Hepatic Abscess; 
WITH SOME 
REMARKS ON DR. HAMMOND S PAPER. 
BY 
WALTER COLES, M. D., 
OF ST. LOUIS, MO. 
{Reprinted from the St. Louis Medical and Surgical Journal, October. 1878.] 
SAINT LOUIS. 
GKO. O. RUM BOLD & CO., PRINTERS AND PUBLISHERS. 
1 8 78. Hepatic Abscess; 
WITH SOME 
V 
REMARKS ON DR. HAMMOND S PAPER. 
BY 
W A L TER C O L E S, M. D., 
OF ST. LOUIS, MO. 
[Reprinted from the St. Louis Medical and Surgical Journal, October. 787S.i 
SA I N T LOUIS. 
GKO. O. HUM BOLD & CO., I'KINTKKS AM) I'UBLISHKK*. 
1 87 8. HEPATIC ABSCESS, WITH SOME REMARKS ON 
DR. HAMMOND’S PAPER. 
From time immemorial the liver has been invested with pe- 
culiar interest in the minds both of the laity and of practition- 
ers of medicine, and has been in one way or another associated 
with nearly all the ills that flesh is heir to. The rapid strides, 
however, which of late years have marked the study of its 
physiological and pathological relations, has led the medical pro- 
fession to view this organ in a new, yet no less important light 
than that in which our forefathers were wont to regard it. Not- 
withstanding advances in the scientific world, many crude no- 
tions and superstitions of the olden time still cling to the peo- 
ple generally, and as a consequence we hear every day of the 
various “liver complaints” with which a large mass of humanity 
is afflicted. Indeed, so prone are persons to charge the liver 
with every vague and undefined illness, that a clever English 
writer has observed that “ it is one of the most curious things in 
human pathology, it not in human nature, that a certain consid- 
erable number of people seem rather pleased than otherwise 
when told that their liver is affected.” And he might have 
added, that, for these reasons, there is scarcely an organ in tlie 
body upon which the empiric and the charlatan has thriven and 2 
IIevatic Abscess. 
fattened to such repletion as upon this same much abused viscus. 
This is a fact well known to medical men, and yet we see no 
means of remedying this wide spread delusion, other than by the 
cultivation of more exact knowledge upon the part of physi- 
cians, and, as a natural consequence, in time, the inculcation of 
sounder views amongst their patients. 
Perhaps in no department of pathology and therapeutics has 
more satisfactory progress been made, in modern medicine, than 
in the matter of hepatic abscess, the general features of which 
have been so thoroughly discussed by the many able writers 
who have devoted their attention to the subject, that they will 
not be formally reproduced here; our object being to confine 
ourselves more particularly to certain practical and important 
points suggested by the recent literature of the disease. 
Fortunately, in this latitude, abscess is so rare that few indi- 
vidual practitioners have opportunities during a life time of wit- 
nessing a sufficient number of cases to gain a very ripe experi 
ence. Some idea of the infrequency of this affection may be 
gleaned from the fact that in response to recent letters inquiring 
as to their experience with the aspirator, several metropolitan 
physicians of extensive private and hospital practice have re- 
plied : “ I have met with no case of abscess of the liver since 
this instrument was introduced,”—some eight or ten years ag<>. 
Stokes, speaking for Great Britain, remarks that “abscess of the 
liver, so common in India, is of rare occurrence in these conn 
tries. A few isolated cases are to be met with in medical 
records, but no series of cases was published as occurring in 
Europe until the appearance of Louis’ researches on the subject. 
(Clyelop. Prao. Med., Vol. iii, p. 160.) Watson says: “ In this 
climate we do not often meet with hepatic abscesses.” (Practice 
of Physic., p. 964.) Dr. S. H. Ward, whose opportunities for 
judging are not surpassed by any physician in London, declares 
idopathic abscess “ almost limited to practitioners in India, and 
to those in this country who are brought into contact with offi- 
cers, seamen, and other individuals, who return invalided from 
tropical climates.” (London Lancet—reprint, Nov., 1868, p. 
658.) Nieme3rer concludes that “it is rare in the temperate 
zones, but more frequent in the tropics, particularly in India, 
although the old accounts of its frequency there are overdrawn.” 
(Practice of Medicine, Vol. i, p. 635.) Dr. Flint asserts that 
“hepatic abscess is extremely rare in cold or temperate climates. Hepatic Abscess. 
3 
It is an affection belonging par excellence to warm climates, 
although not very common in the latter.” (Practice of Medi- 
cine, p. 467.) Such citations as these might be indefinitely ex- 
tended, but are quite sufficient to indicate the universally ac- 
cepted opinions on this subject. Indeed, we know of but one 
exception—that of I)r. Wm. A. Hammond, of New York, whose 
experience has led him to conclude “that hepatic abscesses are 
much more common with us than is generally supposed.” (<St. 
