pointing. Explored the mo?t prominent part of the swelling in the epigastrium with a grooved needle without result;
of liver but
no
13th again explored, found pus near the surface, removed about one pint by aspiration, then passed in an ordinary large trocar and canula ; after a few days substituted a drainage tube for the canula, the end of the tube being
on
received into
a
nest of
carbolized
tow ; carbolic
daily ; the discharge injections continued sweet until the 27th of April, when it
acid
used
were
began
to be foetid.
The of
operation gave relief to urgent symptoms pain, tension and dyspnoea, but no real
progress was made towards recovery ; diarrhoea set in on the 30th with exacerbation of fever. On the 2nd
May his
friends removed him from
hospital. The cavity measured 6 inches in depth, and showed no tendency to contract. There was consolidation of the lung. Nothing more was heard of the case, but there was no hope of a cure under such unfavorable circumstances. No. II.?Hindu male
23rd June
aged
47,
an
out-patient
1882.
7 months ; liver symptoms 2 months. history of bowel complaint or of spirit
Fever No
drinking. Right lower chest and hypochondrium distinctly bulging, oedema over lower ribs; liver greatly enlarged, reaching from the 5th rib to the level of the navel in the mammary line, and extending into the left hypochondrium. Diarrhoea, fever, emaciation and great prostration.
NOTES ON THE SURGICAL TREATMENT OF LIVER ABSCESS IN DISPENSARY PRACTICE?RESULTS OF 14 CASES. M
1
By Surgeon A.
-
r
Tomes,
Civil-Surgeon, Midnapore. Case No. I.?Hindu male 12th of
April
liver
1882.
aged 15, admitted of fever 3 months, months ; none of dy-
History
symptoms
2
sentery or of spirit drinking. and great emaciation, general
Cough, fever enlargement
Aspirated just
the abscess
under the ribs
tense even elastic
through the epigastrium was no pointing but a prominence) ; repeated the
(there
operation three times at a few days' interval, evacuating from 2 to 4 pints of liver pus each time. Relief was decided, but transient only, the general condition of the patient did not improve and the cavity had no tendency to contract. After the 9th July he ceased to attend ; on the 13th was reported to be dying?about 3 months after commencement after the first
tapping.
of illness and
20
days
February, 1884.]
TOMES ON THE TREATMENT OF LIVER ABSCESS.
No. III.?Hindu male
aged 40,
an
out-patient,
abscess after fever.
4th July 1883.
fever
Fever 7 months followed by liver symptoms. No history of dysentery or of spirit drinking.
rhoea present.
Fever, great emaciation,
and
enormous
largement of liver, the measurement ing from the 4th rib above, to a finger's above the
crest of
theilium below.
circumscribed
cedematous
ing
9th
about the
en-
extendbreadth
A somewhat
semi-fluctuating swell-
rib behind.
ounces
of
first tapping the liver contracted to a considerable extent, and no larger quantity than 2^
pints
of pus
occasion.
was
any subsequent of carbolic solution were
drawn off
Injections
on
Marked relief from tension and relaxation of the parietes followed each operation, fever also lessened, but on the 17th dysentery set
used.
in,
the 22nd he
on
reported tapping, and
was
days
after the first
from
commencement of illness.
No. IV.?Hindu male
home
Liver
symptoms 5 monthsj emaciation, cough and diar-
months ;
Aspiration performed 10 times between 25th July and 26th of August, the punctures being made through the right hypochondrium. 18 ounces of pus evacuated on the first occasion, and from 7 to 11 ounces each time afterwards. Carbolic acid washings employed. On 26th
muddy coloured flaky aspirator through the 9th interAgain space in the mid-axillary region. aspirated on the 6th, 15th and 18th. After the
Evacuated 80 liver pus by the
12
35
August inserted a large silver canula subsequently replaced by a piece of drainage tubing ; from the time of changing the
which
was
close for the open method diarrhoea and fever abated, but the feet began to swell. Nothing seen
of the
patient
after 6th
strength
to the extent of
she
suddenly
died after
matter from the
first
tapping
bowel,
and
but heard
about 8 months
I think she would have
woman
a
about to go
month, when profuse discharge of
about
a
2
months from
7 from onset of symptoms. remained under treatment,
Had the
recovered, but being an neglected and the
out-patient, dressings tube allowed to slip out at times. Closure of the opening probably occurred, were
; treated at his
in the bazar.
Two months' history of fever,
being
about her household duties for
to be dead?18
aged 42
October,
from friends that she had recovered health and
none
of bowel
hard drinker. All
complaint. An acknowledged the signs of a large liver abscess present.
At
the first visit it
the
re-accumulation of pus and rupture of the abscess into the intestine. The discharge kept sweet
throughout
while under notice.
No. VI.?Mahomedan male aged 45, treated aspirated through posterior axillary line where as an out-patient from the 13th of September the prominence was most marked, though there 1882: an opium eater, History of fever 4 was no actual pointing; 3 pints of pus were months, liver symptoms recent. No dysentery;
thoracic
was
wall in the
drawn off and a like amount at the second visit a few days later. Three days after that a large canula was introduced with the result of evacuat-
spirit drinking. region bulged, indistinct fluctuation, lower margin of the organ on a level with uming an enormous quantity, about half a gallon, bilicus ; pain, tenderness and prominence most of pus ; the silver canula was replaced by an distinct in epigastrium, but no pointing. elastic tube covered by a nest of carbolic tow. Withdrew 42 ounces of pus by aspiration tube the There was a copious drain through through the 8th interspace, anterior axillary line. until death?15 days after first operation and The patient was not again brought to the disabout 2x/>, months from commencement of illness. pensary, friends reported that he was tapped This was a hopeless case owing to the advanced again by a private practitioner in October, and stage of the disease. There were rales at the in November it was said that a free opening bases of the
no
Liver
purulent expectoration had been made. On 13th November visited him at his lodgprostration. No. V.?Hindu female aged 36, treated as an ing, found him in a very bad state, with general out-patient, 25th July 1882, A case of liver anasarca and a liver reaching down to the ilium, lungs
and
and extreme emaciation and
36
THE INDIAN MEDICAL GAZETTE.
scanty discharge of pus going
a an
opening to
come
through
on
hypochondrium. hospital. Died about
to
recovery, no fever after operation ; discharge bf pus, which kept sweet, gradually decreased With the contraction Of the cavity. The man
Would not
in the
the
end
of
months after first
November,?2 tapping. VII.?Hindu male, aged 30, admitted No.
left
and
mixture ;
squills
the
of his
emaciation and
operation,
a
state of
The
Died
The abscess
progressive
one
month after
about three months from
commence-
debility.
ment of illness.
No.
VIII.?Hindu
male, aged 35, admitted 1882. 14th December, History of dysentery 2 or 3 months, of fever 1 month, followed by localized pain and swelling. Spirit drinking denied. A prominent fluctuating swelling body, occupying right hypochondrium and epigastrium, commencing to point in epigastrium, its limits undefined, passing into the left hypochondrium Emacia-
(
tion
great,
Pus
fever
aspirator
daily.
found
was
in the most
exploration with prominent part of
the the
epigastric swelling, then 24 ounces of bile-stained liver pus were drawn out through a large canula.
depth, 2
inches
drainage abscess
The
cavity measured 4 inches in obliquely upwards and backwards. only directly tube was
was
daily
backwards.
left in
through
tow.
This
A
case
into
large
which the
washed out with
the end of the tube received
phenyle
crosed bone.
a
phenyle, nest
of
progressed steadily
enormous
patient
so
one, and
low that
the
I did not
washings with phenyle was begun, but the from hospital. Death oc-
treatment
removed
was
ne-
Constant
supporting
curred about
months after commencement
5
of illness. No. X.?Hindu tient.
male, about 45, a private pamonths' fever followed by liver sympNo spirit drinking.
2
toms.
