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LETTSOMIAN LECTURES 



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DISEASES OF THE LIVER 



HABERSHON 




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THE LETTSOMIAN LECTURES DELIVERED AT THE 
MEDICAL SOCIETY OP LONDON, 1872, 



PATHOLOGY AND TREATMENT 



DISEASES OF THE LIVER 



BY 

S. 0. HABERSHON, M.D. Lond., F.R.C P 



SECOND EDITION. 



PHILADELPHIA 

P. BLAKISTON, SON & CO. 

1012, WALNUT STREET 

1885 



3&J.3&3 



PREFACE TO SECOND EDITION. 



These Lectures having been for some time out of 
print, I have ventured again to offer them to the 
notice of the profession. Some additions and cor- 
rections have been made, but the Lectures are sub- 
stantially the same. Many years of extended expe- 
rience in the diagnosis and treatment of Diseases of 
the Liver have more firmly impressed upon my mind 
the fact, that functional disturbances of the liver 
take place without direct interference with the bile- 
ducts, and that the nervous system in its influence 
upon the physiological action of the liver is a fertile 
source of disease. In some of these maladies there 
may be no jaundice produced, but possibly abnormal 
pallor. The advance of medical science has shown 
that the old-fashioned blue pill and black draught, 
although often very serviceable, do not reach many 
diseases which are due to the imperfect action of the 
liver. We have not attempted to enlarge the work 
into a treatise on diseases of the liver, and many of the 
affections of this important gland are only very briefly 
alluded to ; neither have we ventured to illustrate our 
opinions by instances that have come under our own 
notice, as it would have increased the book in a 
manner that we did not contemplate. It has rather 
been the object to state some of the deductions brought 
before the mind during years of clinical observation. 



PREFACE TO FIRST EDITION. 



When I accepted the honour of delivering the Lett- 
somian Lectures at the Medical Society of London, 
I hoped that time would have permitted me to enter 
fully upon the subject which I had chosen; and 
although deeply conscious of the imperfect manner in 
which I have carried out my intention, I have pre- 
ferred presenting the Lectures to the public in the 
manner in which they were delivered, rather than to 
enlarge upon the original matter. They are published 
at the request of some members of the Society ; and 
whilst it has been quite foreign to my purpose to give 
a treatise on Diseases of the Liver, the Lectures will 
be found to contain practical suggestions, which will, 
I trust, be of service to those who are engaged in the 
active duties of the profession. 

70, Beook Street ; 1872. 



CONTENTS. 



LECTURE I. 

PAGE 

The Livee and its Nerves.— The function of the liver — 
The secretion modified by the state of the nervous system 
— Symptoms of this condition — Sugar in the urine — The 
distribution of the pneumogastric nerve, and its union 
with the phrenic nerve in the ganglion of the vena cava — 
The vaso-motor nerve — Division of nerves producing gly- 
cosuria — Observations of Bernard, Pavy, &c. — Atonic 
dyspepsia and gout associated with glycosuria — Cold shock 
as affecting the pneumogastric nerve and the liver — The 
action of diseases of the liver upon the nervous system—^ 
Headache, epilepsy, infantile convulsions, sleeplessness, 
melancholia, mental depression, disturbance of the senses, 
of the heart, and of the lungs, of the intestinal tract, and 
of the kidneys — The action of the nervous system upon 
the liver, in melancholia, in intense mental anxiety- 
Mental depression as a cause of cancerous disease of the 
liver — Pain as a symptom of disease of the liver — Pain 
not due to disease of the liver — Neuralgic pain in the 
region of the liver, causes of — Atrophy of the liver — with 
phthisis and other diseases — Bilious attacks connected 
with nerve function — Acute yellow atrophy, causes of — 
Symptoms — Diagnosis, cases of . . . 1 — 45 



LECTURE II. 

The Liver and its Vessels.— The hepatic vein — The vena 
porta? — The hepatic artery — Their arrangement — Patho- 
logical changes — Congestion of the portal vessels — Obstruc- 



Vlll CONTENTS 

PAGE 
tion, external or internal — Cancerous disease in connection 
with the vena portse — Communication with abscess — 
Externa) obstruction — Inflammatory obstruction — Cir- 
rhosis — Senile fibroid degeneration-— Symptoms of cir- 
rhosis ; diagnosis, treatment — Paracentesis abdominis — 
Inflammation of the glandular texture — Hepatitis — 
Abscess, cases of . . . 45 — 77 



LECTURE III. 

The Bile and the Bile-Ducts. — Composition of bile — 
Arrangement of ducts — Views of physiologists — Jaundice, 
varieties of, obstructive, non- obstructive — Spasmodic occlu- 
sion — Resemblance of symptoms to those produced by the 
passage of gall-stone — Catarrh of the bile-ducts — In- 
flammation of ducts, thickening — Rigors — Traction on 
ducts by adhesions — Entozoa — Discharge of hydatids — 
Inflammatory thickening of bile-ducts — Gall-stone — Asso- 
ciation of gall-stone witlyphthisis ; with cancerous disease 
of the liver — Association of the passage of gall-sfcone with 
pleurisy — Sympathy of the kidney during passage of 
biliary calculi — Cancerous disease of gall-bladder and of 
the bile-ducts and of the liver ; diagnosis and treatment 
— Cysts in the liver, varieties of — Hydatid — Serous cysts, 
case of ...... 77—111 



DISEASES OE THE LIYEE. 



LECTURE I. 

THE LIVER AND ITS NERVES. 

The tendency of modern medical practice is often 
to separate the diseases of one organ from those of 
another, and to cKssociate, as if organs had independent 
action, and could perform fully their functional require- 
ments with very little connection with other parts; 
whereas there is the closest unity in the arrangement 
of the structures of the whole body,, and especial means 
are provided to bring one portion of the organism into 
sympathy and intimate relationship with another. 
The two great means by which this living union is 
rendered effectual are the blood and the nervous 
system : the former, the medium by which fresh sup- 
plies of nourishment are afforded, or effete materials 
carried away from the ultimate structures ; and the 
latter, the agent which guides and controls and har- 
monises the mutual workings of the separate parts. 

It is scarcely necessary to advert to the position 

1 



2 DISEASES OF THE LIVER 

which the liver occupies between the stomach and the 
absorbing intestinal mucous membrane, and the lungs 
and the heart. The liver receives the venous supply 
from the whole of the intestinal tract ; the quantity 
of blood passing through the liver is very large, and 
the action upon it is of a most important character, 
although the precise manner in which the liver reacts 
upon the constituents of the blood, physiological 
chemistry has not yet fully made known. The function 
of the liver is complex, and is now generally regarded 
as having a triple action — nutritive, hsematinic, 
and biliary. 1. In its nutritive function, it supplies 
pabulum for the respiratory process ; it is the source 
of a substance which has received the name of glyco- 
gen, resembling dextrine in its composition (C 6 H 10 O 6 ). 
This is converted into sugar by the action of albu- 
minous ferment, and by its resolution into carbonic 
acid and water it is a source of animal heat. 2. It has 
a hsematinic function in maintaining the blood in its 
integrity, the old blood elements are removed, and 
material for new blood is supplied ; this waste nitro- 
genous substance is removed, probably by the forma- 
tion of urea and uric acid, which are got rid of by the 
agency of the kidneys. 3. The third function is the 
secretion of bile. In each of these operations the liver 
is in a great measure under the control of nervous 
centres; and this nervous connection is worthy of 
our close attention. 

It is not known how glandular structures are affected 
by the nerves, whether simply by regulating the quan- 



THE LIVER AND ITS NERVES 3 

tity of blood which is sent to the gland, or by some 
more direct influence upon the secreting cells ; but the 
action upon the vessels does not fully explain the 
phenomena we occasionally observe; for the nervous 
influence is capable of producing not merely a change 
in the quantity, but in the character, of the secretions. 
A sudden fright or intense emotional excitement has 
rendered the secretion from the breasts absolutely de- 
trimental to the infant ; the secretion from the kidneys 
undergoes immediate change, or may be checked, by 
profound nervous impression; under great emotional 
excitement or distress, the appetite is lost, and food 
does not digest if placed in the stomach ; and, whilst 
it has long been recognised that the mind has a causa- 
tive relation in the production of acute yellow atrophy 
of the liver, a state in which the glandular function is 
well-nigh stopped, still, the lesser changes upon the 
liver are continually overlooked. In these days of 
intense mental anxiety — of constant strain upon the 
thought of men — of wrestling as if for life in the com- 
petition and struggle to obtain wealth — there is an 
influence, and that of a deleterious character, upon the 
functions of organic life, and the largest of the glands 
is often impaired in its integrity. Reference is not 
made to hepatic disturbance from excess, in which 
the secretion of bile is altered, the countenance becom- 
ing sallow, the tongue furred, and the excretions 
changed. In the hepatic disturbance to which I now 
refer, there is no sallowness, but a distressed and 
anxious countenance; the bile is excreted as in health, 



4 DISEASES OF THE LIVER 

but the liver does not perform its function properly ; 
the general nutrition of the body is interfered with ; 
the patient is unequal to ordinary exertion ; the cus- 
tomary duties of life become burdensome ; the sleep is 
unrefreshing ; the appetite is lessened; the pulse is 
compressible; in some there may be a gouty dyscrasia 
produced ; in others there is a transient glycosuria ; 
the liver is disturbed by an overstrained nervous sys- 
tem. This condition is not diabetes, neither does it 
present the symptoms of that disease : there may be no 
thirst, no excess of urine; nor is the condition per- 
sistent. It has often surprised me how frequently, in 
some of the forms of atonic dyspepsia, this evidence 
of changed hepatic function is observed; and it is 
important, as directing us not only to the cause of the 
malady, but as suggesting the curative mea.ns — not so 
much the administration of drugs as the diminution 
of that which induces nervous exhaustion. To forget 
the cares of life, to unloose the daily burden, to seek 
the mountain-top and the wild moorland, far from the 
arena of strife and vexation, are the best remedies for 
many of these cases of hepatic indigestion. And, if 
these more effectual means cannot be used, at least the 
long hours of mental effort may be lessened, and time 
allowed for nervous energy to be restored. Sometimes 
a sudden nervous fright will produce severe jaundice, 
as in the case of a poor out-patient of mine at Guy's 
Hospital some years ago. A washerwoman, having 
left her room for a few minutes, returned to find all 
the clothes in flames. Her fright was followed in a 



THE LIVER AND ITS NERVES 5 

few hours by jaundice ; there was no pain, no febrile 
excitement ; but, as the mind became composed, and 
after a few days* interval, the jaundice disappeared. 
If the distress be less sudden, but more prolonged in 
duration, there is also disturbed action of the liver. 
It would be a great mistake to " treat the liver " in 
these instances. " It is only the liver out of order," 
is a common expression, but usually an incorrect one. 
More frequently the hepatic disturbance is only the 
expression of a general state, and is relieved by general 
means. But, before entering further upon pathological 
considerations, it may be well to inquire what are 
those nervous connections whereby this close bond is 
maintained and by which these symptoms are produced. 
The pneumogastric nerve, the vaso-motor nerve, and 
the ganglionic centres by which these nerves are 
brought into union, deserve our attention. 

The pneumogastric is one of the most important 
nerves in the body ; it is extensive in its connections, 
and its functional integrity is essential to life. It 
would be out of place to enter upon all the connections 
of this nerve ; but it will suffice to say, that after union 
with nearly all the nerves in the neck and after giving 
off the laryngeal nerves, it enters into further union in 
the chest, and distributes branches to the lungs and to 
the heart. The nerve is brought into connection with 
the vaso-motor nerve in the chest, but still more 
intimately in the abdomen. The pneumogastric unites 
in the large semilunar ganglion of the vaso-motor, 
which in a chain of enlargements surrounds the coeliac 



6 DISEASES OF THE LIVER 

axis in front of the aorta, and branches from this 
ganglion are distributed upon the coronary artery to the 
stomach, upon the mesenteric vessels to the intestines, 
upon the hepatic artery to the liver, as well as to the 
pancreas and to the spleen, and descending branches 
unite with the renal and other plexuses. The pneumo- 
gastric nerve sends branches to the supra-renal cap- 
sules, and to the kidney ; but there are other branches 
which have especial interest in connection with the 
liver. The right nerve entering the abdomen upon 
the oesophagus, and uniting with its opposite nerve, 
soon sends down a delicate branch which reaches the 
lateral ligament of the liver; another branch passes 
deeply to the plexus, which is situated upon the vena 
cava, whilst others are connected with the semilunar 
ganglion and with branches to the liver and to the 
stomach; these latter pass to the pylorus, and also 
upon the walls of the stomach itself. The branches 
from the semilunar ganglion can be traced around 
the hepatic artery in Grlisson's capsule; others pass 
to the vena portse, and are traced into its walls. One 
of the branches from the pneumogastric appears to 
be quite continuous with the branch upon the vena 
portae, and to join other filaments in Glisson's cap- 
sule. The branches upon the hepatic investments 
are of great interest ; any inflammatory disease of the 
surface of the liver induces pain, and the sympathy 
of the right side of the chest is shown by the lessened 
respiratory effort on that side. The ganglion of the 
vena cava is placed upon the cava, and, as shown from 



THE LIVER AND ITS NERVES 7 

a dissection of mine, made with great care some years 
ago (see c Guy's Beports/ 1857), the pneumogastric is 
by it brought into close union with the phrenic nerve, 
and with the vaso-motor. The phrenic nerve passes 
through the diaphragm, it forms a series of radiating 
branches in that important respiratory muscle, and 
then unites in this ganglion. Not only do we find in 
this union an explanation of the pains which are often 
experienced in the shoulder by patients suffering from 
disease of the liver, the phrenic nerve at its origin in 
the neck having close connection with the nerves of 
the shoulder, but other severe neuroses have an expla- 
nation in this important ganglion. It would be inte- 
resting if experiments could be made upon this gan- 
glionic centre as easily as upon ganglia in the neck ; 
but, it is placed so deeply, that the dissection required, 
to expose its branches would be fatal to the life of the 
animal. There can, however, be no doubt that the 
function of these nerve centres is of great importance ; 
and the pathological facts which are brought out in 
examinations after death, show us some of these func- 
tional connections. 

Division of the pneumogastric nerve does not pro- 
duce such marked effects upon the liver as upon the 
stomach and the lungs ; but this subject requires 
further investigation. In a case of cancerous disease 
of the breast and of the vertebrae, under my care some 
years ago in Guy's Hospital, and in which paralysis 
and atrophy of half of the tongue were produced by a 
cancerous growth pressing upon the ninth nerve, there 



8 DISEASES OF THE LIVER 

was also direct pressure from a similar growth upon 
the left eighth nerve, the pneumogastric ; and there 
was great wasting of the left lobe of the liver, but no 
cirrhosis, and no fatty degeneration of the gland.* 
Claude Bernard, in his ' Letjons de Physiologie/ pub- 
lished in 1855, drew attention to most interesting facts 
connected with the pneumogastric and the functional 
activity of the liver. These experiments are well 
known, and have been fully illustrated and further 
developed in the observations of my colleague, Dr 
Pavy. These investigations were the subject of the 
Lettsomian Lectures in the year I860, and it is not 
necessary that I should do more than allude to them. 
Bernard showed that in diabetes there was an increase 
in the functional activity of the liver, and he produced 
an artificial diabetes by puncturing and irritating tho 
floor of the fourth ventricle, or by galvanising the 
pneumogastric in the neck. His explanation was, that 
the vaso-motor nerve upon the hepatic vessels was 
affected in these experiments ; that the vessels became 
dilated by the paralysis or lessened power of these 
nerves ; that the quantity of blood in the gland was 
thereby increased, and sugar was produced. Dr Pavy 
has indicated still further that division of the superior 
cervical ganglion, and Cyon has shown, that incision of 
the last cervical or the first dorsal ganglion, have a like 
effect. It thus appears, that this action upon the liver 
is one of lessened nerve-power, and the symptoms of 
disease confirm the statement. 

* Eecorded in ' Guy's Hospital Keports,' 1872. 



THE LIVER AND ITS NERVES 9 

We have already alluded to tlie fact of transient 
glycosuria being a not unfrequent symptom in atonic 
dyspepsia; and the same diminished power has been 
often observed, in the presence of considerable quan- 
tities of sugar in the urine for short periods in atonic 
gout. A year or two ago, a gentleman, about sixty- 
five years of age, consulted me for chronic gout. The 
urine was highly albuminous, but I also found that 
there was a very considerable quantity of sugar pre- 
sent. After a few days the sugar entirely disappeared ; 
the quantity of urine was not excessive, nor was there 
the progressive wasting of diabetes. The gouty dis- 
ease of the kidneys continued, although for a time 
relieved ; again there was a transient return of sugar, 
but several months afterwards bronchitis supervened 
— another indication, with him, of weakness of the 
nervous system, and especially of the pneumogastric 
and its associated vaso-motor branches. The bron- 
chial affection led to a fatal termination. It may be 
stated that the urine was of high specific gravity ; and, 
unless there had been an evident gouty dyscrasia, the 
presence of albumen might easily have been over- 
looked. Sometimes in these cases there is a consider- 
able excess of urea. 

Sudden cold shock affecting the branches of the fifth 
nerve and of the pneumogastric nerve has a marked 
action upon the liver. In many cases the respiratory 
branches of the nerve manifest the effect subsequently 
to the more peripheral branches distributed to the 
stomach and to the liver. After the exposure, espe- 



10 DISEASES OF THE LIVER 

cially where the patient is advanced in life or the ner- 
vous system is in an exhausted state, the first sym- 
ptoms may be nausea, vomiting, sallowness of coun- 
tenance, depression, and the ordinary symptoms of a 
bilious attack. There is febrile excitement, the tem- 
perature rises to 102° or 103°, the pulse is quickened, 
the sallowness of the countenance increases to acute 
jaundice, and the bilious vomit is sometimes replaced 
by an almost black grumous fluid. After a short 
time — on the second or third day — the pulmonary 
branches show a disturbed condition, and inflam- 
mation of the pleura and lung takes place. The 
sickness and the hepatic disturbance lessen, but still 
the patient is sallow, feverish, the urine high coloured, 
and often it contains a little albumen. Severe pain 
may be experienced in the side, it may be in the 
region of the liver without any physical signs of 
disease of the pleura, and the whole malady is referred 
to the liver. After a short time the examination of 
the chest shows that it is also affected at the lower 
part ; pleurisy, which at first affects the diaphrag- 
matic pleura, creeps round to the costal pleura, and a 
rub can be detected ; the lung tissue becomes impli- 
cated, and consolidation of the lung rapidly advances. 
Many of these cases recover if the strength of the 
patient be maintained.* The following is a good illus- 
tration of the cases referred to. A. B — , aged 77, a 
gentleman who had been in tolerably good health, 

* Paper read before the Medical Society on "Cold Shock," 
Dec, 1881. See * Proceedings ' of the Society, 1884. 



THE LIVER AND ITS NERVES 11 

except that lie suffered from dyspepsia and flatulent 
distension of the stomach, went out on the morning 
of November 2nd to look after the alterations in a 
chapel, and was standing about on damp ground ; he 
became chilled, and experienced a severe rigor. He 
returned home, but felt ill. Nausea came on and 
then vomiting, and these symptoms continued for 
several days, and on the fifth the vomited matters 
were an almost black coffee-ground substance. On the 
same day distress and shortness of breath came on, 
with pain at first in the right, then in the left side ; 
there was great weakness and shortness of breath. 
The temperature rose to 100°, the urine was free from 
albumen, the bowels open. On the 9th he was slightly 
sallow, distressed and prostrate ; the respiration was 
40, temp. 101°, pulse 100. The abdomen was flatu- 
lent; there was no cough and no expectoration, 
but there was well-marked consolidation of the lower 
lobe* of the right lung. Dr Hall, of Crouch End, 
whom I had the pleasure of meeting in consultation 
in the case, informed me that the chest symptoms 
soon subsided, and the patient made an excellent 
recovery. 

It may be well to examine the subject of the liver 
and the nervous system in three aspects : — I. The 
action of morbid conditions of the liver upon the ner- 
vous system ; II. The action of a disordered state of 
the nervous system upon the liver and its secretions ; 
and III. Pain in the region of the liver as a symptom 
of disease. 



12 DISEASES OF THE LIVER 

I. The action of the morbid conditions of the liver 
upon the nervous system. 

It is probable that there is a direct nervous connec- 
tion between the liver and the nervous centres, for 
although there is no doubt that the action of the ner- 
vous system may alter the secretion of the liver, the 
converse is not equally manifest. The cerebral sym- 
ptoms in both functional and organic disease of the 
liver have been referred to secondary action conse- 
quent upon an altered condition of the blood — by 
some they have been attributed to the presence of the 
bile acids in the blood, by others to the action of 
cholesterine, and lastly, to other elements of bile modi- 
fying the blood itself, or altering the blood pressure. 

