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the abdomen. Respiration became short. The pulse was commonly natural. Death was preceded by constant drowsiness.
The waters of Bichy, * regular bathing, leeches, and an alcoholic preparation of opium, were the remedies employed in this case; which had been by some of the physicians considered as an affection of the right kidney!
Two fortunate cases of liver disease, complicated with colic, jaundice, and pulmonic symptoms, are next detailed. They were treated by vomiting, bleeding from the arm and hæmorrhoidal vessels, blisters, soap-pills, with bitter extracts; infusion of soap-wort and hop; pills of assafætida and sulphur, infusions of borage and other plants with elder-rob; the terra foliata tartari (acetate of potass) dissolved in the juices of plants of the natural families of succory and borage; syrup
of certain aperient roots; warm bathing; flannel dress; the mineral springs of Bichy.
In the fixed or wandering pains of the abdomen, and other parts of the body, consequent on continued or intermitting fevers, injudiciously treated by cinchona, our author recommends gentle vomiting and purging, diaphoretics, the waters of Bichy, the application of leeches to the hæmorrhoidal vessels. By others, as Baillon, general bleeding is preferred, even where symptoms of debility are manifest. We are warned to distinguish such pains from others, dependent upon a febrile state. In the latter, cinchona is indicated.
Our author, in his remarks on hepatalgia, contends that the substance of the liver itself is susceptible of pain, and successfully controverts the once received axiom: “ubi dolor, ibi morbi sedes.” He shows that affections of the biliary system may be accompanied by pains in the umbilical,splenic, nephritic, or other more remote regions of the body. His explanation of the causes and symptoms of angina pectoris (the stenocardia of Brera) is neither satisfactory nor conclusive. He considers the pain of the superior extremities, occurring in that disease, as an affection of the diaphragmatic nerves, produced by the morbid liver; which, in these cases, he asserts, is enlarged, and variously diseased. From an elevation of the diaphragm, and consequent diminution of the thoracic cavity, produced by this or other affection of the abdominal viscera, the heart, he contends, suffers constriction; and hence the peculiar phenomena of angina pectoris. Similar consequences may result from compression of the pericardium by intumescence of the lungs or mediastinum, or by dilatation of the heart or its large vessels, independently of hepatic malady.
are warm, cha
*“All the waters of Bichy,” according to Dr. Saunders, Jybeate and alkaline; probably mixed with some earthy muriats, which in. crease their operation on the bowels."
That such morbid alterations of the thoracic or abdominal viscera must incommode the heart, and exert a pernicious influence upon its functions, it would be idle to deny. That these affections, existing at the same time, might signally favour the development, and aggravate the distressing symptoms of angina pectoris, we are ready to allow. But we do positively, and once for all assert, that the embarrassments resulting to the organ of circulation from such abdominal and thoracic enlargements, do not, whatever be their nature, duration, or degree, constitute the angina pectoris of British pathologists; a distinct and particular disease, having for its invariable cause, an ossification of the coronary arteries of the heart. Science is indebted for the discovery of the cause of angina pectoris to British labour and research.
A section on the general treatment of pains of the liver closes this chapter. Amid a crowd of various and often inert reme. dies, mercury is slightly mentioned, as useful in hepatalgia from a steatomatous and syphilitic taint. The English are reproached with the indiscriminate employment of this powerful mineral in inflammatory or other pains of the liver.
“But we have never," says M. Portal,“ seen them, (mercurial frictions succeed in these cases. M. Vitet, who was a great advocate for such practice in pains of the liver, even when complicated with fever, and in various congestions of that gan, has repeatedly employed them under my observation without effect. On one occasion, frictions with the corrosive muriat (oxymuriat) of mercury were prejudicial.”
How are we to explain results so widely differing from those we daily witness in practice, on this side of the channel? Are we to hold them, as resulting from peculiarity of climate or constitution?
The second chapter treats of enlargement, congestions, and obstructions of the liver; and of diminution, induration, and a softened state of that organ. It comprehends four different articles. Cases of enlargement of the liver, with remarks upon it, constitute the first.
Twenty-three dissections of enlarged liver are here quoted from the works of various pathologists; many of them are highly interesting. In one case, recorded by Bartholine, the morbid organ is said to have weighed forty pounds. A remark made by our author in this place deserves to be commemorated.
“ The liver appears to form a tumour in the abdomen in all those who have effusion in the right cavity of the thorax; and even in those, whose right lung has acquired an extraordinary volume; because the diaphragm is then thrust down towards the abdomen. This sometimes takes place in phthisical diseases, and may lead to erroneous conclusions."
