CHAPTER II.
PATHOLOGICAL CONDITIONS.
Section I. OF THE PERITONEUM.
[=Notice= in examination:—1. _Contents of cavity_—serum; amount, color, coagulable or not; _pus_—amount, consistence, odor, source; _blood_—amount, source; foreign bodies; gall-stones; worms. 2. _Condition of membrane_—color, transparency, rough or smooth, moist or dry, thickness; _adhesions_—position and strength of. Vascularity; ulcers; perforations; tubercles; tumors; wounds, etc.]
This membrane we find liable to _congestion_, _inflammation_, _gangrene_, _effusions_, and _morbid growths_.
=Congestion= of the peritoneum, may result from obstructed circulation through the liver, or ascending vena cava, or from inflammatory action; and may terminate in serous effusions into the abdominal cavity, or thickening of the membrane. The redness of congestion, may be distinguished from that of inflammation, by the larger vessels appearing more involved, and by the absence of any plastic effusions.
=Inflammation= of this membrane, (_Peritonitis_,) may be either acute or chronic.
_Acute peritonitis_, in most instances, commences at some one or more points, and from this gradually diffuses itself over the membrane until it becomes general. Such point of inflammation may commence immediately over some inflamed, or ulcerated, or perforated spot in the intestines, or in the peritoneal covering of an inflamed uterus, liver, etc., or as the result of external injury.
In the early stage of peritonitis, the injected vessels give the membrane a more or less red appearance, which will be more marked in streaks and patches. From the readiness, however, with which fibrinous exudation takes place from this membrane, this redness is seldom very strongly marked, and in some instances will scarcely be noticed, unless the surface is carefully scraped, thus removing the exudation.
Small extravasations of blood are occasionally found in the substance of the membrane. The muscular coat of the intestines, where the peritoneal covering is involved, may become infiltrated with serum, the fibres relaxed and paralyzed, thus permitting of the great tympanitic distension found in these cases.
_Chronic peritonitis_, is not a very common occurrence. It may, however, follow an attack of acute peritonitis, and is sometimes found in connection with ascites, or tubercular deposits in the peritoneum. In examining the body of a colored woman who had died of heart disease, accompanied with general dropsy, and who had suffered abdominal pain and tenderness for a number of weeks previous to death, a large portion of the peritoneum, particularly that reflected upon the abdominal walls, was found intensely red, the blood-vessels having an arborescent arrangement, and being beautifully injected. No plastic matter was found effused upon the surfaces. The cavity contained some twelve quarts of serum.
=Fibrinous Exudation=, as already observed, readily follows inflammation of this membrane. It will often be found as a uniform layer covering the whole surface of the peritoneum, rendered more apparent, however, by separating parts, when it appears as delicate bands or filaments, stretching across the interspace. In cases of acute inflammation, this plastic effusion is often very great, and frequently intermixed with purulent matter, while the serous fluid, which is poured out in considerable quantities in these cases, is rendered turbid by the presence of numerous flakes of fibrin, and quantities of pus cells diffused through the same. More or less extensive and firm adhesion of parts may thus be induced, the plastic matter effused becoming more and more firm, and finally converted into dense bands of fibrous tissue.
Mechanical obstruction and strangulation of the bowels, may be induced by the presence of these bands, stretching between parts, and forming thus an opening through which the bowel passes, and finally becomes incarcerated.
=Suppuration= is not an unfrequent result of acute peritonitis; the matter being found uniformly smeared over the whole surface, or, in some cases, confined to a single part, thus forming a circumscribed abscess. Adhesions having taken place around the boundaries of the suppurating surfaces, in this manner the diffusion of the matter is prevented, and its discharge into the intestinal canal, or in some instances upon the surface of the body, is promoted.
=Gangrene= of the peritoneum may result from intussusception or hernial incarceration of some portion of the bowel, when the part will appear as a softened, dark, offensive mass, limited by a band of highly congested tissue.
=Ascites.= Dropsical accumulations in the abdominal cavity, may result from obstructed circulation, caused by disease of the liver, kidneys, heart or lungs; or from pressure upon the vena cava, or portal vein, by some abnormal growth.
The fluid effused may be nearly colorless, or present various shades of yellow, red or green, and usually coagulates on the application of heat. The peritoneum may appear unchanged, or it may present a thickened, opaque, white or macerated appearance, in chronic cases.
Blood may be found in the peritoneal cavity, as a result of wounds, rupture of some of the abdominal or pelvic organs, or bursting of an aneurism.
=Morbid Growths.=
=Tubercular Deposits=, of the miliary form, are not unfrequent in the peritoneum. They may be diffused over the whole membrane, as semi-transparent, gray granules, but more frequently are found on the under surface of the diaphragm, in the neighborhood of the spleen, and on the viscera generally, while the parietal layer is more free. The tubercles, acting as foreign bodies, give rise to inflammation, usually of a chronic form, but sufficient to result in exudation of lymph, and the formation of adhesions between the adjoining surfaces. Softening of the tubercular deposits sometimes takes place, and perforation of the intestinal wall results, leading to an effusion of the intestinal contents into the peritoneal cavity.
=Cancer= of the peritoneum, is sometimes seen as a primary affection, yet it more frequently extends to this membrane from some of the deeper parts. The encephaloid variety may be met with, but the colloid form is that most frequently seen. The omentum is the occasional seat of this form of cancer, the membrane in such cases becoming enormously increased in size.
=Tumors= of various kinds, including _fibrous_, _fatty_, and _cystic_, may be found in the peritoneal cavity, generally having had their origin, however, in the sub-peritoneal tissues. _Fatty_ tumors may originate within the substance of the omentum or mesentery, while _cystic_ tumors may be found within the broad ligaments of the uterus or ovaries.
Section II. OF THE STOMACH.
[=Notice= in examination:—1. _External characters_—position; size; form; adhesions. 2. _Contents_—quantity, color, odor, reaction. _Food_—its nature, degree of digestion. _Blood_—pure or mixed with food; probable source. _Foreign substances_—powders, metallic particles, spirits, fœcal matter, bile, pus, worms. 3. _Mucous membrane_—general condition of; color, soft or firm, rugæ present or absent; thickness at various points; ulcers; their position, size, etc. 4. _Muscular coat_—thickness; visibility of fibres. 5. _Entire walls_—transparency; wounds; perforations; ruptures; weight. 6. _Condition of orifices_—constricted; dilated. _Tumors_—position, size, character, etc.]
