HEPATIC ABSCESS, SIMULATING ASCITES, AND COMPLICATED WITH EXTENSIVE PERITONITIS -r SYMPTOMS OF ADDISON'S
DISEASE AND TUBERCULOSIS. By J. R. Wallace,
Bengal
P.H.A.,
Service*
Corporal D. Jones, 34th Regiment, aged 33 years, was admitted into the Queen's Hospital, Bareilly, on the 27th Janaary 1879,. with general debility supposed to be dependent upon Phthisis Pulmonalfs, for which his discharge from the service had been recommended. His previous medical history is as follows: he had been three and a half years in India with his regiment, and in August last, while quartered at Ranikhet, he suffered from bilious diarrhoea, and about the same time showed a marked tendency to pulmonary phthisis. The physical signs as noted in liis invaliding documents were " gradual loss of flesh and strength, night sweats, flattening in right infra-clavicular region, with dulness on percussion aver apes and right lung generally, and
April 1,
1879.]
evidences of consolidation; hepatic disease also present." He had been sent, after passing the annual invaliding board, to Bareilly to await the final departxire of the district invalids for Bombay. On admission into the Queen's Hospital he complained chiefly of langour and debility without any appreciable uneasiness or pain anywhere. He appeared exhausted, his pulse was somewhat slow but not deficient in volume, his tongue coated with a yellowish brown fur, his appetite was tolerably fair, bowels inclined to be torpid, skin dry but temperature normal: on further examination respiratory sounds were feebly heard but no evidence of far advanced lung disease; there is dulness over both apices ; heart sounds normal; extensive dulness over hepatic region, extending upwards to nearly the 4th rib, and laterally over left hypochondrium, and downwards to an inch above the umbilicus. No pain or tenderness on
stethoscopic
pressure.
There was no apparent change in the patient's condition from the date of his admission till the 6th February, and hitherto his treatment consisted of salines to act upon his bowels, hepatic alteratives, gentle local counterirritants and mild nourishing diet with stimulants. 6th February.?Severe pain over abdomen which is enlarged and somewhat tympanitic except over region of descending colon where a dull note is elicited on percussion ; bowels constipated ; pulse small and quick; some slight nausea, dyspnoea and hiccough. A warm water and castor oil enema was administered, but was ejected, only discolored and without any expulsion of fasces. Turpentine stupes were applied locally and a sedative draught given to allay the pain. 7 th February?Pain diminished ; hiccough constant; face pinched ; debility increased ; slight nausea; bowels not moved ; abdominal tumefaction rperceptibly increased, shifting resonance on percussion over abdomen, dulness over descending colon still present. Purgative enemata repeated, sinapism over epigastrium to relieve hiccough. 8th February.?Distressing dyspnoea and hiccough and increased prostration; abdominal wall more distended and yielding a clear tympanitic note on percussion ; distinct fluctuation and vibration on palpation, some bronzing of the integument of the loins and anterior chest wall observed ; both feet and ankles have become oedematous ; urine examined but found free from albumen, no pain complained of: bowels still inactive. Effervescing draughts with dilute hydrocyanic acid and local sedative applications are being employed to check the hiccough and repeated enemata given to evacuate the lower
bowel.
12th February.?Emaciation and prostration increas: the abdomen is more distended, and unmistakeable evidence as to the presence of fluid in the peritoneal cavity is given by the fluctuation, shifting resonance on percussion and the characteristic wavy impulse imparted to the fingers on palpation: continued obstinate hiccough, and owing to the increased dyspnoea it is thought necessary to relieve the tension and pressure upon the diaphragm by paracentesis. Accordingly this was resolved upon, but when placing the patient in the sitting posture, the dulness denoting the amount and position of the fluid could only be traced to half an inch below the umbilicus from the pubis, and above this point the tympanitic note of the distended intestine could distinctly be heard. Relief by this means, it was evident, could not be attained as the fluid was too small in quantity to justify the operation, and there was risk of injuring the gut. The bowels had only once been moved during the past four days, and now elaterium was administered, but without any salutary effect. 16^ February ?Still very low ; sordes have collected on teeth and lips : intermittent muttering delirium; the eyelids are caked with the Meibomian secretion pointing to extreme devitalisation ; bowels still excessively constipated, no change in size of abdomen, no tenderness or pain anywhere; hiccough has ceased, dysp-
ing
103
A MIRROR OF HOSPITAL PRACTICE.
noea an
also diminished.
