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abnormal variations that we find material for judging of bad condition, in a big extra growth from natural causes. But, spite of what has just been said, these two or three cases should be esteemed rather unexpected or unusual cases, so far as showing the results of special exercise developing muscle in certain places is concerned. The truth is, as we all ought to be apprised, that exercise, unless in restricted cases, does nothing of the kind. These are exceptions, and so have been cited. For when a man has become what he is intended to be in his ordinary development, exercise will not, generally, greatly change his dimensions.




AN article in your February issue, on an Anti-spitting Association, " meets with my approval from its relations to the demands of the general public, as well as from obvious reasons of common decency. However, in your endeavor to advance public health, together with a desire to promote æstheticism, you incline toward advocating a well-known plan which cannot fail to continue a general evil. You broach the subject with this sentence: "Spitting, except in a proper receptacle, should be prohibited by law in all public buildings, carriages, omnibuses, streetcars, railroad-cars, steamboats, etc." You thereby intimate that you consider the cuspidor as a proper and necessary adjunct of all public places and conveyIn this you are simply sustaining an old and much-abused custom; a custom which will in time, I hope, be completely abolished.


There is no more sense in supplying railroad-cars, station houses, and other public houses with cuspidors, than with bed-room crockery. It has long been recognized by thinking people, that the presence of spittoons was not a necessity, while their absence is noticeable in churches and the better class of places of general assembly, as well as in private houses of people of refinement.

Man is the only animal that I know of, of habitual spitting habits. Yet this proclivity is acquired, and if not stimulated by the use of masticatories or to

bacco, is, in health, readily controlled.

Spittoons, then, are to be alone considered as essential to the male sex, and we may recognize in the nuisance, a desire on the part of all who tolerate them, to uphold a worse than heathenish custom. But, much as I object to promiscuous spitting about the streets and floors, I must confess, that, from a sanitary standpoint, it is, to my way of thinking, far less liable to promote disease, than is the use of cuspidors, as too often followed. The minute organisms, said to exist in saliva and sputum, are more liable to increase and become an ultimate source of infection, when massed together in a common receptacle, than when isolated and subjected to the devastation of natural forces. Neither is this assertion invalidated by your expression regarding the drying of the sputa and the entry of the dried particles into the air.1

An anti-spitting society might accomplish much in the way of promoting public health; but I apprehend that more could be accomplished in cleanliness and good manners by worthy example and sensible advice. It is fair to say that the aims of any association under this fad and it may be called a fad will not succeed so long as spittoons are strewn about our private houses and public buildings.

The man who hawks on the street and constantly clears his throat in company, or expectorates indiscriminately, whether walking or sitting, is surely an object of dread to all refined natures, if not an actual menace to public health in general. I have known one pachydermatous individual, who was suffering with lung trouble, and yet thoughtless enough to foist his undesirable presence on a group of men, quickly clear a room or office of his erst-while sympathizers by coughing, hawking, and spitting in a handy spittoon.

As suggested, the best way for public health and (I may add, for sensitive people) is to have a law to fit the condition, or crime, if you will. As a future measure we can best adopt the plan adopted in certain Pennsylvania schools mentioned, as by early education we may expect to accomplish the most lasting results, and we may add too, discard the cuspidor entirely.

1 A common place for cleaning cuspidors is on the front walk, the contents being poured upon the pavement. This is a quite general practice with barber shops and cheap hotels and saloons.

TRANSLATIONS AND ABSTRACTS subject, it would be profitable to review

the symptoms by which we are enabled to recognize hepatic hyperæmia. I shall not attempt to present all the symptoms of congestion of the liver, but only those which are the most important.

In the symptomatology of hepatic congestions, there is one symptom which. is especially prominent. It is the increase in the volume of the liver. In order to detect this increase in size, we employ two means, percussion and palpation. Percussion has been highly praised as a means of diagnosis, but I consider it one of the most unreliable means of detecting the increase in the volume of the hepatic gland, and have often heard Barth make the same remark. Many causes may modify the line of dullness of the liver. The liver is not fixed in its position, but is

[THE articles in this department are prepared expressly for this journal.]


Member of the Academy of Medicine, Physician to the
Cochin Hospital, Paris.

FIG 1.

Translated by J. H. Kellogg, M. D.

CONGESTION of the liver is a clinical symptom which appears in a great num

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ber of disorders. It is necessary, then, first of all, to consider as methodically as possible the etiology and pathogeny of hepatic congestions, for these affections especially require in their management the application of therapeutic means to the first cause of the disorder. Here is one of the applications of what has been. described under the name of therapeutic etiology, that is, the treatment of causes. But before entering upon this part of my

more or less movable. This mobility may be very greatly exaggerated, producing a condition which may be termed movability of the liver, as has been pointed out, by some Italian authors. Gerard Marchant recently presented a case at the Academy in which he had been obliged to perform an operation for the fixation of the liver, such as is done for the kidney. This mobility of the liver enables it to assume such a position that only a small portion of it can be mapped out by percussion, and at autopsies, one is often astonished to find enormous livers, which, by percussion, had appeared to be livers of small volume. The lung and the intestine introduce other causes of error, without speaking of pleurisy, which sometimes produces a dullness

Position of the Physician and Patient for Employing Glénard's Method of Palpation.

continuous with that of the liver. Emphysema also should be mentioned, which lowers the line of resonance of the lung and depresses the diaphragm, thus rendering very difficult the percussion of the posterior part of the liver. Tympanitis, either of the stomach or of the intestines, often renders it impossible to ascertain with exactness the limits of the liver.

