indigenous to the tropics, is of frequent occurrence, though of
comparatively recent discovery. It has been observed in India, Africa,
Brazil, and the West Indies. It is commonly seen in the embryonic
condition, living in the blood of patients affected with elephantiasis
and certain other diseases, and is also found in the urine. In this
early condition it is a minute worm, scarcely more than the 1/100 of an
inch in length, and occurs together in immense numbers.
In the sexually mature condition the female filaria is a white
hair-like worm three or four inches in length, living in the lymphatic
vessels distally to the glands, especially in those of the lower limbs
and scrotum. The embryos after leaving the parent pass into the
lymphatic stream, and thence into the circulating blood. According to
recent observations of Manson, they enter the blood in the evening and
increase in number until midnight, after which they decrease and
disappear by morning, from which time during the day they remain absent
from the circulation. The investigations of the same authority have
shown that when the blood of infected persons is sucked by mosquitoes
these insects also imbibe the embryos, which subsequently undergo
transformation in the mosquitoes into the larval state. In this
condition the filariæ may be transferred to water, by drinking which
man may become infected with the parasites. The larvæ introduced into
the stomach appear thence to make their way to the lymphatics, within
which they undergo further development to maturity, and thus remain a
long time.
The presence of the worms in the lymphatics, with their numerous brood
in the circulating blood, gives rise to hæmaturia and chyluria. As
results of the obstruction of the lymphatic currents, the parasites
induce inflammation, suppuration, lymphatic abscesses, buboes,
lymphangiectasis, {964} oedema, ascites, chylous hydrocele,
elephantiasis,[3] and certain cutaneous affections.
[Footnote 3: Several years since, with the view of ascertaining the
presence of parasitic worms, the writer examined the blood of a case of
elephantiasis under the charge of T. G. Morton, but none were detected.
From what we have since been informed of the habits of Filaria
sanguinis, the absence of the parasites may have its explanation in the
circumstance that the blood examined was withdrawn in the daytime.]
TREATMENT.--While the treatment of the affection induced by the Filaria
sanguinis is varied and uncertain, the prophylactic measures are
obvious and certain. Under favorable conditions of bright light, high
temperature, and abundant food the stagnant waters of tropical
countries are especially prolific of the minute forms of animals which
harbor parasites. It hence becomes evident that all such waters,
whether obtained from puddles, ponds, tanks, or cisterns, should be
filtered before being used for drinking. Boiling is also effectual in
destroying all the animal life of waters, and thus rendering them
innocuous so far as parasites are concerned.
* * * * *
Several other species of Filaria have been found in the human body, but
are little known and very rare in their occurrence.
* * * * *
FILARIA LOA.--This species occurs in Western Africa, on the Gaboon
River, and is perhaps more frequent than now commonly supposed. It is
an active worm, little more than an inch in length, and is usually
found beneath the conjunctiva of the eye. It probably also occupies
other positions, and a missionary on the Gaboon informed the writer
that he had extracted one from the back of one of his own fingers. Its
presence produced an intense burning pain. The negroes are reported to
extract the worm by means of a thorn. The worm has also been observed
in Brazil and the West Indies.
* * * * *
FILARIA RESTIFORMIS.--Under this name the writer recently described a
large Filaria reported to have been withdrawn from the urethra of a man
in West Virginia. It was obtained by C. L. Garnett, and sent, together
with an account of the case, to the Army Medical Museum of Washington,
where it is now preserved. It was a red cylindrical worm, twenty-six
inches in length, tapering at the head, and thick, incurved, and
obtusely rounded at the tail end.[4]
[Footnote 4: _Proceedings of the Academy of Natural Sciences_,
Philada., 1880, p. 130.]
* * * * *
FILARIA OCULI HUMANI; FILARIA LENTIS.--A few cases are on record of the
occurrence of little worms in the aqueous humor and crystalline lens of
the human eye, to which the accompanying names have been applied.
* * * * *
FILARIA TRACHEALIS.--Recently some minute worms found by Rainey in the
trachea and lungs have been described under this name.
