HEPATIC ABSCESS 
REPORT OF A CASE, 
With Remarks Upon the Amoeba Coli, 
BY 
WII1L1IAM A. EDWARDS, JW. D. 
AND 
tJAJVlES SEARS WATERS A fl, JVI. D. 
San Diego, California. 
RE PRINTED FROM 
Pacific Medical Journal 
March, 1892. 
W. A. WOODWARD &. CO., PRINTERS, 12 SUTTER ST., S. F. HEPATIC ABSCESS 
REPORT OF A CASE 
WITH REMARKS UPOR.THE AMCEBA COLI.1 
By WILLIAM A. EDWARDS, M. D., San Diego, California, 
Fellow of the College of Physicians of Philadelphia, and of the American 
Pediatric and Pathological Societies, formerly Instructor in Clinical 
Medicine and Physician to the Medical Dispensary in the 
University of Pennsylvania, Physician to St. Joseph’s 
Hospital, Associate Pathologist to the 
Philadelphia Hospital, etc. 
AND 
JAMES SEARS WATERMAN, M. D., San Diego, California, 
Late Resident Hou e-Physician Bellevue Hospital, New York. 
(Reprinted from “ Pacific Medical Journal,” March, 1892.) 
J. W.; laborer; aged forty-nine; was sent to Dr. Waterman 
from the mountain region of San Diego County with a diagnosis 
of impending typhoid fever, which examination soon proved to 
be erroneous. Family history negative; has a marked alcoholic 
habit; had gonorrhoea and a chancroid eight years ago, an at- 
tack of dysentery in 1878, and another attack in 1882; not a 
robust man, but was able to work up to three weeks ago, when 
his present illness began in an attack of diarrhoea, rapid emaci- 
ation. Ten days ago had a slight chill; for several days has 
had four or five bloody movements, accompanied by consider- 
able rectal tenesmus; pain in right hypochondriac region, pain 
in throat, and some difficulty in swallowing; no vomiting, but 
has eructations of food. 
Physical Examination.—Emaciated andansemic; tongue moist 
and coated with thick white fur. 
Lungs.—Slight dulness anteriorly at both apices; posteriorly 
dulness and diminished respiration over right base. 
Heart.—Normal in size and position; action regular, some- 
what rapid; no murmur. 
Liver.—Absolute dulness in fifth interspace, on nipple line; 
lower border of liver on line with umbilicus; posteriorly the 
liver dulness reaches to below costal arch. There is a tumefied 
mass occupying left side of right hypochondriac region, and 
right half of epigastric region; mass is hard, somewhat painful 
on pressure, gives a flat percussion note; no fluctuation appreci- 
(1) The accompanying illustrations are reproduced through the courtesy of 
the University of Pennsylvania Press. 2 
Hepatic Abscess. 
able; peritoneum adherent to mass (?); spleen not enlarged; 
abdomen retracted. 
Rectal Examination.—Negative; prostate somewhat enlarged. 
Pharynx and larynx somewhat enflamed; pulse 90; resp. 25; 
temperature 97°; urine, red, acid, 1025, no albumen, microscope 
showed a few red and white blood cells, epithelial cells and bile 
pigment. 
A diagnosis of abscess of the liver was made. An aspirating 
needle was inserted into the tumor, below the free border of 
ribs, at the outer border of right rectus muscle. A cloudy 
serum and thick pus were obtained. Three hours after patient 
first came under our observation he was anaesthetized with chlo- 
roform, although collapse was imminent, temperature 97°. An 
incision three inches in length was made in line of puncture. 
Peritoneum was adherent. An opening about one and a half 
inches in length was made into abscess cavity, which was found 
to be filled with a reddish serum, thick stringy pus, and pieces of 
necrotic liver tissue; about thirty ounces were evacuated. Ab- 
scess cavity was irrigated with a 1-4000 bichloride of mercury 
solution, followed by hot water. It was then packed with iodo- 
form gauze, a drain inserted, and wound dressed. Patient re- 
covered from the anaesthetic fairly well, but his general condi- 
tion did not improve, and notwithstanding liberal stimulation 
with heat, alcohol, digitalis and strychnia, he died in about 
four hours. 
