients with abscess of the liver die of exhaustion from hectic fever or diar- rhoea, either while the abscess is still confined to the liver, or after it has burst. Statistics have been appealed to with the object of proving the uselessness of operative interference. Of 81 cases where the abscess was opened, collected by Mr. Waring, only 15 (or 18'5 per cent.) recovered, and of 24 cases recorded by Morehead, only 8, or one-third, recovered. But in many of these cases death was due, not to the operation, but probably to this having been too long delayed; while several of Waring's cases were examples of multiple abscesses, for which an operation is obviously unsuited. Moreover, of 203 cases collected by Rouis, where the abscess was not opened, 162 (or 80 per cent.) died.* After duly balancing, then, the dangers of operation against the dangers of expectancy, I do not hesitate to recommend to you the propriety of evacuating the pus in a large number of cases of tropical abscess of the liver. The operation may not be free from danger, but to wait in these cases upon Nature, as it is called, is to wait upon Death, and I would suggest for your guidance the following rules :— a. In all cases where there is a visible fluctuating tumour, operate at once. * Frerichs, Op. cit. ii. p. 136. lect. v.] TROPICAL ABSCESS. 179 b. In cases where the symptoms of abscess of the liver are present, with a distinct tumour projecting from the normal contour of the liver; or' causing bulging of the ribs, even though there be no percep- tible fluctuation, it will be well to operate. c. When symptoms of abscess coexist with uniform enlargement of the liver, but with no distinct tumour or bulging, if there be any local oedema, or obliteration of an intercostal space, or acute pain, always loca- lized to one particular spot when the patient takes a full inspiration, it will be well to operate; but if there be no such oedema or obliteration or pain, it may be better to wait, as the enlargement may possibly be due to multiple abscesses, or if there be but one abscess, it is doubtful if it will be reached. When the operation is resolved on, it may be per- formed as follows:— a. When there is distinct pointing with an inflam- matory blush of the skin, an opening may be made with a bistoury. b. Under other circumstances, a small trocar will be preferable, and it ought to be introduced wherever there is the slightest fulness or superficial oedema, or acute pain. c. When the abscess is small, not holding more than ten or twelve ounces, it ought to be completely evacuated, and the canula tied in for two or three days. On its removal, a tent of lint dipped in oil may be substituted. d. When the abscess is very large it will be better N 2 180 ENLARGEMENTS OF THE LIVER, [lect. v. to evacuate it by instalments at short intervals, care- fully excluding the air on each occasion. e. In the exceptional cases, where no adhesions exist, it will be prudent to produce them by the local application of caustic potash, before puncturing. /. After the operation, a large warm poultice should be applied over the liver, and the patient should lie on it, taking care that, if the canula has been left in, pressure upon it is obviated by a suitable pad or pillow. A full dose of morphia ought also to be administered at once. The first of the following cases is an excellent illustration of tropical abscess of the liver independ- ent of dysentery, notwithstanding that after the for- mation of pus, diarrhoea was a prominent symptom. It is a matter of regret that the abscess was not punctured ; but fifteen years ago this operation was rarely practised. Case XXXVII.—Tropical Abscess of the Liver—No Dysenteric Ulceration of the Bowel. Private H. C----, aged 33, of the 2nd European Bengal Fusiliers, was admitted under my care into the Military Hospital at Prome, on November 12, 1853. His habits had been very dissipated ; he had suffered from many attacks of fever and congestion of the liver, and shortly before his admission he had been exposed almost continuously for three weeks to wet on the decks of steamers during the passage from Calcutta to Rangoon and from Rangoon up the Irrawaddi to Prome. He had never had dysentery. He began to suffer from febrile symptoms and pain in the right side in the first week of October during the passage from Calcutta, but his condition did lect. v.] TROPICAL ABSCESS. 181 not prevent him attending to his duty until a few days before admission, when the pain in the side became much more severe. On admission, the patient's pulse was 112, and his skinhot. He complained of much pain in the region of the liver, and stretching from that up to the right shoulder. The pain was greatly increased by coughing or taking a long breath, and there was considerable tenderness on pressure over the epigastrium and below the right ribs. The hepatic dulness in the right mammary line measured 6 inches. Posteriorly and upwards the margins of hepatic dulness were normal, and the increased size appeared due to a bulging from the lower margin. There was no fluctuation and no jaundice or ascites, but there was less movement of the ribs in respiration Fig. 14 represents the Outline of Hepatic Dulness, and the Bulging of the Ribs (a) in H. C-----, on December 2, 1853. on the right side than on the left, and frequent cough. The tongue was moist and coated white ; there was frequent vomiting; a day or two before admission the bowels had been relaxed, but at the time of admission they were costive. There was some scalding in micturition; the urine was high-coloured; sp. gr. 1027; it con- tained no albumen, but deposited crystals of lithic acid. 182 ENLARGEMENTS OF THE LIVER, [lect. v. The patient was cupped to 8 ounces over the liver, and during the first week after admission was treated with calomel and opium, and subsequently with nitro-muriatic acid, quinine, opiates,and wine. On November 18, diarrhoea came on, with profuse night-sweats, but no rigors. The vomiting continued, and the tongue was clean, very red, and deeply fissured. The cough and scalding in micturition had abated, but the vomiting and diarrhoea persisted, notwithstand- ing the use of remedies. On November 20, the tongue was noted as dry and brown, and the patient became very emaciated, but was comparatively free from pain, until November 26, when he was seized with acute pain, shooting up from the region of the liver to the right shoulder. On the following day this had subsided; and after this there was but little vomiting or purging, and the symptoms were mainly those of hectic fever, with increasing prostration, until December 1, when there was noticed below the right ribs, rather to the right of the mammary line, a distinct smooth rounded bulging, with obscure fluctuation in the centre. The hepatic dulness in the right mammary line was now 8 inches, the increase being due to a projection downwards from the lower margin of the normal area of hepatic dulness. There was also considerable bulging of the lower right ribs. The patient was now free from pain, the vomiting and purging had ceased, but the cheeks were sunken and presented a hectic flush, the fever and night-sweats continued, the tongue was dry and brown, and the teeth coated with sordes. On December 8, the patient was in a state of extreme prostration; on the following day his mind was wandering, and at 9-30 p.m. he died. On examination of the body ten hours after death, one enormous abscess was found in the right lobe of the liver. It contained upwards of four quarts of pus, having a reddish tint, and under the microscope presenting numerous pus-corpuscles, with oil- globules and hepatic cells undergoing disintegration. The walls of the abscess were formed by ragged masses of hepatic tissue coated with inflammatory products; at two places the walls were very thin, one situated below the margin of the right ribs, and corresponding to the tumour observed during life, and the other posteriorly near the mesial fissure. The stomach and the small and large intestines presented no trace of cicatrices or of recent ulcera- tion. The spleen, lungs, and heart were normal. There were old lect. v.] TROPICAL ABSCESS. 183 adhesions between the opposed surfaces of the left pleura; and the cavities of the heart, but particularly the right, contained large masses of decolorized fibrine. In the next case, there was ulceration of the colon, but this appeared, from the history and post-mortem appearances, to be secondary to the abscess of the liver. The specimen was exhibited by me to the Pathological Society, and the case is recorded in the 8th volume of the ' Transactions.' Case XXXVIII.—Large Abscess of the Liver opening into the Ascending Colon. J. P----, a man aged 40, was admitted into St. Mary's Hospital, under the care of Dr. Sibson, on April 18, 1856. He stated that he had always enjoyed good health and that, although he had been in the habit of drinking a good deal of malt liquor, he had never been addicted to spirits, and had, on the whole, been a temperate liver. He had never been abroad. About a month before admission, he ' took cold,' and was seized with a shooting pain in the right hypochondriac region, which on the second day became so extreme as to prevent his working. He went to bed, where he remained until the day of admission, the pain in the right side continuing without intermission except when relieved by opium. On examination after admission, there was found to be a great fulness in the right hypochondriac and lumbar regions of the abdomen, with a feeling of a resisting mass extending downwards as far as the crest of the ilium, and forwards to within 3 inches of the linea alba. This space was universally dull on percussion, and the dulness was continuous with that of the liver. The upper margin of the area of hepatic dulness was not elevated, and the dimensions of the left lobe appeared normal. The swelling was of a doughy consistence, and presented indistinct fluctuation. The tongue was loaded, the bowels rather confined. The urine was voided three or four times a day and was acid; sp. gr. 1020. The pulse was 108, weak. Poultices of linseed meal were applied over the swelling, while iodide of patassium (gr. ij ter die), gentle laxatives, opiates, and stimulants were prescribed internally. 184 ENLARGEMENTS OF THE LIVER, [lect. v. On April 24, he had an attack of erysipelas of the face, which continued for four or five days. On April 26, during this ery- sipelas, he was seized with violent diarrhoea. This ceased in a grea,t measure after four or five days, and he then felt himself greatly better; his appetite had improved, the pain had gone, the swelling and dulness were much diminished, and the calls to make water less frequent. He continued to improve until May 11, on which day he had a return of the severe pain and diarrhoea, with purulent stools. The pain was referred chiefly to a spot about two inches below the margin of the ribs, in a line with the right nipple. The stools were of a light buff colour and very offensive. This diarrhoea resisted all treatment, and soon the patient's con- stitution began to give way. He became liable to febrile exacer- bations towards evening, and profuse perspirations during the night. His pulse varied from 100 to 125, and was very weak, his tongue became dry and brown, and he gradually sank until death at 10 p.m. on May 27. Four days before death the swelling in the right side was observed to have very greatly diminished, the dulness in the right lumbar region not extending farther forward than a perpendicular line drawn from the middle of the crest of the ilium to the ribs. Post-mortem examination forty-one hours after death.—On opening the abdomen there were found extensive adhesions of the viscera and other indications of peritonitis, which were, however, entirely limited to the right side, the peritoneum on the left side being perfectly normal. These adhesions of the viscera on the right side rendered their examination extremely difficult. The whole of the anterior margin of the right lobe of the liver was firmly adherent to the peritoneal surface of the abdominal wall, while the under surface of the anterior edge, along with the gall-bladder, was in intimate union with the transverse colon. The texture of the liver was pale. In the lower part of the right lobe was an abscess as large as two fists, containing a quantity of fluid fseculent matter, of a light yellow colour. This abscess involved almost the whole of that portion of the lobe to the right of the fissure of the gall- bladder, and extended to within half an inch of its upper surface. The upper two-thirds of the walls of the abscess were formed by hepatic tissue, and were rough and ragged, without any limiting membrane. The lower part was completed by the kidney, the anterior layer of the fascia lumborum, and about 3 inches of the lect. v.] TROPICAL ABSCESS. 185 ascending and transverse colon. This portion of the colon com- municated freely with the cavity of the abscess. Its upper wall next the abscess presented a cribriform appearance, all that re- mained of it being a few narrow bridles, passing transversely, and easily torn across. There was extensive ulceration of the adjacent portion of the ascending colon, and slight ulceration of Peyer's patches in the ileum. The kidneys were anaemic, and the spleen soft and friable. The thoracic organs were healthy, the left cavities of the heart contain- ing blood, the right being empty. In Case XXXIX. the patient had suffered from dysentery, and died from the bursting of the abscess upwards through the diaphragm. Case XXXIX.