Section Vi. of the Liver.

The liver, in its normal state in the adult, will measure from ten to twelve inches in its transverse diameter, from six to seven in breadth at its widest part, and about three inches thick at the posterior border of the right lobe; its weight being from three to four pounds. The gland is much larger in infants in proportion to the size of the body. In the adult, the average weight of the liver is but one-fortieth of that of the entire body, while in infancy, it may be as much as one-thirtieth or even one-twentieth.

The natural color of the liver may be described as a reddish-brown or mahogany color, yet the shade may vary to a considerable degree in different cases.

In studying the morbid anatomy of this organ, we shall notice first, changes peculiar to the liver itself, and secondly, those connected with the gall-bladder and gall-ducts.

1. Diseases of the Liver.

=Congestion.= From the large size and extensive distribution of vessels through the liver, this gland is capable of containing a large amount of blood, and in cases of retarded circulation in other parts, as in the recession of blood from the cutaneous vessels in a chill, the vessels of the liver may become greatly distended, constituting what is known as congestion. Although the gland is closely invested with the capsule of Glisson, yet, the elasticity of this membrane will admit of considerable distension, and hence the great enlargement attending this condition of the gland. Congestion of the liver may be partial, confined to one or more lobes; or general, involving the whole gland. It may also be active or passive.

Active congestion of the liver may result from blows or injuries over the region of the gland, from suppression of hæmorrhoid discharges, or suppression of the menses in the female. It will then be found presenting a deep red color, may be greatly increased in size, is more firm, and before opening the body, may be frequently felt below the margin of the ribs on the right side.

One of the most frequent causes of passive congestion of the liver, is organic disease of the heart, accompanied with obstruction in the circulation through the lungs, giving rise thus to difficulty in emptying of the right side of the heart, and of the venous system generally. A chronic form of congestion of the liver may result from emphysema of the lungs, large pleuritic effusions, or tumors within the chest, and is frequently found in persons of sedentary habits who have been “high livers,” or in those who have used large quantities of alcoholic or fermented liquors, or in the residents of hot climates or malarial districts.

Temporary congestion of the liver, although very extreme, does not result in structural change; but when arising from a permanent cause, as disease of the heart, etc., it produces the following effects:—“The distended capillaries of the portal-hepatic plexus press on the intervening cells; these become in part atrophied or stunted; in extreme cases almost destroyed; in part they are gorged with yellow matter to such a degree that they appear as opaque masses. The quantity of yellow matter thus formed is far greater than any that exists in a healthy state of the organ, and as some of it is doubtless absorbed and carried into the blood, we find in this circumstance some explanation of the icteric hue which is so often observed in such patients. Whether long-continued congestion produces still further changes is not yet made out clearly.”

Extreme congestion of the liver may sometimes result in

=Hæmorrhagic Effusion=, the blood being either poured out near the surface, and dissecting up the capsule, or more deeply in the substance of the gland; or, rupturing the capsule, it may escape into the peritoneal cavity. Such effusions may be found in new-born children after protracted and difficult labors, or as a result of external violence, and sometimes attend malignant fevers, scurvy, and purpura.

=Perihepatitis.= The peritoneal covering of the liver, very frequently in post-mortem examinations, presents appearances of having been attacked by inflammation, in the presence of bands of adhesion connecting different portions of the surface of the gland to adjoining organs. The whole of the upper surface will sometimes be found closely united in this manner, to the diaphragm. Such appearances are sure indications of the existence at one time, of an attack of peritoneal inflammation. In a cirrhosed condition of the gland, and over the seat of abscesses of the liver, such adhesions almost universally form.

Inflammation of the peritoneal covering of the under surface of the liver, may result from an extension of the disease from an inflamed stomach or duodenum, or from the presence of a biliary calculus impacted in some of the ducts; such inflammation resulting in more or less extensive adhesion of the parts in contact. The presence of hydatid or cancerous masses, are not usually attended with these evidences of inflammation.

=Scar-like Marks=, are not uncommonly found on the surface of the liver. The peritoneum at these points seems drawn into the substance of the gland, at the centre of the mark, while radiating ridges extend in various directions, to the distance of a-half to three-fourths of an inch. The cause of these appearances is evidently inflammation of the peritoneum, extending to the subserous tissue, and perhaps to the liver substance.

=Hepatitis.= Inflammation of the liver may be acute or chronic.

Acute inflammation of the liver, though a frequent occurrence in hot climates, is seldom met with in cold or temperate. The gland in this condition, is found more or less swollen and enlarged, and the tissues somewhat softened. This condition may be confined to one or more lobes, or involve the whole gland. Where a section is made, the turgid swollen tissue rises above the peritoneal covering, along the edges of the incision. As the disease advances to a later stage, the deep red color changes to a brownish or grayish-red, patches of these being mingled with others of a yellowish-red or pale yellow.

Acute inflammation of the liver may terminate in resolution, when there will be a gradual restoration to a normal condition, or in suppuration, and the formation of an abscess; the latter result being much more common.

=Abscess= of the liver may involve the greater portion of the right or left lobe. The substance of the gland immediately around the abscess, will appear unusually red, and perhaps a little hardened, while other portions may present the appearance of health. In some instances, from a complete destruction of the hepatic tissue, the peritoneal covering will form the only protection to the contained matter. The quantity of purulent matter contained in these abscesses may vary from half a pint or less, to one or two quarts.

