Alton Ochsner

Pyogenic abscess of the liver

Abstract 1. 1. An analysis is presented of 830 cases of pyogenic hepatic abscess collected from the world literature and a presentation of 47 additional cases is made. 2. 2. During the ten-year period, 1928–1937 inclusive, there were 186 cases of abscess of the liver admitted to Charity Hospital and Touro Infirmary in New Orleans. Of this number, 139 (74.7 per cent) were amebic abscesses and 47 (25.2 per cent) were pyogenic. During this same period there were 540,776 total admissions to the Charity Hospital, among which there were 160 (0.029 per cent) abscesses of the liver, and 1,152 patients diagnosed as having liver disease, of which 10.2 per cent were amebic abscesses and 3.6 per cent were pyogenic abscesses. The sex incidence of pyogenic hepatic abscess reveals a preponderance of occurrence in the male, 67.4 per cent in the collected series and 70.2 per cent in the authors. This is probably explained by the fact that the etiologic agents occur more frequently in the male. The greatest age incidence is from the third to the fifth decades. There is no significant racial predisposition. 3. 3. Pyogenic liver abscess is primarily a complication of an intra-abdominal suppurative process with the antecedent lesions in the portal area. Of these lesions, suppurative appendicitis is the most frequent. Appendicitis was the etiologic agent in 34.2 per cent of the collected cases and 10.6 per cent of the authors cases. This discrepancy is due to the fact that the majority of reports in the literature represented primarily the authors interest in pylephlebitis and liver abscess as complications of appendicitis. Pyogenic liver abscess can be caused also by direct extension from contiguous suppurative processes, trauma, and by transportation of microorganisms through the hepatic artery from distant foci. There is a relatively large group (59.5 per cent) of the authors series termed “cryptogenic,” idiopathic, or primary pyogenic hepatic abscess in which the antecedent lesion could not be determined. 4. 4. The most frequently found organisms in pyogenic hepatic abscess are B. coli, streptococci, and staphylococci. 5. 5. Pyogenic hepatic abscess may be multiple or single, and usually involves the right lobe. The abscesses were single in 28.8 per cent, multiple in 71.1 per cent, and involved the right lobe alone in 41.8 per cent of the collected cases. In the authors forty-seven cases these incidences were 54.5 per cent, 45.4 per cent, and 68.1 per cent, respectively. 6. 6. The principal symptoms and signs of pyogenic hepatic abscess are fever, pain and tenderness over the hepatic area, liver enlargement, chills, and jaundice. Characteristically, there is a leucocytosis with a proportionate increase in polymorphonuclear leucocytes. The characteristic roentgenologic changes are elevation and immobility of the diaphragm, usually the right. The diagnosis was positive in 82.1 per cent of 28 cases in the authors series in which roentgenologic studies were made. 7. 7. The prognosis in pyogenic hepatic abscess depends upon: (1) the multiplicity of the lesions; (2) the presence or absence of complications; and (3) the type of drainage instituted. Whereas of the twenty-four cases in the authors series with single abscess of the liver nine (37.5 per cent) died, of the twenty cases with multiple abscesses, nineteen (95 per cent) died. The mortality rate was 90.9 per cent in those cases with complications and 36 per cent in the cases without complications. The total mortality rate was 79.6 per cent in the collected cases and 72.3 per cent in the authors series. Whereas in those cases not operated upon the mortality rate was 100 per cent in both series, in the cases in which operation was performed the mortality was 50.9 per cent in the collected series and 64.8 per cent in the authors series. 8. 8. The complications of pyogenic hepatic abscess are usually the result of rupture or direct extension into one of the adjacent viscera. 9. 9. The treatment of pyogenic hepatic abscess may be divided into: (1) prophylactic and (2) surgical. Prophylaxis is particularly applicable to multiple hepatic abscesses which are preceded by appendicitis and pylephlebitis, because once the development has proceeded to the stage of multiple abscess formation, surgical therapy offers only the slightest hope. The treatment of solitary pyogenic hepatic abscess consists of incision and drainage. 10. 10. The employment of that type of drainage which completely avoids the slightest possibility of contamination of the peritoneal or pleural cavity is of paramount importance. The results obtained in the authors series of cases clearly demonstrate this fact. Of the twenty-two cases in which the transperitoneal approach was employed for the institution of drainage, there were sixteen deaths (72.7 per cent). The transpleural method of drainage was used in nine cases with six deaths (66.6 per cent). In contrast to these high mortality rates is the 33.3 per cent mortality obtained in six cases in which the extraserous approach was used.

