This pus does not contain pus cells but only granular débris, cholesterin crystals and is often bacteriologically sterile. The amoebae, being in the abscess wall, are not apt to be found when pus is at first withdrawn. Owing to the tendency of liver abscess to rupture into the lungs the first indication of the true nature of a prolonged hectic fever may be obtained when the characteristic pus is expectorated by the patient. Attended with progressive emaciation and exhaustion the patient, as a rule, after a prolonged illness, dies, unless operative procedures cure him or some intercurrent disease brings about his death. Symptoms in Detail _Onset and the Fever Chart._—The onset is at times so insidious that there may be no symptoms and yet a liver abscess be found at autopsy. Usually following convalescence after amoebic dysentery an irregular fever sets in which becomes hectic in character. Profuse sweats accompany the evening rise. The morning temperature is frequently normal and there may be frequent apyretic intervals. _The Respiratory System._—Crepitation at the right base, a dry cough (tussis hepatica) and shallow respirations are features of the disease. _The Nervous System._—Pains in the right shoulder are connected with irritation of the branches of the phrenic nerve. The patient is irritable and often complains of insomnia. The right rectus tends to be somewhat rigid and decubitus is dorsal or toward the right side. _The Liver and Spleen._—The liver is tender and as the abscess in nine-tenths of the cases is located in the right lobe and generally toward the upper convex surface we have an enlargement upward. There is very rarely any jaundice. The urine shows an excess of urobilin and of nitrogen eliminated as ammonia. When the abscess is in the left lobe the condition is apt to be considered as some gastric disturbance. The spleen, as a rule, shows no enlargement. _Examination of the Blood._—There is usually a moderate leucocytosis with normal polymorphonuclear percentage and increase in the large mononuclears. [Illustration: FIG. 62.—Liver abscess. X-ray photograph taken from the side and showing upward enlargement of liver. (Ruge and zur Verth after Béclére.)] DIAGNOSIS =Clinical Diagnosis.=—Of greatest importance is a history of a previous dysentery although it must be remembered that liver abscess may appear in one who has never had dysenteric symptoms. Fever of a hectic type with crepitation at right base, pain and upward enlargement of the liver are most significant. The X-ray may confirm the diagnosis of upward enlargement which may be as high as the angle of the scapula. The majority of conditions causing enlargement of the liver give a downward enlargement. The amelioration of symptoms by giving emetine hypodermically for two or three days is diagnostically exceedingly important.