Headache is a symptom often produced by disturb- 
ance of the liver, and varies in severity from a slight 
uneasiness or tenderness to intense pain. Sometimes it 
is a frontal pain, or it is located at the vertex, or at the 
occiput, or it may be the exciting cause of pain at the 
temple. The pain from biliary disturbance should be 
distinguished from the severe headaches consequent 
on exhaustion, or the severe neuralgic headaches often 
designated "megrim." The hepatic headache is 
accompanied by furred tongue, sallowness of the 
countenance, disordered condition of the stomach and 
bowels, and there may be uneasiness and pain in the 
region of the liver itself. 

Epilepsy and infantile convulsions may be excited 
by hepatic disturbance where there is a susceptibility 
to these forms of disease. Sleeplessness is often to be 



THE LIVER AND ITS NERVES 13 

referred to disordered function of the liver ; patients 
may remain awake at night for hours, or be unable to 
fall asleep for a considerable time after retiring to 
rest; and closely allied to this condition is mental 
depression merging sometimes into confirmed melan- 
cholia, or even mania. Oftentimes during temporary 
biliary disturbance the most gloomy forebodings are 
entertained as to the relations of life and pecuniary 
obligations. Everything is seen through a coloured 
and distorted medium, and it is curious to observe how 
a few hours of refreshing sleep or correction of the 
liver malady will modify the opinions and correct mis- 
taken impressions. In my student's days, on going 
round the surgical wards at Guy's with the late Aston 
Key, a poor man, who had attempted suicide by cutting 
his throat, was about leaving the hospital well, when 
the surgeon told him that " if ever any such thought 
came into his mind again he was always to take a 
rhubarb pill." A blue pill is often more effectual. 

The senses are each of them liable to be affected by 
hepatic disturbance, perhaps the sight more decidedly 
than any, and in different degrees; sometimes the 
sight becomes confused and indistinct, zigzag lines' 
are seen, or only half the object can be defined. Muscae 
volitantes or dark specks are observed, or the whole 
eye becomes painful, or the pain seems to be at the 
posterior part of the eye. The hearing may be equally 
affected ; noises of different kinds, ringing, whistling, 
droning sounds are subjective sensations referable in 
many cases to hepatic disturbance, and may be most 



14 DISEASES OP THE LIVER 

distressing to the sufferer. The sensation of taste is 
also modified ; patients complain of a bitter taste which 
has been referred to the circulation of the bile acids. 
It is a common expression in these functional maladies 
to say that everything tastes bitter, but the sense 
becomes otherwise perverted, and substances produce 
impressions on the sense different from those ordinarily 
experienced. 

It would be difficult to describe the alterations in 
the sense of ordinary feeling or touch. Numbness in 
the arms and fingers, creeping sensations, twitchings, 
" pins and needles," are oftentimes indirectly due to. 
functional disturbance of the liver. In other instances 
a sense of chilliness or coldness, or actual rigor are 
produced. 

The action of the liver upon the heart is consequent 
upon the intimate connection of the cardiac ganglia 
with the vaso-motor nerves of the abdominal sympa- 
thetic, and also upon an altered condition of the blood. 

Palpitation, irregular action, faintness, or complete 
syncope, and symptoms of angina pectoris, are some- 
times to be traced to disturbance of the liver. It may 
be palpitation on exertion, or an occasional intermis- 
sion, especially at night, followed by increased action. 
These are symptoms often observed in the dyspepsia 
of persons disposed to gout. When the hepatic con- 
dition is rectified, all the cardiac symptoms are removed 
unless they occur in advanced life, with degeneration 
of the vessels or of the kidneys. 

An association of symptoms equally intimate is 



THE LIVER AND ITS NERVES 15 

found between the liver and tlie lungs, and this may- 
be due not only to the connection of the vaso- motor 
nerve, but to the close relationship of the circulation 
in the two structures. Any congestion of the liver 
leads to increased fulness on the right side of the 
heart ; it therefore more or less impedes the capillary 
circulation in the lungs, and it increases the severity 
of symptoms in pulmonary disease ; and where there 
is no special weakness of the lungs, dyspnoea and 
asthma may be induced. 

In reference to the intestinal tract, and the process 
of digestion, there is the association of function, the 
integrity of the action of the liver being required for 
the completion of the normal processes of digestion and 
assimilation. It is difficult to separate the one from 
the other. 

The kidneys also have a double connection ; whilst 
they serve to remove from the blood products of an 
effete character, which are due to secondary assimilative 
changes, there is a connection of nerve supply. The 
deposition of lithates, and excess of urea and of uric acid 
are closely linked with the functional condition of the 
liver ; the presence of the colouring matter of bile in 
the urine and of sugar are not the result of renal but 
of hepatic diseases, but besides these there is a nerve 
connection. In many severe diseases of the liver, as 
in the passage of gall-stone, and inflammation of the 
ducts, we may find that the urine becomes albuminous 
and the patient may die from pysemia. 

Not only does the liver react on the nervous system, 



16 DISEASES OF THE LIVER 

but the converse is equally true, the nervous system 
reacts on the liver. The secretion may be checked, or 
it may be altered in character ; in this respect the ex- 
periments of Claude Bernard are of great interest, and 
we have already referred to them, — how that irritation 
of the medulla at the origin of the pneumogastric will 
induce a diabetic condition of the urine, and how 
sudden nervous shock may so affect the liver as to 
cause well-marked jaundice. The state of the nervous 
system in diabetes is an exceedingly interesting one. 
The mental depression of the patient is sometimes one 
of the earliest symptoms in diabetes. There is often 
restlessness, sleeplessness, a want of mental energy 
and power ; symptoms resembling melancholia are 
produced, and it is surprising how all these symptoms 
are relieved and disappear as the diabetic condition is 
removed under suitable treatment. It would seem 
not only that the disturbance of the glycogenic func- 
tion of the liver will thus react on the nervous system, 
but that the alteration of the nervous supply may cause 
the diabetes. 

Some years ago a young man was admitted into 
Gruy's Hospital, under my care, with well-marked 
diabetes. He had previously suffered from a severe 
burn, but from that he soon recovered. The question 
was discussed whether there was any causative rela- 
tion between the injury to the skin and the subsequent 
diabetes. Dr Hill has recorded in Dr Beale's c Archives 
of Medicine ' some interesting instances of glycosuria 
following upon burns ; and he refers to the nervous 



THE LIVER AND ITS NERVES 17 

shock, and the imperfect elimination of carbon and 
hydrogen by the injured skin, as possible causes of 
the diabetic state. Whilst referring to the liver in 
connection with diabetes, we may advert to another 
indication of change in the functional activity of the 
gland in that disease. In ordinary diabetes, bile is 
secreted as usual, and the excreta are well charged 
with it, whilst the haamatinic relations of the liver are 
altogether disordered. But at the close of diabetes it 
is not unfrequently found that a state of complete 
acholia is induced ; the sugar may have entirely 
ceased, the urine may have become of normal specific 
gravity, but the excreta are white, diarrhoea super- 
venes, and sometimes frothy and fermenting evacua- 
tions are discharged. 

Melancholia. — In true melancholia, independent of 
diabetes, we have the same relation of symptoms. As 
we have previously remarked, disordered liver is a 
common cause of mental depression, hypochondriasis, 
and all its miserable train of symptoms ; but in mental 
disease originating in the disorder of the brain the 
liver becomes disturbed, the bowels become con- 
fined, the countenance sallow, the tongue may be 
furred, and the dejecta changed. The same remark 
applies to acute mania. 

Intense Mental Anxiety. — The harass of constant 
worry and depressing care will so react upon the biliary 
secretion that I have known actual jaundice produced. 

Mental depression a cause of Cancerous disease. — One 
word in reference to the state of the brain and nervous 

2 



18 DISEASES OF THE LIVER 

system in determining to cancerous disease of the liver. 
When, after severe mental strain or shock, especially 
of a depressing kind, general impairment of nutrition 
follows, then cancerous cachexia is soon induced. It 
is in the antecedent condition of cancer that treat- 
ment is most available ; if we can remove the causes 
of distress, and procure rest and change of scene ; or 
if indigestion exist, we can mitigate it by remedies, 
we may avert the full development of a cancerous 
cachexia; for, when once produced, a very slight 
excitement will determine its local manifestation, and 
the presence of gall-stone or direct disturbance of the 
gland may fix the mischief in the liver, just as a blow 
may determine the growth of cancer in the breast. 
When once a growth exists, the time for effective 
treatment is passed ; and when a dyspeptic patient 
between fifty-five and sixty-five years of age becomes 
wasted and exhausted under mental strain, there is 
always danger of cancerous disease, and especially in 
the liver. 

Pain in the region of the Liver. — Pain in the right 
side and in the region of the liver is so often con- 
sidered as an indication of disease of the liver itself, 
that it may be well to dwell upon some of the causes 
of pain in this part which are quite unconnected with 
affections of the gland. 

Pleurisy. — One of the most common sources of 
fallacy in relation to hepatic disease is the presence 
of inflammation of the serous membrane of the dia- 



THE LIVER AND ITS NERVES 19 

phragmatic or costal pleura, and I have been sur- 
prised to find how frequently the mistake is made, 
especially at the earlier stages of the disease. It is 
frequently found that at the commencement of acute 
pleuro-pneumonia, affecting more especially the right 
side, the earlier symptoms point to hepatic disturb- 
ance ; vomiting, constipation, loss of appetite, sallow- 
ness of countenance may be present ; and at first careful 
stethoscopic examination gives no evidence of pul- 
monary or pleuritic disease. The absence of symptoms 
is easily explained by the disease affecting the dia- 
phragmatic surface of the pleura. No friction sound 
can at first be heard, and it is only when the mischief 
has invaded the costal pleura that any friction sound 
can be detected ; the pain may be so intense as to 
resemble that which is produced by the passage of a 
gall-stone and may even induce collapse, the heart's 
action failing, and the patient becoming cold and 
death-like. Some time ago I was asked to go into 
the country to see a patient who was supposed to 
have abscess in the liver. He was a merchant, thirty- 
three years of age, who had had pain at the pit of 
the stomach, followed by slight jaundice ; the sym- 
ptoms were referred, and correctly so, to gall-stone. 
The patient recovered, but five months later, he was 
exposed on the water to cold and had severe chill ; 
the following night severe pain of a stabbing character 
came on in the right side, with dyspnoea. After 
two or three weeks the strength failed, and I was 
requested to see him. He was then extremely pros- 



20 DISEASES OF THE LIVER 

trate, pale, and in profuse perspiration ; the bowels 
were regular, and the motions contained bile. The 
liver extended about one inch below the ribs and was 
felt rounded at the scrobiculus cordis ; there was slight 
tenderness on pressure. On examining the chest, 
there was found to be extensive dulness on the right 
side, there was bronchial breathing and bronchophonic 
cegophony, and the intercostal spaces were full. The 
temperature was 102*5°, the pulse 120 to 130, respi- 
ration 32 to 36; the urine was healthy. Quinine was 
ordered, and it was recommended that the chest should 
be tapped. A day or two after my visit the aspirator 
was used without success, but on a further attempt 
five pints of offensive pus were removed. The patient, 
however, sank a few hours after the operation. The 
previous attack of jaundice, probably from gall-stone, 
misled in this case, and at first the pleurisy was of a 
diaphragmatic character. 

Rheumatism. — It is probable that some cases of 
severe pain in the side are due to rheumatism ; this 
may be produced by cold, as from cold bath ; or the 
pain may be from perichondritis , and be of a specific 
character. 

Strain is another cause of pain in the side. 

Spinal Disease. — The spinal nerves in their course 
extend to the anterior part of the body, and it is very 
common to find that pain at the scrobiculus cordis, or 
over the whole abdomen, or in the right side, is due to 
this cause. It will often be found, that the pain is 
uncertain in its position and will sometimes be on the 



THE LIVER AND ITS NERVES 21 

left side, and that it extends round to the spine. 
These symptoms may exist without any local tender- 
ness of the spinal bones. 

Shingles. — For several days before the onset of 
shingles severe pain may be present, and the cause of 
the pain be quite misunderstood till the rash appears. 
It is easy to mistake this pain for hepatic disease. 

Abscess in the abdominal parietes. It is not easy 
to diagnose some cases of external abscess from internal 
and glandular disease ; for although in most cases the 
function of the liver is not seriously affected, in some 
cases jaundice may be produced. A gentleman, aged 
about fifty, after attending a public meeting, was 
seized with intense pain about the region of the trans- 
verse colon ; the malady was regarded as colic and 
was relieved by chlorodyne and carbonate of ammonia. 
There was much constipation which was followed by 
diarrhoea. A week later, on examination of the abdo- 
men, it was found that there was fulness and some 
projection to the right of the scrobiculus cordis ; there 
was tenderness over the region of the liver, but there 
was resonance on percussion, no pain nor distress after 
food ; there was febrile disturbance and general dis- 
comfort. Still, on careful examination, it seemed as 
if the swelling was due to suppuration in the parietes. 
A surgeon was asked to make an exploratory incision, 
but as it appeared to be below the fascia, the operation 
was postponed. The enlargement increased in size 
and after a time fluctuation could be felt. The abscess, 
which had attained to a great size, was then opened, 



22 DISEASES OP THE LIVER 

and it gradually healed. It was several months before 
health was restored ; it would have been more speedy, 
if an exploratory incision had at first been made. 

In a second case, there was disease of the rib, and 
a large abscess extending to the right hypochondriac 
region ; the patient became sallow and jaundiced, and 
for a time it was very doubtful whether the suppura- 
tion affected the liver itself. The patient gradually 
sank, and the gland was found to be perfectly free. 

Adhesion of the Colon to the Liver. — The colon reaches 
to the under surface of the liver, and it sometimes 
happens that as the result of local inflammation, due 
it may be to a blow or some direct injury, the bowel 
becomes fixed to the gland. In this state of adhesion 
distension of the abdomen or muscular movements of 
the body will bring on pain, and it is referred to the 
liver. 

In disease of the colon, where the affection is at the 
angle of the ascending and transverse colon, pain in 
the earlier stages closely resembles the pain pro- 
duced by disease of gall-bladder. After a time the 
function of the colon is more manifestly disturbed, 
and the character of the disease is more easily 
recognised. 

In perityphlitis the course of the disease, if suppu- 
ration has taken place, is not always in the same 
direction ; more frequently the suppuration passes 
downwards and reaches the venter of the ileum and 
Poupart's ligament, but this is not always the case. 
In a patient admitted under my care into Guy's Hos- 



THE LIVER AND ITS NERVES 23 

pital some years ago, there was suppuration external 
to the caecum from ulceration in the bowel, and it 
extended upwards behind the ascending colon as far 
as the under surface of the liver. He was about fifty- 
three years of age, a spare man, and the symptoms 
presented were severe pain in the right side with 
febrile symptoms ; there was a discharge of pus from 
the bowel, and the case had been regarded as abscess 
of the liver. In the region of the gall-bladder a very 
hard mass was felt, which tended still more to obscure 
the diagnosis. The mass was thought to be a growth 
in the liver or at the gall-bladder. The patient grad- 
ually sank, and post-mortem examination showed the 
mass to be a calcareous hydatid cyst, and it was quite 
unconnected with the symptoms of disease. 

Abscess and suppurative disease of the right kidney 
are found to be in close proximity to the lower surface 
of the liver, and the disease may be attributed to the 
liver instead of the kidney. 

Suppuration connected with the spine sometimes 
reaches to the right hypochondriac region. A year 
or two ago a young naval officer was sent to me from 
Plymouth with severe pain in the right side over the 
lower ribs. He had suffered from a strain, but from no 
direct injury ; he had not been in the tropics nor had 
he shown any evidence of dysentery ; there was neither 
jaundice nor disturbed function of the liver. On careful 
examination, it was found that although there was some 
enlargement of the liver, there was decided bulging 
in the right loin, and that the swelling extended over 



24 DISEASES OF THE LIVER 

the ribs. He returned home, and my colleague, Mr 
Durham, went into the country and opened the abscess. 
The patient went on very well for a time, but was 
allowed to go out, he took a chill, pyaemic symptoms 
came on, and he soon sank. 

Aneurism. — In aneurism of the coeliac axis and its 
branches the symptoms have frequently been referred 
to the stomach, to indigestion, and associated thereby 
with disturbance of the function of the liver. In a 
gentleman whom I had for several years seen when 
he came to town during the London season, flatulence 
and uneasiness at the pit of the stomach and in the 
loins were the prominent symptoms. He consulted 
me first in May, 1873, and was then forty -nine years 
of age ; he told me that he had not been well for ten 
years, and had suffered from lumbago and pain in the 
joints. In 1863 he was said to have congestion of 
the liver and also haemoptysis ; 1867 he had more 
severe rheumatism. In 1868 he saw the late Dr Bence 
Jones, and was relieved by the use of iodide of sodium. 
In 1871 he suffered from pain in the loins and in the 
right side, with flatulence ; the tongue was furred ; 
the respiration was not free at the base of the right 
lung ; the heart was irritable, and the pulse compres- 
sible ; the abdomen was contracted, and nothing could 
be detected on examination. The urine had sp. gr. 
of 1027, it was free from albumen, but contained a 
trace of sugar. This trace of sugar disappeared and 
the symptoms were for a time relieved. In 1874 he 
had a return of the symptoms with headache, palpi- 



THE LIVER AND ITS NERVES 25 

tation, and confined state of the bowels. In 1875 
there was more pain in the loins. In 1878 there was 
a recurrence of the same symptoms, but there was 
more pain in the chest, with headache and flatulence ; 
the heart had strong impulse, 120 per minute; the 
temperature was normal. The pain then passed to 
the region of the heart and to the left side, and it 
sometimes became very severe. The stomach became 
irritable, food was rejected and also mucus. On May 
25th, 1878, the pain was relieved by an opiate enema, 
but the irritability of the stomach continued. There 
was an ill-defined pain in the abdomen, but nothing 
could be felt on tactile examination ; the bowels were 
quiet; the temperature was 98*4°; there was pain 
across the back ; the respiration was good to the base 
of the lung. On the 26th there was slight retching, 
the pulse was feeble, but little food was taken ; the 
pupils were contracted from the opiate. In the even- 
ing the patient felt better; the pulse was 120, and 
feeble, but a pulsating tumour of considerable size 
was now felt at the scrobiculus cordis. There was no 
doubt that an obscure, deep-seated aneurism had given 
way and was probably connected with the coeliac axis. 
Ice was applied and the opiate continued. On the 
28th a diastolic bruit could be heard in the pulsating 
tumour, the patient's strength was less, and it seemed 
that the tumour was increasing towards the left side 
(extravasated blood, a false aneurismal sac). On July 
5th there was faintness with increase of the swelling. 
On the 12th there was vomiting and increase of pain. 



26 DISEASES OP THE LIVER 

On the 15th the lungs and the strength failed still 
more. On the 16th the tumour had disappeared, the 
pain ceased, but the patient soon sank. There was 
evidently increased extravasation of blood. In this 
case, for some time the disease was referred to rheu- 
matism and functional disturbance of the liver, after- 
wards to indigestion. The aneurism was too deeply 
seated near the diaphragm to be recognised till the 
sac gave way, and a false aneurismal sac was formed; 
the effused blood burrowed towards the left side and 
appeared to extend behind the descending colon. 

We have already spoken of the ganglion of the vena 
cava, and of its union both with the pneumogastric 
and with the semilunar ganglion ; and it is in this 
direction that we must look for the explanation of 
some attacks of severe pain which come on in the 
upper part of the abdomen during chronic disease of 
the heart. When from organic disease of the aortic 
or mitral valve, or from dilatation of the left ventricle" 
or other cause, the right ventricle is distended, the 
inferior cava also becomes necessarily dilated, the liver 
is congested, the whole portal system engorged, the 
minute capillary vessels of the mucous membrane 
become congested, and its altered state leads to the 
secretion of thick mucus on the surface of the mem- 
brane. In this state abdominal pain is produced, 
different in kind, and arising from at least three 
different causes. 

First, it may be a sensation of fulness and throbbing, 
and of distress at the scrobiculus cordis, which is due 



THE LIVER AND ITS NERVES 27 

to distention of the right side of the heart. This con- 
dition is relieved by mercurials with squill and digi- 
talis ; by purgatives and by diuretics ; and, in fact, 
by any of those means which lessen the vascular strain 
on the right side of the heart. 

Secondly, the pain may be situated across the epigas- 
tric region, and may be caused by gastric catarrh ; the 
food is imperfectly digested, and becomes coated with 
a thick envelope of mucus, and flatulent distention is 
the result. The pain thus produced is often most 
distressing to the patient; the distention of the stomach 
impedes the action of the diaphragm and embarrasses 
to a greater degree the crippled heart. Hemorrhagic 
erosion may also be induced, with coffee-ground vomit. 
This symptom — pain — is lessened by the remedies 
already indicated, and also by the use of mineral acids, 
by nux vomica, by carbolic acid, &c, the diet being 
meanwhile carefully regulated. 

