Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

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thickly coated, with a black streak down the centre.

Compare also Hemorrhage from the Stomach and Bowels, and also
Jaundice.

Hepai' Adiposum, Fatty Liver.

Its anatomical character consists in enlargement of the whole organ,
a smooth, glistening and transparent, tensely drawn peritoneal sur-
face ; at the same time a doughy consistency, leaving on pressure the
imprint of the finger. Its outside and inside are of a yellowish-red
or even pale-yellowish color, the whole being infiltrated by a fatty
substance, which adheres to the knife, when cutting through, if it be
sufficiently warm.

This fatty degeneration of the parenchyma cells takes place under
two distinct opposite conditions :



COLLOID LIVER. 329

1. In consequence of a defective general nutrition, whicli is attended
by general decline and marasmus.

2. In consequence of overfeeding the organism, wHcli is attended witli
fatty deposits in the subcutaneous areolar tissues, in tbe omentum,
and in different internal organs.

In tbe first place, we find the fatty liver most frequently connected
with tuberculosis of the lungs and other organs, and with cancer-
cachexia. In the second place, it becomes the property of those in-
dolent persons who eat much, and drink a glass of whiskey in order
to digest better; who sleep long, and move slowly mentally and
bodily. (The fatty liver of the goose is produced artificially on the
same principle : by poking a kind of dried noddles down her throat,
and preventing her from moving about.)

Its symptoms are not at all marked ; even its physical signs reveal
only an enlargement of the liver.

Its treatment falls, in the one case, under that of tuberculosis and
cancer-cachexia ; and in the other, it must consist in regulation of
diet and habit.

Colloid Liver, Speck Liver, Waxy Liver, Albuminous
Degeneration of the Liver, Scrofulous Liver.

Its pathological characters are the following : Considerable enlarge-
ment of the whole organ ; in extreme cases greater than in any other
liver complaint, with the exception of cancer, filling almost the whole
abdomen ; a smooth, tensely-drawn, peritoneal surface ; an elastic
consistency, which, on pressure, leaves no imprints. Its substance
is of a grayish, whitish, or reddish-gray, or yellowish color ; and, on
being cut, shows a smooth, almost homogeneous mass, which has been
compared to wax if yellowish, and to pork if of a more whitish color.
It leaves, however, scarcely any trace of fat on the knife. When
examined under the microscope this mass appears glassy, transparent,
filling the parenchyma cells, which gradually become obliterated.

This affection is the result of severe constitutional disorders alone,
such as constitutional syphilis, mercurial cachexia, long-continued in-
termittent fevers, scrofulosis, rhachitis, osteomalacia, Bright's disease,
and chronic dysentery.

Symptoms.

Increasing very slowly and without pain, the original disorder
covers all its symptoms, until it attains such a size that it can be
easily diagnosticated by percussion and palpation.



330 LIVER.

It causes no ascites, because, like fatty liver, it offers no obstruction
to the portal circulation. If ascites exists at tbe same time it is
caused by a concomitant colloid degeneration of the kidneys. Gen-
eral dropsy is the consequence of the original complaint. The feces
are almost always discolored, clayish, as in icterus, probably caused
by want of coloring substance in the very thin bile, but there is no
icterus. Our diagnosis of a colloid liver must, therefore, be based
upon the presence of a largely-increased liver, which attained slowly
that size, and without pain in connection with one of the above-named
dyscrasias.

Therapeutic hints, for obvious reasons, cannot be given.

Carcinoma Hepatis, Cancer of the Liver,

There are three different forms of cancer of the liver ;

1. The carcinoma fasciculatum^ a rare form, characterized by the
pale, yellowish-red color, its glassy, transparent mass, which is en-
veloped in a bag of fibrous tissue.

2. The alveolar cancer, the rarest of all, which is characterized by
its jelly-like substance, developing itself within the areolar tissue
around the ramifications of the portal vein.

3. The medullary or encephaloid cancer^ the most common form, is
characterized by its marrow-like substance, which is mostly of a
whitish color ; sometimes it is red from hemorrhagic effusion, and, at
other times, dark, even black, from a deposition of pigment. It ap-
pears more or less as uneven nodules of various sizes, which, for the
most part, have a hard feel ; although, in some cases, the sense of
touch may detect fluctuation. They increase more or less rapidly in
size, and sometimes undergo changes of fatty degeneration ; or, in still
rarer cases, of softening and decay, or formation of ichor.

