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.
From the beginning of symptoms some cough is experienced: it is short
and dry, but after a time in many cases the cough is catching and
painful, and finally may be accompanied by profuse purulent
expectoration. The breathing is short and catching when by the upward
extension of the mischief the diaphragm is encroached on, and may
become very painful when the pleura is inflamed. Ulceration of an
abscess into the lungs is announced by the signs of a local
pleuro-pneumonia--by the catching inspiration, the friction sound, the
crepitant râle, the bronchophony and bronchial breathing, and bloody
sputa usually, etc. Some time before the abscess really reaches the
diaphragm, preparation is made in the lung for the discharge through a
bronchus. The author has seen {1015} many examples of this, and a very
striking illustration of the same fact is afforded in a case by
Dickinson,[106] in which an abscess holding about four ounces was
contained in the upper part of the right lobe; its walls were irregular
and not lined by a limiting membrane. It is further stated that the
"right pleura was coated with flocculent lymph, and the cavity
contained serous fluid," etc. Here, in advance of the abscess,
preparation was made for its discharge through the lung. The tendency
of an abscess of the abdomen to external discharge is manifested in two
directions: those of the upper part tend to discharge through the
lungs, those of the lower part through the natural openings below.
Abscesses of the liver come within the former rule, but it is not of
invariable application, since some discharge by the stomach or
intestine, some externally; yet a large proportion make their way
through the lungs. Another symptom referable to the pulmonary organs in
cases of hepatic abscess is singultus, or hiccough. This is a symptom
of the period of discharge rather, and is often extremely protracted
and exhausting. Pericarditis occurs in those cases in which discharge
takes place in this direction, and it may develop, as does pleuritis,
in advance of any change in the diaphragm. This preparation of the
thoracic organs for external discharge seems almost like a conscious
purpose, as if an intelligent supervision of these processes were
exercised.
[Footnote 106: _Transactions of the Pathological Society_, vol. xxxii.
p. 127.]
COURSE, DURATION, AND TERMINATION.--As the facts already given have
sufficiently shown, the course of abscess of the liver is extremely
uncertain. From the beginning to the end there may not be a single
indication of its presence. On the other hand, a well-marked case is
perfectly characteristic. Abscesses of the liver are acute and
chronic--the former of short duration, accompanying pyæmia, portal
phlebitis, and similar conditions; the latter, arising in the course of
chronic dysentery or from unknown causes, especially if encysted,
remaining latent for weeks or months. The course of an abscess is much
influenced by the direction taken by the pus in the attempt at
discharge. This portion of the subject requires careful statement and
thorough treatment, and we therefore present it somewhat in detail.
Beginning with his individual observations, the abscess in the author's
12 cases discharged--3 externally, 5 by the lungs, and 4 by the stomach
or intestines. In Waring's[107] collection of 300 fatal cases, 169
remained intact at death, 48 were operated on; consequently, only 83
are left for the purpose of this comparison. Of 83 cases of hepatic
abscess discharging spontaneously in some direction, 42 escaped into
the thoracic cavity or by the right lung (in 28); into the abdominal
cavity (15) or stomach (1) or intestine (7), 23; externally 2, besides
in special directions to be hereafter referred to. Rouis[108] has
tabulated the results in 30 cases of abscess fatal without an operative
influence. Of these, 2 discharged externally, 17 by the thorax (15 by
the lung), 5 by the stomach, 4 by the intestine, and 2 by the biliary
canals.
[Footnote 107: _An Inquiry, etc. into Abscess of the Liver_, _loc.
cit._, p. 131.]
[Footnote 108: _Recherches sur les Suppurations endémiques du Foie,
etc._, _loc. cit._, p. 148.]
The appearances presented when the discharge takes place through the
external parts are by no means uniform. When the epigastric or
umbilical region is the point of discharge, a globular tumor forms,
which may {1016} be mistaken for a fibroid or fatty growth; softening
in the centre of the mass occurs, and ultimately the pus is discharged.
If the pus makes its way outwardly through the right hypochondrium, the
tumor formed is furrowed by the attachment to the ribs, and several
openings usually occur. The pus may burrow under the skin for some
distance and point in the axilla, or, making its way along the
suspensory ligament, emerge at the navel, or, descending, appear in the
lumbar region or under Poupart's ligament.