A third kind of pain is evidently of a neuralgic 
character; it is not angina pectoris, but it is abdo- 
minal ; and I have noticed its locality as situated 
deeply behind the first part of the duodenum. It is 
severe, almost like that from gall-stone, but it is with- 
out jaundice or other symptoms of calculus; it is not 
connected with the stomach, for it is not affected by 
food, but paroxysmal, and recurring sometimes with 
great regularity. The remedies we have mentioned 
may be used to their full extent, mercury even to the 
verge of salivation, digitalis till it can no longer be 
borne ; purgatives may be used freely, and the anasarca 



28 DISEASES OF THE LIVER 

removed by puncturing the legs ; but still this severe 
neurosis continues ; it appears to be due to exhausted 
nerve-function, especially of those nerves of which we 
have already spoken. Narcotics and anodynes afford 
the only means we possess of palliating this distressing 
symptom. 

There are some severe forms of neurosis in connec- 
tion with the liver and stomach which are difficult of 
explanation, and which are often very incorrectly 
referred to gall-stone or to gout. It is perfectly true 
that spasmodic contraction and severe pain are induced 
at the pylorus by inflammatory congestion of the 
mucous membrane following excesses and intemper- 
ance ; so, also, by ulceration and cancerous disease of 
these parts ; but the pain indicated is of a different 
kind, and post-mortem examination does not reveal 
these diseases. 

I might relate other instances which have come 
under my own notice, the symptoms of which were 
very obscure, and in which we were led to attribute 
the pain to some unknown disturbance of the gastro- 
hepatic system of nerves. 

Some of these instances are relieved by nervine 
tonics, as by arsenic and by steel ; and others by 
saline mineral waters, and by complete change of 
thought and scene. 

Having referred to these several causes of pain in 
the region of the liver which are due to causes 
independent of the liver, we pass to the enumeration 
of those cases of hepatic disease in which pain is one 



THE LIVER AND ITS NERVES 29 

of the symptoms. Some of the maladies are due to 
changes in the circulation or in the ducts, and we 
shall have to refer to them again. 

Inflammation of the peritoneal surface of the liver or 
perihepatitis leads to pain of a severe character. 

Congestion of the liver, producing tension of the 
investing tissues, also leads to pain. This is the pro- 
bable cause of the varying attacks of pain often expe- 
rienced in functional disease of the liver, patients 
experiencing pain in the right side at once refer it to 
the liver, and a " touch of the liver " is a common 
expression as indicating the opinion of the sufferer. 

Local suppuration between the liver and the dia- 
phragm is a cause of severe pain, and has been often 
mistaken for pleurisy. Many years ago a woman, 
about fifty years of age, was admitted under my care 
into Guy's Hospital. She was of very intemperate 
habits, and a few days previously was thrown from a 
light cart upon the abdomen. Severe pain in the caecal 
region came on and extended over the whole perito- 
neal surface ; there was evidently inflammation of the 
serous membrane. The symptoms were for a time 
relieved, but soon afterwards she complained of severe 
pain in the right side and was in great distress. As 
she lay in the ward her moans attracted the attention 
of one or another physician who passed her bed. One 
experienced stethoscopist diagnosed the case as one of 
pneumonia; another said, that there was pleuritic 
effusion, empyema. The patient sank, and on the 
post-mortem table a trocar was introduced about the 



30 DISEASES OP THE LIVER 

seventh rib to try and decide the question of diagnosis. 
Pus freely flowed through the cannula, and it was 
supposed that the case was one of empyema by the 
second diagnostician till fuller examination showed 
that the disease was entirely below the diaphragm, and 
a large collection of pus had formed on the right side 
in the peritoneum between the liver and the diaphragm. 
The full clinical history of the case indicated that the 
disease was from the first peritoneal. 

Hepatitis. — Many cases of abscess of the liver 
occur without any pain, but where the surface is 
reached and there is much tension, and especially where 
the peritoneal covering is inflamed, the pain may be 
very severe. In these cases there is also local tender- 
ness, often with enlargement of the side, and, there 
may be, oedema of the parietes. 

Gall-stones often exist, and even in great number 
without producing any pain or distress, in fact, the 
patient may be quite unconscious of their presence. I 
have counted more than 120 gall-stones from a patient 
where no symptoms had been produced ; the patient 
had died at an advanced age from an entirely different 
malady. But the intense pain due to the passage 
of a gall-stone is well known, so intense, indeed, 
that a patient may die from the severity of it and from 
the consequent prostration. Again, inflammation of 
a more or less severe character may extend up the bile- 
ducts into the liver either within or without the ducts ; 
this disease leads to severe pain, especially where sup- 
puration and the collection of pus have taken place. 



THE LIVER AND ITS NERVES 31 

Inflammation of the lining membrane of the gall- 
bladder and ulceration lead to pain, but much less 
severe than that produced by the forcible distention 
of the bile-duct, even when ulceration extends into 
the duodenum or into the parietes of the abdomen. 

Hydatid disease of the liver may exist with im- 
munity from pain, even when the cyst has attained to 
considerable size, but where there is inflammation of 
the sac and suppuration, and especially where there is 
inflammatory thickening of the serous membrane of 
the peritoneum, pain is always present. 

In cancerous disease of the liver pain is most variable 
as a symptom. It is often entirely absent, even when 
very numerous tubera are developed in the gland. In 
other cases the pain seems to be out of all proportion 
to the size of the liver. In several cases that have 
come under my notice in the early state of the disease 
the pain has been intense, but for a time extending 
over weeks, or even months, no enlargement could be 
detected, and no growth felt on careful manipulation. 
Some years ago a patient of that kind was sent to me 
by Mr J. Birkett. The pain in the region of the liver 
was very severe, but the most careful examination 
could detect no enlargement ; a little crackling at the 
base of the right lung could be heard, as if from pleu- 
ritic adhesion, but it was only after several months 
that the true nature of the disease was recognised. 
In another case, a gentleman, aged 35, had the 
testicle removed three years before his death; he 
remained well for two years, his health then became 



32 DISEASES OF THE LIVER 

impaired, and lie suffered very severe pain in the left 
side. The pain was regarded by several physicians as 
simply of a neuralgic character, and strong tonics 
were administered; the pain was also found to be 
more severe when the bowels were confined. In the 
autumn of 1882 he suffered very severely ; there was 
flatulence and great distress from the intensity of the 
pain, and marked emaciation. It was then found 
that the left lobe of the liver was irregularly enlarged ; 
tubera were evidently present. The growth increased 
in size, and although the pain was relieved by the 
hypodermic injection of morphia, and the flatulence 
was lessened by the administration of the hyposulphite 
of soda, still he gradually lost ground and sank on 
December 1st. Here for many months the pain was 
regarded as neuralgic, but was evidently due to disease 
of the left lobe of the liver and pressure on the nerves 
by enlarged glands. 

Atrophy of the Liver. — The connection of the pneu- 
mogastric with the gastro-hepatic nerves is an inte- 
resting one in the pathological study of phthisis ; and 
the atrophic deposition of oil-globules in the liver 
during phthisis is variously explained. A larger 
quantity of carbo-hydrogen may exist in the blood 
from undue absorption, and from the imperfect action 
of the respiratory organs ; but a fatty liver is found 
in other exhausting diseases, in atrophy from in- 
temperance, and from cancerous and other diseases; 
yet we cannot but think that the exhausted nervous 



THE LIVER AND ITS NERVES 33 

energy tends to increase the disease, if so it may be 
termed. This nervous connection has to do with the 
indigestion which often precedes phthisis, and which 
is indicated by pallor, by failing appetite, and by 
diminished strength ; the tongue is furred ; and, as it 
has been remarked by Mr J. Hutchinson, there is often 
the dislike to fatty articles of diet. This is the most 
important time for treatment, before the physical signs 
of disease are manifested ; and that treatment consists 
less in the administration of drugs than in improving 
the nutrition of the patient by fresh bracing air, and by 
cheerful healthy occupation. But, at the later stages of 
phthisis, we sometimes find that the pulmonary sym- 
ptoms become quiet, the cough nearly ceases ; there 
may be no pain, no diarrhoea, but a complete loss of 
appetite, "a gradual dying out •" and although bile is 
secreted, it is lessened in quantity, and sometimes it 
even ceases altogether \ it is especially the vaso-motor 
nerves of the digestive apparatus which seem to have 
lost their energy and their power to work. 

There is a condition of fatty atrophy, or degenera- 
tion of the liver, concerning which we are doubtful 
whether it is due in greater measure to the condition of 
the nervous or to that of the vascular system ; whether 
the supply of nerves to the tissues, or the blood, is most 
at fault. I refer to poisoning by phosphorus ; for it is 
most remarkable that in a very short space of time, a 
few hours or days, not only is jaundice produced, but 
the liver-cells become loaded with oil-globules. 

Again, whether the disturbance of the liver in agues 

3 



34 DISEASES OF THE LIVER 

and in fevers be due to the nervous system or to the 
altered character of the blood, there is no doubt that 
the secretion is changed, and jaundice is produced. 
Such forms of jaundice are referred to altered enerva- 
tion of the gland, and may be due to the development 
of germs. It is, however, in some of the chronic 
forms of marsh-poisoning, and in jungle-remittents, 
when no jaundice may exist, that we find the nervous 
system suffers from extreme depression, and the 
mental energies seem to fail altogether. There is not 
the sudden exhaustion and febrile disturbance of the 
acute attack, but the nervous system lacks its power, 
and the patient becomes unequal to mental or physical 
effort. In no class of cases does the value of right 
treatment manifest itself in a greater degree. Arsenic 
and bark, with or without the iodides and bromides, 
soon effect great benefit, and relieve the symptoms of 
depression. 

There are conditions of atrophy of the liver which 
are due to mechanical causes, such as pressure upon the 
gland, whether partial, as from compression of the 
ribs by belt or stays, or from more general pressure 
of fluid ; or, again, from interference with the supply 
of blood, as when a large branch of the portal vein 
becomes obstructed, and the whole lobe wastes ; or 
from the more diffused obstruction which we find 
in cirrhosis. These are, however, very diverse from 
the forms of atrophy which are due to the nervous 
system, and to which some allusion has been made. 

The function of the liver is a complex one ; it has a 



THE LIVER AND ITS NERVES 35 

relation to the blood on the one hand, and to the bile 
on the other ; and in some of the conditions to which 
we have already referred, the function of the liver is 
altered in an important manner, but still the secretion 
of bile is maintained. There may be no jaundice, but 
we may have evidence either in the formation of sugar, 
or in some other way, that the gland is functionally 
disturbed. It is in these instances, that the treatment 
must often be directed to the nervous system, by im- 
proving the general health, or by removal to a purer 
atmosphere ; and, if medicines be used, those are most 
likely to be of service which act upon the nervous 
system, such as arsenic, nux vomica, nitro- muriatic 
acid, &c. In a second class of liver disturbance, the 
hsematinic relation is affected as well as the secretion 
of bile, but in a transient manner. The urine contains 
an excess of colouring matter, of bile elements or rather 
of uro-haematine. 

We find an evidence of this altered nerve-function in 
the ordinary " bilious attack," and we may ask what is 
the true pathology of this state ? It is sometimes 
spoken of as stomach-disturbance, and it is in the sto- 
mach that the mischief commences. The patient expe- 
riences a sense of faintness and exhaustion, it may be 
with pain at the stomach, vomiting, headache, furred 
tongue and loaded urine. In a short time these sym- 
ptoms subside, and health is restored ; but how is this 
condition produced ? The irritation of the mucous 
membrane of the stomach from excess induces weak- 
ness or paralysis of the vaso-motor nerve of the liver ; 



36 DISEASES OP THE LIVER 

there is more blood contained in the gland, the secre- 
tion of bile is interfered with, the countenance becomes 
sallow, the urine altered and thick ; at the same time 
there are often pallor and faintness, for the vaso-motor 
nerve of the heart is acted upon. Again, the tongue 
is furred, not, we believe, from direct extension of 
mischief from the stomach to the tongue, but from the 
epithelial growth being interfered with by the state 
of the nervous supply and its intimate connection with 
other nerves of the same system. The faintness is 
due to a like cause, and will subside as the irritation 
lessens. It is unfortunate, that this sense of exhaus- 
tion and faintness is relieved by stimulants which, for 
a short time, rouse the exhausted vaso-motor nerve ; 
but the exhaustion as quickly returns, to be relieved 
by the same remedy. It is most difficult to persuade 
the patient that the exhaustion is really increased and 
perpetuated by the stimulant, and that if he will with- 
hold his irritating draught the nerve-power will 
recover, the appetite return, and the functions will be 
restored. It may be that in the ordinary bilious attack 
something may be due to direct absorption by the 
branches of the vena portae, and thus direct irritation 
of the liver may be produced ; but this absorption is 
very slow, and we believe that the symptoms arise prin- 
cipally from the nerve-supply ; just as in poisoning by 
arsenic, we have the same exhausted vaso-motor nerve, 
the faintness, compressible pulse, and loss of power. 

In another state, the action of the liver is more 
profoundly affected ; its functional activity is arrested, 



THE LIVER AND ITS NERVES 37 

bile is not secreted, and a most serious and generally 
fatal train of symptoms is produced. We refer to 
acute yellow atrophy of the liver. This condition has 
been attributed by some to inflammatory change in 
the liver, by others to an altered condition of blood, 
but the state of the nervous system is important in 
its causative relation ; sometimes it is due to intemper- 
ance, or to exposure to cold, or to syphilis, or to 
malarial poisoning, or blood poisoning. The patients 
are frequently young in years. Thus, of cases which 
have presented themselves at Guy's during the last 
few years, were : 

Ellen L — , aged 23, who suffered mental distress a few months 
after marriage. 

Elizabeth B — , aged 30 ; no history of mental distress. 

William B — , aged 25 ; no history of mental distress. 

Frances A — , aged 23 ; a married woman, who had syphilis. 

Isabella R — , aged 21 ; a young woman of good family, who 
had left her home, and had been living as a prostitute. 

John C — , aged 18. 

John S — , aged 35 ; in whom the disease was partial, and in 
whom there was neither febrile excitement nor delirium. 

It will be seen that the greater proportion of these 
cases is in young women ; and in some, pregnancy 
seems to be connected with the causation of the dis- 
ease, or rather some intense mental emotion conse- 
quent upon that state. The patient feels out of 
health, with malaise and symptoms of gastric catarrh ; 
he is then seized with vomiting and headache, and in 
a short time jaundice follows with cerebral excite- 
ment. The temperature may be normal, but is some- 



38 DISEASES OP THE LIVER 

times increased; the pulse is generally quickened; 
the tongue is furred ; there are abdominal pain, nausea, 
and constipation ; the motions at first contain bile, 
but afterwards become pale in colour ; sometimes blood 
is passed ; the dulness of the liver is diminished, or 
at any rate not increased ; the urine is remarkably 
changed, it may be deep in colour, and contains two 
abnormal products — leucine and tyrosine— with dimi- 
nution of urea, and, according to Frerichs, of phos- 
phate of lime also. The patient becomes comatose, 
and sinks from exhaustion generally during the first 
week. Frerichs states that of 31 cases 13 died in the 
first week, 6 in the second week, 5 in the third week, 
and 4 in the fourth week. Cases of this disease have 
been recorded by Bright, by Graves, by Budd, 
Frerichs, Murchison, Harley, &c. ; and the anatomical 
changes in the liver are as remarkable as the physical 
signs. The liver is lessened in size, the secretion of 
bile is checked, but there is no obstruction to the 
bile-ducts. The jaundice is due either to the secretion 
of the liver being checked, or to defective metamor- 
phosis after secretion. The gland assumes a deep 
yellow colour, and, when the affected parts are exa- 
mined by the microscope, the debris of cells only are 
found; in one instance, I could not find a trace of 
hepatic cells in any portion of the liver. Nothing 
could more strikingly show the profound manner in 
which the gland is affected than this alteration of cell- 
structure, but the presence in the urine of such 
remarkable products as leucine and tyrosine testify to 



THE LIVER AND ITS NERVES 39 

the same fact. In glycosuria we have the formation 
of products closely allied to other normal constituents, 
glycocoll, &c; in ordinary bilious disturbance the 
presence of uro-haematine in excess shows also that 
the blood-relation function is changed ; but in acute 
yellow atrophy we have, to use the expression of the 
late Professor Miller, the elements of putrefactive 
change ; for these abnormal products that have been 
mentioned may be produced from albuminoid sub- 
stance by fusing with caustic alkali, ammonia is 
thereby evolved, and an offensive faecal odour is 
admitted. Leucine is an unctuous substance, but 
tyrosine is easily obtained in long fibrous crystals, 
sparingly soluble in water. Acute yellow atrophy is 
nearly always fatal, and its whole history testifies to its 
close connection with the nervous system. We believe 
that successful treatment must be in the same direction; 
the administration of mercury is probably as likely 
to be successful as when given in severe septicaemia. 

There are, however, instances of the disease in a 
partial as well as in a more chronic form, in which 
there is red discoloration of the liver, and these cases 
sometimes recover ; we have thought that the partial 
fatty degeneration may have been due to some such 
cause. The microscopical examination of the gland 
in acute yellow atrophy shows that the hepatic cells 
are degenerated, or replaced by granular matter — 
crystals of tyrosine may be observed ; but in instances 
of red discoloration fibroid tissue may be detected 
permeating the minute structure of the acini. In the 



40 DISEASES OP THE LIVER 

diagnosis, there is some danger lest we confound with 
acute yellow atrophy the jaundice which comes on with 
typhus, or with enteric fever, with ague, or with the epi- 
demic jaundice which occasionally occurs, as at Rother- 
ham a few years ago, and which closely resembles a 
milder form of yellow fever. There is a severe form of 
jaundice which accrues after irritation of the duodenum 
and inflammatory disease of the bile-ducts; but in 
these leucine and tyrosine are absent from the urine, 
and the cerebral symptoms are, at any rate in the 
latter case, less severe. Local inflammatory diseases 
producing jaundice differ also in a similar manner, 
but the diagnosis is sometimes attended with consider- 
able difficulty. The narration of several instances 
which have come under my own care will best illus- 
trate this remarkable and rare disease. 



CASE I.— Acute Yellow Atrophy* 

Isabella R — , aged 21, was admitted into Guy's Hospital, 
February 11th, 1867. She was of: good family, but had left her 
home three months previously, and had since been living an 
abandoned life. Her temper was obstinate. On Friday week, 
February 1st, she was taken ill with vomiting, headache, and jaun- 
dice, which gradually increased in severity. On the 10th she 
became insensible, and was brought to the hospital at 6 p.m. of 
the 11th. On admission she was scarcely sensible, but was throw- 
ing herself about rather violently. She was fairly nourished, of 
dark complexion, and dark hair. The whole body was deeply 
jaundiced ; the face was flushed, and the conjunctiva was injected ; 
the tongue at the tip and the lips were of a dark red colour, but 
black sordes covered the dorsum of the tongue, the teeth, and part 

* Reported by Dr Frederick Taylor. 



THE LIVER AND ITS NERVES 41 

of the lips ; the edges of the teeth were tinged with blood ; the 
pupils were widely dilated. She resisted food, twisting and 
throwing her head from side to side, and jerking the shoulders, 
arms, and legs ; occasionally she groaned ; the urine was discharged 
involuntarily ; the pulse was 128, and feeble ; the respiration 30, 
and irregular ; the temperature 97*2°. The liver dulness extended 
from 1^ inches below the nipple to the margin of the ribs ; there 
were purpuric spots on the legs, and bruises on the knees. The 
urine was drawn off at 2 p.m. ; it was of a bright orange colour ; 
its sp. gr. T025, free from albumen, it became green with nitric 
acid, and it deposited on standing a quantity of renal epithelial 
casts, deeply stained yellow. By concentration of the urine, balls 
of leucine, and after a day or two needles and tufts of tyrosine, 
were deposited. On admission, a soap injection could not be 
administered, and croton oil was used to act on the bowels. 
During the night she had been screaming, and had muscular 
jactitation. She vomited twice, thick greenish mucus, streaked 
with black blood ; she passed one or two thin and pale motions. 
At 9.30 a.m. of the 12th, the nurse thought she was dying, as breath- 
ing ceased for a time, and the patient became cold and pulseless ; 
after a short time, however, she rallied, and the choreic movements 
returned. Only small quantities of fluid food were forced down. 
At 2 p.m. she had become quiet ; the eyes were open ; the pupils 
unequally dilated ; the conjunctiva were only slightly sensible to 
the touch, and the pupils to light ; the arms appeared insensible 
to touch, but reflex movements could be produced by tickling the 
feet ; she ground the teeth constantly ; respiration 27, more regular ; 
about 10 oz. of bright-coloured urine had been drawn off. At 4 
p.m. she had been in the same position, but was partly roused by 
the sound of her name, and then burst out crying. At 6 p.m. the 
respiration was 36, the pulse 150. Calomel gr. v. was given, and 
a soap injection administered. The bowels were moved about 9 
p.m. ; two or three clots, with bright -coloured motion, were passed, 
but she became more and more comatose, and died about half -past 
10. Inspection was made by Dr Moxon sixteen hours after death. 
The body was well developed, and deeply jaundiced. There were 
scars at the left Poupart's ligament. There were no nodes on the 
cranium. The arachnoid and pia mater were adherent, so as to 
tear the brain substance on removal. The brain was healthy, and 



42 DISEASES OP THE LIVER 

the ventricles contained very little fluid. There was ecchymosis 
at the posterior part of both pleurae. The lungs were congested 
with blood, and did not collapse freely. The pericardium was 
maculated on the posterior part, and still more so the fat surround- 
ing it, some patches of blood being as large as horse-beans. The 
cavities on the right side contained fluid blood, with yellow, soft, 
gelatinous flocculi. The left ventricle presented extensive ecchy- 
moses on the endocardium, especially of the septum. The muscle 
was very fatty. The stomach contained 9 oz. of soot-like fluid 
and water. The gall-duct was pervious. The bowels contained 
blackish clay-coloured stool. The consistency of the liver was 
gone, so that it formed a tremulous mass, and when cut the 
contents bulged over the edges. Externally the liver was clay- 
colour ; the section was of cadmium yellow, with redder parts 
around the portal veins, and under the capsule. The substance 
was very flabby ; the yellow portion was softer than that which 
was of a deep red colour. The hepatic cells were in great measure 
destroyed. Both the ducts and veins were free from obstruction. 
The weight of the gland was 31 oz. The gall-bladder was shrunken 
with pink-red walls ; it contained a plug of deep pale-green mottled 
mucus. The spleen was 6 oz. in weight, and rather soft. The 
kidneys were 10 oz. in weight, plump, and the cortex swollen ; the 
Malpighian tufts were highly fatty. The left ovary was shrivelled ; 
the right ovary was enlarged, and contained a recent false corpus 
luteum. The ovaries were adherent to the Fallopian tubes, which 
were turned back. There was an ulcer on the inner surface of the 
vagina, near the urethral orifice ; it had a soft base, and was 
shallow. The fibres of the pectoralis major were degenerated ; the 
colour was bright, but many fibres had lost their striation, and 
much granular matter was present where the striation was yet 
perfect. The renal epithelium was fatty, so that the nuclei could 
not be seen ; the stroma was healthy, but some yellow balls were 
present in the tubules here and there ; these were epithelial cells, 
charged with bile pigment. 

