Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 164

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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Liver is rather small (221/2 x 16 x 5 cm.). Surface smooth. Left lobe is adherent to the stomach. On section organ is soft and flabby, but tough. In the right lobe the lobulation is marked. The general color is brownish red. The left lobe is homogeneous in color. The lobules are scarcely visible. In a number, but not in all, of the interlobular veins of the right lobe, there are antemortem clots, reddish and sometimes with white centers. These are continuous with a small thrombus in the portal vein. There are very few thrombi in the interlobular veins

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of the left lobe, although they occur, and a small thrombus enters the large portal radical of the left lobe.

Here the thrombus occluding the portal vein had no effect upon the liver parenchyma. No doubt the localized peritonitis was the direct cause of the thrombosis.

7. H. S., white male, age 49 years. Autopsy No. 649.

.. Anatomical Diagnosis .- Diabetes mellitus; cirrhosis of liver; thrombosis of portal, splenic and mesenteric veins; hemorrhagic infarction of intestine; acute peritonitis (serofibrinous, due to gas bacillus) ; subcutaneous œdema and emphysema, etc.

Liver is firmly bound to the diaphragm over the right lobe. Here the capsule is much thickened (4 mm.) and of cartilaginous appearance. Surface of liver is rough and coarsely granular. On section coarse cirrhosis is visible. The cut surface has a yellow color. Portal vein contains a decolorized thrombus firmly ad- herent to the wall of the vein, and extending beyond the hilum into some of the main branches.

No definite cause for the thrombus formation in the liver was evident in this case. It is probable that portal stasis referable to the cirrhosis was an important factor.

8. C. H. C., white male, age 58 years. Autopsy No. 850. Dr. Flexner.

Anatomical Diagnosis .- Thrombosis of mesenteric veins; nec- rosis and gangrene of small intestine; general fibrino-purulent peritonitis; abscess in omentum (operation wound); extension of venous thrombus into portal vein; congestion of liver and spleen.

Liver free from adhesions, weight 2500 grams. On section cloudy, markings distinct owing to moderate congestion. Consist- ency not increased.

Mesenteric vein is thrombosed. The thrombus in the main branch is partly decolorized, dry and adherent to the vein wall, etc. The thrombus can be traced into the portal and extends into the hilum of the liver. The main branch of the portal vein is apparently completely occluded by the firm, grayish-red mass which is moderately adherent to the vein wall. Beyond the main vein and extending into the left branch, but not into the right, is a recent soft red clot.

Here the occluding mass was a propagative thrombus from the mesenteric vein.

9. Outside Case. Autopsy No. 1398. Dr. MacCallum.

Anatomical Diagnosis .- Primary splenomegaly; thrombosis of splenic mesenteric and portal veins; splenic and intestinal in- farcts; post mortem gas bacillus invasion.

The liver is bound to the diaphragm and surrounding viscera by fibrous adhesions. The portal veins on section are everywhere totally or partly occluded by thrombus masses which are fairly adherent to the vein wall. The liver tissue is much distinte- grated by gas formation. The splenic vein is dilated to a diameter of 5 cm. and is distended with an elastic chicken-fat clot which shows points of opacity. This clot can be traced into the portal radicals. It completely occludes the portal vein throughout its length. As the clot approaches the liver it becomes darker. On section it is almost diffluent, especially in the more central part, where it has a purplish-brown color. On the lesser curvature and serous surface of the stomach there are several distended veins which are completely occluded by thrombi, as are also the omental veins.

Microscopically the clot in the mesenteric vein is organized and partly canalized. Surrounding the vein is a sheath of very vascu- lar tissue.

The liver shows microscopically no definite increase in con- nectivo tissue. The spleen has a thickened capsule, but the

trabeculæ are not much thickened and the connective tis. the sinuses is much increased.

