substantive affection, but secondary to some constitutional malady or
to long-continued suppuration, its course must be considered in
relation to the agency producing it. It is very silent in its origin
and progress, and causes no pronounced symptoms until it attains
considerable size and its functions are interfered with by the extent
of the deposits. The history of the affection to which it is secondary
therefore precedes the onset of the amyloid change and accompanies it
throughout. The enlarged organ, with the results of its enlargement in
altered functions of the abdominal organs, is a symptom superadded to
existing disturbances. The period elapsing in the course of a chronic
suppurative disease before the amyloid change occurs differs greatly in
different cases, and may be stated as from three months (Cohnheim's
case) to many years. Many of the cases terminate by an intercurrent
disease; others by uræmic {1045} convulsions; a very few by hemorrhage
from the stomach or intestines; and those pursuing their course
uninterruptedly, by exhaustion.
The prognosis is very unfavorable. By some a cure at the beginning of
the morbid deposits is regarded as possible, and examples of cures have
been reported. The writer has seen supposed cases of amyloid liver
terminate in recovery. There must always remain an impression that in
such instances an error of diagnosis was committed. Those of syphilitic
origin are probably more curable, but syphiloma of the liver may be
confounded with amyloid disease, and hence the cure may be referred to
the latter.
DIAGNOSIS.--Amyloid degeneration of the liver may be confounded with
the various non-febrile enlargements of the organ. An important element
in making the differentiation is the history of suppuration in
connection with bone, with lung cavities, with constitutional syphilis,
with chronic malarial toxæmia, etc. From fatty liver, amyloid
degeneration is distinguished by the history as just sketched; by the
fatty tendencies of the body in the former, emaciation in the latter;
by the concomitant changes in the spleen, kidneys, and elsewhere; and
by the subsequent history, fatty liver terminating by a weak heart
usually, whilst the amyloid disease ends in the modes described in the
preceding paragraph. From hydatid disease, amyloid liver is
differentiated by the history, by the difference in the physical
characteristics of the enlargement, by the presence of the purring
tremor in the one, its absence in the other, and especially by the
subsequent course. In all doubtful cases the use of an aspirator-needle
and the withdrawal of some fluid containing the characteristic hooklets
of the echinococcus will serve to determine the nature of the growth.
From cancer, amyloid liver is separated by the previous history, by the
nodular character of the enlargement, by the pain, and by the cachexia
and associated derangements. Whilst amyloid liver is secondary to
suppurative diseases, cancer is usually secondary to cancer of the
stomach or other organ within the limits of the portal circulation.
TREATMENT.--As amyloid disease owes its origin to syphilis, to chronic
malarial toxæmia, to suppuration, these, so far as they are remediable
conditions, should be cured as speedily as may be, to prevent the
development of the amyloid disease or to arrest it if begun.
Unfortunately, the condition of the liver is not recognized until the
morbid change is effected, and therefore practically irremediable.
The treatment necessarily involves that of the morbid state to which
the amyloid deposits are owing. The syphilitic disease requires iodine
and mercury; the malarial, quinine, iodine and the iodides, eucalyptus,
iron, etc., according to the state of each case; and surgical diseases,
especially necrosis of bone, should be effectively treated by suitable
surgical expedients. The cause being removed if possible, what means,
if any, can be resorted to to cause the absorption of the amyloid
matter? The only specific plan of treatment hitherto proposed is that
of Dickinson,[147] based on his theory of the constitution of amyloid
matter; according to which the amyloid deposits consist of fibrin
altered by the separation of the potash and soda salts, which have been
eliminated in the pus. If this theory be admitted, the obvious
indication is to supply the alkaline materials. The cases reported by
Dickinson in which this theory was {1046} practically demonstrated were
not sufficiently improved to lend any empirical support to this method.
