process of digestion is going on. The afferent vessels dilate, and not
only more blood, but various materials taken up from the foods and
products of digestion, many of them having directly stimulating
effects, also pass to the organ. Frequent and large indulgence in food,
especially if rich in quality and highly seasoned with spices, mustard,
etc., the consumption of malt liquors, wines, and alcoholic fluids in
general, the habitual use of strong coffee and tea, gradually induce a
state of hyperæmia. If to the consumption of a large quantity of
highly-stimulating food there is added the mischief of insufficient
waste, the danger of congestion of the liver is the greater. Persons
addicted to the pleasures of the table are apt to pursue sedentary
lives, and hence, besides the inappropriation of the material digested,
the process of oxidation is insufficient to burn off the surplus. A
sedentary life further tends to make the circulation in the hepatic
veins sluggish by lessening the number and depth of the respirations,
and with the obesity developed under these conditions the propelling
power of the heart is diminished by fatty degeneration or fatty
substitution of the cardiac muscle. Disease of the semilunar ganglion,
the solar plexus, and of the splanchnics under circumstances and of a
nature not now well understood may cause dilatation of the hepatic
vessels.
Suppression of a long-existing hemorrhage from piles and from the
uterine system has caused hyperæmia of the liver. Evidences of hepatic
congestion are comparatively common about the menstrual period in
consequence of the tardy appearance of the flow, of its insufficiency,
or of its sudden suppression. There is a form of jaundice known as
icterus menstrualis, and attacks of hepatic congestion are not uncommon
at the climacteric period.
The most important causes of hyperæmia of the liver are mechanical, and
consist in obstruction to the circulation in the ascending vena cava
from disease of the heart or lungs. Dilatation of the right cavities,
incompetence of the tricuspid, and stenosis of the mitral orifice are
the usual cardiac changes leading to congestion of the liver. The same
effect, to a much less extent, however, is produced by any cause which
weakens the propelling power of the heart, as myocarditis,
pericarditis, etc. Amongst the pulmonary lesions obstructing the venous
circulation are emphysema, interstitial and croupous pneumonia,
effusions into the pleura, intrathoracic aneurisms or tumors, etc. It
should not be forgotten that effusions into the left pleura, as was
demonstrated by Bartels[39] and confirmed by Roser,[40] so push over
the mediastinum toward the right and bend the vena cava in the same
direction, just as it emerges from the opening in the diaphragm, that
the circulation in this vessel is impeded, and consequently congestion
of the liver induced.
[Footnote 39: _Deutsches Archiv für klin. Medicin_, Band iv. p. 265.]
[Footnote 40: _Archiv der Heilkunde_, Band vi. p. 40.]
The influence of climate, especially of long-continued high
temperature, has been warmly disputed. On the whole, it seems probable
that in warm climates congestion of the liver is much more common.
Malarial infection is an unquestionable cause. In the section on
Jaundice it was stated that this symptom may occur without the
phenomena of fever, and, indeed, without any other disturbance of the
system. In a large proportion of cases of intermittent fever, probably
in all, more or less congestion of the liver occurs.
{985} PATHOLOGICAL ANATOMY.--Congestion may take place in the portal
system, and be due to conditions of the gastro-intestinal mucous
membrane, or in the hepatic vein and radicles, due to obstructive
troubles in the heart or lungs. The appearances vary accordingly.
Restricting the observations to the hyperæmia, and not including
subsequent lesions, it suffices to say that the liver is somewhat
enlarged, rather darker in color than the normal, and uniformly so; the
radicles and branches of the portal vein in the liver, the trunk of the
vein itself, and the veins of the spleen, stomach, intestines,
mesentery, etc. are distended with black blood, and the tissue of the
liver rather wet, inclined to soften, and here and there marked by
minute hemorrhages from rupture of small vessels. The extravasations of
blood accompany the hepatic congestion of hot climates, and probably
are the preludes to suppurative inflammation. The portal system the
more readily suffers from a passive congestion because of the provision
for the alternate expansion and contraction of the tunics of the
vessel, scantily supplied with contractile elements. An acute
congestion of the liver produced by sudden dilatation of the
capillaries of the hepatic artery has not been described, but it would
appear to be possible.
