Volume 2 — DISEASES OF THE DIGESTIVE SYSTEM. (continued 24)

⁸⁷ On Abscess of the Liver, supra.

⁸⁸ Des Abcès du Foie des Pays chauds, et de leur Traitement chirurgical, par le Dr. S. V. Castro (d'Alexandrie d'Egypte).

⁸⁹ Clinical Lectures, loc. cit., p. 178.

⁹⁰ Virchow's Archiv für path. Anat., etc., Band xl. pp. 380, 408.

Dilatation and ulceration of the bile-ducts were the principal causes of hepatic abscess, as ascertained by Von Baerensprung, in the Berlin Pathological Institute. Duodenal catarrh involving the orifice of the common duct, catarrh of the biliary passages leading to obstruction, and plugging with a gall-stone have resulted in abscess, the initial lesion being probably rupture of one or more of the finer tubes or inflammation leading to suppuration.⁹¹

⁹¹ Grainger Stewart, The Edinburgh Medical Journal, January, 1873.

Finally, a considerable proportion of cases of hepatic abscess arise under unknown conditions. In such cases, however, it is usually found that there has been more or less indulgence in alcoholic drinks, or the liver has been taxed by excesses in the use of rich foods and condiments, or exposure to extreme degrees of temperature has occurred. In the interior valley of this continent, where hepatic abscess is comparatively common, the causes are to be found in malarial influences, in alcoholic indulgence, in dysenteric attacks the product of climatic variations and improper alimentation, and in the formation and arrest in transitu of hepatic calculi also the result of long-continued gastro-duodenal and biliary catarrh.

PATHOLOGICAL ANATOMY.—Great differences of opinion have been expressed as to the initial lesions in hepatic abscess. It is probable, however, that these differences are due to the character of the abscess. Some have their origin in the hepatic cells, others in the connective tissue, and others still in the vessels. There may be a number of points at which the suppurative process begins, or it may be limited to one. Virchow⁹² describes the initial lesion as beginning in the cells, which first become coarsely granular, then opaque, and finally soften, and pus appears. Klebs, who maintains the constant agency of septic micrococci, affirms that the changes in the cells are due to compression exerted by the mass of these organisms distending the neighboring vessels, and then suppuration begins on the portal side of the lobules. Liebermeister originally held that the initial lesion is in the connective tissue; and this view is also supported by Köster, who brings to bear experimental data. In the walls of the vessels of the connective tissue and about them, between the hepatic cells, great numbers of lymphoid cells accumulate. The intercellular spaces are also distended with plasma and round cells, and in the vicinity of the central vein the swollen hepatic cells are pressed together; soon pus-corpuscles appear, and the proper anatomical elements are broken up into a diffluent mass composed of fat-granules, pus-corpuscles, and disintegrating hepatic cells.

⁹² Archiv für path. Anat., etc., Band iv. p. 314.

When suppurative hepatitis arises from an embolus, or emboli, the first step is the change in the appearance of the acini, which are enlarged and grow softer by disintegration of their cells; then at the centre a yellowish spot appears, and is made up of the detritus, granules of fat, and pus. Surrounding such softening portions of the hepatic tissue is a zone of congestion. When the morbid processes are excited by emboli, there will be as many centres of pus-formation as there are particles distributed by the vessels—from two or three to fifty or more. They may be uniformly distributed through the organ or be collected in one part. Emboli conveyed by the portal vein will be arranged with a certain regularity and through the substance of the liver, whilst those coming from some part of the systemic circulation tend to form at the periphery under the capsule. Small abscesses in close proximity unite ultimately by the softening and disintegration of the intervening tissue.

In the so-called tropical abscess, which is the variety so frequently met with in the interior of this country, the mode of development is different from the embolic, above described. Owing to the deposit of some morbific matter whose nature is now unknown, the vessels dilate and hyperæmia of the part to become the seat of suppuration ensues. The cells become cloudy, granular, and opaque from the deposit of an albuminous matter in them. Within the area of congestion a yellowish spot soon appears, surrounded by a translucent, pale-gray ring, and here suppuration begins; the neighboring cells disintegrate and a purulent collection is formed, which enlarges by the destruction in succession of the adjacent portions of hepatic tissue. Whilst this process is going on there is a border of deep congestion about the abscess, fading off gradually into the normal tint of the hepatic parenchyma; the walls of the abscess are rough and irregular from projections of tissue just beginning to disintegrate, and the pus burrows in various directions more or less deeply into the softening parts. The size to which such purulent collections attain is largely determined by the condition of the liver as a whole. If the organ attacked is healthy otherwise and the general health is not deteriorated, the area of the abscess may be limited by a well-defined membrane and continue inactive for a long time. This limiting membrane is of inflammatory origin, developed from the connective tissue, and varies in thickness from a mere line to several. It was formerly called a pyogenic membrane, because the pus discharged was supposed to be formed by it. When such a limiting inflammation cannot take place, the abscess continually enlarges by the softening and destruction of the adjacent hepatic tissue, and may finally attain to enormous proportions. The embolic abscesses vary in size from that of a pea to that of an orange. The so-called tropical abscesses are usually single—in three-fourths of the cases, according to Rouis;⁹³ in 62.1 per cent., according to Waring.⁹⁴ Of the fatal cases collected by the latter author, 285 in number, a single abscess existed in 177, and multiple abscesses in 108. In 11 per cent. there were two abscesses; in 3.6 per cent., three; and in 5.6 per cent. there were four abscesses. As regards the part of the liver in which abscess occurs, the statistics show a great preponderance in favor of the right lobe. In Waring's collection of 300 cases the right lobe was the seat of the abscess in 163, or 67.3 per cent.; the left lobe was affected in 16, or 6.6 per cent.; and both lobes in 35, or 14.4 per cent. The preponderance of cases affecting the right lobe is the more striking when it is understood that, other parts being invaded, the right is included with them in the morbid process. In my own cases the right lobe was the seat of the abscess in 70 per cent.

⁹³ Recherches sur les Suppurations endémiques du Foie, loc. cit., p. 146.

⁹⁴ An Inquiry into the Statistics and Pathology, etc. connected with Abscess of the Liver, loc. cit., p. 125.

The contents of the abscesses are affected in character by the form of the disease, whether embolic or tropical, by its rate of development, by the condition of the hepatic parenchyma, by the formation of a limiting membrane, etc. In the more chronic cases, surrounded by a dense membrane, the pus is usually laudable or dry and cheesy; in the acute embolic cases the pus is dark brown, ichorous or grumous, and contains a good deal of detritus of the hepatic parenchyma; and in the tropical cases it is of a sanguinolent, dark color, or more frequently of a grayish purulent fluid; and in the acute forms contains much broken-down tissue, whilst in the chronic cases, in direct ratio to their duration, the pus approaches the laudable character. The source of an abscess discharging from the neighborhood of the liver may be ascertained by a microscopical examination and the discovery of the hepatic elements (the cells) in the fluid. Bile may also be present in the pus.

The abscesses not confined by a limiting membrane constantly enlarge by the softening and disintegration of the adjacent liver substance, and those enclosed or encysted after a period of quiescence of variable duration begin active efforts to establish communication outwardly. The point to which a purulent collection in the liver tends becomes an important element in diagnosis and in treatment. As the abscess approaches the surface of the liver the capsule inflames, and if adhesions are not formed more or less sloughing occurs, and the contents are discharged into the abdominal cavity. Adhesions may form to the parietes, an external swelling appear, and after a time discharge take place in the right hypochondrium at some point. Pus may escape at the umbilicus, in the right inguinal region, posteriorly at the sacro-iliac junction, and in other situations. Adhesions may form to the stomach, duodenum, the ascending vena cava, to the diaphragm opening the thoracic cavity, the pericardium, or the mediastinum; and the accumulated pus may thus find a vent. According to Waring,⁹⁵ the termination of hepatic abscess is as follows: Of 300 cases, 169, or 56.3 per cent., remained intact—that is, had not advanced beyond the liver; 48 were evacuated by operation, or 16 per cent.; 14, or 4.6 per cent., entered the thoracic cavity; 28, or 9.3 per cent., opened into the right lung; 15, or 5 per cent., entered the abdominal cavity; 7, or 2.3 per cent., opened into the colon; 1 entered the stomach; 3 entered the hepatic vein near the vena cava; 1 communicated with the hepatic ducts, 2 with the right kidney, etc. The termination of 162 fatal cases, according to Rouis,⁹⁶ was as follows: 125 proved fatal in consequence of the extent of the abscess or of the severity of the accompanying dysentery; 3 terminated by gangrene of the walls of the abscess; 3 by peritonitis; 12 by opening of the abscess; 2 by rupture of adhesions; 11 by opening of the abscess into the pleura; 2 by intercurrent and 3 by secondary pneumonia. Notwithstanding the differences in the mode of expressing the conditions, the general results are the same.

⁹⁵ An Inquiry into the Statistics and Pathology, etc. of Abscess in the Liver, loc. cit.

⁹⁶ Recherches sur les Suppurations endémiques, etc., p. 149.

An abscess of the liver having discharged in a favorable way, healing may take place. There may be such an extent of injury—the whole secreting structure of the liver being destroyed—that repair is beyond the power of the organism. The best results are attained when discharge occurs by the most direct route externally; the next, by way of the right lung; the third, by the stomach or intestine. Repair cannot be hoped for when a large part of the normal hepatic structure is destroyed. When the pus escapes the walls of the abscess approximate, and union takes place by connective tissue, leaving a radiated or a merely linear cicatrix to mark the site of the purulent collection. So perfectly does repair take place in suitable subjects that no trace of the lesion may remain.

Those portions of the liver outside the borders of the abscess, and beyond the vascular derangements produced by it, may be entirely healthy. In the cases terminating in recovery the portion of the liver unaffected by abscess continues to functionate normally. More or less of the liver may be destroyed; hence it follows that recovery may be partial. According to the damage done to the proper secreting structure of the organ will the recovery be partial, limited, or complete.

SYMPTOMS.—The existence of an abscess of the liver is determined by systemic or general and by local symptoms, and they may be acute or chronic.

