sensation or pain in the right shoulder. His friends observed that his face had become muddy and haggard. He was uneasy if he lay on his left side. The quotidian rise of temperature now became a regular feature, the thermometer every evening touching 102° F.— sometimes more, sometimes less and sinking to near normal by morning. He now began to perspire profusely at night, and even during the day when he chanced to fall asleep. He had to change his sleeping clothes once or even twice every night on account of the drenching sweats.
On examination it is found that the patient is somewhat emaciated; his complexion thick and muddy; his pulse 80 to 100; his tongue furred and yellowish; the palms of his hands and soles of his feet cold and clammy. As he lies on his back it is obvious, on inspection, that the epigastrium is too full for one so emaciated; and it is seen that the breathing is shallow and mainly thoracic. The right rectus muscle is rigid. Considerable discomfort, if not pain, is elicited by attempts at palpation and percussion over the right hypochondrium. The liver dullness extends an inch too high, and an inch or more beyond the costal border in the nipple line; posteriorly it rises to about the eighth rib in the line of the angle of the scapula. It is further observed that the line of dullness is arched along its upper border; and that it is altered by changes of position, the upper line descending when the patient lies on his left side or stands up; in the latter position the lower margin descends markedly in the epigastrium. On deep inspiration, percussion below the right costal border gives rise to much uneasiness or even to acute pain. Very likely one or two tender spots can be discovered on firm pressure being made with the finger-tips in some of the lower right intercostal spaces, or below the right costal margin. The spleen is not usually enlarged. Auscultation may detect pleuritic friction somewhere over the base of the right lung, or peritoneal friction over the liver itself. The urine, free from albumin, is scanty, high-coloured, and deposits urates. The blood shows well-marked polymorphonuclear leucocytosis.