We do not know any cause for this malignant disease. It is found
sometimes as a primary affection of the liver, but more frequently it
accompanies cancerous deposits in other organs. Its most frequent
occurrence and its most rapid development have been observed after
extirpation of cancerous growths from other organs, especially from
those of the mammaa. Persons between the ages of fifty and sixty
years are most liable to its invasion.

Symptoms.

1. Enlargement and uneven surface of the liver. Its size is some-
times enormous, reaching far over into the left hypochondrium and
far down into the abdomen; in fact, no other disease except that of



CANCER. 331

colloid liver causes such extensive enlargement of tliis organ. Its
enormous size presses out the right hypochondriac region, and its
uneven surface is then easily detected by inspection and palpation.

In such prominent cases there is no difficulty in the diagnosis.
But there are cases where those morbid nodules lie oat of the reach
of palpation, either deep in the substance of the liver, or on its
opposite surface. So is also the enlargement of the liver at the
beginning of the disease very inconsiderable ; and, in cases of few
and small cancerous deposits, attended with general anasmia and
marasmus, the liver may appear even smaller.

2. Tenderness in the region of the liver, which is almost always mani-
fest, at least on deep pressure, but it varies much in degree. A
radiating pain towards the spine and the right shoulder-blade, as in
other liver complaints, is a frequent attendant of this disease.

3. Icterus is likewise a frequent attendant of the disease, occasioned
by the pressure of the morbid mass upon the biliary ducts ; but it is
by no means an invariable one. When this sign is present, however,
the skin generally has a peculiar ash-colored, dirty-yellowish hue,
and, being dry and brittle, it peels off in minute little scales.

4. Ascites results only in those cases where the morbid mass is
suflB.ciently large, and so situated that it impedes the portal circula-
tion, by pressure upon its vessels, or it comes and grows with genei'al
dropsy.

5. Disturhed nutrition and gastric symptoms are almost always pres-
ent, and show nothing characteristic of this complaint.

6. Fever is, as a rule, quite slight, amounting at the most to febrile
motions. Where we find high fever, it is occasioned by some other
complication.

We see, then, that the diagnosis of cancer of the liver is by no
means always easy. Where the characteristic enlargement and uneven
surface of the liver has not yet been developed, (in the incipient state of
the disease,) or where it does not develop itself, (in cases of general
aneemia and marasmus, or where the diseased part occupies the poste-
rior part of the liver,) in such cases we will have to balance the
following points :

1. Can it he colloid liver ? No ; because it is not the result of syphil-
itic or mercurial cachexia, &c. See Colloid Liver.

2. Can it he fatty liver f No ; because it is not the result of tuber-
culosis or over-feeding.

3. Can it he syphilitic inflammation of the liver f No ; because there
is no constitutional syphilis present.



332 LIVEE.

4. Can it he cirrhosis ? No ; because there is no enlargement of the
spleen.

5. Can it not le nutmeg liver ? No ; because there is no heart or
lung disease for its foundation. After having thus narrowed the field
of possibilities, we now observe, in addition, swollen jugular glands,
which Virshow considers of great diagnostical importance, we ascer-
tain whether there is any cancerous formation in any other organ^ or a
hereditary tendency to it.

Further, it is among the rarest events, that cancer of the liver
coexists with tuberculosis, organic heart-diseases, typhus or acute
exanthematic fevers ; whilst, on the contrary, it is frequently found
simultaneously with Bright's disease of the kidneys, and other can-
cerous affections, especially of those within the abdominal cavity.
Finally, we consider the age of the patient. Cancer scarcely ever
happens before the thirty-fifth year of age; usually between the
years of fifty to sixty.

Therapeutic hints are rather a scarcity in this complaint. I do not
know of a well-attested case, that ever has been made known as cured.
The principal remedies promising the best alleviating results are :
Arsen., Bell., Garb, an., Con., Hydrastis, Lye, Sepia, Silic. ; and others
according to special indications.