The inflammation attending the formation of an hepatic abscess, will usually extend to the peritoneum, resulting in the formation of adhesions to the adjoining organs, and thus preventing the abscess, in many instances, from discharging into the peritoneal cavity, as it otherwise would be likely to do. Abscesses thus formed, may discharge: 1st, by the adhesive process through the diaphragm into the chest, and if adhesions had previously taken place between the diaphragm and lung, by an extension of the ulcerative process, the matter may find its way into the bronchial tubes, and thus be discharged by expectoration; 2d, by a similar process into the stomach, duodenum or colon; 3d, upon the surface of the body; and 4th, within the peritoneal cavity. In the latter case, death is inevitable; in the others recovery is possible. The following case illustrates discharge and recovery by the first method:

CASE.—Abscess of the Left Lobe of the Liver, discharging through the diaphragm, a portion of the matter expectorated, the balance discharged upon the surface of the body—Recovery.

In the winter of 1856–7, I was called to see Mrs. B——, aged 40, of Broad street. She had been given up by the physicians previously in attendance. Found her greatly emaciated, suffering from a terrible cough, and expectorating great quantities of excessively offensive matter. Diarrhœa, hectic fever, night sweats, with occasional chills, completed the picture, and appeared to render the case perfectly hopeless. Upon inquiry, learned that she had been taken ill some months previously, with what the attending physician had pronounced as acute hepatitis. After the usual acute symptoms, the formation of an abscess became evident from the fulness in the region of the left lobe, accompanied with chills, hectic, etc. A violent cough, with evidences of inflammation in the left lung, accompanying the other symptoms, the case was supposed to be complicated with tuberculosis. The expectoration finally became greenish, thick and exceedingly offensive, indicating that the abscess had worked its way into the bronchial tubes. In examining the chest, after the case had been under my care a few days, I noticed between the ninth and tenth ribs a fulness and slight redness. After the application of poultices for a few days, a distinct “pointing” appeared, from which, after the use of the lance, came a most copious discharge of the same green, offensive matter, as was being discharged by expectoration. From this time, a slight improvement was noticed in the patient. The external opening was carefully kept from closing. The cough gradually improved. Little or none of the offensive matter was raised after the establishment of the external opening. In six months the health was fully restored, and now, fifteen years after, she is a stout, healthy woman.

In the progress of formation of an abscess in the liver, as branches of the portal or hepatic veins are reached, inflammation of their coats is excited, which results in their obliteration, thus generally preventing the admission of pus into the venous system. But as the enlarging abscess encroaches upon the hepatic ducts, instead of these becoming closed by inflammation, they ulcerate through, and thus establish a communication between these vessels and the cavity of the abscess. Hence the pus contained in these abscesses, is very likely to be mingled with more or less bile; while at the same time, a portion of the contents may be discharged through the common duct into the bowels.

Abscess of the liver may result from inflammation and ulceration of the bile ducts, from the irritation of impacted calculi, or from the presence of intestinal worms that have entered by the ductus communis; or from the lodgment of emboli in some branch of the portal vein or hepatic artery.

=Secondary, Pyæmic or Metastatic Abscess.= The liver is occasionally the seat of abscesses forming as a result of pyæmia, induced by absorption of pus from some wound of a joint, vein, or bone; or from a diffused abscess or erysipelas of the skin. These abscesses usually contain a somewhat thin and oily-looking pus. They also differ from ordinary abscesses in the rapidity with which they form, a few days generally sufficing to give them a large size. The insidious manner in which they form—the tissues breaking down, as it were, without any inflammation—constitutes a distinguishing feature of these collections. Pyæmic abscesses of the liver are usually many in number, and varying in size from a pea to that of a walnut. The gland is usually enlarged at the same time, and in some cases to such an extent as to reach quite to the umbilicus. This form of abscess is not confined to the liver, but may be found in the lungs, spleen, in the joints, or in the serous cavities, and sometimes diffused through the connective tissues and muscles of the limbs or trunk.

Degenerations of the Liver.

=Waxy, Lardaceous, or Amaloyd Liver.= In this form of disease, the liver undergoes greater enlargement than in any other disease excepting cancer. The enlargement is uniform in every direction, so that the form of the gland is unchanged. Pain and tenderness are never prominent symptoms of this disease, hence the liver may be manipulated during life with impunity, the patient complaining only of weight and tightness in the right hypochondrium.

The progress of the disease is usually slow, extending, in most cases, over several years. The spleen, kidneys and intestines will frequently be found presenting this change at the same time.

The tissue of the gland in these cases is very firm, so that the organ generally retains its form when laid with its convex surface on the table. The external surface is smooth and free from adhesions. When cut, a peculiar translucent substance is found infiltrated through the tissues, giving it a firm, glistening appearance, known as waxy, lardaceous, amaloyd, albuminous, or sometimes scrofulous liver. This substance is stained a deep red by the action of a weak solution of iodine.

The change appears to commence first, in the small blood-vessels, finally extending to the lobules, appearing first in the centre, and ultimately involving the whole lobule.