On 12th
February 1883
pus ; when
seen a
few
;
slight
said to have vomited
days
later
pulse 126;
tem-
Liver found to be much
perature 103 weak.
larged
on
admitted
operate for the removal of the
venture to
case
aged 25,
was an
condition of the
and
and below to the level of the navel.
twd
23rd Spirit drinking admitted ; 5 months months' fever and pain in right side ; 1 a perceptible swelling of right side ; had been treated by a private practitioner, who first explored; then freely incised the liver through the chest wall behind the posterior axillary line* leaving a tube in; about a sefer of pus said to have flowed out, and a discharge has kept up ever since. Liver area very much enlarged, a continufoetid pils ous profuse discharge of thick flaky from the opening ; on exploration with the finger about 2 inches of the end of a rib in a necrosed state could be felt projecting into the cavity.
; it measured 3 inches Nevember ; lung symp22nd November left hospital
accord in
own
operation,
1882.
December,
cavity partly contracted in depth on the 13th of toms increased ; on
month after
a
?No. IX.?Hindu male
discharge
continued free and sweet, fever abated.
cured
hospital
after commencement of illness.
29th October, 1882. No history of dysentery or spirit drinking, but of fever 2 months, with cough and pain in right side, pain during last 10 or 12 days localized to region of liver. No pointing, bulging of right hypochondrium, area of liver dulness 6 inches deep in nipple line, 22 moist rales at right base. of pus ozs. evacuated by aspiration in the mammary line just under costal margin, a large trocar and canula introduced and subsequently a drainage tube instead of the canula. Cavity washed out daily with a phenyle lotion; ammonia, ether
[February, 1884}'
oedema of
en-
integument; axillary a rise of temperaof bulging hypochGH-
line. The fever contiriued with ture every evening, distinct
drium; and epigastrium but tion very marked;
ho
pointing
'
r
; erhacia"
? .
Found pus by exploration through epigastrium, and inserted a large silver canula into the abscess about evacuated The
%
of
cavity
drainage
tube
the canula,
inch below costal
an
of liver pus. measured inches in a
margirij
pint
depth,
a
subsequently substituted for through which the abscess was daily was
TOMES ON THE TREATMENT OE LIVER ABSCESS.
February, 1884.] washed with
a
permanganate of potash solution,
phenylized pads being placed during the intervals. The
cavity
contracted to
the liver decreased in
bulk;
entirely disappeared
over
pain,
from date of
threatened attack of dysentery
a
off
extent and
some
local
the tube
and fever
operation,
was
warded
discharge of pus continued sweet and free, injections of phenyle lotion were used latterly. Death took place from The
by drugs.
exhaustion
10
days
after
persistent uncontrollable 3 days. The duration of
tapping. hiccough the
There
was
for the last
case was
about 3
months.
male, aged 38, admitted 21st June, 1883 greatly emaciated. History of fever, pain and swelling of the right side 2 months ; no dysentery : an acknowledged spirit No. XI.?Hindu :
l?w and
drinker. Liver much
enlarged,
area
6 inches in
depth
in mammary line and extending 3 inches below the ribs. Under chloroform and phenyle spray, explored below the ribs in right epigastrium,
result; explored 7th interspace to right of mammary line, found pus, put in a large trocar and canula after incising the integument, etc., so as to expose the surface of the liver; washed out with phenyle, flow of pus scanty, patient in collapse, failure of pulse, respiration gasping, revived by artificial means, and stimulants ; he never recovered from the shock, and was removed moribund on the following day. I suspected a rupture and escape of pus into the peritoneal cavity. No. XII.?Hindu male, aged 26, admitted 2nd of May, 1883, a healthy, well nourished young no
man.
A
pain
history of and
some
swelling
month's duration ; A distinct ing.
fever 3 months ago, and of of the right side of one
dysentery, no spirit drinkprominence of right lower chest and hypochondrium. The liver found to extend to midway between the costal margin and the umbilicus, fluctuation perceptible, no tenderness, slight dull pain at times, no pointing. Admitted for observation. Up to 9th May there was no rise of temperano
37
normal, dull pain only complained of, swelling and fluctuation became more distinct it seemed ; patient anxious to have something
ture above
done.
9th May.?Under chloroform and spray aspirated, 15 ounces of thick yellow pus, no shreds ; blood appeared towards the last. The matter was reached at a depth of about one inch. After the operation the lower edge of the liver retreated to one finger's breadth below costal margin. On the 13th May began to get slight fever, and the abscess appeared to be refilling ; on 16th May again aspirated, 14 ounces of thinner pus. This was followed by no fever ; patient left hospital on the 27th, feeling perfectly cured, but still a having slight enlargement of the liver. On 9th of June was reported to be working in the fields as usual. 14th June?came again to the dispensary because of reappearance of the swelling. On 19th June again aspirated, 14 ounces of thin olive green opaque oily liquid suggestive of seropus mixed with bile. No fever after operation.
30th June.?No sign of refilling, could just feel the edge of the liver below the ribs. Discharged. Seen again on the 7th July in perfect health ; last seen on 14th July with a normal extent of liver dulness, and no difference in measurement of the two sides.
No. XIII.?Hindu
male,aged 42,admitted 14th July, 1883, from the same village as No. XII. History of fever one month, with pain in the side. No bowel complaint ; no spirit drinking. Condition now extremely low and emaciated, pulse, 120, temperature 99.0 Obvious enlargement of liver region. The upper limit of liver area corresponded to the 5th rib ; downwards it extended to the level of the navel in the mammary line, distinct fluctuation, no pointing, but general uniform swelling; enlargement of superficial veins, no
oedema.
Under
chloroform and
incised the abdominal
spray an inch below costal
line, exposed
phenyle
parietes
about
in the mammary the adherent liver, found pus
margin
grooved needle, inserted a large silcanula, through which about half a pint of liver' pus flowed out at once, cavity very deep, with ver
a
THE INDIAN MEDICAL GAZETTE.
3s
exactly the depth of an ordinary silver probe, enlarged the opening and left the abscess to drain through a large India-rubber drainage tube into a nest composed of boric-wool and phenyle tow, the whole covered with a piece of oiled paper and a liver bandage. No injection used. The after treatment consisted of renewal of dressings at first twice, subsequently thrice a day, the withdrawal of the residual pus by means of a large-eyed gum elastic catheter attached to the aspirator, and washing of the cavity with carbolic lotion. Quinine was given internally. In spite of the strict antiseptic precautions used, decomposition of residual pus took place. I decided to make a counter-opening at ?a more dependent spot, as it was clear the patient was suffering from septic poisoning. On the 20th, on a probe passed through the upper opening, I again punctured the abscess through the 9th interspace axillary region at a point 4 inches lower than the first incision, free haemorrhage from the parietes had to be arrested by iron and plugging. After the operation the temperature fell one degree, to 100?. The next day the temperature was normal, all pus was draining out through the lower opening, horribly foetid. Thoroughly irrigated the cavity by a stream of phenyle wash directed through the upper opening. This was done 3 times in the day, an iodine solution was also occasionally used. After this second operation there was decided relief?foetidity of discharge diminished, temperature kept below ioo?; previously it had gone up to ioi??103? in the evening ; there had also been rigors which now ceased. CEdema of the left foot noticed soon after first tapping did not increase ; there
bowel
;
appetite
progressed.
was no
looseness of the
ravenous, emaciation however
Stimulants, milk,
sago, etc., were not loss of strength. did arrest but
freely given, The belly previously distended, became shrunken, examination of the cavity from time to time showed that there was a tendency for its walls to fall together. On the 23rd I had to the Mofussil, whereon the man was go into removed by his friends. Nothing more heard of the case, but death must very
shortly
have
The
occurred.
