TWO CASES OF ABSCESS OF THE LIVER, 
WITH REMARKS ON DIAGNOSIS, 
BY 
H. B. Whitney, M. D„ 
Professor of Children’s Diseases and Physical Diagnosis 
in State University. 
Denver, Colo. 
Read Before The Colorado State Medical Society, 
June, 1895. TWO CASES OF ABSCESS OF THE LIVER, WITH REMARKS 
ON DIAGNOSIS. 
H. B. WHITNEY, M. D., DENVER, COLO. 
I wish to present to your attention a brief report of cases 
not of daily occurrence in this region, and to offer a few remarks 
concerning the diagnosis of hepatic abscess. 
Case I.—N. F. Martin, aged 44, miner, entered the hospital 
on February 10, 1892. Well until five months before, when he 
had an attack of pain in the right iliac region without chills or 
noticeable fever. He did not take to bed, and was kept from 
work only one day. Two week later the same pain returned, 
and this time it lasted several days. He said it came with a 
cold, presumably fever, and it was attended by swelling of the 
abdomen. Since this attack he has done no work because of a 
constantly increasing weakness with anorexia, and, he thought, 
a steady though mild fever. About three weeks ago pain 
came on in the hepatic region, described as a dull ache without 
tenderness. During the whole five months there was a mod- 
erate diarrhoea, at no time bloody. No dyspeptic disturbance, 
no chills or jaundice. For two or three weeks he had a slight 
cough. 
Physical examination: Somewhat cachectic appearance, 
considerable anaemia, no jaundice, evening temperature, 100.5 ° ; 
tongue moist and clean. Examination of the chest showed on 
the left a normal condition. On the right side there was flat- 
ness below a line extending from the spine slightly upward 
and outward across the middle of the scapula to the upper ax- 
illa, from which it dropped in front so as to reach the sternum 
at its junction with the fifth rib. Above this line resonance 
was slightly tympanitic, with normal respiration; below, the 
latter was somewhat bronchial for a considerable distance, while 
vocal fremitus was little, if at all, diminished. The heart was 
displaced about to the left. There was some fullness of 
the chest-wall, with a localized oedema over the lateral aspect of 
the liver, and the lower border of the latterpiyneciiM^ditUii. three inches below the free margin of the ribs in the mammary 
line. It was even, and tender on pressure. Although the 
upper line of flatness corresponded very closely with the “ S ,7 
curve of pleuritic effusion, my diagnosis was hepatic or sub- 
phrenic abscess, and I attributed this high line of flatness and 
the cardiac displacement to an upward pressure of the dia- 
phragm. In this I was mistaken; for exploratory puncture, first 
in the seventh interspace behind and in the sixth in front gave 
serum, while a third puncture in the eighth in front gave a 
thick, light-reddish, apparently purulent fluid. It was, of 
course, now evident that we had to deal with an hepatic abscess, 
complicated by a secondary pleuritic effusion. 
Since the present paper deals solely with the diagnosis of 
hepatic abscess, I will only take from the records the following 
data as regards the subsequent history of this patient: 
On February 12, two days after admission, I aspirated the 
abscess, going in twice to the depth of four or five inches in the 
eighth space between the mammary and axillary line. About 
one ounce of the same reddish fluid was obtained. This pro- 
cedure, although done with all possible antiseptic precautions, 
was the apparent cause of an acute localized peritonitis, which 
for a few days seriously jeopardized the patient's life. He 
passed safely through it, however, and on March 1, nineteen 
days later, aspiration was again performed by Dr. E. J. A. Rog- 
ers, and about a quart of the same stuff as before withdrawn. 
The opening was then enlarged, a drainage tube inserted, and 
from this time the patient went on to complete recovery, the 
pleuritic effusion being absorbed without operative interference. 
Case II. Antonio Conti, aged 50, was admitted to the hos- 
pital on January 11, 1895. Spoke no English, hence no history 
could be obtained. We could only learn that he was apparently 
well until three months before, when fora week he had a bloody 
diarrhoea, with vomiting. Upon admission his chief complaint 
was of pain in the epigastrium and along lower border of ribs be- 
hind. Not confined strictly to bed; appetite fair, with slight 
digestive disturbance, and a moderate diarrhoea. 
