of the hepatic cells and the consequent shrinking of the interlobular
connective tissue, goes on slowly. Several months may be occupied in an
amount of atrophy distinct enough to be recognized by the narrowing of
the area of hepatic dulness. Especially difficult is the recognition of
the contraction when ascites has fully distended the abdomen. It may be
necessary under such circumstances to postpone a decision until tapping
has removed the fluid. If the organ can be felt by depressing the walls
of the abdomen, more or less unevenness of surface may be detected, and
the inferior margin may give the impression of hardness and sharpness
of outline. At the same time, the increased dulness of the epigastric
region observed during the hypertrophic stage will have gradually
ceased because of the shrinking of the left lobe. The liver may be
undergoing the atrophic degeneration to a marked extent and yet remain
large--larger even than normal. Such a state of things may be due to
conjoint amyloid or fatty degeneration of the organ, and, indeed, more
or less fatty change occurs in all cases of cirrhosis. The shrinking of
the liver persists until the area of dulness is not greater in area
than two or three ribs.
The disturbances of function in sclerosis of the liver are not limited
to the chylopoietic system. As the secreting structure of the liver is
continually lessened in extent by the atrophy, symptoms result from the
necessary interference in the hepatic functions. These symptoms are
concerned with the liver, with the nutrition of the tissues of the
body, and with the kidneys. As regards the biliary function of the
liver, the quantity of bile acids and pigment is reduced below the
normal in proportion to the damage done to the organ. As a rule, there
is little jaundice in sclerosis, and very little bile-pigment present
in the urine. Hence there must be little produced. Instead of a
jaundiced hue of the skin, it has a fawn color--an earthy, sallow tint
eminently characteristic of a chronic affection in which the power to
produce bile is much impaired. Occasionally it happens, particularly in
the early stages of cirrhosis, that a well-marked jaundice appears in
the face and body, but this probably is due to a catarrh of the
bile-ducts. In most cases the integument presents the earthy and sallow
hue above mentioned. Graves[77] appears to have been the first to
interpret aright the greater significance of this appearance of the
skin than the purely jaundiced tint. The glycogenic {998} function of
the liver must be impaired in the same ratio as the biliary. The
nutrition of the body suffers; the skin becomes dry and harsh; the fat
disappears; the temperature of the body, unless the conditions for
producing fever are present, is barely up to normal, if not somewhat
below; a marked degree of anæmia supervenes; and the action of the
heart becomes feeble and rapid after a period of slowness. The blood is
altered in quality, and hence hemorrhages--epistaxis especially--occur,
petechiæ and ecchymoses appear in the skin, and stigmata are numerous
about the face and nose.
[Footnote 77: _Clinical Medicine_, _op. cit._]
The urine in cirrhosis is high-colored because of the abundance of
pigment, and in the early stages of the disease is increased in amount,
although of lower specific gravity. When much effusion takes place into
the peritoneal sac, the compression of the renal veins by the fluid
lessens the activity of the kidneys and diminishes the urinary flow.
Much discussion has taken place over the quantity of urea present in
the urine in cases of cirrhosis, but it has been established that the
relative quantity of urea lessens in proportion to the damage suffered
by the liver.[78] The urates are in excess.
[Footnote 78: Charcot, _Leçons sur les Maladies du Foie_, _loc. cit._,
p. 252; also, _Essai sur les Variations de l'Urée dans les Maladies du
Foie_, par F. Genevoix, Paris, 1876; _Des Rapports de l'Urée avec le
Foie_, par A. Martin, Paris, 1877; _Sur l'Urée et ces Variations dans
la Cirrhose_, Thèse de Paris, Audiguier; _Contribution à l'Étude du
Rôle du Foie dans la Product. de l'Urée_, Reufflet.]
