DISEASES OF THE LIVER. 



SYMPTOMS AND COURSE. The typical description usually given of 

 parenchymatous hepatitis answers, as Sudd aptly says, only for the 

 traumatic cases, including those induced by impacted gall-stones; but, 

 as we have already stated, this is the rarest form of the disease. If, 

 after a blow, or some other violence, affecting the region of the liver, 

 there be severe pain there, if the liver swells, and there be high fever 

 with general suffering, there is no difficulty in the diagnosis. 



The case is altogether different when hepatitis comes on during 

 some gangrenous process in the abdomen, when it complicates a dysen- 

 tery, or when it develops during peripheral suppuration, after injuries 

 of the head, great surgical operations, etc. The cases related by Budd, 

 Andral, and others, show a number of instances where abscesses of 

 the liver, occurring in this way, were recognized very late, or not at all. 

 In chronic ulcerations of the intestines, in perityphlitis, and similar dis- 

 eases, as well as after operations on the rectum or abdomen, we may 

 suspect the occurrence of hepatitis, if the patient has a chill, if the 

 liver swells and becomes painful, and there be icterus. But none of 

 these symptoms are constant; and cases where local symptoms of 

 hepatic disease are absent, in metastases starting from one of the ab- 

 dominal organs, are at least as frequent as those of metastases in the 

 lungs, which run then* course without pain in the chest or bloody ex- 

 pectoration. The chills and fever may also depend on other causes, 

 and cannot, by any means, be regarded as sure signs of secondary hepa- 

 titis. It is still more difficult to recognize the occurrence of hepatitis 

 during endemic dysentery. For, in this disease, the liver is not unfre- 

 quently swollen and painful, even when it is not inflamed ; the fever 

 present does not decide the question, for it is present in dysentery 

 alone ; in many cases there is no icterus, and, when it occurs, it is no 

 sure sign of hepatitis. The parenchymatous hepatitis which occurs in 

 peripheral suppurations, or after surgical operations, and is one symp- 

 tom of the so-called pysemia, is the most difficult to recognize. Under 

 such circumstances, we should not expect the prostrate patient, who is 

 much depressed mentally, to complain of pain about the liver ; the 

 chills and high fever, and even excessive icterus, do not render it abso- 

 lutely certain that there is disease of the liver. 



If we add, to what has already been said, that the abscesses, which 

 have formed during the above-named diseases, always enlarge slowly, 

 and are accompanied by very unimportant symptoms, it may readily be 

 understood that a subsequent chronic disease, with the symptoms here- 

 after mentioned, may first excite the suspicion, or render it certain that 

 the original disease has been complicated with hepatitis. 



The symptoms of the abscess wliich remains and gradually in- 

 3r eases are quite varied. There is almost alwavs a dull pain in the 



