Chapter II: Structural Diseases of the Liver (2)

Any fully-developed case of cirrhosis can only terminate in one way, for we possess no means of restoring the hepatic cells when once destroyed. At the outset of the disease, before any serious changes have taken place, it is probable it may be arrested. Proceeding to its natural termination without complications or intercurrent affections, death finally occurs from exhaustion. The emaciation becomes extreme, the stomach gets to be excessively irritable, and an exhausting diarrhoea consumes the last remains of strength. Then an oedema of the lungs or failure of the heart or a deep coma ends the scene.

DIAGNOSIS.--Cirrhosis in its first stage is to be distinguished from diseases which cause enlargement of the liver, and in its second or contracting stage from diseases that induce contraction of the organ. The history of alcoholic excess is an important means of differentiating this {1000} from other affections. The enlargement belonging to alcoholism is distinguished from that due to amyloid disease by the permanent character of the latter and by its history of chronic suppuration, in addition to, it may be, alcoholic excess; from cancer, by the character of the enlargement, by its permanence, by the secondary deposits in the mesentery and elsewhere, by the severe and persistent pain; from hydatids or echinococci cysts by the painless enlargement of the latter, by the absence, usually, of any interference with the hepatic functions, by the purring thrill, and by the presence of the characteristic hooklets in the fluid withdrawn. From the maladies characterized by the contraction of the organ it is distinguished by the rapidity with which the case is developed in acute yellow atrophy, and by the profound constitutional disturbance characteristic of this form of contraction. When the liver is lessened in size in consequence of the compression exercised by the contracting exudation of a local peritonitis, there is a history of pain and soreness of the right hypochondrium, followed by the symptoms of contraction--a very different history from that of cirrhosis, in which the local attacks of pain and distress succeed to or accompany the symptoms of contraction. Occlusion of the gall-ducts by a calculus may set up a slow atrophy having some points of resemblance to cirrhosis; but in this malady attacks of hepatic colic precede the signs of obstruction, the jaundice, and gray evacuations, and the evidences of contraction succeed to these very characteristic symptoms; whereas in cirrhosis paroxysms of pain followed by jaundice are not known. Occlusion of the portal vein may also be followed by atrophy, but this is usually due to some other affection of the abdominal organs, and the change in the condition of the liver occurs very promptly, there being neither the history nor the course of symptoms belonging to cirrhosis.

TREATMENT.--As the abuse of alcoholic liquors--even their habitual use in moderation--is the chief pathogenetic factor, they should be entirely given up. Condiments, coffee and tea, highly-seasoned animal foods, are of less importance as causes, but are sufficiently injurious to require them to be discontinued. The food of such subjects should not contain fat, because the bile is necessary to its right assimilation, and should have but a small proportion relatively of starch and sugar, since these articles readily ferment in the presence of an excess of mucus and in the absence of the bile. The succulent vegetables, as lettuce, celery, spinach, etc., should be substituted for the starchy and saccharine. A diet largely composed of skimmed milk renders an important service both as a nutrient and a diuretic and depurant. Lean meats, acid fruits, and the weak alkaline mineral waters should be the basis of a proper system of alimentation.

As malarial intoxication is a cause now distinctly recognized, patients should be removed from such influences. If this be impracticable, the effects of the poison should, as far as possible, be removed, especially the glandular complications. To this end, such remedies should be employed as will affect the overgrowth of the connective tissue, as the compound solution of iodine, the bichloride of mercury, and the chloride of gold (or gold and sodium). Quinine will be necessary, according to circumstances.

Do we possess any means to check the overgrowth of connective tissue {1001} in cases of sclerosis? The writer believes that those remedies have this power to a less or greater extent which are separated by the liver from the blood. These are chiefly the salts of gold, silver, copper, arsenic, and mercury (chloride), and phosphorus. The most useful of these are the chloride of gold and sodium and the chloride of mercury, and some phosphates. The writer has had, he thinks, curative results in the commencement of the disease from the chloride of gold and sodium and the phosphate of sodium. German practitioners believe that the chloride of ammonium is a powerful alterant and deobstruent, and prescribe it in this affection to stop the overgrowth of connective tissue. That it does have this effect can hardly be disputed, but the daily quantity necessary is large, the taste very disagreeable, and the stomachal effect that of an irritant. Hence it is by no means so effective as the chlorides above mentioned. The chloride of gold and sodium (1/10 grain) can be given at the same time with chloride of mercury (1/20 grain) if it is desirable to combine their effects. The writer has seen what appeared to be cases of cirrhosis in the first stage yield to the persistent administration of phosphate of sodium--drachm j ter in die--and the chloride of gold and sodium.

When contraction of the liver has ensued, and hemorrhages, effusion into the cavity of the peritoneum, and a high degree of gastro-intestinal catarrh have occurred, the relief of the secondary symptoms takes the first place in importance. There are but three modes by which an effusion into the abdomen can be removed: by the skin, by the kidneys, by the intestinal canal. Each of these may be employed in turn. By the skin warm baths, vapor baths, digitalis stupes, and especially the subcutaneous injection of pilocarpin, may be employed. These alone may be sufficient in some cases--rather rarely, however. They may all be used simultaneously or in turn to effect the purpose. A digitalis stupe may be made to have the effect of a vapor bath: a large one is placed on the abdomen and the body is covered with blankets, which results in the production of abundant sweating. The vapor bath is applied in the ordinary way, so that no explanation is needed. If there be no contraindication in the state of the heart, pilocarpin salts can be injected in sufficient quantity to induce active diaphoresis. These measures proving inadequate, an attempt should be made to dispose of the fluid by acting on the kidneys and promoting diuresis. Amongst the diuretics in ascites, Wilks places the resin of copaiba first. The dose ranges from two to five grains, and it may be given in combination with gold or mercury chloride. When this remedy increases the flow of urine, it does good, but if the quantity of urine remains unchanged, it does no good, and should be discontinued.