The most important form of hepatic congestion is the mechanical,
arising from obstruction of the circulation in the heart or lungs. In
consequence of this obstruction the blood accumulates on the venous
side, and there is in consequence an ischæmia of the arterial side. The
hepatic vein becomes distended, and its terminal radicle in the centre
of each acinus--the central vein--enlarges with the increased pressure.
It follows that the minute capillaries emptying into the central vein
are also distended with blood, and finally the portal vein and its
radicles throughout are similarly affected. The same condition of the
hepatic circulation was long ago observed by Virchow[41] as a result of
weakness of the muscular tissue of the heart, and consequently
diminished propelling power of the organ. On section of the liver much
black blood flows out; each central vein is a distinct dark object in
the centre of each acinus, and contrasts strongly with the surrounding
paler substance, whence the common term for this appearance is nutmeg
liver. The long-continued distension of the central vein leads to
sclerosis of its walls,[42] and the neighboring hepatic cells undergo
atrophy in consequence of the greater pressure. A relatively increased
quantity of connective tissue seems to result, but whether hyperplasia
occurs is disputed. By Talamon[43] such increase of the connective
tissue is denied, but Thierfelder[44] admits that there is an apparent
and also in some cases a real increase. The atrophy of the cells
induces more or less shrinking and consolidation of the liver; it is
therefore smaller in size and firmer in texture, and presents a
brownish-red color. The atrophic change in the hepatic cells is
represented finally by some brownish or black pigment, but it is rare,
indeed, for all the cells of an acinus to disappear. To this change has
been applied the term cyanotic atrophy. In some instances
Liebermeister[45] {986} has found an increase of the connective tissue
of the liver; and this opinion is confirmed by Legg.[46] When this
multiplication of the connective tissue occurs, the condition of the
liver is entitled cyanotic induration. The sclerosis originating in
this way is distinguished from true cirrhosis by its less extent,
irregularity, situation, and the marked degree of hepatic congestion.
[Footnote 41: _Archiv für path. Anat., etc._, Band v. p. 289.]
[Footnote 42: Talamon, _Recherches anatomo-pathologiques et cliniques
sur le Foie cardiaque_, Paris, 1881 (pamphlet).]
[Footnote 43: _Ibid._]
[Footnote 44: _Atlas_.]
[Footnote 45: _Beiträge zur path. Anat. u. Klinik der
Leberkrankheiten_, Tubingen, 1864, p. 209 _et seq._]
[Footnote 46: _Medico-Chirurgical Transactions_, vol. lviii. p. 345.]
SYMPTOMS.--Hyperæmia of the liver is usually one of the complex
conditions of a morbid state, and hence is associated in its
symptomatology with the connected maladies. On the one hand associated
with gastro-intestinal disorders, on the other with cardiac and
pulmonary diseases, the symptoms must be varied accordingly. It is
necessary, however, to indicate as clearly as may be those belonging to
the hepatic circulation.
Congestion of the portal circulation is a condition to which frequent
references are made, but which is rarely clearly defined. As seen in
the West and South, it signifies a gastro-intestinal catarrh more or
less acute, with an obvious condition of biliousness, as manifested in
a faint jaundiced tint of the skin and of the conjunctivæ, uneasiness
in the right hypochondrium, with enlargement of the area of hepatic
dulness, the evacuations from the bowels being either grayish or
clay-colored, or more frequently bilious, acrid, and offensive.
The gastro-intestinal disorder which initiates the hepatic disturbance
should not be confounded with that which succeeds to congestion of the
hepatic veins. The latter invariably comes on after the obstruction at
the heart or lungs has continued for some time. There occurs in this
state very extensive hyperæmia of the gastro-intestinal mucous
membrane, and consequent disorders of stomachal and intestinal
digestion. The former is a reflex cause of disturbance, probably
through the intermediation of the solar plexus. The gastro-intestinal
irritation, by depressing the functions of the hepatic through the
solar plexus, induces a paresis of the muscular layer of the portal
system, and thus congestion ensues. Such a result is aided by high
temperature, but especially by the constitutional tendencies of some
subjects to hepatic disturbances. In such examples of hyperæmia the
symptoms consist of those belonging to gastro-intestinal catarrh,
succeeded by those referable to the liver, consisting in uneasiness,
heaviness, and fulness of the right hypochondrium, increase in the area
of hepatic dulness, soreness on pressure along the inferior margin of
the ribs and over the epigastric region, yellowness of the conjunctivæ,
a fawn color of the skin generally, and high-colored rather scanty
urine, depositing abundantly uric acid and urates. A liver considerably
enlarged and projecting one or two fingers' breadths below the ribs may
be quickly relieved and return to the normal size on the occurrence of
hemorrhage from piles or after free watery evacuations produced by a
hydragogue cathartic.