Hydatids of the Liver, Echinococcus-cysts,

They consist of a thick, fibrous, white-glistening or yellowish sac
of a roundish shape, and of various sizes, attaining even that of a
head. This sac is lined on its inner surface by a half-transparent,
gelatinous bladder, which contains a watery, somewhat turbid fluid,
in large quantities, and at the same time a number of smaller cysts,
of the same structure, which again contain still smaller cysts, and so
on to the fourth generation. Besides this, we observe, within these
cysts and adhering to some part of their interior surface, groups of
whitish granules, which are the echinococci. Under the miscroscope
thej appear with heads which are perfectly similar to that of the
taenia solium or the common tape-worm ; having four sucking cups,
in the middle of each of them a nozzle or snout, which is encircled
by a double row of hooks. This echinococcus-cyst has been found in
any and every part of the liver, sometimes single, sometimes in great
numbers, so that the whole organ appeared to be a conglomeration of
such cysts. The parenchyma of the liver, nevertheless, retains its
integrity, and only where it is compressed by them, its cells obliterate,



HYDATIDS. 833

and that part of the liver assumes, according to Eokitansky, some-
times a nutmeg-like appearance. The cysts themselves may undergo
difi'erent changes. Its fluid content may be converted into a cheesy
substance, whereby its inmates perish.

The inner surface of the sac may become inflamed and lead to ob-
literation of the cyst, or the cyst may burst and pour its contents
either into the abdominal cavity, where it almost always causes a fatal
peritonitis, or into other organs, with which, by previous inflamma-
tion, adhesions had been formed ; exactly as in the case of an abscess
of the liver. There are cases on record, where echinococcus-cysts,
by perforating the diaphragm, emptied their contents into the pleural
cavity, from which they were discharged through the bronchial tubes,
by means of abscess formations in the lungs. There are cases also
where they were discharged through the abdominal walls, or into the
intestines, gall-bladder, or a large blood-vessel. Almost always such
perforations are followed by a fatal termination ; although, in favora-
ble cases, where, for example, the discharge takes place into the intes-
tines, or through the abdominal walls, the cysts are obliterated and a
perfect cure has followed.

The echinococcus, when found in the liver, is also frequently found
in other organs : the spleen, lungs, kidneys, and the omentum.

Their origin we do not know, although, according to the latest
researches, it seems most probable that their germs are introduced
into the alimentary canal somehow, and that these echinococci are
like the cysticerci or finnen of the pig, a form of the common tape-
worm, which only in the intestines attains its full growth. Liebold
succeeded in demonstrating this fact by feeding animals with such
echinococci, when they became transformed into tape-worms.

Symptoms.

This complaint, of all liver diseases, causes the least disturbance
in the system ; and the occasional symptoms, caused by its pressure
upon this or another organ, are of the least diagnostic value. Only
when rupture and perforation take place, we observe, as in the case
of liver abscesses, a series of violent symptoms, all which are conse-
quences of inflammation of those organs into which the perforation
or rupture takes place.

Our diagnosis is therefore confined to its physical signs alone.
These are the following :

1. A round, smooth^ elastic sioelling in the region of the liver.

2. A sense of fluctuation on percussing the part in short, abrupt



334 LIVER.

strokes, whilst the examining fingers of the other hand lie in close
neighborhood. What Piorry has called the vibratory sense of hy-
datids is nothing more nor less than the above-mentioned sense of
fluctuation ; ascites or ovarian cysts yield it just as clear, under cer-
tain conditions even clearer.

Differential Diagnosis.

Liver abscess is attended by fever, pain, and great constitutional
disturbances.

Distended gall-bladder is preceded by colicky pains, is usually ac-
companied by jaundice, and the swelling corresponds to the normal
position of the gall-bladder.

Encysted ]3leuritic exudation does not alter the place of dull percus-
sion sound on deep inspiration ; whilst the outline of the dulness on
percussion lowers considerably by deep inspiration in hydatids,

2. Diseases of the Biliary Ducts.

Catarrhal Inflammation of the Mucous Lining of the Gall-
Ducts.

Pathologically, it is characterized by the same appearance that
an inflammation of any other mucous membrane offers : redness and
swelling ; and, when it becomes chronic, livid or palish color ; thick-
ening and blennorrhoeic secretion. It is spread over smaller or
larger tracts, is usually developed, however, in the ductus chole-
dochus, where it frequently causes constriction of its outlet into the
duodenum. This is mostly a secondary process, a continuation of
catarrhal inflammation of the stomach and small intestines, and there-
fore similar in its symptoms to those affections, with the addition of —

1. Jaundice, which frequently attains to a high degree, and causes
the pulse to sink below sixty beats in a minute ; and,

2. Swelling of the liver, which is painful to external pressure.

Therapeutic Mints, — Compare Catarrh of the Stomach and In-
testines, also Jaundice.