[February, 1884. of this
duration
case
would
appear to have been about 2 months. No. XIV.?Hindu male, aged 35, admitted nth August, 1883. Cachexia and emaciation moderate months ;
only. History none
of bowel
of fever
one
complaint
and-a-half
or
of
spirit
drinking. bulging of right lower ribs, hypoepigastrium, pain complained of in the latter region, right side measures one inch more than left ; no pointing, no oedema. Alleged daily fever ; no rise in temperature on Uniform
chondrium and
admission. Liver
area
from fourth rib to two inches below
costal
margin in nipple line, about six inches depth. Aspirated through 7th interspace, mammary line, to the extent of 53 ounces of uniform brick red pus free from flakes, of sour smell. After operation liver receded up to the costal margin. The vertical depth of dulness being reducin
ed from six to four inches.
No fever followed.
In four
days' time the abscess was felt to be filling up again, accordingly a second tapping with the aspirator was performed in the same place and 32 ounces of like pus withdrawn A day or two after this there was a rise in temperature to i00'4o. Examination of the chest revealed tympanitic resonance over previously dull area, while the liver area again began to increase with pain and tenderness ; decomposition of contents of cavity with development of gas evident. Under chloroform explored epigastric swelling with grooved needle with a view to inserting a tube here by preference ; failed to reach cavity, but succeeded in the old site (7th space), and let out some stinking gas and pus. Opened freely with a knife along a trocar as a guide, inserted a silver catheter, withdrew 1 y2 pints of pus and blood, thoroughly irrigated the ca\ity with a 1 in 80 carbolic wash. Cavity found to
measure
wards towards the
counter-opening owing
to
6 inches in
spine.
in the
the intervention
cavity.
direction back,
Attempted axillary line, of
amount of liver tissue between scess
a
The end of a
a
to make
but
a
failed,
considerable
parietes and ablong probe passed in at
TOMES ON THE TREATMENT OF LIVER ABSCESS.
February, 1884.] the anterior the
point
could not be made to strike
opening
of a grooved needle
level in the axillary line, to
passed
in at
a
lower
could it be made
nor
impinge against and bulge out any interspace region. A free incision was then avoided
has not yet
39
He
appeared.
There is every
in that
sionally.
for fear of
when the malarial
season
health will further
improve
haemorrhage. drainage tube was
A
and
left in the
opening cavity was exhausted of its residual pus twice daily by means of a syringe and gum-elastic catheter and the usual
dressing applied,
washed out with
a
weak carbolic solution.
discharge quantity. Five days after its insertion the tube was found to be pinched between the ribs ; subit sequently slipped out and could not be introduced, nor could the cavity be reached by a probe owing to an alteration in the relation of in
the
the chest-wall ; contraction had altered the position of the organ. It was found liver
however the
to
cavity;
a
into the sinus
of oiled
strip as
injected into was passed possible, along which a be
could
that lotion far
as
lint
certain amount of pus found its exit. As was feared residual pus lodged and decomposed,
causing a distension.
rise in temperature again and gaseous On the 29th an attempt was made
to reach the cavity with
but it failed
a
large aspirating
trocar,
attempt was made some also later which failed, except that a better days
condition did not
greatly improve
; pretty free but there was a
discharge of sweet pus continued, a daily rise of temperature in the evening 99?
to
Early in the month I left the station on leave, and on the 29th Dr. Peck, who was acting for me, succeeded in evacuating about 8 ounces of pus, after which the or
101 ?.
feverish symptoms subsided. On the 2nd, of October the man left hospital, the tube being in its
place
; and the
discharge
but
some
discharge
After my return in November I sent to come in for my
inspection,
is
to
over
hope his
that
general
and the sinus close.
melancholy one enough, 3 recoveries out of 14, or 21 per cent only. Better results were scarcely to be hoped for among these dispensary patients, the majority of whom did not
a
for relief until the disease
apply
was
too far advanced and their vital powers reduced to the lowest The recoveries in 81 cases
collected
degree. by Waring
cent.; and in 24
cases
were
collected
15,
18 per
or
by Curran, only
4 recovered, or 12*5 per cent. (These were Euro, pean soldiers of ages varying from 25 to 37). I have seen the reports of 67 cases of tapping recorded in various these the
journals
cures were
33,
or
since
1878,
49^2 per cent.
among This
high proportion is accounted for by the fact that it is chiefly the successful cases that get into print, and more than half of them were Europeans with fairly good constitutions who came under treatment at There liver above
are
two
abscess, the 67 cases 29
a
stage
not too far advanced.
methods of
dealing the close;
open and were treated
on
with
a
of the
the close
method with 24'i percent, of recoveries, and 38 the open with 68*4 per cent. ; prima facie
on
speaks largely in favour of the open method, scarcely a fair comparison, the cases varied so much. It is extremely difficult to make a comparison of this sort between groups this
but it is
of
cases
or
even
between
individual
cases*
scarcely any two are alike in respect of age, state of health and constitution of patient, size and
out to
done in those advanced
from the
open sinus continued.
induce him
reason
but he
free ; he attended
the 7th, having removed the tube which could not be re-introduced ; his general condition had
improved,
(on 7th
position of abscess. Sometimes treatment begun on the close has to be completed on the open method, and there is no doubt that anti septic precautions now so generally practised add to the safety and success of that method. In dispensary practice among natives the question has yet to be answered what is to be
on
much
The list is
; another
track for the natural escape of pus resulted. During the month of September the patient's
found
General Remarks.
the
continued sweet and lessened
The
was
December) to be in pretty much the same state, able to move about as usual, the sinus still open and giving vent to a little pus ; slight fever occa-
?
cases
where the liver
THE INDIAN MEDICAL GAZETTE.
4?
a bag of pus measurable rather than by ounces, and where the state by quarts of health and strength has been reduced to the
is converted into
very lowest stage by malarial cachexia and the presence of the disease, examples of which are
given
in the
foregoing
interference be
notes.
attempted
or
Should
any
not? and which
of the two methods should be In
some
instances these
employed if any? subjects will not remain
and for them the open method is inadmissible ; if a tube be put in there is danger as
in-patients,
of its
slipping out of the cavity and closure of the opening, or it may get lost altogether in the cavity; dressings cannot be regularly or properly applied, consequently the risk of decomposition and septic poisoning is very great. Whichever plan is adopted suppuration is increased by it, and the extra call upon the feeble vitality of the patient appears to hasten the inevitable end.
Suffering is always temporarily relieved by drawing off the pus, and perhaps it is right to offer this relief, often, indeed, applied for, even at the risk of
Of my
shortening life,
such
as
it is.
I have arrived at the conclusion that in
cases
hope of a cure cannot be entertained, the partial emptying of the cavity at intervals on the close method by means of an aspirator, is the wisest course to pursue. By this means suffering is relieved, septic poisoning is avoided, and the risk of sudden death by rupture of the abscess internally is lessened,?all with the least drain upon the strength of the patient. Complete emptying is to be avoided, for the effect of be to favour the rapid a large vacuum can only of the cavity with broken down refilling liver tissue and pus. T-.vo cases so treated, Nos. 2 and 3, lived 20 and 18 days respectively ; where
of three somewhat similar
cases
treated
of death
cause
poisoning
in
being
15 days, the exhaustion with septic
10
and
one
one.
always easy tc decide whehopeless or not, and it must be borne in mind that some very large abscesses in debilitated patients have been cured on the open method, for example, case No. 14, and one reported in the Indian Medical Gazette of July 1883. The close method is also suitable for "quiescent abscesses" (of which Nos. 12 and Of
ther
course
a case
it is not
is
14 are examples), where constitutional disturbance is absent or slight, general health good, and age not advanced.
These
large, they probably
are not as a
on
the
rule
mem-
limiting possess brane which has the power of cicatrization. Experience teaches that the class of patients a
of whom this paper treats may be divided into 3 groups. Those with 1st.
large abscesses and broken constitutions, who will only submit to treatment as out-patients. For these the best one can do is to partially empty the cavity at down
intervals to
of this
description, 2 lived 10 one one one 18, days, 15, 20, and one 2% months after the first tapping. Observation of an equal number of similar cases not operated on is not available for comparison. The relief to pain, tension, fever, and general discomfort afforded by evacuating the contents of a large abscess is always most marked, and cases
lived
two
plan,
open
[February, 1884.
relieve urgent symptoms and der life easier. The
2nd.
in-patients.
ren-
kind of cases, admitted as In most of them it is right to atsame
My method is first to aspirate once 01* gain information as to character of pus, size of abscess, its position, &c.; if symptoms abate and the patient's powers tempt
a
cure.
oftener to
hold up, the open may be substituted for the close method. The younger the subject and the healthier his
the greater the hope of success; for extreme cases the palliative method is the appropriate one.
