CASE OF 
MULTIPLE ABSCESS OE THE LIVER. 
BY 
SAMUEL W. DANA, M.D., 
LATE SURGEON TO THE NEW YORK DISPENSARY. 
[REPRINTED FROM THE TRANSACTIONS OF THE NEW YORK ACADEMY 
OF MEDICINE FOR JULY, 1875.] 
UNA FIDES ALTARE COMMUNE. 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1876. CASK OF 
MULTIPLE ABSCESS OE THE LIVER, 
BY 
SAMUEL W. DANA, M.D., 
DATE SURGEON TO THE NEW YORK DISPENSARY. 
[REPRINTED FROM THE TRANSACTIONS OF THE HEW YORK ACADEMY 
OF MEDICINE FOR JULY.\ 1875.] 
ON A PIDES ALT ABE COMMUNE. 
NEW YORK: 
D. APPLETON AND COMPANY, 
649 & 661 BROADWAY. 
1876. CASE OF MULTIPLE ABSCESS OF THE LIVER. 
By SAMUEL W. DANA, M. D., 
LATE SURGEON TO THE NEW YORK DISPENSARY. 
Read July 1, 1875. 
The case of “ Multiple Abscess of the Liver,” which I 
have the honor briefly to report this evening, was seen during 
some part of its course by several Fellows of this Academy, and 
is believed to possess some points of rarity and interest. 
The patient—a widow lady, fifty-two years of age, en- 
gaged during the previous ten years in active business pur- 
suits, and during this period enjoying good general health— 
was attacked on the 3d of June, 1873, after unusual indulgence 
in eating, with severe epigastric pain and persistent vomiting. 
These symptoms, partially relieved during abstinence, were 
excited anew by every attempt to introduce even the blandest 
form of nourishment into the stomach. 
After a few days, pain in the right hypochondrium extend- 
ing around to the back began to be complained of, and a slight 
bilious tinge appeared upon the skin. The bowels were con- 
stipated unless acted on by medicine or injections. 
On June 22d the patient was seen by my friend Dr. 
Purple. She had then been eighteen days sick. Her condi- 
tion was one of great exhaustion. There was also decided 
emaciation. From this point, however, she began slowly to 
improve, and by the middle of July was sufficiently recovered 
to leave for the country. Her convalescence was apparently 
perfect. Subsequently, for more than a year, she was in the 
enjoyment of excellent health. 
On the 14th of September last (1874), nine months and 4 
three days before her death, the patient complained of pain 
in the head and hack, with a feeling of general malaise • said 
she had spent some time in the park the previous evening, and 
thought she had taken cold. The following day she felt as 
well as usual. On the 16th she suffered an attack similar to 
that of the 14th. In reply to inquiries, she said that she had 
never suffered from fever and ague; hut in July of the pre- 
vious year she had spent two w'eeks in Greenwich, Conn., a 
malarial district. 
On the 18th she had a chill, followed by fever and sweating. 
Quinine was then given, and the chills interrupted for the 
time. 
On the 17th of October, after partaking of a hearty dinner, 
the patient was attacked with severe epigastric pain and 
vomiting. During the next ten days the attack much resem- 
bled that of June of the previous year, being characterized 
by occasional severe epigastric pain, vomiting, inability to 
take food, rapid emaciation, and loss of strength. There were 
also some pain and tenderness in the right hypochondrium, and 
paroxysms of chills and fever, though nearly controlled by 
quinine, showed a tendency to recur every second day. 
Dr. Purple sawr the patient on the 28th of October, and 
occasionally afterward during the next three weeks. At the 
above date a slight yellow tint had appeared on the skin, 
which in the following days rapidly deepened to that of in- 
tense jaundice. Bile disappeared from the faeces, while the 
secretion of the kidneys, which was scanty, resembled, both in 
color and consistence, bile rather than normal urine. 
With the development of jaundice the pain and tenderness 
in the right hypochondrium increased, and a chill came every 
forenoon with an exacerbation of fever in the evening; the 
temperature, as indicated by the thermometer in the axilla, 
ranging from 101 in the morning to in the evening. 
At this period slight fullness in the region of the right hypo- 
chondrium was noticed. The free margin of the liver extended 
about two inches below the cartilages of the ribs, and yielded 
on palpation a feeling of increased resistance. 5 
At this time the case was regarded as one of malarial fever 
which had passed from the intermittent to the remittent type. 
The jaundice remained quite intense for about a week, then 
gradually declined. The pain and tenderness in the region of 
the liver diminished, and the fever abated; the temperature 
during the fourth week varied from 100° to 101° at the 
evening exacerbation. It was during the decline of the jaun- 
dice that a new symptom appeared which came into some- 
what prominent notice during the subsequent course of this 
case, namely chills, often slight, sometimes quite severe, oc- 
curring with irregular intervals, usually one or two, sometimes 
three or four, in the course of twenty-four hours. 