Systemic.—In acute cases the beginning of mischief may be announced by a rigor, but more frequently this indicates the onset of suppuration, and is one of the phenomena of the chronic form. As the disease occurs in this country, a chill takes place suddenly in a case which presents the usual symptoms of proctitis (dysentery) during the course of this affection or soon after its apparent cure; then a febrile movement occurs, and subsequently an irregular intermittent, the rise of temperature being preceded by rigors or mere transient chilliness. With these febrile symptoms there may be associated uneasiness in the right hypochondrium, acute pain, or a feeling of weight and pressure, with jaundice, etc. The fever is septicæmic, intermittent, or remittent if it have any special type. In the septicæmic form the rigors are severe, occur irregularly, sometimes daily, sometimes twice a day, and at intervals of two or three days or longer; the fever rises to a high point—104°, 105°, or higher—and the sweats are profuse. In the intermittent form the fever usually has the quotidian type; some slight chilliness is experienced in the early morning as a rule, and the exacerbation occurs in the afternoon and evening, the sweating being slight toward the morning. More frequently, in the writer's observation, the type of fever has been remittent, with periodical, but not regularly so, exacerbations. In such cases the morning temperature has been at 99° or 100°, and the evening 102° or 103°. Such a range of temperature may be present during three or four weeks or even longer, the abscess gradually making its way outwardly. Conclusions may be drawn from the behavior of the febrile movement as to the character of the local affection, with the limitations imposed by the necessary uncertainty of the data. If the chills are decided rigors, the fever high, and the sweats profuse, either pyæmic abscesses or large tropical abscesses implicating neighboring organs exist. The simple intermittent, especially the remittent, form of fever suggests abscesses of medium size making their way outwardly, with only partial injury to the parts traversed. In a certain portion of the cases the type of fever changes when a large accumulation of pus takes place; after several weeks of a mild remittent the fever becomes irregularly intermittent with rigors, strong exacerbations, and profuse sweats. In protracted cases the fever assumes the typhoid aspect; there is profound adynamia, dry tongue, sordes, diarrhoea, and the usual symptoms of this state. When the secreting structure of the liver is destroyed to a large extent, the condition of acholia is superadded to the typhoid state.

The pulse is irritable and quick from the beginning of the symptoms. In a few instances a slow pulse, such as occurs in jaundice, has been observed, but generally the number of cardiac contractions is in a direct ratio with the body temperature. When typhoid symptoms supervene in advanced cases the pulse becomes weak and dicrotic.

Not every case presents the symptom sweating. The chronic cases with mild remittent fever have little more than slight moisture of the surface, whilst the acute and pyæmic cases are characterized by profuse sweats. If to an irregular febrile movement, preceded by chills and followed by sweats, there is added the tendency to sweat on all occasions—on slight exertion, on sleeping, under any excitement—suppuration may be suspected.

General malaise, a sense of fatigue and exhaustion, and progressive decline in flesh and strength occur. It is remarkable, however, how some obese subjects preserve their roundness and apparent fulness of habit. Usually, however, emaciation advances pari passu with the progress of the suppuration. The more acute the symptoms, the more rapid the wasting. When an encysted abscess develops in the course of a chronic dysentery, there may be no appreciable change in the condition of the patient properly attributable to the additional lesion. The loss of appetite, the frequent vomiting, and often the dysenteric troubles, contribute materially to the exhaustion and the wasting of the tissues. The stomachal derangements may be present with the initial symptoms, but they are usually more pronounced when the abscess attains to considerable size.

A peculiar tint of the skin, especially of the face, is observed in those cases without jaundice. There is an earthy or sallow hue, which to the practised eye signifies suppuration. Jaundice is present in a less proportion of cases. In 13 of Waring's cases the skin is said to be sallow. In Rouis's collection icterus was present in 17 per cent., or 26 times in 155 patients. According to Waring, jaundice is rarely present. In the 12 cases in my own hands actual jaundice was not present in one, but 9 had an earthy hue or presented some yellowness of the conjunctiva. In fact, jaundice does not have the importance as a symptom which might, a priori, have been expected.

The mental condition of these subjects is that of depression. They sleep poorly, are disturbed by vivid dreams of a horrifying character, and the nocturnal sweats increase the tendency to wakefulness. Hypochondria, or at least marked symptoms of mental depression, as Hammond⁹⁷ has shown, are present in many cases. So frequent, indeed, seems to be the association of a depressed mental state with hepatic abscess that in every case of the former the liver should be carefully explored. Hammond goes so far as to say that in every case of hypochondriasis puncture of the liver with the aspirator needle should be practised when any symptom, however indefinite, indicates the existence of an abscess. Besides the condition of hypochondriasis in many cases, there may be stupor, hebetude of mind, confusion due to acholia, cholæmia (Flint's cholesteræmia), when a large part of the liver structure is destroyed.

⁹⁷ Neurological Contributions, vol. i. No. 3, p. 68: "On Obscure Abscesses of the Liver, their association with Hypochondria and other Forms of Mental Derangement, and their Treatment."

Sweating has already been referred to as a phenomenon connected with the febrile movement. It is necessary to state further that this may vary in amount from a mere moisture of the surface connected with sleep, or it may be a profuse diaphoresis with which the febrile paroxysm terminates. As a systemic symptom, sweating is strongly suggestive of suppuration, and may therefore be extremely significant, in this connection, of suppuration in the liver. According to Waring, of 75 cases specifically interrogated on this point, 72 presented this symptom. Rouis refers (p. 123) to it as very constantly present, coming on chiefly at night—sometimes generally over the body, sometimes limited to the head, and always accompanied by an accelerated pulse.

The urine in cases of hepatic abscess varies; it is never normal. There may be merely an excess of urates—a symptom common enough in all febrile affections and in suppuration. It is usually high-colored, deficient in urea, and contains leucin and tyrosin, and not often bile-pigment, except when jaundice is present, which, as we have seen, is rather uncommon.

It should be borne in mind that whilst the above-described mental and cerebral and other symptoms are often present, they are by no means invariably so. There are cases, usually of encysted abscess, in which no functional disturbance of any kind exists. But the systemic symptoms are by no means so important as the local. To these we must now direct attention.

Local.—The position, size, and shape of the liver are not without significance, but it is strictly correct to say that an abscess of the liver may exist without any change in the size of the organ or in its relations to the surrounding organs. In 2 of 12 cases in the hands of the writer there was no evidence of enlargement of the right hypochondrium, but a difference in circumference of half an inch was ascertained in favor of the left side. In 4 cases there was no appreciable change in the size of the hepatic region; in one-half there was an increase in the area of hepatic dulness. In one of the cases in which the left side was the larger the abscess was of enormous extent, and discharged by the stomach and intestine. The enlargement of the liver may be very great. In one instance observed by the author the abscess reached to the upper border of the third rib. Rarely does the dulness extend more than two fingers' breadth below the inferior margin of the ribs, although cases are reported in which the enlarged organ reached to the crest of the ileum. As a rule, the diaphragm is pushed up and the lung displaced, rather than the dulness is extended downward. When the first tumefaction due to the initial congestion takes place, the organ may be much larger than subsequently, the pus becoming encysted and the normal state outside of the area of suppuration being restored. The purulent collection in a large proportion of the cases taking place in the right lobe, the extension of dulness is in the same lines as the normal. When, however, the right lobe is the seat of abscess, or a purulent collection forms around an impacted calculus, the swelling may appear in the outer border of the epigastrium next the ribs, and the increased area of dulness will be across the epigastrium and occupying the superior portion of this region. The general experience on these points corresponds to my own. Thus, according to Waring, there was an evident enlargement of the liver in 90 cases, and no enlargement in 11. In most cases the increase in size gives the impression of a fulness or hardness of the liver or of a diffused swelling or tumor of the epigastrium. In some instances the right hypochondrium is bulged out, the intercostal spaces widened, and the side appears to be or is actually elevated, and occasionally enlarged veins form, as in cases of the obstructed portal circulation of cirrhosis. In a case recently presented at Jefferson College Hospital clinic by the author, a globular swelling formed in the walls of the abdomen just below the inferior margin of the ribs near the site of the gall-bladder, and was held by an eminent surgeon to be a tumor of this locality; but it had the history of an hepatic abscess, and ultimately proved to be one. Rouis furnishes statistical evidence of the time when the increase in size of the liver occurs with respect to the other symptoms. He has noted an enlargement of the organ 73 times in 122 cases. Of 51 cases, the liver was enlarged in 12 before suppuration, in 22 at the onset of suppuration, and in 17 after suppuration was established. In 49 examples the liver was enlarged in 2 before any other symptom was manifest, in 8 at the onset of symptoms, and in 39 after the symptoms were well declared.

Fluctuation is not referred to by the writers in general, and there are no statistical data on this symptom, so far as our observation extends. No symptom could be more uncertain in all doubtful cases. When a large accumulation has taken place and the parietes of the sac are thin, fluctuation may be detected, but it cannot then be regarded as decisive. When an abscess in the interior of the right lobe is encysted, no fluctuation can be effected. The best mode of eliciting fluctuation, according to Hammond, is to place the extremities of the fingers of the left hand in the depression between the ribs over the most prominent part of the right hypochondrium, and gently tap with the fingers of the right hand the right border of the epigastrium. In 3 out of 12 cases this method has apparently elicited fluctuation in my own experience. The elasticity of the hepatic structure is such that the method of palpation, however practised, must return a sensation nearly allied to that of fluctuation in a purulent accumulation. It is certain, therefore, that errors of observation are liable to occur, and hence conclusions based on an apparent fluctuation should be accepted with caution; under any circumstances it should be very distinct, and even then should not be acted on unless supported by other suggestive evidence.

