Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

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elicited only by hard strokes, sounding through the layer of the lung-
tissue that covers the liver. Inferiorly the liver reaches to the tenth
rib in the right hypochondrium, whence it ascends in a somewhat semi-
lunar line across the epigastrium, midway (or often a little higher
than midway) between the ensiform cartilage and the navel, towards
the left hypochondrium. Percussion in a horizontal line from the
ensiform cartilage towards the left, a little under the region where the
apex of the heart strikes, tells us how far into the left hypochondrium
the left lobe of the liver reaches.

This normal position, however, may be changed without indicating
any disease of the liver itself. The liver is dislocated downwards by
emphysema, pleuritic effusions, pneumo, pyo or hydrothorax of the
right lung ; it is dislocated upwards by fluid or gaseous collections,
or tumors within the abdominal cavity, or in consequence of a shrink-
ing of the right lung. Its surface becomes grooved by tight lacing of
corsets and waists of petticoats in females, and of pantaloons in males.
Part of the right lobe may, by this long-continued process, be brought
down to the anterior superior spinous process.

In speaking of the several liver complaints, I shall bring to notice,
1, those which affect the substance of the liver or its parenchyma ; 2,
those which have their seat in the hiliary ducts ; and, lastly, those
which originate in its blood-vessels.

1. Diseases of the Hepatic Parenchyma.

Hyperaemia, or Congestion of the Liver.

Pathologically, the liver is overfilled with blood, more or less
enlarged ; its surface is smooth, tense, glistening and firm to the touch ;
if cut, black blood oozes from it, and its parenchyma appears of a
dark hue.

Its most frequent cause is an impediment in the circulation of blood,
in consequence of diseases of the heart and of the lungs. To the
first belong diseases of the mitral and tricuspid valves ; and to the
latter pneumonia, pleuritic effusions (not so frequent) and emphysema.



CONGESTION OF THE LIVER. 819

Another cause is more general morbid processes of the orga,nism,
as, intermittent fever, typhus, exanthematic fevers, puerperal fevers,
scurvy, &c. But these do not invariably produce such results. Like-
wise we find it often in connection after suppression of menstrual and
hemorrhoidal discharges, and it either precedes or succeeds a number
of complaints which befall the liver specifically, of which we shall speak
hereafter. Lastly, it is said to be much more prevalent in hot than
in temperate climates.

Its symptoms are, heaviness, tension, pressure in the right hypo-
chondrium, frequent gastric derangement, nausea, vomiting, headache,
depression of spirits.

Palpation and percussion reveal an enlargement of the organ, but
of a perfectly normal shape. The volume, however, frequently
changes.

Therapeutic Mints.

Bellad., high fever; congestion of the head; severe headache;
vomiting of a watery, slimy, and bilious fluid ; great thirst ; region
of the liver painful and sore to the touch.

Bryon., bilious vomiting; bitter taste; white tongue; great thirst
or only dryness in the month ; inclination to keep still ; soreness of
the liver to pressure ; costiveness.

Cham., after anger or chagrin ; very annoying pressure in the region
of the liver ; colicky pains in the bowels ; vomiting of bile ; feverish
restlessness ; crossness ; icteric color of the face.

China, pale, wretched complexion ; diarrhoea, worse at night or
after eating ; sensitiveness to external cold ; great weakness and
lassitude ; after severe illness, loss of vital fluids, or abuse of mer-
cury.

Ignatia, after grief or fright, especially in the female sex ; menstru-
ation profuse and irregular ; leucorrhoea, with bearing-down pain.

Merc, bad taste ; bad smell from the mouth ; tongue white, flabby,
showing the imprints of the teeth ; feverishness ; sweating without
relief.

Nux vom., fulness; pressure; stitches in the liver, worse from
motion or contact ; swelling of the liver ; yellow color of the face^
especially if the color of the face is florid with a yellowish tinge ; all
worse in the morning ; great irritability and hypochondriac mood ;
costiveness.

When this congestion becomes a chronic stagnation of blood in the
liver it gives rise to what is called —



320 LIVER.

Nutmeg Liver.

It consists of an enlargement of tlie venous capillaries of tlie liver,
whicli, being filled with venous blood, look dark, whilst those por-
tions of the parenchyma around them look lighter, in some cases,
where there is an accumulation of bile, even yellowish, thus giving
the liver, when cut, a variegated, nutmeg-like appearance. This
shines even through its surface ; we see dark and light dots and
stripes close together.

