662 DISEASES OF THE UVER. 



attention from the examination, by questions, etc. In many cases of 

 enlargement of the liver, that can be certainly recognized by percus- 

 sion, it is true, we find great resistance in the right hypochondrium, 

 but we cannot clearly make out the edge of the liver. This is particu- 

 larly the case where the resistance of the liver is not increased, and 

 still more so when it is diminished. In other cases, palpation gives 

 the best evidence concerning the amount of enlargement, and also, 

 about the shape of the margin and surface ; and this is the more dis- 

 tinct the greater the resistance of the enlarged organ. 



Percussion is the most important physical aid in the diagnosis of 

 the enlargement of the liver. In determining the upper boundary, it 

 is not customary to decide by the commencing flatness of percussion 

 at those points where there is a thin layer of lung between the liver 

 and the walls of the thorax, but by the absolute dulness where the 

 liver comes in contact with the thoracic wall. Hereafter, in speaking 

 of the upper border of the liver, we shall always mean the line of ab- 

 solute dulness. The highest point of the liver lies about 3 cm. 

 above this line. Normally, on the mammillary line, the upper margin 

 of the liver lies at the lower border of the sixth rib ; on deep inspira- 

 tion it descends to the seventh rib, on complete expiration it ascends 

 to the fifth. In the axillary line the upper margin lies about the 

 eighth rib, near the spine about the level of the eleventh rib. 

 In the median line, the upper margin of the liver lies on a level 

 with the union of the xiphoid cartilage and the body of the ster- 

 num, but its position cannot usually be determined, as the liver dul- 

 ness passes into that of the heart Normally, in the mammillary line, 

 the lower border of the liver lies at the margin of the ribs or a little 

 below ; in the axillary line it is usually above the eleventh rib ; in the 

 median line about half way between the xiphoid cartilage and the 

 navel; near the spine its position cannot be determined. As the 

 thorax is shorter in women and children, the lower border of the liver 

 lies somewhat below the edge of the ribs. Neither the sharp border 

 of the liver, which extends a few centimeters below the ribs, nor its 

 left lobe, if not thickened, causes any decided dulness on percussion. 

 In forty-nine cases, of persons between twenty and forty years of age, 

 examined by Frerichs, the distance from the upper line of dulness to 

 the lower averaged, in the mammillary line, 9.5 cm., in the axillary 

 line, 9.36 cm., in the sternal line, 5.82 cm. (The observations of 

 Bamberger differ decidedly from these : in thirty measurements made 

 in adults, he found hi the mammillary line, in women, 9 cm., in men, 

 11 cm., in the axillary line, in women, 10.5 cm., in men, 12 cm., and 

 in a line one inch to the right of the median line, in women, 8.5 cm., 

 in men, 11 cm., as the average extension of dulness.) 



