A CASE OP ABSCESS OF THE LIVER. By Gopaul Ciiundeb Rot
Teacher, Nagpoor Medical School. Much has been said of late regarding the pathology and treatment of hepatic abscess, and various opposite reasonings I have been brought forward on the points in question. lately treated a case of liver abscess in the Nagpoor City Hospital ; and although the case itself presents no peculiarity in its symptoms, yet the singular failure in its treatment has put me in possession of some facts which, I daro say, may be utilized by the enquiring profession. Muhammad Ali, aged 25 years, a Munshi, native of Hyderabad, but a resident of Raipoor, was admitted on the 29th October, 1867, with a swelling on the region of the liver. He stated that four months ago he had had fever of an intermittent nature, which continued irregularly for two or three months, when it was followed by a pain in the hepatic region. The fever and pain continued for a month, when a swelling in the The inflammatory region of the liver became apparent. symptoms were aggravated, and were attended with shivering tor some days, but the pyrexia abated in severity afterwards, and latterly became so slight as not to be appreciable by the patient. After four or five months' suffering, he was led to seek for relief at the hospital. When admitted be was very weak, emaciated, and anaemic. He had no jaundice or ascites. Liver duiness was enlarged in area, and continuous downwards over a fluctuating swelling, situated under the costal cartilages at the upper arid right side of abdomen while he was in a sitting posand extended close to the The navel. ture, patient was very intemperate in his habits, and had been long in the habit of drinkand ardent ing liquors smoking hemp. He was kept under treatment till the 13th November, when, seeing him daily more and more exhausted by the hectic, and disliking the idea of allowing him to die (for die he would), without any measure taken for his relief, I thought of letting out the pus. There was no adhesion between the liver and the abdominal parietes, and a quantity of peritoneal fluid that had lately collected had evidently pushed the organ backwards and upwards from its former position, thus obscuring the seat of abscess. However, I pressed the skin back upon the liver, and introduced a trocar and canula a little below the right costal cartilage. To my surprise, nothing but thin dark blood flowed from the canula ! After some blood had beeu withdrawn, and pus did not appear, tile canula was plugged, pressed back, and bandaged in situ. The patient expressed some relief after operation. No peritonitis ensued, and he was at all events not in the least worse for the paracentesis. The plug was removed from the canula on the 15th December, and as no bleeding occurred, the cauula was removed also. Some clear peritoneal fluid oozed out of the opening, which was closed with sticking plaister and bandaged. The patient died on the 16th December. On post-mortem examination, the liver was found enormously enlarged. Its right lobe was occupied by a large abscess, bounded in front and behind by a thin wall of hepatic sub-
Maech 2,
A MEDICAL DIRECTORY FOR INDIA.
1868.]
stance. At the lower part the wall was rather thick, and it was there (a finger's breadth from the thinned parietes) that the canula had entered, bnt had not reached the cavity of the abscess, which was therefore not emptied. There was no periThe great tonitis. and not a drop of blood in the abdomen. omentum was just adherent to the margin of the puncture. Remakks This instance of a case of liver abscess, the only one in the conrse of five long years in the city of Nagpoor, is worth recording; for, considering its topography, it must be inferred that Nagpoor bears a greater immunity from such hepatic derangeTrue it is ments than most places situated in the torrid zone. that a hot climate brings on torpidity of the liver, and add to this a sedentary habit, hiphly-spiced food, and the use of alcoholic drinks, and you complete the etiology of hepatic affections. When the liver is thus overworked with alcoholic stimulants, and its tissues barely nourished, it is nof surprising that a slight inflammation should pass on to disintegration and suppuration of the organ. It is one to ten, therefore, that, in case of hepatic abscess, yon find your patient a sober and temperate man. In a paper read before the recent Medical Congress by Dr. Eainirey, it is stated by him that puncture of the hepatic parenchyma is quite innocuous. This opinion is criticized in your November number by your Paris correspondent (No. 1), who asserts that these punctures are so serious that they are rarely practised ; and in illustration he quotes one case on record of a lad whose liver was thus punctured, and who died. I may quote here my case to show that, as far as the puncture was concerned, no mischief resulted beyond a slight haemorrhage. The existence of such a larcre superficial abscess, without a corresponding degree of inflammation sufficient to cause adhesion in the surrounding parts, is also an exceptional
point.
As regards treatment, I may be allowed to remark that, when the liver is thus ineffectually punctured, the best treatto ment to follow is to retain the canula in situ and plug it up ; for, should there be no adhesion in the surrounding parts, the blood from such a vascular organ will continue to flow into the peritoneal cavity unchecked, and will cause death, either primarily by internal hasmorrhnge, or secondarily by extensive peritonitis; whereas plugging the canula stops the bleeding effectually, and the irritation of the instrument excites adhesive inflammation around the puncture.