The uneasiness or pain felt in the right hypochondrium varies greatly according to the position of the abscess, the degree and kind of pressure exerted on neighboring organs, and the period of its development. When the peritoneal layer of the liver is involved, there will usually be acute pain, and this happens at two periods—when the abscess first forms from an impacted calculus or from any cause which includes the peritoneum, and subsequently when the pus, making its way from the liver, excites inflammation in the peritoneal investment of the liver, of the diaphragm, or affects ultimately the pleural membrane. In the so-called pyæmic abscesses there is very little pain, and in the case of the large single abscess in the interior of the right lobe there is rather a sensation of weight or of heaviness, of dragging than of acute pain. When the capsule of the liver is put on the stretch or the peritoneal investment is inflamed, then acute pain may be felt. More or less pain or local distress is, on the whole, a usual symptom. According to Rouis,⁹⁸ local pain is present in 141 out of 177 cases, or in 85 per cent. The statistics of Waring⁹⁹ closely correspond, for of 173 patients affected with this malady, in 153 there was more or less pain referable to the affected organ. The position of the pain has some influence in determining the seat of the malady, and often indicates the position of the abscess. As respects the character of the pain, there is little uniformity; in general it is a tensive, heavy, throbbing sensation, but under the circumstances above mentioned this may have an acute or lancinating character, as when the capsule or the peritoneal investment of the organ becomes involved.

⁹⁸ Recherches, etc., loc. cit.

⁹⁹ An Inquiry, etc. into Abscess of the Liver, loc. cit.

Besides the pain directly referable to the liver there are painful sensations felt in the neighboring parts, of very considerable significance. These are often described as sympathetic pains, and are referred to the shoulder—to the right shoulder when the right lobe is the seat of mischief, and to the left shoulder when the abscess forms in the left lobe of the liver. Although this statement has many limitations, it is not without diagnostic importance. Rouis ascertained the existence of the shoulder pain in 17 per cent. of the cases, or in 28 in a total of 163. Waring reports that this symptom was observed in 52 in a total of 76 cases. The right shoulder seems to be affected in about the same ratio as the right lobe of the liver in 25 times out of 26 cases, according to Rouis. The shoulder pain appears at the same time, in a majority of cases, as the hepatic pain, but it is very capricious. It is most frequently at the top of the shoulder, but it may be at the end of the clavicle, in the scapula, or extend down the arm. Its duration is very irregular, appearing occasionally during the existence of the disease, coming on at the outset, and lasting weeks or months, or only felt on pressure over the liver, on coughing, or on taking a full inspiration. The character of the pain is equally uncertain. It is usually heavy, tensive, stinging, or may be merely a sensation of soreness or of uneasiness or of weariness. The behavior of the shoulder pain is partly explicable by reference to the path by which the reflex is conveyed. As Luschka¹⁰⁰ has shown, the filaments of the phrenic nerve supplied to the suspensory ligament and capsule of the liver, put on the stretch or irritated, convey the impression to the cord, and it is reflected over the sensory fibres of the fourth cervical distributed to the shoulder. Rouis reports an instance in which the deltoid was wasted.

¹⁰⁰ Quoted by Thierfelder, op. cit.

The decubitus of patients affected with hepatic abscess is often extremely characteristic. To obviate the pressure on the swollen and inflamed organ the position assumed is right lateral-dorsal, the body inclined to the right, the right thigh flexed on the pelvis, and the spinal column so curved as to relax the abdominal muscles of the right side. When the pain and tenderness are not great there may be frequent changes of position, but in repose the lateral-dorsal decubitus is assumed. When the suppuration is well advanced and the accumulation large, the patient keeps in that position nearly constantly. If pressure interferes with the normal play of the lungs, and dyspnoea is produced on assuming the recumbent posture, the attitude taken expresses this state also: then the decubitus is lateral and partly dorsal, but the body is raised to a half-upright. There are many exceptions to these rules. Some lie easiest on the back, some on the left side; but it is quite certain that much the largest number, when uninfluenced by special circumstances, naturally place themselves as above described.

Jaundice is amongst the rarer symptoms. Rouis finds it to be present in 17 per cent. of the cases, Thierfelder in 16 per cent., and Waring in somewhat less than 6 per cent. Referring to my own observation, jaundice has rarely been present, but some yellowness of the conjunctivæ and a faint yellow tint of the skin generally have been evident. The peculiar aspect of the countenance connected with suppuration has rarely been wanting. When jaundice does occur, it is referable to two conditions—to a catarrhal swelling of the bile-ducts, which may be coincident with the onset of the suppurative inflammation; to the pressure of the abscess on the hepatic or common duct, which must happen at a late period.

As an abscess of the liver forms and enlarges, pressure is exerted on neighboring organs, producing very decided disturbances. Nausea and vomiting, anorexia, a coated or glazed tongue, diarrhoea or dysentery, are amongst the disorders of this kind involving the digestive apparatus. Each of these symptoms will require examination.

There is nothing characteristic in the condition of the tongue which does not belong to suppuration in any situation. Nevertheless, there are some appearances that have a certain value in conjunction with other diagnostic signs. At the onset of the suppurative inflammation the tongue is more or less heavily coated, but as the case proceeds it becomes dry and glazed in parts, whilst covered with a well-defined membrane-like crust at the base and margins. This appearance is very characteristic of the cases of suppuration, the abscess enlarging. In a very important case observed by me lately there was a well-marked diphtheritic-like exudation of the tongue and fauces toward the termination of the case, the membrane forming as the pus accumulated. This appearance was coincident with a typhoid state.

Nausea and vomiting appear with the beginning of symptoms, are associated with the general signs of systemic disturbance, and are especially prominent when an accumulation of pus takes place, being due under these circumstances to pressure on the hepatic and solar plexuses or to direct encroachment on the stomach—probably to both causes. The frequency and persistence of the vomiting are points of much diagnostic importance, according to Maclean¹⁰¹ and Fayrer,¹⁰² which I am able to fully confirm from my own experience. The matters ejected by vomiting consist of the contents of the stomach—glairy mucus, the accumulation in the gall-bladder, altered blood (coffee-grounds)—and the contents of the abscess if it discharge by the stomach. The vomiting is most apt to occur during the febrile exacerbation or at the time of sweating. The statistics are conclusive as to the frequency of vomiting as a symptom. Of 84 cases in which special reference was made to this point, in 74 nausea or vomiting existed. In my own experience this symptom has never been wanting.

¹⁰¹ "The Diagnostic Value of Uncontrollable Vomiting," by W. C. Maclean, Brit. Med. Journ., August 1, 1873.

¹⁰² Ibid., September 26, 1873.

The relation between abscess of the liver and dysentery has been much discussed. Under the head of Causes the influence of dysentery as a pathogenetic factor has already been examined. We have now to study its symptomatic relations. A considerable proportion of the cases occurring in this country have been preceded by proctitis—simple, sporadic dysentery affecting the rectum. In India a close relationship has been traced between ulcerations of the intestinal canal and abscess. According to Waring, 75 per cent. of the cases have occurred in those who were actually suffering from dysentery or recent or old ulcerations. As observed by Rouis in Algiers, out of 143 cases there were 128 with dysentery, or 90 per cent. Budd¹⁰³ long ago maintained that a peculiar poison generated at an open ulceration in the intestine was the true cause. Moxon,¹⁰⁴ Dickinson, and others have lately reaffirmed this explanation. A case by the latter¹⁰⁵ casts a strong light on this question: A patient had extensive dysenteric ulceration of the intestine and an abscess of the liver, without any symptoms indicating their existence. Such a case teaches the instructive lesson that dysenteric ulcerations may escape detection, and hence the connection between abscess and the intestinal lesion remains unknown. In a small proportion of cases—about 5 per cent.—dysentery is a result, apparently, of hepatic abscess. Whether the relation is admitted to exist or not, it is a curious fact that in so many cases ulcerative disease of the intestinal canal accompanies the hepatic affection. Hemorrhoids, prolapse of the rectum, gastro-intestinal catarrh, etc. are produced by the pressure of an enlarging abscess on the portal vein.

¹⁰³ Diseases of the Liver, 3d ed., p. 82.

¹⁰⁴ Pathological Transactions, 1862 and subsequently. Numerous cases are recorded in the various volumes up to 1880.

¹⁰⁵ Ibid., vol. xiii. p. 120.

The urine contains bile-pigment when jaundice is present, is usually loaded with urates, and the amount of urea may be deficient when much of the hepatic tissue is destroyed.

From the beginning of symptoms some cough is experienced: it is short and dry, but after a time in many cases the cough is catching and painful, and finally may be accompanied by profuse purulent expectoration. The breathing is short and catching when by the upward extension of the mischief the diaphragm is encroached on, and may become very painful when the pleura is inflamed. Ulceration of an abscess into the lungs is announced by the signs of a local pleuro-pneumonia—by the catching inspiration, the friction sound, the crepitant râle, the bronchophony and bronchial breathing, and bloody sputa usually, etc. Some time before the abscess really reaches the diaphragm, preparation is made in the lung for the discharge through a bronchus. The author has seen many examples of this, and a very striking illustration of the same fact is afforded in a case by Dickinson,¹⁰⁶ in which an abscess holding about four ounces was contained in the upper part of the right lobe; its walls were irregular and not lined by a limiting membrane. It is further stated that the "right pleura was coated with flocculent lymph, and the cavity contained serous fluid," etc. Here, in advance of the abscess, preparation was made for its discharge through the lung. The tendency of an abscess of the abdomen to external discharge is manifested in two directions: those of the upper part tend to discharge through the lungs, those of the lower part through the natural openings below. Abscesses of the liver come within the former rule, but it is not of invariable application, since some discharge by the stomach or intestine, some externally; yet a large proportion make their way through the lungs. Another symptom referable to the pulmonary organs in cases of hepatic abscess is singultus, or hiccough. This is a symptom of the period of discharge rather, and is often extremely protracted and exhausting. Pericarditis occurs in those cases in which discharge takes place in this direction, and it may develop, as does pleuritis, in advance of any change in the diaphragm. This preparation of the thoracic organs for external discharge seems almost like a conscious purpose, as if an intelligent supervision of these processes were exercised.

¹⁰⁶ Transactions of the Pathological Society, vol. xxxii. p. 127.

