presence of this newly-formed tissue is often manifest, in the form of white lines, to the naked eye. The pressure of this tissue upon the lobules induces atrophy; hence the contraction of the organ. Its shrinking causes the granular and nodulated appearance. Compressing the terminal branches of the vena portæ, it occasions obstruction to the passage of blood through the liver, and consequently portal congestion ensues, giving rise to dropsy and sometimes hemorrhage from the mucous membrane of the stomach and intestines. Pressure upon the bile ducts causes biliary congestion and a jaundiced condition of the organ. The hepatic cells are diminished in size and number, and contain minute, greenish-colored oil drops. These differ notably in appearance from the cells in cases of ordinary fatty liver. The fatty liver and cirrhosis, however, may be combined, and the organ may then be not diminished but increased in size. The point of departure for the morbid changes just stated is supposed to be an inflammatory exudation within the interlobular spaces; and cirrhosis is, therefore, regarded as a diffused, subacute inflammation of the areolar or connective tissue existing between the lobules, forming an extension of Glisson's capsule. This is the pathological view generally held at the present time. All pathologists, however, do not accept it. According to Beale, the change commences in the hepatic cells, those near the circumference of the lobules being first affected, and the affection extending gradually to the centre. As a consequence of the altered condition of the cells, he thinks the attractive force inherent in the organ, which determines the flow of portal blood, is lessened; consequently the interlobular veins shrink and there is an impediment to the portal circulation through the liver. He bases this opinion respecting the primary essential change on the number of interlobular vessels which remain permeable as shown by injections; and he supposes that the appearance of an abnormal abundance of fibrous tissue may be due to the remains of the wasted and shrunken vessels and ducts rather than to the presence of an adventitious tissue. Agreeably to this doctrine, the pathological process in cirrhosis is not inflammatory, but a degenerative change having its point of departure in the secreting cells of the liver.1 Enlargement of the spleen is found after death, and is determinable during life, in a certain proportion of cases. The enlargement is sometimes very great. Notable enlargement, however, in my experience, is the exception rather than the rule. Coexisting cardiac disease has been supposed to be common. This has not been true in my experience. Of ten fatal cases, in seven the heart was free from disease; of the remaining three cases, in two old pericardial adhesions existed, the heart being moderately enlarged in one and below the normal volume in the other case. In the third case, there was moderate enlargement (weight, 11 oz.) with rigidity of the aortic valves. Of 22 cases in which autopsies were not made, in 15 there were no physical signs of disease of the heart, and of the remaining 7 cases, in 4 the only evidence was a systolic murmur at the base; in the other three cases, mitral lesions were denoted by the signs together with enlargement of the heart. Thus, of 32 cases in which the condition of the heart was noted, as determined by either autopsical examination or physical signs, in only 5 were there lesions involving enlargement of this organ. These facts go to show that cardiac disease and cirrhosis of the liver are not associated sufficiently often to denote the existence of any pathological connection between them. When they coexist, the association is probably merely a coincidence." 1 Vide Beale's Archives of Medicine. No. 2, 1858. Disease of the kidneys coexists oftener than cardiac disease. In 11 fatal cases under my observation, autopsical examination showed more or less renal disease in 6. The concurrence would seem to be sufficient to denote either some pathological connection between disease of the kidneys and cirrhosis, 'or that both are effects of the same causative conditions. As will be presently seen, evidence of renal disease is rarely afforded by albuminuria in cases of cirrhosis. Cirrhosis, as a rule, gives rise to few or no symptoms which point to the liver as the seat of disease prior to the occurrence of hydro-peritoneum. Preceding this event, and afterward, pain in the region of the liver exists in only a small proportion of cases. Dropsical effusion is usually the first symptom to suggest the existence of the affection. And the dropsy may occur when the patient supposes himself to be in his habitual state of health, or it may be preceded and accompanied by indefinite ailments. The dropsical accumulation increases, and, usually, with considerable or great rapidity. It is rare for the quantity of liquid to remain at a moderate amount for a considerable period. Edema of the lower limbs, in a moderate degree, precedes the hydro-peritoneum in a large proportion of cases (11 of 21 cases). It has been stated that the coexistence of either cardiac or renal disease is to be inferred from the pre-existence of oedema of the lower limbs; but the facts developed by the analysis of cases which I have recorded are opposed to this statement. Of the 11 cases in which the oedema preceded, 5 were fatal. Of these 5 cases, in three the heart and kidneys were found, on examination after death, to be free from disease; in one case there were old pericardial adhesions with moderate enlargement, and in the other case there was granular degeneration of the kidneys. In not one of the 6 cases which did not end fatally under my observation was the urine albuminous, or were there present physical signs of cardiac disease. After the occurrence of hydro-peritoneum, cedema of the lower limbs is apt to occur, if not already existing, and it sometimes becomes great under these circumstances, being