SECT. XLVI.—ON THE AFFECTIONS OF THE LIVER.
The affections of the liver being various (for it is subject to atony, inflammation, erysipelas, scirrhus, apostemes, ulcers, and obstructions), we shall treat first of atony of it, in which case, particularly those affected with it, are usually called hepatics. If, therefore, it evacuate the excrements in a state of chyle, but more liquid than natural, the distribution of the food to the liver being either diminished or altogether stopped, while the stomach is unaffected, it is to be inferred that the attractive power of the liver is in a weak state. But if they resemble the washings of newly-killed flesh, it is the alterative, and, as it has been called, the sanguificative power that is affected. But if the atony arise from a hot intemperament, in process of time it appears more feculent and very fetid, the bile being high-coloured and thick. Wherefore, the substance of the liver being already melted, the whole body also is melted down; and there is fever, anorexia, and vomiting of bile. When the intemperament is cold, the discharges are neither constant nor many, for the affection is a chronic one; and for several days the discharges from the belly will be more abundant, but less fetid, like the lees of thick blood, approaching to black bile. And many and various colours indicate a cold intemperament; for the fever is obscure, the face not collapsed, and there is rather a desire of food. Whichever of these intemperaments prevails, if complicated with the dry, the excrements appear drier and fewer in number, and there is more thirst; but, if the humid, they are more liquid and abundant, and the patients have less thirst. When the liver is inflamed, there is, in all cases, pain in the right hypochondrium, extending upwards as far as the clavicle, but downwards as far as the false ribs; an acute fever, dry cough, thirst, loathing of food, and difficulty of breathing; the tongue at first appears red, but afterwards black; there is vomiting of bile, and the belly is constipated. These symptoms being like to those of pleurisy, we have stated the difference under the head of pleurisy. When erysipelas is seated in the liver, the inflammatory heat is intense, there is ardent fever, and marasmus supervenes. In particular, when the concave parts of the liver are inflamed, there is nausea and vomitings, anorexia, intense inflammatory heat, deliquium animi; and the parts often become congealed, so that dropsical effusions derive their origin from hence. When the convex parts are inflamed, the other symptoms just now enumerated are present, with a visible swelling along its circumference, which swelling is manifest both to the sight and the touch. These are the symptoms of a strong and great inflammation; but if it is weak, we must order the patient to take in a large inspiration, and, if he says that he has pain in the right hypochondrium, we may conclude that there is moderate inflammation of the liver. But if an oblong tumour of a phlegmonous nature appear in the position of the muscles which lie over it, and none of the aforesaid symptoms be present, we know that the muscles themselves are inflamed. Weight with distension, and a sensation of pain in the right hypochondrium, without swelling or fever, indicate an obstruction of the veins, at the place where those of the porta and concave parts of the liver join those of its convex parts. When the inflammation is converted into an abscess, the pain and distension increase, inordinate rigors come on, and they cannot lie on the left side without increasing the pain in the liver. When the abscess bursts, the matter is discharged freely by the urine or bowels. If the tumour pass into a scirrhous state, the pain is diminished, but there is a manifest swelling, attended with hardness, and the surrounding parts become emaciated. But, in process of time, the diagnosis becomes difficult; for dropsy supervenes, and the whole hypochondrium is concealed by the water. For a hot intemperament of the Liver, we must use those things which have the properties of moderately cooling and strengthening the viscus, such as endive and succory, sometimes eaten raw and sometimes boiled with coriander; and the decoction and juice of them may be drunk; and not only thus, but the plant, when sprinkled dry upon honied water, relieves hot and cold intemperaments of the liver. And the species of those herbs called intybus, and troximus, and the sow-thistle, are possessed of similar properties. And a cupful of the juice of citron added to honied water has the same effect, and that of the brake in like manner. But if the intemperament is moderate and complicated with obstruction, these things may be given in some light wine, or some of the diuretics. And the following pill may be taken: Of succory, dr. iv; of the root of ground-pine, dr. iv; give in boiled honey to the size of a Pontic nut, and let the patient take some warm water, and then let him be made to drink the propomata from opium and the seed of hyoscyamus, and the antidote of Philo. In those cases in which the heat is intense, it may be very proper to give of the oil of roses, or of apples, in a draught. For food, let them take of the juice of ptisan, or chondrus, with