Autopsy.—Body of an ill-nourished man, panniculus adiposus 
almost absent, subcutaneous venous system dilated, no jaun- 
dice, marked anaemia, heart slightly dilated, right side normal, 
tricuspid valves dilated; left side, walls thick, slight atheroma of 
aorta near valves, mitral valves normal. 
Lungs:—Left, intensely congested, heavy, apex and upper 
fourth of lower lobe contain a large indurated area, very dense 
and hard. There are numerous small tubercle-like nodules 
scattered through lower lobe. Many dense pleural adhesions. 
Right lung, dense adhesions everywhere, separated with great 
difficulty. Apex contains a large fibrous nodule, size of an 
orange. Lung is intensely congested and oedematous; glands at 
root are deeply pigmented and enlarged. Spleen:—Normal size, 
is softened and very friable. Kidneys:—Left, capsule slightly 
adherent. Organ nearly normal. Right, slightly larger than the 
left. Capsule not adherent, organ nearly normal. Liver:— Hepatic Abscess. 
3 
Adherent to the abdominal wall and to the surrounding viscera; 
left lobe not much enlarged, but shows signs of chronic paren- 
chymatous inflammation. The bile ducts are surcharged with 
bile. Right lobe much increased in size, and contains five 
abscess cavities, three are very large and two somewhat smaller; 
they all contain pus, serum, and necrotic liver tissue. On the 
under surface of this lobe there is a hemorrhagic infarct, about 
25 millimetres in diameter, not broken down but apparently 
of recent origin. The operation wound is seen about the 
median line of this lobe at a point corresponding to the dome 
of the liver. Gall-bladder is filled with a thin light colored 
bile, and the common bile duct is pervious. 
The vermiform appendix is in an abnormal position, having 
fallen through an ovoid opening in the mesentery of the small 
intestine, taking a direction downward and into the pelvis, and 
is found two inches below the bifurcation of the aorta. 
About two feet above the csecum there is a Meckel’s diverticu- 
lum. The mucous membrane of the csecum and whole colon to 
rectum, is covered with innumerable ulcers; some of these 
ulcers, especially in the caput, are recent, others are very deep 
subacute ulcers. The mucous membrane in places is gan- 
grenous. 
Hepatic abscess has a wide geographical distribution, it is 
not confined to any clime or any nation. It is, however, most 
common in the tropics; in tropical Asia, Africa, Egypt and 
Algiers, the disease is endemic, and constitutes five per cent of 
all diseases. Bartholow has found it very common in the valley 
of the Mississippi and its tributaries, and Delafield says it is 
common in New York City. Barensprung found from the rec- 
ords of Berlin Path. Institute (1859 to 1873), 108 cases of he- 
patic abscess and lesions of the liver out of 7,326 autopsies, 
being 1.48 per cent. Bueckling in the same institute finds thirty- 
six cases of hepatic abscess, being 1.5 per cent. Satterwaite, in 
251 autopsies at St. Luke’s Hospital, reports 9 cases of hepatic 
abscess or nearly 3.6 per cent. Norman Moore, quoted by 
Harley, finds 20 cases out of 22,464 autopsies at St. Bartholo- 
mew’s Hospital, less than 1 per cent. Musser (Transactions of 
Phila. Path. Soc., 1857 to 1881) in 430 cases where the condi- 
tion of the liver was mentioned, found abscess thirteen times or 
nearly 3 per cent of the total. Mejia in 88,416 deaths for ten 
years in the City of Mexico, reports that 1,985 were due to sup- 4 
Hepatic Abscess. 
purative hepatitis, a little over two per cent; these figures we 
are unable to verify and consequently assume no responsibility 
in reporting them. The Transactions of the Philadelphia Patholo- 
gical Society, 1881 to 1887 inclusive, present 2 additional cases. 
Osier in the last two years has seen six or seven cases (personal 
communication). 
Hepatic abscess is rare in children. Musser (Keating’s Cycl.) 
has tabulated 34 cases in children under 15 years of age. We 
have been able to add but four more to this list, those reported 
by Ashby, Meckel, Milduer and Riveling and Stewart. 
It is more common in men than in women, Eichorst says in the 
proportion of thirty to one. Nine cases at St. Luke’s Hospital 
presented but one female. Roms’ series contains 250 men and 8 
women. Bartholow reports 12 cases, one a woman. Of War- 
ing’s 300 collected cases but 9 were women. 