Few organs of the body are subject to such a variety, or to such early _post-mortem_ changes as the stomach, many of which, being closely simulative of the effects of disease, render a satisfactory examination of this organ, in many instances, very difficult. Therefore, before entering upon an account of the morbid anatomy of the organ, I shall briefly notice those changes which are _post-mortem_ in their origin.
The ordinary interval which intervenes between death and a post-mortem examination, is, in most instances, sufficient to seriously change the appearance even of the healthy stomach. Hence our knowledge of the healthy appearance of that organ, at least, previous to the experiments of Dr. Beaumont upon the stomach of Alexis St. Martin, was quite imperfect.
=Post-Mortem Changes.=
Among those changes taking place after death, which are no evidence of disease during life, may be mentioned:
_First._ _Appearances of Congestion._ Very soon after death, or at least within ten or twelve hours, by gravitation of the blood, the same _hypostatic congestion_ will be found in the most dependent portion of the stomach, that is seen in a more marked degree in the lungs, or in the subcutaneous tissues.
_Second._ _Coloring of Tissues._ Not unfrequently, the tissue of the stomach will be found strongly tinged by coloring matter of food or medicine, such as the red color of wine or logwood, or the black color of the metallic sulphurets, etc.
_Third._ _Change of Shape and Size._ Variations in the shape and size of the stomach from the normal standard, are not unfrequently found after death. It is sometimes found unusually small, apparently from the influence of the _rigor mortis_, the contraction necessarily resulting in increased thickness of the walls. What is known as hour-glass contraction, although sometimes congenital in its origin, is frequently but a manifestation of the _rigor mortis_, when it may be distinguished from the former by inflation. Extreme dilatation, with thinning of the walls, is also sometimes seen, this condition resulting apparently from an absence of the post-mortem contraction.
_Fourth._ _Exfoliation of Epithelium._ The stomach of young adults, dying of some acute disease, not unfrequently is found to have thrown off the epithelial layer of its mucous lining, even when the examination is made soon after death, and in cold weather. In many of the healthiest animals slaughtered for food, the same change has been noticed as early as two hours after death. The detached cells are found floating in a thick mucus, the microscope also showing that the gastric follicles have thrown off their epithelial lining, with their pepsinous contents. With this change commences the post-mortem digestion of the stomach, to be soon noticed.
The younger and healthier the subject, and the more acute the disease causing death, as a general rule, the more rapidly and effectively does this exfoliation take place. It may affect only the summit of the folds into which the mucous membrane is thrown by the contraction of the muscular coat, or it may uniformly involve the whole mucous surface.
_Fifth._ _Softening and Perforation._ It is an interesting fact, that while the tissues of the stomach during life are unaffected by the gastric juice—the vitality of the tissues enabling them to resist its solvent power—after death, they immediately yield to its influence, and hence results a greater or less degree of softening of the coats, or even in some instances, complete perforation of the walls, the extent of the change depending upon the quantity of gastric fluid in the stomach at the time of death. In these cases there is, of course, no evidence of inflammation, while the tissues present a pulpy, gelatinous appearance, the walls being greatly thinned, and breaking down under the slightest force. In most instances, probably the _actual perforation_ is the result of the force employed in lifting the stomach from its position. The opening in these cases is an irregular ragged hole, with soft, pulpy margins, and will more frequently be found at the large or cardiac extremity of the organ.
In some extreme cases, the process of softening has not been confined to the _walls_ of the stomach, but has extended to the adjoining organs, as the spleen, liver, or diaphragm.
The whitish-gray and gelatinous appearances of these cases, will enable us to distinguish them from ordinary cases of softening and perforation from ulceration.
This form of softening is especially observed in cases of sudden death immediately after a meal, while the stomach contains a large quantity of gastric juice. It is also seen much more frequently in children and young persons than in the aged, or those dying from chronic forms of disease. It has often been noticed in cases of consumption, however, which is to be accounted for upon the fact that many of these patients retain a good appetite to the last.
Brinton, is of the opinion, that the solvent action of the gastric fluids upon the walls of the stomach, is promoted by the presence of vegetable or starchy food:—(1) by offering little substance upon which the fluids can expend themselves; and (2) by producing by its decomposition, an amount of acid, favoring an energetic action of the gastric fluids; while on the other hand, the action of those fluids is retarded, (1) by the presence of alkaline saliva, or bile in any quantity; and (2) by the presence of animal food upon which the juices may act.
CASE.—_Perforation of the Stomach in a child two years of age—death from Hydrocephalus._
A child of Mr. T——, in its second summer, had an attack of hydrocephalus, finally dying in convulsions. The autopsy, made twenty-four hours after death, disclosed great congestion of the membranes of the brain, with two ounces of serum in the ventricles. Upon opening the abdominal cavity, all the viscera appeared healthy. In lifting the stomach from its position, a gush of colored fluid appeared from behind it, which at once led to the suspicion of a rupture. The whole organ was then carefully removed, when a ragged rent, through which the thumb could readily be passed, was discovered at the posterior portion of the cardiac end. The walls of the stomach at this point were extremely thin, soft and jelly-like; this condition being plainly the result of the post-mortem action of the gastric juice, while the rupture was the immediate consequence of lifting the organ from its position.
Pathological States of the Stomach.
=Gastritis.= _Acute inflammation_ of the stomach rarely occurs, except as a result of some chemical or mechanical irritation. From the experiments of Dr. Beaumont, however, we learn that the stomach is extremely liable to various grades of inflammatory action, which passing rapidly through their several stages, end finally in recovery. By watching the effects of excesses in the use of alcoholic stimulants, food, condiments, and of exercise after meals, etc., he observed that the pale, pink color, natural to the mucous membrane of the healthy stomach, was exchanged for a somewhat livid erythematous redness, which was distributed throughout the organ in irregular patches of various sizes, and in its most intense form, amounted to a kind of ecchymosis.
Again, he noticed an excessive growth of epithelium, forming patches of false membrane like, which at various points appeared distended by an accumulation of a puriform fluid beneath, giving the appearance of little pustules.
