where the abscess was pointing. There was fever, temperature being 102'3?, pulse 109, dry cough, dyspnoea, enlargement of liver on all sides. Patient

so

operation

BAHAWALPORE

STATE

SADAR

HOSPITAL.

NOTES ON THE SURGICAL TREATMENT OP A HUGE LIVER-ABSCESS. By Assistant-Surgeon Dulip

Singh, L.M.S. Hindu* male, aged 28, admitted into the hospital, 25th January 1885. Previous History.?He suffered from malarious intermittent fevers during the last four months. No regular hospital treatment received during that time, and the fever was for the most part of a quartan type. During the last two months he from liver compliant, which suffer to began added to his former complaint of fever, symptoms of pain in the right side, severe chilliness. The fever from that time, as the patient says, " constant inward was never off, and was of a were now and then exacerbations There type." of pain and shivering, followed by a bad attack of fever. No history of dysentery, none of drinking spirits or wines. It may be remarked that the place where he lived is highly malarious, and situated on the woody bank of a river. Even when in good health, the patient was every now and then very susceptible to chills aud exposure to cold and wet. Present state, i.e., condition on admission: The patient was brought in a doolee, aud I happened to be in the hospital at the time. He was in a moribund condition, with difficulty of breathing and inability to stand erect, on account of pain and extreme weakness. On examination, the right side of the chest was found

Jamnoo,

bulging

a

out at two

points,

one

corresponding

to

the other to the 7th, intercostal latter bulging was more near the The spaces. sternum than the former, and situated exactly in the nipple line. These were the two places the

8th, and

weak as to be unable to mount the table without being lifted by four or

five persons. Treatment.?The operation was proposed immediately after admission. No chloroform was given. The aspiration needle was introduced at the point which protruded out most, which was in the 7th intercostal space in the nipple line. The aspiration apparatus being worked, a little more than 3-^ pounds of thick yellowish-white pus drawn off, no blood Pus was sweet. or flakes. Any more pus ceasing to flow, and the other bulging, i.e., in 8til intercostal space, diminishing with the evacuation, the needle was taken out. A drainage tube of small calibre was introduced into the opening left by the aspiration needle, but it required a little enlarging by knife. All this was done with strict antiseptic precautions. The drainage tube introduced, the small wound was dressed antiseptically with a thick bag (3 inches thickness and 9 inches broad and 12 inches long) of clean Deodar sawdust antisepticised with eucalyptus oil. Over this bag or pad a common muslin bandage was applied, and the patient removed to the wards. A little brandy and water was given immediately after the operation, with some aromatic spirit of ammonia, as the patient seemed to pant. The strength of eucalyptus sawdust was 4 drams of oil to 6 seers of sawdust. The patient was ordered to have 2 drams of cod-liver oil with extract of malt twice daily ; and two doses of tincture steel x m., quinine sulph. gr. v (one

dose) daily.

Temperature on the morning of 26th January lOO^0, and patient complained of very little pain, but of greater dyspnoea; I do not know why. Evening of 26th January, temperature lOO'S0. Cod-liver oil, steel, and quinine given as before. January 27th.?Morning temperature 100'8?; evening i00*8?. January 28th.?Temperature throughout the day was 100?; patient complained of a little more pain this evening; cod-liver oil, quinine, and was

steel

as

before.

January 29th.?Morning temperature 99*6?; evening 99*8?. January 30th.?Dressing changed, the sawdust pad was caked by the pus about the thickness of two inches. Nothing was injected into the abscess cavity, a fresh drainage

Eucalypticised sawdust and secured with a broad bandage. I can say from guess that the pus which caked the sawdust pad would be more than a pound. Once for all,?the cod-liver oil, quinine and iron were given from beginning to the last date of discharge of patient.

tube

being introduced.

pad again applied,

THE INDIAN MEDICAL GAZETTE.

46

Patient remained in

January 31s?.?Temperature normal, i. e., 98*8?; patient complained of very little pain, and was in good spirits. Progressing favourably till

February, when a fever with chilliness came This being so, dressings on in the afternoon. were changed on 12th February as usual, there being very little soaking of pus in the sawdust; a large dose of quinine of 15 grains given after the case was dressed. Drainage tube on this occasion not placed in the cavity more than i an inch. Dressing was changed for the third and last time on 28th February, when there was very little caking and soaking of pus, and drainage tube could not be introduced, the abscess cavity having contracted, and granulations filling up to surface. Superficial dressing, consisting of lint moistened with eucalypticised glycerine (of my own make, strength 1 dram of eucalyptus oil to 8 oz. of glycerine) was applied on the small wound, and secured with a bandage. This was opened on 1st March 1885, and the patient left the hospital same day, the wound being .all healed and patient in good health. Cod-liver oil, quinine, and steel treatment was continued for a month longer, and the liver examined at the end of April 1885, when the liver dullness was found to be diminished on all sides, but much more so in front than below. The patient is in sound health aud following his occupation as a shop-keeper. Remarks.?This case is of some interest on account of? (1) Showing how soon a patient, even in a moribund condition and evideutly on the verge of death, rallies, when a large accumulation of pus is got rid of. (2) The great benefit which the antiseptic treatment of wounds secures for the patients who seem hopeless without such treatment. (3) How soon does the constitution shattered by malaria and really in a state of malarious cachexia comes round under quinine and steel treatment, much more so when these are combined with cod-liver oil. (4) That antiseptic treatment may be successfully practised with very little expense and trouble, and without having such things at hand as Boric wool, Hartman's antiseptic wood wool, sublimated serum cotton, &c. In this case the expenditure on all dressings applied is as given below, which is sufficient to show how little money and time may be spent. In four dressings of this case the following things priced below were used:?

Daily

cost of

Us. A. P.

Carbolic acid used for lotions

Total cost

1

0

0

...

0 0 0 0

2 0 6 4

0 3 0 0

...

1

12

3

...

... ... ...

hospital for dressings?

35

1886'.

days.

lis. As. 1\

11 tli

(1) Cloth for bandage, 8 yards?price (2) Muslin, or gauze cloth, for making bags to fill with sawdust (3) Deodar sawdust, G seers, for (4) Eucalyptus oil, 4 drachms

[Feb.,

* 35

12?? days

=

nearlyJ

11

pies.

1

This is less than one anna per day, so that sueli serious ease cost less than one anna per day for his dressings. Time spent for dressing the case, 4 hours. Per day time

a

4 h. X GO 35

The

m.

a

little

more

days method

of

than 6 minutes per diem.:.

dressing abscesses and with eucalypticised

purating surfaces, &c., dust is of great value

in

antiseptic

supsaw-

treatment,

account of dust not allowing pus and other secretions to ran off under the dressing but the on

pus just soaks into the sawdust, and is caught there wherever it meets the sawdust as water soaks into a porous sand or earth, and thus there is very little danger of pus meeting the air and putrifying if the thickness of pad is sufficient. The method of treating wounds discharging pus in the antiseptic way by sawdust is the same I saw done in the Mayo Hospital, Lahore, by Dr. E. Lawrie, M.B., when a student in the Lahore Medical College.

Bhawalpore State Sadar Hospital: Notes on the Surgical Treatment of a Huge Liver-Abscess.

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