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Mr. Cooper explains, that in the treatment of sympathetic ophthalmitis by operation, we have the choice of two proceedings, the one consisting in excising a portion of the eye originally injured sufficient to allow of the escape of its contents, and the other extirpation of the globe. He confesses that though the former has its advantages, he leans to the latter as the more likely to save the eye threatened with sympathetic dieease (p. 304).
In the operation of extirpation, according to O'Ferrall's method, Mr. Cooper directs the conjunctiva to be divided "at the point of reflection." (p. 310.) It is better, however, to remove as little of the conjunctiva as possible, as the more of it that is left, a better cushion will be formed for the application of an artificial eye. The conjunctiva, therefore, should be divided as close to the cornea as possible; the membrane should then be pressed aside, and the recti divided one after the other.
In all cases in which an artificial eye is to be worn, it is important, no doubt, to apply it early, so as to prevent the eyelids from contracting, and sinking it upon the stump. We should doubt, however, if the time specified by Mr. Cooper for the introduction of an artificial eye after accidental evulsion of the eye, will be sufficientnamely, "about a week." (p. 228.) A month, or a couple of months, will generally be soon enough.
After removal of the tube in O'Ferrall's method, it might be supposed that nothing would be easier than the successful adaptation of an artificial eye.
"When the eye has been excised in the manner described, the muscles being left, form in the process of healing a solid projecting mass, admirably adapted," says Mr. Cooper, "for supporting an artificial eye. . . . . Not only is the orbit fit to receive it in from four to eight days after the operation, but by raising and supporting the flaccid lids, it affords positive relief." (p. 311.)
As to the successful adapting of an artificial eye after extirpation of the globe, we have found it easier said than done; and we observe that Mr. Gray, a well-known artificial-eye-maker, states that
"When the globe has been excised, it is still a desideratum that some artificial support for the artificial eye should be found. Mr. Moon, the late house-surgeon of the Royal London Ophthalmic Hospital, suggested artificial eyes with the edges inverted. Such eyes succeeded in removing the sunken appearance, but in the course of time caused irritation and accumulation of discharge.*
Dieffenbach, it is well known, went the length of transplanting a flap from the temple into the orbit, in order to form a cushion for an artificial eye after extirpation of the globe.
The perusal of Mr. Cooper's work affords abundant proofs of the necessity of more attention being paid to eye-diseases in the education of the general practitioner. He refers to many cases in which injuries of the eye had been wofully mis-treated before coming under his care, or that of some other well-informed surgeon.
Among the vast variety of subjects to which the medical student's attention is directed, there is some danger of the object of all his study, namely, the practice of his profession, and the cure of disease, being well nigh overlooked. The essential thing to teach the student is the business of the medical and surgical practitioner, so that he may be able to treat according to just principles the common cases of injury and disease which will come before him. To this all his education should directly point. The dissecting-room and the hospital are the places where his studies ought chiefly to be carried on, and nowhere, we should say, is knowledge more improving or useful to be obtained than in an extensive and well-conducted eye-hospital, with such a work in the student's hand as the very valuable one of Mr. Cooper, which we have now reviewed. It is an excellent practical book, abounding in most interesting facts, and
* Ophthalmic Hospital Reports, Jan. 1859, p. 805.
proving the careful observation and the sound practice of the author, with no nonsense or extravagant pretence, and well worthy of a place in the library of every practitioner. The illustrations-both the coloured lithographic figures and the woodcuts-are extremely good.
Klinik der Leberkrankheiten. Von DR. FRIED. THEOD. FRERICHS, Professer in Breslau. Erster Band. Mit einem Atlas von 12 colorirten Stahlstichtafeln und zahlreichen in den Texte eingedructen Holzschnitten.-Braunschweig, 1858. 8vo. pp. 409. A Clinical Treatise on Diseases of the Liver. By DR. FRIED. THEOD. FRERICHS. Vol. I. Accompanied by an Atlas of 12 coloured engravings on steel, and nunerous woodcuts..