During the third w'eek of November—the fifth week of 
the attack—the condition of the patient was far from prom- 
ising. Chills were of frequent occurrence. Coldness of the 
extremities made necessary the application of artificial heat 
during a considerable part of each twenty-four hours, while a 
slight evening exacerbation of fever was followed by copious 
sweating during the earlier part of the night. There were 
great emaciation and weakness, and marked sallowness of 
complexion. The lips showed great pallor. The pulse was 
quite feeble and rapid; the tongue pale and dry ; a frequent, 
short, dry cough began to harass the patient, her feet and legs 
became oedematous, while the facial expression assumed such a 
character as to add to the solicitude which the symptoms just 
mentioned had aroused. This condition of extreme prostra- 
tion seemed partly due to the patient’s inability to take and 
appropriate nourishment. The stomach had been quite irri- 
table from the first; milk, eggs, and alcoholic stimulants, it 
rejected utterly. Beef-tea was the only nourishment taken 
during the first four weeks, and that in amount quite inade- 
quate. But even that the stomach now rejected unless the 
solid particles constituting its sediment were first strained out, 
leaving it nearly worthless. Yarious extracts of beef made 
into tea were next tried, and though tolerated by the stomach 
were found in point of nutrition quite insufficient. Beef-tea 
prepared after Liebig’s method was tried with better success. 6 
The stomach bore it well and in sufficient quantity. Its em- 
ployment at this time seems to have been the means of rescu- 
ing the patient. The improvement, however, was quite slow. 
Frequent chills still harassed the patient, and seemed to neu- 
tralize every tendency toward convalescence. By the middle 
of December, however, substantial improvement had been 
made. The chills had diminished in force and frequency. 
The patient had gained in strength. During the last two 
weeks of December the chills entirely disappeared, and the 
patient was able gradually to resume her ordinary diet of 
solid food. From December 22d to January 18th the patient 
had no marked chill, though she noticed an occasional cold- 
ness of the extremities, which caused her to keep near the fire 
for an hour or two at a time. During this period, however, her 
convalescence was quite rapid. She was free from pain, ate 
heartily, and slept well, gained in flesh and strength, re- 
sumed her usual avocations, and received the congratulations 
of her friends on her supposed recovery. 
On January 18th a chill occurred. Quinine, of which 
five grains a day had been given since January 1st, was now 
increased to ten grains, and, although a tendency to the recur- 
rence of chills occasionally manifested itself, yet during the 
next four weeks, to the middle of February, the patient en- 
joyed very fair health. On February 16th, after an indiscre- 
tion in eating, she had an attack of indigestion, which kept her 
in bed three days. From this point during the following four 
months, to the time of her death, with some brief periods of 
improvement, there was on the whole a gradual and steady 
decline. About this time the irritative chills again made 
their appearance, though slight and of infrequent occurrence. 
Near the 1st of March, in connection with an attack of in- 
digestion, the patient complained of pain in the right liypo- 
chondrium, for which a blister was applied. The pain was of 
short duration, and this was the only occasion on which she 
had complained of pain since the previous November. During 
the month of April there was more frequent recurrence of the 
chills, with progressive loss of strength and digestive power. She found it necessary again to relinquish solid food and 
return to beef-tea, which she now took with reluctance, and in 
quantities insufficient to sustain life for a prolonged period. 
About the middle of May, increasing weakness compelled her 
to take to her bed, from which she scarcely rose during the 
last four weeks of her life. Increased tenderness over the liver 
was noticed some days prior to the 1st of June. The abdomi- 
nal muscles also at times were remarkably rigid. In the first 
week of June a tumor was detected on the upper surface of 
the liver, just beneath the cartilages of the ribs, which did not, 
however, yield a sense of fluctuation. With the exception of 
the local symptoms just referred to, no new symptom ap- 
peared during the last few weeks of life. Progressive emacia- 
tion and increasing feebleness seemed alone to mark the 
progress of the case. But little food was taken during the last 
two weeks ; none during the last forty-eight hours. The 
patient’s intellect remained clear until a few hours before 
her death, which occurred on the morning of the 17th of 
June, seven months and a half from the occurrence of the 
jaundice, seven months from the occurrence of the irregular 
or irritative chills, and four months from the time of their 
recurrence in February. 
The post-mortem examination was made fifteen hours after 
death—present, Drs. Purple, Clark, Prescott, Campbell, and 
Dana. On turning aside the abdominal coverings, the lower 
margin of the liver was seen projecting about two inches 
below the cartilages of the ribs, and normal in appearance. 
On attempting to bring the entire organ into view, it was 
found adherent by its superior surface to the abdominal wall 
in front, the adhesion being about one square inch in extent. 