The abscess is most often located in the right lobe, or in both 
lobes; rarely in the left lobe alone. An analysis of 90 cases 
shows the cite of the abscess to be the right lobe in 62 cases, 
the left lobe in 6 instances, and both lobes in 22. When we 
consider the large size of the right lobe as compared to the left— 
as six is to one—the larger capacity of the right branches of the 
portal vein, hepatic artery and hepatic duct, the fact that the 
veins of the gall-bladder usually empty into the right branch of 
the portal vein, and the more exposed situation of the right lobe, 
it will be readily understood why this lobe should be the most 
common seat of trauma, and why septic material should the 
more readily seek this lobe and find permanent lodgment there. 
In 297 cases observed by Jimenez, 198 were on the convex sur- 
face of the right lobe, with 242 deaths. {The Satellite, Feb., 
1892.) 
Hepatic abscess may be divided into two great classes: pri- 
mary and secondary, the former including traumatic and the 
so-called idiopathic abscesses, the latter, metastatic, pysemic 
and abscess by continuity and contiguity of tissue, and those due 
to the amoeba coli. 
It has now been shown that the so-called primary or tropical 
abscess so common in India is due more to the habits of the 
individual, excesses in food and drink, than to the climatic con- 
ditions that for so long a time were considered the sole factors 
in its production. The disease is rare among the native popu- 
lation and common among the overfed, alcoholic English resi- Hepatic'Abscess. 
5 
dents. As a further example, Sachs has shown that in Cairo, 
hepatic abscess is rare among the Mahommedans, and is found 
only among those who indulge to excess in alcoholics; this 
writer is further of the opinion that the same causes which will 
produce cirrhosis in a cold climate, will, in a hot environment, 
produce an acute purulent hepatitis. 
As is well known, trauma may produce an abscess of the liver, 
but when the literature is somewhat carefully searched, one is 
surprised at the paucity of recorded cases of liver abscess fol- 
lowing an injury. Thirty years’ literature on this subject pre- 
sents, according to Thierfelder, but 12 cases due to trauma; 
Louis and Andrell report one case and Musser (ibid) records 
8 instances, John Harley one, Formad one, Rively and 
Stewart one. Whitaker’s case was due to an injury of the wall 
of the thorax over the liver, Sheet’s was due to a fractured rib. 
Barensprung’s 108 examples of this disease present 13 traumatic 
cases. 
A trauma or a suppurating focus may very readily be followed 
by abscess of the liver as the infection from the pus collection 
may be carried directly to the liver, either by the arterial circu- 
lation, through the hepatic artery, having, as a rule, been car- 
ried through the lungs and heart, or through the venous circu- 
lation by the portal vein, umbilical vein, or, as Eichorst would 
have us believe, by the action of gravity, entering the hepatic 
veins from the vena cava, and as Flint says, owing to the very 
low blood pressure and slowness of the circulation through the 
liver, we not infrequently have suppuration here when the lungs 
have escaped. On the other hand, Waldeyer finds that sixty-six and 
two-thirds per cent of the deaths from surgical diseases and in- 
juries had pulmonary abscess, while only six per cent had hepatic 
abscess. At one time it was thought that there was a special 
relation between injuries of the head and hepatic abscess, but it 
has now been demonstrated that abscesses of the lungs are more 
frequent from this cause. 
Another very prolific cause of the condition under considera- 
tion is biliary concretion, either in the gall-bladder or ducts. 
Barensprung records 11 cases under this head and Satterwaite, 
from a study of his 33 cases, concludes that after dysentery, 
this is the next most frequent cause of liver-abscess. Ogle re- 
cords a case of abscess of the right lobe in which there was a 
mass of biliary concretions the size of hens’ eggs; Harley has 6 
Hepatic Abscess. 
recorded two similar cases, and Satterwaite one in which the 
common duct was occluded by stone causing ulceration and 
rupture. 
While one of us was resident house-physician in the Bellevue 
Hospital, N. Y., a case of multiple abscess was observed in the 
service of W. B. James. Autopsy showed the duodenum to be 
adherent to the gall-bladder. The remains of the gall-bladder 
were found imbedded in a mass of cicatricial tissue; the bladder 
was about the size of a hickory nut and contained a large num- 
ber of irregularly shaped gall-stones, lying in a collection of 
yellow pus; the hepatic ducts contained similar stones and pus. 
