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 NA 
 
 KXSAt IIBUARY 
 C A N \ D A 
 
 ^ 
 
 CASE OF 
 
 AiORlSM OF THE HEPATIC MERI 
 
 WITH 
 
 MULTIPLE ABSCESSES OF THE LIVER. 
 
 BY 
 
 V 
 
 XEORGE ROSS, A.M., M.D., 
 
 Pkofkssou ok Clinical Medicine, McCJilt. Univbrsity, Attbndinc. Physiciak 
 to thb montheal general hospital. 
 
 AND 
 
 WILLIA.M OSLER, M.D., L.R.C.P., LoND. 
 
 Prokhssor OF Institutes of Mbdicine, McGill Univbhsity. 
 
 (Read before the Medico-Cliirurgical Society of Montreal.) 
 
 iKi,printed from Canada Medical and Sur(mcal. Journal, July, x'^'ji.) 
 
 
 PIUNTEIV AT TIIK "GAZETTE" PRINTINCr HOUSE 
 
 1877. 
 
 >-2 
 
 lUtmmmm^m^mit^ 
 
,^ 
 
 I 
 
CASE OF 
 
 F 
 
 WITH 
 
 MULTIPLE ABSCESSES OF THE LIVER. 
 
 GEORGE ROSS, A.M., M.D., 
 
 PnOnSSOR OF 'UNICAL Mf.DICINE, McGlLL UCIVEBSITY, ATTENDING PhYSICUIT 
 TO THK MONTKEAL GENERAL IIOSPITAL. 
 
 i 
 
 AND 
 
 WILLIAM OSLER, M.D., L.R.C.P., Lonb. 
 
 Professor of Institotbs of Medicine, MoGill Univiubity. 
 
 (Read before the Medico-Chirurgical Society of Montreal.) 
 
 iRtprinted from Canada Medical and Surgical Journat, >/>', 1877.). 
 
 Pontrenl : 
 
 PRINTED AT THE "GAZTTTE" PRTNTING ITOISE 
 
 1877. 
 

,/ 
 
 - ./' 
 
 ANEURISM OF THE HEPATIC ARTERY. 
 
 (o) Hep.. tic artery, (6) riiarht branch mainly Involved, (o) left branch, <d) ffaa- 
 tro-duodenalis, («) cystic arteriM, (Z) oooladed braiiobea of ri^ht trunk. 
 
ANEURISM OF HEPATIC ARTERY; 
 MULTIPLE ABSCESSES 01' THE LIVER. 
 
 BY GEORGE ROSS, A.M., M.D. 
 
 raofEssoB OK Clinical Mbdioine, McGill UmvBnsiTY, Attendino Physiciah 
 TO THE Montreal Gineiial Hospital. 
 
 — AND — 
 
 WILLIAM OSLER, M.D., L.R.C.P., 
 
 rBOFKSSon OF Institutes of Medicine, McGill Univekbitt. 
 
 (Read before the Medico-Chirurgical Society of Montreal.) 
 
 Aneurism of the hepatic artery being of such very rare 
 occurrence and the case which we are about to relate presenting 
 in addition some remarkable pathological features, we are led to 
 believe that it will be found of considerable interest. 
 
 For the notes of the case we are indebted to Mr. John 
 Brodie, ward clerk. 
 
 W. H., £et. 21, single ; height 5 feet 11^ inches; weight, 
 about 140 lbs, — was admitted into the Montreal General 
 Hospital on the 8th of November, 1876, complaining of pains 
 in the right side and great weakness. 
 
 The patient was born in Wisconsin, U. S., and lived there 
 until about two years ago, since which time he has resided in this 
 city. His family history, as far as could be ascertained, is good, 
 lias never been ill with the exception of small-pox, and a mild 
 pneumonia of the left lung. Has never had dysentery nor 
 
• ANEURIS5I OF ilEPAKO AHTKEY. 
 
 piles, nor any abdominal or rental trouble of any kind. Ilaa. 
 always been of extremely temperate habits. 
 
