Liver abscess

“ Supplementary causes.— It is conceivable that in a highly predisposed liver exciting causes other than dysentery, such as a blow or sudden aggravation of chronic congestion by chill or excess, may suffice at times to determine suppuration. Liver abscess is most prone to develop at the commencement of the cold season. Further, one can conceive that in a hyperæmic liver struggling to resist dysenteric suppurative influences some third condition, such as the blow, chill, or surfeit referred to, may contribute to or determine the formation of abscess which, in its absence, might have been averted. ”

“ Occasionally a liver abscess becomes encysted and gives rise to no further symptoms, its existence being discovered only on the post-mortem table, the patient having died of quite another and independent disease.
Terminations.— Apart from operative inter- ference, liver abscess may terminate in various ways. It may end in spontaneous rupture leading to death or recovery. Death may also be brought about in other ways— by the severity of the local disease; by prolonged hectic and exhaustion; by concurrent dysentery ”

“ In liver abscess, as with blackwater fever, it is education rather than acclimatization that brings about a diminution of these tropical diseases.
For several years subsequent to the American occupation of the Philippines amoebic dysentery and liver abscess were common but in more recent years liver abscess has become rare in Americans and amoebic dysentery much reduced in prevalence.
More temperate living results in less storing up of fat in the liver and an organ more resistant to infection. ”

“ In multiple abscess, or in single abscess if there is active dysentery or other serious complication, prognosis is bad. In multiple abscess, if there are more than two or three abscesses, it is necessarily hopeless.
The question of return to the tropics after recovery from liver abscess frequently crops up. If feasible, and if the patient has not to make too great a sacrifice, he ought to remain in a temperate and healthy climate. There are many instances, however, of individuals who have enjoyed permanent good health in the tropics after recovery from liver abscess. ”

“ Natives of India very rarely develop liver abscess but it has been noted that when they begin to follow the customs of Europeans, as to eating and drinking, such lesions become more common in them.
As to the proportion of cases of amoebic dysentery which give rise to liver abscess only the statistics of those who have differentiated between bacillary and amoebic dysentery are of any value. Such statistics would indicate that about 20% of the cases of amoebic dysentery are complicated by liver abscess. ”

“ Perhaps the most common error is to regard the hectic of liver abscess as attributable to malaria. The regularity with which the daily fever recurs, the daily chilliness or even rigor coming on about the same hour, the profuse sweating, and other circumstances so compatible with a diagnosis of malaria, all contribute to this mistake. So common is the error that Osier says he hardly ever meets with a case of liver abscess which has not been drenched with quinine. My experience is the same. I have seen medical men make this mistake not only in their patients but in their own persons. ”

“ Suppurating hydatid cyst which may be confused with liver abscess is most surely differentiated by finding echinococcus hooklets.
Then too the complement fixation test for hydatid disease will differentiate.
Tuberculosis is often thought of, particularly when a liver abscess ruptures through the lungs. Malaria is also usually suspected. Abscess in the kidney or perinephritic region may be very confusing. In an abscess of the abdominal wall an exploring needle does not move up and down with respiration as it does when penetrating a liver abscess cavity. ”

“ The novice in tropical practice is some time in realizing that grave disease of so important an organ as the liver may, for a long time, be unattended with urgent symptoms, whether local, or constitutional, or both.
The most common mistakes in diagnosis are: (1) Failure to recognize the presence of disease of any description, even when an enormous abscess may occupy the liver. (2) Misinterpretation of the significance and nature of a basic pneumonia— a condition so often accompanying suppurative hepatitis. (3) Attributing the fever symptomatic of liver abscess to malaria. ”

“ 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. ”

“ It feeds on the tissues, in fact, and to grow and multiply it must disintegrate their structures and consume their cells. Amœbæ occur much more frequently in liver abscess than is generally supposed; a circumstance strengthening the argument for regarding this parasite as being in causal relationship to that lesion, and therefore, pro tanto, to dysentery. ”

“ Many times a correct diagnosis can be arrived at only by repeated and careful study of the case in all its aspects. Golden rules in tropical practice are to think of hepatic abscess in all cases of progressive deterioration of health; and to suspect liver abscess in all obscure abdominal cases associated with evening rise of temperature, and this particularly if there be enlargement of or pain in the liver, leucocytosis, and a history of dysentery not necessarily recent dysentery. ”

“ Liver Abscess.—Schilling-Torgau brings out the point that even with an absence of the usual blood findings it is possible to diagnose the disease and make a just prognosis with his method of differential counting. Ordinarily we have a leucocytosis of from twelve to twenty thousand with only about 70% of polymorphonuclears and about 12 to 15% of large mononuclears. When a bacterial infection accompanies the amoebic one of course the leucocytosis and polymorphonuclear percentage reach higher figures. The eosinophiles may entirely disappear in an uncomplicated case of amoebic abscess. ”

“ A Typical Case of Liver Abscess.—Following a case of amoebic dysentery, during the period of convalescence or subsequently, a rather irregular type of fever is noted, which shows an evening rise with sweatings which tend to become colliquative. From a marked feeling of weight in the region of the liver there may later develop tenderness or pain upon palpation of the liver. Of importance is the fact that there is no associated splenic enlargement. In the majority of cases the right side of the liver enlarges in an upward direction. A tape-measure will often show enlargement of the right side. ”

