The first observations on malarial cirrhosis come from Haspel, yet these are limited to a simple description of the macroscopic appearance of the liver at autopsy, without a further study of the nature of the condition.
We owe to Frerichs the statement of the fact that there are cases of Lsennec's cirrhosis in which the anamnesis showed no misuse of alcohol, but, instead, a long continuing intermittent, which probably played the same role. Yet Frerichs asserted that the granular liver was rare in individuals who succumbed to malarial cachexia. Bamberger adopted Frerichs' opinion on account of encountering similar cases. Colin frequently observed enlargement of the liver, with increase in the connective tissue and consequently with increased consistence, yet rarely granular cirrhosis. Lancereaux also gave his attention to this subject, though the most thorough investigation comes from Kelsch and Kiener. Among the Italians, Tommasi, Cantani, and Cardarelli put themselves on the side of malarial cirrhosis.
Still, opposition is not wanting. Marchiafava and Bignami have especially pronounced against the development of cirrhosis as a result of malaria . In their experience Lsennec's was especially rare, the hypertrophic with icterus somewhat more frequent. Their principal argument, as will be mentioned again in the anatomic part, was based on the differences between the histologic structure of the liver tumor after malaria and that of cirrhosis.
It cannot be denied that the arguments on both sides, supported as they are by large experiences, deserve attention. Considering the many sided etiology of cirrhoses and their protean histologic structure, overthrowing every outline made for them, much more work will be required before the question is decided.
In particular cases of cirrhosis it is not always easy to determine whether or not malaria played an etiologic role. The misuse of alcohol is so wide spread that it usually comes into consideration. Only when it can be disposed of is the way clear. Unfortunately, the majority of cases in the literature suffered from this concurrence of alcohol. The cases in which it was entirely excluded are very few. Frerichs could point to only a single one.
As precarious as the matter is in the case of Lsennec's cirrhosis, it is even much more so in the other forms, especially the different subclasses of hypertrophic and biliary cirrhoses, since the etiology of this category of liver diseases is uncommonly rich in material. Gallstones, gastro intestinal and general infectious diseases, metallic poisons, alcohol, autointoxications, diabetes, and malaria have all been brought forward as exciting causes. In tropical regions these are increased by dysentery and certain climatic telluric influences not yet sufficiently understood.
Despite all this it seems permissible, from the evidence before us, to conclude that malaria may be the cause of Lsennec's as well as hypertrophic biliary or mixed cirrhosis.
Lancereaux, and also Kelsch and Kiener, go further and assert that the malarial cirrhosis manifests particular histologic characteristics which differentiate it from other cirrhoses. The last two express themselves as follows: "Chaque fois que nons avons mis en parallele la serie de preparations de notre collection qui se rapporte aux hepatites d'Algerie avec celle qui se rapporte aux hepatites nostras, nous avons ete frappes de leur dissemblance." To go into the details of this question would lead us too far. In the anatomic part we will recur to the subject.
I have sifted the cases of cirrhosis of the liver that came under observation in the first medical clinic in Vienna during the last fifteen years and find the following: Among 65 cases of atrophic cirrhosis without icterus, there were 6 in whose history malaria occurred. Of these 6, 5 were more or less strong drinkers. In the one case remaining the anamnesis showed (apart from a typhoid fever) a malaria lasting three years, which might be regarded as the cause of the cirrhosis, yet this case is not absolute, since it never came to autopsy.
Among 46 cases of cirrhosis with icterus five showed a long lasting malaria . Of these, one must be excluded on account of potus and paroxysms of pain that were possibly gall stone colic, leaving four cases, which corresponds to a percentage of 8.7 per cent.
The liver cirrhosis develops either immediately subsequently to the malaria or after a shorter or longer interval, sometimes amounting to years. It usually progresses gradually, with occasional improvement, until toward the end, when its advance is rapid.
I would like to call attention to a little matter that frequently struck me in practice. It applies to the genuine Hanot's cirrhosis, as well as to the other forms described as biliary. These cirrhoses not rarely begin with a frank intermittent fever, usually quotidian in type. It was introduced into the literature by French writers under the name "fievre intermittente hepatique." This fever presents not the slightest difficulty in diagnosis if it begins when the other symptoms of the disease-icterus, tumor of the liver and spleen -are developed; yet there are cases in which this fever constitutes the beginning of the disease, and in these a confusion with malaria is not impossible, only, however, by ignoring the blood examination. If, following this, the symptoms of cirrhosis gradually appear, the second error may be made and this cirrhosis diagnosed as malarial cirrhosis.
The symptoms and course of malarial cirrhosis are naturally very different, depending on whether Laennec's, Hanot's, or a mixed form is present.
We must deny ourselves the pleasure of going further into the symptomatology of this condition, and content ourselves with adding that Lancereaux has drawn a special picture for malarial cirrhosis which corresponds to Hanot's form. Though this may apply in a number of cases, a study of the literature shows that it cannot be considered the rule. Kelsch and Kiener, for instance, expressly insist that icterus rarely comes into the symptom complex, and that ascites occurs in the majority of cases.