 His present illness be{j;an, ho says, about the Ist of Septem- 
 ber last, with what he describes as a severe cramping pain in 
 the stomach, which began in the morning and continued all day. 
 At 4.80 p.m. of that day he had a violent rigor, lasting about 
 twenty minutes. This was followed by high fever and perspira- 
 tion. Similar chills recurred, ho says, with great regularity, 
 every second day for five or six times, and then ceased after he 
 had taken some medicine from the Hospital Dispensary. At this 
 time liis appetite became poor, he felt weak and was very low- 
 spirited, and observed that his skin assumed a sallow colour- 
 Ever since he has been gradually getting weaker an 1 losing 
 flesh pretty rr.pidly, and the sallow tint of the skin has been 
 sloadily increasing in intensity. There has also been almost 
 constantly present a dull, aching pain in the right side over the 
 region of the liver. Slighter rigors, followed by fever and some 
 perspiration, have also occurred several times at irregulai 
 intervals. 
 
 Present Condition. — Much emaciated, somewhat ansemic, 
 but the whole skin of a dirty, dingy, sallow hue, without any 
 jaundice, — the sclerotic clear, and not yelloAvish, There is a 
 very peculiar, pungent, somewhat feculent and extremely disa- 
 greeable odor exhaled from the suri'ace of the body. 
 
 There is slight fullness of the right hypochondriac region 
 which is also somewhat tender upon pressure. Liver. — Dulness 
 extends from the 4th interspace to one inch below the margin of 
 the ribs. The belly is full and tumid, and tenderness is also 
 found on pressure over the epigastrium. Splenic dulness not 
 increased. Tongue slightly furred, rather dry, and with red 
 edges. Bowels have been, and still are, considerably relaxed, the 
 motions being light-coloured and especially offensive. Urine, 
 sp. gr. 1019, high-coloured, but containing neither bile pigment, 
 albumen nor sugar. 
 
 Heart — Situation and sounds normal, pulse 116. Lungs. 
 Resonance and breathing normal throughout, except at the base of 
 
ANEURIHM or HEPATIC ARTERY. O 
 
 the right lunfi; whoro there is an area of dulness with enfeebled 
 .rospiration. Temperature 10')^ F. 
 
 Ordered (juinine gr. xx each evening. 
 
 Nov. llth. — lias not complained miioh of the pain. Disngrcc- 
 ablo odour from the body very marked. BowcIh are regular, 
 but motions aro ochre-coloured ai.d ofTonsivo. Tongue clean. 
 A dull rod flush on cheeks especially in afternoon. IJas occa- 
 sional slight epistaxis. Temperature lias ranged between 102^. 
 and 103" V. 
 
 IGth. — Is getting weaker but is (piite cheerful, and feels well. 
 Tongue moist and clean. Takes nourishing food very well, and 
 bowels remain regular. Never vomits. Temperature continues 
 •equally high, always rising 2'^ or more in the evening, followed 
 by sweating which is sometimes very profuse. This usually 
 commences at G p.m. Urine 43 oz. sp. gr. 1022. No bile pig- 
 ment, albumen or sugar. 
 
 2Srd. — The volume of the liver has considerably increased, 
 :and, owing to the progressive emaciation, bulging of the lower 
 ribs on the right side has become quite apparent. Dulness ex- 
 tends from the top of the 4th rib to two inches below the margin 
 of the ribs. The lower edge of the liver cannot be felt owing 
 to the fulness of the abdomen and its tender condition. Pain 
 
 • on pressure over liver region and epigastrium increased. Ilia 
 fltrength is failing fast, and the sallow colour has become deep- 
 
 • ened. The odour from his body has been so offensive in the ward 
 , for some time tliat the House Surgeon has been obliged to em- 
 j ploy spcjgings with carbolized solutions, and disinfectants round 
 
 the bed. He lies almost continuously on his back, occasionally 
 
 .turning slightly towards the right side, bat any attempt at turn- 
 
 .ingon his left side is accompanied by severe pain and a feeling 
 
 , -of a dragging and weight in the region of the liver. The 
 
 ^.superficial veins on the right side of the chest are very large 
 
 t^and prominent. Ordered linseed poultices over the liver. 
 
