The diagnosis. Hepatic abscess may be confounded for a time with
malarial fever but the absence of plasmodia from the blood and the inefl&cacy
of quinine are sufficient to exclude the latter. When upward perforation
has taken place and the previous symptoms have not been characteristic the
condition may be considered to be an empyaema or pulmonary abscess but
428 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
the presence of the anchovy sauce sputum and of amoebae renders the diagnosis
simple.
Infected echinococcus cyst may be diagnosticated as abscess but its character
is hardly recognizable unless booklets are found in the aspirated pus. The
employment of the exploring needle is to be advised in suspected abscess of
all varieties but a failure to withdraw pus does not exclude the possibility of
its presence. The needle should be of moderate calibre and the operation
should be performed under general anaesthesia. The usual points of puncture
are bver the point of maximum dulness, in the seventh interspace in the an-
terior axillary line or in the seventh space in the mid-axillary line.
Hepatic intermittent fever due to the presence of calculi is associated with
a history of biliary colic and the presence of more extreme icterus; in other
respects, such as in its temperature curve, chills, sweating and liver tenderness,
it may resemble the more serious condition of abscess.
Leucocytosis is usually marked in abscesses of the liver of the pyaemic
variety; it is likely to be absent in those due to the presence of the amoeba
coli.
The prognosis, since early operation has become the preferred mode of
treatment, seems to be more favorable than previously. In any case, however,
the condition is a very serious one and the probability of a fatal outcome is
great.
Treatment. If the patient is seen early he should be kept in bed upon a
fluid diet and an ice bag should be applied over the liver; cupping is advised
and the application of a number of leeches to the hepatic region and about
the anus, In order to relieve the congestion of the portal system, may be em-
ployed. The bowels should be kept freely open by the administration of mild
laxatives and ammonium chloride in 20 grain (1.33) doses 3 times daily may
be given empirically. In the futiire we may be able to treat the condition
by means of the hypodermatic injection of a bactericidal serum, examination
of the patient's blood revealing the character of the causative micro-organism
and the type of serum indicated.
As soon as the presence of an abscess is determined surgical measiires
should be undertaken. These consist of various procedures such as aspiration,
which is most likely to be successful in tropical abscesses; puncture with
drainage, a large canula being employed and left in situ — later it may be
replaced by a drainage tube of rubber; and free opening with the knife. The
interior of the cavity should be thoroughly investigated and neighboring
abscesses, if present, also evacuated. After incision free drainage should be
provided. Rupture into the peritonaeum, pleura, lung, pelvis of the kidney
or pericardium necessitates immediate surgical interference. In rupture
into the intestine without peritonaeal involvement, operation need not be
undertaken unless the contents of the gut enters the abscess cavity and pro-
CIRRHOSIS OF THE LI\^R. 429
duces a gangrenous process; here external opening and drainage are indi-
cated.
During convalescence the patient should seek a change of climate, either
at the seashore or the mountains, and tonics with abundant nourishing food
should be prescribed.
Multiple pyaemic and pylephlebitic abscesses are fatal, usually without
exception, and unless signs of localization become evident, radical measures
are hardly ad\dsable, the treatment being that of ordinary pyemia.
CIRRHOSIS OF THE LIVER.
Synonyms. Interstitial Hepatitis; Gin-drinker's Liver; Hob-nail Liver;
Sclerosis of the Liver.
Definition. A chronic inflammation of the connective tissue framework
of the Hver resulting fiirst in an hypertrophy of the organ and later, because
of the tendency of the newly produced connective tissue to contract, in a
diminution in its size and a consequent compression of its parenchymatous
structure.
.Etiology. The causation of this disease has been in too great a degree
attributed to the abuse of alcohol. WTiile there is no doubt that alcoholic
beverages exercise a certain amount of influence in its aetiology, it is probably
true that this influence is rather the result of their adulteration with deleterious
substances and the fact that many wines are to-day artificially made from \'ine-
gar, logwood, etc., mixed with alcohol, than due to the alcohol itself. It is
also true that hepatic cirrhosis may be artificially produced in the lower
animals in a short time, without the use of alcohol, by the administration
of lactic, but}Tic, acetic and valerianic acids. Of these substances, aU except
the last may, in the human organism, result from digestive disorders, which
are frequently caused by the ingestion of sophisticated wines, such as those
mentioned above, beers adulterated with picrotoxin, aloes, glucose, etc. Con-
sequently the tendency to take a broader view of the disease should be encour-
aged and the cause should be sought in the alimentary canal.