The liver weighed 6 lbs. 7oz. It contained numerous large and 
Bmall collections of pus. Suppuration appeared to have followed 
the portal channels. The intestines were normal. 
Ascarides entering the intestine through the common bile 
duct may cause suppuration. Musser has collected 8 such cases 
occurring in children. In Hornblower’s case (N. F. Med. Rep., 
1813) intestinal worms were discharged from an abscess of the 
liver. Bates’ case presented 42 lumbricoid worms in the sub- 
stance of the liver imbedded in an abscess. Suppurating hy- 
datids have been recorded as etiological factors in the produc- 
tion of liver suppuration. Murchison and Harley have recorded 
such cases. Frequent mention is made in the books of abscess 
resulting from infection from the umbilical vein. With the means 
at our command, we are able to find but three cases, two of 
these are recorded by Thierfelder, and one is quoted by Musser 
as occurring in a child of one year of age. 
Hepatic abscess has been observed as a sequel of the follow- 
ing conditions: Ulcerative endocarditis (Meyer), emboli from 
an aneurism or the bifurcation of the hepatic artery (Ross and 
Osier), abscess of the thymus in a child (Musser), encysted pyo- 
thorax (Thierfelder), splenic abscess, also bruise on left hip (Mus- 
ser), specific (?) abscess over right internal malleolus (Harris, 
Lancet, 1887); in Barensprung’s series, so often referred to, one 
followed a fracture of the femur, four pulmonary abscess and 
gangrene of lung, eight injuries of the head, and twenty-two 
injuries of other portions of the body; putrid bronchitis 
(Meyer); hepatic tuberculosis (Burton); Bruen’s case (Phila. 
Path. Soc., 1878) was apparently secondary to a subdiaphrag- 
matic abscess, and Pepper’s case (ibid, 1874) is incompletely 
reported in that no examination was made for the seat of pri- Hepatic Abscess. 
7 
mary suppuration; pancreatic abscess (Buckling), cancroid of 
oesophagus (Tuengel), gastric ulcer (Bruen, For mad, Murchi- 
son, Bamberger), phlegmanous gastritis (Akerman), suppurat- 
ing cancerous processes (Barensprung, five: one cancer of stom- 
ach, one cancer of pancreas, three, cancer of uterus and vagina), 
cancer of rectum (Dance), cancer of penis (Thierfelder). 
Intestinal tuberculosis produced tubercular abscess in the 
liver in 12 cases (Bristow), suppurative inflammation of the 
portal vein, seven cases, thrombosis of the portal vein (Southy), 
pylephlebitis due to an impacted fishbone, two cases (Winge 
and Jane way), typhlitis and perityphlitis have furnished several 
interesting cases. Harley, Payne, Whipman, Ashby, Legg and 
Church have all reported cases where the typhlitis was caused 
by a pin lodging in or penetrating the appendix. Harley cites 
a case of Wettenger’s where the typhilitis was caused by a fish- 
bone, and several abscesses were found in the left lobe of the 
liver. Eskridge’s case of paratyphilitis was followed by a liver 
abscess, and Fergus’ case of perityphilitis became a general 
peritonitis and produced a suppuration of the liver. Ulcerative 
processes in the caecum and appendix produced abscess in 8 of 
Barensprung’s cases. Dunn reports a case of liver abscess in a 
child secondary to pelvic peritonitis; the abscess was incised, 
the child'recovered. Lee’s case (N. Y. Path. Soc.) was also due 
to a pelvic cellulitis. Proctitis (Bartholow), malaria (Emmus?), 
diabetes mellitus, phosphorus poisoning (Barensprung). 
Typhoid fever does not by any means take the prominent place 
as a causative agent in the production of liver abscess that one 
would naturally suppose. Bueckling mentions two cases, 
Tuengel one, Harley one, Bernhard (quoted by Musser), one. 
Operations on the rectum have not infrequently caused the con- 
dition that we are considering. Dance reports one following an 
operation for fistula, Pirigoff one after an operation for prolapse, 
Oruvellier after forcible replacement of a neglected prolapsed 
rectum, Dance one that followed suppuration in a portion of 
the omentum that could not be replaced after a herniotomy, 
and Wilkes an abscess secondary to a suppurating rectal 
stricture. 
