for  if  the  latter  be  hard,  even  if  only  projecting  a  finger  breadth 
below  the  costal  margin,  hepatic  changes  are  certain  to  be  advanced. 
Adhesions  may  prevent  the  descent  of  the  spleen,  and  in  some  cases, 
where  the  liver  has  been  markedly  cirrhosed,  the  former  organ  could 
not  be  felt  on  abdominal  examination. 
The  duration  of  this  stage  may  apparently  be  indefinite.  The 
longest  interval  noted  before  the  appearance  of  ascites  was  fifteen 
years.  Many  mild  cases  may  show  no  further  symptoms,  and  the 
progress  of  the  disease  be  arrested  or  the  patient  be  carried  off  by 
some  intercurrent  illness.  (Plate  XL) 
The  disease,  however,  attracts  most  notice  when  the  hepatic 
cirrhosis  is  followed  by  ascites  with  its  attendant  miseries.  This 
serious  event  may  be  due  to  the  gradual  obliteration  of  hepatic 
vessels,  but  in  many  cases  the  history  suggests  that  a  fresh  infection, 
acting  on  an  already  cirrhotic  organ,  may  be  responsible.  Evidences 
of  portal  congestion,  such  as  nausea,  vomiting,  haematemesis, 
melaena  and  haemorrhage  from  the  bowel  or  from  piles  may  precede 
its  onset.  Rapid  emaciation  follows. 
At  this  stage  the  patient  presents  the  familiar  picture  of  cirrhotic 
ascites.  (Plate  XI 1.)  The  pinched  features  and  wasted  limbs 
offer  a  striking  contrast  to  the  greatly  swollen  abdomen.  The  effect 
of  the  high  intra-abdominal  pressure  is  seen  in  the  protuberant 
umbilicus  and  network  of  dilated  superficial  veins  which  return  blood 
from  the  oedematous  legs  into  anastomoses  with  the  thoracic  vessels. 
Jaundice  is  rare  except  as  a  terminal  event.  Upon  palpation  the 
cirrhosed  liver  can  usually  be  felt  in  the  epigastric  angle,  and  the 
enlarged  spleen  recognised  by  ‘  dipping.’  Most  cases  with  ascites 
require  tapping  on  admission,  and  this  has  to  be  repeated  on  an 
average  every  ten  days,  about  eight  kilos  being  withdrawn  on  each 
occasion.  After  removal  of  the  fluid  these  organs  can  be  better 
investigated,  when  the  liver  is  more  often  found  enlarged  than 
contracted,  and  the  spleen  hard  and  of  considerable  size.  The  heart 
is  displaced  upwards,  the  urine  may  show  traces  of  albumen,  and 
congestion  of  the  bases  of  the  lungs  with  bronchitis  usually  follows. 
These  latter  signs  may  be  an  indication  of  heart  failure  and  be 
complicated  by  the  development  of  hydrothorax. 
The  duration  of  this  stage  is  considerably  shorter,  and  may  be 
reckoned  in  months  instead  of  years ;  the  consequent  prognosis  ’S 