[Footnote 147: _The Pathology and Treatment of Albuminuria_, p. 214 _et
seq._]
The medicinal remedies which do any good are the iodides--notably the
iodides of ammonium, of iron, of manganese, etc., the compound solution
of iodine, and the double iodide of iron and manganese. As the
officinal ointment of the red iodide of mercury, rubbed in over the
splenic region, does so much good in chronic enlargement of the spleen,
it is probable that it will prove effective in this form of enlargement
of the liver. The writer has observed results from it in such cases
that justify him in strongly urging its employment. The method of its
application consists in rubbing perseveringly a piece of the ointment,
a large pea in size, over the whole hepatic area, and repeating it
daily until some irritation and desquamation of the skin is produced,
when it should be suspended until the parts will bear renewed
applications. Besides the topical application of the red iodide, this
remedy may be given internally with advantage without reference to
syphilitic infection. It seems to the writer probable that bichloride
of mercury may be as useful, as it is certainly more manageable. The
chloride of gold and sodium, arsenic in small doses, and the metallic
tonics, so called, may be useful carefully administered, especially the
first mentioned, which the writer believes has some real power over the
disease.
Dietetic rules are of great importance. As the hepatic functions are
much disturbed, if not entirely suspended, it is necessary to give
those foods which are converted into peptones in the stomach. As a
rule, fats, starches, and sweets are mischievous, and milk, meats,
oysters, and the nitrogenous foods best adapted to nourish the patient.
If the diarrhoea should prove exhausting, the mineral acids, with
opium, are the best remedies. Nausea and vomiting are best relieved by
carbolic acid mixture, and hemorrhages by the solution of the chloride
or subsulphate of iron.
Fatty Liver; Fatty Degeneration of the Liver (Hepar Adiposum).
DEFINITION.--By the term fatty liver is meant a change in the organ
characterized by the excessive quantity of fat- or oil-globules
contained in the cells of the parenchyma.
CAUSES.--The liver acts, under normal conditions, as a reservoir for
the surplus fat, which it gives out as the demand is made. It is not
only the fat brought to the liver by the blood which accumulates in the
organ, but it apparently possesses the power to transform certain
substances--albumen, for example--into fat. An important causative
element, therefore, is the quantity of fat present in the food
habitually consumed. This has been proved by the investigations of
Radziejewsky[148] and others, who have shown that the fat in the food
is stored up in the normal places of deposit, one of which, of course,
is the liver. Another causative element is the formation of fat from
the albumen of the hepatic cells in consequence of diminished
oxidation. In respect to both causes the consumption of oxygen is an
important factor. The insufficient supply of oxygen {1047} which is a
necessary result of a sedentary life leads thus, directly, to the
accumulation of fat in the liver-cells. A constitutional predisposition
is also an important factor. There are those who under certain
conditions of daily life store up large supplies of fat, and others who
under the same conditions continue lean. Women more than men are
subject to such inherited predispositions.
[Footnote 148: _Virchow's Archiv für path. Anat., etc._, Band lvi. p.
211.]
Again, fatty liver occurs in the course of certain cachexiæ, notably
phthisis. In this case the obstructive pulmonary lesions interfere with
the process of oxidation, and also maintain a constant hyperæmia of the
portal system. This condition of the liver also occurs in the cancerous
cachexia, in anæmia and chlorosis of long standing, in chronic
suppurative diseases, etc. The dyscrasia of chronic alcoholism is a
very common cause of fatty liver. At the same time that hyperplasia of
the connective tissue is taking place the fat is accumulating in the
hepatic cells. So great is the accumulation of fat in the blood that
the serum presents a milky appearance. This excess in the quantity of
fat is rather due to diminished oxidation, to lessened combustion, than
to increased production. Another causative element of the
fat-production in cases of alcoholism is the interference of alcohol
with the process of digestion and assimilation.
Poisoning by phosphorus, antimony, arsenic, and other metals sets up an
acute fatty degeneration of the liver. Pregnancy, lactation, and
suppuration also have the same effect, but to a slighter and less
permanent extent.
