CHAPTER III.
DISEASES OF THE LIVER.
Icterus (Jaundice).
Remember that icterus, or jaundice, is a symptom, and may be found in a variety of conditions. It is due to alteration of bile or occlusion of ducts.
Examine the urine before diagnosing jaundice, al- though the tissues be discolored. When the urine contains bile pigments, the froth formed by shaking it is colored yellow. Nitric acid will give the play of colors, best observed on a white porcelain dish. Albumin will usually be found in the urine.
Remember that the pulse and respirations are greatly reduced in frequency, especially the respira- tory rate.
Remember that cholemic intoxication may occur, manifested by delirium, coma, convulsions, and death.
Remember that hemorrhages are frequent, and no operation should be attempted unless absolutely nec- essary.
Intense pruritus and sweating, often localized to the palms and abdomen, occur in chronic icterus.
Grayish-colored stools, with putrid odor, are due to the absence of bile in the intestine.
Always examine the liver and gallbladder care- fully in all cases of jaundice.
46 diseases of the liver.
Treatment.
Diet. Avoid fats, alcohol, tea, coffee, and meats. An exclusive milk diet is best. Calomel in broken doses (gr. ^ hourly until gr. iij are taken), followed in four hours by saline. The bowels may be regu- lated by copious enemata; these are supposed to stimulate contractions of the gallbladder. Or saline aperient waters may be given; best given on arising before food is taken.
Where gastrointestinal catarrh exists, the follow- ing may be used :
B Acidi hydrochlorici diluti 3 j
Tincturae nucis vomicae 3 iv
Tincturae gentianae compositse q. s. ad 3 iv Misce. Sig. : Teaspoonful after meals.
Or:
IJ Creosoti TTl, iv
Bismuthi subcarbonatis 3 j
Aquae calcis q. s. ad S j
Misce.
Sig.: Teaspoonful every half hour.
Catarrh of bile duct use:
IJ Sodii salicylatis 3 iv
Ammonii muriatici § j
Aquae menthae piperitae . . . . q. s. ad ^ vj Misce. Sig. : Dessertspoonful after meals.
Or:
IJ Fel bovis gr. xxx
Salolis 3 ij
Misce et fiant capsulae No. XII.
Sig. : Capsule three hours after meals.
ICTEEUS POETAL CLRRHOSIS. 47
Or:
IJ Extract! aloes 3 ss
Sodii biearbonatis 3 j
Extract! taraxaci q. s
Misce et fiant p!lulge Xo. LX.
S!g. : 2 p!Il3 mght and mormng. f Catarrhal.)
Or:
E Suce! taraxaci B !j
Sod!! bicarbonatis 3 vj
Tincturse rhei 3 vj
Infus! gent!an£E q. s. ad § x!j
Misce et fiat misturse.
Sig. : Tablespoonful three times daily. ( Catarrhal. )-
Urotropin gr. v-gr. vj three times a day should be administered for its po^ver over any inflammatory condition in the gallbladder. Sodium salicylate in 5-grain doses every four hours also has a beneficial influence on the consistency of the bile. For the itching use Trarm baths, or pilocarpin, given hypo- dermatically gr. Yio-gT. Yq, has been highly recom- mended. The chilling of the skin must be prevented by warm clothing. In chronic cases dilute nitro- hydrochloric acid in 20-minim doses in half an ounce of the infusion of calumba an hour before meals is often used. Silver nitrate gr. % three times daily over long period is highly spoken of, but should be used cautiously.
Portal Cirrhosis (Laennec's Cirrhosis, Alcoholic Cirrhosis).
Remember that it usually occurs past forty years of age, and frequently vith an alcoholic history. The
48 DISEASES OF THE LIVER.
liver is shrunken; hence dullness on percussion is diminished, especially over the left lobe. In ad- vanced cases nodules may be felt along the borders of the liver.
Remember that jaundice is rare in this form of cirrhosis, but obstruction to the portal vein radicles causes congestion of gastrointestinal mucosa. Hemorrhage is frequent, either from esophageal veins, the stomach, the intestines, or hemorrhoids. Ascites occurs, and the amount of fluid in the abdo- men may be so large as to endanger life unless re- lieved. Dropsy of lower extremities (anasarca) oc- curs after the ascites, and is caused by the pressure of the ascitic fluid upon the large veins.
Remember that in the nutmeg liver, due to car- diac lesion, the anasarca precedes the ascites and is due to failing cardiac force.
Remember that in portal cirrhosis the abdominal veins are distended, due to an attempt to establish collateral circulation.
Remember that nutrition suffers, urea excretion is less, and albumin is usually found in the urine.
Always make a pelvic examination in women, so as to exclude an ovarian cyst.
Treatment.
Alcohol in any form must be absolutely prohibited. Do not prescribe tinctures in the treatment. All spices and irritants must be excluded.
