vein or of peritonaeal metastases. If tapping reveals the presence of blood-
tinged fluid in association with a growth of the liver the probability of
malignant tumor is great.
CANCER OF THE LIVER. 445
The blood is that of a secondary anaemia and consequent oedema is fre-
quent. A febrile movement is not uncommon especially in the late stages;
it is often continuous â€” iooÂ° to 102Â° F. (37.8Â° to 38.9Â° C.) â€” but may be inter-
mittent. Chills may be noted.
Physical Examination. Upon inspection the patient is seen to be emaciated
and cachectic in appearance. The skin may be of icteric color and there is
usually a prominence of the upper abdomen with a dilatation of the superfi-
cial veins. Palpation reveals the edge of the liver from an inch or two below
the margin of the ribs to the level of the umbilicus or even lower. The surface
of the organ may be smooth but in nodular cancer the prominences and some-
times the depressions in their centers may be felt. Tenderness may be
present. The increase in size is also evident upon percussion and it usually
involves the whole organ but may affect one lobe more than the other. Splenic
enlargement is not characteristic nor frequent.
Primary neoplasms may be difficult of differentiation from those of secondary
type unless there is a demonstrable primary growth elsewhere in the body.
The diagnosis may be 'difficult in the absence of primary carcinoma of
other structures. The presence of firm nodules on the siurface of the organ
simplifies the diagnosis but the smooth cancerous liver is a more complicated
problem. It may be differentiated from the fatty liver by its hardness, the
absence of cachexia and jaundice. These two latter are also absent in the
amyloid liver and here the spleen is usually enlarged. In abscess we have
the history of colitis or the presence of a septic temperature to aid us, the
organ is usually soft and fluctuation may be elicited. The nodules which
occwi in hydatid disease with an enlarged liver are soft, the cachexia is not
present and the course of the disease is more protracted than that of cancer.
Aspiration of one of the cysts may show the presence of booklets.
Another difficult problem is the separation of the amyloid liver with a surface
studded with gummata. Here the presence of a history of S}^hilis and the
benign course of the affection are diagnostic points. In hypertrophic cirrhosis
we have an enlarged liver vnih jaundice but the onset of cachexia is deferred,
wasting is not extreme, pain is absent, the liver is smooth and the ascitic fluid
does not contain blood nor cancer cells; the spleen is usually enlarged. That
form of carcinoma which is associated with cirrhosis is extremely difficult of
differentiation from atrophic cirrhosis; the emaciation is, however, more
rapid in the former affection.
Melano-sarcoma usually follows pigmented growths in other parts, partic-
ularly the choroid of the eye and the skin; there is great enlargement in the
liver and often metastatic growths in the kidneys, lungs and other organs are
The importance, in instances of hepatic affection in which a malignant
nature is suspected, of thoroughly searching for the presence of primary cancer
446 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
elsewhere, cannot be over-rated. The stomach, uterus and rectum, in partic-
ular, should be investigated by all the means at our command.
The prognosis of hepatic cancer is, of course, distinctly unfavorable, the
condition usually resulting in death in a few months; exceptionally life may be
prolonged for a year or slightly longer.
Treatment. Medical treatment can be but palliative. For the pain the
hypodermatic administration of morphine may be prescribed without com-
punction for the character of the disease is such as to render the induction of
theihabit harmless. The addition of small quantities of atropine to the former
drug will lessen the tendency to constipation. This symptom, when present,
is preferably treated by means of the vegetable purges such as cascara, senna,
aloes, etc.; the saline waters, according to German observers should not be
Hepatic pain may be relieved by the application of hot or cold compresses,
poultices, anodyne plasters or counterirritants such as tincture of iodine, or
The appetite may be improved by the vegetable bitters and dilute hydro-
chloric acid â€” 10 drops (0.66) in a glass of water with each meal.
Vomiting may be controlled by the administration of bits of cracked ice,
sodium bicarbonate and cerium oxalate in milk, small doses of dilute hydro-
cyanic acid or of creosote. Gastric lavage is often effective. Intestinal
fermentation is benefited by the bismuth salts especially the naphtholate or
iodophenolphthaleinate in doses of 5 grains (0.33) 3 times daily.
