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weeks after admission, he suddenly expectorated a teacupful of pus. On the next day, the psoas abscess was found diminished in size, with very

evident fluctuation. The existence of gas could be ascertained where previously only pus had been found. His liver had been, and was still, enlarged, and his breath was of that sweetish odor indicative of suppuration. His pulse was frequent from the first, and his temperature ranged from 98° to 99° in the morning, and from 99° to 103° in the evening, until the four days preceding death, after which it did not reach 100°. He died rather suddenly, while straining at stool. He persistently refused to submit to any exploration or operation.

The autopsy revealed an abscess situated in the convexity of the right lobe of the liver, which had perforated the diaphragm and opened into a bronchus in the right lower lobe, this explaining the sudden expectoration of pus. In his liver, in addition to the large abscess, there were several necrotic areas. The psoas abscess communicated with the descending colon, which was the seat of follicular dysentery. He had, in addition, a single kidney situated on the right side.

From the order of events in this case, it is certain that the psoas abscess was primary. Next followed the dysentery, and, accompanying it, the abscess of the liver. During life, these sequences were not so easily made out, for, when the diagnosis of psoas abscess had been made, the accompanying diarrhea seemed possibly the result of tubercular rather than of simple follicular ulceration; and, moreover, the friction-sounds over each lower lobe seemed to point toward a possible generalization of the supposed tuberculosis, whereas the subsequent evidence showed it to be due, on the left side, to a propagation of the inflammation, and on the right, to the hepatic abscess. Again, when, following a discharge of pus from the lung, air was found in the abscess-sac, it seemed probable that the abscess had discharged per bronchia, especially as I made careful inquiry as to whether there had been any blood or matter in the stool which would indicate a perforation of the bowels; and, receiving a negative answer, I felt justified in considering the pus voided by the lungs as coming from the psoas abscess. The cause which led

to the mistake about the evacuation was that the pus had a slaty hue due to the bismuth which he had been taking.

CASE VII.—Thomas Coogan, aged forty years, a longshoreman by occupation. No good history could be obtained from this patient, he having been sent to the hospital as a case of alcoholism. From his account, which was probably incorrect, he had been ill for only five days. His symptoms consisted of delirium, fever, and a large, tense abdomen, the last due in great measure to a marked increase in the size of the liver. To dyspnea was added marked and rapid prostration of the vital forces. His bowels were constipated and required a laxative. On inspection of this patient, I reached the conclusion that he had inflammation of the liver, which either had formed or was forming an abscess. There was no clew to the exciting cause. A single exploration was made, with a negative result. The case terminated fatally.

The autopsy showed multiple abscesses of the liver, varying in size from that of a marble to that of a small apple. The extent of liver-tissue involved in the abscesses seemed greater than that which was unaffected. In several places these abscesses had excited a perihepatitis. The only other organ involved was the cæcum, in which there was an ulcer at its dependent portion, which had destroyed the mucous membrane for a space an inch and a half in length by half an inch in width, and also a follicular ulcer about the size of a large pea.

My reason for introducing this case is that it shows how severe an affection can start from a limited infecting surface. The ulcer was undoubtedly of older date than the hepatic trouble. It seems not improbable, in view of the fact that I, as well as others, have met with a number of cases of solitary abscess following dysentery, that some of the so-called idiopathic abscesses are in reality dependent upon an infecting surface in the stomach or bowels.

The symptoms of abscess of the liver are not uniform; for in some cases we have the action of the cause still persisting and adding its phenomena to the effect produced by the suppuration of the liver. There exist, also, differences in the situation and

ense.

size of the abscess as well as peculiarities in the patient. The main phenomena, however, are few. They consist of a more or less marked enlargement of the liver as a whole, or of that lobe which is the site of the disease; of a hectic type of temperature, the limits of which, in many cases, are not great, and in some cases, with no thermometric record, it may be denied that fever has occurred; of pain and tenderness over the liver, especially if perihepatitis co-exist; in not a few instances, of a reflected pain in the right shoulder in cases affecting the right lobe; and of progressive loss of flesh and strength. Jaundice is much more conspicuous by its absence than by its pres

The same may be said, so far as my experience goes, of melancholia. Of late years, owing to the extravagant statements of some writers, I have paid particular attention to this point, and have been strongly impressed by the absence of marked depression of spirits in these cases. One of my patients, in reply to the question, why he was not melancholy, replied : “What is the use? I may as well put up with what is the matter with me.” I am convinced, therefore, that the connection which has been supposed to exist between these conditions is fancied rather than real. Moreover, autopsies in persons who have died with melancholia do not afford correlative proof.

