Granular liver is one of the most important, though in many respects, and especially in reference to its pathogeny, one of the most enigmatical affections of the liver; it is termed by Laenncc cirrhosis: older authors have considered it identical with or related to scirrhus; and if viewed in reference to its termination only, it may be called induration of the liver.

It undoubtedly presents many degrees, which merge into one another; from the very unsatisfactory state of our knowledge, however, in reference to the elementary process and fundamental nature of the disease, we consider it necessary to sketch the affection as seen in a marked case, without any further complication, and subsequently to state what is known of the earlier stages of the disease, and of the later metamorphoses of the organ.

In a case of the kind alluded to, the viscus appears considerably diminished in size, and this decrease is accompanied by a characteristic change of form. The margins are thinned down to such a degree, as to represent a cellulo-fibrous seam, which is folded upon the remainder of the organ; the vertical diameter of the liver has increased, and is found to consist chiefly of the hemispherical or globular right lobe. (Vide p. 103).

The external surface presents a granular, warty, racemose appearance, which results from the projection of the peripheral so-called granulations, of the liver. These granulations may all have the same size, e. g. that of a hemp-seed, and the surface then is uniformly racemose: or they vary in size, and the surface is then unevenly racemose.

The hepatic surface intervening between the granulations is of a dull white color, tendinous, shrivelled, and contracted; the granulations are thus circumscribed, separated from one another, and even occasionally pediculated.

The viscus, when it has this appearance, is to a certain extent elastic and tough, and even indurated, so as to offer a cartilaginous resiliency; it cannot be broken, as it possesses the tenacity of leather.

The scalpel itself confirms the fact of induration, as the instrument meets with a scirrhoid substance, which may even cause a crunching sound.

A section shows the above-mentioned granulations to be either isolated or grouped together; an accumulation of dirty white, dense, resilient cellular tissue, which is almost destitute of bloodvessels, and which forms a nidus for the former, is seen between them.

The color of the organ is variously modified; being dependent upon the color, either of the granulations, which we shall have still further to examine, or of the intervening fibro-cellular tissue.

The liver is frequently attached to adjacent parts, especially to the diaphragm, by means of cords or laminae of new matter; the adjoining peritoneum, and especially the peritoneal covering of the gall-bladder, and the folds which leave the liver, are opaque, shrivelled, and tendinous.

The granulations have given rise to the name of granular liver; and from the coexisting atrophy and diminution of size, the affection is also termed granular atrophy of the liver.

The granulations are the most prominent sign in the sketch we have given, and the question arises as to their nature.

Laennec viewed the granulations as an adventitious product, and as his specimens offered a yellow color, he termed it cirrhosis [xippos, fulvus).

One may easily be convinced of the incorrectness of this view, as a careful examination at once proves that the granulations consist of nothing but hepatic parenchyma, which, however, as we shall subsequently have occasion to show, is variously modified.

It follows from our demonstration that in granular liver the hepatic parenchyma has become reduced to the granulations, and that the portion which has disappeared, has been replaced by fibro-cellular tissue.

The desire to obtain more accurate views as to the nature of the granulations and their mode of origin, has caused the promulgation of various doctrines which are untenable or incomprehensive in proportion as their authors attached too much importance to the ideas of hypertrophy and atrophy and their combination, or attempted to construct a theory from isolated observations, or because they did not sufficiently distinguish between the diseases of the hepatic parenchyma preceding the formation of granulations, and those affecting the granulations themselves, and other morbid conditions not essentially connected with them.

According to Bouillaud, with whom Andral coincides in the main, the granulations are the result of hypertrophic development of the so-called white or secreting substance, accompanied by obliteration and gradual atrophy of the red or vascular tissue.

Cruveilhier advocates a different opinion. He thinks that cirrhosis consists in the atrophy of a considerable number of the hepatic acini, accompanied by hypertrophy of the remainder, which, as it were, take the place of the former.

We pass over the unsatisfactory and erroneous doctrines of other writers, which are based upon investigations of solitary cases, or of anomalies in the elementary tissue, and merely remark, that we do not adopt any one of the above views exclusively, as they do not appear to us to embrace the entire characters of granular liver.

Granular liver presents considerable varieties. The granulations themselves offer numerous variations in reference to texture, number, size and form.