—Abscess of the Liver opening upwards through the Diaphragm—Secondary Abscess of Liver. I show you here a specimen which I removed some years ago from the body of a patient—a man, aged 34, who died in this hospital, and which illustrates the bursting of a large abscess upwards through the diaphragm. In this case, the patient had suffered some years before from dysentery, in India and Malta. His symptoms during the nine days that he was in the hospital before his death were hectic fever and emaciation, dyspnoea, cough, and purulent expectoration, with a painful enlargement of the liver, producing an outward bulging of the ribs. The hepatic dulness extended only 2 inches below the margin of the ribs in the right mammary Hue, but upwards it reached to the third intercostal space. The enlargement felt smooth, but did not involve the whole organ uniformly. The tongue was unusually red; there was no vomiting, jaundice, or diarrhoea, but the abdomen generally was tender, and there was distinct evidence of fluid in the peri- toneum. After death, three or four pints of flaky serum were found in the peritoneum. The liver was firmly adherent to the diaphragm and abdominal parietes, and in the upperpart of the right lobe was an abscess as large as a cocoa-nut, which had perforated the dia- phragm so as to be bounded above by the base of the right lung. The abscess was enclosed in a dense capsule of areolar tissue, and 186 ENLARGEMENTS OF THE LIVER, [lect. v. contained yellow pus with large fibrinous flakes. In the lower lobe of the right lung was another abscess, the size of a large orange, distinct from the former, and containing pinkish pus. The descending colon and sigmoid flexure were much contracted; their coats were thickened; the mucous membrane was of a slaty hue, but presented no recent ulcers or distinct cicatrices. The last case which I shall mention is a good illustration of the benefit which may often be derived from evacuation of the abscess. Case XL.—Tropical Abscess of the Liver—Puncture with a Large Trocar—Recovery. Mr. C. D----, aged 23, consulted me on June 11, 1867. He had arrived from Calcutta the day before, and gave the following account of himself. He had resided in Calcutta for about three years, and had lived freely, but had never suffered from dysentery. He had been taken ill about the end of March with febrile symptoms, and rapidly increasing prostration. He had no pain in the side, no diarrhoea, and no jaundice, but about April 12 a tumour made its appearance below the right ribs, which rapidly increased until the 19th, when it was opened with a large trocar, and upwards of a pint of matter let out. The canula was left in the wound, and on the 21st the patient was put on board the overland steamer in so prostrate a state that he was hardly ex- pected to recover. He slowly improved, however, during the voyage, and the canula was removed at Aden about a fortnight afterwards. I found an opening with pouting granulations about half-way between the umbilicus and the ribs, and 2 inches to the right of the median line, from which about two drachms of thin pus escaped daily. The patient was weak and anaemic, but in other respects appeared to have nothing amiss. He was treated with mineral acids, quinine, and iron, and within three months he had regained his usual health and strength. There was no evidence of enlargement of the liver, and the opening had permanently closed. (With the exception of an attack of gout in January, which he had previously suffered from, and of which disease his father had died, he remained in good health until he returned to India in February 1868.) LECT. VI.] CANCER. 187 LECTURE VI. ENLARGEMENTS OF THE LIVER. CANCEE. TUBERCULAR ENLARGEMENT—LYMPHATIC ENLARGEMENT—MULTI- L0CULAR HYDATIDS—ENLARGEMENTS OF GALL-BLADDER. The last form of enlargement of the liver, the clinical characters and treatment of which have to be considered, is that which is due to cancerous deposit. X. CANCER OP THE LIVEE. Cancer of the liver may be recognized by the fol- lowing clinical characters. 1. The size of the liver is increased, and not uncom- monly the enlargement is very great, so that the organ fills a great part of the abdominal cavity. A cancerous liver has been known to weigh 250 ounces, or about five times the normal weight.* The enlarge- ment is progressive, and in the softer forms of cancer may be so rapid that a weekly increase may be noted. On the other hand, it must be remembered that the * See Budd, Dis. of Liv. 3rd ed. p. 407, and Path. Trans, xviii. p. 145. 188 ENLARGEMENTS OF THE LIVER, [lect. vi. liver may contain a considerable amount-of cancer, and yet the enlargement may not be appreciable during life. The liver may have been originally a small one, and the addition of the cancer may not cause it to project beyond the costal arch, or the lower mar- gin may be overlapped by a distended bowel. You will remember the case of Mary T----, a very fat woman, 54 years of age, who died recently in the hospital, of apoplexy supervening upon white softening of the brain (with hemiplegia), and whose liver was unex- pectedly found studded with large cancerous nodules, although the organ did not project beyond the costal arch, and there had been no symptoms during life of disease of the liver. A similar observation was made in two other cases, which I shall detail to you imme- diately (Cases XLVI. and XLVII.). 2. The enlargement is usually irregular, from the presence of nodular cancerous excrescences projecting from the surface or from the margin of the liver, which can often be felt on palpation, and are some- times even visible through the abdominal parietes. Occasionally the cancerous deposit forms one large excrescence or tumour at a particular portion of the organ. Dr. Bright has recorded some remarkable cases in which the tumour was confined to the left lobe, and projected downwards into the abdomen, or upwards into the left side of the chest; * and the specimen I show you here, obtained from the body of * Abdom. Tumours, Syd. Soc. Ed. pp. 261 and 308. LECT. VI.] CANCER. 189 a patient who died under my care in the Fever Hospi- tal, is another illustration of the same condition (Case XLV.). More commonly a number of nodu- lated outgrowths, about the size of cherries or small oranges, project from the portion of liver which is Fig. 15 shows Area of Hepatic Dulness, in Hannah C----(Case XLL), with nodulated lower margin. opposed to the abdominal parietes (see fig. 15). Care must be taken not to mistake for such excrescences the rigid bellies of the recti muscles (see page 20). It is necessary also to remember that a nodular character is not essential, as might be inferred from some descriptions, to cancerous enlarge- ment of the liver. In certain cases the cancer is not 190 ENLARGEMENTS OF THE LIVER, [lect.vi. deposited in the liver in isolated nodules, but is infil- trated through the hepatic tissue in such a way that, although the organ may be greatly enlarged, its natural outline is but little altered ; and even in the nodular form of cancer, the portion of liver below the ribs is sometimes quite smooth (Case XLIL). 3. The enlargement feels very hard and resistant on palpation, and nowhere exhibits any fluctuation. In very rare cases some of the cancerous nodules may be so softened as to present obscure fluctuation. 4. A cancerous liver is almost always painful and tender on pressure, and very often the pain radiates to the shoulder, back, and loins. At first there may only be a feeling of weight and uneasiness in the right hypochondrium; but after a time the pain is often lancinating, and the tenderness acute, and both are particularly severe in cases where the growth is rapid, or where, as often happens, there is inflamma- tion of the superimposed peritoneum. 5. Jaundice is present in a large number of cases, and when once developed it never disappears. The coexistence of enlargement of the liver with persistent jaundice ought always to raise the suspicion of can- cer. The jaundice usually results from the compres- sion of the bile-duct by a cancerous nodule in the liver or by enlarged glands in the portal fissure. If the ducts be not thus compressed, almost the whole of the secreting tissue may be destroyed without any jaundice resulting. Of 91 cases of cancer of the liver collected by Ererichs, 52 died without ever having been jaundiced. LECT. VI.] CANCER. 191 6. Fluid in the peritoneum is observed in more than one-half of the cases of cancer of the liver, before the fatal result. It may concur with jaundice, or each may exist independently (see Cases XLL XLIL and XLIIL). The fluid may be a simple drop- sical collection, due to compression or obstruction with cancerous matter of the trunk or large branches of the portal vein, but the amount is usually small as compared with what is observed in cirrhosis. Oftener it is the result of a chronic peritonitis origi- nating on the surface of the liver. Now and then, as in Cases XLIV. and XLV., blood is thrown out into the peritoneum from a rupture in a fungating or softened cancerous mass in the liver. 7. The superficial abdominal veins are only en- larged in those comparatively rare cases where the portal circulation is seriously obstructed. 8. Enlargement of the spleen is rare, and this con- stitutes an important distinction of the cancerous from the waxy or cirrhotic liver. 9. The constitutional symptoms, in the first place, are mainly those of deranged digestion, such as nausea, flatulence, and constipation, and occasionally attacks of vomiting or diarrhoea. A short dry cough is not uncommon. When the cancer grows rapidly, there is often a certain amount of pyrexia, with a furred tongue, and scanty high-coloured urine throw- ing down a copious deposit of lithites. Before the disease has lasted long, the patient presents in a marked degree the phenomena of the cancerous ca- chexia—extreme anaemia, with an earthy chlorotic 192 ENLARGEMENTS OF THE LIVER, [lect.vi. colour of the integuments (unless there be jaundice), and rapidly increasing debility and emaciation. These symptoms are always aggravated by the co-exist- ence of cancer of the stomach. 10. Cancer of the liver is, in most cases (fully three- fourths), secondary to cancer of some other organ, such as the stomach, uterus, the female breast, the rectum, or the vertebrse. In more than one-third of the cases it is secondary to cancer of the stomach. The symptoms of cancer in these various organs will there- fore materially aid the diagnosis. Even when the cancer is deposited first in the liver, other parts, such as the coeliac, mediastinal and cervical glands, and the lungs, are apt to become affected, and thus throw fresh light on the primary disease (see Case XLIIL). 11. Cancer of the liver always runs a rapid course. The medullary cancer often grows very rapidly, and is fatal within a few weeks or months; and although scirrhus is said sometimes to last for two years,* it is rarely prolonged beyond twelve months. The very fact of an enlargement of the liver having lasted much longer than this, would be an argument against its being due to cancer. 12. The age of the patient is sometimes of assis- tance in diagnosis. Cases are extremely rare where the liver is primarily affected with cancer before 35 or 40. Secondary cancer of the liver, it is true, may occur at any age, but then the primary disease will point to the nature of the case. * Budd, Dis. of Liver, 3rd ed. p. 413. LECT. VI.] CANCER. 193 13. The mistakes most likely to occur in diagnosis consist in mistaking cancer of the liver for waxy disease or cirrhosis. (See also p. 61.) a. The smooth infiltrated form of cancer may be mistaken for waxy degeneration. In both there is a smooth, uniform, very hard enlargement of the liver; but in the waxy enlargement the progress of the disease is slow, there is an absence of pain or of the cancerous cachexia, and there is usually also en- largement of the spleen, with albuminuria, and a history of constitutional syphilis, caries of bone, or protracted discharge from a suppurating surface; whereas in cancer there is no enlargement of the spleen or albuminuria, but the course of the disease is rapid, and there are pain, cachexia, and often signs of cancer elsewhere. b. More rare cases, where cirrhosis and waxy di- sease coexist (see pp. 26 and 42), may be mistaken for nodular cancer. In both there may be a nodulated hard enlargement of the liver with ascites. The points of distinction are the same as between the smooth forms of waxy disease and cancer. Treatment.—The treatment of cancer of the liver must be entirely palliative. There is no known remedy which can arrest or retard its progress. Mercury, iodine, arsenic, and the Sanguinaria Canadensis, which at different times have been recommended for the purpose, have been shown to be worse than useless. In none of the many diseases of the liver for which it has been the fashion to give mercury, o 194 ENLARGEMENTS OF THE LIVER, [lect. vi. has it been productive of so much injury as in cancer. The treatment must be restricted to supporting the patient's strength and nutrition by appropriate food, correcting errors in digestion, relieving pain, and procuring sleep. 