TNDIAN MEDICAL GAZETTE.
84
% 3$liiii[0i[ of Hospital fpttiq. LIVER ABSCESS ?INCISION ?DRAINAGE?RECOVERY. By Surg.-Capt. Townsend Shaw.
This case, together with one published in the Lancet of August 20th, 1892, is an example of It seems unilocular tropical liver abscess. to be generally allowed, now that tropical abscess, is as a rule, single. Korte, in the Berlin Klin. IVocli., 8th August 1892, quotes from Jiinenz's figures?viz., out of 297 cases in only 6 per cent, were there multilocular collections of pus,?a more a definite statement to work on than that made by the writer in Quoin's Dictionary, i.e., "most commonly the abscess is single, but fre" A cause quently there are several abscesses. the in of abscess liver, which I have not seen mentioned anywhere except in Korte's article, is the spread upwards of an inflammation starting in the retro-caecal tissue, and that too without developing any local symptom till it reachThis is more commones the liver substance. a single abscess. R. 13., a native, age 25, occupation labourer, was admitted on 17th July last. Stated thatfor the last two mouths he has suffered from pain in the liver and general dyspepsia. Has had occasional attacks of dysentery (acute), but nothing like a chronic affection. Examined carefully, nothing definite except the'tenderness on pressure was elicited. There was no enlargement of the liver in From the 17th to to the 28th the any direction.
ly
liver began to enlarge. The following is the condition noted :?" Superficial dulness, one inch internal to mammary line, reaches lower border of fifth rib: deep dulness -the upper border of 6th. In a line perpendicular to 8 th costal cartilage the dulness extends four iuclies downwards. Here is a small but well-marked tumour. The the liver is scarcely tender at all upper part of the fiuger, the tenderness comwith ou tapping 8th intercostal Hue, and the in meucing being most intense near the edge of the liver. There redness of the skin. is no Behind, was found but faiut crepitus ou ausculnothing tation. (Korte states that enlargement upwards is one of the first alterations in the contour of the liver. In neither of toy patients was this
perceptible
the~case). "
Bowels
and hard.
constipated. Stools, light-coloured Tongue, pale, covered with light
at tip, which was red and irritable '-looking. Vomiting, none at any There was a time. No cough or headache.
yellowish fur, except
'
little fever at night, accompanied by sweats. The' abscess is probably towards the anterior part of the right lobe. I cannot detect any alteration in size of left lobe. The border of the right lobe shows a much sharper curve
[March
1893.
Pulse 72, than normal. There is 110 jaundice. He is getting enunciated." and rather weak. Although the abscess wan undoubtedly near the surface, and there was perihepatitis, I could not detect any crepitus, a sign said by Korte to occur under those conditions. A severe attack of diarrhoea had started on the 26th or 27th, and operation was postponed for a few From the absence of redness and tension, days. from the mobility of the tissues lying superficial I thought that peritoneal adhesions did not exist. Over the tumour a slight but distinct doughy sort of fluctuation was to be detected. The man was very weak and nervous when placed 011 the table. He ultimately fell into a state of chloroform collapse. Operation, 1st August.?A 3-inch incision, one inch below and parallel to costal margin. Various layers dissected through 011 a director. No bleeding. On cutting through abdominal wall a quantity of glutinous yellowish-red matter welled slowly up. I put in my finger and pressed up what I erroneously thought to be the wall of the abscess in the liver. I found, however, that this fluid lay in a sort of ante-chamber between At the other the liver and the abdominal wall. side of the cavity I could just see the abscess opening; it was nearly circular, about threefourths of an inch in diameter, hard and rough to the touch. There were adhesions all round except below, where they were indefinite ; but I did not, of course, venture to settle this poiut by probing the place with my finger. The abscess cavity could just be spanned by my finger. It was roughly three inches wide. It was filled with the viscid broken-down liver substance which had The walls of the abscess welled out at first. were as rough as a large file. By means of an irrigator and piece of muslin (boiled previously) I washed and swabbed the two cavities out. until, applying Mr; Treves' method of dealing with tubercular abscesses, J got them as dry as was possible under the circumstauces. Careful measurment shewed that from the surface of the skin to furthest point of cavity was just The breadth was about twounder four inches. and-a-half inches; its direction obliquely upwards and backwards ; its position iu the right lobe. Instead of a drainage tube I put in Two large strips of muslin soaked in sublimate solution (1-4000) and dusted over with iodoform. Woodwool and bandage completed the
operation. Subsequent progress, although seriously impeded by the chloroform collapse, was excellent. Temperature rose the first night to 100, but soon become normal. The dressings were changed on the fourth day. They were soaked with a thin sanious fluid. Abscess syringed out. On the ninth day I found that a valve-like flap of liver substance hung over the mouth of of the cavity. This was snipped off without any haemorrhage occurring. No drainage tube was
MAnctt
1893.]
used sit first. malt.
