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(Cheadle.) Not always is the syphilitic liver large ; it may be small,
and is thus often confounded with the alcoholic liver. This is especially
to be regretted from a therapeutic standpoint, knowing as we do how
invaluable antisyphilitic treatment is in these cases. Perihepatitis, while
not pathognomonic of syphilitic liver, occurs very frequently in connec-
tion with it. Moreover, in this form a similar condition is more apt
to extend to other organs, particularly to the peritoneum, where it
causes that adhesive inflammation which of itself is quite characteristic.
Where syphilitic cirrhosis exists it may be more or less advanced.
Indeed, its presence may only be revealed by a slight scarring of the
free surface and some thickening of the hepatic capsule. Such patho-
logical conditions may serve to fix a diagnosis post-mortem where there
has been no syphilitic history and where signs and symptoms during life
left one in reasonable doubt as to the etiology of the case. Inasmuch
as syphilis of the liver is a late form of the disease, I have known
instances where the patient seemed almost oblivious of his ever having
had it, and where he could only with some difficulty be made to under-
stand any connection between his previous history and his actual symp-
tom?. I am now having in mind educated and fairly intelligent men
of the world. This is a practical observation of importance from the
point of view of insistence upon antisyphilitic treatment at times, even
though the patient is skeptical and disposed to resist or follow out his
own impressions of his ailment. No organ at times becomes more
important in the history of hepatic cirrhosis than the heart. As soon
as it shows symptoms even of dynamic inefficiency immediately there
is a tendency to venous stagnation, which must promote growth of
fibrous tissue and development of ascites. Alcohol, as we know, affects
the heart as- it does other organs ; but here it seems rather, as a rule,
to produce fatty or other degeneration of the muscular fibres than
deposits in interstitial tissues. No doubt these cardiac changes account
for many sudden deaths in syncope, or sudden asthenia otherwise unex-
plained. Frequent stimulation may tide over some of these attacks,
but to be effective it must be employed without delay.

I have already indicated the effect of alcohol upon many abdominal



CIRRH08E8 OF THE LIVER. 161

organs. Of course, we can understand if these organs are much impli-
• cated their influence upon the rapid march of hepatic cirrhosis is greatly
felt. Hepatic cirrhosis is particularly liable to be complicated with
acute miliary tuberculosis of some organs, and very many patients die
from this rather than the hepatic disease itself. In this way it is shown
how imperative it is for these patients to keep up good nutrition and
live all the while nearly in the open air. The statements of many
observers corroborate this. Thus Osier writes : "In seven of my
series the patients died with either acute tuberculous peritonitis or
acute tuberculous pleurisy." 1 It is curious, on the other hand, that
distinguished and careful clinicians like Flint and Fagge apparently
make no note of it.

The prognosis of hepatic cirrhosis has usually been most gloomy.
Once ascites is revealed the patient's lease of life appears very
limited. To-day we are more encouraged and regard certain cases
very hopefully. Even in the advanced cases of atrophic cirrhosis we
cannot always be sure to what extent some, not to say many, of the
liver cells retain good functional power — at all events, power sufficient
to help continue good nutrition if attending conditions be treated
rationally.

It is recognized generally that we have no remedy which will make
disappear the formation of fibrous tissue in the liver ; but the ascites
may ba removed, even in these extreme cases, and allow the collateral
circulation to act, with relief, to a certain degree, of the obstructed
portal circulation. Then, every time effusion becomes considerable and
organs are interfered with in their action through pressure, let para-
centesis be repeated.

It has been shown by Fagge that cirrhosis often becomes quiescent
before it reaches its final stage. 2 Flint seems to corroborate this view,
because he says emphatically that life has lasted months and years after
ascites had become developed and been recognized. Even in some
atrophic cases of advanced type nutrition is still preserved, and this is
always of good augury, because, despite the ascites, it shows some liver
cells able to function normally. Of course, there is a possibility in
these cases that we have not to do with a true cirrhosis of the liver
itself, but with a perihepatitis or chronic peritonitis which was very
probably the cause of the abdominal effusion. In this connection I
would quote Fagge 3 again to corroborate my statement.

In hypertrophic and syphilitic cirrhosis the prognosis is much more
hopeful. In the former case the development of fibrous tissue is of
immature form, and occurs more rapidly with intercurrent conspicuous

i Ibid, cit., p. 571.

