Pathological anatomy, pathology and physical diagnosis. : A series of clinical reports comprising the principal diseases of the human body: Volume 2

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DISEASE OF THE LIVER, TABLE IV. FIGS. 1, 2, 3, 4 represent extraordinary dilatations and hypertrophy of the tlio‘acic duct and groups of lymphatics, co-existing with enormous dilatatioiis of many large arterial trunks iii difi'ci'ent portions of the body, reported by Jules Clog/(cl in l'zz/Iinlo'r/ic ('lu'ru)‘gz'calc, and drawn by If. Cars-21:116. Fig. 1.-Ancurisin of basilar artery. (A), cavity of aiicurism; (B), portion of basilar artery; ((‘), the vertebral arteries. Fig. 2.-I'ortion of the brachial, ulnar, and radial arteries, extensively affected with aneurisinal dilatation. The size of the tumors were different in the same vessel. (A), brachial artery laid open; (I3), ulnar; (U), 'adial artery; (I) I)), aneurisinal tumors projecting from the external surface of those arteries: (E E), aneurismal sacs conimuni 'ating with the b 'aeliial. Fig. 3,-Varicose dilatations of the iliac arteries. 'I‘hcse vessels and their chief b "am-hes PLEEX, A) I) L} )IPIIATICS. SECTION (VIII. into the mesentcric glands. The mucous membrane (13 B) is in some places an eighth of an inch thie; and raised in a number of convolutions-like the surface of the brain-tinged with red. showimr incipient lncmorrhage. At (I) 1)) the primary stage of the discus?: is r ‘adily noticeable. In many parts the villositibs are vcrv large (E E) and prominent. Very many lacteals, arising from the iiiucoiis membrane (Gr (3:), and connected with the villi at (F). The glands arcinfiltrated with cerebriform ‘anccrousmatte‘andhighly 'asculai'. (A), mucous coat. Fm. (i.-Tubcrculons infiltration into the mesentcric glands. A portion ofthe ileum laid open and spread out, to which are attached a piece of the mescntery, sevc ‘al inesentrie glands and lacteals. The tuberculous matter occupies the follicles of an enlarged agminatcd plaque (A), It also projects from the orifices of the solitary follicles (I3). At (C) a less advanced stage of tuberculous infiltration, small, presented a remarkable increase of bulk; flexuous and elongated they formed numerous sinuses and dilatations of various forms and dimensions. The walls ofthc dilated portions were soft, flaccid, and round, slightly conical elevations, of a straw color, or light gray, upon the mucous surface indicate the early stages. Ulce‘ation of the solitary follicles and plaques of the mucous, muscular, and serous collapsed; their color paler than natural, the middle coat had lost its yellow tint, its circular fibers were less apparent. In some parts they were sclerotic. (A), termination of abdominal aorta; (B), inferior mesenteric artery: (C), left common; (1)), right common iliac arteries; (K K), sinnositics; (M M), dilatations. Fig. 4.-A portion of the thoracic duct, etc. (A), portion of the diaph 'agm; (Ii), thoracic duct; (C 0), two large branches; (I) 1)), lymphatics, some of which are drawn in outline. FIG. 5.-Specimen of carcinoma confined to the mucous coat of the duodenum, With thickening of the muscular coat, and infiltration ducts are usually not injured and may, on the contrary, increase in extent. xlclwrnnmn. has injected into the newly-formed bile ducts from the hepatic duct. Circulation in the formed periportal con- nective tissue is conside ‘able. However, many portal-vein branches are by the inflammatory process destroyed, but many interlobular branches remain intact. In the portal regions venous stasis often takes place, producing swelling of the spleen, ascetis, and very often static haemorrhage. The hepatic artery circulation is not nearly as much involved as the other circulation. Its branches dilate and many new arterioles are produced and furnish nutrition to the thickened capsule of Glissnlr as well as to the lobular structures. In atrophic iiidurative hepatitis the artery is injured and many of its branches oblite ated. Not supplying the lobular cells with sufficient circulation they either decay or undergo fatty change. In consequence of obstruction of the portal circulation within the, liver many communicating veins with the portal-vein region of supply which, under ordinary circumstances, are so