10. F. S., white male, age 62 years. Autopsy No. 144 Marshall.

Anatomical Diagnosis .- Carcinoma of stomach with measi- to liver, etc .; occlusion of portal vein at hilum of liver by er tases; propagated thrombus in hepatic branches of portal ca:

Liver weighs 1300 grams, measures 26 x 15 x 616 cm. Cor ency decreased. Surface uneven, due to tumor nodules, e .. . section liver substance is pale, rather opaque and fatty. A. nodule is found completely blocking the splenic vein, about: from junction of splenic and portal veins. The metastasis ere: into the portal, completely occluding it beyond the bilum ! liver. It is firmly attached to the vessel wall, giving it a diaz of 1 to 3 cm. Where this growth ends beyond the bilum c.' liver a thrombus begins, extending into the main branches at . portal vein.

11. J. M., white male, age 48 years. Autopsy No. 27% : Whipple.

Clinical Diagnosis .- Primitive splenomegaly.

Anatomical Diagnosis .- Chronic splenic tumor; sclerosis splenic and portal veins; cirrhosis of liver and thromboi. portal branches; chronic passive congestion of pancreas ac: : testine; œesophageal varices with rupture; hemorrhage inte - stomach and intestine; anemia; chronic fibroid pulmonary :" culosis; chronic tuberculous lymphadenitis; miliary tuber - in spleen and liver.

Spleen weighs 1050 grams; measures 21 x 14 x 615 cm. 5% vein shows definite sclerosis everywhere, especially marked a. one leaves the hilum of the spleen. At the junction of the sp2: vein with the mesenteric vein a large thrombus mase 1: 45. tightly adherent to the anterior wall of the mesenteric veins .: only partly occluding its lumen. Thrombus is of a gray mr showing definite ridges and furrows on its surface. The pa vein, however, is completely occluded by a firm thrombos Ex which shows some fresh central blood clot, but is mostly ms :: : of gray translucent tissue. As one goes upward, one finde : two branches of the portal vein completely obliterated by sinis appearing thrombus masses. These thrombi show fibrous t. lucent tissue at the margin, merging into the vessel wall the central portions show a greater or lesser degree of brow .: red blood clot, or even fluid blood. Some of these vessels - to show small channels full of fluid blood, in the organized Et: thrombus mass.

Liver weighs 1200 grams; measures 22 x 16 x 7 cm. Its E. surface, as a rule, is pretty smooth and of a pale browz * Near its anterior margins it shows considerable granulatis: its surface, prominent nodules of opaque tissue alternating r depressed areas in which are dilated blood vessels. The 5 surface of the liver has a more marked granular appears" especially around the fissure at the entrance of the portal s" tures. Cut surface in the upper portion shows great anemis little increase in connective tissue. As one approaches the verse fissure, however, the connective tissue becomes conside :. in amount; embedded in it are irregular nodules of opaque : 1 appearance, apparently hypertrophied islands of liver tissue. I. connective tissue increase seems localized pretty sharply ar. .. the branches of the portal vein and becomes progressively in amount as we approach the larger thrombosed branches c : portal vein.

The esophagus, opened up from behind, shows tremendous tention of the veins underneath its mucosa. These veins art tortuous; some of them, dilated to a diameter of 3 mm., form ) : miliary saccular aneurysms which bulge very definitely frez walls of the dilated venules. Some show superficial necros : the mucosa covering them and are seemingly just on the poi"

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be can be passed with ease. Blood can be squeezed through s opening. The stomach contains 650 cc. of dark jelly-like od clot. Its mucosa is intact everywhere. Just around the diac orifice it shows a network of large tortuous dilated veins, ich, however, only persist for a distance of 5 cm. from the iction with the @esophagus. The duodenum is normal. Dissec- n of the dilated veins around the cardiac orifice shows them to nmunicate with branches of the splenic vein given off 3 or 4 . from the origin of the vein at the hilum of the spleen. A few the smaller veins in this position seem to anastomose with the ns along the lesser curvature of the stomach.

