xl NOTE ON LIVER
ABSCESS, DYSENTERY
AND THE AMCEBA. By SuRGt.-CAPT. W. J. Buchanan, m.a., m.b., i.m.s.
There is probably no single subject in the whole range of tropical pathology, about which more has been written than the causative relations of abscess of the liver. Accurate descriptions of what is known as,.-fliiiopbic dysentery and amoebic liver abscess being now available, it is worth while very briefly to discuss the whole question of the origin and nature^ of liver abscesses in the hopes of thereby gaining some clear understanding about them. The following statements have the authority of the best reputed writers. (i) Amoebic liver abscess is invariably associated with amoebic dysentery, whether the bowel complaint pre-
166
INDIAN MEDICAL GAZETTE.
accompanies, follows or is only latent in fact the abscess may fairly be looked upon as a somewhat common complication of amoebic dysentery. (ii) What we may provisionally liver abscess may, in tropical call " idiopathic countries, be met with, with or without dysentery. It is an expression of hepatic insufficiency, and the dysentery, when associated with it, is only a strong predisposing factor. (Hi) Dysentery is very common among the native inhabitants of most tropical countries, whereas liver abscess (contrasted with dysentery) is comparatively rare. In India we know how common dysentery in many forms is, among prisoners for instance ; yet among them liver abscess is at least uncommon, and the same is true of many native races elsewhere. (iv) Europeans in India are very liable to liver abscess, (y) Even the very severe forms of dysentery in temperate climates are very rarely followed by liver abscess, e.g., there was not a single case after the many hundred cases of dysentery in the Millbank prison epidemic, and it was very rare in the dysenteries from which our troops suffered in the Crimea. (vi) Portal pysemic or metastatic multiple abscesses may be met with in India from the same causes as in Europe. (vii) There is the remarkable fact that while dysentery and malaria are well known in the West Indies, yet liver abscess is very rare both among Europeans and natives. Take these statements as far as possible separately and in order. Firstly, as regards the amoebic abscess, it may be either single or multiple; it is invariably found in connection with amoebic dysentery. The bowel
cedes,
"
may, however, precede or follow, or be " latent," that is, only found on post-mortem examination. Kartulis, from his large experience in Egypt, claims that though the amoebjB play the principal, yet they do not play the sole, part in the causation of suppurative hepatitis; he considers them rather as the vehicles by which are carried to the liver the micro-organisms which cause the suppuration. They do, however, aid the suppurative process by their active movements, causing rupture of capillaries. On the other hand, Lafleur and Councilman, of the Johns Hopkins University, consider that the amoebae are the direct and active agents in the suppuration. It will also be remembered that amoebae practically indistinguishable from the amoeba of dysentery are also found in healthy intestines, hence the supporters of the amoebic theory are compelled to admit two kinds of intestinal amoebfe (a) the coli. specific one of dysentery, (6) the amoeba " and Councilman Lafleur to dysenAccording teric abscess" of the liver is synonymous " with amoebic abscess." Thej7- also state that amoebic abscess and amoebic dysentery are extremely fatal complaints (operation or no operation); how then do they explain the numerous cases of tropical liver abscess, associated with
complaint may
even
[May
1898.
which have been successfully operated have recovered ? In this case (e'xto fatality) the as hypothesi dysentery could scarcely have been amoebic or death should have ensued; therefore, they must needs admit that the accompanying dysentery could not have been amoebic and, therefore, contrary to their own statement, dysenteric liver abscess which is non-amoebic must exist. Moreover, according to Kartulis of 500 liver abscess cases about 60 per cent, were of dysenteric origin (and accordingly, therefore, amoebic) so that even 011 their own showing the amoebic theorists must admit about 40 per cent, of cases as of nonamoebic origin. Next consider the statement made above, that idiopathic abscess may or may not be connected with dysentery, and that this form of abscess is an expression of hepatic insufficiency. According to Davidson, a hepatitis may end in resolution or may go on to suppuration, forming This a liver abscess of large size, usually single. form is an expression of hepatic insufficiency and is met with in Europeans transferred from a cold to a hot climate in whom the change gives rise to nutritive functional and structural changes in the liver. In Europe a chill means a respiratory catarrh; in a hot climate it results in liver congestion and intestinal catarrh. Congestive liver affections and bowel complaints cause six to ten times as many admissions to hospital among soldiers in India as in Europe. The function of the liver, which is concerned in the transformation of toxins, becomes impaired; the toxins act upon the disabled liver, and in fact in the liver areas of lesser resistance result. In the case of a healthy or "sufficient" liver, some of the micro-organisms which exist in their millions in the bowels may often find their way through even healthy tissues to that organ and are thus destroyed, " but in the insufficient" liver they are not deand excite suppuration. As regards stro}red dysentery, the presence of this disease at once favours the establishment of a locus of minor resistance, and, by the intestinal lesions it causes, facilitates the entrance of pus-producing bacteria into the vena portce. Therefore, above all factors, it is this want of adaptation of the organs of the European to his new tropical environment which renders him so liable to liver abscess. In tropical liver abscess the pathological change is primary and determines the microbic infection, while in pysemic abscess, which of course may occur in the tropics, it is the impaction of minute infective emboli derived from some local focus of suppuration which is the primary lesion. Next consider the statement made above as to the relative commonness of dysentery and liver abscess in natives of tropical countries. As in the case of Europeans in warm climates, we postulate a non-adaptation to environment, so in the
dysentery, upon and
May
FRACTURE OF THE PATELLA
1898.]
