No.1342.

MAY 19, 1849.

LecturesON

CLINICAL MEDICINE,Delivered at University College Hospital,

BY W. H. WALSHE, M.D.,PROFESSOR OF CLINICAL MEDICINE AT UNIVERSITY COLLEGE, LONDON;PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL, CONSULTING PHYSICIANTO THE HOSPITAL FOR CONSUMPTION, ETC.

(Reported by WILLIAM TIDMAS, ESQ., late Physician’s Assistantat University College Hospital.)

LECTURE XIV.

A woman, aged forty, after severe and continued privation, growsgradually weaker and weaker, and is seized, Christmas, 1847,with pain in the right hypochondrium, which becomes acute in thefollowing February. Admitted on eighth day of this; diagnosis,sub-acute hepatitis; reasons for this opinion; characters, value,and presumed mechanism of " hepatic compression-rhonchus;"progress of abscess-formation in liver; marked deficiency ofurea; causes of the disease; state of the urine during four dif-ferent periods; albuminuria (temporary) with corpuscles, howexplicable; question of absorption and elimination by the kid-neys of pus in substance glanced at; treatment; possibility ofproducing salivation in suppurative hepatitis; evacuation ofthirty ounces of pus by trocar; adhesions in peritonœum provedto exist by peritonœal friction-sound; complete recovery.

ANN FAIRBANK, aged forty, admitted March 4th; 1848, ofmiddle stature; skin generally of dusky hue; complexionsallow; a needlewoman; never suffered from want till lastChristmas. Catamenia appeared at the age of twelve; agednineteen, married, had two children; aged thirty-two re-

married, no children. Father died of stone (?); mother ofdropsy; one sister of a diseased knee.Previous diseases.—Has had continued fever twice, at the

ages of ten and fifteen years; since the age of fourteen hassuffered from cephalalgia; after her first delivery had metritis;on death of first husband complained much of palpitation,also pain in right side, accompanied with cough; a puncturewas made about the fourth intercostal space, behind themamma, (where a minute scar is visible,) when a large quantity of greenish-yellow fluid escaped; the wound dischargedabout half-a-pint daily for three weeks, after which she gotwell. After separation from her second husband (owing tohis insanity) she had a similar attack, as regards her ownfeelings, but no opening was made in the side. During firstpregnancy had haemorrhoids, which have bled frequentlysince; never had jaundice. Last summer had several attacksof diarrhoea, and cough of five or six days’ duration, duringwhich ate nothing, and drank water.Present Attack.-Last Christmas pain in right side; deficient

nourishment, and frequent exposure to cold and damp, fromeffects of which she has never recovered. On February the26th, was forced by weakness to remain in bed; on the follow-ing morning, acute pain over region of liver, rigors, heat, andthirst; total anorexia; bowels constipated; nausea, no vomit-ing. On March the 1st took some castor oil, which openedthe bowels.March 4th.—Present state: Skin faintly but distinctly yellow-

ish, of medium heat; conjunctivse natural; thirst, headach,and nausea; bowels confined; disgust for food; pulse 120,respiration 28; respiration audible to very base of right chest,but very weak inferiorly, where resonance under percussionless than natural; no rhonchus, asgophony, or friction; nosputa; liver-dulness begins about two fingers’ breadth belownipple, and extends slightly below false ribs; pain in righthypochondrium, which is tense and tender. To be cuppedover hepatic region to six ounces; at bedtime to take four

grains of calomel, and the next morning, one ounce and ahalf of house medicine; also the following draught thrice daily:- Nitrate of potash, five grains; extract of taraxacum, fourgrains; infusion of taraxacum, one ounce. Mix.6th.-Pain very much relieved, only troublesome on

motion; bowels fully relieved, motions dark, soft, excessivelyfoetid; headach considerable; much thirst; no appetite; pulse104, small and compressible ; respiration 24; skin hot, notacrid; perspired slightly last night; expectoration flaky; fullinspiration produces pain in right hypochondrium. To-day a ’’

slight prominence appears below false ribs, solid, resistant,nodulated, size of half-a-crown, tender to touch, not separablefrom liver, unconnected with the abdominal walls, which are

unaltered in colour and pliability, otherwise the abdomen isnatural. Great irritability of recti muscles; respiration lostabout sixth intercostal right side, and becomes null, turninground to infra-axillary region, except in full inspiration; nearspine it is distinct, at left base exaggerated; at end of first fullinspiration only (right base behind) there is audible an exces-sively fine, dry, prolonged, slowly evolved crackling rhonchus(compression species) absent in expiration; dulness right basedistinct, with much resistance; vocal fremitus more markedat left than right base; noaegophony. Eight leeches to hypo-chondrium ; to omit the mixture, and to take the followingpill every three hours :-Mercury with chalk, two grains;opium, one-sixth of a grain.8th.-Pain much relieved by leeches; tongue covered with

brown fur; complains of flatulence; is still unable to bearpressure; pulse 128; respiration 28; skin very hot. Intumes-cence below right false ribs more distinct to-day than hitherto;nodular fulness distinct in point already mentioned, extendsto within two fingers’ breadth of umbilicus; is dull on percus-

sion, and continuous with liver, the dulness of both togethermeasures seven inches and a half vertically; the liver bordercan be felt inferiorly a little below the fulness; great tender-ness over liver, none in iliac fossa; splenic dulness not higherthan usual; respiration fuller at left than right base; norhonchus at either. Ten leeches to right hypochondrium.9th.-Much the same; bowels confined. To have a simple

enema, with half an ounce of assafætida mixture, and one dropof cajeput oil. At bedtime, owing to insomnia, extract of let-tuce, five grains.

