collection of 203 cases, 162 died, 39 recovered entirely, and 2
improved; 80 per cent., therefore, proved fatal. According to De
Castro,[111] whose observations were made at Alexandria, Egypt, 93 in
208 cases died, this being 72.5 per cent. According to Ramirez,[112] of
11 cases of which an account is given in his memoir, 10 died and 1
recovered--a mortality of 90 per cent. De Castro (p. 40) also gives the
results arrived at by the Medico-chirurgical Society of Alexandria, who
collected 72 cases of abscess, of which 58 died, making the percentage
of deaths 80.5. Various circumstances besides the abscess affect the
result. An early successful operation, the mode of discharge, the
amount of hepatic tissue destroyed by the {1018} suppuration, the
extent of pre-existing lesions--especially ulcerations of the
intestinal canal--are important factors in the result. In respect to
some of these we have valuable statistical data. The discharge through
the lungs is the most favorable route, next by the parietes of the
abdomen, and lastly by the intestinal canal. One-half of those cases in
which discharge is effected by the right lung get well. This is my own
experience, and it accords with the observations of Rouis, of De
Castro, and others. Rouis gives the result in 30 cases of hepatic
abscess discharging by the right lung; of these 15 recovered. Of 25
cases observed by De Castro, discharging by the lungs, 19 recovered.
Next to the discharge by the bronchi, the most favorable mode of exit
is externally, through the parietes of the abdomen; much less favorable
is by the stomach or intestine; but still more fatal is the discharge
into the cavity of the peritoneum. When the abscesses are multiple and
due to pyæmia, the termination is always in death. The numerous lesions
besides the hepatic accelerate the fatal issue. In the case of large
single abscesses the result is in a great measure due to exhaustion
from protracted suppuration. When in addition to the formation of a
great quantity of pus there is frequent vomiting and rejection of
aliment, the failure of strength is proportionally rapid. In favorable
cases, after an abscess is evacuated through the right lung, recovery
takes place promptly. When the discharge occurs through the abdominal
wall, the process is much slower, and often fistulous passages with
several orifices, very slow to heal, are formed. Complete recovery may
ultimately take place. The recovery will be incomplete in those cases
with large loss of hepatic substance, especially when this coincides,
as it usually does, with catarrh, ulceration, and other lesions of the
intestinal tube. Again, the recovery will be incomplete in those cases
where there are imperfect healing of the abscess site and a fistulous
communication with the exterior.
[Footnote 111: _Des Abcès du Foie des Pays chauds, et de leur
Traitement chirurgical_, _loc. cit._, p. 40, Paris, 1870.]
[Footnote 112: _Du Traitement des Abcès du Foie, Observations
receuilles à Mexico et en Espagne_, par Lino Ramirez, M.D., Paris,
1867, _loc. cit._]
It is possible for the arrest and healing of a suppurative inflammation
of the liver to take place without discharge. Under such circumstances
the watery part of the pus is absorbed, the solid constituents undergo
a fatty metamorphosis, are emulsionized, and thus absorbed, and
gradually closure of the damaged area is effected by a
connective-tissue formation. We must, however, accept with caution
those examples of this process which are supposed to have occurred
because radiating cicatrices are discovered on the surface of the
liver. In a case of hepatic abscess discharging through the lung, known
to the writer, after death, which occurred fifteen years subsequently,
there was no trace of the mischief, so perfectly had repair been
effected. Radiating cicatrices are so often of syphilitic origin that
they cannot be accepted as proof of the former existence of an abscess.