The form of hepatic congestion most usually observed is that of the
hepatic vein, caused by obstructive troubles of the heart or lungs, and
known as the nutmeg liver. The increase of size of the liver under
these circumstances may be very considerable. To determine an increase
in the area of hepatic dulness the position of the organ must be
ascertained with reference to the position of the body, whether
recumbent or erect. In the former position the liver gravitates toward
the thorax; in the {987} latter, downward into the abdomen. If
palpation only were employed to detect an increase in the size of the
organ, an error might readily be committed in this respect. Some
congestion may doubtless exist without an actual increase of size
recognizable by our means of investigation; there may be merely some
distension manifested by a sense of increased resistance; the liver may
project a hand's breadth below the ribs; and between these extremes
there may be all possible degrees of enlargement. When the liver, in
consequence of hyperæmia, projects below the ribs, it offers to the
sense of touch the impression of a smooth, elastic, rather rounded
surface, and not the hardness and nodular character of sclerosis, and
not the sharpness of border and hardness of texture belonging to
amyloid disease. The enlargement of the liver due to hyperæmia is
further distinguished by the fact that it varies much in size at
different times, and may be much reduced by hemorrhage from the portal
system, and increased suddenly by an attack of dyspnoea.
When the liver is enlarged by hyperæmia the patient usually has a
distinct appreciation of the fact, feels a sense of weight, tenderness,
and oppression in the right hypochondrium, and experiences a painful
dragging from the right toward the left when turned on the left side.
In some cases pain is felt in the shoulder, or, if not pain, a feeling
of weight. A slight icteroid hue of the conjunctiva, face, upper
extremities, and trunk is often present, but the stools are not wanting
in bile and the urine contains but little pigment--facts indicating
that the obstruction is limited to a small number of ducts. If the
jaundice is decided, the stools clay-colored, and the urine loaded with
pigment, a catarrhal swelling of the common or hepatic duct exists.
As nutmeg liver is an incident in the course of the venous stasis from
cardiac or pulmonary obstructive disease, it is not unusual to find
ascites and general dropsy occur. When ascites precedes the other
manifestations of dropsy, and is relatively more important, the hepatic
congestion has led to atrophy of the cells and contraction of the
organ, or to cyanotic induration, as it has been designated in
contradistinction to cirrhotic induration.
The subjects of hepatic congestion, especially of that form of the
malady due to gastro-intestinal irritation, are apt to experience no
little mental depression, even hypochondriasis, as, indeed, is usual in
most cases of hepatic disease.
COURSE, DURATION, AND TERMINATION.--The behavior of any case of
hyperæmia of the liver is determined, first, by the character of the
cause, and, secondly, by the extension of the mischief and the atrophic
changes which ensue. The congestion arising from gastro-intestinal
irritation is comparatively short-lived, since the causal conditions
may usually be promptly removed. It is far different in the cases due
to pulmonary or cardiac disease. If caused by a left pleuritic
exudation, the congestion will disappear as soon as the bend in the
ascending vena cava is removed by paracentesis. If, however, produced
by a permanent pulmonary obstruction, the course of the hepatic disease
is toward cyanotic induration. The same is true of obstructive cardiac
lesions. If compensation--as, for example, of a mitral
regurgitation--is not effected, the continual congestion must lead to
the ultimate lesions of the liver; but if compensation can be brought
about, the liver will be saved the irremediable {988} changes. The
prognosis, therapeutical and pathological, must necessarily be
dependent on the lesions of which the hyperæmia of the liver is merely
a symptom.
