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CHRONIC HEPATITIS.

159

possible, the patient should also have recourse to walking.

But there is another functional affection of the liver very common in dyspepsia, and which seems to be connected with diminished secretion of bile. In this state the alvine evacuations are pale in colour, and generally loose and very offensive. The appetite is variable, often craving; the abdomen much distended with flatus. There is general debility, and the sleep is broken and unrefreshing.

Small doses of mercury are very valuable in cases of this kind, followed in a short time by a course of the mineral acids. The bowels should be carefully regulated, but all severe purgatives ought to be avoided. I have in some cases found cod-liver oil very useful, and I have seen the alvine evacuations assume a more healthy appearance a few hours after its use has been commenced. Iodine, iron, and other tonics are generally required in the after treatment.

In most of the cases of liver disease in which I have examined the stomach microscopically, the patients have died of chronic hepatitis. In this complaint Frerichs reports that, "Of thirty-six observations, the mucous membrane of the stomach was pale in eight, and in twenty-six it was in a state of catarrhal tumefaction, and of a more or less livid hue; hæmorrhagic erosions existed in four cases, and cicatrices in two; in six cases the stomach and intestines contained a bloody fluid." If the eight cases in which the mucous membrane was pale had been

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1 Diseases of the Liver. New Sydenham Society, vol. ii. p. 45.

examined with the microscope, it is probable that in them also disease would have been discovered in the stomach.

In the later stage of chronic hepatitis, in which hospital patients generally come beneath our notice, there is not much difficulty in diagnosing the disease; but in private practice, where we meet with it in its incipient forms, the real nature of the complaint is frequently overlooked. The liver is often not much. increased in size, and the symptoms appear only to indicate chronic gastritis.

The following practical hints may be useful in preventing mistakes in diagnosis in the earlier stages. If the symptoms of chronic gastritis occur frequently and yield slowly to treatment, if the patient at each attack lose flesh and colour, and complain of debility in a greater degree than the dyspepsia would appear to warrant, and if he be in the habit of spiritdrinking, there is good reason to suspect that an abnormal state of the liver is the cause of the disease. The suspicion of hepatic disorder will be strengthened, if the alvine evacuations are found to be constantly varying in colour and appearance; showing at one time an increase, at another a deficiency of bile.

There are two other circumstances which, when they occur in persons affected with chronic gastritis, should direct our attention to the liver-viz., chronic diarrhoea, and attacks of peri-hepatitis.

The diarrhoea comes on gradually, and is never severe. The stools are variable in colour, and watery. We search in vain for any indication of disease in the lungs, kidneys, or intestines; and yet the patient

INFLAMMATION OF THE CAPSULE OF THE LIVER. 161

complains of great debility, and gradually loses flesh. In some cases of this kind, if we succeed in checking the diarrhoea, ascites and other evidences of hepatic disease make their appearance.

The attacks, which I believe to arise from inflammation of its capsule, should at once attract the attention of the practitioner to the liver. The patient seems dull, heavy, and unwilling to answer questions. He has occasional vomiting, and an entire loss of appetite. The tongue is thickly coated, and although it is dry, there is no great complaint of thirst. The pulse is but little quickened. The bowels are confined, the stools dark, the urine scanty, highcoloured, and loaded with lithates. Notwithstanding the threatening nature of these symptoms, they soon subside under treatment, and in a few days the patient is able to resume his accustomed occupation; to be perhaps again affected in a similar manner a few weeks or months afterwards.

In all the persons whom I have been in the habit of attending for such attacks, and in whom I have afterwards had the opportunity of making postmortem examinations, I have found "hob-nail liver;" the organ being united to the neighbouring parts by an unusually great amount of adhesions.

In the treatment of gastritis arising from, or complicated with chronic hepatitis, all stimulating liquors should be strictly forbidden, and the food should be. of the mildest and most digestible character. Outof-door exercise should be taken regularly and systematically. Frictions with iodine and mercurial ointments over the hepatic region are very valuable, and preparations of iodine may be given internally.

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In order to obtain any benefit, even in the earliest stages, remedial measures must be perseveringly employed.

As long-continued congestion of the liver produces chronic gastritis, so a sudden and complete obstruction to the portal circulation will give rise to more serious effects. This is shown in the following

case:

CASE 17.-I was requested to see a sailor who had vomited a large quantity of dark-coloured blood. He was so faint from the hæmorrhage that he was unable to give much account of his illness; but I learned from his friends, that he had been out of health for about one month with slight fever, which had obliged him to leave his ship and return home. I could not detect any increase in the size of the liver in the epigastrium, but in the back there was dulness on percussion over a large space. He died in an hour or two after my .visit. On post-mortem examination, the liver was found to be very large posteriorly, and was divided in the greater lobe by a deep, wide scar, which extended into its substance to a considerable depth, and seemed to pucker up its anterior surface. The vena portæ and all its leading branches were plugged with a mass of fibrine that seemed to have been gradually deposited in layers. The stomach was distended with a large quantity of dark-coloured blood. On microscopical examination, the whole of its mucous membrane was found to be infiltrated with blood. The gastric tubes adhered firmly to each other, and in some places scarcely a trace of the glandular structure could be discovered.

OBLITERATION OF THE PORTAL VEIN.

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In the above case, the plugging of the vena portæ was probably occasioned by the obstruction to the circulation through the liver; but in the following, the origin of the disease appeared to be in the spleen. I was indebted to the kindness of Dr. Peart for the opportunity of seeing the patient during life, and of being present at the post-mortem examination.

CASE 18." The subject of the following narration was a servant girl, aged 19, who was reported to have suffered when young from mesenteric disease, to have been pale-faced and weak for some months, with a slight diarrhoea immediately after taking her meals, and to have presented lately a remarkable fulness of the breasts and abdomen, so as to have excited in her friends the suspicion of pregnancy. She occasionally frequented dancing saloons, but there was no reason to suspect her of drinking, and her conduct in general was opposed to that supposition.

"She awoke during the night in October last, with a desire to vomit, which she did without suspecting anything, and was surprised in the morning on looking at the vomited matter, to find it was blood. She went to her place that day, where she had a further return of the hæmorrhage, and again during the following morning while in bed, to the extent of two or three pints of bright-red, coagulable blood. She was then found almost blanched, tossing restlessly about, with an extremely rapid, feeble pulse, and an almost insatiable thirst for cold water. The bleeding then seemed stayed through the depressed state of the circulation. The liver when percussed was of natural size; the spleen did not project forward.

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