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Book XII.]

ON MALIGNANT HEPATITIS.

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The respiration is laborious, hiccough frequent, and as M. Richard has pointed out, when this state increases or is prolonged, a profound dist alteration in the features comes on; the eyes become fixed, some urbanes convulsions are manifest in the face and muscles of the limbs; the R. an child falls into a collapse, becomes cold, and dies.

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Sometimes this form of acute hepatitis is accompanied by erysipelatous more m redness of the skin, subcutaneous inflammation around the situation of the insertion of the cord, and on different parts of the body; aphthæ and purulent ulcerations on the lips, commissures of the mouth, eyelids, and at the orifice of the prepuce and the anus. Sometimes indeed these various inflammations terminate in gangrene. Malignant hepatitis causes the death of the children in some days; I am not aware, at present, if any recover from this disease. It is then disease and possessing a most fatal prognosis.

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Prag. And

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en are strong and vigorous, we might then perhaps
vo leeches at the region of the liver, taking the precaution
7 arresting the flow of blood. I should prefer prolonged
tepid baths twice a day, fomentations, poultices, oily
enemata; in order to arrest the vomitings, cold water,
lower water by teaspoonfuls, one drop of laudanum
id lastly, a flying blister over the region of the liver.
abscesses of the skin, and gangrenous inflammations of
issue, the collections of pus should be opened early, Emula

e carefully washed, cleaned with aromatic wine, tincture
olution of the chloride of soda, and they should be covered
d cinchona, and dressed with ointment and with styrax
note cicatrization.

ON CHRONIC HEPATITIS.

hepatitis of the newly-born has also been alluded to,
s given a description of it, but the facts which this author

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reports are very incomplete, and cannot, at present, serve for a history
of this disease. I have not myself observed it, for it is very rare,^
therefore I shall abstain from describing it in detail. However, it
is perhaps to this affection that certain particular lesions of the liver,
vaguely indicated by ancient authors as appertaining to syphilis, and
very well described, quite recently, by M. Gubler, with this qualification,
must be referred. Apart from his interpretation, the fact exists, and
amongst several infants tainted with congenital syphilis, the liver is
considerably changed, unequally indurated and discoloured, yellowish
and infiltrated by a quantity of the elements of fibro-plastic tissue, more
numerous than those of the normal state. It is a profound alteration,
always of long standing, and which may be very properly looked upon
as a chronic venereal hepatitis. The description of it will be reserved,

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and further on it will be found in the chapter devoted to the syphilis of infants.

4TH. ON TRAUMATIC HEPATITIS.

This is a form of hepatitis entirely different from that just described. It is observed in every age; and in our country, with our temperature, saving the cases of purulent infection, abscesses of the liver are usually the result of contusions of this organ. Here is a case observed by Oulust M. Renaud, in a child sixteen months old. The hepatitis was caused by a contusion over the right hypochondrium, it was followed by the formation of an abscess which opened externally and ended in the death of the child.

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Case. Abscess of the liver opening externally in a child sixteen months old, by M. Renaud. Called on the 27th of March last to a child sixteen months old, which 4 I learnt had been ill for six weeks, having at that time had a fall from a height more than three feet, receiving a violent blow on the right hypochondrium. Previous to this time it enjoyed very good health; but at the decline of the day of its fall, the physiognomy expressed a continual suffering; it gradually dwindled away. However, the parents, in their culpable negligence, never had recourse to medical aid; they only thought they observed the formation of a tumour which appeared extraordinary to them. The information obtained at the time of my first visit, on the first symptoms experienced by my little patient, is not sufficiently precise to be transmitted here; but I positively ascertained that the child had never had jaundice, nor any derangement referable to the digestive functions.