of natives we can fairly claim a perfect adaptation, and so they escape the idiopathic abscess. The variety of abscess compared with the universality of dysentery points to the fact that amoebic dysentery must also be rare, for, if otherwise, there should be, ex hypothesi, plenty of liver abscess. If idiopathic and amoebic abscesses are rare in natives of tropical countries, then the cases which do occur must in most instances be of portal pysemic origin. The fact that hepatic abscess is so rare among Europeans in the West Indies and the Straits Settlements, where all the other factors are the same as in India, viz., alcohol, want of exercise, rich food, great heat, &c., certainly must be considered to detract from the value of the " hepatic insufficiency theory of the origin of liver abscess, and, as far as we know, no explanation of tliis strange fact is yet forthcoming. If, therefore, the premises and arguments above set forth are correct, we are led to the following conclusions, that while pysemic abscess of the liver ma}?- occur in India as in Europe the socalled tropical abscess of the liver is of two kinds (1) the amoebic,which is in reality a complication of the comparatively rare amoebic dysentery, and (2) the " idiopathic," due primarily to hepatic insufficienc}' and secondarily to suppurative micro-organisms derived from the intestinal tract which may or may not have dysentery as a powerful cooperating and precedent cause. If this is true, it would not be far wrong to talk of " climatic" abscess of the liver rather than use the absurd, if useful, term idiopathic." Moreover, as even the upholders of the amoebic theory admit the existence of another (non-specific) amoeba in the intestines, whether healthy or otherwise, and as Kartulis inclines to the view that the amcebte are not the cause of suppuration but merely the vehicles for conveying the microbial cause, and, as I have endeavoured to show by my arguments that both amoebic dj^sentery and amoebic abscess must be rare in India, it is clear that after all the amoebte cannot be so powerful a factor in the dysenteries and liver abscesses of India as a perusal of the works of the French and American school would lead us to believe. case
"
"
"
"
:
HATCH.
167
ABSCESS, DYSENTERY
AND THE AMCEBA. By SuRGt.-CAPT. W. J. Buchanan, m.a., m.b., i.m.s.
There is probably no single subject in the whole range of tropical pathology, about which more has been written than the causative relations of abscess of the liver. Accurate descriptions of what is known as,.-fliiiopbic dysentery and amoebic liver abscess being now available, it is worth while very briefly to discuss the whole question of the origin and nature^ of liver abscesses in the hopes of thereby gaining some clear understanding about them. The following statements have the authority of the best reputed writers. (i) Amoebic liver abscess is invariably associated with amoebic dysentery, whether the bowel complaint pre-
166
INDIAN MEDICAL GAZETTE.
accompanies, follows or is only latent in fact the abscess may fairly be looked upon as a somewhat common complication of amoebic dysentery. (ii) What we may provisionally liver abscess may, in tropical call " idiopathic countries, be met with, with or without dysentery. It is an expression of hepatic insufficiency, and the dysentery, when associated with it, is only a strong predisposing factor. (Hi) Dysentery is very common among the native inhabitants of most tropical countries, whereas liver abscess (contrasted with dysentery) is comparatively rare. In India we know how common dysentery in many forms is, among prisoners for instance ; yet among them liver abscess is at least uncommon, and the same is true of many native races elsewhere. (iv) Europeans in India are very liable to liver abscess, (y) Even the very severe forms of dysentery in temperate climates are very rarely followed by liver abscess, e.g., there was not a single case after the many hundred cases of dysentery in the Millbank prison epidemic, and it was very rare in the dysenteries from which our troops suffered in the Crimea. (vi) Portal pysemic or metastatic multiple abscesses may be met with in India from the same causes as in Europe. (vii) There is the remarkable fact that while dysentery and malaria are well known in the West Indies, yet liver abscess is very rare both among Europeans and natives. Take these statements as far as possible separately and in order. Firstly, as regards the amoebic abscess, it may be either single or multiple; it is invariably found in connection with amoebic dysentery. The bowel
cedes,
"
may, however, precede or follow, or be " latent," that is, only found on post-mortem examination. Kartulis, from his large experience in Egypt, claims that though the amoebjB play the principal, yet they do not play the sole, part in the causation of suppurative hepatitis; he considers them rather as the vehicles by which are carried to the liver the micro-organisms which cause the suppuration. They do, however, aid the suppurative process by their active movements, causing rupture of capillaries. On the other hand, Lafleur and Councilman, of the Johns Hopkins University, consider that the amoebae are the direct and active agents in the suppuration. It will also be remembered that amoebae practically indistinguishable from the amoeba of dysentery are also found in healthy intestines, hence the supporters of the amoebic theory are compelled to admit two kinds of intestinal amoebfe (a) the coli. specific one of dysentery, (6) the amoeba " and Councilman Lafleur to dysenAccording teric abscess" of the liver is synonymous " with amoebic abscess." Thej7- also state that amoebic abscess and amoebic dysentery are extremely fatal complaints (operation or no operation); how then do they explain the numerous cases of tropical liver abscess, associated with
complaint may
even
[May
1898.
