SUPPURATIVE HEPATITIS. 667 



These vary in size ; often there is only one ; in other cases, numbers 

 of them are scattered through the liver. 



We rarely see the post-mortem appearances of the disease in the 

 commencing stage. The description of the inflamed parts as dark-red, 

 resistant places, which become slightly prominent when we cut into 

 the engorged liver, is probably taken more from analogy than from 

 actual observation. On the other hand, in commencing hepatitis, we 

 do find discolored, yellowish, and very soft spots in the hyperaemic 

 liver. When these are superficial, before opening them, we may readily 

 mistake them for abscesses. At these spots, on microscopical exami- 

 nation, Virchow found, according to the degree of discoloration and 

 softening, either that the liver-cells were cloudy, transparent, and gran- 

 ular, or that their number was decreased, and between those still ex- 

 isting there was effused a finely-granular mass, or, lastly (at the most 

 discolored and softened spots), that the liver-cells had entirely disap- 

 peared, and in their place there was only a finely-granular detritus. 



Far more frequently, parenchymatous hepatitis is not seen till its 

 later stages. Then we find abscesses in the liver, from the size of a 

 pea to that of a hen's egg ; Jf several of these have united, or if the 

 disintegration has progressed further, these form irregular collections 

 of pus, which are often very large. They are surrounded by disinte- 

 grating, discolored parenchymatous substance, and contain a creamy 

 pus, which is often greenish from admixture of bile. When the de- 

 struction advances to the surface, these abscesses of the liver may 

 break. This may occur into the abdominal cavity, or, if there has been 

 previous adhesion of the liver to the abdominal wall, the perforation 

 may be outwardly ; in other cases, after the liver has become adherent 

 to the diaphragm, the latter is perforated, and the pus enters the 

 pleural sac or the lung, if that be adherent to the pleura costarum. 

 In rare cases, abscesses of the liver have been known to perforate into 

 the pericardium, stomach, intestines, gall-bladder, even into the portal 

 vein, and into the ascending vena cava. 



If the patient lives after the opening of the abscess, in favorable 

 cases, the walls may unite ; then there is a proliferation of connective 

 tissue, and finally a hard cicatrix forms, which often contains thickened 

 and calcified masses of pus. And where perforation does not occur, 

 after an abscess has existed a long time, there is usually a proliferation 

 of connective tissue in the wall and vicinity of the abscess ; its inner 

 surface becomes smooth, the pus is incapsulated, and gradually thick- 

 ened by reabsorption of its fluid constituents. Then the abscess may 

 be diminished in size by the shrinking of the surrounding connective 

 tissue, till finally only a dense cicatrix remains, enclosing a calcareou? 

 mass. 



