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There was excess of clear serous fluid round the part of the liver exposed, but no subphrenic
abscess. A large bore exploring needle was thrust into the liver, and thick yellow pus, smelling
strongly of B. coli, was reached at a depth of 1¼ inches. This area of liver was packed off with
gauze, and a pair of forceps pushed into the liver alongside the exploring needle; when the
blades were opened more pus gushed out. The cavity was explored with the finger. It appeared
to be part of a suppurative pylephlebitis. A drain was inserted into the cavity, and some
pus sent for examination.
27.10.34. The condition was unchanged and the pyrexia markedly remittent.
29.10.34. No improvement. Emaciation becoming marked. Still same pyrexia. Pus
draining freely from the tube and still very offensive.
2.11.34. Not much change. Still same pyrexia. The discharge was now chiefly bilious
and no longer offensive.
5.11.34. Condition deteriorating. T. 101.8°. P. 116. Discharge lessening, clear and bile
stained.
9.11.34. Condition worse. T. 102°. Stools pale. Discharge watery and bile stained.
12.11.34. Not so well. Patient complained of sharp intermittent pain in the region of the
umbilicus. Slight general abdominal distension. T. last night 104°. Chest wound healing.
Very little discharge from the liver abscess now. Bowels open and stools normal in colour.
Pathological report from the pus from the liver abscess states that "cultures from this pus
have grown a Gram-negative streptothrix strictly anærobic, and in spite of its staining reaction
must be considered as a form of actinomyces." Large doses of potassium were administered.
In spite of this, the patient continued rapidly to go downhill, and he died on 18.11.34.
Post-mortem
examination.
A post-mortem examination of the abdomen only was obtained, but it showed nothing
grossly abnormal except the liver. There were no localised masses of the granuloma in the
right iliac fossa or loin. The liver was riddled with groups of abscesses, which appeared to follow
the course of the portal vein. They were encapsuled and loculated, but did not present the
characteristic honeycomb appearance, but were larger cavities doubtless due to the confluence
of small ones, and were filled with thick greenish yellow pus. A slice of the liver was sent to the
group laboratory, which reported "multiple abscesses in the liver, with the typical histological
appearances of actinomycosis. The mycelium, however, stains Gram-negative, as did the
streptothrix isolated from the pus."
Actinomycosis is a common disease in cattle, though rare in man; it belongs
to the group of infective granulomata, and is caused by the actinomyces or ray
fungus, which belongs to the group of streptothriceæ, more than one species of
which may produce the disease. In the common form the mycelium stains Grampositive.
The particular species in the case here recorded stained Gram-negative,
but it produced the typical histological appearances of actinomycosis.
The mode of infection is doubtful, though it is usually attributed to eating
infected corn or grasses. This patient was closely questioned on this point, but
he was a Londoner born, and had hardly ever been in the country, and was positive
that he had never plucked and eaten any form of corn. At any rate the parasite
gains entrance through the alimentary canal and enters the tissues perhaps through
carious teeth, and causes lesions in four different sites, 60 per cent. in the head and
neck, 20 per cent. in the gastro-intestinal tract usually in the caecum and appendix,
15 per cent. in the lungs and the remainder in the skin.
In this case it is probable that the site of infection was in the appendix, and
that spread to the liver occurred via the portal vein, as there were no granulomata
in the abdomen, and no involvement of the abdominal wall with sinus formation
as is usual in such cases. Moreover, the nests of abscesses in the liver had a distribution
similar to that found in portal pyæmia.
The clinical course was interesting. It began with an unusually high temperature
for an acute appendicitis. This is a point which I noted in my only other personal
case, that of a girl, aged 11, who presented all the usual signs of acute appendicitis,
except that on admission to hospital her temperature was 106°. An immediate
operation was performed and a gangrenous perforated appendix removed. The
operation wound healed, and she was discharged apparently cured, but returned
a month later with actinomycotic granulomata in the right iliac fossa.
The initial pyrexia, in the case now recorded, never subsided, although otherwise
the patient's condition for some time appeared satisfactory. This continued
remittent fever was obscure, as none of the usual causes could be found. It was
presumed to be due to some infection, and there was a persistent polymorph leucocytosis.
The diagnosis was eventually revealed by the formation of liver abscesses.
The course of the disease was steadily downhill and treatment was without effect.