The disease is more common in males than females, and is frequently caused by constitutional syphilis. In some instances, it would appear to be produced by a tubercular diathesis, and coexists with some local form of scrofulous disease, or by a long exposure to malarial influences.

=Fatty Liver.= This form of disease we find in drunkards; in persons who have been large eaters and sedentary in habit; in several wasting diseases, as in chronic diarrhœa, and especially in phthisis pulmonalis. There is a moderate degree of enlargement which affects all portions of the gland. The consistency is softer, and the resistance less than in waxy liver, giving it a doughy feel. The color varies, but is usually lighter than normal, approaching a yellow, and more or less mottled. When cut, the substance presents a decidedly oily appearance, both to the feel and sight. The disease is unaccompanied with pain from first to last; neither is its function materially interfered with, hence jaundice is not usually a symptom of the disease.

A microscopic examination shows the lobules of the liver filled with fat globules, which appear to have originated in the hepatic cells. The change appears to commence at the circumference of the lobule, the centre remaining normal in color, thus giving a mottled appearance to the cut surface.

Other organs are very liable to be affected at the same time by this form of disease, as the heart, kidneys, etc., the symptoms which the case presents, such as albuminous urine, tendency to dropsy, dyspnœa, etc., arising from these organs, rather than from the fatty liver.

=Pigmentary Degeneration.= In cases of malarial poisoning, we sometimes find the liver with other organs of the body, as the spleen, lungs, brain, kidneys, etc., presenting a peculiar dark color, the result of the presence of a black or brown pigment in the blood, filling the vessels of these organs. The pigment appears to be formed of small granules either free or contained in irregular cells. In the liver, this pigment is found most abundant in the blood of the portal vein, but may be present in the hepatic artery, and in all the venous capillaries.

The liver may be normal in size, or it may be atrophied or hypertrophied, or may have undergone fatty or waxy degenerations.

=Granular Degeneration.= A peculiar change in the liver substance is sometimes found after death from various acute or infectious diseases, as the exanthemata, pyæmia, septicæmia, erysipelas, typhus, typhoid, and yellow fever, etc.; or from thrombosis of the portal vein, abscesses or cirrhosis, as well as in poisoning by arsenic, phosphorus or antimony.

The change in the early stage consists in an accumulation in the liver cells, of a fine granular substance, soluble in alkalies, and apparently of an albuminous nature; and, at a later stage, of coarser shining particles of a fatty character, and soluble in æther or alcohol.

=Atrophy= of the liver may be divided into the following forms:

I. Simple Atrophy.

II. Acute or Yellow Atrophy.

III. Chronic Atrophy, or Cirrhosis.

=Simple Atrophy.= By this, we understand a diminution in the size of the liver, without any alteration in its structure. In this state, the liver may be reduced to one-half its normal weight and bulk. It is found to occur:

1. Old age. Hence this form of atrophy is sometimes called “senile atrophy.” With the loss of adipose tissue in advancing years, there is also a tendency either to degeneration or wasting (atrophy) of many of the organs, and especially of the liver. In this manner, the liver may be reduced to one-half its normal size and weight without any change of structure.

2. Inanition, arising either from an insufficient supply of food, or from diseases which interfere with the assimilation of food, may result in simple atrophy of the liver.

3. External pressure may also produce the same result, as from tight lacing, pleuritic, pericardial, or peritoneal effusions, or from enlargement of organs, or presence of tumors near the liver.

Simple atrophy is rarely attended with jaundice unless pressure upon the bile ducts has been such as to obstruct the flow of that fluid.

=Acute, or Yellow Atrophy.= In this somewhat rare form of disease, the liver becomes rapidly atrophied, accompanied with jaundice and cerebral symptoms. After death, the organ is found greatly reduced in size, extremely soft and yellow, with no appearance of lobules, and upon microscopic examination, the secreting cells found more or less changed into granular matter and oil globules. The weight of the gland in these cases, may be reduced from three to four pounds, the average normal weight, to less than two pounds.

This form of disease is frequently attended with hæmorrhages, particularly of the stomach and bowels, and in some instances, from the uterus or nose.

Pregnant females suffering from this affection usually abort.

Among the causes of this form of disease of the liver may be mentioned pregnancy, dissipation, constitutional syphilis, malaria, and the blood-poisoning of typhus fever.

Females appear much more liable to the disease than males, and most persons attacked are under middle age.

=Chronic Atrophy, Cirrhosis or Hob-nail Liver.= The form of atrophy of the liver which we now have to consider, is slow in its progress, and is usually associated with abdominal dropsy. The appearance and density of the gland varies to a considerable extent in different cases of chronic atrophy, yet the usual appearance is that seen in what is known as cirrhosis, or “hob-nail liver,” also sometimes called “gin-drinker’s liver.” Here the liver has become reduced in size, from a slow destruction of the secreting tissue, while, at the same time, the fibrous tissue of Glisson’s capsule has become thickened and hardened, from a chronic inflammatory action, often due to the use of spirituous liquors. The outer surface presents a granular or nodulated character, which has given rise to the term “hob-nail,” as applied to this disease; while, upon section, the interior presents firm fibrous bands, surrounding yellow patches of secreting tissue. While, in the majority of cases, this disease is plainly owing to an abuse of spirituous liquors, in others, it is found associated with disease of the heart, or with constitutional syphilis, where the patient has been strictly temperate.

