410 CLINICAL APPLIED ANATOMY. 



Abscesses in the usual position in the right lobe are best 

 reached by the transpleural route. 



Tuberculosis of the Liver. The routes by which tubercle 

 bacilli may reach the liver are the same as those already men- 

 tioned as giving access to pyogenic infections. Miliary tuber- 

 culosis is due to infection which is carried to the liver by the 

 hepatic artery. Tuberculous pericholangitis, curiously enough, 

 is probably a portal infection, the bile ducts being invaded from 

 the portal radicles which lie alongside the ducts in the portal 

 canals. Tuberculous infection of the liver along the lymphatics 

 is rare, for the liver is not interposed in the lymph stream from 

 the intestines to the thoracic duct. 



Syphilis of the Liver. The liver is more likely than any 

 other viscus to be the site of gummata in acquired syphilis. 

 They mostly lie on the anterior surface, this being exposed to 

 slight injuries ; and in the right lobe, which, being the larger, 

 offers a wider field for infection. Gummata in the region of the 

 portal fissure may compress the bile ducts and portal vein, 

 giving rise to jaundice, ascites, and splenic enlargement, but 

 these symptoms are uncommon. Fever may be present. 

 Gummata are usually accompanied by perihepatitis, and if this 

 is extensive, the action of the diaphragm may be interfered with, 

 and partial collapse of the base of the right lung occur. At the 

 same time pain may be reflected along the phrenic nerve to the 

 branches of the cervical plexus, which supply the point of the 

 shoulder. In such cases the condition is apt to be confounded 

 with subdiaphragmatic suppuration or basal pneumonia. 



Carcinoma of the liver is usually secondary to some part of 

 the alimentary track which is drained by the portal vein. 

 Venous transfer is unusual in carcinoma, but growths in the 

 intestine are prone to ulcerate, and may open up the portal 

 radicles in this way. Moreover, as already pointed out, the liver 

 lies off the track of the main lymphatic stream from the in- 

 testines. Carcinoma may reach the liver by other routes, for it 

 is sometimes secondary to growths in the breast, or may extend 

 from the gall bladder or pylorus by direct continuity. 