This interesting case of acute yellow atrophy of the liver pre- 
sented many symptoms closely resembling acute poisoning by 
phosphorus in the delirium associated with jaundice, and in the 
fatty degeneration of muscular fibre and of glandular tissue ; but 
the degenerative changes in the liver were of a different kind, 



THE LIVER AND ITS NERVES 43 

and the extreme fatty degeneration observed after poisoning by 
phosphorus was wanting. 

CASE II. — Acute Yellow Atrophy. 

William B — , aged 25, was admitted into Guy's Hospital, on 
September 8th, 1858, under my care. He was a young man of 
dark complexion, a tailor by trade, of temperate and steady habits ; 
he had resided at Walworth. For several years he had had occa- 
sional pain in the lower part of the abdomen, but no definite cause 
could be found for the present illness — no history of unusual 
exposure, over-anxiety, nor of intemperance. Three weeks before 
admission he felt great lassitude, sense of faintness, and was " ill 
all over." One week later, jaundice came on, preceded by itching 
of the skin ; and he had also noticed, prior to the discoloration of 
the skin, that the urine was of a very deep colour. One week 
before admission, on September 2nd, vomiting came on ; it took 
place in the morning directly after awaking, and was preceded by 
a sense of " heaviness in the chest." On the 8th he was of a deep 
icteroid colour ; the countenance was somewhat anxious, the mind 
oppressed and sluggish, but quite intelligent ; the body was mode- 
rately nourished, the tongue clean, bowels confined, the pulse com- 
pressible, but normal in frequency ; the appetite was bad, and, except 
a feeling of slight discomfort across the chest, he had not suffered 
from any pain. The heart and lungs were healthy ; the abdomen 
collapsed ; and there was no evidence of enlargement of the liver, 
spleen, or gall-bladder ; and no tenderness in the hypochondriac 
region. The urine was abundant, and loaded with the colouring 
matters of bile. A full dose of colocynth and calomel was 
ordered, but did not produce any action of the bowels. On the 
9th, compound jalap powder was given, and acted slightly ; potash, 
with compound decoction of aloes and infusion of calumba, was 
prescribed. The symptoms were as on admission. On the 10th, 
more severe vomiting came on, of dark green, almost black fluid ; 
there was no complaint of pain ; the abdomen was collapsed, the 
pulse compressible, the mind intelligent. On the 11th the vomit- 
ing continued ; all aperients and food were at once rejected from 
the stomach. On the 12th the patient became semi-comatose, but 



44 DISEASES OF THE LIVER 

the same irritability of stomach continued ; the urine was passed 
freely ; an injection of castor-oil was rejected, at once from the 
bowels ; water, or any fluid placed in the mouth, was only very 
partially swallowed. 13th. — Still in a comatose condition ; during 
the whole of the night he had been moaning or raving ; he refused 
food ; the face and hands were clammy and perspiring ; the 
pupils enlarged, but acted sluggishly under the influence of light ; 
there were sordes on the teeth ; the abdomen was collapsed, and 
free from tenderness ; placing food in the mouth produced an 
attempt to retch ; the pulse was moderately full and sharp, 116 ; 
respiration, 20. The left eye was partially closed, and there was 
less movement of the left than of the right arm. Urine passed 
very freely ; the bladder not distended. 

He died on tfye 14th, at 1 a.m., after partial convulsion. In- 
spection was made thirteen hours after death. Brain. — The 
vessels were tolerably full of blood ; the arachnoid in several places 
on the surface of the brain presented slight opacity. The brain 
substance was normal, and there was no excess of fluid in the 
ventricles. Chest. — Slight adhesions of the pleural surfaces were 
found at the apex of the left lung, and puckering of the lung 
beneath, with one or two lobules of iron-grey colour from old 
disease. The lower lobes of the lungs presented hypostatic con- 
gestion ; on the surface of the pleura, towards the bases, were 
several patches of ecchymosis. Heart. — Pericardium healthy; 
heart small ; blood dark, fluid, and scarcely any clot was present 
in the cavities ; the valves were healthy. The surface of the left 
ventricle, near the aortic orifice, presented some partial red patches 
of ecchymosis beneath the endocardium. Abdomen. — Intestines 
not distended ; no hernia, and no obstruction nor gall-stone ; the 
peritoneum healthy. Liver small ; weight, 2 lb. 2 oz. ; its section 
was of a deep yellow colour, and it had a somewhat mottled 
appearance ; the acini were distinct. There was considerable vas- 
cularity of Glisson's capsule, but no distension of the bile-ducts. 
Under microscopical examination of the liver structure very few 
hepatic cells could be observed, and those found did not present 
the usual well-marked cell-wall and distinct nucleus, but appeared 
filled with granules ; there was a great abundance of granular and 
fatty particles, and in the acini clusters of granules were observed 
arranged in lines as if in the position of the hepatic cells ; some 



THE LIVER AND ITS NERVES 45 

of the minute bile-ducts were also observed to be full of granules. 
The gall-bladder contained about 5ij of dark-coloured thick bile ; 
the bile-ducts were healthy, and no increase of vascularity existed 
at the orifice in the duodenum. The stomach contained about a 
pint of dark-green fluid ; the mucous membrane presented nume- 
rous patches of arborescent injection, and some ecchymoses were 
found towards the cardiac and pyloric extremities, and at the lesser 
curvature. The examination of the mucous membrane showed 
considerable injection of the capillaries ; some granular colouring 
matter of blood was observed on the surface of the membrane ; 
the glandular structure was normal. There was some grey dis- 
coloration of the mucous membrane of the duodenum ; the jejunum 
was healthy ; the ileum presented slight enlargement of some soli- 
tary glan'ds at its termination ; Peyer's glands were not enlarged. 
In the ascending and transverse colon the solitary glands were 
generally distinct, and a layer of thick mucus adhered to the 
intestine. The spleen was slightly enlarged and soft ; the pancreas 
and adjoining glands were healthy ; so also were the supra-renal 
capsules and semi-lunar ganglia. The kidneys were large, but 
otherwise healthy. This case had been diagnosed as one of jaun- 
dice, arising from change in the structure of the liver, and the 
post-mortem examination confirmed that opinion. 

We have tried to show that the nervous system has 
a most intimate relation with the morbid processes of 
the liver, even without the production of jaundice ; 
and we are convinced that the treatment must in these 
cases consist in the removal of nervous disturbance 
and exhaustion. In a second class of diseases of the 
liver, the circulatory system is especially modified in 
the morbid processes ; and in these, mercurial medi- 
cines and others having like effect are constantly of 
value. In a third lecture we hope to speak of some 
diseases of the ducts in which alkalies are often of 
signal service to the patient. 



LECTURE II. 

THE LIVER AND ITS VESSELS. 

The connection of the liver with the nervous system 
occupied our attention at the last lecture, and we will 
now pass to the consideration of some of those patho- 
logical conditions which are connected with the vascular 
supply of the gland. The hepatic veins, the vena 
portae, and the hepatic artery, constitute three blood- 
channels to or from the gland; they unite at the 
minute lobules, but the import of their pathological 
changes is very different, and the symptoms which in- 
dicate those changes are also diverse in their character 
and in their results. I would premise a few words in 
reference to the arrangement of these vessels. 

The Hepatic Vein. — At the convex margin of the 
liver, close to the diaphragm, this large vessel enters 
the cava, having received the whole of the blood from 
the gland. It is a large venous reservoir, which 
divides into branches in the substance of the liver, 
forming the sub-lobular veins of Kiernan, and from 
these vessels minute branches pass into the lobules, 
the intra-lobular veins; within the lobules a minute 
capillary plexus is formed, which extends through the 
acinus, and within it joins the corresponding branches 



THE LIVER AND ITS VESSELS 47 

from the vena portae. The hepatic veins are destitute 
of valves ; they have very little cellular tissue around 
them, so that they remain patulous after division, and 
there is nothing to prevent the blood from distending 
these hepatic venous canals (Kiernan), if there be any 
obstruction in the passage of the blood from the right 
ventricle of the heart. The close contact of the 
hepatic vein with the lobulus Spigelii is an arrangement 
of some pathological interest in connection with peri- 
hepatitis, and the production of anasarca of the lower 
extremities, for I have frequently found contraction at 
that part and consequent constriction of the vessel. 

. The vena portx is a large venous trunk, which is 
composed of the united superior mesenteric and splenic 
veins ; the minute venous capillaries from the whole of 
the intestinal tract, as well as from the spleen and the 
pancreas, are brought to this vessel, the vena portae, 
before it again divides in the substance of the liver. 
The vena portae has a distinct muscular coat, which 
is in many instances of hepatic obstruction greatly 
hypertrophied ; in one instance lately I found it more 
than one-fiftieth of an inch in thickness; and this 
muscular wall is evidently an auxiliary force in the 
propulsion of blood. The vein is destitute of valves, 
and the whole of its branches are subjected to varying 
degrees of distension. The portal vein reaches the 
liver at the transverse fissure, in company with the 
bile-duct and with the hepatic artery; it receives fila- 
ments of nerves from the pneumogastric, and from the 
semilunar ganglia, and these filaments are lost upon 



48 DISEASES OP THE LIVER 

the coats of the veins ; lymphatic vessels accompany 
these vascular structures, and the whole are surrounded 
by cellular tissue, which constitutes what is well known 
as Grlisson's capsule, and which extends around the 
vessels as far as the acini of the liver. The vena 
portae divides into two large branches, and some 
minute offshoots pass into the sheath of the canal, 
and form plexuses with branches from the hepatic 
artery in Glisson's capsule ; the more important dis- 
tribution, however, is to the acini or lobules of the 
liver; after numerous divisions a minute capillary 
arrangement is formed around the lobules, the inter- 
lobular plexuses, and passing within the lobule, that 
is to say, reaching the hepatic cells, another plexus is 
formed, the intra-lobular, which joins corresponding 
capillaries of the hepatic veins; the inter-lobular 
vessels freely communicate. Throughout the sub- 
stance of the gland the vena portae is accompanied by 
branches of the hepatic artery, and by minute bile- 
ducts ; and when the vena portae is obstructed, fresh 
channels of communication are opened, or rather, 
small ones become enlarged, and the blood receives a 
new direction, as in the union of the internal haemor- 
rhoidal with the inferior haemorrhoidal veins, and the 
left coronary with the oesophageal and diaphragmatic 
veins. 

Frerichs (quoting from Sappey) draws especial 
attention to the minute branches of the portal veins 
which pass upon the falciform ligament to reach the 
under surface of the diaphragm, and the epigastric 



THE LIVER AND ITS VESSELS 49 

branches of the abdominal wall, the branches of which 
reach the internal mammary and the superficial abdo- 
minal veins ; and these collateral means of circulation 
are of great importance in obstruction of the larger 
portal vessels. The only remaining vascular supply to 
the liver is the hepatic artery, and this is perhaps the 
most important in many earlier stages of disease. 
It is a branch of the coeliac axis, and passing to the 
transverse fissure of the liver in connection with the 
vena portse, it gives off minute branches in the sheath 
of Glisson's capsule to the ducts and other structures 
in the capsule, and ultimately it reaches the inter- 
lobular plexus of the vena portse. In lardaceous dis- 
ease the capillary arteries are thickened, and easily 
recognised under the microscope ; and in this affection 
of the liver the minute branches of the artery may be 
traced as far as the lobule itself, but scarcely within 
the intra-lobular plexus. The hepatic artery is covered 
with numerous nerve filaments, and its pathological 
relations are most important. 

The acinus of the liver receives branches from three 
different sources : the hepatic capillary veins occupy 
the centre, the portal capillaries are at the circum- 
ference, and the latter are joined by the capillaries of 
the hepatic artery. According to Virchow, these three 
portions have different pathological relations : the 
circumference of the lobule presents us with fatty 
changes — the portal part — that which is in closest con- 
nection with the absorbent mucous membrane of the 
intestine (and the blood of this vein has been shown to 

4 



50 DISEASES OF THE LIVER 

be of a milky character after digestion) ; the central 
part first shows indication of increased pigmental 
deposit — the part that is nearer to the heart, and more 
indicative of hsematinic change ; and, thirdly, larda- 
ceous disease, which he states, is most marked at the 
centre of the lobule. 

The pigmental deposit may certainly be seen in the 
centre of the lobule, and in partial fatty degeneration, 
globules are more abundant at the circumference ; but 
in many instances of lardaceous disease that I have 
examined, it was quite impossible to establish any such 
definite limit of disease, probably from the change 
having assumed a more general character. The capil- 
lary vessels surround the cells of the liver, which are 
contained in the meshes between them; they are 
extremely delicate in their character, and with diffi- 
culty defined. The injections of the liver are not 
satisfactory ; but, by careful washing and gentle 
manipulation, the hepatic cells may be washed away, 
and the capillary vessels are left. As to the cells of 
the liver, they vary in size, and sometimes undergo 
atrophy, independently of the deposit of oleaginous 
particles or albuminoid substance in them. It is 
important to bear in mind that, as the function of the 
liver is a double one, having a relation to the blood as 
well as to the bile, so also is the circulation double in 
character ; there is a constant current of blood towards 
the heart, whilst there is a constant secretion of bile 
and flow towards the bile-ducts. 

The pathological changes in the hepatic veins are 



THE LIVER AND ITS VESSELS 51 

comparatively f ew, and are generally of a passive kind. 
In the distention from heart-disease and chronic bron- 
chitis, &c, these veins first present signs of congestion : 
the centre of the lobule is deepened in colour, the 
capillaries are enlarged, and the mottled appearance 
(called nutmeg-liver) is produced in some cases. I 
have seen fibroid cells in the acini as if from ante- 
mortem fibrillation of the blood. We rarely find con- 
traction of the hepatic veins from inflammatory fibroid 
deposit, as with the portal vessels ; but in some cases 
hepatic abscess, extending into the veins, leads to 
disease and thickening of the coats of the vessels. 

In passive congestion of the hepatic veins the gland 
gradually becomes enlarged, and after a time may be 
felt several inches below the ribs. It is found, on 
manipulation, to be harder than natural ; the increase 
in size is uniform, the surface is smooth, and the thin 
edge may be recognised by sudden but gentle pressure. 
The secretion of bile is altered, and the countenance 
of the patient becomes sallow ; the urine is deepened 
in colour, and is often scanty in quantity ; there is a 
sense of painful tension produced by the stretching of 
the fibrous envelope ; the bowels are irregular, and 
sometimes the excreta are paler than usual. All these 
symptoms are more marked if the congestion extend to 
the portal venous capillaries, and if there be distention 
of the vena portae ; then there is evidence of conges- 
tion of the mucous membrane of the stomach, the 
digestion is impaired, catarrhal mucus is secreted in 
excess, food does not digest, but flatulent distention 



52 DISEASES OF THE LIVER 

is produced, with increased dyspnoea and distress ; the 
intestinal mucous membrane is congested, and colic 
and irregular action of the bowels may be produced, 
whilst similar congestion of the hemorrhoidal veins 
induces piles. If the congestion of the liver and of its 
vessels increase, serous effusion into the peritoneum 
follows, with the attendant symptoms of ascites. 

This form of disease is distinguished from the fatty 
enlargement of the liver by the more congested appear- 
ance of the skin ; it wants the smoothness that occurs 
in fatty degeneration, and it is also distinguished by 
the presence of obstructive disease of the glands and 
of the circulation. Another form of enlargement, 
which is free from vascular distention, is produced by 
lardaceous, waxy, or amyloid disease; the gland is 
dense, and has an albuminous waxy appearance ; the 
minute vessels with iodine test may be observed with 
thickened walls external to the lobule. It is asso- 
ciated with similar disease in other parts, and is 
referred by Dickinson to a de-alkalised fibrinous state 
of the blood. It is generally attributed to chronic 
suppuration with disease of bone, syphilis, or other 
exhausting disease ; it is, however, sometimes difficult 
to recognise simple enlargement of the liver from that 
which is due to effusion on the upper surface towards 
the diaphragm, pushing down the gland. A few years 
ago a young woman was admitted into Guy's under 
my care with enlargement of the liver ; no other dis- 
ease could be found, and the general health was not 
much interfered with; the surface of the liver was 



THE LIVER AND ITS VESSELS 53 

smooth, the edge was easily defined; there was no 
disease in the lungs, nor of the heart; the malady 
progressed, and the patient died from exhaustion. On 
the post-mortem table, when the abdomen was opened, 
an enormous liver was observed, smooth, and appa- 
rently of normal structure ; but when it was separated 
from the diaphragm, a very large hydatid cyst was 
found to have pushed down the gland, and had given 
the indications of simple enlargement of the liver; 
the pressure on adjoining structures was the cause of 
death. 

The passive enlargement and congestion of the liver, 
to which we have referred, is greatly relieved by those 
remedial measures which unload the capillary vessels 
of the intestinal tract and of the abdominal glands, 
— free mercurial purgatives, with or without squill, 
saline purgatives, as the aperient salts of soda and 
magnesia, and by saline mineral waters, &c. But it is 
a great mistake to regard this condition of the liver 
as the primary disease; it is only a secondary one, 
though, unfortunately, often regarded as the most 
important malady. 

Portal Vessels. — In the portal vessels the morbid pro- 
cesses are more numerous, and are often of a very dis- 
tinctive character. The congestion to which we have 
already referred is secondary to that of the hepatic 
veins, and is dependent on obstructive disease affecting 
the pulmonary circulation. If the congestion reaches 
the interlobular plexus, the nutmeg mottling is more 



54 DISEASES OF THE LIVER 

intense, and the gland sometimes assumes a coarse 
and granular appearance, as if it were undergoing 
fibroid degeneration ; a form of cirrhosis in which the 
lobule is said to be atrophied first in its central portion. 

Acute Congestion. — The congestion of the portal 
system is, however, sometimes of an acute character, 
and quite independent of pulmonary and cardiac dis- 
ease ; it is the interlobular venous plexus which then 
alone becomes congested ; and it is this change which 
we find in the hyperemia after intemperance, after 
malaria, and other allied states. 

The liver is enlarged and tense, and the symptoms 
that are produced by this acute congestion are of a 
distinctive character; the countenance is generally 
sallow, and the cornea loses its clearness ; there may 
be headache and some febrile excitement ; sleep is 
disturbed ; there is nausea, sometimes vomiting, loss 
of appetite, so that even the sight and smell of food 
is distasteful ; the tongue is furred, and the bowels 
irregular. There is uneasiness or pain in the region 
of the liver, and often in the right shoulder. The 
pulse is often compressible, and the urine turbid and 
loaded with lithates. This acute congestion may be a 
temporary condition, and quickly subside under the 
simplest treatment and the avoidance of fresh causes 
of excitement ; it may be associated with catarrh of 
the gastric mucous membrane, or be connected with 
gouty mal-assimilation ; or it may be more persistent 
and severe, as we find after long-continued irritation, 



THE LIVER AND ITS VESSELS 55 

or from the exposure to severe malarial poison, as in 
the jungles of India. 

