383 
(3)  Local  symplovis  and  signs.  A  dragging  pain  in  the  Irfl  side 
clue  to  the  enlarged  spleen  is  common.  Discomfort  after  meals  and 
tenderness  over  the  hypochondrium  is  generally  present  at  some 
stage,  caused  by  commencing  perisplenitis  and  perihepatitis.  In 
advanced  cirrhosis,  congestion  of  the  stomach  and  fixation  by 
adhesions  may  set  up  a  chronic  dyspepsia  which  the  patient  seeks  to 
relieve  by  inducing  vomiting  after  a  heavy  meal.  Ilaeniatemesis  is 
not  common,  but  may  be  the  first  symptom  of  the  disease  and  be 
accompanied  by  other  signs  of  portal  congestion.  These  complaints 
are  often  illustrated  by  the  scars  of  cauteries,  setons,  etc.,  with  which 
the  patient  has  sought  to  relieve  his  pain.  See  photos  A  and  D. 
Upon  examination  the  abdomen  is  seen  to  present  the  charac¬ 
teristic  shape  illustrated  in  Plates  VIII,  IX,  X.  There  is  an  outward 
expansion  of  the  lower  ribs,  a  widening  out  of  the  costal  angle,  and 
a  general  enlargement  of  the  upper  part  of  the  abdomen  —often  with 
separation  of  the  recti  muscles — the  result  of  the  pressure  exerted 
by  the  enlargement  of  the  liver  and  spleen,  which  may  indeed  form 
visible  swellings. 
The  condition  of  these  viscera  varies  within  considerable  limits, 
and  is  influenced  by  the  duration  and  severity  of  the  disease,  and 
possibly  also  by  the  age  of  the  patient.  The  liver  is  felt  uniformly 
enlarged,  smooth  at  first  and  of  firmer  consistence  than  normal. 
Later  this  enlargement  is  attended  with  fibrotic  contraction  which 
gives  it  an  irregular  granular  surface.  The  largest  liver  noted  in 
this  stage  measured  six  inches  downwards  from  the  costal  margin 
m  the  nipple  line.  With  increasing  cirrhosis  the  organ  shrinks,  but 
IS  larely  reduced  to  less  than  its  normal  weight.  When  the  spleen  i.s 
much  enlarged  the  hepatic  changes  are  obscured,  since  this  organ 
is  displaced  upwards  and  to  the  right. 
The  spleen  attains  its  greatest  dimensions  when  the  disease  is 
advancing  rapidly,  more  especially  in  young  subjects  below  the  age 
of  20.  Two  illustrative  cases  are  shown  in  Plates  VllI  and  X.  In 
such  patients  it  may  reach  some  distance  beyond  the  umbilicus,  and 
the  diaphragm  with  the  thoracic  viscera  are  displaced  upwards.  It 
may  overlap  the  liver  if  the  latter  be  also  much  enlarged. 
With  the  gradual  development  of  hepatic  cirrhosis  the  spleen 
becomes  much  harder  and  may  shrink  somewhat.  Thus  the  state  of 
the  liver  can  generally  be  inferred  from  the  consistence  of  the  spleen, 
