108 REVIEW — TROPICAL MEDICINE, ETC. 



Liver than 20 to 40 grains once or twice a day, with the usual precautions), may rapidly abort an 



Abscess— early pre-suppurative amoebic hepatitis by curing the latent amoebic dysentery which 

 contiiuKd produces it. 



Stannus' has recently reported an African case similar to those described by Eogers. 

 It occurred in Nyasaland and was rapidly cured by ipecacuanha given in 20 grain doses on 

 two consecutive days. 



Rogers and Wilson- describe two cases of amoebic abscess of liver cured by aspiration 

 and injection of quinine into the cavity without drainage. In the first place, Eogers 

 mentions his previous work,^ which demonstrated that : — 



1. Living amcebas can be found in the walls of every case of tropical abscess of the liver examined at the 

 time of or shortly after operation, as well as post mortem, if they have not been previously drained for some days. 



2. Two-thirds of tropical abscesses of the liver seen in Calcutta are free from staphylococci and bacteria 

 when first opened, even in the late stage of the disease so commonly met with in native patients, while, as a 

 matter of fact, in nearly half of the remaining cases, but one or two colonies of cocci were obtained on culture, 

 which were probably accidental contaminations or at least played no part in the causation of the disease. 



3. The active amoebaj in the wall of a liver abscess could be killed with great rapidity and certainty by 

 weak solutions of quinine, and when such solutions are used for washing out liver abscess cavities which are 

 discharging thick pus swarming with amcebae, these parasites very r.apidly disappear, and the discharge becomes 

 much less copious and almost serous in character, as long as it remains fi-ee from septic cocci. 



The form of quinine recommended is the soluble bi-hydrochlorate. Two solutions are 

 made up, each containing 30 grains, but in one this amount is dissolved in 2 oz. of water 

 and in the other in 4 oz. The former is used if the abscess contain less than 10 oz. of pus, 

 and the latter if it be larger, because the greater quantity of fluid enables the drug to be 

 brought into contact with all parts of the cavity. It is admitted that two cases do not 

 furnish sufficient material on which to base any conclusions, but the cases were of such a 

 nature that it is very unlikely that aspiration alone would have resulted in cure. The first 

 case was very acute, the second very chronic. 



Cantlie' deals with liver abscess from the surgeon's point of view. After stating that 

 supra-hepatic abscesses seldom give a history of dysentery, nor show bowel lesions post 

 mortem, that intra-hepatic abscesses are always associated with, and probably caused by, 

 dysentery, and that sub-hepatic abscesses are not due to dysentery, he proceeds to indicate 

 what in his opinion is the appropriate operation for pus in various positions. He says : — 



The operation I prefer {a) when pus is deep-seated over or in the right half of the liver, is evacuation by 

 siphonage, the siphon tube being introduced through a cannula. Search is made first by the needle of an 

 aspirating syringe — in length not more that 3i in., so as to avoid wounding the inferior vena cava. Where the pus 

 is localised a large trocar and cannula is introduced trans-thoracically ; the trocar is withdrawn, and a drainage 

 tube, 12 in. long, stretched on a long steel rod, introduced through the cannula to the bottom of the cavity. The 

 cannula is then withdrawn over the tube whilst it is still stretched, the steel rod by which it is stretched is also 

 withdrawn, and a long rubber tube fitted to the drainage tube protruding from the side by means of a short glass 

 tube. The siphonage is kept up until the pus ceases to flow, or until bile appears in the discharge. The original 

 tube is then removed from the side, and a shorter and smaller tube suljstituted. The wound is gradually allowed 

 to close. (6) When the pus is superficial — that is, close beneath the right ribs, an advanced condition, a hepatic 

 abscess should never be allowed to attain — the trocar and cannula and siphonage may be used, or the abscess may 

 be cut down upon by a scalpel. The removal of a piece of rib may or may not be necessary. If the knife happen 

 to enter the lowest point of the abscess cavity, removal of a piece of rib is unnecessary ; but, if not, it is well to do 

 80. (c) When the pus is in the left halt of the liver — a rather rare occurrence — do not attempt to confirm the 

 diagnosis by introducing an exploratory needle, nor use the trocar or cannula, but cut down upon the liver through 

 the abdominal wall and evacuate the pus in the usual way. In 90 of the 100 cases I have operated upon I employed 

 the trocar and cannula and siphonage method of treatment ; and from a long experience I look upon this method 

 of treating deep-seated liver abscesses of the right half of the organ as not only the most easy of performance (an 

 important point if one is single-handed, as one is in many tropical countries) and most successful, but the only 

 justifiable operation when the pus is deep seated in the right side, that is, three or more inches from the surface. 



Bradshaw''' relates an interesting case of tropical liver abscess associated with ascites, 

 a rare condition and one which tends to confuse the diagnosis. He mentions certain 

 points which, though well known, are apt to be forgotten. One is that a normal temperature 

 may be present for days together in patients with abscess of the liver. Another, that one 



1 Stannus, H. S. (July 4th, 1908), " A Note on Latent Dysentery in Central Africa." Lancet, Vol. II. 



••' Rogers, L., and Wilson, R. (June 16th, 1906), "Two Cases of Amcebic Abscess of Liver." British Medical 

 Journal, p. 1397, Vol. I. 



' British Medical Journal, September 20th, 1902. 



'' Cantlie, J. (November 9th, 1907), "One Hundred Cases of Liver Abscess." British Medical Journal, 

 p. 1342, Vol. II. 



^ Bradshaw, T. R. (January 18th, 1908), "A Clinical Lecture on Tropical Abscess of the Liver." Lancet, 

 p. 146, Vol. I. 



