Acute Hepatic Congestion is marked by rapid enlargement of the liver and febrile symptoms. It occurs after dietetic indiscretions, including the abuse of alcohol, during malarial fever, acute intestinal inflammation, and after chilling. In tropical countries, especially among foreigners, these causes are most likely to become effective.

Prophylaxis consists in an avoidance of the causes and, in general, in following not too rigidly, the dietetic and other customs of the tropics.

Treatment involves abstention from food for a few days or at most a restricted diet of milk, peptonized if necessary, cereals and fruit juice.

The most frequent liver disease of temperate climates is Sclerosis or Cirrhosis. The more frequent form consists in an overgrowth of connective tissue, resulting in contraction and in resistance to the portal circulation so that haemorrhoidal masses may develop in the oesophagus or stomach or intestine, from which haemorrhage may occur, either slight and dribbling, imitating the clinical picture of cancer of the stomach and bowel, or else copious, resembling that from gastric ulcer. Chronic catarrh of the stomach and intestine also results. Frequently, if the diagnosis is limited to conspicuous cases, rather infrequently and late in the course of the disease if it is recognized in its milder forms, ascites develops. In the dietetic management, it should be remembered that similar changes in the kidneys and pancreas are quite likely to be present and that the cirrhosis may be, not so much a local hepatic disease, as part of a general fibroid change including angiosclerosis.

The less common form of hepatic cirrhosis is hypertrophic, which may be, in some cases, a variety of the ordinary form in which the connective tissue increases more than it contracts. Other cases, to which the term hypertrophic cirrhosis is commonly but not so correctly applied, are due to inflammatory - mainly infectious - processes extending up the biliary passages, with more or less consequent interstitial change. This form is more likely to be marked by jaundice and the ascites is less as are the other changes due to portal obstruction.

Hepatic cirrhosis is commonly described as a disease of alcoholics and the hypertrophic, biliary type is especially due to this cause. The writer's experience is that ordinary atrophic cirrhosis is quite common in total abstainers and that it may be merely part of the fibrosis of senility. Obviously, since most men drink alcoholic beverages to some degree, hepatic cirrhosis is usually found with an alcoholic history but, unless the use of alcohol has been considerable, other etiologic factors should be sought.

Fusel oil in poor whisky, spices, excess of salt, medicines taken for prolonged periods, food preservatives but, probably most important of all, products of fermentation and putrefaction in the alimentary canal, are to be considered among the causes of hepatic cirrhosis. Indican has been experimentally demonstrated to be a cause. Thus, almost any continued or repeated dietetic error or even the neglect of appropriate diet in mild forms of dyspepsia, may be considered as the cause of hepatic cirrhosis.

For many years, hepatic cirrhosis does not, as a rule, interfere conspicuously with hepatic function and, even in advanced cases, the disturbance of health seems to be directly ascribable to the gastro-enteric catarrh, and the development of a toxaemia from impairment of the excretory function of the liver or of its vaguely known function of modifying oxidation products, rather than to any obvious impairment of the function of modifying products of digestion. The mechanic effects of ascites are also important. Cases presenting glycosuria, and marked failure of digestive power, are frequently due directly to concomitant pancreatic lesion, not diagnosed.

Established hepatic cirrhosis is often marked by obesity, in the earlier stages, especially if fatty changes occur also in the liver, but by relative emaciation in the later stages. Anaemia is also present. Thus, in spite of the indication not to overburden either the liver or the system generally with toxins, the diet should include a moderate amount of meat but not viscera. The possibility of favoring fatty changes in the liver by administering much fat has been mentioned. Thus, the diet should be maintained, if possible, at about the physiologic standard and relying mainly on cereals, legumes, milk, eggs and moderate quantities of meat.

Hard particles, large boluses of unmasticated food, spicy, or alcoholic or very hot ingesta should be avoided as tending either mechanically or by stimulating local blood supply, to cause rupture of varices. Strong tea and coffee are to be avoided, largely because of their effect upon blood pressure but also because of their tannin and the unfavorable action of caffeine upon the hepatic cells.

While somewhat dangerous on account of the chance of producing haemorrhage, especially when the blood supply to the stomach is already increased by the digestive reflex, considerable quantities of hot water with salt or soda, used some time before meals, tend to remove mucus and, by absorption, to wash impurities through the liver and ultimately out of the system by the kidneys. The beneficial effect of such use, is promptly seen. Lavage may also be practiced, with the same benefit and danger. This method is more efficacious and, on the other hand, while probably no more dangerous, the apparent responsibility of the physician in case of haemorrhage is greater.

Soft pulpy fruits are beneficial as laxatives and diuretics and they may have a truly cholagogue action. Grapes have been recommended as a "cure." Lemon and lime juices seem to have a stimulant effect upon the liver.

It will be noted that the diet is very similar to that for gastroenteric catarrh and, indeed, largely because of the almost inevitable existence of the latter condition.

The presence of ascites does not specifically influence the diet but, obviously, ascitic patients are mostly those with advanced cirrhosis so that there is more necessity for care, more frequently the demand for peptonized milk or other direct assistants of digestion and less probability of administering sufficient nourishment. The increase of abdominal tension renders the development of gases more noticeable and requires greater precautions against fermentation. The dietetic indications to relieve the dropsy are also to be considered, and are mainly the same as in other forms. Too strict reduction of water must not be attempted and, as in other forms, the use of hot saline enemata may actually favor absorption by stimulating renal elimination.

Gall Stones are favored by infections of the gall bladder of rather moderate virulence, colon and typhoid bacilli being apparently the principal germs thus acting. Concentration of the bile, lack of exercise and possibly diet or metabolic conditions increasing the content of calcium or cholesterin as well as the lapse of considerable time, are other factors. For these reasons, they are to be expected especially in fat, over-fed and under-exercised, middle-aged or elderly women.

Dietetic prophylaxis consists in the use of a reasonable quantity of digestible food, with sufficient water, which should not be hard and the prophylaxis of alimentary saprophytosis, especially of the form consisting mainly in colon virulence with putrefaction of proteins, and the regimen suited to maintenance of vitality and prompt convalescence from typhoid, are also important factors.

It cannot be said that there is any satisfactory dietetic treatment of gall stones but a light milk-cereal diet, the use of alkaline waters and the moderate application of the graps or buttermilk cures, or similar methods to insure an abundant supply of water and salines, will usually prevent further deposits, secure drainage of the biliary passages, tend to reduce the frequently associated obesity and thus prepare the patient for simpler and safer operative measures, and allow more exercise to be taken.