XII, B, 3 Abriol: Amoebic Abscess of the Liver 141 



and collodion applied externally. If only a few ounces of pus are. obtained, 

 it will be sufficient to inject 2 oz. of the quinine solution, but if a pint or 

 more is present then 4 oz. containing 40 grains of quinine should be used, 

 so as to saturate the whole wall. In some cases the temperature falls 

 finally, all the symptoms disappear and weight is rapidly gained after a 

 single injection, as happened in eight cases. More frequently the effect is 

 only temporary, and it is then advisable to repeat the little operation after 

 about a week, when less pus is commonly obtained, A third injection is not 

 rarely required, but in large abscesses even more, perhaps even four or five, 

 may be required. I have noticed that if an originally present leucocytosis 

 completely disappears, little or no pus is usually obtained at a second 

 aspiration, and uninterrupted convalescence ensues. The continued pres- 

 ence of even a slight leucocytosis is generally an indication for repeating 

 the aspiration. In the common fibrous-walled single abscess no cinchonism 

 results, even from the injection of as much as sixty grains of quinine, but 

 in more acute ones the drug may be absprbed to some extent into the circu- 

 lation. 



ROGERS'S FLEXIBLE SHEATHED TROCAR FOR STERILE SIPHON DRAINAGE AND 



QUININE IRRIGATION 



With a special apparatus Rogers drains aseptically the cavity 

 of the abscess and washes it out with sterile quinine solution 

 to kill the amoebae. 



OPEN OPERATIONS WITH DRAINAGE 



There are various ways of approaching the liver with a view 

 of performing a simply oncotomy. In the main they are 

 divided into two types : the transpleural route and the abdominal 

 route. Some surgeons prefer to explore the liver to determine 

 the presence and location of the abscess before proceeding to 

 operate; others expose the liver and use the needle to locate or 

 determine the presence of an abscess. 



Transpleural route. — Several surgeons describe various tech- 

 nics of the transpleural route; all have their advantages and 

 objectionable points. McDill(i6) describes a technic in which 

 pneumothorax is obviated. Essentially it is as follow: A curvi- 

 linear incision to expose the right ninth and tenth ribs is made in 

 the midaxillary line. All the tissues down to, but not including, 

 the fascia overlying the muscles are reflected in one flap. The 

 periosteum of the exposed ninth rib is dissected out and 10 centi- 

 meters of it is resected. The resulting gutter is closed with a 

 running catgut suture through the entire thickness of the muscu- 

 lature. Just above the tenth rib an incision is made through all 

 layers of the chest wall and the diaphragm. While this incision 

 is accomplished, the fingers of an assistant firmly press the loos- 

 ened chest wall inward and against the diaphragm to prevent 



