CIRRHOSIS OF THE LIVER.
Definition.—Suggested by Laennec as a name for one particular condition of the liver, the term "cirrhosis" was not only found to be of immediate utility, but, like many other useful words, has rapidly acqnired secondary meanings, and unfortunately the pathologist and the clinician disagree in the secondary meaning which they assign to the term. Hence a definition of "cirrhosis" satisfac tory to all parties cannot well be given. In short, the word, by becoming too use ful, threatens to outlive its usefulness. The pathologist employs it to indicate all those conditions in which there is a generalized, as opposed to localized or focal, development of increased amounts of fibrous tissue in the organ; the clini cian recognizes as included in the term all those conditions characterized by con nective-tissue overgrowth in connection with the liver, whether the overgrowth be focal or general, whether it affect the interior of the organ or the peritoneal capsule, and urges in favor of this view that all these conditions may give rise to a like series of symptoms; while, on the other hand, he is unwilling to include under the terms such forms of connect ive-tissue overgrowth as give rise to no recognizable symptoms. According to this view, the gummatous liver of tertiary syphilis is cirrhotic, as is also the condi tion of chronic productive perihepatitis in which the capsule alone is affected, while the development of fibrous tissue in the centres of the lobules which may accompany chronic venous congestion of the organ is not to be classed as a cir rhosis.
Remembering that Laennec employed the word in association with a general ized fibrosis of the organ, and not to in dicate the complex of symptoms induced by this condition, and recognizing, also, that it is impossible to restrict it nowa days to the one form which he described, the definition accepted by the patholo gists more nearly approaches the original acceptation of the term, and will be ad hered to in this article. At the same time, adequate reference will be made to such conditions as are not included in that definition, but which are regarded as cirrhosis by a large number of clini cians.
Classification.—Starting, then, with
this definition, and including under the term all those states in which there is a generalized overdevelopment of connect ive tissue throughout the liver, it will be well, before attempting any classi fication, to pass in review the factors which primarily induce this overgrowth.
Our knowledge of the causes leading to fibrosis elsewhere, imperfect as it is, leads to the belief that inflammation is the main factor,—not acute, but, as it is termed, "productive." It may be brought about by the action of a mild irritant extending over a relatively-long period, or by the recurrent action of a somewhat more severe irritant. In either case there is a stimulus afforded to the proliferation of the connective-tissne cells of the part—and the new growth corresponds to the granulation-tissue seen in a healing exposed wound. A prominent feature in fibroid tissue of this nature is its liability to contract. It would appear that in the commonest form of cirrhosis, the portal, or atrophic, this is the main process at work, the irritant reaching the liver by the portal vein and especially manifesting its ac tivity by setting up an irritation along the interlobular branches of that vein.
This, however, is not the only form of inflammatory fibrosis. There may be a new development of connective tissue—a replacement fibrosis—to take the place of cells of a higher order, which, through the action of some irritant or disturb ance, have undergone destruction, and it is still a matter of debate whether, in portal cirrhosis even, such replacement fibrosis is not largely concerned in the new growth. Of more recent observers Sieveking, examining twenty atrophic cirrhotic livers by the Van Gieson method of staining, concluded that the connective-tissue growth was the first disturbance. Markwald came to the op posite conclusion: that necrosis of the peripheral liver-cells is the first event in the disease; and Ruppert describes both productive formation of connective tissues and inflammatory atrophy of the liver-cells. Personally I cannot but re gard this last view as the one most in harmony with the appearances seen in the majority of cases of well-defined portal cirrhosis.