The pruritus which sometimes accompanies the jaundice may be relieved
by warm baths containing sodium carbonate, lotions of i to 50 phenol
and the other means suggested under the treatment of catarrhal jaundice.
Calcium chloride, 15 grains (i.o) 3 times daily and hypodermatic injections
of pilocarpine, | of a grain (o.oii), are said to be effective.
The diet should be nourishing and easily digestible. Frequent small meals
are preferable to larger ones at longer intervals. Milk when well borne is
very valuable but if large amounts are taken at once heavy curds may form in
the stomach. To obviate this Vichy or lime water may be added. Kumyss
and matzoon are excellent substitutes when the patient cannot take milk
or is tired of it. Meat and fats are often not well tolerated but the various
meat extracts may be employed if desired. Cereals and gruels are excellent.
Usually the patient may be allowed to select the foods which he likes if they
are not disturbing to the digestion.
Surgical treatment may be effective when the growth is single, primary and
in a favorable situation. Recovery has followed in at least one instance of
secondary tumor, the primary growth in the stomach having been excised and
at the same time a secondary nodule in the liver was extirpated. The advances
which are daily being made in surgical technique lead us to hope that it may
PARASITES OF THE LIVER. 447
soon be possible to undertake operations upon the liver which were previously
If marked ascites is present repeated tapping may be necessary.
PARASITES OF THE LIVER.
Echinococcus Disease of the Liver.
Synonym. Hydatid Disease of the Liver.
Definition. \ disease of the liver due to invasion of the embryo or larva
of the txEnia echinococcus and characterized by the formation of cysts within
the substance of the organ.
.Etiology and Pathogenesis. The tcenia echinococcus is a minute cestode of
three or four segments and about \ of an inch (4 to 5 mm.) in length; the head
is small and possesses four sucking disks and a rostellum with two rows of hook-
lets. The natural habitat of this parasite is the upper intestine of the dog. The
worm is rarely met in the United States possibly because it is so small as to
be easily overlooked. Echinococcus disease is most common in those countries
Avhere the relation between dogs and men is intimate, as in Iceland and Aus-
The terminal segment of the parasite, containing several thousand eggs, is
cast off by the dog in the intestinal evacuations of this animal and entering
the human alimentary tract with food or drink, the egg shell is dissolved and
the larva is liberated. . It bores its way into some branch of the portal
circulation and is carried by the blood stream to the liver. Here it lodges
and the booklets, by means of which it entered the blood-vessel, disappear.
The embryo now becomes a small cyst consisting of two layers, the external
or ectocyst which is laminated and cuticular in structure and the internal
or endocyst, a parenchymatous or germinal layer. The fluid of the cyst is
clear and the w^iole vesicle is enclosed by a capsule of connective tissue which
develops as a result of inflammatory reaction. When the primary cyst has
increased to a diameter of y to -|- of an inch (15 to 20 mm.) buds develop
from the germinal layer which gradually become cysts themselves with a
structure identical with that of the primary vesicle. These daughter cysts
are at first attached to the lining of the mother cyst but later free themselves
and become in turn the parents of a third generation of vesicles.
From the granular inner layer of parent and daughter cysts brood capsules
develop by a budding process, and from their lining membrane projections
are formed which ultimately become scolices which really are the heads of
tanicB echinococci with their suckers and booklets. These when freed and
ingested by the dog may develop into the adult parasite.
The preceding is the usual form of the development of the echinococcus in
448 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
man; at other times the daughter and granddaughter cysts remain within the
parent and in animals the buds may force their way between the two layers
of the cyst waU and grow outward â€” the exogenous type. In still another
type â€” the multilocular â€” the buds which are formed from the parent cyst
become completely cut off and are enclosed by a fiirm connective tissue capsule;
a number of these may unite and form a dense mass of fibrous tissue in the
meshes of which are spaces of about the size of a large pea in which at times
booklets and scolices may be found.
The fluid contained in the young cysts is clear, of a specific gravity of 1005
to 1009 or slightly higher and contains no albumin except after a number of
tappings; at times traces of sugar, succinic acid and hsmatoidin are present.