* * * * *
In conclusion, the writer acknowledges his indebtedness for much of the
information of this article to the articles on "Intestinal Parasites"
and "Diseases from Migratory Parasites" in _Ziemssen's Cyclopædia of
the Practice of Medicine_, and to Glazier's _Report on Trichina and
Trichinosis_.
{965}
DISEASES OF THE LIVER.
BY ROBERTS BARTHOLOW, A.M., M.D., LL.D.
I. FUNCTIONAL DISORDERS.
Biliousness.
DEFINITION.--The term biliousness is used to signify a disturbance of
the gastro-intestinal digestion, with coincident excess in the
production of bile. According to the popular conception, both lay and
medical, the excess of bile is the cause of the symptoms; but when the
whole subject is carefully examined it will be found that biliousness
is made up of several factors, and that the hepatic disorder, if it
exist at all, is a mere incident.
PATHOGENY.--From the time of Galen biliousness has been regarded as a
morbid entity and the liver as the organ affected. Stoll, amongst
moderns, first revived the Galenical doctrines. Abernethy[1] was
amongst English physicians the most conspicuous advocate of the
condition called biliousness, and was the apostle of blue pill and
black draught. Copland in his great dictionary[2] more distinctly
formulated the views of the English school--especially that portion of
it influenced by the results of Indian practice--than had been
previously attempted, and hence his work best represents the opinions
and practice of the time amongst the English-speaking peoples. In this
country the great Rush first promulgated the notions of biliousness
which have since so dominated the medical opinion of this continent. A
large part of the United States has proved a fruitful soil for the
cultivation of theories of biliousness, since the condition known under
this name is a frequent accompaniment of malarial poisoning. To this
fact must be attributed the preponderating importance of biliary
derangements in the practice of the physicians of India also.
[Footnote 1: _Surgical Works_, London, 1811, vol. i. p. 36.]
[Footnote 2: _A Dictionary of Practical Medicine_, vol. ii. p. 723.]
It is a fact which will be hereafter more fully developed that malarial
infection may, and often does, derange the hepatic functions without
producing fever. The malarial poison irritates the liver, and thus more
bile is produced, but the quality deteriorates with the increase in
quantity. The functions of the liver are more disturbed during an
access of intermittent fever: the organ is swollen, the skin is muddy,
the eyes yellow, the tongue coated with a thick yellow fur, and the
urine is deeply tinged with bile-pigment.
Many of the metals employed as medicines and as poisons, as gold, {966}
silver, antimony, arsenic, phosphorus, etc., irritate the liver both in
their entrance and in their exit from the organism, and cause
biliousness; and the same fact is true of some vegetable alkaloids and
animal poisons. The liver excretes many of these substances, and in
their passage out from the blood the hepatic cells are irritated and an
increased production of bile is a result. Improper food, indulgence in
fats, sweets, condiments, and all kinds of fermented and alcoholic
liquors, intestinal indigestion arising from any cause, and
gastro-duodenal catarrh, are the most usual and obvious pathogenic
factors. In respect to food and indigestion as etiological factors
there are several points requiring more explicit statement. When
nitrogenous elements (albuminoids) are in excess in quantity or as
respects the power to digest and convert them, immature products, of
which uric acid is the chief, accumulate in the blood. When the fats,
sugars, and starches are in excess of the requirements of the organism
or are imperfectly disposed of in the small intestines, a local
irritation of the mucous membrane is produced, and various complicated,
immature products enter the blood. With these troubles and faults of
intestinal digestion a gastro-duodenal catarrh is usually associated.
Without the production of catarrhal jaundice, gastro-duodenal catarrh,
with the forms of indigestion accompanying it, keeps up a reflex
irritation of the liver. Just as the presence of normal chyme induces
the flow of bile, so the unhealthy products of intestinal indigestion
excite an irritation of the liver. The continued operation of this
cause maintains an abnormal activity of the liver, and more bile is
produced than is easily disposed of.
