Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

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is caused by a catarrhal inflammation and swelling of the mucous
membranes of the gall-ducts ; but such is not the case according to
Bamberger's numerous observations. It has also been said that it is
caused by a spasmodic contraction of those ducts ; but such cannot
be the case, as the ductus hepaticus has no muscular fibres at all ; and
the ductus cysticus and choledochus so few of them, that even the



JAUNDICE. 339

strongest galvanic current cannot contract tliera sufficiently to become
an obstacle to the passage of bile. For this reason it has been the
opinion of a number of inquiring minds that jaundice is not the con-
sequence of reahsorption of bile into the blood; but that it is the result
of a dissolution of the blood corpuscles, which contain all the constituents
of bile in preformation.

This view explains even jaundice in inflammation of the portal
veins, where the returning blood is entirely prevented by the clogged-
up state of that organ from entering the liver ; whilst there is no
obstacle to the free exit of bile out of the duct; therefore no reason-
able ground to be supposed that in this case bile were to be reab-
sorbed again. No ; on the contrary, bile is not secreted in this case ;
because the venous blood cannot enter the liver, but is carried by a
collateral circuit, without touching the liver, (therefore without get-
ting freed of its biliary constituents,) into the vena cava, and thence
into the general circulation again, where by some process or other it
rids itself of these elements and produces jaundice in all grades of
discoloration.

It seems, then, that jaundice may be produced by reabsorption as
well as by dissolution. If we review the different diseases of the
liver in regard to their being the cause of icterus, we find: 1, that
icterus is invariably present in obstruction of the larger gall-ducts and
acute yelloio atrophy ; 2, icterus is always absent in fatty liver and in
colloid liver; and, lastly, that icterus may or may not be present, in a
slight or high degree, in all the rest of liver diseases; as, nutmeg-
liver, abscesses, granulated liver, echinococcus, cancer, &c.

In addition to the yellow discoloration of the skin, jaundice may
present the following symptoms :

1. Itching of the shin, (pruritus,) sometimes confined to single local-
ities, (back, chest, extremities,) sometimes all over ; in some cases to
such a degree that it causes sleepless nights.

2. Sloioness of pulse, which sinks even to fifty or forty beats in a
minute. Acceleration of the pulse only in acute yellow atrophy, in
suppurative inflammation of the liver, and in complication with acute
diseases.

3. Yellow sight, (xanthopia;) everything white appears yellow to
the patient, yet not in all cases.

Hemeralopia, or night-blindness, in cases of granulated liver and
obstruction of the gall ducts, proved fatal. Bamberger.

4. Brain symptoms: depression, coma, sopor, tremors, paralytical



340 LIVER.

affection; or headache, dizziness, delirium, excited, wild state, con-
vulsion ; or both series in alternation.

5. Altered urine — it contains more or less of coloring gall- elements,
by which the urine receives a darker hue, from deep yellow to dark
brown. If held towards the light, its upper portion shows a light
greenish hue, and when agitated, its foam appears yellow. White
paper or linen, when dipped in, becomes yellow, and nitric acid
causes a green color, which soon changes into violet, blue, red and
orange color.

6. Altered feces of a whitish, grayish color. But only in cases of ob-
struction, where the bile is prevented from entering the duodenum.
A perfect discoloration of stools is, therefore, a sign of obstruction
in the ductus choledochus.

There are a few forms of icterus, which I have to mention espe-
cially :

The icterus neonatorum, or' jaundice of neio-horn children. It is of
frequent occurrence : generally shows itself a few days after birth ;
lasts a few days. It is met with alike frequently in strong as in weak
children. Its most probable cause is, according to Bamberger, an
accumulation of mucus within the gall-ducts, which by the smallness
of their diameters is perfectly sufficient to cause a temporary obstruc-
tion in these ducts, and consequently a short spell of jaundice, until
the forward pressing bile clears it away and sets it all right. Of much
graver meaning are those cases which develop out of an inflammation
of the umbilical vessels, and consequent py83mia. Such cases belong
to that class which is caused by nonsecretion of bile, and conse-
quently by a dissolution of the blood-corpuscles.

Very rare are those cases which are caused by anomalies of the
biliary ducts.

Jaundice of new-born children ought not to be confounded with
that slight yellowish color of the skin which, in most children, is
seen a few days after birth, and is nothing but a change of color of the
hasmatin; which, in consequence of the great hypersemia of the
skin in the first moments of life — new-born children look at first
almost always very red — becomes deposited in the skin. In such
cases there is one important symptom wanting : the yellow color of
the white of the eye.