1 Oth.- Lies on back; knees raised; suffering great; abdomengreatly distended with flatus; tenderness on pressure round to.flank; pain from shoulder to hip; the dulness from mammadown diminishes along the abdomen, gradually becomingmixed with deep-seated intestinal note; the dulness extendsa shade above the middle point of nipple. Respiration audiblequite at base without rhonchus or friction; pulse 116; respira-tion 28; bowels open yesterday, motions very dark and offen-sive ; no sickness. Eight leeches to side.

11th.—Lies on back; easier; skin clear; slept about fivehours; pulse 106; mucous membrane of mouth and faucessore, dull-red and thickened; voice slightly hoarse; breathfoul; no thirst; no sickness; total anorexia; no motion butfrom enema. Right flank rather less full than yesterday; thelocal intumescence now extends inferiorly to level of umbilicus;the surface is irregular, without nodulation; skin over righthypochondrium not hotter than left; cough at night; expec-toration greyish, watery, mucous, and aerated ; dulness at rightposterior base does not rise quite so high as a few days ago;no sweats nor rigors; splenic dulness rather below than aboveaverage dimensions. No piles; leucorrhosa.; no palpitation,although heart is pushed upwards to left; heart sounds dullwithout murmur. Ten leeches to side; continue the pills;also, at bedtime, extract of lettuce, four grains; blue pill, fivegrains.

12th.-Liver dulness measures vertically eight inches andthree-quarters, commencing half an inch below mid-nipple; ten-dernessunchanged; the outline of the dulness,caused by the liverand intumescence, curves abruptly upwards and inwards nearthe middle line, thus, (see diagram,) so that there is a differ-

The vertical dotted line shows the height of the liver dul-ness; the transverse, the inferior outline of the dulness.

ence of three inches in the height of the dulness on the ver-tical level of nipple and at the middle line; in the latter pointthe dulness does not extend more than two inches below theensiform cartilage; pulse 112.

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13th.-Cheeks much flushed; gums tender; tongue moist,thick, brown fur; pulse 108; mouth and throat dry; faucesdirty reddish; one motion; fseces moulded, speckled, clayey,and dark; nitric acid added to them produces great efferves-cence, but no green colour; inferior border of liver reaches towithin two fingers’ breadth of anterior superior spine of ilium;abdomen less flatulent, its circumference = twenty-nine inchesand three-eighths, (three inches and a quarter above middleof umbilicus;) upper part of lumbar region full, not resistantnor tender. Omit the pill; effervescing medicine.

15th.-Liver reaches to within one inch and a half of theanterior-superior spine of the ilium; the parietes can be raisedup at the prominence as completely and as readily as on theopposite side; over the prominence there is strong rubbingfriction-sound on full inspiration; dulness at right posteriorbase of chest extends downwards into the renal region; abovecrista ilii, posteriorly and laterally, intestinal percussion note;mouth is under the influence of mercury; three spontaneousmotions. Blisters, three inches by three, to right side.17th.-Complains of heat and pain in micturition; pulse 96,

respiration 21.18tli.-Rigors in night; insomnia; face is now anxious, and

of dusky yellow hue; vomited this morning nearly a pint ofreddish fluid, (thrown away;) imperfect fluctuation at intu-mescence ; bowels open; line of dulness lowered by nearlytwo inches; transversely, it seems to have retreated some-what, so as to narrow the width of the dulness; pulse 136;respiration 26. Saline diaphoretic in camphor mixture.

20th.-Fluctuation less distinct. -

21st.-Surface of liver feels irregularly nodulated.22nd.-Vomited greenish-yellow matter; features drawn ;

general distress; pain in back of right flank and thigh; a newpointing place is appearing at the lower part laterally; frictioncontinues over centre of fulness; line of dulness rises a littleabove nipple.

24th.-Sickness has ceased; prostration increases; promi-nence more distinctly limited in front, and tense; fluctuationindistinct; considerable pain in left back; tension in lumbarregion posteriorly is much more marked. Two ounces of portwine.27th.-Fluctuation now perfectly well marked; passed a

good night.29th.—Prominence in front still more marked, and is nearer

the median line; border of liver as distinct as before; fluctua-tion still more distinct; no blush on surface; parietes over pro-minence do not appear attenuated; bears pressure well.30th.-Exhaustion; bowels confined; insomnia; cough; Mr.