 25th. — Tenderness less. Hepatic dulness increased in area, 
 
 uneasuring 8 inches vertically at the line of the nipple. No 
 
 localized fulness or redness of the skin or fluctuation to be found 
 
6 
 
 ANEURISM OF HEPATIC ARTERY. 
 
 anywhere. The enlargement of the organ is very general and' 
 unifoi'm. Pulse 128, very small and feeble. Temperature 
 continues high with evening perspirations. Is remarkably cheer- 
 ful, saying ho feels well but Aveak, althougli he suffers a good, 
 deal of pain. Ordered acid nitro-mur. dil. Tr. calumb., a a 3s3 
 ter die. 
 
 29ch. — Pain and tenderness low down on the right side, 
 Excessive pain is caused by the slightest change of posture. Lies 
 constantly on the right side. Pulse 130. His diet throughout 
 has been of a most nourishing kind. Milk abvmdantly, beef-tea,, 
 eggs, wine, &c. 
 
 Dec. Srd. — This morning there occcurred a temporary col- 
 lapse, marked by a rapid fall of the thermometer to a remarka- 
 bly low level, 94.8°. F., accompanied by great prostration and a 
 cold sweat. In the evening the temperature rose to 102,4. '^ F.,, 
 and during the night great pain was felt in the left iliac region, 
 which was tender. 
 
 Ordered an opiate, and a small blister to this region, 
 
 ()th. — Is rapidly sinking. The signs of effusion in the right- 
 pleura, hitherto stationary, have in the last few days, rapidly 
 extended, and there is now dulness over the lower two-thirdji 
 of that side, with absence of breathing, and an amphoric ^noto 
 beneath the right clavicle. ' : " ■ 
 
 1th.— Died at G.OO a.m. *'; * ; "^ [■' ■ ~ 
 
 Autopsy, 81 hours after Death. ' ' 
 
 Rigor mortis present. Skin of a dirty-brown colour. In the 
 abdomen about 22 oz. of yellow turbid fluid. In the right pleural 
 cavity about 20 oz. of similar fluid. Right lumj collapsed. 
 The pleura covered with a thin layer of greenish-yellow lymph. 
 On section, the lung is dark, airless and sodden. Left Lung. 
 On the visceral layer of the pleura, especially behind, are 
 numerous small ecchymoses. On section, organ contains 
 much blood, is firm, and only slightly crepitant. Heart 
 normal. Kidneys rather pale, cortex swollen, and malpighiau 
 tufts injected. Spleen, weight 445 grms. (14 oz). adherent to- 
 tbe stomach. Organ soft. On section dark and congested.. 
 
ANEURISM OP HEPATIC ARTERY. 7 
 
 Intestines normal. No trace of ulceration in the large intestine. 
 Bladder and prostate, normal. 
 
 Liver, 4879| grammes, (lOf lbs). The peritoneum around 
 it in many places showing signs of inflammation. The left lobe 
 intimately adherent to the stomach by a thick layer of firm 
 yellowish-coloured lymph. The right lobe also cemented to parts 
 in its neighbourhood by lymph of a similar character. A small 
 amount is also observed on the descending colon, but the general 
 peritoneal surface is not affected, the serous covering of the 
 intestines being clear and glistening. The liver itself retains 
 its normal shape, the upper surface is smooth and not adherent. 
 Towards the right border a yellowish-coloured swelling is evident 
 •which is perceptibly fluctuating. Other less distinct yellowish 
 spots are seen scattered over the organ. To the touch the upper 
 and back part of the right lobe is exceedingly soft and fluctuat- 
 ing. On the under surface many yellowish-white nodules are 
 apparent, some large, others quite small, all distinctly fluctuat- 
 ing. A similar one of large size is apparent on the under surface 
 of the left lobe. A transverse incision through both lobes reveals 
 the fact that we have to deal with a diffuse suppurative hepatitis. 
 An immense quantity of yellowish-white, custard-like pus flowed 
 out. The right lobe is completely honey-combed by a series of 
 small, closely united abscesses, ranging in size from a marble to 
 a walnut. The septa between these absceses are composed of 
 a dark-red tissue. Most of these small abscesses communicate 
 together; some have merged to form larger ones, They all 
 possess distinct lining membranes which are frequently stained 
 with bile. The left lobe is in a similar condition, and in both 
 the abscesses extend throuffhout the thickness of the organ. 
 Thus, the only portions ot liver-substance which are found 
 comparatively free are the lobus quadratus and that portion of 
 the organ lying immediately above and a little to the left of the 
 gall bladder. These parts on section are of a dark colour, 
 lobules distinct, small bile vessels very evident. The gall- 
 bladder is small, contains about three drachms of a clear, some- 
 ■what viscid secretion. On pressing it and along its ducts no 
 fluid could be forced out at the papilla biliaria. It was with 
 