1. The diet ought to be nutritious, but digestible, and ought to contain a large proportion of the nitro- genous principles of food, and comparatively little of saccharine and oily substances, which are calculated to "increase the work thrown upon the liver. Alcoholic ■stimulants will often be necessary in the advanced stages of the disease, but ought to be given in mode- ration and well-diluted. In those hopeless cases where the primary disease is cancer of the stomach, the ;diet must consist mainly of milk and animal soups. .2. Various remedies will often be necessary to correct errors in digestion. For vomiting, bismuth, hydrocyanic acid, lime-water, creosote, or ice, will be -useful, and likewise the occasional application to the epigastrium of a sinapism or small blister. In the latter case, great advantage is often derived from sprinkling over the blistered surface a quarter of a grain of morphia. The use of blisters for any other object can do no good, and can only weaken the patient and put him to unnecessary pain. Fla- tulence will be relieved by the ethers and essential oils, but better still by such remedies as charcoal, creosote, or carbolic acid, which absorb the gas, or, by arresting decomposition, prevent its formation. A dose of from fifteen to thirty mimims of a saturated LECT. VI.] CANCER. 195 aqueous solution of carbolic acid, with a few drops of chloric ether in peppermint water, is often a most effectual remedy for this symptom. The bowels are often constipated, and will require relief, but care must be taken to avoid castor-oil and powerful pur- gatives, which will either nauseate the stomach, or lower the patient by producing copious watery dis- charges. Four or five grains of the compound rhu- barb pill with a grain of blue pill and a grain of extract of henbane, will usually produce the desired result satisfactorily and safely, or the bowels may be cleared out from time to time by a simple enema. 3. Sooner or later, in most cases, anodynes will be necessary to relieve pain or procure sleep. Belladonna conium, or Indian hemp, will often be found useful for these objects, and ought to receive a trial in the first instance ; but in most cases it will be necessary to have recourse ultimately to one of the various preparations of opium or morphia. The solution of the bimeconate of morphia, which is of the same strength as laudanum, has less tendency to derange the stomach or constipate the bowels than most other forms in which opium is given; and these disad- vantages of opium will also be, in a great measure, avoided by the subcutaneous injection of morphia. Lastly, poultices and warm fomentations, with or without a few leeches, may be required for intercurrent attacks of peri-hepatitis. The following cases, which, with two exceptions, o 2 196 ENLARGEMENTS OF THE LIVER, [lect. vi. have been under your observation, illustrate the remarks that have now been made on cancer of the liver. Case XLI.— Cancer of the Liver and Ovary—Jaundice, but no Ascites. Hannah C----, aged 50, a cook of large build and rather stout, married, and mother of one child, was admitted into the Middlesex Hospital under my care on July 28, 1863. She stated that for many years she had been subject to lbilious attacks' (vomiting and headache), but that about two years before admission, these attacks became much less frequent and severe, and she had enjoyed good health, until about ten weeks before admission, when she was attacked somewhat suddenly with pain in the epigastrium and right hypochondrium and in both shoulders, accompanied by great lan- guor, and followed next day by diarrhoea, which lasted a week. A month before admission, the pain became much increased, and the urine was noticed to be of a dark greenish-brown colour; a week later the skin became yellow, and since then, the patient has suffered much from itchiness. From the first she had been losing flesh. The symptoms, while the patient was under my observation, were as follows :—The skin, conjunctivas, and serum of a blister were of a bright orange colour, and there was great itchiness of the entire surface. The tongue, at first clean, became afterwards coated with a thin white fur. At first, there was no vomiting, but frequent attacks of nausea and a feeling of distention and oppression after meals. The appetite was very bad. The motions were destitute of any trace of bile ; they were pultaceous, clay-coloured, and very offensive. Much pain was complained of in both shoulders, and in the epigastrium and right hypochondrium; this was much greater a few days after admission than subsequently. The liver was much enlarged, the hepatic dulness, in the right mammary line, extending from \ an inch below the nipple to l£ inch below the ribs, and measuring 6£ inches. The portion of liver below the ribs was hard, tender, and distinctly nodulated (fig. 15, p. 189). There was no evidence of ascites. The urine was scanty, only about one-half of the normal quantity, sp. gr. 1030, acid, dark like porter, and threw down a copious deposit of lithates. It contained abundance of bile- LECT. VI.] CANCER. 197 pigment, but no bile-acids (by Harley's test), and no albumen. The pulse was 60 ; the cardiac and respiratory signs were normal, except that occasionally * crackling sounds' were heard over the base of the right lung. On August 6, and again on August 15, it was noted that the patient vomited after her medicine. On August 29, there was a considerable increase of the pain and tenderness in the ab- domen, with vomiting and pinched features. Under treatment, these symptoms abated somewhat, but the vomiting returned from time to time, while the languor and prostration rapidly increased. On September 28, the vomiting became incessant, and from this date the patient gradually sank, until death on October 3. The treatment consisted in bismuth, hydrocyanic acid, and opiates, sinapisms to epigastrium, and nutritious but digestible food. Autopsy.—The body was well nourished, and there was a thick layer of fat everywhere beneath the skin, in the omentum, and around the kidneys. The tissues throughout the body were deeply stained with bile. There was no fluid in the peritoneum, and no sign of recent peritonitis. The mucous membrane of the stomach and in- testines was normal, but the contents of the bowel contained no trace of bile, and none could be squeezed from the gall-bladder into the duodenum. The liver was very large, weighing 97 oz., and its right lobe, measuring 13 inches from before backwards. Its surface was studded with elevated yellowish white, moderately firm nodules, varying in size from a pea to a walnut, and many of them depressed in their centres. Similar masses were seen in the interior of the liver on section. One mass, the size of a large orange, occupied the entire thickness of the right lobe in front, extending back to the transverse fissure, and in contact with the upper surface of the gall- bladder. These masses yielded a creamy juice on section, which contained characteristic' cancer-cells ;' some of them were softened in the centre into a yellow pulp, and here the cancer-cells contained much oil, and there were many compound granular cells. The hepatic lobules between the cancerous masses had a peculiar appearance. The central third of each lobule had a dark olive- green colour, and the hepatic cells in it contained much bile- pigment ; the outer two-thirds were pale-yellow, and there the se- creting cells were loaded with oil. Several stellate crystals of tyrosine were found in the secreting tissue. The gall-bladder contained no bile, but was filled with faceted gall-stones. The hepatic ducts were considerably dilated, but the common duct passed into a mass 198 ENLARGEMENTS OF THE LIVER, [lect. vi. of dense areolar tissue and enlarged glands in the portal fissure, through which its continuity could not be traced. The capsule of the liver was at many places adherent by firm fibrous bands. The uterus was normal. The left ovary was as large as a walnut, rather soft, and nodulated. It contained a little semi-fluid dark blood; and its substance was soft and yellow, and exuded a creamy juice containing ' cancer-cells.' A cancerous nodule, the size of a pea, projected from the surface of the left ovary. The mesen- teric and lumbar glands presented no abnormal appearance. The lungs and heart were normal, with the exception of pul- monary congestion and patches of atheroma in the mitral flaps and in the commencement of the aorta. There were no cancerous de- posits in either the spleen or kidneys. Case XLII.—Cancer of Uterus and Liveo—Ascites, but no Jaundice. On October 18, 1866, Charlotte D----, aged 56, was transferred to my care, having been for two months before under the care of the Obstetric Physician for cancer of the uterus. She was married, and the mother of nine children; the catamenia had ceased at the age of 49. Three years before she came under my care, she had an attack of what appeared to be gall-stones, sudden spasmodic pain in the right side, with vomiting andslight jaundice, and ever since she had suffered from a feeling of uneasiness and fulness below the right ribs. Twelve months before, she first noticed a slight but very offensive and persistent yellow discharge from the vagina, and ever since she had suffered from costiveness and pain in defecation and some difficulty in micturition. On two occasions, nine months and three months before she came under my observation, she had rather copious uterine haemorrhage, last- ing for about a fortnight. Two months before, she first noticed her abdomen to swell, and she began to suffer from vomiting after food. She had been losing flesh for twelve, and rapidly for three, months. On admission the patient was weak and emaciated, and her countenance was expressive of pain. There was extensive indu- ration and ulceration of the cervix uteri and upper part of the vagina, with a fetid discharge. The abdomen was much distended, measuring 35| inches at the umbilicus, and exhibiting all the si°ns of fluid in the peritoneum. The liver was much enlarged in the LECT. VI.] CANCER. 199 right mammary line, measuring 6^ inches, and projecting fully 2 inches below the costal margin. The portion that could be felt was hard and tender, but had no feeling of nodulation The superficial abdominal veins were slightly enlarged, but there was no jaundice. The tongue was moist and slightly furred, the vomiting had ceased, but the bowels had not acted for several days. The urine was loaded with lithates, but contained no albumen. There was no anasarca of the trunk or extremities. The pulse was 108 and feeble ; there was no dyspnoea, and the cardiac and respiratory signs were normal, with the exception of slight dulness and fine crepitation at end of inspiration at base of right lung. The patient was treated with bismuth and chloric ether, sub- cutaneous injections of morphia, mild laxatives, and a nutritious diet, with a small allowance of brandy. The vomiting did not re- turn ; but every night she suffered from intense pain in the abdomen, which was only partially relieved by the morphia injections. The belly slowly increased in size; the prostration became daily greater, until death occurred on October 30. Autopsy.—The peritoneum contained several quarts of turbid serum, with flakes of soft lymph, chiefly on the fundus uteri and in the pouches before and behind. The cervix uteri was entirely destroyed by cancerous ulceration, which extended for 1| inch down the anterior wall of the vagina ; the lower two-thirds of the uterus were infiltrated with cancerous matter. The lumbar glands were sligjitly enlarged from cancerous deposit, and in the portal fissure was a mass of enlarged cancerous glands pressing on the portal vein. The liver was of enormous size, weighing 115 ounces, and the portion opposed to the thoracic and abdominal wall measuring 7 inches. The entire liver was studded with numerous isolated nodules of cancer, from a pea up to a walnut in size, but none of them were much raised above the outer surface, so that the portion of the organ projecting beyond the ribs was perfectly smooth and even. On section, many of the nodules were found to be softening in the centre into a flaky serous fluid. On microscopic examination, the nodules, both at the circumference and in the centre, were seen to consist mainly of nuclear elements, with but few cells; the hepatic tissue intervening between the nodules was free from cancerous infiltration. The mucous membrane of the stomach and intestines was healthy, but small nodules of cancer, up to the size of a cherry, were scattered through the lower lobe of the right lung. 200 ENLARGEMENTS OF THE LIVER, [lect. vi. Although no opportunity was afforded for a post- mortem examination in the following case, the dia- gnosis, as I frequently pointed out in the wards, was sufficiently clear. Case XLIII.