8 Paper read before British Medical Association, 1883, vol. ii. p. 566.

3 Practice of Medicine, vol. ii. p. 315.



162 CIRRHOSES OF THE LIVER.

cell proliferation. This rapidly formed connective tissue is never so
dense nor is it so destructive to the liver cells as that of the atrophic
form of cirrhosis. In these cases there is often relative youth and good
nutrition. Hence, from all these standpoints the prognosis is more
favorable.

The prognosis of hepatic syphilis is even more hopeful. Of ten cases
reported by Einhorn " only one patient died, and even this one had
been considerably benefited for five or six months, whereas all the
others were either perfectly cured or much improved." 1

Of course, if cirrhosis could be recognized at an early stage, and
before the advent of ascites, the outlook would not be immediately
unfavorable. Sometimes we are able to make this diagnosis from
certain prominent signs or symptoms : the indurated, large liver — an
organ enlarged — and also irregular, vascular stigmata on the skin and
face, and passing jaundice ; an enlarged heart, constipation, dyspeptic
symptoms, palpitations, and, it may be, some emaciation. We should
act in accordance with the manifest indications, and among these is
one primary and essential to correct absolutely — an alcoholic habit, if,
as is usual, it has previously existed.

We often meet with combined cases of alcoholic and syphilitic cir-
rhosis. Some such cases have been known to recover during several
years. This recovery was evident through subsidence of the ascites
and recovery of the general health. (Cheadle.)

The first and most important indication of useful treatment arises
from the point of view of arresting growth of fibrous tissue in the liver,
and in this way the preservation of the remaining healthy liver cells.
This is accomplished, if at all, by abandonment of the use of alcohol,
which cannot be too urgently insisted upon in the great majority of in-
stances. Of course, there may arise states of anaemia, prostration, or
great weakness in which a moderate amount of good alcoholic stimu-
lant may be imperatively required, at least for a time, and under such
circumstances should surely not be withheld. This must be regarded
merely as a temporary necessity, and we must have in view constantly
the fact that it has been shown that even if fatty degeneration of liver
cells be begun it will often be arrested if alcohol be wholly given up.
A judiciously arranged dietary is only of secondary importance, and
yet it is undoubtedly true that the digestive organs must be supplied
with suitable food products, properly prepared, to sustain active nutri-
tion and to ward off, as far as may be, certain functional or even
organic disturbances in part dependent upon auto-intoxication of
gastro-intestinal origin. Fats and sugars should be notably diminished
in the dietary, for the reason that in the impaired liver functional power

i Ibid. cit.



CIRRHOSE8 OF THE LIVER. 163

is decreased, and is shown especially in its inability for proper assimi-
lation of foods containing many such elements. The simplest dietary
of milk, eggs, stewed fruits, well-cooked fresh vegetables, and the
lighter meats is of decided utility. Semmola's is the only rational
treatment, viz., to reduce the quantity of food to a minimum and give
it in a form which will tax the liver cells least. Milk is undeniably
the best of all ; but when this becomes intolerable, as it often does,
eggs and other light food may be added. No doubt some instances of
cirrhosis of the liver originate in auto-inloxication from the stomach
and bowels. In all instances aggravation of the developed disease may
result from it ; hence over and beyond appropriate dietary the use of
suitable antiseptic remedies like guaiaquin and benzosol (Gasper) may
be formally indicated. Among drugs which have a decided action,
aad one most beneficial in almost all syphilitic cases, iodide of potas
sium easily ranks first. There can be no question, in view of very
many recorded cases, that guramata in their early stages are reabsorbed
through its action. It is highly probable, also, that perihepatitis and
similar conditions of other abdominal organs (spleen, peritoneum) are
very favorably affected. It is not a sufficient reason to proscribe the use
of the iodide because the syphilitic nature of the case is not always per-
fectly clear. In many instances doubt may legitimately exist. Indeed,
in many combined alcoholic and syphilitic cases a positive differential
diagnosis as to how much is due to alcohol, how much caused by
syphilis, is impossible. The only safe rule, then, is to give up alcohol
and take the iodide. Again, in instances where there is no history of
syphilis and no evidence discoverable of its presence, it is yet wise at
times to administer the iodide, the reason being that purely alcoholic 1
cases and those due to syphilis of the nature of an interstitial hepatitis
are often confounded one with the other.