As the statistics prove, the most usual route for discharge to take
place is by the thoracic cavity, especially the right lung. Some time
in advance of an opening in the diaphragm a localized pleuro-pneumonia
occurs, adhesions form between the pulmonary and costal pleura, and a
channel is tunnelled out for the passage of the pus to a bronchus. The
discharge of pus suddenly occurs after some days of cough and bloody
expectoration. Even in favorable cases the amount is so large that the
patient has extreme difficulty in disposing of it, and in unfavorable
cases, the quantity being large, the patient's life is ended by apnoea.
In still other cases an extensive purulent accumulation may form in the
pleural cavity, the lung is compressed, and all the phenomena of an
empyema superadded to those of a hepatic abscess. In a case reported by
Westphalen[109] all the bile secreted by the patient came out by an
opening in the fifth intercostal space. The empyema thus induced may
indeed be the principal lesion, as in the case of the late Gen.
Breckenridge, on whom thoracentesis was performed by Sayre of New York,
and in a case reported by Löwer.[110] So far from this being uncommon,
as asserted by Thierfelder, when an abscess of the liver approaches the
diaphragm inflammatory symptoms begin on the pleural side, and thus
pyothorax may occur in advance of the perforation of this septum.
[Footnote 109: _Deutsches Archiv für klin. Med._, 1873, Band xi. p.
588.]
[Footnote 110: _Berliner klinische Wochenschrift_, 1864, p. 461.]
The opening of an hepatic abscess into the pericardium is rare, since
in Waring's collection of 300 fatal cases there was not one. When it
does occur, pain is experienced about the heart; the action of the
organ becomes irregular; præcordial anxiety and oppression are felt;
suffocative attacks occur; and very soon the symptoms of pericarditis
arise. Perforation of the ascending vena cava or of the hepatic vein
happens in about 2 per cent. of the cases. When a quantity of pus is
thus turned into the circulation, disastrous results follow, not so
much from the infective nature of the pus as from the sudden increased
pressure within the vascular system and the labor imposed on the heart,
already failing.
The escape of the pus into the peritoneal cavity occurs in about 11 per
cent. of the cases of spontaneous evacuation, according to Waring. Of
the 162 fatal cases collected by Rouis, 14 opened into the
peritoneum--about the same proportion as Waring gives. When discharge
takes place into the peritoneum, the patient passes into a condition of
collapse, or peritonitis is excited and rapidly proves fatal. In rare
instances the inflammatory reaction is restricted to a small area,
ulceration takes place through the abdominal parietes, and thus
discharge is effected.
An opening may be made into the intestine or into the pelvis of the
kidney. In the former case pus is discharged by stool or by vomit, and
often in enormous quantity; in the latter by the urine, frequent and
{1017} painful micturition, with much pus, being the evidence of the
accident. In either case communication may be kept up with the abscess,
and the patient be worn out with the exhausting discharge maintained by
the intercommunication between the abscess and the canal through which
discharge takes place.
Cases of hepatic abscess prove fatal without perforation. In Waring's
collection of 300 cases, 169 remained intact, in the words of the
author--that is, did not extend beyond the boundaries of the liver. Of
203 cases collected by Rouis, 96 did not extend beyond the liver.
According to Thierfelder, about one-half of the cases of hepatic
abscess perforate the liver. These statistics therefore closely
correspond, and the general conclusion is very nearly expressed in the
formulated statement of Thierfelder.
The duration of hepatic abscess cannot readily be expressed in figures.
The acute cases terminate early by reason of the various complicating
conditions. The chronic cases are much influenced in their duration by
the presence of a limiting membrane, for if this be formed the duration
will be protracted over weeks or months; and those cases not thus
confined are necessarily of shorter duration. A period of latency may
result when the extension of the morbid process is thus hindered.
Forming a conclusion from the general conduct of the cases, it may be
said that the duration of hepatic abscess is from two weeks to six
months. Of 220 cases collected by Waring, the average duration was 39
days. Rouis fixes the average duration in 179 cases at 60 days. Of
Waring's cases, the largest number (59) terminated in from 10 to 20
days; whilst Rouis places the maximum number (104) at from 11 to 60
days, the shortest duration of any case being 10 days, and the longest
480 days.
The termination may be accelerated by the manner of discharge, as when
the abscess opens into the ascending vena cava, into the sac of the
pericardium, or into the peritoneal cavity. In my own cases, carefully
selected for these observations, death occurred in one during discharge
by the right lung, one within twelve hours after discharge by the
intestine, and one within ten days after discharge by the stomach and
intestine, the mortality of the whole being 75 per cent. In Waring's
collection of 300 fatal cases, 169 died whilst the abscess was still
intact--that is, in the liver.