Louis Clinical Record, June, 1878, p. 56.) 
The comparative immunity irom abscess of tbe liver in this 
latitude is interesting, not only as a matter of pathological his- 
tory, but assumes great importance in connection with the ques- 
tion of etiology. There remain certain physiological points 
which are not as yet sufficiently mastered to enable us to inter- 
pret fully the mechanism of heat in the production of hepatitis 
and abscess. That itisan important factor is certain, but perhaps 
its participation lies more in its influence upon the general sur- 
roundings of the patient than by direct action upon bis physical 
organism. It influences the air that he breathes, his food, his 
drinks, his habits, and in short all his relations with nature. 
That an elevated temperature alone, even where it is combined 
with many well-known exciting causes, is not sufficient to pro- 
duce suppurative hepatitis in northern latitudes, is sufficiently 
illustrated in the lives of certain artisans and mechanics of our 
own country and Europe, whose avocations compel them to re- 
main subjected to great heat, with but brief intervals of rest, 
for many successive years; yet there is no evidence that these 
classes are peculiarly liable to the disease. An admirable paper 
on “Abscess of the Liver,” by I)r. J. C. Davis, of New York, 
(iV. Y. Medical Journal, June, 1878,) contains many interesting 
observations bearing on this question. After giving a brief 
“ geographical distribution ” of abscess, he says: “It is much 
less frequent on the Western continent than on the Eastern. It 
is much less frequent in certain of the West India Islands than 
others of the same group, under the same climatical influences; 
as to beat, rainfall, direction of wind, geological formation, etc.” 
Dr. Davis’field of observation was in Zacatecas, Mexico, a city 
of 50,000 inhabitants, situated in an elevated, mountainous re- 
gion, where the mean temperature is 60° Fahr. Here, in ten 
years, be met with thirt}r six cases, and yet he tells us that in 
several of the Mexican States subjected to a much higher tern- 4 
Hepatic Abscess. 
perature, “ abscess of the liver is among the rarest of the rare 
diseases.” These are interesting facts, and in many cases diffi- 
cult of explanation, save by taking into consideration other ex- 
ternal causes. 
Stokes reminds us of the fact that abscess sometimes appears 
to be epidemic. The pyeemic and embolic variety is frequently 
so; indeed, if we accept the apparently well substantiated 
theory which Ribes and Budd founded on the researches of Gas- 
pard, Cruveilhier and others, that hepatic abscess follows in a 
large proportion of cases from dysentery, we have little diffi- 
culty in recognizing the epidemic feature. The fact, however, 
that even the most malignant epidemics of dysentery in milder 
climates are only exceptionally followed by abscess, whilst in 
tropical regions this is quite commonly the case, has led to much 
discussion as to the true relations between these two affections as 
to cause and effect. It cannot be doubted that there is much 
truth on both sides of this question; either disease being capa- 
ble of determining the other, with the essential difference, how- 
ever, that in temperate regions there is the absence of that 
peculiar malignancy born of those general conditions recognized 
as the “ tropical cachexia.” 
The causes of liver abscess, as at present generally conceded, 
may be briefly summed up as follows: 1, Traumatic; 2, 
Hemorrhagic infarction; 3, Inflammation of hydatid cysts; 4, 
Ulceration of gall ducts; 5, Entozoa; 6, Metastatic,—such as 
septicaemia' pyaemia, embolism, and including organic lesions 
of alimentary canal, and other parts; 7, Tuberculosis; 8, Ma- 
laria, and other deteriorating and poisonous agents, acting 
through the blood, such as heat, alcohol, etc. 
We cannot permit the present opportunity to pass without 
some additional remarks, suggested by Dr. Hammond’s paper 
on “ Obscure Abscesses of the Liver, etc.,” which appeared in 
the Juno number of the Clinical Record, and to which refer- 
ence has already been made. In this paper the writer sets out 
with the declaration, “ that abscesses of the liver may exist with- 
out giving rise to any marked local or general symptoms is a 
point with which those who have investigated the subject have 
long been familiar.” Now, the foregoing as a general proposi- 
tion should most undoubtedly be accepted; since it is based on 
facts, well known to all who have studied the clinical history of 
this, sometimes, very obscure affection. And, if I)r. Hammond Hepatic Abscess. 
5 
had stuck to his text, wo should have had nothingto say j but that 
he has not done so, either in his preliminary assumptions, or 
subsequent deductions, we think can be easily shown. Indeed, 
the paper in question, when closely scanned, reminds one of a 
legal brief in which an evident effort has been made to establish 
a certain proposition, regardless of countervailing facts,—filets 
which cannot be suppressed without detriment alike to the im- 
perishable principles of science and the best interests of hu- 
manity. 