hydrorosatum, and bread in like manner out of water, with some of the sweet potions; and, in a word, let them take such food as is moderately cooling without being obstruent; abstaining altogether from wine, unless they require it for some other cause, such as atony of the stomach, and in that case the kind which is given should be thin, weak, and watery. And erysipelas of the liver must be cured in like manner. When the intemperament is cold, we must proceed on the opposite mode; we must give them bread with wine, and cabbage which has been twice or three times boiled. Let them taste lightly of chesnuts, take what is sufficient of grapes, and of the flesh of fowls, and drink wine. Let them get a propoma from eupatorium, asarabacca, or the medicine from pepper; and a selection must be made for them from among the remedies formerly mentioned for colic and dysentery. The medicines called cyphoid do not suit entirely with the hot intemperaments, unless the heat be small and joined to much humidity; but they are excellent remedies for the cold, and more especially if complicated with humidity or obstruction of the liver. When the obstruction is occasioned by thick and viscid humours, we may give the myacantha (wild asparagus?), more especially the fruit of it, and the rind of the root of bay, agrimony in oxymel, or in the decoction of bitter lupines, with rue and pepper. And the flour of lupines in a draught; and of roots of cappers, p. ij; of costus, p. j, with wine; and the medicine from cacanus, are of use for obstructions occasioned by thick and viscid humours; also the iris, the fruit and rind of pistaches, horehound, and bitter almonds, and the trochisks from them, the root of dracunculus, and wakerobin, agaric, vinegar of squills, and oxymel. And the dried liver of a wolf, powdered and given with sweet wine to the amount of a spoonful, is applicable for all affections of the liver. And the antidote Theodoretus is one of the best remedies for obstructions of the liver, scirrhus, chronic inflammation, colics, and jaundice; and in like manner the picra with oxymel. The food which is given should be of a heating and deobstruent nature, such as leeks in oxymel, marsh asparagus, and capers in like manner; and the other articles of food should be boiled with some of the calefacient and deobstruent condiments. They should drink light old wine, avoiding such as are thicker, and also frequent baths, more especially after food. If the affection be protracted, we may have recourse to venesection and purging, if nothing prevent. When the liver is inflamed, we must bleed from the right arm without delay, and take away a great quantity, if the strength permit. And over the viscus we must apply externally a cataplasm made of the flour of barley, of fenugreek, and of linseed, with dates, or quinces and the flower of melilot, wormwood, and oil of chamomile; in a word, we must mix astringents with emollients. The epithemes to be applied are that of Nileus, the fragrant, the Philagrianum, that of Apollophanes, that made of melilots, and the one called Copton. For great inflammations, the following one is of tried efficacy: Of the flowers of wormwood, of Celtic nard, of asarabacca, of saffron, of each, oz. j; of iris, of myrrh, of storax, of bdellium, of ammoniac perfume, of each, oz. ij; of a calf’s marrow, oz. iv; of cerate of lentisk, lb. iv. Oxymel is also to be given to them, and the simple remedies, such as asarabacca, Celtic or Indian nard, bog-rush, and Macedonian parsley. We must stimulate the bowels by nettle, or the herb mercury eaten boiled; and during the decline of the complaint we must give of dodder of thyme (epithymum), and of polypody in honied water; and evacuate the bowels with a clyster, in the beginning by means of honied water with salts or nitre, but in the decline mix with hyssop, marjoram, or bastard saffron, or centaury and colocynth. In a word, the concave parts of the liver are to be purged by the belly, and the convex by the urine. For food, give them the juice of ptisan in which parsley has been boiled. We have already stated the cure of erysipelatous inflammation. When an aposteme is formed, we must promote its rupture, by applying a cataplasm of the composition called trispermus, with rosin, manna, pitch, the roots of marshmallows, pigeon’s dung, and goat’s dung. But let them take the propoma from the decoction of poley, that of the fumitory which grows in hedges, reduced to a third part, the decoction of treacle-mustard or of succory, and of the root of wall-germander. When the rupture takes place, honied water and the other things mentioned for ulcerated kidneys may be given; and externally the plaster of Mnasæus, and the other emollient plasters, and the Icesian, or that from willows may be applied. When the liver is in a scirrhous state, there is little hope of recovery, as the affection will pass into dropsy; and yet it may be attempted by mixing ammoniac, bdellium, marrow, grease, and things of similar properties, with emollients. The patients may take draughts of such things as will act as deobstruents and detergents of the viscus, such as diuretics and lithontriptics, along with those just now mentioned for obstruction of the liver; the diet being regulated accordingly.