“ The latter incision favors hernia if prolonged drainage is required. The hand is introduced into the abdominal cavity and the liver palpated. Often the borders of the site of a liver abscess give a hard feeling on palpation. If adhesions are not present the area should be packed off with gauze and the cavity opened by a dressing forceps, haemostat or thermo-cautery. It is often advisable to introduce a trocar and cannula and to drain off the excess of pus.
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Where the abscess is situated far back or high up in the liver the transpleural route is to be preferred to the abdominal one. ”

“ In malaria, if the liver be enlarged the spleen is still more so; the reverse is the case in liver abscess. (3) The malaria parasite cannot be found in the blood in non-malarial hepatitis. (4) In liver abscess the fever is almost invariably an evening one; in malaria it most frequently comes on earlier in the day. (5) Quotidian periodicity, contrary to what is the case with tertian or quartan periodicity, is by no means pathognomonic of, or peculiar to, malaria. (6) The almost invariable history of antecedent dysentery, or, at least, of bowel complaint, in liver abscess. ”

“ As liver abscess is developed principally in tropical climates and in European visitors there, and much more rarely in the native, it would seem that tropical conditions in those unaccustomed to them are in some way bound up with this predisposing element; and as liver abscess is rare in European women and children, it would seem that these conditions are in some way specially operative on European men. ”

“ From the pharynx the worm may enter the larynx and trachea, or advance farther into the air-passages, giving rise to the usual symptoms of foreign bodies in these parts. Occasionally the parasite forces its way through the bile-ducts into the liver and gall-bladder, creating disturbance in those organs proportioned to the number and size of the worms and the extent of their progress. In the liver it may occasion inflammation and the formation of an abscess attended with all the usual symptoms of hepatitis. ”

“ Periodicity of fever in liver abscess; diagnosis from malaria.—— Particularly is this the case in suppuration connected with the liver a condition peculiarly liable to occur in tropical practice. Simulation of malarial fever by hepatic abscess is very common; it is a pitfall into which the inexperienced tropical practitioner often tumbles. ”

“ Loose stools often prove critical, and carry off the disease.
If an abscess or imposthume is formed in the liver, all methods should be tried to make it break and discharge itself outwardly, as fomentations, the application of poultices, ripening cataplasms, &c. Sometimes indeed the matter of an abscess comes away in the urine, and sometimes it is discharged by stool, but these are efforts of Nature which no means can promote. When the abscess bursts into the cavity of the abdomen at large, death must ensue ”

“ There is good reason, however, for believing that, while they represent the truth, they do not represent the whole truth, and that the association is even more frequent than they indicate. As has been pointed out by McLeod and others, the occurrence of antecedent dysentery in cases of liver abscess is very often overlooked; for, without a postmortem examination, it may be impossible to pronounce definitely on this point in every instance. It is also well known that extensive dysenteric ulceration may be present and yet give rise to no active subjective symptoms whatever. ”

“ Geographical Distribution.—Concisely one may state that the distribution of liver abscess is in relation to the existence of amoebic dysentery. It is particularly prevalent in those centers of amoebic infection where there are many white men having little knowledge of the conditions necessary for the maintenance of health in the tropics. ”

“ Hepatic abscess may follow on an attack of amoebic dysentery, and is produced either by infection through the portal vein, or by direct infection from the adjacent colon. In general pyaemia multiple small abscesses may occur in the liver.
The Gall-Bladder.—The formation of biliary calculi in the gall-bladder is the chief point of interest here. At least 75% of such cases occur in women, especially in those who have borne children. Tight-lacing has been stated to act as an exciting cause, owing to the consequent retardation of the flow of bile. ”

“ There may be such an extent of injury—the whole secreting structure of the liver being destroyed—that repair is beyond the power of the organism. The best results are attained when discharge occurs by the most direct route externally; the next, by way of the right lung; the third, by the stomach or intestine. Repair cannot be hoped for when a large part of the normal hepatic structure is destroyed. When the pus escapes the walls of the abscess approximate, and union takes place by connective tissue, leaving a radiated or a merely linear cicatrix to mark the site of the purulent collection. ”

“ 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. ”

“ Monotony of food should be guarded against. Wonderful results are sometimes got from a sea- voyage.
Hepatitis.—During the whole course of an attack of dysentery, and for months thereafter, the condition of the liver must receive the most careful attention. We may not be able to prevent abscess of this organ; but if pain and swelling seem to suggest it as threatening we can try by means of full and repeated doses of ipecacuanha, emetine, saline aperients, rest, low diet, fomentations, dry cupping, and similar measures to avert what, to say the least, is a very grave complication. ”

“ The autopsy on the mother took place on the nineteenth. It is certainly worthy of note that the uterus, peritoneum and intestines showed nothing special, but the liver was full of metastatic abscesses. At the exit of the hepatic vein from the liver there was pus, and its walls were ulcerated at this place. The pus from the liver abscesses was filled with the pyogenic vibrio. Even the liver tissues, at a distance from the visible abscesses, gave abundant cultures of the same organism. ”