8 ANEURISM OF IIFPATIC ARTERY. 
 
 much difficulty that a probe could be passed along tlic cystic 
 dact, owing to an unusual number of irregular folds of its mucous 
 membrane which were evident when the duct was slit up. The 
 common bile duct itself was patent, the mucous membrane of its 
 \ipper two-thirds stained with bile. There were no clots in the 
 superior mesenteric, gastric, or splenic veins. On slitting up 
 the portal vein itself, a small abscess was found to project 
 into the calibre of one of its right divisions. The tissue 
 in the neighborhood of these main divisions was infiltrated with 
 pus. A firm nodule was felt at the portal fissure and mistaken 
 at first for a bunch of lymph glands. Section of this, however, 
 showed it to be distinctly laminated, and careful dissection of 
 the part revealed the existence of an aneurism just at the bifur- 
 cation of the Hepatic Artery, but occupying chiefly the right 
 branch, (see plate.) The dilatation begins immediately beyond 
 the gastro-duodenalis, (i) and extends for about 3 inches as a 
 somewhat conical swelling. The left hepatic artery (c) arises 
 from the obtuse end of the aneurism and is unaffected. At its 
 thickest part its circumference measures 3 inches. For 2| inches 
 it passes to the right and gives off two branches if) which appear 
 occluded, then turns at right angles and passes backward forl^ 
 in., towards the posterior border of the liver, terminating by a 
 conical extremity which is continuous with the main branch of the 
 artery. The arteries of the body had been injected, and the red 
 mass is found in the trunk of the hepatic before its bifurcation, 
 in the gastro-duodenalis, and the left hepatic branches, all of which 
 are full and tense. The hepatic artery appears to enter the 
 aneurism about J of an inch from the obtuse end, the gastro- 
 duodenalis and left hepatic being given off apparently from the 
 dilatation itself; and on slitting up the hepatic artery it appears 
 at first sight as if these were its only branches, and that its com- 
 munication with the aneurismal sac had become obliterated. Care- 
 ful inspection, however, of the lower and posterior wall reveals 
 a small canal, the calibre of a hypodermic needle, which leads 
 directly into the sac. The aneurism being opened by a longi- 
 tudinal cut on the upper surface, it is seen that the anterior 
 third, comprising the rounded end, is completely filled with firm 
 