Obstruction. — The vena portse and its branches are 
subject to obstruction from causes affecting either the 
interior or the exterior of the vessels. As to the 
former, the vessel is obstructed by the coagulation of 
blood, thrombosis, or by the entrance into the vein of 
cancerous growth, or the perforation of an abscess or 
cyst ; in the latter case, external disease, inflammation 
of the coats of the vein, produces fibrinous effusion and 
contraction, even to the complete obstruction of the 
vein; oedema and fibrinous effusion into Grlisson's 
capsule, acute inflammatory disease and suppuration, 
chronic inflammation of the peripheral portions of 
Glisson's capsule — as in ordinary cirrhosis — senile 
fibroid degeneration, each produce contraction of the 
vena portse. The inflammatory disease set up by the 
passage of gall-stones, the pressure from abnormal 
growths, from hydatid cyst, from enlarged glands, 
from chronic peritonitis, may also affect the vena portae 
in a partial or general manner. 

To revert, however, to those obstructions that are 
of an internal character, we will mention, first, the 
coagulation of blood in the portal vein. This coagu- 
lation is more frequent than is usually supposed, and 
it is the cause of some of the symptoms which are 
observed in great exhaustion : the obstruction may be 
in the trunk of the vein or in its branches. In the 
coronary veins of the stomach, it is the cause of the 



56 DISEASES OF THE LIVER 

effusion of blood and the coffee-ground vomit which 
are sometimes observed towards the termination of 
disease, and in which no ulceration of the stomach can 
be found. In the mesenteric veins, this venous coagu- 
lation leads to appearances closely resembling internal 
strangulation'. 

Thomas C — , aged 43, was admitted into Guy's Hospital, Decem- 
ber 7th, 1853, and died on the 31st. He was by trade a sail- 
maker, and for several years had been very intemperate in his 
habits ; he was admitted suffering from oedema of the legs, with 
albuminous urine ; diarrhoea and wasting supervened, and there 
was partial coma before death. On examination, the body was 
pale and spare. The lungs were found to be very cedematous, and 
some lobules of the lung were softened and breaking down. There 
was slight atheroma of the mitral and aortic valves. Abdomen : 
the intestines were distended ; there was general peritonitis, which 
was most intense in the right iliac region ; the peritoneum was 
injected where the intestines were in contact ; eight inches from 
the ileo-csecal valve the peritoneal surface of the intestine for 
several inches was of a dark grey colour, as if on the point of 
sloughing ; there was no constriction, no strangulation, no hernia 
nor intussusception. The mucous membrane at the lower part of 
the ileum was in a sloughing condition, defined and intensely 
congested at the margin ; this thin slough affected the whole of 
the mucous membrane, and was not confined to Peyer's glands. The 
mesenteric veins were filled with clot. The left lobe of the liver was 
wasted, forming a fibroas mass, and white in colour ; the remaining 
part of the gland was fatty. The kidneys were large and white. 

Thrombosis is also found in some cases in the glan- 
dular branches of the portal vein. 

Cancerous Disease in connection with the Portal Ves- 
sels. — Another form of internal obstruction, however, 
is the extension of disease of a cancerous character into 



THE LIVER AND ITS VESSELS 57 

the canal of the vena portas. Several instances of this 
kind have come under my own notice. In one, under 
the care of my late colleague, Dr Addison, the portal 
vein became suddenly obstructed by the entrance of 
cancerous products, and the liver was injected with 
the abnormal growth. Severe hemorrhage from the 
stomach and intestinal mucous membrane supervened, 
and in a few hours the patient died. 

This form of portal injection and obstruction must 
be distinguished from another kind of cancerous dis- 
ease, in which the heterogeneous product passes along 
the exterior of the portal vessels to its minutest 
branches, and may be seen distending Glisson's capsule 
throughout the liver. In an instance of this nature, 
there was carcinomatous disease of the cervical and 
axillary glands, as well as similar disease of the spleen, 
liver, and mesenteric glands. 

Communication of the Portal Vein with Abscess. — The 
vena portse sometimes communicates with abscess in 
the liver, with hydatid cyst, and thus leads to haomor- 
rhagic effusions. Our limits will not permit us to enter 
upon many interesting cases of this kind. 

External Obstruction of the Vena Portse. — The vena 
portae may, however, be obstructed by disease external 
to it, or from inflammation of the coats of the vein 
itself. The result of this is sometimes seen in the 
entire wasting of considerable portions of the gland, 
as we have seen of the whole of the left lobe ; and, if 
the obstruction have occurred during foetal or early 



58 DISEASES OF THE LIVER 

infantile life, the appearance is still more remarkable. 
The walls of the vein sometimes become thick and 
fibroid, and the vein completely obstructed, as in the 
following instance, which was under my care in Guy's 
Hospital during the year 1870. A large blood-cyst 
had been formed at the base of the liver. 

Coedelia W — , aged 34, was admitted in November, under my 
care. She had been a spirit-drinker. Eight months before, she 
first presented symptoms of ascites, and in two months was tapped ; 
she left the hospital relieved, but returned in an almost dying 
state in five months, and was shortly afterwards tapped again. 
The fluid soon re-collected, and on November 2nd paracentesis 
abdominis was performed a third time, and thirty-seven pints were 
removed. On the 5th, the peritoneum was filling rapidly, but the 
patient sank from exhaustion. A dull, " heavy " pain had pre- 
ceded the swelling of the abdomen, and five months afterwards 
was followed by anasarca of the legs. The skin was dry and 
sallow ; the body was wasted ; there was no jaundice ; the urine 
was healthy and free, and menstruation regular. The post-mortem 
examination was made by Dr Moxon. The pleura presented acute 
recent inflammation at the lower part of the right lung. The lungs 
were collapsed, and partially carnified. The bronchi were healthy ; 
the heart small and healthy. The abdominal cavity contained turbid 
serum. The peritoneum showed subacute peritonitis, long shreds 
of lymph passing between the coils of the intestine. The intes- 
tines were gathered together in front of the spine ; the omentum 
was thickened, and was drawn up ; the stomach, colon, and liver 
were adherent ; and the gall-bladder was adherent to the duodenum. 
The liver was fatty and softened ; many lobules were wasted ; 
some were small, others were large and pale from fatty degenera- 
tion. At the back and under surface of the liver was a large 
apoplectic cyst, distending the hinder and middle part of the organ, 
so as to deflect the cava. The cyst was placed beneath the hepatic 
capsule ; it was of the size of an orange, and contained laminated 
clots. The neck of the cyst was like a flattened tube towards the 
fissure of the liver, and it extended to the region of the head of 



THE LIVER AND ITS VESSELS 59 

the pancreas : at that part an old dense portion was found to be 
surrounded by thick tissue, and was connected with the portal vein. 
The portal vein itself was occluded throughout the liver, and the 
fusiform aneurism of the vein had given way, forming a blood- 
cyst. The walls of the aneurism were of stony hardness from 
calcareous patches. The stomach was covered with thick mucus. 
The spleen was very large, and contained embolic patches. The 
kidneys were pale ; the genitalia were normal. 

In this remarkable case there was no true cirrhosis, 
but the liver was fatty and degenerated. 

Fibrous bands sometimes extend throughout the 
liver ; or, if local obstruction have taken place, con- 
siderable depression and pits are observed upon the 
surface, indicating fibroid contraction and atrophy. 

Inflammatory Obstruction. — Cirrhosis. — A more fre- 
quent cause of portal obstruction is inflammatory 
change in Glisson's capsule, the chronic form of 
which is called cirrhosis. We have already adverted 
to the contraction of the liver which follows venous 
congestion ; this kind, however, is due to inflammation 
of Grlisson's capsule and the tissues connected with it, 
and must be distinguished from a third form of 
cirrhosis — namely, senile fibroid degeneration. Before 
speaking of cirrhosis, it may be well to refer to the 
hepatic artery and to some pathological considerations 
connected with it, for the hepatic artery is essentially 
connected with the early stages of inflammatoiy 
cirrhosis, although the portal vein is secondarily 
affected, and causes many of the prominent symptoms 
of the disease. The hepatic artery is probably con- 



60 DISEASES OF THE LIVER 

cerned in all acute inflammatory diseases of the liver ; 
it receives a large supply of nerves, and the pressure 
of blood is greatly affected by the division of the nerves 
in the neck, according to the observations of Cyon. 
The capillary branches of the hepatic artery are largely 
distributed in the capsule throughout the liver ; it is 
probable, that direct absorption takes place by means 
of the branches of the portal veins in the stomach and 
intestine, and that the glandular structure of the liver 
is thereby irritated by acrid ingesta. Still, very many 
of the symptoms of ordinary hepatic disturbance are 
due to the vaso-motor nerves upon the vessels ; if the 
nerves become paralysed there is undue congestion ; 
and we believe, that we are warranted in this opinion 
from the phenomena observed in other parts when the 
sympathetic is divided. Congestion of the hepatic 
capillaries is followed by the effusion of serum, by 
oedematous swelling, by the effusion of fibrin, and by 
alteration in the secreting power of the hepatic cells. 
These are the stages of cirrhosis ; the congestion of 
the vessels and effusion of serum causes swelling and 
enlargement of the whole gland ; and it is probable 
that in inflammatory cirrhosis increase in size always 
takes place at an early stage. This inflammatory pro- 
duct extends as far as Grlisson's capsule to the lobules 
themselves, and in many instances the fibroid capsule 
of the liver also takes part in the morbid process, and 
perihepatitis is the result. The tissue forming Grlis- 
son's capsule does not in man so completely separate 
the lobules one from another as in some of the lower 



THE LIVER AND ITS VESSELS 61 

animals ; but we find it permeating between groups of 
acini, and probably in a lesser degree between every 
lobule. The inflammatory product thus diffused 
throughout the gland becomes more fully organised; 
it contracts and becomes firmer, and most important 
secondary changes ensue. As to the changes in the 
lobules themselves, the cells waste, at first towards 
the periphery ; fibroid tissue may be seen even between 
the cells, or rather between small groups of them ; 
clusters of acini are separated and give the gland a 
granular appearance ; and, as larger groups stand out 
on the surface from the contraction of intervening 
fibroid tissue, the more distinct irregularities are pro- 
duced, and the " hob-nail liver " is the result. Similar 
effusion and contraction takes place in the larger portal 
canals, and the obstruction of the portal veins becomes 
extreme ; the liver is wasted, its colour is changed, 
and it is paler ; its edge is rounded, its surface 
roughened, and the gland has a rounded appearance. 
The wasting in the gland is not uniform, sometimes it 
is more marked in the left lobe, sometimes at the 
margin of the right lobe ; but the wasted appearance 
is greatly altered if fatty degeneration be associated 
with the fibrous disease, and if the tissues are stained 
from jaundice. In many cases of cirrhosis the capsule 
of the liver, continuous as it is with Glisson's capsule, 
becomes inflamed, fibrin is effused, the capsule is 
thickened and opaque, and frequently a thick covering 
is spread out upon the serous surface ; this fibrin may 
be peeled off ; it forms adhesions with adjoining 



62 DISEASES OF THE LIVER 

tissues ; it becomes vascular in character, and some- 
times presents a hard and nodular appearance. The 
local obstruction of the portal circulation in cirrhosis 
produces enlargement of the spleen, which is often 
covered with a thick fibrinous investment. The 
branches of the vena portae are greatly distended, 
sometimes to actual rupturing of capillary vessels, and 
haemorrhage may take place from the stomach, or from 
the haemorrhoidal veins of the rectum. As the obstruc- 
tion increases, serous effusion into the peritoneal cavity 
and ascites supervene ; and it must always be borne 
in mind that the capillary vessels of the peritoneum 
and mucous membrane are in a state of intense con- 
gestion. This congestion is important, for it interferes 
with the absorption of medicines, and diuretics &c. 
are powerless; and, again, if paracentesis be per- 
formed, there is great danger of peritonitis. Another 
result of this long-continued venous obstruction is 
hypertrophy of the coats of the vena portae, to which 
I have previously referred. 

It is a great mistake to regard cirrhosis as a merely 
local disease ; it must be considered in its general rela- 
tions, as well as in reference to those local changes 
which arise from the contraction of the liver-structure. 
It is essentially a wasting disease ; changes take place 
in other structures ; there is atrophy of the cerebro- 
spinal system, the lungs often become affected, and we 
observe fibroid disease of the lung and true phthisical 
disease, for it is erroneous to suppose that excess 
prevents phthisis. Again, the kidneys are often in- 



THE LIVER AND AND ITS VESSELS 03 

volved, and renal disease constitutes a most serious 
complication in cirrhosis of the liver. A patient with 
sallow countenance, bloated, but pale, with enlargement 
of the liver, with loss of appetite and impaired diges- 
tion, with nervous exhaustion, and depression, may- 
have cirrhosis at an early stage, and the patient may 
be relieved, if he will manfully stay his evil course ; 
but, if with these symptoms we find the urine albu- 
minous, and there be attacks of momentary loss of con- 
sciousness or vertigo, the condition is infinitely more 
serious. In senile cirrhosis, a contracted state of the 
kidney is frequently observed; reference is, however, 
now made to the acute inflammatory congestion from 
great excess. It is quite true that the wasting of cir- 
rhosis is greatly increased by the imperfect absorption 
of nourishment, and by defective digestion ; but this 
will not explain the whole of the symptoms. 

A patient affected with cirrhosis often presents a 
wasted appearance; the skin is dry and harsh; the 
capillary vessels on the cheek are enlarged ; the eyes 
are sunken ; the nervous power and mental courage 
are lessened ; the gait is less vigorous ; the digestion 
is impaired ; the appetite is dainty ; the tongue is in- 
jected at the tip, irregularly furred, and, at later stages, 
becomes red and irritable, or aphthous ; there is flatu- 
lent distention of the abdomen, sometimes with heart- 
burn and acid eructations. Vomiting and irritability of 
the stomach are often present at one or other stage ; the 
bowels are irregular, confined or loose, and often with 
symptoms of catarrhal irritation of the colon ; haemor- 



64 DISEASES OF THE LIVER 

rhoids and consequent loss of blood are not unfrequent. 
The urine is scanty, high coloured, having a deposit of 
lithates, or of uric acid, or of brighter coloured pur- 
purates ; and with nitric acid the urine assumes a very 
deep tint. On the surface of the skin spots of purpura 
are often observed ; and if there be any ascites and 
anasarca, the veins on the surface of the abdomen are 
enlarged, the superficial epigastric joining the mam- 
mary. The countenance is often sallow, but jaundice 
is not a constant symptom of cirrhosis ; pressure on the 
bile-ducts or catarrhal inflammation of these ducts may, 
however, induce it. The blood in cirrhosis becomes 
changed in character ; there is diminished power of 
coagulation, and if epistaxis occur, it is with difficulty 
checked ; the gums are spongy and readily bleed, and 
we have known haemorrhage from the nose and mouth 
lead to a fatal result ; and in former medical treatment, 
when leeches and the cupping-glass were more fre- 
quently used, the persistent oozing of blood sometimes 
became a most serious question. Ascites follows as 
a later symptom, and afterwards anasarca of the lower 
extremities ; but the legs in cirrhosis are often found 
to be small and withered, without any dropsical swell- 
ing. If there be inflammatory disease of the surface 
of the liver, pain in the side and pain in the shoulder 
are often present. Cirrhosis occurs at a very early 
period in life, when the wretched parent has allowed 
her child to be poisoned by alcohol; one instance 
occurred at Guy's even at 7, others at 8 and 10 years 
of age ; but the disease may continue to an indefinite 



THE LIVER AND ITS VESSELS 65 

period. Some persons of intemperate habits at an 
advanced age have cirrhosis ; but in these cases it is 
impossible to decide when the disease commenced. 
So also as to the prognosis : at an early stage, if the 
patient will submit to treatment, the disease may cer- 
tainly be checked ; and, even when contraction has 
taken place, our means of alleviation may be effective ; 
but when the disease has advanced to a chronic stage, 
and when exhaustion is indicated by attacks of bron- 
chitis and of pneumonia, the prognosis is very unfavour- 
able. It is also a very unfavourable sign in cirrhosis* 
when the appetite having completely failed, the bowels 
become irritable, and the tongue has a morbidly clean 
and red appearance. The association of renal disease, 
as we often find in senile cirrhosis, is a very serious 
complication ; for it not only shows that another most 
important excretory organ is affected, but that degen- 
eration arises from general senile change ; in these 
cases the patient is very likely to become comatose. 
The diagnosis is, however, at an early stage obscure, 
and when the disease is ?mattended with inflammatory 
symptoms on the surface of the gland, the onset of the 
malady is very insidious ; it is often by a process of 
exclusion, that we are led to suspect cirrhosis. Wast- 
ing with ascites, without pulmonary or cardiac disease, 
when no cancerous disease can be detected, when the 
liver is diminished in size, and there is no albumen in 
the urine, indicates cirrhosis ; and, if with these sym- 
ptoms we find enlargement of the abdominal veins and 
disordered digestion, we may strongly suspect chronic 

5 



66 DISEASES OF THE LIVER 

inflammatory disease of the liver ; but pressure on the 
vena portae from enlarged glands, &c., may cause 
ascites ; it is sometimes very difficult to distinguish 
the ascites produced by cancerous tubera upon the 
peritoneum from the ascites of cirrhosis, and so, also, 
when it is the result of chronic disease about the 
uterus and ovaries. A case of the latter kind occurred 
under my care in the clinical ward at Guy's three years 
ago. 

An old woman was admitted in a prostrate condition 
with ascites. She had pain in the right side and in 
the region of the sigmoid flexure, but there was no 
indication of thoracic disease ; the pulse was regular ; 
there was no cough, no bruit, and no abnormal physi- 
cal signs ; the mind was clear ; the urine was healthy ; 
there was no uterine discharge, and no complaint of 
" bearing down," &c. The distention of the abdomen, 
evidently from fluid, with pain in the right side and in 
the region of the sigmoid flexure, were the only signs 
of disease beside the general weakness. Cirrhosis was 
regarded as the probable cause of the ascites, especially 
as we bad evidence of some perihepatitis in a friction- 
sound audible over the region of the liver. The patient 
was allowed to sit up, and soon afterwards became 
faint, not, however, having left her bedside ; increased 
exhaustion supervened, and she died on the second day. 
There was some thickening of the peritoneal covering 
of the liver, and so far the diagnosis was correct, but 
the disease was uterine ; there was cancerous disease of 
the body of the uterus, with but little enlargement; 



THE LIVER AND ITS VESSELS 67 

the os uteri was blocked up, so that there was no vaginal 
discharge ; local inflammatory disease and suppuration 
had supervened in the walls of the uterus, and the 
walls gave way, causing fatal peritonitis. The ascites 
was atrophic in character. In that form of ascites 
which is apt to be mistaken for cirrhosis, but which 
arises from carcinomatous tubera upon the peritoneum, 
the disease is gradual ; it occurs after the middle period 
of life, inflammatory disease of the surface of the viscera 
is set up, and it is only by close attention to the general 
symptoms that a correct diagnosis can be made. 

In the treatment of cirrhosis, the co-operation of the 
patient is essential for success ; for if after partial im- 
provement, there is a return to injudicious habits and 
to excess, the disease soon makes rapid progress. At 
an early stage, the cautious use of mercurial medicines 
lessens the engorgement of the portal system, and 
promotes the absorption of fibrin ; but it is most impor- 
tant to bear in mind that in proportion as general 
degenerative changes take place, mercury is injurious, 
and when the powers of digestion are thoroughly 
impaired, mercury increases the weakness of digestion. 
The long-continued use of iodide of potassium is often 
of service, but generally the patient discontinues it as 
soon as partial relief is afforded, instead of persevering 
in the remedy for several months. Euonymin used for 
some time with saline aperient medicines sometimes 
proves of great service. The hydrochlorate of ammonia 
has been recommended, and so, also, the bromide of 
potassium. If, however, there be great exhaustion 



68 DISEASES OF THE LIVER 

with ascites, these remedies are ineffectual, and in no 
disease is there greater disappointment in the action 
of diuretics ; they are valueless, but are often given, 
the one after the other, without effect. The reason is 
patent — the medicine is not absorbed; the disease 
produces distention of the vena portae, and the remedies 
do not enter the blood nor reach the kidney. In this 
state, I have often found more benefit from quinine 
with mineral acids and sulphate of magnesia or sulphate 
of soda, and from those means which are likely to 
improve the general health of the patient, than from 
measures more directly calculated to promote the ab- 
sorption of fibrin effused in the glandular texture. 

An important question arises in cirrhosis as to the 
propriety of withdrawing the fluid by tapping ; and I 
believe, that the operation is often deferred till it is too 
late. It is quite true, that at an early stage we are 
anxious to employ other measures less alarming to the 
patient ; but, in several instances in which it has been 
performed early, patients have soon recovered without 
the re-collection of the fluid, whereas in the later stages 
paracentesis is always attended with danger, for the 
peritoneal vessels are intensely congested, and peri- 
tonitis is easily induced. Many patients with chronic 
cirrhosis die a few days after tapping. Peritonitis 
does not, in these cases, produce pain, but rather 
typhoid exhaustion. The continued use of saline 
aperient waters is often attended with the greatest 
benefit in this form of chronic disease of the liver. 