On December 27th, the child presented a decubitus on the right side; out of the cradle it inclines towards the right side, the position which it preferred from the day of the accident. The skin is pale, dry; the respiration anxious; the pulse small, accelerated. The maternal milk is taken on each occasion with avidity; the alvine excretions are yellow and of natural consistence; no vomiting. The abdomen large, indurated, presents on the right hypochondrium a considerably flattened, fluctuating, pulsative tumour.

On the 1st of January, 1851, after a slight exploratory puncture, I made a sufficient opening, and an enormous quantity of phlegmonous pus escaped from the interior of the tumour, which collapsed.

4th. The flow of pus has always been abundant; the skin which covers the tumour is thinned; at several points fistulous tracts are observed.

5th. The skin adheres to the poultice, and presents a white surface covered with purulent matter. The wound is circular; it appears as if made with a punch; its dimensions are 24 inches by 24 inches.

7th. The membranes which cover the convex surface of the liver are gangrenous; I removed them. The tenth rib forms a projection of one eighth of an inch in the interior of the wound, and offers resistance to the hepatic gland, when this is carried outwards in the act of inspiration.

8th. The surface of the liver presents a greyish tint; an ulceration has formed on the part compressed by the rib.

9th. The rib is laid bare in its projecting portion; it appears to me floating between the abdominal wall of the liver, simply retained by the vertebral extremity, and attacked with necrosis.

11th. The liver fills up the circular opening, at the superior part of which it presents a notch of 1.2 inch in length and .4 in depth. The pus, always abundant, has become fœtid, mixed with the detritus of the hepatic tissue.

15th. The dressings are impregnated with unaltered bile, the escape of which lasted until death. This child is in the most extreme state of marasmus and debility possible; it is seized with hiccough, the face is pinched, the skin of a well marked pallor, the pulse filiform and accelerated. Nevertheless, no disturbance was observed referable to the digestive tube. To the internal treatment, which consisted of cod-liver oil and syrup of bark, a little broth and sweetened wine were added. Death occurred two days afterwards.

MM. Gros, Oviou, and Duhamel assisted at the last stages of this truly rare and interesting disease, and also at the autopsy, which the opposition of the parents rendered incomplete. We remarked adhesion of the liver with the abdominal wall, by means of extensive pseudo-membranes, which were covered with pus; a cavity situated on the superior and external portion of its convex surface, capable of holding a large nut; the walls of this cavity were indurated, of a whitish colour, from one fifth to one fourth of an inch in thickness; the surrounding tissue of the liver bluish and indurated; at a distance of 1.2 inch the organ presented the normal texture, but in its inferior and external third many small deep-seated abscesses were observed.

BOOK XIII.

ON DISEASES OF THE KIDNEYS.

CHAPTER I.

ON ALBUMINOUS NEPHRITIS.

Baste.

Albuminous nephritis is an organic affection of the kidneys, accompanied by albuminous urine. It is a very frequent disease in the adult, and one well known since the investigations of M. Rayer. It eas is sometimes observed in young children, but the fact is rare, and it is not without use to support it by some proofs.

This disease is announced by decoloration of the integument, oedema of the feet and hands, swelling of the abdomen, in consequence of an abdominal serous effusion, puffiness of the countenance, and lastly, by the passage of blood or of albumen into the urine.

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TREATMENT.

Common hepatitis, or, as some call it, the icterus of infants, should be treated by tepid baths, either simple or aromatic, for one half hour, and repeated once or twice a day. Slight frictions should be made with spirits over the abdomen and the region of the liver. The children should also be wrapped in flannel. These means are sufficient to cause the disappearance of the disease in a few days.

When it is accompanied by enteritis or sclerema, the medicines recommended in the chapter devoted to these diseases should be made au use of.

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ON MALIGNANT OR SEVERE HEPATITIS.

This second form of acute hepatitis is more rarely met with than the preceding, and most physicians have probably never observed it; aurus Baumes, Richard de Nancy, Martin of Lyons, and Heinke, have related It is havi some cases of it.

