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Less ostentatious, than that hero, physicians do their work;
CIRCUMSCRIBED SUPPURATIVE HEPATITIS.
BY WILLIAM E. QUINE, M. D., CHICAGO, ILLINOIS. Professor of the Principles and Practice of Medicine and Clinical Medicine in the
College of Physicians and Surgeons, Chicago, Illinois.
GENTLEMEN: At the close of a recent lecture I directed your attention, in somewhat general terms, to the subject of circumscribed suppurative hepatitis, or abscess of the liver. I told you that this disease usually occurs in tropical climates; that it rarely originates in temperate climates; that it is practically unknown in very cold climates, and that, when the disease is encouutered in temperate or very cold localities, it will be found to have been imported there from tropical or sub-tropical regions. The geographical range of prevalence of abscess of the liver coincides pretty accurately with that of epidemic dysentery, and the more malignant types of malarial fever. The history of epidemic dysentery, or ulceration of the intestinal mucous membrane, obtains in cases of abscess of the liver in seventy-five to ninety per cent. of all the cases. The disease is not as uncommon in our section of the country as is usually supposed. The mere knowledge that a patient has had an attack of severe dysentery in his early life, or had been raised in a tropical locality, should be regarded as presumptive evidence in favor of the possibility, at least, of the existence of hepatic abscess. Malo subjects, at or after the middle period of life, are the ones who are almost exclusively prone to this type of disease. It occurs but rarely in young persons, and but three to five per cent. only of all the cases are furnished by females.
Direct injury of the liver from a fall or blow may result in suppurative inflammation. Operations performed upon the rectum or pelvic viscera, involving the introduction of septic material into the wound, and the probable absorption of septic matters from that wound, and the entrance of this septico-putrid material into the portal circulation, may result in the formation of suppurative inflammation likewise.
The initial lesions of abscess of the liver vary; they depend almost exclusively upon the mode of origin of the suppurative inflammation. I refer prominently to two modes of origin: the one resulting in the development of embolic abscesses, the other in the development of so-called tropical abscesses. In the case of embolism of the liver, consequent upon ulceration or sloughing of the intestinal mucous membrane from a wound or injury to the rectum or pelvic viscera in which septic material has been introduced, septic embolism of the liver usually results in the production of multiple foci of suppurative imflammation. The lobules of the liver in the affected area are more or less enlarged and softened. The central parts of these lobules exhibit very early minute yellowish spots, which are surrounded by zones of inflammation. This yellowish spot, or spots, as the case may be, indicates the point of origin of the suppurative process, and the zone, or area of inflammation or congestion, indicates the walls limiting the extension of the abscess. Usually from one to fifty of these foci of suppurative inflammation exist in the liver at one time. As the process of suppuration extends from molecular death of the walls of the abscess cavity, these abscesses may coalesce and form cavities of larger size. The rule in relation to embolic abscesses of the liver is, that they are of small size and multiple; they rarely attain the size of an orange. Commonly, they are as small as a pea or bean; more frequently they attain the size of a walnut, and from one to fifty of them may be found in the organ after death, or a smaller number of larger size in cases where the liver has been affected in this way for a considerable length of time.
It will be seen that there is a cloudy swelling of the hepatic cells, which constitute the hepatic lobules. In the center of the mass affected a yellowish spot soon makes its appearance, which is surrounded by a pale, grayish zone. Here the process of suppuration begins its existence by a molecular destruction of the boundaries of the abscess cavity, the boundaries of the abscess cavity being always conspicuous by the presence of a zone of congestion. In some instances, especially in the case of very old abscesses, the abscess walls may be constituted of the so-called pyogenic membrane; but in cases of acute origin no such pyogenic membrane is developed, and the process of enlargement of the abscess from breaking down of its walls is
still going on.
The right lobe of the liver exhibits a decided liability to this form of disease. It is affected in sixty-seven and three-tenths per cent. of all the cases; the left lobe is affected in six and six-tenths per cent of all the cases; both lobes are affected in twenty-six and one-tenth per cent. of all the cases; so that ninety-four per cent. of all the cases of hepatic abscess are found in the right lobe. It is true, a small percentage may exist in the left lobe. You will observe the rule, then, with respect to the differential diagnosis, which points to the fact that most of these abscesses exist in the right lobe of the liver. The size of a hepatic abscess is subject to a considerable diversity of development. In some instances they are found to contain a quart of pus—indeed, I have seen cases in which more than a quart of pus was removed at a single aspiration. In other cases of the disease, the abscesses are of small size; but, generally, when the size is small, the number is great. The contents of a hepatic abscess depends somewhat upon the age of it. An abscess of recent development is found filled with a thickish, semi-fluid, grumous material, which resembles, in a general way, coffee-grounds mixed with water. This grumouslike material consists of the detritus of the disintegrated hepatic substance. On the other hand, abscesses of older and more mature growth contain pus. In some instances this pus is streaked with a coffee-ground-like material, while in others it is mixed with blood and bile pigment; but ordinarily the pus is perfectly laudable and unmixed with any foreign elements.