In order to establish his declaration that abscess is frequently 
unaccompanied by any “ marked ” general or local symptoms, he 
quotes freely from many authors; among the rest Frerichs, 
whose exhaustive work on diseases of the liver is universally 
accepted as one of the most authoritative extant. Frerichs, he 
says, “asserts that the fundamental lesion is either indicated by no 
symptoms whatever, or by insignificant derangements, which are 
easily overlooked. (The words in italics are taken from Frerichs, 
vol ii. p. 121.) It is scarcely necessary to remark that the author 
thus quoted, commits himself to no such doctrine as this. But 
in order to illustrate the unfairness of I)r. Hammond, when he 
wishes to make a point in his own favor, we give below what 
Frerichs does say, when it will be seen that the Doctor appro- 
priates only the part of a sentence, thus destroying, not only all 
sense, hut entirely changes the meaning of the author, whom he 
unceremoniously attempts to impress into his service. Here is the 
sentence complete (those words being in italics which have been 
omitted). “ In other cases the symptoms of morbid processes consec- 
utive upon the hepatitis, or which precede and give rise to it, are 
the most prominent, whilst the essential fundamental lesion is indica- 
ted either by no symptoms whatever, or by insignificant derange- 
ments, which are easily overlooked.” To indicate further the ex- 
tent to which the views o< Frerichs have been misrepresented, we 
proceed to give the remaining portion of the paragraph, of which 
the foregoing is the opening sentence—we beg that the reader 
will put the two fragments together. It is as follows : “In our 
own climate this is in a marked degree the clinical history of so- 
called pyamiic infection, in the course of which latent hepatic 
abscesses are wont to be developed. In warm countries it is 
mostly dysentery or intermittent fever, and, according to Haspel, 
particularly the tertian form, which masks inflammation of the 
liver. Sometimes morbid processes induced by the hepatitis, 6 
Hepatic Abscess. 
such as peritonitis, or still more frequently pleurisy, or right 
pneumonia, give rise to such prominent symptoms that the real 
seat of the disease is overlooked and mistaken.” 
Again, Dr. Hammond states that Frerichs, Andral, Catteloup 
and others have not untrequently met with cases “ where local 
examination furnishes no data whatever tor proving a diagnosis ; 
when neither the size nor the form of the gland is altered, and 
where there is no increase of tenderness.” Doubtless this is the 
experience of many who have seen much of this disease, hut it 
by no means follows that in such cases there are “ no symptoms 
whatever.” On the contrary, as Frerichs has explained in the 
sentence which the Doctor so unmercifully mutilates, there are 
frequently attendant symptoms of so prominent and violent a 
nature as to completely mask the suppurative process. This hap- 
pens to be precisely true in Andral’s case, to which allusion has 
been made. It is that of a young man, who, after a fatiguing 
ride on horseback, had an attack of fever, for which no local 
cause could be discovered. On the 4th day he had a rigor and 
severe headache; his tongue was white, he had no appetite and 
suffered from obstinate constipation ; on the 12th day he became 
delirious, and on the 17th he died. During the entire progress 
of the disease there were no local symptoms; there was no vom- 
iting, and no jaundice ; the various internal organs were carefully 
examined without discovering any local disease. A t the autopsy 
all the organs were found free from any lesion of importance, 
arid oven the liver appeared normal, until an accidental punc- 
ture with the scalpel laid open an abscess as large as an orange, 
filled with pus, destitute of odor, and surrounded by softened 
red hepatic tissue. (Clinique Medic T. II. p. 303.) This case is 
interesting and instructive, but surely Dr. Hammond will not 
contend that it was marked by 11 insignificant derangements,” nor 
will he go so far as to assert that the symptoms were not directly 
connected with the rapid and deadly changes going on in the 
liver; for the post mortem too clearly reveals the facts, and leaves 
us only the sad regret that this young man’s medical attendant 
was not possessed of the wonderful tactus eruditus, which the 
Doctor has developed in the detection of fluctuation. It is 
doubtless to this case that Stokes alludes when he says, “in all 
the cases of abscess of the liver recorded by Andral, there is but 
a single instance where the disease occurred without compliea 
tion with lesion of other organs. (Ibid vol. iii.p. 169.) Hepatic Abscess. 
7 
Dr. Hammond further says : “ Rouis, who has written a most 
elaborate memoir on hepatic abscess, gives it as the result of 
his observations, that of,143 cases, the symptoms prior to sup- 
puration were either entirely absent, or were undefined in 62 
cases, while in 30 cases they were undefined during the whole 
progress of disease, and in 19 cases were either masked or latent.” 
