In every case of secondary abscess in the liver, following wounds of the head, or after amputation or operations upon bones, Cruveil hier has found phlebitis of the vessels situated in the structure of the bones. Hence he esta blishes an important general proposition, that " le phlehite des os est une des causes les plus frequentes des absces visceraux suite des p]aies et des operations chirurgicales dans lesquelles ces os ont 60. int6ress6s." The re moval of hemorrhoids and operations upon the uterus are sometimes followed by abscess of the liver, a circumstance which is easily expli cable upon the principles so clearly demon strated by this author.
An excellent instance of secondary abscess of larger size than usual has been kindly fur nished to me by my friend and colleague Mr. Rutherford Alcock, who, from his official posi tion in Spain and Portugal during the recent struggles, has had much experience in injuries to the head. A man received a bayonet wound in the scalp, and died upon the fourteenth day after his admission into the hospital. Upon inspection there was observed thickening of the dura mater and a small quantity of matter upon the pia mater. No pus was discovered in the lungs, but a large abscess was found occupying the greater part of the right lobe. A statistical report from a work upon gunshot wounds by the same author is also interesting. Of scalp wounds, with and without abrasion, there were sixty-one; two only died, and one onlypresented disease of the liver; the other died from an attack of erysipelas." The pathological changes which take place in the liver in these cases are, in the first instance, effusion of blood and lymph and induration around the inflamed vein ; secondly, a secretion of a yellow concrete pus into the ninute veins and among the lobules, giving to the liver, as Cruveilhier remarks, a granite-like appearance. In the next place the pus collects into small abscesses lodged in irregular cells, which increase in size by continued secretion and by communication with other cells. All these collections of matter are surrounded by a congested circle, which gives them a peculiar and characteristic appearance. After having existed for some time Cruveilhier has observed that the pus becomes converted into a concrete mass, very closely resembling the matter of scrofulous tubercle.
h. Tubercle in the liver is a disease of rare occurrence, and has seldom been observed independently of the existence of similar depo sitions in the lungs and other organs of the body, and of general indications of a scrofulous diathesis. When present, it exists in the form of small rounded tubercles, generally numerous, and varying in size from that of a millet-seed to a hazel-nut. They are composed of the soft cheesy or curdy deposit which is characteristic of this disease, and have a tendency to a brownish colour. The tuberculous matter is deposited in the tissue of the lobules by infil tration, and the lobules immediately surround ing the tumours are compressed and congested. The obstruction to the circulation in the organ being general on account of the number of the tubercles, the entire liver is more or less con gested.
i. Scirrhus.—Carcinoma affects the liver under a variety of forms, but appears most frequently as tubercles of different size and consistence. These tubercles are more fre quent than those of scrofulous origin, and are generally accompanied by symptoms denoting a cancerous diathesis, and by the existence at the same time of similar tumours in other parts of the body. In their earliest development in the liver nearly all carcinomatous tumours pre sent the same characters, resembling small, whitish, semi-opaque patches,- occupying the tissue of one or of several of the lobules. As they increase in size they put on certain peculiar appearances, which have gained for them a subdivision into species and varieties. I. do not intend in this place to enter into the ar rangements proposed by authors, but will briefly describe the most striking varieties that have fallen beneath my own examination. The sim plest of these tumours has been termed scir rhtnis tubercle, a name which appears particu larly applicable from its resemblance in cha racters and structure to the same form of tu mour occurring in other parts of the body. Commencing like the carcinomatous tumour generally in a semi-opaque patch, the outline of the lobules is for some time distinctly percep tible through its area, but at a later period the centre of the patch becomes quite opaque, and presents a cartilaginous hardness nd creaking sound when divided with the knife. The cir cumference is gradually diffused in the sur rounding textures, and the progressive increase of the tumour seems to take place by the se cretion of a milky albuminous fluid into the meshes of the lobular venous plexuses. The circulation in these plexuses is at first unim peded, but by the increase and induration of the secretion it is gradually arrested, and the vessels obliterated. The obliterated vessels give rise to the appearance of small cells, in which the carcinomatous matter is deposited, and the larger area are produced by the tissue of the capsules of the lobules variously dis torted from their original form by the increased deposition. As the tumours become more and more large, white lines, formed by compressed cellular tissue, are observed radiating from the centre towards the circumference. \% hen seen upon the surface of the liver, the scirrhous tubercle appears flat, or very slightly depressed towards the centre. In a preparation of this form of tubercle now before me, the whole tumour is slightly raised above the surface; it presents no central depression, is cartilaginous in appearance, and has an irregular outline. Its section is dense and hard like cartilage, with no appearance of vessels, and of that pearly and semitransparent whiteness which is generally observed, in scirrhous tubercle, particularly in the variety which this prepara tion illustrates. Sometimes these tubers are
