Cirrhosis of the Liver.
Synonyms:—Interstitial hepatitis; sclerosis of the liver; hob-nailed liver; gin-drinker's liver; nutmeg liver.
Definition:—A chronic disorder of the liver characterized by an overgrowth of connective tissue, but with a degeneration of the parenchyma of the organ and usually a consequent reduction in size. (Atrophic cirrhosis.) Occasionally the overgrowth increases the size of the organ. (Hypertrophic cirrhosis.)
Etiology:—Alcoholism is believed to be an almost universal cause of the atrophic variety of cirrhosis, and those who habitually drink the stronger liquors are most liable to it. It occurs, of course, most frequently in males, and according to the acquirement of the habit of drinking. It occurs at variable periods, from thirty-five to fifty years of age, very rarely in women. There are exceptional cases in which this form follows infectious diseases, or it occurs as a result of tuberculosis, syphilis, malaria, gout, rickets, diabetes or cancer. It also has been traced to the persistent use of excessively seasoned foods, or persistent overeating. The ingestion of inorganic poisons leads to this disorder, as well as the conditions which induce gall stones. In disorders of the gastrointestinal tract there are present an excess of lactic, butyric, acetic or valerianic acids. These substances have been used in experiments upon animals and cirrhosis has been thus induced.
Hypertrophic cirrhosis is of rare occurrence and of unknown origin. It occurs more frequently in males than in females in the proportion of about six to one. It occurs more frequently in hot climates.
Symptomatology of Atrophic Cirrhosis:—This disorder may progress until an advanced stage is reached before any distinguishing symptoms are apparent. Among the early appreciable symptoms is the sensation of fulness or weight in the right hypochondrium, with a sensation of distention in the epigastric region. There is tenderness on pressure under the edge of the ribs, with occasional little quick, shooting pains. Quickly following these there is loss of appetite, nausea, occasional vomiting, accumulations of gas in the gastrointestinal tract, with frequent eructations, and occasionally palpitation. There is constipation or diarrhea, or these may alternate.
With the serious impairment of the nutrition the patient becomes emaciated, loses strength and inclination to physical exercise, the face is pinched and discolored or sallow, there is a dusky hue, and it may ultimately become jaundiced; later the eyes are sunken, the cheeks hollow and the face pinched, with a dark discoloration of the tip of the nose. The yellowness of the skin is especially apparent on the trunk of the body. Hematemesis is not an uncommon complication. This occurs after the mucous membranes of the gastrointestinal tract become congested. Other hemorrhages are apt to appear, and hemorrhoids and other varicosities form.
A compensatory circulation is early established in this disease and continues throughout its course. From this there is occasionally extreme enlargement of the superficial epigastric and mammary veins, and there is formed around the umbilicus the so-called caput medusae. If the compensatory circulation should fail, abdominal dropsy will develop. This sometimes becomes extreme, and the spleen becomes greatly enlarged. From this there is a pronounced difficulty in breathing and interference with the action of the heart, which may later lead to general dropsy. In rare cases when other symptoms have not been pronounced, there will develop from the accumulation of toxins in the system a rather sudden train of brain symptoms, characterized at first by a violent headache, with extreme nervous excitability and a noisy but happy delirium. This becomes wild and violent later, and convulsions may follow, or the patient may subside into dulness, stupor, and ultimately into that form of coma which is described as hepatic coma. This condition may occur in other cases when the symptoms are pronounced and where there have been rapid evacuations of the bowels. These symptoms resemble those of uremic poisoning, and may be mistaken for that condition, unless pronounced jaundice is present, which is not the case in more than thirty per cent of the cases. The urine is rather scanty, and although there is an increased specific gravity, bile being present in considerable quantity, there is a deficiency of urea with an excess of urates, and the occasional presence of albumin and tube casts. There is but little dulness on percussion as compared with other conditions, and the lower margin of the liver is sometimes difficult to define.
Symptomatology of Hypertrophic Cirrhosis:—This form is present in adults who are not addicted to alcohol, and is found in children and in early life. A classic symptom is extreme enlargement of the liver. This may be found so great that the organ extends around to the left side and below the navel. In thin patients its outlines can be plainly defined on the surface of the abdomen. The edges are well rounded and the surface smooth. It also extends upward and around as far as the sixth rib. It causes an upward displacement of the diaphragm and compresses the lung. There is tenderness over the spleen quite early, and this organ also becomes enlarged. With the development of the enlargement of the liver the derangement of the stomach and bowels is observed, and these symptoms, with gastric catarrh, sometimes become quite serious. A mild icterus is an early symptom, and this condition increases until it is pronounced. Bile is found in both the urine and feces. With extreme jaundice, itching of the skin becomes a troublesome symptom, and occasionally fever develops. Pain resembling that of hepatic colic may occur at irregular intervals; dropsy is rare, but hemorrhages into the skin and mucous membranes are not uncommon. These cases are of slow development and may continue two, three or four years before serious symptoms appear. In other cases the disease may run from seven to ten years before extreme cachexia, pronounced jaundice and other serious symptoms develop.
Diagnosis:—This depends upon the history of the case and the length of time and character of the development. If the patient is addicted to alcohol, and hemorrhages with jaundice and serious gastric disturbances are present, with pain in the liver, atrophic cirrhosis will be suspected. If there is rapid enlargement of the liver, with colicky pains, and finally jaundice with hemorrhages, this will point to the hypertrophic variety.
Prognosis:—If a collateral circulation is early established and maintained, the prognosis is good; if dropsy develops rapidly, or hemorrhages occur, or the jaundice becomes extreme, the case becomes serious. An early diagnosis is of importance, and specific treatment early administered will accomplish beneficial results and render the prognosis more favorable.
Treatment:—These patients should be placed under circumstances in every way favorable. If the alcohol habit is fixed, I believe it a good plan to submit the patient to specific treatment for the cure of this habit, provided the cirrhosis is not too far advanced. The patient should have that class of tonic remedies which are calculated to sustain the nervous force and to materially encourage and promote the digestion and assimilation of the most concentrated nutritious foods. These must be selected and administered with the utmost care, and should be given in sufficient quantity, preferably at short intervals. The use of hydrastis canadensis, tincture of capsicum, nux vomica, and tincture of the red cinchona bark, with cola, in some cases, will exercise an immediate beneficial influence upon the general condition. With this may be combined chionanthus if the jaundice is at all pronounced, although I prefer to give this remedy separately in hot water four or five times daily. If the tissues are flabby and the skin is dingy or sallow and dry, chelidonium and iris may be given. Occasionally iris and leptandra in small doses in port wine, for patients not addicted to alcohol, will prove very serviceable. The remedies may be given in infusion with the tincture of xanthoxylum to alcoholic patients. Sodium phosphate, begun early and continued in varying doses, sufficient to overcome constipation when it exists and short of producing irritation when diarrhea is present, will be found to be a very valuable remedy. The use of haircap moss and apocynum will be of much benefit in dropsical conditions. If there is heart weakness and irregularity before the dropsical symptoms appear, apocynum will prove of much service. If the condition is due to syphilis, specific blood remedies calculated to correct this condition must be given. In the hypertrophic form persistent heat in the developing stages, or the occasional use of a mild galvanic current, will materially retard the progress of this serious disease.