which have been successfully operated have recovered ? In this case (e'xto fatality) the as hypothesi dysentery could scarcely have been amoebic or death should have ensued; therefore, they must needs admit that the accompanying dysentery could not have been amoebic and, therefore, contrary to their own statement, dysenteric liver abscess which is non-amoebic must exist. Moreover, according to Kartulis of 500 liver abscess cases about 60 per cent, were of dysenteric origin (and accordingly, therefore, amoebic) so that even 011 their own showing the amoebic theorists must admit about 40 per cent, of cases as of nonamoebic origin. Next consider the statement made above, that idiopathic abscess may or may not be connected with dysentery, and that this form of abscess is an expression of hepatic insufficiency. According to Davidson, a hepatitis may end in resolution or may go on to suppuration, forming This a liver abscess of large size, usually single. form is an expression of hepatic insufficiency and is met with in Europeans transferred from a cold to a hot climate in whom the change gives rise to nutritive functional and structural changes in the liver. In Europe a chill means a respiratory catarrh; in a hot climate it results in liver congestion and intestinal catarrh. Congestive liver affections and bowel complaints cause six to ten times as many admissions to hospital among soldiers in India as in Europe. The function of the liver, which is concerned in the transformation of toxins, becomes impaired; the toxins act upon the disabled liver, and in fact in the liver areas of lesser resistance result. In the case of a healthy or "sufficient" liver, some of the micro-organisms which exist in their millions in the bowels may often find their way through even healthy tissues to that organ and are thus destroyed, " but in the insufficient" liver they are not deand excite suppuration. As regards stro}red dysentery, the presence of this disease at once favours the establishment of a locus of minor resistance, and, by the intestinal lesions it causes, facilitates the entrance of pus-producing bacteria into the vena portce. Therefore, above all factors, it is this want of adaptation of the organs of the European to his new tropical environment which renders him so liable to liver abscess. In tropical liver abscess the pathological change is primary and determines the microbic infection, while in pysemic abscess, which of course may occur in the tropics, it is the impaction of minute infective emboli derived from some local focus of suppuration which is the primary lesion. Next consider the statement made above as to the relative commonness of dysentery and liver abscess in natives of tropical countries. As in the case of Europeans in warm climates, we postulate a non-adaptation to environment, so in the
dysentery, upon and
May
FRACTURE OF THE PATELLA
1898.]
of natives we can fairly claim a perfect adaptation, and so they escape the idiopathic abscess. The variety of abscess compared with the universality of dysentery points to the fact that amoebic dysentery must also be rare, for, if otherwise, there should be, ex hypothesi, plenty of liver abscess. If idiopathic and amoebic abscesses are rare in natives of tropical countries, then the cases which do occur must in most instances be of portal pysemic origin. The fact that hepatic abscess is so rare among Europeans in the West Indies and the Straits Settlements, where all the other factors are the same as in India, viz., alcohol, want of exercise, rich food, great heat, &c., certainly must be considered to detract from the value of the " hepatic insufficiency theory of the origin of liver abscess, and, as far as we know, no explanation of tliis strange fact is yet forthcoming. If, therefore, the premises and arguments above set forth are correct, we are led to the following conclusions, that while pysemic abscess of the liver ma}?- occur in India as in Europe the socalled tropical abscess of the liver is of two kinds (1) the amoebic,which is in reality a complication of the comparatively rare amoebic dysentery, and (2) the " idiopathic," due primarily to hepatic insufficienc}' and secondarily to suppurative micro-organisms derived from the intestinal tract which may or may not have dysentery as a powerful cooperating and precedent cause. If this is true, it would not be far wrong to talk of " climatic" abscess of the liver rather than use the absurd, if useful, term idiopathic." Moreover, as even the upholders of the amoebic theory admit the existence of another (non-specific) amoeba in the intestines, whether healthy or otherwise, and as Kartulis inclines to the view that the amcebte are not the cause of suppuration but merely the vehicles for conveying the microbial cause, and, as I have endeavoured to show by my arguments that both amoebic dj^sentery and amoebic abscess must be rare in India, it is clear that after all the amoebte cannot be so powerful a factor in the dysenteries and liver abscesses of India as a perusal of the works of the French and American school would lead us to believe. case
"
"
"
"
:
HATCH.
167