Gonorrhoea has, in Harley’s experience, been responsible for 
the production of an abscess in the liver. 
Of all the diseases that are apt to cause liver abscess, dysen- 
tery beyond all doubt is the most important and is responsible 8 
Hepatic Abscess. 
for more oases than all the other causes oombined. Indeed, as 
early as 1842 George Budd stated that dysentery was a primary 
cause of hepatic abscess, and most of us to-day would feel in- 
clined to agree with that statement. Moore in the Annals of Mili- 
tary Surgery reports 1,532 cases which, in 259 instances, were 
followed by liver abscess, being 19.2 p.c. Luchtinan in 102 autop- 
sies, where abscess existed, found the following interesting 
facts: that in 11 cases the intestinal canal was normal, in 14 
chronic catarrh of the colon existed, follicular ulcers of the 
colon in 52, follicular ulcers of the ilium 9, dysentery in various 
stages 16. Roins’ observations are even more decided in that 90 
per cent of the cases had dysentery (128 out of 143). The lit- 
erature contains many other cases, notably those of Osier 
(three), Guiteras, Wilson, Formad, Bruen, Ridlon and Musser. 
To recapitulate, hepatic abscess in a total of 699 cases reviewed 
in this paper has been observed in association with the follow- 
ing diseases in their order of frequency: Dysentery, 524 times; 
traumatism, 38; general injuries, 23; perityphlitis, 18; intes- 
tinal tuberculosis, 12; ascarides, 10; injuries to head, 8; pyle- 
phlebitis, 7; typhoid fever, 5; biliary concretions, 5; gastric 
ulcer, 5; cancer of stomach, 5; cancer of uterus and vagina, 4; 
gangrene of lungs and pulmonary abscess, 3; suppuration of 
umbilical vein, 3; hydatids, 2; operation for prolapse, 2. Space 
forbids a recapitulation of the causes in the remaining 26 cases. 
They are mentioned in the body of the paper. 
A study of this series of cases will convince one that hepatic 
abscess is rarely if ever a primary disease, and that if cases are 
examined with great care a primary focus of suppuration'will, 
in all probability, be found, and the chances are that it will be 
situated in the portal area. We have long since learned that 
the word idiopathic is of doubtful significance in the pathology 
of to-day, and as Harley says every form of hepatic abscess is in- 
variably preceded by a recognizable cause and that the so-called 
idiopathic abscess may be only a form of metastatic abscess whose 
origin has eluded detection. 
THE AMOEBA COLI. 
The investigations of Kartulis, of Alexandria, Gentralblatt/. 
Bacteriologie und ParisitenJcunde, March 21st, 1891, foreshad- 
owed by Lambe in 1852, and later by Losch in 1873, have now 
been confirmed in almost all parts of the world. At Prague by 
Hlava, Sonsino at Cairo, Grasse, Perroncito and Lontino in 
Italy, Klava in Austria, Cunningham and Lewis in India, Koch Hepatic A&scess. 
9 
and Gaffky in Germany. In Bohemia, in Greece and in America 
first by Osier, whose investigations are so painstaking and reli- 
able, then by Councilman, Loefleur, Simon, later Dock, Eich- 
berg, Musser and Stengel, from whose article we will quote ex- 
tensively and reproduce his illustrations of the different forms 
of the amceba coli. They are most readily seen in the fresh 
mucous stools of dysentery, most abundant in the yellowish and 
blood-streaked mucous particles, or in the shreds of necrotic 
tissue and have been frequently found in hepatic abscess, also 
in the expectoration of a case in which the pus burrowed from 
the liver into the bronchi (Osier). They may be readily seen 
with the one-sixth-inch objective and low eye-piece, and can be 
very satisfactorily studied with an immersion lens of one- 
twelfth-inch focus. 
Figure 1.— Changes in an Amceba found in a case of endemic dysentery. 
The changes of shape and production of pseudopodia are 
also the massing and flowing of the granular matter. (Stengel.) gawis- 
Observed for four minutes. 
The amoeba is a pale, somewhat granular protoplasmic mass 
varying in size from 12 micromillimetres to 35 micromillimetres, 
Losch and Kartulis (10 micromillimetres to 20 micromillimetres, 
Osier). It varies in size from five to ten times that of a red 
blood corpuscle. 