DIAGNOSIS.--The decision in any case of hyperæmia of the liver must
rest on the determination of the gastro-intestinal, pulmonary, or
cardiac diseases causative. When, for example, to the gastro-intestinal
disturbance or cardiac disease there are added heaviness, uneasiness,
increased area of dulness of the right hypochondrium, a hyperæmia of
the liver may be concluded to exist. The extent to which the organ is
damaged may be judged from its size, the duration of the congestion,
and the character of the determining cause. If the area of hepatic
dulness declines steadily after having been increased, the causative
conditions continuing, the shrinking is due to atrophy. This view is
confirmed if ascites has appeared and increased out of proportion to
the general dropsy.
TREATMENT.--Those cases of hyperæmia dependent on excesses in eating
and drinking require the substitution of a diet composed of lean meat,
skimmed milk, acid fruits, and such succulent vegetables as lettuce,
tomatoes, celery, etc. When there is a high degree of gastro-intestinal
catarrh, an absolute milk diet may be enforced with great advantage.
The diet, exercise, bathing, etc. enjoined in the section devoted to
lithæmia are equally applicable here. Amongst the special plans of diet
sometimes advocated in the condition of abdominal plethora or portal
congestion are the grape cure, the whey cure, etc. Great good is
accomplished by a simple diet and a course of the Saratoga saline
laxative waters--the Congress, Hathorn, Geyser, etc. The alkaline
waters of Wisconsin and Michigan, the White Sulphur of Virginia, and
others having similar properties in this country may be employed for
the same purpose. The saline laxatives, Pullna, Friedrichshall, and
other purgative salines, may be used in robust, plethoric subjects with
much portal congestion, hemorrhoids, etc. Phosphate of soda, given in
sufficient quantity to maintain a soluble state of the bowels, is also
a useful remedy. The resinous cathartics, podophyllin, jalap, rhubarb,
aloes, euonymin, iridin, baptisin, etc., are all useful when the
indication is to unload the portal circulation. The mercurials,
formerly so much used, are now discredited to an unwarranted degree. In
an irritable state of the gastro-intestinal mucous membrane calomel in
small doses is remarkably useful.
The treatment of congestion of the hepatic vein is included in that of
the lesion causing it. In some rather exceptional cases the liver
enlarges considerably in consequence of incompetence of the mitral,
without there being any other conspicuous evidence of the lesion.
Remarkable relief is afforded to the hepatic symptoms by the
administration of digitalis. The important point in all cases due to
cardiac disease is to bring about compensation, and thus obviate the
consequences of the lesion. Remediable pulmonary affections should be
cured as promptly as possible, and the evil results of incurable
affections lessened by efforts to remove the hepatic hyperæmia. Careful
alimentation, saline laxatives, and diuretics are the most efficient
measures. It would be encroaching on the subjects of pulmonary and of
cardiac diseases to enter more minutely into the therapeutical
questions connected with a symptom of these affections.
{989} Perihepatitis.
DEFINITION.--By the term perihepatitis is meant an acute inflammation
of the serous envelope of the liver. It may be acute or chronic, very
rarely the latter, and it is usually a secondary affection, although
primary cases are not uncommon.
PATHOGENY.--Inflammation of the hepatic portion of the peritoneum may
arise by an extension of the morbid process from neighboring parts, as
in perforation of the stomach or duodenum, pleuritis of that part of
the membrane reflected from the diaphragm, etc. More frequently it
arises by contiguity from some disease of the liver itself, as chronic
interstitial hepatitis, abscess, echinococci cysts, cancer, etc. The
author has frequently (comparatively) seen perihepatitis follow the
passage of gall-stones. It is usual to find considerable organized
exudation at the hilus of the liver in the case of those who have had
several attacks of hepatic colic, and attachments to various
neighboring parts also. In those instances of secondary hepatitis there
may be more or less extensive connective-tissue formation and
compression of the hepatic substance (Budd).[47]
[Footnote 47: _Diseases of the Liver_; also, Bamberger, _Krankheiten
des Chlylopoietic Systems_, p. 495, 2d ed.]
Direct perihepatitis arises from traumatic causes--from contusions of
the right hypochondrium by spent balls, blows and falls, etc.
