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lief. That a previous history of dysentery can often be obtained is
true, and that perhaps preceding intestinal disease is almost always to
be traced in one form is a part of the facts, but that form, I think
we have reason to believe, is the least frequent. It is only my inten-
tion to speak of abscess of the liver as I have seen it and interpreted
it in the five cases under observation in the last fifteen months. Four
of these cases were verified by the aspirator ; three were subjected to
operation ; one passed into other hands, and the fifth case, which re-
jected surgery, ruptured into the bowel, and death took place from ex-
haustion. Two of these cases pursued distinctly an acute course,
and were in my judgment due to a direct infection ; one through the
common duct and one through the lymphatic and portal circulation.

As we understand acute infection, we know that aside from pyemic
metastasis and acute virulent sepsis we do not have frequei^ or indeed
probable lodgment of suppurating germs which may be circulating in

*Read before the Louisville Medlco-Chirurgical Society, May 5, 1899. For discussion see p. 471.

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the blood of a healthy individual. Consequently when such infections
present, we look for the direct route. A moment's reflection shows the
liver to be particularly liable. Direct communication is offered through
the duct, not only for germs ascending from dysenteric ulcers (a rare
condition) but also from many times more frequent diseases of the gall-
bladder, the gall-duct itself, the stomach, and indirectly by lymphatic
and circulatory connection, from peri-nephritic inflammations, to say
nothing of direct kidney disease, inflammatory lesions in the thoracic
viscera, septic lesions of the appendix, local peritonitis, and disease of
the uterine appendages, etc.

It is the common explanation that septic and phlegmonous diseases
of the gall-bladder originate from these sources, and there is no need
to have a dysentery and the amebo germ of the colon to account for a
fulminating cholecystitis. What, then, is the conclusion ? Clearly that
abscess of the liver is much more frequent than formerly supposed, and
that it originates oftener from acute septic sources than long-standing
and infrequent disease of the colon.

It is not intimated that these sources of infection are not known
and accepted by all pathologists, but that their application too fre-
quently escapes consideration, and the results are upon us without
preparation. Why else is hepatic abscess overlooked so often ? The
diagnosis, if it be suspected, is not more difficult than that of pyosal-
pinx or extra-uterine pregnancy. Perhaps in the earlier stages of
chronic abscess attention is not so directly drawn to the site of the
lesion, but in ample time in the majority of cases reported signs were
present which should have been correctly interpreted.

The symptoms of hepatic abscess are well described by Johnston*
and Fontan.f Pain is a constant symptom of abscess of the liver, at-
tended with tenderness on pressure, and often by its location indicat-
ing the site of pus. Respiratory movement and exertion of any kind
increase the pain, and if there be any peri-hepatitis the sensation may
be a very sharp one. Bad digestion, poor appetite, coated tongue, fetid
breath, sluggish temperament, nausea, vomiting — which is often bile
staiued — with intestinal disturbances dependent upon the course of the
disease, are always characteristic. Jaundice is not a symptom unless
the duct be compressed, but the skin is sallow, as is usual in septic
patients. The temperature is irregular, though in all cases some
elevation is^ present at some time in the twenty-four hours, ranging
from 99.5° to usually as much as 102°. Some days it may be found

♦ Annals Surgery, October, 1897. t British Medical Journal, April 33, 1898.