At rest the body presents two zones, an outer or mucous-like 
layer and an inner granular matter; the former the translucent 
homogenous ectosarc or motile portion, the latter the granular 
endosarc containing the nucleus, vacuoles and granules as de- 
scribed by Osier. When active the amoeba sends out pseudo- 
podia which are illustrated in figure 1. 
The number of pseudopodia rarely exceeds three or four, 
generally but one or two. The manner of projection of these 
pseudopodia is important and serves in distinguishing the 
organism, in the amoeba coli it is always forward and backward 
in the same line. 
The motion of the pigment granules within the amoeba is a 10 
Hepatic Abscess. 
striking feature; it is dancing, rapid and constant, and resem- 
bles the motions seen in Lavaran’s germ—the plasmodium mala- 
riae. This motion is unceasing until the death of the organism. 
The nucleus measures from 4.8 micromillimetres to 6.8 micro- 
millimetres in diameter and occasionally contains a nucleolus; 
there may be one or as many as ten vacuoles in a single amoeba, 
their size may vary from the most minute to half the size of the 
organism itself. On the other hand these vacuoles may be en- 
tirely absent; this is particularly true of the amoeba found in 
the pus of liver abscess. 
Cunningham has called attention to an encysted form, illus- 
trated in figure 2, A andB. 
These are met with when the surrounding conditions are not 
such as favor the life of the organism, the amoeba is now dor- 
mant, but ready to assume active life. 
The amoeba probably reproduces itself, both by the common 
method of cell division and by sporulation. The latter method 
is illustrated by figure 3. 
Figure 2. 
The evidence at our command to date seems to be strongly in 
favor of the statement that the amoeba bears a direct causative 
relation to the production of liver abscess, as Stengle remarks: 
“ It seems certain that post-dysenteric abscesses result from the 
action of micro-organisms conveyed to the liver by the amoebae, 
and that the organism may play some part in the tissue-de- 
struction,” 
Figure 3.—Sporulation. Hepatic Abscess. 
11 
literature. 
The more recent contributions to the literature of Hepatic 
Abscesses are as follows: 
Bettelheim—Leberabscess. Deutsches Archiv f. Klinische Medi- 
cin, Band XLYIII, Heft 3 v. 4, 1891. 
Pease—Weekly Med. Rev., St. Louis, 1891, XXIII, 243. 
Schmidt—Ueber Leberabscess, Bonn, 1890, J. Bach, Vienna, p. 
43, 8°. 
Altobelli—Boll. de. clin, Milano, 1891, VIII, 58-62. 
Pecokabo—Sicilia Med., Palermo, 1890, 11, 701-724. 
Sale—Med. Press and Girc., London, 1891, n. s. LI, 349. 
Kalendebu—Glinica, Bucuresci, 1891, 11, 37; 61; 85. 
Leo—Arch, de Med. Nav., Par., 1891, LV, 265-277. 
Mackenzie—Tr. Path. Soc., Lond., 1889-90, XLI, 156-160. 
Peybot—Bull, et Mem. Soc. de Ghir., de Par., 1891, n. s.,XVII, 
39-45. 
Redmond—Tr. Royal Acad. Med., Ireland, Dubl., 1890, VIII, 
397-399. 
Villabi—Med. Rec., N. Y., 1891, XXXIX, 522. 
West— Tr. Path. Soc., Lond., 1889-90, XLI, 146-152. 
Gabbiel—Lancet, Lond., 1891, 1, 1149. 
Rho—Gior. Med., d. r., escercito, e/c., Roma, 1891, XXXIX, 
145; 289. 
Bobgeb—Munchen, 1891, Lehmann, p. 19.8°. 
Eichbebo—Med. News, Phila., 1891, LIX, 201-205. 
Mobbis—Lancet, Lond., 1891, II, 175. 
Xibilia—Sicilia Med., Torino-Palermo, 1891, III, 174-194. 
Roughton—Lancet, Lond., 1891, II, 417-419. 
Wilson—North Carolina Med. J., Wilmington, 1891, XXVIII, 
95-97. 
Zubkovski—Russk. Med., St. Petersburg, 1891, XVII, 236- 
239. 
Aubebt—Par., 1891, p. 78, 4°, No. 285. 
Danin—Par., 1891, p. 48, No. 320, 4°. 