In cirrhosis, the disease is diffused ; but sometimes 



THE LIVER AND ITS VESSELS 69 

a hard fibroid mass is situated in one or other part of the 
liver, or on its surface, local in character and closely 
resembling syphiloma. In these cases there has been 
a local source of irritation or injury at the part. In 
reference to tapping at an early stage of cirrhosis, I 
may advert to an instance which was under my care 
in Guy's Hospital. 

Maey C — , aged 29, was admitted into the clinical ward on 
October 27th, 1871. She had been a servant at eating-houses for 
ten years, and had been in the habit of taking very freely of beer, 
and sometimes of spirits. Two months before admission, her 
appetite failed ; there was nausea and occasional vomiting. Two 
weeks later, the abdomen and then the legs began to swell ; the 
bowels were constipated ; aperient medicines produced vomiting, 
and she brought up half a pint of dark blood. She had suffered from 
haemorrhoids. The patient was well nourished. There was con- 
siderable ascites and oedema of the parietes as well as of the lower 
extremities. There was no enlargement of the veins ; but there 
was tenderness over the region of the liver, and the dulness was 
increased. She had not menstruated for two months. There was 
a blue line along the margin of the gums ; the urine was scanty 
and high-coloured ; the specific gravity 1*021 ; it was free from 
albumen. The bowels were constipated. Purgatives were used 
freely ; but, as the quantity' of fluid increased, on November 9th 
seventeen pints of fluid were drawn off, with great relief to the 
patient. Some fluid re-collected ; but, under the use of the per- 
chloride of mercury, and afterwards of iodide of potassium, it 
disappeared. The whole of the oedema ceased. Steel was after- 
wards given, and she left the hospital, nearly well, at the begin- 
ning of the following year. 

It may be said that mercurials and iodide of potas- 
sium alone would have cured this affection — and we 
certainly could not state that the disease would not 
have been so cured — but the paracentesis at an early 



70 DISEASES OF THE LIVER 

stage certainly promoted recovery ; it saved much, time, 
and spared the patient a long continuance of medical 
treatment. Whilst adverting to this instance of dis- 
ease, I may mention that, whilst cirrhosis is especially 
an inflammatory disease of Grlisson's capsule, there is a 
condition in which the glandular tissue of the liver is 
especially involved; the liver becomes considerably 
enlarged — often permanently so; its tissue is indu- 
rated ; and this form of disease is, at its commence- 
ment, with great difficulty distinguished from early 
cirrhosis. In this stage there is greater sallowness 
than in cirrhosis, and even jaundice : it has been called 
inflammatory induration. 

The inflammatory disease in Grlisson's capsule, of 
which we have spoken, is fibroid in character ; but we 
sometimes find that acute suppuration follows the 
course of this fibrous tissue or investment, and extends 
from the transverse fissure almost throughout the liver. 
The symptoms of this state are obscure ; they are 
typhoid in character ; and almost every case that I 
have seen has been connected with abscess or with 
extension of the disease from the lesser omentum, or 
with disease of the bile-ducts. This condition maybe 
connected with an abnormal state of the lymphatic 
vessels and glands, for numerous lymphatics pass 
freely within Grlisson's capsule. Perihepatitis is also 
productive, in some instances, of a local collection of 
pus on the upper surface of the liver. 

Cirrhosis may be a partial as well as a general dis- 
ease, and we sometimes find that fatty degeneration is 



THE LIVER AND ITS VESSELS 71 

present, or that some portions of a cirrhotic liver are 
involved in lardaceous degeneration. Cirrhosis may be 
also associated with acute yellow atrophy, or with in- 
flammatory jaundice. 

An old man, aged 67, was admitted into Guy's Hospital on 
February 1st, 1854, and died on March 5th. He was an emaciated 
spirit drinker, with ascites and with jaundice. His strength had 
only failed for three months, the date of the ascites and jaundice. 
The skin was hot and dry ; the liver could not be felt ; the legs 
were cedematous ; there was a cachectic lichenous rash on the body ; 
the urine contained colouring matter of bile ; and there were 
several spots of purpura on the hands. On inspection, there were 
atheromatous condition of the vessels of the brain, and subarachnoid 
effusion, as well as degeneration of the coronary arteries and of 
the muscular fibre of the heart. The peritoneum contained two 
gallons of clear serum, with flakes of lymph. The liver weighed 
4 lbs. ; its surface was roughened from contraction ; its section was 
irregular, congested, and lardaceous. The kidneys were granular ; 
their arteries rigid ; their weight 7\ oz. On examining the acini of 
the liver, fibroid tissue could be seen between the cells of the liver 
in the lobules. This condition was one of general degeneration, 
and the cirrhosis was a part of that general atrophy. 

Hepatitis. — We cannot enter fully into the subject 
of inflammation of the glandular tissue of the liver 
itself; but only remark that the cellular structure 
undergoes remarkable change of a partial or general 
character, and abscess is sometimes the result. The 
symptoms are those of acute inflammatory congestion 
of the liver, pain and sense of fulness in the right side, 
loss of appetite, furred tongue, sallowness of counte- 
nance, disturbed condition of the bowels and of the 
urine ; these conditions are modified, if there have been 
previous dysentery or malarial fever. There is some 



72 DISEASES OF THE LIVER 

elevation of temperature, ranging from 101° to 104°, 
or even higher, and more or less irritation of stomach, 
with furred tongue. The state of the bowels is also 
variable. The symptoms may pass into those of great 
exhaustion, and the patient die in a short time, or 
they may gradually subside. Abscess is not an unfre- 
quent result, and in many cases that present themselves 
in England, the more acute febrile symptoms have 
subsided, but the patient is found to be oftentimes pale 
and prostrate, but not necessarily sallow or jaundiced ; 
the temperature may be nearly normal, or be raised to 
102° or 103°, with elevations in the evening; there 
may be local tenderness, and even severe pain, but 
the pain is often comparatively slight. The pus may 
be absorbed and the abscess contract, or it increases 
in size, and may attain considerable proportions, 
holding many ounces of pus ; these cases have single 
abscesses rather than multiple ones. The subsequent 
course of the symptoms depends on the duration of 
the abscess and the locality where it may empty its 
contents. It is well, if there be any projection or 
tendency to point on the surface or within reach, to 
introduce an aspirator and remove the contents ; the 
danger is thereby greatly lessened of fatal inflamma- 
tion from the untoward discharge of the contents. 
Perforation into the peritoneum leads to sudden col- 
lapse and death in a few hours. Scarcely less fatal 
is perforation into the pleura ; if pleuritic adhesion 
take place it may open into the bronchi, and lead to 
great, if not fatal exhaustion from damaged lung. 



THE LIVER AND ITS VESSELS 73 

Sometimes it opens into tlie bile-ducts and is dis- 
charged through them, or it may reach the duodenum. 
The symptoms are, however, very obscure in many 
cases, till perforation produces the most alarming 
symptoms. 

The prognosis should always be a very guarded one, 
and the treatment by quinine with mineral acids should 
be associated with removal to healthy localities and 
sustaining diet. 

I am convinced that abscess may be either from 
simple inflammation, in which the symptoms may be 
obscure and the progress slow, although sometimes in- 
tensely acute and rapid ; and connected, possibly, with 
intermittents, or with acute disease of the abdomen, 
as dysentery ; and secondly, suppurative disease may 
be associated with a changed state of the blood, as in 
pyaemia, in which the symptoms are especially typhoid, 
and always fatal, and the abscesses peripheral. The 
two following cases illustrate the obscurity in dia- 
gnosis in these forms of disease : in the one, the 
abscess was probably of eight months 5 duration, 
pleurisy was produced, and the patient had severe pain 
in the shoulder; in the second case it was very 
doubtful whether the abscess consisted in the softening 
down of a syphilomatous mass, or was of a simple in- 
flammatory character. 



74 DISEASES OF THE LIVER 

HEPATIC ABSCESS— LOCAL PLEUEISY SEROUS EFFUSION ON 

BOTH SIDES SEVERE PAIN IN THE SHOULDER NO 

JAUNDICE. 

William W — , aged 22, was admitted into Guy's Hospital, 
under my care, on November 2nd. For six years he had been 
engaged on vessels trading on the West Coast of Africa, and 
latterly he had acted as steward. On these voyages his health had 
been good, and he had never suffered from any intermittent fevers, 
from dysentery, nor from jaundice. He was a man of steady and 
temperate habits ; he had married, but had no family. Whilst in 
England, eight months before admission to Guy's, when sitting 
quietly at tea, severe pain came on in the right shoulder ; this was 
shortly followed by more intense pain in the right side. This 
severe and almost agonising pain in the side continued for four 
months, and it never entirely left him. 

He was a small man, with a haggard, wasted and anaemic 
appearance ; and he applied at Guy's amongst the out-patients, 
saying that his malady was abscess in the liver. On examination 
the liver could be felt below the margin of the ribs ; but there 
were indications of pleuritic mischief on the right side. (This was 
shown on inspection to have arisen from the abscess in the liver 
causing local pleurisy on the opposed side of the diaphragm.) He 
refused to come into the hospital, and continued to attend as an 
out-patient. The pain in the right side persisted, and he always 
had a distressed appearance. On November 2nd his wife applied, 
stating that the pain had become more distressing, and that he 
was very ill. He was at once admitted. The pain was severe, and 
the right side was tender. He was very pale ; the skin hot ; slight 
cough troubled him. The chest was poorly developed ; the left 
apex was flattened ; the respiration was coarse ; and the voice was 
more resonant than on the right side. There was dulness at the 
base of both lungs posteriorly, and in several parts coarse breath- 
ing and crepitation could be heard. The dulness on the right side 
was more evident in front than behind, and it extended from the 
nipple to an inch below the margin of the ribs. There was an 
absence of healthy respiratory murmur, and some crackling could 
be heard, but not a well-marked rale. The tongue was clean ; 



THE LIVER AND ITS VESSELS /O 

the bowels quiet. Dover's powder, gr. v, was given three times a 
day. Quinine was subsequently added, and given in the form of 
pill. 

On November 14th the pain in the right side became more 
severe, and he was very ill. The general symptoms were, however, 
the same. Julep of acetate of ammonia, with solution of acetate 
of morphia, was given, and a blister was applied on the side. 

On the 16th he was still worse, and he was unable to move from 
the left side, upon which he rested. There was no projection of 
the intercostal spaces, but great tenderness on pressure. No 
friction sound could be heard, and the general signs were those of 
local suppuration at the part. The pain was agonising. The 
tongue was rather dry, slightly furred ; the pulse compressible. 
Mind perfectly sensible. He complained of thirst and of profuse 
perspiration ; but no rigors were observed. He sank on the 16th. 

Inspection. — The body was very pale. The head was not 
examined. Chest : On the left side there was about a pint of 
serum, with some patches of recent lymph on the lower lobe. The 
lobe was partially compressed and congested, so also the posterior 
part of the upper lobe ; there were no tubercles. There was some 
serous effusion into the right pleura, but the diaphragmatic surfaces 
of the pleura on the right side were lirmly adherent. The right 
lung was in the same state as the left. The heart was healthy. 
Abdomen : The liver was seen to extend about one inch below the 
ribs ; its surface was granular. The general peritoneum was 
healthy ; the intestines were contracted. The upper surface of the 
liver was firmly adherent to the . diaphragm, and on partially 
separating it, yellow projecting patches were observed from suppu- 
ration in the substance of the liver beneath. One or two of these 
abscesses broke, being very near to the peritoneum. On section of 
the right lobe of the liver from its convex surface, six or eight 
abscesses, one to one-and-a-half inches in diameter, were observed ; 
they were filled with yellow healthy pus, and were bounded by 
dense walls ; external to the abscesses the liver tissue was pale and 
softened, and had evidently become involved in acute diseased 
action. There was no disease of the gall bladder, nor any at the 
transverse section of the liver. The softened part of the liver 
presented under the microscope hepatic cells mixed with fibre cells 



76 DISEASES OF THE LIVER 

— elongated nucleated fibre, and inflammatory cells. The spleen 
was healthy, so also the intestines. 



ABSCESS IN THE LIVER DYSENTERY SYPHILIS. 

John P — , aged 34, was admitted into Guy's Hospital, October 
9th, 1871. He was a groom, and had been a soldier in India for 
eleven years ; he returned eighteen months ago, and had since 
suffered from diarrhoea and the discharge of blood ; he had had 
intermittent fever in India, but no jaundice, and there was a 
history of syphilis. A month before admission, he experienced pain 
in the right hypochondrium, and there was tenderness on pressure. 
There were no rigors, but profuse perspirations. There was occa- 
sional nausea, but no vomiting. The patient was sallow and spare ; 
he slept badly ; the appetite was poor, tongue coated, the pulse slow, 
the heart and lungs were healthy. In the right lobe of the liver, 
an oblong swelling extended nearly to the umbilicus, and was 
tender on percussion. On the 17th October, there was throbbing 
pain on the right hypochondrium, and on the 23rd it was thought 
that fluctuation could be felt. On the 3rd November, Mr Durham 
made an exploratory puncture ; reddish fluid exuded, but fibroid 
tissue rather than pus was found on microscopical examination. 
During November, the swelling increased in size ; and since the 
patient had had syphilis, and there was some doubt whether the 
swelling consisted of a syphiloma, iodide of potassium was given 
freely. The tenderness and pain increased, and there was consti- 
tutional disturbance. On the 27th November Mr Durham drew 
off 6 oz. of thick sanguineous pus by means of a trochar ; on the 
30th, the abscess was opened more freely, and 8 oz. of pus 
discharged. There was afterwards constant oozing of thick red 
pus into the poultice. Quinine was given, the discharge gradually 
lessened, and the opening almost healed, leaving a hard zone about 
an inch and a half on each side of the irregular cicatrix. A small 
quantity of discharge remained when he left the hospital, on 
January 16th. The character of the pus more closely resembled 
the degeneration of fibroid growth, than the ordinary pus of a 
hepatic abscess. 



THE LTVER AND ITS VESSELS 77 

I have sought to give such practical illustrations as 
may aid in the diagnosis, and promote the scientific 
treatment of those maladies which are especially con- 
nected with the vascular supply of the gland. The 
full elucidation of these diseases would be impossible 
in the limits of one lecture. 



LECTURE III. 

THE BILE AND THE BILE-DUCTS. 

The liver and the bile are frequently regarded by 
unprofessional minds as inimical to tlie healthy work- 
ing of man' s organism . Like friends unjustly maligned, 
who are made to bear their own faults as well as their 
neighbours', scarcely anything too bad can be said of 
them by some persons, whilst they are really constant 
benefactors ; and there is truth in the remark, that even 
in medical diagnosis the liver is often " the refuge for 
the destitute." 

It is generally considered by physiologists, that 
whilst some of the constituents of the bile are secreted 
by the liver, others are merely strained off from the 
blood ; and this is the probable reason, as well shown 
by Dr Harley, that in some morbid states, certain 
elements of bile may be present in the urine, whilst 
others are absent. The bile is a thick, greenish-yellow 
fluid, varying greatly both in colour and consistency ; 
it has a specific gravity greater than water — 1*026 to 
1*030; a bitter taste, an alkaline reaction, and, from 
the presence of some organic products that readily 



THE BILE AND BILE-DUCTS 79 

undergo change, it soon putrifies. According to the 
analysis of Berzelius many years ago its constituents 
are : 

Water 90*44 

Biliary and fatty acids . . 8*00 

Mucus 0*30 

Watery extract, chlorides, phos- 
phates, and lactates . . 0*85 
Soda . . . . . 0*41 



100*00 



The relative proportion of these constituents varies 
exceedingly. Sometimes, indeed, we find the gall- 
bladder and hepatic ducts filled with a clear, almost 
colourless watery fluid ; the essential elements of bile 
are wanting, and it is evident that the power of the 
liver has received a check in its functional activity. Dr 
Moxon informed me, that he has several times found 
colourless biliary secretion in the post-mortem exami- 
nations after fever. Some time ago, a man admitted 
into Guy's under my name (although he died before 
I had an opportunity of seeing him) had this colourless 
bile. He was a brewer's man, who had pain in the 
joints of a rheumatic character, and had also delirium 
tremens. His death was comparatively sudden. The 
liver was large, healthy in appearance, but it presented 
congestion of the hepatic veins ; the heart was com- 
paratively healthy; the kidneys were hypertrophied, 
17 oz. in weight ; the whole contents of the bile-ducts 



80 DISEASES OF THE LIVER 

were like mucus and water, and the intestines were free 
from the colouring matter of bile. 

The Biliary Acids are in the proportion of about 
8 per cent., and are important elements of bile ; glyco- 
cholic and taurocholic acids, as they have been termed, 
are secreted by the liver ; they are of a resinoid 
character, and are in combination with soda. After 
they have passed into the duodenum they promote the 
emulsifying of the fatty elements of food, and become 
reabsorbed. With care, these acids can be detected in 
the urine incases of jaundice arising from obstruction. 
It is probable, that the presence of these acids promotes 
the solubility of another constituent of bile — namely, 
cholesterine — and that the deposition of cholesterine in 
biliary calculi is due to an abnormal relative propor- 
tion of these ingredients. Bile also contains a small 
quantity of fatty acids, stearic acid, oleic acid, as well as 
lactic acid, combined with ammonia and potash. Cho- 
lesterine occurs in white tubular plates, and is not formed 
in the liver, although present in its secretion ; it is a 
normal constituent of the blood, and is often seen in 
considerable quantities in pus, and in serous effusions; 
it is found in brain tissue, and has also been detected 
in the vegetable kingdom. Colouring matter is a con- 
stant element in bile ; the colour of bile is not uniform ; 
it may be green, or of a reddish-brown colour, and we 
find the green portion described as the biliverdine of 
Berzelius ; the brown has been called bilifuscin ; the 
red, bilirubin ; the yellow cholepyrrhine. These colour- 
ing agents are derived from changes in the blood from 



THE BILE AND THE BILE- DUCTS 81 

haemoglobin, and they are in great measure discharged 
from the alimentary canal, but are also converted into 
urinary pigment. Sugar is not a natural constituent 
of bile, but a substance may be obtained from all 
healthy livers which has received the name of glycogen, 
and which has an intimate relation with the sugar-pro- 
ducing function of the liver. In a former lecture, 
whilst speaking of acute yellow atrophy of the liver, I 
adverted to leucine and tyrosine, as being present in 
the urine in that disease ; but these are not elements of 
healthy bile. There has been much discussion as to the 
arrangement of the minute capillary bile ducts ; they 
may be traced to the periphery of the lobules, but there 
the difficulty of following them commences. Kolliker 
supports the view that the ducts communicate with the 
hepatic cells ; Dr Handheld Jones, that they end in 
blind extremities ; Dr Beale has made careful injec- 
tions of these ducts, and describes their direct contin- 
uity with a " cell containing network " within the 
lobules, and so far supporting the original supposition 
of an interlobular biliary plexus of Mr Kiernan. 
Hering (Strieker's " Histology/' New Syd. Tr.) de- 
scribes intra-lobular biliary canals or passages, which 
do " not possess a membrana propria lined by hepatic 
cells, but are immediately bounded by these cells them- 
selves." The minute ducts unite in larger branches, 
which pass in the course of the portal veins, and there- 
fore in Grlisson's capsule to the transverse fissure of 
the liver; and there the two ducts, from the right and 
left lobes, unite in the common hepatic duct ; in its 

6 



82 DISEASES OF THE LIVER 

passage towards the duodenum, the duct is joined by 
the cystic at an acute angle, and following this, in a 
retrograde direction towards the free margin of the 
liver, the bile flows into its reservoir, the gall-bladder. 
The minute ducts have a tesselated epithelium, whilst 
in the larger ducts it is columnar. The bile-ducts have 
also minute crypts or tubes, passing from their sides 
almost in a regularly arranged double line, and some 
communicate the one with the other at the transverse 
fissure. It is doubtful whether they are minute biliary 
receptacles, or mucous follicles ; the larger offshoots 
from the bile-ducts in the peritoneal folds form anasto- 
moses, and have been designated the vasa aberrantia. 
The gall-bladder is capable of holding an ounce to an 
ounce and a half of fluid ; it has a cellular and a 
mucous coat, and although no defined muscular coat 
can be distinguished, the gall-bladder may be seen to 
contract in newly-killed animals, and in some larger 
animals plain muscular fibres are recognised. The 
mucous coat in the gall-bladder has a cellular appear- 
ance, and in the orifice of the duct there are several 
folds of the mucous and cellular coats. 

The most common symptom of disease of the bile- 
ducts is jaundice ; but it is important to bear in mind 
that this condition is not necessarily due to the state 
of the bile-ducts, but may arise from causes affecting 
the secreting structure of the liver. There are thus 
two forms of jaundice : 

1. That which is due to obstruction of the bile- 
ducts, and in which the yellow colour of the skin and 



THE BILE AND THE BILE-DUCTS 83 

the presence of bile in the secretions is produced by re- 
absorption of bile after its secretion. Such as we find — 
In obstruction of the duct from gall-stone; 

— from catarrhal inflammation of the ducts ; 

— from spasmodic contraction of the duct, with con- 

gestion of duodenal mucous membrane ; 

— from pressure or occlusion of the duct from the 

pressure of cancerous growths ; 

— from diseased glands ; 

— from diseased pancreas ; 

— from hydatid cysts ; 

— from aneurismal or other tumours ; 

— from disease of the duodenum ; 

— from pressure on the minute ducts in the liver in 

cirrhosis ; 

— from entozoa obstructing the duct ; 

— from pregnancy. 