As the effusion of fluid is due to the portal obstruction, it follows that depletion of the terminal radicles of this system will act most directly on the origin of the troubles. Hydragogue cathartics have, therefore, an important place in the treatment of ascites of hepatic origin. One of the most generally efficient of these remedies is the compound jalap powder, for whilst it produces free watery evacuations, it also stimulates the kidneys somewhat. It is generally better to give a full dose--one or two teaspoonfuls--in the early morning, so that the disturbance caused by it will subside before the time for taking food. Several free watery evacuations should be produced by it. Sometimes the resin or extract of podophyllin is added to the compound jalap powder to increase its activity. {1002} Purgative combinations of colocynth, gamboge, and resin of podophyllin are also occasionally employed, but the most efficient hydragogue is elaterium. The last-mentioned may act very efficiently without causing any considerable depression, but the results obtained by it are usually fleeting. After even a very free discharge of fluid the effusion quickly increases, and further purgation is required. Tapping is a palliative expedient which must sometimes be considered. With the present improved aspirator and the antiseptic method the fluid may be withdrawn with ease and safety. It is not necessary in any case to remove all the fluid--merely that quantity which will relieve the pressure on the diaphragm and on the renal vessels. The author has seen general peritonitis result from tapping. As such a complication will increase all the difficulties of a case, it is very desirable to prevent it by careful application of the antiseptic method and sealing of the punctured orifice to prevent the entrance of germs.

In the protracted cases of cirrhosis there ensues, finally, a highly catarrhal state of the mucous membrane, the bowels become very irritable, and frequent offensive and watery discharges occur. If under these circumstances the abdominal effusion increases, the remedies must consist of diuretics and diaphoretics rather than purgatives. Indeed, an exhaustive colliquative diarrhoea may require bismuth, copper, and other astringents, combined with opium, to prevent the patient passing into the condition of collapse. Hemorrhage by vomiting or by stool will demand ice, subsulphate of iron, ipecac, ergotin in the form of subcutaneous injection especially, and other remedies which have been found useful in gastric or intestinal hemorrhage.

Topical remedies are not without utility if used early. When the changes in the liver are secondary to peritonitis of the hepatic portion, the application of leeches and cups renders an important service. At any time during the course of cirrhosis wet or dry cups may be used with advantage whenever local pain, tenderness, and a catching respiration indicate the extension of mischief to the peritoneum. The tincture of iodine or flying blisters, or both in turn, may be applied over the right hypochondrium after cups and leeches, or at any time when local distress indicates the need of counter-irritants. Probably the most efficient topical application during the hypertrophic stage of cirrhosis is the official ung. hydrarg. iodidi rubri. A piece the size of a large pea should be thoroughly rubbed in over the hepatic region daily until some irritation of the skin is produced. When this irritation has subsided the applications should be renewed.

Suppurative Hepatitis; Abscess of the Liver.

DEFINITION.--Suppurative hepatitis is an acute inflammation of the hepatic parenchyma, terminating in suppuration. The inflammation may be primary or due to local conditions entirely, or it may arise from morbid processes occurring in parts or organs in anatomical relation to the liver.

CAUSES.--Climate exercises an unquestionable influence in the production of hepatic abscess. Those warm countries visited by dysentery, {1003} says Lombard,[83] are almost exclusively affected by this disease. Hirsch,[84] whilst recognizing the influence of climate, shows that the natives are not affected to the same extent as are Europeans. Both writers maintain that hepatic abscess does not occur frequently in the corresponding parallels of latitude in the United States; which is true of the Atlantic border, but is not correct for the interior continent, the valley of the Mississippi, and its tributaries. In this vast region the conditions for the production of hepatitis exist abundantly. The mean annual temperature, the malaria-breeding soil, the social and personal habits of the people (males), combine to favor the production of hepatic abscess. As the native population and females in tropical countries are not affected, there must be other influences to the action of which the high temperature contributes. The rich and highly-seasoned food in which Europeans indulge and the large consumption of alcoholic drinks are doubtless responsible in a large measure for the occurrence of this malady in such excessive proportions amongst them.

[Footnote 83: _Traité de Climatologie médicale_, tome iv. p. 386.]

[Footnote 84: _Handbuch der historisch-geographischen Pathologie_, Band ii. p. 300.]

Sex has a remarkable influence in securing immunity against hepatic abscess. According to the statistics of Rouis,[85] of 258 cases of hepatic abscess, only 8 were in women. He rightly enough attributes this exemption rather to the difference in habits of the two sexes than to any merely sexual peculiarity. In 12 cases observed by the writer, only 1 was in a woman. In Waring's[86] collection of 300 fatal cases of tropical dysentery, only 9 occurred in women. These facts are most conclusive regarding the relatively greater frequency of the affection in men. As might be expected, the age at which this disease occurs is the period of adult life, when exposure to the conditions developing it is most likely to happen. In general, then, hepatic abscess may be referred to the period mentioned by Rouis--from twelve to seventy-five years of age. In my own cases the youngest was eleven years and the oldest fifty-four years of age. It is not the broken-down subject of mature age or the weakling of youth who is attacked by hepatic abscess, but the more vigorous and able-bodied, who have, because of their strength and activity, been exposed to the manifold conditions producing it.