due, probably, to pressure upon the iliac veins. The genital organs may become more or less oedematous. Edema of the face and upper extremities does not occur, save in cases in which cardiac or renal disease coexists. Edema of the lower limbs does not occur in all cases. In Jaundice occurs in a small proportion of cases (7 of 46 cases); it is rarely great. Pallor of the prolabia and skin exists in the majority of cases. general, the anæmic aspect is marked in proportion as other symptoms show the condition of the patient to be unfavorable. Febrile movement does not accompany the disease in its progress. The pulse may be not increased in frequency, or it may be more or less accelerated; it is generally soft and feeble. When frequent, the other characters denote diminution of the vital forces or asthenia. The obstruction of the portal circulation is compensated for, in a measure, by new channels of communication between the portal and hepatic veins. The most important of these, as shown by Sappey,' are anastomosing branches which pass to the liver between the folds of the falciform ligament and in the ligamentum teres, communicating with the veins of the abdominal parietes. The course of the blood in these anastomosing branches, in cases of cirrhosis, is the reverse of that in health, being in the latter in a direction from, and in the former toward, the liver. Owing to this, the abdominal veins become dilated, and those superficially situated in some cases are seen to be more or less enlarged. Hemorrhage from the stomach and bowels is an occasional event. Gas 1 Bulletin de l'Académie de Médecine, tom. xxiv., Paris, 1859. trorrhagia occurred in 6 of about 40 cases which I have analyzed, the history of all the cases not being complete. It preceded the hydro-peritoneum in 3 cases. Enterorrhagia coexisted in 2 cases, and occurred alone in 2 Vomiting is occasionally a prominent symptom, and diarrhoea is prominent in a small proportion of cases. cases. The appetite is usually impaired. A sense of fulness after taking food is. generally complained of, if the dropsy be sufficient to distend the abdomen. Progressive emaciation attends the progress of the disease, and, in an advanced stage, the attenuation of the upper portion of the body, the distended abdomen, and the lower limbs enlarged by oedema, render the general aspect highly characteristic. Albuminuria is rare in cases of cirrhosis. Of 28 cases in which the condition of the urine in this respect was noted, in only one case was albumen present. The urine is generally scanty, but in some cases abundant. In one case under my observation, the urine was habitually of a bright vermilion color, as if it contained blood. The microscope, however, showed absence of the blood-globules, and no albumen was present. The urates were very abundant in this case, the deposit being of the same color as the liquid. The appearances corresponded with those described by Bird as belonging to purpurine. If, In the great majority of cases there are no important symptoms pertaining to the nervous system. The mode of dying is usually by slow asthenia. however, the abdomen be greatly distended, or if the dropsical accumulation take place very rapidly, death may be due to the extent to which the respiratory function is compromised. The mental faculties are generally preserved up to the last moments of life. To this rule there are exceptions. In 3 cases I have noted the occurrence of delirium several days before death. In one case the delirium was hilarious; in one case the patient appeared bewildered, and in one case the patient lapsed from childishness into imbecility. These cases ended in coma. In three other cases the patients died comatose. In one case convulsions occurred followed by coma.1 Cirrhosis, in the vast majority of cases, is due to spirit-drinking. Of 20 fatal cases in which the habits of the patients were ascertained, in 17 intemperance was admitted, and in one of the three remaining cases habits of drinking were admitted, but not to excess. Of all the cases, fatal and nonfatal, in which the form of alcoholic stimulant used is noted (24), in all save one the patients were accustomed to drink spirits. In the excepted case the patient stated that he drank only beer. Hence the significance of the term gin or whiskey liver, applied by British writers to this affection. In all the cases in which information as to the mode of drinking was noted (15), the custom was to take raw spirits at different periods of the day, before breakfast and at other times on an empty stomach, a little water being generally drank after the spirits. This accords with the observations of others as to the mode of spirit-drinking which gives rise to cirrhosis. As to the action of alcohol in producing this affection, the explanation now commonly received is, that, passing readily into the portal blood from the stomach, and carried at once to the liver, it excites, by contact, inflammation of a low grade in the interlobular spaces, and hence exudation and the production of adventi tious tissue. The facts, however, are perhaps not less consistent with the hypothesis of cirrhosis being a degeneration taking its point of departure This account of the symptomatology is based on an analysis of 46 cases of hydroperitoneum, cirrhosis existing in nearly all the cases. Vide Clinical Report, already referred to. from the cells of the lobules. So far as my observations go, they furnish no evidence of the agency of disease of the heart in the causation of this affection. Cirrhosis very rarely occurs under thirty years of age, and, in the majority of cases the age exceeds fifty years. The affection is generally a result of the habitual abuse of alcohol continued for a long period. Males are affected much oftener than females, a fact readily explained by the dependence of the affection on the use of spirits in the manner stated. The diagnosis in most cases of cirrhosis, after dropsy has occurred, is made