—Cancer of the Liver, Lungs, and Cervical Glands—Jaundice and Ascites. John B----, aged 47, a cowman, was admitted under my care, on August 24, 1866. Twelve years before admission he had been confined to bed for a week with rheumatism ; and two years before he had suffered for two months from severe pain at the epigastrium, usually worse after food. With these exceptions, he had enjoyed good health until eight weeks before he came to the hospital, when he was seized somewhat suddenly, while at work, with violent pain in the region of the liver and stomach, which had never ceased, although it had been sometimes more severe than at others. Eight days after this, he noticed that his motions had lost their colour, and that his urine was very dark, and after six more days, the conjunctivae, and then the skin, became yellow. On admission, the patient was weak and emaciated, and had intense jaundice of the entire surface. He complained of severe pain in the region of the liver, coming on in paroxysms, which would last for many hours, were sometimes attended by vomiting, and often prevented sleep. The liver was enlarged, measuring 5^ inches in the right mammary line; in the epigastrium, it felt hard and obscurely nodulated, and was very tender. No tumour could be felt corresponding to the gall-bladder. There was neither ascites nor enlargement of the abdominal veins or spleen. The tongue was coated with a creamy fur; the bowels were costive; the motions clay-coloured and very offensive ; the urine was of the colour of porter, and contained abundance of bile-pigment, but no albumen. The pulse was 96; the cardiac and respiratory signs were normal, and there was no dropsy. The patient was treated with mineral acids and gentian, anodyne draughts with drachm doses of tincture of henbane, and mild laxatives. On August 28, he first noticed a tumour in the left side of the LECT. VI.] CANCER. 201 neck, immediately above the clavicle. It was about the size of a hen's egg, hard, nodulated, and slightly tender. This tumour in- creased in size, and soon became the seat of severe pain, like that in the liver. Patient also complained often of severe pain down the back, but there was no tenderness of the spine. Indian hemp and henbane failed to give relief to these pains, and on September 9, the subcutaneous injections of morphia were resorted to, at first with great benefit. On September 5, ascites was first noticed which from this date con- tinued to increase, and on September 24, both feet and the lower half of both legs were noted as swollen and oedematous. The tu- mour in the neck now filled up the whole of the lower triangle, and at its circumference were several large and movable glands quite distinct from the general mass: the patient vomited occa- sionally after his breakfast, and was becoming daily thinner and weaker. On October 1, the patient was noted as vomiting almost every thing he swallowed. The pulse was 84, weak, and intermittent. The ascites and tumour of the neck continued to increase, the liver appeared larger and more distinctly nodulated, and the pains were only relieved by the morphia injections, which were repeated twice daily. There was no cough, and the respiration was slow and easy, but over the middle of the left lung posteriorly there was marked dulness over a space 3 or 4 inches square, with absence of vesicular murmur, but no friction or crepitation. On October 5, the left arm and hand were noted as oedematous, and the vomited matter, which from the first had resembled yeast, was found to contain abundance of sarcinae. A mixture was or- dered every six hours, containing 10 minims of chloric ether, and 1 drachm of a saturated aqueous solution of carbolic acid in pepper- mint water. The patient was now so weak that he obviously could not live many days, but his wife came, and insisted on removing him to the country. The preparation which I now show you was re- moved from the body of a patient in this hospital while I was pathologist, and was exhibited to the Pathological Society (Trans, vol. xiii. p. 100). It 202 ENLARGEMENTS OF THE LIVER, [lect. vi. illustrates a rare mode of fatal termination of cancer of the liver* Case XLIV.—Primary Cancer of the Liver—Death from Haemorrhage into the Peritoneum. Patrick S----, aged 50, became an out-patient at the Middlesex Hospital, under Dr. Greenhow, in August 1861. At a former period of his life, he had been very intemperate, and he had been in the habit of drinking a large quantity of spirits. For some months he had been losing flesh, and he had been suffering from occasional nausea and other dyspeptic symptoms, and from pains in the epigastrium. Dr. Greenhow discovered that the liver was enlarged and distinctly nodulated below the margin of the right ribs, and recognized the peculiar physiognomy characteristic of the cancerous cachexia. There was no jaundice, and little or no ascites; and nothing was observed to indicate an immediate fatal termin- ation. On August 26, the patient was brought to the hospital, and ad- mitted under Dr. Goodfellow, his condition having become suddenly worse about two days before. His symptoms on admission were great prostration and cachectic countenance; marked jaundice of skin, conjunctivae and urine; complete loss of appetite, urgent vomiting, intense pain and tenderness in the region of the liver, which was much enlarged, hard, and nodulated; abdomen much distended and fluctuating; small, rapid pulse. No improvement took place ; and on the day after admission, the patient vomited a large quantity of dark bloody-looking fluid. During the night of the 27th, he fell into a state of col- lapse, which continued until death at 2.30 p.m. of the 28th of August. Autopsy.—Moderate emaciation; marked jaundiced tint of con- junctivae and skin and of the tissues generally, including the * For additional cases, see Frerichs, Dis. of Liver, Syd. Soc. Trans. ii. p. 333; Murchison, Path. Trans, xiii. p. 102; also Budd, Dis. of Liver, 3rd ed. p. 396. In Freriebs's case, the haemorrhage seemed to commence three days before death, and the appearances in the liver were very similar to those above described. LECT. VI.] CANCER. 203 internal organs and the bones. Between five and six quarts of dark-red bloody serum were found in the peritoneal cavity, and lying on the upper surface of the right lobe of the liver towards its right extremity, between it and the diaphragm, was a dark coagulum of blood which weighed 5 ounces avoirdupois. The serous coat of the intestines, which was bathed by the bloody fluid, presented no abnormal injection or deposit of lymph. The liver weighed 72 ounces. The right lobe was relatively much enlarged, measuring 9 inches transversely, while the left lobe was much atrophied, and a mere appendage to the right, not exceeding 1| inch in its transverse diameter. The greater part of the diminutive left lobe was granular on the surface, and presented on section the ap- pearances characteristic of cirrhosis. Corresponding to the lobus quadratus was a rounded mass, about the size of a large walnut, attached by a narrow pedicle, and likewise composed of cirrhotic glandular tissue. The whole surface of the right lobe of the liver was covered with prominent nodules, varying in size from a pea to a large cherry, the largest being elastic or presenting fluctuation. These nodules were most developed near the anterior margin of the right lobe on the upper surface. The coagulum on the surface of the right lobe was adherent at one spot near the right extremity of the organ, corresponding to one of the softened nodules, which was ruptured. The structure of the right lobe of the liver was extremely dense ; and on making a section, it appeared to consist of two abnormal elements, a groundwork of firm grey scirrhiis- looking tissue, infiltrated with a creamy yellowish juice, and con- taining a number of cavities up to the size of a cherry, filled with a soft pulpy bright yellow substance. The whole of the right lobe appeared to be made up of these abnormal elements, and scarcely presented at any part a trace of the natural glandular parenchyma or of bile-ducts. The scirrhous structure had encroached to some extent along the anterior margin of the left lobe. On examining with the microscope the juice scraped from the denser scirrhous portions, it was found to contain a multitude of rounded, elliptical, and fusiform cells, up to — of an inch in diameter, with one or sometimes two large nuclei about one-third the size of the cell; many of the cells, likewise, included brownish pigment granules. In the softened portions, similar cells were discovered, mixed up with a large quantity of oily and pigmentary matter, both inside and outside the cells. The other abdominal organs were normal. The heart was 204 ENLARGEMENTS OF THE LIVER, [lect. vi. normal. The apices of both lungs were condensed and puckered, and contained encysted calcareous masses up to the size of a pea. In Case XLV. the immediate cause of death was also probably haemorrhage into the peritoneum. The preparation which I show you appears to be an illustration of that rare form of disease described by Dr. Bright and other writers as ' fungus hsematodes' of the liver, where the growth projects greatly from the general surface of the organ. The transition between the secreting cells of the liver and the large cells of the growth determined by myself and Dr. Cayley, is likewise a matter of considerable pathologi- cal interest. Case XLV.—Cancerous Tumour {Fungus Hmmatodes), projecting from upper surface of Liver—Hemorrhage into Peritoneum. Luke T——, aged 57, was sent to the London Fever Hospital on January 20, 1868, supposed to be suffering from 'fever.' He had no friends, and could give no account of his previous history. On admission, he had a heavy stupid countenance, and his mind was confused. He was very emaciated; the pulse varied from 76 to 88, and was very weak. The tongue was dry and brown; the bowels were rather loose, and the abdomen was ascertained to be slightly distended, partly from tympanitis, but partly also from fluid in the peritoneum. The hepatic dulness appeared to be normal. There was an occasional cough, with thin frothy ex- pectoration, and there was slight dulness over both lungs pos- teriorly and rather fine crepitation, but no tubular breathing. There were no night-sweats, and there was neither jaundice, dropsy, nor albumen in the urine. The patient was treated with ammonia, and subsequently with iron and mineral acids, along with beef-tea, milk, and brandy ; but the symptoms became gradually worse, the emaciation and ascites increased, there was frequent low muttering delirium; and on lect. vi.] CANCER. 205 February 2, slight jaundice was noted, but the motions still con- tained bile. The pulse rarely exceeded 80. The patient became every day weaker ; but no fresh symptom of importance appeared. He died on February 16. Autopsy.—The peritoneum contained between 3 and 4 quarts of dark sanguinolent fluid. The liver was separated from the diaphragm in front and from the anterior abdominal wall, for 2 or 3 inches, by a space filled with this sanguineous fluid. The suspensory ligament was elongated in a corresponding degree. The liver weighed 04 ounces ; the capsule was slightly thickened and opaque, but the surface was smooth. On section it appeared un- usually dense and tenacious. Projecting from the upper and back part of the right lobe was a rounded tumour, as big as a man's fist. This was embedded in a hollowin the diaphragm, to which it was so firmly adherent that part of it was left behind in removing the Fig. 16 shows the microscopic appearances of the Tumour of the Liver in Case XLV. a. Large nucleated cells of various shapes, and some with a double nucleus; b, similar cells containing oil-globules; c, large cell containing bile-pigment; d, cells resembling in every re- spect the glandular epithelium of the liver; e, transitional forms between these last cells and the large cells. liver. This tumour was of pulpy softness, and reflected over it was the thickened capsule of the liver, from the inner surface of which 206 ENLARGEMENTS OF THE LIVER, [lect. vi. the pulpy mass could be easily scraped with the handle of the knife. On section, there was seen to be a sharp line of separation between it and the dense tissue of the rest of the liver. The pulpy substance was torn with the greatest facility, and was very vascular, so that it was obviously the source of the blood in the peritoneum. On mi- croscopic examination, it was found to be made up of large nucleated cells, with an average diameter of ^ inch, or about three times that of an hepatic gland-cell. The cells were rounded, pyriform, or caudate, and each contained one or sometimes two nuclei, with much fine granular matter; some were full of oil-globules, and some contained brown pigment-granules exactly like what is seen in the gland-cells of the liver. Along with these large cells, which were much the more numerous, were others of smaller size, and not to be distinguished from the secreting cells found in other parts of the liver (fig: 16). The stomach and intestines were healthy; the walls of the heart were thin and soft; both lungs were firmly adherent, and much congested in their dependent parts. There was nothing noteworthy in any other organ. Case XLVI. is an illustration of cancer implicating the liver, without producing any symptoms or signs which could lead to its existence being suspected during life. One of the supra-renal capsules also was destroyed by cancer, and yet there was no vomiting or bronzing of the skin. It is now well known that the supra-renal capsules may be destroyed by cancer, without any of the symptoms of Addison's disease resulting, so that these symptoms must be ascribed, not to the destruction of the capsules, but to the morbid process by which this is effected. Case XLVI.—Cancer of Vertebra?, Supra-renal Capsule, Liver, and Lung—No Symptoms of Disease of Liver. Alfred T----, aged 55, was admitted into the Middlesex LECT. VI.] CANCER. 