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CHAPTER II.

ON INFLAMMATION OF THE LIVER.

In the observations already made respecting the more frequent functional disorders of the liver in warm climates, I have endeavoured to illustrate these disorders in their more simple and less complicated forms, and as giving rise to all the other derangements observed to accompany them, short of occasioning disease of a more determinate and specific kind. This mode of considering the subject seemed most advisable, inasmuch as those more dangerous and violent forms of disease which are to be considered hereafter, and which are often accompanied with functional disorders of the liver, will be better understood from the attention previously paid to this particular part of the subject. Besides, many of those more severe and fatal diseases to which Europeans are liable in a high range of temperature, originate in disturbances occasioned in the healthy functions of the biliary organs. The history of many cases of fever, dysentery, and diarrhoea, proves this position; and the remarks I have now to make will show the frequent dependance of the different degrees of inflammation of the liver upon those disorders of the viscus which have been discussed.

In many cases, inflammation of the liver will be ushered in by an increased secretion of bile, marking the dependance of such increase upon augmented determination of blood to the secreting substance of the viscus. In this case the additional afflux of blood runs on to active inflammation of the substance of the organ; and as inflammation, when originating in this manner, is often imperfectly and obscurely characterised by symptoms, or by the usually accompanying signs of vascular action, abscess frequently supervenes before the real state of disorder is detected. Such cases are often met with amongst those patients which, in public practice within the tropics, are admitted with the more prominent symptoms of fever or of dysentery; the disordered biliary secretion, resulting from increased determination of blood to, or inflammation of, the substance of the liver, occasioning the febrile or dysenteric symptoms, the urgency of which attracts the patient's whole attention masks the real source of mischief, and misleads the unwary or inattentive practitioner. In other instances, the accumulation of bile

upon the substance of the liver, and its acrid and stimulating properties, become a source of irritation, and kindles up that inflammatory action which the organ is already but too prone to undergo. And this result is still more to be dreaded, if, along with the accumulation of morbid bile, there also exist any degree of congestion of the blood-vessels,-a coincidence which may be considered as very generally obtaining.

As to the frequent supervention of inflammation upon congestion of blood in the vessels of the liver, there can be but little doubt. The knowledge of the connexion subsisting between both states of disorder is important, inasmuch as a suspicion even of the existence of congestion ought to lead to the adoption of such remedies as should prevent the supervention of consequences so much to be dreaded as inflammation and abscess of the substance of the liver. When, however, inflammation commences, as it frequently does, either in congestion of the blood-vessels of the organ, or in accumulations of acrid bile in the biliary ducts,-owing to the slight degree of disorder such states frequently occasion to the feelings of the patient, it seldom comes under the observation of the practitioner until the inflammatory action is very far advanced; and the derangements from which it originates are still less frequently the subjects of his notice, they are the preliminary states of disorder, which, particularly when supervening slowly, excite no alarm in the patient until their consequences are fully effected, or have reached that state which is beyond the powers of science and art.

From these brief remarks, it may be seen that inflammation of the liver is very generally the consequence of some one or more of the functional derangements of the viscus which have already engaged our attention; and that when hepatitis does not actually proceed from these disorders as a direct consequence, it generally arises from the state of predisposition to inflammatory action, which functional disorders of the liver invariably generate. This is the conviction on my mind, and it is the result of a long and extensive experience; I am, therefore, most anxious particularly to direct attention to the subject.

SECT. I.-On the Nature, Symptoms, and Causes of Inflammation of the Liver.

Inflammation of the liver generally supervenes either as a primary disease, without any very apparent state of previous disorder, or as

a consequence of one or more of the functional derangements before alluded to. This latter mode of commencement appears to be the most common, and is frequently to be recognised in those cases of hepatitis which supervene upon intermittent, remittent, and continued fevers, and dysentery. In many instances the functional disorder ushering in the well-marked inflammatory state of the organ may not be attended to on the part of the patient, and may not come under the observation of the physician until the hepatitis is fully formed, or even advanced to some one of its usual terminations,— namely, abscess, chronic enlargement, &c. Even acute inflammation may commence primarily, and proceed for a number of days without producing so much disturbance or alarm to the patient as to induce him to apply for professional assistance. This is still more remarkably the case where the substance of the organ is the seat of the inflammation, when the danger of neglect is greatly augmented by the very ready disposition of inflammation of this structure to run into abscess. Hepatitis may, therefore, originate primarily without previous disorder; or it may supervene to functional derangement of longer or shorter duration.

