An acute inflammation of the structure of the liver, in which the course of the disease is similar to that of inflammation of the other organs, with a possibility of a termination by resolution, is not described by other writers. Acute inflammation with an immediate inclination to the formation of abscess is recognized as suppurative hepatitis, or hepatic abscess, and a chronic interstitial inflammation known as cirrhosis of the liver is recognized.
Acute Suppurative Hepatitis.
Synonyms:—Acute hepatitis; hepatic abscess; abscess of the liver.
Definition:—A condition in which the consecutive stages of acute hyperemia, inflammation and exudation proceed so rapidly to suppuration as to be often unrecognized. It is characterized usually by an erratic temperature, and always by the presence of an abscess in the hepatic parenchyma.
Etiology:—While the disease may result directly from cold and sudden suppression of the secretions, as other acute inflammations, this is rarer. It follows direct blows over the liver or upon the abdomen, falls and severe muscular strain, as well as other severe direct traumatisms, as a gunshot or knife wound. It will follow remote injuries also, as a blow upon the spinal column or upon the head.
Other causes are the introduction of infections into the portal circulation, or infectious disease of the hepatic blood vessels. These infections may result in an embolus or in a thrombus, or a pyemic embolus may be formed from contiguous or remote suppuration in other parts. In hot climates the condition follows dysentery directly, and assumes the form of a large single abscess of rapid formation, known as tropical abscess.
It also follows other severe disorders, as typhus, typhoid and malarial fevers, appendicitis, endocarditis and pulmonary gangrene or adhesions from gastric ulcer, as well as purulent cystitis and hemorrhoids. Tropical abscess following dysentery is, of course, directly due to the amebae coli, but other microbes are discovered also, such as the balantidium coli. This condition may occur idiopathically. Parasites and occasionally foreign bodies will induce it.
Suppurative hepatitis occurs quite frequently in the warmer parts of the United States and in southern Europe. It is common among Americans and English who sojourn in tropical climates. It is more apt to occur among those who are high livers, or among alcoholics and those of other dissipated habits.
Symptomatology:—There is considerable difference in the onset of acute and chronic cases. In acute cases the temperature will rise rapidly to perhaps 103° F. during twenty-four hours. There may be a decided chill, but usually there are rigors. There is no regular course to the fever; it is erratic, and may be remittent or intermittent, with some resemblance to malarial fever, or it may be of a hectic character. It may be followed by profuse perspiration, and this by rigors, with an abrupt rise in the temperature again. Or it may continue high for a number of days with slight morning and evening remissions. It occasionally reaches 104° or 104.5° F. In rare cases there is no fever, or the temperature may be subnormal. The pulse is round and full, or rapid, corresponding with the temperature. The tongue is heavily coated with a yellowish or yellowish brown coat; there is anorexia, impairment of the digestion and nausea. If pyemia is pronounced, the fever assumes a pronouncedly typhoid type. The tongue becomes dry and harsh with a brown or black coat; the mucous membranes are dark colored and dry, and there are sordes upon the teeth. Usually diarrhea prevails, but constipation is not uncommon. At times constipation and diarrhea alternate. The patient loses strength rapidly and becomes emaciated. The skin is flabby and of a dingy color, or it may be slightly jaundiced.
Pain is usually a conspicuous symptom from the first. It is located under the ribs on the right side and radiates upward into the shoulder. It increases as the disease progresses and is affected by change of position, being more severe when the patient lies upon the left side. It is dull, heavy and tensive or boring in character, and occasionally it is intermittent.
It will be observed upon inspection and palpation that the liver extends downward into the abdominal cavity and is uniformly enlarged. The area of dulness is uniformly increased, extending upward also, and to the right, and to a level with the angle of the scapula. If the abscess should occur upon the lower margin of the liver, this may alter the uniform projection downward. There may be some bulging of the ribs over the right lobe. The spleen becomes somewhat enlarged, and ascites may soon develop. There is edema of the skin when the pus is near the surface, and fluctuation may be apparent, and it is not uncommon that the pressure upon the lungs will produce a peculiar cough, with a brownish sputum. Later the patient becomes anemic, the skin is dry and harsh and the jaundice, which at first is but slight, may become intense.
As the disease progresses toward a fatal termination, there is increased mental dulness, delirium, varying in character in different patients, subsultus tendinum, and ultimately coma. After the disease has developed, the patient lies upon the right side with the right leg flexed upon the body to reduce the tension of the abdominal muscles.
Diagnosis:—The condition is easily confounded with empyema, gall stone or malarial fever. The fact that quinin makes no impression upon the disease will determine that it is not due to malaria. The symptoms must be taken together and all factors considered to confirm the diagnosis. The introduction of an aspirating needle in obscure cases will permit the withdrawal and examination of the fluid.
Prognosis:—The prognosis is unfavorable, the mortality ranging above sixty per cent. The disease in the acute form runs a rapid course. In large single abscesses an early operation will materially reduce the mortality. Where multiple abscesses are present the mortality is greater.
Treatment:—During the stage of development the best of results are obtained by treating the specific symptoms as they appear, with directness and positiveness. If an abscess formation can be anticipated, the treatment should be begun with small doses of aconite, frequently repeated, to regulate the temperature. Drop doses of belladonna every hour, to overcome the local congestion, and from twelve to fifteen minims of echinacea every two hours, to antagonize the formation of abscess, should be given. External heat will stimulate the capillary circulation and assist in the removal of morbific products, and will at first materially assist in antagonizing necrosis. Later phytolacca, polymnia uvedalia, and the use of full doses of the tincture of the chlorid of iron are indicated. Much attention should be paid to the condition of the stomach, and easily digested, nutritious foods should be administered. Occasionally a large mustard poultice over the region of the liver will be of service, both as a derivative agent and in relieving the pain.
When evidences point to the formation of pus, an exploratory puncture should be made. If pus is found, the expediency of an immediate operation must be considered, as early evacuation is desirable.