Indications for and Results of Inferior Vena Caval Ligation for Thromboembolic Disease

Indications for venous ligation in the treatment of thromboembolic disease are limited to two types of cases, phlebothrombosis and suppurative thrombophlebitis. Although ligation of the superficial femoral veins is satisfactory in many instances, there is increasing evidence that ligation of the inferior vena cava is often preferable. Indications for this procedure are discussed, the technic is described, and results in 117 cases are evaluated.

THE EARLY RECOGNITION OF BRONCHOGENIC CARCINOMA

Although early diagnosis is desirable in practically all illnesses, it is of utmost importance in malignant neoplastic disease. Cancer is primarily a disease of older persons. As a result of better medical care and increased longevity, the older age group in our population has increased, and thus the total number of cancer cases has steadily multiplied in spite of efforts to control and correct precancerous lesions. Of all the cancers of the body, bronchogenic carcinoma is increasing more rapidly than any other. In 1912, Adler (1) was able to collect only 374 cases of cancer of the lung and stated, “On one point, however, there is complete consensus of opinion and that is that primary malignant neoplasms of the lung are among the rarest form of disease.” In the brief span of forty years, primary cancer of the bronchus has become one of the most frequent malignant lesions in general, and is the most frequent malignant lesion in men. In the ten-year period from 1938 to 1948, the deaths from bronchogenic carcinoma in the United States increased 144 per cent (from 6,732 in 1938 to 16,450 in 1948). During this same period, deaths from all types of cancer increased 31 per cent (from 149,214 in 1938 to 195,594 in 1948). From 1920 to 1948, the death rate from bronchogenic carcinoma in theunited States increased over ten times (1.1 per hundred thousand population in 1920 to 11.3 per hundred thousand in 1948). The proportion of deaths from cancer of the lung to all cancer deaths has also increased throughout the years. In 1920, lung cancer represented 1.1 per cent of all cancer deaths; in 1930, 2.2 per cent; and in 1948, 8.3 per cent. We have the temerity to predict that if the increase in the incidence of bronchogenic carcinoma continues proportionately as it has up to the present time, in 1970 it will represent 18 per cent of all cancers, or almost 1 in 5. It is obvious, therefore, that the early recognition of bronchogenic carcinoma is imperative, provided, of course, that something can be accomplished if such recognition is made early. That bronchogenic carcinoma is a disease primarily of older persons is illustrated by our experience in 1,122 cases, of which 38 per cent were in the sixth decade and 40 per cent in the seventh decade; only approximately one-fourth were less than 50 years of age. Overholt (2) and others (3,4) have shown that the resectability of lung cancer can approach 100 per cent if the diagnosis is made and treatment instituted early, even before the patient has symptoms. In this consideration, one should define what is meant by early recognition. The desideratum, of course, is recognition of the condition early in the course of the disease, which does not necessarily mean shortly after the onset of symptoms. There is undoubtedly a great deal of variation in the rate of growth of bronchogenic carcinoma, since it has been our experience that not infrequently patients who have had symptoms for a considerable period of time have operable lesions