Icterus of pregnant females happens sometimes in the last months
of pregnancy, and is mostly of no great importance, unless combined
with serious derangements of the liver, which in the individual case
must be found out.



■ JAUNDICE. 341

Icterus in consequence of violent mental emotions, especially vexations
and anger, seems to be most probably caused by a catarrhal swell-
ing of the mucous membranes within the biliary ducts, as it is almost
always accompanied by gastro-duodenal irritation, no appetite, nausea
and vomiting, and thus it seems to co-operate with the popular notion
that it is hurtful to eat soon after mental excitement, which of course
would only increase the trouble.

nierapeiitic Hints:

Aeon., pain changing about from the stomach to the liver, or to
the navel ; fever, great thirst; catarrh of small intestines; constipa-
tion or diarrhoea, sometimes in alternation- during pregnancy; in
new-born children ; after fright.

Arsen., in difterent liver affections; in consequence of intermittent
fevers ; heat, restlessness, anxiety, irritable mood alternating with
low-spiritedness.

Aurum, pain in the liver and upper part of the abdomen ; bowels
constipated ; stool grayish, ashy ; urine scanty, green, brownish ;
lower extremities, from the knees down to the feet, painful and tired.

Bellad., after the abuse of Peruvian bark or mercury; in compli-
cation with stones in the gall-bladder; hardness of the liver; conges:
tion to the head.

Berberis, spells of icterus with pale, tough alvine discharges, or
profuse acrid, watery diarrhoea ; urine dark, turbid, with copious
sediment ; morbid hunger alternating with loathing of food, or great
thirst alternating with aversion to all kinds of drink ; constant,
troublesome bloatedness of the abdomen, with occasional forcible and
noisy discharge of flatus.

Bryonia, stitching pain on pressure in the liver ; pressure in the pit
of the stomach; pain in the limbs, worse from motion; obstinate con-
stipation ; thick, white, coated tongue ; nausea ; gagging ; vomiting
after eating and drinking ; general malaise ; disinclination to move.

Calo. c, stitches in the liver during or after stooping ; cannot bear
tight clothing around the waist ; enlargement of the liver ; habitual
constipation ; grayish, whitish feces ; indigestion ; pit of the stomach
swollen out, like a saucer turned bottom up.

Carduus marianus, in complication with gall-stones; great sensi-
tiveness of the head to cold ; loss of memory and smell ; colicky pains
in the stomach, with water-brash ; vomiting.

Carbo veg., psoric taint; scorbutic and intermittent fevers; ca-
chexia; irritable, vehement disposition; loathing of meat, butter,



34:2 LIVER.

fat; constipation, or pale, whitisli stools; dark red, Lloodj-looking
urine.

Cham., after chagrin, imprudent diet, or taking cold ; in new-born
children.

Chelid., pain in the liver, which shoots into the back towards the
inner corner of the right shoulder-blade ; very irregular palpitation
of the heart.

China, gastro-duodenal catarrh, particularly after great loss of ani-
mal fluids, or after heavy illness ; dulness and muddled condition of
the head ; oppressive, tearing headache, particularly at night ; rest-
less, unrefreshing sleep ; yellow coating of the tongue ; dry lips, loss
of appetite ; loathing of meat ; loathing, and yet canine hunger ; bitter
or sour eructations and taste ; gagging ; oppression of the stomach
and chest, especially after eating ; frequent whitish stools; emission
of fetid flatulence without relief; great languor, out of humor, and
vehement.

Con., hard swelling of the liver; glandular swellings elsewhere;
the flow of urine stops suddenly, but continues again after a while ;
cough worse after lying down.

Digitalis, constant nausea and gagging, with a clear tongue covered
with white slime ; soreness and bloatedness of the pit of the stomach ;
soreness and hardness in the region of the liver ; stool delayed, chalky ;
urine scanty, thick, turbid, blackish; pulse full, slow; chilliness and
shuddering alternating with heat; tearfuhiess, low-spirited.

Gelsem., prostration ; clay-colored, creamy stools.

Hepar, especially after mercurial poisoning.

Hydrastis, gastro-duodenal catarrh ; sense of sinking and prostra-
tion at the epigastrium, with violent and continued palpitation of the
heart.

lodium, dirty, yellowish skin ; great emaciation ; downcast, irrita-
ble mood ; yellow, almost dark-brown, color of the face ; thick coat-
ing of the tongue ; much thirst ; nausea, white diarrhoeic stools alter-
nating with constipation ; dark, yellowish-green, corroding urine ;
after mercurial poisoning ; organic lesions of the liver ; dyscratic
states of the system with hectic fever.

