DISEASES OF THE HEPATIC VESSELS.

DISEASES OF THE PORTAL VEIN.

Obstruction of the portal vein may result from the growth of tumors pressing upon this vessel. The most common causes of compression are tumors of the stomach, pancreas, and the mesentery, and enlargement of the retroperitoneal glands, or from the liver itself. It may result from thrombosis, this being due to roughening of the endothelial coat, and is often of syphilitic origin. Obstruction may result from cirrhosis, but complete obstruction from this cause is rare. Obstruction has been known to result from great numbers of the distoma hematobium in the finer capillaries. The thrombus may organize, and the portal vein has been known to be completely occluded by fibrous connective tissue, nothing but the fibrous cord remaining, this condition being called pylephlebitis adhesiva.

Symptoms. Narrowing of the portal vein through thrombosis may give rise to symptoms which show the sudden onset occurring in the course of cirrhosis of the liver, chronic peritonitis, or tumors of the abdomen. They consist in the sudden appearance of symptoms due to stasis, marked epigastric pain, with vomiting and diarrhea, hematemesis and enterorrhagia. In the course of a few days ascites and enlargement of the spleen occur. The ascites soon leads to edema of the lower extremities, as a result of the pressure upon the vena cava. A caput medusæ forms, and even cutaneous edema may occur. If, after paracentesis abdominis-which soon becomes necessary-has been performed, the liver is examined, it will be noted that it has decreased in size. Occasionally, jaundice occurs. In rare instances these symptoms just enumerated may come on gradually, and may closely resemble the development of atrophic cirrhosis. The urine is decreased in amount, and, according to some authorities, glycosuria occurs. This is explained by the fact that the sugar-forming elements are carried through the collateral circulation to the heart, and then through the general circulation, reaching the kidneys without having undergone metabolistic change in the liver.

Duration.-The duration of the disease varies from a few

days to several years. If profuse hemorrhages occur, the disease may rapidly prove fatal.

Prognosis. The prognosis is always unfavorable, the only cases amenable to cure being those due to syphilis with gummata formation.

Treatment. The cases in which syphilis is suspected should be treated by mercury and iodid of potassium. From other causes the treatment is purely symptomatic.

INFLAMMATION OF THE PORTAL VEIN.-
PYLEPHLEBITIS.

ACUTE PYLEPHLEBITIS.

Synonyms. Suppurative pylephlebitis; ulcerative pylephlebitis.

Etiology. In rare instances an acute inflammation of the portal vein may be due to foreign bodies, which have traversed the wall of the bowel, and in this way reached the portal vein. It may also result from a purulent exudate from the lymph-glands reaching the portal vein. More frequently the inflammation begins in the terminal branches of the portal vein, which are in close relation to the abdominal viscera, particularly those of the bowel, especially the appendix vermiformis. Fistula in ano, hemorrhoids, and carcinoma may cause the condition. It may result from trauma, such as might arise from the careless introduction of the rectal tube, and may follow abdominal operations. It may also result from inflammation of the uterus and its appendages or of the bladder, ulceration of the stomach, splenic abscesses, mesenteric abscesses, purulent pancreatitis, and, in the new-born, from inflammation around the umbilicus. It may result from empyema of the gall-bladder, and from other inflammatory conditions of the biliary passages.

Pathology.-At first the veins become thickened and the walls infiltrated with an inflammatory exudate; a thrombus may then result; often it is broken up, producing emboli, which lodge in the liver, giving rise to small abscesses. The walls of the vein may reveal ulcerated areas, and in some instances may rupture. This acute inflammatory infection is always of bacteriologic origin. Large solitary abscesses, as well as small ones, may arise in the liver from this cause.

Symptoms. The symptoms are those of septic processes

joined to those of the primary affection. There is an irregular, high temperature, either intermittent or remittent in type, accompanied by chills, sweating, and collapse. Occasionally, the liver is enlarged, owing to cloudy swelling. The spleen is enlarged in the majority of cases. There is anorexia, vomiting, diarrhea, jaundice in some cases, and, toward the close of the affection, enterorrhagia. The urine is diminished in amount and is albuminous.

Duration. The duration of the disease is from two to six weeks.

Prognosis.

Treatment.

The prognosis is always unfavorable.
The treatment is expectant symptomatic.

CHRONIC PYLEPHLEBITIS.

As in other blood-vessels, sclerotic changes may take place in the portal vein, with thickening of the intima or with calcareous infiltration. The vessel wall becomes inelastic, the lumen narrowed, and, as previously stated, may become occluded (pylephlebitis adhæsiva). Syphilis is a cause of this condition. Weigert describes tuberculosis of the portal vein.

