INFLAMMATION OF THE VEINS OF THE LIVER. 167

leave the hospital, when he died almost suddenly from erysipelatous inflammation of the larynx (cynanche laryngea). The liver was enlarged and presented a curious mottled appearance, from being studded with small irregular white masses, which, to the naked eye, looked very much like small masses of tuberculous matter, but which, on microscopic examination, were found to consist of hepatic cells. The cells were opaque, and contained a good deal of granular matter, and about the normal quantity of oil. I had some time before observed a similar appearance of the liver, where death had occurred during convalescence from fever.

SECT. IV.-Inflammation of the Veins of the Liver-Suppurative Inflammation of the Portal Vein-Adhesive Inflammation of Branches of the Portal Vein-Inflammation of Branches of the Hepatic Vein.

Inflammation of the Veins of the Liver.-Inflammation in veins, as in other textures, may be suppurative, that is, it may lead to the formation of pus; or it may be adhesive, and lead only to the effusion of coagulable lymph, which blocks up and obliterates the vein. But in the inflammation of veins that leads to the formation of pus, coagulable lymph is usually poured out as well as pus: and the pus does not fill all the inflamed portion of the vein, but is interrupted here and there by plugs of fibrine, or coagulated blood, so as to form a string of abscesses along the vein.

Inflammation of the trunk of the vena portæ is of very rare occurrence. From being so deep-seated, this vein is not liable to wounds or other injuries-the most common causes of inflammation of other large veins.

The following case, published by M. Lambron, in the Archives Générales de Médecine, for June, 1842, is the most complete case of the kind I have met with. Inflammation of the trunk of the vena porta was here caused by a fish-bone, which passed through the pyloric extremity of the stomach and the head of the pancreas, and stuck in the superior mesenteric vein.

The patient, a man 69 years of age, was admitted into the hospital, La Pitié, on the 4th of June, 1841. For some weeks he had been suffering

pain in the stomach, with occasional nausea, and his bowels had been much confined. On account of these ailments, a week before his admission he took a grain of tartar-emetic, which produced no amendment.

The day he entered the hospital, he was seized with shivering and nausea, and the following night he slept ill.

On the morning of the 5th, he was carefully examined. His pulse was nearly natural, and his breathing quite tranquil. His tongue was white, he had some degree of nausea, and his bowels were confined. He complained of constant uneasiness, with paroxysms of pain, which he compared to very severe cramp, in the right hypochondrium, but pressure on that part gave hardly any pain. The liver and the spleen were of natural size. The other functions seemed duly performed. (Wine-lemonade; low diet.)

The 6th and 7th of June, he had no rigors. The pain in the right hypochondrium was very severe, but there was no tenderness. The tongue was covered with a whitish coat, there was some nausea, and the bowels were still costive. (A grain of tartar-emetic; veal broth; julep.)

On the 8th, he suffered still more, and the skin and conjunctiva had become slightly yellow.

On the 11th, the jaundice was more marked, and the urine, as tested by nitric acid, contained bile. The pain in the right hypochondrium persisted, with exacerbation from time to time. About f3 vj of blood were taken from the side, by cupping.

On the 12th, the pain was less, but he had nausea, and in the evening, a shiver, followed by heat and sweating. His tongue was dry, and covered with a blackish coat. Hiccough, and some greenish liquid evacuations. Pulse 96. The spleen was not perceptibly enlarged. (Quinæ sulphat. grs. iij.) On the 13th, he was nearly in the same state. Some rigors occurred during the night, but they were not succeeded by a hot stage, and the sweating was less profuse than before. Occasional hiccough. Pulse 80. (A blister was applied to the stomach; the quinine was continued.) The rigors and the hiccough continued to recur.

On the 15th, the fits, like those of ague, recurring more or less regularly, and not yielding to sulphate of quinine, the hiccough, the jaundice, the pain in the right hypochondrium, the absence of disease in other parts of the body, and the nearly natural size of the spleen, led to the inference that the disease was hepatic phlebitis.

The 17th, the patient was in a typhoid state. The 18th, he was a little better, and the jaundice less marked.

The 24th, he felt better, and asked for something to eat. In the evening, he was seized with violent shivering with fever, but now the different stages were confounded, and he shivered while his body was covered with sweat. The urine contained much less bile.