The liver shows an increase in connective tissue between the ules. This, however, is not uniform, being most marked in tions taken from the region of the transverse fissure. The inective tissue is sharply confined to the margins of the lobules i does not extend into the central portion, except where the ule has undergone complete degeneration. The portal vein ›ws a thrombus made up of old fibrous tissue into which merous capillaries have grown. Some of these have become arged to a considerable size and contain fresh blood. The e ducts in this neighborhood show signs of active proliferation .*

The above report of Autopsy No. 2706 has been given in ater detail because the findings do not correspond with the nical diagnosis of primitive splenomegaly.

These 11 cases do not present any new features. In all, : portal vein and its radicals alone were involved. In all, , finest interlobular veins were free. In all, the general culation was maintained to a sufficient extent to prevent y striking changes in the liver directly attributable to the lusion. In 3, the thrombi were the direct result of nor invasion; in 2, they were the result of a localized 'itonitis (one of these was possibly a syphilitic process) ; 1, they accompanied a syphilitic liver; in 2, they were ondary to cirrhosis; in 1, they were a direct extension m a thrombosed mesenteric vein ; in 1, a secondary process urring in the course of a general tuberculosis, where there ; amyloidosis; and in 1, the process seemed primary.

t is interesting to compare the findings in the above cases h the much more extensive series of Lissauer. In his es, 6 of the 68 cases of thrombosis of the portal vein were ciated with atrophic cirrhosis of the liver; in 7, with hilis of the liver; in 2, with primary carcinoma of the r; in 7, with carcinoma of the stomach, accompanied by astatic growths in the liver; in 2, with secondary carci- la of the liver; in 6, with primary carcinoma of the biliary sages; in 9, with gall-stones and inflammatory lesions of gall-bladder; in 10, with diseases of the pancreas; in 1, 1 suppurative inflammation of the umbilical vein; in 6, 1 diseases of the spleen; in 6, with gangrenous appendicitis; !, with carcinoma of the intestine; in 1, with a pelvic ess ; and in 1, with no definite cause."

There are two other cases of portal thrombosis in our first 3500 psies: one autopsy, No. 224, where there was only a small stal thrombus of the portal vein, and autopsy No. 1409, where picture in the liver was so obscured by complicating conditions the result of the portal occlusion upon the hepatic paren- ha was indefinite.

noted by Lewis and Rosenau.

of the spleen, the anemia which so often occurs, and the in- tegrity of the liver may often suggest the clinical picture of Banti's disease. Very great enlargement of the spleen may result from simple vascular changes accompanying portal thrombosis; and he concludes that only then may we speak of a primary splenomegaly, when absolutely every other or- ganic cause has been excluded. The above cases are not in- stances of primary splenomegaly, since the extensive throm- bosis is quite enough to explain the findings.

It is essential to remember portal thrombosis in the differ- ential diagnosis of splenomegaly.

EMBOLIC OR THROMBOTIC AREAS OF CONGESTION.

Despite the extensive anastomosis between the branches of the portal vein and the hepatic artery, in rare instances and under accessory circumstances a condition somewhat resembling the macroscopic picture of hemorrhagic infarction, and often spoken of as the " atrophic red infarct of Zahn," may follow plugging of branches of the portal vein. The "atrophic red infarcts of Zahn " are triangular, rectangular or irregularly wedge-shaped areas with their apices at the occluded vessel. As a rule they are dark red or reddish-brown, but pale areas have also been observed. Microscopically there is simply a congestion of the intralobular capillaries with slight atrophy of the liver cells and possibly some pigmentation. It is of importance to note that necrosis does not occur in these areas. Ruczynski ' explains their production in the following way. The blood from the portal vein no longer flows into the hepatic vein and the latter is only poorly filled by the blood of the hepatic artery. As a result there is a stasis in the hepatic vein due to the deficient vis a tergo, and the picture of a con- gested liver with dilatation of the central veins and capillaries and atrophy of the liver columns is gradually produced. This is the condition which was described by Zahn." Orth " had described it previously and in his text-book expresses clearly that they are the result of an aseptic embolic or thrombotic process. He calls them areas of circumscribed congestion, atrophy or cyanotic atrophy which may be viewed as a type of hemorrhagic infarction but never as a complete infarct.

