With regard to their texture, we sometimes find that they consist of normal, or at least tolerably normal, hepatic parenchyma. Commonly, however, this is not the case; the parenchyma of the granulations is itself abnormal, and variously diseased; such cases render the analysis of the hepatic granulations difficult, and cause errors in the conclusions arrived at, as not sufficient attention is paid to the distinction between the essential and non-essential characters of the abnormity. The alterations of tissue in the granulations are either such as constitute the causa proxima of the entire metamorphosis, i. e. they are essential, or they are mere accidental complications, which may either precede or accompany the formation of granulations. As we shall subsequently have to show the development of the granulations from the former, and as we are also compelled to examine into the complications of granular liver, we here give a summary of the abnormal conditions, without reference to the above distinctions.

Firstly

The parenchyma of the hepatic granulations occasionally presents a coarse-grained hypertrophy of the acini, the granulations projecting on a sectional surface in the shape of dark reddish-brown and elastic points.

Secondly

It frequently appears in the various degrees of the nutmeg liver (Laennec's cirrhosis of a low degree).

Thirdly

The granulations appear in the shape of rounded or lobular convolutions of dilated, turgid, yellow, gall-ducts, the red vascular substance in the vicinity having disappeared. This yields one of the commonest and most exquisite forms of the granular liver; it is genuine cirrhosis, which originates in the first variety of the nutmeg-liver, dependent upon stasis and dilatation of the biliary ducts. The majority of authors have evidently taken their description of granular liver from specimens of this kind.

Fourthly

The parenchyma of the granulations is frequently infiltrated with fatty matter or similar products, and the granulation then presents on a small scale all the signs discussed at page 98. Gluge has evidently employed a specimen of this description for his investigations.

Fifthly

We occasionally find the granulations in the condition of what we have termed yellow acute atrophy; they are then yellow throughout, and appear at the surface and on section as pulpy, collapsed, friable, yellow masses.

Sixthly

The parenchyma of the hepatic granulations frequently presents symptoms of an inflammatory condition; it then appears pale, of a homogeneous structure, with obstruction of the small biliary canali-culi, commencing induration and obliteration.

The granulations vary much as to number, and are either uniformly distributed through the surrounding cellulo-fibrous tissue, or they coalesce into groups of various extent. The more numerous they are, the less the hepatic parenchyma is destroyed; the number of the granulations therefore indicates the degree of atrophy that has taken place, and, if we take the quality and quantity of the textural changes into consideration, the stage of the disease generally.

The size of the granulations varies from that of a pin's head to that of a horse-bean, according as a single acinus, or an entire lobule, or a large portion of the organ is affected; they are generally of a rounded form, though they are very frequently of an irregular and especially of a tabulated shape. In the majority of instances we find one size and form to prevail.

The cellulo-fibrous tissue intervening between the granulations, is either diminished or increased in amount. There is generally an inverse ratio between this tissue and the number of granulations; but we find exceptional cases in which the granulations are very numerous, and the interstitial cellular tissue is also much increased. The latter varies much as to density, resiliency, vascularity, succulence, and color. Sometimes it is loose, friable, vascular, more or less reddened, and succulent; at other times it is tough, less succulent, of a dirty gray or greenish color, at others again, dense, indurated, dirty white, of fibro-cartilaginous, scirrhoid, resiliency and elasticity, crepitating when cut, etc.

Having discussed the two constituent parts of granular liver, we must now examine into the origin of the metamorphosis.

We have seen that in granular liver the granulations represent the persistent hepatic tissue, and that the parenchyma which has been removed is replaced by cellule-fibrous tissue. The question arises whether this reduction is primary or secondary, and supposing the latter case, which is the primary anomaly? It is commonly set down as mere atrophy, in consonance with the view of the French observers above quoted.

We are not of opinion that granular liver always takes its origin in the same fundamental affection; we are inclined to adopt two morbid states as the essential and original anomalies, which give rise to granulations in the hepatic parenchyma as a secondary affection.

a. In one case there is a morbid development of the capillary gall-ducts (the so-called secreting tissue); an accumulation of the secretion, and probably also a hypertrophy of the parietes of those vessels giving rise to the nutmeg liver, and to an obliteration of the capillary bloodvessels, the so-called vascular substance. We then have to do with the gradual reduction of the organ, already described under the head of Atrophy, as an advanced stage of cirrhosis; in this condition granular liver takes its origin, for the granulations are formed by the biliary ducts coalescing into rounded fasciculi or coils of the size of a pin's head or hemp-seed. They are more or less of a yellow color, containing fat, and either solitary or collected into lobular groups; they are surrounded by a spongy, cellular, soft, succulent, red, and vascular tissue, from which they can only be separated by rupture of the latter and of its vessels. This anomaly is commonly met with in various degrees of development at different parts of the viscus; it is generally more advanced in the peripheral portions, the deeper portions presenting at the same time the appearance of the nutmeg degeneration; the liver is frequently enlarged, but certainly not diminished in size, and preserves the thick, massive edges peculiar to the nutmeg liver.

A secondary metamorphosis now gradually supervenes, the stage of obliteration and atrophy. The interstitial tissue gradually loses its vascularity, its red color, succulence, and spongy texture; it becomes more and more pale, of a grayish-red, and dirty white color; it shrivels up, and becomes denser and drier, coriaceous, and even of scirrhoid hardness; and it presents a cellulo-fibrous, fibrocartilaginous structure. The granulations at the same time undergo important modifications. The obliteration of the interstitial tissue not only destroys the vascular connection between the latter and the granulations, but, as their nutrition becomes impaired, their secreting power also ceases. We now find the granulation enclosed in a cellulo-fibrous case, from which it may be easily removed, as it is only connected with its investment by a few delicate cellular threads, or is even quite detached, with the exception of a single vascular pedicle; it is found collapsed, pulpy, of a dirty yellow color; it gradually diminishes in size, the surrounding tissue also becoming atrophied; it soon appears only as a minute yellow or greenish spot, and at last vanishes entirely. In exceptional cases, in which the liver has become so much indurated as to be incapable of further condensation, the tissue surrounding the individual granulations is converted into a cyst with a serous lining, in which the granule floats, attached only by a vascular footstalk, and surrounded by a yellowish or pale green, watery, or gelatinous fluid. In consequence of the vascular obliteration, it is gradually so much reduced as at last to present nothing but a minute nodule attached to the internal surface of the cyst, which is now entirely filled with the fluid.