DIAGNOSIS.--He who finds the diagnosis of abscess of the liver easy
under all circumstances can have had but little experience with the
numerous difficulties in the way of a correct opinion. There are cases
so plain that the most casual inspection suffices to form a conclusion;
there are cases so difficult that the most elaborate study fails to
unravel the mystery. The maladies with which hepatic abscess may be
confounded are echinococcus of the liver, dropsy of the gall-bladder,
cancer, abscess of the abdominal wall, empyema, or hydrothorax, etc. As
regards echinococcus, the difference consists in the slow and painless
enlargement characteristic of echinococcus, and the absence of any
symptoms other than those {1019} due to the mere pressure of the
enlarging mass. In abscess there may be no apparent enlargement, or the
increase in the area of dulness may be very great, or after a period of
increase of size there may be contraction due to the formation of pus,
and hence limitation of the inflammation; finally, the accumulation of
fluid may be sufficient to cause dulness up to the inferior margin of
the second rib. There are no corresponding changes of size in the
echinococcus cyst. Furthermore, abscess of the liver large enough to be
recognized by the increased dimensions of the organ will be accompanied
by more or less pain in the right hypochondrium and by a septicæmic
fever. On the other hand, an echinococcus tumor is not accompanied by
fever, pain, or tenderness, and it has that peculiar elastic trembling
known as the purring tremor. The most certain means of differential
diagnosis is the use of an aspiration-needle and the withdrawal of a
portion of the fluid. The presence of pus with hepatic cells will be
conclusive of abscess, whilst a serous fluid with echinococci hooklets
will prove the existence of the echinococcus cyst.
In cases of dropsy of the gall-bladder there are no febrile symptoms,
no chills, and the tenderness when present is limited to the pyriform
body, the seat of the accumulation of fluid, and no general enlargement
of the liver can be made out. At the point of swelling fluctuation may
be detected, or if the gall-bladder is filled with calculi the
sensation imparted to the touch is that of a hard, nodular body of an
area and position corresponding to that of the gall-bladder. Tapping
the gall-bladder, an easy and safe procedure, will resolve all doubts.
When an impaction of a gall-stone is the cause of abscess, the clinical
history is eminently characteristic: there are attacks of hepatic
colic, after one of which the chills, fever, and sweats belonging to
hepatic abscess occur.
The differentiation of cancer of the liver from abscess rests on the
following considerations: In cancer there is slow enlargement, with
pain; a more or less nodular state of the organ without fluctuation;
usually ascites; no rigors; no fever and sweats. In abscess the liver
may or may not be enlarged; there are rigors, fever, and sweating, and
the surface of the organ, so far as it can be reached, is smooth and
elastic, and it may be fluctuating. Cancer happens in persons after
middle life, develops very slowly, and is accompanied by a peculiar
cachexia; abscess occurs at any period, very often succeeds to or is
accompanied by dysentery and by the usual phenomena of suppuration.
It is extremely difficult to separate an abscess in the abdominal wall,
in the right hypochondrium, or a tumor in this region, from an abscess
of the liver. The history of the case, the existence of a dysentery or
of an apparent intermittent or remittent fever before the appearance of
a purulent collection, will indicate the liver as the probable source
of the trouble. Attention has already been called to a case in which an
abscess of the liver was supposed by an eminent surgeon to be a tumor
of the abdominal wall. The history in this case of an obstinate
remittent fever, followed by the appearance of a tumor of the
hypochondrium and by a preliminary discharge at the umbilicus, clearly
indicated the nature of the trouble. In the absence of any history of
the case it is extremely difficult to fix the origin of a suppurating
tumor originating, apparently, in the depth of the right hypochondrium.
Mistakes are frequently made in the case of an abscess developing in
{1020} the convexity of the right lobe of the liver and pushing the
diaphragm up to the third, even to the second, rib, and thus producing
conditions identical with empyema of the right thorax. Such instances
of hepatic abscess are peculiarly difficult of recognition, because,
the physical signs being the same as those of empyema, the
differentiation must rest on the clinical history. In cases of empyema
proper the effusion in the chest is preceded by pain and accompanied by
an increasing difficulty of breathing; in hepatic abscess there are, as
a rule, symptoms of disturbance in the hepatic functions, fluctuation
in the hepatic region, dysentery, etc., long anterior to any
disturbance in the thoracic organs. Again, empyema may be a latent
affection, without any symptom except some obscure pain and a
progressive increase in the difficulty of breathing; on the other hand,
abscess of the liver is preceded by symptoms of liver disease and of
associated maladies. A dry, purposeless cough is present in many cases
of abscess; a painful cough with bloody expectoration occurs when
preparation is making for discharge through the lungs.