Many observers have described this picture. Bertog " de- scribed two cases in which a " chronic red atrophy " of the liver was the result of decreased portal blood supply from com- pression of portal roots by chronic peritonitis. He considered that any hindrance to the free flow of portal blood to the. liver might produce an atrophy of the liver similar to what occurs in a liver of congestion. Cohnheim and Litten " de- scribed a "nutmeg" liver involving the part of the gland

" Ruczynski: Ztschr. f. Heilk., 1905, XXVI, 147.

1º Zahn: Verhandl. d. Gesellsch. deutsch. Naturf. u. Aerzte 1897. Leipz. 1898, Part 2, p. 9; or Centralbl. f. allg. Path., 1897, VIII, p. 860.

" Orth: Lehrbuch der Path. Anatomie, 1887, I, 917.

12 Bertog: Greifswalder Beiträge, 1863. Quoted by Chiari.

13 Cohnheim and Litten: Virchow's Archiv., 1876, LXVII, 153.

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supplied by an occluded portal radical. Klebs " cited the pres- ence of wedge-shaped areas after occlusion of radicals of the portal vein; these areas showed microscopically only a granular degeneration. Wagner 15 described an instance of narrowing and thrombosis of several portal radicals resulting in deep red or pale wedge-shaped areas. Köhler 16 reported three cases of cyanotic atrophy after occlusion of large portal radi- cals. His first case concerned a man who, 7 days before death, underwent an operation, i. e., excision of rectum for carci- noma. At autopsy one of the portal veins contained an ante- mortem clot and the liver supplied by the branch showed the usual picture macroscopically. Sections showed less fat in the atrophied cells and an increase of brown pigment. The second case was one of malignant tumor of the peritoneum with thrombosis of a portal radical and the usual picture of pseudo infarction. In the third case there was a septic embolus in the right branch of the portal vein, and a large hyperemic wedge-shaped area of liver containing multiple small abscesses corresponded to the distribution of the occluded vein. The thrombus arose in the splenic vein. Köhler concluded that not only portal thrombosis, but also weakened heart action was essential to obtain the above picture of congestion. He considered the atrophy of the liver cells to result from pressure of the dilated capillaries and inactivity of the liver cells. Pitt " added three more cases. The first concerned an indi- vidual who died 5 days after an operation for relief of an in- carcerated scrotal hernia. The liver showed an atrophic zone 2 inches in diameter and the corresponding vein was occluded. Sections only showed dilatation of the capillaries. His second case, an old man who died of cerebral hemorrhage, showed corresponding to many thrombosed branches of the portal vein, numerous sharply demarcated pale or dark areas with dilatation of the capillaries in the latter. In the third case there was a pale area of liver, the result of embolie plugging of a portal branch following operation for ovariotomy. Ruc- zynski " explained the pale areas of the third and second cases by the persistence of anemia following the portal occlusion. Chiari " in a very comprehensive report published in 1898 collected most of the above cases and added 17 cases observed by him from 1877 to 1898. On account of the large number of personal observations he is inclined to consider this con- dition not at all uncommon. Of his 17 cases, 15 resulted from emboli arising in branches of the portal vein. These he sub- divided into those cases where the thrombosis of the portal roots followed by hepatic emboli occurred without any external influence (7 cases) and those where some operative procedure involving the portal roots occurred shortly before death- (8 cases). The two remaining cases resulted from thrombi arising within the intra-hepatic radicals of the portal vein. Of the group of emboli occurring without external cause, 4

" Klebs: Handbuch der Path. Anatomie, 1896, I.