SyphiHs, particularly of the congenital t}"pe, is not an infrequent cause of
cirrhosis, especially in children, and chronic malarial poisoning must be con-
sidered as a factor in the astiolog}^ of this condition.
Trauma cannot be considered a true cause of hepatic cirrhosis but it may
result in a localized perihepatitis beneath which a patch of interstitial cica-
tricial tissue may exist. This however never spreads through the organ.
The disease is usually seen in adults and in males more often than in females.
It does, however, occiir in children, in whom it may or may not be the result
of congenital syphilis.
430 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONAEUM. J
Pathology. The liver after death may be found to be either enlarged, of
normal size, or contracted. Its surface may be smooth or nodular. On
section it may be yellowish-red — especially in alcoholic patients — or yeUow
as a result of staining with bile pigments.
The chronic productive inflammation results in an increase in the connec-
tive tissue stroma of the organ. This new tissue may surround groups of
the liver acini or may be diffusely distributed among the liver cells, which are
constricted by it and it may be the seat of a fatty degeneration. The flow of
blood through the organ is obstructed by the new growth of tissue and as a
result of this the spleen becomes enlarged, there may be ascites and the lining
of the stomach and intestines becomes congested. The increase of the stroma
in the liver also may obliterate the small bile ducts and the large ones frequently
are the seat of a catarrhal inflammation.
In many patients there is a general accompanying increase in the connec-
tive tissues throughout the body resulting in arteriosclerosis, fibromyocarditis,
nephritis, etc.
Symptoms. The symptoms of hepatic cirrhosis may be classed as
follows :
1. Those due to the co-existent inflammation of the gastric mucosa.
2. Those due to the interference with the secretion of bile.
3. Those due to the interference with the portal circulation.
4. Those due to the accompanying connective tissue inflammations in
the heart, arteries, kidneys and lungs.
The gastric symptoms may by several years antedate those of the cirrhosis
itself, and usually are those of a chronic gastritis, with nausea, and vomiting —
which may often be the early morning "water brash" of alcoholic gastritis —
eructations and constipation. The gastric symptoms are more pronounced
in patients with an enlarged liver.
Jaundice of greater or less degree is a common symptom and occurs more
frequently in the presence of an enlarged liver than in the atrophic form of
the inflammation. With this symptom the urine contains bile and the faeces
are more or less clay-colored. In certain cases a rapidly fatal form of jaun-
dice occurs with emaciation, fever, and marked gastric and cerebral symptoms.
This variety resiilts in death within a short period.
Haemorrhages from the oesophagus, stomach, intestines and more rarely
from the uterus, nose, kidneys and bladder, are symptoms referable to the
obstruction of the portal circulation by the new growth of connective tissue.
They may be large and at times alarming but only seldom result fatally,
their usual effect being beneficent since they relieve the portal congestion.
Dilatation of the superficial veins of the epigastrium and lower part of the
chest is due to the damming back of the blood in the portal into the systemic
circulation. This in extreme cases may result in the formation of the caput
CIRRHOSIS OF THE LIVER. 43 1
MeduscB, the name given to the plexus of largely dilated veins about the
umbilicus.
Ascites of greater or less degree is a common symptom of cirrhosis with a
contracted liver. The abdominal fluid results from the portal obstruction and
varies in quantity from a pint (^ litre) or two to an amount so large that the
abdomen is distended to such an extent that there is protrusion of the umbil-
icus. Hydrothorax may occur and oedema of the legs may result from the
pressure exerted by the ascitic fluid upon the veins returning the blood from
the lower limbs. These symptoms are more frequently seen in the atrophic
variety of the disease.
Splenic enlargement exists in a considerable number of cases, especially
when the Hver is smaU; often the presence of ascites makes examination of
the spleen, as weU as of the Hver, so unsatisfactory that it is necessary to wait
until paracentesis has been performed.