COURSE, DURATION, AND TERMINATION.—As the facts already given have sufficiently shown, the course of abscess of the liver is extremely uncertain. From the beginning to the end there may not be a single indication of its presence. On the other hand, a well-marked case is perfectly characteristic. Abscesses of the liver are acute and chronic—the former of short duration, accompanying pyæmia, portal phlebitis, and similar conditions; the latter, arising in the course of chronic dysentery or from unknown causes, especially if encysted, remaining latent for weeks or months. The course of an abscess is much influenced by the direction taken by the pus in the attempt at discharge. This portion of the subject requires careful statement and thorough treatment, and we therefore present it somewhat in detail. Beginning with his individual observations, the abscess in the author's 12 cases discharged—3 externally, 5 by the lungs, and 4 by the stomach or intestines. In Waring's¹⁰⁷ collection of 300 fatal cases, 169 remained intact at death, 48 were operated on; consequently, only 83 are left for the purpose of this comparison. Of 83 cases of hepatic abscess discharging spontaneously in some direction, 42 escaped into the thoracic cavity or by the right lung (in 28); into the abdominal cavity (15) or stomach (1) or intestine (7), 23; externally 2, besides in special directions to be hereafter referred to. Rouis¹⁰⁸ has tabulated the results in 30 cases of abscess fatal without an operative influence. Of these, 2 discharged externally, 17 by the thorax (15 by the lung), 5 by the stomach, 4 by the intestine, and 2 by the biliary canals.

¹⁰⁷ An Inquiry, etc. into Abscess of the Liver, loc. cit., p. 131.

¹⁰⁸ Recherches sur les Suppurations endémiques du Foie, etc., loc. cit., p. 148.

The appearances presented when the discharge takes place through the external parts are by no means uniform. When the epigastric or umbilical region is the point of discharge, a globular tumor forms, which may be mistaken for a fibroid or fatty growth; softening in the centre of the mass occurs, and ultimately the pus is discharged. If the pus makes its way outwardly through the right hypochondrium, the tumor formed is furrowed by the attachment to the ribs, and several openings usually occur. The pus may burrow under the skin for some distance and point in the axilla, or, making its way along the suspensory ligament, emerge at the navel, or, descending, appear in the lumbar region or under Poupart's ligament.

As the statistics prove, the most usual route for discharge to take place is by the thoracic cavity, especially the right lung. Some time in advance of an opening in the diaphragm a localized pleuro-pneumonia occurs, adhesions form between the pulmonary and costal pleura, and a channel is tunnelled out for the passage of the pus to a bronchus. The discharge of pus suddenly occurs after some days of cough and bloody expectoration. Even in favorable cases the amount is so large that the patient has extreme difficulty in disposing of it, and in unfavorable cases, the quantity being large, the patient's life is ended by apnoea. In still other cases an extensive purulent accumulation may form in the pleural cavity, the lung is compressed, and all the phenomena of an empyema superadded to those of a hepatic abscess. In a case reported by Westphalen¹⁰⁹ all the bile secreted by the patient came out by an opening in the fifth intercostal space. The empyema thus induced may indeed be the principal lesion, as in the case of the late Gen. Breckenridge, on whom thoracentesis was performed by Sayre of New York, and in a case reported by Löwer.¹¹⁰ So far from this being uncommon, as asserted by Thierfelder, when an abscess of the liver approaches the diaphragm inflammatory symptoms begin on the pleural side, and thus pyothorax may occur in advance of the perforation of this septum.

¹⁰⁹ Deutsches Archiv für klin. Med., 1873, Band xi. p. 588.

¹¹⁰ Berliner klinische Wochenschrift, 1864, p. 461.

The opening of an hepatic abscess into the pericardium is rare, since in Waring's collection of 300 fatal cases there was not one. When it does occur, pain is experienced about the heart; the action of the organ becomes irregular; præcordial anxiety and oppression are felt; suffocative attacks occur; and very soon the symptoms of pericarditis arise. Perforation of the ascending vena cava or of the hepatic vein happens in about 2 per cent. of the cases. When a quantity of pus is thus turned into the circulation, disastrous results follow, not so much from the infective nature of the pus as from the sudden increased pressure within the vascular system and the labor imposed on the heart, already failing.

The escape of the pus into the peritoneal cavity occurs in about 11 per cent. of the cases of spontaneous evacuation, according to Waring. Of the 162 fatal cases collected by Rouis, 14 opened into the peritoneum—about the same proportion as Waring gives. When discharge takes place into the peritoneum, the patient passes into a condition of collapse, or peritonitis is excited and rapidly proves fatal. In rare instances the inflammatory reaction is restricted to a small area, ulceration takes place through the abdominal parietes, and thus discharge is effected.

An opening may be made into the intestine or into the pelvis of the kidney. In the former case pus is discharged by stool or by vomit, and often in enormous quantity; in the latter by the urine, frequent and painful micturition, with much pus, being the evidence of the accident. In either case communication may be kept up with the abscess, and the patient be worn out with the exhausting discharge maintained by the intercommunication between the abscess and the canal through which discharge takes place.

Cases of hepatic abscess prove fatal without perforation. In Waring's collection of 300 cases, 169 remained intact, in the words of the author—that is, did not extend beyond the boundaries of the liver. Of 203 cases collected by Rouis, 96 did not extend beyond the liver. According to Thierfelder, about one-half of the cases of hepatic abscess perforate the liver. These statistics therefore closely correspond, and the general conclusion is very nearly expressed in the formulated statement of Thierfelder.

The duration of hepatic abscess cannot readily be expressed in figures. The acute cases terminate early by reason of the various complicating conditions. The chronic cases are much influenced in their duration by the presence of a limiting membrane, for if this be formed the duration will be protracted over weeks or months; and those cases not thus confined are necessarily of shorter duration. A period of latency may result when the extension of the morbid process is thus hindered. Forming a conclusion from the general conduct of the cases, it may be said that the duration of hepatic abscess is from two weeks to six months. Of 220 cases collected by Waring, the average duration was 39 days. Rouis fixes the average duration in 179 cases at 60 days. Of Waring's cases, the largest number (59) terminated in from 10 to 20 days; whilst Rouis places the maximum number (104) at from 11 to 60 days, the shortest duration of any case being 10 days, and the longest 480 days.

The termination may be accelerated by the manner of discharge, as when the abscess opens into the ascending vena cava, into the sac of the pericardium, or into the peritoneal cavity. In my own cases, carefully selected for these observations, death occurred in one during discharge by the right lung, one within twelve hours after discharge by the intestine, and one within ten days after discharge by the stomach and intestine, the mortality of the whole being 75 per cent. In Waring's collection of 300 fatal cases, 169 died whilst the abscess was still intact—that is, in the liver.

The mortality from abscess of the liver is very large. In Rouis's collection of 203 cases, 162 died, 39 recovered entirely, and 2 improved; 80 per cent., therefore, proved fatal. According to De Castro,¹¹¹ whose observations were made at Alexandria, Egypt, 93 in 208 cases died, this being 72.5 per cent. According to Ramirez,¹¹² of 11 cases of which an account is given in his memoir, 10 died and 1 recovered—a mortality of 90 per cent. De Castro (p. 40) also gives the results arrived at by the Medico-chirurgical Society of Alexandria, who collected 72 cases of abscess, of which 58 died, making the percentage of deaths 80.5. Various circumstances besides the abscess affect the result. An early successful operation, the mode of discharge, the amount of hepatic tissue destroyed by the suppuration, the extent of pre-existing lesions—especially ulcerations of the intestinal canal—are important factors in the result. In respect to some of these we have valuable statistical data. The discharge through the lungs is the most favorable route, next by the parietes of the abdomen, and lastly by the intestinal canal. One-half of those cases in which discharge is effected by the right lung get well. This is my own experience, and it accords with the observations of Rouis, of De Castro, and others. Rouis gives the result in 30 cases of hepatic abscess discharging by the right lung; of these 15 recovered. Of 25 cases observed by De Castro, discharging by the lungs, 19 recovered. Next to the discharge by the bronchi, the most favorable mode of exit is externally, through the parietes of the abdomen; much less favorable is by the stomach or intestine; but still more fatal is the discharge into the cavity of the peritoneum. When the abscesses are multiple and due to pyæmia, the termination is always in death. The numerous lesions besides the hepatic accelerate the fatal issue. In the case of large single abscesses the result is in a great measure due to exhaustion from protracted suppuration. When in addition to the formation of a great quantity of pus there is frequent vomiting and rejection of aliment, the failure of strength is proportionally rapid. In favorable cases, after an abscess is evacuated through the right lung, recovery takes place promptly. When the discharge occurs through the abdominal wall, the process is much slower, and often fistulous passages with several orifices, very slow to heal, are formed. Complete recovery may ultimately take place. The recovery will be incomplete in those cases with large loss of hepatic substance, especially when this coincides, as it usually does, with catarrh, ulceration, and other lesions of the intestinal tube. Again, the recovery will be incomplete in those cases where there are imperfect healing of the abscess site and a fistulous communication with the exterior.

¹¹¹ Des Abcès du Foie des Pays chauds, et de leur Traitement chirurgical, loc. cit., p. 40, Paris, 1870.

¹¹² Du Traitement des Abcès du Foie, Observations receuilles à Mexico et en Espagne, par Lino Ramirez, M.D., Paris, 1867, loc. cit.

It is possible for the arrest and healing of a suppurative inflammation of the liver to take place without discharge. Under such circumstances the watery part of the pus is absorbed, the solid constituents undergo a fatty metamorphosis, are emulsionized, and thus absorbed, and gradually closure of the damaged area is effected by a connective-tissue formation. We must, however, accept with caution those examples of this process which are supposed to have occurred because radiating cicatrices are discovered on the surface of the liver. In a case of hepatic abscess discharging through the lung, known to the writer, after death, which occurred fifteen years subsequently, there was no trace of the mischief, so perfectly had repair been effected. Radiating cicatrices are so often of syphilitic origin that they cannot be accepted as proof of the former existence of an abscess.