THE ancients considered the liver to be the central organ of the vegetative functions. Plato, in his Timæus, styles it a péμua äypiov, to indicate its importance in relation to vegetative life, as distinguished from animal or spiritual. Galen regarded the liver as the origin of animal heat; from the liver sprung the veins; in the liver chyle was transformed into blood. The doctrine of yellow and black bile outlived the rest of Galen's Pathology, and even the opposition of Vesalius (1542), based upon his anatomical researches, failed to produce any immediate effect. It was not until Aselli (1622) had discovered the chyliferous vessels, and Pequet (1647) had for the first time demonstrated the thoracic duct, that the ancient opinions on the liver and its functions were modified or abandoned. Bartholin and Glisson (1653 and 1665), maintained that the portal vein and liver had no share in conducting the chyle and assimilating it to blood. This view met with great favour at a time when, through the discovery of Harvey, a new physiology had been introduced. The opposition of Riolan and De Bils only afforded food for the humour of Bartholin, who after having "buried the liver," now doubted the possibility of its "resurrection," and wrote an epitaph, announcing the end of its reign. Swammerdam once more enunciated the ancient doctrine, but with so little effect that Boerhaave remarked: "Dudum in meliori parte Europa obsolevit hæc sanguificatio nunquam ab eo viscere expectanda." The opinion became prevalent that the function of the liver is limited to the secretion of bile.
Whether it was that Galen was more lucky in his imaginations than Bartholin would admit, or that he was more experimental than the relics of his works, in garbled editions, permitted an inexpert mental age to perceive; it came to pass that the nineteenth century found reason to revive much of the Galenic doctrine on the liver, and Magendie, Tiedemann, and Gmelin showed that a share of the digested contents of the gastro-intestinal canal makes its way to the blood through the portal vein and liver. The liver again came to be regarded as the seat of important changes in the composi tion of the portal blood (Lehmann). It was perceived that the hydrocarbons are in some way metamorphosed in this gland (Bernard). This discussion, which has for some time been carried on amongst a number of cotemporary physiologists, has not yet become a matter of history. Among some collateral functions of the foetal liver there appears to be the production of blood corpuscles. The calorific result of the function of the liver has found another defender; and thus it is, that the views of Galen, although modified, have risen into fresh life and significance. The liver is once more the central organ of metamorphoses in the vegetative sphere of the animal economy. Sensible as appears to us the view which the ancients held of the function of the liver, it did not serve them as the basis of their pathology. In diseases which admit of being easily referred to the liver, anatomically or functionally, the diagnosis of the an
cients was as perfect as our own. Inflammation, abscess, obstruction in the liver were recognisable enough to them. But when the many obscure general distempers of the body had to be referred to a fons et origo, imagination was allowed free credit, and generally drew upon the liver. Sanguificatio vitiatur hepate vitiato. The responsibility of the liver became unlimited, and plethora, anæmia, cachexia, and dropsy were all and always debited to its account, upon the faith of the Latin flourish. Yellow and black bile, from the position of elementary ingredients of the organism, advanced to an etiological dignity, and either equivocally or at the call of some higher and still less known force, could assume a morbific agency. Through fourteen centuries few doubted the relation of yellow bile to acute diseases, accompanied by a febrile rise of the temperature of the body; and in selecting those diseases which they would attribute, on the other hand, to black bile, writers unconsciously poetic and figurative merely depicted the prospect that met their eyes when they contemplated those dark diseases, which, like convulsions and mental disorders, seem only to remind us of blackness and gloom.
The great advance in anatomy and physiology which signalizes the seventeenth century, had the effect of diverting the attention of physicians from the organ, which hitherto had enjoyed an unmerited share of favour and of blame. The followers of Sylvius, the Iatro-chemists, as well as the Iatro-physicists, were more given to theoretical fabrications based on the weakest foundation of facts, than to observation or experiment. Even the restoration of the practical, truthful, Hippocratic simplicity of clinical experience by Sydenham, failed to advance the pathology of the liver. The age acquiesced in the theory of Franz de la Boë Sylvius, who maintained that the fermentation of the juices formed by the spleen, pancreas, and liver, was of great importance to chlylification and the proper mixture of the blood. But practical medicine paid no attention to affections of the liver.
Meanwhile morbid anatomy had begun in silence to store up materials, from which the pathology of the future might draw supplies for its construction. Benivieni, Vesalius, and Fallopia were the first to give accurate descriptions of biliary calculi, and of the consequences of their presence in the gall-bladder. Vesalius reported a case of bursting of the portal vein in consequence of cirrhosis of the liver; he observed the deleterious influence of spirituous liquors upon the liver, the connexion of intumescence of the spleen with liver diseases, and many similar points which are now well established by accumulated observations.
