A case of deep-seated tropical abscess of the liver treated by trans-thoracic hepatotomy : recovery / by Byrom Bramwell and Harold J. Stiles.

  • Byrom Bramwell
Date:
1896
Catalogue details

Licence: Public Domain Mark

Credit: A case of deep-seated tropical abscess of the liver treated by trans-thoracic hepatotomy : recovery / by Byrom Bramwell and Harold J. Stiles. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    The breath sounds over this area were feeble, otherwise they were normal. There was no friction. There was some falling in of the chest wall on the right side opposite the seventh, eighth, and ninth ribs, but the expansion of the chest was •equally good on the two sides. The patient was seen again a few weeks ago and appeared to be in perfect health; he had gained two stones in weight since the operation, and was in the habit of taking a great deal of exercise ; his digestion left nothing to be complained of. The cicatrix was somewhat depressed and became drawn in during inspiration. The physical signs were much the same as they were five months ago. The whole of the costal angle was still free from liver dulness, but the breath sounds at the base of the right lung were more distinct and could be heard almost down to the same level as on the left side. Remarks hy Mr. Stiles. — In reviewing this case from the surgical aspect there are one or two points to which further allusion may be made. Although the history, the discomfort in the hepatic region, the constitutional symptoms, and the healthy condition of the other organs all pointed to suppurative hepatitis, it nevertheless remained for the aspirator to establish the diagnosis, to determine the situation and size of the abscess, and to decide as to the nature of the operation which would be required to be performed. If pus be present in the liver without giving rise to any external manifesta- tions, then we must conclude that we have to deal either with small multiple abscesses or with a single abscess which, if of considerable size, will in all probability be situated either in the upper or the upper and back part of the right lobe. The question therefore arises as to the best site from which to make an exploratory puncture in order to reach the pus by the safest and most direct route. As the result of investi- •gations in the post-mortem room I came to the conclusion that the seventh intercostal space in the mid or anterior axillary line should be the point first chosen, and the trocar passed either vertically to the surface, or with more or less inclination upwards and backwards. The lower part of the pleural cavity, if not obliterated by adhesions, will of course be traversed, but the lower edge of the lung will be above the puncture. Should this fail to strike the pus, further exploration should be made through the seventh space in the scapular line, and, if necessary, from the sixth and eighth spaces. If there be no downward enlargement of the liver.
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