HYPEILEMIA OF THE LITER. 



If the liver be enlarged, the liver dulness will extend into the right 

 hypochondrium and epigastrium. Near the edge of the liver the dul- 

 ness becomes indistinct or disappears entirely, a fact which we must 

 know, or we shall suppose the organ is smaller than it really is. Be- 

 fore deciding, from the extension of dulness into the right hypochon- 

 drium, that the liver is enlarged, we must determine that it is not 

 displaced downward. We have already spoken at length of some im- 

 portant points for the diagnosis between enlargement and displace- 

 ment of the liver. Moreover, without being enlarged, a greater part 

 of the liver may He in contact with the abdominal walls, if it has sunk 

 downward from pressure on the lower part of the thorax or from re- 

 laxation of its tissue, or if it has an abnormal form. Among the 

 anomalies of form the most frequent are those induced in women by 

 tight-lacing and still more by wearing then* waistbands tight. As a 

 result of this constant pressure on it, without increase of its volume, 

 the liver may become much flattened and so elongated as to descend 

 several finger-breadths below the ribs, or in some few cases even down 

 to the crest of the ileum. We must bear in mind these deviations in 

 position and form of the liver, if we would rightly interpret the results 

 of physical examination. 



Hyperaemic swelling of the liver can rarely be perceived by simple 

 inspection. From the decided increase of thickness of the organ, per- 

 cussion gives great dulness, which may extend from the right to the left 

 hypochondrium, and as far down as the navel or even below it. And 

 as the resistance of the liver is increased, we can usually feel its mar- 

 gin, and satisfy ourselves that its form is unchanged and its surface 

 smooth. A characteristic of hepatic enlargements caused by hyper- 

 aemia is that they grow more rapidly than any other form, and decrease 

 again rapidly. 



It is remarkable that the symptoms of atrophic nutmeg-liver 

 have not received proper attention until lately, when Liebermeister 

 has paid a great attention to them. As the symptoms of this disease 

 are characteristic, it may be quickly sketched. The patients affected 

 have disease of the heart or emphysema, or some other disease of the 

 lung, which impedes the flow of blood through the right side of the 

 heart. This obstruction of the circulation has caused enlargement of 

 the liver, cyanosis, and general dropsy. As is usual in heart and lunsr 

 diseases, the dropsy began in the lower extremities, and afterward in- 

 vaded the serous cavities. Subsequently the state of affairs is changed : 

 the ascites becomes more decided than the anasarca ; or the ascites 

 sontinues, while we may succeed in removing the other symptoms of 

 dropsy for a time by suitable remedies. On examining the liver, we 

 find it smaller than at first, its lower border is some finger-breadths 



