—Symptoms of the solitary type may be at the onset acute, with or without history of previous sickness, the patient being suddenly seized with severe epigastric or hypochondriac pain, which is followed by prostration, with fever, chills, and sometimes cough. Characteristic rigidity and tenderness follow and the liver increases in size, the whole type of illness being one of acute abdominal infection. The slower forms appear to come on without early liver symptoms, patients complaining of cough and discomfort in the chest, with loss of flesh and appetite. Gradually the indications point to the hepatic region, while chills or intermittent fever occur, the liver gradually increasing in size and becoming tender. Again, in some cases, the trouble begins with irregular fever, patients running down rapidly, yet showing few local signs until the abscess invades the subphrenic region. In such instances examination of the chest gives negative evidence, save that there may be found elevation of the diaphragm due to accumulation below it. In nearly all instances there arise, sooner or later, severe chest pains, with enlargement of the liver, tenderness, and often indications of fluid in the right pleural cavity, which on aspiration may be found clear or purulent. Tenderness along the liver border will be most marked among characteristic features. Sometimes there is intercostal tenderness. Any indication of local peritonitis should be taken as evidence of approach of pus toward the surface. Jaundice is an occasional accompaniment. Previous malaria should be excluded if possible and a careful case history is a great help.
Diagnosis is usually to be made between hepatic and subphrenic abscess and between the single and multiple forms of the former. The possibility of empyema or of one or two subphrenic abscesses should be carefully determined. In fact, first of all, the surgeon has to determine whether the lesion is above or below the diaphragm. Some of the subphrenic abscesses contain gas, and, should indications of its presence be found below the level of dulness due to the presence of fluid, interpretation of the facts is easy. Localized edema of the chest wall, or of the region of the liver, is of importance when present. It is necessary, also, to exclude phlegmons of the abdominal wall. These are cases where it is justifiable to use an exploring needle repeatedly, if necessary, in order to determine the presence and location of pus. After anesthesia the needle may be used even more freely, its use being not only of assistance in diagnosis, but it appearing to be an agent of great value in the relief of pain. I have known painful affections of the liver to be much relieved by such exploration.
The accompaniment of dysentery of amebic type, and the discovery of amebas in the stools, would quite settle the question of the origin and nature of such abscess. Hydatids are of slow growth and are almost symptomless until they produce pressure disturbances or those due to the presence of pus. The fluid withdrawn from them is clear and may contain hooklets. Cancer eventually produces jaundice and the resulting enlargements are nodular, while the lower border is irregular, and the liver itself less tender and more movable, and there is usually more or less ascitic fluid present. Syphilitic gumma may cause enormous enlargement of the liver, with difficulty in diagnosis, especially in the absence of a significant history. Under vigorous mercurial treatment it will steadily improve; without it such gummatous tumors may suppurate. It will often be advisable, in case of doubt, to make this therapeutic test. Actinomycosis produces granulomas which tend to increase, infiltrate, produce adhesions, and gradually work toward the surface, as well as eventually to break down, the débris thus produced containing not only pus, but the peculiar calcareous particles characteristic of this disease.
Treatment.
—Multiple foci in the liver scarcely admit of successful operative treatment and are nearly inevitably fatal. The solitary liver abscess, even though large, is, on the other hand, usually satisfactorily treated by the general method of free incision and drainage, although, in exceptional cases, aspiration alone has seemed to suffice. Any collection of pus, no matter what the internal condition, so long as it be not distinctly cancerous, which tends to present externally, no matter at what point, should be thus treated. Incision may be made over any protruding or edematous area where pus seems to be nearing the surface. With a considerable collection of this fluid in the right lobe, especially nearer its diaphragm-covered portion, it is usually safe to assume that the upper surface of the liver has become adherent to the diaphragmatic dome above it, and that there one may follow the costal border or may enter between the lowermost ribs, or may even resect one or more ribs if necessary, and drain posteriorly or by counteropening, as may be indicated. When approached from beneath, the lower surface of liver thus affected will usually be found more or less matted to the colon, omentum, or pyloric region, as the case may be, so that by carefully opening the abdominal cavity, and walling it off with gauze, pus may be evacuated from below and cavities satisfactorily drained. In this work it is of advantage to use an exploring needle, the operator guiding his further procedures largely by what it may reveal. Vessels which may be divided and spurt should be ligated or secured en masse, while oozing is overcome by gauze pressure. Drainage of a cavity already protected is simple; otherwise it may require a very careful combination of large fenestrated tube, if possible sewed in place, with the margins of the opening carefully puckered and secured around it and protected with gauze. Counteropening may be made, as well as drainage of any neighboring purulent focus.
Fig. 626
Abscess of liver, opened by transperitoneal hepatostomy. (Pantaloni.)
HYDATIDS OF THE LIVER.
Echinococcus disease is almost a surgical curiosity in the central portions of the North American continent, whereas in some parts of the world it is extremely common. Thus while very rare in the United States, in Winnipeg it is an exceedingly common disease, being brought there by immigrants from a locality where it is still more prevalent, namely, Iceland, where it is said that nearly half the inhabitants die of some form of hydatid disease. In New Zealand, also, as elsewhere, this form of parasitic invasion is very common. With most American practitioners, however, it is so seldom seen that its mere possibility may be overlooked. In the liver it produces cystic disease whose symptoms are rarely significant until the cysts have attained considerable size and have begun to suppurate. That the liver is so frequently affected is easily understood, as the parasites make their first invasion along the duct from the intestinal tract. The history of these cases is always slow, as four years is a short time and twenty-five years not an exceedingly long one in which hydatid cysts run their course. Small cysts may even undergo spontaneous retrogression and calcify. These cysts when large may rupture, just as do hepatic abscesses, and in various directions. (See [above].) Ordinarily it is only when suppuration occurs that the general health suffers, and not until that time are they, at least intentionally, seen by the surgeon.