TREATMENT 



1915 



It, however, an abscess is believed to have formed, there should 

 be no delay in making an exploratory puncture. 



For this purpose a needle 3 J inches in length, but preferably not 

 longer, because of the danger of injuring the vena cava, should be 

 rendered sterile by boiling in plain water, but must not be dipped 

 into an antiseptic lotion nor into spirit. This needle should be 

 capable of being fitted on to a glass syringe or an aspirator. 



The patient should be placed under chloroform, and all arrange- 

 ments should be made so that an operation can be performed at 

 once if necessary. 



The needle should be driven into the liver in the region of any 

 definite swelling or pain, or, failing these, through the eighth inter- 

 costal space in the anterior axillary line, about i or ij inches from 

 the costal margin. 



The direction of the needle should be inward, slightly upward 

 and backward, because the usual site of an abscess is in the upper 

 and back part of the right lobe. 



Aspiration by the syringe or the aspirator may reveal pus, or 

 may fail to do so, in which latter event the needle must be carefullv 

 and slowly withdrawn, and its contents ejected on to a clean white 

 dish, to see if it is composed of the grumous material of liver abscess. 

 The needle should now be driven into the liver in different places 

 and directions until some six to twelve punctures have been made. 

 There is no danger in this procedure if performed with reasonable 

 care, and it may even benefit the patient by performing what has 

 baen termed ' hepatic phlebotomy.' When the abscess has been 

 located, the needle should be left in situ as a guide, and one of two 

 procedures may be carried out : A. Aspiration; B. Operation. 



The operation should, however, always be performed if the 

 abscess has already burst into the lungs, the peritoneal or pleural 

 cavities. 



A. Aspiration.— This is preferable if the abscess is small, and 

 consists of evacuating its contents, and the injection of a solution 

 of I grain of emetine hydrobromide in 2 ounces of water, or the 

 repeated irrigation of the cavity with a solution of bi-hydrochloride 

 of quinine (3 to 5 grains to the ounce) by means of Rogers' flexible 

 sheathed aspiration cannula. 



B. Operation. — An operation is necessary if the abscess is large, 

 if the pus is not sterile, if the abscess has burst into the lungs or a 

 serous cavity. fH 



The site of the operation depends upon where the pus has been 

 obtained. Two principal places may be mentioned: (i) through 

 the thoracic wall ; (2) through the abdominal wall below the ribs. 



Giordano and others have recommended a laparotomy and the 

 localization of the abscess by the hand prior to the actual operation 

 for evacuation of the pus. This may be useful in c rtain cases when 

 there are no signs indicating the position of the abscess. 



I. Operation through th^ Thoracic Wall. — An incision should be 

 made through the parietes, including the site of the puncture, 