Hepatic enlargement, either with or without tenderness, and fever of a hectic type, with some loss of flesh and strength, are in

many cases the only symptoms of the disease. When the abscess discharges or is in the way of discharging, we meet with additional symptoms, which are varied according to the course taken by the discharge. The channels thus sought, in my experience, have been, the plenra, bronchial tubes, pericardium, peritoneum, and intestine. Cases are on record of other avenues of exit. Of these you will find mention in literature. I may add that I have never met with an abscess of the liver which had spontaneously discharged externally. All such as were about to discharge in this way were opened.

In order to bring this paper within the limits of the time allotted to me, I desire to call attention briefly to certain points in connection with the subject.

1. Abscesses of the liver can practically be divided into those affecting the left lobe or the lower part of the right lobe, so that the abscess when formed produces an elastic or fluctuating tumor below the free borders of the ribs, and those situated in the upper or posterior portion of the right lobe. The reason for this division is that abscesses in the first two situations are readily recognized and are easy of access for the purpose of operative interference. The abscess in the last-mentioned situation is the one that oftener gives rise to difficulty in diagnosis, or, if diagnosticated, to doubt as to the best and the safest methods of treatment.

2. There are several methods by which the existence or the non-existence of adhesions between the liver and the abdominal wall can be made out. The presence of hepatic friction, audible or tactile, indicates the absence of adhesions but a probability that they will soon be formed. If, on palpation, the edge of the liver be found to remain fixed and not to descend with respiration, adhesions have in all probability taken place. Again, a long needle, either of a hypodermic syringe or an aspirator, introduced into the liver, will, if the outer end be left projecting, be seen to move upward as the liver descends, and downward as the liver ascends, in case no adhesions exist. But, if these have formed, the needle does not move.

3. The difficulties which arise in the diagnosis of liver-abscess may in many cases be surmounted by a careful survey of the history and of the condition of the liver, and by exclusion of the existence of sufficient disease in other organs to account for the symptoms.

The mistakes which I have seen made have been the following:

a. To mistake a liver-abscess for some other trouble, as malarial fever (remittent and intermittent), typhoid fever, or tuberculosis.

6. To mistake an abscess of the liver for some other disease of the liver, as hydatids, cancer, congestion, fatty liver, or hyperplasia.

c. To mistake the swollen liver for an aneurism of the aorta,

especially in cases of abscess of the left lobe of the liver, when pulsation is communicated to it by the aorta.

d. To mistake an abscess of the gall-bladder for an abscess of the liver, or the reverse.

e. To mistake a supra-hepatic abscess for an abscess of the liver.

f. To mistake an abscess of the liver for an abscess of the abdominal wall, or the reverse.

Some years since, I supposed that a distinction could be made between liver-abscess and cancer of the liver by careful attention to the patient's temperature; but subsequent investigation has shown that, in cases of rapidly growing or disseminating cancers, a hectic type of temperature may exist.

4. As regards the ætiology of liver-abscess, I believe that many of the apparently idiopathic cases are of traumatic origin. I have in several instances noted its occurrence in persons who were in the habit of lifting heavy weights, particularly those who did so in hot places, as firemen, those unloading vessels, etc., by placing the right elbow firmly against the side as the weight is raised. By this statement, I do not mean to deny the probable influence of bacteria in the origination of abscesses, but to attribute to traumatism the establishment of that favorable condition which will allow of abscess-formation.

In conclusion, I may add to this paper, which is intended to present the subject in a practical manner, a few remarks on treatment. I believe that all accessible abscesses associated with an adherent liver are best dealt with by free incision, washing out with an antiseptic liquid, the introduction of a drainage-tube, and antiseptic dressing.

I had occasion, in one case of non-adherent liver with abscess, to employ the following means for promoting adhesions : The abscess was situated in the lower portion of the right lobe, so as to be reached below the free border of the ribs. An abdominal bandage was wound with moderate tightness around the body, and the abscess was then emptied by aspiration through a canula, a trocar being used instead of the needle. After emptying the abscess, the canula was allowed to remain, care being taken to

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