A further indication of the altered or thinned condition of the blood is the not-infrequent existence of a venous hum in the cpigastric region noted by several recent observers and of a splenic souffle first noted by Bouchard.
Other Symptoms 1?eferable to Disturbed Hepatic Function.—Very characteristic toward the latter stage are certain nerv ous symptoms, which also are, in general, attributed to a toxic condition of the blood. These are, by some, classed as manifestations of chohemia, although, as they may be present when there is no evi dence of the passage of bile into the blood, this use of the term is scarcely ex act. I refer to the drowsiness of many patients and the more marked nervous conditions of coma and delirium. Where death is not due to hTmorrhage or inter current disease, such as tuberculosis, it is these nervous disturbances which are the prominent feature in the fatal event. These nervous symptoms may be mis taken for the onset of urmmia. There may be marked excitation, or, on the other hand, a progressive and deepening stupor passing into complete coma.
Case of hwmonlage from the larynx in the course of alcoholic cirrhosis.
hbematemesis and cpistaxis also occurred.
Laryngeal luemorrhage ascribed to the interference with the hTmatopoietic functions of the liver by the atrophic cirrhosis of that organ. Lubet Barbou (Archives de latryn., July, Aug., '97).
Study of sixty cases of fatal gastro intestinal hmmorrhage due to cirrhosis of the liver. 1. Fatal gastro-intestinal hmmorrhage is an infrequent, but not rare, complication of cirrhosis of the liver. 2. In the great majority of the eases the cirrhosis is atrophic, but it may be hypertrophic. 3. In one-third of the cases the first haemorrhage is fatal; in the other two-thirds the hmorrhages continue at intervals over a period vary ing from a few months to several years, the maximum given being 11 years. 4. In one-third of the cases the diagnosis can be made at or before the time of the first lnemorrhage. In the other cases the diagnosis cannot be made at all or only after months or years, during which time other symptoms of cirrhosis may have developed. 5. CEsophageal yarices are
present in SO per cent. of the cases, and in more than half of this SO per cent. the varices show macroscopical ruptures, and it is probable many other ruptures would be found if the varices were tested by injections of air or fluid. 6. Fatal hmmorrhages occur in cases which show no cesophageal yarices, and they are prob ably due to the simultaneous rupture of many capillaries of the gastro-intestinal mucous membrane. 7. The hmorrhages in this class of cases are usually preceded by other symptoms of cirrhosis, but the first symptom may be a fatal hEemor rhage. S. In 6 per cent. only of the cases which showed cesophageal varices was the cirrhosis typical: i.e., showed ascites, enlarged spleen, and subcutaneous ab dominal varices. R. B. Preble (Amer. Jour. Med. Sci., Mar., 1900).
Differential Diagnosis.—The preced ing pages will have given in fairly full detail the main features characterizing the different forms of hepatic cirrhosis. Here, however, it may be worth while to point out again that there are four forms of hepatic cirrhosis, or of conditions clin ically regarded as cirrhosis, between which we have to distinguish, namely: portal cirrhosis proper, biliary cirrhosis, chronic perihepatitis, and gummatous syphilis of the liver. All other forms, with the exception of the pericellular syphilitic cirrhosis of the infant, are clinically unrecognizable.
Leaving aside, for the moment, the most important of these,—namely, portal cirrhosis,—the main features whereby the biliary form of the disease is to be differentiated are the progressive icterus, the enlargement of the organ, the ab sence of marked digestive disturbances, the long continuance of the condition, and the retention of appetite and strength. The coloration of the stools by bile and the more extensive enlarge ment of the organ must be the main factors in diagnosing between what we may term the catarrhal form of biliary cirrhosis and the very rare purely-ob structive form.