COURSE, DURATION, AND TERMINATION.--There are enormous variations in
the course of the disease as respects the rate of its progress. In
general, it may be said that the whole duration is from three months to
six years. The onset is often insidious, and little distress is
occasioned until effusion begins in the abdomen. In other cases there
is considerable pain in the right hypochondrium, severe disorders of
digestion and intestinal derangements, rapid emaciation, ascites, and
some intercurrent malady which terminates them, often quite
unexpectedly. The usual course is as follows: After the protracted use
of alcoholic stimulants the symptoms of gastro-intestinal catarrh
appear; there occur acidity, pyrosis, morning vomiting, and distress
after meals; the bowels are irregular, the stools rather dark and
offensive; the bodily vigor declines and the mental condition is
depressed and hypochondriacal; emaciation progresses; the skin becomes
dry, harsh, and fawn-colored; stigmata appear on the face; some
uneasiness is felt in the abdomen, through the right hypochondrium, and
about the umbilicus; presently the abdomen enlarges and the feet and
legs swell; after a time the abdominal enlargement is extreme and the
walls become thin, the genitals and thighs are greatly distended, and
the prepuce is so swollen that urination grows more and more difficult,
the penis almost disappearing in the surrounding oedema;
notwithstanding the immense size of the abdomen and lower extremities,
the chest, face, and upper extremities are wasted away; to lie down is
impossible, and only snatches of disturbed sleep are procured in the
upright sitting posture; breathing grows more and more difficult, and a
sense of suffocation is imminent; and, thus worn out by suffering and
want of sleep, the patient at last sinks into a soporose state and dies
comatose, if not cut off before by some acute serous
inflammation--pleuritis, peritonitis, peri- or endocarditis, pneumonia,
etc.
{999} The course of any case of cirrhosis is much influenced by the
amount of damage to the hepatic cells and by the extent of the
compensatory changes in the circulation. Ulcers of the stomach or
intestine, opening vessels, or hemorrhages from the mucous membranes
may have a pronounced effect on the progress of any case. A fatal
result was determined in a case under the writer's charge by hemorrhage
from ulcers near the pylorus, which were caused by thromboses of the
stomach veins at that point. Occasionally, the occurrence of thrombosis
of the portal vein adds an embarrassing and dangerous complication. The
liver, besides the change due to cirrhosis, may be affected by amyloid
or fatty degeneration, or by both combined. It should not be forgotten
that more or less fatty change takes place in the hepatic cells
undergoing atrophy, whence the appearance called cirrhosis. Sclerosis
may be a general condition in which several organs participate, the
kidneys notably. These organs are changed by a hyperplasia of the
connective tissue, and especially by fatty degeneration of the
epithelium. In the brain the sclerosis consists in chronic
pachymeningitis, adhesions of the dura, etc., and with these
connective-tissue changes are often associated extravasations of blood.
These lesions are probably due to chronic alcoholism rather than to the
cirrhosis--are simultaneous lesions, instead of consecutive.
The duration of cirrhosis must necessarily depend largely on the
occurrence of the complications above mentioned and on the appearance
of intercurrent diseases. The most usual intercurrent maladies are
peritonitis, pleuritis, and other serous inflammations. An attack of
cerebral (meningeal) hemorrhage may occur. Failure of the heart may be
due to fatty degeneration of its muscular tissue. Stupor, coma, and
insensibility may come on toward the close in consequence of the
retention of excrementitious matters. By Flint, Jr., these cerebral
symptoms were referred to the retained cholesterin, and hence he
designated this state cholesteræmia. Numerous experimentalists
(Pagès,[79] Chomjakow,[80] Von Krusenstern,[81] Koloman Müller[82])
have studied this question, and only Müller has been able to confirm
Flint's theory. The condition is more suitably designated cholæmia,
which signifies blood-poisoning from the excrementitious biliary
matters retained in the system.
[Footnote 79: Quoted by Legg, p. 233.]
[Footnote 80: Quoted by Krusenstern.]
[Footnote 81: _Virchow's Archiv_, Band lxv. p. 412.]
[Footnote 82: _Archiv für experimentelle Pathologie und Pharmakologie_,
Band i. p. 213.]
Any fully-developed case of cirrhosis can only terminate in one way,
for we possess no means of restoring the hepatic cells when once
destroyed. At the outset of the disease, before any serious changes
have taken place, it is probable it may be arrested. Proceeding to its
natural termination without complications or intercurrent affections,
death finally occurs from exhaustion. The emaciation becomes extreme,
the stomach gets to be excessively irritable, and an exhausting
diarrhoea consumes the last remains of strength. Then an oedema of the
lungs or failure of the heart or a deep coma ends the scene.
