c. Atrophy of the liver is a condition of the nutritive functions of the organ which may succeed chronic inflammation or even hyper trophy ; it occurs more rarely than hypertrophy, to which its comparative frequency has beeu estimated by Portal as 5 to 93. The substance of the liver diminishes in bulk, the lobules become indistinct and variously congested, and they appear intermingled and pressed upon by the cellular structure with which they are surrounded. Sometimes the proper structure of the liver is entirely removed and replaced by a loose or condensed cellular tissue. At other times the entire substance of the organ appears to have been absorbed by an enormous abscess, which has evacuated its contents into the intestinal canal, and the parietes have after terwards contracted and degenerated into an atrophied mass. Lieutaud gives an account of a liver that was shrivelled into a mass not larger than his fist. Portal found the liver in a case of ascites not bigger than an apple of ordinary size. Partial atrophy of the liver conjoined with hepatic venous congestion is not an infrequent consequenceof the practice of tight lacing. I have before me a very interesting speci men of this affection. The surface of the Imcr is marked by deep fissures into irregular poly gonal divisions resembling very strikingly the lobulated appearance of the fcetal kidney. In one situation the stages of this change are dis tinctly apparent ; a certain portion of the organ, about half an inch in breadth, has become partially atrophied from the pressure of two adjoining and protuberant portions of the liver, and in the lobulated portion the hepatic sub stance of this atrophied mass has been com pletely removed by absorption, leaving a kind of condensed cellular cicatrix extending like a septum for some distance into the organ. It is in this way that many of the grooves and fissures upon the convex surface of the liver are formed.
But the most interesting form of atrophy of the liver is that which was named by Laennec cirrhosis. In cirrhosis, the liver is diminished in volume to the extent of one-half or one third of its natural bulk, the relative size of the right and left lobes is destroyed, and the surface is rendered shapeless by the projection of a number of ridges or granular points. The entire organ appears wrinkled and shrivelled, and of a yellow or greenish colour, varying in tint from a bright chrome to a yellowish or greenish brown. Upon dividing it with a knife it is observed to be more dense than usual, and the surface of the section presents a number of patches of variable size and of a roundish form, which resemble granules; henc this condition of the organ is named by th French authors " foie granuleux." In an ad vanced stage it is accompanied with jaundic and ascites, and is frequently preceded by sonid disease, either of the lungs or heart.
Kiernan is, I believe, the first pathologist who distinguished the true nature of cirrhosis, which he called atrophy of the liver. A very interesting case of this disease occurred in St. Bartholomew's Hospital, under the care o Dr. Latham, in 1832, an account of which was published in the Lancet in November of that E year. The patient died with jaundice and ascites. The liver, eportion of which I pos sess, presented a fine specimen of granulated cirrhosis ; it " was diminished to one-half its natural size, and Mr. Kiernan on injecting it, discovered that a collateral venous circulation had been established by way if the diaphragm." In another case in a woman who had been tapped ninety times, Kiernan upon injecting the liver found that the same kind of collateral circulation had been formed. The circulation
through the liver had been impeded by the developement of condensed cellular tissue, and the greater part of the blood of the portal vein had made its way through dilated vessels upon the surface of the organ to the diaphragm, and from thence into the general venous circulation. In this case there were numerous bands of ad hesion between the liver and diaphragm, and between the intestines and the walls of the abdomen, and these also were traversed by large veins conveying blood from the portal vein into the general venous current.
With regard to the pathological riature of the disease many opinions have been enter tained by different writers. Laennec, dazzled by an ingenious theory deduced from his ob servations upon the nature and progress of scrofulous tubercle, saw in the mottled and granular section of cirrhosis only a " morbid deposit," a special accidental tissue existing in the two states of crudity and softening. But I quote the words of this author as detailed by Farms,* for while he errs in his speculations with regard to the nature of the disease, he draws an excellent picture of its general cha racters and appearance. " Les cirrhons ex istent dans l'etat de erudite et de ramollisse ment. Dans le premier de ces etats elles presentent un tissu d'une couleur fauve plus au moins foncee, qui quelquefois tire un pen sur le verdatre ; on ne peat s'en faire une meilleure idee qu'en la comparant celle qu'offrent les capsules surrenales chez l'adulte Ce tissu, quoique fort consistant, a une sorte de flaccidite que je ne puffs mieux comparer qu' celle de certain fongus, ou d'un cuir mou Le tissu des cyrrhoses est d'ailleurs compact assez humide et tres-delie. On n'y distingui aucune trace de fibres, quoiqu'il presence et terrains cas des divisions en forme de squames Les cyrrhoses prennent en se ramollissant un i couleur plus brunatre." " Laennec admet trois sortes de cyrrhoses cyrrhoses en masses • 20. en plaques 3°. en kystes. Lorsqu'il existe, dit-il, de cyrrhoses dans le foie, elles Torment ordinaire meat de petites masses dont le volume n surpasse jamais celui d'un noyau de cerise, quelquefois egale peine mint d'un gros grai de millet. Ces masses sont toujours extreme went nombreuses, et tout le tissu du foie e est par: eine. Leur petitesse fait que lorsqu'o incise un foie dans lequel it en existe un gran nombre, son tissu parait an premier coup d'ce homogene et d'une couleur Janne fauve. Ma si on examine plus attentivement le tissu hept tique, on s'apercoit facilement qu'il est Temp d'une innombrable quantite de corpuscules assez semblables, pour l'aspect a ces lobules de graisse durcie et roussektre que l'on trouve communement dans le tissu cellulaire sous cutane de la cuisse et de la jambe des sujets attaques d'anasarque. Ces petites masses sont quelquefois unies trbs-intimement an tissu du foie ; mais assex sou vent elles en sont separees par une couche mince de tissu cellulaire qui leur forme une enveloppe tenue, et alors ils se detachent assez facilement. La surface ext.& rieure du foie devient Mule, rugueuse, et mtatinee a-peu-pres de la mane maniere qu'arfrpomme fletrie." Bouillands considers this condition of the liver a dissociation of the two natural elements of the organ : " les masses jaunes fauves con stituant le tissu accidentel, appele cirrhose, ne sont autres chose que les granulations secre toires se desorganisant graduellement par l'effet de l'obliteration du !acts vasculaire, et de l'obstacle a la circulation hepatique qui en resulte." We have already combatted the ex istence of two substances, and further remark upon this subject must be quite unnecessary.