In the event of evidences of heart weakness, and in view of the
well-known post-mortem findings, digitalis and heart tonics should be
employed judiciously. Salines and diuretics are of some use in the
relief of ascites, but, as a rule, are of more value in warding off its
return for a while after paracentesis than in preventing the necessity of
this operation. The explanation of this is not perfectly clear, although
a theory for it may be readily offered, viz., that the absorbents re-
lieved from pressure are more efficient. 2 Very active purgation by
the use of hydragogue cathartics is at no time indicated, as it is useless
and may become directly injurious by depleting the patient's strength
very much or by bringing on diarrhoea often difficult to arrest. On

1 Of the frequency of this form, one may judge from Flexner's report of autopsies done at
the Philadelphia Hospital. Among eighty-eight cases of syphilis of the liver, forty had inter-
stitial hepatitis.— Medical Record, October 19, 1901.

2 Thromboses of the portal vein may cause rapid re-accumulation of ascites.



164 CIRRHOSES OF THE LIVER.

the other hand, the moderate use of mineral waters to keep the bowels
regular may be very necessary to the patient's welfare.

In the treatment of hypertrophic cirrhosis Nothnagel has wisely
insisted upon small, repeated doses of calomel. Vaughan believes that
later this form of disease will be treated mainly by surgery, as it is the
only way by which the gall-bladder and biliary vessels can be disin-
fected.

Billings quotes Kussmaul as using chloride of ammonium to prevent
proliferation of the connective tissue cells, and he (B.) claims in this
way he has seen induration of the liver disappear as well as some local
symptoms connected with the disease.

Whatever may have been the objections in former years to paracen-
tesis, legitimate or unsupported, to-day it seems very clear that in early
and repeated paracentesis the best hope of the patient lies. Even in
advanced instances of atrophic cirrhosis life is prolonged and suffering
diminished ; but in instances where we have an enlarged liver with
ascites, which in such cases often occurs when the disease is not far
advanced, we get our best results from paracentesis. The fluid may
recur in smaller quantity after each paracentesis, and in some
undoubted examples, after several operations, no fluid has recurred,
and so far as symptoms are concerned, we may properly say a recov-
ery has taken place. This may last for many years. I have had
at least one such instance in my practice. The patient recovered
from the ascites, and subsequently died of another disease than hepatic
cirrhosis, as was evident at the autopsy. The danger to-day of peri-
tonitis arising from paracentesis is very slight, indeed, if ordinary
aseptic precautions be observed. I do believe it is wiser to employ the
ordinary aspirator or Flint's modification of the Davidson syringe,
than the trocar and canula, and mainly because the flow of fluid is
easily regulated, and thus there is less danger of syncope or heart
failure, which might be directly caused by too rapid evacuation of fluid
where cardiac degeneration is present. This accident may also be
obviated, as we know, by the prompt use of a binder as the fluid flows
from the abdomen. The binder also is useful in delaying return of
ascites. There is less risk of serious injury to the intestines with the
small needle attached to the aspirator than with a moderate-sized trocar. 1

Unfortunately, paracentesis is not always thoroughly satisfactory.
The canula may become blocked in different ways and for different
reasons, not always easy to obviate. In our very desire to benefit our
patient and withdraw most of the fluid from the cavity we may run
the risk of wounding the intestine. Sometimes the cause of the obstruc-
tion of the canula is a piece of false membrane ; again it seems to be the

i British Medical Journal, 1883.



CIRRH08ES OF THE LIVER. 165

intestinal wall, and we must be careful not to injure it. In some in-
stances where we expect to obtain a large quantity of fluid we really
get very little, which is discouragiug both to patient and physician.
Occasionally it seems as though the posture of the patient was respon-
sible for this, but I have found the difficulty to arise when the patient
was sitting up and also when the patient was lying down.