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subnormal and others perhaps 103° at the same hour the next day.
Johnston regards subnormal temperature, if persistent or frequently re-
peated, as an important indication of hepatic abscess. Chills and sweats,
as in other septic conditions, are a constant part of the history after the
case has developed. The progress of the case may extend over a period
of two or three months, as is more common in the tropical and dysenteric
variety, or it may rapidly succeed an infection and develop in a couple
of weeks. Sooner or later, however, there appears what Johnston
declares as the most invariable symptom of hepatic abscess — enlarge-
ment. In all but one of the seventeen cases he reports a tumor is
mentioned, and in that exception no statement is made concerning it.
The enlargement is either outward, pushing out the ribs and often
obliterating the intercostal spaces, or downward below their border.
Usually it is most palpable. Fluctuation was easily made out in two
of my cases. It is mentioned as a symptom in one fourth of those
seen by Johnston. It is probably not an early symptom, and in
abscesses deeply seated can not appear until a very grave constitutional
condition has resulted from the long suppuration. The use of the
aspirating needle is not approved by some surgeons, and while perhaps
it is a little risky in trans-pleural puncture, even here a small needle
and prompt operation if indicated can rarely, if ever, do damage.
Ochsner condemns it because he has found it fail to reveal pus when it
was really present, and thus masked the diagnosis. If the needle finds
the collection, however, a good aspirator should not fail to bring signs
of it to the surface, and if it can not find it, the risk of operation must be
almost too great to justify. It has given most satisfactory returns in my
hands, and in Johnston's cases seems to have succeeded well. It should,
of course, be introduced at the point most indicated, which may be
either below the rib or at about the eighth interspace, through both
pleura and diaphragm.

The opinion generally entertained that the abscess should be
allowed to become prominent before it is attacked is, I think, most
unwise ; not alone that such a course allows more septic intoxication
and longer suflFering, but it renders multiple abscess more likely, and
auto-infection from such a source may be constantly repeated. The
exploration and operation should be made as early as diagnosis is
suspected and confirmed.

With the so-called subphrenic abscess, which is located in the
spaces about the stomach on either side below the diaphragm, I have

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had no experience. The causes and the symptoms are described by
Waring* as much like those of acute septic abscess in the liver sub-
stance, except that, of course, the tumor may in some cases present on
the splenic sides. The diagnosis by the aspiration and evacuation in
the most favorable direction oflfer a more favorable prognosis than
hepatic abcess.

We approach the subject of hepatic abscess, then, with an appreci-
tion of a chronic, slowly growing form, and of a more acute septic
infection with localization in the liver. We base the diagnosis upon a
consideration that in the chronic form we have the history of tender-
ness, more or less constant pain, impaired appetite, coated tongue,
burdened oflFensive breath, dull expression, irregular temperature,
usually not very high and at times subnormal, with an occasional
chilly sensation and sweats. These symptoms persist, with many
variations, somewhat resembling an irregular course of typhoid fever,
with moderate severity usually, for from two or three weeks to perhaps
as many months before the prominence of the accumulation is dis-
tinctly made out. It is this form of abscess which we have been
accustomed to consider as due to tropical climatic influences and
diseases of the bowel ; and for the reason of its slow growth the diag-
nosis has not been made usually until such exhaustion existed as to
render operative treatment practically of little service. In the acute
form the tenderness and pain follow an attack resembling typhoid fever,
more severe than the above, with frequently a history of diarrhea,
gastric disturbances, and an irregular temperature, ranging oftentimes
as high as 105^. The tongue is usually red and frequently clean. A
little later chills and hectic, and the more pronounced irregularity in
the temperature, with the other indications of an acute septic disease,
pursuing a much more rapid and severe course. Here, too, a tumor
usually forms in from four to five weeks at the latest, frequently earlier,
and in one case under my observation succeeded apparent perfect
health in two weeks. Fluctuation is more common in the acute abscess.
The confirmation of the suspicion by the use of the aspirator should be
early employed and the treatment promptly instituted.

The details of the surgery will not be taken up at this time, but the
outline of the operative steps may be briefly indicated. If the explora-
tion is to be made through the peritoneum, of course controlled by the
situation of prominence of the tumor, the incision dpwn to the liver is
stopped at the surface of that organ until the existence of firm adhesions