207 Hospital, under my care, on January 28, 1868. He was very weak and emaciated, and not very connected in his replies. Seventeen years before admission, he contracted syphilis, followed by con- stitutional symptoms, but his < present attack ' commenced only three months before admission, with severe pain in the spine, ac- companied by emaciation and weakness. His symptoms while under observation were as follows :—Pro- gressive emaciation and debility, and anaemic chlorotic colour of face; but no jaundice, or bronzing of skin, or discoloration of mucous membrane of mouth, or perspirations. Persistent pain and tenderness on pressure over spinous process of the third and fourth lumbar vertebrae, but no sign of tumour or of paraplegia, ex- cepting retention of urine for the last two or three weeks of life. Tongue dry, red, and fissured; no vomiting ; constipation alterna- ting with diarrhoea. Abdomen distended and tympanitic, with slight tenderness on deep pressure to the left of the umbilicus : a few days before death the abdominal swelling subsided, and the aorta could be felt passing down along the spine, but there was no appreciable tumour. The hepatic dulness was 4 inches in the right mammary line : at no time was there tenderness, or a feeling of nodulation in the region of the liver, or ascites. The pulse varied from 84 to 120, and was always small and weak; the cardiac dulness was diminished; there was at no time any cough or ex- pectoration, and at the time of admission, no notable sign of mischief could be discovered in the lungs. The urine was alkaline and contained phosphates, but no albumen or bile-pigment. The temperature was either normal, or but slightly increased. Through- out the mind was confused, and there was a tendency to low muttering delirium, increasing towards death, which occurred on March 22. Autopsy.—There was a soft cancerous tumour of the bodies of the third and fourth lumbar vertebrae, projecting about half an inch from the surface, chiefly on the left side, where it invaded the texture of the psoas muscle, and encroaching about half-way to the spinal canal, which, as well as the spinous processes, appeared normal. There was cancerous enlargement of the lumbar and bronchial glands, and a mass of soft cancer, the size of a large walnut, com- pressing a large branch of the pulmonary artery in the upper part of the lower lobe of right lung. The liver was not enlarged, and its lower margin did not project beyond the edge of the ribs, but it contained from a dozen to twenty isolated cancerous nodules 208 ENLARGEMENTS OF THE LIVER, [lect. vi. from the size of a pea to that of a walnut, several of which were excavated in the centre. One of these nodules was in a portion of liver which was firmly adherent to the right supra-renal capsule. The latter organ was greatly enlarged, and converted into a mass of hard cancer, measuring 2| inches in diameter. The left capsule, the kidneys, and the brain presented nothing abnormal. The following case came under my notice while I was House Surgeon in the Edinburgh Eoyal Infir- mary. It is an example of a rare form of cancer im- plicating the liver, but causing no symptoms of hepatic disease. Case XLVII.—Melanotic Cancer of the Penis, Lym- phatic Glands, Liver, Pleura, etc. James L----, aged 54, a butler, was admitted into the Royal Infirmary, Edinburgh, on February 4, 1851. He was a tall, robust man ; his hair was dark brown, and his eyeballs were remarkable for their prominence, and for a bluish tint of the sclerotics. At- tached to the lower and outer surface of the prepuce, and extending a considerable way along its free margin, there was a tumour, the size of a chestnut, of a dark b own, almost black colour, and with its surface nodulated and covered with a fetid, dirty yellow, puri- form discharge. When pricked with a pin, it bled profusely, and it was often the seat of acute pain, especially during, and for a short time after, micturition. It had been growing for two years, and commenced as a small black wart on the outer surface of the prepuce, about an inch from its free margin : this wart for six months re- mained stationary, but afterwards increased more rapidly. On reflecting the prepuce, which was done with some difficulty, there were displayed on the surface of the glans several warty excrescences of a bluish black colour, and varying in size from that of a pin's head to that of half a pea. In each groin, there was a swelling of the size of a hen's egg, which had first appeared about three months before admission. For three months the patient had complained of dyspnoea and cough; and on examining the chest, the left side presented a uniform bulging, measuring fully 1 inch more in circumference than the LECT. VI.] CANCER. 209 • right. There was also on this side marked dulness on percussion, imperfect expansion, and absence of the natural respiratory murmur and of vocal thrill. The apex of the heart was displaced to the left margin of the sternum. The physical signs of the right lung were normal. Pulse 90, and very feeble. After this, the patient got rapidly worse; he lost all relish for food, and became very prostrate. The fits of dyspnoea increased in frequency and in severity, lasting sometimes for several hours, and dulness with suppression of the respiratory murmur was observed over the base of the right lung. The tumour on the penis and the swellings in the groins increased slightly in size. There was no jaundice, ascites, or enlargement or pain of the liver. On the morning of March 26, he had an unusually severe attack of dyspnoea ; the pulse was 84, and almost imperceptible; the ex- tremities cold; face livid and the eyeballs more prominent. These symptoms continued until death on the evening of the 27th. Autopsy.—The tumour on the penis presented on section a smooth, black surface, yielding on section a copious inky juice. The lumbar, inguinal, and femoral glands, were enlarged and infiltrated with black matter; and some of them were entirely converted into a pulpy black fluid. The lymphatics of the spermatic chord con- tained 1 or 2 small melanotic nodules. Along the whole of the abdominal aorta, there was a chain of enlarged glands. Some of these exhibited, on section, a black pulpy mass, while others, which were but slightly enlarged, presented the normal glandular structure, with circumscribed brownish black points. The hypogastric and sacral lymphatics were normal. Left pleura distended with several quarts of fluid tinged with blood and black pigmentary matter, which pushed the apex of heart towards right side. Scattered over the whole of the parietal and pulmonary pleura, were masses of a dark deposit, varying in size from the smallest appreciable point to half an inch in diameter, and, for the most part, presenting a circular outline. The largest of these nodules projected about one-sixth of an inch from the sur- face of the pleura; the smallest were not appreciably elevated, presenting a punctiform appearance not unlike the shading of a chalk drawing. The large nodules were almost black, while the punctiform deposit had a brownish black tint, tinged more or less with purple. Most of the nodules were covered by the epithelial layer of the pleura, but at the back part of the cavity, where they were confluent and aggregated into flattened masses, this mem- P 210 ENLARGEMENTS OF THE LIVER, [lect. vi. branous lining was at some places wanting, and the masses exhibited a pulpy irregular surface, and yielded on pressure a large quantity of dark juice very like liquid sepia. The left lung was completely compressed and carnified. At the reflection of the pleura from the root of the lung upon the ribs, there was a layer of recently extra- vasated blood, at some parts half an inch in thickness. Right pleura contained a few ounces of fluid similar to that in left, and its surface exhibited nodules of deposit of the same character, but much less extensive. Embedded in the substance of the right lung, were a few circumscribed black nodules, the largest about the size of a cherry : around them, the pulmonary tissue was normal and crepitant. The bronchial glands were all black, but not much en- larged. In the posterior mediastinum, the glasds were greatly en- larged, and a cluster of them, forming a mass the size of an orange, was situated in the angle of bifurcation of the trachea, in front of the oesophagus. The deep cervical glands contained black pig- ment. Between the mucous and muscular coats of the oesophagus there were one or two rounded nodules, the size of a barley-corn, con- taining black pigment; the rest of the alimentary canal and the mesenteric glands were normal. On the surface of the liver there were seen about a dozen nodules of the black deposit, about one- third of an inch in diameter; and numerous similar masses were found embedded in the substance of the organ which was but slightly increased in size. In the spleen there was a single mass of black deposit, the size of a pea. The kidneys contained in various parts of their cortical substance melanotic nodules, the size of a swan-shot. Between the muscular and mucous coats of the bladder and of the urethra, were a few black nodules the size of barley-corns. Chemical Examination of Melanotic Matter.—The following analysis of the pigmentary matter was made by Dr. James Drummond :— ' It was insoluble in water, alcohol, and ether. When treated with hydrochloric, nitric, and sulphuric acids, it was dissolved; the solution being nearly colourless. When chlorine gas was passed through it suspended in water, it was bleached to a certain extent, but not entirely. When boiled with potash, it dissolved, with disengagement of ammonia. The ultimate analysis yielded the following result:— lect. vi.] RARE FORMS OF ENLARGEMENT. 211 Carbon .... 67-01 Hydrogen 6-45 Nitrogen .... 11-4/5 Oxygen .... 8-36 Ash .... 673 100-00 1 Tne ash consisted, in great part, of peroxide of iron.' Microscopic Examination of the Melanotic Deposit.—The dark juice from the tumour on the penis was found to contain a large quantity of granular matter of a sienna brown colour. The granules were solid and angular, and refracted the light strongly. Acetic acid produced no change upon them ; but strong nitric acid ren- dered them much lighter. Mixed up with these granules were a few nucleated cells, having a circular or oval outline, and a diameter of about -gig of an inch. Some of the cells were more elongated, and one or two exhibited a caudate appearance. Most of them were loaded with the coloured granules, which quite obscured all appearance of a nucleus. In some of the cells, however, which con- tained little or none of the coloured granules, one and sometimes two nuclei could be detected with one or two distinct nucleoli. When a small particle of the tumour was torn out with needles and examined, it exhibited a network of fine filamentous tissue, in- filtrated through the meshes of which were the elements of the dark coloured juice just described. The melanotic deposits in the pleura, lumbar and inguinal glands were also subjected to careful microscropic examination, and were all found to possess a structure similar to that of the tumour on the penis. The morbid conditions considered in this and the preceding lectures comprise almost all the enlarge- ments of the liver ordinarily met with in practice; but there are others of rarer occurrence, with the clinical characters of which we are yet imperfectly acquainted. 1. Tubercular Enlargement.—I have already de- tailed to you the particulars of a case where a con- P 2 212 ENLARGEMENTS OF THE LIVER, [lect. vi. siderable enlargement of the liver was found to be mainly due to tubercular deposit (Case XXX, page 140). The case was one of acute tuberculosis, and possibly the enlargement of the liver which occurs in this condition may occasionally be due to tubercle, rather than to fatty or waxy deposit. There are no means, however, by which at present tubercular enlargement can be distinguished during life, and its discovery would probably in no way modify the pro- gnosis or the treatment. 2. Lymphatic Enlargement.—In leukaemia and in certain other affections where there is a general ten- dency to enlargement of the lymphatic system, the liver may be found studded with greyish white new formations, not unlike miliary tubercles,* but occa- sionally as large as peas, which may cause the whole organ to be enlarged. Structurally these formations resemble minute lymphatic glands and they are believed to be developments in connection with the lymphatic system. When therefore in a case of leukaemia the liver is found to be enlarged, the en- largement may be due either to this cause or to sim- ple hypertrophy (see page 53) ; but it will call for no special treatment apart from that of the general condition. 3. Multilocular Hydatid Tumour.—This is a very rare form of tumour, composed of numerous small hydatid vesicles embedded in an alveolar structure of * Frerichs, Dis. of Liver, Syd. Soc. Transl. ii. p. 222. lect. vi.] RARE FORMS OF ENLARGEMENT. 213 fibrous tissue, and not like an ordinary hydatid en- veloped in a parent cyst. Its clinical characters have not yet been sufficiently studied, but are very different from those of an ordinary hydatid tumour of the liver. The tumour is not smooth, fluctuating and painless, but is nodulated, hard and tender. In most cases also there is enlargement of the spleen with jaundice and signs of fluid in the peritoneum, in consequence of the tendency which the disease has to implicate the bile-ducts and the portal vein. In most cases the tumour ultimately suppurates in the centre and induces symptoms of hectic fever. The disease for which it would be most readily mistaken is a cancerous tumour, and like cancer it sometimes runs a rapid course of a few months; but in other cases the tumour has been known to exist for ten years and more prior to death. The treatment re- commended for ordinary hydatid tumours is ob- viously inapplicable here, and our efforts must be limited to the relief of symptoms as they arise. 