Somewhere in the paper we are reviewing, Dr. Hammond 
remarks: “At present we move in the dark, or at least 
in a very obscure atmosphere.” Certainly his surroundings must 
have been somewhat hazy when he wrote the foregoing! 
Wherein he commences by telling us that Rouis has written an 
elaborate memoir, etc., on hepatic abscess, and continues, all in 
one sentanee, to announce that “ the symptoms prior to suppura- 
tion were either entirely absent or were undefined in 62 cases.” 
What the symptoms were during suppuration or after suppura- 
tion—after there actually urns abscess, the doctor conveniently 
omits to tell, though this is the point we are really after. 
The following is an analysis of the clinical history of Rouis’ 
cases, taken from Freriehs, (Ibid. p. 129\ “ Out of 143 cases, 80 
commenced with symptoms of dysentery, 14 with those of gastric 
or gastro enteric catarrh, 1 with those of gastralgia, 5 com- 
menced under the form of irregular intermittent fever, and 5 
were perfectly latent. In 21 eases, the symptoms of acute 
hepatitis, or of acute hepatitis complicated with a tendency to 
dysentery, were piesent from the first; while in 17 there were 
the symptoms of subacute or chronic hepatitis with dysentery.” 
Such is the analysis of Rouis’ cases, which nuty7 be taken as a 
fair example of the clinical history of hepatic abscess every- 
where and as it has presented itself to all observers, with the ex- 
ception of Dr. Hammond, whom we have consulted. The con- 
trast between the latter’s experience and that of Rouis is indeed 
remarkable when we come to a matter of statistics, for whilst 
of Rouis’ 143 cases only 5 were “perfectly latent,” Hammond 
tells us he encountered this feature in no less than 100 per cent ! 
Still another statement of Dr. Hammond’s needs correction, 
wherein a great man and a close clinical observer, now dead, is 
placed in a liilse attitude. He quotes Stokes to prove the latency 
of liver abscess, and refers to several cases cited by him, from 
the writings of Andral; in one of these cases the Doctor says, 
“The patient never had either sickness or pain, either in the hy- 
pochondrium or right side of the chest.” Who could read this 8 
Hepatic Abscess. 
quotation, under the authority of such a name as Stokes, with- 
out perceiving at a glance how nicely it dovetails with Dr. Ham 
mond’s cases? The history of these cases and their wonderfully 
successful treatment has been extensively circulated and read by 
thousands, yet how many of these numerous readers have thought 
or had the opportunity to inquire whether ■ 'tokes ever penned 
such a statement? Well, he never did, or anything like it. The 
truth is, Stokes mentions this particular case as an illustration 
of the manner in which abscess of the liver may be complicated 
with other diseases, wh’ch by their very gravity c nnpletely mask 
the liver trouble; in this instance, “a schirrus state of the 
stomach” was revealed at the autopsy, ([bid p. 69.) 
But although Dr. Hammond attempts to fortify his position 
with an imposing array of authorities, he cannot find one of 
them who will assent that hepatic abscess can proceed from in- 
cubation to maturity and yet present, as he contends, “ no symp 
toms whatever.” 
Obscure it often is, masked it sometimes is, latent it may be, 
but never without something more than “ insignificant derange- 
ments” somewhere in the line of its history. Should thoabscess 
besmalland become encysted, it may remain latent for years with- 
out giving rise to serious trouble. This is the opinion of Frerichs, 
who mentions by way of illustration the case of Mr. Lawson, a 
colleague of Dr. Budd’s, who “followed his profession for ten 
years after an attack of hepatitis, which left behind several ab- 
scesses.” Here is a case where the patient enjoyed even “ tol- 
erable health ” says Budd.yet it cannot be said that it was char- 
acterized by “no symptoms whatever;” on the contrary, these 
abscesses supervened on an attack of hepatitis, which is the 
usually recognized “ marked commencement.” The abscesses in 
this instance however, were very small, but had they been 
larger, the symptoms and constitutional effects would have been 
more pronounced, for, declares Budd, a large abscess “ never 
exists without very serious impairment of health.” (Diseases 
of the Liver, p. 460.) There need be no high degree of fever, 
neither is it continuous, rather intermittent in character, but 
always present at some stage of the suppuration. Frerichs makes 
this very judicious commentary on the uncertain symptomatol- 
ogy of abscess. He says, “ We must not always expect to meet 
with the entire train of symptoms perfectly developed; this is 
rarely the case; they are usual ljr observed either in whole or in Hepatic Abscess. 
part at certain stages of the disease only, or, indeed, all symptoms 
indicative of a local lesion maybe entirely absent.” (Ibid p. 128.) 
