some perplexity to the patient and physician, unless their nature be understood. These are simply the undigested remains of some tendinous expansions, which contain a great deal of yellow elastic fibre, on which the gastric juice seems to act with much less energy than on the white. Rokitansky says that "the occurrence of an excessive elimination of feces from the intestinal secretions is an established fact. It takes place as a critical discharge in various diseases," but may also occur as an idiopathic affection, "which may, by the excessive drain it causes, give rise to atrophy of the intestinal coats, and to general emaciation.

Concretions are occasionally met with in the intestinal canal, and in rare instances of very large size. Dr. Monro (Primus) observed some varying from five to eight inches in circumference, and Monro (Secundus) removed one from the colon which weighed four pounds. Sometimes several, as many as thirty, exist together, but commonly there are not more than two. The color of the smaller resembles that of iron ochre, the larger are more of a coffee color, and occasionally whitish. "They are generally found in concentric layers, and are often radiated, sometimes very obscurely from nuclei. They are more or less porous, either spheroidal or oblong, and vary from the size of a pea to that of a hen's egg, or still larger." The nuclei of concretions may be gall-stones, fragments of bones, fruit, seed, &c., round which saline and animal or undigested matters collect and become condensed. In Scotland, where oatmeal is much used as an article of food, the fibres of the husk of the oats have been found to constitute a large part, or nearly the whole of the concretion; and in a similar manner, chewed paper, the several portions being matted together by mucus with fecal and earthy matter, has been known to cause their formation. Such concretions often exhibit no distinct nucleus. Concretions, which may be mistaken for gall-stones, but which are of a fatty nature, are sometimes voided by persons who suffer from a torpid state of the bowels, and deficient digestive function. Dr. Copland describes them as of a globular form, varying from the size of a pea to that of a large grape, of a cream color, slightly translucent, and of the consistence of soft wax. It is probable that these concretions, as well as the evacuations of a more fluid fat which occasionally take place, are connected in some measure with disease of the pancreas. Observation of disease has in several instances shown the coincidence of the two phenomena; and Bernard has offered a physiological explanation, viz: that the use of the pancreatic secretion is to make the fat contained in the food capable of being absorbed. His results, however, are denied by Frerichs, Bidder, and Schmidt. Blood is sometimes effused in greater or smaller quantities into the intestinal canal. This may result from active or passive hyperæmia, ulcerations, purpura, scorbutic dysentery, and we have once seen it in a case of death from a severe fall.

CHAPTER XXXIII.

ABNORMAL CONDITIONS OF THE LIVER.

CONGENITAL malformations are rare; absence of the liver is only observed in extreme cases. Sometimes the left lobe retains, in a greater or less degree, its fœtal proportion to the right.

Congestion. The vascular apparatus of the liver is very large, its capillaries are more capacious than those of most other parts, and the caliber of the portal, and especially of the hepatic veins is extremely ample. It is, therefore, capable of containing a very large quantity of blood. Though its surface is closely invested by its capsule, yet this membrane allows of a good deal of distension, and this is also attested by the tortuosities of the arterioles of the surface, which probably exist for the purpose of allowing the vessels to be elongated without injury to their texture. Congestion of the liver may be general or partial. The latter is far the more common condition, and, indeed, in its lower degrees is not morbid. The central parts of the lobules, in perfectly healthy livers, are often seen to be marked by a spot of redness which occupies about the middle two-fourths of the whole diameter. This is produced by the blood, as the circulation gradually failed, having stagnated in the hepatic veins, in their radicles, the intra-lobular veins, and the surrounding capillaries. Mr. Kiernan named this, "Hepatic Venous Congestion of the first degree." When the congestion extends further in the direction backwards, there are seen no longer mere spots of redness, but patches of very irregular shape surrounding, more or less completely, portions that are not congested. These portions are situated at the interlobular spaces, where three or more lobules adjoin. Such a condition was named by Mr. Kiernan, "Hepatic Venous Congestion of the second degree." This may coexist with a perfectly healthy condition of the cells which occupy the meshes of the capillary plexus, but not unfrequently these are variously altered, and thus give rise to some modification of the appearance.

The "nutmeg" condition may be here referred to; it consists, in its best-marked instances, of deep red congestion, forming patches and streaks, occupying the central parts of the lobules, and surrounded by patches of a grayish, or dirty white color. The congested portions are most definitely limited, and the contrast between them and the pale parts is extremely striking. This probably depends on the circumstance that the portions thus devoid of blood are affected with fatty degeneration, a change which, by causing the cells to increase in bulk, occasions compression of the interwoven capillaries. That this is the true cause of

the limitation of the congestion is proved by its exactly ceasing at the inner margin of the zone of fatty degeneration. Many of the cells in the congested part are seen filled with dark yellow matter; very many,

also, are atrophied, probably in consequence of the pressure exerted by the distended capillaries. The nutmeg appearance may be exhibited in some degree, by livers which are quite free from fatty degeneration, but it is never so marked as in the condition just described.

