; jaundice disappeared ; has improved in appearance, and is very cheerful and hopeful ; very little fever ; pain in the abdomen abated ; hands and feet cedematous. 27tli.?Pulse 90 ; pain in the abdomen completely gone ; has got an abscess at the margin of the anus which was opened ; can bear pressure over the liver ; no indication yet of the filling of the abscess. 3rd March.?The dysenteric symptoms have returned ; stools contain broken feculent matter and mucus, but no pus ; appetite reduced ; is very much pulled down in 2 days ; no shivering. The abscess is filling up fast but still the liver can be palpated without pain. The stitch in the back has returned also. 4tli March.?About 5 pints of fluid drawn off with the aspirator through the site of the old puncture. The first pint was sero-sanguinolent as before, but the last portion consisted of healthy pus. There was no foetor or stink. As the cavity was being emptied, the patient complained of pain as of pressure being applied over the liver, produced probably by the suction force of the aspirator. The fulness of the abdomen immediately subsided ; the skin over it was wrinkled, and the liver fell back from the abdominal wall. Again there was a respite from pain and improvement in the general symptoms, but the patient grew more and With the more antemic and wasted away to a skeleton. temporary relief of the dysenteric symptoms thejr returned with aggravated severity as the period of filling up of the abscess approached. After an interval of 10 days (i e.) on the 15th instant, the patient and the relations became importunate for another operation which had given so much relief on former occasions. In accorddance with their wishes the abscess was emptied on that day through the same opening. About 3 pints of sweet fluid were evacuated by Native Doctor Hari Mohan Bhuttacharjea in the presence of the Civil Surgeon. The first portion consisted of a thin fluid deeply tinged with bile, and the rest was laudable pus. There was again some amelioration of symptoms, but the wasting of the body and the loss of strength rendered a chance of recovery almost hopeless. In this condition he was removed by his friends, when he died at home on the 18th March.
getting regular
A CASE OF ABSCESS OF THE LIVER
TREATED BY ASPIRATION: Under the
care
of Du. G. C.
Hoy ;
reported by
Native Doctor Hari Mohan Bhuttacharjea
of Soory. Toroney Ghose, aged 25 years, came under treatment on the 22nd February with fever and pain in the right hepatic region. He suffered from fever of an intermittent
about 4 months ago. After the fever abated he began to feel a shifting pain on the right side. The pain has persisted up to the present, and the fever, though it is said to have disappeared outwardly, has not left him altogether. About a month ago he had dysenteric symptoms, passing from 15 to 20 stools in 24 hours, consisting
type
of mucus and blood with a good deal of straining. This has prostrated him a good deal, and constitutes one of the chief complaints. He was in the habit of taking country spirits now and then, but was not a habitual drinker. The patient is very much emaciated; eyes slightly jaundiced ; appetite bad; bowels loose. The right hepatic region bulged out. Has got a short dry cough. Liver dulness extended in the mammary line from an inch below the nipple to the umbilicus and laterally to a line with the left nipple.^ The intercostal spaces were expanded. The swelling was more prominent under the false cartilages, and over them distinct fluctuation was
perceptible.
An incision was made one inch outside the line of the niple and under the false cartilages. The smallest needle of the aspirator having been introduced and fluid detected, the biggest trocar and canula was thrust in and the contents syringed out. About 6 pints of fluid were evacuated. The first portion was thin and sanious, but The as it flowed on it became thicker and more laudable. latter portion of the fluid was mixed up with air bubbles which must have found their entrance by the instrument notwithstanding the great care taken to prevent the The patient felt himself much relieved occurrence. after the operation. 23rd February.?Pulse 116 ; jaundice less ; passed a comfortable night; appetite improved and has a relish for food ; no pain in the back ; bowels not so frequent, straining less ; fever much abated; some pain in the lower part of the abdomen. 24^?Pulse 112; improving in other respects, but the pain in the abdomen continues. 25^.?Pulse 100; has got a keen appetite ; bowels
Remarks by Dr. Roy. in this case was delayed too long to be of permanant benefit to the patient. From the quantity of pus evacuated at each sitting it can be inferred that the whole gland structure was destroyed by suppuration, reducing it to a mere shell enclosing a big cavity. The walls of such an abscess after emptying never can approximate together to cause obliteration by subsequent adhesion. The cavity remaining patent, the secretion of pus and refilling was only a question of time, and yet unmistakable evidence of general contraction of the abscess was derived from the gradual diminution of its capacity and contents. If the abscess had not been so big and strength so completely undermined, recovery would have_ been possible, for the progress of the case left nothing to be desired. With suoh operations the abscess would have been contracted till the lust portion of pus left would have remained encysted and undergone caseous degeneration and absorption. Of this I had a beautiful instance lately in the jail in the case of a prisoner who died of anasarca and dropsy. On the left general lobe of the liver was a depressed cicatrix which extended deep into the substance of the organ, terminating at the lower part in a small cavity about tho size of a nut, which contained thick caseous matter deeply tinged with bile. This irritation had produced thickening of the Glisson's capsule as well, and the liver was in the first stage of cirrhosis. The absence of putrefaction and foetor in the fluid after 3 operations is a triumph of the antiseptic surgery of the present age. Although a few bubbles of air The
operation
Jun-e 2,
1879.]
A MIRROR OF HOSPITAL PRACTICE.
entered in the cavity of the abscess, it must have got filtered and aseptic. The evacuation each time was complete and attended with no evii consequence. Dr. Furnell objects to the aspirator on the ground that the force of suction causes rupture of the pyogenic membrane and increases irritation. In the present instance the patient did complain as if the abscess was being pressed out or squeezed, but there was no irritation produced and the contents of the third operation showed absence of
haemorrhage.