Scolices and booklets are usually found and are characteristic of hydatid
The cysts vary in size from that of a pin head to 5 inches (12 cm.) or more
in diameter and are of slow growth; the parasite may remain alive perhaps as
long as 20 years. When death finally takes place the cyst walls contract and
the contents becomes inspissated; partial calcification may occur. Rupture
into the bile ducts, the vena cava, the intestine and elsewhere may happen
and is a serious complication; the same is true of suppuration.
Symptoms. Small cysts are often unsuspected until revealed at autopsy.
The larger ones give rise to the symptoms of hepatic tumor associated with a
very slow and gradual decline in health. The large cysts cause a dragging
sensation referred to the region of the liver, jaundice, if there is obstruction
to the flow of bile, and when there is interference with the action of the heart
or lungs, dyspnoea and irregular cardiac action.
Suppuration gives rise to a septic temperature with rigors and sweats and
if rupture takes place various symptoms result depending upon the site of the
rupture. Invasion of the lungs may be accompanied by the expectoration of
sputum containing booklets; rupture into the bile passages is succeeded by
jaundice and by the evacuation of faeces in which booklets may be found;
rupture into the stomach may be followed by vomiting of booklets and cysts;
the bursting of a cyst into the vena cava causes interference with the right
heart action and thrombosis of the lungs due to the lodgment of cysts. The
cysts may also rupture into the pericardium in which case pericarditis ensues ;
into the peritonaeal cavity with resulting peritonitis; or externally through the
abdominal wall. Urticaria may appear coincident with rupture or even
with aspiration due perhaps to the absorption of a toxic material contained
in the fluid.
The physical signs depend upon the situation of the tumor. Cysts near the
upper surface of the liver may manifest themselves by demonstrable elastic
or fluctuating swellings and may give the so-called hydatid fremitus which is
elicited by applying one hand to the tumor and at the same time percussing
ECHINOCOCCUS DISEASE OF THE LIVER. 449
lightly with the other. The fremitus is evidenced by a vibrating or trembling
movement thought to be produced by the impact of the daughter cysts against
The diagnosis often requires puncture and aspiration of the cyst contents
for its confirmation; the characteristics of the fluid withdrawn are as described
above. The presence of booklets is pathognomonic and that of glucose,
probable evidence of hydatid disease. Hepatic syphilis may be differentiated
by its history, and cancer of the liver by the more rapidly developing
The prognosis in instances of the affection which are characterized by
evident symptoms is unfavorable, unless operative interference is undertaken,
except in the instance of spontaneous external rupture.
Treatment. Prophylaxis consists in impounding and destroying stray
dogs and also in decreasing the number of these animals by means of an in-
creased license fee. Strict cleanliness should be observed by those who keep
dogs in the house as the ova are to a very great extent conveyed by the faeces
of these animals. Where the disease is prevalent all drinking water should
be filtered and boiled and all fruit and vegetables which are eaten uncooked
must be thoroughly washed with filtered and boiled water. Meat should be
inspected for the echinococcus and all the offal of infected sheep and oxen
should be burned lest they be eaten by dogs. Pet dogs should receive an
anthelmintic about once a year.
Numerous drugs have been employed in the treatment of echinococcus
disease but none of them has proved of any benefit, the only efficient curative
means which we possess being surgical.
Simple aspiration of the cyst contents, a canula of moderate size being
employed, may result in cure but is not to be undertaken without due con-
sideration, for death has been known to follow the operation. Aspiration is
contraindicated if suppuration is present. Aspiration with injection of anti-
septic solutions such as i to 1000 mercury bichloride, 5 percent, copper sul-
phate and 0.5 percent, beta-naphthol has been recommended but is not with-
out danger and is to be avoided.
The treatment by means of electrolysis is carried out by passing two needles,
each connected to the negative pole of a galvanic battery, into the cyst, while
a sponge electrode attached to the positive pole is applied externally to the
abdomen or over the cyst. Success has followed this method in a few instances
but it is not to be advised.
Radical surgical treatment should always be employed when possible, the
object being to remove the cyst wall and its contents entire; if this is imprac-
ticable simple evacuation of the fluid may result in cure. When suppuration
has taken place the management of the condition is identical with that of
450 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONJLUM.
Other Parasites of the Liver.