enema
Nux Vomica
was
given during the evening
and followed by matter. Diet
given to-day, was
a large mass of scybalous and stimulants continued. llth February.?Still delirious, almost "in articulo mortis right hand has become oedematous ; passed some more scybalse. Treatment the same. 18tli and 19th February.?Constant delirium ; involuntary motions, first of a scybalous and afterwards of a bloody mucous nature ; urine examined, clear, free from sediment and not yielding any albumen on testing ; pulse almost imperceptible, sinking rapidly ; died comatose on the morning of the 20th February at 3 o'clock.
expulsion of
of "post mortem," examination held seven hours after death. Body emaciated; rigor mortis well marked, slight hypostatic discoloration, distinct bronzed hue over integument of loins and chest; lower thoracic (from margin of third costal interspace on either side) and abdominal walls greatly distended; upper portion of chest depressed Notes
and flattened; anasarca of both feet and ankles and right hand. Cranial cavity.?Brain congested, otherwise healthy. Weight 3 lbs. Thoracic cavity.?Pulmonary space greatly diminished by encroachment of diaphragm, the position of which was marked by a line extending from the fourth rib on one side to the same point on the other ; lungs greatly compressed and diminished in size, face of right found adherent to diaphragm by thickly organised lymph. On section general substance healthy, some circumscribed miliary deposit in both apices ; weight of right 15 ozs., left 16 ozs.: pericardium healthy; heart, muscular fibre firm, valves normal, weight 11 ozs.; signs of early
atheroma in aortic arch. Abdominal cavity.?On laying open the parietes a largo quantity of sanious pus gushed out, it measured in all 192 ounces. The whole of the omentum and intestines presented signs of far advanced peritonitis?a thick cake-like layer of yellow organised lymph being spread over their surface and extending between the interstices and folds of the large and small intestines, matting them almost inseparably together, and with the darkened condition of the intestinal coats, persented a decomposed, gangrenous mass. The intestines were displaced and pushed upwards and the right iliac fossa as well as the true pelvic cavity were filled with pus which pressed upon and flattened both the bladder and rectum. The left iliac fossa contained the dislodged gut enclosing a quantity of hardened faecal matter. Liver immensely enlarged, occupying three-fourths of the abdominal cavity and encroaching upon the chest cavity as far as the third intercostal space on either side. Its upper surface was covered with a thick layer of gelatiniform yellow lymph. Its right lobe at its lower margin waa found firmly adherent to the deep fascia and adjacent structures, and on removing it parts of it were torn. The right lobe contained an abscess cavity the size of a child's head which had burst and the contents escaped into the peritoneal cavity ; numerous secondary multiple abscesses were seen throughout the substance of the liver; weight after removal of the pus 6^ lbs : gall bladder full, duct free,- bile thin and void of coloring matter; kidneys enlarged and congested; summit of right kidney (about one-twelfth of the substance of the whole organ) with its supra renal capsule had been destroyed by extended ulcerative process from the liver which was adherent to the unhealthy portion of the kidney ; a pyogenic membrane limited the healthy from the unhealthy portion of the kidney; weight of right 8 ozs.; left 8 ozs.: spleen enlarged and congested, weight 13 ozs.; pancreas normal. Remarks on Case.?The points of practical importance and interest in this case are (a.) the absence of symptoms indicative of hepatic abscess; (b.) the exten-
THE INDIAN MEDICAL GAZETTE.
104
on the bursting of the abscess ; the destruction of renal tissue with a total absence of abnormal urinary products; (d.) the diagnosis formed during life. In reading the above case, one cannot fail to observe the striking exclusion during life of the cardinal symptoms and signs of the pathological lesions exhibited in the post mortem room, and it is only by the light of an autopsy that certain symptoms which manifested themselves during the course of the disease can reasonably be accounted for. Suppuration in the liver most probably began early during the patient's stay in hospital, on the 6th February rupture of the abscess most likely took place, giving rise to the distension of the abdominal walls, hiccough and dyspnoea, dependent upon the pressure of the fluid on the diaphragm, the peritonitis and consequent pain complained of, on this date. The want of vitality and reactive power in the system will account in a great measure for an absence of the more acute and sthenic evidences of suppuration and peritonitis. The characteristic bronzed hue of the integument as seen in Addison's disease was markedly present in this case, and was dependent upon the destruction of the supra renal capsule which, with the summit of the kidney it capped, was disintegrated by extended ulcerative process from the liver. The absence of pus or morbid products in the urine was dependent upon the limitation of the disease in the kidney by the line of organised inflammatory lymph, proving that inflammation did not begin primarily in the kidney, but by an extension of diseased action by contact of the healthy kidney, or that portion of it, with the pus.
sive
(c.)
peritonitis consequent
[April 1,
1879.
