After having thus briefly passed in review the important functions of a healthy active liver, let us now say a few words about its examination. The liver is one of the few ductless glands which are available for manual examination by percussion and palpation. We must ascertain if it extends considerably below the costal margin, and by palpation we must ascertain whether the enlarged liver is soft or hard and cirrhotic. In the former condition we can diagnose hyperactivity of the liver, probably due to its efforts to safeguard the body against a long-continued intoxication, as may be the case in those who overeat, and also in long-continued digestive troubles, especially with dilatation of the stomach, chronic constipation, etc. Following on this hyperactivity, as is the case with all organs, there may come an exhaustion, more especially after long-continued intoxications. Thus in chronic alcoholism a simple hypertrophy of the liver may go on to cirrhosis, and later the hypertrophy may be followed by an atrophy, with all its harmful consequences, as ascites, etc. On examining the liver we must not forget the sclerotics, and must note whether, on looking upward, there is any yellow discoloration. While palpating the liver we must specially note whether it is tender, and also if the gall-bladder is tender. This is a typical symptom of chronic inflammation of the gall-bladder, or cholecystitis, which is so frequently associated with gall-stones. We find such a tender gall-bladder very frequently in elderly women, in whom gall-stones are particularly common. In fact, they occur so frequently that Halck[135] in Copenhagen, found them in 29 per cent. of 4140 autopsies on persons above 50 years of age. However the mere presence of gall-stones does not constitute gall-stone disease, the essential point being an inflammation of the gall-bladder and bile-ducts. Such an inflammation of the gall-bladder is revealed by tenderness on pressure with the examining hand. It is a frequent symptom of all those conditions (as we have found and communicated to the French Congress of Medicine, 1905) in which the thyroid or sexual glands are diseased. For instance, after pregnancies, after infectious diseases in old age, etc., it is often accompanied and preceded by obesity, which is also a consequence of inactivity of the thyroid and sexual glands. Frerich, many years ago, observed enlargement of the liver and a tender gall-bladder in women at the climacteric, and many other authors have made similar observations. Hertoghe found such conditions common in women suffering from inactivity of the thyroid or hypothyroidia. Footnote 135: Quoted from Hoppe-Seyler in Nothnagel’s “Practice,” p. 548, 1904. It has been found by experiments, made by Blumenthal and Jacobi, that extirpation of the thyroid is followed by a dilation of the gall-bladder, and many authors have noted the presence of biliary constituents in the urine of animals whose thyroid has been extirpated.