Tight-lacing and wearing a strap to support the trousers are supposed
to excite a slow, chronic hepatitis, but the latter is more certain to
bring about such a result than the former.
SYMPTOMS.--Acute perihepatitis, if of sufficient extent, causes more or
less fever; pain is felt in the right hypochondrium, and is increased
by pressure and by deep inspirations, and in some rare instances a
friction murmur is audible synchronous with the respiratory movements.
These symptoms succeed to attacks of hepatic colic, perforation of the
stomach or intestine, and contusions of the abdominal wall. The chronic
form is not febrile; there is a feeling of soreness instead of acute
pain; pressure, the movements of the body, respiration, etc. increase
the distress, and on turning on the left side a painful dragging is
experienced. A slight degree of icterus may be present in both acute
and chronic cases.
COURSE, DURATION, AND TERMINATION.--The course of the acute cases is
toward recovery. In two or three days the inflammation reaches the
maximum, adhesions form, and then the morbid process declines. The
whole course of an acute perihepatitis caused by external injury or by
the passage of gall-stones is terminated in a week or ten days. The
mischief done may not be limited to the adhesions formed. The large
quantity of newly-organized connective tissue may, in its subsequent
contraction, compress the common, cystic, or hepatic duct, or the
portal, or both ducts and vein. The course of the chronic cases is
determined by the causative lesion. The contraction of the new-formed
connective tissue may compress the organ and lead to sclerotic changes
which cannot be distinguished from cirrhosis. In some instances
contusions set up suppurative inflammation, and an abscess forms
between the parietal and glandular layer of the peritoneum. Such a case
will then present the phenomena of hepatic abscess.
DIAGNOSIS.--The determination of the character of the case will be
{990} largely influenced by the history. If the attack has followed a
blow on the side or a paroxysm of hepatic colic or the symptoms of
perforation, there will be no difficulty in determining its seat and
character. In the absence of the history the differentiation must be
made between perihepatitis and pleuritis. The distinction consists in
the fact that in the former the pain and soreness are below the line of
respiratory sounds, although synchronous with them. In chronic
perihepatitis the symptoms come on in the course of the hepatic
disorder, or are consequent on a local injury, as the pressure of stays
or a band.
TREATMENT.--If the symptoms are acute and the subject robust, the local
abstraction of blood by leeches affords relief and diminishes the
violence of the disease. A bandage should be tightly applied around the
body at the level of the hypochondrium to restrain the movements of the
affected organ. A turpentine stupe may be confined in this way, or a
compress of water may be utilized to serve the same purpose. If the
pain is acute and the peritonitis due to perforation or to the passage
of calculi, the hypodermatic injection of morphia is the most important
resource.
Interstitial Hepatitis; Sclerosis of the Liver; Cirrhosis.
DEFINITION.--The terms interstitial hepatitis and sclerosis of the
liver express the nature of the malady: they signify an inflammation of
the intervening connective tissue, resulting in a sclerosis--an
induration of the organ. The term cirrhosis, now so largely in use, was
originally proposed by Laennec[48] because of the yellowish tint of the
granulations, from the Greek word, [Greek: chirros], yellow. As
Laennec's theory of cirrhosis was erroneous, having regarded these
granulations as new formations, the word is a very faulty one, and
hence it would be preferable to use the term sclerosis, since a similar
change in other organs is thus designated, as sclerosis of the kidney,
sclerosis of the lungs, etc. It is also called in England gin-drinker's
liver, hobnail liver. Carswell[49] first described the anatomical
changes with accuracy, and illustrated them with correct drawings. The
following year Hallmann[50] confirmed the truth of Carswell's
descriptions, and contributed a good account of the morbid anatomy; and
subsequently French, German, and English authorities added new facts,
which will be set forth in the further discussion of the subject.
[Footnote 48: _Traité de l'Auscultatlon médiate_, tome ii. p. 501.]
[Footnote 49: _Illustrations of the Elementary Form of Diseases_,
fasciculus 10, plate 2.]
[Footnote 50: _De Cirrhosi hep._, Diss. Inaug., Berolini, 1839, quoted
by Thierfelder.]