Kali c, swelling of the liver ; pain in the right side of the chest
through to the shoulder; pressive, sprained pain in the liver ; can lie
only on the right side ; complete exhaustion ; neither thirst nor appe-
tite ; purulent sediment in the urine ; abscess of the liver.

Lach., in different liver complaints ; during the climacteric age ;
after intermittent fevers ; pain as if something had lodged in the right



JAUNDICE. 813

side, witTi stinging and sensation as if forming into a lump moving
towards the stomach ; inability to bear any thing tight around the
waist, not even the pressure of the night-jacket ; pain when coughing
as if ulcerated.

Leptandra, full, aching pain in the region of the gall-bladder ; hot,
aching pain in the liver extending to the spine ; with chilliness along
the spine ; clay-colored diarrhoea.

Lycop., chronic liver complaints ; after fright ; obstinate constipa-
tion ; incarcerated flatulence ; chronic intestinal catarrh.

Magn. mur., chronic hard swelling of the liver, with pressive pain
extending to back and stomach; face dirty, dark-yellow; tongue
dirty, yellowish ; bowels distended and hard, with pressure and
heaviness ; stool hard, gray ; urine turbid ; dyspnoea ; palpitation of
the heart; oedema of the feet up to the calves of the legs; weak,
emaciated ; fearful, easily frightened.

Merc, one of the most frequently indicated remedies, with and
without fever ; duodenal catarrh, thickly coated, flabby tongue ; show-
ing the imprints of the teeth ; bad smell from the mouth ; nausea,
loathing; vomiting j soreness in the region of the liver ; diarrhoea;
gall-stones; jaundice of new-born children; after abuse of Peruvian
bark.

IVIyrica cerifera, dragging pain in the back ; miserable feeling all
over ; dull pain in the hepatic region ; tongue thickly coated of a
dirty white or yellowish color ; no appetite, loathing of food, strong
desire for acids; sleeplessness, unrefreshing sleep.

Nitr. ac, in consequence of chronic derangements of the liver;
costiveness ; great tearing pain in the rectum, continuing a long time
alter stool, even more intense after a loose stool.

Mux vom., gastro-duodenal catarrh ; after allopathic dosing ; over-
loaded stomach ; use of coffee, liquor, sedentary life ; anger. In com-
plication with gall-stones. Headache, dizziness, loss of appetite, bit-
ter taste; nausea, vomiting, gagging; pressure in the stomach, better
from belching, soreness of pit, stomach and bowels; unsuccessful
urging to stool, constipation. Itching of the skin in the evening ;
restless sleep ; wakes about three or four o'clock in the morning and
falls again into a heavy, unrefreshing morning sleep ; peevish, irritable.

Phos., in complication with pneumonia or deep-seated brain dis-
eases. Atrophy of the liver ; during pregnancy, with dry cough and
involuntary discharge of urine.

Podoph., in complication with gall-stone ; then the pain extends
from the region of the stomach towards the region of the gall-bladder,



344: - SPLEEN.

and when at its height is mostly attended with excessive nausea ; or
in complication with inflammatory or hyperjemic states of the liver ;
then there is a fulness, with pain and soreness, in the right hypochon-
drium ; chronic costiveness or alternate constipation and diarrhoea.

Pulsat., in consequence of chronic susceptibility to hepatitis and
derangement of the secretion of bile, with looseness of the bowels;
duodenal catarrh ; disordered digestion ; feverishness and thirstless-
ness ; after quinine.

Rheum, in consequence of eating unripe fruit, and accompanied
with white diarrhoea.

Sepia, with pain confined to the liver ; yellow saddle across the
bridge of the nose ; brown, yellowish color of the eyelids.

Silic, hardness and swelling of the region of the liver; throbbing,
ulcerative pain in the right hypochondrium, increased by contact and
walking.

Sulphur, in psoric persons, with or without hardness and swelling
of the liver ; vomiting of ingesta or blood ; pain in the pit of the
stomach and right hypochondrium ; abdomen bloated ; stool consti-
pated ; sleeplessness ; nightly itching of the skin ; hectic fever ; red
lips.

According to Hartman compare, if icterus be caused by chagrin,
anger: Aeon., Bry., Cham., China, Ign., Nux v., Natr. m.. Sulphur.

By taking cold in consequence of sudden changes of temperature: Dulc,
Nux v., Cham.

By impro'per food and overloading the stomach: Puis., Ant. cr., Bry.,
Carbo veg., Cham., Natr. c, Nux v.