The increased density, in connection with the diminution of size, and granulated character of the surface, renders the disease readily recognizable in a post-mortem examination.

The early stage of this disease appears to be accompanied with a degree of enlargement of the gland, resulting from the congestion attending the inflammation of the fibrous structure. As this structure increases in density, by pressure it causes a gradual absorption of the secreting lobules, and thus results in a reduction in the size and weight of the organ.

The secreting cells of the lobules of the liver, may undergo fatty change, or they may become entirely destroyed. Thrombi may be found in the portal vein. The hepatic artery and its branches become increased in size, while the interlobular hepatic veins become quite destroyed. The obstruction to the circulation through the liver, resulting from these changes, gives rise to the dropsical effusions usually found in this disease.

Prominent among the symptoms attending this disease, during life, may be mentioned:—1st. Diminished area of hepatic dulness. 2d. Ascites, particularly in advanced stages of the disease, although patients may die before dropsy sets in. 3d. Enlargement of the spleen—this being present at least in about one-half the cases. 4th. Enlargements of the superficial veins of the abdomen, from obstructed flow of the portal blood, or from pressure upon the vena cava, from abdominal distension. 5th. Hæmorrhoids, epistaxis, hæmatemesis, etc. 6th. The rare occurrence of decided jaundice. 7th. In all cases, the advance of the disease is marked by progressive emaciation and debility, the patient usually dying of exhaustion, although in some cases death is due to an attack of pneumonia, œdema of the lungs, or acute peritonitis.

=Hypertrophy.= We sometimes find an evident increase in the size of the liver, without any alteration of structure, or the presence of any prominent symptoms. Such cases may be considered as instances of simple hypertrophy. This condition has been observed in cases of leukæmia, and in some exceptional cases of saccharine diabetes, heart disease and phthisis.

Morbid Growths.

=Cancer of the Liver.= Every variety of cancer may be found in the liver, though the scirrhus or medullary forms are more common. The disease is invariably accompanied with enlargement, and in some instances the increase is enormous. The progress of the disease is rapid, a few weeks in many instances, a few months at the longest, being required to fully develop the disease. The enlargement is not uniform. The surface becomes irregular and uneven, nodules of various size are found projecting from its surface and borders, which are usually harder than those of the surrounding portions. The disease is nearly always accompanied with pain, and considerable tenderness is felt upon touch.

Jaundice is present in many cases, but in ninety-one cases collected by Frerichs, fifty-two showed no symptoms of jaundice. Abdominal dropsy to any considerable extent, rarely attends the disease, although usually a small quantity of fluid will be found in the peritoneal cavity. These characters will usually enable us to make a correct diagnosis of these cases during life.

The post-mortem examination, discloses, in the majority of cases, a greater or less number of irregular, rounded masses, projecting from the surface of the liver, and varying in size from a kernel of corn to an orange. Through the peritoneum, these bodies present a light, straw-colored appearance, and when divided, the interior is found of a whitish-gray color, and of the consistence of tallow or cheese. Examined very carefully, the substance has the appearance of infinitely minute granules, aggregated together.

These masses may be confined to one of the lobes, or involve the whole organ; they are of an irregularly rounded or globular form, and in some cases two or three appear to have coalesced into one mass.

In other, and more rare cases, the cancerous matter, instead of being collected in masses, is found more or less infiltrated through the liver substance, as in Case I.

They may soften, and form cysts filled with a thin serous fluid, or they may undergo a form of fatty degeneration.

In such cases the disease is liable to be mistaken for waxy degeneration. In both, there is a uniform hard enlargement, but in the waxy enlargement, the progress is slow, and without pain, and there is usually enlargement of the spleen, with albuminuria, and a syphilitic taint; while in cancer there is no enlargement of the spleen, or albuminuria, and the course of the disease is rapid; there is pain, cachexia, and often signs of cancer elsewhere.

Cancer of the liver, in the majority of instances, is secondary to cancer of some other part, as of the stomach, rectum, or female breast. In more than one-third of the cases, it is said to be secondary to cancer of the stomach.

Cases are rare where the liver is primarily affected with cancer. Before thirty-five or forty years of age, secondary cancer seldom occurs.

The following cases will serve to illustrate the two forms of cancer of the liver:

CASE I.—Primary Cancer of the Liver, with great enlargement—Rupture of Stomach from post-mortem softening.

Mrs. K——, aged 38, light complexion, short and fleshy, commenced complaining about New Year’s, 1868, of pain in the “stomach,” as she expressed it, with loss of appetite, restlessness at night, accompanied with weakness and prostration. These symptoms continued for a couple of weeks, when she commenced to complain of soreness in stooping, and inability to wear her clothes tight. This led to an inspection of the abdomen in bed. I then found projecting below the margin of the chest on the right side, a hard rounded tumor, nearly of the size of the fist, somewhat sensitive to the touch, and evidently springing from the liver. The pain daily increased in severity, and coming on as it did, in paroxysms, resembled much the pain attending the passage of biliary calculi.