DIAGNOSIS.--Cirrhosis in its first stage is to be distinguished from
diseases which cause enlargement of the liver, and in its second or
contracting stage from diseases that induce contraction of the organ.
The history of alcoholic excess is an important means of
differentiating this {1000} from other affections. The enlargement
belonging to alcoholism is distinguished from that due to amyloid
disease by the permanent character of the latter and by its history of
chronic suppuration, in addition to, it may be, alcoholic excess; from
cancer, by the character of the enlargement, by its permanence, by the
secondary deposits in the mesentery and elsewhere, by the severe and
persistent pain; from hydatids or echinococci cysts by the painless
enlargement of the latter, by the absence, usually, of any interference
with the hepatic functions, by the purring thrill, and by the presence
of the characteristic hooklets in the fluid withdrawn. From the
maladies characterized by the contraction of the organ it is
distinguished by the rapidity with which the case is developed in acute
yellow atrophy, and by the profound constitutional disturbance
characteristic of this form of contraction. When the liver is lessened
in size in consequence of the compression exercised by the contracting
exudation of a local peritonitis, there is a history of pain and
soreness of the right hypochondrium, followed by the symptoms of
contraction--a very different history from that of cirrhosis, in which
the local attacks of pain and distress succeed to or accompany the
symptoms of contraction. Occlusion of the gall-ducts by a calculus may
set up a slow atrophy having some points of resemblance to cirrhosis;
but in this malady attacks of hepatic colic precede the signs of
obstruction, the jaundice, and gray evacuations, and the evidences of
contraction succeed to these very characteristic symptoms; whereas in
cirrhosis paroxysms of pain followed by jaundice are not known.
Occlusion of the portal vein may also be followed by atrophy, but this
is usually due to some other affection of the abdominal organs, and the
change in the condition of the liver occurs very promptly, there being
neither the history nor the course of symptoms belonging to cirrhosis.
TREATMENT.--As the abuse of alcoholic liquors--even their habitual use
in moderation--is the chief pathogenetic factor, they should be
entirely given up. Condiments, coffee and tea, highly-seasoned animal
foods, are of less importance as causes, but are sufficiently injurious
to require them to be discontinued. The food of such subjects should
not contain fat, because the bile is necessary to its right
assimilation, and should have but a small proportion relatively of
starch and sugar, since these articles readily ferment in the presence
of an excess of mucus and in the absence of the bile. The succulent
vegetables, as lettuce, celery, spinach, etc., should be substituted
for the starchy and saccharine. A diet largely composed of skimmed milk
renders an important service both as a nutrient and a diuretic and
depurant. Lean meats, acid fruits, and the weak alkaline mineral waters
should be the basis of a proper system of alimentation.
As malarial intoxication is a cause now distinctly recognized, patients
should be removed from such influences. If this be impracticable, the
effects of the poison should, as far as possible, be removed,
especially the glandular complications. To this end, such remedies
should be employed as will affect the overgrowth of the connective
tissue, as the compound solution of iodine, the bichloride of mercury,
and the chloride of gold (or gold and sodium). Quinine will be
necessary, according to circumstances.
Do we possess any means to check the overgrowth of connective tissue
{1001} in cases of sclerosis? The writer believes that those remedies
have this power to a less or greater extent which are separated by the
liver from the blood. These are chiefly the salts of gold, silver,
copper, arsenic, and mercury (chloride), and phosphorus. The most
useful of these are the chloride of gold and sodium and the chloride of
mercury, and some phosphates. The writer has had, he thinks, curative
results in the commencement of the disease from the chloride of gold
and sodium and the phosphate of sodium. German practitioners believe
that the chloride of ammonium is a powerful alterant and deobstruent,
and prescribe it in this affection to stop the overgrowth of connective
tissue. That it does have this effect can hardly be disputed, but the
daily quantity necessary is large, the taste very disagreeable, and the
stomachal effect that of an irritant. Hence it is by no means so
effective as the chlorides above mentioned. The chloride of gold and
sodium (1/10 grain) can be given at the same time with chloride of
mercury (1/20 grain) if it is desirable to combine their effects. The
writer has seen what appeared to be cases of cirrhosis in the first
stage yield to the persistent administration of phosphate of
sodium--drachm j ter in die--and the chloride of gold and sodium.
