§ 1. Inflammation.—Congestion.—Abscess.—Ilepabitis, which occurs with such frequency in tropical climates, is usually asso ciated among ourselves with injury to the side, or with circum stances giving rise to secondary suppuration; very rarely, indeed, does any case present itself in which some such antecedent cannot. be traced, for its association with chronic dysentery or intestinal ulceration is, no doubt, a phenomenon of the same kind.. The sensations of tire patient refer to pain or sense of weight on the right side—perhaps with coincident pain in the right shoulder; we observe some indications of febrile disturbance, the tongue especially being thickly coated, and the urine loaded with pink or lateritious sediments : perhaps a faint bronzing of the skin, with yellowness of the eyes, exists as a condition of partial jaun dice. By means of palpation and percussion, fulness, tension, and tendernets in the right hypochondrium can be made out, along with dulness extending some way below the ribs. The patient usually lies on his back, and complains of a sense of dragging, or of actual pain in the right side, if he turn on the left; vomit ing, hiccup, or cough may be caused by the extension of tbe inflammation to adjoining organs; and frequently pain is excited. on deep inspiration, by the pressure of the diaphragm on the liver and the partial movement of its inflamed surface, which is its most sensitive part, against adjoining viscera. It is almost unne cessary to remind the student that an examination of the chest must always be made in such cases, because the whole of these symptoms, even the jaundice itself, may be caused by an attack of pleuro-pneumonia on the right side.
In congestion, the symptoms by which our attention is called to the liver as the seat of disorder, are not unlike those present in inflammation; the chief difference is the absence of pyrexia: in the hypochondriac region there may be uneasiness, but seldom anything more; pain is more constant in the right shoulder, and not unfrequent in the right iliac region: tenderness is only ren dered perceptible by pushing the fingers deeply under the ribs; and as there is no peritoneal inflammation, there can be comparatively no irritation of ad joining organs. They are still more distinguished by their causes, those exciting hepatitis being comparatively few, while congestion may be produced either as a passive state by obstructed circulation, or as an active onety excesses in eating, and especially in drinking, exposure to cold, or inflamma tion of the lungs and pleura.
Considering merely the results of pathological research, we may be disposed to believe that congestion really in many cases passes into inflammation, and that the existence of cirrhosis, for example, proves that at one time or other, perhaps on several occasions, this has been the case: clinically, however, we have not the means of recognizing it; and, except, in the more marked in stances. we must be content with the observation that the liver is large and tender, whether that be an effect of congestion only, or, more properly, of a form of inflammation.
Abscess of the liver is acknowledged as a very frequent result of true hepatitis. It appears either as a single e,avity filled with pus, or as a number of smaller abscesses; the former is the case chiefly when the inflammation is caused by injury, the latter is the form always presented, when the liver has been the seat of secondary suppuration; but it also occurs when no such explana tion of the hepatitis ean be offered. Obscure as are the early symptoms, it is still more difficult to say with any degree of cer tainty that suppuration has taken place, except when the matter is in a large cyst, and comes near the surface. We have in gene ral only the two facts clearly before us of tendeniess and enlarge ment of the liver, and of the recurrence of rigor: but there are so many other circumstances which might occasion these two symptoms, and the whole phenomena of the case are so complex, that any definite conclusion is not easily arrived at. One point is perhaps deserving of especial notice, that the general disturb ante may be very much less than could have been anticipated, while such a condition existed : the tongue may be tolerably clean, the skin clear and free from jaundice, and the stools may be tolerably healthy, which is not what we should have expected a priori, in suppuration of the liver.
Another form in which a similar train of symptoms is presented is when suppuration occurs within an hydatid cyst, which is one of the common causes of enlargement of the organ : its existence is sometimes made out without difficulty ; in other instances we cannot feel any confidence in the diagnosis. The recurrence of rigor and the symptoms of hectic are among the circumstances most distinctly pointing to suppuration ; and these must be weighed with the signs of the presence of a cyst, or in a still more general manner, with the evidence of enlargement : in all such cases an opinion must be pronounced with much hesitation.
Diagnosis in all these cases must depend in great measure on knowledge of the antecedent circumstances, and readiness in perceiving the relation which they have to the condition of the liver. And while this knowledge will aid in preserving us from overlooking symptoms mere directly traceable to that viscus, among the complex group which some of these cases present, it will also prevent our assuming congestion or inflammation of the liver as an explanation of an obscure case, when its exciting causes cannot be traced; moreover, such an assumption is not warranted, unless manifest enlargement can also be made out; but yet enlargement is not of itself to be taken as evidence of inflammation. Under all circumstances, such cases require careful analysis of symptoms, and cautious exercise of judgment, before ven turing to pronounce a diagnosis ; and the opinion must always be liable to modification by subsequent events.