[Footnote 85: _Recherches sur les Suppurations endémiques du Foie d'apres des Observations recueilles dans le Nord de l'Afrique_, par J. L. Rouis, Paris, 1860, p. 189.]

[Footnote 86: _An Inquiry into the Statistics and Pathology of Some Points connected with Abscess of the Liver_, by Ed. John Waring, Resident Surgeon of Travancore, 1854, p. iii.]

Rouis finds that a combination of the lymphatic and nervous temperaments seems most favorable to the production of this malady. It is certain that those who have the bodily conditions influential in the formation of gall-stones are not unfrequently attacked by abscess. The passage of the calculi may induce a local peritonitis of considerable severity; their arrest in the duct, with the result of ulcerating through, producing peritonitis and adhesions, are conditions eventuating in the formation of an abscess always large and sometimes of enormous size. Under such circumstances the element of temperament has a secondary place in the aggregate of causes.

Not very often hepatic abscess results from external blows, contusions, and from penetrating wounds. The liver is so placed as to glide aside when a blow is inflicted on the right hypochondrium, and thus escapes {1004} direct compression. An injury which elsewhere would have but little effect may excite suppurative inflammation in the tropical--or, as it may be entitled, the hepatic--abscess zone. Climatic conditions, or the changed habits of Europeans in tropical and subtropical regions, exert a distinct influence in traumatic cases.

The most important causes of hepatic abscess exist in the state of the portal vein, hepatic artery, and the hepatic veins. In the valley of the Mississippi and its tributaries, where abscess of the liver is a comparatively common disease, it has been found that in a large proportion of the cases the initial stage is an affection of the rectum--a form of dysentery properly entitled proctitis. So far as this vast region is concerned, the intestinal disease which precedes abscess of the liver, and stands in a causative relation to it, is an affection of the mucous membrane from which the inferior hemorrhoidal veins arise. This disease, although having a dysenteric form, is not ordinary dysentery. The onset of the disease and its symptomatic expression are those of a mild affection of the mucous membrane of the rectum--so insignificant in some cases as to be recalled with difficulty. In tropical countries abscess of the liver may be associated with dysenteric ulcerations. This relation has been frequently observed, but is far from constant. In Waring's[87] cases, which occurred in India, 31 per cent. of the fatal cases of hepatic abscess arose during the course of acute or chronic dysentery. De Castro of Alexandria[88] finds that dysentery is the most frequent cause of abscess in that region, especially in the Greek hospital. Murchison[89] considers tropical abscess of the liver as secondary to dysentery in a considerable proportion of the cases, but by no means in all. In non-tropical countries abscess of the liver is found to succeed to ulcerations of the stomach, the intestines, the bile-ducts, etc. In the case of ulceration of any part of the mucous membrane from which the portal vein receives branches a morbific material may be conveyed to the liver. This morbific material may be some unknown septic principle the presence of which in the liver will excite suppurative inflammation; it may consist of an embolus having septic power or a merely mechanical irritant; it may be micrococci or some other living organisms, which, arrested in the portal radicles, set up inflammatory foci, etc. There are many examples of hepatic abscess connected with dysenteric ulcerations of the intestine in which no embolus can be found. Admitting the presence of the embolus originally, its disappearance is readily understood by reference to the changes induced by suppuration. Excepting these cases there must be many in which no embolus can be found, because none existed; an unknown septic substance has excited the suppurative inflammation. Emboli may be lodged in the liver from thrombi formed in the peripheral distribution of the portal vein, or from distant parts of the systemic circulation, as in bone diseases. There has been no satisfactory explanation of the manner in which such emboli pass the pulmonary capillaries to be lodged in the liver. At one time there was supposed to be a special relation between injuries of the bones of the head and hepatic abscess, but it is now known {1005} that these cases are not more numerous than those due to osteo-myelitis in any situation. Abscesses in the lungs are greatly more frequent than in the liver in cases of this kind. According to Waldeyer,[90] whilst in two-thirds of the cases of death from surgical diseases and injuries there were abscesses in the lungs, in only 6 per cent. were there abscesses of the liver. It is evident that the emboli entering the systemic circulation are usually arrested in the pulmonary capillaries. Klebs maintains that such emboli consist of parasitic organisms.

[Footnote 87: _On Abscess of the Liver_, _supra_.]

[Footnote 88: _Des Abcès du Foie des Pays chauds, et de leur Traitement chirurgical_, par le Dr. S. V. Castro (d'Alexandrie d'Egypte).]

[Footnote 89: _Clinical Lectures_, _loc. cit._, p. 178.]

[Footnote 90: _Virchow's Archiv für path. Anat., etc._, Band xl. pp. 380, 408.]

Dilatation and ulceration of the bile-ducts were the principal causes of hepatic abscess, as ascertained by Von Baerensprung, in the Berlin Pathological Institute. Duodenal catarrh involving the orifice of the common duct, catarrh of the biliary passages leading to obstruction, and plugging with a gall-stone have resulted in abscess, the initial lesion being probably rupture of one or more of the finer tubes or inflammation leading to suppuration.[91]

[Footnote 91: Grainger Stewart, _The Edinburgh Medical Journal_, January, 1873.]