By the abuse of chamomile tea: Ign., Nux v.. Puis., China.

By the abuse of mercury : China, Hepar, Sulph., Nitr. ac, Asa foet.,
lod., Ars.

By the abuse of Peruvian barh : Puis., Ars., Merc, Ipec.

If being attended with much flatulence^ according to Boenning-
hausen : Carbo veg., Cham., Chin., Ignat., Lye, Nux v., Plumb.

E. Diseases of the Spleen.

Physical examination. When of normal size — which in an adult
is as follows: length, four to five inches ; breadth, three to four inches;
thickness, one to one and a half inches — the spleen yields on percus-
sion a dull sound, bounded as follows : posteriorly by the body of the
eleventh dorsal vertebra ; in front by a vertical line drawn from the
anterior border of the axilla to the free end of the eleventh rib ; supe-



GENEEAL EEMAEKS. ' 8 45

riorly by tlie nint'k rib ; and inferiorily by the free end of the eleventh
rib. In order to obtain a clear result by percussion, the patient oaght
to be placed upon his right side. It must likewise be considered,
whether the stomach be not filled at the time of percussion. In cases
of accumulation of fluids in the left thoracic cavity, either pleuritic
or pericardial, in accumulation of gas, abdominal or thoracic, in
tumors of neighboring organs, the liver, omentum, kidney, it may
sometimes be next to impossible to define the size and position of
the spleen.

A considerably-enlarged spleen, however, under ordinary circum-
stances is easily detected by percussion. And it is sometimes enor-
mously enlarged and displaced, reaching inferiorly to the os pubis,
and anteriorly to the median line of the abdomen; in some cases
even filling almost the whole abdominal cavity.

In such cases it is also accessible to palpation. Even a moderate
enlargement may be felt, if it extend below the eleventh rib. Its
surface, except when invaded by cancer, is always smooth ; and its
form oval and sometimes wedge-shaped. Its rounded apex, and the
notch which corresponds to the middle line of the spleen, and which
becomes the more marked the larger the spleen grows, are character-
istic signs by which to distinguish it from any other abdominal
tumor. Notwithstanding great and laborious experiments, we know
as yet but little concerning the functions of this organ. Only so
much seems to be certain, that it bears an important relation to the
formation of white blood-corjouscles, although we do not know yet
how and in what manner. And this seems to be corroborated by the
fact, that diseases of the blood always affect the spleen, altering it in
size and consistence and, vice versa, that lasting diseases of the spleen
lead to a diseased state of the blood, causing anemia, leukasmia,
hydrops, scurvy.

Cases in which such a connection does not seem to exist prove,
perhaps, only that the function of the spleen may under certain cir-
cumstances be performed by some other organ or organs instead.

Anatomieal Peculiarities of the Spleen.

It consists of a much softer and looser texture than any other
glandular organ of the body ; its areolar framework is made up of
the elastic tunic which forms sheaths for the vessels in their ramifi-
cations through the organ, which again are loosely connected by
small fibrous bands, issuing in all directions from said sheaths. In
this way a multitude of interstices is formed, which contain a soft,



3-16 SPLEEisr.

granular substance. This peculiarly loose construction makes the
organ pre-eminently fit for the reception of large quantities of blood ;
and the more so as its capsule is also of a lax nature, offering little
resistance to extension ; so that, on the other hand, if once over-dis-
tended, it regains its previous normal state very slowly ; and this on
account of the inelasticity of its tissue. The veins of the spleen con-
stitute, by their numerous dilatations, the principal part of its bulk ;
they pour their blood, after uniting with the veins in the stomach, and
other less important vessels, into the portal vein.

The whole organ is held loosely in its position by a duplicature of
the peritoneum.

The knowledge of these anatomical peculiarities of the spleen at
once explains its participation in various abdominal and pectoral affec-
tions. All hepatic troubles, and all diseases of the heart and lungs
which obstruct the portal circulation, must necessarily retard or pre-
vent the normal egress of blood from the spleen, and cause it to swell;
a stagnation of blood in the splenic vein must cause a like stagna-
tion in the veins from the stomach, and thus bring on vomiting of
blood, and its loose connection explains at once the possibility of its
sinking quite low down into the abdominal cavity under certain cir-
cumstances.

The Hemorrhagic infarct and Splenitis, Lienltis or Inflam-
mation of the Spleen.

