This is a chronic fibrosis not obvi ously dependent upon inflammation in the majority of cases. Ac cording to the distribution of the adventitious fibrous tissue, multilobular (atrophic), uni-lobular (hypertrophic), and inter cellular varieties are recognized. The commonest causes are alcohol and syphilis, but probably bacterial toxins are effective in certain cases. As the fibrous tissue undergoes the gradual con traction to which it is liable, liver cells are destroyed by pressure atrophy, thus inducing digestive disorder ; bile ducts are ob structed, leading to jaundice; and the flow of blood through the liver is impeded leading to dropsy in the belly (ascites) and, secondarily, to other morbid conditions.
(hepatitis).—In a strict sense this disease is rare and usually septic and secondary. Thus blood passing from an inflamed appendix to the liver by the portal vein may carry pyogenic organisms and lead to a widespread and suppurative thrombosis in the liver (pyle-phlebitis), or the liver may be affected along with other parts in pyaemia or suppurative blood-poisoning. In tertiary syphilis the specific inflammation may manifest itself by the formation of a gummatous mass in the liver. Under treatment with potassium iodide the gumma may be absorbed, leaving merely a puckered scar.
Apart from that form of suppuration men tioned in the last paragraph, hepatic abscess is especially common in persons from the East who have suffered from amoebic dysen tery, and is usually single and large. In addition to local pain and tenderness, there is a high temperature, accompanied with shiver ings or occasional rigors, the patient becoming daily more thin and miserable. Sometimes the abscess declares itself by a bulging at the surface, but if not, an incision should be made through the belly-wall over the most tender spot and a direct examination of the surface of the liver made. A bulging having been found, that part of the liver which apparently overlies the abscess should be stitched up to the sides of the opening made in the belly-wall, and should then be explored by a hollow needle. Pus being found, the abscess should be freely opened and drained. It is inadvisable to explore for a suspected abscess with a hollow needle without first opening the abdomen, as septic fluid might thus leak out and infect the general peritoneal cavity. If a hepatic abscess is in
judiciously left to itself it may eventually discharge into the chest, lungs or belly, or it may establish a communication with a piece of intestine. The only safe way for an abscess to evacu ate itself is on to the surface of the body.
These growths are often met with in the liver, particularly in Australia. They are due to a development of the eggs of the tape-worm of the dog, which have been received into the alimentary canal with infected water or uncooked vege tables, such as watercress. The embryo of Taenia echinococcus finds its way from the stomach or intestine into a vein passing to the liver and, lodging there, becomes surrounded by a capsule of fibrous tissue. Inside this wall is the special covering of the embryo, which shortly becomes distended with clear hydatid fluid. The cyst should be treated like a liver-abscess, by incision through the abdominal or thoracic wall, by circumferential sutur ing, and by exploration and drainage.
These may be innocent or malignant. The commonest innocent variety is naevus. The commonest form of malignant tumour is the result of the growth of cancerous elements from the breast along the round ligament, or brought to the liver by the veins coming from a primary focus of the stomach or large intestine. Occasionally cancer is primary in the liver. Active surgical treatment of such a tumour is out of the question. Fortunately it is, as a rule,-painless.
The gall-bladder may be ruptured by external violence and then should be removed surgically or peritonitis will be set up.
Biliary concretions, known as gall-stones, are apt to form in the gall-bladder. They may be composed of cholesterin or of , bile pigments combined with calcium and are deposited from an organic basis such as a collection of epithelial cells or of bacilli in a slightly abnormal gall-bladder. Sometimes, in the course of a
examination a gall-bladder is found full of gall stones, which during life had caused no inconvenience and had given rise to no suspicion of their presence. In other cases gall stones set up inflammation (cholecystitis), which may go on to abscess. As the result of long-continued irritation the gall bladder may become the seat of cancer.