THE LIVER. 



599 



: 





In rare cases a very peculiar dilatation of the cutaneous veins about 

 the umbilicus is observed. The enlarged veins form a circular network 

 around the umbilicus, or a pyramidal 

 tumor beside it, or all the veins of the 

 abdominal wall, from the epigastrium 

 to the inguinal region, are dilated. 

 This condition is said to be depend- 

 ent upon the congenital non- closure 

 and subsequent dilatation of the um- 

 bilical vein and its anastomoses with 

 the internal mammary, epigastric, and 

 cutaneous veins. According to Sap- 

 pey, it is not the umbilical vein which 

 is dilated, but a vein which accom- 

 panies the ligameutuni teres. 



There is very frequently also a 

 dilatation of the veins of the abdomi- 

 nal wall, which has a diiferent origin. 

 It is produced by the pressure of the 

 fluid of ascites on the vena cava, and 

 is found with ascites from any cause 

 and with abdominal tumors. 



Ascites is the most common sec- 

 ondary lesion of atrophic cirrhosis. 

 It usually begins at an early stage of 

 the disease, and is apt to increase 



constantly. It generally precedes oedema of the feet, but both may ap- 

 pear at the same time. This fluid is of a clear yellow or brown, green 

 or red ; it is sometimes mixed with shreds of fibrin, and more rarely 

 with blood. The peritoneum remains normal, or becomes opaque and 

 thick, or there may be adhesions between the viscera. 



The spleen is very frequently enlarged, and the enlargement may be 

 considerable. When it is not increased in size this seems usually due 

 to previous atrophy of the organ, or to fibrous thickening of its capsule, 

 or to haemorrhages from the stomach and bowels occurring just before 

 death. 



The stomach and intestines are often secondarily affected by the ob- 

 struction to the portal circulation. Profuse haemorrhage from the stom- 

 ach and intestines may occur and sometimes cause sudden death. The 

 mucous membrane is then found pale, or congested, or with haemor- 

 rhagic erosions. The haemorrhage not infrequently results from rupture 

 of ossophageal varices which are present, especially in the lower portion, 

 in a noteworthy proportion of cases of atrophic cirrhosis. ' Sometimes 

 the blood is infiltrated in the coats of the stomach and intestines. 



The mucous membrane of the stomach, and of the entire length of the 

 intestines, is frequently the seat of chronic catarrhal inflammation, and 



1 For a critical summary of gastro-intestinal haemorrhage in cirrhosis with bibliog- 

 raphy see Preble, Am. Jour. Med. Sciences, vol. cxix., p. 263, 1900. 



FIG. 364. NKW-FORMED GALL DUCTS IN CIR- 

 RHOSIS. 



The section shows the projection into the new 

 connective tissue from the rows of old liver cells, 

 of cell masses resembling gall-duct epithelium. 

 This may be interpreted as an example of rever- 

 sion of the differentiated liver cells to a simpler 

 type. 