When contraction of the liver has ensued, and hemorrhages, effusion
into the cavity of the peritoneum, and a high degree of
gastro-intestinal catarrh have occurred, the relief of the secondary
symptoms takes the first place in importance. There are but three modes
by which an effusion into the abdomen can be removed: by the skin, by
the kidneys, by the intestinal canal. Each of these may be employed in
turn. By the skin warm baths, vapor baths, digitalis stupes, and
especially the subcutaneous injection of pilocarpin, may be employed.
These alone may be sufficient in some cases--rather rarely, however.
They may all be used simultaneously or in turn to effect the purpose. A
digitalis stupe may be made to have the effect of a vapor bath: a large
one is placed on the abdomen and the body is covered with blankets,
which results in the production of abundant sweating. The vapor bath is
applied in the ordinary way, so that no explanation is needed. If there
be no contraindication in the state of the heart, pilocarpin salts can
be injected in sufficient quantity to induce active diaphoresis. These
measures proving inadequate, an attempt should be made to dispose of
the fluid by acting on the kidneys and promoting diuresis. Amongst the
diuretics in ascites, Wilks places the resin of copaiba first. The dose
ranges from two to five grains, and it may be given in combination with
gold or mercury chloride. When this remedy increases the flow of urine,
it does good, but if the quantity of urine remains unchanged, it does
no good, and should be discontinued.
As the effusion of fluid is due to the portal obstruction, it follows
that depletion of the terminal radicles of this system will act most
directly on the origin of the troubles. Hydragogue cathartics have,
therefore, an important place in the treatment of ascites of hepatic
origin. One of the most generally efficient of these remedies is the
compound jalap powder, for whilst it produces free watery evacuations,
it also stimulates the kidneys somewhat. It is generally better to give
a full dose--one or two teaspoonfuls--in the early morning, so that the
disturbance caused by it will subside before the time for taking food.
Several free watery evacuations should be produced by it. Sometimes the
resin or extract of podophyllin is added to the compound jalap powder
to increase its activity. {1002} Purgative combinations of colocynth,
gamboge, and resin of podophyllin are also occasionally employed, but
the most efficient hydragogue is elaterium. The last-mentioned may act
very efficiently without causing any considerable depression, but the
results obtained by it are usually fleeting. After even a very free
discharge of fluid the effusion quickly increases, and further
purgation is required. Tapping is a palliative expedient which must
sometimes be considered. With the present improved aspirator and the
antiseptic method the fluid may be withdrawn with ease and safety. It
is not necessary in any case to remove all the fluid--merely that
quantity which will relieve the pressure on the diaphragm and on the
renal vessels. The author has seen general peritonitis result from
tapping. As such a complication will increase all the difficulties of a
case, it is very desirable to prevent it by careful application of the
antiseptic method and sealing of the punctured orifice to prevent the
entrance of germs.
In the protracted cases of cirrhosis there ensues, finally, a highly
catarrhal state of the mucous membrane, the bowels become very
irritable, and frequent offensive and watery discharges occur. If under
these circumstances the abdominal effusion increases, the remedies must
consist of diuretics and diaphoretics rather than purgatives. Indeed,
an exhaustive colliquative diarrhoea may require bismuth, copper, and
other astringents, combined with opium, to prevent the patient passing
into the condition of collapse. Hemorrhage by vomiting or by stool will
demand ice, subsulphate of iron, ipecac, ergotin in the form of
subcutaneous injection especially, and other remedies which have been
found useful in gastric or intestinal hemorrhage.
Topical remedies are not without utility if used early. When the
changes in the liver are secondary to peritonitis of the hepatic
portion, the application of leeches and cups renders an important
service. At any time during the course of cirrhosis wet or dry cups may
be used with advantage whenever local pain, tenderness, and a catching
respiration indicate the extension of mischief to the peritoneum. The
tincture of iodine or flying blisters, or both in turn, may be applied
over the right hypochondrium after cups and leeches, or at any time
when local distress indicates the need of counter-irritants. Probably
the most efficient topical application during the hypertrophic stage of
cirrhosis is the official ung. hydrarg. iodidi rubri. A piece the size
of a large pea should be thoroughly rubbed in over the hepatic region
daily until some irritation of the skin is produced. When this
irritation has subsided the applications should be renewed.