The subsequent history of a hepatic abscess depends somewhat upon the size and location of it. The pus may exulcerate into some adjacent organ, and this is particularly liable to occur in cases of acute development in which no pyogenic membrane is produced; for in these cases there is progressive disintegration or destruction of the abscess wall, and consequently enlargement of the abscess cavity. The process of exulceration from molecular death of the abscess wall may go on, and the pus finally escape from the liver. Exulceration occurs in onehalf or fifty per cent. of all the cases. This exulcerative process usually occurs in a direction towards the thoracic cavity. Hepatic abscess, which results in ulceration, breaks into the thoracic cavity in twenty-five per cent of all the cases.
The pus may escape into the pleural cavity, giving rise to spontaneous empyema; it may escape into the substance of the lungs, the bronchial tubes, and the patient may suddenly cough enormous quantities of pus-a pint or a pint and a half at a single effort.
Under other circumstances, the abscess may exulcerate by way of the alimentary canal. Hepatic abscess opens into the stomach or bowels in fifteen to twenty per cent of all the cases that result in exulceration. In from seven and onehalf to ten per cent. of all the cases the abscess breaks into the alimentary canal. In six per cent. of all the cases there is exulceration of the abscess into the peritoneal cavity, followed speedily by collapse, and usually sudden death, peritonitis being found after death. In from two to three per cent. of all the cases exulceration externally occurs, and the abscess breaks between the ribs. Instances are recorded in the annals of medicine of hepatic abscesses opening into the vena cava, the aorta, the thorax, the pericardial cavity, and even into the cavity of the heart itself; but these are very extreme cases, and by far the greater number of them in which, if exul. ceration occurs at all, the pus is found to escape in the directions I have already referred to. The uninvolved parts of the liver may be entirely healthy, and this enables you to understand how it is that a man may have abscess of the liver in which it will be developed that the abscess contains a quart of pus, and still he may have have liver enough left to perform a fairly active function. The uninvolved portions of the liver, then, are unchanged in their anatomico-pathological appearance. Finally, the pus may be absorbed. It is not necessary that exulceration of pus should occur in all cases in order that recovery of the patient take place, for numerous cases are cited in medical literature which appear to demonstrate that hepatic abscess may terminate in spontaneous recovery without exulceration occurring at all-absorption of the liquor puris, fatty degeneration, and absorption of the organic constituents of the abscess, collapse of the cavity and cicatrization. A recovery of abscess of the liver may be complete or incomplete. Usually recovery is incomplete, but in many instances such a grade of recovery occurs as to be consistent with a reasonable degree of longevity and a fair degree of health. We would naturally and reasonably assume that the symptomatology of a disease, whose morbid anatomy is so gross and conspicuous, would be strongly and characteristically marked. This, however, is very far from being the fact.
The subject of circumscribed suppurative hepatitis must be regarded from two points of view: There are cases of an acute character-cases that are characterized by acute, unmistakable manifestations. There are others, however, of a very slow, insidious character, in which the symptomatology is extremely vague. If the history of the case be a perfectly classical one, there will be little or no difficulty in recognizing the affection. I have seen but one or two cases of hepatic abscess in which a classical history was presented.
Acute hepatic abscess begins with rigors or a pronounced chill. These rigors or chills are usually followed by a grade of fever which is extremely variable in its intensity. The fever is much like that of septicæmia; it is characterized by irregularly recurring chills, irregular exacerbations and remissions of fever. Under other circumstances, the fever is of a distinctly remittent type; and in still other cases, it is imperfectly intermittent in its character. The temperature is extremely variable; it may reach 105°; it may not exceed 100°. The pulse is likewise extremely changeable; it may not exceed ninety beats in the minute, or it may reach at times one hundred and thirty beats in the minute. Profuse sweating is almost invariably present in cases of this disease. It occurs in ninety-six per cent of all the cases of the acute type. Anorexia, more or less malaise, are concomitants of the febrile disturbance. The tongue is almost always thickly coated, usually brown, dry, disposed to fever. There is rapid amaciation, waste of strength, and nausea and vomiting occur in ninety per cent. of all the cases. The bowels are usually constipated. With respect to the condition of the skin, you would naturally presume that it must of necessity be jaundiced; but that is not so-jaundice rarely occurs in this disease. The skin is always muddy, dirty-looking, and occasionally, but only very occasionally, is it faintly jaundiced. The rule is for jaundice to be absent; but you will remember the rule also is for the skin to present a muddy, dirty appearance. There is mental depression, amounting to more or less melancholia; the urine is dark colored; it usually contains bile pigment, but often biliary elements are absent.
We will now dwell cursorily upon the physical examination of the patient. The liver is found enlarged in ninety per cent. of all the cases. It is enlarged in some one direction, and usually that direction is upward into the cavity of the right thorax. It is commonly assumed in practice that the liver enlarges downward; that is not so, as careful and patient observation will teach you. The lower margin may not project below the margin of the ribs farther than it does in health, and still the organ may be enlarged to an enormous degree in the direction of the cavity of the right thorax. Enlargement then