hepatic fibrosis
of Himsworth, 1947), there is an initial reversible change characterized chiefly by fatty infiltration, which is later followed by an irreversible change characterized chiefly by increasing fibrosis. The amount of fibrous tissue in the liver may be used to estimate the extent of damage and hence the prognosis in cases of cirrhosis. Since, neither liver function tests nor histological studies gauge accurately the extent of damage or fibrosis of the liver, quantitative estimation of fibrous tissue in cirrhotic livers would give a correct index to the degree of permanent damage to .the liver (Warren and Wahi, 1947). For a complete evaluation of a diseased liver, combined study with function tests, puncture biopsy, and estimation of fibrous tissue in cirrhotic livers would thus be most informative. The utility and limitations of these diagnostic procedures will be considered below in light of experience gained by the studies carried out at the laboratories of Pathology of the Agra Medical College and the New England Deaconess Hospital, Boston.
a
Special Article
Liver
DIAGNOSTIC METHODS IN DISEASES OF THE LIVER By P. N. WAHI, m.d., m.r.c.p. (London) (From the Department of Pathology, Medical College, Agra, and the Laboratory of Pathology, Children'& Hospital, Harvard Medical School, Boston, Mass.) Recent studies of intrahepatic diseases have shown that serious lesions of the liver may arise not only from the presence of noxious substances but also from the deficiency of essential nutriments. In order to foresee the future course of the disease and institute adequate therapeutic measures in such cases, the clinician wants to learn more than just the presence of hepatic damage; he wants to know the anatomic form of the lesion and the extent to which it has progressed. Until recently, this expectation has only been partially fulfilled. Although numerous tests of liver function have been devised, these have only proved useful in so far as indicating the presence and degree of hepatic damage, and following its progress, rather than the means of accurate lesion diagnosis. Wahi and Chakravarti (1946) and Hoffbauer al. (1945) in correlative studies of the clinical, chemical and histological findings, showed the difficulties in the interpretation of liver function tests in the light of histological findings and concluded that the cause of the liver damage in most cases can be established by biopsy studies alone. It was further shown that a combined study of the liver functions and the histological findings in the biopsy specimens provided a more definite information about the nature and extent of the underlying lesion. et
Furthermore, in the development of alcoholic and other nutritional types of cirrhosis (diffuse
function
tests
The liver is a composite organ with multiple functions, and as such, several or all of these functions may be disturbed by hepatic disease. Broadly speaking, the tests of liver function fall into three categories depending upon the function disturbed?tests of excretory function, tests of ability to synthesize, and certain empirical tests for liver damage. The function disturbed depends upon the type and the stage of the disease, and may vary in different patients in the same stage of the same disease. It is comprehensible because in this complex organ, there are in addition to the vascular and supporting structures three other well-differentiated tissues with highly specialized functions : the parenchyma, the cells of the biliary tract and the reticulo-endothelial system represented by Kupffer cells. The composite nature of the organ as a whole is preserved even in the smallest anatomical unit, the lobule. Consequently, injury to any part of the liver commonly involves contiguous though distinct tissues, and the symptomatology of any hepaticdamage is thus the end-result of disturbed functions of these different tissues. It is thus obvious that no single test can be expected to give adequate information concerning the underlying
pathology. For purposes of clinical analysis, the sympof hepatic failure can be separated into three syndromes?excretory failure, parenchymal failure and portal obstruction. However, the patient usually presents a complex picture comprising of more than one syndrome. It is necessary, therefore, to employ a group of tests in any suspected case. This is all the more essential in early or mild cases where only one of the many tests may be positive. Besides,
tomatology
of Himsworth, 1947), there is an initial reversible change characterized chiefly by fatty infiltration, which is later followed by an irreversible change characterized chiefly by increasing fibrosis. The amount of fibrous tissue in the liver may be used to estimate the extent of damage and hence the prognosis in cases of cirrhosis. Since, neither liver function tests nor histological studies gauge accurately the extent of damage or fibrosis of the liver, quantitative estimation of fibrous tissue in cirrhotic livers would give a correct index to the degree of permanent damage to .the liver (Warren and Wahi, 1947). For a complete evaluation of a diseased liver, combined study with function tests, puncture biopsy, and estimation of fibrous tissue in cirrhotic livers would thus be most informative. The utility and limitations of these diagnostic procedures will be considered below in light of experience gained by the studies carried out at the laboratories of Pathology of the Agra Medical College and the New England Deaconess Hospital, Boston.
a
Special Article
Liver
DIAGNOSTIC METHODS IN DISEASES OF THE LIVER By P. N. WAHI, m.d., m.r.c.p. (London) (From the Department of Pathology, Medical College, Agra, and the Laboratory of Pathology, Children'& Hospital, Harvard Medical School, Boston, Mass.) Recent studies of intrahepatic diseases have shown that serious lesions of the liver may arise not only from the presence of noxious substances but also from the deficiency of essential nutriments. In order to foresee the future course of the disease and institute adequate therapeutic measures in such cases, the clinician wants to learn more than just the presence of hepatic damage; he wants to know the anatomic form of the lesion and the extent to which it has progressed. Until recently, this expectation has only been partially fulfilled. Although numerous tests of liver function have been devised, these have only proved useful in so far as indicating the presence and degree of hepatic damage, and following its progress, rather than the means of accurate lesion diagnosis. Wahi and Chakravarti (1946) and Hoffbauer al. (1945) in correlative studies of the clinical, chemical and histological findings, showed the difficulties in the interpretation of liver function tests in the light of histological findings and concluded that the cause of the liver damage in most cases can be established by biopsy studies alone. It was further shown that a combined study of the liver functions and the histological findings in the biopsy specimens provided a more definite information about the nature and extent of the underlying lesion. et
Furthermore, in the development of alcoholic and other nutritional types of cirrhosis (diffuse
function
tests
The liver is a composite organ with multiple functions, and as such, several or all of these functions may be disturbed by hepatic disease. Broadly speaking, the tests of liver function fall into three categories depending upon the function disturbed?tests of excretory function, tests of ability to synthesize, and certain empirical tests for liver damage. The function disturbed depends upon the type and the stage of the disease, and may vary in different patients in the same stage of the same disease. It is comprehensible because in this complex organ, there are in addition to the vascular and supporting structures three other well-differentiated tissues with highly specialized functions : the parenchyma, the cells of the biliary tract and the reticulo-endothelial system represented by Kupffer cells. The composite nature of the organ as a whole is preserved even in the smallest anatomical unit, the lobule. Consequently, injury to any part of the liver commonly involves contiguous though distinct tissues, and the symptomatology of any hepaticdamage is thus the end-result of disturbed functions of these different tissues. It is thus obvious that no single test can be expected to give adequate information concerning the underlying
pathology. For purposes of clinical analysis, the sympof hepatic failure can be separated into three syndromes?excretory failure, parenchymal failure and portal obstruction. However, the patient usually presents a complex picture comprising of more than one syndrome. It is necessary, therefore, to employ a group of tests in any suspected case. This is all the more essential in early or mild cases where only one of the many tests may be positive. Besides,
tomatology