The following forms of gastritis are generally recognized:
1. _Catarrhal Gastritis._ This, in its _acute_ form, is seldom seen in post-mortem examinations. _Chronic Catarrhal Gastritis_, however, is by no means uncommon, and may be a result of the use of alcoholic drinks, the presence of various irritating substances taken either as food or medicine, and may attend many forms of chronic disease of other organs, or may be caused by obstruction to the circulation from disease of the heart, liver or lungs.
The post-mortem appearances are neither very marked, nor constant. The mucous membrane may be found red, or of a dark color, thickened and sometimes roughened. The submucous and muscular coats may also be thickened, while less frequently, small ulcers may be found.
2. _Croupous Gastritis._ This form is very rare, and seldom diagnosticated during life, but may be found with children who have died with croupous inflammation of the air passages, when small patches of false membrane may be found adhering to the mucous surfaces. It may be found in adults also, as an attendant of certain grave forms of disease, as typhus, puerperal fever, cholera, dysentery, or in death from irritating poisons.
3. _Phlegmonous Gastritis_, is another very rare form of inflammation of the stomach, in which the disease involves all the coats, although originating in the submucous, and may destroy the patient in a few days with symptoms of peritonitis. The submucous tissues will be found filled with an exudation of a sero-plastic, yellowish substance, which produces thickening of the walls, and which may be confined to a portion or involve the whole organ.
=Effects of Poisons.= The effects of caustic and other irritant poisons upon the stomach, as exposed by a post-mortem examination, will vary according to the nature of the substance, and the time it may have remained in the stomach. Redness in various degrees, and of various shades, ulceration, softening and perforation, may one or all, be detected in different cases.
In large quantities, the mineral acids may leave the mucous membrane black, and of a soft, tarry consistence, readily breaking down upon handling the stomach.
The peculiar action of the several poisons will be noticed in another place. (See Part IV.)
=Gastric Ulcer.= Ulceration of the mucous membrane of the stomach, is much less frequent than of other portions of the intestinal canal, except as a result of the corrosive action of poisons.[20] A peculiar kind of ulcer, however—rare in this country, but said to be common on the Continent of Europe and in England—is sometimes found, which is of interest, from its occurring in tissues otherwise healthy, and often leading to a rapidly fatal termination. Rokitansky terms it the _perforating gastric ulcer_, from its marked tendency to perforate the walls of the stomach. It is situated in the region of the pylorus, and more frequently at the posterior surface and near the lesser curve. It is of a circular form, of three to six lines in diameter, and with as sharp edges as if a round piece of the walls had been punched out; the edges being bevelled off, however, from within, leaving the peritoneal opening less than that in the muscular or mucous coats. Being usually situated near the lesser curve of the stomach, some of the larger blood-vessels are liable to become involved, giving rise to hæmorrhage more or less severe. While but a single ulcer of this description is generally found, two, three or more, may be present.
A peculiarity of this form of ulcer, consists in its not being dependent upon irritation or inflammation, but rather upon a loss of vital assimulative power in the part affected.
This form of ulcer may heal at any time previous to perforation, and it is not uncommon to find a cicatrix in the mucous membrane of the stomach which has probably arisen in that way.
Gastric ulcer is much more frequent in females than males, and is mainly a disease of middle and advanced life.
=Hæmorrhagic Erosions.= The appearance of the stomach, where there has been frequent vomiting of blood from this cause, is thus described by Rokitansky: “There are several roundish spots of the size of a pin’s head or pea, or narrow elongated streaks at which the mucous membrane appears dark red, lax, soft and bleeding, and presenting a depression in consequence of loss of substance or slight erosion. This condition is invariably accompanied by hæmorrhage, the effused blood being mixed, in a more or less altered state, with gastric mucus. The erosions are often very numerous, studding, perhaps, every part of the stomach except the fundus, the pylorus being their chief seat.”
This condition of the stomach is not peculiar to any form of disease, or age, but is frequently associated with intemperance. It is rarely fatal, except by inducing some other lesion of the stomach, or by being united with some more general malady.
=Softening of the Stomach.= We have already referred to that form of softening of the stomach, which is attributed to the action of the gastric juice after death. Another form is sometimes met with, which evidently takes place during life, and in most instances is attributable to a chronic form of inflammation. It is not always easy to distinguish the two forms of softening without a knowledge of the previous history of the case. The distinction may, however, generally be made by attending to the following points:—1. The presence during life, of symptoms of disease of the stomach. 2. Appearances of congestion or inflammation, as well as softening, after death. 3. Extension of the morbid change to other portions than that affected by post-mortem softening, the latter being usually confined to the posterior portion of the cardiac end.
=Cirrhosis of the Stomach.= In some obscure cases of gastric disease, upon opening the abdominal cavity in a post-mortem examination, we may at once notice a marked change in the appearance of the stomach. It presents a peculiar whiteness and opacity, an appearance which is partially due to a dulness of the peritoneal coat, in marked contrast with its usual brilliancy; at the same time the organ may be either larger or smaller than the average size. Upon removing the organ, we find it greatly increased in weight and density, and presenting a hard, gristly feel, and with so much elasticity as to fail to collapse. An incision shows the walls uniformly thickened, to the extent of six or eight times their normal condition; the whole organ is comparatively bloodless, a condition strongly in contrast with the usual appearance after death.
A close inspection of such a specimen, shows the several coats—muscular, mucous and fibrous—to be remarkably alike, the thickening and increased density, resulting from the presence of a generally diffused imperfect fibrous structure, similar to that found in common fibrous tumors. The several coats of the stomach will be found unequally affected by this deposit. The submucous structure, as seen in a vertical section, being increased from ten to twenty fold, while the serous with the subserous may be increased seven to ten fold. The muscular tunic may be found from five to eight times its normal thickness, while the mucous membrane proper, is seldom more than double.
Notwithstanding the bloodless character of the walls of the stomach in this disease, the abnormal condition is unquestionably the result of a chronic form of inflammation. The symptoms during life are usually obscure, and although the hard contracted stomach may form a sort of epigastric tumor, noticeable upon the surface, the absence of acute symptoms, with the age at which the disease makes its appearance—usually between twenty and thirty—permits of a ready distinction being made between this disease and cancer, with which it might otherwise be confounded.
