1. Syphilis

The changes in the liver in syphilis are very marked, and somewhat frequent. It manifests itself for the most part as an indurative interstitial inflammation, with or without the formation of gummata. There may be a Cirrhosis indistinguishable from the ordinary forms of this disease, and only judged to be syphilitic from other circumstances. Sometimes in the midst of the general new-formation of connective tissue there are numerous Small gummata about the size of peas, distinguished especially by their caseous condition.

For the most part, however, the disease is localized. To the naked eye the liver is seen to present one or several Cicatrices which often make deep indentations in its surface. These cicatrices are most frequent in the neighbourhood of the suspensory ligament. On cutting into the middle of the cicatrix a Gumma with its central part caseous is usually divided. The periphery of the gumma is not distinctly demarcated from the surrounding connective tissue which extends outwards into the hepatic tissue. Other gummata may be found more deeply in the liver tissue, and these also are surrounded by cicatricial tissue.

Fig. 410. - Gumma of liver, a, Normal hepatic lobules; b, recent tissue of gumma, with dilated blood-vessels; c, caseous part of gumma; d, d, d, connective tissue outside gumma extending into the hepatic tissue, x 16.

The cicatrix is composed of fibrous tissue, and the gumma itself frequently presents irregular strands of connective tissue, but giving place to round-cell tissue. The central caseous portion contains merely granular debris (see Fig. 410). Sometimes at the periphery of the gumma there is great dilatation of blood-vessels, giving almost a cavernous appearance.

When there are a considerable number of gummata, the cirrhosis may be nearly continuous, but with special cicatricial contractions at intervals corresponding to the gummata. The liver in this way may assume a very striking appearance,'as if subdivided into manifold small lobes. Be the cicatrices large or small in number, the lobed and subdivided condition is characteristic of the syphilitic liver.

The liver is sometimes found affected in infants who are the subjects of Congenital syphilis. It may be a general induration forming a cirrhosis, usually with enlargement and perhaps numerous small gummata; or the induration may be more localized, but never with that cicatricial condition which we find in acquired syphilis. The connective-tissue formation in this case does not confine itself to the neighbourhood of the portal vessels, but extends into the lobules, so that between the cells and around the capillaries there is connective tissue, forming the so-called Monocellular cirrhosis of Charcot.

2. Tuberculosis

Secondary tuberculosis of the liver is very frequent, while primary tuberculosis is exceedingly rare.

Primary tuberculosis, in the few cases which have been recorded, was in the form of solitary tubercles like those in the brain. In one recorded case the mass reached thesize of the fist.

Secondary Tuberculosis

In ordinary local tuberculosis of various organs a few bacilli get into the blood and reach the liver at intervals, where the conditions of the circulation allow of their settlement. The resulting tubercles are so small as to be scarcely visible to the naked eye. The tubercles are not very numerous but sufficiently so as to be readily detected in microscopic sections. In this class of cases the tubercles are in various stages, most of them old and degenerated in their central parts. Small tubercles are thus frequent in the liver, yet they rarely attain to more than microscopic dimensions, and the condition can scarcely be called a tuberculosis.

In acute miliary tuberculosis the bacilli are abundant in the blood and the tubercles in the liver are very numerous, although still so small as to be with difficulty seen with the naked eye. The tubercles here are usually found in an earlier stage and they present the typical structure, the giant-cells being often very prominent.

A very rare form is Tuberculosis of the bile ducts. It occurs in the form of large caseous nodules with cavities in the centres which arc filled with softened matter coloured with bile. The wall of the cavities shows tubercles. It is possible that in this form the extension may be by the lymphatics from the porta of the liver.

Besides syphilis and tuberculosis we have Glanders manifesting itself in the liver, especially in horses. The nodules are moderate in size and tend to calcify. Leprosy produces nodules in the connective tissue. There are also new-formations occasionally in typhoid fever and diphtheria.

Literature

Syphilis - Lang, (with literature) Vorles. uber d. Syph., 1885; Baumler, in Ziemssen's Cycl., iii., 1875; Birch-Hirschfeld, (Hereditai'y syph.) Arch. d. Heilk., xvi.; Moxon, Path, trans., xxiii., 1872; Hutchinson, Syphilis, 1887. Tuberculoma - Simmonds, Deutsch. Arch. f. klin. Med., xxvii., 1880; Arnold, Virch. Arch., lxxxii., 1880; Orth, ibid., lxvi., 1876.