A CASE OF ABSCESS OF THE LIVER FOLLOWING 
AMCEBIC DYSENTERY: 
WITH REMARKS. 
BY 
J. H. MUSSER, M.D., 
ASSISTANT PROFESSOR OF CLINICAL MEDICINE, UNIVERSITY OF PENNSYLVANIA ; PHYSICIAN 
TO THE PHILADELPHIA AND THE PRESBYTERIAN HOSPITALS ; 
AND 
DEFOREST WILLARD/ 
SURGEON TO THE PRESBYTERIAN HOSPITAL ; PROFESSOR OF OKS«ip.^Sl-»aERY, 
UNIVERSITY OF PENNSYLVANIA 
REPRINTED FROM THE TRANSACTIONS 
OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY, 
1893. A CASE OF ABSCESS OF THE LIVER FOLLOWING 
AMCEBIC DYSENTERY: WITH REMARKS. 
By J. H. MUSSER, M.D., 
ASSISTANT PROFESSOR OF CLINICAL MEDICINE, UNIVERSITY OF PENNSYLVANIA ; PHYSICIAN 
TO THE PHILADELPHIA AND THE PRESRYTERIAN HOSPITALS ; 
AND 
DEFOREST WILLARD, M.D., 
SURGEON TO THE PRESBYTERIAN HOSPITAL; PROFESSOR OF ORTHOPEDIC SURGERY, 
UNIVERSITY OF PENNSYLVANIA. 
[Read February 22, 1893.] 
The patient, a male, aged thirty-one years, white, galvanizer by occupation, 
was admitted to the wards of the Presbyterian Hospital on the 16th of 
November last. He sought the hospital on account of prostration following 
an attack of dysentery. It appears that throughout the entire summer he 
had been ailing. He lost his appetite, and was dull and depressed in spirits. 
He had little aptitude for exertion, and observed that his bowels were irreg- 
ular, constipation alternating with diarrhoea. At the same time he felt con- 
siderable soreness in the loins when lying down. Vertigo troubled him very 
much. The symptoms increased in severity and seemed to culminate in an 
attack of dysentery seven weeks prior to admission. The attack was, clinically, 
like that of the amoebic variety. The stools were bloody, contained mucus, 
and were discharged with tormina and tenesmus. During the seven weeks of 
illness he had several exacerbations, each followed by an amelioration of 
symptoms. Four weeks ago vesical tenesmus began, with frequent micturition. 
Three days prior to admission the diarrhoea ceased. 
Before detailing the state of the patient at the time of admission, it may be 
well to remark that he resided in this city in a most unsanitary neighborhood, 
and had been accustomed to drink water from the usual city supply. 
For possible aid in the diagnosis we further gleaned from the patient that 
he was a widower, the father of five healthy children, that he had smallpox, 
besides the usual diseases of childhood, and typhoid fever at twenty-one; 
that his personal history regarding habits, etc., was good, and that he never 
had any venereal disease. His mother, one sister and three brothers are in 
good health. The father died of some gastric affection, and two sisters of 
phthisis florida. The grandparents of the previous generation were very 
healthy. 
On admission the patient was very weak, emaciated, and pale. 
The anaemia was striking, and on examination of the blood it was found so 2 
MUSSER, WILLARD, 
reduced that only 2,800,000 red corpuscles were counted in a c.mm., with pro- 
portionate decrease of the white corpuscles. The patient was so weak as to be 
compelled to remain in bed. He weighed thirty pounds less than in health. 
The cerebro spinal system was free from disease. He had no appetite, but a 
furred tongue and some flatulent dyspepsia. His bowels had not been moved 
for twenty-four hours. An enema was necessary to relieve the impaction. 
No mucus was passed. The abdomen was not distended. The liver and 
spleen were not enlarged. 
The lungs were normal. At the pulmonary and mitral areas systolic mur- 
murs, low in pitch, were heard, due to anaemia. Murmurs from similar cause 
were heard in the vessels of the neck. The urine was abundant, of low 
specific gravity, and did not contain pathological elements. 
Diagnosis : anaemia following dysentery. 
With rest and careful feeding, strength returned and the color improved. 
On December 1st the patient began to complain of pain in the lower portion 
of the right chest, anteriorly. It increased in severity and soon became 
localized to an area the size of a half-dollar in the seventh interspace, anterior 
axillary line. On account of its severity, the patient was compelled to lie on 
his back. Movement increased the pain, after a short time, and lying on the 
left side or sitting in the erect position caused agony. The liver was enlarged 
upward. The upper limit of dulness was found at the fifth rib anteriorly. 