♦Brit. Med. Journal, March 12, 1898,

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The American Practitioner and News. 457

is made out. If there are no adhesions the operator may wall oflF the
cavity and then follow the aspirating needle with a bistoury into the
abscess cavity, wash out and drain. Better, I think, and the plan I
have twice followed, is to pack the wound when the liver is reached,
and wait thirty-six hours until firm adhesions have formed. Then
incise and perhaps curette and drain in safety. If adhesions are found
at the first incision, of course no delay is necessary. The hemorrhage
after division of the liver walls, if the cavity is deep, may be trouble-
some, but it yields to sutures or packing. If the abscess is single,
success will follow a large percentage of chronic abscesses so treated.
In the acute septic form the prognosis is less hopeful. Perhaps 60 per
cent of abscesses are more accessible through the diaphragm. These are
reached after the use of the aspirating needle by excising a part of the
eighth or ninth rib, and if the pleura can not be peeled oflF the ribs and
diaphragm, carefully incising it and sewing the costal to the diaphrag-
matic portion, thus shutting the pleura oflF from certain infection,
then incising the liver through the diaphragm, and, if possible,
stitching the liver wound to the diaphragmatic opening ; after this,
irrigation and drainage constitute the treatment. In multiple abscess
a recurrence of the symptoms will indicate pockets which have not
been reached. Such cases will usually resist any form of surgery, but
of course, if the accumulation can be found, the same rational surgical
treatment is indicated.

The prognosis in single abscess of the liver, in which severe sepsis
is not present, and where treatment is promptly instituted and care-
fully carried out, is believed to indicate recovery in at least 75 per cent.

I will report the following cases :

Case i. Mrs. S., aged thirty-five years, was attacked with what
seemed to be an acute dysentery, but which ran a chronic course. It
must have been five or six weeks before from the continued fever, pain
in the liver, and general evidences of pronounced constitutional dis-
turbance, sweats, and emaciation led to the appreciation of a tumor in
the right hypochondrium. Exploration was not made in this case,
because the patient declined all surgery, but five days after it was
suggested there was a profuse discharge of pus by the bowel, and in
about two weeks the patient died of exhaustion.

Case 2. Miss K., aged thirty-one, presented many of the indications
of chronic tuberculosis, except that the physical signs were not pro-
nounced. She had a cough, emaciation, slight elevation of temperature,

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but continued as an oflSce patient for some two months before a tumor
was discovered. As soon as possible after its discovery she was
removed to the infirmary ; a portion of the eighth rib was excised and
the pleura stitched as described, so as to shut oflF the lung from infec-
tion, and the abscess incised through the diaphragm. The knife was
made to follow an aspirating needle pushed into the tumor. A large
amount of chocolate-colored pus was evacuated and the abscess washed
out. Though the temperature remained down after the operation, the
profound sepsis from which she suflFered was never overcome, and she
died exhausted on the eleventh day. Drainage was kept up through-
out the case.

Case 3. Mr. F., aged thirty-seven, was treated for what was sup-
posed to be typhoid fever of moderate severity. In the fifth week his
physician detected a tumor in the region of the liver, his attention
being called to it by the continued pain which the patient suffered in
this region. This man had a red tongue, a temperature varying in
height from subnormal to 104°. His intelligence was perfect, never
had any delirium, and his appetite was fair. The tumor presented
most prominently below the ribs. Incision was made upon an aspirat-
ing needle, the wound packed, and adhesions waited for ; on the third
day the wound was opened and the abscess drained and irrigated. The
patient did well for ten days or more, when his symptoms again became
those of sepsis. Various attempts were made to find new pockets, but
the drainage seemed always imperfect. He died five weeks after the
operation from exhaustion and sepsis. A post-mortem examination
disclosed multiple abscess in both lobes of the liver.

Case 4. Man, aged forty years, presented the symptoms of appen-
dicitis, with pain and tenderness. I saw him after he had been sick
three weeks; there was an appreciable tumor, and aspiration disclosed
pus. After a suggestion of an operation he passed into other hands and
was subjected to an operation a little later, and died in a week or so
from exhaustion.

