Tropical Diseases/Chapter 33
CHAPTER XXXIII
TROPICAL LIVER
THE subject of liver disease is everywhere a difficult and complicated one. It is especially difficult in tropical countries; for not only is the resident there liable to all the forms found in temperate climates, but he is exposed, in addition, to various potent predisposing and exciting causes of liver disease not present, or only present in a very mild degree, in more temperate latitudes. These additional causes of liver disease, inseparable from the tropics, are heat, malaria, and, especially, amoebic dysentery. To these, too often, have to be added injudicious personal habits, a tendency to over-full and over-rich feeding, to over-stimulation by alcohol, and deficiency of muscular exercise.
The young European who finds himself in the tropics for the first time is surrounded very often by luxuries in the shape of food, wine, carriages, servants— luxuries to which he had not been accustomed perhaps in his home. At first the change, the excitement of novelty, and the high temperature act as stimulants to appetite, and the excessive loss of fluid by cutaneous transpiration creates a powerful thirst. Little wonder, therefore, that in such circumstances the youth, having the appetite and the opportunity of gratifying it, is apt to indulge in food and drink beyond safe physiological limits. He is made lazy by the heat ; he cannot exercise during the day, and when evening comes he prefers lounging on the veranda or hanging about the club bar to walking or riding or games. Very likely he sits up late at night, drinking and smoking, so that in the morning he is too sleepy to ride out or take any other form of exercise. And so it comes about, what with a surcharge of aliment and alcohol, and the diminished activity of lung metabolism and excretion incident to high temperature and muscular inactivity, that a very large and unusual amount of physiological work is thrown on the liver. With this large amount of work there is a corresponding hyperæmia. This may be considered the first stage of tropical liver hyperæmia from functional activity; up to this point it is a purely physiological condition.
Pushed a step farther, this physiological hyperæmia passes into congestion with blood stasis, and a consequent diminution of functional activity. Hyperæmia of a physiological character will be evidenced by increase of functional activity, and there will be a copious flow of bile, sometimes causing diarrhœa of a bilious character, particularly morning diarrhœa. But when the limits of physiological hyperæmia are passed, and congestion of a pathological character sets in, the consequent arrest of function will be evidenced by pale stools, perhaps diarrhœa of a pale, watery, frothy, fermenting character in the last case the diarrhœa doubtless depending, in part at least, on fermentative processes set up in the contents of an alimentary canal no longer kept relatively aseptic by an adequate supply of healthy bile. Other symptoms of this condition are headache; furred tongue; scanty, high-coloured, loaded urine; a feeling of weight or fullness, or even of pain, in the region of the liver, and probably enlargement of the percussion area and other physical signs of enlargement of that organ. One step farther, and such a condition may pass into actual hepatitis attended with fever, smart pain in the liver, tenderness on percussion, and still more marked increase of the hepatic area.
A functionally very active hyperæmic organ is prone to inflammation, even on slight cause. In the case of the hyperæmic liver a common cause of inflammation is chill, such as may arise from a cold bath, a wetting, or from lying uncovered on a warm night in a current of air. The experienced resident knows this very well, and is at great pains to guard against such an occurrence. He very likely wears what is known as a cholera belt; he sleeps, even on the warmest night, in flannel pyjamas, and with a thin blanket drawn over his abdomen; during the day he wears a woollen undervest and very likely serge or thin tweed clothes. He does not sit down in damp clothes, and he has a great respect for a shower of rain. Besides chill, there are other causes which may convert the hyperæmia into congestion or inflammation; a blow may operate in the same way, so may a surfeit of eating or drinking, so may exposure to the sun, so may an attack of malarial fever or of dysentery.
