The Live* and Gall Bladder. 203 



Clinical Examination. Percussion of the hepa- 

 tic region. When the thorax is percussed from above 

 downwards, the normal resonance begins to change as the 

 fifth rib, in front, is reached, or, as the lower border of 

 the sixth in the midaxillary line, or the eighth in the scap- 

 ular line is reached, and from these points, the dullness, 

 termed "relative hepatic dullness," increases in degree 

 until, below the level of the sixth in front, the eighth at the 

 side, and the tenth behind, it becomes complete, and is 

 termed "absolute hepatic dullness." The limit of dullness 

 may be increased upwards, as already mentioned, in hyda- 

 tids, etc., and downwards in enlargement due to hyper- 

 trophic cirrhosis, etc. The area of dullness may be dimin- 

 ished in acute yellow atrophy, or in atrophic cirrhosis, 

 or, it may be lost in gaseous distention of the abdomen, 

 due to perforation of a hollow viscus, in which case the 

 gas insinuates itself between the diaphragm and the liver, 

 and thus prevents, the normal hepatic dullness from being 

 elicited. 



In distention of the gall bladder there may be found, 

 on percussion, a dull area which corresponds to the dilated 

 sac, and which merges above into the area of hepatic dull- 

 ness. On palpation, the pear-shaped tumor formed by 

 the dilated gall bladder, and extending somewhat inwards 

 towards the middle line, may be felt in the manner de- 

 scribed by Osier, viz. : "Sitting by the side of the patient, 

 with the left hand beneath the lower ribs, and with the 

 right on the abdomen, a little below the costal margin in 

 the nipple line, gentle palpation with the pads of the fin- 

 gers is first made during quiet breathing. The patient is 

 then asked to draw a deep breath and gentle but firm pal- 

 pation repeated, the fingers of the right hand following 

 the receding abdominal walls. The anterior edge of a 

 normal liver can in this wav be readilv felt and any mark- 