Physical examination; Temperature, 100° ; pulse, 96; res- 
piration, 22. Great emaciation, color decidedly anaemic and muddy without cachexia. There was no oedema. Heart and 
lungs negative except a moderate condition of emphysema. 
Spleen enlarged to about double normal size. Abdomen not 
distended and otherwise negative except in its relation to the 
liver. The liver was very considerably enlarged. Though its 
lower border could not be felt, percussion showed that it ex- 
tended nearly two inches below the margin of the ribs in the 
mammary line. There was marked spasmodic contraction of 
the right rectus muscle, and the epigastrium was tense and quite 
painful on pressure. It seemed as if the lower border of the 
liver bulged downward in the epigastrium, and the liver flatness 
extended farther to the left than normal. The most noticeable 
feature of the hepatic enlargement was its extension upward. 
The upper border of the liver wras found at the fifth instead of 
the sixth rib, in the mammary line, extending around to the 
spine in a nearly horizontal line which behind was also about 
two inches higher than normal. There was no jaundice, and the 
urine was negative. 
The above examination was not made until the patient had 
been several days in the hospital, and it lead to the diagnosis of 
probable abscess of the liver. The temperature had meanwhile 
been irregular, varying between normal and 100 degrees; but it 
had now begun to assume the hectic type. There were no chills 
or jaundice, and the liver remained as before; the epigastric 
tenderness and upward enlargement without apparent cause of 
displacement still being the noticeable features of the case. 
The history of apparent dysentery was also a suggestive factor 
in diagnosis. No operation was, however, considered at this 
time, because of the absence of any exact indication as to the 
seat of the supposed abscess, and the doubt even as to whether 
there was a single abscess or multiple small foci of suppuration. 
During the month of February, the patient grew progres- 
sively weaker, and a pretty steady hectic was maintained, the 
temperature averaging about 102 degrees P. M., and in the 
morning dropping to normal. The area of hepatic flatness con- 
tinued to extend upward, until, on March 1, it had reached the 
fourth rib. Its upper border was even and regular. Otherwise, -4 
with the exception of anorexia and a troublesome diarrhoea, 
both the general and local conditions showed no change. 
About the first of March, however, jaundice appeared for 
the first time, and with it rigors. From now on, until his death 
on March 10, rigors were frequent, and jaundice became quite 
intense. About the same time oedema of the feet appeared, and 
also a moderate ascites. In the last two or three days friction 
was found at the base of the right back, and death occurred 
from exhaustion on March 10. 
The autopsy was made by Dr. Freeman on the following 
day. The abdomen was filled with straw-colored fluid. Spleen 
considerably enlarged, with evidence of recent perisplenitis. 
In the liver was a large abscess situated between the two lobes, 
near the convexity, and containing a pint of pus. Signs of 
fresh pleurisy were found on the right side of the chest. 
Case III.—Anna Pierson, aged 19, entered the hospital 
February 5, 1895. There was a doubtful history of past syphi- 
lis—patient thought she had had a “ bad disease ” and there 
had been eruptions on the feet and legs. Three years before 
she had been treated in the County Hospital for pelvic peri- 
tonitis. 
For the past two months had been feeling poorly, though 
not confined to bed. There had been malaise, chilly fevers in 
the afternoon followed by fever, and irregularity of the bowels 
with small but often frequent movements. Her chief com- 
plaint on entrance was of great tenderness, and some pain over 
the region of the liver. 
Physical examination showed fair nutrition. Confined to 
bed but did not appear to be very ill. Tongue moist, with 
thick, white coat. T., 103; P., 100; R., 24. Urine contained 
moderate quantity of albumen, without casts, was acid, and had 
a specific gravity of 10.10. 
The heart and lungs were negative, spleen apparently en- 
larged. Abdomen not distended, and without rose spots. 
There was no pelvic tenderness. The free margin of the liver 
was exceedingly sensitive to pressure, and extended about an 
inch below the costal edge. The upper margin of liver flat, 
ness was at the fourth interspace in the mammary line, at least two inches higher than normal, without any sufficient cause for 
upward displacement. It was even and regular. 
Without giving a daily report of the progress of this case, 
I will simply say that up to her death, on the 20th of March, 
about six weeks after admission, no new symptoms of import- 
ance developed, with the exception that at one time some blood 
was found in the rather thin and frequent stools. Her temper- 
ature during nearly the whole of the period was pretty regularly 
102 to 103 degrees in the afternoon and below 100 in the morning. 
