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The liver of the human subject, in an erect posture, descends lower than in the horizontal; protruding more than two fingers' breadth below the false ribs, in the former situation; where, in the latter, it is entirely concealed by them. Hence, our author takes occasion to expose the error of the common practice of laying the patient in a recumbent posture to examine the condition of the liver. He should stand up or be seated. The spine should be inclined anteriorly and towards the left. For obvious reasons, the liver will be most advantageously examined during inspiration.
As the liver may be pushed downwards by effusion in the thoracic cavities, or by enlargement of the viscera which they contain; so, on the contrary, it may be elevated to such a de
, gree from its natural site, by curvature of the spine, abdominal dropsies, tumours of the spleen, mesentery, kidneys, ovaries, or uterus, that even considerable enlargements of that organ can no longer be detected by external examination. The situation of the liver may also be considerably changed by other deviations of the body, from its wonted form.“These notions," says our author, “ are necessary to enable us to distinguish accurately, by the touch, if the liver be diseased or not."
In examining a subject in the horizontal position, we should take care that the bed on which he is laid, be not too yielding. The head should be raised, and supported by a firm pillow; the lower limbs bent, and the knees brought together: in fact, the abdominal muscles, and particularly the recti, should be put
in the utmost possible state of relaxation; and in examining the condition of the various contained viscera, the hand will be most advantageously applied during the act of expiration.
A section on the general causes of obstructions of the liver follows. These causes are manifold, as catarrhal affections, syphilitic, scorbutic, scrofulous, &c. suppressed or excessive excretions, inflammations, compressions, various fevers, mental disturbances; but our author attempts not to explain their mode of operation. Obstructions of the liver, he adds, may be formed by blood, by bile, by lymph, or some one of the constituents of the latter, as albumen, gelatine, mucus. How far these distinctions and refinements are founded on correct observation; how far they may admit of discrimination in the living subject of disease, and hence be turned to good account in practice, our readers will presently have an opportunity of deciding for themselves.
A fourth section contains some valuable remarks upon the prognosis in hepatic obstructions. At the fifth, on the treatment of these diseases, we shall not pause. With the exception of a few remedies, the practice recommended is very inert. Mercury, the sheet-anchor of British physicians, is barely mentioned. To this subject we shall, ere long, have occasion to revert.
Article third treats of obstructions of the liver by various fuids. Its first section is upon sanguineous congestion of that organ.
“ There are few parts of the body,” observes our author, “so prone to sanguineous congestion as the liver; doubtless, not only because it receives a greater proportionate supply of blood by the hepatic artery and vena portarum, than other viscera; but because its veins are proportionally smaller than in other organs; and particularly so in relation to the capacity of the former vessels."
Obstructions, existing in the pulmonary cavities of the heart; dilatations of those cavities; disorders of the respiratory organs, by opposing an impediment to the free circulation of the pulmonary artery, may occasionally determine congestion of the liver, as may thoracic effusions or morbid affections of the diaphragm. Obstructions of the spleen, by embarrassing the circulation of the splenic division of the common cæliac trunk, and hence determining an unusual quantity of blood to the hepatic division; disease or augmentation of the volume of the stomach by immoderate eating, whence arises impeded circulation of the coronary artery of that organ, and of the gastric branches of the hepatic, may produce a similar effect upon the
а liver.* Thus gluttons have frequently been found to have enlarged liver, with spleen much diminished by the pressure of the cardiac extremity of the stomach. Upon the same obvious
• Our anatomical readers will recollect that the coronary stomachic artery, the splenic, and hepatic, are the primary divisions of one common trunk (the cæliac.) Upon this foundation was raised, some years since, an ingeni. ous but too mechanical and limited theory of the physiology of the spleen. principle, tumours or dropsies of the abdomen, or compression of the abdominal parietes by tight clothing, may operate in producing congestions of the liver.
The phenomena peculiar to this morbid condition of the liver are pourtrayed by our author with great fidelity and precision. He considers the evacuation of pure blood by the mouth and rectum, so often occurring in these cases, as, in general, salutary; though sometimes followed by fatal exhaustion. It flows into the stomach or intestines from the cysto-hepatic duct. Abstraction of blood from the arm and hæmorrhoidal vessels, constitutes, with cream of tartar (supertartrite of potass) and certain vegetable preparations, of questionable efficacy, our author's principal remedies in this form of hepatic congestion.
