Hepatis,(from the liver.) Ax inflammation of the liver. An inflammation may be in different parts of the liver, as in its membranes or substance; in its concave or the convex side. Inflammation in the hepatic arteries is said to cause some symptoms not unlike those of the hydrophobia. See Hippocrates Coac. lib. cxxxix. Are-taeus de Curatione Acutorum, lib. i. and Trallianus, lib. i. c. xv.
Dr. Cullen places this disease in the class pyrexiae, and order phlegmasiae, and defines it a febrile affection, attended with tension and pain of the right hypochon-drium, often pungent, like that of a pleurisy, but more frequently dull, or obtuse; a pain at the clavicle, and at the top of the right shoulder; muchuneasiness in lying down on the left side; difficulty of breathing; a dry cough; vomiting; hiccough. Sauvagesand Sagar, he says, amongst the symptoms have placed a yellow colour of the face, of the urine, of the serum of the blood, and of the eruptions, which appear on the skin: but these symptoms of a regurgitation, and reabsorp-tion of the bile, have been, he thinks, very properly-omitted by Linnaeus and Vogel; because such symptoms occur very rarely. Of this disease he makes two varieties, the acute, and the chronic. The pathognomonic symptoms of the first are above recited. The chronic often affords no signs by which it can be distinguished. It may, however, be suspected from some causes of the hepatitis having preceded; from a sense of fulness and weight, or from occasional pain in the right hypochon-drium; from pain, on pressing the same part, or from lying down on the left side; and lastly, from a slight fever occasionally appearing.
Dr. Saunders, with great reason, supposes it owing to an inflammatory state of the system of the vena portae; while the acute kind is owing to the same state of the hepatic artery.
Winslow thinks the seat of the inflammation is in the ramifications of the vena portae, or the hepatic artery; Dr. Heberden that the liver is never primarily affected; and Dr. Cullen that the inflammation is only in the extremities of the hepatic artery.
The acute hepatitis may be seated either on the convex or on the concave side of the liver. In the former case, a more pungent pain and hiccough may be produced, and the respiration is more considerably affected. In the latter the pain is less, and a vomiting attends from the communication of inflammation to the stomach. The inflammation of the concave surface of the liver may be readily communicated to the gall bladder and bilious ducts; and this perhaps is the only case of idiopathic hepatitis attended with jaundice.
The disorder is most frequent in warm climates; it is produced by the common causes of internal inflammation, and is then preceded by fever, and by obstruction of the hepatic ducts. Hepatitis is sometimes communicated to the liver from the lungs, and it then follows peripneumony, and is apparently an exacerbation of the same disease, communicated to the adjoining membranes. Its remote causes are unsertain.
When the seat of the disorder is in the membranes, the pain is more acute, and resembles a pleurisy more than when the substance of the liver is the part affected. In this acute kind, the pain is pungent; the fever very considerable; the pulse frequent, strong, and hard; the urine high coloured.
In general, when the substance of the liver is inflamed, the pain is not very acute at first; but gradually increasing, it shoots up to the top of the right shoulder, and sometimes into the throat and about the clavicle. The pain darting into the throat is said to be a pathognomonic symptom. The pulse is not much altered in the beginning, if the disease be not very acute; and often inflammation is only known to have existed by the abscess. When the convex part of the liver is affected, a tumour is visible externally, and occasions a cough and a difficulty of breathing: the pulse is then quickened, and the patient cannot well lie on his left side. In all cases of inflammation in this viscus, the quantity of the bile thrown into the duodenum is increased, and the evacuations become bilious.
Dr. Cullen observes, that the acute hepatitis may be Known by a pain in the right hypochondrium, increased by pressing upon the part. The pain is very often so pungent as to resemble that of a pleurisy; frequently, as in pleurisy, is increased on inspiration, and the patient can then only lie on the side affected. The disease is sometimes also attended with a cough, commonly dry, but sometimes followed by expectoration.
Inflammation in the liver when highly acute is short, and terminates by resolution; but when less active it more generally ends in suppuration, and proves fatal by-inducing hectic, unless the matter can be discharged externally. If properly treated in the beginning, it is rarely mortal.
The resolution of the hepatitis is often the consequence of, or is attended with, evacuations of different kinds. A haemorrhage, sometimes from the nose, sometimes from the haemorrhoidal vessels, relieves the disease. More commonly, a bilious diarrhoea or external erysipelas contributes to the same event; and the resolution of the hepatitis, as of the other inflammations, is attended with sweating, and with an evacuation of urine, depositing a copious sediment.