=Atrophy of the Stomach.= This condition of the stomach can hardly be looked upon as an independent malady, being rather an attendant of the general wasting of certain diseases, particularly of pulmonary consumption, marasmus, and starvation. The organ, in these cases, may be reduced to less than half its normal proportions, while its walls may be thinned and frequently softened.
=Dilatation of the Stomach=, is another condition that can scarcely be considered as a primary affection. A great variation in the size of this organ is evidently compatible with health, large eaters having necessarily large stomachs, yet as the result of certain other morbid conditions, dilatation to an enormous extent may be induced.
The following conditions may result in dilatation:
1. Obstruction of the pylorus, as in scirrhus of that portion of the stomach.
2. Destruction of a segment of the muscular coat by ulceration, or by becoming involved in a cancerous growth. Here the loss of contracting power, permits of a gradual dilatation, from the inability of the segment involved to aid in carrying on the contents, their accumulation above this point aiding in the distension.
3. An acute form of dilatation is sometimes met with, which can only be attributed to a paralysis of the muscular and secreting structures of the organ. It occasionally happens to a patient recovering from a fever. He has perhaps overindulged in eating, as is not unfrequently the case with convalescents, and is suddenly seized with intense pain in the stomach, followed by rapid and great distension, and finally death. The autopsy discloses the stomach enormously distended, and its contents, including matters, in some cases, which were ingested many days before. The mucous membrane appears but little changed, while the muscular coat is so thinned and stretched, as to appear like a scattered net-work of fibres.
Morbid Growths.
=Cancer.= This formidable disease occurs more frequently in the stomach, than in any other organ of the body, excepting the uterus of the female. The disease is usually primary in this organ, but frequently springs up secondarily in other parts.
The disease may occur in the three following forms—the _scirrhus_, _medullary_, and _colloid_; while Dr. Brinton adds a fourth, the _villous_ cancer of the mucous membrane. The usual seat of the disease is at the pylorus. It may involve a portion or the whole circumference of this opening, and from this extend along the lesser curve. In some cases, it commences at the cardiac orifice, and very rarely involves the whole organ, the fundus usually remaining free. The walls of the stomach may become greatly thickened in this disease, the inner surface tuberculated and roughened, and the cavity much diminished in size. When situated at the pyloric end, the disease seldom or never extends into the duodenum, but when at the cardiac, it generally involves the lower portion of the œsophagus.
The _fibrous_ or _scirrhus_ form of the disease, is by far more commonly met with than any other, although it may be found occasionally combined with the medullary, or both these with colloid. Indeed, it is not improbable, but that in many cases, a growth originally scirrhus, becomes gradually converted into one of the other forms.
In almost all cases, cancer commences in the submucous tissue, in the form of a dense mass, of a white color. When cut, the surface presents a whitish-gray appearance, contrasting strongly with the vascular mucous membrane of the stomach, and presenting a distinctly striated appearance. A small portion under the microscope, or the juice scraped from the cut surface, will show the peculiar cancer cell, with granular matter.
_Encephaloid_ or medullary cancer, may be developed upon or within the fibrous form, or it may occur primarily as knotty tumors projecting through the mucous membrane. The microscopic appearance is much the same as in the fibrous variety, except that the cells are not so closely packed, but are loosely held together by an abundant, soft, or liquid substance.
The _colloid_ form of the disease, may originate either in the mucous membrane itself, or in the submucous tissue. It is known by its presenting a tough, fibrous-looking, white tissue, which, arranged in intersecting bands, incloses irregular spaces, which are filled with a clear, soft, or semi-liquid material, the proper colloid substance.
The _villous cancer_, Dr. Brinton describes as arising in the basement membrane of the mucous coat, and as but a modification of the epithelial cancer of other parts of the body.
The mucous membrane covering cancerous growths, is subject to a variety of changes. It may become converted into a sort of fungoid growth, which at points suppurates, showing the submucous scirrhus tissue; or it gradually softens, giving rise to hæmorrhages.
The cancerous mass itself, may also soften or suppurate, resulting perhaps in perforation and peritonitis; or adhesions may take place, followed by extension of the disease to the liver, spleen, pancreas, kidneys, etc.
Cancer of the stomach, in the great majority of cases, occurs in persons between fifty and sixty years, although it may appear as early as forty, or as late as sixty. Males appear to be more subject to the disease than females, in the proportion of four to three.
The _obstruction_ which the presence of cancer of the stomach is liable to produce, may result in one or more of the following conditions:
First, _hypertrophy_ of the muscular coat. From increased nutrition, the muscular fibres of the stomach may become considerably increased in size and darker in color, thus better enabling them to overcome the obstruction, which in some cases, amounts almost to occlusion.
Second, _dilatation_. This condition frequently attends the former, and indeed is seldom seen alone. It is confined to those cases where the cancer is at the pylorus, and is more noticeable at the fundus of the organ.
Third, _contraction_. This is seldom seen in connection with hypertrophy, and is far less common than dilatation. Generally found in connection with cancer at the cardiac orifice, it may be looked upon as the result of the constant regurgitation which the obstruction produces, preventing thus the cavity of the organ from undergoing its normal distension, by the presence of any quantity of food.
=Tumors.= With the exception of cancerous growths, tumors of the stomach are by no means common.
_Fatty tumors_ are sometimes met with, originating in the submucous tissues, and as they increase in size, they may crowd either inwards towards the gastric cavity, or outwards towards the peritoneum.
_Fibroid tumors_, are also occasionally met with in the submucous tissues, generally in the line of the lesser curve, and about the cardiac orifice.
_Polypoid growths_ may also be found springing from the mucous surface, presenting the character of those formations usually.
Section 2. THE INTESTINES.
