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ABSCESS OF THE LIVER.
By E. G. JANEWAY, M, D., of New York County.
Read November 20, 1884.
The subject which I have chosen for presentation is not new, and it is one the literature of which is well advanced; yet it has appeared to me that it might not be inopportune to reintroduce an old acquaintance. The reasons for my selection have been the comparatively large number of cases that I have met with this year, the impression, which is pretty general, that the disease is of very uncommon occurrence in our climate, with the consequent failure to be on the lookout for it, and the mistaken opinions concerning the nature of the symptoms which very good clinical observers at times fall into.
“Abscess of the liver” is not a homogeneous subject, but is one requiring considerable subdivision for intelligent consideration. Suppuration in the liver may occur, either in the form of single or multiple abscess, of suppurative pyle- (or portal) phlebitis, or of purulent catarrh of the bile ducts; and, in close relationship with the liver, we may meet with abscess of the gall-bladder, or abscess between the liver and the diaphragm, properly called subdiaphragmatic, or, perhaps better, supra-hepatic abscess.
It is my intention to limit my remarks to the proper abscesses of the liver. These, as has been observed, are single or multiple; and the former may have no apparent cause, being, as it is termed, idiopathic, while the latter are dependent upon infection through the portal system, or are a part of a pyæmia from systemic infection, in contradistinction to portal. I believe, how
ever, that some simple abscesses of the liver are due to infection through the portal system, several small abscesses uniting to form larger ones. During the present year, I have met with seven cases of abscess of the liver, two of abscess between the diaphragm and the liver, and one of abscess of the gall-bladder. Of the seven cases of liver-abscess, four of the patients are living, three having recovered as the result of operative procedure, and one, with spontaneous perforation, is on the way to recovery Three cases have terminated fatally; one as the result of exhaustion from the original disease, the abscess of the liver having perforated the lower lobe of the right lung and discharged per bronchia ; one as the result of perforation of the pleura and the exhaustion accompanying this; and the third, from the severity of the liver-affection. Let me invite your attention to some of the details in these seven cases :
CASE I.-Dr. B. D. This gentleman was of active habits, without decided tendency to disease. Some years ago, he was supposed to have phthisical trouble in his right lung. The beginning of his present illness was in September, 1883. The symptoms were those of malarial trouble, and, during the course of his illness, he had jaundice of moderate grade. From this he recovered sufficiently to go to Arkansas on a shooting-trip; but, while there, during December, he was thrown from his horse, striking on his right side over the region of the liver. After this he became worse, and severe pain developed in the hepatic region, which, later, extended to the right shoulder. The temperature became hectic in character, and he lost flesh and strength. When I saw him, in February, 1884, he had intense pain in the cervical plexus of the right side, a markedly enlarged liver, a large spleen, and evidence of dry pleurisy on the right side, with feeble respiration and slight crumpling sounds at the right apex. He also had perspirations at night. The enlarged liver was tender on pressure, but no hepatic friction could be developed. His skin was dark, but not decidedly jaundiced. The temperature was high at night, but normal, or nearly so, in the morning. He was unable to move about much on account of pain and shortness of breath which were produced by exertion.
The questions which arose in the diagnosis of his case were the following:
1. To what are these symptoms to be attributed ? Are they due to the combination of several morbid processes, or is there only one at work?
2. Is it simple malaria ?
4. Is it abscess of the liver ? If so, did the fall in December originate it, or should it date back to the time of the malarial attack in the early autumn ?
My own impression was, and I so stated to the physicians accompanying him, Dr. Johnson and Dr. Scott, that he had hepatitis, with developing abscess of the liver ; that the signs at the apex of the right lung were indicative of the old process which existed some years before ; that it was impossible to decide whether the disease dated back to the fall and injury to the side, or whether it should be referred to the time when he first became ill; but that the fall upon a liver enlarged by a previous malarial trouble would be more likely to produce disease, and would better explain the conditions and history. It was admitted that an absolutely positive opinion could not be given without exploration. He was seen at the same time by two other physicians. He went to Nassau, but he did this in opposition to the opinion I had expressed when consulting about his condition ; for a tropical climate did not seem well adapted to a case of possible abscess of the liver.