63
Teacher, Nagpoor Medical School. Much has been said of late regarding the pathology and treatment of hepatic abscess, and various opposite reasonings I have been brought forward on the points in question. lately treated a case of liver abscess in the Nagpoor City Hospital ; and although the case itself presents no peculiarity in its symptoms, yet the singular failure in its treatment has put me in possession of some facts which, I daro say, may be utilized by the enquiring profession. Muhammad Ali, aged 25 years, a Munshi, native of Hyderabad, but a resident of Raipoor, was admitted on the 29th October, 1867, with a swelling on the region of the liver. He stated that four months ago he had had fever of an intermittent nature, which continued irregularly for two or three months, when it was followed by a pain in the hepatic region. The fever and pain continued for a month, when a swelling in the The inflammatory region of the liver became apparent. symptoms were aggravated, and were attended with shivering tor some days, but the pyrexia abated in severity afterwards, and latterly became so slight as not to be appreciable by the patient. After four or five months' suffering, he was led to seek for relief at the hospital. When admitted be was very weak, emaciated, and anaemic. He had no jaundice or ascites. Liver duiness was enlarged in area, and continuous downwards over a fluctuating swelling, situated under the costal cartilages at the upper arid right side of abdomen while he was in a sitting posand extended close to the The navel. ture, patient was very intemperate in his habits, and had been long in the habit of drinkand ardent ing liquors smoking hemp. He was kept under treatment till the 13th November, when, seeing him daily more and more exhausted by the hectic, and disliking the idea of allowing him to die (for die he would), without any measure taken for his relief, I thought of letting out the pus. There was no adhesion between the liver and the abdominal parietes, and a quantity of peritoneal fluid that had lately collected had evidently pushed the organ backwards and upwards from its former position, thus obscuring the seat of abscess. However, I pressed the skin back upon the liver, and introduced a trocar and canula a little below the right costal cartilage. To my surprise, nothing but thin dark blood flowed from the canula ! After some blood had beeu withdrawn, and pus did not appear, tile canula was plugged, pressed back, and bandaged in situ. The patient expressed some relief after operation. No peritonitis ensued, and he was at all events not in the least worse for the paracentesis. The plug was removed from the canula on the 15th December, and as no bleeding occurred, the cauula was removed also. Some clear peritoneal fluid oozed out of the opening, which was closed with sticking plaister and bandaged. The patient died on the 16th December. On post-mortem examination, the liver was found enormously enlarged. Its right lobe was occupied by a large abscess, bounded in front and behind by a thin wall of hepatic sub-
Maech 2,
A MEDICAL DIRECTORY FOR INDIA.
1868.]
stance. At the lower part the wall was rather thick, and it was there (a finger's breadth from the thinned parietes) that the canula had entered, bnt had not reached the cavity of the abscess, which was therefore not emptied. There was no periThe great tonitis. and not a drop of blood in the abdomen. omentum was just adherent to the margin of the puncture. Remakks This instance of a case of liver abscess, the only one in the conrse of five long years in the city of Nagpoor, is worth recording; for, considering its topography, it must be inferred that Nagpoor bears a greater immunity from such hepatic derangeTrue it is ments than most places situated in the torrid zone. that a hot climate brings on torpidity of the liver, and add to this a sedentary habit, hiphly-spiced food, and the use of alcoholic drinks, and you complete the etiology of hepatic affections. When the liver is thus overworked with alcoholic stimulants, and its tissues barely nourished, it is nof surprising that a slight inflammation should pass on to disintegration and suppuration of the organ. It is one to ten, therefore, that, in case of hepatic abscess, yon find your patient a sober and temperate man. In a paper read before the recent Medical Congress by Dr. Eainirey, it is stated by him that puncture of the hepatic parenchyma is quite innocuous. This opinion is criticized in your November number by your Paris correspondent (No. 1), who asserts that these punctures are so serious that they are rarely practised ; and in illustration he quotes one case on record of a lad whose liver was thus punctured, and who died. I may quote here my case to show that, as far as the puncture was concerned, no mischief resulted beyond a slight haemorrhage. The existence of such a larcre superficial abscess, without a corresponding degree of inflammation sufficient to cause adhesion in the surrounding parts, is also an exceptional
point.
As regards treatment, I may be allowed to remark that, when the liver is thus ineffectually punctured, the best treatto ment to follow is to retain the canula in situ and plug it up ; for, should there be no adhesion in the surrounding parts, the blood from such a vascular organ will continue to flow into the peritoneal cavity unchecked, and will cause death, either primarily by internal hasmorrhnge, or secondarily by extensive peritonitis; whereas plugging the canula stops the bleeding effectually, and the irritation of the instrument excites adhesive inflammation around the puncture.
63
