REMARKS ON 
Abscess of the Liver. 
KY 
J. MARION STMS, M. D., LL*. D., 
NEW YORK, 
Ex-President American Medical Association; Honorary Fellow of the Medical 
Society of Virginia, etc. REMARKS 
ABSCESS OF THE LIVER, 
•ON 
Made before the Medical Society of Virginia, at 
its Tenth Annual Session, 
HELD AT 
ALEXANDRIA, OCTOBER 23th, 1&7$> 
By J. MARION SIMS, M. D., LL. D., 
Ex-Prest Amer. Med. Association; H«®n. Fel. of the Med. Society 
Mr. President: I have a word to say on abscess of the liver. I 
have only recently given the subject a moment’s thought. On r«y 
return from Europe a few weeks ago, I found that Dr. Hammond, 
of New York, had written some articles on it, which had elicited 
discussion and drawn out adverse criticism. 
Hammond, in common with preceding authors, tells us that ab- 
scess of the liver may exist without giving rise to any characteristic 
general or local symptoms. 
Dr. Hammond’s attention was first drawn specially to this subject 
a few years ago by a patient of his (with spinal paralysis) falling 
out of bed and striking the right side against a wooden bucket. 
After a while, the patient complained of some gastric derangement 
and pain occasionally in the right shoulder. But the most marked 
symptom was hypochondria. There was no decided pain in the 
liver, and no enlargement of the organ. Dr. Hammond thought he 
detected slight fluctuation, but was by no means certain of it. 
However, he determined to aspirate the liver. He did so, and evac- 
uated fifteen ounces and a half of pus. 
The general health and mental condition of the patient at once 
improved, and he remained well after this, suffering only from pa- 
ralysis. 
In April, 1876, Dr. Hammond saw another case, where he was 2 
led to believe there was abscess of the liver, not because there were 
any local evidences of it, but because of the mental and moral con- 
dition of the patient. There was no pain in the liver ; no enlarge- 
ment of the hepatic region ; no tenderness on pressure, and he was 
not sure there was fluctuation. Knowing that aspiration, properly 
performed, was a harmless operation, he did it on the 16th of 
August, 1866, and removed eight and a half ounces of pus. The 
mental symptoms disappeared at once, and his patient was perma- 
nently restored to health. 
From this time, Dr. Hammond began to-associate abscess of the 
liver with hypermmia of the brain, depression of spirits, hypochon- 
dria, insomnia, and unpleasant dreams, with occasional gastric de- 
rangement. Guided by brain symptoms alone, Dr. Hammond has 
repeatedly aspirated the liver where there were no physical signs of 
disease and evacuated pus. But in the majority of cases, he has 
detected the presence of pus by palpation—in some where there was 
no seeming enlargement of the organ, and no pain on pressure. 
Some writers have severely criticized Dr. Hammond’s views on 
this subject, and I am sorry to say a few have doubted the correct- 
ness of his reports. 
A case of this sort came under my observation in Paris some six, 
or eight months ago. T. G. Si, of Rhode Island., came from Nice 
to Park to see me. saying he bad been aspirated by Dr. Hammond 
before leaving, home for abscess of the liver, and that be feared the 
abscess had refilled. I called I>r. Brown-Sequard in consultation r 
and turned the case over to him. On minute examination', my 
friend,Brown-Sequard, did not hesitate to say that Mr. S. had never 
had abscess of the liver at all, and that there must be some mistake 
in the history Mr.. S. gave us. Since my return home, I have taken 
pains tO'get the history of this case from Dr. Hammond. 
Mr. S. is 48 years of age,, and was engaged in an immense busi- 
ness, which overworked a naturally strong constitution, mental and 
physical. He had pain in the head, vertigo, wakefulness, mental 
depression, dyspepsia, and other symptoms of eerebral hyperseraia. 
He gradually went from bad to worse, till his condition became deplo- 
rable. His mind was morbid to the last degree. He lost all interest 
in life, and was full of the most gloomy apprehensions in regard to 
himself. He could nut concentrate his mind on any subject, and 
passed whole nights without sleeping. He was sure he would either 
die or go to a mad-house. At last,Dr. Hammond began to suspect 
abscess of the liver. He examined- the abdomen thoroughly, but 
could detect no signs of liver disease. But guided by the hypo- 
DIAGNOSIS OF ABSCESS OF THE LIVEK BY SYMPTOMS OF CEREBRAL HYPEREMIA. 
3 
chondriaeal state, he determined to aspirate the liver ; and on the 
10th of May, 1878, he did so in the presence of Dr. Clinton Wagner 
and Dr. Olden, Surgeon U. S. Army. 
