G72 DISEASES OF THE LIVER. 



which gives the liver a fleshy look, and which is shown by the micro- 

 scope to consist of delicate connective-tissue striae with spindle-shaped 

 cells. Between this tissue, the original parenchyma appears as large 

 and only slightly-prominent granulations. 



The second stage, into which the first gradually passes, is excel- 

 lently described by Rokitansky. According to him, in typical cases, 

 the liver is much smaller than normal ; its form is altered, the edges 

 becoming thinned, and finally changed to an indurated border, which 

 contains no liver-tissue : on the other hand, the thickness, particularly 

 of the right lobe, is relatively greater. Lastly, the whole organ often 

 consists of the spherical right lobe, to which the left is attached as a 

 flat appendix. In this stage we may see granular or watery projec- 

 tions (granulations) on the surface, to which the disease owes its name 

 of " granular liver." If the granulations are all of the same size, as 

 large as a hemp-seed, for instance, the surface appears regularly gran- 

 ular ; if they vary in size, it is irregularly granular. Between the 

 prominences the serous coat is whitish, tendinous, shrunken, and re- 

 tracted ; if deep retractions separate large portions of the liver from 

 each other, it appears lobular. The serous coat is also usually attached 

 to the surrounding parts, particularly to the diaphragm, by short, firm 

 adhesions, or by bands. The substance of the cirrhotic liver is very 

 hard and of leathery toughness. On section, there is often as much 

 resistance as on cutting into scirrhus, and on the cut surface we find 

 the same granulations as on the surface of the liver. They are embed- 

 ded in a dirty-white, dense, non-vascular tissue. At some places the 

 parenchyma has entirely disappeared, and the dense tissue alone re- 

 mains. On microscopic examination in this stage, we no longer find 

 the first elements of connective tissue, but this is fully formed, and en- 

 closes in concentric layers groups of liver-cells (the granulations). The 

 btill existing liver-cells are partly affected with fatty degeneration and 

 partly intensely yellow, as a result of the retention of bile induced by 

 obstruction of the bile-ducts. The fatty metamorphosis of the liver- 

 cells, and still more the pigment in them, gives the entire liver, but 

 particularly the granulations, the yellow color to which it gives its 

 name, " cirrhosis." 



SYMPTOMS AND COURSE. The symptoms of the first stage of cir- 

 rhosis are very similar to those of simple hyperaemia of the liver ; the 

 inflammatory process within the liver and in its covering is usually ac- 

 companied by little pain, although the patient may be more sensitive 

 to pressure over the liver than is the case in simple hyperaemia. In 

 some cases, however, the feeling of fulness in the right hypochondrium 

 increases to painful tension or even to burning pain. Besides these 

 symptoms, there are various troubles in the first stage of cirrhosis. 