insignificant as to escape the notice of most anatoinists, beeonie gradually enormously dilated and assume unexpectedly large proportions. Such are some of the veinlcts of the susl'iensory ligament. of the liver lately observed and described by Suppey. The veins of the abdominal walls, of the diaphragm and :esophagns, also those which anastoinose with some of the veins of the lower extremities enlarge to an cxt‘aordinary degree, become often very tortuous and dilate into many 'aricosities. The extent of the inflammatory process corresponds to the extent and intensity of the exciting cause. \thn the inflammation issues from the b‘anches of the portal vein or of the hepatic artery, the extent of inflammation will be according to how many branches of the vessels are prin'iarily involved; circumscrilml when a few, more. diffused when many of them are affected. But when the inflammation proceeds from the periportal connective tissue and expands into the interlobular spaces it will be very gene ‘al. A peculiarity of the inflammation, when arising in the biliary ducts, is that it appears in the shape of globular, circums'cribed centers, containing biliary coloring matter, situated partly in the lobulcs. partly in the periportal tissuc. Biliary hepatitis is sometimes liypeiq'ilastic, sometimes pyogenic. In recent inflammation of the liver there is always enlargement of the organ, which is the more considerable the more extensive the inflammatory process is. Large centers of inflammation show the unassisted eye grayish or greenisli-colored spots (Section VII. Table I, Fig. 1, U C). \Vheii connective tissue is developed by hyperplasia, the organ will still further increase in size. In diffuse hepatitis the enlargement will be necessarilygreatest. In appearance such an organ is very much like an infilt 'atcd liver (Section VII. Table II, Figs. 4'), (5). In the region of the portal-vein connective tissue and in the lobulcs there are accumulated lymphoid corpuscles and biliary pigment, also coniieetive-tissue cel , the whole infiltrate being either g'ayish-red (Section VII, Table II, Figs. 3, 4, 5, (i), yellowish, or greenish, according to the amount of the coloring inattcr of the bile or the blood. Similar appearances exist when there is retention of bile by enormous development of connective tissue in the interlobular spaces, by mechanical stagnation of bile, or obstruction within the gall ducts. The lobulcs are then also either brownish-red, brown, yellow, or g 'ziy (Section VII, Table II, Figs. 1, 2, 3, 4). The quantity of such newly-develo]ied connective tissue is some: times very great. and the enlargement of the organ extraordinary tunics of the intestine are indicated at (I) E F) in consequence of the tuberculous deposit in the tissue. Ulceration of the mucous follicles seen at (D); ulcerations of the mucous, sub-mucous, muscular, and sub-peritoneal tissues are presented at (E F). The muscular coat is denuded and ulce'ated. The sub-mucous tissue filled with iniliary tubercles. The laetcals are dilated and filled with tuberculous matter (Gr); the niesenteric glands (II K L) are enlarged, some exceedingly, and all filled with tnbcrcular masses. At (M) the lactcal communicates with an ulcerated plaque, passing beneath the atrophic mucous tissue. follmvs), the whole liver becomes smaller, and often very small. Its surface then assumes an embossed appearance, the depressions formed of the shrunken connective tissue, the elevations of the remnants of the parenchyma (Section VII, Table I, Figs. 2, 3, 4, 5; Table II, Figs. 5, (i). The smaller the remnants the smaller will be the elc 'atioiis, and the more abundant the depressions between them. The seve'al appea‘ances produced thereby have received the names of granular, lobular, and [o/mr ciz'r/ioffc atrophy; the last also passes as Lacin'v‘s cirrlmsis. Of late years, chronic interstitial hepatitis has been the subject of very numerous researches and of as numerous exi'ierimcnts, which have led to attempts at subdivision of the disease into many classes, but which were really of no practical 'aluc. At present. the English, French, and some American pathologists assume two main forms (advo -atcd by (film-col and (Jinn/Jun"), viz: biliary cfrr/msi's, having a hypertrol'iliic character, and 'z'usr'u/ar, with