Quain was requested to pass an exploring needle into the in-tumescence ; pus followed, and immediately thirty-threeounces of laudable pus (the last few ounces tinged with floridblood) were drawn off by trocar and canula; thickness of ab-dominal wall passed by trocar on the way to abscess, three-quarters of an inch; on the removal of the canula, the openingwas closed with lint and adhesive plaster; a bandage was thenpassed round the abdomen. The contents of the abscess were,liquor puris, pus corpuscles, compound granule-corpuscles,molecular matter and fat; no shreddy substance; no biliphsein;no cholesterin. [After the operation, bowels acted; faintness,relieved by wine and ammonia.]

31st.-Looks better; dulness in abscess region, only reachesone inch and a quarter below umbilicus to-day, no separationcan be traced by finger between it and the liver border; theparts about here are tender; pulse 116, small; flatus abundant,no peritonreal friction; liver dulness in front and above hasfallen a little below the nipple; behind = six inches in height;cough; sub-crepitant, and sub-mucous rhonchus at both bases.Six leeches to tender point; effervescing medicine.

April 3rd.-Liver surface flat; dulness has risen a little aboveumbilicus; pulse 116.5th.-Says feels quite well, but for weakness; pulse 84

(unless when excited); the right and left flanks do not lookmaterially different in shape now; tenderness gone; hepaticcompression-rhonchus gone; dryish crackling rhonchus at bothbases.

7th.-Entire hepatic region flatter and less tense thanever.

12th.-Strength increases; total height of liver dulness, sixinches and three quarters; inferiorily it reaches level of um-bilicus, but the lower inch of this dulness is imperfect; coughcontinues.14th.-The vertical line of dulness towards middle line has

drawn in somewhat; otherwise same; liquid, fine bronchiticrhonchi at bases.19th.-Dull percussion sound continues in site of abscess,

and as before is not separable from dulness of liver.

24th.-Feels quite well; line of liver-dulness and resistanceabout three fingers breadth above umbilicus; liver dulnessreaches to nipple, superiorly imperfect; the edge of rightfalse ribs visible now, not seen before; absolute liver dulnessceases at the costal border, below this it is mixed withi ntes-tinal note. Dilute sulphuric acid, six minims; infusion of rosesone ounce; twice daily.

26th.-Dulness only one finger’s breadth below false ribs;posteriorly, only reaches three fingers’ breadth below inferiorangle of right scapula; peculiar "hepatic compression-rhon’chus" audible again. Fish and chop on alternate days.May lst.-Pain and tenderness in right iliac fossa. Four

leeches there; simple enema.5th.-Iliac tenderness, which was immediately reduced by

leeches, now completely gone.] 9th.-Right costal angle more obtuse than left; costal line

equally marked both sides; slight dulness begins a finger’sbreadth below nipple; total height, six inches and a quarter,which is perfect one inch and a half below false ribs; vocalfremitus absolutely lost at upper line of dulness.

23rd.-Discharged, cured; flesh, looks, strength, and spirits,good; and skin almost completely free from dusky tint.Cornmentar.- ]. There were three separate periods at

which the diagnosis of the case we have just heard requiredto be examined. First, on the patient’s admission; secondly,when local intumescence became obvious; thirdly, just beforeand after the fact of the existence of abscess was proved bythe evacuation of pus.

(a.) The patient on admission obviously laboured under aninflammatory affection, seated at the confines of the right hypo-chondrium, and base of the chest-an affection which hadreached the eighth day of its progress, symptomically con-sidered. What was its nature ? The slight dulness at theposterior base of the chest suggested the idea of limitedpneumonia; but the absence of crepitant rhonchus, or of anyform of bronchial or blowing respiration, the deficiency ofcharacteristic sputa, and the natural state of the pulse-re-spiration ratio, (4.3 : 1,) were positive and negative conditions,proving that pneumonia was not present. Neither could werefer the patient’s sufferings to pleurisy. It is true, that slightdulness under percussion, weakness of respiration, and com-parative deficiency of vocal fremitus, at the extreme rightbase, might, on first thought, seem characters sufficiently dis-tinctive of that disease. But the dulness was not verymarked, and the failure of fremitus otherwise explicable;there was no friction-sound audible, the pulse-respiration ratiowas natural, and abrupt inspiration did not excite sufficientlysharp pain.Of inflammation of the diaphragm I know nothing apart

from that of the pleura investing it; and even concerning thislatter form of the disease, as a special affection, information issufficiently limited. The easy condition of the patient’s reospiration, the absence of hiccup and of any very great generaldistress, coupled with the deficiency of some of the pleuritic

signs already referred to, appeared to justify the exclusion ofthis rare affection. I have never heard of rheumatism of thediaphragm unless preceded or accompanied with rheumatismelsewhere; now, our patient had no articular or other rheu-matic suffering.