After she took to her bed, which was in the latter part of January, there was a rapid increase in the size of the liver, with a marked aggravation of all the symptoms. The pain was most agonizing; slight chills occurred from day to day; the flesh rapidly wasted, and the outline of the lower border of the liver could be distinctly traced through the abdominal walls. There were no symptoms of jaundice. The skin was pale and waxen in hue. In the latter part of February, frequent epistaxis, and bleeding of the gums set in, while from the pressure upwards upon the diaphragm, the lungs were so embarrassed as to give rise to great dyspnœa. Rapidly sinking, she died on the first of March.

Autopsy, made thirteen hours after death. Anterior portion of the body pale; posterior dark from gravitation of the blood. Rigor mortis scarcely noticeable. Upon opening the abdomen, found four to six ounces of serum in the peritoneal cavity.

The liver was enormously enlarged, filling a great portion of the abdominal cavity, pushing the diaphragm high up into the chest, and giving the lungs less than half their normal amount of room for expansion. The upper surface of the right lobe was found adhered to the under surface of the diaphragm, and to the anterior abdominal walls, and the under surface to the stomach, duodenum and transverse colon.

The surface of the liver was dark, mottled, and somewhat nodulated. The whole gland was quite firm, yet evidently just entering upon a softened stage at numerous points. No trace of an abscess forming at any point.

Upon lifting the left lobe of the liver, a dark, brownish fluid appeared behind the stomach, the origin of which was not at first apparent. The removal of the liver, however, completely exposing the stomach, showed the posterior wall at the large end, softened and ruptured. This softening was evidently a post-mortem action of the gastric juice; the rupture resulting from the tension upon the same, in tearing away the adhesions between the stomach and liver.

Upon the removal of the liver, found it to weigh eighteen pounds. The gall-bladder was empty and contracted. The only portion of the gland not involved in the disease, was one of the small lobes, the lobus Spigelii, and a portion of the left lobe. Incisions, showed the interior presenting a similar mottled appearance as the surface; dark, almost black spots, intermixed with spots of brown and gray. The blood-vessels of the liver were enlarged, and filled with dark defibrinated blood. No trace of coagulated blood, in any of the blood-vessels of the body.

Microscopic examination. An examination of a small portion taken from the right lobe, with a power of 350 diameters, showed innumerable cells of an irregular outline, and varying in size; oil globules, and granular matter. The action of acetic acid, rendered the nuclei of the cells faintly visible. Many cells of a large size were found filled with a growth of smaller ones. All other organs of the body normal.

CASE II.—Cancer of the Liver, secondary to Cancer of the Rectum, with diffused Abscess in the Neck.

Mr. A——, of Doylestown, Pa., aged 60, had been suffering for some months with symptoms of disease of the rectum, with also inflammation of the bladder. His passages were painful, and accompanied with more or less bloody, purulent matter. His urine was thick, at first from presence of large quantities of mucus, later of pus. His appetite and digestion were poor; his color pale and cachectic.

Some six months previous to death, he commenced passing with his urine, small quantities of seeds of berries, tomatoes, etc. These gradually increased in quantity, until, for some weeks previous to death, there was a free discharge of feculent matter from the bladder, and at the same time much urine passed per rectum. A few days before death, there appeared a diffused swelling upon the front of the neck, extending from the clavicles as high as the upper portion of the larynx. There was no discoloration of the surface. The swelling presented a boggy feel, without any positive fluctuation.

On the 15th of July, 1871, I was called by Dr. George Wright, who had been treating the case for the past year, and from whom I learned the above facts, to make a post-mortem examination, the patient having died the day before.

Found the body very thin, surface pale. No serum in the peritoneal cavity. Upon lifting the small intestines from the cavity of the pelvis, found the rectum closely adhered to the posterior surface of the bladder, completely obliterating the recto-vesical cul-de-sac. Considerable dense scirrhus matter, was found upon either side of the rectum and bladder.

Upon removing the rectum and bladder, a large opening (one inch in diameter) was found communicating between the two. The edges of this opening were thick and ragged. The walls of the bladder and rectum generally, were thick and hard from scirrhus deposits. The bladder contained considerable purulent and feculent matter, with also a cherry-stone. Upon examining the liver, found upon the under side of the left lobe, a large cancerous mass, imbedded in the substance, but projecting from the surface, and quite as large as a goose egg. Other portions of the liver healthy.

The lungs were healthy. The muscular walls of the heart were pale and soft, while each of the cavities contained soft, imperfectly formed fibrinous clots.

The right pleural cavity contained nearly a pint of serum, while the pleura presented a red, inflamed appearance.

In removing the sternum from its position, noticed purulent matter beneath the upper end, which appeared to come down from the neck. Upon carrying an incision upwards to the hyoid bone, found the whole region of the neck infiltrated with pus, without being confined by any limiting membrane or sac, and evidently metastatic in its origin.

=Tubercles.= The peritoneum covering the liver, like other portions of this membrane, will sometimes (more frequently with children) be found filled with numerous minute tubercular particles, the presence of which are liable to give rise to appearances of inflammation, such as redness, roughness, and perhaps adhesions.

=Fibroid and Cartilaginous Tumors= are of extreme rarity in the liver. When present, they exhibit the characters of those growths in other parts.

=Adenoid Tumors= have been detected in this gland. They vary in size and number, but are usually enclosed in a fibrous capsule, and appear to be made up of glandular cells, resembling the hepatic cells, but of larger size and greater density.

