b. Disorders of the Liver.—Next in order to the stomach, the liver is more directly exposed to the action of alcohol than any other viscus. For this reason lesions of the liver are frequent and grave. It is worthy of note, however, that in a small proportion of cases of chronic alcoholism terminating fatally, with widespread evidences of the destructive action of alcohol upon the other organs of the body, the liver has been found, both in its macroscopic and microscopic appearances, wholly normal. Absorbed by the gastric vessels, alcohol passes directly, by way of the portal vein, into the parenchyma of the liver, there giving rise to various disturbances, the nature of which is determined by the tendencies of the individual on the one hand, and on the other hand by the character of the alcohol consumed. The danger of hepatic disease is in direct proportion to the amount and the concentration of the alcohol habitually taken. The steady drinkers of spirits of whatever kind, whether gin, brandy, whiskey, or rum, present the largest proportion of diseases of the liver. These affections are far less common among beer-drinkers, and infrequent among wine-drinkers in wine-growing countries. In this connection it is to be borne in mind that the presence of food in the stomach retards to some degree the absorption of the alcohol ingested, and to a certain extent constitutes a means of dilution.
Hepatic disorders due to alcohol may be arranged in two groups: first, congestion and inflammation; second, fatty infiltration or steatosis; and the inflammatory process may affect chiefly the interstitial connective tissue on the one hand, giving rise to sclerosis, or on the other the glandular substance, constituting a true parenchymatous inflammation.
Congestion.—Congestion of the liver is an early lesion. It is brought about by the direct irritant action of the alcohol itself in part, and in part by the extension of inflammation from the stomach by continuous mucous tracts. Its development is insidious. Anatomically, the condition is characterized by vascular dilatation, moderate tumefaction, slight increase in the consistence of the organ; the surface is of a deeper red than normal; on section the color is more intense and the oozing more abundant. At a later period we have, as the result of chronic congestion, the cyanotic liver; the color is brownish or violet, mottled, and on section the surface is granular and the lobules distinct. The organ may now be somewhat diminished in size, but it lacks the firmness of sclerosis and the hobnail appearance due to the contraction of the interlobular connective tissue in that condition.
The symptoms of congestion of the liver are the familiar symptoms of gastro-hepatic catarrh, varying from the transient disturbance known as biliousness to serious sickness, characterized by acute gastro-intestinal phenomena, with vomiting, headache, and other derangements of the nervous system—constipation, succeeded by diarrhœa and by more or less distinct jaundice. The graver forms of hepatic congestion are characterized by intense nausea, frequent vomiting, pain and soreness in the epigastrium and right hypogastrium, the physical signs of augmentation of the volume of the liver, and well-marked yellow discoloration of the conjunctivæ and skin. These attacks are usually afebrile: the pulse is slow; there is considerable nervous and mental depression, a tendency to vertigo, and occasional syncope. The urine is scanty and high-colored, and presents the reactions of bile-pigment. Muscular tremor, especially marked in the extremities and tongue, is often present, but is to be attributed rather to the direct action of alcohol upon the nervous system than to the condition of the liver.
Hepatitis.—There are two principal forms of inflammation of the liver induced by alcohol—parenchymatous hepatitis and interstitial hepatitis or sclerosis.
Several varieties of parenchymatous hepatitis have been described. The anatomical discrimination of these varieties is attended with less difficulty than their clinical diagnosis. One of the more serious is diffused parenchymatous hepatitis or acute yellow atrophy. Alcoholic excesses appear to constitute a predisposing influence to this grave disorder (Lentz). In several cases prolonged and repeated excesses have preceded its development. It is a true parenchymatous inflammation, in which the glandular elements of the organ undergo disintegration. The liver is diminished in volume in all its diameters. It is of a uniform yellow color; its tissue is soft and friable; upon section the hepatic cells are found to be replaced by a granular detritus mingled with globules of coloring matter and a greasy, grayish-yellow liquid exudation.
The symptoms of this affection are those of an acute parenchymatous hepatitis of the gravest kind. In the early stages there is intense jaundice, gastro-intestinal disturbance, and fever, followed by speedy evidences of profound toxæmia. The patient rapidly falls into the so-called typhoid state, with a tendency to coma. The prognosis is, in the greater number or cases, a fatal one. So close is the resemblance between acute yellow atrophy of the liver and the phenomena of acute phosphorus-poisoning that by many observers these two conditions are held to be identical.33
33 Consult this System of Medicine, Vol. II., article “Acute Yellow Atrophy of the Liver.”
There is little doubt that the view now generally held, that acute yellow atrophy is due to the action of some unknown toxic principle, is correct. Alcoholic excess must therefore be regarded merely in the light of a predisposing influence. Acute yellow atrophy of the liver is an exceedingly rare disease.
Suppurative Hepatitis.—Abscess of the liver is in temperate climates infrequent as the direct result of alcoholic excess. It is frequently ascribed, however, to improper alcoholic indulgence, especially when combined with the eating of large quantities of improper food, in tropical and subtropical climates. A form of hepatitis has been described by Leudet under the head of chronic interstitial hepatitis with atrophy. The symptoms are for the most part not very well marked, and consist chiefly in general malnutrition, which may in fact be dependent upon the associated gastric disturbance. Chronic jaundice is usually present.