The diet must be plain and simple, easy to digest,
POETAI. CIRRHOSIS. 49
and nutritious. At tlie beginning of treatment an exclusive milk diet is best. Vegetables may be added; always use those containing least amount of starcb. Later white meats may be allowed. Com- plete rest and plenty of fresh air is necessary. Bowels should be kept open by salines or calomel. Avoid drastic purgatives; rhubarb, senna, cascara. or cream of tartar may be used.
If hematemesis occurs, rest in bed and treatment outlined under that head should be followed.
Remember that diarrhea in these cases is often beneficial, and do not be too anxious about checking it, for ascites can be relieved by drugs only through the kidneys or bowels.
To increase urination, the following is good:
B Hydrargyri chloridi mitis,
Pulveris digitalis,
Pulveris scillse aa gr. vj
Misce et fiant pilulse No. VI. Sig. : Pill three times daily.
Or:
R Potassii citratis,
Potassii acetatis aa 3 iiss
Spiritus setheris nitrosi 3 iv
Liquoris ammonii acetatis § i j
Tineturse digitalis TT[, Ixxx
Syrupi acidi citriei q. s. ad ^ iv
Misce.
Sig.: Dessertspoonful four times daily.
To purge, use:
IJ Elaterini gr. j
Pulveris glycyrrhizse q. s.
Misce et fiant pilulse No. VIII.
Sig. : 1 pill every four hours until free catharsis.
50 DISEASES OF THE LIVER.
Apocynmn cannabinum is an excellent drug. Specific tincture (Lloyd) is generally used in doses of 2 to 3 minims every three hours; often called the vegetable trochar. The iodids and ammonium chlo- rid are thought by some to be beneficial.
I^ Ammonii iodidi 3 j
Tincturae eardamomi compositse . . 3 iv
Aquae menthse piperitse . . . . q. s. ad § i j Misee. Sig. : Teaspoonful before meals.
Or:
IJ Ilydrargyri perchloridi gr. j
Ammonii chloridi 3 ij
Syrupi tolutani o j
Aquae q. s. ad c| ii j
Misce.
Sig.: Teaspoonful three times daily.
Ascites should be relieved by paracentesis. This is by far the safest course, and, with very ordinary care and cleanliness, is practically harmless. Don't wait for a large accumulation of fluid, so that res- piration, digestion, and cardiac contractions are in- terfered with. Tonics should be used, and of these none are better than the following:
IJ Elixiris ferri, quininae et strychninae 5 ij Sig.: Dessertspoonful after meals.
It should be remembered that each dose contains %o grain of strychnin.
Surgery offers no better result than medicine in these cases. Collateral circulation will relieve por- tal congestion, but throws products directly into the systemic circulation that should first be modified by specific action of liver.
BILIARY CIRRHOSIS. 51
Biliary Cirrhosis.
Remember that in this form of cirrhosis there is no ascites, but chronic jaundice and an enlarged spleen. It occurs in early adult life. Heredity is a factor, and many cases are on record of families developing this condition. In many of the specific fevers, as scarlatina and typhoid, it develops. Pyogenic cocci have been found in many cases; hence it is probably of toxic origin.
Remember that this occurs between the twentieth and thirty-fifth years; there is no alcoholic history. Chronic icterus without ascites, with bile pigments in the urine. The stools are of normal color, and the liver and spleen are enlarged. These are the char- acteristics of Hanot's cirrhosis.
Remember that the onset is announced by fever, anorexia, pain and dragging in hepatic region, with swelling of liver and spleen. The fever subsides, the patient feels well, but the liver and spleen re- main large. These acute exacerbations occur peri- odically. Hemorrhage is very rare.
Remember that it is rare to find jaundice in por- tal cirrhosis, while ascites is common.
The presence of gallstone causes attack of colic, in which the pain is severe and agonizing, but the spleen is not enlarged, the jaundice is deeper, and the stools are clay-colored.
Malignant disease of the liver runs a much shorter course; there is great wasting and frequent occur- rence of complete obstruction, with jaundice. The
52 DISEASES OF THE LIVER.
spleen is not enlarged. Cancer of the liver occurs in advanced life.
Remember that jaundice begins early and gradu- ally deepens in contradistinction to portal cirrhosis. The liver is also enlarged.
Treatment.
Patient should lead a quiet life, with regulated exercise. During crisis of the disease he should be confined to the bed. Must avoid fatigue and ex- posure to cold.
Diet must be simple, nutritious, and easily di- gested. Should contain no stimulating substances. During crisis an exclusive milk diet is best. Bowels must be kept open, and salines are the best. Calomel gr. Yw-gr. V-i every three hours for three days or longer is highly recommended. Salol gr. v- gr. X after meals is indicated in offensive stools. The saline mineral waters are allowable. Give glass be- fore breakfast and give it hot.
Abscess of the Liver.