Tongue remained moist throughout, and there were no rose 
spots, abdominal distention, or tenderness, except when the 
edge of the liver was touched; this always provoked an expres- 
sion of pain. The upward growth of the liver increased some- 
what, but it was symmetrical. The spleen became easily felt. 
Until after operation, patient was, as a rule, rather stupid, but 
continued in fairly good general condition and strength, though 
it was apparent that the constant fever was slowly wearing her 
out. 
My first thought as to the diagnosis of this case was of he- 
patic suppuration. In a few days, however, the enlarged 
spleen, constant fever, and moderate diarrhoea, lead to the pre- 
sumption of typhoid, and this diagnosis was moderately satis- 
factory for a time. Since, however, the fever showed no signs 
of abating, and the hepatic tenderness and enlargement became 
more pronounced as the case advanced, I soon began to doubt 
the correctness of the diagnosis, and the question of hepatic 
abscess again arose. About March 17 a consultation was held 
with Drs. McLaughlin and Rogers, and an exploratory puncture 
■of the liver was considered advisable. This was done by Dr. 
Rogers in several different regions of the hepatic area on 
March 20, but with a negative result. The operation had, appar- 
ently, no harmful effect, but the patient was already weak, and 
six days later she sank into a condition of collapse and died. 
Unfortunately the record of the autopsy, as dictated by Dr. 
Freeman, was lost. I was, however, present at the examination 
and the only pathological condition of importance we could dis- 
cover was in connection with the liver The latter was mark- 
edly enlarged, chiefly upwards, and it was amyloid. It was 6 
surrounded and bound to the thoracic wall by a dense mass of 
fibrous tissue, the result of old perihepatitis. There were also 
areas of fresh perihepatitis, with recently exuded lymph. The 
kidneys were also slightly amyloid. There was no suppuration 
in the liver. 
It may prove of interest and profit to base upon these cases 
a brief consideration of the important points of diagnosis of 
abscess of the liver. While the disease is by no means common, 
my own experience would indicate that it is liable to be en- 
countered. 
As you are all aware, hepatic suppuration, aside from trau- 
matic abscesses, usually occurs in one of three forms: 1.—As 
the so-called solitary or tropical abscess, most frequent in hot 
climates, but occurring also in temperate zones, where it follows 
often upon an attack of dysentery. Its frequent cause is the 
amoeba coli, which has recently been found in a consider- 
able proportion of solitary abscesses. 2.—Suppuration of the 
gall ducts or suppurative cholangitis, associated ottenest with 
gall stones and permanent obstruction. 3. Multiple abscesses, 
occurring in connection with infected emboli, which lodge in 
branches of the portal vein or hepatic artery, and oftenest 
secondary to some form of intestinal ulceration. 
Bearing in mind, then, the fact that hepatic suppuration is 
nearly always a secondary infection, it will at once be evident 
that the etiological factor is of prime importance in diagnosis. 
I know of no disease in which the recent history of the patient 
should be more carefully elicited and weighed than in suspected 
abscess of the liver. In the first of the above cases there had 
been, both a long-continued diarrhoea and symptoms suggestive 
of appendicitis. In the second there was quite a clear history 
of dysentery. While, in the third, the one of mistaken diag- 
nosis, there was only a history of syphilis, and the disease from 
which she died proved finally to have been of syphilitic char- 
acter. 
A rational symptom of great constancy is pain over the 
hepatic region, which may or may not radiate into the shoulder. 
There are a great variety of affections which may be attended 
by pain in the region of the liver, but if it be borne in mind that i 
hepatic abscess is usually a subacute, sometimes almost chronic 
disease, many of these can be readily eliminated. Empyema, 
subphrenic abscess, perihepatitis, and cancer of the liver are 
perhaps the most important of the disease to be carefully con- 
sidered, and this can be more profitably done after physical 
examination. 
