In kala-azar the liver does not begin to enlarge until after about three months from the time of onset at which time the spleen will be quite large. Decided enlargement is generally noted by the sixth month.
The liver cirrhoses due to schistosomiasis or malaria may show slight enlargement or no particular change.
Sprue is a disease which gives a decided atrophy of the liver. Some authorities have noted a decrease of the size of the liver in cholera. The liver of yellow fever is of normal size and is not associated with splenic enlargement.
In the tropics one must always keep in mind the possibility of a liver enlargement being due to syphilis.
Pains of the Liver
In tropical liver there is more a sensation of weight than one of pain. In liver abscess, however, there are painful dragging sensations and, at times, with abscess of the upper right lobe, pain referred to the right shoulder. There is a marked tendency to splint the liver as shown by the costal breathing and moderate rigidity of the right rectus. The patient tends to lie on his back as shifting to either side, especially the left, causes pain. The legs are drawn up to relieve tension. Any jolting of the liver in palpation is exquisitely painful.
When active suppuration is going on in the liver the pain may be of an acute throbbing character. With abscess of the left lobe the pains may suggest gastric disease while with an abscess of the concave surface of the liver there may be referred pain in the appendix region.
In blackwater fever and bilious remittent fever there may be tenderness of the liver as well as the more prominent pain in the spleen.
Epidemic jaundice shows tenderness of the liver.