4. Enlargements of the Gall-bladder.—The gall- bladder may be enlarged from various causes, so as to form a tumour attached to the liver, and appreciable through the abdominal parietes. The causes, the symptoms, and the treatment of these enlargements we shall reserve for consideration in a future lecture (Lect. XII.). Lastly, the liver has been noticed to be enlarged and tender in cases of a rare and remarkable skin eruption known as Vitiligoidea. The enlargement is 214 ENLARGEMENTS OF THE LIVER, [lect. vi. usually accompanied with jaundice, and both may last for years. Of the cause of the enlargement we are as yet ignorant, but we shall have occasion to recur to the subject when we come to speak of Jaundice (Lect. VIII.). lect. vii.] CONTRACTIONS OF THE LIVER. 215 LECTURE VII. CONTRACTIONS OF THE LIVER. SIMPLE ATROPHY—ACUTE OR YELLOW ATROPHY--CHRONIC A.TROT'H\ - (CIREHOSIS--SIMPLE INDURATION—BED ATROPHY.) Gentlemen,—Li previous lectures I have described to you the normal limits of the area of hepatic dul- ness (p. 3), as well as the principal causes of apparent and real enlargement of the liver, with the means of recognizing them. We have now to con- sider the chief causes of a diminution in the area of hepatic dulness, and their distinctive characters. And in the first place you must remember, that the area of hepatic dulness often appears diminished, although the organ in reality retains its normal weight and bulk. SPURIOUS CONTRACTIONS OF THE LIVER. The main conditions likely to induce an apparent diminution in the size of the liver are as follows :— 1. Tympanitic distention of the bowels, and par- ticularly of the transverse colon and stomach, may prevent the lower margin of the liver being felt, and diminish the area of hepatic dulness in several ways. a. A portion of stomach or intestine distended 216 CONTRACTIONS OF THE LIVER, [lect. vii. with gas may become interposed between the sur- face of the liver and the abdominal parietes. b. When the lower margin of the liver is thin, and when there is excessive tympanitic distention of the subjacent bowels pushing the liver forwards and rendering the abdominal parietes tense, the lower edge of the liver may escape detection on palpation, and its dulness or percussion may be imperceptible. c. In excessive tympanitis the autero-posterior diameter of the abdominal cavity is increased, and the lower portion of the liver may be elevated so that a smaller portion of it than is natural is in contact with the abdominal parietes. In one or more of these ways the normal hepatic dulness may be diminished, or may even entirely disappear, so that the pulmonary sound is immediately succeeded by that of the bowel. The liver may thus appear greatly diminished, although its size may in reality not be altered. You will find a remarkable case of this sort recorded by Dr. Bright, where, on opening the body, neither the liver nor the colon presented itself to view, but, in their stead, the convolutions of the small intestines, which were found to have come completely in front of the liver, the colon and the omentum doubling over the liver and pressing it back, so as to have made deep furrows on its anterior surface.'55' The fact of hepatic contraction being of this spurious character ought always to be suspected under the following circumstances :— * Abdom. Tumours, Syd. Soc. Ed. p. 259. lect. vii.] SPURIOUS CONTRACTIONS. 217 a. The very fact of there being tympanitic disten- tion of the bowels ought to suggest caution in in- ferring the existence of real atrophy of the liver from a diminished area of hepatic dulness. The same caution is necessary in cases of ascites. The fluid in the peritoneum may push up the bowels which may be only moderately distended with gas, but which may thus come to produce the same result as more extensive tympanitis; and this fallacy is of the greater importance inasmuch as ascites is a common consequence of real atrophy of the liver. b. Variations in the extent of hepatic dulness at different times is a character of spurious atrophy of the liver most useful in diagnosis. The dulness of the liver will vary in its extent according to the amount of gas in the stomach and bowels. The diagnosis will therefore be facilitated by oft-repeated examinations, and particularly by examinations made before meals, and after the bowels have been cleared out by a purgative. c. Variations in the extent of hepatic dulness at different places is not uncommon in cases of spurious atrophy. Tympanitic distention of the stomach and bowels may diminish or obliterate the hepatic dulness in the median and right mammary lines, but is not likely to affect it materially in the axillary or dorsal lines. Occasionally too the space where the hepatic dulness is obscured may be even more circumscribed, as when a knuckle of intestine intervenes between the liver and the abdominal wall. 218 CONTRACTIONS OF THE LIVER, [lect. vii. d. There is an absence of other signs or symptoms of real disease of the liver, but the possibility of there being ascites independently of hepatic disease, already referred to, must be kept in view. 2. General or partial accumulations of gas in the peritoneal cavity, such as may result from perforation of the stomach or bowels, may obscure, to a greater or less extent, the area of hepatic dulness; but usually the nature of these cases will be sufficiently clear from— a. The arched tympanitic distention of the abdominal parietes; and b. Antecedent history of peritonitis from per- foration. 3. The hepatic tissue may be preternaturally soft, so that the organ may fold on itself and collapse against the spine and the back part of the abdomen, and be covered more or less in front by the stomach and bowels which may not be abnormally distended with gas. I have already pointed out to you that in fatty degeneration, the enlargement may from this cause appear to be increased, a larger portion than natural of the liver being in apposition with the abdominal wall (page 44) ; but if the folding be carried a stage further so as to permit the super-position of bowel, a contrary result may take place. Lastly, in acute atrophy of the liver, the organ is not only reduced in size, but it may be so soft as to collapse against the spine, all trace of it disappearing from the abdo- minal wall in front. lect. vii.] SIMPLE ATROPHY. 219 Keeping in view these sources of fallacy, which are, on the whole, more calculated to mislead than the sources of fallacy in the case of enlargement (see page 9), we may proceed to consider the causes of real atrophy of the liver, which may be conveniently arranged under the three following heads :— I. Simple Atrophy. II. Acute or Yellow Atrophy. III. Chronic Atrophy; under which head will be included the diseases commonly designated ' Cir- rhosis,' ' Simple Induration,' and ' Red Atrophy,' I shall now endeavour to describe to you the lead- ing clinical characters and the appropriate treatment of these several forms of atrophy. I. SIMPLE ATROPHY. By ' simple atrophy,' is understood a diminution in the size of the liver, independent of any alteration in its structure, except a diminished size of the lobules, which may be so small as to be distinguished with difficulty, the cut surface presenting a smooth appearance and often a uniform tint. The liver in this state may be reduced to one half of its normal weight and bulk, or even less. Although this con- dition of liver is not of much practical importance, more or less of it is far from uncommon, and ignorance of its nature and characters may lead to errors in diagnosis. You will recognize this form of atrophy then by the following characters :— 220 CONTRACTIONS OF THE LIVER, [lect. vii. 1. The circumstances under which it occurs. These are mainly two, viz. Old Age and Inanition. a. Old Age—Simple atrophy, has been sometimes described as ' senile atrophy.' With the advance of life, the tendency of the various organs and tissues throughout the body is either to degenerate or to waste. In some persons, the several forms of degener- ation (fatty, calcareous, &c), predominate; while in others we observe a simple wasting. In the latter case, the power which prevailed over the waste of the body in childhood and youth, and which maintained the balance in the vigour of manhood, has failed, and waste now prevails over development. In most cases you will find that the reduction of the Hver in old age is in advance of that of the body generally, and occasionally the liver is reduced by senile atrophy to one half of its normal size and weight. b. Inanition may also induce simple atrophy. There is little or no supply to compensate for the constant waste. When you remember the increase in the bulk of the liver produced by every meal (see page 120), you will readily understand how, in cases of inanition, the liver often wastes out of proportion to the rest of the body. It is difficult to say why it is that the effect of wasting diseases is in some persons to cause wasting of the liver, while in others it leads to the accumulation in the organ of a large quantity of oil (see p. 49). Inanition may arise in two ways, either from an insufficient supply of food, or, as certainly, from diseases which interfere with lect. vii.] SIMPLE ATROPHY. 221 the assimilation of food. Accordingly you will find simple atrophy of the liver extremely common in the bodies of persons who have died of stricture of the pylorus, or of stricture of the oesophagus or cardiac orifice of the stomach. I shall relate to you immediately the particulars of a patient, aged 54, with a cancerous tumour of the lower end of the oesophagus, in whom the area of hepatic dulness was reduced to one half of the normal standard, and whose liver after death was found to weigh only 32 oz., instead of 54 oz., the average weight for his age (Case XLVIII). You will remember also the case of Samuel H., aged 63, who died of a cancer of the oesophagus involving the apex of the left lung, and whose liver was very small and weighed only 42 oz.; and the case of Eliza P., aged 48, who died of cancer of the pharynx, and whose liver weighed only 35 oz. All these were good examples of simple atrophy. c. External Pressure by tight lacing, pleuritic or pericardial effusions, circumscribed peritoneal exu- dations, or enlargement of those portions of the bowel nearest to the liver, may likewise produce simple atrophy of the liver. The atrophy, however, under these circumstances is usually partial and is of little clinical importance, unless the bile-ducts or large blood-vessels have been subjected to the pressure. 2. There is an absence of any sign of hepatic disease or derangement. With the diminution in the size of the liver, there is, no doubt, a loss of functional power, but sufficient secreting tissue remains for the 222 CONTRACTIONS OF THE LIVER, [lect. vii. work to be done. Care, however, must be taken not to mistake for symptoms of diseased liver, those of the primary disease on which the atrophy depends. Simple atrophy of the liver requires no special treatment beyond that adapted to the circumstances under which it occurs. The following case will serve to impress on your memories the clinical characters and post-mortem appearances of simple atrophy of the liver. The case is also interesting as an illustration of cancerous and tubercular deposit taking place simultaneously, of which other examples have been reported by Mr. Sibley,* Dr. Bristowe,f and myself. J It is difficult to account for these cases on the ordinarily accepted view, that tubercle and cancer depend on a ' peculiar diathesis,' regulating the nature of the exudation, for then the diathesis must vary in different parts of the same body. Case XLVIII.—Coexistence of Cancerous Stricture of the Oesophagus, with recent Tubercle in the Lungs. Simple Atrophy of the Liver. Augustus T----, aged 54, a tailor, was admitted into the Mid- dlesex Hospital, under my care, on July 24, 1863. He was of average height, and naturally of spare habit. He had led a very intemperate life, drinking large quantities of gin, but he had always enjoyed good health, until about four weeks before admission, when he began to suffer from sickness, coming on immediately after eating, sometimes even before he thought the food had been swallowed. He had never observed blood in the vomited matters, but he had rapidly lost both flesh and strength. * Med. Chir. Trans, vol. xlii. p. 149. f Trans. Path. Soc. vol. x. p. 284. \ Ibid. vol. xv. p. 104. lect. vn.] SIMPLE ATROPHY. 223 On admission he was very emaciated, and had an anxious expression of countenance. He could swallow solid food; but it was usually rejected, either immediately or within a few minutes. He also brought up from time to time large quantities of clear acid fluid. He complained of pain between the shoulders, but there was no tenderness of the spine, and no abnormal physical sign in either lung. The abdomen was nowhere tender, and nothing like a tumour could be felt at any part of it. The bepatic dulness was much diminished, not exceeding 21 inches in the right mammary line. The splenic dulness was normal, and there was no ascites or jaundice. The tongue was furred and the bowels costive. The pulse was 61 and feeble ; there was no ab- normal bruit with the heart, and no anasarca, nor albumen in the urine. All remedial measures failed to relieve the vomiting, and the patient got rapidly thinner and weaker, while the hepatic dulness was reduced to 2 inches. On August 30, the vomiting abated, but this was due to the patient's taking scarcely any nourishment. He died on September 7. At no period of his illness did he suffer from cough. Autopsy.