Complete Text (Part 41)

have nothing to do with m- flammatory changes. There is, however, one alteration of the cells which, at least according to the definition of Virchow, is to be considered inflammatory, and is consequently called : — (a.) Parenchymatous hepatitis. This affection, like paren- chymatous inflammation elsewhere, has two stages, the one of cloudy swelling of the cells, and the other of fatty degen- eration. The latter stage is quite rare in the liver, and is generally limited to certain definite forms of disease, al- though quite common in the kidney. In those diseases which are usually accompanied by parenchjanatous changes (acute infective diseases, acute exanthemata, etc.), the liver appears, as a rule, in the condition of cloudy swelling. This is characterized by great flaccidity of the organ, by enlarge- ment of the individual lobules and the entire liver, by in- distinctness of the acini, and by a comparatively uniform opaque gray color of the cut surface, which suggests that the latter has been dipped in boiling water (coagulation of the albuminates). The recognition of the milder form of paren- 21 322 DIAGNOSIS IN PATHOLOGICAL ANATOMY. chyraatous hepatitis is one of tlie most difficult things in pathological anatomy, and long practice is requisite for this to be done with a certain degree of sureness. In these cases the diagnosis cannot be greatly aided by observing closely the details ; but the liver, like the kidneys, is to be looked at from a little distance, as the opacity can be thus most easily noticed. Much experience is also necessary in order to make a microscopical examination of use in the diagnosis, as the normal liver cells are very granular, and it is difficult to recognize a slight excess of those granules. In the more severe forms the appearances are quite chara,cteristic, the cells then being opaque, as if spattered with India-ink, the nuclei more or less indistinct under the mass of dark gran- ules, and the volume of the cell increased. On the addition of acetic acid or caustic alkalies the greater part of these granules (albuminates) disappear, but fat granules, if pres- ent, remain unchanged. The more extreme degrees of parenchymatous inflamma- tion, where the cloudy swelling results in fatty degeneration^ occur principally in two affections, in poisoning by phospho- rus (also arsenic, etc.), and in acute atrophy of the liver, the getiology of which has never yet been ascertained. In cases of phosphorus poisoning the nature of the process is by no means universally agreed upon, as an abnormally large, bright, yellow liver with icterus, greatly resembling the or- dinary jaundiced, fatty liver, is often found ; in consequence of this resemblance certain authors have maintained that the two are identical, and deny the existence of the parenchy- matous inflammation. Other authorities (Virchow, Rind- fleisch) contend that the essence of the process is a paren- chymatous inflammation in which, according to Rindfleisch, large fat drops are formed, while according to Virchow both fatty degeneration and fatty infiltration occur, and the latter may also be due to the phosphorus, which may possibly ren- der the cells more capable of retaining fat. At any rate, upon microscopic examination, besides the cells containing large fat drops, like those seen in fatty infiltration, others are THE LIVER. 323 found beginning to disintegrate, which is usually not the case in infiltration. This question might be positively set- tled if atrophy of the liver resulted by the absorption of the fatty detritus, but death always occurs before this can take place, and a well authenticated case of atrophy after phos- phorus poisoning has never been observed. The characteristic appearances in acute yellow atrophy, on the other hand, depend upon this absorption. This affection is met with much more frequently in women than in men, and particularly during pregnancy and the puerperal state. The early stages, which greatly resemble those produced in the liver by phosphorus poisoning, are seldom observed, and if found their consistency is usually less than that occurring in the latter affection, and the liver, instead of being dimin- ished, is increased in size (yellow hypertrophy). In ordinary typical cases the organ is frequently reduced to half its nor- mal size, is flabby and wrinkled, but still rather tough ; icteric, yellow elevations of varied size project from the outer surface of the liver, and still more from the cut surface, and are imbedded in a red ground which is often traversed by single delicate gray trabecule. Sometimes the yellow and at other times the red portion predominates, while in the midst a varying number of punctate haemorrhages are seen, which also occur in many other places, especially in the connective tissue, as is the case also in phosphorus poisoning. The microscopic examination can only be very incompletely made when the organ is fresh, owing to its soft condition, but it shows that the yellow portions are the more nearly normal, as they still contain liver cells, which are filled with fat drops of varied size ; a large quantity of biliary coloring matter is also found, either diffused, granular, or crystalline (crystals of bilirubine), likewise bile-capillaries filled with olive-green bile, which have already been referred to. In the red portions, on the other hand, there is no longer a trace of the liver cells to be found, merely a confused mass of fibres and granular detritus. At the junction of the red and yellow portions the progressive destruction of the liver 324 DIAGNOSIS IN PATHOLOGICAL ANATOMY. cells may be followed. The change is greatest in the red portions, where the structure of the organ is completely lost (^red atrophy, Klebs). Sometimes small islets of granula- tion tissue (interstitial hepatitis) occur here and there, esjDC- cially at the edge of the lobules in the yellow portion, also clusters of epithelial cells, the nature of which is still uncer- tain (hyperplasia of the epithelium lining the gall-ducts?). Certain observers have found numerous colonies of