without difficulty. Hydro-peritoneum, occurring as a local dropsy, that is, irrespective of general dropsy, in a person addicted to spirit-drinking, warrants an inference that this affection exists. Additional proof is afforded by the diminished size of the liver. This is ascertained by percussion. The upper margin of the liver is accurately determined by finding the line of hepatic flatness; the lower border is determined, not so accurately, but approximatively, by the line of demarcation between hepatic flatness and the tympanitic resonance due to gas in the transverse colon. The latter is not exact, because tympanitic resonance is conducted for a certain distance above the lower margin of the liver. The vertical diameter of the liver in health, on the linea mammalis, is about four inches. Directly after the operation of tapping, while the abdominal walls are relaxed, the lower border of the liver may frequently be grasped by the fingers pressed upward beneath the false ribs, and its indurated, nodulated condition appreciated by palpation. The physician is rarely called upon to make the diagnosis prior to the occurrence of dropsy. It may perhaps be practicable, in some cases, to determine, by palpation, induration and a nodulated condition of the lower part of the organ before dropsy has taken place, and, this information obtained, the diagnosis is highly probable if the patient be addicted to spiritdrinking. Hemorrhage from the stomach sometimes precedes the occurrence of dropsy, and, in a spirit-drinker, renders the existence of cirrhosis probable. Cirrhosis is to be regarded as an incurable lesion. After it has led to dropsy, in the majority of cases, its course is progressively onward toward a fatal termination. The duration in sixteen fatal cases, dating from the occurrence of dropsy, varied from six weeks to seventeen months, the average duration being about five months. But doubtless in all cases the disease has existed for a considerable period before dropsy occurs. In a certain proportion of cases, the dropsy being removed, the patient may apparently regain comfortable or even good health, and remain free from any manifestations of the disease for months and years, but sooner or later, as a rule, to which there are very few exceptions, the dropsy returns, and, unless life be destroyed by some intercurrent affection, the disease ends fatally. Circumstances which preclude much expectation of improvement are, the coexistence of cardiac, renal, or any other important disease, considerable emaciation, sufficient debility to keep the patient in bed, greatly impaired appetite and digestion, speedy reaccumulation of liquid after tapping, and the occurrence of jaundice. As regards treatment, in cases of cirrhosis and in the great majority of the cases of hydro-peritoneum, the indications are the same. The reader is, therefore, referred to the treatment of hydro-peritoneum considered in the preceding chapter. CHAPTER XII. DISEASES AFFECTING THE SOLID OR COLLATITIOUS VISCERA OF THE ABDOMEN.-CONTINUED. Fatty Liver-Waxy or Lardaceous Liver-Cancer of the Liver-Tuberculosis of the LiverAcute Atrophy of the Liver-Hydatid Tumors of the Liver-Pigmentary Deposit within the Liver-Hypertrophy of the Liver. HAVING considered the inflammatory affections of the liver, including cir rhosis, which is generally regarded as inflammatory, structural affections are next to be considered. The more important of these are incident to the abnormal deposit of fat, to the waxy or lardaceous degeneration, to the carcinomatous and the tuberculous deposit, to acute atrophy, and to the existence of hydatid tumors. They will be considered briefly in this chapter. FATTY LIVER. The secreting cells of the liver, in their healthy condition, contain oil drops, and these are abundant, normally, in certain inferior animals, espe cially invertebrate animals and fishes. Experimental observations show that in dogs and other animals, the quantity of fat which the liver contains varies considerably with diet, and it is fair to infer that this is true in man. It is a reasonable supposition that the fat which the cells contain in health, is, in some way, useful. An increase of the fat, beyond a certain amount, undoubtedly constitutes a morbid condition; but it is difficult to determine, with our present knowledge, the amount compatible with the state of health. A considerable quantity of fat has been repeatedly found after death in cases in which persons apparently in perfect health, have been accidentally killed. It is probable that the quantity of fat in the same person, in health, varies considerably at different times, according to variations in diet and other cir cumstances. The liver is to be considered as morbidly fatty, when the accumulation of fat is sufficient to increase the size of the organ. An extremely fatty liver is usually enlarged, but not in all cases; the hepatic cells are sometimes filled with oil, the size of the organ not exceeding, and even falling under, that of health. The gross characters of a fatty liver are as follows: Usually, as just stated, the organ is more or less enlarged, the margins are apt to lose their natural sharpness, and become blunted or more rounded than in health. The enlargement is pretty uniform, and the inferior border may extend more or less below the false ribs, so as to be appreciable by palpation in persons with thin and relaxed abdominal walls. The exterior is smooth. The capsule is tense, and when divided the edges of the wound separate. The consistence is less than in health, and pressure with the finger leaves an indentation as in cedematous parts. The specific gravity is light, so that the organ sometimes floats in water. Frerichs found the average weight in 34 cases to be 3 pounds, 84 ounces, avoirdupois. The weight, however, in some cases, is considerably greater than in health. The color is pale or whitish, compared by Rokitansky to that of autumn foliage; the organ is anæmic. |