But it is not only important to be aware of the mode in which hepatitis supervenes,-the practitioner should also bear in mind that it will differ very widely in its form, symptoms, and consequences, according to the particular part of the organ which is affected, and the extent to which the inflammatory action extends itself to adjoining parts. The signs, however, which indicate the existence of inflammatory action in any one particular part of the liver, and its limitation to that part, or its extension to other parts and different structures, are seldom so precise, or admit so very rarely of an obvious connexion with its real seat and extent that the most experienced practitioner cannot take upon himself to state the symptoms which are pathognomonic of inflammation of a particular part of this organ, in all cases and under every circumstance. He may, however, point out the phenomena which his experience has authorised him to consider as most frequently the result of inflammation of a certain surface or part of the viscus ; but he can only offer them as an approximation to the truth, which an intimate observation, and various contingent and often indescribable circumstances in the history and existing state of a patient, viewed in connexion with these more definite signs, will enable the enlightened physician very nearly to approach.

Before I venture to detail the signs by which inflammation of the

liver is to be recognised, and by which we may rationally infer its limitation or extension to particular parts and textures, I shall endeavour to state succinctly the appearances which this organ presents in the inflamed state, and remark upon some of the various organic changes which more usually supervene to it, or with which it is most frequently complicated. As, however, I purpose to devote a section to the consideration of the pathology of abscess of the liver, I shall avoid, in this place, the consideration of such points as relate more intimately to that subject.

Inflammation of the liver may be limited to the following parts of the organ; namely, the superior or convex surface, the inferior or concave surface, the internal or parenchymatous structure, and the right or left lobe. The right lobe is most generally the seat of inflammation: both the right and left lobes are met with in an inflamed state at the same time, next in frequency; and the left lobe alone is the least liable to inflammatory action. Frequently the inflammation, particularly when seated in the superior surface of the organ, is limited by the broad ligament. When the surfaces are the seat of inflammatory action, the adjoining internal structure of the organ generally participates in it to a greater or less extent; and likewise when morbid vascular action commences in the parenchymatous structure, it sometimes extends to the external surface; but this more rarely occurs in India than the former mode of extension the internal structure appearing to be more frequently the seat of the inflammatory state than the surfaces, which seldom participate in it until the more advanced stages of the disease. Sometimes, however, the inflammation of the liver may arise from the extension of morbid vascular action from an adjoining viscus, as from the stomach or duodenum; and in such cases the surfaces first become the seat of disease, which generally soon extends itself to the internal structure of the organ. When inflammation either attacks primarily the surfaces, or is extended to them secondarily, coagulable lymph is generally effused from them; but in such cases the peritoneal covering must be, or has been, actually inflamed; for the parts immediately subjacent to it will present every mark of increased vascular action, and yet the investing membrane will itself not be the seat of inflammatory action, to the extent, at least of throwing out coagulable lymph. In India the internal structure of the liver is frequently seen inflamed to the greatest possible extent, without any effusion of lymph from its surfaces; and the inflammation of structure may go on to the production of several abscesses in both its lobes, or of one very large abscess in the right lobe only,

without any decided marks of inflammation of the envelop of the organ, besides some alterations of colour merely, which shades of colour are usually occasioned by the states of the parts immediately underneath. Nay, even abscesses of the liver may proceed to their utmost extent, and ultimately break into the abdominal cavity, without having induced inflammation of the serous surface where they point, and, consequently, without forming adhesions to the parts with which they are in immediate and most close

contact.

In many cases of inflammatory disease obviously affecting the stomach and biliary organs, it is very difficult to determine, from want of an account of their early progress, whether the inflammation commenced in the stomach, and extended itself to the biliary organs; or whether it began in the latter, and spread to the former. Such complications of disease are by no means uncommon in warm climates. When they end in death, either from the extent of disease in these particular organs, or from its extension to other adjoining viscera, the liver is generally found to be most remarkably diseased, or even the viscera, which were the last to undergo the morbid action; the stomach, which, although the first to evince disorder, presenting the least marks of it upon dissection. This very frequent, and indeed general, course of morbid phenomena, may be very easily explained, even upon the supposition that the stomach was the organ which first became disordered, as no doubt is the case in many instances; for disease, when it has extended to an adjoining organ, often becomes diminished in its original seat; and in cases where this is not the result, and where the superinduced disorder of the liver has led to still farther disease in the alimentary canal, owing to the morbid state of the secretions, the latest derangement in the chain of morbid phenomena not unfrequently mitigates, even when it fails of entirely removing, the originating malady. Illustrations of the above position are frequently observed by the intertropical practitioner, more particularly the military surgeon. He will often have occasion to remark, in soldiers, more especially those who are addicted to the inordinate use of spirituous liquors, that the functions of the stomach are amongst the earliest to suffer, that this organ will present the signs of disordered function of the inflammatory action, and to them will supervene those of deranged secretion of bile, or of inflammation of the liver, -that the usual symptoms of dysentery also will be often added to the foregoing derangements,-that the signs of inflammation of the stomach will gradually disappear as the dysenteric disorder

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