The liver is subject to diseases due to other forms of parasites but these
are rare and of interest rather to the pathologist than the practitioner. The
pentastomiim denticulatum, the larva of the pentastomum or lingelata tcBnioides
may be found in the organ. This is a lancet-shaped worm, the male being
slightly less than an inch (1.8 to 2.5 cm.) long vv^hile the length of the female
is from 3 to 5 inches (8 to 13 cm.).
^he coccidium oviforme is common in the liver of the rabbit and may be
found in the human being where it produces whitish nodules varying in size
from that of a pin head to that of a small pea. The accompanying symp-
toms are intermittent fever, nausea, diarrhoea and enlargement and tenderness
of the liver.
The cysticercus celluloscz is rarely observed in the liver of man.
DISEASES OF THE HEPATIC BLOOD-VESSELS.
Anaemia of the liver is productive of no especial symptoms. The aneemic
condition which is observed after death in the liver of amyloid or fatty degen-
eration is probably not an index of the state of the organ during life.
Hypersemia of the liver occurs in two varieties :
I. Active Hyperemia takes place after eating a full meal and is especially
marked in individuals who eat and drink excessively; in these subjects the
condition may even be continuous. If the over-eating and drinking is persis-
ted in, functional disturbances and even organic structural change, consisting
in an over-production of connective tissue, may resiilt. Active hypersemia
also occurs in diabetes mellitus and in the acute infectious diseases and also
as a result of suppressed menstruation and after the suppression of a haemor-
Symptoms. These are not marked nor important. The condition may be
the cause of the distress and feeling of weight of which persons who habitually
eat and drink too much complain and which is referred to the region of the
liver. The size of the organ is probably subject to daily fluctuations.
Treatment consists chiefly in dietetic measures; a moderate and easily
digestible diet comprised of milk, thin soups, etc., should be substituted for
that to which the patient has been accustomed. Plenty of water should be
taken but alcohol, vnth fats and sugar, should be forbidden.
The pain and discomfort over the liver, if severe, may be relieved by the
application of flaxseed poultices, cold compresses or dry cups. Intestinal
antiseptics especially bismuth naphtholate or phenolphthaleinate (eudoxin)
in doses of 5 grains (0.33) 3 times a day should be given, any gastric irritation
should receive appropriate treatment and the bowels should be kept freely
DISEASES OF THE HEPATIC BLOOD-VESSELS. 45 1
open by means of fractional doses of calomel and the saline laxative waters.
Ammonium chloride in 20 grain (1.33) doses is said to have some influence
in decreasing the congestion of the affected organ.
In many instances a sojourn at one of the spas such as Saratoga, where the
Hathorn water is particularly indicated, is advisable; Vichy upon the continent
of Europe is recommended as a resort for these patients.
2. Passive Hypercemia is a much more common and important affection
than the foregoing.
iEtiology. The condition is the result of obstruction to the flow of blood
through the liver to the heart. The chief cause is valvular endocarditis but
passive congestion of the liver also occurs in pulmonary emphysema and
sclerosis, thoracic tumors, pleuritic diseases and any condition in which
pressure is exerted upon the vena cava.
Pathology. The Hver is increased in size, firm in consistence and dark
reddish in color. Its vessels are distended with blood, the intralobular vein
and the neighboring capillaries being especially affected in this respect. On
section the " nutmeg" appearance, which is the resiilt of the alternating hyper-
aemia and anagmia of the hepatic and portal districts, is apparent. The in-
creasing distention of the vessels in the central portions of the lobules finally
results in an atrophy of the adjacent liver cells; there is a deposition of dark
pigment, the blood-vessels are finally occluded and there is an increase of con-
nective tissue. In the final stage of chronic passive congestion the organ is
decreased in size but its surface is smooth in contradistinction to the condition
obtaining in atrophic cirrhosis in which the surface of the liver is roughened.
Symptoms. There is usually gastric irritation with vomiting, sometimes
of blood; ascites, at times followed by general oedema, is common in the later
stages. There may be slight jaundice, with dark urine and light colored
The physical signs consist of a primary enlargement of the liver, often
with tenderness, followed by a contraction of the organ. The enlarged liver
may pulsate as a result of the regm-gitation of blood from the right side
of the heart. This is not to be confounded with the throbbing which may be
transmitted from the over-acting heart. In this latter condition the liver
appears to move downward while in the former the organ appears to dilate
uniformly. The spleen is often increased in size.
