A MIRROR OF HOSPITAL THE
"
BUEES'
"
PRACTICE.
REGIMENTAL HOSPITAL.
CASE OF HEPATIC ABCESS TREATED BY THE ASPIRATOR.
By Surgeon-Major "William Collis. In the following case, though one of ordinary occurrence in this country, there are some points of importance which will perhaps warrant its being recorded in these pages. Private J. M., aged 31 years, good muscular development,-was admitted into the Buffs' Kegimental Hospital on the 24th of April 1875. The chief facts of interest in his medical history sheet are, that he has 17 years' service, of which 6J have been spent in India. That he has been, during his service, eleven times in hospital, chiefly from slight ailments, with the exception of constitutional syphilis, for -which he was salivated. He has never suffered from dysentery, diarrhoea or fever. His habits are temperate. States he ha3 not been feeling well for some days past, complains of loss of appetite and headache, but on the previous evening intense pain came on in the region of the stomach. He looks ill, in walking towards his bed he bent himself much forward, his countenance is anxious, points to the epigastrium as the seat of pain, where there is an undefined swelling. April 26th.?There is now a tumor in the epigastric region. Its most prominent point is about an inch to the left of the median line, and an inch and a half below the xiphoid cartilage, it is not clearly defined, very gradually lost as the central point is receded from. It has a solid feeling to the touch, and has a distinct pulsation forwards synchronous with the aortic pulsation. Temperature 99 6? F. The pain is not continuous but severe. 27th.?Swelling more prominent; very painful on pressure; obscure feeling of fluctuation pulsation not so distinct; an treatment hitherto consisted of The exists in centre of tumor. fomentations and local applications to relieve pain, and an aperient to regulate the bowels. May Is*.?The swelling is somewhat larger; fluctuation much the same ; temperature 99 4? F.; urine more distinct; pain about high colored, specific gravity 1015, diminution of chlorides, no albumen. 2nd.?Fluctuations very marked to-day over the seat of swelling, but its edges are still hard. On consultation it was agreed to explore the tumor with the needle of an aspirator about two ounces of serum were first drawn off by that -
followed by six
ounces
of pus of
a
brownish color.
means'
THE INDIAN MEDICAL GAZETTE.
242
2rd.?Much relieved by the operation; temperature 98*4?F.; very
Blight pain.
5th.?Patient very comfortable, but the fluctuation is
appearing.
1th.?The tumour
morning,
was
re-
again emptied by the aspirator this
and twelve ounccs of pus removed.
8th.?Was relieved by operation ; temperature normal. 9^.?No change; temperature slightly above normal; his tongue is clean, and appetite fairly good; bowels regular. He is taking chicken diet with six ounces of port wine, beef-tea
pint, and one ounce of brandy. 12th.?Fluctuation again distinct; temperature 101? F., (in rectum); perspires freely. 14th.?Six ounces more of saniouspus removed by aspirator, and about the same quantity of carbolic acid lotion, 1 to 60, injected into abscess, and allowed to remain for a few seconds, and then drawn off; the greatest possible care was taken to prevent the admission of the smallest bubble of air. 17th.?Was again relieved by the operation ; temperature one
varies from 100? to 101? F. 21 st.?About five ounces of very thick sanguineous pus were removed to-day by the aspirator; it was so thick that, it would scarcely pass through the tube ; the carbolic acid injec-
tion was repeated as before. 27th.?The tumor has much increased in size quite suddenly, the needle being introduced into it brought off about half an ounce of liver-colored substance; on pushing the needle still deeper about seven ounces of sanious pus were evacuated. The walls of the tumour have become so dense that it required
perforate them. comfortable; temperature 103'4? F. (in rectum); takes his food well; complains of pain over the considerable force to 28th.?Is fairly
abscess. 29^/t.?Feels rather poorly; tongue foul; temperature has fallen to 100? F. 31?*.?.Rather better, but a little pain. June 2nd.?His health has improved since last report ; temperature but slightly above normal, 99 6? F. The tumor is much smaller and harder than it has been. 7th.?Skin over tumour is distinctly red and feels rather
brawny.