Cattle—Lancet, Lond., 1891, II, 804. 
Bboca—Gaz. hebd. de Med., Par, 1891, 2 s., XXVIII, 474- 
476. 
Bebtband—Gaz. hebd. de Med., Par., 1891, 2 s., XVIII, 43; 
54; 65. 
Veillon et Jayle—Gompt. rend. Soc. de Biol., Par. 9, s., 
Ill, 3. 
Cobonado—Progreso Med., Habana, 1890, II, 145-155. 
Douglas—South. M. Rec., Atlanta, 1890, XX, 541-549. 
Simon—Johns Hopkins Hosp. Bull., Baltimore, 1889-90, I, 97. 
Altobelli—Gior. internaz. de sc. Med., Napoli, 1890, 2 s., XII, 
645-649. 
Habden—Tr. Med. Soc., W. Virg., Wheeling, 1890, 757. 
Mibande—Bordeaux, Par., 1890, p. 64, I, diag. 4°, No. 22. 
Leo—Arch, de Med. Nav., Par., 1890, LIV., 427-445. 
Shattuck—Boston Med. and Surg. Jour., 1891, CXXIV, 3-5 
145; 289. 12 
Hepatic Abscess. 
Toukniee—Province, Med., Lyon, 1890, IV., 566. 
McConnell—Montreal Med. Jour., Dec., 1891. 
The literature of Amoeba Coli is as follows: 
Stengle—Med. News, Nov. 15, 1890. 
XJniv. Med. Mag., Dec. 1891 and Jan., 1892. 
Dock—Daniel’s Texas Med. Journal, Feb., 1891. 
New York Med. Bee., July 4, 1891. 
Lambl—A us dem Franz Joseph Kinderspital in Prag, I Theil. 
Prager Viertel jahrssch f. Prakt. Heilk., Bd., LXI, 
S., 51. 
Lewis—Appendix A. Sixth Annual Keport of the Sanitary 
Commissioner with the Government of India, Cal- 
cutta, 1870. 
Cunningham—Appendix B. Seventh Annual Report of the 
Sanitary Commissioner with the Government 
of India, Calcutta. 
Losch—Arch. Virch. f. Path. Anat., Bd., LXV, 1875. 
Grassi—Gazette Med. Ital., Lomb. 45, 1879. 
Perroncito—I Parasiti, Milan, 1879. 
Koch—Gaffky’s Bericht zur Erf der Cholera, 1883. 
Kartulis—Virch. Arch. f. Path. Anat., Bd., XCIX. 1885. 
Virch. Arch. f. Path. Anat., Bd., CV, 1886. 
Virch. Arch./. Path. Anat., Bd., CXVIII. 
Centralbl.f. Bakt. u.Parasitenk., etc., Bd., II, No.25. 
Gentralbl.f. Bakt.u.Parasitenk., etc. ,Bd.VII,No.25. 
(Abstract) Centralbl. f. Bakt. u. Parasitenk., etc., 
Bd., VII, No. 6,1890. 
Centralbl. f. Bakt. u. Parasitenk., etc., Bd., IX., 
No. 3, 1891. 
Hlava—Zeitsch. d. Boehm. Aerzle in Prag, 1887. 
Abstract in Centralbl. f. Bakt. u. Parasitenk. Bd.,I, 
No. 18. 
Leukart—The Animal Parasitis, Trans, by Hoyle, 1886. 
Massintin—Wratsch, 1889, No. 25. 
Abstract in Centralbt. f. Backt. u. Parasitenk., 
Bd., VI. 
Osler—Centralbt. f. Bakt. u. Parasitenk., Bd., VII, No. 23, 
1890. 
Johns Hopkins Hosp. Bulletin, Vol. I, p. 53, 1890. 
Johns Hopkins Hosp. Bulletin, Vol. I, p. 90, 1890. 
Lafleur—Johns Hopkins Hosp. Bulletin, Vol. I, p. 91, 1890. 
Johns Hopkins Hosp. Bulletin, Vol. II, 1891. 
Simon—Johns Hopkins Hosp. Bulletin, Vol. I, 1890. 
Musser—University Medical Magazine, Dec., 1890. 
Councilman—Journ. Am. Med. Assoc., June 6, 1891. 
Eichberg—Med. Neivs, Aug. 22, 1891. 
