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

Page 100

SECTIoN VII] DISEASES OF TIIE LIVER, SI'LEEN. AND LYMPIIATICS. TABLE I. Fm. 1.-I{_»/pcrwmz'a and Iaflunomzf/nii (filer Lirrr. ,Besides diminution of consistence, which aecomlninies inflammation of this organ, the blood accumulates and is retained in the, 1 and the light gray color; (0 C), cut surface on which the openings of several veins (I) D) are compressed. ‘ .FIG. 4.-A small portion of another live ‘ affected with the same disease. The organ was much reduced in size; its external surface affected parts (congestive liyperaiinia), thus obscuring the lobular l (A), of a yellow color, presented the tiibcrit'orm arrangement of the lobules, which is more conspicuous on its cut snrfaccibv the differstructures. The redness produced by the hype 'zemia becomes deeper ence of the, two classes of tissue. (Ii B B), groups of lobules of and deepe‘ as the inflammation ad ‘ances until it, is almost black. anions sizes of a light or dark brown color. (U C C) show the com(Venous stasis.) These appearances are seen at (A, 7B, C C, and pressed veins as described above. I) D) the surface and in the substance ofthe liver. (CI/rszrcll.) . Fro. 5.-A case ofcirrhosis,in which the whole portal system Ofthe FIG. 2.--C{rrliosi's of flu: Lire): liver was obstructed by coagulated blood, fibrinc, and bile. (A A), This figure represents the (limp/tic form ofthe disease, as produced external surface; (B B), cut surface; ((1 C), peritoneal covering by the presence of contractile fibrous tissue, formed in the -apsnle separated to show the groups of lobules; (D), and their pedieulatcd of Glisson, compressing the lobular structures. It shows the lesion attachments; the same tuberiforin ar ‘aiigeuient ot' the lobulcs of the in its early stage, when the quantity of the connective tissue is not llVCI‘dH well marked at (E E), where they are surrounded with iieo- yet very abundant, neither is the obstruction to the circulation of the plastie connective tissue; (F F), orifices of obstructed branches of blood in the organ nor effusion in the peritoneal 'avity very gr \at. the portal vein, by bright-colored fibriiie stained yellow; (Hr), one of (A A), tuberiforin ar 'angcment of the lobules seen through the perthe veins laid open to show the obstructed orifices of its 1) ‘anchcs; itoneal covering of the liver, of a yellow rust color; (B .13), larger (II), portal branch not obstructed. groups forming irregular projections; (C), a portion of the per, In all the above cases there was ascites. In some of the severer itoneuin removed to show the projections more distinctly; (I) 1)), two of the round groups of lobules separated and suspended by the and older cases there was aiiasarca, with general atrophy. constricted vessels, the corresponding portions of the liver presenting Flo. (i.-Atrophy of the gall-bladder from an abnormal comtwo concave depressions; (E E), in which they were lodged. munication between it and the duodenum. (A A), portion of the Fm. 3.-Fr(ri/icr zit/l'lliltfl‘tl Stage of Cer/msis. intestine; (B It), ductus communis choledochus; (C), hepatic duct; (A A), external surface of the liver studded with groups of lobules (1)), cystic duct; (E), gall-bladder laid open; (If), small probe passed of an orange yellow color. The presence of fibrous tissue (B B) around these groups is very conspicuous from its great quantity from the, intestine into the gall-bladder through the coiiiiiiiiiiication, at the orifice of which are lodged two small gall-stones (G). (Lilac/r in forcc inwhole regions of country. (‘liole 'a, eiiteric typhoid, of each lobiile is formed by a branch of the hepatic vein, from every part of which are derived great quantities of radiary l) 'aiiches, and these are connected by a vast net-work of anastonioting capillaries, in the meshes of which lie the liver cells in such a manner as to bring every little. group of cells in immediate contact on all sides with the blood vessels. In the interlobular spaces and covering ‘tlt‘ll lobiile is a net-work of vessels, branches of the portal vein and their capillaries, which anastomose with those of the central vein, dysentery, etc., are the names given to the collective activities exerted by them, upon the intestinal tract especially. Botanically the" are classed as protophytes, and bear the somewhat indefinite generic names of schizo-inyectcs (fissiparous fungi). In typhoid fever definite species of inicrophytes (typhoid (me/[(1') have been found time and again in several parts of the affected organs. In fact, their constant presence in the diseased portions, their appearance and disappearance corresponding to the progressive intensity and g 'adual cc 'sation of the disease, and their constant localization in the follicles. connect them with the morbid processes going on in those organs. Although their mode of invasion has as yet not been definitely ascertained, yet their development in the ground- water in localities where there is a lack of drainage and in wells, cisterns, or springs, where liquid manure or other vegetable sub- stances iii a high state of decomposition exist, and the constant recurrence of attacks of enteric typhoid upon persons using such infected water, added to the fact that the same micro-organisnis are found in the tissues, and that with the same organisms obtained by culture outside of the body eiiteric typhoid was artificially produced upon animals,- all these facts go to prove that the typhoid bacillus is intimately connected with the morbid process in that disease. The infection is produced by that bacillus. The substances, whatever they be, living or dead, if they contain this micropliyte in forms capable of becoming developed when introduced into the animal body, and where thcyfind conditions favorable to their development, will in 'ariably produce eiiteric typhoid of one form or the other. The contagion, if such it may be called, exists only in this thalopliyte. In any climate, any locality holding stagnant water of a nature favorable to the development of the bacillus ill its several forms, can become a source of permanent affection. (Klein, Socolof, Fisc/d, Rut/er mu] IIH/i/xcr, ll?1[r/4'r,El/cr/li, ch/Is, chzcrz'c/z, Wyss, fifty/er, [foe/i, lift/ca, Ji/iII/IN/Nf, .lzoy/inscn.) The cholc 'a infection is a t ‘ansportable virus, and at home in the East. Indies. It is very probably a inicropliytc; may be 'ai‘i‘ied from there into all latitudes, and may for a time develop in any