GOLOKENATH DISPENSARY. SELECT CASES PROM S.
He
was
given Kepler's extract
SeptemberlOtIi?A small drainage
of
tube was thin the serous for discharge provide came out of the small fistulous opening. The liver now reaches only one inch below the eighth costal cartilage. No pain*on pressure. A few drops of bile were seen in the discharge. September 18th'.'?The patient had to go home. He was quite well ; a very email fistula remained, but the discharge from it was almost nil. Duration of case, about nine weeks. from the man only giving a history of two months' symptoms, it is a very curious fact that the liver should suddenly begin to enlarge so rapidly; that the enlargement was wholly in a downward direction', anil that, not withstanding the rapid enlargement, we should find an apparently' old abscess containing, not liquid debris such-as one might expect in a rapid dissolution of liver substance, but thick glutinous material. An early exploratory puncture ought to have been made. As to other possible methods of dealing with this abscess?aspiration, or puncture with drainage (Sachs' favourite method) would, from the very nature of the contents, have .been useless. I think the man must probably have had the abscess for some considerable time ; that it gave rise to definite symptoms only on reaching the surface of the liver, where it formed what I called its " ante-room; " and in this latter process lies the explanation of the sudden enlargement. If t])is view is correct, peritoneal adhesions don't take hug to form a barrier strong enough to bear the pressure of an irrigator's stream of water. To avoid the entry of discharge into the cavity of the abdomen pressure should be made from the outside (if sutures be not used). Thus the risk that I ran through my own error would be easily escaped. The incision ought not to lie less than one inch below the costal margin, otherwise it will sink under the libs and it will be very difficult to prevent the opening from closing up and interfering with the adequate drainage of the cavity. put in which
to
Remarks.?Apart
85
84
% 3$liiii[0i[ of Hospital fpttiq. LIVER ABSCESS ?INCISION ?DRAINAGE?RECOVERY. By Surg.-Capt. Townsend Shaw.
This case, together with one published in the Lancet of August 20th, 1892, is an example of It seems unilocular tropical liver abscess. to be generally allowed, now that tropical abscess, is as a rule, single. Korte, in the Berlin Klin. IVocli., 8th August 1892, quotes from Jiinenz's figures?viz., out of 297 cases in only 6 per cent, were there multilocular collections of pus,?a more a definite statement to work on than that made by the writer in Quoin's Dictionary, i.e., "most commonly the abscess is single, but fre" A cause quently there are several abscesses. the in of abscess liver, which I have not seen mentioned anywhere except in Korte's article, is the spread upwards of an inflammation starting in the retro-caecal tissue, and that too without developing any local symptom till it reachThis is more commones the liver substance. a single abscess. R. 13., a native, age 25, occupation labourer, was admitted on 17th July last. Stated thatfor the last two mouths he has suffered from pain in the liver and general dyspepsia. Has had occasional attacks of dysentery (acute), but nothing like a chronic affection. Examined carefully, nothing definite except the'tenderness on pressure was elicited. There was no enlargement of the liver in From the 17th to to the 28th the any direction.
ly
liver began to enlarge. The following is the condition noted :?" Superficial dulness, one inch internal to mammary line, reaches lower border of fifth rib: deep dulness -the upper border of 6th. In a line perpendicular to 8 th costal cartilage the dulness extends four iuclies downwards. Here is a small but well-marked tumour. The the liver is scarcely tender at all upper part of the fiuger, the tenderness comwith ou tapping 8th intercostal Hue, and the in meucing being most intense near the edge of the liver. There redness of the skin. is no Behind, was found but faiut crepitus ou ausculnothing tation. (Korte states that enlargement upwards is one of the first alterations in the contour of the liver. In neither of toy patients was this
perceptible
the~case). "
Bowels
and hard.
constipated. Stools, light-coloured Tongue, pale, covered with light
at tip, which was red and irritable '-looking. Vomiting, none at any There was a time. No cough or headache.
yellowish fur, except
'
little fever at night, accompanied by sweats. The' abscess is probably towards the anterior part of the right lobe. I cannot detect any alteration in size of left lobe. The border of the right lobe shows a much sharper curve
[March
1893.