The hemorrhagic infarct is of much more frequent occurrence
in this organ than in any other. It consists in the blocking-up of
the smaller splenic arteries by fibrinous coagula, which have formed
in the left ventricle of the heart in consequence of endocarditis, and
which have been washed away by the stream of blood, and carried
through the splenic arteries into its smaller branches, where they
stick fast. This is of such frequent occurrence that it is very rare not
to find hemorrhagic infarcts in the spleen, in all cases where post-
mortem examination reveals valvular destruction to any considerable
degree ; much more rarely, such emboli come from gangrenous places
of the lungs. In such cases they have to pass through the pulmonary
veins, the left ventricle, aorta and splenic artery. Hemorrhagic in-
farcts form also in consequence of malaria infections, typhus, septi-
caemia, and acute exanthematic fevers ; in these cases, it seems, by
a stagnation of circulation within the splenic veins. These hemor-
rhagic coagula are usually situated at the periphery of the spleen,



SPLENITIS. 847

and are roundisli or wedge-sliaped, their broad base being nearest to
the periphery, whilst their apices point toward the interior.

They appear at first of darker color and harder than the surround-
ing tissue, which appears perfectly sound. By-and-by, however, they
become discolored and changed into a yellow, firm, homogeneous mass,
which during the further progress of the disease may undergo several
changes. It may shrink and leave a cicatrix ; or suppurate and form
abscesses of the spleen ; which, if they are many, may transform the
whole spleen into a mass of corruption.

These abscesses again may go on to different terminations. They
may, by fibrous exudation, become encysted ; or they may cause
pygemia; or they may burst and discharge their contents, like ab-
scesses of the liver, into the peritoneal sac ; or when adhesions may
have been formed with neighboring organs, they may, by perforation,
discharge their contents into the stomach, colon, or the pleural cavity.

A primary inflammation of the spleen is a very rare occurrence ;
even external injuries, a blow, a fall, a wound, are apt to cause a
rupture, rather than an inflammation.

Symptoms. — They are frequently quite occult, and of an uncertain
character ; still a careful consideration of the following conditions
may, in most cases, lead us to a right decision.

1. Enlargement of the spleen^ especially if it be associated with en-
docarditis, it never reaches more than double its normal size ; whilst
in many cases it is so insignificant that it cannot be discovered by
percussion.

2. Pain in the region of the spleen. It originates not in the sub-
stance of the spleen itselfj but in its enveloping membrane or in the
neighboring organs, and is therefore sometimes entirely wanting.
When it does exist, it is of a dull character, and is increased by
deep inspirations, different motions of the body, and percussion. A
sharp pain denotes rather an inflammation of its peritoneal cover-
ing. A radiating pain into the left shoulder is likewise sometimes
observed.

3. Fever, and, when suppuration takes place, shaJcing chills.

4. Gastric symptoms, and, in cases of long standing, scurvy, hydrops,

5. Peritonitis^ in case of rupture or perforation, A number of
symptoms, which we find summed up under the head of Splenitis in
the works of older writers, do not belong to real splenitis, as described
above, but belong to such affections of the spleen as now-a-days are
defined as acute and chronic swelling, hypertrophy, hardening or
softening of this organ. Such are, anxiety, dyspnoea, cough, nausea,



348 SPLEEN.

vomiting, vomiting of blood, darkness before the eyes, dizziness, and
so on.

Therapeutic mnts, — Compare sucli remedies as are pointed
out under the heads of those diseases which are either the causes or
complications of splenitis, as endocarditis, valvular derangements of
the heart, &c.

Acute Tumor, or Hyperemia of the Spleen.

This consists of a more or less copious accumulation of blood
within the gland, by which its volume may become enlarged to five
or six times its normal size. The color of its tissue varies from red
to brown or violet ; and in case of a longer duration it changes to a
dirty gray or slate color. There are no other pathological changes
present.

This acute swelling of the spleen is an almost constant attendant
upon typhus, intermittent, remittent, yellow and puerperal fevers;
likewise upon cholera in its stage of reaction; and of a number of
other complaints, by which a stagnation in the portal circulation
causes stagnation of blood in the spleen. We find it likewise attend-
ing anomalies of menstruation. It is therefore always of a secondary
nature, and its symptoms must vary accordingly. Symptoms, which
belong exclusively to it, are —

1. The conspicuous enlargement ; which can easily be discovered
by percussion and palpation.

2. A rather dull pain in the region of the spleen, which is gen-
erally increased by motion, pressure, deep breathing, and lying on
the left side.

All other symptoms belong to the primary disease which causes
it ; for therapeutic hints compare these diseases.

Hypersemia of the spleen leaves with the primary disease ; in some
cases, however, it assumes a permanent form ; and thus originates —



Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 35 of 65)