In its highest degree it seems that the liver shrinks again; the
parenchyma loses its proper nourishment ; it becomes granulated,
and the surface, which was at first tense and smooth, becomes
wrinkled and thickened. This has been termed —



The Atrophic Form of Nutmeg Liver.

Nutmeg liver is always the consecutive symptom of heart and
lung diseases, which cause a continuance of impeded circulation ;
such are, insuflEiciency of the mitral and tricuspid valves, and hydro-
pericardium, emphysema, cirrhosis of the lungs, large pleuritic effu-
sions, &c.

Its symptoms are, enlargement of the liver, which is discernible by
palpation and percussion; more or less yellowish tinge of the skin
mixed with the bluish hue of cyanosis, in consequence of heart disease ;
more or less dropsy of the abdomen and the lower extremities ;
weight in the right hypochondrium — pressure upon it gives pain ; a
number of gastric symptoms and hemorrhoidal complaints.

Therapeutic Mints. — Compare those disordered states of the
heart and lungs, of which it is more or less a consecutive symptom.
Compare also acute and chronic catarrh of the stomach and intestines.
Besides all this, a special study require — ■

Lachesis, cannot bear tight clothes around the waist ; has even to
loosen the night-jacket to relieve the oppression, which is occasioned
even by laying the arm on the body ; tension ; contractive tightness in
the region of the liver.

Laurocerasus, distention of the region of the liver, with pain as from
subcutaneous ulceration, or as if an abscess would burst ; earthy com-
plexion ; yellowish spots in the face.

Lycop., tension around the hypochondria as from a hoop ; sore



HEPATITIS.



321



aching in the region of the liver, as if caused by a shock, worse from
contact.

Nux moschata, feeling of heaviness in the region of the liver ;
swollen liver ; bloody stools.

Podophyllum, fulness, with pain or soreness in the right hypochon-
drium ; chronic hepatitis, with costiveness ; the patient is constantly
rubbing and stroking with his hands the hypochondriac regions.

Compare also Sulphur and Sepia.

Hepatitis, Inflammation of the Liver.

This has been divided into —

A. Perihepatitis,

Which is nothing more nor less than a partial peritonitis, viz. : that
portion of the peritoneum which covers the liver. I shall not repeat
here what I have said already under the head of Peritonitis.

B. Hepatitis Parenctiymatosa sou Suppurativa,

However, is an inflammation of the substance of the liver itself. It
never involves the whole organs at once, but only parts of it here
and there ; which, in their centre, are soft and yellowish ; at their
periphery they show hyperemia, swelling and softening of the liver
tissue. In the progress of the disease little pus globules form in the
middle of the inflamed spot, they increase in number, unite and form
a small abscess, which again unites v/ith other small abscesses, and
thus, in the course of time, the greater part of the liver may become
an irregular cavity filled with pus.

Such abscesses are found much more frequent in the right than in
the left lobe. When they reach the surface of the liver, they break
through and discharge their contents into the abdominal cavity ; or,
if the surface of the liver has formed adhesions, in consequence of pre-
vious inflammation, with neighboring organs — either with the abdom-
inal walls, the diaphragm, the stomach, the gall-bladder, or one part
of the intestines — it perforates these organs, and discharges itself
either through the abdominal walls, or into the thoracic cavity,
stomach, gall-bladder, or intestines, according to its situation and
adhesion.

Hepatitis is primarily a very rare disease, and is mostly brought
on by external injuries — a fall, a blow, a wound, &c.

Secondarily it is caused by the irritation of hardened concrements
within the gall-ducts, or by ulcerative processes within the stomach

21



322 LIVER.

and the intestines, whicTi perforate and spread upon the surface of the
liver.

In tropical climates it has most frequently been found in connection
with dysentery.

Pyasmia, in consequence of wounds on the head or on any other
part of the body, is also a cause of it.

Symptoms.

A primary hepatitis caused by a blow, fall, or other mechanical in-
jury occasions pain in the right hypochondrium; frequently very
acute, as its lining portion of the peritoneum is likewise inflamed ; it
is worse from any motion. There is also pain in the right shoulder,
and on tension, in the right straight abdominal muscle. The liver is
swollen ; the skin more or less yellowish discolored, (icterus ;) fevers,
alternating with rigors,

A secondary hepatitis, in the course of ulcerative processes in the
stomach and intestines, manifests itself by shaking chills ; pain in the
liver ; swelling of the liver ; and icterus.

Hepatitis in consequence of pyaemia manifests itself likewise in
swelling of the liver, icterus, and shaking chills. Formation of ab-
scesses on the convex portion of the liver often bulge out, and may be
detected by palpation. Those on its concave side compress the portal
vein, and cause swelling of the spleen, and ascites.