Four ounces more of sanious pus evacuated by aspirator. 11 th.?Skin red and brawny over tumour; slight oozing from the site of the last punctures. 19;A.?Skin le3s brawny and tense. 25th.?Has improved greatly since last report; skin still red and indurated, though much less so since last note. A needle was pushed into the tumor, but no pus obtained. July 5th.?A small superficial abscess has formed in the skin ; temperature normal. 8th.?A few drops of pus were obtained from the superficial
abscess.
18/A.?Has gained in weight ljlbs. during the last week; skin over epigastrium looks much more healthy. 20th.?Is well; gets about readily without any help; no skin infiltration remaining. 28/A.?Has gained in weight 2lb3. since the 24th. Remarks.?The diagnosis of this ease, though at first rather ob3cure, cleared up as time went on. That it was a hepatic abscess, seated on the left lobe of the liver, there is not much room for doubt. Its walls must have been unusually dense and thick for it to have received so plainly the aortic impulse. The next point to notice is the slight effect it had' on tho patient's temperature, 103'4? F. in rectum being the highest point registered. This is not unusual in hepatic abscess; a fatal case that wa3 nnder observation for days never showed a higher therraometric reading than 101? F.; a comparatively low temperature, instead of excluding liver abscess, with other symptoms tends perhaps to confirm our suspicion of it. The fact that the patient is a British soldier renders his previous medical history peculiarly trustworthy. From this it is proved that the man could never havo had dysentery, the starting point of so many cases of hepatic abscess, that Dr. liudd has thought it an essential link in their etiology. That the successful treatment in this case was solely due to tho use of the aspirator is most probable. The care used to prevent the admission of air during the carbolic acid injection contributed greatly; the abscess, had it not for this, would either have burst internally with all the risk thereto attaching leading to a doubtful convalescence at the best. This was obviated by repeatedly emptying tho cavity by the aspirator, forty-two ounces of fluid being removed in all in seven operations, the greater quantity being typical a hopatie pus." The treatment of
abscess advance.
hepatic
by aspiration
July 28th, 1875.
[September 1, is without doubt a
1875.
great step
in
"
BUEES'
"
PRACTICE.
REGIMENTAL HOSPITAL.
CASE OF HEPATIC ABCESS TREATED BY THE ASPIRATOR.
By Surgeon-Major "William Collis. In the following case, though one of ordinary occurrence in this country, there are some points of importance which will perhaps warrant its being recorded in these pages. Private J. M., aged 31 years, good muscular development,-was admitted into the Buffs' Kegimental Hospital on the 24th of April 1875. The chief facts of interest in his medical history sheet are, that he has 17 years' service, of which 6J have been spent in India. That he has been, during his service, eleven times in hospital, chiefly from slight ailments, with the exception of constitutional syphilis, for -which he was salivated. He has never suffered from dysentery, diarrhoea or fever. His habits are temperate. States he ha3 not been feeling well for some days past, complains of loss of appetite and headache, but on the previous evening intense pain came on in the region of the stomach. He looks ill, in walking towards his bed he bent himself much forward, his countenance is anxious, points to the epigastrium as the seat of pain, where there is an undefined swelling. April 26th.?There is now a tumor in the epigastric region. Its most prominent point is about an inch to the left of the median line, and an inch and a half below the xiphoid cartilage, it is not clearly defined, very gradually lost as the central point is receded from. It has a solid feeling to the touch, and has a distinct pulsation forwards synchronous with the aortic pulsation. Temperature 99 6? F. The pain is not continuous but severe. 27th.?Swelling more prominent; very painful on pressure; obscure feeling of fluctuation pulsation not so distinct; an treatment hitherto consisted of The exists in centre of tumor. fomentations and local applications to relieve pain, and an aperient to regulate the bowels. May Is*.?The swelling is somewhat larger; fluctuation much the same ; temperature 99 4? F.; urine more distinct; pain about high colored, specific gravity 1015, diminution of chlorides, no albumen. 2nd.?Fluctuations very marked to-day over the seat of swelling, but its edges are still hard. On consultation it was agreed to explore the tumor with the needle of an aspirator about two ounces of serum were first drawn off by that -
followed by six
ounces
of pus of
a
brownish color.
means'
THE INDIAN MEDICAL GAZETTE.
