C78 DISEASES OF THE LIVER. 



not so much out of the reach of palpation as is generally asserted. If. 

 by placing the patient on the left side, and so removing the fluid in the 

 abdomen from the liver, we succeed in reaching the edge of the liver 

 we perceive that its resistance is even greater than in the first stage, 

 and on the surface we may feel hard, roundish prominences of unequal 

 size. If the ascites be not too great, in the second stage also percus- 

 sion shows in some cases an increase, in others (but, according to my 

 experience, not at all frequently) a decrease of the normal liver dul- 

 ness. In estimating the latter symptom, we must be more careful than 

 when the extent of the dulness is abnormally great ; for, as the numer- 

 ous measurements of Frerichs prove, the size of the liver and the ex- 

 tent of its dulness vary greatly within certain bounds. Moreover, any 

 abnormal position of the liver, such as occurs by decided inflation of 

 the abdomen, causes the organ to come in contact with the anterior wall 

 of the abdomen and thorax only by its sharp border. Finally, portions 

 of the intestines, filled with gases, pressing between the' liver and the 

 abdominal wall, may diminish or entirely remove the normal liver dul- 

 ness. If we bear these facts in mind, the diminution of liver dulness is 

 a very important symptom in cirrhosis. As the left lobe of the liver is 

 the first to decrease in size, the abnormally clear percussion-sound in 

 the epigastrium is first noticed ; subsequently the dulness over the right 

 lobe may so decrease that it will be reduced to one or two inches hi the 

 mammillary line (Bamberger). The most certain point in diagnosis is 

 the gradual decrease in size of the previously enlarged organ, as shown 

 by repeated examinations. 



Having introduced the symptoms of interstitial hepatitis individ- 

 ually, and weighed them as a whole, we will add a short and general 

 description of the disease. The patients are mostly men in middle or 

 advanced life, and addicted to drink. In the commencement the symp- 

 toms are slight and obscure ; the patients complain of pressure and ful- 

 ness in the right hypochondrium ; more rarely, when the serous cover- 

 ing is more affected and intensely inflamed ; there is pain in the region 

 of the liver. In this stage, the most prominent symptoms are enlarge- 

 ment of the liver, dyspepsia, flatulence, and emaciation. Gradually, 

 often not for years, the abdomen swells, from an effusion of fluid into 

 the peritonaeum, while there is no simultaneous oedema of the feet. 

 The skin becomes dirty yellow, the urine dark red, and rich in urates 

 the faeces slate-colored; the dyspepsia and emaciation increase. Ii 

 this stage, the liver is sometimes smaller, the spleen almost always en 

 larged. In some patients there is bleeding from the intestinal canal ; 

 in almost all, haemorrhoids. The increasing ascites interferes with 

 breathing, and induces oedema of the legs, genitals, and abdominal 

 walls. Finally, after months or years, the patients die, excessively 