My reasons for the diagnosis were that, so far as his lungs were concerned, there seemed to be no such active process as would account for the symptoms present. In fact, what previous trouble he had suffered would account for the physical signs, except the evidences of dry pleurisy below. That while this might, perhaps, be due to tuberculosis starting from some infecting point, yet, in view of the condition of the liver and spleen and the history of the case, it would do more violence to the facts to suppose this, than to think it either intercurrent or possibly due to an irritation propagated from below.
While in Nassau, he had for a time a severe fever, with pain in his side, and was generally confined to the house. He reached home in May, and for a time seemed to improve; but at the end of the month he was seized with dyspnea and collapse, from which,
thanks to the careful skill of his physicians, he had rallied when I visited him on the 3d of June. They had found his right pleural cavity filled, and, in connection with the past history, supposed this was due to the bursting of an abscess of the liver through the pleura.
He had emaciated considerably since the time I had previously seen him, and had, owing to the loss of the use of the right lung, marked dyspnea. By aspiration, three and a half pints of a liquid resembling tomato-catsup in color were drawn off. This, examined microscopically, was found to contain red blood-globules, fatty pus-cells, and granular matter, but no well-formed or recent pus-cells. Moreover, these cells were not close together in the liquid. The liquid coagulated on the addition of acetic acid. Under these circumstances, and in view of the difficulty of dealing with the abscess of the liver in case of a free incision, it was decided to aspirate two or three times more, and, if the liquid should be offensive, or if severe hectic or marked suppuration should develop, then free incision into the chest, with efficient counter-opening to secure good drainage, should be made, and the chest washed out. The following letter, which gives the subsequent history of the case, I received from Dr. M. L. Scott, his attending physician :
“Our friend, Dr. D., died at 10 A. M. on the 3d of July. You left him on the 4th of June. On the 9th, I withdrew 24 pints of liquid ; on the 13th, 3 pints ; on the 17th, 34 pints; and on the 24th, 4 pints and 2 ounces. At all these aspirations, we got liquid of an appearance similar to that which you saw. Only at the last aspiration was the fluid offensive. On June 27th, we did drainage, and thoroughly washed out, not only then, but until the end, with antiseptic precautions. His course, especially after the drainage, was downward. He rapidly passed into an asthenic state, the pulse rising and the temperature falling. At the last, morphia was necessary to quiet his restlessness. A persistent dysentery developed four days before drainage was performed, and, resisting all treatment, continued until the end.
“I made the autopsy six hours after death. Emaciation and jaundice were everywhere extreme. The heart was found somewhat displaced to the left. The left lung and pleura were perfectly normal, with the exception of a few filiform adhesions at the base. The right lung was completely collapsed and was firmly adherent to the pleura at the apex and anteriorly, at the junction of the second and third ribs with the sternum. Both surfaces of the right pleura were much thickened. The drainage-tube traversed the cavity for four inches, and was in the best possible position for drainage. Through the diaphragm we found an irregular opening, two inches in diameter, leading downward into an hepatic abscess. The abscess held twenty-four ounces. Its walls were eroded and surrounded by a dense cicatricial tissue half an inch thick. The abscess had burst through the highest portion of the diaphragmatic arch. It was nearest the peritonæum at its lower and anterior portion. Here it was an inch and a half from the free surface. The liver weighed seven pounds and a half. The left lobe was as large as the right. On the anterior surface, we found an irregular, retracted cicatrix marking the site of a former perihepatitis. On the concave surface of the left lobe, we found an abscess, as large as a hen's egg, about to burst into the peritoneum. In various situations through the hepatic structure, we found half a dozen small purulent accumulations of a pyæmic nature. The kidneys were three times their natural size and had undergone waxy degeneration. The spleen was enlarged, and, as well as the liver, had undergone waxy degeneration. No tubercular or malignant change was found at any point. The rectum was inflamed and superficially ulcerated. The mesenteric glands were normal. “ Yours, very respectfully,
“ M. L. SCOTT. “LEXINGTON, Ky."
In this case, it seems certain that the small abscesses were secondary and of a pyæmic nature, as Dr. Scott has written in his description.
CASE II.—This was in a child, three years and a half old, brought to me by Dr. Taylor, of the Hospital for the Ruptured and Crippled, in May last. This child lived on Long Island, and had been gradually growing weaker, without, as the mother said, having had fever or anything beyond a swelling in the abdomen. A careful cross-examination, after a decision as to the nature of the trouble had been reached, failed to establish any cause for the liver-abscess from which this child suffered. The mother denied