Aspiration
constitution,
should
always
be
employed first;
it may alone effect a cure even in advanced cases, for example, that remarkable case pubin the I. M. G. of
lished
June 1878,
where
re-
covery followed the withdrawal by aspiration of pus from the liver of a Hindu was admitted in an who almost moriaged 50, bund condition.
of 30
ounces
3rd.
Patients with small
abscesses
more
or
quiescent
ones.
If
less
or
medium-sized
superficial, including out-patients the close me-
TOMES ON THE TREATMENT OF LIVER ABSCESS.
February, 1884.]
thod, if in-patients the close first, and if that fails the open. Firm bandaging should be applied after every aspiration to assist contraction. A
good
deal is
learned
be
to
from
the
character of the pus. If on successive tappings it decreases in quantity and becomes thinner and the
more same
pain
serous,
time,
cure
a
ample ly largely
and fever
is to be
If also from
case 12.
subsiding
expected,
for
at
ex-
at first evident-
being
made up of broken down liver tissue and shreddy, it becomes either thin and serous, or of a uniform colour and consistence like laudable
disposing
cause
records at
I
am
Midnapore
41
convinced.
show
an
Dispensary
increase in the
number of cases treated in recent years corresponding with a graver incidence of malarial
people of this town and its neighbourhood. It is probable, though by no means proved, that intemperance is a cause of hepatic suppuration among European soldiers resident in the tropics, and if intemperance is a fevers upon the
cause, then these natives of
a
malarious country
pus, the prognosis is favourable. The cessation of the breaking down process is indicated and the formation of a limiting membrane, as in case
indulge in spirit drinking must render themselves doubly liable to the disease. Possibly arterial embolism so apt to occur in malarial subjects (Fayrer) is a mode of its commencement, but the pathology of the affection cannot
No. 8.
be entered
A
free
opening
with
thorough drainage
should expedite the contraction of a large cavity where a decrease in the quantity of pus aspirated indicates that the process has menced. If after
cavity
already
com-
gaseous distension of the due to of air or the result entrance occurs,
aspiration
of decomposition without
or
with
both, together
constitutional disturbance, it is absolutely necessary to adopt the open method without further
delay care
; this accident occurred in
should be taken that
aspiration,
no
case 14. air enters
and the needle should
be
Great
during passed pressed
through a pledget of carbolized cotton closely around it at the point of entrance retained there of air into
than into the
on
its withdrawal.
closed
a an
aspirated
cavity
is
and
a
disease among natives than formerly is due to their increasing habit of indulgence in alcoholic
liquors. (Nos.
patients
4, 9, and
present in all.
3 admitted malarial 11;,
spirit drinking cachexia
was
That malaria is the chief pre-
name-
pointgenerally uniform and diffused ; in two cases only was there an attempt at pointing,?Nos. 3 and 8. Though general the prominence was sometimes more distinct in one region, sometimes in another ; fluctuation was generally perceptible, and the integument over the prominence, when abdominal, was usually smooth tense and displayed enlarged veins. Pointing is hardly to be expected except in superficial abscesses ; by the time a deep seated one approaches the surface it has involved a large the
swelling
extent of liver at
sure
a
site for
and to break up shreds. As to the causation of liver abscess, it has been said that the greater frequency of the
Of my 14
ly, ing,
dangerous drainage. If an antiseptic
wash may be used to dilute it
One character struck
upon here.
as being very constant in my cases, the absence of anything amounting to
The entrance
wash should be used, or if the contents are too thick to flow through the needle (the largest size
should be used),
me
the skin in
more
open one with free fluid becomes foetid
who
We
was
tissue, and does
not
limited spot. There cases 2 and 3 only. the
to
now come
exert pres-
was
question
oedema of
of the best
liver abscess.
puncturing general rule
the puncture should be made where the abscess is nearest As
a
for
aspiration
be ascertained ; but for the open method preference should be to the epigastrium or hypochondrium, for the
surface,
so
far
as
that
can
given
several
reasons.
There is
a
danger
to the
lung
and of necrosis of ribs when
an pleura intercostal an space, opening is established in Sir J. Payrer warned we are which by against (Tropical Diseases) ; moreover a soft flexible tube is liable to compression when inserted between the ribs (case I4)> especially if far back when there is less room. If a rigid tube be employed
and
THE INDIAN MEDICAL GAZETTE.
42
the likelihood of necrosis is increased.
Where
practicable it is best to make the opening below the ribs; we have it on the high authority referred to above that adhesions may
generally be supposplace. Carrington has cases in the Seamans' Hospital by the abdominal through wall; in
ed to have taken treated many free incision one
only
did
Dr.
he
noticed at
was
extravasation
find
them
absent.
the time of
This and
operation,
successfully prevented by carefully adjusted pressure.?(Lancet, October 6, 1883). I do not pretend to any great originality in my method of conducting the open method of treatment. Though experience has taught me some useful points in its application. The administration of an anaesthetic when making the incision is all important to avoid unnecessary pain and the risk of internal rupture of the abscess during the flinching of the patient. means
In
was
of
one case,
No. 12,
I feared the accident did
actually occur although he was chloroformed ; perhaps through careless manipulation. I may mention that this was the only instance in which I failed to reach pus on the first exploration. No post-mortem The as
was
application
allowed.
of antiseptics in these
cases
is
necessary as it is difficult to thoroughly carry The spray is unnecessary, its inefficiency
[February, 1884.
age of the cavity is as its disinfection.
equally important matter large, neither the aspirator nor the drainage tube, however large or long, will effect this alone, there will always be some residual pus, the decomposition of which constitutes a serious source of danger to the patient. Cases Nos. 13 and 14 illustrate this. I have found the best way of getting rid of the residual pus is to draw it off morning and evening through a soft flexible tube passed to the full depth of the abscess cavity, and used in connexion with the aspirator ; a gum elastic catheter with a large eye serves the purpose, first throwing in some weak antiseptic solution to dilute the pus an
If very
A stronger soluif decomposition has taken
and facilitate its evacuation. tion
being employed place. Another way of obtaining complete drainage of the cavity is by the establishment of a counter-opening, but this is not always practicable. Case 13 shows its usefulness; the signs of septic poisoning disappeared on the establishment of the second opening, though health was With a broken down too far for recovery. second aperture irrigation can be carried out in the most perfect manner, a stream of lotion can be directed into the tube
placed in the washings
cavity through
a
funnel and
upper and allowed to escape of the abscess from the lower.
out.
with the
protection against germs has been conclusively proved by Professor Duncan's scientific experiments. (Edin. Med. Journal, March, 1883). Lister himself admits that it is only useful as a mild form of antiseptic irrigation, and as it is powerless to throw the solution into the interior of a large cavity with a small opening, it may be placed aside and its place more usefully taken by the injection-syringe in liver abscess. The precaution of washing hands,
This paper would be more complete with a report on the post-mortem appearances of the
as a
instruments, and site of wound with
a
antiseptic must never be omitted ; the end tube must be received into a bunch of
strong
pf
the
some
antiseptic material. As soon as the discharge begins to be at all offensive, antiseptic injections must be freely used ; iodine I think is absorbent
the best. The
complete emptying
and
thorough
drain-
fatal
cases.
Owing
to
the
prejudices
friends I have not been able to make ination of any
one
opportunities
for
an
of the exam-
of them, and thus valuable learning more of the nature
and tendencies of the disease have been lost.
