XIX. Diseases of the Liver and Gall Bladder.
Hepatic hyperemia—congestion of the liver—is a physiological process in the exercise of the normal functional operations of the organ at given times. It becomes pathological when, from excessive eating or from eating highly seasoned or indigestible food, or from other causes, there is interference with the normal action of the organ. It is common also among alcoholics. It occurs from hemorrhage in certain cases, and as a result of suppression of menstruation. It may be a vicarious condition.
This is not a clearly defined condition. It is transient in its character, lasting sometimes only as long as the causes are present; at other times disappearing spontaneously after a short period.
Symptomatology:—There is a sensation of weight and fulness in the right hypochondrium, to which the attention may be attracted by little sharp, shooting pains, and there may be also some tenderness. The liver dulness will be found to be increased somewhat, and at times this will vary quite perceptibly on two consecutive days. When the condition persists the patient becomes irritable and indisposed to exertion. There is headache, vertigo, nausea, a badly coated tongue, with a bad taste in the mouth, constipation and perhaps a slight jaundice.
Treatment:—Tf these patients be permitted to fast, there will be a natural decrease in the quantity of blood in the liver, without treatment. The first indication, and often the only one to which I resort in simple cases, is the application of dry heat over the liver, for a period of from two to six hours. In the severer cases moist heat will be perferable. I use belladonna and bryonia internally as the specific remedies. They have been the most efficient. Agents which are supposed to increase the functional activity of the liver are to be avoided at the onset. Phosphate of sodium will relieve the partial retention of bile and provide all the stimulation needed at this time. I have found podophyllin, even in small doses, to be harsh in its action, and seldom indicated during the active stage of this condition. I prefer leptandrin and iris in small doses. The patient should be kept upon very plain food for perhaps two weeks, and should drink an abundance of water between meals.
Etiology:—This condition differs in many particulars from the active form of hyperemia. The causes are similar to those which induce other hyperemias. One of the first causes is chronic disease of the heart. Other conditions which interfere with the flow of the blood from the liver or retard the flow within the superior vena cava, or impede its escape into the heart, may act as a cause. Among these are bronchiectasis, pulmonary emphysema, a fibroid condition of the lungs, and obstructions within the heart. Farther influences which retard the free escape of the blood are pleuritic effusions, chronic pneumonia and tumors, within the chest, as well also as disease of the walls of the veins and thrombosis of the portal vein.
Symptomatology:—The symptoms of passive congestion are early jaundice with disorder of the digestion, and more or less pain in the region of the liver with considerable enlargement, the organ extending much below the margin of the ribs. The fulness and heaviness observed in passive congestion are more or less constant, but are often observed only when the patient is tired or during a possible exacerbation of the disorder. As the disorder of digestion increases, there is headache, vertigo, nausea, and occasionally hematemesis; there is loss of appetite, constipation, and usually scanty, high-colored urine, which becomes cloudy and deposits a heavy sediment upon standing. The feces are clay colored and light. From the obstruction to the portal circulation, dropsy occurs. Occasionally there is an expansile pulsation in the liver, synchronous with the cardiac systole, which is quite pronounced upon palpation.
When passive congestion is due to thrombosis within the portal vein, the symptoms are those above described, or are somewhat similar to those of cirrhosis. They usually develop more rapidly, however, and there is enlargement usually of the spleen. The thrombus may be caused by gall stones, or by an injury, or from infection, or it may be induced by the presence of a tumor. It may develop rapidly and cause an immediate closure of the vein, as would be the result from an embolus, or it may gradually develop. There may be no serious results from this to the liver, because of the free anastomosing circulation. But there is considerable disturbance in the circulation of the abdominal vessels. These are apt to become engorged to such an extent that hemorrhage may be a consequence.
When, from disintegration of the thrombus, with suppuration, or when the thrombus from other purulent inflammation becomes necrosed, and is infectious in character, the clot not only interferes with the circulation in the vein, but it causes septic infection of the walls of the vessels and of the contiguous hepatic tissues. From this, suppuration may take place; from these structures the infective material conveys the infection to the minute veins in the portal circulation, resulting in the development of smaller abscesses—multiple abscess—in the liver structure. This may result from appendicitis, abscess in the gastrointestinal tract, abscess of the spleen, or infection from the umbilical cord or from penetrating wounds. With the suppuration there are, of course, the usual symptoms of septic invasion; there is chilliness, irregular fever, or hectic fever, and profuse sweating, or night sweats, and more or less progressive debility.
Treatment:—In the treatment of passive congestion of the liver and of the conditions which induce it, the condition of the general circulation must be kept constantly in mind. The nervous system must be strengthened, those influences which interfere with the action of the heart must be overcome, and the local portal circulation must be equalized through equalization of the general circulation. The use of physics to unload the blood vessels has long been adopted, but the specific use of belladonna and the application of heat, or the mild faradic current, will accomplish this result to a very much better advantage, without danger of gastrointestinal irritation and further hemorrhage.
The use of leptandra, chionanthus, or iris will tend to the desired result. The remedies should be carefully selected according to the indications. They may be given separately or in conjunction with hydrastis, xanthoxylum or capsicum. Podophyllin, one part to one hundred parts of sugar of milk, is occasionally beneficial, but I have obtained the best results from the persistent use of bryonia and belladonna. The indications for these remedies are usually very plain. There is enlargement of the organ, tenderness, sharp, shooting pains and occasional chilliness. Equal parts of these remedies are combined and twenty drops of the mixture are added to two ounces of water. Of this a teaspoonful should be given every hour during the waking hours for from seven to ten days, and dry heat should be applied during the night. It is certainly rational to treat the condition within the capillaries, rather than to stimulate the functional action of the liver.
As a laxative an occasional dose of magnesium sulphate may be given, especially if there is a tendency to dropsy; or the sodium phosphate is an excellent remedy. The use of well selected mineral waters is frequently of advantage also, and occasional colonic flushings may be administered, but active cathartics should be avoided.
When there are heart complications, cactus, digitalis, lycopus, or iris will be needed. If dropsy is present, apocynum will be the superior remedy; if there is greatly reduced arterial tonus, with irritation of the nervous system, or a tendency to spasmodic conditions, gelsemium in full doses, or the tincture of lobelia seeds in small doses, may exercise a desirable influence.
If the dropsical condition, whether induced by passive congestion direct, or by thrombosis, is not readily relieved by the apocynum, full doses of magnesium sulphate or other well selected remedies may be tried. Occasionally surgical intervention will be necessary.
When the obstruction to the portal circulation is septic in character, the treatment will not be satisfactory. The internal measures will be those calculated to antagonize the influence of septic infection and the formation of pus, such as echinacea, calcium sulphid or the calcium iodid. if a single large abscess can be diagnosed, this should be evacuated, but local measures should be advised with caution.
Dieting is important in all cases of passive congestion, although the influence of a strict diet is not so apparent as in active congestion. Plain, easily absorbed, highly nutritious foods are always required. I have found it a good plan to limit the number of articles of food taken at each meal to two or three, and to insist upon this rigid course for a period of weeks. Out of door exercise, judiciously indulged in, is an important accessory.
The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.