Wasdin—Medical News, 1891, Vol. LIX, No. 23. 
Editorial—Med. News, July 25, 1891. 
Councilman and Lafleur—Johns Hopkins Hospital Reports, 
Nos. VII, VIII and IX with six plates. PRIVATE HOSPITAL, 
San Diego, California. 
DR. WILLIAM A. KRWARRS. 
"The strongest testimonial that a man can present is the 
opinion of his neighbor."—Emerson. 
-KEFEKEMCES 
HORATIO C. WOOD, M. D., LL. D., Philadelphia, Prof, of Therapeutics and 
Clinical Prof. Diseases of the Nervous System, Univ. of Pennsylvania. 
WILLIAM PEPPER, M. D., LL. D., Philadelphia, Provost and Prof, of Theory 
and Practice of Medicine, Univ. of Pennsylvania. 
GEORGE E. DeSCHWEINITZ, A. M., M. D., Philadelphia, Ophthalmic Surgeon to 
the Philadelphia Hosp. and to the Children's Hosp.; Ophthalmologist to the 
Orthopaedic Hosp.; Lecturer on Ophthalmology, Univ. of Pennsylvania. 
' WILLIAM GOODELL, A. M., M. D., Philadelphia, Prof, of Clinical Gynecology, 
Univ. of Pennsylvania. 
J. M. DA COSTA, M. D., LL. D., Philadelphia, Prof, of Theory and Practice of 
Medicine (Emeritus), Jefferson Medical Coll. 
CHARLES K. MILLS, M. D., Philadelphia, Prof, of Dis. of Mind and Nerv. Syst., 
Phila. Polyclinic and Coll, for Grad, in Medicine; Lecturer on Mental Diseases, 
Univ. of Pennsylvania. ♦ 
WILLIAM OSLER, M. D., Baltimore, Prof, of Theory and Practice of Medicine, 
Johns Hopkins Hosp. 
HOW ARD A. KELLEY, M. D., Baltimore, Gynecologist, and Obstetrician to the 
Johns Hopkins Hosp. 
F. FORCHIIEIMER, M. D., Cincinnati, Prof, of Physiology and Clinical Dis. ot 
Children, Medical Coll, of Ohio. 
JOHN M. KEATING, A. M., M. D., Philadelphia, Visiting Obstetrician to the Phila. 
Hosp.; Gynecologist, to St. Joseph's Hosp., Edit. Cyclop. Dis. of Children, etc. 
MARCUS P. HATFIELD, M. D., Chicago, Trof. Dis. of Children, Chicago Medical 
College. • 
T. M. ROTCH, M. D., Boston, ASs’t Prof. Dis. of Children, Harvard Univ. 
R. A. KINLOCH, M. D., Prof, of Surgery, Medical Coll. State of South Carolina, 
Charleston, S. C. 
I. N. LOVE, M. D., Consulting Phys. to Dept. Dis. of Children, City Hosp., 
St. Louis, Mo. 
A VAN DEVEFR, M. D., Prof. Didactic, Abdominal and Clinical Surgery, Albany 
Medical Coll. 
ALFRED L. LOOMIS, M. D., LL. D., Prof. Pathology and Practice of Medicine, 
Univ. of City of New York. 
JOSEPH O. HIRSCHFELDER, M. D., Prof. Clinical Medicine, Cooper Medical 
Coll., San Francisco, Cal. 
HARRY M. SHERMAN, A. M., M. D., Prof. Surgery, San Francisco Polyclinic. 
A. D. BLACKADER, M. D., Instructor Dis. of Children, McGill Univ., Montreal, 
Canada. 
THOMAS MORE MADDEN, M. D., F. R. C. S., Dublin, Ireland ; Obstetric Physi- 
cian to Mater. Misericordiae Hosp.; formerly Examiner in Obstetrics and 
Diseases of Women and Children, Queen’s Univ. 
ARTHUR ERNEST SANSOM, M. D., F. R. C. P., London, England, Physician to 
London Hosp.; consulting Physician and Vice-President to Northeastern Hosp. 
for Children. 
J. MITCHELL BRUCE, M. D., F. R. C. P., London, England, Physician and Lect- 
urer on Therapeutics, Charing Cross Hosp. 
FOR FURTHER PARTICULARS COMMUNICATE WITH SUPERINTENDENT.