§ 2. Enlargement.—Besides the congestive or inflammatory in crease of size which is transitory, pathology recognizes several forms which are more or less permanent: certain varieties of nutmeg-liver : fatty degeneration, including that which is now called lardaceous; and also enlargement arising from the pre sence of cancerous growth and of hydatid cysts. To us the only question of importance is, are there any diagnostic signs by which these conditions may be discovered during life ? The history of the case is necessarily entirely silent as to their origin; it is impossible that any date can be assigned for their commencement; very generally, too, there is scarcely any account of symptoms particularly calling attention to the liver until the disease has reached a pretty advanced stage; there may have been jaundice, but much more frequently this sign is wanting. Persisting disorder of stomach and bowels, attended with any sensation of discomfort, should lead to a physical examination of the abdomen ; by percussion it is not difficult to detect any ex tension of dulness below the edges of the ribs. By examination of the chest, it may be ascertained that the liver is not pushed down by fluid from above: and careful palpation determines whether its edge be even or irregular, its surface smooth, pro jecting, or knobbed. The coexistence of phthisis or scrofula would suggest its being possibly fatty or lardaceous; a condition occasionally brought about in childhood, also, as is alleged, by over-feeding: luxurious living and over-stimulation of the organ might lead us to conceive that it would have the "nutmeg" aspect from hypertrophy of the secreting apparatus: the existence else where of medullary cancer would cause a suspicion of this form of disease ; while any obstruction to the circulation might render it probable that it was merely in a condition of passive conges tion.
By careful examination we can generally say whether the dis ease have the character of enlargement or of morbid growth, just in so far as the organ retains its normal shape and is simply hypertrophied, or has acquired any unnatural form. Exceptions to this rule will be found in cases where the foreign growth is limited to the upper and back part of the liver, when the lower edge is pushed forward and downward, very much as if it were displaced by pressure above the diaphragm: in such a case we may possibly obtain some clue to the true explanation from the pleura or lung-structure being irritated by pressure; but, as a general rule, this does not occur unless there be a tendency to suppuration and ulcerative action, when it seems to be provided as a means of protection against extravasation into the perito neum.
The enlargement of interstitial deposit, whether merely the consequence of constant and repeated congestion, active or passive, or of some more distinctly morbid action, as seen in fatty and lardaceous degeneration, has a tendency to cause a thickening and rounding of the edge of the liver, while its general contour is unaltered; and when this can be made out, it also affords direct evidence that the organ is not simply displaced downwards. In the existence
of morbid growth, if the surface or the edge of the organ be at all irregular— if several prominences be perceptible, there can be no doubt of its cancerous nature ; but if, as sometimes happens, only one rounded eminence be felt, or the impression be that one lobe only is enlarged, the question will naturally arise whether it may not be a serous cyst, which we know to be a common form of morbid growth in this organ. Occasionally, the sense of fluctuation is so distinct, that there can be no doubt of the presence of fluid ; but very often, owing to the thickness of the parietes and the depth from the surface, it is almost impossible to distinguish the elasticity of soft medullary cancer from the fluctuation of a cyst imbedded in such a solid structure as the liver; in cases of doubt, an exploratory puncture may be made with a grooved needle. It is well to bear in mind, however, that an enlarged gall-bladder has been mistaken for a serous cyst : its relation to the edge of the liver which can be felt, if felt at all, unaltered in form and above the fluctuating tumor, should prevent such an error.
The occurrence of jaundice in any of these cases is in great measure acci dental : it is not the destruction of the tissue of the gland which causes the discoloration of the skin in cases in which it occurs, but the obstruction of a duct proceeding from a still healthy secreting structure.
§ 3. Cirrhosis.—Under this head it is convenient to include all the forms of atrophy of the liver met with in the living body, as we have no means of distinguishing them one from another.
As an enlargement, the history fails in pointing out when cirrhosis commenced, and there is little to be remarked in the antecedent circumstances, except when along with an account of dyspeptic attacks we are informed of previous habits of dissipa tion : gin-drinking being known as one of the most common causes of bob-nail liver. There may have been jaundice at an earlier period, and even in the advanced stages there is often a degree of yellowness of the sclerotic; perhaps some illness is reported which may seem to have had the characters of an attack of inflammation, but this is not common. Our attention is very often not called to it until peritoneal effusion has caused the abdomen to and in a large proportion of instances in which ascites has been gradually developed, and there has been no illness to arrest the patient's attention, until the feeling of tight ness round the stomach or shortness of breathing leads him to complain, the direct cause of the effusion is the presence of cir rhosis. In his general aspect the patient usually presents a certain degree of sallowness of skin, and he is always more or less ema ciated; the face especially becomes thinner in this disease than in pbthisis or cancer, and sometimes the bones stand out with frightful distinctness.