242
2rd.?Much relieved by the operation; temperature 98*4?F.; very
Blight pain.
5th.?Patient very comfortable, but the fluctuation is
appearing.
1th.?The tumour
morning,
was
re-
again emptied by the aspirator this
and twelve ounccs of pus removed.
8th.?Was relieved by operation ; temperature normal. 9^.?No change; temperature slightly above normal; his tongue is clean, and appetite fairly good; bowels regular. He is taking chicken diet with six ounces of port wine, beef-tea
pint, and one ounce of brandy. 12th.?Fluctuation again distinct; temperature 101? F., (in rectum); perspires freely. 14th.?Six ounces more of saniouspus removed by aspirator, and about the same quantity of carbolic acid lotion, 1 to 60, injected into abscess, and allowed to remain for a few seconds, and then drawn off; the greatest possible care was taken to prevent the admission of the smallest bubble of air. 17th.?Was again relieved by the operation ; temperature one
varies from 100? to 101? F. 21 st.?About five ounces of very thick sanguineous pus were removed to-day by the aspirator; it was so thick that, it would scarcely pass through the tube ; the carbolic acid injec-
tion was repeated as before. 27th.?The tumor has much increased in size quite suddenly, the needle being introduced into it brought off about half an ounce of liver-colored substance; on pushing the needle still deeper about seven ounces of sanious pus were evacuated. The walls of the tumour have become so dense that it required
perforate them. comfortable; temperature 103'4? F. (in rectum); takes his food well; complains of pain over the considerable force to 28th.?Is fairly
abscess. 29^/t.?Feels rather poorly; tongue foul; temperature has fallen to 100? F. 31?*.?.Rather better, but a little pain. June 2nd.?His health has improved since last report ; temperature but slightly above normal, 99 6? F. The tumor is much smaller and harder than it has been. 7th.?Skin over tumour is distinctly red and feels rather
brawny.
Four ounces more of sanious pus evacuated by aspirator. 11 th.?Skin red and brawny over tumour; slight oozing from the site of the last punctures. 19;A.?Skin le3s brawny and tense. 25th.?Has improved greatly since last report; skin still red and indurated, though much less so since last note. A needle was pushed into the tumor, but no pus obtained. July 5th.?A small superficial abscess has formed in the skin ; temperature normal. 8th.?A few drops of pus were obtained from the superficial
abscess.
18/A.?Has gained in weight ljlbs. during the last week; skin over epigastrium looks much more healthy. 20th.?Is well; gets about readily without any help; no skin infiltration remaining. 28/A.?Has gained in weight 2lb3. since the 24th. Remarks.?The diagnosis of this ease, though at first rather ob3cure, cleared up as time went on. That it was a hepatic abscess, seated on the left lobe of the liver, there is not much room for doubt. Its walls must have been unusually dense and thick for it to have received so plainly the aortic impulse. The next point to notice is the slight effect it had' on tho patient's temperature, 103'4? F. in rectum being the highest point registered. This is not unusual in hepatic abscess; a fatal case that wa3 nnder observation for days never showed a higher therraometric reading than 101? F.; a comparatively low temperature, instead of excluding liver abscess, with other symptoms tends perhaps to confirm our suspicion of it. The fact that the patient is a British soldier renders his previous medical history peculiarly trustworthy. From this it is proved that the man could never havo had dysentery, the starting point of so many cases of hepatic abscess, that Dr. liudd has thought it an essential link in their etiology. That the successful treatment in this case was solely due to tho use of the aspirator is most probable. The care used to prevent the admission of air during the carbolic acid injection contributed greatly; the abscess, had it not for this, would either have burst internally with all the risk thereto attaching leading to a doubtful convalescence at the best. This was obviated by repeatedly emptying tho cavity by the aspirator, forty-two ounces of fluid being removed in all in seven operations, the greater quantity being typical a hopatie pus." The treatment of
abscess advance.
hepatic
by aspiration
July 28th, 1875.
[September 1, is without doubt a
1875.
great step
in