Peritonitis had scarcely any claims to consideration here.The tenderness under pressure was not sufficiently marked,and idiopathic peritonitis would scarcely have remained solimited (as this must have been) on the eighth day of seizure;while, on the other hand, the supposition that the case wasone of circumscribed inflammation of the hepatic peritonseum.seemed scarcely reconcilable with the well-marked generalreaction present. Post-mortem examinations, in truth, suf.ficiently prove that patches of solid pseudo-membrane on thesurface of the liver, bands of adhesion and circumscribedagglutinations may be found in persons who have not ex-

perienced during life any more severe symptoms than passing"stitch," or a feeling of weight and traction in the side.The pain was not, in seat or character, precisely that felt

in acute duodenitis, and the bowels were constipated. It ap-peared to me, too, to be excessively probable, that if duodenitisexisted of sufficient severity to cause the general reactionpresent, thickening of the orifice of the ductus communis, andeven extension of the inflammation upwards into that duct,must have ensued. Now, had this ensued, jaundice must havefollowed, whereas Fairbank was not jaundiced. Besides,numerous conditions inexplicable on the idea of duodenitis(and which will, by and by, be passed in review) were observed;without conceiving myself in a position, therefore, absolutelyto deny all participation of the duodenum in the acute diseasepresent, I looked in another quarter for the main affectiou.

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The seat of suffering lay high above that observed in casesof ileo-typhlitis; neither were any of the special intestinal- symptoms, belonging to that affection, present. The patient’s.pain and tenderness might have been referred, in respect of

apparent’seat, to the right angle of the colon; but had inflam-.mation existed here, it must, in accordance with experience,’have, by the eighth day, spread along the bowel,-now there

’ were neither pain nor tenderness in the course of the trans-verse or descending colon. The character of the pain, too,spoke against its intestinal origin; scarcely spontaneous, it

required movement of the trunk, or the action of respiration,for its production, and was neither sharp nor griping. Besides,- the bowels were confined, and there was no vomiting. ’

Did the patient suffer from simple inflammation of thecellular membrane of the abdominal walls ? 1 The evidencebore distinctly against this view. The integuments were un- ’altered, they were neither thickened, infiltrated, nor doughy, ’,-nor was the colour of the skin affected. They could be raisedup with the fingers as readily and completely as at the corre-sponding place on the opposite side. The pain would, in allreasonable probability, have been greater, and more especially

I

the tenderness under pressure more marked, had cellular in-flammation been present. Further reasons will appear, as weadvance, for rejecting the idea of such inflammation, whetherseated superficially or deeply in the parietes.

Rare though true hepatitis be in this country, little doubt,it seemed to me, could be entertained of its existence in thiscase. The seat of pain corresponded precisely to the liver-Tegion; it was of medium acuteness, moderately increased bypressure, and (in the course of the case) radiated towards theshoulder, as (though not with the frequency taught by sys-tematic writers) the pain of hepatitis occasionally does. Thebowels were and had been constipated; the skin was not jaun-diced, but presented a dingy, yellowish tint, not unusual in,persons who, having suffered from a subacute and chroniccondition of hepatitis, are seized with the malady in anactually acute form. The percussion-signs gave evidence ofslight enlargement of the organ; and by auscultation I dis-covered a particular sign, to which I have learned, since I first-observed it, to attach no slight importance, as an evidence ofincreased bulk of the liver. I refer to the sign which I call4’ hepatic compression-1-hol1C!tUS," a rhonchal sound possessingvery peculiar, and, indeed, distinctive characters. I have

repeatedly drawn your attention to the existence of this soundin persons having enlarged livers, and you have, with me, been- able, on attentive examination, to satisfy yourselves that itpossesses the following characters:-It co-exists with inspira-tion only, or, indeed, seems to be rather superadded to thesound of inspiration, than to co-exist with it, not commencinguntil the inspiration-murmur appears almost at an end. It isbrought out in a peculiarly slow, drawling, and (if I may beallowed the expression) lazymannerits mode of evolution beingin this respect the exact reverse of that of the crepitant rhonchusof pneumonia. It consists of a variable (but commonly a great)number of excessively fine, dry crepiti, rather superficial thandeep-seated; is rendered audible by forced inspiration only,and may be heard in front, at the side, and in the back of theright half of the chest, (least commonly in front, however,)at, or near to, the upper edge of the liver. Its existence iscompletely independent of any affection of the lung itself;and I have never found it on the left side, in these cases ofliver-enlargement. The characters of this rhonchal sound areso peculiar, that a mere tyro in the art of auscultation wouldbe able to distinguish it from all other varieties of rhonchus,-it differs essentially, as the description I have just givenproves, from crepitant, sub-crepitant, and dry, crackling, pul-monary rhonchi, and from pleural rhonchus. Of its mechanismI am not prepared, at present, to offer any demonstration; buttaking into consideration all its characters, it appears to meto be most feasibly explicable as follows:-The lower portionsof the lung, pressed upon by the enlarged liver, undergo asort of creasing, or condensation, which, in ordinary breathing,interferes with their expansion. By forced inspiration, theportion of lung implicated will readily be understood to beuncreased, and so conceivably a series of sounds, such as Ihave described, is drawingly produced. Another fact in thehistory of this rhonchus strongly corroborates this hypothesisof its mechanism-namely, that it often ceases to be audible,for a time, after from one to some five or six forced inspira-tions ; the lung seems to require rest and time to be againcreased up. Should further experience give the stamp of de-- monstration to this view of its mode of production, we shallhave collateral support given to the doctrine I have long,taught, (and which, so far as I know, has not been refuted,)that the crepitant rhonchus of pneumonia is formed, not in i