DIAGNOSIS.—He who finds the diagnosis of abscess of the liver easy under all circumstances can have had but little experience with the numerous difficulties in the way of a correct opinion. There are cases so plain that the most casual inspection suffices to form a conclusion; there are cases so difficult that the most elaborate study fails to unravel the mystery. The maladies with which hepatic abscess may be confounded are echinococcus of the liver, dropsy of the gall-bladder, cancer, abscess of the abdominal wall, empyema, or hydrothorax, etc. As regards echinococcus, the difference consists in the slow and painless enlargement characteristic of echinococcus, and the absence of any symptoms other than those due to the mere pressure of the enlarging mass. In abscess there may be no apparent enlargement, or the increase in the area of dulness may be very great, or after a period of increase of size there may be contraction due to the formation of pus, and hence limitation of the inflammation; finally, the accumulation of fluid may be sufficient to cause dulness up to the inferior margin of the second rib. There are no corresponding changes of size in the echinococcus cyst. Furthermore, abscess of the liver large enough to be recognized by the increased dimensions of the organ will be accompanied by more or less pain in the right hypochondrium and by a septicæmic fever. On the other hand, an echinococcus tumor is not accompanied by fever, pain, or tenderness, and it has that peculiar elastic trembling known as the purring tremor. The most certain means of differential diagnosis is the use of an aspiration-needle and the withdrawal of a portion of the fluid. The presence of pus with hepatic cells will be conclusive of abscess, whilst a serous fluid with echinococci hooklets will prove the existence of the echinococcus cyst.

In cases of dropsy of the gall-bladder there are no febrile symptoms, no chills, and the tenderness when present is limited to the pyriform body, the seat of the accumulation of fluid, and no general enlargement of the liver can be made out. At the point of swelling fluctuation may be detected, or if the gall-bladder is filled with calculi the sensation imparted to the touch is that of a hard, nodular body of an area and position corresponding to that of the gall-bladder. Tapping the gall-bladder, an easy and safe procedure, will resolve all doubts. When an impaction of a gall-stone is the cause of abscess, the clinical history is eminently characteristic: there are attacks of hepatic colic, after one of which the chills, fever, and sweats belonging to hepatic abscess occur.

The differentiation of cancer of the liver from abscess rests on the following considerations: In cancer there is slow enlargement, with pain; a more or less nodular state of the organ without fluctuation; usually ascites; no rigors; no fever and sweats. In abscess the liver may or may not be enlarged; there are rigors, fever, and sweating, and the surface of the organ, so far as it can be reached, is smooth and elastic, and it may be fluctuating. Cancer happens in persons after middle life, develops very slowly, and is accompanied by a peculiar cachexia; abscess occurs at any period, very often succeeds to or is accompanied by dysentery and by the usual phenomena of suppuration.

It is extremely difficult to separate an abscess in the abdominal wall, in the right hypochondrium, or a tumor in this region, from an abscess of the liver. The history of the case, the existence of a dysentery or of an apparent intermittent or remittent fever before the appearance of a purulent collection, will indicate the liver as the probable source of the trouble. Attention has already been called to a case in which an abscess of the liver was supposed by an eminent surgeon to be a tumor of the abdominal wall. The history in this case of an obstinate remittent fever, followed by the appearance of a tumor of the hypochondrium and by a preliminary discharge at the umbilicus, clearly indicated the nature of the trouble. In the absence of any history of the case it is extremely difficult to fix the origin of a suppurating tumor originating, apparently, in the depth of the right hypochondrium.

Mistakes are frequently made in the case of an abscess developing in the convexity of the right lobe of the liver and pushing the diaphragm up to the third, even to the second, rib, and thus producing conditions identical with empyema of the right thorax. Such instances of hepatic abscess are peculiarly difficult of recognition, because, the physical signs being the same as those of empyema, the differentiation must rest on the clinical history. In cases of empyema proper the effusion in the chest is preceded by pain and accompanied by an increasing difficulty of breathing; in hepatic abscess there are, as a rule, symptoms of disturbance in the hepatic functions, fluctuation in the hepatic region, dysentery, etc., long anterior to any disturbance in the thoracic organs. Again, empyema may be a latent affection, without any symptom except some obscure pain and a progressive increase in the difficulty of breathing; on the other hand, abscess of the liver is preceded by symptoms of liver disease and of associated maladies. A dry, purposeless cough is present in many cases of abscess; a painful cough with bloody expectoration occurs when preparation is making for discharge through the lungs.

Errors of diagnosis are liable to occur in the consideration of symptoms unquestionably hepatic in origin. Thus, the intermittent fever accompanying some cases of hepatic colic, like the shivering fits and fever which occur in cases of nephro-lithiasis, may be confounded with the septicæmic fever of hepatic abscess. An attentive examination of the attendant circumstances, especially a careful survey of the right hypochondrium, can alone determine the nature of the symptoms. In all doubtful cases the experimentum crucis of puncture with the exploring-needle becomes a measure of necessity. When all diagnostic indications are at fault, the needle of the aspirator may decide the issue. An abundant experience has shown that a needle of suitable size may be introduced into the right lobe without any ill result—often, indeed, with distinctly good effects when there is no suppuration or when pus cannot be detected. In the present state of our knowledge it cannot be determined why puncture of the organ should be beneficial in cases having the symptomatic type of hepatic abscess when none exists; but of this fact there is no doubt.

TREATMENT.—As the formation of pus is coincident with or causative of the first symptoms, it is obvious that treatment directed to prevent an abscess can rarely succeed. Yet it is probable that now and then an abscess just forming has been arrested and healing effected. At the onset of symptoms some large doses of quinine, with a little morphine (scruple j of the former and ¹/8 gr. of the latter), every four or six hours, may have a decided curative effect. During the course of the septicæmic fever, with its chills and febrile exacerbations, quinine in full doses and alcohol according to the conditions present are necessary remedies. As the symptoms develop saline laxatives are useful until the formation of pus becomes evident, when all perturbating treatment of the intestinal canal should cease. If dysentery be present when the hepatic symptoms arise, it should be cured as promptly as possible; and of all remedies for this purpose, ipecac given in the usual antidysenteric quantity offers the best prospect of relief. For the dysentery which succeeds to abscess, and is probably, in part at least, dependent on portal obstruction, the mineral astringents, as copper sulphate, are the most effective remedies. As far as practicable, after an abscess has formed the intestinal canal should be kept quiet, for any considerable disturbance will endanger the escape of pus into the peritoneal cavity. Persistent vomiting is very significant of pressure by an enlarging abscess in the stomach, and usually signifies an abscess associated with impacted calculus. It is important in such cases to maintain, as far as can be done, a quiescent condition of the stomach, for the purpose of preventing rupture into the peritoneal cavity and to favor the nutrition which is seriously endangered by the repeated vomiting. Effervescent soda powders are very useful; carbolic acid in solution, or creasote-water with or without bismuth, is beneficial; champagne, very dry and highly effervescent, has been, in the writer's hands, remarkably efficient. As food becomes a most important need in such cases, milk and lime-water, wine-whey, egg-nog, and similar aliments must be given in small doses and frequently. Nutrient enemata, prepared from eggs, milk, and beef-juice, with the materials for digestion—acid and pepsin—may be made to supplement the stomach, but such efforts have a very limited utility, owing to the state of the hepatic functions and to the obstruction of the portal circuit. In all cases it is necessary to maintain the strength by suitable aliment and the judicious use of stimulants. The long-continued and profuse suppuration makes an enormous demand on the vital resources of the patient, and this must be compensated by suitable food-supplies.

As the formation of pus has taken place in most cases when symptoms have begun, the question of highest importance is, Shall the pus be evacuated? The statistical evidence relating to this question becomes then an extremely valuable guide. As in almost all cases of puncture of the liver for the evacuation of an abscess some part of the liver substance must be passed through, it is necessary to note how far this can be done without inflicting permanent injury on the organ. Hammond has punctured the liver in eight cases without the presence of an abscess, and of these not one has presented any unfavorable symptom. The author has punctured the liver, penetrating well into the interior, in two cases in which no abscess was discovered, but the symptoms of hepatitis existed, with the effect to improve the symptoms. In Condon's¹¹³ collection of 11 cases there were 8 of abscess evacuated by the trocar, and 3 of acute hepatitis in which abscess had not formed, but in which the puncture procured the most decided amelioration of the symptoms. We have heretofore referred to Hammond's experience in the puncture of the liver in cases of hypochondriasis, this condition appearing to depend in some instances on the presence of abscess. In a number of instances abscesses did exist, but in many others there was no apparent lesion of the liver, but in these cases the puncture of the organ was without any ill result. Testimony to the same effect is given by Ramirez,¹¹⁴ who asserts that he had not known a single instance in which any ill result followed puncture of the liver. It may therefore be regarded as certain that exploratory puncture of the organ for the purpose of diagnosis as well as for treatment can at any time be performed with suitable precautions in respect to the size, condition, and character of the instrument.

¹¹³ "On the Use of the Aspirator in Hepatic Abscess," Dr. E. H. Condon, The Lancet (London), August, 1877.

¹¹⁴ Du Traitement des Abcès du Foie, Observations recueilles à Mexico et en Espagne, par Lino Ramirez, M.D., Paris, 1867, p. 65.

The authorities of most experience are agreed that, provided with the aspirator, the abscess may be punctured as soon as a purulent collection can be ascertained to exist. The obvious reason for tapping the abscess is its tendency to extend in various directions, destroying the hepatic substance. In those examples confined by a limiting membrane, after a time of inactivity ulceration begins, and the pus seeks an outlet in some direction. The early evacuation by a suitable aspirator becomes then a measure of the highest necessity. The good effects of puncture with even such a crude instrument as the trocar is well exhibited in the statistics collected by Waring.¹¹⁵ In a collection of 81 cases opened by the knife or trocar there were 66 deaths, making the percentage of recoveries 18.5. In these cases the operative procedure was a final measure, and the mischief had been done almost if not quite in its entirety. The statistics of Waring are concerned with a period anterior to 1850. Although they demonstrate the value of the trocar and evacuation of the abscess, as compared with the results of the natural course of the disease, the far greater success of the treatment by the aspirator is shown by the statistics of recent times. Thus in McConnell's¹¹⁶ 14 cases, also of India, in which the aspirator was used to empty the sac, 8 recovered and 6 died. The statistics of Waring may also be profitably compared with those of Condon,¹¹⁷ in which, of 8 cases of abscess evacuated by the aspirator, 4 recovered, or 50 per cent. They may also be compared with Sach's¹¹⁸ cases, 21 in number, of which 8 recovered, or 38 per cent., and with the cases of De Castro¹¹⁹ of Alexandria, who reports 22 large abscesses operated on, the proportion of cures being 31.8 per 100, and 10 small abscesses, the proportion of cures being 70 per 100. In a case seen in consultation with Collins, in this city, last year, the aspirator was used by us about three months after the symptoms of abscess declared themselves. About a quart of bloody pus was drawn off at once, the opening sealed, and no subsequent accumulation occurred, the patient entirely recovering, for after a year he was seen (December, 1884) in complete health. From these data we draw the important conclusion that early operation is desirable. This fact may be formulated in the expression: In all cases of hepatic abscess use the aspirator whenever the presence of pus is made out. When the abscess is large, and especially when communication is established with the parietes of the abdomen, a free opening, followed by the insertion of a drainage-tube, is the proper method to pursue. If the pus reaccumulates, it is good practice to inject the cavity with tincture or compound solution of iodine after the pus is drawn off, provided the dimensions of the abscess are not too great.