Small abscesses may pass over without any marked symptoms.
Large abscesses cause fever ; shaking chills ; wasting away ; cachectic
appearance.

Perforation through the abdominal walls, after previous adhesion
of the inflamed portion of the liver with the abdominal parietes, is
the most favorable ; as, in this case, the pus is discharged outside.

Perforation into the pleural sac causes pleuritis i a perforation into
the lungs causes the pus to be expectorated; a perforation into the
pericardial sac causes pericarditis, which is fatal. If the perforation
takes place into the stomach, it is thrown up ; and if into the intes-
tines, it is discharged through the bowels.

All this shows that hepatitis and its consequences must cause quite
a variety of symptoms ; that its prognosis generally is unfavorable ;
and lastly, that a successful treatment, without a close study of the
individual case, is quite impossible. Still, if taken cum grano salis, 1
may mention the following remedies, which have proved themselves
more or less beneficial in abscesses of the liver : Bell., Bryon., Lach.,
Nux v.. Puis., Ruta, Sepia, Silic, Kali c, Merc, sal., Hepar, China.



HEPATITIS. 823

Special Sints» — Compare what has been said under the head of
Peritonitis.

Arsen., painful bloatedness in the right hypochondrium, with violent
burning pain ; violent thirst ; vomiting of black masses ; black stools ;
burning heat of the skin ; anxiety and restlessness ; very quick pulse ;
perforation into the stomach or intestines.

Bell., especially with acute pain in the region of the liver; worse
from pressure, breathing, coughing, and Ijang upon the right side ;
extending upwards towards the shoulder and neck ; congestion of the
head ; getting dark before the eyes ; fainting and giddiness ; bloated-
ness of the pit of the stomach ; tension across the epigastrium ; ago-
nizing tossing about; sleeplessness, or wanting to sleep, with inability
to get to sleep.

. Bryon., burning and stitching pain ; worse from motion and contact ;
after chagrin ; fulness of stomach and abdomen ; pain in the right
shoulder ; yellowish face ; white tongue ; great thirst ; constipation.

Chelidon., crampy pain in the inner angle of the right shoulder-blade :
shooting pain from the liver into the back ; pressive pain in the back
part of the head, towards the left ear ; pressure in the eyeballs ; bitter
taste in the mouth ; nausea ; palpitation of the heart, with very quick
and irregular pulsation, and without abnormal sounds ; constipation.

China, pain as from subcutaneous ulceration, worse from touch ;
liver swollen ; diarrhoea ; distended veins on the face and head.

Hepar, when suppuration takes place.

Kali c, pain through to the back; abscess; dryness of the skin,

Lachesis, after Bell, or Merc, very sensitive to any pressure upon
the hypochondriac region ; much flatulence ; palpitation of the heart ;
formation of abscesses.

Leptandra, yellow-coated tongue; constant nausea and vomiting;
aching in the region of the liver ; dark-brownish urine ; black stools.

Lycop., in rather slow cases ; complication with pneumonia ; fan-
like motion of the nostrils when breathing ; one foot hot, the other
cold.

Merc, pressive pain and stitches in the liver ; inability to lie on
the right side ; when coughing or sneezing, a stitch runs directly
through the chest to the back ; yellowish tinge of the face ; perspira-
tion without improvement.

Nux v., pain, stitch-like, or throbbing, or pressive; worse from ex-
ternal pressure ; sour or bitter taste in the mouth ; nausea ; vomiting ;
shortness of breath ; the dress seems oppressive ; the removal of it,



32 i LIVEE.

however, does not relieve; great deal of headache. Previous use of
allopathic medicines, coffee, liquor, &c. ; sedentary habits.

Puis., spells of great anxiety at night; green, slimy diarrhoea;
thirstlessness,

Silicea, hardness and distention of the region of the liver ; throbbing,
ulcerative pain, increased by contact and motion; formation of
abscesses.

Sulphur, especially after ISTux v. and Merc. ; red tip of tongue ; red
lips; sleeplessness.

Cirrhosis, Hob-nail Liver^ Interstitial Inflammation of the
Liver J Granulated Liver.

