On examining the right hypochondrium, the liver is found to be entirely beyond the reach of the fingers, and percussion shows that while on the one hand the ordinary extent of liver dulness has been diminished in the direction of the umbilicus and ilium, it also does not ascend so high as usual in the chest, in short, that the organ has shrunk in every direction.
Another form of disease in which the liver loses bulk is what has received the name of yellow atrophy : it is invariably accom panied by jaundice, and this symptom, in fact, affords the only indication of its existence.
Occasionally, in scirrhus, the actual size of the organ is dimi nished, the natural structure, which is destroyed by the disease, not being replaced, as in the medullary forms of cancer, by mor bid growth in equal or greater amount. It would be vain to attempt to give any rules for diagnosis in such cases : sometimes, however, there is pain, and very often there is jaundice, and these are not met with in cirrhosis • at the same time the disease is one of slow progress, and attended with diminution of size: the hypo thesis of scirrhus would then be at least admissible.
§ 4. Jaundice.
In the present state of pathology we must be content to admit this name into our classification, although it be but a symptom ; for it is one not only known to be dependent on various forms of lesion, but it is also one of which very frequently during life, and occasionally even after death, we cannot deter mine the exact cause. It is probable that in all cases of jaundice some change has really occurred in the liver, the gall-bladder, or the ducts ; but even this baa been denied : progressive knowledge may ultimately enable us to assign its true cause. but at present the name is a convenient one for grouping together cases which cannot be included in any other class from our Lg. norance of their true nature, while they present this common feature. To adopt the name of functional disturbance without advancing in any way. our real knowledge, would only deprive us of the advantage which the prominence of the symptom affords.
Distinct and unmistakable, however, as it would seem to be, an inexperi enced person may be deceived. A patient who has it only in slight degree is quite surprised when told that he has jaundice ; the greenish hue of chlorosis, or the sallow earthy aspect of malignant disease. or the yellowness of the skin
in pytemia, are all apt to be called jaundice. Its clearest indication is to be found in the sclerotic coat of the eve, which presents in the chlorotic or ma lignant condition a pearly or bluisli lustre ; pyiemia it is unchanged, unless jaundice be present. However slight the tinge of the skin generally—and in dark persons it.very often has only an appearance of bronzing—in the scle rotic the yellow tinge is invariably seen.
The circumstances which have preceded its occurrence chiefly indicate whether it has been brought on by mental emotion, fright, &e., or whether there 'has been any paroxysm of pain, possibly indicating the pre.sence of a gall-stone obstructing the duct ; pain, however, is not essential to the diagnosis of gall-stone. The exa mination of the liver may prove it to be associated with conges tion, enlargement, or contraction : and as an aid to diagnosis it has been remarked that the very deep shades of color, tending to a greenish brown, are usually associated with malignant disease, that the yellowbr shades are more commonly functional, while slight bronzing is often seen in its inflammatory or congestive states. Such general inferences must not be too much relied upon.
The liver may be decidedly shrunken and small ; and in the absence of symptoms to show that there was any other cause, we may suspect the existence of yellow atrophy. I am not aware that there is an7 direct evidence by which it can be proved: it presents little difference from the jaundice dependent on func tional causes, except in the severity of its symptoms; the skin becomes intensely yellow, the brain is affected by blood-poisoning, and the disease is rapidly fatal from this cause ; it is by some classed among the acute disease-s of the liver, for this reason, although the very fact of its being a form of atrophy seems op posed to such an idea. Cirrhosis never of itself gives rise to jaundice : cancer, with shrinking of the organ, very commonly leads to obliteration of some duct, and the eftbct of this will be the existence of jaundice of very dark or green eolor.