Midnapore, 13th December, 1883.
.
of liver but
no
13th again explored, found pus near the surface, removed about one pint by aspiration, then passed in an ordinary large trocar and canula ; after a few days substituted a drainage tube for the canula, the end of the tube being
on
received into
a
nest of
carbolized
tow ; carbolic
daily ; the discharge injections continued sweet until the 27th of April, when it
acid
used
were
began
to be foetid.
The of
operation gave relief to urgent symptoms pain, tension and dyspnoea, but no real
progress was made towards recovery ; diarrhoea set in on the 30th with exacerbation of fever. On the 2nd
May his
friends removed him from
hospital. The cavity measured 6 inches in depth, and showed no tendency to contract. There was consolidation of the lung. Nothing more was heard of the case, but there was no hope of a cure under such unfavorable circumstances. No. II.?Hindu male
23rd June
aged
47,
an
out-patient
1882.
7 months ; liver symptoms 2 months. history of bowel complaint or of spirit
Fever No
drinking. Right lower chest and hypochondrium distinctly bulging, oedema over lower ribs; liver greatly enlarged, reaching from the 5th rib to the level of the navel in the mammary line, and extending into the left hypochondrium. Diarrhoea, fever, emaciation and great prostration.
NOTES ON THE SURGICAL TREATMENT OF LIVER ABSCESS IN DISPENSARY PRACTICE?RESULTS OF 14 CASES. M
1
By Surgeon A.
-
r
Tomes,
Civil-Surgeon, Midnapore. Case No. I.?Hindu male 12th of
April
liver
1882.
aged 15, admitted of fever 3 months, months ; none of dy-
History
symptoms
2
sentery or of spirit drinking. and great emaciation, general
Cough, fever enlargement
Aspirated just
the abscess
under the ribs
tense even elastic
through the epigastrium was no pointing but a prominence) ; repeated the
(there
operation three times at a few days' interval, evacuating from 2 to 4 pints of liver pus each time. Relief was decided, but transient only, the general condition of the patient did not improve and the cavity had no tendency to contract. After the 9th July he ceased to attend ; on the 13th was reported to be dying?about 3 months after commencement after the first
tapping.
of illness and
20
days
February, 1884.]
TOMES ON THE TREATMENT OF LIVER ABSCESS.
No. III.?Hindu male
aged 40,
an
out-patient,
abscess after fever.
4th July 1883.
fever
Fever 7 months followed by liver symptoms. No history of dysentery or of spirit drinking.
rhoea present.
Fever, great emaciation,
and
enormous
largement of liver, the measurement ing from the 4th rib above, to a finger's above the
crest of
theilium below.
circumscribed
cedematous
ing
9th
about the
en-
extendbreadth
A somewhat
semi-fluctuating swell-
rib behind.
ounces
of
first tapping the liver contracted to a considerable extent, and no larger quantity than 2^
pints
of pus
occasion.
was
any subsequent of carbolic solution were
drawn off
Injections
on
Marked relief from tension and relaxation of the parietes followed each operation, fever also lessened, but on the 17th dysentery set
used.
in,
the 22nd he
on
reported tapping, and
was
days
after the first
from
commencement of illness.
No. IV.?Hindu male
home
Liver
symptoms 5 monthsj emaciation, cough and diar-
months ;
Aspiration performed 10 times between 25th July and 26th of August, the punctures being made through the right hypochondrium. 18 ounces of pus evacuated on the first occasion, and from 7 to 11 ounces each time afterwards. Carbolic acid washings employed. On 26th
muddy coloured flaky aspirator through the 9th interAgain space in the mid-axillary region. aspirated on the 6th, 15th and 18th. After the
Evacuated 80 liver pus by the
12
35
August inserted a large silver canula subsequently replaced by a piece of drainage tubing ; from the time of changing the
which
was
close for the open method diarrhoea and fever abated, but the feet began to swell. Nothing seen
of the
patient
after 6th
strength
to the extent of
she
suddenly
died after
matter from the
first
tapping
bowel,
and
but heard
about 8 months
I think she would have
woman
a
about to go
month, when profuse discharge of
about
a
2
months from
7 from onset of symptoms. remained under treatment,
Had the
recovered, but being an neglected and the
out-patient, dressings tube allowed to slip out at times. Closure of the opening probably occurred, were
; treated at his
in the bazar.
Two months' history of fever,
being
about her household duties for
to be dead?18
aged 42
October,
from friends that she had recovered health and
none
of bowel
hard drinker. All
complaint. An acknowledged the signs of a large liver abscess present.
At
the first visit it
the
re-accumulation of pus and rupture of the abscess into the intestine. The discharge kept sweet
throughout
while under notice.
No. VI.?Mahomedan male aged 45, treated aspirated through posterior axillary line where as an out-patient from the 13th of September the prominence was most marked, though there 1882: an opium eater, History of fever 4 was no actual pointing; 3 pints of pus were months, liver symptoms recent. No dysentery;
thoracic
was
wall in the
drawn off and a like amount at the second visit a few days later. Three days after that a large canula was introduced with the result of evacuat-
spirit drinking. region bulged, indistinct fluctuation, lower margin of the organ on a level with uming an enormous quantity, about half a gallon, bilicus ; pain, tenderness and prominence most of pus ; the silver canula was replaced by an distinct in epigastrium, but no pointing. elastic tube covered by a nest of carbolic tow. Withdrew 42 ounces of pus by aspiration tube the There was a copious drain through through the 8th interspace, anterior axillary line. until death?15 days after first operation and The patient was not again brought to the disabout 2x/>, months from commencement of illness. pensary, friends reported that he was tapped This was a hopeless case owing to the advanced again by a private practitioner in October, and stage of the disease. There were rales at the in November it was said that a free opening bases of the
no
Liver
purulent expectoration had been made. On 13th November visited him at his lodgprostration. No. V.?Hindu female aged 36, treated as an ing, found him in a very bad state, with general out-patient, 25th July 1882, A case of liver anasarca and a liver reaching down to the ilium, lungs
and
and extreme emaciation and
36
THE INDIAN MEDICAL GAZETTE.
scanty discharge of pus going
a an
opening to
come
through
on
hypochondrium. hospital. Died about
to
recovery, no fever after operation ; discharge bf pus, which kept sweet, gradually decreased With the contraction Of the cavity. The man
Would not
in the
the
end
of
months after first
November,?2 tapping. VII.?Hindu male, aged 30, admitted No.
left
and
mixture ;
squills
the
of his
emaciation and
operation,
a
state of
The
Died
The abscess
progressive
one
month after
about three months from
commence-
debility.
ment of illness.
No.
VIII.?Hindu
male, aged 35, admitted 1882. 14th December, History of dysentery 2 or 3 months, of fever 1 month, followed by localized pain and swelling. Spirit drinking denied. A prominent fluctuating swelling body, occupying right hypochondrium and epigastrium, commencing to point in epigastrium, its limits undefined, passing into the left hypochondrium Emacia-
(
tion
great,
Pus
fever
aspirator
daily.
found
was
in the most
exploration with prominent part of
the the
epigastric swelling, then 24 ounces of bile-stained liver pus were drawn out through a large canula.
depth, 2
inches
drainage abscess
The
cavity measured 4 inches in obliquely upwards and backwards. only directly tube was
was
daily
backwards.
left in
through
tow.
This
A
case
into
large
which the
washed out with
the end of the tube received
phenyle
crosed bone.
a
phenyle, nest
of
progressed steadily
enormous
patient
so
one, and
low that
the
I did not
washings with phenyle was begun, but the from hospital. Death oc-
treatment
removed
was
ne-
Constant
supporting
curred about
months after commencement
5
of illness. No. X.?Hindu tient.
male, about 45, a private pamonths' fever followed by liver sympNo spirit drinking.
2
toms.
