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4. The violence may, be a fall. I have examined cases of this nature, and similar instances have been reported by other observers in different tropical countries. A false step taken by a Chinese pedestrian who has an enlarged spleen, may lead to a severe fracture of the organ.
5. The violence may be severe, yet no indication of such may be found in the splenic area of the abdominal wall. Cases of this nature have frequently been seen at the Public Mortuary.
6. Conversely, subcutaneous læmorrhages in the abdominal wall, and over the spleen, may be found in cases where the violence is extremely slight. This is found in individuals suffering from Bright's disease, syphilis, typhoid fever, plague, purpura, hæmophilia, ete.
7. Spontaneous rupture of the spleen may take place. This may occur in individuals. who have a large spleen, e.g., weighing 3 to 5 lbs. Spleens weighing 3 lbs. are not uncom- mon in Hongkong. Excitement, coupled with sudden contraction of the abdominal muscles, may be sufficient to rupture the organ. In support of my contention, a good example of this mode of fracture of the spleen was published in 1902 in the Indian Medical Gazette. A native barrister of middle age was pleading in one of the Indian Courts when owing to some altercation with the Judge, he became greatly excited. A few minutes afterwards, feeling faint, he left the court room and died in balf an hour from a severe laceration of the spleen. The organ was greatly enlarged and brittle. The deceased had suffered much from malaria during his life.
In this case the size of the rupture was large, so that it is obvious that no deductions may be drawn between the size of the rupture and the force of the blow which causes the injury. Severe laceration may be found in cases of spontaneous rupture; small tears may be present in cases due to severe violence.
8. Ruptures of the spleen due to stabs, heavy prods with bamboo poles, etc., are suffi- ciently clear in themselves and leave no doubt as to the degree of violence exercised.
A
In all cases of rupture of the spleen, it is a matter of great difficulty to estimate the period of survival after the infliction of the injury. In uncomplicated cases, we have no data to stand by regarding the quantity of blood effused before death. The rapidity with which the blood will flow from the spleen in each individual case cannot be estimated. person may walk over some considerable distance after the receipt of the injury. This, undoubtedly will aggravate the hæmorrhage, but it must also be borne in mind that the bleeding will continue after death so long as the blood remains warm and fluid. Such questions of refined speculation, although often leading to different opinions by medical experts, would not appear to assist one in gathering together a concise and correct statement of each case.
9. Amabic Dysentery and its relation to Liver Abscess.-Amoebic Dysentery is a common disease in Hongkong not only amongst Europeans but also amongst the Chinese. Its incidence amongst the Chinese is very evident in the Public Mortuary where an examination of the large gut of every case brought to autopsy, shows the the great frequency of the disease. In at least 50-60 per cent. of the autopsies held by me annually, traces of dysentery can be demonstrated in the large intestine. In the majority of cases the inflamination is due to the presence of the amoeba. In contradistinction to bacillary dysentery, the amoebic form would appear to be extremely chronic in its course. Indeed concluding from the post-mortem appearances met with in such cases, it would be difficult clinically to prognosticate when a perfect cure has taken place.
The presence of amoeba in the large bowel must, in the light of recent research, be regarded as pathological. Diarrhoea or dysentery may not supervene as the result of their advent, yet other affections, e.g., abscess of the liver may be set up.
The question of the relation existing between the presence of ambæ in the bowel and the occurrence of so-called tropical abscess of the liver has been one of great interest to me for some considerable time. At the present moment, I am engaged upon a special enquiry into the subject. I propose to deal with my results, when completed, in a special monograph.
So far as one can gather from a consideration of the literature on this subject, a great deal of doubt would appear to exist as to the exact etiology of liver abscess as met with in the tropics. All sorts of causes e.g., worms, bacteria, amœbæ, etc., have been advanced in order to explain the occurrence of tropical abscess in single individual cases. My own results, as yet incomplete, would lead me to conclude that tropical abscess of the liver is always due to amaba. In the vast majority of cases a history of dysentery is to be obtained-