—Entire absence of fat beneath the integuments and throughout the body. The cesophagns, 1^ inch above the cardia, had its calibre narrowed to that of a goose-quill for about half-an- inch. A hard tumour, the size of half a walnnt, was firmly at- tached to the constricted portion, and formed part of its posterior wall. The mucous membrane corresponding to this presented a puckered cicatrix-like appearance. The substance of the tumour was dense, fibrous, white, and slightly translucent, and dotted over with softer, more opaque, yellow specks. It yielded an opaque juice on scraping. On microscopic examination, the firmer por- tions of the tumour were found to contain numerous (cancer cells,' varying in size up to -^ inch in diameter. They were rounded, elliptical, and caudate, and contained one or two large nuclei with a diameter about one-third of that of the cell. Some of the cells had smaller cells in their interior. In the softer portions of the tumours, the cells were ill-defined and mixed with much oily and granular matter. Neither the bronchial glands, nor the lymphatics in the neighbourhood of the tumour were enlarged. The stomach was small, but otherwise normal. The liver presented the ordi- nary characters of simple atrophy; it weighed only 32 ounces; 224 CONTRACTIONS OF THE LIVE It. [lect. vii. its outer surface was smooth ; the only abnormal appearance seen on section was that the acini were reduced to one-half of their usual size. The secreting cells were small, and contained scarcely any oil, but were otherwise normal. The spleen weighed only 3 ounces; the kidneys were also small and anaemic, but in other respects normal. Both lungs were very small, the right weighing 9f ounces, and the left 8| ounces. The apice3 of both were firmly adherent to the thoracic walls, and marked externally with cicatrices. Several cretified deposits as large as peas, as well as one or two small cavities with thick walls and containing pus, were disclosed on cutting into the cicatrices. Scattered through the upper lobes of both lungs were a number of translucent greyish granules, isolated and collected into groups, as large as a hazel-nut, and presenting all the naked-eye and microscopic characters of miliary tubercles. The heart weighed only 6| ounces, and was destitute of fat, but in other respects was normal. II. ACUTE OR YELLOW ATROPHY. This is a rare but very remarkable disease, in which the liver becomes rapidly atrophied with the develop- ment of jaundice and cerebral symptoms, and where after death, what remains of the organ is found to be extremely soft and yellow, with no appearance of lobules, and with the secreting cells in a great mea- sure, or wholly, broken up into granular matter and oil-globules. The rarity of the disease in this city is attested by the fact that although a brown tongue and delirium constitute a certain passport for the transmission of all diseases to the London Eever Hos- pital, out of about 15,000 cases admitted during the last six years, the only example of the disease which has been noticed is the one of which I shall narrate to you the particulars immediately. The disease, lect. vii.] ACUTE YELLOW ATROPHY. 225 however, is one of the most interesting that can en- gage your attention, and may be recognized by the following clinical characters :— 1. Premonitory symptoms are noticed in many cases, but they are variable in their nature and sometimes absent. The most common are those of gastro-enteric catarrh, such as furred tongue, nausea, and loss of appetite, occasional vomiting and irregular bowels—diarrhoea or constipation, with slight py- rexia. At other times, the patient complains only of rheumatic pains, of an uneasy sensation in the region of the heart, or of a feeling of uneasiness which he is unable to define. These symptoms may last three or four days, or as many weeks, but withal there is not, as a rule, thought to be much amiss, while in not a few cases the patient has no feeling of indisposition until the supervention of symptoms of a more decided character. 2. Jaundice is invariably present, and is usually the first symptom that attracts attention to the patient's condition. The jaundice, however, is rarely intense, and is sometimes confined to the upper part of the body. Like the jaundice of pysemia (see p. 148), it appears to be due to a poisoned condition of the blood, and is independent of any obstruction of the bile-duct, and consequently bile is still found in the stools. 3. A rapid diminution in the area of hepatic dulness is one of the most remarkable features of the disease. In the course of a week or ten days, one-third, or even Q 220 CONTRACTIONS OF THE LIVER, [lect. vii. more than one-half of the liver may disappear (see fig. 17). Bright has recorded a case where the liver after death weighed only nineteen ounces, and its weight in the case which I shall bring under your notice was only twenty-eight ounces. It has been lately suggested that the atrophy in these cases is after all a chronic process, though unattended by symptoms ! ' \ Fig. 17. Area of Hepatic Dulness in Mary Ann M---. (Case XLIX.), on the day before death. until the final explosion ; but this view is opposed by most of the known facts in reference to the etiology of the disease, and also by the circumstance that the atrophy may be traced by percussion during life. Careful examination of the gland after death shows that the atrophy is due to a destructive process com- mencing at the circumference of the lobules and lect. vii.] ACUTE YELLOW ATROPHY. 227 advancing to the centre, as the result of which the secreting cells disappear and in their place we find nothing but granular matter and oil. The disease, in fact, appears to be nothing more nor less than an acute fatty degeneration, resulting from a diffuse in- flammatory process; for, previous to bursting, the cells may often be seen distended with oily and gran- ular contents. During life the atrophy of the liver may appear greater than it really is, because the gland is not only reduced in size, but also softened, so that it folds upon itself and collapses towards the vertebral column, the space corresponding to it in front being occupied by intestines containing gas. 4. Pain at the epigastrium and in the region of the liver is present in most cases. This pain often comes on spontaneously, and can almost always be elicited by pressure, even when the patient is almost unconscious. There is rarely, however, any tympa- nitic distention of the abdomen. 5. Vomiting occurs in most cases, the vomited matters consisting of the ingesta with mucus or bile, but often also containing blood, and resembling the ' black vomit' of yellow fever. The bowels are de- scribed as being usually constipated, but in the case from which this liver was taken (Case XLIX.) there was a considerable amount of diarrhoea. The stools not unfrequently contain blood and are very offensive. 6. The area of splenic dulness is usually increased except in cases where the portal system has been Q 2 228 CONTRACTIONS OF THE LIVER, [lect. vii. drained by diarrhoea or by hemorrhage from the stomach or bowels. 7. The cerebral symptoms of the ' typhoid state' constitute one of the most frequent and striking pecu- liarities of acute atrophy. As a rule, they appear simultaneously with the jaundice, but occasionally not for two or three weeks subsequently. At first there is headache, with despondency, irritability, and great restlessness; and this condition is succeeded by low muttering delirium, tremors, subsultus, muscular rigidity, and carphology, retention or incontinence of urine, involuntary passage of faeces, stupor, coma, and convulsions. These symptoms are independent of any lesion of the brain or of its membranes; but, like the analogous symptoms in typhus fever and in the typhoid state generally, to which I have directed your attention on a former occasion,* they result from the circulation through the brain of blood poisoned by the accumulation in it of urea and other products of metamorphosis which ought to be elimi- nated by the kidneys. 8. Acute atrophy of the liver is not accompanied by much febrile excitement. The pulse varies. In cases ushered in with gastro-enteric catarrh the pulse is usually accelerated at first, but falls to the normal standard, or below this, on the appearance of jaundice, but again rises on the supervention of cerebral symptoms. In the case which I shall relate * On the Pathology and Treatment of the Typhoid State in different Diseases. Abstract of Lecture in Brit. Med. Journ. Jan. 4, 1868. lect. vii.] ACUTE YELLOW ATROPHY. 229 to you it rose to as high as 144. Occasionally it has been found to be very variable at different periods of the day. Careful observations on the temperature in acute atrophy are still wanting. Most writers, such as Bright and Alison, have noted that the skin is cool. According to Frerichs, the temperature is increased at the onset of the disease and again during the period of nervous excitement, and in Case XLIX., where there was peritonitis, it rose to as high as 101° E. After the appearance of cerebral symptoms, the tongue is almost invariably dry and brown, and the teeth crusted with sordes, exactly as in a bad case of typhus fever. 9. The urine undergoes important changes. Its quantity is not materially altered; it is of acid reac- tion; and its specific gravity varies from 1012 to 1024. Its colour is usually dark, but the ordinary re- action of bile-pigment may be faint or indistinct. It often contains a small quantity of albumen or even blood; but after the removal of the urinary pigment, it yields no reaction of bile-acids to Pettenkofer's test. The most remarkable alterations, however, consist in the great diminution or even total disappearance of the urea and uric acid, and also of the chlorides, sul- phates, and earthy phosphates, and the substitution of two new substances of a peculiar nature, leucine and tyrosine. These substances are products of the metamorphosis of matter intermediate between the proteine principles (albumen and fibrine) at one ex- treme, and the less complex bodies, urea, uric acid, 230 CONTRACTIONS OF THE LIVER, [lect. vii. kreatine, &c. at the other, as will be seen by a com- parison of the following formulae:— Fibrine = C216N27S2H169063 Tyrosine = C18XHn06 Leucine = C12NHg04 Uric Acid = C10N4H4O6 Urea = C2N2H402 Leucine and tyrosine, in the crystalline forms represented in the annexed figures (figs. 18, 19, and Fig. 18. Microscopic needle- shaped crystals of tyrosine adhering in bundles and in stellate groups. 20), are found in the tissues of the liver, spleen, and kidneys in cases of acute atrophy, and they are usually also secreted in large quantity in the urine from which they separate as a distinct deposit on standing, or they may be obtained by evaporating a few drops of the urine on a glass slide. The detection of these crystalline bodies in the urine of a case of jaundice may be said to clench the diagnosis of acute atrophy of the liver, but the failure to detect them Fig. 19. Microscopic globular masses composed of acicular crystals of tyrosine. lect. vn] ACUTE YELLOW ATROPHY 231 must not exclude acute atrophy from the diagnosis. For instance, they were not present in the urine of Case XLIX., at all events in such quantity as to reveal their existence by simply evaporating the urine, al- though they were found in considerable quantity in the liver and kidneys after death. It is true that in this case death was accelerated by acute peritonitis; had the patient survived a little longer, leucine and tyro- sine would probably have been found in the urine. Fig. 20. Microscopic laminated crystalline masses of leucine. 10. Haemorrhages are very common, and particu- larly haemorrhage from the stomach or bowels. Blood is often vomited in large quantity. Petechias and vibices may appear on the skin, or in rarer cases there is uterine haemorrhage or epistaxis. 11. Pregnant females, who constitute a large pro- portion of the cases, almost invariably abort or miscarry before dying. 12. The circumstances under which acute atrophy of the liver occurs constitutes not the least interesting part of its clinical history. The causes of the disease still require investigation, but I shall briefly 232 CONTRACTIONS OF THE LIVER, [lect. vii. mention those that are at present known. Among predisposing causes, then we have — a. Age. Most persons attacked with the disease are under the middle age. Of 31 cases collected by Frerichs, 26 were under 30, and all but 2 under 40. b. Sex. The disease is much more common in females than in males. Of the 31 cases collected by Frerichs, 22 were females. c. Pregnancy must be regarded as a predisposing cause, for of the 22 female patients referred to by Frerichs, one half were attacked while pregnant. From the third to the sixth month is the most com- mon period of pregnancy at which the disease shows itself. In the pregnant state it is said to be fre- quently associated with fatty degeneration of the kidneys and albuminous urine. d. Dissipation, including drunkenness and venereal excesses, have been known to precede the disease in a considerable number of cases. e. Constitutional syphilis appears to be a predis- posing cause in some cases. Most writers on syphilis have noted the frequent occurrence of jaundice about the commencement of what is known as the secondary stage; and in some (probably a small proportion) of these cases the jaundice is due to acute atrophy.