Case 5. Boy, aged nine years, whom I saw on the sixth day of what
was supposed to be an attack of appendicitis. There was a pronounced
tumor in the right iliac fossa and tenderness at McBurney's point. His
pulse was 120, and temperature 102°. This boy was sent to the infirm-
ary and kept under observation ; his symptoms improving, operation
was deferred in order that the adhesions might become more firm. He
improved so much that he was able to sit up at the end of the week>

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though his temperature was never below 99° and usually icx>° by
evening, but about this time began to complain of pain in the region of
the liver, and on the eighteenth day from his original attack were
found evidences of a tumor with fluctuation. The aspirating needle
disclosed pus, and an incision was made down upon the liver. During
that night he coughed up two or three ounces of pus resembling that
taken up by aspiration. Next day nearly a quart of pus was evacuated^
a drainage-tube was introduced, and within three weeks the boy was
practically well. He continued to occasionally spit up some pus on
coughing, and to relieve this, incision and drainage by pleura was
made. The causation of this abscess was undoubtedly secondary to the
appendicitis, and as this boy was in apparently perfect health three
weeks before the formation of the abscess, there is little likelihood that
there was any focus in his liver before the acute attack ; and there was
distinctly no source of the infection aside from the appendicitis.

Case No. i was doubtless an infection of the liver, secondary to
disease of the small intestine or perhaps of the colon.

Case No. 2, the source of infection is not so easily made out. There
was no diarrhea and no history of dysenteric trouble previous to this
time. Just what the origin of this abscess was I am not able to say \
doubtless an infection by bowel.

Case No. 3 was undoubtedly a direct infection, most likely from the
typhoid fever.

Cases Nos. 4 and 5 are apparently traceable to appendicitis. It is
my belief that abscess of the liver, if looked for, will be found more
frequent than we have hitherto believed, and also that it will be often
discovered as a complication of acute and chronic septic infections of
the adjacent viscera.



Professor of Surgery, Louisville Medical College.

Practically speaking, peritonitis is as old as the healing art, but old
as the subject is, there yet remains much to be understood about peri-
tonitis and the peritoneum. In the settlement of all unsettled subjects,
and certainly peritonitis is entitled to a membership in this class, it is
well to pause from time to time in order to thoroughly digest the addi-
tions that have been made; to compare the old with the new, to

* Read before the Kentucky State Medical Society at I^ouisville, May i8, 1899.

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emphasize the important over the unimportant, and, in short, to have
a ** round up," so to speak, from which another advance can be made.
This is the object of the present paper, and for this reason it is a some-
what disconnected presentation of facts bearing upon peritonitis rather
than systematic essay upon the subject. The classification of peritonitis
may be based upon its causation or its pathology. Considering its
causation, it has been divided into primary, secondary, and specific.
Viewing it from the standpoint of its pathology, the classification of
Pawlowsky is perhaps the most accurate, namely :

1. An extremely toxic variety, in which the virulence of the
infecting organism is so g^eat that the patient is at once overwhelmed
and dies within forty-eight hours with all the signs of shock. In these
cases the peritoneum is covered with a slimy fluid containing a few
blood-corpuscles, fibrin flakes, and many bacteria.

2. Hemorrhagic peritonitis, in which the virulence of the infection is
also very great. Varying grades of hemorrhagic extravasations, with
a greater or lesser mixture of pus and masses of bacteria, are found.

3. Fibrino-purulent peritonitis, due to a less intense or slower infec-
tion, characterized by masses of fibrino-purulent matter, consisting
principally of pus-corpuscles and bacteria contained in the fibrin

4. Purulent peritonitis, consisting of much pus and fluid matter.
The possibility of a primary or an acute idiopathic peritonitis, either

with or without the presence of pus, is extremely interesting. Accord-
ing to most authorities, the purulent form at least never occurs. Even
where pus is not present the existence of peritonitis is held by the
majority as an evidence of some other trouble within the peritoneal
cavity, and upon which the occurrence of the peritonitis is dependent.
If we consider, however, that in the early stages of the embryo the
thorax and abdomen are represented by one common cavity know as the
pleuro-peritoneal cavity, and only by the advent of the diaphragm are
these cavities separated, we can readily see how difficult it is to recon-
cile ourselves to the impossibility of an idiopathic peritonitis when the
pleura, which is only a part of the original peritoneum, which has
been separated by the diaphragm, is so commonly subjected to
inflammation with or without the occurrence of pus. Some might
contend that the arrangement above the diaphragm is responsible for
the very common idiopathic attacks of pleuritis as compared with the
questionable idiopathic peritonitis below the diaphragm, namely: The

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influence of the proximity of the lungs from within the thorax and the
exposure to changes from without. But this is oflfset by the proximity
of the peritoneum to the alimentary tract filled with a variety of
organisms and the seat of constant chemical action, together with the
same external influences that hold good above the diaphragm. Since
the causes ascribed to idiopathic peritonitis, namely, exposure to cold
and rheumatism, are quite unsatisfactory and apply with the same force
above as below the diaphragm, it leaves the question in any thing but a
settled condition.