Liver abscess part I

Abstract 1. 1. A study of 73 cases of amebic liver abscess is presented. 2. 2. The average age was forty-four years. The ratio of males to females was 8 to 1. 3. 3. Fifty-nine and six-tenths per cent gave a history of an antecedent diarrhea; 17.4 per cent showed amebae in the abscess and 36.1 per cent showed amebae in the stool in those cases in which these examinations were performed. 4. 4. The principal symptoms and signs were pain and tenderness, being found in 79.4 per cent. Fever and enlargement of the liver were found in 69.8 and 65.7 per cent, respectively. A diagnosis of amebic hepatitis was made preoperatively in 68.4 per cent. Positive x -ray diagnoses were made in 87.7 per cent. 5. 5. The prognosis in amebic hepatitis depends largely upon the presence of secondary infection and the type of operation used. In a series of 4035 cases collected from the literature, and including the authors own cases, in which open operation was used, 1908 (47.2 per cent) ended fatally. In a similar series of 459 treated conservatively there were 32 deaths, a mortality rate of 6.9 per cent. 6. 6. In the authors series of 70 cases in which treatment was used, 10 succumbed, 14.2 per cent mortality. Forty-six were operated upon with 9 deaths, a mortality rate of 19.5 per cent. Of these 16 were operated upon, employing the transpleural approach, with 4 deaths, a mortality rate of 25 per cent. Fourteen were operated upon through a right rectus incision with a 21.4 per cent mortality rate. Seven had simple incision and drainage over a presenting mass with a 14.2 per cent mortality rate. Nine had retroperitoneal operations with an 11.1 per cent mortality. 7. 7. The lowest mortality rate (4.1 per cent) was obtained in 24 cases treated conservatively by aspiration and the use of amebicides. 8. 8. The treatment of amebic hepatic abscesses which are not secondarily infected consists of aspiration and the use of amebicides and open operation should be employed only in those cases in which there is infection with pyogenic microorganisms.

Effect of insulin and glucose on normal and obstructed intestine.

Conclusions From these results, it is suggested that glucose alone should not be used postoperatively and certainly not in the presence of intestinal obstruction, because glucose alone in the majority of instances exerted an inhibiting effect on intestinal activity. Insulin, OS the combination of insulin and glucose produced an increase in intestinal activity. The best results were obtained when insulin preceded the administration of glucose by about one-half hours time. There was no correlation betn-een the intestinal activity and the hlood sugar findings.

Diseases of the breast.

As a result of health education programs that have stressed self-examination and the importance of early diagnosis and treatment, less than 5 percent of breast lesions seen in clinical practice today are malignant. Nevertheless, breast cancer is the leading cause of deaths due to cancer in women and the second most common breast lesion. Chronic cystic mastitis, the most common breast lesion seen in women, can often be treated conservatively by aspirating the cystic fluid. Close follow-up is necessary so that if carcinoma develops, it can be treated early. Carcinoma is unpredictable but not hopeless. Although controversy exists regarding treatment, radical mastectomy is still the preferred treatment in most cases. Other breast diseases include adenofibroma, a common lesion requiring excisional biopsy for positive diagnosis; nipple discharge, which should be carefully examined cytologically; and relatively rare breast lesions, including intraductal papilloma, adenosis, traumatic fat necrosis, and cystosarcoma phylloides.

Preventing and treating venous thrombosis.

Unlike thrombophlebitis, phlebothrombosis is a symptomless condition that often causes death by pulmonary embolism. To prevent thrombosis and embolism, physicians must take measures to increase venous flow and return in the legs. If embolism does occur, the patient will usually become apprehensive and will have tachycardia. In such instances, the physician should do a thrombectomy or ligate the vena cava.

Carcinoma of the stomach.

SURGICAL experience with carcinoma of the stomach at the Massachusetts General Hospital has been reviewed by Parsons1 in previous papers covering the years 1922 to 1926, and the period from 1927 to 1936 by Parsons and Welch.2 This report includes all patients admitted to this hospital on whom the diagnosis was made during the ten-year period 1937 to 1946 inclusive. In the compilation of these figures, it is, of course, our hope to show that increased knowledge of the disease and its amenability to surgical attack have resulted in a steadily increasing five-year salvage rate. But it is of equal .xa0.xa0.

PEPTIC ULCER--WHEN AND WHEN NOT TO OPERATE.

Very few patients with duodenal ulcer require operation. Physicians must convince these patients of the importance of avoiding excessive gastric acidity. In the small number of cases in which surgical intervention is necessary, an operation should be done which results in gastric anacidity. Gastric ulcer can undergo malignant change and should be resected. The results of surgical treatment for peptic ulcer at the Ochsner Clinic are reviewed briefly.

Cause and prevention of thromboembolism.

Thromboembolism, although still not very common, is increasing alarmingly in spite of everything that has been done to prevent it. Prophylactic measures, such as early ambulation and other attempts to speed up the blood flow in patients who are confined to bed, have failed miserably to decrease the incidence of thromboembolism. Also, it is not possible to detect approximately 40 per cent of the patients with phlebothrombosis—a fatal type of venous thrombosis—before fatal embolism occurs. Some prophylactic measure which can be used routinely in all patients in whom venous thrombosis is likely to occur must be employed.