* Among causes that appear to act more directly in exciting the disease are the following:— a. Nervous influences, such as severe mental emo- * See Lebert in Virchow's Archiv. 1854, 1855; Andrew in Path. Trans, xvii. p. 158; and Fagge, lb. xviii. p. 138. lect. vii.] ACUTE YELLOW ATROPHY. 233 tions, and particularly fear and grief. Sir Thomas Watson, in his lectures, states that scores of instances are on record, where jaundice has suddenly appeared under such circumstances, and adds that these cases are often fatal, with head symptoms, convulsions, deli- rium, or coma, supervening upon the jaundice.'* In these cases an impression made upon the nervous sys- tem appears to be directed to the liver and to derange its nutrition. b. Malaria. There are other cases where the dis- ease has apparently resulted from some malarious poison, acting probably through the blood and the nervous system. Instances have been recorded by Graves,f Budd,J and others, where several cases of what appears to have been unquestionably this disease occurred in the same house; and when it is considered what a rare disease acute atrophy is, it is impossible to escape from the view that in these cases there must have been some local cause to which all the patients were subjected in common. c. The blood-poisons of typhus fever and allied diseases have been known to give rise to acute atrophy of the liver. § Jaundice is a very rare com- plication of typhus and scarlet fever, but in more than one instance where it has occurred, || I have found crystals of leucine and tyrosine in the tissue of the * Lectures on the Practice of Physic, 3rd ed., ii. p. 557. t Clin. Lect. 2nd ed. ii. p. 255. {. Op. cit. 3rd ed. pp. 255, 270. § See Frerichs' Treatise on Diseases of Liver, Syd. Soc. Ed. i. p. 235 || Treatise on the Continued Fevers of Great Britain, 1862, p. 194. 234 CONTRACTIONS OF THE LIVER. [LECT- VTI- liver and kidney. The liver in these cases has been in a state of fatty degeneration, but without marked atrophy. Most writers on the yellow fever of the tropics have described fatty degeneration of the liver as one of its most characteristic lesions; but observa- tions are still wanting as to the presence or absence of leucine or tyrosine in the urine and in the tissues of the kidneys and liver. d. Lastly, it seems not improbable that in some cases of acute atrophy, the cause may be, as suggested by Dr. Budd, some special poison engendered in the body itself by faulty digestion or assimilation.* The nervous influences already referred to may possibly contribute to the development of such a poison. Treatment.—In acute atrophy of the Hver, all treat- ment has hitherto proved unsatisfactory. The disease, after the supervention of cerebral symptoms, is inmost cases fatal, although well authenticated instances are on record where patients have recovered after falling into a state bordering on coma. It may be well, therefore, to enumerate those remedial measures which have appeared most useful, or which seem indi- cated by our knowledge of the pathology of the disease. 1. Purgatives. In several instances which have been reported as occurring in Ireland, patients, in the same house with others who have died, have recovered after active purging in conjunction with leeches and blisters to the head.f Dr. Budd also states that in several * Op. cit. p. 265. f See cases by Dr. W. Griffin, of Limerick, in Dub. Journ. of Med. and Chem. Science, 1834, and by Dr. Hanlon, in Graves, loc. cit. lect. vii.] ACUTE YELLOW ATROPHY. 235 cases of jaundice which he believed to be of this nature, he has found advantage from a combination of sulphate of magnesia (5J), carbonate of magnesia (gr. xv), and spiritus ammonise aromaticus (3 ss) given three times a day. 2. After the supervention of cerebral symptoms all measures calculated to promote the elimination of urea and uric acid from the system deserve a trial. It is in this way perhaps that purgatives have proved beneficial, and that warm baths, hot air baths, dia- phoretics, diuretics, and colchicum may also be ex- pected to do good. 3. In cases where there is extensive haemorrhage from the stomach or from other mucous membranes, ice cr astringents maybe necessary. 4. It is in the early stages, however, of the malady, before the occurrence of cerebral symptoms, that most advantage may be expected from treatment. Cheering society, holding out hopes of recovery, change of scene, anodynes to procure sound sleep, attention to the condition of the stomach and bowels, and the nitro-muriatic acid, with the infusion of gentian, or some other vegetable bitter, are the measures which appear best calculated for averting those terrible cerebral symptoms from which so few recover. The liver, which I show you here, was taken from the body of a patient who recently died under my care, in the London Fever Hospital, and who presented the symptoms of acute atrophy of the liver in a 236 CONTRACTIONS OF THE LIVER, [lect. vii. typical form, excepting that no leucine or tyrosine was found in the urine passed the day before death. These substances, however, were detected after death in the tissue of the liver and kidneys, and the former of these organs presented all the anatomical charac- ters peculiar to the disease. It may be worth men- tioning, however, that both Dr. Cayley and myself failed to find either leucine or tyrosine in the fresh liver and kidneys, although they were present in large quantity after these organs had been immersed for some days in spirit. Case XLIX.—Acute Atrophy of the Liver—Acute Peritonitis—Leucine and Tyrosine in the Liver and Kidneys, but none detected in the Urine. Mary Ann M----, a sempstress, aged 19, was admitted into the London Fever Hospital, on the evening of February 13, 1868, and was seen by me on the following morning. She was unmarried. Her father was a German, but she had been born and brought up in London. Her sister was not aware that she had suffered from any mental trouble, and believed that her catamenia had been regular; there was no history of syphilis. There had been no other case of illness in the house from which she came. She had been quite well until the middle of January, when she began to complain of loss of appetite and nausea, and, after ten days, her skin was noticed to be slightly yellow. A week before ad- mission she took to her bed, complaining of pain in her stomach, aggravated by any movement, but unattended by vomiting. For about a fortnight before admission her bowels had been relaxed three or four times a day, the motions at first being yellow, but latterly green. Three days before admission she began to be 'light- headed.' On the morning after admission the following note was taken : —'Patient is a well-nourished girl, and has deep jaundice of the skin and conjunctivae. She is scarcely conscious, and can give no account of herself. Since admission she has been very restless and lect. vii.] ACUTE YELLOW ATROPHY. 237 delirious, often screaming out loudly. The pupils are much dilated, but equal. There is no eruption on the skin, which feels dry and hot, the temperature in the axilla being 101° F. The pulse is 116 and weak. The cardiac and respiratory signs are normal. The tongue is dry and brown, and since admission there has been fre- quent vomiting of a dark brownish fluid evidently containing blood. The bowels have acted several times, and from the nurse's ac- count, who describes the motions as having been very dark, watery, and offensive, they probably also contained blood. The abdomen moderately distended, and tympanitic; pressure upon it does not seem to cause pain, but the respiration is thoracic, and there is an obscure thrill, as from fluid, on tapping both flanks. The hepatic dulness is greatly diminished, not exceeding 1£ inch in the right mammary line, and its lower margin being fully 2 inches above that of the ribs (see fig. 17, p. 226). The urine has been passed in bed, but the bladder is now full.' About 2 pints of urine were drawn off by catheter, which had the following characters. It was acid, and had a specific gravity of 1015. It had a dark greenish-brown colour, but presented the reaction of bile-pigment in only a faint degree. Heat produced no change on it; but, on adding nitric acid, after boiling, it became turbid, as well as very dark. Nitrate of urea could be obtained from it in only very small quantity, but no crystals of leucine or tyrosine could be detected, either as a separate deposit on stand- ing, or after evaporation of a few drops of the urine in a watch- glass. Unfortunately the urine was thrown away before it could be submitted to a more careful analysis. • The patient was ordered a mixture containing nitric acid, nitric ether, and nitrate of potash, with milk, beef-tea, and four ounces of gin. She nevertheless became rapidly worse, although she was less noisy and delirious, and seemed to sleep a good deal at intervals. The diarrhoea continued, the motions being passed in bed, and being still liquid and very offensive, but of a light yellow colour. In the evening of the 14th the pulse was 144; respirations 132 and thoracic; temperature in axilla 100-8°. She continued much in the same state, and died, without any convulsions, at 7-50 a.m. on the following morning, five days after the first appearance of cerebral symptoms. Autopsy.—Body well nourished. Much purple lividity of inte- 238 CONTRACTIONS OF THE LIVER, [lect. vii. guments, and deep jaundiced hue of skin and of every tissue of the body. No scars on genitals or in groins. Three or four pints of slightly turbid serum in peritoneum. Considerable fine vascular injection of the serous covering of the small intestines, and particularly of that of the duodenum. The pe- ritoneum of the intestines and of the liver was also coated at many places with a thin film of recent lymph, easily separated. The stomach and intestines were distended with gas, and the liver was completely hidden below the right ribs, not more than an inch of it being opposed to the thoracic wall. The organ was extremely small; its largest diameter measuring 6£ inches, and the autero- post. diameter of the right lobe only 5 inches. It weighed only 28 ounces, or exactly one-half of the standard weight for the girl's age. It was very flabby, and the outer surface was wrinkled, but free from any granular or nodular irregularities. The substance of the gland was extremely friable, and of almost pulpy consistence, and presented, at some places, a tolerably uniform rhubarb-yellow colour, with scarcely any appearance of lobules, and at other parts a similar yellow colour, interspersed with red. Under the micro- scope, there was found a large quantity of free oily and granular matter, with globular masses of leucine, and bundles of needles of tyrosine, and also, more especially at what corresponded to the centres of the lobules, entire secreting cells of large size, and loaded with oil-globules and dark greenish-yellow pigment. The bile-ducts were patent throughout; they were not dilated, and their lining membrane presented no tinge of bile, although the gall-bladder contained about a teaspoonful of dark-green viscid bile, which could be squeezed out through the cystic duct. The contents of the intestine consisted throughout of a very pale yel- lowish pulp. The mucous membrane of the bowels was nowhere ulcerated. The spleen was of normal size, but rather soft. Both kidneys were slightly enlarged, extremely soft, and tinged with bile-pigment. The renal epithelium contained a large quantity of fine granular matter; crystals of both leucine and tyrosine were detected in the renal tissue. The bladder was empty and the uterus was unimpregnated. There was much hypostatic conges- tion of both lungs. The pericardium contained more than an ounce of yellow serum; the heart was healthy; the blood was dark and fluid. Excepting an increased amount of serosity in the lateral ventricles and beneath the arachnoid, neither the brain nor its membranes presented anything abnormal. lect. vii.] CHRONIC ATROPHY. 239 III. CHRONIC ATROPHY. Under this head it will be convenient to consider several diseases, which, in their etiology and anatomi- cal characters, are essentially distinct, but which often present symptoms so similar that it may be impossible during life to distinguish them. The diseases I refer to are these :— I. Cirrhosis, or the so-called 'gin-drinker's liver,' in which the liver becomes reduced in size in consequence of an atrophy or slow destruction of the secreting tissue, but where the fibrous tissue is increased in amount, so that the organ is preter- naturally dense and firm. The outer surface also presents a granular or nodulated character, which has earned for the disease the designation of' hob- nailed liver,' and on section the organ presents firm fibrous bands, including the remains of vessels and bile-ducts and surrounding islets of yellow* secreting tissue. The capsule also is sometimes thickened and adherent to surrounding parts. This disease can almost invariably be traced to the abuse of strong spirits, and especially to the habit of drinking them neat, and accordingly it is most common in those coun- tries and towns where such a habit prevails. (Case L.) * This yellow colour is due to the large quantity of yellow pigment contained in the secreting cells. It is from this character that the term cirrhosis (K