Dr. Wagner, Dr. Olden and Dr. Hammond all failed to find any 
local signs of abscess. “ But,” says Dr. Hammond, “ taking into 
consideration the results of my former experience, recognizing the 
intimate relation existing between the liver and the brain, and the 
comparative freedom from danger of aspiration, when properly per- 
formed, these gentlemen (Wagner and Olden) said nothing to dis- 
suade us from the attempt l proposed to make.” He did the ope- 
ration, and obtained “ nine ounces of light, yellow, creamy-looking 
pus, devoid of any marked odor.” The night after this operation 
was passed in sleep for the first time in several weeks. 
Mr. S. improved greatly in health, and went abroad. When I 
saw him in Paris, he suspected a return of the abscess, simply on 
account of relapse of his mental condition. He was examined, as 
before said, by Brown-Sequard and myself, and we gave him the 
positive opinion that he had no abscess. 
Now, Mr. President, I come to speak of a case in which we all 
feel, not only a scientific, but a deep personal interest. A gentleman 
—well known to most of you personally, and to all of you by repu- 
tation—engaged in the arduous duties of a journalist, and professor 
in a medical college, having lived all his life in a malarious regiou, 
was suddenly stricken with fever in August, 1878. Up to this time, 
he had enjoyed apparently good health, but had been much over- 
worked. The fever was of a remittent type, with a tendency to 
congestion of the brain, but it did not yield to the ordinary reme- 
dies ; and at the end of four weeks he was taken from his home to 
a mountain region. Here he gradually improved, and, in Novem- 
ber, he returned home and began the Winter Course of Lectures. 
During the second lecture, he was taken with convulsions, and was 
obliged to resign his professorial chair. During the winter, he was 
completely invalided. The prominent symptoms were congestion of 
the brain, insomnia and great depression of spirits. In the month 
of March, 1879, he became anxious concerning his own condition, 
and looked forward with great despondency to the future. 
In the month of June, he went to Staunton, Va., where he re- 
mained a month, and was somewhat improved. From there he 
went to the White Sulphur Springs, in West Virginia, where he 
remained two months, but was not the least benefitted. He 
there met many of his old medical friends from this and other 
parts of the South. Many of them feeling a great personal interest 4 
DIAGNOSIS OF ABSCESS OF THE LIVER 
in him, investigated his case minutely, but were unable to afford 
him any relief. 
Early in October he came to New York, still complaining of his 
head, daily paroxysms of fever, complete insomnia, and great de- 
pression of spirits. I saw him, and called in consultation one of our 
most eminent physicians, who, after a thorough examination, de- 
clared his case to be one of profound malarial poisoning. He ad- 
vised him to give up his former residence, and go to a mountain 
region, where there are no causes for malaria. Not being able to 
do this, he concluded to remain in New York. A week passed and 
he was no better. I then called Dr. Wm. A. Hammond to see him. 
Judging from the brain symptoms alone, “he thought it was a case 
of abscess of the liver.” On examination, his liver was found to be 
a little enlarged; and by palpation, he was able to detect fluctua- 
tion, and to say positively that there was an abscess in the right 
lobe of the liver. 
His method of determining this was very simple. He placed the 
patient on the back, put the points of the index and middle fingers 
of the left hand between the eighth and ninth ribs, a little in ad- 
vance of a line falling from the middle of the axilla. Then, by 
gentle tapping or percussion at a point about two inches above the 
umbilicus, and a little to the right of the middle line, fluctuation 
was detected by the fingers of the left hand. I immediately imitated 
his process, and thought that the motion felt by the left hand was 
due to the impulse of the liver alone against the ribs. However, I 
have examined other cases since where the liver was supposed to be 
healthy, and could not produce a similar sensation to that found in 
this case. Dr. Hammond’s practised touch enabled him to say 
positively that there was fluctuation in this case, and therefore an 
abscess. 
On the following day, he verified his diagnosis by aspiration, and 
drew off eight and a half ounces of pus, a specimen of which I now 
show you. I hope you will appoint some expert to examine and 
report upon it.* 
After this operation, our patient had a good night’s rest, the first 
for a very long time; and judging from Dr. Hammond’s experience t 
*This specimen of pus was handed over to Dr. Robert C. Powell, of Alexan- 
dria, Va., who promised to have it examined, etc. The following letter was duly 
received by the Recording Secretary : 
“Alexandria, Va., October 26th, 1879. 
“ Dear Doctor,—I am sorry that the microscopic examination of the pus left by 
Dr. Sims at our late meeting does not furnish anything interesting. It had been BY SYMPTOMS OF CEREBRAL IIYPERiEMIA. 
