Symptoms of Cirrhosis 339 



testinal tract is stagnant, and water escapes into the bowel and 

 causes diarrhoea, or into the peritoneal cavity, producing ascites (p. 316). 

 A dropsy which begins in the peritoneal cavity is generally due to 

 cirrhosis of liver. Haemorrhage may occur along the alimentary 

 canal, giving rise to black stools. 



Because the blood cannot escape freely from the portal vein by the 

 usual route, it learns to reach the general circulation by going through 

 the veins of the abdominal wall, and through those upon the surface 

 of the liver. In the former case a chain of dilated veins may be seen 

 ascending from groin to chest ; in the latter case the collateral route 

 can be recognised only after death. (See the figure on p. 301.) 



Hepatitis. In acute inflammation of the fibrous tissue of the 

 liver there is a tender and deep-seated fulness in the right hypochon- 

 driac region, and the patient lies upon that side, so that there may be 

 no dragging upon the fibrous and peritoneal bands which keep the 

 heavy gland in its place. 



When the right lobe is the chief part involved, and this is usually 

 the case, there is pain in the top of the right shoulder ; and, the left 

 lobe being implicated, there may ^ pain at the left shoulder. This, 

 as shown on p. 147, is due to the fact that filaments of the phrenic 

 nerves enter the substance of the liver ; the phrenic nerve comes 

 from the fourth, fifth, and sixth cervical nerves ; the fourth gives off 

 acromial twigs, and when the phrenic in the liver is implicated the 

 pain is reflected by those supra-clavicular nerves. 



The movements of the diaphragm distress the liver and set up a 

 dry cough or a hiccough, and, by way of resting and protecting the 

 inflamed gland, the abdominal muscles, and especially the right rectus, 

 are rigid. 



The figure on p. 192 shows how close the lung and the pleura 

 are to the liver and peritoneum ; and when there is pain in that 

 neighbourhood, with a short cough and shallow breathing, it may 

 be difficult to say promptly whether the base of the lung or the liver 

 is inflamed. But ' the ear will tell us, if we employ auscultation and 

 percussion, whether the contents of the chest or of the belly are 

 suffering : and my own experience has taught me that sharp pain, 

 with feverishness, occurring in the debatable ground of the right side, 

 denotes pleuritic inflammation far more often than it denotes hepatic.' 

 (Sir Thos. Watson.) 



Acute hepatitis may end in abscess, and, the pus escaping, may 

 set up fatal peritonitis. But more often the inflammation glues the 

 liver to the stomach, bowel, or abdominal wall, a safe evacuation taking 

 place. The pus may also be discharged through the diaphragm 

 into the right pleura or into a bronchial tube, or even into the 

 pericardium. 



A frequent cause of hepatic abscess is dysenteric inflammation of 

 the rectum, thrombi being carried through rootlets of the vena portas, 



7. 2 



