SUPPURATIVE HEPATITIS. 669 



nght hypochondrium, which is increased by pressure. Occasionally 

 there is also a peculiar " sympathetic " pain in the right shoulder, 

 whose frequency and diagnostic importance were formerly much over- 

 rated. The liver almost always projects below the ribs, and in cases 

 where the abscesses are large or numerous, or the hyperasmia is great, 

 the liver may be double its normal size, and bulge out the right half 

 of the thorax, render the hypochondrium prominent, and project deep 

 into the abdomen. When the abscesses are on the convex surface of 

 the liver and are somewhat prominent, we may sometimes, on careful 

 palpation, find slight protuberances or even fluctuation. Icterus is not 

 at all a constant symptom of abscess of the liver, being absent even in 

 the majority of cases. The accumulation and absorption of bile, on 

 which icterus depends, are partly the result of compression of the gall- 

 ducts, and partly due to their obstruction by albuminous and fibrinous 

 coagula (Rokitansky). Large abscesses may compress the ramifica- 

 tions of the portal vein ; such as project from the concave surface may 

 compress its trunk. In such cases, besides the symptoms above de- 

 scribed, there are usually swelling of the spleen and serous effusion 

 into the abdomen. While the abscesses are small there is little or no 

 accompanying fever, and at this time the general health of the patient 

 is little affected, his strength is good, and he may live for years in 

 passable health. But as soon as the abscess has attained some size 

 the fever becomes higher, chills come on from time to time, as we 

 have seen that they do in chronic suppurations elsewhere, the strength 

 and nutrition of the patient suffer, he becomes cachectic and exces- 

 sively emaciated, and in most cases finally dies exhausted and dropsical, 

 of " consumption of the liver." 



If the abscess of the liver perforate into the abdomen, the symp- 

 toms of peritonitis soon set in and quickly cause the death of the 

 patient. If the abscess become adherent to the anterior abdominal 

 wall, this at first becomes cedematous and finally infiltrated; this 

 renders any formerly perceptible fluctuation indistinct, but a super- 

 ficial fluctuation gradually occurs in the abdominal wall, and this is 

 finally perforated by the pus. If the perforation take place through 

 the diaphragm, we either have the symptoms of pleurisy, or, more fre- 

 quently (as the pleural surfaces have become adherent), dark-red or 

 brown purulent masses are suddenly thrown off, from whose appear- 

 ance Budd claims to have frequently made a diagnosis of abscess of 

 the liver. From perforation into the pericardium, pericarditis rapidly 

 develops and soon causes death. In perforation of the stomach, the 

 peculiarly colored masses are vomited. In perforation of the intestine, 

 on the other hand, there are purulent passages from the bowels. 



When the pus is evacuated outwardly or into the stomach, or intes- 