small and very numerous, of a yellowish o brownish colour, and have a great activity o increase; the cells in which they are contained are thick and of larger size, and the albumi nous secretion less firm than in the preceding variety. Occasionally they are reddened in the centre by the effusion of blood, from the con gestion of unobliterated vessels, and some times by the continuation, through the tumours, of dilated vessels, which supply them with nutrition. In their enlarged state they fre quently coalesce and give rise to an irregular compound mass, which assumes the form of the particular part of the organ in which it is placed, and is divided into compartments, marking its original multiple form by septa of condensed Glisson's capsule supporting dilated vessels. It would appear to be this form of tumour which has been described by Farre as the first variety of his tubes ditfusa; he gives them the following character. " Tubera, ele vated at the surface of the organ, but not uni form in their figure, some rising with a regular swell into a round form, others acquiring a margin by being gradually depressed towards the centre, tumours without cysts, almost pulpy in their consistence, cellular in their structure, and containing an opaque white fluid." Another form of the albuminous carcinoma tous tumour is the " large white tubercle" of Baillie, the tubera circumscripta of Farre, by whom they are thus admirably described : " Their colour inclines to a yellowish white, and their projecting surfaces, slightly variegated with red vessels, deviate from a regular swell by a peculiar indentation at or near their cen tres, which are perfectly white and opaque. They vary much in size, which depends on the duration of each tuber, for at its first appear ance it is very minute, but during its growth it assumes the character above described, and at its maturity exceeds an inch in its diameter. They adhere intimately to the liver, and their figure is well defined. They commonly remain distinct at the surface of the liver, but inter nally they ultimately coalesce and form im mense morbid masses which pervade its sub stance. They possess so close a cellular struc ture that the section of them at first view appears solid and inorganic ; but on the edge of the knife, by which they have been disse vered, an opaque white fluid of the consistence of cream is left, and a fresh portion of this fluid is gathered on it at each time that it is repassed over the surface of the section. Their cellular structure becomes more apparent after long maceration." The depression in the centre of carcinoma tous tumours, although generally met with, is not a necessary character of cancer. Its mode of formation has been ably pointed out by Dr. Carswell, in his beautiful work on pathological anatomy: " The depression is not observed unless when the tumour is divided or is situ ated on the surface of an organ, as the liver, where tumours of this kind are generally met with. In the former case the depression arises from the softer substance, after the division of the tumour raising itself by its elasticity above the unyielding nucleus; in the latter it is pro duced by the peritoneum adhering to the sur face of the tumour when small, and preventing its development in that direction. If the tu mour does not come in contact with the peri toneum until it has acquired a considerable size, it presents no such depression, or only a very small one. Hence the reason why, in carci noma of the liver, we meet with some tumours having a smooth globular surface, and others with a central depression of greater or less extent." Another variety of carcinomatous tumour is named the gelatiniform cancer, from the exis tence of a firm and jelly-like deposit which oc cupies the cells of the tumour in place of the albuminous secretion common to the preceding forms. I have before me an interesting speci men of gelatiniform tubercle. The liver con tains a considerable number of these tumours of variable size, and dispersed through every part of its structure. The smallest resemble the small patches described above as the inci pient stage of carcinomatous tumour ger6ally ; the largest are equal in size to a walnut. They are distinctly circumscribed, and the lobules immediately surrounding them are flattened and compressed. In the smaller tubercles the form of the lobules is quite distinct, but in the larger the lobules have yielded to the peculiar characters of the disease. On the surface the centre of the tubercle presents an oval or cir cularly indented ring, around which the tumour swells suddenly and then subsides to the cir cumference. On making a section of one of these tumours, 1 found a central area of about two lines in diameter, transparent, dense, and apparently gelatinous, and distinctly bounded by a white marginal line; the marginal portion of the section forming the bulk of the tumour was elastic, and rose above the central area to subside gradually in the marginal line of the circumference. The whole section bore a stri king resemblance to the conjunctiva affected with chemosis, only that it was paler in its colour, or to a beautiful flower with a single large and expanded circle of petals. On exa mining a thin section with a lens of low power a number of minute parallel injected capillaries were seen traversing the marginal portion of the tubercle towards the boundary line of the area, but no vessels could be traced beyond that line into the central portion. The resem blance to the petals of a flower was produced by white lines which radiated from the boun dary line of the area to the circumference, and divided the marginal portion of the tumour into six or eight compartments. From careful examination it appeared to me that the central area was a single lobule expanded by the gela tinous deposition with which its tissue was in filtrated, and the marginal compartments pre sented a similar character.