country, but nowhere is it able to permanently take position and become endemic or a centrum of propagation except in its place of origin, in Lean BUM/Ill and in the bottoms and banks of the (Jaw/cs and ,Bru/mmpufru. Hun, 188.3.) (Swami, Dz‘c Br/«(on/(unlv/ (/cr (l/IU/l'l'tl, ,D/sA'r'r/II» Its mode of propagation is conveyance by ways of ct)nimniiications~-by land and by water, in vessels, on railroads, in fact, by whatsoever mode the person or persons may travel and be transported when the" are affected with cholera; and their dejccta, or substances containing or infected with dejecta holding the cholc'a-intecting agency, will become temporary sources of infection, and will spread according to the conditions favorable to the development of that noxious microphyte. Dyscntrry. Dysenteric diarrlima presents a character and consequences quite opposite to serous forms of diarrhea. The watery and the saline constituents are in very minute quantities, but in well~developed cases the evacuations contain a great quantity of albuminates mixed with much glairy mucus; in the farthe' advanced stages, fibrinous exudates, blood and pus corpuscles. Losses of such important constituents of the blood very well explain the great debility, the enormous exhaustion following severe cases of dysentery. Aiizeniia very soon becomes assm-iated with a grave attack of even the acute form. Dropsy very often follows this disease. ])/smsws of HM Lawn-Anuromy. The largest gland of the body. the liver, is an excretory as well as a secretory organ, and is supplied, for the pertbrniance of both func~ tions, with circulation from two distinct sources: by the hepatic artery from the abdominal aorta and by the portal veins from the abdominal viscera. The hepatic vein connects the returning venous current, from the organ, with the inferior vena ‘a 'a. The liver con- sists of a great number of lobules, or individual glandular organs, which are conjoined by a vast net-work of larger and smaller vessels, their peri ‘ascnlar structure and a very ample f‘anie-work of connective tissue. in which the liver cells, the blood and lymph vessels, the biliary ducts, and the nerves are iinbedded. The center or axis branches of the hepatic artery, with its abundant ramifications, and the large‘ and smaller bile ducts. The portal veins, which are the largest, the hepati- artery, and the bile ducts run parallel to each other in the iiitcrlobular spaces, mark the limits of the lobiiles which they surround and are enveloped in a quantity of connective tissue, derived from the perihepatie structure, the membraneous continuation of which constitutes the prrilobzllm‘ or Glz'sson's capsule. A section of the liver, perpendicular to the axis of the lobnle, shows a spotted yellow and brownish appearance. The liver cells of the lobular center are more yellow than the brown venous zone. The lymphatics constitute fascicles, and with the braiichlcts from the nerves of the hepatic plexus are sheathed in a firm layer of connective tissue, coming from the hepatico-dnodciial ligament. The liver cells produce, glycogen; within the biliary ducts the biliary components are excreted. That the liver cells should at once produce glycogen and secrete bile is a l‘diysiological impossibility. It is perfectly true that any glandular cell may at times-when certain useless or noxious substances circulate within the blood, even if they were produced in the body itself (urea, urobilin, glycogen, glucose, many poisons, etc), or when even normally useful sub- stances accumulate iii great quantities in the circiilation-perfoim the work of elimination or excretion; yet that such double work should be a normal function seems very improbable. The liver cells certainly, like any other cells, and especially epithelial, are taking up great numbers of finely-divided particles from the blood, use them for certain pliysiologi 'al ends, and eventually eliminate them or remain impregnated with them for an indefinite period. The constituents of thc disorganized blood corpuscles accumulate in the intestines enormously during the whole process of digestion. and are 'arried by the portal vein into the liver and a great portion oftlieni are taken up by the glandular cells and elaborated into substances still useful to the body, or eliminated with the bile, which is most certainly constituted as a peculiar liquid within the fine biliary ducts in the manner of function carried on in tubular glands, aml as [[070 correctly states (in Anuimuy of flu? Vz'sccru, page 221]), that " in the liver the finer biliary ducts are so covered with glandular organs, in the shape of appendicular tubules and racemous structures, that the" appear more like channels carrying secretions from the glandular organs than anything else. If these little glandular organs were simple mucous glands, they would certainly exist in greater number in the larger ducts and in the gall bladder, where the mucus secreted would be needed for the protection of those walls against the action of the bile, which exists in great quantities in those cavities; besides their form gr eatly differs from those found in the depth of surfaces. Their enormous number certainly bespeaks for them a different secretion than simply mucous." Very many anatomical piwuliarities found in morbid conditions of the liver are much in favor of this hypothesis. Besides the 'ariable detritus of the blood structures the portal veins carry in the liver lobnlcs great quantities of fat from the intestinal contents, yvhcreitis taken up in great quantities by cells and retained for a time in the periphery of the lobule, the'vicinity of the, portal circulation. "Ihen large quantities of fat or fatty substances accumulate in the blood,orthe fattvsnbstances are not sufficiently used up in the body, there is always fat infiltration in the liver lobules. In Well-fed individuals taking little exercise, nursliiigs. tuberculous and other consumptives of the lungs, in diseases ofthc heart with structural alterations, produced by venous stasis, in chronic alcoholism, the liver is always found im]'>regnated with fat. In such conditions the portal zone of each lobiile is exceedingly impregnated, the middle zone but little, and the central not at iill, with fat. The difference of color in the several parts of the lobiiles has given this hepatic condition the name of lit/"Mill low, which it very much resembles in its general appearance. More massive infiltration with fat nearly altogether