=Vascular Tumors= are sometimes found in the liver, consisting apparently of a compact, irregular net-work of dilated veins, held together by connective tissues. Of a dark, almost black color, they vary in size from a few lines to two or three inches in diameter, and are very irregular in their outline.

Cysts of small size are occasionally found, developed either in the connective tissues, or from a dilatation of bile ducts. They may be found filled with serum, or colored mucus and epithelial cells.

=Syphilitic Tumors=, from the size of a pin’s head to that of the fist, may be found in the liver. They are of a gray, whitish or yellow color, made up of cells of an irregular form, which show a tendency to cheesy degeneration, or to such softening as to give the appearance of an abscess.

Blood-vessels of the Liver.

The hepatic artery is sometimes found with aneurismal enlargements, and rarely contains an embolus.

The portal vein is frequently found containing a fibrinous clot, constituting thrombosis. Such clots may result from pressure on the vein from the presence of some morbid growth in the liver, or from a tumor in the mesentery or some other part, obstructing the portal vein below the liver; or from suppurative disease of ulceration of the several organs from which the portal vein arises. They may be a cause, or result, of phlebitis, and may give rise to jaundice, and sometimes to abscess of the liver.

Dilatation of the portal vein may result from obstruction of the capillaries of the liver in chronic atrophy or cirrhosis; or from the presence of thrombi, or pressure by various morbid growths.

Calcification, not only of the portal vein within the liver, but of its various branches of origin within the mesentery, omentum, etc., may occasionally be met with.

The hepatic veins may be found presenting the same abnormal conditions as the portal vessels.

Animal Parasites.

The liver has long been known as a favorite resort for different parasitical animals, the most common of which, is that of the larval form of one of the tapeworms—the Tænia echinococus—constituting when developed in the liver, what is known as an acephalocyst or hydatid.

=Hydatid Tumors= of the liver, arise in the following manner:—The several tapeworms pass through three stages of development, these never being completed however in the same animal. The Tænia echinococus, acquires its adult form, only in the intestines of the dog or wolf. The mature segments, each of which are filled with vast numbers of eggs, are voided with the fæces, into which the eggs are discharged. These soon develop into a minute embryo, with one extremity provided with numerous little hooks. If taken into the stomach of an herbivorous animal or man, this embryo pierces the walls of the intestines, enters a blood-vessel, and finally lodges in some of the tissues or organs, more frequently the liver, where it develops into a sac-like body, known as a cysticercus or hydatid, the second larval form. When the embryo is taken into the stomach of other animals, no further development takes place.

While in the hydatid, or second larval form, by a peculiar process known as alternate generation, there may be a reproduction of cysts to an almost endless extent within the parent cyst, or secondarily in other parts.

The adult or third stage of development, can only be attained within the intestinal canal of the dog or wolf. These animals devouring a sheep or other ruminant, or in some rare case perhaps a human being, within which the hydatid has been formed, the cysts thus taken into the stomach, develop into the perfect worm, from which segments containing the eggs are again discharged.

It would appear almost impossible for the embryo from these eggs, to ever enter the human stomach, but it is not difficult to understand that the fæces of the dog containing the ova, may enter a spring or stream, from which the minute embryo may be taken with the water, by either man or a lower animal; or, by attaching themselves to watercresses, etc., they may be eaten with these by the same.

Hydatid tumors of the liver, may vary, greatly, in size, according to their age. From an extremely minute cyst, they may acquire such a size as to fill and distend the abdominal cavity, crowding the several viscera from their position. There may be one or several. They may be confined to the liver, or secondary cysts may appear in other organs.

When opened, the interior is generally filled with numerous smaller cysts of various sizes, each filled with a gelatinous fluid of varying degrees of density and color, and within which, by a careful microscopic examination, may be detected—many times, not always—numerous hooklets, which have been detached from the minute heads. The walls of the parent cyst may become greatly thickened, or even calcified. The contents may degenerate into a purulent mass, with which may be mingled blood or bile.

The development of these tumors is usually slow, and unattended with pain, or functional disturbance of the liver. After they have acquired a large size, they may induce peritonitis, resulting in extensive adhesions.

Rupture of these hydatids sometimes take place, this accident being followed by death, or recovery, according to the point at which the rupture takes place. They may burst in the following directions:

1. Through the diaphragm into the pleural cavity, or into the substance of the lungs.

2. Rarely into the pericardium.

3. Into the peritoneal cavity, resulting in acute peritonitis.

4. Through the abdominal walls, when recovery is possible.

5. Into the stomach or intestines; this being the most favorable point of rupture. In fifteen cases of rupture into the intestines, fourteen recovered.

6. Into the biliary passages or large blood-vessels.

CASE.—Large Hydatid Tumor of the Liver—Death from Exhaustion.

Mr. O——, of this city, aged 75 years, noticed some two years previous to his death that his abdomen was enlarging. An examination disclosed the presence of a large tumor descending from the region of the liver. It was slightly fluctuating, and unattended with pain or soreness. He complained of nothing but weakness with vertigo. All the functions of the body were natural.

