Amœbic Abscess of the Liver: Its Diagnosis and Treatment. A Clinical Study

LOOKING back upon practice in tropical medicine over the last eleven years in this country, no more interesting clinical problem presents itself than the diagnosis and treatment of liver abscess. To a great extent this is a clinical study in which symptoms and signs must be relied upon to give a clue to diagnosis arid in which little help may be obtained from the laboratory. It is generally stated that since the introduction of emetine therapy the incidence of liver abscess has become extremely rare as a sequela of amoebic dysentery, but I do not consider that hepatic amoebiasis has necessarily become a negligible factor in tropical practice. In my experience cases of liver abscess crop up regularly, often unexpectedly, and thereby often afford a clinical study of the greatest initerest. There are many reasons why this is so. Firstly, these cases present the wi(dest range in their clinical manifestations. In one case the diagnosis of liver abscess may be quite obvious, in the next it may be so obscure that the abscess reveals itself eventually on the post-mortem table. In order to avoid catastrophes such as these, one should always carry, as Manson said, the diagnosis of liver abscess at the back of the head. Secondly, hepatic suppuration may commence many years (as long as 20) after leaving the tropics, and a long period may intervene since actual dysenteric symptoms were noted. So that a history of previous dysentery is often difficult or impossible to obtain. Likewise it is necessary to point out that definite association with Entamceba histolytica can usually be inferred, not always definitely proved. Enumeration of the signs and symptoms of liver abscess shows that there are numerous points to guide us in our diagnosis and it is a curious commentary that though they may be so numerous and striking, and may all be present in the same patient, yet they may all be absent and the disease may have to be diagnosed by a process of elimination in the absence of any clinical signs at all. The symptoms of amoebic abscess are as-follows: Emaciation, general malaise, anorexia, continued pyrexia, profuse night sweats, pain. deep and superficial tenderness over the hepatic area, a sense of heaviness over the liver, sometimes a feeling of uneasiness, and in many instances this curious shoulder-pain-which is obviously referred from the diaphragm-of which I shall have more to say. The diagnostic signs are many. There is, for instance, the peculiar hepatic facies-the mud(dy tinge of the complexion, of which so much has been made-the rough and inelastic skin, the increase of dullness over the hepatic area-the displacement of the heart, upwards or outwards, that "asses' bridge" of tropical medicine-those peculiar signs of compression or infiltration at the base of the lung, usually the rigbt, corresponding to the site of the abscess. Local cedema of the chest wall with