1 914 DISEASES OF THE LIVER AND PANCREAS 



Another diagnostic point to which Manson has drawn attention is 

 that the enlarged liver gravitates with changes of position niuch 

 more distinctly than pleural effusions. If the dulness in the mid- 

 axillary line diminishes notably when the patient lies on his left 

 side, the case is probably one of liver abscess. It is to be noted, 

 however, that a right pleural effusion and a liver abscess may 

 coexist. Pneumonia on the right side with congestion of the liver 

 may also lead to difficulties, which must be met by careful physical- 

 examination and the microscopical and bacteriological examination 

 of the sputum. Malarial fever can be diagnosed from the fever of 

 hepatitis by examination of the blood and the presence of the 

 enlarged spleen. In those cases of liver abscess in which fever is 

 the only symptom the diagnosis may be extremely difficult, and 

 may -require all modern bacteriological methods to exclude Malta 

 fever, malaria, septicaemia, and typhoid, etc. When in doubt, an 

 exploratory puncture should always be made, for it can do no harm, 

 and may relieve the congestion. When a long needle is introduced 

 into a liver abscess, it moves regularly with respiration. Purulent 

 cholecystitis in most cases gives no trouble on diagnosis, as the 

 enlarged gall-bladder can be easily felt, and there is generally a 

 history of hepatic colic. 



Syphilitic gumma of the liver may show many symptoms in 

 common with liver abscess, including the intermittent fever, as 

 we have twice noted. The positive Wasserman reaction and the 

 action of potassium iodide in full doses clears the diagnosis. 



Cases of leukaemia, pseudo-leukaemia, tropical splenomegaly, and 

 kala-azar have been mistaken for liver abscess, but in all these con- 

 ditions the spleen is also greatly enlarged. 



In this connection we may emphasize the necessity for the ex- 

 amination of the blood in order to exclude leukaemia, otherwise a 

 fatal haemorrhage may follow such a simple operation as puncture 

 of the liver. Liver abscess is usually easily diagnosed from hydatid 

 disease, but when purulent changes have taken place in the latter 

 the diagnosis may be impossible, except by the history and the 

 eosinophilia. 



Prognosis. — If the abscess is left unoperated for a long time, the 

 prognosis is very bad, as the danger of exhaustion and septic infec- 

 tion is great. If the abscess has burst into the lung, the prognosis 

 is also bad, but better than if it had burst into the bowel. Since 

 operative measures have come into more common use the mortality 

 has decreased, according to Dujardin Beaumetz, from 82 per cent, 

 to 32 per cent. The operation wound may occasionally become 

 phagedaenic. 



Treatment. — If a case is suspected by the symptoms and blood- 

 counts to be in the ' presuppurative stage/ emetine or ipecacuanha 

 should be administered, and should be given with the precautions 

 already mentioned under Amoebic Dysentery, and the latter must 

 be continued for several weeks after every sign of hepatitis has 

 disappeared. 



