Hepatic Disease 337 



atrophy on account of the compression. In the centre of the lobule 

 is the tributary of the hepatic vein (intra-lobular); between the peri- 

 pheral and the central part of the lobule is an intermediate zone, in 

 which the hepatic artery breaks up. 



In disease of heart or lungs the escape of blood from the hepatic 

 veins into the vena cava is delayed, so that the central part of the 

 lobule, which contains the radicle of the hepatic vein, is engorged ; 

 and, on section of the tissue being made, the dark centre and the paler 

 periphery of the lobules give the appearance known as nutmeg-liver. 

 The peripheral cells are pale because they have undergone fatty 

 degeneration ; and the cells of the intermediate zone are stained 

 yellow by the stagnant bile. 



In albuminoid disease the cells in the median zone of the lobule 

 that is, in the region of the chief distribution of the capillaries of the 

 hepatic artery are most infiltrated. In fatty degeneration the peri- 

 pheral cells of the lobule are earliest affected, as the fresh products 

 of digestion which are brought up by the vena portae first come in 

 contact with them. 



As already remarked, the liver may become greatly enlarged in 

 heart-disease (p. 178), reaching even to the umbilicus, and this enlarge- 

 ment is often, as Dr. Wilks remarks, a great help to diagnosis. * A 

 medical man may be called to a patient for the first time, whom he 

 finds dropsical, with albumen in the urine, and a state of heart which, 

 from its weakness and the sounds of bronchitis, is not at once easy to 

 make out.' Is it a case of cardiac or of renal disease ? The former: 

 kidney disease does not cause hepatic enlargement, but morbus cordis 

 entails both that and bronchitis. 



In albuminoid and fatty disease the liver may become enormously 

 enlarged. It makes room for itself partly by pushing up the dia- 

 phragm, but chiefly by thrusting the abdominal viscera downwards 

 and to the left, and by causing a bulging of the lower right ribs and 

 their cartilages. When hepatic enlargement does not implicate the 

 gland evenly throughout, as in abscess or hydatid cyst of right lobe, 

 the encroachment is chiefly towards the thorax, as already noted. 



The portal vein (3 or 4 in. long) is formed behind the pancreas 

 by the confluence of the splenic and superior mesenteric veins ; it also 

 receives the venous blood from the stomach and pancreas. The 

 inferior mesenteric opens into the splenic vein, and the vein from 

 the gall-bladder into the portal vein. The inferior mesenteric vein 

 communicates upon the rectum with the haemorrhoidal plexus ; thus 

 hepatic congestion may be directly relieved by leeching the anal 

 region. 



In hepatic cirrhosis (<ippos, yellowish) on section, the escape of 

 blood from the vena portse is retarded ; the portal capillaries are 

 engorged, and transudation of serum takes place. Thus, the lining of 

 the stomach becomes sodden, and the patient loses appetite and becomes 



Z 