While this was being broken up, although the manipulation 
was quite gentle, pus spurted from a point oh the inferior sur- 
face. When the entire organ was brought into view, that 
portion of the superior surface which in situ was covered by 
the ribs, presented a striking appearance, eliciting the re- 
mark, from one of the gentlemen present, that it was clearly 
a case of cancer. Scattered thickly over this portion of the 8 
surface were slight elevations circular in outline, and from one- 
fourth of an inch to an inch in diameter. Several of these 
elevations, aggregated more closely together, constituted the 
tumor that had been diagnosticated before the patient’s death. 
It was of an irregularly oval outline, about two by two and a 
half inches in diameter, and with an average elevation of six 
or eight lines above the general surface of the liver. The 
scalpel quickly revealed the fact that the elevations referred to 
were abscesses, and further investigation showed that the 
right lobe of the liver was filled with abscesses thickly dis- 
seminated through its entire extent, varying in size from that 
of a pea to that of a lien’s-egg. The pus contained in them 
was light colored, and rather thin and fetid. The left lobe of 
the liver and spleen were normal. The right lobe of the liver 
was about two-thirds of its normal size. 
The post mortem having definitely shown the case, at least 
at its conclusion, to have been one of multiple abscess of the 
liver, dependent on portal infection, or portal phlebitis, three 
questions of interest present themselves : 1. What was the 
source of such infection ? 2. At what period did it occur ? 
3. What was the nature of the chills which formed so promi- 
nent and so persistent a feature in this case ? 
Leaving to others the general diseussion of these questions, 
I shall conclude the report of this case by mentioning a few 
facts observed during the course of the disease, which may tend 
in some degree to their elucidation. In regard to the first ques- 
tion, that of the source of the portal infection, unfortunately, 
facts bearing on this point are meagre. The circumstance that 
the abscesses were limited to the right lobe of the liver, and 
thickly disseminated through it, would seem to indicate that 
the infection did not enter the general portal current, but only 
that portion of it distributed to the right lobe ; and that, there- 
fore, its source was in the liver itself, and not in any other of 
the abdominal viscera. And this view seems in harmony 
with the history of the case, no symptom at any time having 
pointed to suppurative or ulcerative action in any other of 
the abdominal organs, while early in the case the symptoms suggested the probability of suppurative action within the 
liver. 
2. At what period did portal infection occur ? The history 
of the case seems to leave this point in some obscurity. In 
November there were symptoms of suppurative action in the 
liver, pain, tenderness, hardness of the liver, jaundice, frequent 
chills, elevated temperature, night-sweats, great prostration, 
etc. Then followed a period of absence of chills, and of partial 
convalescence; then a period of gradual decline, lasting four 
months. If portal infection occurred at any period subse- 
quent to November, it took place very quietly without pro- 
ducing marked impression on the general system, or giving 
rise to any local symptom as far as is known. As bearing on 
the question of an early origin of the portal infection, there 
is to be noticed the very slow rate of progress of the case 
during the last four months, as indicated by the general symp- 
toms. It had in general the aspect of a case of chronic rather 
than acute disease. During the last three weeks when we 
knew that abscesses of the liver were present, the rate of de- 
cline was as slow as during the previous four months. 
3. What was the nature of the chills ? Were they mala- 
rial, or symptomatic of suppurative action, or in part both ? 
The chills commenced September 14th, five weeks before 
there was any suspicion of local disease. They showed a ten- 
dency to recur every second day throughout the entire course 
of the disease, excepting a short period in November, when 
they came every day. The irregular chills began during the 
decline of the jaundice in the second week of November, and 
continued with greater or less frequency till about the 1st of 
January, when they entirely disappeared. They reappeared 
about the middle of February, and continued except when con- 
trolled, by treatment, to the close. The effect of quinine in 
controlling the chills was remarkable. This came especially 
to notice during the last three months. The patient having 
come to hate the drug and the disease with an almost equal 
hatred, on several occasions she suspended the use of the 
quinine for a few days. The effect in every instance was the 10 
same. The chills, which, while the quinine was being used, 
merely marked their time by a short period of discomfort, 
would, on the suspension of the medicine, come back with de- 
cided severity. A marked instance of this occurred during the 
patient’s illness. On June 1st the patient had concluded to take 
no more quinine. On the evening of that day—it being the 
regular period—she had a slight chill. On the evening of June 
3d she had a severe chill which lasted till midnight. Before 
reaction had fairly set in a second chill occurred, more severe 
than the first. The following morning she was found pulse- 
less, with icy coldness of the extremities, but in fair possession 
of her mental faculties. Death seemed imminent. She was 
now willing to resume the quinine. It was administered to 
her liberally, and reaction gradually set in. After this occur- 
rence the patient lived two weeks, and taking her quinine 
regularly, there was no recurrence of the chill.