[=Notice= in examination:—1. _External characters_—displacements, as in hernia; amount and condition of involved bowel. _Invaginations_—number, position and size; dilatations or contraction of intestines; apparent cause of. _Peritoneal coat_—inflamed or not; adhesions; their position, strength; perforations, etc. 2. _Contents_—gas; mucus; blood; pus; fæcal matter; foreign substances, etc.; particulars in regard to each. _Entozoa_—number and character. 3. _Mucous membrane_—general condition; congested, inflamed, ulcerated. Orifice of bile duct. _Brunner’s glands_—inflamed, enlarged or ulcerated. _Peyer’s patches_—number, situation, general condition, ulceration, etc. 4. _Cæcum_ with _appendix vermiformis_—length, contents, ulcers, perforations, etc. 5. _Rectum_—prolapsus, hæmorrhoids, fistulæ.]
=Malformations.= The intestine is sometimes defective in some part of its course, most usually near its lower extremity, and generally accompanied with an imperforate condition of the anus, (_atresia ani_.) This latter may be of various degrees, consisting sometimes in a simple closure of the anus by a continuation of the integument over it; in other cases the rectum terminates in a blind pouch at a greater or less distance from the anus.
Sometimes the intestine is unusually short, without any distinction as to size between the large and small intestines.
It may terminate at the umbilicus, or in a cloaca common to it and the genito-urinary organs.
Finally, it may consist of several detached cœcal portions.
Andral notes the following malformations:—A single straight canal from the termination of the œsophagus to the commencement of the rectum; a double duodenum; two colons; an unusually large, and at same time, double appendix vermiformis.
Diverticula are not unfrequent. They are cœcal appendages, resembling the finger of a glove, one or more in number, varying in length from a few lines to several inches, and giving off at various points. Like the appendix vermiformis, they may become a source of danger by affording a lodgement for indigestible matters.
In very rare instances the position of the intestines has been found completely transposed, with a corresponding transposition of all the abdominal viscera, or of only one organ.
=Inflammation.= Vascular injection by itself cannot be taken as a decisive proof of the existence of inflammation. Obstruction to the free return of blood by the veins, during life, and the gravitation of blood to the most dependent parts, after death, especially after fevers, can and do produce this very marked injection. In general, however, the smaller and more isolated the patch of injection is, the more likely it is to be inflammatory in its origin.
_Catarrhal inflammation_ may be either acute or chronic, and may either attack the mucous membrane uniformly, or be developed mainly in the villi and follicles.
In the _acute_ form: “There is more or less intense redness and injection of the mucous membrane, affecting its entire surface, or appearing as punctiform reddening from affection of the villi, or as a vascular halo surrounding the follicles; relaxation of the tissue, and intumescence of the mucous membrane, equally affecting the entire surface, or only the villi and follicles; opacity of the mucous membrane and its epithelium, from infiltration of the former and softening of the latter; friability and softening of the mucous membrane. The submucous cellular tissue is injected, relaxed and infiltrated with a watery opaque fluid; the secretion is at first copious and serous; as the affection increases in intensity it becomes opaque, viscid and puriform.”
In the _chronic_ form, besides the above signs, we have also a dark, rusty, livid discoloration, sometimes pervading the entire mucous membrane; the mucous membrane and its follicles are swollen, the tissue has become more dense, and the surface covered with an opaque, grayish-white, or puriform mucus. Polypoid excrescences are sometimes found upon the mucous membrane.
Both the large and the small intestines may be affected by catarrhal inflammation, although the chronic form seems to occur more frequently in the large.
The muscular coat of the intestines is also sometimes the seat of inflammation, rarely if ever, however, as a primary disease, but by extension from the serous covering or mucous lining.
_Croupous Inflammation._ The mucous membrane is also subject to a chronic or sub-acute form of inflammation resulting in the production of an exudation much resembling that of croup. Sometimes it forms in a layer of some thickness, pretty uniformly over the surface, or appearing in the stools as tubular casts of the intestines; sometimes it is very thin, or consists of mere shreds. The anatomical changes observed will be similar to those just noticed.
_Perityphlitis_ is an inflammation of the loose areolar tissue around the cœcum, occurring primarily or in consequence of typhlitis. If not checked, it ends in the formation of abscess in the right iliac fossa, which may discharge either into the neighboring viscera, or externally through the abdominal walls, mostly near Poupart’s ligament.
_Peripractitis_ is an inflammation of the areolar tissue around the rectum. The resulting abscess discharges either externally, back of the anus, or in the perineal region, or internally into the rectum, or more rarely into the bladder, the vagina, the uterus, or into some other part of the intestines. Fistula in ano, frequently originates in this manner.
=Ulceration.= Ulceration may occur as the result of inflammations both catarrhal and croupous, and whether commencing in the mucous or the muscular layer, the ulcers may perforate the intestinal walls and give rise to an escape of the contents; or the ulcers may cicatrize with the formation of the usual fibroid tissue, which, by subsequent contraction, may give rise to puckering or obstruction.
_In follicular ulceration_ of the colon, after lientery or tedious diarrhœa, the follicles are at first tumefied, and project as smaller or larger, round, conical nodules on the internal surface of the intestine, surrounded by a dark red vascular halo. Ulceration takes place in their interior; an abscess with red, spongy walls appears; the follicle is eaten away, and an ulcer of the size of a pea or lentil is formed. The mucous membrane is extensively destroyed, and with great rapidity. The disease is always confined to the colon, but when it runs a very rapid course, it may be accompanied with catarrhal inflammation of the small intestines.
_Typhus ulcers._ In continued fevers where the disease especially attacks the intestines, we find an ulceration of Peyer’s patches and the solitary glands, which is called _typhus ulceration_ by Rokitansky, and is thus described by him:—“After a preceding hyperæmia around the solitary follicles, and in and around Peyer’s patches, there is an enlargement of the glandular structures, followed by a softening and breaking down of the glandular mass. The cavity remaining on the mucous membrane after the discharge of this mass constitutes the typhus ulcer. Its form is elliptical, if a large patch has been destroyed; round, if a smaller patch or a solitary gland has been destroyed. Partial destruction of a patch will produce an ulcer of irregular shape. The size varies also, according to the amount of ulceration.”
The margin of the ulcer is invariably formed by a well defined fringe of mucous membrane, which is a line or more wide, detached, freely movable, of a bluish-red, and subsequently of a slaty or blackish-blue color. The base of the ulcer is formed by a delicate layer of submucous tissue, which covers the muscular coat. The lower third of the small intestine is most liable to be involved in the ulcerative process, the number and size of the ulcers increasing as they advance toward the ileo-cœcal valve.