This kind of inflammation should be distinguished from inflammation of the pleura, of the diaphragm, of the stomach, of the muscles of the belly, and from spasmodic pains.
Inflammation of the pleura, or lungs, so often precedes or accompanies hepatitis, that the distinction is difficult, and fortunately of no great importance, as the same means of relief are employed. The incessant vomiting distinguishes inflammation of the stomach; but that of the diaphragm is often confounded with hepatitis, and sometimes accompanies it. The pain across the body is not easily distinguished from the shooting pain from an affection of the gall ducts; and it is not yet ascertained that either delirium or the risus sardonicus is the peculiar symptom of diaphrag-mitis.
The symptoms in the beginning do not often alarm the patient; and early assistance is not always demanded. At any period before the fifth day, bleeding may be employed; the operation repeated if the pain is considerable, the patient young, strong, and plethoric. After a free bleeding, a large blister should be laid over the part affected; and if there is a free passage for the bile into the duodenum, the bowels kept freely loose with proper doses of antimonium tartarisatum, infusion of tamarinds, vitriolated natron, and rhubarb.
Dr. Curry, combining these ideas with the East Indian practice, which is not well adapted for the more acute hepatitis of this climate, recommends calomel as the most active laxative, and particularly adapted for emulging the glands of the diseased part. When it is rejected from the stomach, he advises washing it with lime water, and giving the powder which remains, joined with opium. In the very irritable state of the stomach which sometimes accompanies the disease, this form of mercury is, he thinks, more easily borne.
If these means fail, or if it is too late for their proper use, and symptoms of a beginning suppuration appear, the powder of bark in the dose of 3 ss. four or five times a day may be given, and the quantity increased until ss. is taken every twenty-four hours.
If the abscess points externally, it must be encouraged by maturating cataplasms, and opened as soon as possible, particularly if, from its immobility, the liver seems to adhere to the peritoneum; and the bark may then be given to two ounces in twenty-four-hours, if the stomach will retain it, and we may thus proceed until suppuration appears. If, from purulent or ichorous stools, it is evident that the abscess has burst into the duodenum, or, from other symptoms, that it hath discharged its contents into the cavity of the belly, the same methods may be used, though equally good effects cannot be expected.
Hepatitis, however, has lately pressed on our notice in very different forms, in consequence of our more extended connections in India. In hot countries, where the circulation is more languid, the liver particularly suffers from any cause of fever, nor can its infarctions be removed by the usual methods of blisters and laxatives. A medicine which, gives tone and activity to the circulating system is necessary, and this medicine is mercury. Even in the early stages of the complaint it is administered both internally and externally, and the limits of its employment are the appearances of its action on the sanguiferous system, by the effect on the gums. Very large quantities, it is said, are often administered before this effect is produced; but as soon as it appears, all the symptoms are relieved.
The long residents in hot climates bring back to this country all the symptoms of chronic hepatitis, with a variety of complaints arising from an infarcted liver, which have apparently little connection with this disease. The peculiar symptoms of chronic hepatitis are, irregular fever, indigestion, costiveness, white stools, swelled legs, the complexion of a sallow yellow, pain or fulness of the hypochondria, dry cough, disturbed sleep, and dejected spirits. Many of these appearances are, however, sometimes wanting; and occasionally the cough only, indigestion, or irregular fever, are observed: but, in every instance where the patient has resided long in a warm climate, a diseased liver may be suspected; and whatever the complaint be, the state of the liver should be examined; and if fulness or tension, if pain or uneasiness, be felt, or experienced on pressure, the appropriate remedy, mercury, must be employed, to which gently stimulating laxatives must be added.
Powerful astringents are less useful than what are styled the aperient bitters, viz. the camomile flowers, columbo root, and quassia, which should be taken in moderate doses, continued for some time; and their use after a little intermission resumed. The Bath waters, formerly so much commended in this complaint, have yielded in credit to those of Cheltenham, whose laxative power is highly useful, and rendered less debilitating than it might otherwise prove by its chalybeate impregnation. Constant but moderate exercise; free air; cheerful society; frequent changes of scene, and tepid sea baths; are generally useful: but all our attempts relieve only - lateri adhaeret vulnus !
See Pringle on the Diseases of the Army. Fordyce's Elements, part the second. Matthews on Hepatic Diseases. Cullen's First Lines, vol. i. p. 376, edit. 4. Bell's Surgery, b. v. p. 387. London Medical Transactions, vol. ii. p. 147. Saunders on the Liver; and Pemberton on Diseases of the Abdominal Viscera.