DISEASE AND TUBERCULOSIS. By J. R. Wallace,
Bengal
P.H.A.,
Service*
Corporal D. Jones, 34th Regiment, aged 33 years, was admitted into the Queen's Hospital, Bareilly, on the 27th Janaary 1879,. with general debility supposed to be dependent upon Phthisis Pulmonalfs, for which his discharge from the service had been recommended. His previous medical history is as follows: he had been three and a half years in India with his regiment, and in August last, while quartered at Ranikhet, he suffered from bilious diarrhoea, and about the same time showed a marked tendency to pulmonary phthisis. The physical signs as noted in liis invaliding documents were " gradual loss of flesh and strength, night sweats, flattening in right infra-clavicular region, with dulness on percussion aver apes and right lung generally, and
April 1,
1879.]
evidences of consolidation; hepatic disease also present." He had been sent, after passing the annual invaliding board, to Bareilly to await the final departxire of the district invalids for Bombay. On admission into the Queen's Hospital he complained chiefly of langour and debility without any appreciable uneasiness or pain anywhere. He appeared exhausted, his pulse was somewhat slow but not deficient in volume, his tongue coated with a yellowish brown fur, his appetite was tolerably fair, bowels inclined to be torpid, skin dry but temperature normal: on further examination respiratory sounds were feebly heard but no evidence of far advanced lung disease; there is dulness over both apices ; heart sounds normal; extensive dulness over hepatic region, extending upwards to nearly the 4th rib, and laterally over left hypochondrium, and downwards to an inch above the umbilicus. No pain or tenderness on
stethoscopic
pressure.
There was no apparent change in the patient's condition from the date of his admission till the 6th February, and hitherto his treatment consisted of salines to act upon his bowels, hepatic alteratives, gentle local counterirritants and mild nourishing diet with stimulants. 6th February.?Severe pain over abdomen which is enlarged and somewhat tympanitic except over region of descending colon where a dull note is elicited on percussion ; bowels constipated ; pulse small and quick; some slight nausea, dyspnoea and hiccough. A warm water and castor oil enema was administered, but was ejected, only discolored and without any expulsion of fasces. Turpentine stupes were applied locally and a sedative draught given to allay the pain. 7 th February?Pain diminished ; hiccough constant; face pinched ; debility increased ; slight nausea; bowels not moved ; abdominal tumefaction rperceptibly increased, shifting resonance on percussion over abdomen, dulness over descending colon still present. Purgative enemata repeated, sinapism over epigastrium to relieve hiccough. 8th February.?Distressing dyspnoea and hiccough and increased prostration; abdominal wall more distended and yielding a clear tympanitic note on percussion ; distinct fluctuation and vibration on palpation, some bronzing of the integument of the loins and anterior chest wall observed ; both feet and ankles have become oedematous ; urine examined but found free from albumen, no pain complained of: bowels still inactive. Effervescing draughts with dilute hydrocyanic acid and local sedative applications are being employed to check the hiccough and repeated enemata given to evacuate the lower
bowel.
12th February.?Emaciation and prostration increas: the abdomen is more distended, and unmistakeable evidence as to the presence of fluid in the peritoneal cavity is given by the fluctuation, shifting resonance on percussion and the characteristic wavy impulse imparted to the fingers on palpation: continued obstinate hiccough, and owing to the increased dyspnoea it is thought necessary to relieve the tension and pressure upon the diaphragm by paracentesis. Accordingly this was resolved upon, but when placing the patient in the sitting posture, the dulness denoting the amount and position of the fluid could only be traced to half an inch below the umbilicus from the pubis, and above this point the tympanitic note of the distended intestine could distinctly be heard. Relief by this means, it was evident, could not be attained as the fluid was too small in quantity to justify the operation, and there was risk of injuring the gut. The bowels had only once been moved during the past four days, and now elaterium was administered, but without any salutary effect. 16^ February ?Still very low ; sordes have collected on teeth and lips : intermittent muttering delirium; the eyelids are caked with the Meibomian secretion pointing to extreme devitalisation ; bowels still excessively constipated, no change in size of abdomen, no tenderness or pain anywhere; hiccough has ceased, dysp-
ing
103
A MIRROR OF HOSPITAL PRACTICE.
noea an
also diminished.