Our author, in his remarks upon this article asserts, that great eaters have a larger liver than sedentary, hard-working, or abstemious persons. The latter have often a contracted stomach, and very small liver. In rickety, scorbutic, scrofulous, and syphilitic affections; in those who have suffered from protracted fever, the liver is commonly augmented in bulk, often in weight. The increase of weight does not, however, invariably occur with increase of volume; an enlarged liver being sometimes lighter, or a diminished one heavier, than the organ in its natural state. He also exposes, in a rather humourous and sarcastic strain, the fallacy of an opinion entertained by some physicians, that the Spigellian lobe can be, when enlarged, felt by examination through the parietes of the abdomen. The effects which an enlarged liver may produce by mechanical pressure upon the surrounding organs, are next considered.
“But it is not,” says M. Portal, “ only by the effects of compression which the liver exercises upon these organs, that their functions are disturbed. It may operate upon them, as upon the parts more remotely situated, by the medium of the nerves, the blood-vessels and lymphatics, or the cellular structure, which compose its substance; and of the membranes with which it is invested. And what influence, moreover, may not the liver exert, by means of its secreted fluid, upon the bowels, the lungs, fact, upon
the brain and nerves; upon the urinary organs; the skin; and, in
all the solids and fluids of the body, as well in health as in disease?"
Disordered action of the heart, palpitations, syncope with constriction of the chest, pains and numbness of the superior extremities:
“ Indeed,” says our author, "all that assemblage of symptoms, erroneously described by the English as a distinct discase, by the name of angina pectoris, may result from the pressure of the diaphragm against the pericardium, by a liver enlarged generally or solely in its left or horizontal lobe.”
Upon the error of this reasoning we have before delivered our opinions; it would be superfluous to repeat them.
The stomach may be thrust to the left when the right lobe of the liver is enlarged; downwards, by the pressure of the tumid left lobe. The spleen may, from a like cause, suffer compression, and be made to displace the left kidney. The inferior extremity of the esophagus may be compressed and lengthened in the abdomen by the voluminous liver; especially at that part where the tube is lodged in an excavation of the latter organ posteriorly.* The cardiac orifice of the stomach may, in like manner, become contracted by the pressure of the hepatic tumour. The right kidney is often much depressed, from an elongation of the inferior extremity of the corresponding lobe of the liver.
The second article includes general considerations on the symptoms, causes, prognosis, and treatment of the enlarged and obstructed liver, from anatomical and clinical observations.
“ Almost all chronic diseases, fevers, derangements of digestion, colics, as well as flatulence, jaundice, vomiting, diarrhæa, melæna, edema, and the various species of dropsy, are accompanied by a general congestion of the abdominal viscera, and particularly of the liver."
The symptoms of hepatic obstruction are drawn with a very clear and masterly hand, in this chapter; from which obstruc
* We are told, on the authority of Bartholine, that obstinate vomiting may arise from compression of the æsophagus, in its passage behind the tumefied liver. Hence, perhaps, sometimes the fatal vomiting which occasionally takes place in liver diseases. VOL. VI.
tion, cutaneous diseases, in our author's opinion, frequently originate; and he finds that they yield to remedies capable of re-establishing the wonted course of the biliary secretion.
“The piles are a frequent consequence of disordered liver. They are sometimes so considerable as to occupy not only the margin of the anus, but to extend through the whole of the rectum, and even higher in the colon. We need only consider the circulation of the vena portarum, and the situation of this vein in the liver, to understand how frequently piles must be in. duced by obstructions in that organ."
“From the same cause, the cutaneous veins of the inferior extremities swell and become sometimes varicose; and this inference is supported by the salutary effect of aperient medicines in removing such dilatations, especially when they procure evacuations of bile."
We cannot, for ourselves, comprehend how the obstructed circulation of the vena portarum should operate in determining a varicose state of the superficial veins of the leg, although we have been long aware of its influence in producing hæmorrhoidal affections. Our author would probably have been more correct, in referring the former of these morbid phenomena to the compression which, under some circumstances, the inferior vena cava may suffer from the tumid liver.
Congestions of the liver may terminate variously; in inflammation and suppuration, chronic and occult, or acute; and manifested by hepatic pains, colic, jaundice, pyrexia with shiverings, colliquative sweats, diarrhea, extreme emaciation: ar gangrene, announced by cessation of pain and febrile excitement, prostration of strength, and syncope. Or they may, in other cases, take on the form of scirrhous induration; which, after existing a long time, falls commonly into painless, unhealthy suppuration; and thus the liver may be disorganized without any symptom clearly indicating this morbid and de structive process.
The gall-bladder, when distended with bile, may be felt by external examination: indeed, by light compression, bile may be made to flow from it into the intestines. When considerably enlarged, the posterior inferior extremity of the right lobe of the liver may be felt, particularly in an emaciated subject, through the numerous muscles by which it is covered.