¹¹⁵ An Inquiry into the Statistics of Abscess of the Liver, loc. cit.

¹¹⁶ "Remarks on Pneumatic Aspiration, with Cases of Abscess of the Liver treated by this Method," Indian Annals of Medical Science, July, 1872, quoted.

¹¹⁷ Lancet, supra.

¹¹⁸ Ueber die Hepatitis der heissen Länder, etc., von Dr. Sachs in Cairo.

¹¹⁹ Des Abcès du Foie des Pays chauds, et de leur Traitement chirurgical, par le Docteur S. V. de Castro (d'Alexandrie d'Egypte), Paris, 1870, p. 59.

As regards the mode of proceeding, the following are useful rules: Ascertain, if possible, the existence of fluctuation; locate the point where the walls of the abscess are thinnest; insert an exploring-needle, and if the dépôt of pus is reached substitute a trocar having a sufficient calibre to evacuate the contents of the abscess; observe antiseptic precautions in respect to each detail of the operative procedure, and after the removal of the canula or needle, if a drainage-tube is not necessary, close the wound antiseptically. If drainage is necessary, keep the cavity empty and use proper solutions to prevent septic decomposition. When an abscess of the liver is pointing, the best place to puncture is where the abscess is most prominent and it walls thinnest, but if the accumulation of pus is encysted and there is no attempt at effecting an exit, the exploring-needle should be passed into the interior of the right lobe, the most usual site of suppuration. If pus be reached, a larger trocar may be inserted to evacuate the cavity thoroughly. Repeated insertion of the needle-trocar is preferable when the abscess is small, but when the accumulation is large and sufficiently firm attachments to the abdominal parietes exist, a drainage-tube will be necessary.

In what direction soever discharge of an abscess may take place, the general indications are to support the powers of life by food and stimulants. The utmost quietude should be maintained. It is useful, by the application of a firm flannel bandage, to keep the liver in its proper position and maintain it there. When pointing of an abscess occurs, a large flaxseed poultice is a soothing and a mechanically supporting application.

Acute Yellow Atrophy.

DEFINITION.—By the term acute yellow atrophy is meant an acute affection of the liver, characterized by rapid wasting or degeneration of the organ, accompanied by the systemic symptoms belonging to an acute acholia or cholæmia. It is an acute, diffused inflammation, with atrophy of the proper gland-elements. It has been called icterus gravis, malignant icterus, hemorrhagic icterus, malignant jaundice, etc.

HISTORY.—Cases having a more or less exact resemblance to acute yellow atrophy have been occasionally reported from the earliest period. Amongst English physicians, Bright¹²⁰ was one of the first to give an accurate account of the clinical history of some well-defined cases. Rokitansky¹²¹ was really the first to define the disease from the pathological standpoint, and it was he who designated it acute yellow atrophy, this term being intended to signify the nature of the objective changes. The first treatise ever published on the disease as a distinct morbid entity was the monograph of Horaezek,¹²² which appeared in 1843. Amongst the French, Ozonam in 1847 was the first to recognize and describe the disease as a distinct affection, although Andral¹²³ had several years before mentioned an affection of the liver which corresponded in some of its features to this affection. In 1862, Wagner¹²⁴ asserted that many of the cases of acute yellow atrophy were only examples of acute phosphorus-poisoning, and that no real distinction exists between the two affections. This statement has been warmly disputed by various German observers, but there is no doubt a close resemblance between the two affections.

¹²⁰ Guy's Hospital Reports, 1836, vol. i. p. 621.

¹²¹ Handbook of Pathological Anatomy, Am. ed.

¹²² Quoted by Legg, On the Bile, Jaundice, and Bilious Diseases, loc. cit.

¹²³ Clinique médicale, 1839, tome ii. p. 363.

¹²⁴ Archiv der Heilkunde, 1862, p. 364.

CAUSES.—There can be no doubt that acute yellow atrophy is a very rare disease, since so few examples are found post-mortem. In the course of a very large experience in autopsical examinations I have met with but one characteristic example.¹²⁵ According to Legg, it is "one of the rarest diseases known to man."

¹²⁵ General Field Hospital, December, 1863.

Several theories have been proposed to explain the occurrence of this affection, but without success. It has been ascribed to an excess in the production of bile, to stasis in the bile, and to a sudden saturation of the hepatic cells with biliary matters contained in the portal vein. That these supposed causes are really influential in producing the malady can hardly be entertained. That there is a peculiar poison which has a causative relation to the disease is rendered probable by the fact that a condition closely allied to this disease is produced by phosphorus, antimony, arsenic, and other poisons. Is it not a ptomaine generated under unknown conditions in the intestine? Especially does the morbid anatomy of phosphorus-poisoning nearly agree in all its details with icterus gravis—so nearly that by many German authorities they are held to be identical.

Age has a certain influence in the causation of this disease. It is rarely seen in early life, Lebert in a collection of 63 cases having found only 2 before ten years of age, yet there has been a well-marked case at three, and Hilton Fagge reports one at two and a half years of age. Nevertheless, much the largest number occur between fifteen and twenty-five years of age, and the maximum age may be fixed at sixty.

The influence of sex in the pathogeny is most remarkable. It is true in Lebert's collection of 72 cases there were 44 men and 28 women, but it is now known that he did not properly discriminate in his selection of supposed examples of the disease. The statistics of all other observers are opposed to those of Lebert. Thus, in Frerichs' collection of 31 cases, carefully sifted to eliminate error, there were 22 women and 9 men. Legg has also collected 100 cases of acute yellow atrophy, and of these 69 were women or girls. The most active period of life—from twenty to thirty years of age—is the usual period for the appearance of this disease. More than one-half of Lebert's cases occurred between fifteen and twenty-five; and of Frerichs', two-thirds happened between twenty and thirty years of age. In Legg's collection of 100 cases, 76 were between fifteen and thirty-five years of age. What is the condition of women at this period in life which renders them so susceptible to this malady? There can be no doubt that pregnancy is the great factor. Of 69 cases especially interrogated on this point, examined into by Legg, in 25 pregnancy was ascertained to exist. In Frerichs' collection one-half were women in the condition of pregnancy. The period of pregnancy at which the disease appears varies from the fourth to the ninth month, the greatest number occurring at the sixth month. So long ago as 1848, Virchow drew attention to the remarkable changes in the liver due to pregnancy. Sinety¹²⁶ has studied the effect of lactation on the liver, and has ascertained the existence of fatty degeneration. There is a form of jaundice which accompanies menstruation, as shown by Senator,¹²⁷ Hirschberg, and others. These facts indicate a certain relationship between the sexual system of the female and the liver, but they do not indicate the nature of the connection, if any exist, between this condition and acute yellow atrophy.

¹²⁶ De l'État du Foie chez les Femelles en Lactation, Paris, 1873 (pamphlet).

¹²⁷ Berliner klinische Wochenschrift, 1872, p. 615, "Ueber Menstruelle Gelbsucht."

The influence of depressing emotions has been supposed to be effective in producing this disease, but it is more than doubtful if such a relationship exists. Lebert, however, refers 13 of his cases to this cause, but Legg, who bases his statements on the study of 100 carefully-recorded cases, is sceptical regarding the effect of such influences. Syphilis has in some instances appeared to be the principal, if not the only, pathogenetic factor, and Legg¹²⁸ compares the action of the virus of syphilis to the effect of phosphorus, mercury, etc.

¹²⁸ On the Bile, Jaundice, and Bilious Diseases, loc. cit.

PATHOLOGICAL ANATOMY.—The anatomical changes occurring in this disease indicate the existence of a systemic condition: the lesions are not limited to the liver, but involve various other organs. The changes in the liver should be first described, since the name of the disease is derived from the alterations in this organ. As the name indicates, the lesions are atrophic, but not all examples show this. In some cases there is little change in the size of the organ; in others the wasting is extreme; certainly in all typical examples the liver is reduced in size. The variations in size observed are probably due to the stage at which the inspection is made: if early, the organ may not be reduced in size, may be even somewhat enlarged by the deposition of new material; if later, the atrophic changes will be more or less pronounced. When the atrophy has taken place, the size of the liver is reduced to one-half, even to one-third, of its original dimensions; it is then soft, almost like pulp, and cannot maintain its shape, but flattens out on the table. The capsule is much wrinkled and the color of the organ is yellowish, variegated by islets of reddish or brownish-red color, these spots being somewhat depressed below the general surface and having a firm texture. On section the boundaries of the lobules are either lost or have become very indistinct, the line of section being bloodless. The knife with which the sections are made becomes greasy. In some instances ecchymoses are discovered under the capsule, and rarely hemorrhagic extravasations in the substance of the liver. The bile-ducts are found intact, as a rule. The greatest change in the size of the liver is observed in the left lobe. The duration of the disease, as has been indicated above, has a marked influence over the size and condition of the liver. The atrophic shrinking of the liver occurs more decidedly after the ninth day. In general, the tissue of the liver is soft and pulpy in consistence. On microscopic examination the most important alterations are seen to have occurred in the hepatic cells; ultimately, these cells disappear, being replaced by fatty and connective-tissue detritus; but before this stage is reached important alterations have taken place in the form and structure of these bodies: the cells become granular and fatty, and lose their sharpness and regularity of contour, especially at the periphery of the lobule, but ultimately all the cells within the lobule undergo atrophic degeneration. In this atrophic degeneration of the hepatic cells, in their fatty degeneration, and ultimately entire disappearance, consist the real proofs of the disease. The red islets of tissue already alluded to consist of the fatty detritus mixed with crystals of hæmatoidin.