After discussing the question ol diagnosis at length and remind- 
ing us that abscess may be so masked as to be entirely over- 
looked even by the most skillful surgeon, Stokes says, but such 
cases are comparatively rare and should not discourage the stu- 
dent or render him skeptical as to the powers of diagnosis. 
Before proceeding to explore the liver, we hold that there 
should be a reasonable suspicion of abscess. Our conclusion must 
be founded on a close and careful scrutiny of the whole history 
of the case; bearing in mind that many cases, though masked, 
oi- latent at the moment ol' observation, may be connected with 
antecedent phenomena calculated to lend valuable assistance in 
lorining a correct judgment. When all local symptoms are 
absent, the diagnosis must necessarily be very difficult. For- 
tunately, in what might be termed “walking cases,” this is less 
apt to be the case than when there are severe complications, dis- 
tracting the attention of the nerve centers to other organs. The 
fact that authors la}’ so little stress upon fluctuation is significant 
that they deem it a sign of little or no value, when the abscess is 
not sufficiently large,‘or so situated as to bulge out the right 
'*yi )ochondrium, or cause the gland to extend downwards below 
the margin of the ribs. Even in that case, if the abscess be deep, 
it is generally absent. Any one who has attempted to detect 
fluctuation in the adult under such circumstances can appreciate 
the difficulty, and lor obvious reasons. The writer recalls the 
case of a child, three years old, who suffered from hepatic ab- 
scess following a violent attack ol' dysentery. In this instance 
the local symptoms, such as pain and tenderness were well 
marked; the liver enlarged,yet even in this child, with its small 
yielding chest, there was no sign of fluctuation until the pus was 
pressing out the intercostal spaces; when a large ahsess contain- 
ing ten ounces of healthy pits was evacuated with a bistoury, 
resulting in complete recover}-. This, b} the way, is the only 
case of hepatic abscess occurring in so young a subject, within 
our personal knowledge; the patient was the child of a gentle- 
man residing near Parkersburg, W. Ya. 
We should not forget that there is a trouble, sometimes met 
with closely simulating abscess of the liver, and which Stokes 
says may bo easily mistaken for it. We allude to superficial 
fascial abscess of the walls of the abdomen over the right hypo- 10 
Hepatic Abscess. 
chondrium. Stokes speaks of it as a “singular disease,” gener- 
ally quite innocent, though he has seen a patient die of it. 
(Stokes and Bell, p. 530.) We well remember a puzzling case 
of this nature many years ago in Bellevue Hospital, New York, 
which was not without difficulty diagnosed b}r Dr. Alonzo Clark. 
The improved instruments which we now possess render it 
much easier and safer to test our diagnosis in obscure abscesses 
than formerly. Though we repeat, that no one is justifiable 
in puncturing the liver unless he has a reasonable conviction 
that it is the seat of abscess. On this point it does seem to us, 
that the teachings of Dr. Hammond partake too much of the 
enthusiast, and are well calculated to bring an important and 
useful surgical device into disrepute. He actually goes so far as 
to annunciate the proposition, “That in all cases of hypochondria 
or melancholia, the region of the liver should be carefully ex- 
plored, and that even if no fluctuation be detected, or any other 
sign of abscess be discovered, aspiration being a harmless opera- 
tion, should be performed”! To array a 113- formal argument 
against such a doctrine as this would be a manifest reflection 
upon the intelligence of our readers, who are familiar with the 
fact that whilst hypochondria, insomnia, elc., are common accom- 
paniments of nearly all affections of the liver, yet that they are 
symptoms which by no means belong to this organ par excellence. 
If this rule of the Doctor’s were universally adopted during 
these times, when there is so much mental depression from busi- 
ness and other causes, what a pecuniary harvest it would prove 
for the doctors, even at a moderate fee per puncture ! Aspirators 
would soon be in greater demand than “blue glass,” or “ Hol- 
man’s pads,” and we might all do a lucrative business, “ pros- 
pecting the liver,” as Prof. Aitken derisively terms this “ hap- 
hazard ” practice. (Science and Practice of Med., Vol. 11, 
page 834.) 
As before remarked, Dr. Hammond has been at great pains, 
to quote everything he could find bearing favorably on the 
points which he wishes to inculcate, whilst equally studious m 
omitting all counter-balancing testimony. He makes much of, 
and even founds a new theory of hepatic abscess upon, the recent 
researches of Cyon and Aladoff, into the anatomical distribution 
of the vaso motor nerves of the liver; yet he brings forward not 
one atom of proof that these discoveries account for a single 
case of abscess. The nerves in question, like the rivulet of the Hepatic Abscess. 