On 12th
February 1883
pus ; when
seen a
few
;
slight
said to have vomited
days
later
pulse 126;
tem-
Liver found to be much
perature 103 weak.
larged
on
admitted
operate for the removal of the
venture to
case
aged 25,
was an
condition of the
and
and below to the level of the navel.
twd
23rd Spirit drinking admitted ; 5 months months' fever and pain in right side ; 1 a perceptible swelling of right side ; had been treated by a private practitioner, who first explored; then freely incised the liver through the chest wall behind the posterior axillary line* leaving a tube in; about a sefer of pus said to have flowed out, and a discharge has kept up ever since. Liver area very much enlarged, a continufoetid pils ous profuse discharge of thick flaky from the opening ; on exploration with the finger about 2 inches of the end of a rib in a necrosed state could be felt projecting into the cavity.
; it measured 3 inches Nevember ; lung symp22nd November left hospital
accord in
own
operation,
1882.
December,
cavity partly contracted in depth on the 13th of toms increased ; on
month after
a
?No. IX.?Hindu male
discharge
continued free and sweet, fever abated.
cured
hospital
after commencement of illness.
29th October, 1882. No history of dysentery or spirit drinking, but of fever 2 months, with cough and pain in right side, pain during last 10 or 12 days localized to region of liver. No pointing, bulging of right hypochondrium, area of liver dulness 6 inches deep in nipple line, 22 moist rales at right base. of pus ozs. evacuated by aspiration in the mammary line just under costal margin, a large trocar and canula introduced and subsequently a drainage tube instead of the canula. Cavity washed out daily with a phenyle lotion; ammonia, ether
[February, 1884}'
oedema of
en-
integument; axillary a rise of temperaof bulging hypochGH-
line. The fever contiriued with ture every evening, distinct
drium; and epigastrium but tion very marked;
ho
pointing
'
r
; erhacia"
? .
Found pus by exploration through epigastrium, and inserted a large silver canula into the abscess about evacuated The
%
of
cavity
drainage
tube
the canula,
inch below costal
an
of liver pus. measured inches in a
margirij
pint
depth,
a
subsequently substituted for through which the abscess was daily was
TOMES ON THE TREATMENT OE LIVER ABSCESS.
February, 1884.] washed with
a
permanganate of potash solution,
phenylized pads being placed during the intervals. The
cavity
contracted to
the liver decreased in
bulk;
entirely disappeared
over
pain,
from date of
threatened attack of dysentery
a
off
extent and
some
local
the tube
and fever
operation,
was
warded
discharge of pus continued sweet and free, injections of phenyle lotion were used latterly. Death took place from The
by drugs.
exhaustion
10
days
after
persistent uncontrollable 3 days. The duration of
tapping. hiccough the
There
was
for the last
case was
about 3
months.
male, aged 38, admitted 21st June, 1883 greatly emaciated. History of fever, pain and swelling of the right side 2 months ; no dysentery : an acknowledged spirit No. XI.?Hindu :
l?w and
drinker. Liver much
enlarged,
area
6 inches in
depth
in mammary line and extending 3 inches below the ribs. Under chloroform and phenyle spray, explored below the ribs in right epigastrium,
result; explored 7th interspace to right of mammary line, found pus, put in a large trocar and canula after incising the integument, etc., so as to expose the surface of the liver; washed out with phenyle, flow of pus scanty, patient in collapse, failure of pulse, respiration gasping, revived by artificial means, and stimulants ; he never recovered from the shock, and was removed moribund on the following day. I suspected a rupture and escape of pus into the peritoneal cavity. No. XII.?Hindu male, aged 26, admitted 2nd of May, 1883, a healthy, well nourished young no
man.
A
pain
history of and
some
swelling
month's duration ; A distinct ing.
fever 3 months ago, and of of the right side of one
dysentery, no spirit drinkprominence of right lower chest and hypochondrium. The liver found to extend to midway between the costal margin and the umbilicus, fluctuation perceptible, no tenderness, slight dull pain at times, no pointing. Admitted for observation. Up to 9th May there was no rise of temperano
37
normal, dull pain only complained of, swelling and fluctuation became more distinct it seemed ; patient anxious to have something
ture above
done.
9th May.?Under chloroform and spray aspirated, 15 ounces of thick yellow pus, no shreds ; blood appeared towards the last. The matter was reached at a depth of about one inch. After the operation the lower edge of the liver retreated to one finger's breadth below costal margin. On the 13th May began to get slight fever, and the abscess appeared to be refilling ; on 16th May again aspirated, 14 ounces of thinner pus. This was followed by no fever ; patient left hospital on the 27th, feeling perfectly cured, but still a having slight enlargement of the liver. On 9th of June was reported to be working in the fields as usual. 14th June?came again to the dispensary because of reappearance of the swelling. On 19th June again aspirated, 14 ounces of thin olive green opaque oily liquid suggestive of seropus mixed with bile. No fever after operation.
30th June.?No sign of refilling, could just feel the edge of the liver below the ribs. Discharged. Seen again on the 7th July in perfect health ; last seen on 14th July with a normal extent of liver dulness, and no difference in measurement of the two sides.
No. XIII.?Hindu
male,aged 42,admitted 14th July, 1883, from the same village as No. XII. History of fever one month, with pain in the side. No bowel complaint ; no spirit drinking. Condition now extremely low and emaciated, pulse, 120, temperature 99.0 Obvious enlargement of liver region. The upper limit of liver area corresponded to the 5th rib ; downwards it extended to the level of the navel in the mammary line, distinct fluctuation, no pointing, but general uniform swelling; enlargement of superficial veins, no
oedema.
Under
chloroform and
incised the abdominal
spray an inch below costal
line, exposed
phenyle
parietes
about
in the mammary the adherent liver, found pus
margin
grooved needle, inserted a large silcanula, through which about half a pint of liver' pus flowed out at once, cavity very deep, with ver
a
THE INDIAN MEDICAL GAZETTE.
3s
exactly the depth of an ordinary silver probe, enlarged the opening and left the abscess to drain through a large India-rubber drainage tube into a nest composed of boric-wool and phenyle tow, the whole covered with a piece of oiled paper and a liver bandage. No injection used. The after treatment consisted of renewal of dressings at first twice, subsequently thrice a day, the withdrawal of the residual pus by means of a large-eyed gum elastic catheter attached to the aspirator, and washing of the cavity with carbolic lotion. Quinine was given internally. In spite of the strict antiseptic precautions used, decomposition of residual pus took place. I decided to make a counter-opening at ?a more dependent spot, as it was clear the patient was suffering from septic poisoning. On the 20th, on a probe passed through the upper opening, I again punctured the abscess through the 9th interspace axillary region at a point 4 inches lower than the first incision, free haemorrhage from the parietes had to be arrested by iron and plugging. After the operation the temperature fell one degree, to 100?. The next day the temperature was normal, all pus was draining out through the lower opening, horribly foetid. Thoroughly irrigated the cavity by a stream of phenyle wash directed through the upper opening. This was done 3 times in the day, an iodine solution was also occasionally used. After this second operation there was decided relief?foetidity of discharge diminished, temperature kept below ioo?; previously it had gone up to ioi??103? in the evening ; there had also been rigors which now ceased. CEdema of the left foot noticed soon after first tapping did not increase ; there
bowel
;
appetite
progressed.
was no
looseness of the
ravenous, emaciation however
Stimulants, milk,
sago, etc., were not loss of strength. did arrest but
freely given, The belly previously distended, became shrunken, examination of the cavity from time to time showed that there was a tendency for its walls to fall together. On the 23rd I had to the Mofussil, whereon the man was go into removed by his friends. Nothing more heard of the case, but death must very
shortly
have
The
occurred.