More or less increase of the connective tissue is noted in many of the cases—increase of connective tissue with numerous young cells formed around the vessels and the bile-ducts (Waldeyer¹²⁹). The changes in the liver would surely be incomplete without some references to the minute organisms which play so important a part in modern pathology. Waldeyer was the first to demonstrate the presence of bacteria in the pigment-remains of the hepatic cells. Other observers have been unable to detect them, so that at present the parasitic origin of this affection remains sub judice.

¹²⁹ Arch. für path. Anat., 1868, p. 536, Band xliii.

Important changes also take place in the spleen, but the opinions on this point are somewhat contradictory. Frerichs found the spleen enlarged in most of his cases; Liebermeister, on the other hand, and Legg,¹³⁰ find that the spleen is enlarged in about one-third of the cases. When the atrophic changes occur in the liver, more or less swelling of the splenic veins must occur in consequence of portal obstruction. The peritoneum, especially the omental part, is the seat of multiple ecchymoses, and the endothelium is fatty. The mesenteric glands are usually swollen. More or less blackish or brownish fluid, consisting of altered blood, is usually found in the stomach, and the same, assuming a tar-like consistence, in the large intestine. Ecchymoses of rather small size are distributed over the stomach and intestines. The epithelium of the stomach-glands is found granular and disintegrating, and a catarrhal state of the gastro-intestinal mucous membrane exists throughout. The secretions are never normal, and the stools are wanting in bile or present a tarry appearance, due to the presence of blood.

¹³⁰ On the Bile, Jaundice, and Bilious Diseases, supra.

Important changes take place in the kidneys. They consist essentially in a granular and fatty degeneration of the tubular epithelium, whence the altered appearance of the cortex. Multitudes of bacteria crowd the pyramids. Ecchymoses also are found in the mucous membrane of the pelvis of the kidney, in the bladder, and indeed all along the genito-urinary tract.

The muscular tissue of the heart is in a state of acute fatty degeneration, beginning with a granular change which may at the outset be of very limited extent and involve but few fibres. The endo- and pericardium are studded with ecchymoses or marked by hemorrhagic extravasations, and the pleura presents similar appearances, but not to the same extent.

The brain does not always show evidences of change, but in many instances there are ecchymoses of the meninges; the walls of the vessels are affected by fatty degeneration.

The tissues of the body are more or less deeply stained with bile. The pathological change on which the jaundice depends has been variously stated, but the most probable explanation is that which refers it to mechanical obstruction of the bile-ducts, either by catarrhal swelling or fatty degeneration of the epithelium. Notwithstanding the prominence of the hepatic symptoms, acute atrophy of the liver is probably only one element in a constitutional morbid complexus.

SYMPTOMS.—Acute yellow atrophy begins in two modes—the grave symptoms preceded by mild prodromes, or the most serious symptoms appear at the onset. The former mode is the more common. The usual prodromes are referable to the gastro-intestinal canal, and consist of loss of appetite, nausea, vomiting, a bitter taste in the mouth, headache, and general malaise. Indeed, the opening attack may be much like an ordinary bilious seizure or acute gastro-duodenal catarrh or a sick headache. In some cases the initial symptoms—nausea and diarrhoea—appear to be induced by an indigestible article of food. Jaundice never fails to be present at some period, but is usually one of the prodromic symptoms. It has no special characteristics by which the gravity of the approaching seizure may be measured. It is usually rather deep, and all parts are deeply stained, but the coloration may be limited to the body and upper extremities. No change in pulse or temperature, except the usual depression of both functions, is to be observed; the urine is deeply stained with pigment, and the feces are grayish, colorless, or parti-colored.

The period of time elapsing before the serious symptoms come on is not constant; from one week to several months have been the variations observed. In a minority of the cases no prodromes have occurred, but the grave symptoms have declared themselves at once. From the appearance of the jaundice up to the onset of severe symptoms the time has varied from two weeks to several months, but has rarely exceeded three months. During this time there may be nothing to indicate the gravity of the approaching symptoms; in fact, the case then, as at the onset, seems to be one of simple gastro-duodenal catarrh associated with catarrhal jaundice. The onset of serious symptoms is most usually announced by dilatation of the pupil. If, therefore, in a case of apparently simple catarrhal jaundice, especially in a pregnant female, there should occur without apparent reason a marked and persistent dilatation of the pupil, the possibility of the case being one of acute atrophy should be apprehended. This symptom is not, alone, of sufficient value to decide the character of the case, but then an obstinate insomnia comes on, violent headache is experienced, there is more or less confusion of mind, and jactitations or an extreme restlessness occurs. When such pronounced nervous symptoms appear the character of the attack is explained.

Various divisions have been proposed to mark the type of the symptoms: thus, the icteric period embraces the prodromal symptoms with jaundice; the toxæmic period is that stage characterized by profound nervous disturbances. Ozonam has divided the symptoms into those of the prodromal period and those of the serious stage, the latter being subdivided into the symptoms of excitation and those of collapse. There may be no prodromal period, however; without any preliminary symptoms the patient is suddenly seized with delirium and passes into a condition of coma and insensibility, or the first evidence of serious illness may be convulsions. It is probable, however, that in even the most sudden cases mild prodromal symptoms had occurred, but were overlooked. There is much variability in the symptoms of the toxæmic period. There are three symptoms: excitement with delirium, sometimes delirium ferox; coma, less or more profound; and convulsions. Legg has numerically expressed the relative frequency of these symptoms thus: Of 100 cases of unquestionable acute atrophy, 76 had become comatose, 59 were delirious, and 32 had suffered convulsions.¹³¹ According to the same authority, delirium and coma were associated together in about one-half of the cases, but in pregnant women coma often occurs alone (Legg). Usually, when convulsions happen there has been either coma or delirium. With these cerebral symptoms there are often present various disturbances of motility and sensibility, such as local convulsions, jactitations, hiccough, extreme restlessness, paralysis of the sphincters, and incontinence of urine and feces or retention, grinding of the teeth, exalted sensibility of the skin, or it may be complete anæsthesia, severe itching of the surface, etc.

¹³¹ On the Bile, Jaundice, and Bilious Diseases, loc. cit.

During the toxæmic period, and directly dependent on the retention of excrementitious matters in the blood, hemorrhages occur from the mucous surfaces, from wounds, and into the various serous membranes. A changed state of the blood being present in all cases of this disease, the proportion in which extravasations take place is high—in about 71.3 per cent. according to Liebermeister, and 80 per cent. according to Legg. The latter author regards these estimates as rather low. When hemorrhage occurs in the stomach in small amount, it presents itself as coffee-grounds or as black vomit, and in the intestine in the form of black, tarry stools or melæna. Hemorrhage may also occur from the surface of an ulcer, from a fresh wound, a leech-bite, etc.; but the most usual form of extravasation of blood after the gastro-intestinal is epistaxis or bleeding from the nose. Women who abort, as they are very apt to do when this disease comes on, may suffer from frightful hemorrhage, and deaths have been thus caused. Various opinions have been expressed as to the cause of the hemorrhagic condition—by some attributed to the changes in the composition of the blood; by others to the alterations of the vessel walls; both factors are doubtless concerned.

During the prodromic period the temperature of the body, as in the case of ordinary uncomplicated jaundice, is rather depressed below normal, sometimes as much as two degrees; but when the toxæmic stage comes on the body-heat rises to a variable extent, but usually over 100° F. In some cases no febrile movement can be detected; in others a very considerable elevation of temperature occurs, but very rarely attains to 105° or 106° F. The pulse becomes very rapid, in some instances rising to 140; but without any apparent cause it may fall suddenly to 70 or 80, and these fluctuations may take place several times a day. The rise of temperature and a very rapid pulse may come on in the final coma only; and immediately after death, as Legg points out, the body-heat may attain the maximum elevation.

As the toxæmic period develops the tongue becomes dry, glazed, fissured, sordes form on the teeth and lips, the breath becomes fetid, and the breathing may assume the Cheyne-Stokes type. The nausea and vomiting of the prodromal period persist, and the ominous coffee-grounds appear in the rejected matters, or grumous masses—clots acted on by the gastric juice—are brought up. Black, pitch-like, or tarry stools, the result of hemorrhage, are passed toward the end—involuntarily when liquid. When no blood is present the stools are grayish and without bile. Constipation may be the condition instead of diarrhoea in about one-third of the cases.

Various eruptions have been observed on the skin, such as petechiæ, roseola, eczema, etc., but their very variety, as their occasional appearance, indicates their accidental relationship to the disease.

The urine is much altered in character, but it is usually acid in reaction, although it has been observed neutral or alkaline. The specific gravity is at or nearly normal, and it has a deep-brownish or bilious hue due to the presence of bile-pigment. The most important change in the composition of the urine is the diminished quantity of urea or its entire disappearance; the phosphates, and especially the chlorides, are also usually diminished in amount; and albumen and leucin and tyrosin appear to a lesser or greater extent, together with hyaline, fatty, and granular casts.

Although the observations are somewhat contradictory, it seems pretty definitely established that the blood is more or less altered in composition, morphological and chemical. The red corpuscles are diminished in amount, and often deformed; the white corpuscles are increased; and excrementitious products—urea, leucin, tyrosin, and cholesterin—are found in greater or less quantity.

COURSE, DURATION, AND TERMINATION.—Although, as a rule, the course of acute atrophy is rapid, it is not invariably so. In some instances the prodromic symptoms have continued through several months, but, according to Thierfelder, one-half of the cases terminate in from three to five weeks, and in only 10 per cent. is the duration continued into eight weeks. The course of the disease is extremely rapid in pregnant females, rarely extending beyond the second week. An extended course of the disease is due to delay in the prodromic stage, the toxæmic period being always absolutely and relatively shorter. In the condition of pregnancy the danger is increased by the hemorrhages, and the early termination is due chiefly to this factor. When the duration of the disease is protracted and its evolution normal, the accumulation of hepatic excrementitious matters sets up cerebral disturbance, which becomes a pronounced feature of the case.