Pulse 72, than normal. There is 110 jaundice. He is getting enunciated." and rather weak. Although the abscess wan undoubtedly near the surface, and there was perihepatitis, I could not detect any crepitus, a sign said by Korte to occur under those conditions. A severe attack of diarrhoea had started on the 26th or 27th, and operation was postponed for a few From the absence of redness and tension, days. from the mobility of the tissues lying superficial I thought that peritoneal adhesions did not exist. Over the tumour a slight but distinct doughy sort of fluctuation was to be detected. The man was very weak and nervous when placed 011 the table. He ultimately fell into a state of chloroform collapse. Operation, 1st August.?A 3-inch incision, one inch below and parallel to costal margin. Various layers dissected through 011 a director. No bleeding. On cutting through abdominal wall a quantity of glutinous yellowish-red matter welled slowly up. I put in my finger and pressed up what I erroneously thought to be the wall of the abscess in the liver. I found, however, that this fluid lay in a sort of ante-chamber between At the other the liver and the abdominal wall. side of the cavity I could just see the abscess opening; it was nearly circular, about threefourths of an inch in diameter, hard and rough to the touch. There were adhesions all round except below, where they were indefinite ; but I did not, of course, venture to settle this poiut by probing the place with my finger. The abscess cavity could just be spanned by my finger. It was roughly three inches wide. It was filled with the viscid broken-down liver substance which had The walls of the abscess welled out at first. were as rough as a large file. By means of an irrigator and piece of muslin (boiled previously) I washed and swabbed the two cavities out. until, applying Mr; Treves' method of dealing with tubercular abscesses, J got them as dry as was possible under the circumstauces. Careful measurment shewed that from the surface of the skin to furthest point of cavity was just The breadth was about twounder four inches. and-a-half inches; its direction obliquely upwards and backwards ; its position iu the right lobe. Instead of a drainage tube I put in Two large strips of muslin soaked in sublimate solution (1-4000) and dusted over with iodoform. Woodwool and bandage completed the
operation. Subsequent progress, although seriously impeded by the chloroform collapse, was excellent. Temperature rose the first night to 100, but soon become normal. The dressings were changed on the fourth day. They were soaked with a thin sanious fluid. Abscess syringed out. On the ninth day I found that a valve-like flap of liver substance hung over the mouth of of the cavity. This was snipped off without any haemorrhage occurring. No drainage tube was
MAnctt
1893.]
used sit first. malt.
GOLOKENATH DISPENSARY. SELECT CASES PROM S.
He
was
given Kepler's extract
SeptemberlOtIi?A small drainage
of
tube was thin the serous for discharge provide came out of the small fistulous opening. The liver now reaches only one inch below the eighth costal cartilage. No pain*on pressure. A few drops of bile were seen in the discharge. September 18th'.'?The patient had to go home. He was quite well ; a very email fistula remained, but the discharge from it was almost nil. Duration of case, about nine weeks. from the man only giving a history of two months' symptoms, it is a very curious fact that the liver should suddenly begin to enlarge so rapidly; that the enlargement was wholly in a downward direction', anil that, not withstanding the rapid enlargement, we should find an apparently' old abscess containing, not liquid debris such-as one might expect in a rapid dissolution of liver substance, but thick glutinous material. An early exploratory puncture ought to have been made. As to other possible methods of dealing with this abscess?aspiration, or puncture with drainage (Sachs' favourite method) would, from the very nature of the contents, have .been useless. I think the man must probably have had the abscess for some considerable time ; that it gave rise to definite symptoms only on reaching the surface of the liver, where it formed what I called its " ante-room; " and in this latter process lies the explanation of the sudden enlargement. If t])is view is correct, peritoneal adhesions don't take hug to form a barrier strong enough to bear the pressure of an irrigator's stream of water. To avoid the entry of discharge into the cavity of the abdomen pressure should be made from the outside (if sutures be not used). Thus the risk that I ran through my own error would be easily escaped. The incision ought not to lie less than one inch below the costal margin, otherwise it will sink under the libs and it will be very difficult to prevent the opening from closing up and interfering with the adequate drainage of the cavity. put in which
to
Remarks.?Apart
85