SYMPTOMS.--The condition of biliousness, as now understood, is made up
of derangement of the gastro-duodenal mucous membrane, with
bile-production in excess and bile-absorption probably delayed. The
symptoms are the product of these complicated conditions. The
complexion is muddy; the conjunctivæ are yellow; the tongue is heavily
coated with a yellowish-white fur; a bitter taste persists in the
mouth; the breath is heavy in odor, even fetid; the appetite may be
keen or there may be complete anorexia; a sensation of nausea, of
heaviness, and fulness of the stomach is experienced, especially after
eating; the bowels are confined usually, but occasionally the movements
are relaxed, bilious in appearance, and cause heat and irritation about
the anus; headache is constantly present to some extent, and there is a
sense of fulness with more or less dizziness, and singing in the ears;
vision is rather blurred, and there is a hebetude of mind; the urine is
high-colored, high in specific gravity, and deposits lithates
abundantly on cooling. When these symptoms are conjoined with
hemicrania, nausea, and vomiting, the case is called bilious sick
headache, and when diarrhoea supervenes, the discharges apparently
containing much bile, it is bilious diarrhoea. The symptoms which above
all others give the character to the morbid complexus are the muddy
(bilious) complexion, the yellow-coated tongue, the yellow conjunctivæ,
and the high-colored urine. The first departure from the normal may be
scarcely observed. Gradually, owing chiefly to errors of diet, to
climatic changes, or to malarial influences, or to these several
factors combined, the affected person drifts into the condition of
biliousness above described. Besides the general malaise, he
experiences no little despondency, inaptitude for exertion, and indeed
actual weakness. Finally, he is unable to apply himself to business,
relinquishes the effort, and seeks advice.
{967} COURSE, DURATION, AND TERMINATION.--Those who are accustomed to
experience attacks of biliousness suffer from them at certain intervals
which may be tolerably regular--at intervals of a few days, two, three,
or four weeks--when the cause is uniform; but they may happen very
irregularly when the conditions producing them are variable. The
duration of an attack is from two days to a week or more, according to
the severity of the symptoms and to the character of the measures
instituted for relief. The termination is in a return to the normal
state. If the conditions which produced it continue, when one attack is
ended the preparations for another begin at once, and at length
sufficient derangement of the organs concerned arises to constitute the
morbid complexus of biliousness.
TREATMENT.--Prophylaxis has great importance, since the causes of the
malady are to a considerable extent, at least, preventable. Errors of
diet in respect to the use of condiments, fats, meat, pastry, etc. must
be corrected. When there is pronounced gastro-duodenal catarrh and acid
fermentation in the duodenum, the saccharine, fatty, and starchy
elements of the food must rather be excluded and lean meats allowed.
Abundant exercise, bathing, and an open-air life in general should be
directed. Whenever a malarial infection is causative a change of
climate becomes imperative. Heredity cannot, of course, be excluded,
but the tendency to hepatic derangement can be rendered inoperative by
an abstemious life.
The remedial management includes the dietetic as well as the medicinal
treatment. When the distress has reached sufficient proportions to
justify such an extreme measure, the patient should be restricted to a
diet exclusively of skimmed milk, of which he is directed to take a
gill or more every three hours. This serves a double purpose, as
aliment and as a depurative agent, for this considerable quantity of
fluid promotes the urinary excretion and the elimination of waste
products. If the case is not severe enough to allow of such an
expedient, the diet should in any event be restricted to skimmed milk
hot, milk and hot water, hot lemonade, a little chicken or mutton
broth, a bit of dry toast, etc. As a rule, although not so palatable,
hot drinks are more beneficial than cold, but if the preference is
decidedly for cold, they may be allowed. After the more severe symptoms
have subsided a little lean meat broiled may be added, and as the cure
proceeds the succulent vegetables and acid fruits may be permitted.
Abstinence from potatoes, hominy, cracked wheat, and oatmeal should be
enjoined during the convalescence of those who suffer from habitual
attacks.
