Part 170

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, local pain is present in 141 out of 177 cases, or in 85 per cent. The statistics of Waring 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.

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 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.

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 and Fayrer, 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.

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 long ago maintained that a peculiar poison generated at an open ulceration in the intestine was the true cause. Moxon, Dickinson, and others have lately reaffirmed this explanation. A case by the latter 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.

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, 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.

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 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 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.

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 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. 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.

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.

The mortality from abscess of the liver is very large. In Rouis's collection of 203 cases, 162 died, 39 recovered entirely, and 2 improved; 80 per cent., therefore, proved fatal. According to De Castro, whose observations were made at Alexandria, Egypt, 93 in 208 cases died, this being 72.5 per cent. According to Ramirez, of 11 cases of which an account is given in his memoir, 10 died and 1 recovered--a mortality of 90 per cent. De Castro (p. 40) also gives the results arrived at by the Medico-chirurgical Society of Alexandria, who collected 72 cases of abscess, of which 58 died, making the percentage of deaths 80.5. Various circumstances besides the abscess affect the result. An early successful operation, the mode of discharge, the amount of hepatic tissue destroyed by the {1018} suppuration, the extent of pre-existing lesions--especially ulcerations of the intestinal canal--are important factors in the result. In respect to some of these we have valuable statistical data. The discharge through the lungs is the most favorable route, next by the parietes of the abdomen, and lastly by the intestinal canal. One-half of those cases in which discharge is effected by the right lung get well. This is my own experience, and it accords with the observations of Rouis, of De Castro, and others. Rouis gives the result in 30 cases of hepatic abscess discharging by the right lung; of these 15 recovered. Of 25 cases observed by De Castro, discharging by the lungs, 19 recovered. Next to the discharge by the bronchi, the most favorable mode of exit is externally, through the parietes of the abdomen; much less favorable is by the stomach or intestine; but still more fatal is the discharge into the cavity of the peritoneum. When the abscesses are multiple and due to pyæmia, the termination is always in death. The numerous lesions besides the hepatic accelerate the fatal issue. In the case of large single abscesses the result is in a great measure due to exhaustion from protracted suppuration. When in addition to the formation of a great quantity of pus there is frequent vomiting and rejection of aliment, the failure of strength is proportionally rapid. In favorable cases, after an abscess is evacuated through the right lung, recovery takes place promptly. When the discharge occurs through the abdominal wall, the process is much slower, and often fistulous passages with several orifices, very slow to heal, are formed. Complete recovery may ultimately take place. The recovery will be incomplete in those cases with large loss of hepatic substance, especially when this coincides, as it usually does, with catarrh, ulceration, and other lesions of the intestinal tube. Again, the recovery will be incomplete in those cases where there are imperfect healing of the abscess site and a fistulous communication with the exterior.

It is possible for the arrest and healing of a suppurative inflammation of the liver to take place without discharge. Under such circumstances the watery part of the pus is absorbed, the solid constituents undergo a fatty metamorphosis, are emulsionized, and thus absorbed, and gradually closure of the damaged area is effected by a connective-tissue formation. We must, however, accept with caution those examples of this process which are supposed to have occurred because radiating cicatrices are discovered on the surface of the liver. In a case of hepatic abscess discharging through the lung, known to the writer, after death, which occurred fifteen years subsequently, there was no trace of the mischief, so perfectly had repair been effected. Radiating cicatrices are so often of syphilitic origin that they cannot be accepted as proof of the former existence of an abscess.

DIAGNOSIS.--He who finds the diagnosis of abscess of the liver easy under all circumstances can have had but little experience with the numerous difficulties in the way of a correct opinion. There are cases so plain that the most casual inspection suffices to form a conclusion; there are cases so difficult that the most elaborate study fails to unravel the mystery. The maladies with which hepatic abscess may be confounded are echinococcus of the liver, dropsy of the gall-bladder, cancer, abscess of the abdominal wall, empyema, or hydrothorax, etc. As regards echinococcus, the difference consists in the slow and painless enlargement characteristic of echinococcus, and the absence of any symptoms other than those {1019} due to the mere pressure of the enlarging mass. In abscess there may be no apparent enlargement, or the increase in the area of dulness may be very great, or after a period of increase of size there may be contraction due to the formation of pus, and hence limitation of the inflammation; finally, the accumulation of fluid may be sufficient to cause dulness up to the inferior margin of the second rib. There are no corresponding changes of size in the echinococcus cyst. Furthermore, abscess of the liver large enough to be recognized by the increased dimensions of the organ will be accompanied by more or less pain in the right hypochondrium and by a septicæmic fever. On the other hand, an echinococcus tumor is not accompanied by fever, pain, or tenderness, and it has that peculiar elastic trembling known as the purring tremor. The most certain means of differential diagnosis is the use of an aspiration-needle and the withdrawal of a portion of the fluid. The presence of pus with hepatic cells will be conclusive of abscess, whilst a serous fluid with echinococci hooklets will prove the existence of the echinococcus cyst.

