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which has an edge which can be readily felt on deep palpation,
particularly when the patient takes a long-drawn, deep breath, the
mass is probably an enlarged liver or a liver pushed down into the
abdominal cavity by a large pleural effusion, pneumothorax, a sub-
phrenic abscess, or sometimes by an emphysematous lung. The
causes of enlargement are lymphadenoma and amyloid degeneration,
congestion, hypertrophic cirrhosis, abscess, carcinoma, sarcoma.
When the surface is found to be smooth, the condition is probably
amyloid or fatty degeneration, or congestion. If the surface is

Fig. 121. —Showing percussion dulness of liver and heart. The outside line shows tlie area
of partial dulness of heart and liver, modified by lung. The solid area is that of true hepatic
dulness. At x, Traube's semilunar space.

rough, it will probably be due to cirrhosis, which a granular
sensation to the hand when the abdominal wall is moved over the
organ. In malignant growth large and small nodules may often be
found, and depressions or umbilications of its surface may be marked,
but it must be remembered that cancer of the liver is not necessarily
associated with the presence of nodular masses. On the contrary,
the growth or growths may be large, yet project so slightly above the
hepatic surface that they cannot be felt. In such cases there may be
pain, marked emaciation, cachexia, and the organ be found much

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The physician who feels distinct nodules on the surface of the liver
should not immediately conclude that these are necessarily carcino-
matous, for syphilis often produces a very extraordinary nodulation
of the surface of this organ. So great is this, that when nodulation
is excessive the possibility of syphilis being the cause is to be con-
sidered. This form of disease is, however, rarely accompanied by
as great hepatic enlargement as is that due to cancer with marked
and multiple nodules.

The consistency of the liver is usually very hard in cases of cirrho-
sis, carcinoma, and amyloid degeneration. In cirrhosis there will be
some ascites in many cases, some swelling of the legs perhaps, and
dull pain in the hepatic region. The digestion will be disordered,
there will be marked loss of flesh, and often hematemesis. Some-
times'corna comes on. In the case of amyloid liver there will be
a history of prolonged suppuration elsewhere, and there will be
present disordered digestion, irregular bowel movements, and little

Marked tenderness of the hypochondrium is usually found in
congestion of the liver, in inflammation of its tissues, such as that
caused by an infection or by gallstones in its substance, and in malig-
nant growth. Tenderness is practically absent in amyloid liver and
in fatty degeneration.

In cases of cirrhosis of the liver, whether it be in the hypertrophic
or atrophic form, the patient rarely complains of the organ, and no
symptoms which seem to him hepatic in origin may be present, save
that in the hypertrophic state its size is increased, so that it can be
felt below the ribs, whereas in the atrophic state it cannot be felt
except by pushing the fingers well up under the ribs. The symptoms
accompanying cirrhosis are chiefly connected with disorders of the
alimentary canal, either through direct failure in the digestion and
assimilation of food, or from changes in the blood supply of the
abdominal contents. The following excellent diagram, from Sey-
mour Taylor's Index of Medicine, shows what these symptoms are,
and discovers their cause at a glance, the cirrhotic process, of course,
obstructing the flow of blood in the liver, (Fig. 122). It is a note-

worthy fact that in the atrophic form jaundice is rare even in the
very last stages of the disease, whereas in the hypertrophic form it is
commonly met with. Ascites is common in the atrophic form, rare
in the hypertrophic variety.

Sometimes enlargement of the liver and ascites are due to adhesive
pericardiiis. The diagnostic signs of adhesive pericarditis consist in
systolic retraction of the intercostal spaces in the anterior axillary

line, and posteriorly at about the fifth or sixth rib on the left side,
which retraction is followed by a diastolic rebound. If the patient is
told to forcibly inspire or expire, the natural change in the position

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