The erflarged liver may be tender and is usually smooth of surface, while
the atrophic organ may be nodular.
The blood usuaUy shows a considerable diminution in both red cells and
haemoglobin.
The urine of the hypertrophic liver is usually of normal specific gravity
and is not likely to contain albumin. Bile pigment is frequently present.
The urea content is not usually diminished.
In the urine of atrophic cases, bile pigment is seldom present, the specific
gravity is low, albumin and casts may exist, the urea is usually diminished,
and in the later stages of the disease blood may be found.
The symptoms of the concomitant connective tissue inflammations of the
lungs, heart, arteries, etc., are those of these conditions when they occur sepa-
rately.
Rise in temperature is not a feature of the disease but may occur when
death is about to take place.
Physical Signs. These differ greatly in different cases and with the stage
of the disease. On inspection the patient's skin and mucous membranes
are usuaUy seen to be pale; jaundice of the skin may be present or there may
be merely the sub-icteroid hue and slight yellowness of the whites of the eyes.
There may be oedema of the feet or general anasarca. When much intra-
abdominal fluid is present the abdomen is likely to be prominent and tense;
its superficial veins are dilated and at times the varicose condition of these
structures known as the caput Medtiscs is present. Palpation may reveal
a large, small or normal sized liver with a rough or smooth surface. The
spleen may or may not be palpable. Percussion may give us additional
information as to the size of the liver and spleen and when ascites is present
the note, while the patient lies upon his back, wiU be flat over the flanks,
while that over the umbilical region, unless the abdominal cavity is entirely
432 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONAEUM.
filled with fluid, will be tympanitic. Upon turning the patient's body to
its side the flatness in the flanks will be found movable if the fluid does not
wholly fill the abdomen.
The physical signs of the accompanying heart, arterial, kidney and pul-
monary involvement will likewise be present (see the sections upon the
diseases of these structures), as well as those due to displacement of the ab-
dominal viscera by the ascitic fluid.
The prognosis. Cirrhosis of the liver is a serious, though by no means
always fatal condition. In certain cases the progress of the inflammation
may cease and the patient may die of some other disease. Its course is
usually chronic, lasting a year or two, although cases proving rapidly fatal
have been reported. The hypertrophic form seems more rapid in its evolu-
tion than does the atrophic.
Treatment. The treatment of this condition may be separated into the
following heads:
1. The diminution of the excessive connective tissue in the liver.
2. The treatment of the symptoms of the disease as they arise.
3. The prevention of further connective tissue change in the liver and
consequent destruction of its parenchyma.
Toward accomplishing the first of these objects it is hardly probable that
much can be done. The absorption of connective tissue growth, especially
when syphilitic in origin, should always be attempted by the use of some form
of iodine. Consequently this drug should be given tentatively whenever
specific disease is even suspected. To achieve any effect its administration
should be continued for a very considerable period. In all cases it is wise to
give this agent a thorough trial. In the opinion of the author the preferable
method of administering iodine is in the ofl&cial S}Tupus acidi hydriodici of
the pharmacopoeia. It should be given in doses of one drachm (4.0) well
diluted I hour before each meal, and is preferable to potassium iodide, being
less likely to cause iodism.
The Treatment of Symptoms. Ascites. This symptom may be treated
by, a. Depletion by means of diuretics and purgatives : Free diuresis may
be produced and moderate ascites diminished by the administration of the
Guy's diuretic piU — calomel, powdered digitalis, powdered squill, aa i grain
(0.065) — '^ith the addition of j grain (0.016) of extract of hyoscyamus to pre-
vent griping. One of these piUs should be given 3 times a day for one week,
then omitted for a week, repeated for a week and so on. Numerous other
diuretic drugs may be employed in this connection. Of the potassium salts
the acetate, bitartrate, or citrate may be employed; the preference is in favor
of the first. It may be given in doses of 20 grains (1.33) 3 times a day. Theo-
bromine has given different results in the hands of different observers but
the consensus of opinion that it is inferior in ascites due to hepatic cirrhosis
CIRRHOSIS OF THE LIVER. 433
to a number of other diuretics. Small doses of calomel frequently repeated
increase the excretion of urine. Citrated caffeine in doses of from 2 to 5
grains (0.13 to 0.33) may be employed. The fluid extract of apocynum can-
nabinum is an active diuretic in ascites, but should be given with care on
account of its tendency to disturb the digestion. Its dose is from 10 to 20
drops (0.66 to 1.33). The resin of copaiba increases the secretion of the
kidneys but on account of its liability to cause gastric irritation should be
given in capsules coated with keratin, 10 to 20 grains (0.66 to 1.33) in each
capsule. The fluid extract of asparagus in drachm (4.0) doses is a diuretic
drug which may be tried.