The secondary variety always follows some primary lesion, usually
a perforation of some of the hollow viscera.

By the specific variety it is usually understood as meaning tuber-
cular peritonitis. From the masterly contribution upon intra-peritoneal
drainage by Dr. J. G. Clark, of Baltimore, I have taken the following
abstract :

"According to Wegner, the peritoneal surface measuring 17,182
square centimeters is practically equal to the skin surface, which measures
17,502 square centimeters. Its absorbing capacity enables it to take up
three to eight per cent of the entire body weight within an hour.
Under the influence of toxic or irritant substances an equal transuda-
tion into the peritoneal cavity may take place.

As the final results of a series of experiments, Muscatello concludes
that the diaphragmatic part of the peritoneum is the only place where
the lymph from the peritoneal cavity is absorbed, and the lymph-
glands of the mediastinum are the collecting organs for this area.

Recklinghausen investigated the mechanism of the absorption of
fluids in the peritoneal cavity of rabbits, and afiSrms that the fluid is
taken up through the stomata between the endothelium of the dia-
phragmatic peritoneum.

To summarize, the points in the anatomy and function of the peri-
toneum which bear upon the subject of intra-peritoneal drainage and
the etiology of peritonitis are as follows :

1. Fluids and solids may pass through the endothelial layer of the
peritoneum, the fluids in many places, the solid particles only through
the spaces in the diaphragm.

2. Minute solid particles are carried from the peritoneal cavity
through the diaphragm into the mediastinal lymph-vessels and glands,
and thence into the blood circulation, by which they are distributed to
the abdominal organs, to appear later in the collecting lymph-glands of
these organs.

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462 The American Practitioner and News.

3. Large quantities of fluids may be absorbed by the peritoneum in
an astonishingly short time.

4. The leucocytes are largely the bearers of foreign bodies from the
peritoneal cavity, which carries fluids and foreign particles toward the
diaphragm, regardless of the posture of the animal, although gravity
can greatly favor or retard the current.

Grawitz took up the experimental study of infection of peritoneum,
pursuing his work under improved bacteriological technique. The
results of his investigations, which appear to have been very thorough,
were as follows:

1. The introduction of non-pyogenic organisms into the abdominal
•cavity, either in small or large quantity, or mixed with formed particles,
produce no harm.

2. Great quantities of organisms, which ordinarily produce no dis-
turbance, may give rise to a general sepsis if the absorptive ability of
the peritoneum is impaired.

3. The injection into the peritoneal cavity of pyogenic organisms
may be quite as harmless as the non-pathogenic varieties. In these
-experiments he employed a flocculent emulsion of staphylococcus
albus, staphylococcus aureus, and streptococcus pyogenes in ten cubic
centimeters of water without any visible reaction.

4. The introduction of pus-producing cocci into the normal peri-
toneal cavity produces a purulent peritonitis (a) if the culture fluid is
difiScult of absorption ; {b) if irritating material is present which
destroys the tissues of the peritoneum, and thus prepares a place for
the lodgment of the organisms ; (c) a pilrulent peritonitis will cer-
tainly be produced if a wound of the abdominal wall is present, which
forms a nidus for the infectious process.

The experiments of Cobbett and Melsome make more prominent
the fact brought out by previous observers, that even after the injec-
tion of virulent streptococci little or no peritonitis may be produced if
the peritoneum is normal.

From the collective literature the following conclusions may be
drawn :

1. Under normal conditions the peritoneum can dispose of pyogenic
organisms in varying quantities, depending upon the virulence of the
organism, without producing peritonitis.

2. The less the absorption from the peritoneal cavity the greater the

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