Glisson's anatomy of the liver contains some valuable observations on tumours of this organ in rhachitis. Abscesses and concretions in it were described in Bartholin's history of anatomy. Baillou, a very practical physician, gave an account of malignant icterus. The comprehensive work of Th. Bonnet (1679) contains a series of postmortem examinations of persons dead of jaundice, and observations of cases of inflammation, tumour, scirrhus, obstruction, cysts, calculi, &c. This author's discussion of many of his observations is very defective, but some subjects are remarkably well treated. The description of cirrhosis, for example, might have been written in our days.
Bianchi endeavoured to collect the scattered materials of the history of diseases of the liver and bile into a monograph, which, although it contains much crude and illdigested matter, and was therefore justly subjected to severe criticisms by Morgagni and Haller, nevertheless went through three editions. Its influence upon hepatic pathology, never very great, was soon eclipsed by the clinical works of Boerhaave and Stahl, and by the morbid anatomy of Morgagni.
Boerhaave extended the technical system of observation, which Sydenham had revived, to the disorders of the liver, in which he saw the local origin of the majority of chronic diseases affecting the whole system. The primary cause of those morbid processes he correctly observed to be an aberration of the digestive function, producing a diminution of the quantity of bile secreted. In accordance with this latter supposition he endeavoured to explain dropsy, cachexia, leucophlegmasia, &c., as consequences of a faulty chylification. His pathogenesis had a further resource in his ingenious error as to the portal circulation. The motion of the blood in the portal vessels was to him
independent of the propulsion of the heart. By endowing Glisson's capsule with contractile powers, he created a separate heart for the liver-" cum sinus portarum pariter sit cor hepatis, uti cor dictum universo corpori." Notwithstanding the assistance which he believed must be afforded to this propelling apparatus by the pressure of the abdominal muscles, this machinery was particularly liable to impediments and arrests. Here was the nidus of the humor atrabiliarius-here the doorway by which a host of diseases effected their entrance-" vena portæ porta malorum." One perceives, with astonishment, that a sensible physiology of the liver failed to produce the slightest effect upon pathology, which adopting the worst relics of ancient doctrine, superadded the creations of fancy, and thus became enveloped in a tangle, from which the science of our days has not yet been able to extricate it.
When G. E. Stahl maintained "that no less a share of chyle was conducted to the blood by the mesenteric veins and through the liver, than entered by the lacteal vessels," he opened a new road to pathology. The diseases of the portal vein, to which he referred the disorders of all the abdominal organs standing in communication with that vessel, were classified accordingly. His theory was, however, more the result of a process of thought upon the basis of anatomy, than a deduction worked out by physiological experiment. Less fortunate than the great chemical theory of the illustrious philosopher, this hepatic pathology found few professional followers, but the doctrine of abdominal plethora and congestion became deeply rooted in the minds of the laity. It offered an easy and fanciful explanation of all abdominal ailments, and thereby naturally retarded the progress of their true diagnosis.
There can be no doubt that during the entire century commencing with Stahl, medical practice did everything to neutralize the efforts of medical science. The haughty ignorance of routine found favour and culminated in Kaempf's abdominal infarctus and clysmata.
But rescue was now near at hand, for a hero had gathered his followers and irresistible they were. By dissections and clinical labours Morgagni for the first time investigated, in a clear and comprehensive manner, the seats and proximate causes of diseases, and drew the precise outlines of what we now consider to constitute the morbid anatomy of the liver. The changes in the structure of that organ, and their genesis and consequences, so far as they could be investigated with the naked eye, were for the most part clearly established. To these, sixty years later, were added the results of microscopical study. The store of facts recorded in the works of Lieutaud, A. Portal, Matthew Baillie, Carswell, Andral, Cruveilhier, Rokitansky, is the nucleus round which the modern pathology of the liver has consolidated itself.
The minute structure of the liver, as first recognized by Henle and Kiernan, has in some minor details been further analysed by assiduous labourers. But physiological anatomy brings home the conviction with irresistible force, that structure alone cannot teach function that form is only one of the elements by which we ascertain the properties of matter-that quality, behaviour under metamorphosing influences, and relative quantity-that is, quantity as it exists during a limited and given time-must be equally ascertained before we can ascribe to any substance, or peculiarly-shaped chemical compound, such as a gland or an organism, its place in the household of nature. The result of this conviction is, that the physiology of the liver has in our days been immensely extended by chemical investigation. Plattner's discovery of crystallized bile, Strecker's lucid researches on the composition of that secretion, Bernard's discovery of sugar and of the dextrine-like material from which it is formed, the discovery by various observers of a series of products of the retrograde metamorphosis, such as uric acid, xanthic oxide, sarkine, creatine, of the changes which fibrine and blood corpuscles undergo during their passage through the capillaries of the liver, and of the changes which take place in fats within the liver-cells, are recent additions to our already rich store of hepatic chemistry.