The termination cannot probably be otherwise than fatal. As in the course of the disease the hepatic cells undergo solution and disintegration, their restoration can hardly be regarded as possible, certainly not probable. Any curative result must, then, be wrought in the prodromic period, when the diagnosis must be viewed with some mistrust.

DIAGNOSIS.—George Harley¹³² maintains the singular doctrine that acute yellow atrophy is only the "sporadic form of the contagious jaundice of the tropics," or yellow fever. He bases his opinion on the identity of their symptoms, pathological anatomy, mortality, and contagious character; for he affirms that acute yellow atrophy may exhibit contagious power in temperate climates.

¹³² Diseases of the Liver, Amer. ed., 1882, p. 255.

As acute yellow atrophy comes on as an ordinary catarrhal jaundice, it is impossible to distinguish it from the latter affection during the prodromal period. When cerebral symptoms, black vomit, and tarry stools appear, the area of hepatic dulness very decidedly diminishes, and leucin and tyrosin replace urea in the urine, acute atrophy may be suspected.

Acute phosphorus-poisoning, as regards its symptomatology and morbid anatomy, does not differ from acute yellow atrophy, and many cases of the latter have been mistaken, it is supposed, for the former. To distinguish between them the history of the case must be carefully ascertained.

When, after the prodromal symptoms, which may not be accurately diagnosticated, there occurs a rapid decline in the area of hepatic dulness, hemorrhages take place from the mucous surfaces, stupor and delirium supervene, and urea disappears from the urine, being replaced by leucin and tyrosin, there can be no difficulty in coming to a conclusion: the case must be one of acute yellow atrophy.

TREATMENT.—It was formerly supposed that a case of acute yellow atrophy must necessarily prove fatal, but this opinion must now be modified, since examples of cure of supposed cases have been reported from Oppolzer's clinic,¹³³ by Lebert,¹³⁴ by Harley,¹³⁵ and others. As at the onset the symptoms cannot be distinguished from a bilious attack or from catarrhal jaundice, the treatment must be appropriate to these states. When the serious symptoms begin, a large dose (scruple j) of quinine should be at once administered, and half the quantity at regular intervals to keep up the cinchonism. Phosphate of soda, with some arseniate and such mild hepatic stimulants as euonymin, iridin, etc., should be given to maintain a gentle aperient action. Experience has proved that active or drastic cathartics do harm rather than good; on the other hand, mild laxatives, especially those having cholagogue action, seem to do good.

¹³³ Thierfelder, op. cit.

¹³⁴ Ibid.

¹³⁵ Diseases of the Liver, Amer. ed., supra.

Important symptoms arising during the toxæmic period require remedies to combat them. Nausea and vomiting, and also diarrhoea, are best relieved by carbolic acid and bismuth in combination. Hemorrhage requires, when intestinal, the chloride and perchloride of iron; when from other mucous surfaces, ergotin, gallic acid, and other hæmostatics. The depression of the vital forces should be treated by small and frequently-repeated doses of alcohol, by quinine, by iron, and, under some conditions, by digitalis. After the disintegration of the hepatic cells has been produced no remedies can be of any service. Until this occurs, however, it seems to the author well worth while to attempt to stay the destruction by the administration of those remedies which, by their accumulation in that organ, indicate a special affinity for its tissue. These drugs are phosphorus, antimony, gold, silver, and mercuric chloride. By the timely administration of one or more of these would it not be possible to stay the progress of the atrophic degeneration?

The Liver in Phosphorus-Poisoning.

DEFINITION.—Poisoning by phosphorus may seem to be a toxicological question rather than a merely hepatic disease, but as the morbid complexus thus induced is so similar to acute yellow atrophy that the conditions are regarded as identical by many of our German colleagues, it is necessary to enter into some details regarding it.

PATHOGENY.—Phosphorus-poisoning occurs at any period from youth to old age, but is most common from twenty to thirty years of age. Women seem more inclined to effect self-destruction in this way than are men, probably because phosphorus matches are so readily obtained. Children may munch match-heads in a spirit of mischief. That form of chronic poisoning seen in workmen in match-factories, and consisting in necrosis of bone, etc., does not come within the scope of the present inquiry.

A body poisoned by phosphorus does not exhibit a tendency to putrefactive decomposition within the usual period. The tissues are more or less deeply stained by bile-pigment, and this coloration extends to pathological fluids as well. The serous and mucous membranes contain points of blood-extravasation, but they are especially numerous in the serous membranes. Hemorrhages of this kind are due to two causes—to the disorganization of the blood, and to fatty degeneration of the arterioles. The heart is also more or less advanced in fatty degeneration, the muscles granular, the striations obscure or obliterated, and the whole soft and easily torn. The spleen is usually enlarged—often, indeed, to twice its natural size. The liver presents highly-characteristic alterations. When death occurs early the organ is generally enlarged, infiltrated with fat, the connective tissue undergoing hyperplasia; but in more advanced cases atrophy has taken place, the cells have disappeared and are replaced by fat-granules, crystals of leucin and tyrosin, connective tissue, etc.—in fact, the changes characteristic of acute yellow atrophy. The jaundice has been variously interpreted. As the bile-ducts in advanced cases are found to contain no bile, but only a colorless mucus, the advocates of a hæmatogenic jaundice hold that the jaundice is due to a failure of the liver to excrete the biliary principles in the blood; whilst the opponents of this view maintain the existence of an obstruction in the ultimate ducts. Harley¹³⁶ has recently brought forward some strong facts and arguments—which we believe can be successfully controverted—maintaining the former view. The jaundice of phosphorus-poisoning, if Harley's opinion prove to be correct, must be regarded as a hæmatogenic jaundice.

¹³⁶ Diseases of the Liver, loc. cit.

The mucous membrane of the stomach, as might be supposed, is more or less ulcerated or in an advanced state of catarrh, and the gastric glands are affected by fatty degeneration.

The kidneys are affected in a similar manner to the liver; the epithelium is fatty and sometimes detached, and the same process is found to occur in the vessels and epithelium of the cortex.

SYMPTOMS.—Not only in the morbid anatomy, but in the symptoms, do we find that a very remarkable resemblance exists between acute yellow atrophy and phosphorus-poisoning. As phosphorus is usually swallowed in bulk, some hours may elapse before the local symptoms begin, for the contents of the stomach and the tough mucus lining the mucous membrane may, and usually do, prevent immediate contact of the poison with the mucous membrane. When the stomach is entirely empty the symptoms may begin in an hour or two. The symptoms produced may be arranged in two groups—those due to the local irritation excited by the poison; those due to its systemic impression. In the first group belong burning in the gullet, pain, nausea, and vomiting. According to Lewin,¹³⁷ who has collected a number of cases for analysis, vomiting occurs in 26 out of 32 instances of poisoning. Some hours—often, indeed, three or four days—then elapse before the systemic symptoms begin. Vomiting, which was for the time being suspended, occurs again, and instead of the mere contents of the stomach, containing more or less phosphorus, blood, somewhat changed by the gastric juice—chocolate-colored or as coffee-grounds—appears in the vomited matters. The evacuations from the bowels may at first, as the contents of the stomach, appear phosphorescent, and afterward exhibit the appearances due to the presence in them of altered blood. At this time, if the liver be examined it will be found somewhat enlarged and tender to pressure, and on or about the third day jaundice appears; but it should not be overlooked that jaundice, as Bamberger¹³⁸ has shown, may be postponed to the second or third week after the phosphorus has been taken.

¹³⁷ Virchow's Archiv für path. Anat., etc., Band xxi. p. 514 et seq.

¹³⁸ Legg, On the Bile, Jaundice, and Bilious Diseases, loc. cit.

In favorable cases the area of hepatic dulness decreases and the jaundice declines. In the fatal cases certain nervous phenomena become prominent. There occur drowsiness, developing into coma, with intercurrent attacks of delirium which may be of a maniacal character; convulsions, spasmodic attacks, dilated pupils, and involuntary evacuations. The disorganization of the blood and the fatty change in the vessels are exhibited in the hemorrhages from the gastro-intestinal mucous membrane. The nervous phenomena are due chiefly to the retention in the blood of various excrementitious matters which it is the function of the liver to separate from the blood. Flint's theory of cholesteræmia has been so abundantly disproved that no one upholds it at the present time, but the cerebral symptoms are properly referred to the retention of all hepatic excrement.

The temperature in phosphorus-poisoning rises from 99° to 102° F., but it may reach in severe cases to 103° to 105° F., and at death or immediately afterward to 105°, even to 107° F. The same fact is true of acute yellow atrophy. With the jaundice the pulse declines, but in the further progress of the case, especially toward the close, the pulse becomes rapid and small.

The changes occurring in the urine are highly significant. The amount of urea decreases as the symptoms increase in severity, and leucin and tyrosin take its place. If the case tends to recovery the urea again increases in amount, but if the tendency is in the opposite direction the quantity of urea steadily diminishes. Bile acids and bile-pigment are found in quantity, and albumen is present in small amount.

COURSE, DURATION, AND TERMINATION.—Phosphorus-poisoning is necessarily an acute affection, but the duration of cases is much influenced by the form in which the poison is taken. If in a liquid and diffusible form, as oleum phosphoratum, the local and systemic symptoms will develop in a few hours, but if in solid masses, as particles of match-heads, many hours (six to ten) may elapse before the local irritation begins. The proportion of cures in phosphorus-poisoning varies from one-fourth to one-half of the cases. Much depends, however, on the promptness and efficiency of the treatment. The prognosis is the more favorable the earlier proper measures of relief have been instituted. If the case has proceeded to jaundice, hemorrhages, black vomit, etc. without the administration of suitable antidotes, little can be expected from any kind of treatment.

DIAGNOSIS.—The history of any case involved in doubt is indispensable to a correct conclusion. The phosphorescent appearance of the matters vomited or passed by stool may make the differentiation comparatively easy; but if the case has passed beyond this stage, phosphorus-poisoning can be separated from acute yellow atrophy only by the history of the case. If the fact of the administration of phosphorus is successfully concealed, no differentiation can be made, since even the best authorities hold to the identity of the toxic symptoms produced by this poison and of the morbid anatomy, with the symptoms and lesions of acute yellow atrophy.