Some authors have objected to paracentesis because, they say, after
it the ascites recurs more rapidly, and that, besides the risks alluded
to, it is very depressing through loss of albumin from the blood on
every occasion it is performed. This objection has little or no value,
as a rule, especially if the patient be in fairly good general condition.
Of course, if the patient is very old and feeble, or the disease very
advanced, paracentesis is likely to hasten the fatal termination. On
the other hand, where the abdominal and thoracic organs have been
compressed or pushed away from their normal position by excess of
abdominal fluid there is no question that the fluid should be speedily
removed. Thus great distress is often relieved, the kidneys begin to
function with renewed activity, and the general condition of the patient
is notably improved. The lungs are enabled to breathe freely again,
and the heart becomes regular and fails to intermit. While getting
additional power very rapidly, cough, expectoration, hypostasis, and
even pleuritic effusion due to upward pressure soon disappear. Some-
times after paracentesis there is more or less leakage from the abdomen
through the hole made with the needle or trocar. This is often very
annoying to the patient, as his clothes and bedding become thoroughly
wet ; and yet it may be useful in a few instances from the fact that
the drainage continues for several hours after the operation is
concluded, and from regions the needle could not reach. In this
connection it is proper to refer to continuous abdominal drainage
by means of a permanent canula left in the abdomen after the trocar
is withdrawn. I performed this operation on one occasion, with
apparently some good result ; but the dangers from aspiration of air
into the cavity, peritonitis, and suppuration are such that I felt later
that better ultimate results could be expected from repeated puncture
and before the fluid was permitted to reaccumulate in too large quan-
tity, or caused any notable distress, or interfered much with the healthy
function of any important organ.

-" The removal of fluid by continuous drainage has been practised
with some success by Dr. Caille and Dr. Elliot in America, and by Dr.
Urso in Italy." 1 And certainly in some cases it would appear to be
safer and quite as effective as the radical operation to produce new
anastomoses.

On the other hand, Weir, 2 who used permanent drainage in connec-

1 Cheadle, p. 88. 2 The American Journal of the Medical Sciences, 1899, p. 723.



166 CIRRHOSES OF THE LIVER.

tion with or rather subsequent to the radical operation, " would here-
after prefer to resort to paracentesis if it became necessary, as the risk
seems less."

It is surprising at times to remark the powerful diuretic effect of
paracentesis. Kidneys that previous to it were inactive become active,
urine that was albuminous, of high specific gravity, and contained casts
accompanied by urcemic symptoms, has changed remarkably. The
flow of urine has wonderfully increased in quantity, and its characters
have become almost normal, while all ursemic evidences have soon disap-
peared. Without the paracentesis both purgatives and diuretics seemed
wholly worthless to produce these much-desired effects.

If we wish to get the best effects from repeated tapping we must have
patients under our immediate care, so that they may be tapped again
when the proper moment arrives. Tapping should be repeated in
proper cases until fluid ceases to reaccumulate. During this period
it should be our effort to maintain the patient's nutrition to the highest
degree possible. Through constant care and attention we obtain the
best results ; through carelessness or permitting the patient to absent
himself too long from observation we have often cause for regret, and
the patient relapses into an impoverished and threatening state.

On the other hand, Hale White's observations would go to show
" that in the cases of cirrhosis of the liver with chronic peritonitis the
survival for a considerable length of time was due to the fact that the
latter lesion assists in some way in the formation of a collateral circu-
lation." 1

Now, as Osier writes : " We know that extreme grades of contraction
of the liver may persist for years without symptoms when the com-
pensatory circulation exists. The so-called cure of cirrhosis means the
re- establishment of this compensation." 2

Upon this idea of re-establishment of this compensation rests the
modern radical surgical treatment of cirrhosis of the liver. The method
is to promote adhesions between the liver, spleen, and abdominal walls
and diaphragm, thus helping collateral circulation by new vascular
channels. This is attempted, first, by completely evacuating the
abdominal contents, and then, by thorough scrubbing of the organs
referred to, set up a certain amount of irritation which shall tend to
make the formation of new vessels more probable. In this connection
Cheadle is of the opinion that if we consider the conditions where the
new vessels are found naturally they do not seem favorable, being,
associated with the worst cases, and do not lead one to try to produce
them artificially. Opposed to this view we would cite three cases-

i The American Journal of the Medical Sciences, March, 1901, p. 259.
2 Ibid, cit., p. 566.