micro- cocci in the atrophied livers, but as yet they have not been able to establish an setiological connection between the two. When the liver of acute atrophy is exposed to the air for some time after its removal, the cut surface and the walls of the vessels are usually found coated with a thin, white, frost- like layer, which is found upon microscopic examination to be composed of crystals of leucine and tyrosine, especially the latter. Leucine occurs in the form of spherical crystalline masses, which are often arranged in groups ; tyrosine, on the other hand, is in the form of acicular crystals arranged in sheaves, somewhat resembling crystals of fatty acids, though generally larger ; they may be easily distinguished, however, as they are not affected by heat, while the latter readily liquefy when warmed. (5.) There are still a number of inflammatory affections in which the cells are altered as a secondary condition. First among these are the metastatic (jembolie) inflam- mations, which are in general rare, but often occur in certain affections, as, for instance, endocai^ditis ulcerosa. The in- farctions usually lie just beneath the capsule, are wedge- shaped and of a yellow color. The acini are still apparent in the recent forms, but as the infarctions become older the central lobules disappear and are replaced by a soft, puriform mass. This so-called metastatic abscess is always separated from the normal surrounding tissue by a zone of somewhat enlarged yellow lobules (parenchymatous inflammation). Numerous colonies of micrococci are seen in microscopic sec- tions, especially after acetic acid, caustic potash, or soda has been added, and are situated not only in the larger, interlob- THE LIVER. 325 ular vessel, but fill the capillaries also for a long distance. Very few pus corpuscles are present, the greater part of the infarction being composed of disintegrated liver cells. If sections are made from places which appear to be still unchanged, the micrococci will almost always be found on thorough examination; there may be no changes in their vicinity, or slight traces of inflammation may be present, which become more pronounced, till finally the inflammatory alterations are evident to the naked eye. This gradation of appearances leads to the conclusion that the micrococci are .the cause of the disturbances. (c.) The interstitial inflammatory affections of the liver include : — 1. Purulent inflammation, which appears in the form of abscesses and is of rare occurrence. Two sorts of abscesses, the acute and chronic, are to be distinguished ; the latter is characterized by the formation of a firm fibrous tissue, in addition to the pus, which may not only surround the ab- scess (encapsulated abscess), but also extend through it in the form of numerous septa. The abscesses may be of trau- matic origin (the greater number of which are found in con- nection with injuries of the head, and have nothing to do with metastasis), or they may arise from the roots of the portal vein (in the spleen, stomach, intestine [especially in perityphlitis], also from the umbilical vein), or from the gall-ducts ; in the latter case the abscesses may be caused by inflammation which is continued from the intestine (typhoid fever, dysentei-y), or by the formations of concretions in the ducts, or by the entrance of parasites (ascaris). The abscesses may cause secondary changes, by an exten- sion of the inflammation, both in the portal (pylephlebitis) and in the hepatic veins (hepatophlebitis) ; these veins are then filled with softened thrombi, of a puriform, or dirty grayish-brown appearance, which extend into the larger branches, and the thrombi, in the hepatic vein may even give rise to embolism of the lungs. It is frequently possible to see that the suppuration follows the course of the inflamed 326 DIAGNOSIS IN PATHOLOGICAL ANATOMY. vessels. Under the microscope the pus corpuscles, especially in old infarctions, are found to have become disintegrated. These abscesses must not be confounded with suppurating Echinococcus cysts, in which the presence of membranes or booklets will render the diagnosis certain. 2. The inflammatory processes which have been thus far considered are more or less acute in character. There re- mains a very important chronic inflammation to be described, namely, chr^onic interstitial hej^atitis. The volume of the liver is increased or diminished in this affection, according to the stage of the process, as is the case in parenchymatous inflammation. It is only accidentally met with in its early stages, as it is then not detrimental to life. The principal change produced in the liver consists in an increase of the interlobular tissue, and the appearance of small grayish masses at the periphery of the lobules. The consistency of the liver is increased. The cause of this change may be seen in microscopic sections to consist of a growth of granulation tissue from Glisson's capsule, from which small projections extend into the acini. Even in this early stage, the disposition of the newly formed tissue to become more highly organized may be recognized, for besides the round cells there are numbers having a spindle shape. All the further changes depend upon this peculiarity. In the later stages of chronic interstitial inflammation the liver is more or less diminished in size, in rare cases fully one half ; its surface is uneven and covered with prominences, which vary from the size of a millet-grain to that of a pea (^granular atrojyh^^, and are usually of a yellow, icteric color. At the edge of the liver, especially in front where it is sharp, single nodules are frequently found, completely iso- lated, as the capsule belonging to the two surfaces comes in contact here. Upon section a similar condition of things is seen ; numberless islets of parenchyma, from the size of a millet-grain to that of a pea, project from the cut surface in the form of round masses, which are infiltrated with fat and bile (hence the old name cirrhosis from Ktppos, tawny. THE LIVER. 