ANEURISM OP HEPATIC ARTERY. ' 9 
 
 •decolourized laminge of fibrin, concentrically arranged. The 
 middle third of the sac contains semi-coagulated blood, and red 
 injection mass, after emptying which there is seen a cavity about 
 the size of a small \ walnut. This is in communication with the 
 hepatic artery by the small canal already referred to, which 
 passes for rather more than half an inch through the fibrinous 
 laminae of the anterior end. Two small branches, both containing 
 injection pass from the cavity, one the cystic, (^ej going to the 
 gall-bladder, the other a somewhat larger branch, passing to the 
 central part of the organ. The sac is lined with sheets of fibrin, 
 which, at the under part were thinner than elsewhere, and cit 
 this point the blood has infiltrated the proper coats of the aneu- 
 rism, which, in consequence, look reddish black. The terminal 
 portion of the sac lay chiefly in the substance of the right lobe, 
 surrounded by suppurating hepatic tissue, which had to be 
 dissected away to expose it ; and on section the cavity is found 
 almost completely obliterated by fibrinous laminie, which in the 
 centre are softer, and not so colourless as the other end of the 
 eac. No direct passage could be traced through this from the 
 central cavity, and the main branches given off from the aneu- 
 rism are found empty, and at their commencement plugged with 
 fibrin, which in several extends as a thin sheet along the intima. 
 The condition appears to be one of simple aneurismal dilata- 
 tion of the vessel, the walls being thin, slightly roughened on 
 the interior, but not markedly atheromatous. The trunk of the 
 hepatic artery itself looks healthy, and there are no evidences of 
 general vascular degeneration. 
 
 Remarks. — Aneurismal dilatation of the Hepatic Artery 
 would appear to be of rare occurrence, the chief reason, of course, 
 being that its main cause — atheromatous degeneration — is very 
 seldom met with in this situation. Embolism of this artery 
 Frerichs has never seen — the situation and mode of giving off 
 of the vessel being such as to hinder the entrance therein of 
 foreign substances from the stream of the aorta. One single 
 case of the kind has been recorded by Virchow, where an hepatic 
 abscess followed embolism from a gangrened lung. 
 
 The same author (Frerichs) alludes to four, or possibly five, 
 
10 AUERI8M OP HEPATIC ARTERY. 
 
 as the only recorded cases of Aneurism of the Hepatic Artery. 
 They are those of Ledieu, Stokes, Sestier, Wallmann and 
 Lebert. In the case of Ledieu, the patient died of some pul- 
 monary complaint, and had never had any symptoms of hepatic 
 disease. There was found, just before the giving off of the 
 pyloric branch, on the hepatic artery, a small hard tumour the 
 size of a hazel nut. It was entirely composed of firm laminated 
 fibrin, and had completely occluded the main artery. The case 
 of Sestier was also obscure. There had been " symptoms of 
 some chronic painful affection of the stomach." The right 
 branch of the vessel was found occluded by a small aneurism 
 filled with clots, and T,he gall-bladder was gangrenous. 
 
 In Wallmann's patient — a female— there was an account 
 of attacks of violent pain in the upper part of the abdomen,, 
 coming on after intervals of several days, gradual loss of strength, 
 and emaciation. There was enlargement of both liver and spleen. 
 No ascites ; no fever 'I'lien there supervened obstruction of 
 the ducts with percc, ible fulness of the gall-bladder, and very 
 deep Jaundice. She ^ believed to be suffering from gall- 
 stones. Then fever, abdominal tenderness, collapse and death. 
 A large aneurismal tumour was found in the situation of the 
 lesser omentum. It was the size of a child's head, and showed 
 a rent communicating with the cavity of the abdomen. 
 
 Lebert's case was accompanied by severe pains in the pit of 
 the stomach, followed after a time by hoematemesis and melsena. 
 Vomiting was persistent, and the patient soon died. The aneu- 
 rism involved the main trunk of the vessel, and communicated 
 by a fistulous opening with the gall-bladder, by which means the 
 blood had found its way into the duodenum and stomach. 
 
 From a relation of these cases Frerichs sums up as follows 
 the clinical features resulting from this lesion : 
 
 " The symptoms to which aneurism of the hepatic artery gives 
 rise are accordingly of a three-fold nature. In the first place 
 there is the tumour, which is sometimes remarkably large and 
 displaces the liver ; secondly, there is the neuralgic pain, pro- 
 duced by pressure upon the hepatic plexus of nerves ; and lastly 
 there is jaundice caused by compression of the bile ducts. The 
 
ANEURI3M OP HEPATIC ARTERY. • 11 
 
 fatal termination in most cases takes place under symptoms 
 of internal hemorrhage." 
 