The same may be said of hepatic tenderness, as indicated 
by palpation of the free margin of the liver. Although cases 
have been reported where all tenderness was lacking, in the 
great majority of instances the organ will be exquisitely sensi- 
tive to pressure, and other signs would have to be exception- 
ally unequivocal to warrant a diagnosis of abscess in the ab- 
sence of this symptom. Perihepatitis may cause a like tender- 
ness, but is not often accompanied by a steady hectic. Tin* 
tenderness of cancer is much iess pronounced indeed, often ab- 
sent; and I have never seen it to any marked degree with af- 
fections of the pleura. 
A hectic fever nearly always attends the development of 
hepatic abscess, the usual range of temperature being perhaps 
between 100° and 102° Fahr. It is stated that fever may be 
wholly lacking. Such a case would be extremely difficult to 
diagnosis in the absence of tumor, and is fortunately of rare 
occurrence. Every diagnostician of experience will appreciate 
the great weight to be attached in hepatic abscess, as elsewhere, 
to a temperature chart suggesting suppuration, and it must 
certainly be accorded a high rank among the physical signs of 
this disease. 
Of the importance of a perceptible bulging of the ribs, or 
a palpable tumor connected with the liver, it is unnecessary to 
speak. The diagnosis is at once narrowed down to suppurat- 
ing echinococcus, empyema of the gall bladder, or, possibly, of 
the pleura, cancer of the liver, and hepatic abscess. The gall 
bladder can usually be distinguished by its position and form. 
Cancer is not a febrile affection, and the nodular infiltration is 
usually diffuse. Echinococcus may be suggested by other 
round, hard tumors of the abdomen, or it may not be possible 
to exclude it until the contents of the abscess have been re- 
moved. Usually the diagnosis of an hepatic abscess which has 8 
produced a local bulging with superficial oedema or a palpable 
fluctuating tumor is comparatively easy. 
It is, however, exceedingly desirable to make at least a 
probable diagnosis before this stage is reached and when the 
chances of operative interference are most hopeful. This, I am 
convinced, can frequently be done by the aid of a careful physi- 
cal examination of the liver, guided by a knowledge of the exact 
conditions to be looked for. The three cases above cited are, it 
seems to me, of some slight value to this end, both as conform- 
ing the experience of other observers, and also as suggesting a 
possible source of fallacy. 
In the first case there was found, first, a line of flatness 
over the right chest, presenting approximately the letter of “8” 
curve and therefore strongly suggestive of pleural effusion. 
Second, a slight displacement of the heart toward the left, still 
further pointing to effusion. Third, inferior border of the 
liver nearly three inches below its normal position. That this 
could not be a simple displacement of the liver was obvious. A 
presumable pleural effusion only reaching the middle of the 
scapula and but very slightly displacing the heart could not 
possibly account for any such degree of displacement of the 
liver. On the other hand, it is well known that both hepatic 
abscess and cancer frequently cause a secondary pleuritis, and 
everything therefore pointed to hepatic enlargement with sec- 
ondary pleuritic effusion. Fortunately the diagnosis between 
cancer and abscess was not difficult because of the slight oedem- 
atious bulging over the liver. The only question was between 
hepatic and subphrenic abscess, a point which was measurably 
settled by the color of the aspirated fluid. 
The second case still more instructive as regards phys- 
ical diagnosis. Osier has called especial attention to the sig- 
nificance in solitary abscess of an upward enlargement of the 
liver, due to the fact that such abscesses frequently occupy the 
convexity of the organ, and therefore, like any other tumor in 
that situation, produces an upward bulging. He also points out 
that owing to this local bulging, the upper line of hepatic flat- 
ness is often irregular, presenting perhaps a curve with upward 
convexity at the spine, which in the axilla drops considerably toward the base of the lung. In our case there was no such 
curve; the upper border of hepatic flatness was an even hori- 
zontal line. It was, however, about two inches higher than 
normal, and, since displacement was out of the question, the 
only plausible explanation was that of a local bulging of its 
convex upper surface. This point was of great weight with me 
in the diagnosis of this case. The history was, it is time, some- 
what suggestive, but there were no chills or jaundice at the time, 
and there was no tumor. The hectic fever, the hepatic pain 
and tenderness, and this upper enlargement, were the three 
symptoms which led to an early diagnosis some six weeks before 
death. Unfortunately this did not benefit the patient, I blame 
myself severely for not having proposed an operation at the out- 
set. The question was brought up later in consultation with 
Dr. McLauthlin, but it was then deemed inadvisable because of 
the great weakness of the patient, and the doubt as to whether 
the suppuration was not multiple. With my present knowl- 
edge, I think this upward enlargement should have been re- 
garded as strong presumptive evidence of solitary abscess. I 
would not, of course, go so far as to affirm that a symmetrical 
upward extension of the area of hepatic flatness is an unequivo- 
cal sign of abscess or new growth. It cannot possibly have the 
diagnostic significance of an irregular line as described by Osier. 