enema
Nux Vomica
was
given during the evening
and followed by matter. Diet
given to-day, was
a large mass of scybalous and stimulants continued. llth February.?Still delirious, almost "in articulo mortis right hand has become oedematous ; passed some more scybalse. Treatment the same. 18tli and 19th February.?Constant delirium ; involuntary motions, first of a scybalous and afterwards of a bloody mucous nature ; urine examined, clear, free from sediment and not yielding any albumen on testing ; pulse almost imperceptible, sinking rapidly ; died comatose on the morning of the 20th February at 3 o'clock.
expulsion of
of "post mortem," examination held seven hours after death. Body emaciated; rigor mortis well marked, slight hypostatic discoloration, distinct bronzed hue over integument of loins and chest; lower thoracic (from margin of third costal interspace on either side) and abdominal walls greatly distended; upper portion of chest depressed Notes
and flattened; anasarca of both feet and ankles and right hand. Cranial cavity.?Brain congested, otherwise healthy. Weight 3 lbs. Thoracic cavity.?Pulmonary space greatly diminished by encroachment of diaphragm, the position of which was marked by a line extending from the fourth rib on one side to the same point on the other ; lungs greatly compressed and diminished in size, face of right found adherent to diaphragm by thickly organised lymph. On section general substance healthy, some circumscribed miliary deposit in both apices ; weight of right 15 ozs., left 16 ozs.: pericardium healthy; heart, muscular fibre firm, valves normal, weight 11 ozs.; signs of early
atheroma in aortic arch. Abdominal cavity.?On laying open the parietes a largo quantity of sanious pus gushed out, it measured in all 192 ounces. The whole of the omentum and intestines presented signs of far advanced peritonitis?a thick cake-like layer of yellow organised lymph being spread over their surface and extending between the interstices and folds of the large and small intestines, matting them almost inseparably together, and with the darkened condition of the intestinal coats, persented a decomposed, gangrenous mass. The intestines were displaced and pushed upwards and the right iliac fossa as well as the true pelvic cavity were filled with pus which pressed upon and flattened both the bladder and rectum. The left iliac fossa contained the dislodged gut enclosing a quantity of hardened faecal matter. Liver immensely enlarged, occupying three-fourths of the abdominal cavity and encroaching upon the chest cavity as far as the third intercostal space on either side. Its upper surface was covered with a thick layer of gelatiniform yellow lymph. Its right lobe at its lower margin waa found firmly adherent to the deep fascia and adjacent structures, and on removing it parts of it were torn. The right lobe contained an abscess cavity the size of a child's head which had burst and the contents escaped into the peritoneal cavity ; numerous secondary multiple abscesses were seen throughout the substance of the liver; weight after removal of the pus 6^ lbs : gall bladder full, duct free,- bile thin and void of coloring matter; kidneys enlarged and congested; summit of right kidney (about one-twelfth of the substance of the whole organ) with its supra renal capsule had been destroyed by extended ulcerative process from the liver which was adherent to the unhealthy portion of the kidney ; a pyogenic membrane limited the healthy from the unhealthy portion of the kidney; weight of right 8 ozs.; left 8 ozs.: spleen enlarged and congested, weight 13 ozs.; pancreas normal. Remarks on Case.?The points of practical importance and interest in this case are (a.) the absence of symptoms indicative of hepatic abscess; (b.) the exten-
THE INDIAN MEDICAL GAZETTE.
104
on the bursting of the abscess ; the destruction of renal tissue with a total absence of abnormal urinary products; (d.) the diagnosis formed during life. In reading the above case, one cannot fail to observe the striking exclusion during life of the cardinal symptoms and signs of the pathological lesions exhibited in the post mortem room, and it is only by the light of an autopsy that certain symptoms which manifested themselves during the course of the disease can reasonably be accounted for. Suppuration in the liver most probably began early during the patient's stay in hospital, on the 6th February rupture of the abscess most likely took place, giving rise to the distension of the abdominal walls, hiccough and dyspnoea, dependent upon the pressure of the fluid on the diaphragm, the peritonitis and consequent pain complained of, on this date. The want of vitality and reactive power in the system will account in a great measure for an absence of the more acute and sthenic evidences of suppuration and peritonitis. The characteristic bronzed hue of the integument as seen in Addison's disease was markedly present in this case, and was dependent upon the destruction of the supra renal capsule which, with the summit of the kidney it capped, was disintegrated by extended ulcerative process from the liver. The absence of pus or morbid products in the urine was dependent upon the limitation of the disease in the kidney by the line of organised inflammatory lymph, proving that inflammation did not begin primarily in the kidney, but by an extension of diseased action by contact of the healthy kidney, or that portion of it, with the pus.
sive
(c.)
peritonitis consequent
[April 1,
1879.