327 orange-tawny). These are separated by bands of varying width, composed of very tough, grayish fibrous tissue, which creaks under the knife, and within which little yellow spots are scattered about. Sometimes this process produces a thrombosis of the portal vein. Upon microscopic examination round cells are still found in very few places within the tough interstitial tissue, but more frequently those of a spindle shape; the bands are essen- tially composed of tough, interlacing connective tissue fibres, between which wide vessels are met with, which may be in- jected from the hepatic artery or portal vein. The project- ing granules consist of fatty infiltrated and icteric liver tis- sue. They do not always represent single lobules or groups of them, for although the process extends from the inter- lobular connective tissue, it does not always follow the boundaries of the lobules in its progress, as these do not possess a connective tissue capsule ; they are frequently composed only of very small portions of acini or groups of acini, which are detached by the irregular penetration of the granulation tissue into them. The most common cause of this form of interstitial hepa- titis, which extends uniformly over the whole organ, is usu- ally considered to be the intemperate use of alcohol (gin- drinker's liver), still this is not necessary; most drunkards do not have a cirrhotic but a fatty liver, and many persons with cirrhosis are not in the habit of dram-drinking. There is another quite different form, in which the formation of fibrous tissue is confined to certain regions, so that large lobes, and not small granules, are separated by the contrac- tion of the fibrous tissue (lohulated liver). This form is usu- ally due to syphilis. The greater part of this fibrous tissue usually occurs in the vicinity of the suspensory ligament, and fibrous bands extend from this region into the surrounding tissue. The variations in shape which it produces in the or- gan are sometimes very great. For instance, the right lobe may become so atrophied as to be much smaller than the left, which then, of course, frequently undergoes compen- satory hypertrophy. 328 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 3. In addition to this pui-e interstitial syphilitic affection of the liver, which of itself can never be diagnosticated as due to syphilis, another form occurs, more rarely but still rather frequently ; this is manifested by irregular and rounded, homogeneous, yellow, tough, and elastic masses (jgummata), which are imbedded in the fibrous tissue (hep- atitis interstitialis gummosa}. The structure of these nod- ules does not differ essentially from that of the similar for- mations in the testis and other places, which have been fully described. 6. The foregoing affections lead to the consideration of the tumors of the liver. (a.) Gummata, without interstitial inflammation, are al- most never observed in adults, but there are hereditary forms, which occur in new-born children, where the inter- stitial inflammation at least is less prominent, so that the affection has more the character of a true new formation. In these cases the gummata are sometimes in the form of large, separate tumors. Again, the whole liver, in which the lobules are almost indistinguishable, is studded with an end- less number of small, pale yellow bodies of irregular shape, very minute gummata. (5.) Tuberculosis of the liver usually appears in one of two forms, either as a disseminated miliary tuberculosis of the parenchyma, or as tuberculosis of the gall-ducts. Dis- seminated tuberculosis is always secondary, and of very fre- quent occurrence ; it is never absent from the liver, after even a few organs have become affected by secondary tuber- culosis. The tubercles of the liver are among the smallest known, and are consequently very liable to be overlooked. In order to be perfectly sure of their presence the microscopic examination must alwaj'S be made whenever there is the least possibility of tuberculosis of this organ ; it can then be seen how many thousands of tubercles would escape notice, without the aid of the microscope. The largest ones are evident to the naked eye as minute gray granules the size of a pin's head. They are situated at the periphery of THE LIVER. 329 the lobules, but the microscope shows that they are not only between but also within them, so that a portion of the par- enchyma is replaced by the nodules. Some of the nodules are situated upon the smallest bile-ducts, and, consequently, have a yellowish-green color, which thus renders them more readily recognized. In children the tubercles become larger, from the size of a millet-grain to that of a pea ; they are then composed of an aggregation of minute tubercles. Upon microscopic examination the tubercles often present the frequently described reticulated structure and giant-cells, but both giant- cells and a coarse reticulum are frequently absent. The second form is chiefly seated within the walls of the Mle-ducts, not in the small ones between the lobules but in the larger tubes. The disintegration of the tubercles leads to ulceration of the surface, as in the ureters, and the canal is filled with cheesy material and bile, so that a cavity of the size of a pea, bean, or even cherry, is seen on section, the walls of which are composed of a firm cheesy mass, and the contents are pultaceous, stained yellow or green by bile. Although large tubercular nodules are rare in the liver, it is necessary to know that they are occasionally met with from the size of a walnut to that of the fist. These are dis- tinguished from cancer, which they may greatly resemble in form, by their uniformly dry and cheesy character, and the entire absence of any milky fluid when squeezed. Isolated submiliary nodules are seen with the microscope in the most recently affected places, which indicate that these nodules also consist of a conglomeration of small tubercles. (c.) The tumor-like lymphomatous growths, which are occasionally found in the liver in typhoid fever, and more frequently in leuccemia, are closely allied to tubercles. In leucaemia, especially, they