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Grave or malignant hepatitis becomes developed under precisely the same conditions as common hepatitis, only its anatomical lesions, progress, and fatal termination separate it in an absolute manner, to the same extent as we must distinguish common variola, scarlatina, and measles from malignant scarlatina and variola, &c.

Here, as we have previously remarked, the anatomical lesion is no longer simply a general icterus with sanguineous congestion of the liver, accompanied with hypertrophy of the organ, which takes place in common hepatitis; there is, in addition, considerable softening, and partial decoloration of the hepatic lobules, and here and there collections of pus disseminated in the lobes of the liver. Baumes, Richard, and Martin of Lyons, have, as I have before observed, reported several instances of multiple abscesses of the liver, with or without abscesses in other regions of the body.

In this last case it is very probable that the hepatitis is the consequence of umbilical phlebitis, and that the disseminated abscesses are the anatomical manifestation of purulent infection.

Newly-born children attacked with malignant hepatitis are feverish; their face is flushed, the skin of the body warm, red, yellowish, then completely yellow; the conjunctivæ and the under surface of the tongue yellowish, the urine highly coloured with yellow, tinging the linen. The jaundice is always perfectly evident.

The abdomen is hard, tense, painful at the right hypochondrium, and the swollen liver much exceeds its limits. The children have nausea, sometimes reject reddish matters, and void an abundant meconium, of a dark colour, or only a meconium discoloured yellow. According to Heinke, these matters are often grey, which seems to me to be opposed to the result of all observers.

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Erysipelas,

The respiration is laborious, hiccough frequent, and as M. Richard has pointed out, when this state increases or is prolonged, a profound alteration in the features comes on; the eyes become fixed, some convulsions are manifest in the face and muscles of the limbs; the child falls into a collapse, becomes cold, and dies. Sometimes this form of acute hepatitis is accompanied by erysipelatous more redness of the skin, subcutaneous inflammation around the situation of the insertion of the cord, and on different parts of the body; aphthæ and purulent ulcerations on the lips, commissures of the mouth, eyelids, keer alen and at the orifice of the prepuce and the anus. Sometimes indeed these ab. & various inflammations terminate in gangrene. Malignant hepatitis causes the death of the children in some days; I am not aware, at present, if any recover from this disease. It is then a serious disease and possessing a most fatal prognosis.

If the children are strong and vigorous, we might then perhaps apply one or two leeches at the region of the liver, taking the precaution of very speedily arresting the flow of blood. I should prefer prolonged and repeated tepid baths twice a day, fomentations, poultices, oily and purgative enemata; in order to arrest the vomitings, cold water, pure orange flower water by teaspoonfuls, one drop of laudanum every hour, and lastly, a flying blister over the region of the liver.

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In case of abscesses of the skin, and gangrenous inflammations of us. the cellular tissue, the collections of pus should be opened early, mata

they should be carefully washed, cleaned with aromatic wine, tincture of bark, or a solution of the chloride of soda, and they should be covered with powdered cinchona, and dressed with ointment and with styrax so as to promote cicatrization.

3RD. ON CHRONIC HEPATITIS.

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A chronic hepatitis of the newly-born has also been alluded to, and Burns has given a description of it, but the facts which this author reports are very incomplete, and cannot, at present, serve for a history of this disease. I have not myself observed it, for it is very rare, therefore I shall abstain from describing it in detail. However, it is perhaps to this affection that certain particular lesions of the liver, / vaguely indicated by ancient authors as appertaining to syphilis, and very well described, quite recently, by M. Gubler, with this qualification, must be referred. Apart from his interpretation, the fact exists, and amongst several infants tainted with congenital syphilis, the liver is considerably changed, unequally indurated and discoloured, yellowish and infiltrated by a quantity of the elements of fibro-plastic tissue, more numerous than those of the normal state. It is a profound alteration, always of long standing, and which may be very properly looked upon as a chronic venereal hepatitis. The description of it will be reserved,

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