the air-cells or capillary bronchi, but in the pulmonary pa-renchyma itself. I am not able, as yet, to make any positiveassertion concerning the frequency with which the rhonchusunder consideration attends on enlargement of the liver; but,on the other hand, I am in a position to affirm, that in nosingle case of notable increase of bulk of that organ whichhas fallen under my observation, since my first discovery ofthe rhonchus, have I failed to substantiate its existence. Thesound may, it is true, escape detection on one or more occa-sions, but has never been absent for a series of days. On theother hand, I have not met with it in other conditions ofdisease; though doubtless, if my theory concerning its forma-tion be well founded, it will probably be ascertained to accom-pany a variety of conditions, causing slight compression ofthe lung.The discovery of this " hepatic compression-rhonchus" in.

Fairbank gave material aid to the diagnosis of liver-enlarge-ment from hepatitis; in itself it of course told nothing asto the acute or chronic nature of the enlargement; forelucidation of that point we were obliged to turn to conco-mitant conditions. But this rhonchus helped us in the ex-clusion of duodenitis, and of deep-seated inflammation of theabdominal walls,-the affections which, on the day of thepatient’s admission, it was least easy, on other grounds, toset aside. The condition of the woman’s health, previousto her acute attack, gave further warranty to the diagnosis;and the chest-symptoms observed were precisely such as ex-perience connects with hepatitis. I did not attach importanceto the irritability of the recti muscles, as this peculiar statehas appeared to me to accompany all painful affections local-ized in their vicinity.

(b.) On the second day of the patient’s stay with us, anintumescence appeared below the false ribs, not separable, bymanipulation or by percussion,from the liver,and not connected,as far as could be ascertained by careful examination, withthe abdominal parietes. Its position, and, in some degree,its shape, suggested the idea of a distended gall-bladder pro-truding beyond the edge of the liver. Had the case, then,been from the first one of cholecystitis, (a disease, both in itsacute and chronic form not so uncommon as is supposed,)which had entailed distention of the sac with altered bile?The situation of the pain felt by the patient, the degree oftenderness, and the constipation, were all circumstances notunaccordant with this idea; but I rejected it, because (settingaside the question of fluctuation) it appeared to me that a dis-tended gall-bladder would not have offered the solid resistanceand nodulated feel which this circumscribed swelling actually "did.The facts, that the intumescence could not be separated

from the liver, and that the mass of the organ generally wasundergoing obvious enlargement, taken in conjunction withthe previous course of events, led me to infer that the sourceof enlargement was in the liver itself.

(c.) Henceforth, this circumscribed enlargement continuedto increase, and the narratives of our daily observations uponits characters, show that it throughout maintained its appear-ances of hepatic seat, and inflammatory origin. That an ab-scess of the liver existed here, had appeared to me to admitof scarcely a doubt for some days before fluctuation becameperceptible; on the day we discovered imperfect fluctuation,(the twenty-second of the attack,) the evidence in favour ofthis view of the case was placed before you at the bed-side, asfollows :-Starting from the sub-acute hepatitis, (held, for pre-viously explained reasons, to have existed,) nothing is moreeasily conceivable than the sequence of abscess. The symp-toms agree with this notion: rigors, sweats, local pain radiatingto the shoulder, constipation followed by tarry and clayeystools. But how speak the physical signs ? Why, rememberthat the swelling, which eventually became so great, couldnever be separated from the liver, and that when the fulnessextended down-to the close vicinity of the crista of the ileum,(see diagram,) its lower edge still retained the characters ofthe border of the liver. If it occur to you to raise the ob-jection that a deep-seated infiltration of pus in the abdo-minal walls might have stimulated at its inferior edge the freeborder of the liver, I reply :-(1.) Admitting for the momentthat such was the case, we had a fair right to expect superiorly,also, a condition of the outline of the abscess simulating thefree border of a liver; now there was nothing of the kind.(2.) On the supposition you start, the enlargement of theliver upwards is utterly inexplicable; and still more fatal toyour hypothesis is the displacement of the heart upwards, andto the left, (vide report, March 11.) (3.) The hepatic compres-sion-rhonchus" also, is thus incapable of explanation. Nowall these three peculiarities are, on the contrary, fully com-

