inflamed gall-ducts less viscid, and has the same sort of efficacy in these cases as in catarrhal diseases of the lungs, in which this and other alkalies have been long used as expectorants. The muriate of ammonia is another medicine which is often of service in inflammatory diseases of the gall-bladder and gall-ducts. It has a less special action on the liver than the salts of soda, but a more general action on other secreting organs; and does good, not only by increasing the flow of bile, but also by the indirect relief it gives to the liver, by exciting the action of the kidneys and skin. As most diseases of the biliary passages may be traced to a faulty condition of the bile, so it may be stated, as a general principle, that, as far as medicines are concerned, the best remedies for them are to be found among those agents which modify the qualities of that fluid. Among these, taraxacum holds an important rank. Its powers, in increasing the secretion and modifying the qualities of the bile, are very variously estimated, but reasons have already been given for believing that its efficacy, like that of cholagogue medicines generally, is more likely to be under than overrated. That it should continue to be held in such high esteem by so many accurate observers is a strong testimony in its favor, and as it has the further advantage of being perfectly safe and harmless, there is every motive for giving it an extensive trial in the treatment of these forms of disease. When the process of inflammation is over, and the organic changes produced by it alone remain, the inefficacy of all active treatment is obvious. When, for example-to take an extreme case-the common duct is obliterated, mercury and other lowering measures must do positive mischief, and the rule of treatment becomes that of avoiding all active interference. In such a case as this, there is little more to be done than to regulate the diet; to endeavor to control, by the appropriate remedies, whatever disorder there may be of the stomach and bowels; to keep up the action of the kidneys and skin; and to obviate all avoidable causes of exhaustion. The great question is, how is the fact of occlusion to be made out? When complete jaundice has lasted a long time, this, of itself, is almost proof of permanent closure of the duct in some way or other, and should deter us from the use of mercury and all lowering remedies; but in the absence of this evidence, the point must remain doubtful. In that case it is right to give the patient the chance afforded by more active treatment, and in the endeavor to do good we must run the risk of doing harm. This is but one of the countless questions which con tinually call up the remark that, in diseases of the liver, beyond all others, diagnosis is the very foundation of treatment, and that to render our diagnosis more sure, should, for the present, be the chief object of our researches. This end will be best attained by more perfect knowledge of the physiology and uses of the bile, and by a more accurate study of the circumstances under which the various diseases of the liver arise. CHAPTER III. DISEASES WHICH RESULT FROM FAULTY NUTRITION OF THE SECT. I.-Softening of the Liver-Destruction of the Hepatic Cells— Suppressed Secretion of Bile-Fatal Jaundice. HAVING considered the inflammatory diseases of the liver, we may pass on to a class of diseases quite as important, but at present less understood; diseases in which, without any process to which the term inflammation can be rightly employed, the secreting power, or the nutrition of the hepatic cells, is seriously disordered. These diseases may be divided into two principal groups. One of these groups is characterized by suspension of the secretion of bile; the principal feature of the other is that the hepatic cells separate from the blood some abnormal matter, which, instead of passing freely out of the liver in the bile, is retained there, adding to the size of the liver, and more or less changing its appearance and texture. To understand how changes in the appearance and texture of the liver are produced in this way, we must again refer for a moment to the intimate structure of the organ. We have seen that the lobules of the liver are spaces mapped out by the ultimate twigs of the portal vein, which are hairy, as it were, with capillaries springing from them on every side, and forming a close and continuous network; and that the interstices of these capillaries are filled with nucleated cells. It is in these cells that the vital chemistry of secretion goes on. It is seen by the microscope that in different livers the cells vary in size; that in some they are almost transparent, in others opaque, and apparently more solid; that in some they contain but a few very small oil-globules, while in others they are distended almost to bursting with globules of oil; that in some they are colorless, or nearly so, and in others yellow with bile; that in some specimens, again, as in cases before related, they are broken down and destroyed. It is probable, too, that in some cases the cells are only slowly reproduced; so that, at length, the number of active cells in the lobular substance is much diminished. These differences in the condition of the cells cause, of course, corresponding differences in the size, color, and texture of the liver; differences which were noticed