Finally, a considerable proportion of cases of hepatic abscess arise under unknown conditions. In such cases, however, it is usually found that there has been more or less indulgence in alcoholic drinks, or the liver has been taxed by excesses in the use of rich foods and condiments, or exposure to extreme degrees of temperature has occurred. In the interior valley of this continent, where hepatic abscess is comparatively common, the causes are to be found in malarial influences, in alcoholic indulgence, in dysenteric attacks the product of climatic variations and improper alimentation, and in the formation and arrest in transitu of hepatic calculi also the result of long-continued gastro-duodenal and biliary catarrh.

PATHOLOGICAL ANATOMY.--Great differences of opinion have been expressed as to the initial lesions in hepatic abscess. It is probable, however, that these differences are due to the character of the abscess. Some have their origin in the hepatic cells, others in the connective tissue, and others still in the vessels. There may be a number of points at which the suppurative process begins, or it may be limited to one. Virchow[92] describes the initial lesion as beginning in the cells, which first become coarsely granular, then opaque, and finally soften, and pus appears. Klebs, who maintains the constant agency of septic micrococci, affirms that the changes in the cells are due to compression exerted by the mass of these organisms distending the neighboring vessels, and then suppuration begins on the portal side of the lobules. Liebermeister originally held that the initial lesion is in the connective tissue; and this view is also supported by Köster, who brings to bear experimental data. In the walls of the vessels of the connective tissue and about them, between the hepatic cells, great numbers of lymphoid cells accumulate. The intercellular spaces are also distended with plasma and round cells, and in the vicinity of the central vein the swollen hepatic cells are pressed together; soon pus-corpuscles appear, and the proper anatomical elements are broken up into a diffluent mass composed of fat-granules, pus-corpuscles, and disintegrating hepatic cells.

[Footnote 92: _Archiv für path. Anat., etc._, Band iv. p. 314.]

When suppurative hepatitis arises from an embolus, or emboli, the {1006} first step is the change in the appearance of the acini, which are enlarged and grow softer by disintegration of their cells; then at the centre a yellowish spot appears, and is made up of the detritus, granules of fat, and pus. Surrounding such softening portions of the hepatic tissue is a zone of congestion. When the morbid processes are excited by emboli, there will be as many centres of pus-formation as there are particles distributed by the vessels--from two or three to fifty or more. They may be uniformly distributed through the organ or be collected in one part. Emboli conveyed by the portal vein will be arranged with a certain regularity and through the substance of the liver, whilst those coming from some part of the systemic circulation tend to form at the periphery under the capsule. Small abscesses in close proximity unite ultimately by the softening and disintegration of the intervening tissue.

In the so-called tropical abscess, which is the variety so frequently met with in the interior of this country, the mode of development is different from the embolic, above described. Owing to the deposit of some morbific matter whose nature is now unknown, the vessels dilate and hyperæmia of the part to become the seat of suppuration ensues. The cells become cloudy, granular, and opaque from the deposit of an albuminous matter in them. Within the area of congestion a yellowish spot soon appears, surrounded by a translucent, pale-gray ring, and here suppuration begins; the neighboring cells disintegrate and a purulent collection is formed, which enlarges by the destruction in succession of the adjacent portions of hepatic tissue. Whilst this process is going on there is a border of deep congestion about the abscess, fading off gradually into the normal tint of the hepatic parenchyma; the walls of the abscess are rough and irregular from projections of tissue just beginning to disintegrate, and the pus burrows in various directions more or less deeply into the softening parts. The size to which such purulent collections attain is largely determined by the condition of the liver as a whole. If the organ attacked is healthy otherwise and the general health is not deteriorated, the area of the abscess may be limited by a well-defined membrane and continue inactive for a long time. This limiting membrane is of inflammatory origin, developed from the connective tissue, and varies in thickness from a mere line to several. It was formerly called a pyogenic membrane, because the pus discharged was supposed to be formed by it. When such a limiting inflammation cannot take place, the abscess continually enlarges by the softening and destruction of the adjacent hepatic tissue, and may finally attain to enormous proportions. The embolic abscesses vary in size from that of a pea to that of an orange. The so-called tropical abscesses are usually single--in three-fourths of the cases, according to Rouis;[93] in 62.1 per cent., according to Waring.[94] Of the fatal cases collected by the latter author, 285 in number, a single abscess existed in 177, and multiple abscesses in 108. In 11 per cent. there were two abscesses; in 3.6 per cent., three; and in 5.6 per cent. there were four abscesses. As regards the part of the liver in which abscess occurs, the statistics show a great preponderance in favor of the right lobe. In Waring's collection of 300 cases the right lobe was the {1007} seat of the abscess in 163, or 67.3 per cent.; the left lobe was affected in 16, or 6.6 per cent.; and both lobes in 35, or 14.4 per cent. The preponderance of cases affecting the right lobe is the more striking when it is understood that, other parts being invaded, the right is included with them in the morbid process. In my own cases the right lobe was the seat of the abscess in 70 per cent.

[Footnote 93: _Recherches sur les Suppurations endémiques du Foie_, _loc. cit._, p. 146.]

[Footnote 94: _An Inquiry into the Statistics and Pathology, etc. connected with Abscess of the Liver_, _loc. cit._, p. 125.]

The contents of the abscesses are affected in character by the form of the disease, whether embolic or tropical, by its rate of development, by the condition of the hepatic parenchyma, by the formation of a limiting membrane, etc. In the more chronic cases, surrounded by a dense membrane, the pus is usually laudable or dry and cheesy; in the acute embolic cases the pus is dark brown, ichorous or grumous, and contains a good deal of detritus of the hepatic parenchyma; and in the tropical cases it is of a sanguinolent, dark color, or more frequently of a grayish purulent fluid; and in the acute forms contains much broken-down tissue, whilst in the chronic cases, in direct ratio to their duration, the pus approaches the laudable character. The source of an abscess discharging from the neighborhood of the liver may be ascertained by a microscopical examination and the discovery of the hepatic elements (the cells) in the fluid. Bile may also be present in the pus.