5 
we have a right to expect that he will be again soon restored to 
health and usefulness. 
Many of you will be surprised, and all of you will feel special 
interest in the case, when I tell you that the subject of this operation 
was Dr. E. S. Gaillard, lately of Louisville, Kentucky. 
Dr. Hammond has aspirated the liver for abscess twenty-six 
times within the last two years. In fifteen cases he evacuated ab- 
scesses and effected cures. In eleven cases the operation was un- 
successful, but attended with no ill effects whatever.* 
Dr. Hammond passes the aspirating needle through the inter- 
costal space between the eighth and ninth ribs, at a point about an 
inch in advance of a line drawn from the axilla to the pelvis. In 
very nervous subjects, he administers an anaesthetic. In very many 
he deadens the sensibility of the skin by the application of ice and 
salt. Everything being ready for operation, he pulls the skin up 
for an inch over the point to be punctured, so as to make a valvular 
opening ; and then thrusts the needle, previously antisepticised with 
carbolic oil, into the substance of the liver, from the depth of one 
and a half to two and a half inches. If, at the depth of two and a 
half inches, matter does not appear, then there is no abscess in the 
right lobe of the liver. 
Abscesses exist sometimes in the left lobe of the liver, but far 
more frequently in the right. 
All of Dr. Hammond’s cases (except two—one in Western New 
York, and one in Rhode Island) have been residents of malarious 
districts, either in the South or West. 
Abscesses of the liver have been long before this recognized and 
treated by operation. In tropical climates, it is very frequent. But 
so long drawn from the abscess, that the corpuscles were broken down by disin- 
tegration, and it was difficult to get a view of a perfect one. Besides the debris 
of pus corpuscles, the fluid contained a large number of hepatic cells, imbedded 
in which were oil globules. But this fact does not prove fatty degeneration of 
the liver, except that portion of it in contact with the abscess. There was also 
some blue coloring matter in the pus, which was doubtless derived from what the 
bottle contained previous to holding the pus, as it was neither indican nor the 
blue opalescence produced by vibriones; it was probably some ferric salt.” 
Yours truly, R. C. Powell. 
P. S.—The examination of the pus was made by Dr. J. J. Woodward, of Wash- 
ington, D. C., with ‘Ross’ large compound microscope,’ with a magnifying power 
of 500 diameters. Very few objects can escape such an instrument as that. 
R. C. P. 
*Jn one case there were two abscesses separated from each other by a seeming- 
ly narrow partition. In one, there was pure pus in small quantity; in the other, 
there was a larger quantity of decomposed pus, with broken down liver tissue; 
All of them were in the right lobe of the liver, and all punctured between the 
eighth and ninth, or ninth and tenth ribs. DIAGNOSIS OF ABSCESS OF THE LIVER. 
I believe that Dr. Hammond is the first man who has associated 
abscess of the liver with “ cerebral hypersemia.” 
In an admirable paper on this subject, read before the New York 
Neurological Society, June 3d, 1878, and published in the June 
number of the St. Louis Clinical Record, for 1878, Dr. Hammond 
formulates the following propositions: 
1st. That hepatic abscesses are probably much more common 
with us than is generally supposed. 
2d. That they may exist without any local symptoms, or such 
general disturbance of the system as is commonly regarded as indi- 
cating their presence. 
3d. That they may be associated with hypochondria and other 
evidences of cerebral disturbance. 
4th. That they should be opened at the earliest possible moment, 
and without waiting for adhesions to form between the liver and the 
abdominal wall. 
5th. That the proper place for performing the operation of aspi- 
ration is in one of the intercostal spaces. This point is strongly in- 
sisted upon by Dr. Davis in his memoir. 
6th. That the operation by aspiration is free from danger. Dr- 
Davis never saw any ill consequences from it, and Dr. Jiminez, of 
Mexico, states, that of the hundreds of times he has punctured the 
liver through the intercostal spaces for abscess, he has never once 
seen the operation followed by peritonitis. In a very admirable 
paper, Dr. Lansky, of New York, expresses like opinion. 
8th. That in all cases of hypochondria or melancholia, the region 
of the liver should be carefully explored; and that even if no fluc- 
tuation be detected, or any other sign of abscess be discovered, as- 
piration—being a harmless operation—should be performed. 
8th. That if the pus be evacuated, the operation may be expected 
to be followed by a cure of the mental disorder as well as by the 
preservation of the life of the patient from the probably fatal con- 
sequences of hepatic abscess. 
9th. That if no abscess be found, the patient will, at least, be no 
worse off than be was before.