Commentary. Consult Hippocrates (de Intern. Affect. 30); Galen (Meth. Med. xiii; Sec. Loc. vii); Aretæus (Morb. Acut. ii, 7; Morb. Chron. i, 13); Celsus (iv. 8); Alexander (vii, 19); Aëtius (x, i); Oribasius (Loc. Affec. iv, 96); Nonnus (182); Cælius Aurelianus (Pass. Tard. iii, 4); Octavius Horatianus (ii, 13); Marcellus (de Med. 22); Scribonius Largus (30); Avicenna (iii, 14, 1); Avenzoar (i, 13); Haly Abbas (Theor. ix, 30; Pract. vii, 31); Alsaharavius (Pract. xviii); Serapion (iv); Rhases (Divis. 62; ad Mansor. ix, 67; Contin. xvi.)
Hippocrates describes three varieties of hepatic disease, which appear to have been bilious fevers. It is not easy to define the principles upon which his practice is directed. He mentions, however, emollient applications, bleeding, purging, and vomiting; and, when the disease is protracted, recommends the side to be burned with spindles of box-wood smeared with oil. He directs abscesses of the liver to be opened by the cautery. (Coac. 457.) He states that abscesses of the liver are least dangerous when they open externally; more so when they open internally; and most of all when they open both internally and externally. (Prognost. 7.) He makes mention of hydatids, and says of them that when they burst into the cavity of the peritoneum, the case proves fatal. (vii, 54; where see the Comment. of Theophilus and Damascius, ed. Dietz, p. 540.)
Galen has laid down the principles upon which inflammation of the liver should be treated in the 13th book of his ‘Methodus Medendi.’ We can only afford room for his conclusions. He approves of venesection with the intention of producing revulsion. Such articles of food and medicine are to be given as will emulge the biliary ducts without occasioning irritation, and everything of the opposite kind is to be abstained from. Wherefore such things as are sweet and viscid are to be avoided, and only such as are detergent without pungency are to be allowed. Of this class are ptisan and oxymel much diluted. Astringents, such as pomegranates, are improper, because they occasion contraction of the vessels; and they are more especially to be avoided when the concave side of the liver is affected. When the convex is affected, these articles, being altered by the action of the liver before they reach the seat of the disease, prove less prejudicial. When the concave side is the seat of the disease, he directs us to evacuate by the bowels, which may be accomplished by mixing with the food cnicus (carthamus tinctorius?) the herb mercury, &c.; but, if stronger medicines are required, black hellebore, colocynth, the small centaury, and the like, may be given. When the convex side is affected, he directs us to give diuretics; at first parsley, but, after the inflammation has subsided, the stronger ones, such as Celtic nard, valerian, spignel, &c. He animadverts in strong terms upon the practice of the Thessalian Asses, so he calls the Methodists.
We regret that our limits prevent us from doing justice to the views of Aretæus. The liver, he states, is the grand seat of sanguification, being itself but a concretion of blood. Hence, he says, diseases of it prove speedily fatal. He accounts for the pain which is felt at the top of the shoulder or clavicle in this way: the liver, being enlarged and becoming heavier than natural, drags down the diaphragm to which it is attached, and thus stretches also the pleura from its upper adhesions, whereby pain in the part is produced. A crisis, he says, may take place by a hemorrhage, a copious discharge of bile, or of urine; or the disease may terminate in suppuration, or in dropsy. When pus is formed, it may be discharged by urine, by the bowels, or it may point outwardly. In this last case, he recommends us to open it with an instrument red hot. When it does not suppurate it is apt to end in scirrhus, which is marked by a dull pain in the part. His treatment of acute hepatitis consists of venesection, refrigerant and discutient applications externally, cupping or leeching the side affected, then applying cerates and emollient ointments, consisting of attenuants and diuretics, such as wormwood, cider, &c. The food is to be light, of easy distribution, and diuretic. His treatment of chronic disease is varied, according as the matter passes by the urine or the bowels; but the chapter on it is incomplete.