CIRRHOSES OF THE LIVER. 167

cured : one of Osier's, 1 operated on by Dr. Bloodgood at Johns Hopkins
Hospital ; another of Brown's, 2 another of Frazier's. 3 In one instance
under my care, operated on by Dr. F. H. Markoe, nearly two years
ago, the patient has had recurrent ascites, necessitating repeated tap-
pings since the radical operation. Two of Osier's cases were unsuc-
cessful. As regards one or two tappings after the operation, this we
should expect where a drainage-tube has not been introduced, the
reason being that time is required for the formation of adhesions and
new veins ; and the introduction of the drainage-tube is now shown to
be bad from a surgical standpoint, as it opens a channel of infection.
(Frazier.)

In Dr. Brown's successful case, at first referred to in the Presbyterian
Hospital Reports for 1900, and the patient subsequently presented at a
meeting of the New York State Medical Society, held October 16, 1901,
at the New York Academy of Medicine, the condition was one of
atrophic cirrhosis, due to alcohol. There was no syphilis and no malaria,
although the spleen was enlarged. There was no pronounced venous
engorgement on the abdominal walls. The patient was operated upon
over two years ago. There has been no recurrence of ascites, and the
nutrition remains good. The patient is doing his usual work — that
of a day laborer.

Frazier 4 in the remarks he makes, prompted no doubt by a success-
ful case, wisely insists, as a formal contraindication to the operation,
upon the absolute lack of functional power in the liver cells — i. e. y
shown usually by extreme atrophy. (Packard.) In his judgment, the
presence of cardiac and renal degeneration is only a relative contra-
indication. He also states that it is essential, in order to avoid fatal
toxaemia, that the collateral circulation should be formed gradually.
Where the cases have been carefully selected he " believes the opera-
tion has a future."

Fourteen cases are thus far reported, seven of which appear to have
been materially benefited or cured by the operation (Brown) and three
died from the operation. 5 " The many instances of practical cure fol-
lowing tapping, and the uncertainty of the exact pathological state of
the liver, together with the somewhat formidable character of the opera-
tion and liability of infection, invest the operation at present with a.
large element of doubtful expediency." 6 These remarks, cited textu-
ally from Dr. J. D. Bryant's work on Operative Surgery, appear to me
eminently wise.

1 Ibid, cit., p. 577. - New York Medical Eecord, October 19, 1901, p. 637.

3 The American Journal of the Medical Sciences, December, 1900, p. 661. 4 Loc. cit.

6 Later Packard reports twenty-two cases, with nine recoveries and eight deaths (The
American Journal of the Medical Sciences, March, 1901, p. 265), and in a "note" one
death— one doubtful.

6 Bryant, Operative Surgery, 1901, vol. ii. pp. 802, 803.



168 CTBEHOSES OF THE LIVEE.

la all these cases, moreover, it is judicious to properly estimate the
amount of functional disturbance, if possible, of the liver cells (icterus,
acholic stools, urobilinuria, etc.) as well as the physical changes of the
liver itself. In it may be found, as Brown says, a formal contraindi-
cation to the wisdom of the operation. Neumann 1 also wisely insists
" that the liver cells be not too greatly impaired in their functional
capacities, and that every precaution should be taken in selecting
proper cases, in order not to permit discredit to fall upon so valuable
an operation."

Brown " feels assured that the great risks attending operations on
advanced and failing cases will be notably wanting in similar pro-
cedures applied in earlier stages of the disease." 2 No doubt this state-
ment is correct, but in my judgment it is correct only so far as it
applies to all important or dangerous surgical procedures. The great
difficulty is to convince the pure physician with the facts as reported
up to date, and allowing for errors of diagnosis with respect of the pre-
cise nature of the liver condition and for the concomitant conditions
almost always present (heart, kidneys, spleen, pancreas, etc.) that such
a stand is justified. I am scarcely of that opinion until it be shown
that the radical operation in similar instances gives better results than
the far less serious procedure of simple and repeated paracentesis.

Dr. Weir's standpoint appears to be a more rational one, viz., " The
operation was worthy of trial in apparently hopeless cases of liver
cirrhosis in which the abdomen rapidly refilled after repeated tapping,
and in which the large quantity of the fluid was producing fatal
exhaustion." 3

Dr. McBurney in discussing Dr. Weir's paper thought that analogy


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