15 Wagner: Arch. f. klin. Med., 1884, XXXIV, 520.

15 Köhler: Arb. a. d. path. Institut in Göttingen, 1893, 121.

17 Pitt: Tr. Path. Soc. Lond., 1895, XLVI, 74. " Ruczynski: Loc. cit.

19 Chiari: Ztschr. f. Heilk. 1898, XIX, 475.

were carcinomatous in nature, 1 occurred in a case of ". mus," 1 in typhoid ulcerative enteritis and 1 wne: from a thrombus formed in the splenic vein, the za. pressure from an aneurysm of the splenic artery. In .. cases of the second group the thrombi in the roots of the; vein were the direct result of ligatures applied p . branches at the time of operation.

Chiari considered the dark areas of the liver to bear mechanical result following occlusion of the large bran !. the portal vein, namely, local areas of congestion in primarily the central vein and the neighboring capillar- the central portion of the lobule with atrophy of the live. The smallest branches of the portal vein in the affertele- of the liver were free of obstruction. Similarly the (:" veins and the hepatic arteries in these areas were unior Blood extravasation only occurred twice and then small amounts. Necrosis of the liver cells was never! Chiari's findings confirmed the observations of other !: concerning the origin of these areas, i. e., that they were circumscribed areas of congestion. The liver cells Me- enough fresh blood through the inner portal roots to. The vis a tergo, however, was not sufficient to keep ty normal circulation, and as a result there was a reflux : gestion of the blood from the right auricle which. v." with the constantly decreasing nourishment of the liver caused them to atrophy. It was worthy of note thr ... number of cases the liver cells of the affected zone. Welt " tically fat free, while in the remaining liver the ir present in considerable amounts. This Chiari explain- the stoppage of the flow of the portal blood through the . Finally Chiari concluded with Kohler that simple of of branches of the portal vein was not sufficient to bring: the formation of the so-called atrophic red infarct. [ must be added to the occlusion one of the following moul:

a. Weakening of the arterial current to the liver.

b. Venous congestion.

c. A combination of the two above conditions, or

d. Impaired cardiac action.

This latter he considered to be the most important. Ruczynski adds several more cases.

That of Lazarus Barlow, concerned a young man. wl, been crushed between the buffers of two railroad car -. [! followed in three days. At autopsy there was a lacz in the right lobe of the liver. In the center of this te!" a thrombosed portal vein and corresponding to the distr": of this vessel was a large wedge or grayish-white 1- Lazarus Barlow considered this an anemic infarct. hu" . zynski disagreed with this diagnosis since the author dis- mention in his microscopical findings the presence of the liver cells.

Longeope reports a case where, besides numerous mets- cancer nodules from a primary gastric growth, there deep red triangular area whose base measured 3 cm. portal vein leading to this discolored zone was oxchyl .. Finally, Versé " reports a case where in a young 20 Versé: Verhandl. d. deutsch. path. Gesellsch., 1909, XI !! Google

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war" studied the effect of injection of sterile mercury the mesenteric veins of dogs. After eight days, the test period, there were red, triangular areas in the liver h were typical of the atrophic red infarct in 35 days. ; showed microscopically the picture of congestion and phy of the hepatic parenchyma, but there was no necrosis. ne following three cases belong to this group of liver ges following occlusion of the portal vein radicals.

ne first case is so unique that a rather detailed account be given.

