334 The Abdominal Viscera 



intestines, the liver is pushed up into and hidden in the dome of the 

 diaphragm. 



Ordinarily the liver-dulness extends to the eighth rib at the side 

 of the chest, and, on account of the slope of the ribs, to the sixth rib 

 near the sternum ; near the spine, where the base of the lung comes 

 well down, the tenth rib marks the upper border of liver-dulness. At 

 the side of the chest the lower limit of dulness is the tenth or eleventh 

 rib. In emphysema the dull area is much diminished because of the 

 liver being shrouded by lung. 



In the case of enlargement of liver, with ascites, Sibson used to 

 teach us to find the liver through the fluid by what he called 'dipping,' 

 that is, suddenly thrusting the tips of the fingers into the depths of the 

 right infra-costal region splashing the fingers through the fluid. 



A liver, uniformly enlarged, grows downwards, dropping by its own 

 weight, as it were ; but when its upper surface is the seat of hydatid 

 or malignant tumour, or abscess, it raises the diaphragm and the 

 thoracic viscera, and pushes the heart towards the left. 



Relations. The upper surface, smooth and convex, is directed a 

 good deal forwards, so as to lie against the six or seven lower ribs 

 and the abdominal wall ; its chief extent, however, occupies the phrenic 

 vault. And thus it happens that hydatid cyst or abscess is apt to 

 burst into pleura and lung. To the upper surface the base of the 

 falciform ligament is attached ; through the free border and the 

 depths of that ligament the umbilical vein, or round ligament, reaches 

 the transverse fissure. 



Probably the liver is placed between the diaphragm and the ab- 

 dominal walls so that the movements of respiration may stimulate its 

 circulation. Certainly it often happens that when a free-living man is 

 suddenly laid on his back say on account of a broken thigh-bone 

 the portal circulation becomes congested, ' biliousness ' resulting. 



Though usually hidden behind the ribs, the lower border of the 

 liver may descend within touch of the fingers on a deep inspiration 

 being taken, and in the epigastric region, even after expiration, its 

 border, overlapping the stomach and colon, may give a dull percus- 

 sion-note. It is also thrust down in the case of emphysema, hydro- 

 thorax, and other conditions involving distension of the right side 

 of the thorax ; and from tight-lacing it may descend even to the iliac 

 fossa. In hydatid or other tumour of the liver a more or less rounded 

 mass descends with inspiration ; the very weight of the liver, more- 

 over, keeps the area of dulness depressed. But when the right lobe 

 is implicated in abscess or hydatids the dull area ascends, the right 

 lung is encroached upon, and the heart is pushed upwards and to the 

 left. On the other hand, in phthisis and in collapse of lung the liver 

 ascends, so that even the right hypochondriac region is resonant on 

 account of the encroachment of inflated bowel. 



When the peritoneal covering of the liver is roughened by intlam- 



