This is a chronic disease of the liver, characterized by hyperplasia of
the connective tissue with destruction of the liver cells, resulting in
the organ becoming hard and usually small.
=Etiology.=—The disease usually occurs in the male sex and in middle
life. When occurring in children, it is commonly of the syphilitic
form, though it may be due to other infections. The abuse of spirituous
liquors is a common cause. It follows chronic diseases, such as
syphilis, long continued malarial intoxication, gout and tuberculosis.
Passive congestion, due to chronic heart and lung disease, causes some
cases. A few cases are caused by inflammation of the bile ducts, due to
infection and obstructing calculi; others to a stimulating diet, while
some cases are inexplicable.
=Pathologically=, the =first stage= is hyperplasia of the connective
tissue and consequent enlargement of the organ. As this increases the
connective tissue destroys immense numbers of the hepatic cells, owing
to the pressure. Often the enlargement is accompanied by tenderness. In
the =later stage= the overgrowth of imperfectly developed tissue seems
to contract the hepatic cells that still remain, causing atrophy and
degeneration of most of them, and thus reducing the size of the organ,
which is followed by sclerosis. The portal and hepatic circulations
are greatly obstructed. An occasional form is termed =hypertrophic
sclerosis= in which sclerosis is found while the organ continues
enlarged.
There are two common and well defined varieties, atrophic cirrhosis and
hypertrophic cirrhosis; other forms (rare) are met with.
=Atrophic cirrhosis= is the common form, and is usually due to
alcoholic excess. The surface of the liver is rough and uneven in
addition to its hardness and reduction in size. It may also be greatly
deformed and covered with granulations (“hob-nails”). The normal weight
is four or five pounds, but it may be so reduced as to weigh no more
than one pound or a pound and one-half. Sometimes there is =fatty
infiltration=, which enlarges the liver to such an extent that the
contraction is not noticed. There is an overgrowth of the connective
tissue, which contracts and constricts the branches of the portal
vein, causes atrophy and degeneration of the hepatic cells, and even
sometimes obliterates the bile ducts. The new connective tissue is
well supplied with blood-vessels from the hepatic artery, thus aiding
greatly in the growth.
In the =hypertrophic form=, as well as in the atrophic cirrhosis, there
is an overgrowth of connective tissue, but in the hypertrophic form the
new form of tissue exhibits no disposition to contract. The enlargement
of the organ is largely due to hyperemia. As the tissue does not
contract there is no pressure on the portal vein and atrophy is
prevented. There is early jaundice (which is a characteristic symptom)
owing to obstruction of the biliary channels. The surface is smooth and
its color is greenish yellow.
=Symptoms.=—=Atrophic Form.=—There may be practically no symptoms.
As there is obstruction of the portal circulation, there may be
congestion of the stomach and intestines, resulting in chronic
gastric or intestinal catarrh having the following symptoms—anorexia,
distress after eating, distention, constipation and coated tongue.
Owing to the anastomotic communication between the portal and caval
circulations, as the portal circulation becomes more obstructed, the
superficial abdominal veins become greatly distended. Hemorrhoids
occur, owing to the communication of the superior hemorrhoidal,
which is a branch of the portal vein through the inferior middle
hemorrhoids, with the hypogastric vein and the vena cava; hence
hemorrhoids are a characteristic symptom. There is enlargement of the
spleen and hemorrhage from the stomach or bowels. Edema of the legs
and ascites are due to engorgement of the portal system. Ascites is
much more common than edema of the legs. There may be slight jaundice,
although this is a rare symptom in atrophic cirrhosis. There is
always decided emaciation. On examination there is a diminished area
of hepatic dullness, while the splenic dullness is enlarged. It is
often impossible to outline these organs, as the abdominal distention
prevents it. The urine is scanty, high colored and often loaded with
urates, but seldom bile-stained.
In the =hypertrophic form= slight jaundice appears at the onset, which
gradually deepens until it is intense and persistent. Occasionally
there is fever. The disease as a rule is decidedly chronic, though
acute symptoms may develop at any period. The urine is often
bile-stained, but of normal quantity. On examination the liver is
large, smooth and round and can be felt below the ribs. The spleen is
greatly enlarged.
=Diagnosis.=—In =atropic cirrhosis=.—With ascites without dropsy
elsewhere, history of alcoholism, hemorrhage from stomach or bowels and
reduction in size of liver, the diagnosis is absolute.
=Hypertrophic cirrhosis.=—In =cancer= of the liver the patient is
advanced in years, has no splenic enlargement, and more commonly
ascites is present; while in hypertrophic cirrhosis there is chronic
biliary obstruction, the liver is only moderately enlarged and hard,
marked jaundice, with causes leading to or evidence of hepatic
obstruction. This form of cirrhosis is also to be differentiated from
=amyloid liver= and =echinococcus cyst=.
=Prognosis.=—Unfavorable, although in some cases the disease can be
arrested during the early stage, provided the habits are regulated
and treatment is continuous and persistent. Death usually occurs from
one to two years after appearance of dropsy. Ascites is difficult to
contend with.
=Treatment.=—If the disease is recognized at the beginning and
persistent treatment given to the liver, the chances are that atrophy
of the cells and connective tissue formation will not take place. But
ordinarily cases of cirrhosis are incurable. The most that can be done
is to reestablish a compensatory circulation in the liver. Otherwise
it would be no more unreasonable to say that one could cure a chronic
valvular lesion of the heart. The patient should live a quiet outdoor
life. Alcoholic drinking should be stopped. The diet should be light
and nutritious, preferably a milk diet. The bowels should be kept open,
the skin active and the kidneys closely watched.