Cholelithiasis, Formation of Gall- Stones.

Gall-stones are found mostly in the gall-bladder, now and then in
the larger biliary passages, the ductus choledochus, hepaticus and
cysticus. Their smaller ramifications contain occasionally only sand.
The size of the gall-stones varies much. There have been found some



GALL-STONES. 335

as large as a lien's egg. These are generally of a roundish or oval
shape, especially if found singly ; and more angular and serrated,
when there are many together. Their color varies from white to
black, yellow, brown, green, reddish, bluish ; generally, however, they
look brownish or blackish or greenish or variegated. Most of them
are lighter than water, they swim upon water, and their consistence
is not very great ; they are easily crushed between the fingers, and,
when dry, they crumble to pieces.

They consist of a chalky mixture with pigment mucus and chole-
stearin around a nucleus of lime and pigment. The cause of their
formation is not at all well cleared up yet. Some think it the conse-
quence of a surplus of gall-fat or cholestearin ; others lay its origin
into a surplus of calcareous substances from drinking limestone water.
. Without doubt they are caused by mechanical obstacles, which pre-
vent the free exit of gall ; and therefore they are found in all such
liver complaints as cause obstructions in the biliary passages, like in-
flammation of the gall-ducts, cancer, and the like. Also sedentary
life, disposition to fatness, seems to predispose to it.

Symptoms.

Gall-stones may lie for years in the gall-bladder without causing
any symptoms whatsoever. If, however, they become incarcerated
in the gall-ducts, then they cause the most violent symptoms, which
are known under the name of gall-stone colic.

1. It sometimes commences all at once, with an excruciating pain
in the right hypochondrium and epigastrium, radiating down to the
navel ; back towards the spine ; upwards into the chest ; to the
shoulder-blades, and in some cases even down the arms to the very
fingers' ends. The slightest touch increases the pain.

2. Vomiting soon sets in, in bad cases, with small, frequent pulse,
cold perspiration, sunken face, sunken eyes, pointed nose, cramps
in the extremities, similar to cholera.

8. Jaundice, soon after the first attack is over, continuino- as lonsr
as the stone obstructs the biliary duct ; not, however, in such cases
where the stone is incarcerated in the ductus cysticus, for the obvious
reason that it does not prevent the exit of the secreted bile from the
liver into the duodenum.

4. In nervous persons we may observe, in addition, singultus^ de-
lirium, convulsions, syncope, speechlessness. The duration of such
spells is quite different ; it may last hours, even days ; in the latter
case, however, there are intervals of comparative ease. As soon as



336 LIVER.

the stone gets out of the duct the pain ceases; and we may find the
corpus delicti afterwards in the stool.

All cases, however, do not terminate so favorably.

1. The stones may perforate either the gall-lladder or the hiliary duct ;
wherever it is encased. This causes peritonitis and usually death.
Or, in case of adhesions in consequence of previous inflammation, the
stone may find its way, like abscesses and hydatids, into the stomach
or the intestines, or through the abdominal walls. Or the stone by
obstructing the gall-ducts may cause —

2. Abscesses loithin the liver, with all their consequences, which I
have detailed under the head of hepatitis suppurativa ; or,

3. The total obstruction of the ductus hepaticus or choledochus
may cause the blood to become so overcharged with bile (choleemia)
that under the signs of the most intense icterus, sopor, delirium or
convulsions the patient dies ; or when the gall-ducts are not perfectly
closed or fistulous communications with the intestines have been formed,
the patient may linger, with the signs of deep jaundice and obstructed
biliary secretion, for a longer time.

The diagnosis is very easy, where gall-stones pass off with the stool,
or where we can feel them in the gall-bladder. Icterus is also quite
a constant symptom ; and those spells of colic are important in help-
ing to distinguish the presence of gall-stones from other complaints.

Therapeutic Mints.

Bellad. seems to be the most important remedy. Where those
Cholera symptoms supervene, Ars., Yer. Likewise Nux v., Coloc,
Oocculus, Merc, may come under consideration. Eademacher recom-
mends Carduus marianus, and others Alumen, Lye, Terebinth., and

gaU-st07ies.

3. Diseases of the Portal Vein.

Pylephlebitis, Inflammation of the Portal Vems, Coagulwn
in the Poi^tal Veins.