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prehensible, if we grant that the abscess was seated in theliver; the displacement of the heart I more especially regardas a sign of singular importance. The posture of the patient(right lateral decumbency, with the head inclined forwards)was precisely that observed in hepatic abscess, and would bea very unlikely one to be assumed by persons having a collec-tion of pus accumulated in the right division of the abdominalwalls, or in a circumscribed sac in the peritonaeum. Again,the condition of the urine pointed to hepatic disease. Thelow specific gravity of the fluid was fully established to dependon deficiency of urea; on one occasion analysis showed thatthe proportion of this principle was only six per 1000. Nowthe observations of Dr. Parkes* seem to show that in suppu-rative hepatitis the kidneys fail to excrete the natural quantityof urea; while it is physiologically inconceivable, and clinicallyunproved, that abscess situated in the other localities re-

ferred to, shall produce such effect.The possibility of such great and comparatively sudden en-

largement of the liver as I here argue for may on first thoughtappear difficult of admission. But such enlargement is lessuncommon than may be imagined. Setting aside the expe-rience of our Indian brethren, which it might, on this particularpoint, be fallacious to apply to cases occurring in these lati-tudes, I find observations made in France and England demon-strating great rapidity of enlargement of the liver. ThusLouis* records a case of hepatic abscess fatal on the thirty-first day, in which the liver actually reached the crista of theilium inferiorly. Dr. Abercrombie, on the other hand, shows,by a case recorded with sufficient clearness, that abscess, withnotable enlargement of the liver, may be fatal in ten days fromthe first appearance of symptoms.

It may be, further, well to observe, that the peculiar form ofthe enlargement, as rudely exhibited in the diagram, does notargue against its hepatic origin; for the right lobe of theorgan is very frequently affected with abscess independentlyef the left. In the present case, indeed, some congestive en-largement of the left lobe had in all probability taken place,otherwise the heart would not have been pushed out of itsplace in the manner described.

Finally, I could not believe that the intumescence was dueto distention of the pelvis and infundibula of the kidney, withsero-urine, (hydronephrosis,) or with pus, (pyelitis,) because-(1,) no intestinal percussion-note was at any time discoverablein front of the swelling; (2,) the flank was comparatively flac-cid on manipulation, and clear-sounding on percussion; (3,) thecharacter of the symptoms, the commemorative history, andthe rapidity of the enlargement, were alike hostile to thisnotion.The operation of puncture settled the question in the

affirmative, as to the existence of abscess, and in two waysconfirmed the diagnosis of its seat. In the first place, thethickness of the abdominal wall (three-quarters of an inch)traversed by the trocar on its way to the purulent collection, is(especially when allowance is made for necessary attenuationby stretching) scarcely intelligible on the notion of parietalabscess, while readily conceivable on that of hepatic. Had theabscess been parietal, the dull sound on percussion should havedisappeared at once after evacuation of the pus; but it didnot do so, (vide April 19,) because, doubtless, the liver itselfhad to undergo contraction first. Had the abscess been aparietal one, again, the patient would have felt her originalpain, not above in the hypochondrium, but in the localitywhere the abscess mainly formed; the original seat of pain andof pus-formation must have been carried downwards, as thedisease advanced-a peculiar circumstance, only explicable onthe idea of hepatic origin. The pus was of laudable character,and contained no bile products; the absence of these, however,raised no argument against the pus having been formed in theliver, as the cyst which surrounds such abscesses prevents, inthe majority of cases, all admixture of the natural secretion ofthe organ.

§ 2. The agencies, which experience teaches us play someimportant part in causing hepatic disease, had very clearlybeen in force here. The patient’s hfe,iiom early years, appearsto have been one of constant anxiety and mental suffering.To the violence of this she appears to have owed a miscarriage.Her first husband died soon; her second, to add to her trou-bles, became insane a year after marriage; her means becamegradually reduced, and she fell from a sphere of respectabilityinto one of misery. In the summer previous to her admissionhere, she had several attacks of diarrhoea, accompanied withcough; and about Christmas, after great privation in regard of

* On the Dysentery and Hepatitis of India.t Mémoires Anat.-Patbologiques.

food, and the other necessaries of life, began to suffer frompain in the right hypochondrium and lower chest regionslaterally and in front-a pain which never left her, until itmerged in the acute suffering discovered on her admission.The course of events points to the existence of chronic

(almost latent) hepatitis, of some two months’ duration, fol-lowed by more acute inflammation, with abscess. Now this isprecisely one of the combinations which has been well esta-blished to arise by those observers (especially Dr. Parkes)who have carefully investigated the morbid habitudes of theliver in India. The frequent attacks of diarrhoea were veryprobably of dysenteric character; indeed I think I rememberhaving ascertained from the patient the fact of their having,occasionally at least, had that character; but as the statementdoes not appear in the original report, we must regard it asunestablished. While under our notice, she had no dysen-teric symptoms; but these symptoms, when secondary to sup-puration, are particularly met with in cases of chronic abscess.Dr. Parkes has noticed that secondary dysentery may beabsent when the hepatic abscess is seated towards the uppersurface, and is circumscribed; so it may also be absent (beingstill circumscribed) when occupying the anterior surface.