[February, 1884. of this
duration
case
would
appear to have been about 2 months. No. XIV.?Hindu male, aged 35, admitted nth August, 1883. Cachexia and emaciation moderate months ;
only. History none
of bowel
of fever
one
complaint
and-a-half
or
of
spirit
drinking. bulging of right lower ribs, hypoepigastrium, pain complained of in the latter region, right side measures one inch more than left ; no pointing, no oedema. Alleged daily fever ; no rise in temperature on Uniform
chondrium and
admission. Liver
area
from fourth rib to two inches below
costal
margin in nipple line, about six inches depth. Aspirated through 7th interspace, mammary line, to the extent of 53 ounces of uniform brick red pus free from flakes, of sour smell. After operation liver receded up to the costal margin. The vertical depth of dulness being reducin
ed from six to four inches.
No fever followed.
In four
days' time the abscess was felt to be filling up again, accordingly a second tapping with the aspirator was performed in the same place and 32 ounces of like pus withdrawn A day or two after this there was a rise in temperature to i00'4o. Examination of the chest revealed tympanitic resonance over previously dull area, while the liver area again began to increase with pain and tenderness ; decomposition of contents of cavity with development of gas evident. Under chloroform explored epigastric swelling with grooved needle with a view to inserting a tube here by preference ; failed to reach cavity, but succeeded in the old site (7th space), and let out some stinking gas and pus. Opened freely with a knife along a trocar as a guide, inserted a silver catheter, withdrew 1 y2 pints of pus and blood, thoroughly irrigated the ca\ity with a 1 in 80 carbolic wash. Cavity found to
measure
wards towards the
counter-opening owing
to
6 inches in
spine.
in the
the intervention
cavity.
direction back,
Attempted axillary line, of
amount of liver tissue between scess
a
The end of a
a
to make
but
a
failed,
considerable
parietes and ablong probe passed in at
TOMES ON THE TREATMENT OF LIVER ABSCESS.
February, 1884.] the anterior the
point
could not be made to strike
opening
of a grooved needle
level in the axillary line, to
passed
in at
a
lower
could it be made
nor
impinge against and bulge out any interspace region. A free incision was then avoided
has not yet
39
He
appeared.
There is every
in that
sionally.
for fear of
when the malarial
season
health will further
improve
haemorrhage. drainage tube was
A
and
left in the
opening cavity was exhausted of its residual pus twice daily by means of a syringe and gum-elastic catheter and the usual
dressing applied,
washed out with
a
weak carbolic solution.
discharge quantity. Five days after its insertion the tube was found to be pinched between the ribs ; subit sequently slipped out and could not be introduced, nor could the cavity be reached by a probe owing to an alteration in the relation of in
the
the chest-wall ; contraction had altered the position of the organ. It was found liver
however the
to
cavity;
a
into the sinus
of oiled
strip as
injected into was passed possible, along which a be
could
that lotion far
as
lint
certain amount of pus found its exit. As was feared residual pus lodged and decomposed,
causing a distension.
rise in temperature again and gaseous On the 29th an attempt was made
to reach the cavity with
but it failed
a
large aspirating
trocar,
attempt was made some also later which failed, except that a better days
condition did not
greatly improve
; pretty free but there was a
discharge of sweet pus continued, a daily rise of temperature in the evening 99?
to
Early in the month I left the station on leave, and on the 29th Dr. Peck, who was acting for me, succeeded in evacuating about 8 ounces of pus, after which the or
101 ?.
feverish symptoms subsided. On the 2nd, of October the man left hospital, the tube being in its
place
; and the
discharge
but
some
discharge
After my return in November I sent to come in for my
inspection,
is
to
over
hope his
that
general
and the sinus close.
melancholy one enough, 3 recoveries out of 14, or 21 per cent only. Better results were scarcely to be hoped for among these dispensary patients, the majority of whom did not
a
for relief until the disease
apply
was
too far advanced and their vital powers reduced to the lowest The recoveries in 81 cases
collected
degree. by Waring
cent.; and in 24
cases
were
collected
15,
18 per
or
by Curran, only
4 recovered, or 12*5 per cent. (These were Euro, pean soldiers of ages varying from 25 to 37). I have seen the reports of 67 cases of tapping recorded in various these the
journals
cures were
33,
or
since
1878,
49^2 per cent.
among This
high proportion is accounted for by the fact that it is chiefly the successful cases that get into print, and more than half of them were Europeans with fairly good constitutions who came under treatment at There liver above
are
two
abscess, the 67 cases 29
a
stage
not too far advanced.
methods of
dealing the close;
open and were treated
on
with
a
of the
the close
method with 24'i percent, of recoveries, and 38 the open with 68*4 per cent. ; prima facie
on
speaks largely in favour of the open method, scarcely a fair comparison, the cases varied so much. It is extremely difficult to make a comparison of this sort between groups this
but it is
of
cases
or
even
between
individual
cases*
scarcely any two are alike in respect of age, state of health and constitution of patient, size and
out to
done in those advanced
from the
open sinus continued.
induce him
reason
but he
free ; he attended
the 7th, having removed the tube which could not be re-introduced ; his general condition had
improved,
(on 7th
position of abscess. Sometimes treatment begun on the close has to be completed on the open method, and there is no doubt that anti septic precautions now so generally practised add to the safety and success of that method. In dispensary practice among natives the question has yet to be answered what is to be
on
much
The list is
; another
track for the natural escape of pus resulted. During the month of September the patient's
found
General Remarks.
the
continued sweet and lessened
The
was
December) to be in pretty much the same state, able to move about as usual, the sinus still open and giving vent to a little pus ; slight fever occa-
?
cases
where the liver
THE INDIAN MEDICAL GAZETTE.
4?
a bag of pus measurable rather than by ounces, and where the state by quarts of health and strength has been reduced to the
is converted into
very lowest stage by malarial cachexia and the presence of the disease, examples of which are
given
in the
foregoing
interference be
notes.
attempted
or
Should
any
not? and which
of the two methods should be In
some
instances these
employed if any? subjects will not remain
and for them the open method is inadmissible ; if a tube be put in there is danger as
in-patients,
of its
slipping out of the cavity and closure of the opening, or it may get lost altogether in the cavity; dressings cannot be regularly or properly applied, consequently the risk of decomposition and septic poisoning is very great. Whichever plan is adopted suppuration is increased by it, and the extra call upon the feeble vitality of the patient appears to hasten the inevitable end.
Suffering is always temporarily relieved by drawing off the pus, and perhaps it is right to offer this relief, often, indeed, applied for, even at the risk of
Of my
shortening life,
such
as
it is.
I have arrived at the conclusion that in
cases
hope of a cure cannot be entertained, the partial emptying of the cavity at intervals on the close method by means of an aspirator, is the wisest course to pursue. By this means suffering is relieved, septic poisoning is avoided, and the risk of sudden death by rupture of the abscess internally is lessened,?all with the least drain upon the strength of the patient. Complete emptying is to be avoided, for the effect of be to favour the rapid a large vacuum can only of the cavity with broken down refilling liver tissue and pus. T-.vo cases so treated, Nos. 2 and 3, lived 20 and 18 days respectively ; where
of three somewhat similar
cases
treated
of death
cause
poisoning
in
being
15 days, the exhaustion with septic
10
and
one
one.
always easy tc decide whehopeless or not, and it must be borne in mind that some very large abscesses in debilitated patients have been cured on the open method, for example, case No. 14, and one reported in the Indian Medical Gazette of July 1883. The close method is also suitable for "quiescent abscesses" (of which Nos. 12 and Of
ther
course
a case
it is not
is
14 are examples), where constitutional disturbance is absent or slight, general health good, and age not advanced.
These
large, they probably
are not as a
on
the
rule
mem-
limiting possess brane which has the power of cicatrization. Experience teaches that the class of patients a
of whom this paper treats may be divided into 3 groups. Those with 1st.
large abscesses and broken constitutions, who will only submit to treatment as out-patients. For these the best one can do is to partially empty the cavity at down
intervals to
of this
description, 2 lived 10 one one one 18, days, 15, 20, and one 2% months after the first tapping. Observation of an equal number of similar cases not operated on is not available for comparison. The relief to pain, tension, fever, and general discomfort afforded by evacuating the contents of a large abscess is always most marked, and cases
lived
two
plan,
open
[February, 1884.
relieve urgent symptoms and der life easier. The
2nd.
in-patients.
ren-
kind of cases, admitted as In most of them it is right to atsame
My method is first to aspirate once 01* gain information as to character of pus, size of abscess, its position, &c.; if symptoms abate and the patient's powers tempt
a
cure.
oftener to
hold up, the open may be substituted for the close method. The younger the subject and the healthier his
the greater the hope of success; for extreme cases the palliative method is the appropriate one.