Suppurative Hepatitis; Abscess of the Liver.
DEFINITION.--Suppurative hepatitis is an acute inflammation of the
hepatic parenchyma, terminating in suppuration. The inflammation may be
primary or due to local conditions entirely, or it may arise from
morbid processes occurring in parts or organs in anatomical relation to
the liver.
CAUSES.--Climate exercises an unquestionable influence in the
production of hepatic abscess. Those warm countries visited by
dysentery, {1003} says Lombard,[83] are almost exclusively affected by
this disease. Hirsch,[84] whilst recognizing the influence of climate,
shows that the natives are not affected to the same extent as are
Europeans. Both writers maintain that hepatic abscess does not occur
frequently in the corresponding parallels of latitude in the United
States; which is true of the Atlantic border, but is not correct for
the interior continent, the valley of the Mississippi, and its
tributaries. In this vast region the conditions for the production of
hepatitis exist abundantly. The mean annual temperature, the
malaria-breeding soil, the social and personal habits of the people
(males), combine to favor the production of hepatic abscess. As the
native population and females in tropical countries are not affected,
there must be other influences to the action of which the high
temperature contributes. The rich and highly-seasoned food in which
Europeans indulge and the large consumption of alcoholic drinks are
doubtless responsible in a large measure for the occurrence of this
malady in such excessive proportions amongst them.
[Footnote 83: _Traité de Climatologie médicale_, tome iv. p. 386.]
[Footnote 84: _Handbuch der historisch-geographischen Pathologie_, Band
ii. p. 300.]
Sex has a remarkable influence in securing immunity against hepatic
abscess. According to the statistics of Rouis,[85] of 258 cases of
hepatic abscess, only 8 were in women. He rightly enough attributes
this exemption rather to the difference in habits of the two sexes than
to any merely sexual peculiarity. In 12 cases observed by the writer,
only 1 was in a woman. In Waring's[86] collection of 300 fatal cases of
tropical dysentery, only 9 occurred in women. These facts are most
conclusive regarding the relatively greater frequency of the affection
in men. As might be expected, the age at which this disease occurs is
the period of adult life, when exposure to the conditions developing it
is most likely to happen. In general, then, hepatic abscess may be
referred to the period mentioned by Rouis--from twelve to seventy-five
years of age. In my own cases the youngest was eleven years and the
oldest fifty-four years of age. It is not the broken-down subject of
mature age or the weakling of youth who is attacked by hepatic abscess,
but the more vigorous and able-bodied, who have, because of their
strength and activity, been exposed to the manifold conditions
producing it.
[Footnote 85: _Recherches sur les Suppurations endémiques du Foie
d'apres des Observations recueilles dans le Nord de l'Afrique_, par J.
L. Rouis, Paris, 1860, p. 189.]
[Footnote 86: _An Inquiry into the Statistics and Pathology of Some
Points connected with Abscess of the Liver_, by Ed. John Waring,
Resident Surgeon of Travancore, 1854, p. iii.]
Rouis finds that a combination of the lymphatic and nervous
temperaments seems most favorable to the production of this malady. It
is certain that those who have the bodily conditions influential in the
formation of gall-stones are not unfrequently attacked by abscess. The
passage of the calculi may induce a local peritonitis of considerable
severity; their arrest in the duct, with the result of ulcerating
through, producing peritonitis and adhesions, are conditions
eventuating in the formation of an abscess always large and sometimes
of enormous size. Under such circumstances the element of temperament
has a secondary place in the aggregate of causes.
Not very often hepatic abscess results from external blows, contusions,
and from penetrating wounds. The liver is so placed as to glide aside
when a blow is inflicted on the right hypochondrium, and thus escapes
{1004} direct compression. An injury which elsewhere would have but
little effect may excite suppurative inflammation in the tropical--or,
as it may be entitled, the hepatic--abscess zone. Climatic conditions,
or the changed habits of Europeans in tropical and subtropical regions,
exert a distinct influence in traumatic cases.