Medicines may not be necessary to those who have the resolution to
adhere to skimmed milk for several days or who can abstain from food
altogether for a day. Many experienced sufferers, especially through
the South and West and in England, procure rather prompt relief from a
blue pill of ten to fifteen grains or from one to five grains of
calomel at night, followed by a Seidlitz powder, Rochelle or Epsom
salts, or phosphate of soda on the following morning. Such patients
find that no other treatment is as serviceable. They get relief from
other measures, it is true, but neither as promptly nor as
satisfactorily. It is held by the advocates of this practice that the
mercurial acts on the liver--that the surplus bile is carried off; and
they point to the peculiar stools and to {968} the relief experienced
in evidence of the truth of this theory. Without entering on the
argument, which would occupy too much space, it must suffice here to
state that calomel and blue pill do not increase bile-production,[3]
but they do stimulate the intestinal glands and increase excretion from
them. The peculiar greenish stools produced by these mercurials do not
owe their characteristic appearance to the presence of bile, but rather
to the chemical transformations of the mercury itself and to the waste
products excreted by the intestinal glands. Since the researches of
Rutherford have been published, euonymin has been much prescribed in
cases of biliousness. From three to five grains are taken at the
bed-hour, and a mild laxative in the morning. In the same group of
cholagogues are ipecac, iridin, sanguinarin, and especially
podophyllin; but the serious objection to their use is that they
stimulate the liver when this organ is in an irritable state. As
calomel and blue pill have a sedative rather than a stimulant action on
the liver, they are more useful in biliousness than are the true
cholagogues. It should be borne in mind that one-half of a grain of
calomel will have a distinct purgative action on many persons, and that
one grain will rarely need to be exceeded.
[Footnote 3: That calomel, the type of a mercurial purgative, does not
increase the discharge of bile has been demonstrated on dogs by Röhrig
and Rutherford, and confirmed by observation of the effects of 20
grains on Westphalen's case of biliary fistula in man--a case in which,
for a time, all the bile escaped externally, and none apparently
entered the intestine (_Deutsch. Archiv f. klin. Med._, 1873, Band xi.
pp. 598 and 600).]
In general, notwithstanding the unquestionable utility of the
mercurial, it is better to relieve cases of biliousness by less
objectionable measures. A saline which acts at the same time on the
intestines and kidneys, as Rochelle salts, is usually effective in
bringing relief. A bottle of solution of magnesia citrate, of Saratoga
water (Congress, Hathorn, or High Rock), and of Blue Lick, the famous
sulphurous laxative of Kentucky, may remove the disorder in mild cases
if at the same time a suitable diet is enjoined. Phosphate of soda in
laxative doses, with or without Vichy water, is also a good remedy, if
somewhat slow. The warm purgatives, rhubarb, colocynth, aloes, etc.,
are useful when there is pronounced constipation.
Lithæmia.
DEFINITION.--By the term lithæmia is meant a condition of the system in
which uric (lithic) acid is produced in excess, and in which certain
derangements occur in consequence of the accumulation of this material
in the blood. Uricæmia was the term first suggested by Flint, Sr.,[4]
to express this state, and subsequently lithæmia was employed by
Murchison.[5] The latter has been more generally accepted. In one of
the most recent and valuable contributions to this subject by
DaCosta[6] lithæmia is the term used to designate the complex of
symptoms produced by uric acid in excess.
[Footnote 4: _The Principles and Practice of Medicine_, Philada.,
1882.]
[Footnote 5: _Clinical Lectures on Diseases of the Liver_, 2d ed., p.
565.]
[Footnote 6: _The Medical News_, vol. ii., 1883.]
PATHOGENY.--The ultimate product of albuminoid substances in the
organism prepared for final excretion is urea. That this substance is
{969} finally formed in the liver, to be excreted by the kidneys, seems
now well established.[7] In acute yellow atrophy of the liver, with the
disappearance of the proper structure of the organs urea ceases to be
produced, and instead leucin and tyrosin are excreted. In certain
states of the system characterized by deficient oxidation urea is not
sufficiently formed, and instead uric acid, a lower grade of oxidation
and a product of the disintegration of albuminoid substances, results.
An excess of urates is not always pathological. Their excretion seems
to be in a certain sense a safety-valve function. When albuminoid
matters are taken in excess of the power of the system to convert them,
or when the supply of oxygen to the blood is deficient from any cause,
urea is not formed, but uric acid and urates are abundantly excreted by
the urine.[8] Imperfect digestion of the albuminoids when they are not
taken in relatively too large an amount, and limitation below the
normal of the oxidation process when the supply of oxygen is not
insufficient, will have the same effect: in place of urea, uric acid
and urates will be formed and excreted. One of the early results of the
persistent presence of an excess of uric acid is the production of
lithæmia, the morbid complexus of which this excess is at once the
cause and the proof.