Treatment consists in restoring the circulation to its normal state which
is often possible, when the condition is the result of vahoilar heart disease, by
the administration of cardiac tonics. Co-existing pulmonary disease should
receive appropriate treatment and abdominal paracentesis may be necessary.
Confinement to bed is usually indicated.
The congestion of the liver may be further relieved by saline laxatives
and hydrogogue cathartics such as elaterium, jalap, etc. Calomel and blue
452 DISEASES or THE DIGESTIVE SYSTEM AND PERITONEUM.
mass are also valuable. The method of depletion advocated by Hay, which
consists in the administration before retiring of 2 ounces (60.0) of magnesium
sulphate which have been dissolved in boiling water and then allowed to cool,
is an excellent method of relieving the portal congestion. The general dropsy
may be diminished by eliminating the chlorides from the diet (see the section
on the treatment of the oedema of chronic nephritis). The withdrawal of
from 15 to 20 ounces (450.0 to 600.0) of blood directly from the liver may
be practised but is not without danger.
The pain over the liver may be relieved by the means suggested in acute
hepatic congestion (p. 450). The diet shoiild be nourishing and easily
digestible because of the possibility of increasing the dropsy.
During convalescence a residence at one of the water cures suggested under
the treatment of active hypersemia is often of benefit to the patient.
Thrombosis and Embolism of the Portal Vem.
Thrombosis of the small branches of the portal vein occurs as a result of
the obliteration which takes place in hepatic cirrhosis; obstruction of larger
branches may foUow cancerous invasion, the lodgment of a parasite or of a
calculus which has iilcerated through the vessel waU. The blood may coagu-
late in the vein in cirrhosis and syphilis of the liver or the vessel may become
occluded as a result of a proliferative inflammation of its wall. Collateral
circulation may become established around the obstruction and the affected
vessel may degenerate into a fibrous cord.
Symptoms. Associated with those of cirrhosis or of another of the causa-
tive conditions the sudden occurrence of ascites, extreme distention of the
branches of the portal circulation with splenic enlargement, haematemesis
and bloody stools is suggestive of portal thrombosis. The diagnosis is a
very difi&cult one.
Hepatic infarct is not common and is of no especial clinical importance
except when the embolus is septic.
Pylephlebitis is probably consequent upon portal thrombosis but is of no
particular significance unless the thrombus is infective. Septic pylephlebitis
follows the lodgment of an infective embolus from some part of the territory
of the portal circulation. It may occur in dysenteric conditions or in sepsis
of the umbilical vein in the new-born; its chief importance is its relation to
The symptoms are the usual ones of pyagmic infection, irregular tempera-
ture with rigors, sweats and prostration. There is usually pain over the
liver and jaundice with the manifestations of portal obstruction. Co-existent
purulent peritonitis has been observed.
Changes in the Hepatic Artery and Vein are uncommon. The artery
DISEASES OF THE BILIARY TRACT. 453
may be the seat of dilatation in cirrhosis of the liver. Arteriosclerosis and
endarteritis as well as aneurysm of the hepatic artery have been observed.
The last of these is evidenced by an expansile tumor over which a bruit may
be audible. Its symptoms are pain over the liver, jaundice from obstruction
of the biliary ducts due to pressture, melaena, and the vomiting of blood.
The hepatic vein may be dilated in conjunction with right cardiac enlarge-
ment. Embolism from the right auricle has been noted and a stenosis of the
openings of the veins has been described as occurring in connection with
a fibrous obliteration of the inferior vena cava.
DISEASES OF THE BILIARY TRACT.
Definition. A condition, rather symptom than disease, characterized by a
yellowish discoloration of the skin and other tissues, as well as of the body
secretions, by the bile pigments. Jaundice was formerly considered as occur-
ring in two types, hepatogenous, or obstructive, and hcematogenous. At present
it is held as probable, if not certain that there is no hsematogenous jaundice
but that obstruction is responsible for the condition in all instances.
Obstruction to the normal flow of bile and consequent jaundice may result
from various causes of which the following are the most frequent: i.
Inflammation with accompanying sweUing of the duodenal mucous membrane