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 Hammond97 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.
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 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 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 Waring99 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.