_Dysentery_ may also produce extensive ulceration of the colon, with considerable loss of substance. This loss may be repaired by cicatrization. In some cases, the cicatrix tissue, condensed into fibrous bands, forms projections into the cavity of the intestine, and not unfrequently encroaches upon its calibre in the shape of valvular or annular folds, giving rise to stricture of the colon.
=Dilatation.= Disease of the nervous centres, inflammation of its serous tissue, or simple atony of the muscular fibres, may be the cause of inaction of the intestine and consequent distension. Stricture will also produce distension above itself, by an accumulation of the contents of the intestine. In these latter cases, the dilatation is often enormous.
=Contraction= of the intestines may occur throughout a considerable extent, or in a very small part.
In the former case, it results from the canal having been for some time empty, and is most likely to occur below a stricture. It can hardly be considered in itself a morbid condition.
The second kind of contraction or constriction, is generally morbid, and may result either from external pressure by tumor or otherwise, or from a disease of the tissue itself. The cicatrices of ulcers which have assumed an annular shape, are the most frequent causes of stricture originating in the intestine itself.
=Displacements.= The most common of these constitute the various forms of hernia.
1. _Inguinal Hernia._ Here the intestines escape by the inguinal canal, and it is _Scrotal_ in man, when they descend into the scrotum, and _Pudendal_ or _Vulvar_ in woman, when into the labia majora.
2. _Crural_ or _Femoral Hernia_; when the intestines escape by the crural canal.
3. _Hernia at the Foramen Ovalis_; when the viscera escape through the opening which gives passage to the obturator vessels.
4. _Ischiatic_ or _Sciatic Hernia_; when it takes place through the sacro-sciatic notch.
5. _Umbilical Hernia_; when it occurs at or near the umbilicus.
6. _Epigastric Hernia_; occurring through the linea alba, above the umbilicus.
7. _Hypogastric Hernia_; when it occurs through the linea alba, below the umbilicus.
8. _Perineal Hernia_; when it occurs through the levatorani and appears at the perineum.
9. _Vaginal Hernia_; occurring through the parietes of the vagina.
10. _Diaphragmatic Hernia_; when it passes through the diaphragm.
A more detailed description of hernia belongs to works on surgery.
A hernia, if not reducible, may, by becoming strangulated, give rise to constipation, hiccough, vomiting, and all the signs of violent inflammation. Gangrene supervenes, with alteration of the features, small pulse, cold extremities, and death.
=Incarceration=, is a form of mechanical obstruction of the bowels, differing from hernia, in there being no escape of the intestine from the abdominal cavity, as in the latter case. It may arise in various ways, but the most frequent form is that in which a portion of intestine becomes constricted by means of fibrous bands which have formed as a result of peritoneal inflammation. Passing from one portion of the intestines to another, or from the intestines to the abdominal walls, a loop of bowel may slip beneath or between these bands, and become so compressed, as to interfere with the passage of the contents, and result in great dilatation of the gut above the point of stricture. Complete strangulation may finally result, and the patient die with symptoms of mechanical obstruction.
Another, but less frequent form of incarceration, is where a portion of intestine slips through the foramen of Winslow, or through a congenital opening in the mesentery, as in the following
CASE:—_Death from Strangulation of the Bowel, from becoming Incarcerated in an opening in the omentum_.
Mary H——, aged five years, was taken suddenly with great pain in the bowels at 2 o’clock A. M., having retired the night before in perfect health. Vomiting soon set in, accompanied with great thirst, and the whole body became bathed in a profuse cold perspiration. The severe pain continued, and the vomited matter became stercoraceous. I saw the case at 10 o’clock A. M., and then found the child in a moribund condition. The breathing was rapid; pulse very small and frequent; skin pale, damp and cold; eyes sunken and nose pinched. Rapidly sinking, she died at 12 M.
Autopsy twenty-four hours after death. Upon opening the abdominal cavity, a large portion of the intestines was found of a dark purple or black color, while the remainder was perfectly natural in color. Upon lifting the bowels and exposing the mesentery, there was found an opening in the latter, of sufficient size to receive the thumb, and through which a large portion of the small intestines had become crowded, producing such a twist in the border of the mesentery as to have produced complete strangulation of the bowel, which had rapidly passed into a gangrenous state, resulting in violent shock and death in less than twelve hours.
The opening was situated at about one inch from the intestinal border of the mesentery, and was plainly congenital in its origin, as indicated by its smooth and rounded edges.[21]
Another form of obstruction is sometimes found, and known as
=Volvulus=, in which a loop of bowel, generally of the small intestines, becomes twisted upon itself, the constriction at the base of the loop, finally resulting in complete closure.
=Intussusception=, or invagination of the bowels, consists in the slipping of a portion of intestine into itself, and generally from above downwards. Either the large or small intestines may be found in this condition, but it is much more frequent in the lower portion of the small bowels. From a few inches to a foot or more of the bowel may thus become slipped into itself, and it may be found at more than one point.
From the constriction which must necessarily attend such a displacement, congestion with hæmorrhage may result, or peritoneal inflammation, gangrene, and death, with symptoms of mechanical obstruction. In some rare cases, the inner or invaginated portion of the bowel sloughs off, adhesion takes place at the point of commencement of the intussusception, and the patient recovers.
This form of displacement may be found in both children and adults, where the appearance of the parts are such as to render it apparent that it had not been a source of trouble during life.
=Rupture= of the intestines may result from severe injury by blows, or from a crushing force applied to the abdominal walls.
_Penetrating wounds_ of the bowels may be followed by escape of the intestinal contents into the peritoneal cavity, acute peritonitis, and death. If the bowel be empty at the time, adhesions may form between the adjoining parts, the wound thus closed, and recovery follow.
_Prolapsus_ of the rectum consists in a protrusion of the mucous membrane or entire walls from the anus. The only post-mortem change that may be detected is a relaxed condition of the coats of the bowel, with congestion of the mucous membrane.
=Diseases of the Anus.= These include _ulcer and fissure_ of the _anus_, _fistula in ano_, and _hæmorrhoids_.