Celsus at the commencement recommends bleeding, purging even with black hellebore, cataplasms at first repellent and then calefacient. Diuretics are to be given, such as thyme, hyssop, &c.; and all cold things are to be avoided. When a vomica forms, it is to be opened and burnt.
Alexander’s account is full and judicious. He says that, in cases of obstruction of the liver, when deobstruents are given before the swelling is softened, the juices being overheated become like stones and cannot be discussed. He alludes, of course, to hepatic calculi, or gall-stones. He gives copious directions for emollient ointments to be rubbed into the side to dispel the enlargement of the liver.
In treating of scirrhus, Aëtius recommends the emollient ointments, cupping, leeching, calefacient plasters, sinapisms, burning by medicines or by the actual cautery.
The account given by Actuarius is in so far important, as it shows that the views of practice had not changed in his days. In inflammation, he recommends to bleed two or three times, and to unite emollients with deobstruents in the external applications.
For a full exposition of the doctrines of the Methodists, we must refer to Cælius Aurelianus, of whose opinions we can afford room only for a very brief outline. The symptoms of scirrhus of the liver, as stated by him, are a round circumscribed tumour felt below the ribs, the colour jaundiced, the urine muddy, pain extending to the throat of the affected side, difficulty of lying on the left side, as this posture suspends the enlarged viscus. (By the way, Cassius assigns the same reason why persons labouring under disease of the liver or spleen lie easiest on the affected side. Probl. vi.) At the commencement he recommends fomentations, cataplasms, laxative food, and then cupping, scarifications, and leeching. When the attack is violent, venesection is to be premised. Frequent changes, acrid food, and emetics with vinegar of squills or hellebore are also mentioned. He recommends a sea-voyage, vapour-baths, hot springs, the sand-bath, and various stimulant and rubefacient applications to the side. He delivers his strictures very freely upon the practice of the other sects. Thus he justly condemns as too bold and dangerous a measure the proposal of Erasistratus to lay bare the liver, and apply the remedies direct to the part affected. He thinks Asclepiades improperly rejected gestation, baths, cataplasms, and emollient ointments. He also condemns the free use of cauteries to the affected side.
Serapion, like Alexander, states strongly the danger of using discutients before emollients, lest the juices become indurated. No ancient author has treated of the diseases of the liver so fully as Avicenna. He is most minute in his distinctions of disease, and particular in his application of remedies. Among other diseased states of the viscus, he mentions diminution of bulk. Had not inspectiones cadaverum been common in ancient times, the existence of this state of diseased structure could not have been ascertained. In abscess, he and Serapion make mention of taraxacum or the dandelion, which was recommended by the late Dr. Pemberton in cases of diseased liver, and is still used occasionally. Haly Abbas directs us, when suppuration takes place, to determine to the kidneys by diuretics; and, when the abscess bursts into the cavity of the peritoneum, he advises us to open it. When it makes its way to the stomach or bowels, he recommends us to promote its discharge by purging. He remarks that sometimes an abscess will form externally to the liver and put on the appearance of hepatic abscess. He directs it to be opened with aperient medicines or the lancet. He takes notice of the pain at the top of the shoulder, which, like Aretæus, he attributes to the dragging down of the parts by the heavy liver. In the cold aposteme (chronic inflammation?) he recommends wormwood, fenugreek, hyssop, spikenard, fennel, and the like. One of his favourite remedies for hepatic disease is rhubarb. Alsaharavius gives a long account of these diseases. Inflammation he treats by bleeding, various laxative and cooling medicines, emollient plasters, &c. In obstruction he gives rhubarb, wormwood, fennel, endive, &c.; and bleeds, if there be a sanguineous plethora. He treats fully of a discharge of blood from the liver. When it arises from the bursting of a vein after excessive fatigue, he directs us to bleed; but when it proceeds from relaxation and debility, he recommends astringents externally and internally. The account of hepatic diseases given by Rhases in his ‘Continens’ is particularly excellent, but it is too lengthy for our limits. He explains the pain at the top of the shoulder in the same way as Aretæus. He mentions that gross food produces enlargement of the liver, and hence animals fed on figs have large livers. For inflammation he recommends at first depletion and afterwards refrigerants, such as camphor, fleawort, and even snow-water. He recommends aloes with wormwood as a deobstruent cathartic.