PATHOLOGICAL ANATOMY.--Fatty liver agrees with amyloid liver in that
the fatty deposits increase the size and weight of the organ. The
surface is smooth, the peritoneal investment unaltered, and the margins
rounded. Sometimes the organ is merely increased in thickness,
sometimes in diameter. It has a greasy feel and cuts like a mass of
fatty tissue. Examined at a low temperature--below freezing--it seems
like a mass of suet, the proper structure being almost extinguished in
the fatty metamorphosis. The outline of the lobules remains distinct
even in cases far advanced in the fatty degeneration, but in the
extreme cases it is obliterated, the cut surface presenting a uniformly
yellowish or grayish-yellow tint. The fatty liver is also wanting in
blood; it is dry, and on section only the largest vessels contain any
blood. When cardiac disease of a kind to produce congestion of the
venous system exists--for example, mitral or tricuspid lesions--the
same relative decrease in the quantity of blood in the liver is
observable after death, although during the life of the subject the
opposite condition may have been present. The cause of this
bloodlessness of the fatty liver is to be sought in the pressure
exerted by the growing fat-cells.
Not all cases of fatty liver are advanced to the degree indicated in
the above description. From the normal size up to the maximum attained
by the most advanced fatty liver there are numerous gradations in the
quantity of fat and in the dimensions of the organ. Fatty degeneration
may accompany cirrhosis, in which the liver is contracted. The deposits
of fat may take place in particular areas. In cases of fatty liver per
se the deposit occurs within the liver-cells, as may be demonstrated on
microscopic examination, the initial change consisting in the formation
of granules in the protoplasm which ultimately coalesce, thus producing
{1048} fat-globules or cells. The fatty change in the hepatic cells
proceeds in a certain methodical manner from the cells at the periphery
of each lobule to the centre. The quantity of fat deposited in the
liver in cases of fatty change is very great. In the normal condition
of the organ fat exists, according to Perls,[149] in the proportion of
3 per cent. of the weight of the liver. When the condition of fatty
liver exists the quantity of fat rises to 40, even 45, per
cent.--almost one-half. It is important to note, as was pointed out by
Frerichs, that in an inverse ratio with the increase of fat was the
quantity of water.
[Footnote 149: _Virchow's Archiv_, _supra_.]
That more or less fatty change in the liver is not incompatible with a
normal functional activity is quite certain, but the boundary between
health and disease is by no means well defined in respect to the
quantity of fatty change in the liver-cells. The liver, within certain
limits, is a mere reservoir of the surplus fat of the body, and hence a
variable, but not excessive, amount of accumulation of fat is not
incompatible with a normal functional performance of the organ. The
limits of a merely functional state and of a diseased state are not,
therefore, very clearly defined. In certain inferior animals, as
Frerichs has shown, a fatty condition of the liver is normal.
SYMPTOMS.--The signs and symptoms of fatty liver are by no means well
defined. This state of the organ, as a rule, accompanies the general
tendency to fatty metamorphosis and deposit in the body. It is a
symptom in the course of phthisis, of chronic alcoholism, and of
various forms of metallic poisoning, but under these circumstances
there is no material change in the course of the symptoms produced by
this complication. As an independent affection it rarely, if ever,
exists alone. So far as its symptoms can be defined, they are referable
to the organs of digestion and assimilation and to the liver itself.
The appetite is generally good, but distress after eating, acidity and
heartburn, eructations of acid liquid and of certain articles of diet,
are experienced. The stools are usually rather soft or liquid, wanting
in color, whitish or pasty, and occasionally dark, almost black, owing
to the presence of blood. Hemorrhoids are usually present. The
discharges are often offensive from the decomposition of certain
constituents of the food, acid and burning because of the presence of
acetic, butyric, and other fat acids, or merely offensive because of
the formation of hydrogen compounds with sulphur and phosphorus.
Notwithstanding the derangement of the stomachal and intestinal
digestion, the deposition of fat continues in an abnormal ratio. With
the increase in body-weight a decline in muscular power takes place.
The respiration is hurried on the slightest exertion, and dyspnoea is
produced by any prolonged muscular effort. The circulation is feeble
and the pulse slow in the state of repose, but on active exertion the
pulse becomes rapid and at the same time feeble. The sleep is disturbed
by horrifying dreams, and only on assuming a nearly sitting posture can
the patient sleep with any degree of quietude.
In these cases of fatty liver a very considerable mental inquietude,
despondency, even hypochondria and melancholia, result. The relation of
insufficient hepatic excretion to the mental state is yet sub judice,
but there can be no doubt that some connection exists. From the
earliest {1049} period hepatic derangements--as the term hypochondria
denotes--have been associated with certain disorders of the mind. This
relation certainly holds good in respect to the mental perturbation
occurring in cases of fatty liver. With a rotund countenance and a
well-nourished body there is associated very considerable mental
despondency.
