litrsistent hypermnia leads in time to :tructural changes. As the intra lobular veins are greatly dilated, the iiNer-eells around them atrophy from prtssure, and blood-pigment is deposited. The centre of the lobule becomes dark, contrasting strongly with the periphery, hich becomes yellowish, on. account of fatty titTeneration of its cells; hence the -nutmeg- appearance of the section.
In course of time atroplry of the liver cells is succeeded by increase of connect ive tissue. Induration and shrinking re sult. and may lead to considerable re duction in the size of the liver.
TREATMENT.—The treatment is chiefly that of the condition of the heart or lunr.s that causes it, at the same time endeavoring. to relieve portal congestion. The latter is usually effected by the ac tion of cathartics. A more rapid effect may be obtained by local depletion with leeches, five or six being applied over the liyer. Their application is usually at tended by marked relief w-hen there is pain and distress in this region.
Calomel, in repeated doses, is not only an active cathartic, but also an efficient diuretic in such cases. Digitalis may be combined with it to increase the power of the heart and secure greater diuretic effect. The condition of the heart re cruires the administration of heart-tonies, as digitalis, strychnine, ete. Vegetable cathartics — as podophyllin, colocynth, jalap, aloes, etc.—may be used, or salines, such as sulphate of soda, sulphate of magnesia, or the natural purgative waters (such as Apenta or Hunyadi, Rubinat, Hawthorn. Friedrichshall), etc.
Perihepatitis.
This consis.ts in an inflammation of the peritoneal capsule of the liver. In llammation of the fibrous capsule apart from the peritoneal occurs only as sec ondary to interstitial hepatitis.
Inflammation of the peritoneal cover ing of the liver may occur either as a part of general peritonitis or as a local disease. It may be acute or chronic, the former being usually suppurative while the latter is always fibrinous or adhesive.
Acute Perihepatitis; Subphreuic Ab scess; Pyopueumoperihepatitis.
SY3IPTOMS.—The development of the disease may be with striking symptoms suggestive of perforatiye peritonitis of the upper part of the abdomen, or it may be so insidious as not to attract atten tion until the abscess has attained a large size.
Pain in the rig,ht hypochondrium or epigastrium is the most prominent symp tom. It is increased by pressure and movement; hence the respiration is shallow and costal. Fever, often ush ered in by a chill, is present; it may be quite remittent. There may also be abdominal distension, vomiting, hic cough, slight jaundice, weak pulse, etc.
The physical signs presented will de pend largely on the size of the abscess. In the beginning there may be a friction rub. If the abscess is large there is pre sented great fullness in the right hypo chondrium, with extension upward of hepatic dullness, even to the angle of the scapula, and of the edge of liver downward, it may be, to the umbilicus.
The upper limit of dullness is convex toward the thorax, following. the curve of the diaphragm. Over this area there is absence of all respiratory signs. The course of acute perihepatitis, in the ab sence of suppuration, may be rapid, re covery taking place in a few days; in suppurative cases it may be prolonged for months with all the symptoms of chronic suppuration, as irregular tem perature, sweats, loss of flesh, etc. In many cases fistulous openings take place through the diaphragm, causing a local ized empyema, which, in time, perforates the lung into a bronchus, with abundant purulent expectoration, or externally through an intercostal space. In others. the abscess discharges into the stomach or intestine. The general course of sub phrenic abscess resembles that of em pyema or abscess of the liver. The re sult is usually fatal, unless efficient drainage be established. Of all the cases recorded only about twenty have recov ered.
— In subphrenic abscess the signs are so indefinite that a diag nosis is only exceptionally made. The abscess is usually mistaken for empyema. A history of disease of the stomach, duodenum, or gall-bladder would indi cate a perihepatitis, as would also a his tory of abscess from appendicitis. The absence of a history of intrathoracic symptoms—such as cough, expectora tion, etc.—renders pleuritic disease im probable.
The physical signs are those of massive enlargement of the liver; if the abscess cavity contains air, the signs of movable dullness and tympany of pneumothorax are added. However, the bulging of the right side is greatest below the dia phragm rather than above. The dia phragm may be pressed upward to the third, or even the second rib, but, how ever high it is, its limits are well de fined and above it the respiratory sounds are not obscured. The lower border of the liver may be greatly depressed. The heart is not much displaced, as it is in pleural effusion.
On exploratory puncture, if the pus is reached, the spurting is most forcible on inspiration, owing to the descent of the diaphragm. This would practically be conclusive evidence of the seat of the abscess. The presence of bile-pigment in the pus would also indicate that the abscess is below the diaphragm.
This may occur in one of five ways: As a localized abscess, a. part of general purulent peritonitis; by extension of the diseased process from the appendix to the subphrenie region by an intra peritoneal route; by extension of the diseased process by all extraperitoneal route. either by way of the lymphatics or by infiltration through the retro peritoneal tissue; by way of the blood current. as part of a general embolic sep tic process; or as a sequence of liver abscesses which are of embolic origin by way of the portal vein. H. A. Christian and L. C. Lehr (Medical Ne»-s, Jan. 24,