Cirrhosis of the Liver.
Synonyms.—Interstitial Hepatitis; Gindrinker's Liver, Sclerosis of the Liver; Nutmeg Liver; Hobnailed Liver.
Definition.—A chronic disease of the liver, characterized by an increase in its connective tissue, a reduction in the size of the organ, and a degeneration of the parenchymatous constituents.
Etiology.—Fibrous cirrhosis is due to irritants of various kinds carried to the liver by the blood-vessels, especially the portal vein, the bile-ducts, or by way of the peritoneal capsule.
In the great majority of cases, the disease is clue to alcohol; in fact, more cases are due to this cause than all other irritants combined; hence the term, gindrinker's or drunkard's liver. The time required for the development of the disease depends upon the quantity and strength of the alcohol digested.
Syphilis, so often contracted as the result of drinking, also holds a prominent place as a causal agent.
Highly spiced and very rich foods, ptomains, lead, arsenic, phosphorus, and antimony are also considered as factors in producing the disease. Irritants due to the infectious fevers, especially scarlet fever, typhus fever, dysentery, cholera, and chronic malaria, are occasionally responsible for the disease.
Cirrhosis may result from chronic obstruction of the bile-ducts, due to gall-stones, tuberculosis, or congenital causes.
Eichorst believes that cirrhosis may result from cardio-vascular changes, and constitutes the cardiac liver. The cause of the hypertrophic cirrhosis of Hanot is obscure. It is a comparatively rare affection, occurring most frequently in the male, and between the ages of twenty and thirty-five years.
Cirrhosis most frequently occurs between the ages of thirty and sixty years, although it may be found in the extremes of life. Men are more liable than women to contract the disease, owing to greater dissipations.
Pathology.—Two conditions of drunkard's liver are found: the atrophic cirrhosis of Laennec and the fatty cirrhotic liver.
Atrophic Cirrhosis.—The liver is greatly reduced in volume, sometimes being-no more than one-third the normal size. It is firm, hard, and cuts with great resistance. It is rough with granules or nodules, which vary in size from a small shot to that of a marble, which gives it the name hobnailed liver.
A cut surface reveals grayish-white bands of connective tissue, surrounding yellowish parenchymatous patches. The process of degeneration commences in the tissues surrounding the terminal branches of the portal vein, and gradually extends to the larger branches.
As the disease progresses, the hepatic cells and portal vein become more and more compressed, with an increased obstruction of the circulation. A cut surface reveals, at first, a pulpy mass, which is gradually replaced by connective tissue, with shrinking or atrophy of the organ.
Fatty Cirrhotic Liver.—In this form the liver is large, smooth, or but slightly granular, yellowish-white in color, and cuts with much resistance. The fat is greatly increased, and resembles somewhat a fatty liver. The connective tissue, as in atrophic cirrhosis, is greatly increased. In both forms degeneration of the hepatic cells and obstruction of the portal circulation are the chief characteristics.
The capsule of the liver, especially between the nodules, is thickened and opaque, and is frequently united to the peritoneum by fibrous bands.
The. peritoneum is generally involved, being opaque, thickened, and sometimes infiltrated with blood pigment, and stained with bile. More or less fluid is found in the cavity.
The stomach and intestines show a catarrhal condition, and the spleen is enlarged.
The hypertrophic liver (Hanot) is greatly increased in size, sometimes weighing as much as four hundred grams. It is yellowish green in color, smooth or granular on the surface, is tough, and cuts with much resistance. The peritoneal covering is frequently adhered, and is much thickened. The liver cells are enlarged and contain more than one nucleus.
Large, round cells and fibroblasts are found in the intralobular portion of the organ. Syphilitic cirrhosis, either congenital or acquired, reveals a large, tough, resistant liver, resembling very much an amyloid liver. The microscope shows a great increase in the connective tissue, with areas in which are found many round and spindle cells. Gummata, varying in size from a small shot to a pigeon's egg, are also found.
In biliary cirrhosis, the liver is large, firm, and usually smooth. A cut section reveals a reddish-yellow surface. The bile-ducts are dilated, with frequently sclerotic thickening about them.
In Glissonian cirrhosis, as a result of peritonitis involving the perihepatic membrane, the capsule undergoes fibrous degeneration, becomes thick, hard, and resisting, and adheres to surrounding organs. As a result of this hypertrophy of the capsule, the liver, by pressure, becomes atrophied.
Symptoms.—Atrophic Cirrhosis.—Where the compensatory circulation is maintained, the disease may exist for months without any characteristic symptoms. The first noticeable, are often attributed to wrongs of digestion, rather than to diseases of the liver, and consist of anorexia, belching, full red tongue, bad taste in the mouth, vomiting, flatulency, constipation alternating with diarrhea, sensation of pressure in the epigastrium, and tenderness in the right hypochondrium—symptoms due to obstructed portal circulation.