Without distinct jaundice the skin has an earthen or tallow-like hue,
the conjunctiva is muddy or distinctly yellow, and now and then
well-defined jaundice appears.
The urine is rather scanty, high-colored because of the presence of
bile-pigments, and deposits urates abundantly. When jaundice
accompanies fatty liver the urine will be very dark, muddy, thick, and
will react to the usual tests for bile, urates, etc.
The area of hepatic dulness is, as a rule, enlarged in cases of fatty
liver. The deposition of fat in the cells adds to the gross size of the
organ, and hence the inferior margin extends below the border of the
ribs to a degree determined by the amount of increase in its substance.
If the liver can be felt, it is smooth, not hard and resisting, and is
free from nodules. Usually, however, owing to deposits of fat in the
omentum and in the abdominal walls, the outlines and condition of the
liver cannot be ascertained, and must remain merely conjectural.
Rather, therefore, by implication than by direct examination can the
condition of the liver be ascertained.
COURSE, DURATION, AND TERMINATION.--The course of fatty liver, as an
element in a general change not of a toxic character, is essentially of
a chronic character. The fatty liver of acute phosphorus, antimonial,
and other forms of poisoning is acute and fatal, but it is not these
forms with which we are here concerned. Acting the part of a reservoir
of the surplus fat stored up in the body, which may be disposed of
under normal and physiological conditions, the fatty liver becomes by
careful management a normal organ again. The course, duration, and
termination will therefore largely depend on the nature of the
management pursued. A fatty liver cannot, then, be regarded as fatal,
or even as dangerous to life per se. The course and termination will
therefore be those of the associated condition.
DIAGNOSIS.--The determination of the existence of fatty liver will not
be difficult in all those cases in which this condition may properly be
suspected; for example, in phthisis, in chronic alcoholismus, in
obesity, and in cases of habitual indulgence in eating and drinking. If
in these cases the organ is distinctly enlarged, is smooth, and is
flabby in outline; if at the same time the digestion is deranged, the
stools are light in color, there are hemorrhoids, flatulence, acid
indigestion, and torpid bowels,--a fatty liver may be reasonably
suspected. The subjects of fatty liver are usually obese, and present
the characteristics typical of that condition, or they are the victims
of alcoholismus or present the evidence of habitual indulgence in the
pleasures of the table. The differentiation of fatty liver from amyloid
degeneration, from cystic disease, and from other maladies causing
enlargement of the organ is made by reference to these points in the
etiological history--by a careful study of the condition of the organ
itself and of the organs associated with it in function. As the amyloid
liver is more likely to be confounded with the fatty liver, it should
be noted that the former is an outgrowth of the process of suppuration,
that the organ {1050} is hard in texture, and that amyloid change
occurs at the same time in other organs--conditions opposed to those
characteristic of the fatty liver. Cancer of the liver is accompanied
by a peculiar cachexia; the body wastes, and the enlarged liver is hard
and nodular instead of being smooth and flabby.
TREATMENT.--When fatty liver is a symptom merely, its treatment is
merged into that of the primary condition. Thus, in phthisis and in the
various forms of metallic and phosphorus-poisoning the condition of the
liver is quite secondary. There are cases of obesity, however, in which
the fatty change in the liver is a part of the general morbid process,
and must be treated accordingly. There are still other cases in which,
without a decided tendency to obesity, the food habitually consumed is
of a fatty or fat-forming nature. The first requisite in the treatment
of fatty liver is to amend the diet. From the time of Hippocrates down
to Mr. Banting it has been recognized that the starchy and saccharine
constituents of the food, as well as the fatty, contribute to the
formation of fat. In arranging a dietary in cases of fatty liver this
fact should be regarded. Besides excluding the fats, saccharine and
starchy substances should be cut off. The diet should be composed of
fresh animal foods, game, fish, oysters, and such succulent vegetables
as lettuce, celery, spinach, raw cabbage (cole-slaw), etc. Amongst the
articles excluded should be bread, but the greatest difficulty is
experienced in its withdrawal, many patients declaring themselves
unable to live without it. In such instances a small biscuit
(water-cracker) may be allowed, but, as far as may be accomplished,
bread should be cut off from the diet.