The lower border could not be felt, and on percussion the limit of dulness was 
not beyond the edge of the ribs. 
The remaining organs were normal. The cardiac and vascular murmurs 
had lessened and the blood increased in richness to 3,800,000 red corpuscles 
per c.mm. Appetite remained poor, and there was constipation. Has gained 
in flesh and strength. 
1th. Pain has continued in spite of blisters and other external applications. 
Morphine was required. The liver continued to enlarge. The upper border of 
the liver in the mid-clavicular line begins in the fourth interspace, in the 
axillary region in the fifth interspace, and posteriorly, one inch below angle of 
scapula. The hepatic region has increased in size, but there is no local 
bulging. The lower right chest does not expand freely as compared with the 
left. There are no friction sounds or signs of pleural effusion. Anaemia much 
improved, and patient has gained flesh. There has been no fever but occa- 
sional sweats. Appetite not improved. 
15fA. Pain not relieved. Liver about the same size. The upper limit of 
dulness is not movable. The organ does not extend beyond the margin of the 
ribs. When the patient turns on the left side the extent of dulness lessens in 
the axillary region, and is found between the fifth and seventh ribs. On his 
back the lower border of dulness extends to the margin of the ribs. The 
dulness begins at the ninth rib, in mid-scapular line. Appetite poor. No 
fever. Strength greater. With a fine hypodermatic needle introduced in 
anterior axillary line in seventh interspace, pus was withdrawn. Admitted to 
surgical ward. 
During the time the patient was in the hospital ward, the stools were not 
studied because of the absence of mucus or any material likely to contain 
amoebae. In fact, constipation had to be combated. Nevertheless, the 
diagnosis of abscess of the liver secondary to dysentery was made because of ABSCESS OF THE LIVER. 
3 
this possible sequence, and because of painful enlargement of the organ-an 
enlargement that could not be satisfactorily explained by any other patho- 
logical process. Persistent poor appetite, in spite of improvement in general 
health, was also believed to be significant of the presence of pus. 
The above conclusion was arrived at notwithstanding the absence 
of fever. The interesting features of the case are worthy of consid- 
eration seriatim. 
1. Improvement in general health in spite of the extensive sup- 
puration. This seemed to the writer remarkable. The blood-count 
showed improvement; the weight and strength increased. If to 
this is added the absence of fever (considered in the next paragraph), it 
is seen that the general phenomena did not indicate the gravity of 
the local process. 
2. Fever. The absence of fever is worthy of comment. The 
temperature did not vary from the normal during the entire time in 
the medical ward. At different periods a two-hour temperature 
observation was taken, with negative results. Rigors were never 
present, and slight sweats only occasionally noticed. The latter 
were not sufficiently pronounced to be suggestive. 
3. Loss of appetite. The. writer has previously suggested the 
importance of this symptom in obscure cases of suppuration. If the 
loss of appetite can be explained in any other way, as by local gastric 
disorder, it is not noteworthy. But if there is loss of appetite 
without cause, and if such impairment is attended by slight nausea 
or revulsion at the sight of food, or after a few portions are taken, 
it is highly suggestive of suppuration and pus-absorption. The writer 
has seen these relations most strikingly in pelvic disease and suppu- 
ration about the appendix. The symptom is not an indication of 
the seat of pus, but that somewhere pus-formation, with its imprison- 
ment, is in progress. Unexplained loss of appetite, without fever, 
but with failure in health, may serve to explain the nature of a local 
process which does not show any signs of pus. 
4. Pain. At first, on account of the profound anaemia, intercostal 
neuralgia was thought to be the cause of the localized pain. Although 
the anaemia improved, the pain increased in severity and was the 
cause of attention to the liver. The pain was increased by pressure 
and by movement. No localized peritonitis or pleuritis could be 
detected to explain the symptom. Pain in the right shoulder was 
not observed. 
5. Enlargement of the liver and of the affected side. The exten- 
sion of the enlargement upward was of interest. The writer has had 4 
MUSSER, WILLARD, 
the privilege of observing a number of cases of hepatic abscess. In 
all save one the increase in size of the organ was downward, and the 
organ itself, or the portion in which the abscess was situated, could 
be readily outlined below the ribs in the hypochondriac or epigastric 
regions. While there was no distinct localized bulging, an enlarge- 
ment of the right lower half of the chest could easily be detected. 
6. Pleural friction sounds. It may be noted that friction sounds 
and other physical signs of inflammation above the diaphragm were 
absent. This is all the more remarkable because of the close prox- 
imity of the abscess to the diaphragm. 