§ 3. There was no jaundice, properly so called, from first tolast. True, the patient’s skin had a certain dingy-brownishand very faintly-yellow tint; but this was obviously, and fromher own account, a condition, in the main, long established,and only very slightly increased by the existing acute disease.Neither was there any colouring matter of the bile to be foundin the urine,* and the examination of the fseces, both in theirphysical characters, and by the addition of nitric acid, showeda deficiency of that priiwiple. There seems to have been agreat alteration in the quality of the bile secreted, (the mattersvomited on the 22nd of March showed its presence,) as wellas a diminution in its quantity. The absence of jaundice underthese circumstances, however, is nothing unusual; on the con-trary, in cases of hepatic abscess, where the formation of bilehas been totally suspended, no jaundice follows in the verygreat majority of cases. So true is this, that in cases of ab-scess, where jaundice does occur, the symptom may with muchsecurity be referred to some concomitant condition preventingthe excretion of bile which has been formed.As far as this case goes, it supports the opinion of those who

consider rigors an infallible sign that hepatitis has passedinto the suppurative stage. Some observers have noticed,that patients with hepatic abscess constantly feel chilly; andan attempt has been founded on such cases to prove the im-portance of the liver, quoad the production of animal heat.No complaint of such suffering was made by Fairbank.

Flatulence was here, as it often is, a prominent symptom;the early total absence of vomiting observed in this case isso far from being unusual, (though speculatively to be lookedfor,) that some persons consider its occurrence in hepaticabscess altogether exceptional.The conditions of the urine deserve attention, and may be

considered, at four different periods of the disease, as follows:-

During the period (a,) both the mean quantity and specificgravity were lowest. On one day of this period, the fluid,submitted to careful analysis, was found to contain but sixper 1000 of urea, a fact already referred to. The urea, too,appears, from the occasional alkaline reaction, to have readilyundergone decomposition. With the progress of recovery,the natural reaction of the urine returned, but its meanspecific gravity continued low (never but on one occasionrising so high as 1018) as long as the patient remained underobservation. Clinica observations on the state of the urea indisease have as yet been published on so limited a scale, thatit would be premature to enter into speculations concerningits deficiency in such cases as the present; let us, meanwhile,note the fact, as corroborative of those put forward by Dr.Parkes.

* It is not perhaps sufficiently known that there may be well-markedjaundice, without bile being discoverable in the urine; and that conversely,the urine of persons, whose skin is completely fi ee from yellowness, maycontain bile.

527

During the periods a, b, c, extending from the 16th of Marchto the 5th of May, there was albumen in the urine. At firsta mere trace was discovered; subsequently the quantity in-creased, but never exceeded a twentieth of the specimen ex-amined. During the period d, no trace of this principle wasto be discovered. Similarly there were visible during theperiods a, b, and the early part of c, corpuscles of peculiarcharacter, which disappeared at the close of the period c, anddid not return during the period d. These corpuscles, a thirdlarger than blood-discs, granulated, spherical, and disclosing adistinct nucleus under the action of acetic acid, some of them,isolated, others aggregated, and associated with epitheliumscales in great abundance, had the characters of those ofmuco-pus. Many observers would be ready to ascribe thisalbuminuria and excretion of corpuscles to absorption andelimination of fluid and solid contents of the hepatic abscess;and I confess to you that, considering all the circumstancesof the case, their peculiarities are more favourable to thatview than in any other it has fallen to my lot to observe.I have already mentioned to you that this kind of eliminationof pus, " with its properties retained," rests upon the slenderestclinical evidence, (vide ante, p. 417;) and its possibility mayfairly be questioned on the ground of the excess of thedimensions of pus-corpuscles over the calibre of the capillaryvessels. But the liquor puris (the albuminous part of pus)being fluid, requires no disintegration (as the corpuscleswould) for the purposes of absorption, and may be conceivablyabsorbed by the vessels of the pyogenic membrane, andthence whirled into the general circulation. It seems, then,a possible hypothesis, that the albuminuria in this case mayhave been, in part at least, due to the absorptive action ofthe cyst of the abscess on the fluid portion of its contents.But the appearance of the corpuscles cannot be thus ac-counted for. I believe that they (associated as they werewith abundant epithelium) were produced in the renal pas-sages by sub-acute pyelitis,-itself the result of irritativepressure on the kidney by the enlarged liver. The influenceof pressure in producing pyelitis has been fully recognised byclose observers of renal disease. It may be well to remarkthat the albuminuria here present cannot have depended onthe disease in its mere character of an acute febrile affection,.it was of altogether too protracted duration to admit of thisview of its nature.At the commencement of period c, oxalates temporarily

appeared; uric acid crystals were once observed duringperiod b ; lithates were more or less abundant during the firstthree periods, and not wholly absent during the fourth. Theurine continued more or less opaque (at first it was actuallymuddy) till the 24th of April, (third day of period c ;) thence-forth it was transparent above the deposit, which was smallin quantity.The pulse ranged, previous to the opening of the abscess,

between 140 and 96; the respiration, between 36 and 16. Themean ratio, given by observations on ten different days, was4.8:1; hence I infer, that unless there be actual disease of thelungs accidentally present, the functions of those organs arenot seriously affected in hepatic abscess.