[Footnote 7: This proposition is not universally accepted. Valmont
(Thèse de Paris, _Étude sur les Causes des Variations de l'Urée dans
quelques Maladies du Foie_, 1879) has carefully studied the excretion
of urea in several diseases in which the proper structure of the liver
is damaged--in atrophic cirrhosis and in cancer. As in these maladies
not all the secreting portion of the organ is destroyed, the argument
is so far weakened. His conclusions are as follows: "1. Patients with
cirrhosis or cancer of the liver who eat little excrete but little
urea. If they eat and do not absorb, or vomit or have diarrhoea, the
result is the same. When they partake largely of nitrogenous aliment
the proportion of urea rapidly increases. 2. In a cachectic or simply
anæmic patient the urea falls, apparently in proportion to the state of
the general nutrition and of the work done by the organic functions. 3.
Absolute immobility of the patient seems to have an influence on the
amount of urea excreted. 4. In sclerosis or cancer the quantity of urea
falls rapidly on the occurrence of ascites or oedema, when a notable
quantity of urea is found in the fluid. 5. The digitalis often used in
the treatment also contributed to the loss of urea." If these
conclusions are verified, the formation of urea must depend on some
other function.]
[Footnote 8: Genevoix, _Essai sur les Variations de l'Urée et de
l'Acide urique dans les Maladies du Foie_, Paris, 1876.]
The persons who suffer from lithæmia are usually those who indulge in
the pleasures of the table and habitually consume much meat, pastry,
and highly-seasoned and rich food of all kinds. The idle, luxurious,
and indolent, literary men of sedentary habits, men who have led active
lives, but on retiring from business have continued to indulge in a
full diet, are apt to suffer from this malady. Women are less disposed
to it, but if subjected to the same conditions may also be similarly
affected. Especially do those suffer from lithæmia who indulge in malt
liquors or in alcoholic drinks of any kind. These substances act by
deranging digestion, and thus preventing the proper conversion of the
albuminoids, by inducing congestion of the liver, and also by
interfering with the process of oxidation.
SYMPTOMS.--The symptoms of lithæmia include derangements of the
digestive organs and of the liver, of the circulation, and of the
nervous system. As these subjects suffer from gastric and
gastro-duodenal catarrh, they present the usual symptomatology of these
affections, as a sense of weight and oppression at the epigastrium,
acidity, pyrosis, a capricious--sometimes voracious, sometimes
good--appetite, a coated {970} tongue, a bitter taste, etc. The bowels
are irregular, sometimes constipated, occasionally relaxed, with
scybalæ. The stools may be liquid, almost black or light-yellow and
grayish. The motions are apt to be offensive, and a good deal of
offensive gas is discharged with them. Hemorrhoids are often present,
and there may be heat and irritation about the anus, and not
unfrequently intolerable itching. After meals there is much depression,
and often an insupportable drowsiness. Irregularity in the rhythm, even
intermissions, of the pulse are not infrequent.
The nervous symptoms, as DaCosta has lately insisted on, are the most
important and pronounced. The connection between oxaluria and mental
despondency has long been known, but the nature of the relation remains
undetermined. Headache, frontal and occipital, especially the former,
dizziness, tinnitus aurium, suffusion of the eyes, ecchymoses of the
conjunctiva, are usually present. Not unfrequently the subjects of this
affection experience sudden attacks of vertigo, accompanied by dimness
of vision and intense headache, and are supposed to have some organic
lesion of the brain. They are irritable, despondent, and often
intensely hypochondriacal, almost suicidal--are subject to neuralgic
attacks, and have aching in the limbs, a sense of weariness, and more
or less burning in the palms and soles.
The skin is rather dry and the complexion muddy. Urticaria is of
frequent occurrence, and sudden attacks of nausea, vomiting, and
intestinal pain coincide with the appearance of the eruption on the
skin.