Depletion by means of pvirgatives may be used as an adjunct to that by
means of diuresis and numerous drugs of this class may be employed. Epsom
salts, 2 ounces (60.0), dissolved in 4 ounces (120.0) of boiling water and
allowed to cool, if given in the morning before breakfast, no liquid having been
drunk since supper the night before, will produce 5 to 6 watery stools during
the dav. This mbcture given twice a week will often ward off tapping for
some time. Sodium phosphate is also an excellent purge and an hepatic
stimulant as weU; it may be given in doses of ^ to 2 drachms (2.0 to 8.0) at
var^-ing intervals according to the effect produced. Laxative mineral waters
or their artificial salts may also be employed in this connection. Vegetable
cathartics such as cascara sagrada, rhubarb, aloes and jalap may be used
alternating with the salines. It is unwise to endeavor to remove ascites by
marked purgation by means of the stronger hydrogogues for the attempt may
be made at the sacrifice of the patient's strength.
Diminution of the ingested fluids in ascites is hardly to be advised since,
while it may reduce the quantity of the transudate, this good is more than
counterbalanced by the resulting diminution in the urine and tendency to
constipation.
The treatment of dropsical conditions by the elimination from the diet
of chloride containing substances is receiving much attention and for it great
claims are made. As a tentative meas\u-e it can do no harm in cirrhotic
ascites and futiire research may throw more light upon the subject. For
a consideration of the dechloridation treatment the reader is referred to the
section upon chronic nephritis.
b. Abdominal paracentesis or tapping. At the present time it is considered
wise to tap the abdominal cavity as soon as the fluid is of sufficient quantity
to annoy the patient; the old statement that a patient seldom survived two
tappings no longer holds, perhaps because of the present lessened danger
of infection and the fact that the procedure is not now employed as a last
resort. Accordingly, paracentesis should be performed as soon as the fluid
causes any mechanical interference with the functions of the abdominal or
thoracic viscera. Complaint of discomfort on the part of the patient is an
28
434 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
indication for the operation as well as a diminution of urine due to pressure
upon the vessels of the kidneys by the fluid, interference with digestion or
respiration due to the same cause, pulmonary congestion, as evidenced by the
presence of rales at the bases of the lungs posteriorly, etc. In cases of ascites
with haematemesis due to venous congestion in the mucous membrane lining
the stomach the procediu-e is also indicated.
Technique of Abdominal 'Paracentesis. The only apparatus needed is a
trocar and canula of rather small calibre (-^ to \ in.) and of sufficient length
to J)enetrate the abdominal wall of the case in hand, and a few feet of rubber
tubing to be attached to the canula, after the puncture, to lead the fluid to a
vessel of sufficient size which is placed upon the floor.
The patient's bladder should be emptied, and the site of the intended
puncture sterilized by scrubbing with soap and hot water, alcohol, aether and
1-5000 mercury bichloride solution. The usual site is in the mid-line of the
anterior aspect of the abdomen about equidistant between the os pubis and
the umbilicus; the situation chosen must be flat upon percussion. If no fluid
is obtained at the situation above mentioned the puncture may be made
at about the same level either to the right or left. The right iliac fossa should
be carefully avoided because of the possibility of puncturing the coecum in
this vicinity.