The 25th, the fever had not ceased, and seemed likely to become continued. The skin was covered with sweat. The tongue, which had been moist for some days before, had become again dry; and the pain, which had ceased for five or six days, came on again.

The 26th and 27th, the shivers recurred, with occasional hiccough, the fever became remittent, the pulse was firm and tolerably full, but the patient was much depressed.

The 28th and 29th, he sank lower and lower, and became slightly delirious. Pulse 104, small, and compressible. He died in the night of the 29th.

All the tissues were

The body was examined thirty hours after death. slightly jaundiced. There was no serous fluid in the abdomen. The liver was of a natural size, and of a dark-greenish yellow, or bronze color. It adhered at some points to the diaphragm, but its investing membranes were otherwise healthy. The gall-bladder was of natural size, and had also formed some adhesions to contiguous parts. It was filled with bile, which had all the characters of ordinary bile. The gall-ducts were healthy.

The trunk of the vena portæ contained a sanious fluid, with some flakes of pus.

On tracing the mesenteric roots of the vein, a fish-bone, the size of a large pin, was found stuck into the trunk of the superior mesenteric vein. The bone, implanted in the head of the pancreas, transfixed the vein from above downwards, and from before backwards. At the point where it was pierced by the bone, the mesenteric vein was blocked up by false membranes, which adhered firmly to its inner coat. The false membranes extended from the mouths of the small veins which come directly from the upper part of the duodenum to the orifice of the splenic vein, becoming less and less firmly adherent. Below this obstruction the roots of the mesenteric vein contained some fibrinous coagula for an extent of some inches, but were otherwise healthy.

The splenic vein was healthy, but contained some reddish fluid like that in the portal vein, from which it had probably flowed into the splenic vein after death.

The trunk of the portal vein was not closed, but was narrowed by false membranes adhering slightly to its coats, which were only a little thickened. It contained pus mixed with blood, and, at some points, pus like that of an abscess. The hepatic divisions of the vein were some of them filled with the same reddish liquid; their coats being in some parts healthy, in other parts inflamed, thickened, and coated by false membranes. Others contained only clots of blood, which extended to very small ramifications of the vein. Other branches again were perfectly healthy.

The liver contained no abscesses, but its tissue about the transverse fissure was very soft. In parts of the liver supplied by those branches of the portal vein that remained healthy, there was no change of texture. The lobules,

of a greenish-yellow color, were distinct, and the interlobular spaces, as well as the intralobular vein, were red from the blood they contained.

In the parts supplied by those branches that were filled with coagula, the lobules were likewise distinct, but were less red at their margins and centres. Lastly, in the parts supplied by the branches of the vein that contained pus and were inflamed, the form of the lobules was still preserved, but the interlobular tissue was very soft, and the divided intralobular veins seemed empty of blood and gaping.

The hepatic veins were quite healthy, and contained very little blood.

On the posterior wall of the stomach, near the pylorus, was a brownish spot, corresponding to one end of the fish-bone, and on the inside, at the same spot, there was a slight depression capable of lodging the head of a pin. It was clear that the bone had passed through the stomach at this spot, pierced the head of the pancreas, and, going still onwards, had stuck into the mesenteric vein, and caused all the subsequent disorder.

The kidneys, the spleen, and the intestines were healthy. In the right lung, there was some degree of hypostatic pneumonia, but neither lung contained anything like an abscess.

The heart was large, and contained some clots. The right ventricle contained a fibrinous clot, which extended into the pulmonary artery.

This case is very simple. The inflammation of the vein was caused by a mechanical injury, and there was no other disease to interfere with or to mask its effects. The vein most probably became inflamed on the 4th of June, when the patient was first shivered. The pain at the stomach and the occasional nausea he had some weeks previous, were most likely caused by the fish-bone then passing through the stomach and pancreas. After the 4th of June, the symptoms were just those which might have been expected. There were frequently recurring rigors, followed by heat of skin and sweating, and, after a short time, typhoid symptoms-as in suppurative inflammation of other large veins-while the pain in the region of the liver, the nausea, the hiccough, the jaundice, and the absence of marked disorder of other organs, showed that the liver was the chief seat of the local disease. The deep situation of the vein explains the absence of tenderness.