The abscesses not confined by a limiting membrane constantly enlarge by the softening and disintegration of the adjacent liver substance, and those enclosed or encysted after a period of quiescence of variable duration begin active efforts to establish communication outwardly. The point to which a purulent collection in the liver tends becomes an important element in diagnosis and in treatment. As the abscess approaches the surface of the liver the capsule inflames, and if adhesions are not formed more or less sloughing occurs, and the contents are discharged into the abdominal cavity. Adhesions may form to the parietes, an external swelling appear, and after a time discharge take place in the right hypochondrium at some point. Pus may escape at the umbilicus, in the right inguinal region, posteriorly at the sacro-iliac junction, and in other situations. Adhesions may form to the stomach, duodenum, the ascending vena cava, to the diaphragm opening the thoracic cavity, the pericardium, or the mediastinum; and the accumulated pus may thus find a vent. According to Waring,[95] the termination of hepatic abscess is as follows: Of 300 cases, 169, or 56.3 per cent., remained intact--that is, had not advanced beyond the liver; 48 were evacuated by operation, or 16 per cent.; 14, or 4.6 per cent., entered the thoracic cavity; 28, or 9.3 per cent., opened into the right lung; 15, or 5 per cent., entered the abdominal cavity; 7, or 2.3 per cent., opened into the colon; 1 entered the stomach; 3 entered the hepatic vein near the vena cava; 1 communicated with the hepatic ducts, 2 with the right kidney, etc. The termination of 162 fatal cases, according to Rouis,[96] was as follows: 125 proved fatal in consequence of the extent of the abscess or of the severity of the accompanying dysentery; 3 terminated by gangrene of the walls of the abscess; 3 by peritonitis; 12 by opening of the abscess; 2 by rupture of adhesions; 11 by opening of the abscess into the pleura; 2 by intercurrent and 3 by secondary pneumonia. Notwithstanding the differences {1008} in the mode of expressing the conditions, the general results are the same.

[Footnote 95: _An Inquiry into the Statistics and Pathology, etc. of Abscess in the Liver_, _loc. cit._]

[Footnote 96: _Recherches sur les Suppurations endémiques, etc._, p. 149.]

An abscess of the liver having discharged in a favorable way, healing may take place. There may be such an extent of injury--the whole secreting structure of the liver being destroyed--that repair is beyond the power of the organism. The best results are attained when discharge occurs by the most direct route externally; the next, by way of the right lung; the third, by the stomach or intestine. Repair cannot be hoped for when a large part of the normal hepatic structure is destroyed. When the pus escapes the walls of the abscess approximate, and union takes place by connective tissue, leaving a radiated or a merely linear cicatrix to mark the site of the purulent collection. So perfectly does repair take place in suitable subjects that no trace of the lesion may remain.

Those portions of the liver outside the borders of the abscess, and beyond the vascular derangements produced by it, may be entirely healthy. In the cases terminating in recovery the portion of the liver unaffected by abscess continues to functionate normally. More or less of the liver may be destroyed; hence it follows that recovery may be partial. According to the damage done to the proper secreting structure of the organ will the recovery be partial, limited, or complete.

SYMPTOMS.--The existence of an abscess of the liver is determined by systemic or general and by local symptoms, and they may be acute or chronic.

Systemic.--In acute cases the beginning of mischief may be announced by a rigor, but more frequently this indicates the onset of suppuration, and is one of the phenomena of the chronic form. As the disease occurs in this country, a chill takes place suddenly in a case which presents the usual symptoms of proctitis (dysentery) during the course of this affection or soon after its apparent cure; then a febrile movement occurs, and subsequently an irregular intermittent, the rise of temperature being preceded by rigors or mere transient chilliness. With these febrile symptoms there may be associated uneasiness in the right hypochondrium, acute pain, or a feeling of weight and pressure, with jaundice, etc. The fever is septicæmic, intermittent, or remittent if it have any special type. In the septicæmic form the rigors are severe, occur irregularly, sometimes daily, sometimes twice a day, and at intervals of two or three days or longer; the fever rises to a high point--104°, 105°, or higher--and the sweats are profuse. In the intermittent form the fever usually has the quotidian type; some slight chilliness is experienced in the early morning as a rule, and the exacerbation occurs in the afternoon and evening, the sweating being slight toward the morning. More frequently, in the writer's observation, the type of fever has been remittent, with periodical, but not regularly so, exacerbations. In such cases the morning temperature has been at 99° or 100°, and the evening 102° or 103°. Such a range of temperature may be present during three or four weeks or even longer, the abscess gradually making its way outwardly. Conclusions may be drawn from the behavior of the febrile movement as to the character of the local affection, with the limitations imposed by the necessary uncertainty of the data. If the chills are decided rigors, the fever {1009} high, and the sweats profuse, either pyæmic abscesses or large tropical abscesses implicating neighboring organs exist. The simple intermittent, especially the remittent, form of fever suggests abscesses of medium size making their way outwardly, with only partial injury to the parts traversed. In a certain portion of the cases the type of fever changes when a large accumulation of pus takes place; after several weeks of a mild remittent the fever becomes irregularly intermittent with rigors, strong exacerbations, and profuse sweats. In protracted cases the fever assumes the typhoid aspect; there is profound adynamia, dry tongue, sordes, diarrhoea, and the usual symptoms of this state. When the secreting structure of the liver is destroyed to a large extent, the condition of acholia is superadded to the typhoid state.