These causes of error place percussion in the secondary rank as a means of determining the position of the inferior border of the liver. Palpation is a better means of diagnosis, but in order to utilize the advantages of palpation, it is necessary to employ certain subterfuges. First of all, it is important, and this is a capital point, to cause the patient to.execute deep inspiratory movements. My master, Behier, strongly insisted upon this point, and with good reason. Thanks to these forced inspiratory movements, the diaphragm depresses the liver, and the hand applied upon the abdomen and pressed beneath the border of the ribs, may explore very completely the entire artificial border of the liver.

There are some cases, however, in which we cannot successfully employ this mode of investigation, as, when the border of the liver, instead of being in contact with the abdominal wall, is incurved and directed toward the posterior side of the abdomen. In these cases it is necessary to employ the method of Glénard, called the thumb method." 66 In this method, in addition to the depression of the liver by respiratory movements, an effort is made to carry it toward the an terior wall of the abdomen. The following is Glenard's mode of procedure:

The physician, seated upon the bed of the patient, usually on the right side of the bed, facing the patient, grasps the side of the patient's body just below the ribs, the thumb placed anteriorly while the four fingers are placed behind, and endeavors to force the liver toward the anterior wall. The right hand applied upon the abdomen at the median line, endeavors to fix, immovable as possible, the entire hypochondrium of the same side. The accompanying figures, borrowed from the work of Glénard, indicate not only the position of the physician and that of his patient, but also the different movements which are executed by the hand for the purpose of securing

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of the liver by simple palpation, the method of Glenard may be employed. So much for the methods of the physical examination of the liver, by which an increase in its volume may be determined.

To these symptoms it is also necessary to add others which are of notable importance. Certain cases of hepatic congestion are not accompanied with painful phenomena, while in others, on the contrary, the patients experience pain or other unpleasant sensations in the region of the liver, especially in taking a deep breath. There are sometimes, even, sensations of constriction of the chest at the level of the xiphoid cartilage. These symptoms are not so much a result of the congestion of the liver itself, as are the peri-hepatic disturbances which so frequently accompany these congestions. The sensations of constriction of the chest are the result of adhesions about the liver. These symptoms appear especially when the liver tends to return to its normal size.

Another very constant symptom is urinary disturbances. It may be asserted that no congestion of the liver exists without the appearance of urobilin in the urine and often also of bilirubin. The method recognizing this substance in the

urine has already been given in the preceding lessons.

In connection with this alteration in the urine, there is also a modification of the complexion. The eyes and also the mucous membrane, acquire a slight brownish tinge; and sometimes a true icterus, but more often a sub-icterus complexion, accompanies hepatic congestions.

To these three great symptoms, an increase in the volume, painful phenomena in the region of the liver, and the presence of urobilin in the urine, it is necessary to add febrile symptoms.

Monneret, who devoted much time to the study of hepatic congestion, and who gave an excellent description of this condition, called attention to the remittent and intermittent character of febrile phenomena in hepatic congestion. According to Monneret, this is a characteristic symptom of this condition. To-day it is necessary to modify that opinion somewhat.

While it is true that intermittent febrile phenomena are very frequently encountered in hepatic congestion, this symptom is much more often the result of infection of the liver than of congestion itself. I have already told you, in a preceding lesson, that in the physiological state the bile contains no micro-organism, and that in spite of its intimate relation to the intestine. But in the pathological condition, microbes enter the biliary passages, and infect the liver. It is to this microbic invasion that you must attribute these intermittent febrile phenomena, which sometimes assume a very grave character, sometimes actually constituting actual pernicious fever.

Aside from these symptoms, there exist still others of a very important character. These are secondary symptoms; for example, we observe an increase in the volume of the spleen, more or less serious disturbances of the portal circulation, and particularly the production of hemorrhoids. The occurrence of hemorrhoids in affections of the liver was known to the ancients, and Stahl attributed to this symptom a capital importance. The cardiac circulation may be disturbed, and Potain has shown us what changes occur in the right heart in patients suffering from chronic disease of the liver.

Finally, the digestive functions are disturbed, and as a result, we find in patients suffering from congestion of the liver a

bad state of the general nutrition, from which results rapid emaciation and notable deterioration of the bodily forces.

There is another secondary trouble which possesses great importance from a therapeutic standpoint. This is the occurrence of certain hemorrhages, and particularly obstinate nosebleed.