Treatment.— Nature sometimes effects a cure in these cases of hepatic congestion by establishing a smart diarrhœa. In the treatment of such cases we cannot do better than to imitate Nature, and even to supplement her efforts. A few doses of the sulphates, in the shape of some kind of bitter water or of Carlsbad salts, generally give prompt relief. But if the subject of such attacks does not profit by experience and mend his ways, very likely his liver, in time, will become chronically hyperæmic and extremely liable to intercurrent attacks of congestion of a character more or less acute. The subjects of this type of " liver " ought to be most careful in their habits. They must not lie abed too long; they must not take cold baths; they must not take cold drinks, nor expose themselves to cold in any form; they must clothe warmly; and they must eschew alcohol in every shape. Animal food they must partake of but sparingly; and they should give the preference to fowl and fish over beef and mutton. Fruit and farinaceous food may be more freely partaken of, but over-eating in every form must be avoided. Exercise should be taken at least twice a day; and, at least once in twenty-four hours, the exercise should be of such a character as to provoke perspiration. A gallop on horseback, a smart game of tennis or rackets, are excellent hepatic stimulants. Occasionally, once a week or not so often, particularly when a sense of fullness or aching in the right side seems to indicate that all is not right with the liver, a dose of Carlsbad salts or bitter water, preceded perhaps by a few grains of calomel, may avert more serious trouble. When hyperæmia becomes chronic, when the patient is continually suffering with "liver," he should leave the tropics for a time. Nothing relieves these cases of chronic congestion so quickly or so effectively as a visit to Carlsbad or to Harrogate, and a thorough course of the waters there and of the dietetic restrictions imposed in the Carlsbad cure. This should be followed up by country life in England and the active pursuit of country sports; the usual precautions in the shape of warm clothing, avoidance of cold baths, chills, alcohol, and high living being scrupulously observed and a weekly saline purge taken.
A serviceable imitation of the natural Carlsbad water may be made by dissolving 53 gr. of the powdered salt in a pint of boiling water.*[1] This may be divided into three equal portions, which are to be sipped as hot us possible, at intervals of twenty minutes, on an empty stomach, the first thing in the morning. While taking the solution, gentle exercise, as moving about the room, should be indulged in. Breakfast must not be taken till an hour after the last dose. If the bowels are not gently acted on, an increased quantity of the salts should be taken. During the course, which should be persevered in for three weeks, the diet must be carefully regulated; butter, fat, nuts, fruits, pastry, preserves, tinned foods, cheese, salads, wines, spirits, and beer are to be avoided. Too much meat must not be taken; a small meat meal once a day must suffice. The quantity of food, too, should be restricted, and clothing, exercise, and bathing be carefully attended to. Much excellent advice on the subject of the Carlsbad treatment will be found in Surgeon-Major Young's book, " The Carlsbad Treatment for Tropical Ailments."
During severe attacks of acute congestion, or of severe hepatitis attended with fever and much local distress, the patient must be kept in bed and placed on a very low diet of thin broths, barley-water or rice-water, or milk and water. He should be purged freely and often with salines. A large hot poultice, two feet or more in length by one foot in breadth, should be laid over the region of the liver; such a poultice to be effective should pass from the centre of the back to well over the epigastrium. Dry cupping sometimes gives marked relief. Muriate of ammonia has a certain reputation in these cases; it should be prescribed in 20-gr. doses every six or eight hours. I have often used it, but I cannot vouch for its virtues; it does 110 harm.
When such a hepatitis is associated with dysentery, perhaps latent or antecedent, should it resist these milder measures hypodermic injections of emetine, as in amoebic dysentery, or 30 to 60 gr. of ipecacuanha often give marked relief, and should be repeated every twelve or twenty-four hours for two or three times. When the hepatitis is associated with malarial fever, full doses of quinine, in addition to the purging and the other measures already mentioned, are indicated.
Whether hepatitis, unless associated with dysentery, ever passes on to suppuration is a moot point. Some say that it may ; others resolutely deny that there is such a thing as "tropical abscess" unassociated with dysentery. This subject will be discussed in the following chapter. Malarial hepatitis has already been considered (p. 97).
- ↑ * A good substitute for Carlsbad salts consists of sod. sulph. 2 parts, sod. bicarb. 1 part, sod. chloride 1 part.