and, therefore, may not give rise to septic peritonitis. I have seen recovery after this accident, the peritoneum having been well washed out and drained.
Rupture through the skin is said to be the most favourable, though a rare termination of liver abscess.
Mortality.— Rouis (203 cases), in Algiers, observed a mortality of 80 per cent.; Castro (125 cases), in Egypt, a mortality of 72.5 per cent., or, excluding cases operated on, of 76 per cent. In the Indian army, during the period 1891-4 (prior to which abscess of the liver, in the statistical returns, is not separated from hepatitis), and, presumably, including cases operated on, the mortality was 57.7 per cent.
Causes of death.— In Rouis's 162 fatal cases the causes of death are stated as follow: Severity of the local disease, or through the associated dysentery, 125; bursting of the abscess into the peritoneal cavity, 12; into the pleura, 11; gangrene of abscess wall, 3; peritonitis, 3; pneumonia from effusion of liver pus into the lung, 3; rupture of adhesions, 2; pneumonia, 2; rupture into the pericardium, 1. Abscess in the brain is a rare but occasional cause of death; in one recorded case amoebae were found in the pus.
Diagnosis.— Of all the grave tropical diseases none is so frequently overlooked as abscess of the liver. Acute sthenic cases are readily enough recognized; not so the insidious asthenic cases. The novice in tropical practice is some time in realizing that grave disease of so important an organ as the liver may, for a long time, be unattended with urgent symptoms, whether local, or constitutional, or both.
The most common mistakes in diagnosis are: (1) Failure to recognize the presence of disease of any description, even when an enormous abscess may occupy the liver. (2) Misinterpretation of the significance and nature of a basic pneumonia— a condition so often accompanying suppurative hepatitis. (3) Attributing the fever symptomatic of liver abscess to malaria. (4) Mistaking other diseases for abscess of the liver, and vice versa— for example,