K., white male, age 40 years. Admitted to the medical clinic e Johns Hopkins Hospital, January 5, 1911, complaining of ach trouble. Previous to present illness, history was nega-

P. I. began 5 months before admission, with sudden, acute minal pain and vomiting. This was first blackish and gradu- became paler. The vomiting persisted and there was loss of ht, amounting to 100 pounds. Examination revealed nothing portance except a HCI deficit of 10, and a total acidity of 8; in increased resistance in left epigastrium. The Wassermann ion was negative. Occult blood was repeatedly demonstrated e stools. On March 20, an exploratory laparotomy was per- ed by Dr. Finney. The stomach was found greatly dilated. valls were atonic, but there was no evidence of new growth. e duodenum was greatly enlarged and relaxed, being almost : its normal diameter, with soft, flabby walls. Aside from : dense adhesions, some of which were severed, nothing of rtance was observed. The patient did not recover from the ition.

ed, 8 p. m., March 21, 1911.

topsy, 10 p. m., March 21, 1911. Autopsy No. 3519. Dr. Win- tz.

atomical Diagnosis .- Chronic inflammatory stricture of the um, probably following strangulation of the bowel after a ilus; multiple thrombi in the mesenteric vessels; dilatation omach and duodenum; extensive scarring and atrophy of of jejunum; chronic adhesive peritonitis, particularly marked : the region of the stricture; chronic mesenteric lymphadeni- pressure of inflammatory mass on retroperitoneal tissues, re- ig in thrombosis of left renal vein; slight atrophy of left y; (exploratory laparotomy); dislodgment of portion of ibus in renal vein; embolus into one of the smaller radicals e pulmonary artery with hemorrhagic infarction of lung. igement of mesenteric thrombus; embolism into large right I vein with formation of a localized area of congestion in the

lominal cavity. The adhesions are chiefly in the left hypo- rium. The omentum is bound tightly to the pancreas and with the duodenum and spleen forms one compact mass, over the jejunum passes emerging from a small knot of adhesion. er measures 28 x 20 x 91/2 cm. Its surface is smooth. On o it presents an extremely striking picture. A large area in ght lobe has a much deeper brown color than the remaining :issue. This area is irregularly wedge-shaped extending to lus of the gland where the apex of the triangle is found. ghout this darker portion of the liver the portal vein Is are occluded by large ante mortem clots which are quite '. These converge to one large hilic branch of the portal There a large non-adherent clot is found. The two areas of namely, the darker area in which the portal vessels are ed and the surrounding paler brown areas present other- nly minor differences. In both zones the lobules are dis- In the darker portion they are somewhat smaller.

han: Loc. cit.

thinner, the vessels slightly dilated. The change is so slight that it might not be noted were one's attention not specially directed towards it. Neither the interlobular veins, hepatic arteries nor the central veins are involved by thrombus.

This case represents a typical example of the result of embolism of a large portal radical. The embolus arose from a thrombus in the mesenteric vein which was probably dis- lodged at the time of operation: The area of pseudo infare- tion in the liver is consequently very young, probably less than 24 hours.

13. R. F., white male, age 40 years. Autopsy No. 1691. Dr. Opie.

'Anatomical Diagnosis .- Cholelithiasis; calculus impacted in diverticulum of Vater only partly filling it and occluding its duo- denal orifice; acute hemorrhagic pancreatitis; disseminated ab- dominal fat necrosis; partial thrombosis of splenic vein; em- bolism and thrombosis of portal vein.

Liver weighs 1350 grams. Surface is smooth. Upon the upper surface of the right lobe are three irregular, very slightly de- pressed areas conspicuous from the fact that they are of a dull red color while the remainder of the surface is yellowish. The cut surface has a bright yellow color. The periphery of the lobules are golden yellow, the central part reddish, corresponding to the areas mentioned on the surface, on section; the tissue be- low has a similar appearance, the corresponding area being narrower as the surface becomes distant (i. e. irregularly wedge- shaped). Here this tissue is of a dull red color. Within such areas are seen sections of veins plugged, and distended with red thrombus. These are found to be portal veins. The vein in one of these areas has a diameter of about 4 mm. It is plugged with a red thrombus, which stops abruptly at the apex of the wedge, where it ends in a yellowish-white embolus. In addition to these large areas mentioned, several distinctly wedge-shaped smaller ones are present. The large portal branches are normal.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 164

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189