Remember that some cases can be diagnosed with certainty, some probably, and in some the diagnosis is impossible.
Make it a rule, which should never be broken, to make a positive diagnosis of liver abscess only when a source for the formation of pus has been demonstrated or can be surmised with a great de- gree of probability.
ABSCESS OF LIVER. 53
Always pay special attention to inflammations in the region of the portal vein — gastric ulcer, appen- dicitis, dysentery, purulent hemorrhoids.
Remember that it may follow wounds, especially of bones of the head or of body; gallstones, pulmon- ary gangrene, endocarditis.
Remember that the presence of fever narrows the diagnosis to hepatic abscess and acute yellow atro- phy. Fever is very rare in carcinoma.
Remember that the liver is usually enlarged, and it is most marked in the right lobe; in contradistinc- tion to all other enlargements, it is upward. It is most. pronounced in midaxillary line on percussion, and is usually normal at the vertebral column and at the midsternal and parasternal lines. While there is some icterus present, marked jaundice is rare. There is usually pain, but the intensity varies, and the liver is painful on palpation, especially so over <;ertain areas, probably corresponding to the abscess area or to circumscribed peritonitis caused by the abscess.
Remember that the spleen is never enlarged, ex- cept where the abscess is caused by pylephlebitis or pyemia.
Remember that some cases closely resemble ma- laria. The fever intermits, and the patient has chills and sweats.
Remember in malaria the presence of the Plas- modium in the blood and the enlarged, hard spleen, and that quinin properly administered invariably effects a cure.
54 DISEASES OF THE LIVER.
In right side pleuritic exudate the area of dullness, spoken of as characteristic of liver abscess, is absent, and a dislocation of the heart to the left is present.
Remember that the evidence obtained by punctur- ing the liver with the needle is conclusive if the needle enters the abscess.
Teeatmekt.
Pyemic abscess and suppurative pylephlebitis are invariably fatal, and surgical intervention is not in- dicated. Abscess following dysentery is usually sin- gle, and surgery offers the best results — practically the only hope. If the abscess ruptures into the pleura and the patient cough up pus, an operation is not indicated. There is no drug that can stop or modify it in any way after the onset. The best treatment is preventive.
Acute Yellow Atrophy.
Fortunately this fatal ailment is rare.
Remember that pregnancy is an etiologic factor in nearly one-half of the reported cases.
Remember that it may occur in the course of biliary cirrhosis.
The onset is deceptive, and is usually announced by gastroduodenal catarrh, accompanied by slight icterus, but soon headache, delirium, trembling of the muscles, vomiting, and deepening of the icterus sets in.
Coma may develop early and deepens until death, or it may develop later.
ACUTE YELLOW ATROPHY CANCER OF LIVER. 55
Urinalysis shows bile pigments, tube casts, with, marked reduction of urea excreted, Leucin and tyrosin, either one or both, are usually, but not al- ways, present. The stools are clay-colored.
A rapid reduction in the size of the liver, usually most pronounced in the left lobe, and, as a rule, the afebrile course following the initial elevation of tem- perature, confirms the diagnosis.
Treatment.
The disease is invariably fatal. Being of a toxic nature, the channels of elimination should be stimu- lated. Saline solution intravenously and free ca- tharsis. Gastric sedatives, as bismuth subnitrate, may be used to allay the vomiting. We are power- less to check its progress.
Cancer of the Liver.
Remember that here, as elsewhere in the body, cancer, as a rule, occurs in those past midlife — at that period where reconstructive changes fall below the call of the tissue cells.
The secondary cancer is more common than the primary, but, unless the seat of the primary cancer can be located — as in the uterus, rectum, or breast — it is impossible to make a differential diagnosis.
Remember that cancer may be one large tumor, when the liver will be large, but smooth; or it may be of the nodular form, when nodules can be felt over lower border of the liver, or at times even seen.
56 DISEASES OF THE LIVER.
Always look for enlarged lymph glands in the axilla, inguinal region, or beneath the skin of the abdomen in suspected cases.
Remember that the liver dullness is increased, but that it is downward and toward the umbilicus, while the upper border remains normal.
Palpation shows the consistence of the liver to be hard, while protuberances may be felt. Emaciation and loss of strength is progressive.
Remember that the enlargement of the liver is progressive, and the lower border may eventually reach to the umbilicus.
Remember that the spleen, as a rule, is not en- larged.
Ascites and icterus are produced by pressure of the tumor, and both may be extreme or slight. The skin is dry, wrinkled, and has a muddy color. Fever may be present, and be of intermittent or remittent type.
Remember that cancer of the liver kills in from three to fifteen months.
Treatment.
The treatment is palliative. There is no thera- peutic measure that offers much hope. Surgeons have operated on a few early cases with fair results, but this therapeutic measure has not been used often enough to form a basis from which to draw conclu- sions.