If there are localizing signs, such as a tender spot, a fixed pain, a localized œdema, localized pneumonic crepitus, pleuritic or peritoneal friction, these should be taken as indicating, with some probability, the seat of the abscess and the most promising spot for exploratory puncture. If none of these localizing signs is present, then, considering the fact that the majority of liver abscesses are situated in the upper and back part of the right lobe, the needle should, in the first instance, be inserted in the anterior axillary line in the 8th or 9th interspace, about 1 in. or 1½ in. from the costal margin and well below the limit of the pleura. The instrument should be carried in a direction inwards and slightly upwards and backwards and, if found necessary, to 3 to 3⅓ in. If pus be not struck the needle must be slowly withdrawn, a good vacuum being maintained the while in case the abscess has been transfixed and the point of the needle lodged in the sound tissue beyond. No pus appearing in the aspirator, the remainder of the dull hepatic area must be systematically explored, both in front and behind, regard being had to the lung and pleura on the one hand, and to the gall-bladder, large vessels, and intestine on the other. The peculiar colour— often like dirty-brown thick blood— of liver pus must not be allowed to deceive the operator into thinking that he has failed to strike the abscess.*[1]
At least six punctures should be made before the attempt to find pus is abandoned. Provided there is complete absence of breath sounds, of vocal fremitus and resonance over the lower part of the right lung, and pus has not been reached from lower down, then the pleura or lung may be disregarded and puncture made anywhere below the line of the nipple and angle of the scapula, or wherever the physical signs suggest.
The surgeon should be encouraged to make early use of the aspirator by the fact that its employment,
- ↑ * I have seen the peculiar brownish fluid resulting from the action on blood of the carbolic lotion that had been used to sterilize the exploring syringe, mistaken for pus. To obviate so grave a mistake the exploring syringe should be washed out with boiled water before use.