These secondary symptoms have sometimes been unduly exaggerated. Poucel has divided them into three classes,mechanical disturbances, reflex disturbances, and trophic disturbances. Our confrére of Marseilles has thus made all pathology dependent upon hepatic congestion. gestion. Likewise Glenard, who, observing the great frequency of enlargement of the liver in invalids, proposed to substitute hepatism for rheumatism.

While recognizing the great influence of hepatic congestion in the genesis of diseases, it is certainly an error to consider it as almost the sole cause of disease. While the role of congestion of the liver is exaggerated, on the one hand, it is, on the other hand, by others too much restricted. In the recent treatises upon hepatic affections, congestion of the liver is scarcely noticed; for example, in the excellent treatise of LadabieLagrave, the chapter devoted to congestion of the liver is very short and is devoted entirely to etiology. The same is true of the very remarkable work which Chauffard has devoted in Vol. 3 of the Traite de Medicine to diseases of the liver and the biliary passages. He devotes himself almost exclusively to the cardiac liver, as does Labadie-Lagrave. I believe that the truth is between these two extreme opinions, as I shall endeavor to demonstrate.

I pass now to a consideration of the etiology and the pathogeny of these affections. Many divisions have been proposed for grouping in a mathematical manner the different cases of hepatic congestion. I propose the following division In the first class we will place congestion the origin of which is the intestinal canal. These will be congestions of gastro-intestinal origin. This group is much the largest, and we shall be obliged to make several subdivisions, in order to study it fully.

In the second class, we will study congestions of infectious origin. Infectious diseases and malarial poisoning will be included in this group.

In the third class we will place diathetic congestions; for example, the hepatic congestions so frequently encountered in rheumatics.

In the fourth class we shall find congestions of mechanical origin. To this type belongs the cardiac liver.

Finally, we will range into the fifth class, hepatic congestions which result from a local cause, or which precede inflammatory phenomena of the hepatic gland. Wounds of the liver, foreign bodies in the liver, hepatitis, etc., belong to this group; but as this last class does not give rise to special considerations from a therapeutic point of view, I cite them here only for the purpose of classification.

Let us now consider the first group. These congestions are the most interesting, especially when viewed from the standpoint of therapeutics. In order to study them well, it is necessary to make the following subdivisions:

1. Congestions of a purely alimentary origin. Stimulating meats, badly masticated foods, alcohol, etc., belong to this group.

2. Congestions due to toxines, either those which result from indigestion or which are derived from the food itself.

3. Poisoning by lead, arsenic, phosphoras, etc., from which result congestions of the hepatic glands.

Let us now examine briefly these three subdivisions. The most frequent cause of hepatic congestion is dietetic excesses. And it may be said that all great eaters, and especially great drinkers, are subject to these congestions. In countries where excessive eating is general, as in Germany, in Russia, and in the northern portions of France, these congestions are very frequent. They are also often observed on the seashore among persons who are accustomed to reside in large cities, who go to spend the summer season at the watering places. Their appetite is greatly increased by exercise and the sea air, and as they make large use of fish, especially of shell-fish, congestion of the liver occurs very speedily. This congestion may be said to be almost universal. In addition to the conditions above mentioned, we have a high temperature on the Mediterranean, at the resorts of the Riviera from Hyères to Mentone. Thus, cases of hepatic congestion of this sort are very frequently encountered. Rapid eating and the incomplete mastication of

foods, by favoring gastro-duodenitis, also predisposes to congestion of the liver through inflammation of the bile ducts. These facts have been well brought out by Naunyn in relation to the pathogeny of biliary lithiasis.

But the first place incontestably belongs to alcohol. Recalling the fact that all liquids introduced into the digestive tube and absorbed by the portal vein, pass through the liver, it is apparent that all irritating liquids must be a cause of hepatic congestion.

Lead, arsenic, copper, and other metallic poisons, by fixing themselves in the liver, produce temporary or chronic congestion of this organ. In a subsequent chapter I shall consider those congestions of the liver which result from toxines contained in the food, such as tainted fishes, game too long kept, and canned lobsters, causes of hepatic congestion which are sometimes very serious. The mechanism of such congestions is easily understood. It is by exciting the activity of the hepatic cells that a flux of blood is produced, resulting in conges

In other cases, the congestion is the result of toxines produced in the gastrointestinal tube as the result of indigestion. To Bouchard belongs the credit of having been the first to show us the predisposing influence of intestinal dilatation in the production of congestions of the liver. The vicious fermentations which result from dilatation of the stomach occasion the formation of putrid products, which absorb from the surface of the intestine, and which exert a damaging influence upon the hepatic cells.

A very important role should also be attributed to inactivity of the large intestine. Absorption of putrid products occurs most easily from the fæcal matters of the large intestine, resulting in a group of pathological symptoms to which Bouchard has given the name of "stercoremie."

This absorption of toxines is encouraged by the too rapid shedding of the epithelium, and by ulcerations of the mucous membrane. It has long been shown that in dysentery, ulcerations of the colon are the origin, not only of congestions of the liver, but even of hepatic suppurations. But it is only in recent years that attention has been called to the frequent cases of hepatic congestion

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