As the disease progresses, all the above symptoms become aggravated, with occasional hemorrhage from the gastro-intestinal tract. When the hemorrhage occurs from the distended veins of the stomach or esophagus, it is vomited; and when from the intestines, it is passed from the rectum. These hemorrhages occur at irregular intervals, and may persist for months. Sometimes large quantities of blood are thus lost, though it seldom ever results fatally.
Hemorrhoids are quite common, and are due to passive congestion of the inferior hemorrhoidal veins.
The liver is at first enlarged, and may extend a handbreadth below the ribs. Later it atrophies, though to what extent can not be determined by palpation. The abdomen becomes puffy, and the superficial epigastric and internal mammary veins, enlarging, form the "caput medusa" about the umbilicus.
With the progress of the disease, emaciation becomes marked, the features are pinched, and the skin assumes a dirty or muddy hue, rather than the jaundiced. The spleen becomes greatly enlarged, owing to enormous congestion. As compensatory circulation fails, ascites develops, sometimes leading to enormous distention of the abdomen, and crowding of the diaphragm, which, in turn, gives rise to marked dyspnea, the result of pressure upon heart and lungs. As a result of ascitic pressure upon the inferior cava and ileac veins, and also enfeeblement of the general circulation, edema of the legs, feet, and external genitals occurs.
The urine is scanty, high-colored, and contains bile, and is loaded with urates, and rarely contains albumin and tube-casts. When albumin is found, it is usually due to fibrous changes in the kidney.
The temperature is usually normal, or subnormal, though there may be slight fever, the temperature registering 100° or 102°. Although the toxic agent has not yet been determined, a toxemia sometimes develops, attended by an active delirium or stupor, coma, and convulsions.
Fatty Cirrhosis.—The symptoms of fatty cirrhosis so closely resemble those of atrophic cirrhosis that, aside from the increased size of the liver, one is not able to differentiate the one from the other.
Hypertrophic Cirrhosis.—The early symptoms of this form do not differ materially from those of the forms already considered; viz., gastro-intestinal; and it is only after the liver enlarges, grows painful, and jaundice becomes marked, that the symptoms become characteristic.
When the liver reaches its maximum size, it encroaches upon the adjoining parts, and is quite tender on palpation. Jaundice is a marked feature, and icterus gravis, attended by high fever and delirium, may develop at any time during the disease.
The spleen is greatly enlarged, and, when very painful, is due to a peripleuritis arising. The urine is quite scanty, concentrated, and of a high specific gravity, and contains bile pigment. Ascites does not occur. Hemorrhages from various parts of the body occur, especially from the mucous surfaces. The disease runs from three to ten years, the patient finally dying, with symptoms of icterus gravis, from extreme cachexia, or from hemorrhage.
Syphilitic cirrhosis, aside from the history of infection, has similar symptoms to the atrophic form, while capsular cirrhosis has no characteristic symptoms.
Biliary Cirrhosis.—Perhaps the most characteristic symptom is the rapidity with which jaundice appears, and frequent attacks of hepatic colic. If due to gall-stones, and their passage is affected, the jaundice disappears. Where the liver remains enlarged, the symptoms are the same as those of ordinary cirrhosis, with an exaggerated jaundice and ascites.
Diagnosis.—The history of alcoholic indulgence, enlarged abdomen, ascites, and hemorrhage from stomach and bowels, would give a comparatively positive diagnosis, while marked difference in the size of the liver would suggest the variety, whether fatty or atrophic. If there be a history of syphilis, and syphilitic lesions are known in other organs, and if the liver be enlarged, hard, and irregular, this form would be recognized.
The hypertrophic form would be suggested by its chronicity, absence of ascites, marked jaundice, hemorrhages from various parts, and enlarged liver-and spleen.
Prognosis.—This is generally unfavorable. The absence of characteristic symptoms during the early stage renders an early diagnosis difficult, if not impossible, and the process of degeneration has proceeded so far, in most cases, that a permanent cure is the exception. Early treatment may, however, stay the progress of the disease, and render the patient comparatively comfortable for years.
Treatment.—Alcohol must positively be prohibited, and all highly seasoned food restricted. The diet should consist of the blandest kinds of food; such as milk, wheys, broths, the more easily digested cereals, and fruits.
To relieve the nausea and vomiting, nux vomica, hydrastin, rhus tox., ipecac, bismuth subnitrate, and like remedies, will be found useful. Where the tongue is broad and coated with a moist, dirty yellow coating, and there are full tissues, Podophyllin will be useful.
Where the skin is sallow and the tissues sodden, chelidonium .will be indicated.
Chionanthus, from ten to twenty drop doses, will be called for where the jaundice is pronounced.
The bowels should be kept in a soluble condition, and some one of the many saline waters may be used.
Apocynum will be suggested by dropsical effusions. When the abdomen becomes filled with fluid, temporary relief will be afforded by resorting to paracentesis abdominalis.
Syphilitic cirrhosis will call for echinacea, phytolacca, rumex, iris, corydalis, berberis, Donovan's solution of arsenic, and iodide of potassium.