In consequence of inflammation the blood coagulates within the
trunk of the portal vein, or within its ramifications, over shorter or
longer tracts, sometimes throughout. Sometimes it begins in the
trunk and spreads into all its ramifications, at other times it com-
mences in the ramifications and extends towards the trunk of the
portal veins : the first, traumatic ; the latter, caused by pyasmia.

This clot of blood either loses all its fluid constituents and becomes



PYLEPHLEBITIS. 837

thick and tougli, adhering to the walls of the veins, and obliterating
them, in which case it is called adhesive inflammation ; or it is con-
verted into pus, and then is called suppurative inflammation. It is
caused either by external injuries, or by inflammation of neighboring
organs, which spreads, or by compression occasioned by stones in the
ductus choledochus, or by tumors. Its most frequent occurrence is,
however, in consequence of pyasmia, and it has been observed in new-
born children in consequence of inflammation of the navel, spread-
ing through the umbilical veins into the portal veins.

Symptoms.

The adhesive inflammation, if it produces an obliteration of the
trunk of the portal vein, causes all the signs of obstructed portal
circulation : ascites ; enlargement of the spleen ; disturbed digestion ;
vomiting ; hemorrhages from the bowels and stomach ; hemorrhoides ;
collateral circulation in form of the caput medusa, if the umbilical
veins be not obliterated, and dilatation of the external abdominal
veins. Hence it is most difficult to distinguish this complaint from
cirrhosis of the liver, unless we consider the causes of both : pyle-
phlebitis, previous external injury or inflammation of a neighboring
organ ; cirrhosis, previous abuse of spirituous liquors.

The suppurative inflammation shows all the symptoms of suppura-
tive inflammation of the liver : shaking chills, with or without fever ;
tenderness; enlargement of the liver; icterus; meteorismus ; co-exist-
ing enlargement of the spleen ; ascites. Hemorrhages from the
stomach and bowels are signs which distinguish it from hepatitis.

Therapeutic Mints. — Compare Hepatitis, Icterus.
Inflammation of the navel in new-born children : Oalc. c.



Icterus, Jaundice.

I have deferred speaking of this affection until I had finished the
description of liver complaints in detail. By this it is at once clear,
that jaundice is not a disease in itself, but only a symptom, caused
by the most dissimilar morbid conditions of the liver. What I shall
have to say about it will be more perspicuous now than if I had
commenced explaining it before we had gone through the examin-
ation of the different liver complaints.

Jaundice is, as I have said, not a disease, but only a symptom,

and consists in a yellow discoloration of the skin by the deposition

22



838 LIVER.

of the coloring constituents of bile, namely: biliary pigment, bili-
phasin, cholepyrrhin. But it is not the skin alone that is invaded
by this coloring matter : it has been found also in the hair, nails and
enamel of the teeth. The substance of the brain and nerves remains
free from it; and. on mucous membranes, which abound in blood-
vessels, it is seen only after death, or after the natural redness is
removed by pressure upon them. The yellow discoloration is first
seen on the white of the eyes ; then on the wings of the nose, and on
the lips ; then it spreads over the forehead, and so gradually all over
the body.

The so-called liver-spots (chloasmata, maculse hepaticse) have no
relation to diseases of the liver, but are partial deposits of pigment
from various causes; and in some cases they are a disease of the
skin, pityriasis versicolor, which consists in a fungus-like formation
of vegetable parasites. The yellow discoloration of icterus varies
greatly in degree, from a slight and light yellow through all shades
to a blackish and greenish-brown color.

Now the question : How does this coloring matter come into the
blood, to be deposited everywhere ? is one which has not yet been
fully solved, although men like Liebig, Lehmann, F. C. Schmidt,
Strecker, Blondlot, Bernard, Frerichs, and many more, have been at
work to solve it.

According to one opinion, the bile is, in consequence of obstruction
in the biliary ducts, reabsorbed again by the blood in the liver and thus
carried everywhere. And this is no doubt the case in different affec-
tions of the liver, where, as we have seen, jaundice follows upon such
an obstruction and leaves again, when the obstructed passages again
become free. But this view does not by any means explain all
cases of jaundice. We find icterus in a number of diseases where
anatomical examination reveals not the slightest mechanical cause of
obstruction in the liver to give rise to a reabsorption of bile into the
blood again. Such cases are : pneumonia, py£emia, puerperal fever,
intermittent fever, yellow fever, poisoning by drugs and provings of
drugs, the bite of snakes, and chloroform inhalations. In order to
comprise such cases under the above head, it has been said that it



Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 34 of 65)