subsequent atrophy. iThe Germans contend for two stages of the same disease, the primary or hypertrophic, and the secondary or scmmrl slag/c, as the atrophic. Both may have their origin in the biliary or ‘ascular apparatus, or in the pcrivascular or interlobular connective tissue. vIaundice, which is sometimes very prominent, and at other times but very slight or nearly imperceptible in cirrhosis, does not seem to be directly connected with either the one or the other form or stage of the disease. iS'g/p/n'li‘tz'c IIcpm‘Ztis. Acquired syphilis may give rise to a form of hepatitis which very much resembles, anatomically, the described forms of cirrhOsis. Only concomitant symptoms in other parts of the body can furnish means of diflercntial diagnosis of syphilis and cirrhosis. ['sually si/p/n'l/tic otters-title! hepatitis is not diffused throughout the organ, but, as a rule, affects limited portions. The surface of the liver is generally uneven, as in cirrhosis, most frequently near the suspensory ligament. It has, in places, the appca 'ance of ci -ati'icial contractions, and the covering membrane is thick and wrinkled (Section VII, Table 2, Figs. 5, U). A section upon a contracted spot shows accumulation of connective tissue, which spreads from a common center in different directions in a radiary form. This constitutes a gummatous syphiloma of the liver. The parenchyma of the organ between these cicati'icial s/riu' is in an atrophic condition, of brown color, the lobulcs very minute. The connective tissue lodges very small eascous nodules of a gray color, somewhat diaphanous. Similar groin/mm are found in the organ itself, very often in great numbers. Many such ci ‘atrices produce upon the surface of the live‘ a lobulated arrangement. The center of the f/IUII'IN/l. consists of homer/encous', (Inez/clam, decaying tissue, or gran- ular detritus with some de 'aying cells; the histological cha ‘acter showing that of atropliied liver structure and infiltrated lymphoid cells, which never developed into connective tissue. This destructive process in the early stages of the inflammation shows the total inability ofthe parenehyma to become regenc ‘atcd, or even to cause (ICVUIOPIIIOIlt of the neoplasm into living tissue. The cells die from lack of nutrition, because the syphilitic virus destroys the vascular structure, and the circulation ceases. In hereditary syphilis similar infiltrations and minute gummata are. found in the liver, especially of new-born babes. or those dying in utero in very early fix-tail life. These infiltrates are all of microscopic size and can not be seen by the uiiasisted eye. Indurative syphilis is common in both kinds and are often associated With enlargement of the organ. The color of the liver is, in such con» (10 to 12, 271.). This condition has been ‘allcd Io/pcI'I‘I‘I‘Jp/u'c I'm/u- ration. or }z_i//)c/‘rrop/z[c ci'rr/zosis. The surface of the liver is then smooth, the texture tough and dense. The lobular structure, according to the quantity of new tissue, is more or less oblite 'atcd. The parenohyniatous tissue remains sometimes preserved to some slight extent. At other times it becomes so atrophied that the whole organ shrinks. In the atrophic stage the tissue is crossed often vast numbers of iniliai‘y guminata are diffused through the liver, producing innumerable small gangrenous spots which nearly destroy the function ofthc organ altogether. . IIepatic tuberculosis is cithe ' a partial lesion of general systemic by a greater or lesser number of strict of grayislnred, yellow. or iniliarv tnberciilosis, or a local tuhcrcular lesion. vbllowisli-grecn~colored connective tissue, in the meshes of which lie remnants of the parenchyma of the liver. having a reddishbrown, vellow, or gray color (Section VII, Table 1, Figs. 3, 4-, :3). VVith the shrinkage of the connective tissue (which gradually use the tubercles are of iniliarv size. difiiiscd in the periportal and acinons structures; in the second they form larger caseous and-ulcer: (litions, red, yellow, gray, or speckled according to the nature of the infilt ate and the intensity of the tinge it assumed. ating focal deposits in all its tissues. (Gilli/tr.) Very In the first There is always formation of hylwrplasia, which encloses the tuberculous masses.