In cases of dropsy of the gall-bladder there are no febrile symptoms, no chills, and the tenderness when present is limited to the pyriform body, the seat of the accumulation of fluid, and no general enlargement of the liver can be made out. At the point of swelling fluctuation may be detected, or if the gall-bladder is filled with calculi the sensation imparted to the touch is that of a hard, nodular body of an area and position corresponding to that of the gall-bladder. Tapping the gall-bladder, an easy and safe procedure, will resolve all doubts. When an impaction of a gall-stone is the cause of abscess, the clinical history is eminently characteristic: there are attacks of hepatic colic, after one of which the chills, fever, and sweats belonging to hepatic abscess occur.

The differentiation of cancer of the liver from abscess rests on the following considerations: In cancer there is slow enlargement, with pain; a more or less nodular state of the organ without fluctuation; usually ascites; no rigors; no fever and sweats. In abscess the liver may or may not be enlarged; there are rigors, fever, and sweating, and the surface of the organ, so far as it can be reached, is smooth and elastic, and it may be fluctuating. Cancer happens in persons after middle life, develops very slowly, and is accompanied by a peculiar cachexia; abscess occurs at any period, very often succeeds to or is accompanied by dysentery and by the usual phenomena of suppuration.

It is extremely difficult to separate an abscess in the abdominal wall, in the right hypochondrium, or a tumor in this region, from an abscess of the liver. The history of the case, the existence of a dysentery or of an apparent intermittent or remittent fever before the appearance of a purulent collection, will indicate the liver as the probable source of the trouble. Attention has already been called to a case in which an abscess of the liver was supposed by an eminent surgeon to be a tumor of the abdominal wall. The history in this case of an obstinate remittent fever, followed by the appearance of a tumor of the hypochondrium and by a preliminary discharge at the umbilicus, clearly indicated the nature of the trouble. In the absence of any history of the case it is extremely difficult to fix the origin of a suppurating tumor originating, apparently, in the depth of the right hypochondrium.

Mistakes are frequently made in the case of an abscess developing in {1020} the convexity of the right lobe of the liver and pushing the diaphragm up to the third, even to the second, rib, and thus producing conditions identical with empyema of the right thorax. Such instances of hepatic abscess are peculiarly difficult of recognition, because, the physical signs being the same as those of empyema, the differentiation must rest on the clinical history. In cases of empyema proper the effusion in the chest is preceded by pain and accompanied by an increasing difficulty of breathing; in hepatic abscess there are, as a rule, symptoms of disturbance in the hepatic functions, fluctuation in the hepatic region, dysentery, etc., long anterior to any disturbance in the thoracic organs. Again, empyema may be a latent affection, without any symptom except some obscure pain and a progressive increase in the difficulty of breathing; on the other hand, abscess of the liver is preceded by symptoms of liver disease and of associated maladies. A dry, purposeless cough is present in many cases of abscess; a painful cough with bloody expectoration occurs when preparation is making for discharge through the lungs.

Errors of diagnosis are liable to occur in the consideration of symptoms unquestionably hepatic in origin. Thus, the intermittent fever accompanying some cases of hepatic colic, like the shivering fits and fever which occur in cases of nephro-lithiasis, may be confounded with the septicæmic fever of hepatic abscess. An attentive examination of the attendant circumstances, especially a careful survey of the right hypochondrium, can alone determine the nature of the symptoms. In all doubtful cases the experimentum crucis of puncture with the exploring-needle becomes a measure of necessity. When all diagnostic indications are at fault, the needle of the aspirator may decide the issue. An abundant experience has shown that a needle of suitable size may be introduced into the right lobe without any ill result--often, indeed, with distinctly good effects when there is no suppuration or when pus cannot be detected. In the present state of our knowledge it cannot be determined why puncture of the organ should be beneficial in cases having the symptomatic type of hepatic abscess when none exists; but of this fact there is no doubt.