 We are inclined, therefore, to look at the record of the present 
 case as of considerable importance, inasmuch as it clearly 
 shows that besides, or even without, any of the symptoms 
 mentioned by writers as accompanying aneurism of the 
 hepatic artery, it may actually inscitute an entirely different 
 series, — those namely of acute suppurative hepatitis of a 
 diffuse character. The case as it came under observation was 
 one presenting the marked characteristics of the latter disease, 
 and every possible source of contamination of the portal system 
 which might have given rise to it was interrogated in vain. Of 
 course, we need hardly say that the real cause was entirely 
 unsuspected, nor do we see but that the diagnosis of the aneu- 
 rism was truly impossible. In the future, however, we must 
 admit, in cases owning no other evident cause, that hepatic 
 aneurism may be the starting point of acute hepatic abscess. 
 
 Among the many interesting points in connection with this 
 case, the causation of the multiple abscesses takes the front rank ; 
 not only because in this one alone among the recorded cases 
 was the fatal termination due to a suppurative hepatitis, but 
 also on account of the extreme rarity in the human subject of 
 opportunities of studying upon this organ the effects of disease 
 of the hepatic artery. Taking for granted, as from the careful 
 examination we may justly do, that the portal system did not in 
 this instance furnish the raafcories morbi, wc have to consider 
 the consequence of total obliteration of the hepatic arter}', 
 or of its main branches, and also the effect of small emboli, in 
 the form of particles of fibrin, plugging its terminal twigs. 
 
 It will be necessary first to refer briefly to a few anatomical 
 and pathological pohits in connection with the blood supply of 
 the liver. This, as in the lungs, is two-fold ; the j ortal vein min- 
 istering solely to the functions of the gland, the hepatic artery 
 chiefly to its nutrition. The ultimate branches of the portal 
 vein ramify at the periphery of the lobules, forming the inter- 
 lobular vessels, from which numerous capillaries pass into the 
 interior, and finally converge to the centres of the lobules, as 
 
12 ANEL'RrSM OP IIEPATIC AHTERY. 
 
 the ultimate radicals of the hepatic veins. The hepatic artery 
 furnishes blood to the bile ducts, portal and hepatic veins, and 
 the connective tissue of Glisscn's sheath. Its capillaries empty 
 their blood by small venules into the interlobt ir veins. Hence, 
 remembering this distribution of the hepatic artery, it is easy 
 to understand how that in caaes of thrombosis of the portal vein, 
 even where the obstruction is complete, the functions of the 
 organ may bo mahitained, and both bile and glycogen secreted ; 
 for the capillary plexus of the lobules continues to receive 
 through the interlobular veins the blood which has been 
 emptied into the latter from the venules of the hepatic artery. 
 The nutritive blood serves as a substitute, acts vicariously, for 
 the functional. It has been maintained, and the statement passes 
 carrent in the text-books, that the converse -f this is true, viz: 
 that the portal blood can replace the hepatic, the functional act 
 for the nutritive. This view is based on experiments made 
 upon the lower animals. Schiff states that in the cat the func- 
 tions of the liver are performed just as well after ligature of the 
 hepatic artery as before ; and Betz found that in the dog, after 
 lying the trunk of the hepatic and all the collateral branches, 
 no important alteration took place either in the structure of the 
 liver or in its secretion. 
 
 Cohnheim and Litten have shown, however, in a very impor- 
 tant paper on " Disturbances in the Circulation of the Liver," 
 {Virchow's Archiv. May, 1876), that in experiments on dogs 
 arterial blood still reaches the liver even after ligation of the 
 hepatic, the coronaria ventriculi, and the gastro-duodenalis, 
 owing to the very extensive anastomoses and connections of these 
 vessels. In the guinea pig, on the other hand, the supply of 
 arterial blood can be completely shut off, either from the whole 
 organ or from individual lobes. In the former case the operation 
 is always fatal within 24 hours, and even in this time important 
 changes are found to have to have taken place in the organ. 
 These are all the more marked if, instead of ligating all the 
 arteries, only the one going to the extreme right lobe be tied. 
 The result is an entire necrosis of the portion of the liver sup- 
 plied by the ligatured artery, and in every instance the animal 
 died within two days. 
 