Errors of diagnosis are liable to occur in the consideration of
symptoms unquestionably hepatic in origin. Thus, the intermittent fever
accompanying some cases of hepatic colic, like the shivering fits and
fever which occur in cases of nephro-lithiasis, may be confounded with
the septicæmic fever of hepatic abscess. An attentive examination of
the attendant circumstances, especially a careful survey of the right
hypochondrium, can alone determine the nature of the symptoms. In all
doubtful cases the experimentum crucis of puncture with the
exploring-needle becomes a measure of necessity. When all diagnostic
indications are at fault, the needle of the aspirator may decide the
issue. An abundant experience has shown that a needle of suitable size
may be introduced into the right lobe without any ill result--often,
indeed, with distinctly good effects when there is no suppuration or
when pus cannot be detected. In the present state of our knowledge it
cannot be determined why puncture of the organ should be beneficial in
cases having the symptomatic type of hepatic abscess when none exists;
but of this fact there is no doubt.
TREATMENT.--As the formation of pus is coincident with or causative of
the first symptoms, it is obvious that treatment directed to prevent an
abscess can rarely succeed. Yet it is probable that now and then an
abscess just forming has been arrested and healing effected. At the
onset of symptoms some large doses of quinine, with a little morphine
(scruple j of the former and 1/8 gr. of the latter), every four or six
hours, may have a decided curative effect. During the course of the
septicæmic fever, with its chills and febrile exacerbations, quinine in
full doses and alcohol according to the conditions present are
necessary remedies. As the symptoms develop saline laxatives are useful
until the formation of pus becomes evident, when all perturbating
treatment of the intestinal canal should cease. If dysentery be present
when the hepatic symptoms arise, it should be cured as promptly as
possible; and of all remedies for this purpose, ipecac given in the
usual antidysenteric quantity offers the best prospect of relief. For
the dysentery which succeeds to abscess, and is probably, in part at
least, dependent on portal obstruction, the mineral astringents, as
copper sulphate, are the most effective remedies. As far as
practicable, after an abscess has formed the intestinal canal should be
kept quiet, for any considerable disturbance will {1021} endanger the
escape of pus into the peritoneal cavity. Persistent vomiting is very
significant of pressure by an enlarging abscess in the stomach, and
usually signifies an abscess associated with impacted calculus. It is
important in such cases to maintain, as far as can be done, a quiescent
condition of the stomach, for the purpose of preventing rupture into
the peritoneal cavity and to favor the nutrition which is seriously
endangered by the repeated vomiting. Effervescent soda powders are very
useful; carbolic acid in solution, or creasote-water with or without
bismuth, is beneficial; champagne, very dry and highly effervescent,
has been, in the writer's hands, remarkably efficient. As food becomes
a most important need in such cases, milk and lime-water, wine-whey,
egg-nog, and similar aliments must be given in small doses and
frequently. Nutrient enemata, prepared from eggs, milk, and beef-juice,
with the materials for digestion--acid and pepsin--may be made to
supplement the stomach, but such efforts have a very limited utility,
owing to the state of the hepatic functions and to the obstruction of
the portal circuit. In all cases it is necessary to maintain the
strength by suitable aliment and the judicious use of stimulants. The
long-continued and profuse suppuration makes an enormous demand on the
vital resources of the patient, and this must be compensated by
suitable food-supplies.
As the formation of pus has taken place in most cases when symptoms
have begun, the question of highest importance is, Shall the pus be
evacuated? The statistical evidence relating to this question becomes
then an extremely valuable guide. As in almost all cases of puncture of
the liver for the evacuation of an abscess some part of the liver
substance must be passed through, it is necessary to note how far this
can be done without inflicting permanent injury on the organ. Hammond
has punctured the liver in eight cases without the presence of an
abscess, and of these not one has presented any unfavorable symptom.
The author has punctured the liver, penetrating well into the interior,
in two cases in which no abscess was discovered, but the symptoms of
hepatitis existed, with the effect to improve the symptoms. In
Condon's[113] collection of 11 cases there were 8 of abscess evacuated
by the trocar, and 3 of acute hepatitis in which abscess had not
formed, but in which the puncture procured the most decided
amelioration of the symptoms. We have heretofore referred to Hammond's
experience in the puncture of the liver in cases of hypochondriasis,
this condition appearing to depend in some instances on the presence of
abscess. In a number of instances abscesses did exist, but in many
others there was no apparent lesion of the liver, but in these cases
the puncture of the organ was without any ill result. Testimony to the
same effect is given by Ramirez,[114] who asserts that he had not known
a single instance in which any ill result followed puncture of the
liver. It may therefore be regarded as certain that exploratory
puncture of the organ for the purpose of diagnosis as well as for
treatment can at any time be performed with suitable precautions in
respect to the size, condition, and character of the instrument.
