The Question of Opening Hepatic Abscess: With a Case
BMJ (Clinical Research Edition)
HEPATIC abscess is a disease of comparatively rare occurrence in temperate climates; and hence we derive our knowledge of it, and otir rules for its treatment, chiefly from the experience of tropical service. Still we do occasionally meet witll it here, sometimes as the result of acute inflammation of the organ, rarely of dysentery; sometimes, and perhaps mnost frequently, after slow subacuite action producinig few special symptoms during life, and found unexpectedly after death. I do not
... ath. I do not incluide in this notice those deposits of pus in the liver wlich are often found after pyarmia and local itnjuries, and of wlich it is difficult to give a satisfactory explanation. The opinion of authorities on the question of surgical interference is much divided; and I have thought that the following case presents features of interest in this, as we11 as in some other respects. Mr. J. R. is a powerful, energetic man, aged 52, of sedentary occupation and habitually abstemious and regullar habits, and(l enjoys generally robust liealth. Two or three years ago, how-ever, he l1ad an attack of chronic hepatitis or extreme coiuaestion of the liver, which pre senited, as I understand, all the usuial symptorns of that conidition in a violent forrn. From this attack he completely recovered, and continued well till the latter months of last year, when he complained of general indisposition and ltassitu(le. In Novem-lber lie applied to his medical attendants, AMessrs. Hardey and Roberts, who treated him for congestion. of tite liver, with relief. In the early part of Deceniher, a diffused enlargement was perceived in the right hypochondrium, wlicih coiltinnued to increase. On December 15tb, I was called in consultation. TIte coLnstitutional syrriptoms liad now become very severe. He liacl lad no rigor; lie was not jautudiced, nor were the secretions mulch affected; but lIectic anld sweats had set in, he wvas m-uchi atteiiuated, and(1 his appetite ha(l failed. There was general fulun ss, witlh dulness of the right hypochlondritim, anid a promiiinenit portion, of tlte size of the fist, mnidwvay between tile ribs and the clrista ilii. No tenderniess, but obsculre Ilietuiationl. For a few days the swelling appeared to increase; it thueil became stationary, or evel, as we elieved, receded; but the general symptoms inicreased in gravity. Diarrlhea set in, and we suspected that the matter lad found its way into the intestine. Mlicioscopic observatioin did Lnot, lhowever, c(olfirm this viewv; and the pur-ilg-subsided, to return from time to tinme. A few days after, he lhad a severe bronchial attack; bu.t this, toco, passed oft without any proof that it was connected witlh the liver, unless throug,h the irritation arising from colttiguity. By this time the patient's condition had become perilous; and it was clear somethinug mnust be done, as nature did not make any progress towards the solution of the difficulty, either externally, or by any of the usual channels. Then ar ose the question of openingtr the abscess. The general enlargement remained unaltered; the central prominence certainly not increased; tlle fluctuation still obscure. Dulness extended alimost to the crista ilii, where thje lsaldetued edge of the oi'gan couild be felt. A raised margin could be traced routud tlhe base of the central prominence; and it was on this ring only that tenderness was comyplained of on pressure. A coil of intestine lay over the lower and innei angle of the swelling, or portion nearest thte unubilicus. In this state, two dangers threatened the patientescape of pus into the peritorleal cavity, and death by exh,austion. The rule of practice in these cases is not settled. The one great essential, on which all are atreed, is the neces-536 sity of adhllesionis to previ-nt per-itoiteal effusion. Freriels say s (Treatise on Diseases of the Liver, p. 1-17, New Sydenham's Society's edit., : " Whien the abscess talkes a direction outwards, we onuht niot to delav inl miaking an artificial opening." He then goes oni to deseribe the processes adopted by 1egin asud Recam-iier ftor securing aclhuesions before. thie openinig is made, either by an iincision carried down to the peritoneum, in which iitfamnmatio11 is excited by charpie dressings; or by a caustic issueS eating through the abdotlminal parietes to the same point, arid vith. like intent. Dr. Graves gives a case (Lectures ont Pr actical Mledicine, vol. ii, p. 2Th) in vhichl an exploratory itncision was made, fluctuation being absent; aLnd the pus escaped by a lateral channel, on thie patietut making ana effort, seven days afterwards. On the other blanid, Dr. Budd advises leavinig the evacuation of the abscess to niatuire; and ouir Inidian autihorities seem to be of the sanme opirnion, wlich tlhev confirm by a forniidable table of' statistics of mortality after opeiation. SirIRanald MaL,tin, in liis recent woik onl the Inifluentce Of ]l'opic(il Climiates, p. 4.8,5, says: " It is little we can do tbr the uihappy sufferer fromi helpatt, abscess"-" in no instance did the operation (opening) appear to me to resu-lt in eventuLal good"; and lie then proceeds to express his agreement with Budd, that " it is generally best, wleni an abscess of the liver projects at the side, to allow it to open itself." Dr. Wating of tlue IMadras Army says that, of eighuty-one operated oni, only fifteeni recovered, an(l sixty-six died (Aut Inquiiry iuuto the Statistics anid Pathology of some Points cominectea7 with Al)scess of the Liver, as miet 2with in the East Iuudies ) and so TM. R1ouis gives, as tlhe result of Algerianu experience, fouri-deathis of' five cases operated oni (llecherches surt' ls Suppurations Endemiiquies dus F'oie, Iar,is, istI)). The Frenchi mlethlod ot' exciting peritonitis lby chuarlie and caustics is open to the obsions objectioni of' pro. soking the very danger we are seekingy to avoid. If the adhesions lhave not formiield alreadv, we are exciting" ani iitlanmnmation on wlsiclh wve have no mrieans of imposing a lilit; if they lave, the proceeding is ununecessary. Ilt either case, these processes, especially the caustic, interpose a serious delay at a very critical period. The tiuth, I believe, to be that, in all cases in wvhiclh the snippnration has extended so near thje surface of thje liver as to give the senise of fluctuation, irritatioii, effusion, ind adlhesion of the contigulous membranes, lhave tnken place. This tendency of a foreign body to seek the surlace, and secure for itself a safe openingfr, is too 'tell established to be furthler dwelt on. '1 lie proposal to leave tfie opening enitirely to nature is undoubtedtv SItund aiid good, provided the powaet's of the patient are adequate to tlte long process of ulceratioii through the textures. B1ut tlJis is asstuming a greater anmount of vital poswer titan is usual at this stage of the disease anid it must not be forgotten that the patienit is thus exposed to tlhe constant risk of spontaneous rupture and its fearful consequences. The formidable Indian statistics above alluded to must be taken witlh thie imnportanjt reservation, tluat we have nio mDeans of judging howsfar the niortaiity was dtie to the operation itself, and how' far to the disease and tite state of general health i duced by climiiate aind otlier causes. To return to M1r. R.'s case. WNe had no doubt as to tile existenice of matter, anad very little as to its site. 'T'lhere was also reason for thinking that tile desired adliesions had taken place, chiiefly from tile tender edge which surrounded the central prnominence; and, further, tilere was no time for delay. It was finally determined to open directly ifito the abscess by incisioIn and trocar; an exploring needle having failed, froiii tile depth of thie structures, to give anv indication. On December Sth, Mlr. Hardley dividedl tile textures to the depth of an inclh and a halt with a bistoiry, and then plung-ed in a trocar. From sixty to sevenity ounces of thick, chocolatecoloured, very foetid, anid tenacious matter was evacuated on 25 April 2019 by guest. Protected by copyright.