Obstructions of the liver by bile and biliary calculi are considered in the second section of this article. We have here a long account of the physical and chemical properties of the bile, of its uses in the animal economy, and a survey of its inAuence in the production of diseases. Jaundice, our author asserts, may arise from absorption of bile from the intestinal canal, under certain circumstances of disease. He has even seen in the absorbents of the mesentery of patients thus affected, a "yellowish bitter fluid.” The biliary ducts may become greatly enlarged, and the gall-bladder itself has been known to form an immense tumour, containing several pints of bile. After our author's remarks on the seat, symptoms, and physical properties of biliary calculi, and a sketch of the analysis of bile, by the latest French chemists, the following distribution of the former, by M. Fourcroy, is presented to us.
“ There are six species of biliary calculi; the hepato-biliary, the hepato-adipocerous, the cysto-biliary, the cysto-cortical, the cysto-adipocerous, the cystic of a mixed character or adipobiliary; of these species, some are brown, blackish, irregular, tuberculous. Others are more hard, of a brown, yellow, or greenish colour, present concentric layers; the external one frequently dry, smooth and gray. The third variety compre. hends white ovoid concretions, of a form more or less irregular, covered by a whitish, commonly unequal, crust, formed, as it were, of sparry layers or crystalline scales. All these calculi
are soluble in the pure alkalis, in solutions of soap, and in the fixed oils."
Upon the causes and treatment of biliary obstructions and calculi, nothing very novel or interesting is advanced. For their removal, repeated emetics, soap, bitters, chalybeate waters, and lime-water, borax (borate of soda) are recommended; and it is allowed, evidently with reluctance, that calomel, “le remède de Durande," may be very efficaciously employed in the commencement of the disease; although its salutary effects have been " unduly exaggerated.”
Death may result from a rupture of the distended gall-bladeffusion of its contents into the abdominal der, and consequent cavity. The tumour also, formed externally by a morbid collection of bile, may be readily mistaken for an abscess, and opened; an error which must often prove fatal. The remarks upon the means of distinguishing biliary from purulent collections, we shall briefly transcribe. They are judicious, and pregnant with practical utility; and although confessedly taken from a memoir of M. Petit, in the second volume of "the Memoirs of the Academy of Surgery," they may yet be unknown to the majority of our readers.
The tumour formed by the amplified gall-bladder is situated in the right hypochondrium, near the external border of the cartilages of the false ribs; has a sensible fluctuation, without pastiness; an uniformly smooth surface, without heat or redness. Jaundice, with colics, white alvine excrement, and universal itching of the body usually come on. There is pain shooting towards the umbilicus, and caused by dragging of the cysto-hepatic duct. In the progress of the disease, this pain becomes more diffused, and affects the centre of the epigastrium. Distension going on, the biliary tumour exhibits the characters of inflammation; and is, under these circumstances, with difficulty distinguishable from abscess. Sometimes this inflammation terminates in resolution, without the accumulated bile, which distends the gall-bladder, being discharged into the duodenum. In such case, the possibility of mistaking the collection for an abscess is obviously increased. An attentive observer, aided by the luminous diagnostics laid down here, might, however, be enabled to distinguish them with tolerable precision.
The bile, from long retention in its reservoir, may acquire acrimonious properties, or become of thicker consistence: in the first case, abscess, with fatal effusion into the peritoneal cavity, may ensue; in the other, biliary concretions may be formed, attended by all their train of violent and distressing symptoms. When, in consequence of inflammation, adhesion has taken place between the distended gall-bladder and the peritoneum, the contents of the former may, in some cases, be successfully evacuated by the knife, as they cannot then be effused into the abdominal cavity. Surgeons have even gone so far as to perform this operation; extract biliary calculi; and, by the introduction of a probe through the wound, attempt to remove the obstruction of the cystic duct; but it is a perilous enterprize, and as such has been absolutely rejected by the celebrated Sabatier.
The most common causes of biliary obstructions are, according to our author, calculi lodged in the gall-bladder, the cystic, hepatic, or common ducts; or, "plastry concretions" compressing the parietes of those ducts; scirrhus of the duodenum; and morbid enlargement of the pancreas. Pancreatic calculi, by obstructing the orifice, common to the biliary and pancreatic ducts, may, we suspect, sometimes, though perhaps rarely, operate in producing the same effect.
The whole of this section, a few apparently obscure passages excepted, is written in a very clear manner, and contains much valuable information. We particularly recommend an attentive perusal of it to the reader.
The third article of the second chapter of M. Portal's work is upon obstructions of the liver by various fluids. Its first and second sections, on sanguineous congestions of the liver, and on its obstructions by bile and biliary calculi, have already passed
Lymphatic obstructions of the liver constitute the subject of the third section. Under this generic title are comprehended three different species of obstruction: the albuminous, the gelatinous, the mucous. We shall attempt to elucidate our author's opinions upon these differences, and to expose the base on which they are founded, by a statement of the morbid appearances peculiar to each species, which examination of the liver after death presented.