A gradual increase of size took place, with occasional attacks of inflammation, until the abdomen acquired the dimensions of that of a woman at full term. The oppression now became so great, from the crowding of the lungs, that I decided to resort to paracentisis. Some two quarts of a thick, gelatinous fluid were drawn off from the tumor, with several quarts of ascitic fluid from the peritoneal cavity. The operation was followed by great relief. Rapidly refilling, the oppression again became severe, and the operation was repeated a few months later with similar results. Death finally followed from exhaustion.

The post-mortem revealed an immense tumor, filling the abdominal cavity with extensive, firm adhesions, and crowding the lungs into the upper part of the chest. The walls of the sac were thick and semi-cartilaginous, and the interior divided into numerous compartments by septa passing in various directions. These compartments were filled with a gelatinous fluid, in which were innumerable cysts of various sizes, each filled with a similar fluid as that with which they were surrounded. The microscope showed the presence of numerous cholesterine scales in this fluid.

The weight of the entire tumor was over fifty pounds. A portion was preserved and deposited in the College Museum.

The following parasites are also sometimes found in the human liver, or its ducts:

Distoma hepaticum, or liver fluke. Common in the bile passages of lower animals, rare in that of man. It is flat, oval, from two to four lines long, and a-half to one line broad. Its presence in the hepatic ducts, may give rise to enlargement, some degree of obstruction, or calcification.

Distoma lanceolatum. This parasite, something smaller than the above, is still more rare in the bile passages of man.

Pentastoma denticulatum. This animal is found as a small cyst, with calcified walls, and containing fatty and calcareous matter, with the remains of the dead parasite. It is considered as the larval form of a worm sometimes found in the nasal cavity of the dog, and some other animals.

The Ascaris lumbricoides may be found in some of the bile passages, it having entered by the opening of the common duct into the intestine.

2. Affections of the Gall-bladder and Ducts.

The gall-bladder is sometimes wanting, this being the normal condition in the horse and some other animals. When thus absent, the hepatic ducts are so increased in size, as to be able to contain the accumulating bile in the intervals of digestion.

=Inflammation= of the gall-bladder and common duct, involving their mucous lining, is not uncommon. Such inflammation may be either catarrhal or suppurative.

Catarrhal inflammation may result in thickening or calcification of the lining membrane of the ducts and bladder, with the accumulation of such quantities of thick tenacious mucus, as to become a source of impediment to the flow of the bile, and thus give rise to jaundice. Such inflammation becoming chronic in the common duct, may result in great dilatation of the gall-bladder, from the accumulation of bile.

In many cases, this form of inflammation would seem to have originated in the duodenum, reaching the biliary passages by extension through the opening of the duct into the intestine. It may also result from the presence of calculi or parasites in the passages, or from inflammation of the liver.

Suppurative inflammation may attend different forms of fevers, or result from the presence of calculi. The gall-bladder, with the bile ducts, in such cases, may be filled with a purulent fluid, or the same may be found infiltrated through their walls.

Perforation of the walls of the gall-bladder may result from this form of inflammation, with escape of contents into the peritoneal cavity, inducing thus fatal peritonitis. Fistulous communication may also form between the bladder and colon, duodenum or stomach, or through the abdominal walls, adhesions having first taken place between these parts.

Dilatation, both of the bladder and ducts, may occur as a result of obstruction of the gall-ducts. That of the former may be very great, giving rise to a tumor that may be plainly felt through the abdominal walls. Dilatation of the ducts may involve either the common, or large hepatic ducts, or the smaller branches within the liver. Such dilatations may be sacculated in form, or general, involving the whole tube.

Morbid Growths.

Cancer of the walls of the gall-bladder is not unfrequent, and may be either primary or secondary. The cavity of the bladder may in this way become obliterated, and the common duct obstructed, thus inducing jaundice.

In a case examined for the Drs. Pettingill, the gall-bladder was as large as the fist, from scirrhus cancer; its cavity obliterated; adhered to the pylorus to which the disease had extended; and the bile ducts greatly dilated and filled with a large quantity of puriform fluid. The patient had been for many months extremely jaundiced.

Fibroid tumors are very rarely observed in connection with the gall-bladder.

Tubercular deposits may be found beneath its peritoneal covering.

=Biliary Calculi.= The presence of biliary calculi, or gall-stones in the gall-bladder, or some of the ducts, is a very common occurrence. These bodies are composed of the elements of the bile, largely however of cholesterine, sometimes in an almost pure state, in others, more or less mixed with inspissated bile. In many cases, a nucleus of nearly pure cholesterine will be surrounded by a deposit of biliary matter mixed also with scales of cholesterine.

Cholesterine is a peculiar spermaceti, or fatty-like substance, found not only in the bile, but also in the nervous tissues, insoluble in water, but soluble in æther or boiling alcohol. When found in a pure state, it is of a yellowish-white color, with the particles arranged in the form of shining thrombic scales.

Gall-stones may occur of all sizes, from a pin’s head to that of a hen’s egg. When small, they are generally numerous; in some instances fifty to one hundred being found in the gall-bladder at one time. When several are present in the bladder, they will be more or less angular or polyhedral in form from contact and attrition with one another. Where there are but one or two, the size may be considerable, while the form will be rounded, oblong or pear-shaped, and more or less regular.

These bodies, when first removed, are usually heavier than water, but, after being dried, become considerably lighter. They are inflammable, and may be reduced to almost pure charcoal by burning. After having being exposed to the air for some time, they are very liable to crumble more or less completely.