11 
wilderness, ran thus, even before they were dreampt of by 
man. And yet, is -it not strange that they have only re- 
cently, and all of a sudden, developed potency in the production 
of abscess ? Why is it that prior to the discovery of Cyon and Al- 
adoff, hypochondria and cerebral hypereemia were scarcely ever 
known to be complicated with abscess of the liver? Facts are 
far more eloquent than mere theories; let us see what the former 
teach us. Prichard says, “Medical writers formerly attached 
great importance to the liver, in disorders affecting the mind; 
later researches have by no means confirmed this prejudice. 
Esquirol found two instances of diseased liver in 168 melanchol- 
ics, while in the same number there were 65 morbid changes in 
the h.ngs.” (Prichard on Insanity, p. 178.) The san.e author re 
marks that in 60 autopsies of cases of dementia there were only 
2 in which the liver showed evidences of disease. In 259 post 
mortemsof insane persons displaying morbid changes of structure 
in various organs, other than the brain, Scipion Pinel found 
lesion of the liver in only 5. (Gruislain, p. 138.) 
But the question arises, under what circumstances shall we 
explore ‘he liver for abscess? Dr. Davis, whose recent paper 
on this subject may be regarded as the most valuable and prac- 
tical yet contributed to American literature, lays down the 
following rule as to the proper time for exploration. He says: 
“ What are we to do in an acute case of-hepatitis, when well 
marked symptoms of suppurative fever arise? I answer, un- 
hesitatingly, ascertain if possible the seat of abscess, and unless 
well defined symptoms are present, which point to the lungs as 
the probable outlet for the pus—puncture.” 
Dr. W. H. Ford, of this city, who has seen quite a n unber of 
cases of hepatic abscess, and has had a good deal of experience 
with the aspirator, makes the following remarks in reporting a 
fatal case of abscess in which he had employed that instrument, 
in the St. Louis Cliniral Record for July, 1876. lie says: 
“ Though puncture of the liver by Dieulaf'oy’s needles is not an 
absolutely innocent procedure, notwithstanding his assertions in 
this respect, which, perhaps, are a little too emphatic, neverthe- 
less, like most other well devised and properly guarded surgical 
measures, it is infinite!}' less dangerous than the condition it is 
intended to remove. When, therefore, symptoms point to the 
formation of abscess in the liver threatening to perforate the 
diaphragm, the pus ought to be withdrawn by the aspirator. The 12 
Hepatic Abscess. 
symptoms denoting the propriety of this, will be the usual ones 
indicative of hepatic abscess, etc., etc.” 
Prof. Maclean, of Netrley, an ardent advocate of tentative 
aspiration, declares that when he has a case of dysentery with 
hepatic symptoms so acute as to lead to the suspicion that pus 
has formed, he always punctures; believing that if there is ah 
scess the sooner it is evacuated the better, and should thero be 
none the. local abstraction of a little blood proves salutary. 
(Lancet, October, 1873.) Cameron, Condon, and others coin- 
cide in these views. Dr. Dieulafoy, whose name is indissolubly 
connected with the aspirator, and who is certainly as enthusiastic 
an advocate of his invention as any one can be, declares in favor 
of early exploration, and would resort to it “ when palpation 
and percussion disclose an increase of volume in the liver; when 
this increase has been rapid and accompanied with pain in the 
lower border of the organ and in the right shoulder; when 
these local symptoms are connected with general phenomena 
such as sweats and fever, more or less intermittent.” (Pneu- 
matic Aspiration, p. 93.) 
We might thus go on and cite other authorities, but thone are 
amply sufficient to indicate the generally accepted views of the 
most advanced advocates of the aspirator, as a diagnostic instru- 
ment. 
But having thus verified the existence of abscess, what is t<> 
be done ? The indications are plain ; the pus should be evacuated 
without removing the needle, provided it is of sufficient size not 
to clog, which will be the case even with those of 
larger calibre—the cavity being cleansed with some suitable an- 
tiseptic fluid. The needle may then be withdrawn and the patient 
kept quiet (a point insisted on by Dieulafoy) with a hope that 
the cavity may contract and no further collection of matter take 
place. This has been known to occur in several instances, even 
when the abscess was large—(it occurred in all of Dr. Ham- 
mond’s cases without even the precautionary washing out) though 
this is b}r no means the rule. The tendency to re-formation of 
pus in all abscess cavities is well known. In 15 chronic and 
metastatic abscesses, not of the liver, tabulated by Dieulafoy, 
there were 39 aspirations; 10 are reported cured and 5 improved. 
Only 3 were cured by one aspiration. (Ibid p. 355.) The same 
author recites in detail the treatment by aspiration of seven 
cases of hydatid c}'sts of the liver. In 3 cases one aspiration et Hepatic Abscess. 