Disease of the Hepatic Artery.-The hepatic artery may be the seat of aneurysm or of sclerotic changes.

Disease of the Hepatic Veins.-Stenosis may result from compression through new growths or cicatrices, most often of syphilitic origin, which develop in the liver structure, or from inflammation of the hepatic vein, which is rarely primary. Thrombosis may also occur and give rise to occlusion. Emboli may lodge in the hepatic veins as a result of a regurgitating blood stream from the right heart, particularly the right auricle, sometimes during forced expiratory movements, as coughing.

Inflammation of the Hepatic Veins.-This may be either acute or chronic. Acute inflammation is most frequent, and is due to suppurative inflammation of the liver, such as suppurative pylephlebitis, to echinococcus cysts, or to purulent cholangitis. The chronic variety is most often due to syphilis. There are no symptoms by which this condition can be recognized.

DISEASES OF THE PANCREAS.

INFLAMMATION OF THE PANCREAS.

ACUTE HEMORRHAGIC PANCREATITIS.

The whole or only a part of the pancreas may be involved by this process, in which the inflammation is combined with hemorrhage.

Etiology.-Trauma may be a cause.

Chronic alcoholism has been noted in a number of the cases; it is, however, most commonly due to an extension of inflammation from the duodenum to the pancreas through Virsung's duct.

Pathology. The organ may be enlarged and deeply stained with blood. On section, large areas or only punctiform ones may be seen. Extensive fatty necrosis of the pancreas and surrounding structures, as well as inflammatory changes, are noted.

Symptoms. As a rule, the symptoms appear suddenly. Severe pains in the epigastrium, in the region of the umbilicus, nausea, vomiting, with constipation and signs of rapid collapse, are pronounced symptoms. There is great uneasiness, marked rapidity of the pulse (tachycardia),—140 to 160 per minute, dyspnea, subnormal temperature, and rapid loss of strength; death occurs from exhaustion in from a few hours to a few days.

PURULENT PANCREATITIS (ABSCESS OF THE PANCREAS). (a) Primary Pancreatitis.—As etiologic factors, alcoholism, pregnancy, suppression of the menses, and poisoning from mercury have been given. Trauma may also be a cause. Necessarily, pyogenic organisms must find their way into the pancreas. The disease occurs much more frequently in men than in women, and arises most commonly between the ages of twenty and thirty.

Pathology. The organ is enlarged, and abscesses are found scattered throughout, or they may be more numerous in certain parts. The necrotic process may destroy a part or the whole organ, and through rupture the pus may find its way into the peritoneal cavity.

Symptoms. As a rule, the symptoms occur suddenly in the course of or following hepatic colic or digestive disturb

ance. There is violent pain, coming on suddenly in the epigastrium, which is localized and does not radiate from the abdomen. However, this is not invariable, as cases have been recorded without pain. In rare instances pains may show themselves in the splenic region, the spleen being tender, pain being elicited in this area upon palpation. Nausea and vomiting, with eructations, are almost constant symptoms, the vomited material often being bile-stained. With these symptoms there is rapidly oncoming and marked prostration. Fever of an irregular type, accompanied by rigors, is present, but in rare instances the fever may be absent. As a rule, constipation occurs. In rare instances diarrhea is present, which later may become profuse. Occasionally, diarrhea may alternate with constipation. The feces may contain blood and fetid pus, the abscess having ruptured into the bowel. Albumin and fat may be present in the stool. The liver is enlarged, and also the spleen, but to a less extent. There is considerable tympany of the abdomen. In some cases fluid may be found in the belly, or there may be other signs of accompanying peritonitis. Upon physical examination the epigastrium is resistant, or even a tumor may be found in the abdomen. The urine is usually of low specific gravity-1002 to 1005. Peptone, albumin, sugar, and indican have been found present. Jaundice occurs in about 25% of the cases. In cases that run a chronic course marked emaciation and petechia, or other purpuric manifestations, may

occur.

Treatment. The treatment is surgical.

(b) Secondary Acute Purulent Pancreatitis.-The secondary variety may arise from inflammation of surrounding organs from continuity of structure, also in the course of pyemia, puerperal fever, and from malignant disease of the pancreas or other surrounding organs. Rarely it may result from acute peritonitis.

The symptoms are those of the underlying affection, linked with those just enumerated in the primary variety.

GANGRENOUS PANCREATITIS.

Gangrenous pancreatitis may result from suppurative inflammation or in the course of chronic pancreatitis. Necrosis may occur from hemorrhage. It is doubtful whether fat necrosis of the pancreas ever leads to gangrene; some authorities, however, have recorded such instances. Gall-stones may