The pathology of the author of the work placed at the head of this article, purports to start from this physiological basis, and to try it by researches at the bed-side and on the dissecting table. This task is very difficult, not only from the want of unity in the basis itself, but also for various other reasons, such as the inaccessible situation of the
liver, the fact that its secretion, being discharged into the upper part of the intestinal canal, cannot be procured unmixed from the living body-its relations to intermediate metamorphoses the products of which do not directly appear in the excreta. Experience, in showing us that affections of the liver are often associated with diseases of the digestive canal, of the spleen, and general disorders influencing sanguification and metamorphosis, exhibits us a long series of complications, which warn us to use the greatest caution in the construction of pathological theories.
The work before us offers many questions without attempting to solve them, and others to which the reply is only fragmentary; but many and important points in the clinical history of the liver are treated of in a complete and satisfactory manner. The author not only investigated the anatomical lesions, but also their physiological influences upon the metamorphoses of matters carried on in the gland. He has combined with morbid anatomy the chemical method of investigation, and has, on a limited field, reaped a harvest which augurs well for the cultivation of the large area that offers itself to the zeal and industry of the rising generation of physicians.
The size and weight of the liver in its diseased and healthy state, with the natural modifications due to age and sex, the influence of food upon the quantity of blood contained in it, form the subject of a chapter, which is full of original observations. It is followed by a clinical chapter, which minutely details the manner in which the anomalies of form, and size, and position of the liver may be discovered during life. This chapter is illustrated by numerous diagrammatic woodents.
The fourth chapter is devoted to icterus. As the author does not share the opinion of Budd and Bamberger concerning the existence of a form of jaundice from insufficient or deficient secretory activity of the liver, two modes only remain by which, according to him, an accumulation of bile in the blood can take place, namely, an increased absorption of bile from the liver into the blood, and a diminished disintegration of biliary matters taken into the blood. Thus an excessive production of bile, polycholia, may lead to some forms of jaundice. The whole doctrine is well supported by arguments, observations on man, and experiments on animals; the changes which the tissues of the kidneys undergo under the continued influence of icteric blood and urine are well described and illustrated by some excellent engravings in Plate I. of the atlas. The chapter occupies more than a hundred pages. It is succeeded by a review of bilious fevers and epidemic forms of jaundice; this latter symptom our author, conformably to Annesley and Griesinger, derives from polycholia. An appendix on icterus neonatorum leads us on to acute or yellow atrophy of the liver, otherwise termed malignant icterus. We will give an extract of one of the author's cases, No. 15, p. 212, which is highly interesting as illustrative of his method of investigation and
A married woman, twenty-four years of age, was received in the clinical ward of the hospital Allerheiligen, on January 21st, 1858. She was well formed, in excellent condition, and in the seventh month of pregnancy. She had for some days been suffering from loss of appetite, constipation, headache, and low spirits. On the day on which she entered the hospital a slight icteric coloration of the face supervened. During the night after her reception she repeatedly vomited a dirty greyish fluid, and then became suddenly delirious. The pulse was 80 per minute, respirations 20. The temperature of the skin was not raised. The pupils of the eyes were not enlarged, reacting slowly upon exposure to light. The conjunctiva had a slight yellow tinge, as also the skin of the face and neck, while the abdomen and lower extremities exhibited no sign of discoloration. The abdomen was soft, and contained only a moderate amount of gas; the epigastric and both hypochondriac regions were tender ou pressure. On percussion hardly any dulness was discovered in the hepatic region, except at the axillary line, where it was found for about an inch and a half; at the other places the intestinal sound passed directly into the pulmonary. The patient took muriatic acid. In the night between the 21st and 22d the distress of the patient increased; she screamed and threw herself about; the pulse rose to 112, and the breathing became stertorous. On the morning of the 22d she was delivered of a dead foetus of seven months, which had no signs of jaundice on it. There was profuse uterine hæmorrhage. After the abor