ABNORMAL ANATOMY OF THE LIVER. 



183 



union between the peritoneum propriiim and 

 the peritoneum reflexum. In this state, adhe- 

 sions are not uncommonly met with upon the 

 convex surface of the liver, but not so fre- 

 quently upon its concave side. The inflam- 

 matory action is confined to the peritoneum of 

 the organ itself, and that of the parietes of the 

 abdomen immediately in contact with it, and 

 seldom extends to the serous membrane of 

 neighbouring viscera. This is the membranous 

 hepatitis of pathological writers, and is accom- 

 panied by considerable local uneasiness, and 

 by sympathetic pains in various parts of the 

 body, dependent upon the communication of 

 its proper nerves with the nerves of other re- 

 gions, as with the phrenic nerve, giving rise to 

 pain in the right shoulder and chest, with 

 cough; with the pneumogastric nerve, producing 

 uneasiness at the cardia, pain along the oesopha- 

 gus, dysphagia and nausea ; and with the solar 

 plexus and lesser splanchnic nerve, causing 

 pain in the right kidney, &c. This disease is 

 usually associated with chronic congestion of 

 the substance of the liver, but exists, some- 

 times, quite independently of any internal 

 morbid action. 



As a consequence of chronic inflammation, 

 the serous membrane is sometimes thickened 

 and opaque and dense in its consistence ; at 

 other times it is less resisting than natural and 

 easily broken. 



Depositions are occasionally found in the 

 subserous tissue of the liver as a result of 

 chronic inflammation of the serous membrane. 

 They consist most frequently of an athero- 

 matous substance, and occasionally of thin 

 plates, having a cartilaginous density and appear- 

 ance. The gall-bladder is not unfrequently 

 thickened in its coats by the deposition of fat, 

 of tuberculous, or of calcareous substance. 

 The latter has been described as ossified gall- 

 bladder. 



2. Diseases of the mucous membrane. In- 

 flammation of the mucous membrane of the 

 liver is acute or chronic, and is more frequent 

 than that occurring in the serous membrane. 

 Being continuous with the mucous membrane 

 of the duodenum, the lining of the biliary 

 ducts and gall-bladder is constantly subject to 

 sources of irritation from disorders of diges- 

 tion, improper aliment, and stimulating sub- 

 stances taken into the alimentary canal, or from 

 any cause giving rise to undue action in the 

 intestinal mucous surface. Almost all the 

 chronic diseases of the liver are to be referred 

 to this prolific source, and it is also by means 

 of this direct continuity that many of the thera- 

 peutic remedies exert their alterative influence. 

 The effects of inflammation on the mucous 

 membrane, are 



a. Thickening. 



b. Softening. 



c. Haemorrhage. 



d. Suppuration. 



e. Deposition. 



a. Thickening of the submucous tissue is 

 the most frequent consequence of irritation of 

 the mucous membrane ; the calibre of the ducts 

 is in this way diminished ; actual stricture and 



obliteration of the tubes occurs, and the bile, 

 at first but partially impeded, becomes alto- 

 gether obstructed. The gall-bladder is some- 

 times enormously thickened, particularly where 

 the irritation is kept up by the presence of se- 

 veral or a single large gall-stone. The coats 

 are usually very much condensed and con- 

 tracted, and their structure appears lost ; occa- 

 sionally they are dilated. In a case which 

 occurred to Amussat,* wherein the ductus com- 

 munis choledochus was obliterated, and the 

 gall-bladder and ducts were very much distend- 

 ed, the middle coat presented all the characters 

 of muscular fibres. 



b. Softening of the mucous membrane may 

 occur in the biliary ducts, but more particularly 

 in the gall-bladder, and from the same causes 

 which produce it in other mucous surfaces. 

 I have seen two instances in the gall- 

 bladder in which patches of the surface were 

 converted into a softened pulp, which gave 

 way upon the distension of the sac with air. 



c. Hemorrhage. The gall-bladder has been 

 observed filled with blood, having its source in 

 the capillaries of the mucous membrane. In 

 these cases intestinal hsemorrhage had occurred 

 before death, and upon examination, no conges- 

 tion or lesion could be found in the mucous 

 membrane other than that which was seen in 

 the gall-bladder. 



d. Pun has likewise been found in the gall- 

 bladder, and in the larger hepatic ducts, some- 

 time pure, but generally mingled with the bile. 



e. Abnormal deposits in the submucous cel- 

 lular tissue are occasionally seen. They are 

 most frequent in the gall-bladder, and consist 

 generally of calcareous accretions. 



3. Disorders oj' the venous circulation.- 

 Under this head I have to describe the various 

 forms of congestion of the liver. It has been 

 customary hitherto to consider hepatic con- 

 gestion as a pathological condition, and in 

 compliance with that custom I have given it a 

 place under the above title, although I shall 

 have occasion to shew that it is not in itself a 

 disease, but the mere result of diseased actions 

 occurring in other parts, and wholly dependent 

 upon the peculiar anatomical structure of the 

 organ. Andral, in his excellent work on pa- 

 thological anatomy, observes, " L'hyperemie du 

 foie est un des etats morbides que presente le 

 plus frequemment cet organe. Tantot cette 

 hyperemie est generate, alors le foie est partout 

 d'un rouge uniforms ; son volume est aug- 

 mente et sa consistance peu changee, lorsque 

 1'hyperemie est simple. Cette hyperemie est 

 souvent partielle ; alors, en un certain nombre 

 de points, on trouve comme des laches rouges 

 variables en forme et en grandeur, qu'entoure 

 un parenchyme plus pale. 



" Trois especes d'hvpere'mie du foie doivent 

 etre admises, relativement aux conditions de 

 1'economie dans lesquelles elles surviennent. 



" Une premiere espece d'hyperemie est celle 



* Dictionnaire de Medecine, article Foie. Mr. 

 Kiernan was the puj>il of Amussat at this period, 

 and saw this intcrestins>; case. He informs me 

 that the appearance was distinctly muscular. 