When the congestion extends still further and becomes general, occupying every part of the liver, the organ presents a deep red color

(A) Section showing lobules of the liver, bounded by marginal zones in a state of fatty degeneration. The interior of the lobules is deeply congested, and contains much dark yellow pigment in masses. (B) Cells loaded with pigment, atrophied cells and granular matter from the interior of the lobules.

throughout, though, even in this case, the centres of the lobules present the darkest tint; it is also enlarged often to a greatly increased size,

and becomes more firm and prominent, so as to be readily perceptible to the touch, below the margin of the ribs, on the right side. The result of injecting a liver which is nearly drained of its blood, as one taken from a slaughtered sheep, is very instructive as to the amount of enlargement that may be produced by congestion. The organ swells up as the fluid is thrown in, and when fully injected, is of nearly double its former size, greatly more dense and solid, with its thin anterior margin prominent and hard. Such a state may well produce a sense of weight and fulness in the right hypochondrium.

The most frequent cause of congestion to any degree that can be considered morbid is organic disease of the heart, especially such as produces great obstruction to the circulation, and throws the blood back upon the right side of the heart, and the venous system in general. All causes of apnoea produce the same effect, and act in the same way. Congestion thus induced is passive; active congestion takes place in inflammation of the liver, or, as we have observed, when large doses of calomel are administered. The congestion which occurs in the cold stage of ague and other fevers, seems to depend simply on the recession of the blood from the surface, and is, therefore, more of the nature of passive than of active.

Portal venous congestion is a rare variety of partial; the centres of the lobules are pale, and are surrounded by continuous red zones. It is said to occur in children only.

Congestion of the liver, although extreme, does not seem to occasion any structural change, if it is only temporary; but if, as in the case of obstructive cardiac disease, it results from a permanent cause, and is, consequently, itself permanent, it produces the following effects: The distended capillaries of the portal-hepatic plexus, press on the intervening cells; these become, in part, atrophied or stunted, in extreme cases almost destroyed: in part, they are gorged with yellow matter to such a degree that they appear as opaque masses. The quantity of yellow matter thus formed is far greater than any that exists in healthy states of the organ, and, as some of it is doubtless absorbed and carried into the blood, we find in this circumstance some explanation of the icteric hue which is so often observed in such patients. The connection which certainly exists between the congestion and the yellow engorgement of the cells, as cause and effect, gives additional support to the opinion that the yellow bilepigment is a modification of, and derived from, the coloring matter of the blood. Whether long-continued congestion produces still further changes, is not yet made out clearly. We have often thought that the lobular parenchyma was infiltrated by a dense, homogeneous, solidified blastema, distinct from the debris of the atrophied cells, but this may have resulted from a different cause.

Hemorrhagic effusion may take place as the result of extreme congestion, but this is rare; the blood may be poured out either on the surface, detaching the capsule for some extent, or deeper in the substance of the organ. The former occurrence, Rokitansky states, is most common in infants, and may even proceed to such an extent as to rupture the serous investment, and allow the escape of blood into the peritoneal cavity. The deep-seated extravasations occur more frequently in adults

than the superficial, and constitute apoplectic spots of various forms and size. After their partial absorption, a cellulo-fibrous cicatrix remains. Inflammation of the liver must be considered as affecting either the substance of the organ, chiefly, or its capsule. The former is, in temperate climates, a rather rare affection, the latter extremely common. Acute inflammation of the parenchyma of the liver produces general congestion and more or less softening. "These effects," Rokitansky says, "are confined to one or more patches; the congestion, though general, is not universal. The viscus is swollen in proportion to the number and size of the inflammatory patches, and this tumefaction is particularly perceptible when a section is made, the turgid tissue rising above the edges of the incision and the peritoneal sheath." The parenchyma "is loosened and lacerable;" this depends in great part on the cells losing their natural cohesion together, so that they no longer form radiating series. In the latter stages of inflammation, the red color of active congestion fades, and is replaced by a brownish or grayish-red tint in some parts, with yellowish-red or pale-yellow in others. Abscess is a frequent result of acute inflammation of the liver: it is sometimes preceded by a short stage of diffuse suppuration, when the form of the lobules can still be recognized, though their substance is very soft and of a yellowish color. The commencing abscesses are at first very small, like spots of purulent matter dispersed here and there through the inflamed and softened tissue; they gradually enlarge, several coalesce together, and thus form cavities of irregular shape and size. The parietes of the abscess are uneven, presenting the remains of former partitions; they are covered by a kind of pyogenic membrane, which consists, in great part, of pus-globules; external to this, the wall is formed by hepatic tissue, infiltrated with exudation-matter, which serves to bound and limit the abscess, as in the case of a common phlegmon. In very small abscesses, and those of very recent formation, as also in cases where the vital powers are greatly depressed, this limitation of the abscess by exudation-substance does not take place; on the other hand, in old abscesses, and those of very large size, occurring in tolerably healthy systems, a strong enveloping cyst may be found, consisting of fibroid tissue, and amounting sometimes to three or four lines in thickness. If the abscess be deep-seated and encysted, it may continue, especially if of small size, for a long time, without increasing much, or producing serious disturbance of the health; but, if it be near the surface, it excites inflammation of the serous investment, and effusion of lymph, which soon unites its wall with the part with which it is in contact. This may be the wall of the abdomen, or some of its contained hollow viscera, or the diaphragm which roofs it in above; and by any of these various routes the abscess may extend, and at length discharge its contents. By extension, also, in the parenchyma of the liver, the abscess may reach a branch of the portal vein or of the hepatic, excite inflammation of its coats, and consequent obstruction of its canal by exuded fibrin. When the enlarging abscess reaches an hepatic duct-branch, it affects it in a different way; it does not set up inflammation in its walls, and cause its obstruction (though this may no doubt occur in some of the smaller), but it ulcerates through its tunic, and establishes a commu