The pulse is irritable and quick from the beginning of the symptoms. In a few instances a slow pulse, such as occurs in jaundice, has been observed, but generally the number of cardiac contractions is in a direct ratio with the body temperature. When typhoid symptoms supervene in advanced cases the pulse becomes weak and dicrotic.

Not every case presents the symptom sweating. The chronic cases with mild remittent fever have little more than slight moisture of the surface, whilst the acute and pyæmic cases are characterized by profuse sweats. If to an irregular febrile movement, preceded by chills and followed by sweats, there is added the tendency to sweat on all occasions--on slight exertion, on sleeping, under any excitement--suppuration may be suspected.

General malaise, a sense of fatigue and exhaustion, and progressive decline in flesh and strength occur. It is remarkable, however, how some obese subjects preserve their roundness and apparent fulness of habit. Usually, however, emaciation advances pari passu with the progress of the suppuration. The more acute the symptoms, the more rapid the wasting. When an encysted abscess develops in the course of a chronic dysentery, there may be no appreciable change in the condition of the patient properly attributable to the additional lesion. The loss of appetite, the frequent vomiting, and often the dysenteric troubles, contribute materially to the exhaustion and the wasting of the tissues. The stomachal derangements may be present with the initial symptoms, but they are usually more pronounced when the abscess attains to considerable size.

A peculiar tint of the skin, especially of the face, is observed in those cases without jaundice. There is an earthy or sallow hue, which to the practised eye signifies suppuration. Jaundice is present in a less proportion of cases. In 13 of Waring's cases the skin is said to be sallow. In Rouis's collection icterus was present in 17 per cent., or 26 times in 155 patients. According to Waring, jaundice is rarely present. In the 12 cases in my own hands actual jaundice was not present in one, but 9 had an earthy hue or presented some yellowness of the conjunctiva. In fact, jaundice does not have the importance as a symptom which might, a priori, have been expected.

The mental condition of these subjects is that of depression. They sleep poorly, are disturbed by vivid dreams of a horrifying character, and the nocturnal sweats increase the tendency to wakefulness. Hypochondria, or at least marked symptoms of mental depression, as {1010} Hammond[97] has shown, are present in many cases. So frequent, indeed, seems to be the association of a depressed mental state with hepatic abscess that in every case of the former the liver should be carefully explored. Hammond goes so far as to say that in every case of hypochondriasis puncture of the liver with the aspirator needle should be practised when any symptom, however indefinite, indicates the existence of an abscess. Besides the condition of hypochondriasis in many cases, there may be stupor, hebetude of mind, confusion due to acholia, cholæmia (Flint's cholesteræmia), when a large part of the liver structure is destroyed.

[Footnote 97: _Neurological Contributions_, vol. i. No. 3, p. 68: "On Obscure Abscesses of the Liver, their association with Hypochondria and other Forms of Mental Derangement, and their Treatment."]

Sweating has already been referred to as a phenomenon connected with the febrile movement. It is necessary to state further that this may vary in amount from a mere moisture of the surface connected with sleep, or it may be a profuse diaphoresis with which the febrile paroxysm terminates. As a systemic symptom, sweating is strongly suggestive of suppuration, and may therefore be extremely significant, in this connection, of suppuration in the liver. According to Waring, of 75 cases specifically interrogated on this point, 72 presented this symptom. Rouis refers (p. 123) to it as very constantly present, coming on chiefly at night--sometimes generally over the body, sometimes limited to the head, and always accompanied by an accelerated pulse.

The urine in cases of hepatic abscess varies; it is never normal. There may be merely an excess of urates--a symptom common enough in all febrile affections and in suppuration. It is usually high-colored, deficient in urea, and contains leucin and tyrosin, and not often bile-pigment, except when jaundice is present, which, as we have seen, is rather uncommon.

It should be borne in mind that whilst the above-described mental and cerebral and other symptoms are often present, they are by no means invariably so. There are cases, usually of encysted abscess, in which no functional disturbance of any kind exists. But the systemic symptoms are by no means so important as the local. To these we must now direct attention.