The trocar and canula and the operator's hands having been properly
sterilized and the site of the intended puncture anaesthetized by the application
of the ethyl chloride spray or the subcutaneous injection of a few drops of a
4 percent, solution of cocaine hydrochloride, the puncture is made, the trocar
removed and the rubber tubing attached. The patient may remain in a sitting
or semi-reclining position during the procedure and as the fluid is drained
an abdominal binder, which is tightened from time to time, to prevent sudden
intestinal distention, is applied. Should the fluid stop flowing before the
abdominal cavity is empty the canula may be cleared by passing the trocar
through it to dislodge any impediment. When sufficient fluid has been
removed the canula should be withdrawn and the puncture dressed by the
application of a bit of sterile gauze or cotton held in place by adhesive plaster
or collodium. The patient should wear the abdominal bandage for several
days following the operation. When a trocar of small calibre is used there
is little danger that the puncture will not heal without leakage. The consti-
pation which may follow tapping of the abdominal cavity and the possible
tympanites may be relieved by saline laxatives.
c. The treatment of ascites by operation with the view of establishing a
collateral circulation between the systemic and portal veins, the so-called
Talma's operation, has been much discussed but its results from a curative
standpoint are not all that could be desired, which fact in the opinion of some
observers, is due to the procedure being usually employed as a measure of
CLREHOSIS OF THE LI\^R. 435
last resort. It is possible that the results might be more favorable were the
operation undertaken early in the disease. For the description of the opera-
tive technique of omental anastomosis and epiplopexy the reader is referred
to works upon abdominal surgery.
Hcematemesis. The treatment of this distressing symptom of cirrhosis
of the Uver differs little from that of the haematemesis of gastric ulcer, see p.
352. The patient should receive no food by the mouth for three or four
days following the haemorrhage and during this period food may be admin-
istered per rectum. The first food allowed should be in fluid form and may
consist of milk, gruels, and broths, if possible partly predigested by peptoniza-
tion. Gradually the patient should be brought back to solid diet (see feeding
in gastric ulcer, p. 353), and after about 10 days he may be allowed to leave
his bed. The after treatment consists in a regulation of the diet, only easily
digested and non-irritating foods being allowed, and the administration of
tonics. The patient should be advised to conduct his habits and mode of
life in accordance with hygienic principles.
Hcemorrhage evidenced by the appearance of blood in the stools. Blood so
changed by the fluids of digestion that it presents a tarry appearance may be
voided with the faeces even when there has been no vomiting of blood. After
such hemorrhage the patient must remain quiet for a number of days and
his feeding should be carefully conducted. Otherwise the treatment consists
in meeting the indications as they arise.
The management of rectal hemorrhage due to the presence of haemorrhoids
consists in treatment of this complication in accordance with ordinary methods,
(see the section on haemorrhoids.)
The treatment of concomitant digestive disturbances. Alcoholic drinks
are contraindicated and the diet shoifld be so regulated as to prevent the
formation in the digestive tract of such products of- fermentation as lactic,
acetic and butyric acids. The accompanying chronic gastritis with the
excessive production of mucus which is of frequent occurrence may be
relieved by the drinking of a glass of hot water before each meal, which tends
to dissolve the mucus from the wall of the stomach, or by gastric lavage.
Fermentation may also be relieved by the administration of drugs of the
class of internal antiseptics such as phenyl salicylate, resorcinol, sodium phenol-
sulphonate and the bismuth salts, particularly the naphtholate. Small re-
peated doses of calomel are useful in this connection, gr. y-Q (0.006). The
use of this drug will also tend to prevent constipation. The bowels should
not be allowed to become constipated for this condition favors the production
of the toxic substances above mentioned. Constipation may be prevented
by the moderate use of salines such as sodium phosphate or sulphate, the
laxative mineral waters, etc. The drinking of plenty of ordinary water is
to be recommended.
436 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
Atonic conditions of the stomach call for the administration of smaU doses
of strychnine, y-^^ to -g^ of a grain (0.0006 to o.ooi). The use of pepsin
and other artificial digestants, in the opinion of the most advanced observers,
is unnecessary.
The administration of drugs prepared with alcohol is to be avoided in so
far as possible.
The prevention of further connective tissue growth in the liver is to be brought
about by attention to the gastric condition, the treatment of which has been
dealt with above, and by regulation of the diet and mode of life. Alcohol
should be forbidden and the patient should become a total abstainer. Tobacco
should be used in moderation only, if at all. The interdiction of alcohol,
of course, does not apply to those late stages of the disease where its use as
a stimulant is necessary. Some patients, no matter what is said by the phy-