A CASE OF LIVER ABSCESS. By Subgeon-Captain D. M. Moir, ji.a., m b. R. J., cat. 42, a European engine-driver, was admitted to the Presidency General Hospital on 10th June 1894, operated on 26th June 1*94, and discharged cured on 2nd August 1894.

Previous History.?-The patient is a good physique and temperate habits;

man of he has been ten years in India, and has not suffered from malarial fever. In December 1893 he first suffered from dysentery, passing blood and In January 1894 he mucus copiously. caught a bad cold and had a return of the Between the 11th and the 28th February he was treated in the Medical College Hospital for dysentery, hepatitis and pyrexia,?the highest temperature 103o,8 F. was recorded on the 14th February. During March he went on a voyage After his return lie had a to Colombo. relapse, and was readmitted into the same hospital for hepatitis on the 27th April, when his temperature was 102o,4 F. By the end of April he was free from fever, and he improved so rapidly that he was able to leave hospital on the 11th May. Later on the hepatitis recurred, and he was admitted into the General Hospital on the 20th June suffering from well-marked hepatitis.

dyseiftery.

Condition on Admission.?The patient is slightly ansemic, somewhat reduced in streno-th

and

weight.

He is

subject

to occasional head-

aches, frequent insomnia, and low fever which

usually supervenes in the evening. His appetite digestion are bad; nausea is frequent in the morning or evening, but vomiting rare. The tongue is moist, and has a slight white coating The bowels are fairly regular, though there is^i tendency to constipation, and the motions are and

deficient in bile. Urine is high-colored and contains urates. Pulse about 90,?of fair volume and strength. The liver is increased considerably in bulk, the lower margin of the right lobe can be palpated about 1 inch below the costal arch, and the left lobe is markedly enlarged. The whole organ is tender on palpation, and is frequently painful; the pain being worst during an accession of fever. There is often pain about the right shoulder-blade.

340

INDIAN MEDICAL GAZETTE.

Course of the Case.?Between the 15tli and the 26th June he grew steadily worse, and his condition became alarming. There was daily fever, without any rigor or cold stage, with an acme about midnight varying from 100? F. to 102? 4 F. He suffered from copious and exhausting night sweats, and passed restless nights, because the attacks of pain over the liver were always worst at night. He became very anaemic and extremely weak; the decubitus was dorsal, since any movement or other position induced hepatic pain. The tongue was large, flabby, indented by the teeth, and coated with a thick yellowish or whitish fur. The abdomen became tympanitic, recti muscles rigid, bowels costive, motions claylike in colour and consistence. The urine, howThe hepatic ever, was dark with bile pigment. in much varied in site and character, being pain at one time dull and constant, and at another acute and lancinating, with intervals of freedom from pain. Sometimes the pain was worse in the epigastrium, at other times it seemed to be over the seat of the gall-bladder, while frequently it radiated all over the liver. On and after the 21st June, however, the seat of the pain became more

constant, being chiefly localised

to

the 6th costal interspace, slightly external to the right mammary line, and from that spot vertically down to the costal margin. About the same time a slight cough developed and there was some duluess over the lower lobe of the right lung posteriorly. On the 25th June the following note was recorded :?" In the mammary line the total hepatic dulness is7|in., deep dulness 2?in., superficial 4b in. Slight pitting and acute pain on pressure in

the 6th costal space in the mammary line and extending downwards to the costal margin. Left lobe of liver enlarged and tender. Right rectus muscle tense and rigid."

the 26th June.?Assisted by H. W. Pilgrim I introduced the trocar and canula of an aspirator obliquely upwards and inwards between the 7th and 8th ribs about a couple of inches external to the mammary line, and at once found pus. A transverse incision was then made down to the surface of the liver. Using the canula as a guide the index finger was cautiously pushed through more than an inch of the liver substance, and the abscess cavity reached. Its walls were soft and ragged, and the cavity was far too large to explore with the finger; but the bottom of the cavity was nearly on a level with the incision, a circumstance that greatly favoured drainage. On withdrawing the finger about 16 ounces of creamy, yellow and red, typical hepatic pus escaped. A drainage tube 5^in. long, and having a diameter of iin., was introduced.

Operation on Surgeon-Captain

Subsequent Course.?The patient made an The dressings were recovery.

uninterrupted

changed daily

[Sept. for

count of the copious fell to normal on the

1894.

nearly three weeks on acdischarge. The temperature

evening of the day

of opera-

tion, and remained so during the remainder of his stay in hospital. On the 19th July a short, small tube was removed, by the 25th July the wound was healed, and on the 2nd August the patient was discharged at his own request.

drainage

For the daily observations and general care of the case I am greatly indebted to Assistant Surgeon J. T. Parkinson. The interest in this case The connection its etiology. between dysenteric ulceration and liver abscess has been denied by numerous observers. In this particular case there are strong grounds for regarding the hepatitis, culminating in hepatic abscess, as having been initiated by the antecedent dysentery.

Remarks.?(1) hinges mainly on

A strong, healthy man, of regular and temperate habits, suffers from dysentery in December and January, gets hepatitis in February, suffers from it off and on for five months, and finally develops a liver abscess. Hepatic ab-

following dysenteric ulceration or wound of the rectum has been recorded over and over again. The following is a significant case in point which came to my notice about a couple of years ago :? scess

A healthy man, in comfortable circumstances and of sedentary habits, was operated on for a small polypus of the rectum. The operation was of the simplest kind, and consisted in merely snipping the pedicle of the polypus with a pair of scissors. Soon afterwards he began to suffer from low fever, which was supposed to be of malarial origin. No connection between the removal of the polypus and the fever was suspected. As the fever was obstinate the patient was sent on a sea voyage. When he arrived at his destination it was found that a liver abscess had developed, from the effects of which he died. Here, again, there is good reason to believe that the liver abscess was due to septic absorption through the cut pedicle of the polypus and the portal system. (2) During the operation on the patient R. J., the abscess cavity was reached by pushing the index finger along the canula through the liver substance, instead of reaching the cavity by means of a knife. There are so many cases of serious, and even fatal, htemorrhage due to incision of the liver, and there are no means of avoiding this danger, that I doubt if the knife should be used where a blunt instrument, or the finger, will serve one's purpose equally well and with far less risk. (3) The abscess was treated simply by free drainage and dry antiseptic dressings. Not a drop of any antiseptic solution was ever introduced into the abscess cavity.

No 43 B. C. M. M. D.

RECORD OF

Name, R. J.

Caste, European.

Age,

42.

TEMPERATURE,

Disease, Liver Abscess.

(Temperature Chart of

"

Date

PULSE AND RESPIRATION.

of attack,

A Case of Liver Abscess Abseaw

"

10th 10?& June 1894.

Result,

m. Moir.) Mcir.) Burgeon-Captain D. M. by Surgeon-Captain

Cured.

Date of result, 2nd

August

1894.

A Case of Liver Abscess.

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