If there are acidity, heartburn, pyrosis, and regurgitation of acid
liquid, much good may be expected from the administration of diluted
nitric acid before meals, especially if there be considerable uric acid
in the urine. The simultaneous administration of tincture of nux vomica
will prove useful if the appetite is poor and the digestion feeble.
When the complexion is muddy, the conjunctivæ yellow, and the tongue
coated, excellent results are had from the persistent use of phosphate
of sodium. Under these circumstances also arsenic is very beneficial.
Even better results may be had from a combination of the two agents, a
teaspoonful of the pulverized phosphate being given with one-fortieth
of a grain of the arseniate of sodium. Alkalies, as lithium citrate,
solution of potassa, etc., are unquestionably useful as remedies for
obesity and fatty liver, but they must be administered with a proper
caution. Also, the permanganate of potassium has seemed to the author
to be especially valuable as a remedy for these states.
Remedies to increase the activity of the portal circulation and
diminish congestion of the hepatic vessels are useful at the outset,
but the anæmia which succeeds renders their use improper at a later
period. Amongst the hepatic stimulants of great use in those cases
characterized by whitish, pasty stools, yellow conjunctivæ, etc., are
resin of podophyllin, euonymin, baptisin, and others having the same
powers. Saline laxatives are also useful, but to a less extent. It must
be remembered, however, that these subjects are wanting in bodily
vigor, often suffer from weak heart, and always have flabby muscles, so
that they bear all depleting measures badly. The hepatic stimulant of
greatest utility in these cases is sulphate of manganese. The writer
has had excellent results from a {1051} combination of quinine and
manganese. For the general state, which denotes insufficient oxidation
according to the chemical pathologists, permanganate of potassium is a
remedy of value, as above mentioned. The best form in which to
administer this is the compressed tablet, and the dose usually is two
grains. As chalybeate tonics are indicated, the oxidizing power of the
succinate of the ferric peroxide, the remedy so warmly advocated by
Buckler, may be utilized with advantage. The combination of quinine,
iron, and manganese in pill form, or the syrup of the iodides of iron
and manganese, or the phosphate of iron, quinine, and strychnine, are
tonics adapted to the relief of the depression accompanying this
malady.
III. AFFECTIONS OF THE BILIARY PASSAGES.
Catarrh of the Bile-Ducts.
HISTORY AND DEFINITION.--Although catarrh of the bile-ducts had been
incidentally referred to by some previous writers, notably by Stokes of
Dublin, Virchow[150] was the first to treat of this condition
systematically. Amongst recent writers, Harley[151] appears to be the
only one disposed to question the importance of catarrh of the
bile-ducts as a factor in the production of jaundice. Even in
phosphorus-poisoning the appearance of jaundice, at one time supposed
to be hæmatogenic in source, has been referred to a catarrh of the
bile-ducts.[152] It seems probable that opinions have too decidedly
veered toward the importance of this condition as a factor in the
production of jaundice.
[Footnote 150: _Archiv für path. Anat._, Band xxxii. p. 117 _et seq._]
[Footnote 151: _Diseases of the Liver_, _supra_.]
[Footnote 152: Wyss, _Archiv der Heilkunde_, 1867, p. 469 (Legg).]
CAUSES.--Catarrh of the bile-ducts has been referred to all those
causes which can excite a catarrhal process in any situation. These are
systemic and local. Amongst the systemic may be placed peculiarities of
constitution or idiosyncrasy. A tendency to hepatic disorders is a
feature in certain types of constitution, and, as such types are
transmitted, the hepatic disorders seem to be inherited. In such
persons, possessing the so-called bilious nature, catarrh of the
biliary passages is not uncommon, and a special susceptibility to it
apparently exists. The atmospherical and other causes which in some
subjects will set up a catarrh of the bronchi will in the bilious type
induce a catarrh of the duodenum and bile-ducts. The malady is not
inherited; only the character of bodily structure which favors it under
the necessary conditions.