DISEASES OF THE LIVER. 



and granular appearance are caused by "the venae centrales lobu- 

 lorum, and the capillaries opening into them, dilating under the 

 strong pressure of the obstructed blood, and thus inducing atrophy of 

 the liver-cells, lying in their network. The cells lying in the midst of 

 the lobuli atrophy, and, in their place, appears a soft, vascular tissue, 

 consisting of dilated capillaries, and neoplastic connective tissue." 

 This explanation is not exactly correct, or, at least, not entirely com- 

 plete. The liver cannot be diminished in size by a substitution of con- 

 nective tissue, and dilated vessels for liver-cells. The diminution does 

 not occur till the neoplastic tissue shrinks, and is reduced to a small 

 volume. Moreover, according to Liebermeister, the assertion that, in 

 congestive hyperaemias, the proliferation of connective tissue occurs 

 particularly in the vicinity of the venae centrales, is based on theoreti- 

 cal grounds, and not on direct observation. On the contrary, Lieber- 

 meister found that, in the atrophic form of nutmeg-liver, as well as in 

 cirrhosis, the proliferation affected chiefly the vicinity of the venae in- 

 terlobulares, and in some cases led to a typical development of inter- 

 lobular tissue, which, as is well known, hardly exists in healthy human 

 livers. 



SYMPTOMS AND COURSE. There are neither subjective nor objective 

 symptoms of the disease until the hyperaemia of the liver has attained 

 a high grade, and the organ has considerably increased in size. Where 

 the liver is decidedly enlarged, the patients feel that their right hypo- 

 chondrium is unusually full, and this sensation of fulness not unfre- 

 quently increases to a painful feeling of tension, which spreads from 

 the right hypochondrium over the abdomen. The pressure in the right 

 hypochondrium, or the sensation of having a firm hoop around the ab- 

 domen is often, next to the dyspnoea, the chief complaint of patients 

 with heart-disease. And when the liver swells, the sufferings of em- 

 physematous patients, and of those affected with cirrhosis of the 

 lungs, or curvature of the spine, are decidedly increased. Patients 

 with extensive hyperagmic swelling of the liver cannot bear tight 

 clothes, as they interfere with deep inspiration. If, from the causes 

 above mentioned, a slight obstruction of the gall-ducts accompany the 

 nyperaemia of the liver, there will be some icterus ; and, as the patient's 

 color is already somewhat bluish (cyanotic), from the obstruction of the 

 venous circulation, he will have the peculiar greenish color character- 

 istic of patients with heart-disease shortly before death. Besides the 

 symptoms just mentioned, and the physical observation that the liver 

 is enlarged, in simple hyperaemia there may be no symptoms of 

 ilisturbed hepatic function. A slight increase or diminution of the 

 secretion of bile may escape our observation during life ; even hi the 

 cadaver, where there was excessive congestive hyperaemia, Freric/ta 