long before that knowledge of the intimate structure of the organ was obtained by which we are now enabled to explain them. When the cells are small, or few in number, and the spaces between the capillaries in the lobules are not distended with the product of secretion, the lobules are small and indistinct, and the liver is small and flattened, and its lower edge is thin. When, on the contrary, the cells or their interstices are distended with oil, or with any other product of secretion, as in the fatty and the scrofulous liver, the lobules are large and unusually distinct, and the liver is large and thick, and its lower edge is blunted. The most remarkable and most serious change is where the cells are completely broken down and destroyed. It has been seen that this may result from long retention of the secreted bile from closure of the common gall-duct. In consequence of this, the hepatic gallducts become enormously dilated, and the whole liver acquires a deep olive color. Its tissue is then flabby, but not readily broken down by the finger, and presents no appearance of lobules. Every part of the liver is affected alike, and exhibits, under the microscope, in the place of the secreting cells of the lobular substance, nothing but free oil-globules and irregular particles of solid biliary matter. The liver contains but little blood, and partly from this, but chiefly from loss of the cells, it may be smaller than in health, and its surface wrinkled, notwithstanding the biliary matter accumulated in it. But destruction of the hepatic cells may take place rapidly, without any obstruction of the gall-ducts, and, instead of being consequent on protracted jaundice, the impaired nutrition of the cells may be the cause of jaundice that proves rapidly fatal from disorder of the functions of the brain. It has been long known that cases of jaundice now and then occur which prove fatal in this way; and that in such cases it frequently happens that no obstruction can be found in the gall-ducts-which are pale and empty of bile-and no effusions characteristic of inflammation in any part of the liver. In some such cases, no change of structure has been remarked in the liver, and the disease has been described as fatal jaundice from suppressed secretion. In other cases, the liver has been found unusually small, much softened, and changed in color, and the disease has been spoken of as softening of the liver, or simple softening or black softening, according to the color of the liver in the individual case. The two following cases, published by Dr. Alison in the Edinburgh Medical and Surgical Journal for 1835, are examples of this terrible form of disease : CASE I. Peter Schread, aged about 25, a German sailor, was admitted into the clinical ward, the 26th of February, 1826, in a state of complete delirium, with tendency to violence, but alternating with drowsiness. His skin and the tunica conjunctiva of the eyes were of a bright yellow color; he had no tenderness of abdomen; his pulse was 60, of irregular frequency; tongue moist; extremities rather cold; he had occasional singultus; he passed a copious bilious stool, and also urine in bed, soon after his admission. His companion reported that he had a severe attack of flux, in Java, in the summer previous-that he had been in good health at Antwerp, from September till December, but that, since the 1st of January, when he arrived at Leith, he had complained often of pain and heat in the abdomen, chiefly towards the right side, with thirst and chilliness-that eight days before admission he had become jaundiced, and two days before admission had become delirious. His head was shaved, bathed, and blistered, and he had one dose of calomel and several of tartar-emetic (the only medicines that could be got down), which produced copious bilious stools, all passed in bed; but the delirium passed into complete coma, with dilated pupils and stertor; his pulse rose to 120, and became feeble; some purplish spots appeared on the skin, and he died on the evening of the 28th-ten days after the appearance of jaundice. The following account of the dissection was drawn up by Dr. C. Henry, of Manchester, then one of the clinical clerks in the infirmary : : "The skin and subjacent cellular tissue were universally of a bright yellow color. This tinge extended also to the pericranium, and to both surfaces of the dura mater, which was rather more vascular than natural. The other membranes of the brain were dry and glistening. The bloody points were somewhat more numerous than usual. There was very slight distension of the left lateral ventricle, the contained serum not exceeding half a drachm. That found in the right was still less considerable, and there was hardly any at the base of the brain, which appeared somewhat vascular. The consistency of the cerebral structure was perfectly healthy. The surfaces and central points of the cartilages of the ribs were tinged with bile, as were the peritoneum and pleura. "The liver, when incised, appeared of a light yellow color; it was smaller than natural, its structure dense, and resisting compression, but in mass it was remarkably loose1 and flexible. The caliber of the cystic duct seemed 1 In Dr. Alison's paper, it is printed "large and flexible," which, considering what goes before, does not make sense. Large" is probably a misprint for "loose." |