Local.--The position, size, and shape of the liver are not without significance, but it is strictly correct to say that an abscess of the liver may exist without any change in the size of the organ or in its relations to the surrounding organs. In 2 of 12 cases in the hands of the writer there was no evidence of enlargement of the right hypochondrium, but a difference in circumference of half an inch was ascertained in favor of the left side. In 4 cases there was no appreciable change in the size of the hepatic region; in one-half there was an increase in the area of hepatic dulness. In one of the cases in which the left side was the larger the abscess was of enormous extent, and discharged by the stomach and intestine. The enlargement of the liver may be very great. In one instance observed by the author the abscess reached to the upper border of the third rib. Rarely does the dulness extend more than two fingers' breadth below the inferior margin of the ribs, although cases are reported in which the enlarged organ reached to the crest of the ileum. As a rule, the diaphragm is pushed up and the lung displaced, rather than the dulness is extended downward. When the first tumefaction {1011} due to the initial congestion takes place, the organ may be much larger than subsequently, the pus becoming encysted and the normal state outside of the area of suppuration being restored. The purulent collection in a large proportion of the cases taking place in the right lobe, the extension of dulness is in the same lines as the normal. When, however, the right lobe is the seat of abscess, or a purulent collection forms around an impacted calculus, the swelling may appear in the outer border of the epigastrium next the ribs, and the increased area of dulness will be across the epigastrium and occupying the superior portion of this region. The general experience on these points corresponds to my own. Thus, according to Waring, there was an evident enlargement of the liver in 90 cases, and no enlargement in 11. In most cases the increase in size gives the impression of a fulness or hardness of the liver or of a diffused swelling or tumor of the epigastrium. In some instances the right hypochondrium is bulged out, the intercostal spaces widened, and the side appears to be or is actually elevated, and occasionally enlarged veins form, as in cases of the obstructed portal circulation of cirrhosis. In a case recently presented at Jefferson College Hospital clinic by the author, a globular swelling formed in the walls of the abdomen just below the inferior margin of the ribs near the site of the gall-bladder, and was held by an eminent surgeon to be a tumor of this locality; but it had the history of an hepatic abscess, and ultimately proved to be one. Rouis furnishes statistical evidence of the time when the increase in size of the liver occurs with respect to the other symptoms. He has noted an enlargement of the organ 73 times in 122 cases. Of 51 cases, the liver was enlarged in 12 before suppuration, in 22 at the onset of suppuration, and in 17 after suppuration was established. In 49 examples the liver was enlarged in 2 before any other symptom was manifest, in 8 at the onset of symptoms, and in 39 after the symptoms were well declared.

Fluctuation is not referred to by the writers in general, and there are no statistical data on this symptom, so far as our observation extends. No symptom could be more uncertain in all doubtful cases. When a large accumulation has taken place and the parietes of the sac are thin, fluctuation may be detected, but it cannot then be regarded as decisive. When an abscess in the interior of the right lobe is encysted, no fluctuation can be effected. The best mode of eliciting fluctuation, according to Hammond, is to place the extremities of the fingers of the left hand in the depression between the ribs over the most prominent part of the right hypochondrium, and gently tap with the fingers of the right hand the right border of the epigastrium. In 3 out of 12 cases this method has apparently elicited fluctuation in my own experience. The elasticity of the hepatic structure is such that the method of palpation, however practised, must return a sensation nearly allied to that of fluctuation in a purulent accumulation. It is certain, therefore, that errors of observation are liable to occur, and hence conclusions based on an apparent fluctuation should be accepted with caution; under any circumstances it should be very distinct, and even then should not be acted on unless supported by other suggestive evidence.

The uneasiness or pain felt in the right hypochondrium varies greatly according to the position of the abscess, the degree and kind of pressure exerted on neighboring organs, and the period of its development. When {1012} the peritoneal layer of the liver is involved, there will usually be acute pain, and this happens at two periods--when the abscess first forms from an impacted calculus or from any cause which includes the peritoneum, and subsequently when the pus, making its way from the liver, excites inflammation in the peritoneal investment of the liver, of the diaphragm, or affects ultimately the pleural membrane. In the so-called pyæmic abscesses there is very little pain, and in the case of the large single abscess in the interior of the right lobe there is rather a sensation of weight or of heaviness, of dragging than of acute pain. When the capsule of the liver is put on the stretch or the peritoneal investment is inflamed, then acute pain may be felt. More or less pain or local distress is, on the whole, a usual symptom. According to Rouis,[98] local pain is present in 141 out of 177 cases, or in 85 per cent. The statistics of Waring[99] closely correspond, for of 173 patients affected with this malady, in 153 there was more or less pain referable to the affected organ. The position of the pain has some influence in determining the seat of the malady, and often indicates the position of the abscess. As respects the character of the pain, there is little uniformity; in general it is a tensive, heavy, throbbing sensation, but under the circumstances above mentioned this may have an acute or lancinating character, as when the capsule or the peritoneal investment of the organ becomes involved.

[Footnote 98: _Recherches, etc._, _loc. cit._]

[Footnote 99: _An Inquiry, etc. into Abscess of the Liver_, _loc. cit._]

Besides the pain directly referable to the liver there are painful sensations felt in the neighboring parts, of very considerable significance. These are often described as sympathetic pains, and are referred to the shoulder--to the right shoulder when the right lobe is the seat of mischief, and to the left shoulder when the abscess forms in the left lobe of the liver. Although this statement has many limitations, it is not without diagnostic importance. Rouis ascertained the existence of the shoulder pain in 17 per cent. of the cases, or in 28 in a total of 163. Waring reports that this symptom was observed in 52 in a total of 76 cases. The right shoulder seems to be affected in about the same ratio as the right lobe of the liver in 25 times out of 26 cases, according to Rouis. The shoulder pain appears at the same time, in a majority of cases, as the hepatic pain, but it is very capricious. It is most frequently at the top of the shoulder, but it may be at the end of the clavicle, in the scapula, or extend down the arm. Its duration is very irregular, appearing occasionally during the existence of the disease, coming on at the outset, and lasting weeks or months, or only felt on pressure over the liver, on coughing, or on taking a full inspiration. The character of the pain is equally uncertain. It is usually heavy, tensive, stinging, or may be merely a sensation of soreness or of uneasiness or of weariness. The behavior of the shoulder pain is partly explicable by reference to the path by which the reflex is conveyed. As Luschka[100] has shown, the filaments of the phrenic nerve supplied to the suspensory ligament and capsule of the liver, put on the stretch or irritated, convey the impression to the cord, and it is reflected over the sensory fibres of the fourth cervical distributed to the shoulder. Rouis reports an instance in which the deltoid was wasted.

