1 91 6 DISEASES OF THE LIVER AND PANCREAS 



through which pus was obtained. After the skin has been well 

 retracted, a piece of a rib may require to be removed, thus ex- 

 posing the diaphragm below the pleura, which must be incised and 

 stitched to the margins of the wound, and the wound well packed 

 with gauze. 



The liver is now exposed, and two methods of procedure are open 

 to the operator— either to push a pair of dilating forceps along the 

 needle, which has been left in situ, and thus to open up the cavity 

 and evacuate the pus, and then, after inserting a double drainage- 

 tube, to wash out the cavity with the quinine solution mentioned 

 above, close up the wound, fix the drainage-tube in position, and 

 dress the wound aseptically, or to adopt Hanson's special apparatus. 



Manson, after the preliminary incision, thrusts a trocar and 

 cannula into the abscess, and, after withdrawing the trocar, passes 

 a drainage-tube stretched on a probe into the abscess cavity, and 

 then, withdrawing first the trocar and then the probe, the drainage- 

 tube is left in position in the liver abscess, and, being firmly gripped 

 by liver tissue, prevents leakage of pus into the abdominal cavity. 



2. Operation through the Abdominal Wall. — The usual method is to 

 cut down upon the swelling or on to the liver, and if adhesions are 

 found, to evacuate and drain the abscess. If there are no adhesions, 

 the liver is fixed to the peritoneum by a few stitches of thick catgut 

 or kangaroo tendon, but preferably not silk, and the wound is lined 

 by iodoform gauze and left for two days, when, adhesions having 

 formed, the abscess can safely be evacuated as described above. 

 Hanson's apparatus can, of course, be used in this position as well 

 as through the thoracic wall. 



Post-Operative Treatment. — The dangers of the operation itself 

 are but slight. The pleura may be opened, and if this happens, it 

 should be carefully closed by stitches. 



The post- operative complications are many, and include haemor- 

 rhage, pneumothorax, pyothorax, pyopneumothorax, gangrene of 

 the lung, and delayed chloroform poisoning, while a second abscess 

 is not uncommonly met with, and must be relieved. 



After the operation the temperature should fall to normal, and if 

 this does not happen, a second abscess or one of the above complica- 

 tions may be suspected, unless, indeed, it is due to imperfect 

 drainage, which must at once be rectified. 



The dressings should at first be frequently changed, usually twice 

 a day, and the cavity irrigated with quinine lotion. Good drainage 

 is the essential of the post-operative treatment, and care must be 

 taken that the drainage-tube is not too rapidly shortened, other- 

 wise the temperature is apt to rise. 



On recovery, the patient should, if possible, be given a holiday 

 in the Temperate Zone. A short course of emetine or ipecacuanha 

 after the operation wound has quite healed is distinctly indicated 

 in order to prevent the formation of another abscess. 