[Footnote 113: "On the Use of the Aspirator in Hepatic Abscess," Dr. E.
H. Condon, _The Lancet_ (London), August, 1877.]
[Footnote 114: _Du Traitement des Abcès du Foie, Observations
recueilles à Mexico et en Espagne_, par Lino Ramirez, M.D., Paris,
1867, p. 65.]
The authorities of most experience are agreed that, provided with the
{1022} aspirator, the abscess may be punctured as soon as a purulent
collection can be ascertained to exist. The obvious reason for tapping
the abscess is its tendency to extend in various directions, destroying
the hepatic substance. In those examples confined by a limiting
membrane, after a time of inactivity ulceration begins, and the pus
seeks an outlet in some direction. The early evacuation by a suitable
aspirator becomes then a measure of the highest necessity. The good
effects of puncture with even such a crude instrument as the trocar is
well exhibited in the statistics collected by Waring.[115] In a
collection of 81 cases opened by the knife or trocar there were 66
deaths, making the percentage of recoveries 18.5. In these cases the
operative procedure was a final measure, and the mischief had been done
almost if not quite in its entirety. The statistics of Waring are
concerned with a period anterior to 1850. Although they demonstrate the
value of the trocar and evacuation of the abscess, as compared with the
results of the natural course of the disease, the far greater success
of the treatment by the aspirator is shown by the statistics of recent
times. Thus in McConnell's[116] 14 cases, also of India, in which the
aspirator was used to empty the sac, 8 recovered and 6 died. The
statistics of Waring may also be profitably compared with those of
Condon,[117] in which, of 8 cases of abscess evacuated by the
aspirator, 4 recovered, or 50 per cent. They may also be compared with
Sach's[118] cases, 21 in number, of which 8 recovered, or 38 per cent.,
and with the cases of De Castro[119] of Alexandria, who reports 22
large abscesses operated on, the proportion of cures being 31.8 per
100, and 10 small abscesses, the proportion of cures being 70 per 100.
In a case seen in consultation with Collins, in this city, last year,
the aspirator was used by us about three months after the symptoms of
abscess declared themselves. About a quart of bloody pus was drawn off
at once, the opening sealed, and no subsequent accumulation occurred,
the patient entirely recovering, for after a year he was seen
(December, 1884) in complete health. From these data we draw the
important conclusion that early operation is desirable. This fact may
be formulated in the expression: In all cases of hepatic abscess use
the aspirator whenever the presence of pus is made out. When the
abscess is large, and especially when communication is established with
the parietes of the abdomen, a free opening, followed by the insertion
of a drainage-tube, is the proper method to pursue. If the pus
reaccumulates, it is good practice to inject the cavity with tincture
or compound solution of iodine after the pus is drawn off, provided the
dimensions of the abscess are not too great.
[Footnote 115: _An Inquiry into the Statistics of Abscess of the
Liver_, _loc. cit._]
[Footnote 116: "Remarks on Pneumatic Aspiration, with Cases of Abscess
of the Liver treated by this Method," _Indian Annals of Medical
Science_, July, 1872, quoted.]
[Footnote 117: _Lancet_, _supra_.]
[Footnote 118: _Ueber die Hepatitis der heissen Länder, etc._, von Dr.
Sachs in Cairo.]
[Footnote 119: _Des Abcès du Foie des Pays chauds, et de leur
Traitement chirurgical_, par le Docteur S. V. de Castro (d'Alexandrie
d'Egypte), Paris, 1870, p. 59.]
