HfPEILEMJA OF THE LIVER. 



oould not make out such a change. In some few cases only, did he 

 find the bile albuminous. Patients with hyperaemia of the liver have 

 other complaints, it is true ; they suffer from headache, difficulty of di- 

 gestion, irregularity of the bowels, hemorrhoids, etc. These troubles, 

 however, are not the result of the hepatic engorgement, but may have 

 no connection with it, or, as is more frequently the case, they depend 

 on the same causes. Diseases of the heart not only induce hyperaemia 

 of the liver, but also lead to gastric and intestinal catarrh; in the 

 same way, excess in eating and drinking excites gastric and intestinal 

 catarrh even sooner than it does hyperaemia of the liver. It appears 

 to be different with those cases of hyperaemia of the liver which fre- 

 quently occur in the tropics, probably from malaria. These begin 

 with great constitutional disturbance, severe headache, bilious evacua- 

 tions upward and downward, and often with the passage of bloody 

 mucous masses. These symptoms of this disease which is but little 

 known decidedly favor the idea that it is not a simple hyperaemia, 

 but either a coincident anomaly of secretion of the liver, independent 

 of the hyperaemia, or the first stage of a severe organic disease, which, 

 in fact, not unfrequently develops more fully. But perhaps in these 

 cases, also, the hyperaemia of the liver is only the partial expression 

 of a disease affecting all the abdominal organs, particularly the intes- 

 tines ; and this view would best explain the constitutional affection, 

 and the other symptoms. 



When the hyperaemia has reached a high grade, physical examina- 

 tion very clearly shows the swelling of the liver. As we now, for the 

 first time, speak of the physical signs of enlargement of the liver, we 

 must give some account of them. 



As physical aids for recognizing enlargement of the liver, we have 

 inspection, palpation, and percussion. 



In decided swelling of the liver, inspection shows a prominence in 

 the right hypochondrium, extending more or less toward the left side, 

 and gradually disappearing inferiorly. At the same time, the right 

 side of the thorax, which even normally is from half an inch to an inch 

 larger than the left, becomes more prominent at its lower part. Lastly, 

 the inferior ribs may be elevated by the enlarged liver, pressed close 

 together, and their lower edges turned forward. 



If we do not undertake the examination very quietly and carefully, 

 the contractions of the abdominal muscles, which usually occur, greatly 

 interfere with palpation. The inexperienced often mistake contracted 

 portions of the rectus abdominis for tumors of the liver. We should 

 never undertake the examination while the patient is standing or sitting, 

 He should lie down, and draw up the knees a little. At the same 

 time, we should tell him to respire regularly, and should distract his 