Position. 1. Gall-stones may be confined to the gall-bladder. This is the position in which they are more frequently found. There is every reason to believe that they may remain there for a long time without giving rise to any uncomfortable symptoms. We frequently find them after death in the gall-bladder of persons who, during life, exhibited no symptoms of their presence. They are liable, however, when present, and particularly if numerous or large, to give rise to a sense of weight and dragging in the part, and to occasional attacks of pain, derangement of the stomach and vomiting; and may also excite inflammation and ulceration of the walls of the bladder.

The presence of gall-stones, when in large numbers, may frequently be detected through the abdominal walls, as a hard resisting tumor, which, by grasping, may be made to elicit a rattling sensation, like pebbles in a bag.

2. Gall-stones may become impacted in the neck, or cystic duct of the gall-bladder. In this case, it is likely to give rise to an attack of biliary colic, with vomiting, etc. As long as it remains in this position there will be no jaundice. Their presence, however, may excite inflammation; yet we sometimes, in post-mortem examinations, find the neck of the gall-bladder blocked up by a calculus, when no symptoms of such an obstruction existed during life.

3. Gall-stones may form in some of the branches of the hepatic ducts within the liver. This is not a common point for the formation of these bodies. They are sometimes found, however, in cases of obstruction of the ductus communis. The concretions may be small and rounded, or branching casts of the tubes, resembling pieces of coral.

4. Gall-stones may be lodged in the ductus communis choledochus. This is one of the most common situations for these bodies, and they may reach the point, either from the gall-bladder, or from the ducts from the liver. While in this position, the calculus is likely to give rise to jaundice with paroxysms of severe pain, which will be repeated from time to time, until it passes into the intestines.

Effects. As already intimated, gall-stones may remain for an indefinite period in the gall-bladder or ducts, without giving rise to any symptoms. In many instances, also, they may undoubtedly pass the ductus communis when small, and be discharged by the bowels, without the knowledge of the patient. More frequently, however, the passage of these bodies is accompanied with paroxysms of severe pain, the location and character of which will usually serve to indicate the true cause. Where, however, the body is too large to pass, its presence in the gall-bladder or any of the gall-ducts, may excite inflammation and ulceration in those parts, and thus lead to perforation and discharge of contents into the peritoneal cavity.

CASE.—Rupture of the Gall-bladder, with discharge of contents into the peritoneal cavity, followed by peritonitis and death.

Mr. De K. T——, of this city, aged about 60, had suffered from several attacks of severe pain in the region of the gall-bladder, which I had diagnosed as biliary colic, induced by the presence of a calculus. One morning in June, 1863, while working in his garden, he felt a sensation of something giving away in his side, which was immediately followed by an attack of severe pain. A chill and fever soon succeeded; and, in twenty-four hours, a violent peritonitis set in, resulting in death in four days.

Autopsy, thirty-six hours after death. Upon opening the cavity of the abdomen, the peritoneal membrane was found intensely inflamed at all points, and containing nearly a quart of greenish sero-purulent fluid. Slight plastic adhesions were found at various points, uniting the intestines to the abdominal walls, while old, firm and extensive adhesions were found between the same and the liver and gall-bladder. There were evidences that the latter had been largely distended, yet, through a distinct opening, the contents had escaped into the peritoneal cavity, leaving behind a single calculus of a regular oval form, and one inch of its long diameter.

From the appearance of the part, it would seem that the calculus had excited inflammation and ulceration in the walls of the gall-bladder, destroying the latter so completely, that the fluid contents were kept from escaping into the abdominal cavity, only by the adhesions that had formed, and that these had been probably torn away by the exercise of digging with the spade.

In many cases, the adhesions which are induced by the inflammation, will secure a more fortunate result, favoring the working of the calculus, by the ulcerative process, either into the duodenum or colon, and thus, in most cases, securing its passage per anum. In such instances, should an opportunity be had of examining the parts after death, traces will be found remaining, sufficient to indicate the point at which the escape into the bowel was effected.

In some rare instances, gall-stones have been vomited from the stomach. While it might be possible for such bodies to be carried from the duodenum into the stomach by a reversed peristaltic action, it is more probable that, in such cases, the calculus has found its way into the stomach by a direct fistulous communication with the gall-bladder.

Fistulous communications of a permanent character are sometimes left, after an ulcerative discharge of a gall-stone into some portion of the intestinal canal.

Gall-stones, after entering the intestinal canal, may become impacted, thus producing intestinal obstruction. Many fatal cases of this character have been reported. An interesting case of intestinal obstruction from this cause, was reported by Dr. Frieze, of Harrisburg, at the meeting of the American Institute of Homœopathy, in Philadelphia, in June, 1871. A lady sixty-five years of age, had been suffering severe pain in the bowels for over a week, with symptoms of obstruction, when, after a persevering use of injections, she passed a calculus of a cylindrical form, one and three-quarter inches in length, and four and one-half inches in circumference, and weighing four hundred and thirty-seven and one-half grains.

Gall-stones have, in a number of cases, been discharged upon the surface of the body, while in some rarer instances, by the ulcerative process they have worked into the ureter, and even into the vena cava and portal vein.