Its pathological character. It is a chronic inflammation of the areo-
lar tissue, which, being of a fibrous texture, forms a capsule over the
whole liver, and which likewise enters the liver as Glisson's capsule
with the portal vein, lining all its ramifications throughout the whole
organ. The next consequence of inflammatory action of this tissue is
exudation of coagulable lymph, which forms new areolar tissue and
adhesions between those ramifications of minute vessels, and causes
the secreting cells of the liver to beconie isolated and compressed, and
in this way forms those larger and smaller granulations, which have
been compared to hob-nails. In the further progress, this new forma-
tion compresses also the biliary ducts and blood-vessels, and the whole
organ shrinks, becomes hard, tough, pale, anaemic, and, if cut, appears
tinged with bile throughout. Its most frequent cause is the abuse of
alcoholic drinks ; still it has been observed in individuals who were
not addicted to drinking, and where it seemed to be in connection
with intermittent fever, suppressed menstruation, poor living.

Heart diseases, according to Bamberger, do not cause it. It is
much more frequently found in males than females, rarely in chil-
dren, and most frequently between the ages of thirty and forty-five
years.

Symptoms.

1. The liver is, during the stage of exudation, considerably enlarged,
and, during the stage of granulation, loses quite considerably in bulk,
so that the left lobe disappears entirely. If we have an opportunity to
observe its progress long enough, we can witness this increase and
gradual decrease of the liver, and in this way gain one of the most
important aids in our diagnosis.



CIEKHOSIS, 325

Tt is almost always connected with —

2. Enlargement of the spleen, in consequence of tlie obstructed cir-
culation of blood within the portal vein and its branches, which
impairs the free reflux of blood through the vena lienalis. This is an
early symptom.

3. Ascites appears later, and depends upon the same obstruction of
the portal circulation; still later cedema of the lower extremities
occurs.

4. Meteorismus, if strongly developed, causes difficulty in breathing.

5. Dilatation of the abdominal veins, which, however, does not
appear until after an advanced stage of the disease. It is caused by
the obstructed portal circulation. The blood in its way from below
being stopped, forces its way through neighboring veins, widening
and dilating them, and thus forms a collateral circuit around the
liver, until it reaches the vena cava. These widened and dilated
veins appear sometimes like a large net-work over the walls of the
whole abdomen, and even above it.

6. Functional disturbances of the intestinal canal are of a varied
nature. The appetite is, in some cases, not altered till very late ; in
others, again, want of appetite, nausea, belching of wind, and vomit-
ing predominate. In cases of severe obstruction in the portal circu-
lation we find vomiting of blood and bloody stools.

7. Loss of flesh and strength sets in quite early, as a necessary con-
sequence of imperfect circulation.

8. Jaundice is, according to Bamberger, quite a prominent symptom
of cirrhosis ; and, contrary to the opinion of other writers on this
subject, it is almost always found, and sometimes even in a high
degree. And it is not to be wondered at that it is so, when we re-
member the pathological character of the disease, which proves that
the whole gland is made unfit for biliary secretion.

If we consider these symptoms, together with the preceding abuse
of spirituous liquors, we shall be enabled, in most cases, to make out
a sure diagnosis. But for the sake of differential diagnosis I shall
compare a few forms of diseases which might be confounded with it.

Stricture of the biliary duct is usually caused by gall-stones, and has
its peculiar colicky spells, but no swelling of the spleen.

Nutmeg liver is always the consequence of heart and lung diseases,
and has no enlargement of the spleen.

Cancer and tuberculosis of the peritoneum, with highly-developed
ascites, may be sometimes difficult to discern •, still we have here a
quicker wasting away ; perhaps also signs of cancer or tubercles in



826 LIVER.

other organs, and a development of oedema of the lower limbs prior
to the development of ascites; whilst ia cirrhosis we have first ascites
and afterwards oedematous swelling of the lower extremities.

Cancer of the liver distinguishes itself by the peculiarly potato-
shaped surface of the enlarged liver and the normal size of the
spleen.

Hydatids of the liver give, on palpation, the sense of fluctuation ;
they do not impair the general nutrition, nor do they cause an
enlargement of the spleen.

Inflammation of the portal vein, tvith coagula forming in it, is a much
more rapid process, and is not caused by previous abuse of spirituous
liquors.

Inflammation of the areolar tissue surrounding the biliary ducts is
characterized by the highest degree of icterus and the complete dis-
coloration of the stools.

Colloid or fatty infiltration of the liver never decreases in size, causes
no icterus, and is found in scrofulous, rhachitic, or syphilitic individ-
uals, or as consequence of mercurial poisoning.

Prognosis is favorable as long as the disease is still in its first
stage. After granulation has formed throughout the organ I do not
believe that its parenchyma can be reorganized.

