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question worth considering, namely, the shortest and the usual time 
elapsing between the development of the intestinal infection and the 
formation of the abscess. It has already been shown in previous papers 
that the appearance of diarrhoea and of other dysenteric symptoms bears 
little relation to the actual duration of the intestinal disease, and similar 
conclusions are true of the liver infection. The course of the disease, 
as will presently be shown, is slow and the diagnosis of uncomplicated 
abscesses is not usually possible at an early period. 
The course and termination of ameebic liver abscess are both most 
certainly influenced by the bacteria which may be present therein. 
Multiple abscesses showing combined amoebic and bacterial infection, 
develop quite rapidly, and they usually terminate without perforation 
in the death of the patient, with a septic temperature. The same type 
when it is of purely ameebic etiology, has a slower course, the toxemia 
is not so great, and patients often die of intercurrent trouble, with or 
without perforation of the abscess. In large single abscesses the course 
is still more chronic than in the latter case, and here also bacterial 
infection influences the variation and the outcome. It is undoubtedly 
true that, at times, patients having large, single ameebic abscesses of the 
liver remain in fair general health for several years. 
Ameebic abscesses in general terminate in several ways. Where bac- 
teria are associated with amcebe, death may result from sepsis. A 
general amyloid condition is sometimes encountered at autopsy, as a result 
of the chronic sub-intoxication often seen as a sequel of large abscesses. 
Single ones are sometimes arrested and encapsulated, and may only be 
discovered at autopsy, years afterwards, or again they may completely 
heal. However, perforation is the most common termination, particularly 
of single abscesses, or of cases in which there are only a few large ones 
present and this may take place either externally or into any of the con- 
tiguous structures. By far the most frequent perforations are into the 
right lung or pleural cavity or into both. However, empyema of the left 
side, or pulmonitis may also occur, and this must be borne in mind as a 
possible favorable termination of abscess in the left lobe of the liver. 
The diagnosis of abscess in this location is much more difficult than 
when it occurs in other situations and surgical intervention is less likely ; 
therefore, a larger percentage of these abscesses ruptures than of those 
of the right lobe. Perforations also occur into the abdominal cavity, 
intestine, stomach, vena cava, pericardium, retroperitoneal tissues, psoas 
muscle, kidney, urinary bladder, gall bladder, or spleen. I saw one 
case in the Army and Navy Hospital, Hot Springs, Arkansas, with per- 
foration into the right pleural cavity, right lung, and externally through 
the skin. This patient recovered. 
Symptoms and diagnosis.—The clinical picture varies greatly. Some- 
times a large abscess may develop but slight symptoms and the diagnosis 
is not always possible even by exploratory puncture; however, in the 