13 
fected a cure; one case required three punctures, the fluid remain- 
ing limpid to the last. In one other the fluid became turbid, “ but 
had not time to be completely changed into pus, as cure was 
affected after the second puncture.” The sixth and seventh cases 
completely degenerated into abscess; the sixth case was cured in 
six punctures, whilst the seventh was aspirated 300 times, and 
still not cured—a drainage tube having to be introduced.* (Ibid 
pp. 52-87.) Such is the rarity of liver abscess in “European 
countries,” that Dieulaloy was unable, between the years 1869 
and 1873 (the date of the publication of his hook), to find but one 
case in the hospitals of Paris, upon which to try his instrument. 
This case was cured, but required two aspirations. 
The experience of Condon at Madras, in the treatment of 
abscess of the liver exclusively by aspiration, is anything but 
encouraging. He reports 12 cases (London Lancet, Aug. and 
Sept. 1877), though, in reality, he only had 8, since cases 2, -1, 7 
and 10, on being explored, turned out to be free of abscess, and 
finally convalesced—the patients returning to duty as soldiers. 
In two other cases where abscess existed, the aspirator failed to 
reach it; the pus made its way into the lungs and produced 
death. In only 6 cases, therefore, did the aspirator cut any 
figure as a curative instrument. In one, the needle clogged so 
badly as to render aspiration useless. Of these six cases, two 
were cured; one after three, and the other after five punctures, 
whilst four died alter an average of thirteen and one half 
aspirations. 
Dr. Davis has kindly furnished us with the following tabu- 
lated statement of the treatment, result, etc., of thirty-six cases 
of abscess semn by him at Zacatecas. (See table on next page.) 
From ttdloiv-iug, it would appear that the true province 
of the aspirator is restricted. As a diagnostic instrument, 
it is indeed invaluable, and is sufficiently harmless to jus- 
* Note.—In several of Dieulafoy’s cases very dangerous symptoms fol- 
lowed puncture. Davis mentions one case within his knowledge where ex- 
ploratory puncture caused death. Moissennet saw death ensue in eighteen 
hours after puncture with smallest sized trocar. The patient fainted im- 
mediately after the operation, rigors set in, followed by green vomiting and 
cold extremities, pains in the abdomen and death from peritonitis (Archiv 
Gen. de Med.Few., 1859.) Robert, Demarquay, Dolbeau and Jobert have 
all observed symptoms of commencing peritonitis, which were however 
arrested. 14 
Hepatic Abscess. 
tify its use in all cases where there is a well grounded suspi- 
cion of abscess. As a means of cure, simple and repeated punc- 
ture may be tried on all occasions where there are no evident 
symptoms of external pointing. Should, however, the abscess 
No. op Cases. 
Deaths. 
Recovered. 
6 
1 
5 
2 
0. 
2 
1 
0 
1 
ft 
18 
Aspirating trocar (largest size.).... 
4 
10 
J 
8 
1 
1 
0 
1 
1 
0 
2 
Abscess remained intact ...,. 
2 
0 
Total .‘56 
19 
17 
refill, as is apt to be the case, and evince no sigri3 of amend- 
ment, it is better to insert a drainage tube,—keeping up proper 
cleansing and dressing. Maclean says, “when the cavity, after 
being once or twice evacuated in this way, fills again, I believe 
the patient’s best chance of recovery will be to make a free 
opening, after Mr. Lister’s method, which gives the advantages 
of a free drain without the admission of air unfiltered through 
an antiseptic medium.” It is always desirable that the pus re- 
main free from decomposition. According to Davis, “if it be- 
comes fetid, it is of the worst omen.” We can conceive of but 
three conditions under which the contents of an abscess could 
become fetid prior to evacuation, and not necessarily so then 
i. e., gangrene ; hydatid decomposition; proximity to the lung 
or colon. Dr. Davis says, “I have never met with a case where 
fetid pus was found at a primary puncture.” (Autograph 
letter.) Neither can we understand how fetor could exist with- 
out decided local or systemic disturbance. In a clinical lecture 
at St. Bartholomew’s Hospital, Dr. Andrew remarks that hectic 
is by no means a necessary accompaniment of suppuration, “if, 
however, pus, or even serous fluid, were confined in a cavity, 
and ceased to be of laudible quality, a constitutional effect would 
at once be found to ensue.” ( Lancet, 1870, p. 605.) A remark- 
able feature in one of Dr. Hammond’s cases was the abstraction 
of ten ounces of pus of a “highly offensive odor,” yet the 
patient was free from all local symptoms, and had no pyrexia 
whatever. 
We beg leave to advert yet a little further to Dr. Hammond’s 
paper, which we have already shown to he lull of errors both of 
omission and of commission, well calculated to exert a harm Hepatic Abscess. 