Therapeutic Hints, — If the disease is brought on mainly by
the abuse of spirituous liquors, especially whiskey and brandy, the first
prescription, of course, must be, " stop drinking," And, in order to
destroy the appetite for alcoholic stimulants, our second prescription
should be, " drink milk," and nothing but milk ; live on milk-diet.
After this we shall have a choice between these remedies, which are
antidotes to alcohol : Nus v., Bryon., Puis., Carbo v., Sulph,, Ars., &c.

In its second stage we must be guided entirely by the characteristic
symptoms of the individual case.

Syphilitic Inflammation of the Liver.

Like hepatitis, never attacks the whole organ at once, but only
single spots of its parenchyma. Its exudation is partly coagulable
lymph, and partly a peculiar, cheesy, grayish, whitish, or yellow mass.
In its healing process the parts cicatrize, and the cheesy mass becomes
encased, where it remains unaltered or is gradually converted into a
chalky mass. These cicatrices cause constrictions in different parts
of the liver, so that the organ exhibits the uneven appearance of



ACUTE YELLOW ATROPHY. 327

scattered nodules. The disease generally causes partial atrophy of
the liver, and, therefore, is very similar to cirrhosis. In those cases,
however, where there is colloid infiltration of the liver, the liver is
eularged. In some cases the disease does not manifest itself at all
during the lifetime. Still, where there is constitutional syphilis and
nodosity of the liver, it may be suspected. After all, the knowledge
of its character has more of an anatomic-pathological importance,
and, by a careful selection of remedies corresponding to the individual
symptoms of the case, it may be treated and cured without the
slightest suspicion of its existence.

Acute Yellow Atrophy

Consists in a rapid diminution in the size of the liver in all its diam-
•eters, especially that of its depth, in consequence of an acute degener-
ation of its parenchyma. This is infiltrated throughout with bile,
which gives to the whole a deep saffron-yellow appearance. The
surface of the livei* becomes wrinkled, and the gall-bladder shrivelled,
containing but a small quantity of thin, pale bile.

The microscope reveals the destruction of the secreting cells of the
parenchyma ; and in their places, fat-globules and decayed remnants
of those cells.

This disease is of rather rare occurrence; it has been observed,
however, after deep mental emotions ; after excesses in venere, poor
living, and also in the last months of pregnancy.

Its progress is acute and rapid, terminating in twenty-four to forty-
eight hours, sometimes in four to five days, and exceptionally in eight
to fourteen days.

It exhibits the follmoing symptoms:

1. Icterus, which is never absent, and which may make its appear-
ance some time before other urgent symptoms, and sometimes sets in
later.

2. Brain symptoms : headache, dizziness, sopor. Pupils at first are
contracted; later, dilated; features indifferent, or distorted by spas-
modic action; grating of teeth ; chewing motions of the jaws. There
are in some cases involuntary discharges of stool and urine, and in
others no discharges at all, so that the full bladder has to be emptied
by the catheter.

Instead of this stupor, there is in some cases violent agitation, de-
lirium, tremor, spasm, &c. ; whilst in still other cases such excitement
alternates with stupor.



328 LIVER.

3. Fever, more or less violent, sometimes setting in with a cliill.
In cases of jaundice it is always a suspicious symptom. The pulse is
usually frequent, but during deep sopor it becomes full and slow.

4. Gastric derangements ; they consist in nausea, vomiting — even
of bloody secretions — in consequence of erosions into the stomach ;
also bloody discharges from the bowels.

There is also more or less meteorism of the bowels.

The most characteristic symptom, however, is —

6. The rapid decrease in the size of the liver ; which may be ascer-
tained by percussion, and which is first discoverable by the tympanitic
sound over the left lobe of the liver ; which, as in cirrhosis, dwindles
away first.

Its diagnosis is in some cases very difficult, as it may easily be con-
founded with typhus. Indeed there is only one unmistakable sign :
the just-named rapid decrease in the size of the liver.

TTierapeutic Hints,

Aeon., acute, feverish icterus, especially during pregnancy.

Bell., congestion to the head; headache; dizziness; sopor; pupils
at first contracted, and afterwards dilated ; spasmodic jerkings ; grat-
ing of teeth, &c.

Bpyon., chill first and fever afterwards ; typhoid symptoms ; bitter
vomiting ; constipation.

Calc. c, chewing motion of the jaws during sleep.

Ipec, vomiting of blood, and bloody discharges from the bowels.

Leptandra, delirium; complete prostration; heat and dryness of the
skin ; coldness of the extremities ; fetid and tarry stools ; tongue



Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 33 of 65)