2. In the second class we find those forms of jaun- 
dice in which the duct is free, and in which the gland 
is affected by the altered nerve-supply, or from 
changes in the blood, the circulation in the liver and 
the metamorphic changes being interfered with. Or 
according to some, from increased diffusion or aug- 
mented absorption of bile, as — 

In sudden jaundice from nervous shock ; 

— from acute yellow atrophy ; 

— from fever, as typhus, enteric fever, malarial 

f evers, yellow fever ; 

— from poisons : animal poisons, as snake-bites, or 

mineral poisons, as phosphorus ; 



84 DISEASES OF THE LIVEK 

— from congestive states, as acute congestion ; 

— from chronic congestion, as in disease of the heart. 
In these latter cases the bile-ducts are free, and the 

passage of bile into the intestine is not interfered 
with ; the motions, at any rate for a time, may be a 
deep bilious colour and very different from the white and 
putty-like ejecta found in obstructive jaundice. There 
is not the distention of the bile-ducts, nor of the gall- 
bladder, often observed in the former class ; the patho- 
logy of the maladies is different and the differential 
diagnosis is most important. 

Spasmodic Occlusion of the Bile-ducts. — Although no 
definite muscular coat can be traced in the bile- 
ducts, still they possess contractile bands, which 
are susceptible of irregular action. They receive 
nervous supply from the same source as the pylorus 
and the first portion of the duodenum, and in cases of 
gall-stone they are thrown into violent contraction; 
in catarrhal states of the mucous membrane the 
irritability is increased, but spasmodic contraction 
takes place independently of these causes. The gastro- 
duodenal mucous and muscular coats being in a state 
of irritation, and the liver hyperaemic, very slight 
additional disturbance suffices to produce both pyloric 
spasm and contraction of the bile-ducts. The sym- 
ptoms very closely resemble those produced by the 
passage of a gall-stone : there is sudden severe pain 
at the part ; vomiting may be present ; and in a few 
hours the skin becomes moderately jaundiced; but the 



THE BILE AND THE BILE-DUCTS 85 

pain and the jaundice quickly pass off, often without 
the evacuations showing an absence of bile, and with- 
out much deepening of the colour of the urine. It is 
evident that the obstruction has been of a transient 
kind ; but the pain, though much less intense than in 
gall-stone, is of a severe character ; there is some local 
tenderness ; and there is indication of gastro-duodenal 
disturbance, in the nausea or vomiting, furred tongue, 
and flatulence ; but there is no febrile excitement, 
nor quickening of the pulse, beyond that induced by 
the pain. 

This condition is often mistaken for the passage of 
a gall-stone, but the symptoms are less severe and 
more transient ; and we have no proof whatever that 
the symptoms are due, in the instances to which we 
refer, to the discharge of even minute granular calculi. 
In some cases a gall-stone will pass from the gall- 
bladder into the cystic duct for a short distance, and 
then fall back into the gall-bladder; the pain is 
intense, but no jaundice is produced, for neither the 
hepatic duct nor the common bile-duct is obstructed. 
In an instance of this kind that I saw some years ago 
in consultation, the commencement of the cystic duct 
would easily accommodate the little finger for half an 
inch, but the gall-stone was in the gall bladder ; the 
pain, at first intense, suddenly ceased, and there was 
no jaundice. The patient died from uraemic poisoning 
and convulsion, with miscarriage. Spasmodic occlusion 
of the bile-duct is more easily produced by irritation 
of the duodenal extremity of the common bile-duct 



00 DISEASES OP THE LIVER 

than at its glandular commencement ; thus violent 
vomiting, as in sea-sickness, will induce obstruction 
and jaundice. It is well, however, to remember that 
after the passage of a gall-stone, a state of great 
irritability of the duct continues for some time ; and 
that very slight fresh disturbance, without the dis- 
charge of a second calculus, suffices to induce spas- 
modic contraction and pain. 

In catarrhal obstruction of the bile-ducts, the sym- 
ptoms are more gradual, the jaundice more marked 
and enduring ; there is immunity from pain ; and in 
many cases, there is febrile excitement. 

There is another condition, the symptoms of which 
closely resemble those of spasmodic contraction of the 
bile-ducts; namely, the traction produced by old 
adhesion between the gall-bladder and the duodenum, 
or with the colon or the stomach. Local peritonitis 
often takes place in the neighbourhood of the gall- 
bladder from gall-stone or other exciting cause ; and 
we then find that flatulent distention of the stomach 
or transverse colon produces severe pain. A remark- 
able instance of that kind came under my care in 1869, 
in a gentleman aged 60. Eight years previously he 
had had symptoms of gall-stone ; there was great pain 
in the region of the gall-bladder, but no jaundice. 
The symptoms slowly subsided. In September, 1866, 
there was bilious derangement; but in May, 1867, 
during the night after a dinner-party, violent vomiting 
came on, with purging, and the next day he became 
semi-comatose. There was no albumen in the urine; 



THE BILE AND THE BILE- DUCTS 87 

but symptoms of great prostration came on, and after 
a month there was pain at the lower margin of the 
liver, with enlargement of the gland and tenderness. 
Eigors followed ; and it was supposed, that there was 
abscess of the liver. In June, there was evidence of 
pointing, and fluctuation could be felt. The abscess 
was punctured, and a great number of biliary calculi 
were discharged, with green foetid pus ; many of the 
calculi were small, and had smooth facets. The health 
improved ; but in October a sinus two inches in length 
remained, and there was a thin " white of egg " dis- 
charge ; the sinus afterwards closed. In April, 1868, 
there was a " bilious attack/' and in June, symptoms 
of dyspepsia were more manifest. On June 18th, 
there was vomiting of coffee-ground grumous fluid 
and of blood, but there were no black motions; 
pyrosis and uneasiness after food were also present. 
These symptoms partially subsided, but vomiting per- 
sisted, and in November became severe, with nausea 
and pain the back. In February, he was brought to 
London in an extremely prostrate condition. The 
vomited matter consisted of mucus, and the vomiting 
recurred frequently. The tongue was clean, the 
bowels regular ; but free action of the bowels relieved 
the vomiting; the chest was healthy; pulse 56. The 
abdomen was supple, except in the region of the gall- 
bladder, where was a cicatrix, with thickening beneath. 
Morphia was given in small doses, and the stomach 
was allowed to rest as much as possible ; for, when- 
ever either the stomach or the transverse colon became 



OO DISEASES OP THE LIVER 

distended, pain was induced at the seat of the disease, 
and vomiting returned. It was evident that gall-stone 
had been the cause of the severe pain at the onset of 
the complaint. Local inflammation followed ; peri- 
toneal adhesions were formed; suppuration ensued; 
and an abscess was the result. This abscess opened 
externally, and gall-stones were discharged ; but 
whether the suppuration took place within the gall- 
bladder, or externally to it after ulceration had taken 
place, was doubtful. In either case, the gall-bladder 
was probably destroyed. The sinus slowly healed, 
and a cicatrix remained, with firm adhesions to the 
surrounding viscera. It was very distinctly recog- 
nised that, whenever traction upon those adhesions 
was produced by flatulent distention of the stomach 
or by fulness of the transverse colon, severe darting 
pain ensued. Some ulceration of the mucous mem- 
brane of the stomach, or of the first portion of the 
duodenum, caused the hemorrhage into the stomach 
and the coffee-ground vomit. With gentle action on 
the bowels and rest, all the symptoms subsided, health 
was restored, and has since been maintained. 

In the treatment of spasmodic irritability of the 
bile-ducts, it is most important to remember that the 
disease will soon subside if the parts be allowed to rest. 
It is a great mistake to administer stimulants; the 
structures should rather be soothed by demulcents and 
by alkalies. Mercurial medicines only add to the 
irritation; and, if they relieve for a short time, the 
pain soon returns. With rest and patience, the irri- 



THE BILE AND THE BILE-DUCTS 89 

tation will gradually abate. The saline mineral waters 
are often of great service, as those of Carlsbad, Ems, 
Marienbad, &c. 

Another morbid condition of the bile-ducts consists 
in a catarrhal state of the mucous membrane. The mem- 
brane becomes congested; its secretion is altered; the 
free passage of the canal is interfered with by inspis- 
sated mucus and by bile, and jaundice is the result. 
A congested and catarrhal state of the upper portion 
of the duodenum frequently accompanies this catarrh 
of the bile-ducts, and may precede it; and, again, it 
may be associated with chronic organic change in the 
liver itself, as with cirrhosis. 

In the post-mortem examination of persons who have 
died of other disease, whilst this condition of bile-ducts 
existed, we have found very manifest hyperemia of 
the mucous membrane and congestion of the vaginal 
plexus of capillaries upon the ducts. The symptoms 
are those of irritability of the stomach (although this 
is not always present), furred tongue, nausea, and often 
flatulence ; there are febrile excitement, headache, and 
sometimes transient delirium; the bowels are disturbed; 
after a short time (twenty-four to forty-eight hours), 
the surface of the skin becomes jaundiced, the urine 
deep in colour, and the alvine evacuations pale. In a 
few days these symptoms gradually subside. Eleva- 
tion of temperature and febrile disturbance are some- 
times absent; but the symptoms are more severe when 
the mischief is associated with disturbance of the 
stomach and duodenum. In those instances hyper- 



90 DISEASES OF THE LIVER 

aemia of the gastric mucous membrane precedes the 
other symptoms, and the disease spreads by continuity 
of structure to the orifice of the bile-ducts. Exposure 
to cold will itself produce this state of catarrh; espe- 
cially if the exposure be accompanied with indiscretions 
of diet, or with excess of wine or ardent spirits. 

I would advert to a condition of biliary catarrh 
sometimes observed in chronic disease, in which, with 
sallowness of countenance and sense of prostration, 
patients are seized with severe rigor, followed by an 
abundant discharge of bile; there is partial impediment 
to the free discharge ; the secretion itself is altered ; 
and the rigor closely resembles that which is observed 
in some diseases at the base of the urinary bladder and 
about the prostate gland. 

Catarrh of the bile-ducts is distinguished from spas- 
modic contraction and from gall-stone by the absence 
of pain; but there is greater difficulty in distinguishing 
the early stage of acute yellow atrophy from severe 
instances of simple catarrh. The symptoms in the 
former, however, are more severe; the nervous system 
is affected in a more marked degree; the liver is 
diminished in size in acute yellow atrophy, the tem- 
perature is not generally raised, and the urine contains 
tyrosine and leucine. Acute poisoning by phosphorus 
must be borne in mind as a cause of acute jaundice, 
resembling at its onset biliary catarrh. 

Jaundice due to obstruction from catarrh generally 
subsides in a favourable manner, but not always with 
equal rapidity ; and it is apt to be again produced by 



THE BILE AND THE BILE-DUCTS 91 

slight exciting causes. Catarrh of the bile ducts is 
only of serious importance when it is conjoined with 
other diseases of an organic kind. And, when there 
is pressure from enlarged glands, or from malignant 
disease slowly exerted, the diagnosis is at first exceed- 
ingly obscure; in each case the jaundice may come 
on gradually, without pain and without febrile excite- 
ment ; and it is only as the persistent character of the 
disease is shown, that we may be able to recognise the 
true nature of the complaint ; for no growth may be 
perceptible throughout, as in some instances of disease 
of the pancreas. 

The treatment of this form of disease should not be 
too active. If there be furred tongue, with nausea 
• and constipation, a mercurial purgative will often be 
of service, but mercury is generally unnecessary. 
Potash and soda salines are beneficial; and soda with 
rhubarb, although an old and not very palatable 
remedy, is a good one. The saline mineral waters of 
a laxative kind, promote recovery; but the disease 
will subside without medicine, if fresh causes of ex- 
citement are avoided ; and we must place this com- 
plaint amongst those, the tendency of which is natur- 
ally to pass away. 

The inflammatory condition of the bile-ducts is 
sometimes more acute ; and the effusion may be of a 
fibrinous character, or it may be purulent. This un- 
usual state has been observed in pyaemia; and abscess 
is occasionally formed in connection with the ducts. 
Again, ulceration may be produced by persistent 



92 DISEASES OF THE LIVER 

irritation ; it is rare to find this destruction of tissue 
in the bile-ducts, though it has frequently been found 
in the gall-bladder. An angular calculus in the ducts, 
whilst it fails to block up the canal, may cause ulcera- 
tion ; as we have known where several calculi were 
present in the ducts. From the gall-bladder, the 
ulceration may pass through into the peritoneum, or 
into the duodenum, or into the stomach or the colon, 
or it may reach the parietes, as in the case already 
mentioned. The symptoms of this extension of dis- 
ease are generally a fixed pain at the part, with sym- 
pathetic disturbance of the adjoining viscera; but the 
indications may be so slight, that the discharge of the 
calculus from the bowel, or its impaction in the small 
intestine, may be the first evidence we have of the 
passage of the gall-stone from the bladder ; and in an 
instance of a patient who died in Guy's Hospital from 
the administration of chloroform, it was found that an 
ulcerative opening existed between the gall-bladder 
and the duodenum, although the patient had given no 
history of disease at the part. 

Entozoa, as the ascaris lumbricoides, have been 
known to enter the gall-duct from the duodenum; 
and hydatids are in some cases discharged by this 
same channel. 

A far more important pathological condition, how- 
ever, is inflammatory thickening of the duct, with or 
without external inflammation and abscess. The pas- 
sage of a gall-stone will sometimes induce fibroid 
thickening and persistent jaundice; or local inflam- 



THE BILE AND THE BILE-DUCTS 93 

matory action and abscess or ulceration may result. 
It is sometimes found that, after bile has begun again 
to flow freely, there is a continuance of pain and 
febrile disturbance ; there may be prostration, a red 
and dry tongue, diarrhoea, and mental depression ; and 
there is evidence of further disease, although the gall- 
bladder has emptied itself, and the liver, previously 
distended, has lessened in size. This state is one of 
great anxiety, and of doubtful prognosis ; for we 
cannot be certain that local suppuration will not 
supervene; and in not a few cases, fatal peritonitis, 
from the discharge of the pus into the peritoneal 
cavity, has taken place. This form of suppurative 
disease is different in its pathology from suppuration 
in the course of the vena portae, to which reference 
was made at the last lecture, and which is associated 
with pyaemia, and is due to the extension of disease 
along the folds of the lesser omentum. 

As in the state of catarrh, so also in this form of 
inflammation of the deeper coats of the bile-duct, we 
would strongly deprecate an over-active plan of treat- 
ment. If the patient become exhausted by depressing 
remedies, there is a greater probability of degenerative 
changes ; and in those cases where local peritonitis 
and adhesion with the colon induce temporary intes- 
tinal obstruction, it is most important to allow the 
bowels to remain quiet. The symptoms are those of 
hepatic mischief, and of gall-stone with local inflam- 
mation ; and superadded to these may be intestinal 
obstruction, from the cause just mentioned. Purga- 



94 DISEASES OF THE LIVER 

tives would seem to be indicated, but by breaking 
down partial fibrinous adhesion we may inadvertently 
cause extravasation and general peritonitis. 

The next condition of the bile-ducts to which we 
would refer is the passage of a Gall-stone and dis- 
tension of the ducts; but it is quite impossible 
fully to describe their pathological conditions and 
varieties of disease in this lecture. The hepatic 
secretion is found in various degrees of density ; and 
its constituent parts, either from their undue pro- 
portionate quantity and consequent deposition, or 
from local centres of concretion, may constitute 
more or less solid masses. Dr. Thudichum, in his 
elaborate work on Gall-stone, has shown that biliary 
calculi have nuclei of casts from the smaller ducts, 
and very rarely of foreign bodies ; the calculi consist 
especially of cholesterine, or of inspissated colouring 
matter, with more or less of bile-acids, or with 
fatty acids ; and, lastly, phosphate and carbonate of 
lime may be added to other ingredients. Sometimes 
the thickness of the bile itself is sufficient to cause 
obstruction, or minute granular calculi may be detected. 
The size of the calculi varies as much as their number; 
sometimes one or two, as large as hen's eggs, fill up 
the whole of the gall-bladder, and are moulded to its 
form ; in other cases, very large numbers are fitted 
together, so as to constitute an uniform mass. Many 
hundreds have been counted ; and Dr Thudichum 
quotes instances where they were thousands in number. 
They may induce intense suffering as they are dis- 



THE BILE AND THE BILE-DUCTS 95 

charged, or may only be detected by post-mortem 
examination. In an instance where I counted more 
than a hundred and twenty calculi, the gall-bladder 
could be felt during life ; but there had been no pain 
for many years, nor other symptoms of gall-stone. 
The calculus may pass the gall-duct without symptom, 
and some remarkable cases are recorded where large 
ones were thus unconsciously extruded ; but the sym- 
ptoms are generally of great severity. Sudden pain 
in the region of the gall-bladder comes on as soon as 
the calculus begins to stretch the gall-duct; rigor 
may be experienced; the pain radiates across the 
abdomen, and through to the right scapula ; vomiting 
of a severe kind comes on; the pulse is generally 
compressible ; the patient often writhes about in the 
agony of pain, and becomes cold and collapsed, or 
breaks out into perspiration ; the respiration may be 
unaffected, the bowels are often confined, and the 
secretion of urine checked. If the gall-stone pass 
from the cystic to the common bile-duct, or if it be in 
the hepatic duct itself, jaundice follows from the re- 
absorption of the elements of bile into the blood ; and 
this discoloration generally commences on the second 
day; the urine then becomes deep in colour, the 
motions clayey, and the vomited matters are neces- 
sarily free from bile. The intense pain is generally 
moderated in several hours, but it may last for days, 
and, in less degree, for weeks or even months. As it 
came on suddenly, so also as the calculus passes into 
the duodenum, it may as suddenly subside. Some- 



96 DISEASES OF THE LIVER 

times an oval calculus may become fixed, but allow bile 
to pass ; in a case of that kind under my care it was 
believed that the calculus had passed, from the cessa- 
tion of the pain ; the patient, however, died from sup- 
puration in the biliary duct. In some cases, the in- 
tensity of the agony is more than the patient can bear, 
and is the cause of death. In two instances that have 
come under my own notice, the calculus was found pro- 
truding into the duodenum. The calculus produces 
distension of the bile-ducts and of the gall-bladder ; 
the liver is enlarged, but subsequently there is 
wasting of the gland tissue and of the secreting 
power. If the obstruction be permanent, it may cause 
ulceration of the duct or gall-bladder, and the cal- 
culus may then be discharged into the peritoneum 
(causing fatal peritonitis), into the duodenum, the 
colon, the stomach, or through the parietes. 

The bile- ducts sometimes become enormously dis- 
tended, the common duct forming a canal (as in a 
drawing from the museum of Guy's), three inches in 
circumference, like a coil of small intestine; the 
capillary ducts are observed upon the surface of the 
gland like cysts, and throughout the liver the biliary 
canals assume very large proportions; the whole gland 
in these cases acquires a deepish green tint ; the gall- 
bladder can be felt as a globular pear-shaped projec- 
tion at the edge of the liver ; to the touch it gives a 
peculiar elasticity, and yields under gentle pressure in 
a manner which enables us generally to distinguish 
simple distention from cancerous growth. This dia- 



THE BILE AND THE BILE-DUCTS 97 

gnostic indication is of great value ; but in deep- 
coloured jaundice it is sometimes very difficult to 
distinguish the hardened and distended gall-bladder 
from tumour, especially since, as we shall presently 
show, the two diseases are often combined — namely, 
cancerous disease and gall-stone. The gall-bladder 
sometimes acquires a very large size. A remarkable 
case is one recorded by Dr Babington in the ' Guy's 
Hospital Eeports ' of 1842. A young plumber, aged 
27, thirteen months before admission, had a swelling 
of the lower extremities, and nine months previously 
felt a small tumour in the abdomen, which gradually 
increased in size, till it became as large as an uterus 
at term. The tumour occupied the right lumbar, the 
hypochondriac, and umbilical regions ; severe pain 
came on in the abdomen a few hours before death. On 
inspection, tl}e peritoneal cavity contained pus ; the 
cyst was flaccid and nearly surrounded by liver-struc- 
ture ; near the kidney a portion of the cyst walls had 
given way ; the cyst, an enormously distended gall- 
bladder, contained two large washhand-basinfuls of 
reddish, opaque, ropy secretion ; no gall-stones were 
found. 

Gall-stones have been detected in childhood; one 
case is recorded at twelve years of age ; but they are 
more frequent in adult and in advanced life. 

Sedentary habits, constipation, and mental anxiety, 
probably conduce to the production of gall-stones. 
They have often been found in phthisical disease of the 
lungs, but it is not ascertained whether there is any 

7 



98 DISEASES OP THE LIVER 

relation between the fatty condition of the liver and 
the deposition of the biliary constituents in the form 
of gall-stone. Another interesting association of dis- 
ease is the presence of cancerous disease of the liver or 
of the gall-bladder with gall-stone, as in the following 
cases ; in one of which, although no gall-stone existed 
after death, the symptoms had been well marked during 
life. 