15 
ful influence upon practical medicine, emanating as it does from 
a teacher, whose prominence entitles him to the attention and 
respect of the medical world. But the truth is, there is not 
a single original point in the Doctor’s article which can be sus- 
tained either by clinical experience or the teachings of pathol- 
ogy. The salient propositions of Dr. Hammond are: First, 
That abscess of the liver is quite common even in this country. 
Second, It is frequently the result of hypersemia of the brain, 
sufficiently so, to demand exploration of the liver, irrespective of 
symptoms in all cases of hypochondria and melancholia. Third, 
That all cases should be treated by one particular method. 
Fourth, That this method is not only innocent in itself, but that 
its results are altogether satisfactory; so much so indeed, as to 
rob hepatic abscess of all its well known terrors. We say that 
these are natural and just inferences from the Doctor’ paper in 
the review of which we have already had occasion to call atten 
tion to several misquotations and mystifying expressions, calcu- 
lated, if not intended, to convey erroneous impressions. In this 
connection we beg leave to notice another double entendre, lest 
others may be misled by it, as we confess we were when we first 
read it. In speaking of his method of operating, Dr. Hammond 
makes this declaration: “That the operation of aspiration is 
free from danger. Dr. Davis never saw any ill consequences 
from it, and Dr. Jimenez, of Mexico, states that of the hundreds 
of times he has punctured the liver through the intercostal 
spaces for abscesses, he has neves once seen the operation fol- 
lowed by peritonitis.” Now let any one unacquainted with the 
facts read over the above and ask himself what it means ? He 
is bound to conclude that Dr. Hammond intends to conve}T the 
idea that Jimenez employed the aspirator “hundreds of times.” 
The sentences are so framed and connected as to admit of no 
other construction, and such was put upon it, until Dr. Davis’ 
paper subsequently appeared, fully explaining what is known in 
Mexico as the Jimenez method,—of simple and repeated punc- 
tures through the intercostal spaces b}’ the ordinary trocar. 
Whereas Jimenez, who died in 1875, at an advanced age, had 
about completed his professional career before he ever heard of 
the instrument. Again Dr. Hammond misleads his readers when 
he conveys the impression that simple puncture is the accepted 
method of the present school of Mexican surgeons. For al- 
though Jimenez may not have met with “ peritonitis ” as the re- 16 
Hepatic Abscess. 
suit of his numerous operations, he nevertheless encountered 
discouragements in the shape of mortality, which led him finally 
to abandon his method for that of Yertiz, wherein drainage is 
the essential superaddition. Dr. Davis tells us, “ Vertiz’s modi- 
fication was the introduction of the drainage tube. Jimenez at 
once acknowledged its efficiency and used it, lessening, he 
claimed, the death rate 50 per cent over the simple and repeated 
puncture as formerly practiced by him.” (Autograph letter.) 
There are other points in Dr. Hammond’s paper which we 
should like to notice, but must, conclude. We cannot do so, 
however, without calling attention to the most extraordinary of 
all the remarkable features of the Doctor’s experience in hepatic 
abscess. He seems dissatisfied with the hitherto accepted etiology 
when applied to his own cases; he therefore broaches a theory 
of his own, and suggests that these abscesses were due to the 
11 brain disturbance” under which his patients had all previously 
labored. In other words, he regards the abscess as an effect,— 
the brain disturbance, the cause. But, mirabile dictu! he removes 
the effect, and forthwith the cause vanishes! This is indeed a 
specimen of “back action” therapeutics which quite staggers 
our confidence in the established principles of medical art! We 
have pondered over this wonderful denouement until our mind, 
like Noah’s weary dove, has found but one solution, and that is 
suggested in the classic lectures of Dr. Henry Maudsley “On the 
relations between body and mind.” “ Can it be doubted,” says 
he, “ that the strong belief that a bodily disorder will be cured 
by some appliance, itself innocent of good or harm, may so effect 
beneficially the nutrition of the part as actually to effect a cure ? 
Perhaps we do not as 
physicians consider sufficiently the influence of mental states in 
the production of disease, and their importance as symptoms, or 
take all the advantage which one might take of them in our 
efforts to cure it. ()uackcry seems to have here got hold of a 
truth which legitimate medicine fails to appreciate and use ade- 
quately. Assuredly the most successful physician is he who, 
inspiring the greatest confidence in his remedies, strengthens and 
exalts the imagination of his patient; if he orders a few drops 
of peppermint water with the confident air of curing the disease, 
will he not really do more for the patient sometimes than one 
who treats him in the most approved scientific way, but without 
inspiring a conviction of recovery.”-? 
3004 Olive Stree*.