§ 4. On the day of the patient’s admission, I directed thatsix ounces of blood should be taken from the hepatic region,by cupping; that free action from the bowels should be in-duced by four grains of calomel, at night, and a black draughtthe following morning; and gentle influence produced on theliver by taraxacum. The quantity of blood removed was pro-portioned to the feeble vital powers of the patient, and tothe subacute character of the symptoms-a state of privation,bordering on starvation, had, it is to be remembered, beenlong -impoverishing her blood. The local pain, very muchrelieved by this slight abstraction of blood, returned on thefollowing day, and was again (thrice) controlled by the appli-cation of leeches. Low diet was of course ordered in conjunc-tion with these measures.Rather from fear that if the case turned out badly I might

regret its omission, than from any great confidence in itspower of arresting the disease, I administered mercury, withthe view of bringing the system under its influence. As someof you who may have dipped into Indian medical literatureare aware, certain Bengal physicians have contested thepossibility of salivation being produced in suppurative hepa-titis. Thus Dr. Annesley affirms that mercurial action is in-compatible with hepatic suppuration; yet in many of Dr.Annesley’s own cases of abscess, seen, treated, and recordedby himself, all the ordinary evidences of such action werepresent. Strange influence of preconceived theory-bluntingthe senses and stultifying the reason t No doubt can be en-tertained that mercury really does .affect the system, in this

disease, in the same fundamental manner as in others-whether with equal facility, I know not. As far as the caseof Fairbank goes, it tends to show that no great difficulty isto be expected in making the mineral act. The question, then,seems to be, whether such influence is really beneficial wheneffected. I think that any one who reads, without bias, thepages of our writers on Indian diseases, will come to the con-clusion that they contain proofs rather of its mischievouseffects than of its utility. Fairbank’s case cannot fairly besaid to add to the number of its failures, as suppuration, therecan be little doubt, had commenced when the mercurial wasfirst exhibited.

By and by the existence of pus in considerable quantitybeing positive, the question arose, whether we should leave itsevacuation to a natural process, or interfere by making an ex-ternal opening. Considering the position of the abscess, weseemed tolerably safe from the chances of its travelling intothe pleura, lung, or pericardium; but it might very well openinto the duodenum, colon, peritona-al cavity, or stomach.Now although it is said that hepatic abscesses, opening spon-taneously into the intestine, terminate favourably in a largerproportion of cases than those opening spontaneously throughthe external integuments, I did not think the analogy one tobe trusted to in regard of removal by puncture. In the firstplace we could have no surety that the abscess would passdirectly into the bowel, instead of, in whole or in part, escap-ing into the peritonaeum. Secondly, the distinct pointing tothe surface afforded an indication to puncture through theinteguments, not easily to be rejected. Thirdly, the main ob-jection which may, in many instances, be adduced to punc-turing an hepatic abscess, did not hold good here-I refer tothe apprehension of peritonaeal adhesions not having beenestablished over the site of suppuration, and the consequentdread that some of the contents of the cyst, oozing into theperitonmal cavity after the operation, may excite fatal peri-tonitis. I say that this objection did not hold here, because(on the 15th of March) I discovered distinct peritonseal fric-tion-sound over the prominence, the clear proof that localadhesive inflammation had arisen in the desirable locality. Itherefore determined on having the trocar introduced.The subsequent progress of the case was singularly favour-

able, and that no appearance of refilling of the purulent cystensued may be considered an occurrence of very exceptionalcharacter. But in whatever seat an abscess may form, itscomplete and sudden cure, by artificial evacuation, must (pro-vided it have attained any size) be regarded as the exceptionto the rule. The woman was discharged on the eighty-firstday after admission, in a state of sound health, to which shehad long been a stranger.

§ 5. It is, perhaps, as well to remark, before we close ourconsideration of this case, that the fluid discharged by punc-ture in the fourth intercostal space, upwards of eight yearsbefore the patient came under our notice, was, in all proba-bility, pleural. The protracted discharge of half a pint of fluiddaily after that operation, seems, independently of the sitechosen for puncture, sufficient to warrant this view.

THREE CASES OF

SPERMATORRHŒA, IN WHICH ENTOPHYTESWERE FOUND IN THE URINE ALONG WITHSPERMATOZOIDS.

BY T. WHARTON JONES, ESQ., F.R.S.,LECTURER ON ANATOMY AND PHYSIOLOGY AT THE CHARING-

CROSS HOSPITAL.

THE subject of the first case is a gentleman about sixtyyears of age, affected with great muscular weakness of thelower extremities. My friend Dr. Cumming, of Cadogan-place, his ordinary medical attendant, suspecting the exist-ence of spermatorrhoea, called me into consultation.

I The urine being subjected to microscopical examination,was found to contain numerous spermatozoids. But in one

specimen in particular, there were found, besides the sperma-tozoids, entophytes in the form of branched, flat filaments,about of an inch in breadth. Figs. 1, 2, & 3.These vegetable fungi occurred principally in flocculi of

mucus suspended in the urine. In these flocculi, the numberof spermatozoids was greatest.The observation just related was made in the beginning of

January. Dr. Cumming and I having agreed on the pro-priety of cauterizing the urethra after the manner of Lalle-mand, I performed the operation on the 10th of February.The cauterization was slight. In the urine passed next day,