The contents of the abscess deserve soma passing notice. On each occasion of puncture, the first portion drawn off differed from the last?being either a sero-sauguinolent or yellow fluid, differing in color and consistency from laudable pus. There seemed, as it were, two layers of it, thin fluid at the top and the thick pus at the bottom, giving one an idea that the original mischief was a cyst probabiy of hydatid origin which had suppurated, a portion of the fluid having been couverted into purulent matter. I regret that the fluid was not examined for the hooklets of the echinococci, which altogether escaped observation in the first instance. Between the liver and the abdominal wall there was the no contraction of adhesion, as was evident from falling back of the organ after operation as detected by palpation, under such circumstances the operation was not without its danger. In fact the pain in the lower part of the abdomen that followed the first operation was attributed to the escape of a few drops of fluid after the removal of the canula, and caused great anxiety. The dysenteric symptoms were the consequence of obstruction of the portal circulation, and increased and abated as the pressure on those vessels was intensified or withdrawn.
165
getting regular
A CASE OF ABSCESS OF THE LIVER
TREATED BY ASPIRATION: Under the
care
of Du. G. C.
Hoy ;
reported by
Native Doctor Hari Mohan Bhuttacharjea
of Soory. Toroney Ghose, aged 25 years, came under treatment on the 22nd February with fever and pain in the right hepatic region. He suffered from fever of an intermittent
about 4 months ago. After the fever abated he began to feel a shifting pain on the right side. The pain has persisted up to the present, and the fever, though it is said to have disappeared outwardly, has not left him altogether. About a month ago he had dysenteric symptoms, passing from 15 to 20 stools in 24 hours, consisting
type
of mucus and blood with a good deal of straining. This has prostrated him a good deal, and constitutes one of the chief complaints. He was in the habit of taking country spirits now and then, but was not a habitual drinker. The patient is very much emaciated; eyes slightly jaundiced ; appetite bad; bowels loose. The right hepatic region bulged out. Has got a short dry cough. Liver dulness extended in the mammary line from an inch below the nipple to the umbilicus and laterally to a line with the left nipple.^ The intercostal spaces were expanded. The swelling was more prominent under the false cartilages, and over them distinct fluctuation was
perceptible.
An incision was made one inch outside the line of the niple and under the false cartilages. The smallest needle of the aspirator having been introduced and fluid detected, the biggest trocar and canula was thrust in and the contents syringed out. About 6 pints of fluid were evacuated. The first portion was thin and sanious, but The as it flowed on it became thicker and more laudable. latter portion of the fluid was mixed up with air bubbles which must have found their entrance by the instrument notwithstanding the great care taken to prevent the The patient felt himself much relieved occurrence. after the operation. 23rd February.?Pulse 116 ; jaundice less ; passed a comfortable night; appetite improved and has a relish for food ; no pain in the back ; bowels not so frequent, straining less ; fever much abated; some pain in the lower part of the abdomen. 24^?Pulse 112; improving in other respects, but the pain in the abdomen continues. 25^.?Pulse 100; has got a keen appetite ; bowels
Remarks by Dr. Roy. in this case was delayed too long to be of permanant benefit to the patient. From the quantity of pus evacuated at each sitting it can be inferred that the whole gland structure was destroyed by suppuration, reducing it to a mere shell enclosing a big cavity. The walls of such an abscess after emptying never can approximate together to cause obliteration by subsequent adhesion. The cavity remaining patent, the secretion of pus and refilling was only a question of time, and yet unmistakable evidence of general contraction of the abscess was derived from the gradual diminution of its capacity and contents. If the abscess had not been so big and strength so completely undermined, recovery would have_ been possible, for the progress of the case left nothing to be desired. With suoh operations the abscess would have been contracted till the lust portion of pus left would have remained encysted and undergone caseous degeneration and absorption. Of this I had a beautiful instance lately in the jail in the case of a prisoner who died of anasarca and dropsy. On the left general lobe of the liver was a depressed cicatrix which extended deep into the substance of the organ, terminating at the lower part in a small cavity about tho size of a nut, which contained thick caseous matter deeply tinged with bile. This irritation had produced thickening of the Glisson's capsule as well, and the liver was in the first stage of cirrhosis. The absence of putrefaction and foetor in the fluid after 3 operations is a triumph of the antiseptic surgery of the present age. Although a few bubbles of air The
operation
Jun-e 2,
1879.]
A MIRROR OF HOSPITAL PRACTICE.
entered in the cavity of the abscess, it must have got filtered and aseptic. The evacuation each time was complete and attended with no evii consequence. Dr. Furnell objects to the aspirator on the ground that the force of suction causes rupture of the pyogenic membrane and increases irritation. In the present instance the patient did complain as if the abscess was being pressed out or squeezed, but there was no irritation produced and the contents of the third operation showed absence of
haemorrhage.
The contents of the abscess deserve soma passing notice. On each occasion of puncture, the first portion drawn off differed from the last?being either a sero-sauguinolent or yellow fluid, differing in color and consistency from laudable pus. There seemed, as it were, two layers of it, thin fluid at the top and the thick pus at the bottom, giving one an idea that the original mischief was a cyst probabiy of hydatid origin which had suppurated, a portion of the fluid having been couverted into purulent matter. I regret that the fluid was not examined for the hooklets of the echinococci, which altogether escaped observation in the first instance. Between the liver and the abdominal wall there was the no contraction of adhesion, as was evident from falling back of the organ after operation as detected by palpation, under such circumstances the operation was not without its danger. In fact the pain in the lower part of the abdomen that followed the first operation was attributed to the escape of a few drops of fluid after the removal of the canula, and caused great anxiety. The dysenteric symptoms were the consequence of obstruction of the portal circulation, and increased and abated as the pressure on those vessels was intensified or withdrawn.
165