Aspiration
constitution,
should
always
be
employed first;
it may alone effect a cure even in advanced cases, for example, that remarkable case pubin the I. M. G. of
lished
June 1878,
where
re-
covery followed the withdrawal by aspiration of pus from the liver of a Hindu was admitted in an who almost moriaged 50, bund condition.
of 30
ounces
3rd.
Patients with small
abscesses
more
or
quiescent
ones.
If
less
or
medium-sized
superficial, including out-patients the close me-
TOMES ON THE TREATMENT OF LIVER ABSCESS.
February, 1884.]
thod, if in-patients the close first, and if that fails the open. Firm bandaging should be applied after every aspiration to assist contraction. A
good
deal is
learned
be
to
from
the
character of the pus. If on successive tappings it decreases in quantity and becomes thinner and the
more same
pain
serous,
time,
cure
a
ample ly largely
and fever
is to be
If also from
case 12.
subsiding
expected,
for
at
ex-
at first evident-
being
made up of broken down liver tissue and shreddy, it becomes either thin and serous, or of a uniform colour and consistence like laudable
disposing
cause
records at
I
am
Midnapore
41
convinced.
show
an
Dispensary
increase in the
number of cases treated in recent years corresponding with a graver incidence of malarial
people of this town and its neighbourhood. It is probable, though by no means proved, that intemperance is a cause of hepatic suppuration among European soldiers resident in the tropics, and if intemperance is a fevers upon the
cause, then these natives of
a
malarious country
pus, the prognosis is favourable. The cessation of the breaking down process is indicated and the formation of a limiting membrane, as in case
indulge in spirit drinking must render themselves doubly liable to the disease. Possibly arterial embolism so apt to occur in malarial subjects (Fayrer) is a mode of its commencement, but the pathology of the affection cannot
No. 8.
be entered
A
free
opening
with
thorough drainage
should expedite the contraction of a large cavity where a decrease in the quantity of pus aspirated indicates that the process has menced. If after
cavity
already
com-
gaseous distension of the due to of air or the result entrance occurs,
aspiration
of decomposition without
or
with
both, together
constitutional disturbance, it is absolutely necessary to adopt the open method without further
delay care
; this accident occurred in
should be taken that
aspiration,
no
case 14. air enters
and the needle should
be
Great
during passed pressed
through a pledget of carbolized cotton closely around it at the point of entrance retained there of air into
than into the
on
its withdrawal.
closed
a an
aspirated
cavity
is
and
a
disease among natives than formerly is due to their increasing habit of indulgence in alcoholic
liquors. (Nos.
patients
4, 9, and
present in all.
3 admitted malarial 11;,
spirit drinking cachexia
was
That malaria is the chief pre-
name-
pointgenerally uniform and diffused ; in two cases only was there an attempt at pointing,?Nos. 3 and 8. Though general the prominence was sometimes more distinct in one region, sometimes in another ; fluctuation was generally perceptible, and the integument over the prominence, when abdominal, was usually smooth tense and displayed enlarged veins. Pointing is hardly to be expected except in superficial abscesses ; by the time a deep seated one approaches the surface it has involved a large the
swelling
extent of liver at
sure
a
site for
and to break up shreds. As to the causation of liver abscess, it has been said that the greater frequency of the
Of my 14
ly, ing,
dangerous drainage. If an antiseptic
wash may be used to dilute it
One character struck
upon here.
as being very constant in my cases, the absence of anything amounting to
The entrance
wash should be used, or if the contents are too thick to flow through the needle (the largest size
should be used),
me
the skin in
more
open one with free fluid becomes foetid
who
We
was
tissue, and does
not
limited spot. There cases 2 and 3 only. the
to
now come
exert pres-
was
question
oedema of
of the best
liver abscess.
puncturing general rule
the puncture should be made where the abscess is nearest As
a
for
aspiration
be ascertained ; but for the open method preference should be to the epigastrium or hypochondrium, for the
surface,
so
far
as
that
can
given
several
reasons.
There is
a
danger
to the
lung
and of necrosis of ribs when
an pleura intercostal an space, opening is established in Sir J. Payrer warned we are which by against (Tropical Diseases) ; moreover a soft flexible tube is liable to compression when inserted between the ribs (case I4)> especially if far back when there is less room. If a rigid tube be employed
and
THE INDIAN MEDICAL GAZETTE.
42
the likelihood of necrosis is increased.
Where
practicable it is best to make the opening below the ribs; we have it on the high authority referred to above that adhesions may
generally be supposplace. Carrington has cases in the Seamans' Hospital by the abdominal through wall; in
ed to have taken treated many free incision one
only
did
Dr.
he
noticed at
was
extravasation
find
them
absent.
the time of
This and
operation,
successfully prevented by carefully adjusted pressure.?(Lancet, October 6, 1883). I do not pretend to any great originality in my method of conducting the open method of treatment. Though experience has taught me some useful points in its application. The administration of an anaesthetic when making the incision is all important to avoid unnecessary pain and the risk of internal rupture of the abscess during the flinching of the patient. means
In
was
of
one case,
No. 12,
I feared the accident did
actually occur although he was chloroformed ; perhaps through careless manipulation. I may mention that this was the only instance in which I failed to reach pus on the first exploration. No post-mortem The as
was
application
allowed.
of antiseptics in these
cases
is
necessary as it is difficult to thoroughly carry The spray is unnecessary, its inefficiency
[February, 1884.
age of the cavity is as its disinfection.
equally important matter large, neither the aspirator nor the drainage tube, however large or long, will effect this alone, there will always be some residual pus, the decomposition of which constitutes a serious source of danger to the patient. Cases Nos. 13 and 14 illustrate this. I have found the best way of getting rid of the residual pus is to draw it off morning and evening through a soft flexible tube passed to the full depth of the abscess cavity, and used in connexion with the aspirator ; a gum elastic catheter with a large eye serves the purpose, first throwing in some weak antiseptic solution to dilute the pus an
If very
A stronger soluif decomposition has taken
and facilitate its evacuation. tion
being employed place. Another way of obtaining complete drainage of the cavity is by the establishment of a counter-opening, but this is not always practicable. Case 13 shows its usefulness; the signs of septic poisoning disappeared on the establishment of the second opening, though health was With a broken down too far for recovery. second aperture irrigation can be carried out in the most perfect manner, a stream of lotion can be directed into the tube
placed in the washings
cavity through
a
funnel and
upper and allowed to escape of the abscess from the lower.
out.
with the
protection against germs has been conclusively proved by Professor Duncan's scientific experiments. (Edin. Med. Journal, March, 1883). Lister himself admits that it is only useful as a mild form of antiseptic irrigation, and as it is powerless to throw the solution into the interior of a large cavity with a small opening, it may be placed aside and its place more usefully taken by the injection-syringe in liver abscess. The precaution of washing hands,
This paper would be more complete with a report on the post-mortem appearances of the
as a
instruments, and site of wound with
a
antiseptic must never be omitted ; the end tube must be received into a bunch of
strong
pf
the
some
antiseptic material. As soon as the discharge begins to be at all offensive, antiseptic injections must be freely used ; iodine I think is absorbent
the best. The
complete emptying
and
thorough
drain-
fatal
cases.
Owing
to
the
prejudices
friends I have not been able to make ination of any
one
opportunities
for
an
of the exam-
of them, and thus valuable learning more of the nature
and tendencies of the disease have been lost.
Midnapore, 13th December, 1883.
.