Whatever may be the antecedents of cancer, and 
in whatever way nutrition may be modified so as to 
occasion the deposition of cancerous product, there is 
no doubt that when such a state of the system has 
been induced, preternatural hyperemia in any part 
may determine the presence of cancer in that locality. 
Blows upon the breast have in this way become the 
exciting cause of cancerous disease, and so of other 
injuries. The same fact is observed in internal struc- 
tures, and it is exemplified in some diseases of the 
liver and of the ovary. It is found that cancerous 
disease of the liver co-exists with gall-stone ; and the 
presence of calculi and their discharge through the 
bile-ducts may be the determining cause of cancerous 
deposition in the neighbourhood. 

Sabah H — was a poor widow woman from Whitstable ; she 
had been employed as a nurse, and till eight months before admis- 
sion she had enjoyed good health. She had had several children. 
During July, 1868, severe pain in the right side came on in 
paroxysms, followed by jaundice. Six weeks later the abdomen 
began to swell, and then the legs. The motions were pale, and 
the urine was very deep in colour. The jaundice continued for 
six months, and she had frequent pain on the right side. On 



THE BILE AND THE BILE-DUCTS 99 

admission she was emaciated ; the countenance was sallow ; the 
abdomen was very much distended, measuring 40 inches in cir- 
cumference ; the skin was tense, the superficial veins were large ; 
the abdomen was very resonant in front, but elsewhere it was 
dull, fluctuation being very distinct ; the legs and feet were cede- 
matous. Chest : there was slight dulness at the apex of the right 
lung, with bronchial breathing and bronchophony ; there was dul- 
ness at both bases, with some crepitation. The heart healthy. 
Urine was thick, and did not clear entirely on boiling, nor on the 
addition of nitric acid ; no tumour could be felt on the abdomen. 
On the 1st of April, she suffered so much from distention, that 
paracentesis abdominis was performed, and twenty-six pints of 
fluid were drawn off. The liver could then be felt ; she experi- 
enced much relief for a few days ; but diarrhoea and pain soon 
came on, with irritation of the stomach. The fluid slowly col- 
lected, and on the 25th nearly the same quantity was again drawn 
off. The relief was less than before, and on May 20th she was 
again tapped, twenty-eight pints being drawn off. After a few 
hours of partial relief, she quietly sank on the 23rd. Diarrhoea, 
with attacks of severe griping pain, hastened the fatal termination. 
Inspection. — The brain was healthy. Chest — Upon either 
pleura were several small patches of cancer penetrating inwards 
into the lung tissue, but they were more extensive upon the pleura 
than towards the lung. One nodule of cancerous growth was in 
the substance of the lung at a little depth. It was deep red with 
white points throughout it, very firm, and with definitely limited 
edges. There was no disease of the lung tissue, but there was a 
partially airless state of the most dependent part. Heart.—' 
Healthy. Abdomen. — The peritoneum was cedematous, and had 
a sodden appearance ; it contained a large quantity of turbid fluid, 
and it was covered with partially adherent shreds of plastic lymph. 
There were also some nodules of cancer on it ; and these were 
especially numerous in the recto- vaginal pouch. Stomach. — Con- 
tents were acid, and consisted of semi-digested food ; here was 
marked post-mortem solution ; near the pylorus were numerous 
small ulcers penetrating the mucous membrane. — Liver. — Weighed 
56 oz. The left lobe was large, the right was small and puckered ; 
the surface was deeply indented. There were many cancerous 



100 DISEASES OF THE LIVER 

tubera in the liver, and the anterior two-thirds of the right lobe 
were especially affected. The principal mass was very hard, grey, 
pellucid, and " scirrhous." The liver to the right of the gall- 
bladder was very adherent to the colon. The liver tissue was 
highly fatty. The gall-bladder contained half an ounce of yellow 
bile. Pancreas.— The surrounding tissue was tough from chronic 
inflammation; some of the glands contained cancerous deposit.. 
Spleen. — Sixteen ounces in weight ; and was harder than natural. 
The Malpighian corpuscles were very visible. The kidneys were 
healthy, 9 ozs. in weight. Other viscera were normal. Although 
no gall-stones were found, we had no doubt of their previous 
existence. 

William H — , aged 58, was admitted April 16th, and died May 
9th, 1856. He had been employed for many years as a farrier, 
and was a man of steady and industrious habits. In December, 
1855, he experienced pain in his abdomen, and became jaundiced ; 
paroxysms of pain supervened, simulating gall-stone. The appetite 
was moderate ; the colour became more and more deep, but his 
only distressing symptom beyond pain was diarrhoea, with a con- 
stant desire to evacuate the bowels. The stools were white and 
frothy. During three mouths he emaciated considerably. On 
admission the. jaundice was exceedingly deep ; the abdomen was en- 
larged, tender, much distended with fluid, so that no tumour could 
be detected. He gradually sank. Inspection was made twenty-six 
hours after death. The face was almost black from the depth of 
the colour of the jaundice ; the body wasted, and the abdomen 
much distended. The lungs were healthy. The heart healthy, 
except some fibroid degeneration. The abdomen contained several 
pints of bile-coloured serum ; the serous membrane was minutely 
studded over with tubercles, small, white, and firm ; in some parts, 
especially towards the diaphragm, they were united so as to form a 
partial layer. At the position of the gall-bladder was a dense white 
mass, about the size of an ordinary gall-bladder, distended, white, 
hard, and on section having the appearance of scirrhus ; in the centre 
was a small cavity filled with numerous gall-stones, about the size 
of peas, with smooth white facets. The scirrhous growth had 
obliterated the orifice of the cystic duct, and the opening of the 



THE BILE AND THE BILE-DUCTS 101 

common duct into the duodenum. The colon, duodenum, gall- 
bladder, and liver were drawn into close contact by the contraction, 
and by scirrhous infiltration. The walls of the gall-bladder were 
nearly half an inch in thickness, and the growth extended partially 
into the substance of the liver. The growth also pressed con- 
siderably upon the vena portse near the liver, and the whole of the 
bile-ducts were enormously enlarged. Close to the duodenum the 
duct was destroyed ; the pancreatic duct was also very much dis- 
tended, and the head of the pancreas slightly involved. Some of 
the mesenteric glands were infiltrated, and the mesentery was much 
shortened. The liver itself was of a deep greenish colour and 
atrophied. On carefully examining the growth it was found to 
be very dense, fibrous, and it showed, besides elongated fibre cells 
and granule cells, numerous cells with large nuclei : similar ele- 
ments were found in the minute growths on the peritoneum ; they 
were evidently cancerous, but slow in growth, and more closely 
resembling fibrous tissue. It appeared probable that the gall- 
stones set up irritation or inflammatory action, which was suc- 
ceeded by cancerous development. On examining the structure of 
the liver, no hepatic cells were discovered, but decomposition had 
considerably advanced. The spleen was healthy, so also the 
alimentary canal; the kidneys were slightly degenerated. On 
tracing the large branches extending from the right semi-lunar 
ganglion into the liver, they were found to be involved in the 
scirrhous growth, and were destroyed. The mass extended quite 
to the superior mesenteric artery. All the voluntary muscles were 
affected with trichina spiralis, as well as the diaphragm and the 



A third association of disease which we have several 
times found in gall-stone is worthy of consideration — 
namely, that pleuritic effusion is often present on the 
right side. This occurrence might lead a subsequent 
observer to suppose that there had been error in dia- 
gnosis, and that the disease had been one of dia- 
phragmatic pleurisy j but, as we find the liver closely 



102 DISEASES OF THE LIVER 

sympathising in acute pneumonia, so also here. There 
is impeded action of the diaphragm, the pneumogastric 
and phrenic nerves are both concerned, and equally so 
the vaso-motor ; but, however the explanation may be 
made, we have repeatedly witnessed this association 
of symptoms, the effusion taking place a few days at 
least after the onset of the intense pain and the jaun- 
dice. I might adduce several instances of this kind 
that have come under my own observation. 

Again, during the paroxysm of gall-stone there is 
sympathy in the action of the kidney of such a kind that 
the activity of the gland is sometimes checked, and 
ursemic poisoning may be produced ; in one instance 
which I saw in consultation, and to which I have 
already adverted, the symptoms of gall-stone subsided, 
but the patient died from ursemic poisoning with 
miscarriage, and it was supposed that a mistake had 
been made, and that renal instead of biliary calculus 
had been the cause of the earlier symptoms. Again, 
biliary and renal calculus sometimes coexist in the 
same patient; in one of the instances in which the 
biliary calculus was found to be just passing into the 
duodenum, there was also an encysted calculus in the 
kidney. 

The treatment of gall-stone should be divided into 
that which is calculated to relieve the paroxysm ; that 
which lessens the jaundice; and thirdly, that which is 
designed to prevent the recurrence of the attack. As to 
the first, the intensity of the pain calls for immediate 
attention, and, by means of the hypodermic injection 



THE BILE AND THE BILE-DUCTS 103 

of morphia and the inhalation of chloroform, we are 
enabled to afford considerable relief ; these means are 
much more effective and better than the internal use of 
opium, which is with difficulty absorbed, and has some- 
times been given in such large doses as to endanger the 
life of the patient. Externally, hot fomentations may 
be applied, or, what is more effectual, the mixed chloro- 
form liniment, belladonna liniment, and aconite lini- 
ment — half an ounce of the two first, and a drachm of 
the latter. If the bowels are confined, they should be 
acted upon by a free mercurial purgative and warm 
saline draught, or by an enema. 

In hastening the removal of the jaundice, an un- 
stimulating diet should be given and gentle action 
on the bowels maintained ; the saline mineral waters 
are often of great assistance, but must be adminis- 
tered with caution. Alkalies may be used with 
advantage, not only in facilitating the discharge of 
inspissated bile, but in lessening duodenal irritation. 
It is of great importance, also, where other calculi are 
retained, and also where much irritation has been left 
after the passage of a calculus, that there should be no 
fresh source of irritation to the pyloric region of the 
stomach and the first portion of the duodenum. Bis- 
muth with alkalies is of some value in diminishing this 
gastric sensibility ; but whilst anaesthetics and ano- 
dynes afford immediate relief and alkalies promote 
recovery, a great amount of patience is required by 
the medical attendant, as well as by the patient, lest 
the disease be aggravated by over-active treatment. 



104 DISEASES OF THE LIVER 

Cancerous Disease. — The liver is more frequently 
affected with secondary cancerous disease than with 
primary deposit in the gland, and so, also, is the gall- 
bladder and its ducts ; the infiltration of glands at the 
fissure of the liver or in the lesser omentum, as well 
as carcinomatous disease of the stomach and pancreas, 
may exert direct pressure upon the bile-ducts, and 
thus produce jaundice; but the gall-bladder is, in 
some instances, directly affected with one or other 
form of cancer, the slower form of scirrhus, or the 
more rapid one of medullary growth. Besides these, 
however, colloid disease affects both the gall-bladder 
and the ducts, and in some cases we have villous 
cancer ; the first distention of the gall-bladder is with 
difficulty distinguished from hydatid disease in some 
instances of this kind, till, by the more profound con- 
stitutional disturbance, or by the evidence derived 
from puncturing the enlargement, the true character 
of the disease is recognised. 

A little boy, aged 4, who had been ill for twelve 
months, was brought to Guy's, September, 1871. He 
was weak and emaciated, and it was stated that a year 
previously he had had a fall of thirty feet, and had frac- 
tured his thigh ; the abdomen soon afterwards began 
to swell, vomiting came on, and there was progressive 
emaciation. On admission, the abdomen was large, 
and a rounded projection was evident at the liver 
about the position of the gall-bladder. It was doubt- 
ful whether the swelling consisted of a suppurating 
hydatid cyst or of malignant disease. A puncture 



THE BILE AND THE BILE-DUCTS 105 

was made, and five ounces of dark green pus were 
drawn off, mixed with blood, and containing large 
cells, as seen by microscopical examination. The child 
soon sank. The liver was healthy, but a large cyst of 
the size of the child's head was found on the lower 
surface of the gland ; its walls were half an inch in 
thickness, and it consisted of an enormous distention 
of the cystic and hepatic ducts and gall-bladder, and 
from the inner surface large villous processes pro- 
jected ; the contents were pus with colouring matter 
of bile. The duodenum was fixed to this mass, and 
there were four ulcerative openings into the sac, 
communicating with the bowel. The other viscera 
were healthy. 

Patients affected with cancerous disease of the liver 
are generally beyond the middle period of life, and the 
powers of nutrition have become impaired by general 
or local causes. 

The early stage of cancerous disease of the liver is 
often very insidious ; the patient may find that health 
fails without any very definite symptoms. There is wast- 
ing, loss of strength and energy, loss of appetite and 
of the power to digest food, the countenance becomes 
sallow and cachectic ; sometimes there is pain in the 
region of the liver, and irritability of the stomach may 
be present ; in some instances the pain is very severe, 
and the most decided of the symptoms. Jaundice is 
not necessarily present unless there be pressure on the 
bile-ducts, and in some instances there is pallor 
instead of sallowness of countenance. I have often 



106 DISEASES OF THE LIVER 

been surprised at the great extent of cancerous 
effusion into the gland structure without any jaun- 
dice, because the ducts have remained free. As the 
disease advances the presence of tumour in the liver 
or irregular projections from its surface are recog- 
nised. 

The cancerous cachexia becomes more decided and 
emaciation increases. The termination of these cases 
is due to various causes ; the patient may gradually 
sink from exhaustion, the appetite fails, the tongue 
becomes red and injected, or brown and dry ; and the 
pulse becomes weaker as the strength lessens. In other 
cases the bile-ducts are pressed upon, and jaundice of 
a very deep colour is produced, and the exhaustion is 
more rapid than in the former cases. It is generally 
found that the heart is very feeble in organic disease 
of the liver, and I have known the sudden failure of the 
heart's action lead to a fatal result much more speedily 
than had been anticipated from the hepatic disease. 
The patient was beyond the middle period of life, he 
had cancerous disease of the liver, which was easily 
diagnosed, and the diagnosis was afterwards confirmed 
by post-mortem. It was believed that he would have 
lived for several months, but one morning he got up 
as usual, dressed himself, walked across his room, and 
having sat down, died from syncope. The pulse was 
compressible; the muscular fibre of the heart was 
weak and degenerated, but there was no valvular 
disease. 

The diagnosis of cancerous disease of the liver is 



THE BILE AND THE BILE-DUCTS 107 

often difficult. There may be all the general sym- 
ptoms, but no growth can be recognised, no enlarge- 
ment can be felt, and it is only, it may be, that any- 
thing of the kind can be found when the disease is 
far advanced. 

The hard calcareous cyst of an old hydatid may be 
mistaken for cancerous disease, emaciation and exhaus- 
tion being present, but due to other causes. 

The gall-bladder may be distended and filled with 
well-packed gall-stones , which may have never pro- 
duced any symptom, because none may have been 
discharged, but the hard mass felt on tactile examina- 
tion may raise the question of cancerous disease. 

In cirrhosis the surface of the liver is not smooth, 
but the disease is generally easily distinguished from 
cancerous disease, but sometimes the contractions are 
deep, the surface irregularly tuberose, and the dia- 
gnosis then becomes more difficult. 

Syphilitic gummata in the liver are easily mistaken 
for cancerous tubera, but the general symptoms and 
the clinical history enable us generally to form a 
correct opinion as to the nature of the case. It is 
difficult when a residence in a tropical climate has 
produced hepatic disease, and the patient has been 
intemperate in his habits and has also had syphilis, at 
once to recognise the presence of cancerous tubera. 
In these cases it is well not to be too decided on the 
first examination of the patient. 

In the treatment of cancerous disease of the liver it 
is very important not to increase the exhaustion of 



108 DISEASES OF THE LIVER 

the patient by the injudicious use of mercurial medi- 
cines nor of iodide of potassium, which will not pro- 
duce absorption of the growth, but only promote its 
further increase. The treatment should be such as is 
likely to assist digestion and improve the strength of 
the patient. 

An interesting class of cases of diseases of the liver 
are those connected with the formation of cysts. 
These are of several kinds : 

1. Enlargement and distention of the gall-bladder 
may simulate true cysts. 

2. Hydatid cysts. 

3. Cysts arising from the distention of the bile-ducts. 

4. Cysts probably due to changes in the bile-ducts 
or lymphatics, but filled with serum or with sangui- 
neous contents. 

The enlargement of the gall-bladder is recognised 
by its position, its pyriform shape, its compressibility 
if the contents are fluid. The clinical history guides 
us in forming correct diagnosis. The hydatid cyst is 
more frequently in the right lobe of the liver, it is 
generally single, rounded in form, with peculiar 
elastic thrill on percussion, and the patient is free 
from cachectic symptoms or from general disturbance 
of health. The serious symptoms arise from the 
pressure of the cyst upon other structures, and from 
perforation into adjoining oavities. The cyst may 
open into the bile-ducts or into the duodenum or 
stomach, or if it pass into the pleura or into the 
peritoneum fatal inflammation is produced. 



THE BILE AND THE BILE-DUCTS 109 

Hydatid cysts degenerate, and the wall becomes 
hard, dense, and calcareous, or the contents may be- 
come inflamed and lead to suppuration. The most 
satisfactory proof of the true character of the cyst 
is the nature of the contents when drawn off by aspi- 
rator or trochar, namely, clear fluid, without albumen, 
containing saline matter, and echinococci with their 
peculiar ring of hooklets ; sometimes only isolated 
hooklets are found on microscopic examination, but 
one hooklet is sufficient to reveal the nature of the 
cyst ; if there be extravasation of bile into the cyst 
the vitality of the echinococci is destroyed and suppu- 
ration is produced. The hydatid cyst may increase to 
enormous size, and resemble simple enlargement of 
the liver, as in an instance under my care many years 
ago in Guy's previously referred to. 

The hydatid cyst is known by its beautiful laminated 
structure. 

As to treatment no general remedies are of any 
avail; and the only effective plan is to destroy the 
vitality of the echinococcus ; this is done by drawing 
off the contents of the cyst by an aspirator ; some years 
ago the injection of salt and water or of a dilute 
solution of iodine was advocated, but this is unneces- 
sary, for when the specific gravity of the contents is 
altered, the hydatid dies. If suppuration take place, 
then a free opening must be made, and a drainage- 
tube introduced. It was formerly thought desirable 
to secure adhesion between the peritoneal surfaces, and 
local inflammation was induced by the application of 



110 DISEASES OP THE LIVER 

caustic. This, however, is unnecessary. The attempt 
to destroy the vitality of the cyst by the introduction 
of the poles of a galvanic apparatus has been em- 
ployed, but this is less satisfactory than drawing off 
the contents. 

The following case is a good illustration of a form 
of cyst that was supposed to be hydatid, but was found 
to be a simple cyst containing sanguineous fluid. Its 
precise pathology was not made out, whether it was a 
distended bile-duct, or a true cyst of independent 
growth. About eight years ago a gentleman, forty-six 
years of age, consulted me for swelling in the region 
of the liver. His general health was not impaired, 
but six months previously sudden pain came on in 
the chest and abdomen ; it was very severe, and 
accompanied with vomiting; the pain continued 
about twenty-four hours, and the skin became sallow ; 
the attacks recurred nearly every day ; a large pro- 
jection was found connected with the right lobe of 
the liver; this was soft, and fluctuation could be 
felt. I asked the assistance of my friend Mr Durham, 
and he drew off about two and a half pints of deep 
red-coloured serum. The cyst was supposed to have 
been hydatid, but no hooklets were found, and it was 
evidently a serous cyst, the contents coloured by blood. 
The patient quickly recovered, and several years after- 
wards when he called upon me there had been no 
return of disease. 

There are many questions connected with the patho- 
logy of diseases of the liver, the consideration of which 



THE BILE AND THE BILE-DUCTS 111 

is foreign to our present purpose. In our first lecture 
we briefly adverted to some of those forms which are 
connected with the altered nerve-supply of the gland 
and the general condition of the nervous system ; in 
our second, in which the vascular supply was more 
especially noticed, we described conditions of jaundice 
symptomatic of disease. Those, however, which have 
now come before us are essentially connected with 
obstruction ; the bile is prevented from flowing 
onwards after its secretion, and the repletion of the 
ducts leads to the re-absorption of the bile into the 
blood, thus staining all the tissues, and producing 
jaundice of varying intensity, according to the duration 
of the disease, and the completeness of the obstruction. 
I have sought to bring before the Society some 
practical elucidations of disease, rather than to enter 
upon abstruse and recondite subjects. I trust that the 
remarks I have made will afford subject matter for 
useful thought, and that some fragments of instruction 
may be gathered from them. 



PBINTED BY J. E. ADLABD, BARTHOLOMEW CLOSE, 



OTHER WORKS BY DR. HABERSHON, 

Felloio of the Royal College of Physicians ; late Senior Physician to, 
and Lecturer on Medicine at> Guy's Hospital. 



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