As regards the mode of proceeding, the following are useful rules:
Ascertain, if possible, the existence of fluctuation; locate the point
where the walls of the abscess are thinnest; insert an
exploring-needle, and if the dépôt of pus is reached substitute a
trocar having a sufficient calibre to evacuate the contents of the
abscess; observe antiseptic precautions in respect to each detail of
the operative procedure, and after the removal of the canula or needle,
if a drainage-tube is not necessary, close the {1023} wound
antiseptically. If drainage is necessary, keep the cavity empty and use
proper solutions to prevent septic decomposition. When an abscess of
the liver is pointing, the best place to puncture is where the abscess
is most prominent and it walls thinnest, but if the accumulation of pus
is encysted and there is no attempt at effecting an exit, the
exploring-needle should be passed into the interior of the right lobe,
the most usual site of suppuration. If pus be reached, a larger trocar
may be inserted to evacuate the cavity thoroughly. Repeated insertion
of the needle-trocar is preferable when the abscess is small, but when
the accumulation is large and sufficiently firm attachments to the
abdominal parietes exist, a drainage-tube will be necessary.
In what direction soever discharge of an abscess may take place, the
general indications are to support the powers of life by food and
stimulants. The utmost quietude should be maintained. It is useful, by
the application of a firm flannel bandage, to keep the liver in its
proper position and maintain it there. When pointing of an abscess
occurs, a large flaxseed poultice is a soothing and a mechanically
supporting application.
Acute Yellow Atrophy.
DEFINITION.--By the term acute yellow atrophy is meant an acute
affection of the liver, characterized by rapid wasting or degeneration
of the organ, accompanied by the systemic symptoms belonging to an
acute acholia or cholæmia. It is an acute, diffused inflammation, with
atrophy of the proper gland-elements. It has been called icterus
gravis, malignant icterus, hemorrhagic icterus, malignant jaundice,
etc.
HISTORY.--Cases having a more or less exact resemblance to acute yellow
atrophy have been occasionally reported from the earliest period.
Amongst English physicians, Bright[120] was one of the first to give an
accurate account of the clinical history of some well-defined cases.
Rokitansky[121] was really the first to define the disease from the
pathological standpoint, and it was he who designated it acute yellow
atrophy, this term being intended to signify the nature of the
objective changes. The first treatise ever published on the disease as
a distinct morbid entity was the monograph of Horaezek,[122] which
appeared in 1843. Amongst the French, Ozonam in 1847 was the first to
recognize and describe the disease as a distinct affection, although
Andral[123] had several years before mentioned an affection of the
liver which corresponded in some of its features to this affection. In
1862, Wagner[124] asserted that many of the cases of acute yellow
atrophy were only examples of acute phosphorus-poisoning, and that no
real distinction exists between the two affections. This statement has
been warmly disputed by various German observers, but there is no doubt
a close resemblance between the two affections.
[Footnote 120: _Guy's Hospital Reports_, 1836, vol. i. p. 621.]
[Footnote 121: _Handbook of Pathological Anatomy_, Am. ed.]
[Footnote 122: Quoted by Legg, _On the Bile, Jaundice, and Bilious
Diseases_, _loc. cit._]
[Footnote 123: _Clinique médicale_, 1839, tome ii. p. 363.]
[Footnote 124: _Archiv der Heilkunde_, 1862, p. 364.]
CAUSES.--There can be no doubt that acute yellow atrophy is a very rare
disease, since so few examples are found post-mortem. In the course of
a very large experience in autopsical examinations I have met with but
{1024} one characteristic example.[125] According to Legg, it is "one
of the rarest diseases known to man."
[Footnote 125: _General Field Hospital_, December, 1863.]
Several theories have been proposed to explain the occurrence of this
affection, but without success. It has been ascribed to an excess in
the production of bile, to stasis in the bile, and to a sudden
saturation of the hepatic cells with biliary matters contained in the
portal vein. That these supposed causes are really influential in
producing the malady can hardly be entertained. That there is a
peculiar poison which has a causative relation to the disease is
rendered probable by the fact that a condition closely allied to this
disease is produced by phosphorus, antimony, arsenic, and other
poisons. Is it not a ptomaine generated under unknown conditions in the
intestine? Especially does the morbid anatomy of phosphorus-poisoning
nearly agree in all its details with icterus gravis--so nearly that by
many German authorities they are held to be identical.
Age has a certain influence in the causation of this disease. It is
rarely seen in early life, Lebert in a collection of 63 cases having
found only 2 before ten years of age, yet there has been a well-marked
case at three, and Hilton Fagge reports one at two and a half years of
age. Nevertheless, much the largest number occur between fifteen and
twenty-five years of age, and the maximum age may be fixed at sixty.