7. Character of the pus. It partook of the character so well 
described by Councilman and Lafleur, of an anchovy-sauce-like 
fluid. The .amoeba dysenterica was found readily. In addition to 
the usual appearances of purulent fluid and pigment, leucin and 
tyrosin crystals were found in abundance. The case shows that 
amoebic dysentery may arise in this locality. 
Resume: Amoebic dysentery; anaemia; pain in the hepatic region, 
enlargement of the liver upward ; loss of appetite. On exploration, 
pus found. Diagnosis : abscess of the liver. 
Operation.-Admitted to surgical ward December 17, 1892. 
The patient suffers no pain. Temperature normal. Says that he 
feels as well as he ever did in his life. Physical signs as before 
described by Dr. Musser. Large aspirator needle in the seventh 
interspace, at the depth of two and a half inches, secured pus. With- 
drew the trocar and replaced it with a blunt plunger. Camila used 
as a guide to the abscess, and kept in situ until pus was reached 
with the knife. 
An incision, three inches long, was made in the seventh inter- 
space ; three inches of the seventh rib were resected subperiosteally 
without hemorrhage and without opening the pleural cavity. When 
the pleural cavity was opened by an incision, the lung slid upward, 
but there was no great collapse of the lung, nor great depression of 
the patient. The pulse became slightly more rapid, but did not lose 
force. Pressure upon the right ribs permitted only a small amount 
of air to enter the pleural cavity. The pleura was then slit two 
inches. With a long curved needle four catgut sutures were passed 
from the parietal layer of the pleura through the diaphragmatic 
layer, and out again through the parietal layer. Two of these 
stitches were parallel to and a little longer than the wound in the 
pleura; the other two united the two ends of these first sutures well 
beyond the angles of the pleural incision. These stitches enclosed a ABSCESS OF THE LIVER. 
5 
rectangular parallelogram, and were tied separately over the four 
sides surrounding the area of incision, thus closing the pleural cavity 
against air and pus. The stitches were tied lightly, so as to approx- 
imate the two layers of the pleura, and not so tightly as to cut the 
tissues, since adhesive inflammation only was desired. 
With the canula as a guide, the liver was then opened through the 
diaphragm, and a pint of chocolate-colored pus evacuated. The 
cavity was thoroughly washed out with hot distilled water, and a 
large drainage-tube inserted. A finger could be carried round the 
walls of the cavity, but could not detect any softened spots down- 
ward. The finger was unable to reach the bottom of the cavity. 
The wound was packed with sterilized gauze. No hemorrhage 
occurred throughout the operation. The amount of pneumothorax 
was slight. The patient suffered no dyspnoea from ether. His pulse 
and general condition were good. 
Dyspnoea during the remainder of the day and night of operation 
was very marked, but there was but little cough, and no serious 
collapse of the lung. The temperature on the third day was normal. 
There were no signs of pleurisy, and the pneumothorax was dimin- 
ishing. The patient was much stronger. 
On the sixth day he was greatly improved. The quantity of the 
pus steadily decreased. His appetite was good, and his general 
health improved. The drainage-tube was slightly shortened at every 
dressing, and was removed entirely at the end of the fifth week. 
The patient had no bad symptoms whatever during the course of the 
treatment. At present writing the discharge of pus amounts only 
to a few drops daily. 
The main interest in this case consists in the route taken to reach 
the pus. The suturing of the two pleural surfaces in contact over a 
parallelogram of tissue so as to prevent infection from entrance of 
air and pus was, in this instance, effective. The prompt adhesion of 
two pleural surfaces brought gently into contact has been illustrated 
by myself in various operations upon the pleura of dogs,1 the adhe- 
sions having taken place, in some instances, within twenty-four 
hours, and in all without pain or evidences of pleurisy. These 
experiments made me hopeful of union in the human subject, and I 
was not disappointed. 
1 " Pneumonotomy and Pneumonectomy," Transactions Philadelphia College of 
Physicians, November, 1892 ; " Intra-thoracic Surgery," Transactions Am. Surg. Assoc., 
1891; University Medical Magazine, February, 1892. 6 
ABSCESS OF THE LIVER. 
One or two points in technique are important. The sub-periosteal 
resection of rib permits late opening of the pleural cavity, which is 
important. After the opening is made, if violent dyspnoea results, 
partial closure of the opening by pressure or a plug of gauze is 
helpful. 
Again, the retention of the canula as a guide to the pus is a 
helpful procedure, since good surgeons have missed a pus collection 
in the liver, even when their incision was within a quarter of an 
inch of it.