LIVER PRIMARY CARCINOMA. 399 



duced by obstruction of the bile-ducts, though in man it is by 

 no means a constant accompaniment of such an obstruction. 

 In some cases formation of new bile-capillaries is observed. 

 The organ is enlarged, its surface finely granular, and on 

 section yellow to dark green bile-stained patches are noted. 

 Clinically, jaundice is nearly always present, due to the 

 obstruction of the bile-ducts by the newly forming connective 

 tissue; the portal vein is not obstructed as in the atrophic 

 variety, so that ascites is generally absent. 



The specific granulomata : Syphilitic lesions of the liver 

 occur generally as a diffuse cirrhosis, resembling the ordinary 

 atrophic cirrhosis, except that the bands of newly formed 

 connective tissue are much heavier. Characteristic gummata 

 may be present also, or they may occur unassociated with 

 connective-tissue hyperplasia ; they appear as yellowish or 

 grayish, firm rounded masses, with necrotic, cheesy centres, 

 varying in size from a pea to that of a hen's egg. 



Tubercular lesions of the liver are rarely primary. Diffuse 

 miliary tubercles frequently occur, however, in the course of 

 general miliary tuberculosis ; in some instances there are a 

 few large foci only. A diffuse interstitial connective-tissue 

 hyperplasia is sometimes associated with the miliary tubercles. 



TUMORS. 



Primary connective-tissue tumors do not often occur in the 

 liver ; angiomata more frequently than any other. Melanotic 

 sarcoma has been observed, the black nodules of the neoplasm 

 scattered through the organ, varying in size from a millet- 

 seed to that of a man's fist; much more frequently, how- 

 ever, the tumor is secondary to melanotic sarcoma of the eye. 



Primary epithelial tumors of the liver are also rare. 



Primary carcinoma is exceedingly infrequent as compared 

 with the secondary. It occurs either as a large mass, gener- 

 allv in the right lobe, with secondary nodules throughout the 

 organ ; or it may occur as a diffuse infiltration, which resem- 

 bles atrophic cirrhosis of the liver by reason of the nodular 

 appearance of the surface, and the anastomosing bands of 

 fibrous tissue noted on section. But in the islets between 



