54 DISEASES DUE TO PROTOZOA 



normal chest, so that a needle of 3I inches in length can do no harm 

 in any case. 



Do not insert the needle where the liver overlaps the stomach. 



Do not forget that one lobe may be enlarged by overwork becau.se 

 the other is atrophied. 



It is possible to miss the abscess after six punctures. 



Always incise the skin first, then use the needle, or a piece of skin 

 may block the needle. Never aim at the vena cava each time as some 

 areas are thus missed. 



To evacuate the pus a special trocar and cannula are required, 

 that is, when the abscess is in the right half of the liver; the cannula 

 should be 3J inches long; the vena cava is 4J inches distant from the 

 surface. Push the cannula off the trocar when the end is inserted in 

 the liver, and the liver cells are by this means pushed aside and not cut. 



Do not wash the abscess cavity out with carbolic; it coagulates the 

 blood and causes it to resemble pus. 



Remove the ribs below the pleura, if necessary, and put in a tube. 

 This tube can be of greater diameter than the cannula and inserted 

 by stretching it upon a special rod, which is then inserted down the 

 cannula, the cannula withdrawn, the rod liberated from the rubber 

 tube by an appliance and withdrawn, leaving the tube in situ, exer- 

 cising pressure upon the surrounding liver cells and preventing pus 

 from leaking into the pleural cavity. Haemorrhage is also thus pre- 

 vented. Do not evacuate all the pus before the tube is inserted or the 

 abscess cavity will collapse, and there will not be a cavity in which to 

 insert the rubber tube. 



The after-treatment is all-important. 



Drain the abscess by syphoning. Attach to the rubber tube a glass 

 tube, and to this a rubber tube passing to a bucket by the bedside. 



If the syphon action is excessive blood may come ; then raise the 

 bucket on to a stool, then a chair, then on to the bed, and so reduce 

 the suction until the desired effect has been obtained. 



Give emetine at the same time as for amoebic dysentery. 



Retain the tube in position for two to^ ten weeks, shortened from 

 time to time as required, keep it in until the bile comes or the pus has 

 all been evacuated. Then remove the syphon tube, and shorten the 

 rubber tube as the liver pushes it out. 



When bed sores arise turn the patient on to his side. 



If the fever still remains there are more abscesses or the drainage 

 has been insufficient. 



If the abscess is aseptic, irrigate dailv with c}uinine i — 1,000, but 

 remember that such fluids with flocculi of pus may enter the open 

 mouths of the hepatic veins and may prove rapidly fatal. 



Patients treated for Liver Abscess should never return to the tropics. 