I do think, however, that when pronounced, it has a very con- 
siderable diagnostic importance. It is a well-established fact 
that unless the liver is adherent to the thoracic wall, general en- 
largement of the organ, as, for example, amyloid, causes usually 
an extension of the liver flatness downward, and but little, if at 
all, upwmrd. As far as I am aware, in the absence of upward 
displacement and of hepatic adhesions, there can be no cause 
for a position of the upper border of the liver at, for instance, 
the fourth rib in the mammary line, other than sub-phrenic ab- 
scess or some local tumor of the convexity of the liver. That 
an enlarged and adherent organ may produce the same physical 
sign is illustrated by the third case above reported. There also 
we had hectic fever, painful and tender liver, and both upward 
and downward enlargement. With Case II still under obser- 
vation, the impression upon me was strong that I had to do here 
-9 also with a case of hepatic abscess. This proved to be an error, 
A combination of old adhesions and fresh perihepatitis, with 
amyloid enlargement and a peculiar condition of the interalve- 
olar connective tissue, which I may report at another time, ex- 
plained fully the pain and tenderness, with the usual upward 
extension of flatness. The fever, however, was not satisfactorily 
explained, even by the post-mortem examination, and it is for 
this reason especially that I hope to give still further study to 
the microscopical appearance of the liver structure in this case, 
I will merely remind you that the case was syphilitic, and it 
might well be borne in mind in dealing with a suspected hepatic 
suppuration. 
One word more in regard to the possibility of confounding 
abscess of the liver with empyema, a matter often referred to 
and emphasized by writers. It seems to me that many of the 
mistakes have been made because of the persistence of the old 
idea that fluid in the pleural cavity assumes nearly a horizontal 
level. When the upper margin of flatness extends horizontally 
around the side, say at the level of the fourth interspace, there 
should be but litcle thought of effusion. Such a trio would al- 
most invariably be the diaphragm, and could only be due to ef- 
fusion when the latter chanced to be encapsulated by a horizon- 
tally adherent lung. The same would be true of the more ex- 
treme cases of upward bulging of the diaphragm such as have 
been described by Leyden as pyo-pneumothorax subphrenicus, 
cases in which there is a collection of pus and air between the 
diaphragm and liver. Leyden has found flatness in these cases 
as high as the third rib in front, and the same high position of 
the diaphragm has been met with in simple subphrenic abscess. 
An empyema would never present a horizontal line of flatness 
at the third rib. There is, on the contrary, in very large effus- 
ion, a curve with upward concavity which, leaving the sternum 
at say, the third rib, passes outward and then sharply upward 
so as to intersect the clavicle. In the empyema, therefore, 
reaching the third rib, we have a far greater compression of the 
lung, and hence bronchial respiration above the line of flatness, 
while in Leyden’s cases good vesicular respiration was heard 
everywhere above this line. Another important point of dis- tinction, also emphasized by Leyden, is the relative degree of 
displacement of heart and liver. In moderate empyema we 
find both somewhat displaced; in any affection crowding up the 
diaphragm to the third and fourth ribs, the apex of the heart is 
nearly in its normal position, while the liver is pushed down- 
ward in a degree out of all proportion to the slight displace- 
ment of heart and mediastinum. 
These, then, are the conclusions which I must venture to 
suggest from the study of these few and imperfectly reported 
cases:—that with hectic emaciation and hepatic pain and ten- 
derness, an upward enlargement of the liver, even though 
symmetrical, affords strong confirmatory evidence of abscess; 
and that, at the same time, just such a complex of symptoms 
may be caused by a syphilitic affection of the liver, combining 
the pathological conditions of perihepatitis, amyloid degenera- 
tion, and possibly also a form of syphilitic hepatitis capable of 
producing continued fever and not yet hitherto perfectly de- 
scribed.