In the following case, for notes of which, as well as an opportunity of examining the parts after death, I am indebted to Mr. Busk, the inflammation of the portal vein had a different origin, and led to somewhat different results, but was marked by nearly the same train of symptoms. I cannot describe the case better than in Mr. Busk's own words:

"May, 1844.

"I have sent you what I think you will consider a very interesting specimen. It was procured from a man who died last Sunday, after an illness of seven weeks. He was a patient of Mr. Sherwin's, and I have seen him frequently for the last six weeks. His case was extremely obscure, but I surmised from the first that we should find suppuration in the liver.

"He was a very robust man, an engineer in the dockyard at Woolwich, and had never been out of England, and was of very sober, temperate habits, married, with one child. Had always enjoyed good health, with the exception of occasional pain in the abdomen, which was not considered of any importance till his last attack. He never had ague.

"Seven weeks ago, he was seized rather suddenly with severe pain in the abdomen, which obliged him to keep his body bent forward, and he had a severe rigor. I saw him about a week afterwards, and he had then the appearance of great depression. He complained of severe, but only occasional pain in the epigastric region, predominating on the right side. The pain was not increased by pressure. It did not appear to be of a piercing character, but was attended with a feeling of extreme sinking and distress, and relieved by morphia. It recurred several times a day at irregular intervals, and about twice in twenty-four hours he had a severe rigor, followed by

most profuse sweating. There was no distension of the belly, and no enlargement of the liver could be detected on the most careful examination, nor was there any tenderness in the hepatic region,

"When I first saw him, the evacuations from the bowels were light-colored and very fetid, but he was not jaundiced. Soon afterwards, however, he became jaundiced, and the urine contained bile. The jaundice went off in a few days, and the evacuations became of natural color and consistence. At the same time, the urine lost the bile, and threw down a very copious lateritious sediment, which continued to the last. The jaundice passed off suddenly, and the change in the character of the evacuations was preceded by a copious discharge of nearly pure bile.

The symptoms continued with little change to his death. He gradually sank, becoming much emaciated. He never vomited, and had a great desire for oysters, which were almost his whole support.

"On examination of the body, the lungs were found perfectly sound. "The peritoneum contained several pints of straw-colored serous fluid, mixed with flakes of coagulable lymph; and the stomach, transverse colon, and great omentum were all glued together by soft lymph.

"The liver was large, and extended to the left side. Its convex surface had a coating of puriform matter, and was of a dark color. On raising the anterior margin, it was found that the concave surface, including the portal fissure and behind it, was adherent to the stomach and surrounding parts; and on separating the adhesions, the substance of the left lobe was found to be occupied by numerous abscesses, which were bounded externally by the adhesions and by the wall of the stomach. The upper surface of the left lobe was closely adherent to the diaphragm, and in the middle of this portion of the diaphragm there was a circular space, about the size of a shilling, having a semi-gangrenous appearance, opposite to which on the upper surface of the muscle the base of the lung was firmly adherent, and pus was deposited in its substance. On detaching the liver from the other parts, a very large collection of thick pus was found in the portal fissure. Pus could be pressed out in great quantity from the dilated portal vein, and was also deposited in the areolar tissue surrounding it. The whole of the left lobe was occupied by innumerable abscesses of all sizes, so as to resemble a coarse sponge filled with pus. In most of these abscesses, the pus was thick and white, but in a few it was of a bright yellow. There were also numerous abscesses, some of them of considerable size, in the right lobe.

"The portal canals, in the left lobe especially, were thickened, white, and firm; and, as far as I could ascertain, the gall-ducts were healthy. I have no doubt the abscesses were connected with branches of the portal vein. In a portion of the surface of the liver, which I have sent you, near the fissure in the anterior margin, you will observe a chain of small abscesses, apparently following the course of a vessel, and showing in a very striking manner the real nature of the disease.

66

The gall-bladder was distended by a very pale mucous fluid, and, like the ducts, was perfectly healthy.

"The spleen was of natural size, and except two small superficial abscesses on that part of the surface which bounded an abscess beneath the liver, was quite healthy.

66 The pancreas was healthy.

"The splenic and superior mesenteric veins were healthy, but immediately