Page:Tropical Diseases.djvu/636

590 especially by deep inspiration, by coughing and all sudden jarring movements, is very common, and probably indicates perihepatitis from proximity of the abscess to the surface of the organ. Percussion, or firm palpation, especially if practised during deep inspiration and below the ribs in front, generally causes smart pain and decided shrinking, the rectus muscle starting up as if to protect the subjacent inflamed parts. Pain on swallowing, at the moment the bolus of food traverses the lower end of the œsophagus, was mentioned to me by a medical man, himself the subject of hepatic abscess, as being a marked symptom in his own case. Pain on firm pressure with the finger-tips in an intercostal space, and over a limited area, is a common and valuable localizing sign. Among the sympathetic pains may be mentioned shooting pains radiating over the chest and down the right flank and hypochondrium.

Pain in the right shoulder.— This symptom is present in about one-sixth of the cases. It may be persistent, or it may intermit; it may radiate to the side of the neck, or to the region of the scapula, or down the arm; or it may be limited to the shoulder-tip and clavicular region. In some instances it is of a dull, gnawing, aching character; in others it is more acute; and in some it may be represented by a burning sensation, as if the surface of the skin had been flayed by a blister. This symptom is a reflex transmitted from the hepatic terminals of the phrenic through the fourth cervical to the branches of the cervical and brachial plexuses. Cough of a dry, hacking character, doubtless also a reflex from irritation of the diaphragm, or from an inflamed condition of lung or pleura over the seat of abscess, is not uncommon. When the abscess discharges through the lung, cough is sometimes very severe and may cause vomiting. Respiration is generally shallow and proportionately rapid. This is partly symptomatic of the attendant fever; oftener it is owing to the fact that fuller inspiration is attended with stitch. Sometimes the breathing is entirely thoracic, the lower part of