With reference to these figures, it must be remembered that these are statistics, not of cases of portal cirrhosis recognized as portal cirrhosis during life, but in the post-mortem room, and this will explain the low percentage here given. Never theless they show very clearly that ascites is not the frequent and necessary accom paniment that is generally held. The fluid in these cases is clear, but may be slightly bile-stained; after repeated tap ping it assumes more the character of an inflammatory exudate. According. to some French observers, it begins as a subacute peritonitis; this is, however, doubtful. The fluid is alkaline; with a specific gravity varying between 1010 and 1015, though, if there has been any peritonitis, this specific gravity and the percentage of proteid are increased and the fluid may show spontaneous coagula tion. Hale White, in his article on "Peri hepatitis" (Allbutt's "System of Medi cine"); holds that ascites proper is a late event in cirrhosis, for which more than one tapping is rarely required, and re gards those cases in which multiple tap pings are necessary as being complicated with peritonitis; indeed, he goes so far as to hold that, where ascites is directly due to cirrhosis and paracentesis is ne cessitated, the patient rarely lives long enough after the first tapping for the second to be necessary. Of 10.' cases which were recorded during life as hav ing cirrhosis, but were tapped oftener than once, of 4 at post-mortem examina tion, 3 were found to be cases of chronic peritonitis and perihepatitis and 1 of colloid disease of the peritoneum; the remaining 6 had more or less chronic peritonitis associated with the cirrhosis which was present. In fact, he would employ this as of diagnostic value as be tween uncomplicated cirrhosis and peri tonitis or perihepatitis with or without cirrhosis.
Form of cirrhosis of the liver conse quent upon the circulatory obstruction clue to pericardial lesions. There is, at times, a clinical difficulty as to whether an hepatic enlargement with more or less ascites is a primary or secondary disease, especially where there are obvious phys ical signs of a valvular lesion and hardly any of back-pressure. Three cases of this form of pseudoeirrhosis witnessed. Pick (Zeit. f. klin. Med., B. 29, H. 5, 6, '96).
(Edema of the feet is not infrequently secondary to ascites, and is, in the main, due to a pressure of the distended ab dominal contents upon the veins coining from the lower extremities. According to Osler, Cedema of the feet may precede the development of the ascites, in which case it is to be ascribed to the malnutri tion of the patient and the impoverished condition of the blood. The dropsy rarely becomes general.
Enlargement of the Spleen.—This is far more frequent than is ascites. Thier felder found, out of 172 cases, only 39, or 22 to 23 per cent., in which this symp tom was absent; indeed, it may be re garded as the most common of the symp toms associated with portal cirrhosis. Oestreieh is inclined to believe that this enlargement of the spleen is not entirely due to portal obstruction, in that it ap pears at so early a stage of the condition before other marked signs of such ob Aruction are evident; indeed, it is sug crested that the toxic causes which are at work to produce the hepatic lesion bring about enlargement of the spleen.
If passive congestion be the cause of splenie enlargement, why is the spleen so frequently small and hard in cases of chronic passive congestion of the ab dominal viscera. due to heart disease? F. P. Weber (Edin. 3Ied. Jour., N. S., vol. ii, p. 579, '97).
The average weight in the spleen in hepatic cirrhosis is 12.93 ounces, while in cardiac cases it averages only 7.32 ounces. Again, the greatest enlargement of the spleen is not found where the porta) obstruction is greatest, but in those cases of portal cirrhosis where as cites is delayed till the last or is wholly absent. Kelynack (Edin. Med. Jour., N. S., vol. ii, p. 579, '97).
Weber, like Oestreich, is of the opinion that toxannia is the cause of the enlarge ment. The organ is enlarged from half to three times its normal size; in one case of portal cirrhosis which re -cently came under my notice, it weighed 720 grammes. Describing a similar case of large splenic tumor, Banti compares it with the malarial spleen, and urges the probable infectious origin of such cases.
Case of splenomegaly followed by he patic cirrhosis in a middle-aged woman. There was no history of malaria or syph ilis. but she bad suffered for many years from pellagra. There had been no abuse of alcohol. Bonardi (Gazz. degli Osped., Jan. 3, '97).
Case of hypertrophic cirrhosis of the liver in a boy 9 years old. At the au topsy the liver lx-as found to weigh G50 grammes, had a yellowish-green color and an irregular surface; a large num ber of fibrous bands traversed the or gan, the bile-duets were dilated, the spleen hard. Dellemagne and Tordens (Jour. de Olin. et de Th6rap. Inf., vol. v, .No. 17, '97).
Themorrhoids. — While hmmorrhoids are frequent in cases of portal cirrhosis, the majority of recent writers are of the opinion that they are far from being as common as used to be taught.
Pain and Tenderness over the Region of the latter is often most no ticeable in the early stages, and is often accompanied by a sense of epigastric full ness and tension, which may be present through the duration. of the disease. As Ross pointed out and explained in his re markable article in the tenth volume of Brain, besides these sensations referred directly to the diseased organ (or con ditions of splananic pain), there may be other painful sensations which may be termed sovzatie, or referred pains. The liver is innervated from the seventh to the tenth dorsal, and, as a consequence, the pain affecting the organ may be re ferred to the cutaneous branches of these nerves by overflow of irritation in the cord, and, as a matter of fact, pain is frequently felt in the region of the angle of the right scapula. Another pain at times experienced is that at the tip of tbe right shoulder, more rarely of both shoulders. Where this is the case there is an indication of involvement of the upper surface of the organ, extending to the diaphragm, for such pain is brought about by the overflow of irritation at the point of entry of the phrenic nerve into the spinal cord; and so there is reference to pain along the branches of the lower cervical nerves, the phrenic arising chiefly from the fourth cervical with a few fila ments from the third.