_Ulcer, and fissure_ of the anus, usually accompany each other, though either may exist alone. The ulcer, when present, is found just within the anus, while the fissure extends from this across the edge of the sphincter. While these affections are trifling in their post-mortem appearance, they are of great importance from the local trouble and constitutional irritation which they may produce during life.
_Fistula in ano_, consists in the presence of a false passage along side the rectum, usually the result of a small abscess in the ischio-rectal fossa. It is said to be _complete_ when it opens at one end into the bowel, and at the other through the integument near the anus; and _incomplete_, when it has but one opening, whether that be on the surface or in the rectum.
_Hæmorrhoids_ will be noticed under the head of
Morbid Growths.
=Cancer=, in its various forms, may be found in connection with the intestines, where it is usually primary in its origin. The scirrhus form is more frequently met with in the rectum, and is likely to involve the whole circumference of the passage. From the tendency which this form has to contract the parts, stricture of the rectum is likely to result, which may become a source of great suffering, and finally of death. Other forms of cancer may be found in any portion of the intestines; the colon and rectum, however, being their more frequent location.
Cancer of the intestines is very liable to extend to the surrounding tissues and organs, and in many cases, perforations of the bowel, or fistulous communications between the rectum and bladder in the male, or uterus or vagina in the female, may result.
=Tubercles=, generally of the miliary form, may be found within the coats of the intestines, principally confined to the peritoneal covering however. They may occasionally be found in the mucous coat, and in the walls of follicular ulcers of that membrane.
=Tumors= of various kinds may be found in connection with the intestine.
_Fatty tumors_ may originate within the mucous membrane, and project as polypoid growths into the cavity of the bowel; or they may commence in the appendices epiploicæ, and degenerate into a cystic tumor with fluid contents, or become infiltrated with calcareous matter; or the pedicle may become atrophied and the tumor detached, and found free in the peritoneal cavity.
_Adenoid tumors_ may result from hypertrophy of the several forms of glands of the intestines, and appear as soft, rounded, and perhaps pedunculated tumors, which are liable to become ulcerated.
_Fibroid tumors_ of small size and polypoid form, may be found in any part of the intestines, and are generally considered as a result of chronic inflammation.
_Hæmorrhoids or piles_, consist in a dilatation of the veins of the lower portion of the rectum, with a thickening of their walls, and increase of surrounding fibrous tissue. They may be internal or external. The contained blood may coagulate forming a thrombus. The walls may rupture, giving rise to hæmorrhages, or become inflamed and suppurate.
_Abnormal contents._ The normal contents of the bowels may be found mixed with the various products of inflammation, including mucus, serum, blood and pus.
Biliary calculi and foreign bodies of various kinds, may be found, which may have produced no effects, or they may have served as nuclei, around which the salts of lime, bile, mucus, fæcal matter, etc., may have accumulated, producing intestinal concretions.
=Parasites.= The intestinal canal is infested by several forms of entozoa, among which may be found the following:
_Ascaris lumbricoides_; the common round worm, six to ten inches in length. It may be single or in large numbers.
_Oxyuris vermicularis_; a small white worm, measuring from two to four lines in length, and found only in the large intestines, and mainly in the lower part of the rectum, where they may be present in large numbers.
_Trichina spiralis._ This parasite is found in the small intestine, and only in its adult form. It measures from less than a line, to two lines in length. The embryos penetrate the walls of the intestine, and finally locate in the muscles, where they remain encapsulated. If a portion of this muscle is eaten by another animal, the larvæ again become active, and acquiring the mature sexual form, reproduce, the young embryos again migrating to the muscles.
_Tricocephalus dispar._ Found only in the head of the colon, and measures one and a-half to two inches in length; neck long, and body of male covered with wart-like appendages on one side.
_Distoma lanceolatum._ Flat, lancet-shaped, and transparent, a-half inch long, one-quarter wide. Rarely found in upper portion of small intestines, natural habitat appearing to be in the bile passages.
Of tapeworms, the following varieties may be found:
_Tænia solium._ Head about the size of a pin-head, and furnished with sucking disk and double row of hooks; neck long and narrow; body flat and jointed, each segment about a-half inch in length; body may be from ten to fifty or more feet in length.
_Tænia mediocanellata._ Head truncated and destitute of hooks; body jointed and of great length.
_Tænia flavopuncta._ Very rare. Yellow spot at the middle of each joint.
_Bothriocephalus latus_, (broad tapeworm.) Head long, unarmed; neck inconspicuous; body composed of about two thousand joints; mature joints broader than long.
Section IV. THE PANCREAS.
[=Notice= in examination:—1. _External characters_—malformations; position; size; form; adhesions. 2. _Substance_—color; consistence; wounds; abscess; tubercular deposits; cancer; cysts. 3. _Ducts_—calibre; contents; pus or blood, etc.]
=Anomalies= of the pancreas are not common. It is wanting only in very imperfect monstrosities. Excess of development is very rare.
Sometimes the duct is double, up to the point of its entrance into the duodenum.
=Hypertrophy and Atrophy.= The former, when it does occur, which is rarely the case, affects chiefly the cellular tissue which is interwoven with the glandular tissue.
Atrophy often occurs spontaneously in old age, or it may result from chronic inflammation or fatty degeneration. The organ may be soft, or of a leathery consistence.
=Inflammation.= The acute form rarely occurs, and is marked by the same signs of inflammation as are observed in inflammation of similar organs.
“Chronic inflammation induces condensation, induration of the cellular tissue, obliteration of the acini, and either permanent enlargement, or subsequent atrophy of the gland.”
=Fatty Degeneration= is of frequent occurrence in drunkards, associated with fatty liver, but due to the intrusion of the surrounding adipose tissue on the wasting organ.
=Dilatation= of the ducts of the pancreas occurs from an obstruction of its outlets by pressure of a tumor, or by the presence of calcareous concretions. The dilatation may be uniform or saculated, forming cysts which may attain a considerable size.
=Cancer=, only in the forms of scirrhus and encephaloid, affects generally the head of the pancreas. It may occur primarily or secondarily. The ductus choledochus is frequently obstructed by the pressure of the tumor, and jaundice produced. The disease may extend to the duodenum, the omentum, the mesentery, liver, and even the suprarenal capsules and kidneys. As secondary cancer, it is most frequently an extension from a scirrhus pylorus.
