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 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's113 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.
113 "On the Use of the Aspirator in Hepatic Abscess," Dr. E. H. Condon, The Lancet (London), August, 1877.
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 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's116 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's118 cases, 21 in number, of which 8 recovered, or 38 per cent., and with the cases of De Castro119 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.
115 An Inquiry into the Statistics of Abscess of the Liver, loc. cit.
116 "Remarks on Pneumatic Aspiration, with Cases of Abscess of the Liver treated by this Method," Indian Annals of Medical Science, July, 1872, quoted.
117 Lancet, supra.
118 Ueber die Hepatitis der heissen Länder, etc., von Dr. Sachs in Cairo.