ANEURISM OP AEPATIC ARTERY. 13^ 
 
 Cohnheim states that pathological proof of the correctness of 
 this view is as yet wanting but wo are inclined to believe that 
 hy this case the deficiency is supplied ; for we tliink the sup- 
 puration of the organ host explained on the view, that the shut, 
 ting oft' the supply of blood, either by the gradual occlusion of ^ 
 the aneurism by clot8,or by the quicker process of emboli convey- 
 ed away from the interior of the sac, produced numerous areas 
 of necrosis, which subse({uently became, by inflammation and a 
 sequestering suppuration, converted into abscesses. It is impos- 
 sible to determine, in the abs3nce of any positive evidence, , 
 whether the process resulted from emboli or simply by the gra- 
 dual obliteration of an important blood channel ; and in any case 
 there are certain difficulties which will occur to the minds of 
 many in the view which w6 have suggested. There are at 
 least two cases on record of total obliteration of the artery, 
 without consecutive suppuration, one of which was from aneurism. 
 Still, this, if occurring gradually, and not involving the pyloric 
 artery, need not necessarily, as the above-mentioned experiments 
 prove, deprive the liver of arterial blood. There is no reason 
 to suppose that the obliteration in the case before us did not 
 occur slowly, for the fibrinous laminoe, especially at the anterior 
 end, were firm and tough. Again, on an embolic theory it might 
 be urged that in this instance the emboli, consisting of fibrinous 
 shreds from an aneurisraal sac, should have produced simply 
 mechanical effects, infractions, and not, as in the case of emboli 
 proceeding from necrotic or suppurating foci, abscesses. 
 Mechanical emboli do, however, sometimes produce suppuration,, 
 and in the Uver might do so by causing death of the structures 
 supplied by the obstructed arteries, viz : the portal vessels, bile 
 ducts and connective tissue of Glisson. In the present case, 
 supposing the process to depend on emboli, there would be 
 arterial blood enough sent through collateral branches to furnish 
 material for an active suppuration about the necrotic centres. 
 Altogether, we think the embolic theory meets the case better 
 than any other. We must remember, too, that the disease 
 wm not rapidly fatal, but came on slowly, -ited five weeks or 
 saore, and it is not unlikely that during time that much of 
 
14 
 
 ANEUKISM OF HEPATIC AKTERY. 
 
 the fibrin was deposited, and the obliteration of the distal end 
 of the aneurism took place. This is rendered still more proba- 
 ble hy a consideration of the condition of the left liepatic branch, 
 the commencement of which is involved in the aneurism, but 
 which now, owing to the filling of the proximal end of the sac 
 with fibrin, appears to be almost t!io direct continuation of the 
 main trunk. In fact, for a short distance from the bifurcation, 
 the upper wall of the left branch is made up of condensed fibrin, 
 which is grovcd by the blood chan3l. This explains, too, the 
 occurrence of the abscesses in the territories supplied by the left 
 branch. The almost entire obliteration of the obtuse end of the 
 sac occurred, most probably after the mischief had been started 
 by the escape of emboli. The appearance of the abscesses adds 
 further support to this view. None of them looked recent or 
 contained shreds of necrotic liver tissue, but all were filled with 
 a creamy pus, and had walls lined by definite pyogenic mem- 
 branes. 
 
 We have no clue to the origin of the aneurism itself. The 
 age of the patient, and the absence of arterial degeneration else- 
 where, are almost sufficient to exclude atheromatous degenera- 
 tion as a cause, and the walls of the sac appear thinned but not 
 evidently diseased. Of other agencies capable of producing 
 aneurism, especially of smaller vessels, embolism is the most 
 important, and, even in the absence of valvular disease, and 
 remembering the unfavorable position of the hepatic artery for 
 emboli, we are inclined to regard it as the most probable cause.