Section V. THE SPLEEN.
[=Notice= in examination: 1. _External characters_—color, size, weight, form, adhesions; surface smooth or rough; capsule thickened, etc. 2. _Substance_—color; consistence; wounds; rupture; abscesses; tubercle; cancer; degenerations; tumors, etc.]
=Congenital Anomalies.= In acephalous monsters the spleen is generally absent. Occasionally in subjects otherwise well developed, it is wanting, together with the stomach or the fundus of the stomach.
Congenital displacements have been met with.
Supernumerary spleens, varying in number and small in size, are frequently met with.
=Hypertrophy and Atrophy.= Probably no organ of the body is as liable to such great variations in size as the spleen. The normal spleen in the adult, in whom it attains its greatest size, is usually about five inches in length, three to four in breadth, and an inch or an inch and a-half in thickness, and weighs about seven ounces. Its size is increased during and after digestion, and varies considerably according to the state of nutrition of the body. In typhus the spleen is enlarged, the parenchyma exceedingly soft, its color a dirty red, of different shades. In leukæmia it is also found greatly enlarged, but of a denser consistence. Rokitansky states that the spleen not unfrequently measures sixteen inches in length, seven in breadth, and four inches in thickness, and its weight may amount to twelve or fourteen pounds, or, according to others, to twenty or even forty pounds. (Huschke.)
Most of the hypertrophies of the spleen are accompanied not only by an engorgement of the very numerous vessels, but by an alteration and increase of the red, pulpy parenchyma.
_Atrophy_ may reduce the spleen to the size of a hen’s egg or a walnut. It takes place normally in advanced age.
=Displacements.= Some of these are congenital: thus it has been found by the side of the bladder; in the right side of the thorax; in the left thoracic cavity when the diaphragm was absent; and external to the abdomen in large umbilical herniæ, or where the abdominal walls had not closed.
Other displacements are the result of disease. The enlargement or distension of adjacent parts, or increase in its own size with laxity of its ligaments, causes it frequently to be displaced, and even to descend into the pelvis.
=Rupture= occasionally happens as the result of injuries. Spontaneous rupture in intense congestions during typhus, cholera, and the cold stage of ague, has occurred. This always proves fatal.
=Inflammation.= _Primary_ inflammation of the spleen is comparatively rare. Unless it ends in resolution, it gives rise to the formation of laudable pus or fibrin, which may either be contained in a circumscribed abscess, and thence become obsolete, or the cavity may enlarge until the pus penetrates into the left thoracic cavity, the stomach, the transverse colon, or the peritoneum.
_Secondary_ splenitis is regarded as identical with pyæmic deposits. The deposits are well defined, always at the periphery, cuneiform in shape, the apex directed inwards. Their color is darker than the surrounding tissue, and their consistence firmer. They are either converted into a cellulo-fibrous callus, which contracts and causes a cicatrix in the surface; or “into a puriform, creamy mass; or into a sanious greenish, greenish-brown, or chocolate-colored pulp.” There are also fibrinous deposits frequently found in the parenchyma of the spleen, classed by some among the phenomena of secondary splenitis, but regarded by others as a simple exudation of fibrin, from an excess of this in the blood. These deposits appear as a circumscribed yellowish mass, with a margin of darker or lighter red congestion of increased consistence, easily recognized when handling the part, “and showing under the microscope a confused mass of granular with more or less oily matter infiltrated among the remains of the parenchyma. They very commonly undergo fatty degeneration.”
=Chronic Thickening of the Capsule= of the spleen is of frequent occurrence. It seems to take place at the expense of the parenchyma of the organ, and may proceed to a very great extent. It is usually pretty uniform. Ossification of the thickened fibroid layers is rare, except in old persons.
=Amyloid Degeneration of the Spleen.= The disease may be limited to the Malpighian corpuscles, constituting the so-called “sago spleen,” or it may extend and implicate the pulpy parenchyma between the corpuscles.
The sago spleen is more or less enlarged; its weight and density are increased. On section, the surface appears smooth, dry, and studded with glistening sago-like bodies, varying in size. An iodine solution gives them a reddish-brown color.
In the more advanced stage, where the pulp is infiltrated with the new material, the organ generally is much larger than in the sago spleen. It is hard and firm; the capsule tense and transparent. The cut surface is dry, homogeneous, translucent, bloodless, of a uniform dark, reddish-brown color. The organ can be cut like wax. The corpuscles are obscured by the surrounding pulp.
Morbid Growths.
_Tuberculous matter_ is commonly deposited in the spleen, only in connection with general tuberculosis. It appears in the form of gray granulations, miliary crude tubercles, or yellowish cheesy masses of various sizes.
_Cysts_ have been observed in the capsule of the spleen. They are small, of conical shape, and lightish red color, containing numerous granular cells, floating in a transparent liquid.
_Hydatid cysts_ may be found in the spleen alone, or at the same time with one in the liver.
_Cancer_ is rare. The encephaloid is the only form met with, and generally only with similar disease in the liver, stomach or omentum.
Section VI. OF THE LIVER.
[=Notice=: 1. _External characters_—relation to other organs and extent uncovered by cartilages of ribs; _adhesions_—their extent, position, firmness, etc. 2. _After removal_—weight; measurements; form; color; puckerings; rough or smooth; granulations; tubercles; cysts, etc. _Capsule_—thickness, transparency; facility of removal; appearance of liver substance beneath. 3. _Internal structure_—appearance of cut and fractured surfaces; fluids expressible; appearance of lobules; abscesses; fistulæ; calcareous deposits; tubercles; growths; cysts; wounds; rupture, etc. 4. _Gall-bladder_—absent; size; shape; adhesions. _Cavity_—obliterated. _Contents_—bile; quantity, color, consistence; mucus; pus, etc. _Gall-stones_—number, size, form, color, internal character. _Walls_—thickness; deposits; adipose or calcareous; abscess; tubercle; cancer; wounds; rupture. _Ducts_—calibre; dilated or contracted; impervious; from what cause? contents; condition of walls and mucous membrane.]
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.”[22]
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,[23] 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.[24]
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.[25]
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.[26]
_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.[27]
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.[28]
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.[29]
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.