[Footnote 100: Quoted by Thierfelder, _op. cit._]

The decubitus of patients affected with hepatic abscess is often {1013} extremely characteristic. To obviate the pressure on the swollen and inflamed organ the position assumed is right lateral-dorsal, the body inclined to the right, the right thigh flexed on the pelvis, and the spinal column so curved as to relax the abdominal muscles of the right side. When the pain and tenderness are not great there may be frequent changes of position, but in repose the lateral-dorsal decubitus is assumed. When the suppuration is well advanced and the accumulation large, the patient keeps in that position nearly constantly. If pressure interferes with the normal play of the lungs, and dyspnoea is produced on assuming the recumbent posture, the attitude taken expresses this state also: then the decubitus is lateral and partly dorsal, but the body is raised to a half-upright. There are many exceptions to these rules. Some lie easiest on the back, some on the left side; but it is quite certain that much the largest number, when uninfluenced by special circumstances, naturally place themselves as above described.

Jaundice is amongst the rarer symptoms. Rouis finds it to be present in 17 per cent. of the cases, Thierfelder in 16 per cent., and Waring in somewhat less than 6 per cent. Referring to my own observation, jaundice has rarely been present, but some yellowness of the conjunctivæ and a faint yellow tint of the skin generally have been evident. The peculiar aspect of the countenance connected with suppuration has rarely been wanting. When jaundice does occur, it is referable to two conditions--to a catarrhal swelling of the bile-ducts, which may be coincident with the onset of the suppurative inflammation; to the pressure of the abscess on the hepatic or common duct, which must happen at a late period.

As an abscess of the liver forms and enlarges, pressure is exerted on neighboring organs, producing very decided disturbances. Nausea and vomiting, anorexia, a coated or glazed tongue, diarrhoea or dysentery, are amongst the disorders of this kind involving the digestive apparatus. Each of these symptoms will require examination.

There is nothing characteristic in the condition of the tongue which does not belong to suppuration in any situation. Nevertheless, there are some appearances that have a certain value in conjunction with other diagnostic signs. At the onset of the suppurative inflammation the tongue is more or less heavily coated, but as the case proceeds it becomes dry and glazed in parts, whilst covered with a well-defined membrane-like crust at the base and margins. This appearance is very characteristic of the cases of suppuration, the abscess enlarging. In a very important case observed by me lately there was a well-marked diphtheritic-like exudation of the tongue and fauces toward the termination of the case, the membrane forming as the pus accumulated. This appearance was coincident with a typhoid state.

Nausea and vomiting appear with the beginning of symptoms, are associated with the general signs of systemic disturbance, and are especially prominent when an accumulation of pus takes place, being due under these circumstances to pressure on the hepatic and solar plexuses or to direct encroachment on the stomach--probably to both causes. The frequency and persistence of the vomiting are points of much diagnostic importance, according to Maclean[101] and Fayrer,[102] which I {1014} am able to fully confirm from my own experience. The matters ejected by vomiting consist of the contents of the stomach--glairy mucus, the accumulation in the gall-bladder, altered blood (coffee-grounds)--and the contents of the abscess if it discharge by the stomach. The vomiting is most apt to occur during the febrile exacerbation or at the time of sweating. The statistics are conclusive as to the frequency of vomiting as a symptom. Of 84 cases in which special reference was made to this point, in 74 nausea or vomiting existed. In my own experience this symptom has never been wanting.

[Footnote 101: "The Diagnostic Value of Uncontrollable Vomiting," by W. C. Maclean, _Brit. Med. Journ._, August 1, 1873.]

[Footnote 102: _Ibid._, September 26, 1873.]

The relation between abscess of the liver and dysentery has been much discussed. Under the head of Causes the influence of dysentery as a pathogenetic factor has already been examined. We have now to study its symptomatic relations. A considerable proportion of the cases occurring in this country have been preceded by proctitis--simple, sporadic dysentery affecting the rectum. In India a close relationship has been traced between ulcerations of the intestinal canal and abscess. According to Waring, 75 per cent. of the cases have occurred in those who were actually suffering from dysentery or recent or old ulcerations. As observed by Rouis in Algiers, out of 143 cases there were 128 with dysentery, or 90 per cent. Budd[103] long ago maintained that a peculiar poison generated at an open ulceration in the intestine was the true cause. Moxon,[104] Dickinson, and others have lately reaffirmed this explanation. A case by the latter[105] casts a strong light on this question: A patient had extensive dysenteric ulceration of the intestine and an abscess of the liver, without any symptoms indicating their existence. Such a case teaches the instructive lesson that dysenteric ulcerations may escape detection, and hence the connection between abscess and the intestinal lesion remains unknown. In a small proportion of cases--about 5 per cent.--dysentery is a result, apparently, of hepatic abscess. Whether the relation is admitted to exist or not, it is a curious fact that in so many cases ulcerative disease of the intestinal canal accompanies the hepatic affection. Hemorrhoids, prolapse of the rectum, gastro-intestinal catarrh, etc. are produced by the pressure of an enlarging abscess on the portal vein.

[Footnote 103: _Diseases of the Liver_, 3d ed., p. 82.]

[Footnote 104: _Pathological Transactions_, 1862 and subsequently. Numerous cases are recorded in the various volumes up to 1880.]

[Footnote 105: _Ibid._, vol. xiii. p. 120.]

The urine contains bile-pigment when jaundice is present, is usually loaded with urates, and the amount of urea may be deficient when much of the hepatic tissue is destroyed.