tion.
The extensive experience in the J. J. proves that there is no immediate danger of the extravasation of pus following operation, and that the pressure of the abdominal parietes is sufficient to prevent this. Two cases of which I have recorded brief notes, will shew that there is a danger of pus burrowing between the liver and the parietes, during the treatment of hepatic abscess. / T. S., an Amil boy, aged 15 years, a native of Hyderabad, Sind, had been under the treatment of a local practitioner for some weeks, suffering from fever and wasting.^ As he grew rapidly worse I was called in to see the lad and diagnosed an hepatic abscess which (J at once operated upon. Although implicating a large portion of the liver, the effect of the operation was highly encouraging, the temperature fell, the pain disappeared, and the patient gained in strength. The discharge became less, and the tube was considerably shortened. Three weeks after the operation, the temperature, hitherto characterized by a slight evening rise-, rose to over 100? with a marked evening exacerbation. An enlargement of the original incision and careful examination shewed a very superficial liver wound but an extensive circular collection of pus between the parietes and the liver, which even with a free incision it was almost impossible to effectively drain. This circular area was clearly defined at the circumference, its radius from the central original incision being about two inches. A continuous copious discharge marked a steady decline in the patient's strength, to which he succumbed after a month's illness. N. B. was operated upon by Dr. Meyer for hepatic abscess on the 27th of June, and was much benefited thereby. The subsequent history ABSCESS. of the case was uneventful and fairly satisfacTHE TREATMENT OF HEPATIC toiy. Twent}r-five days after the operation, a By W. H. HENDERSON, rise in temperature and a marked change for Surgn.-Lt.-Col., I.M.S., the worse in his symptoms made me suspect hi charge Gokuldass Tejpal Hospital, Bombay. the presence of a collection of pus between the parietes and the liver. An examination proved the supposition correct. A more extensive area While collecting and preparing notes for than in the former case was discovered full of the of the on Treatment of these remarks subject tenacious stringy pus. Hepatic Abscess, I received my copy of the To insure free drainage I at once resected an Indian Medical Gazette, in which Dr. Hatch has inch and-a-half of rib and two days after introarticle and on valuable a contributed interesting duced from without a drainage tube at the most Hepatic Abscess, and in which he elucidated dependant part, as it was still far from free. some of the points, which it was my intention In this case the liver wound admitted only to bring forward for discussion. (' In a very the tip of the little finger and was in every varied up-country practice, I have found that case the the opportunities of studying the disease are wajr satisfactory. As in the previous and the patient died on continued, discharge comparatively small. ) the 5th of August, forty days after the first To discover two cases in the Gokuldass Hospital on taking over charge and to have four fresh operation. /In both these cases the liver wound had nearcases admitted in the following three weeks In Dr. Meyer's case, it was so inmight lead one to suppose, that whatever the ly healedjJ that it could have caused no significant anxiety. exciting cause might be, the climate of Bombay ,1 attribute the unfavourable termination in would seem to decidedly predispose to the affeed
Hospital
1
'
?
374
THE INDIAN MEDICAL GAZETTE.
botli cases, to the drain, on the patient's already enfeebled constitution from the suppurating area beneath the parietes. This would appear to me a not improbable complication, f As an abscess of the liver of any dimensions heals, a considerable amount of contraction must follow, and the parietes being fixed, the contracted organ naturally recedes, having a space certainly potentially, if not actually, dangerous at the time : a space which may become filled with pus and from which it is with difficulty drained. jjC Dr. Hatch does not make it quite clear whether all his fatal cases were subjected to postmortem examinations. If they were and the conditions similar to those just described were never found, they would, perhaps, account for those phenomenally protracted convalescences (out of all proportion to the size of the abscess) which doubtless others, like myself, have experienced in the treatment of this affection. That I should take the precaution, after the experience just recorded, of suturing the edges of the liver wound to the parietes, in the next case I operated upon, is not surprising, j s~ The question remains would such suturing lessen the risk of complications such as I have described ? In my opinion it would./ At any rate the extra time spent upon the operation need not militate against its trial, 011 account of any increased risk or inconvenience to the patient. >
[Oct.
1898.
The extensive experience in the J. J. proves that there is no immediate danger of the extravasation of pus following operation, and that the pressure of the abdominal parietes is sufficient to prevent this. Two cases of which I have recorded brief notes, will shew that there is a danger of pus burrowing between the liver and the parietes, during the treatment of hepatic abscess. / T. S., an Amil boy, aged 15 years, a native of Hyderabad, Sind, had been under the treatment of a local practitioner for some weeks, suffering from fever and wasting.^ As he grew rapidly worse I was called in to see the lad and diagnosed an hepatic abscess which (J at once operated upon. Although implicating a large portion of the liver, the effect of the operation was highly encouraging, the temperature fell, the pain disappeared, and the patient gained in strength. The discharge became less, and the tube was considerably shortened. Three weeks after the operation, the temperature, hitherto characterized by a slight evening rise-, rose to over 100? with a marked evening exacerbation. An enlargement of the original incision and careful examination shewed a very superficial liver wound but an extensive circular collection of pus between the parietes and the liver, which even with a free incision it was almost impossible to effectively drain. This circular area was clearly defined at the circumference, its radius from the central original incision being about two inches. A continuous copious discharge marked a steady decline in the patient's strength, to which he succumbed after a month's illness. N. B. was operated upon by Dr. Meyer for hepatic abscess on the 27th of June, and was much benefited thereby. The subsequent history ABSCESS. of the case was uneventful and fairly satisfacTHE TREATMENT OF HEPATIC toiy. Twent}r-five days after the operation, a By W. H. HENDERSON, rise in temperature and a marked change for Surgn.-Lt.-Col., I.M.S., the worse in his symptoms made me suspect hi charge Gokuldass Tejpal Hospital, Bombay. the presence of a collection of pus between the parietes and the liver. An examination proved the supposition correct. A more extensive area While collecting and preparing notes for than in the former case was discovered full of the of the on Treatment of these remarks subject tenacious stringy pus. Hepatic Abscess, I received my copy of the To insure free drainage I at once resected an Indian Medical Gazette, in which Dr. Hatch has inch and-a-half of rib and two days after introarticle and on valuable a contributed interesting duced from without a drainage tube at the most Hepatic Abscess, and in which he elucidated dependant part, as it was still far from free. some of the points, which it was my intention In this case the liver wound admitted only to bring forward for discussion. (' In a very the tip of the little finger and was in every varied up-country practice, I have found that case the the opportunities of studying the disease are wajr satisfactory. As in the previous and the patient died on continued, discharge comparatively small. ) the 5th of August, forty days after the first To discover two cases in the Gokuldass Hospital on taking over charge and to have four fresh operation. /In both these cases the liver wound had nearcases admitted in the following three weeks In Dr. Meyer's case, it was so inmight lead one to suppose, that whatever the ly healedjJ that it could have caused no significant anxiety. exciting cause might be, the climate of Bombay ,1 attribute the unfavourable termination in would seem to decidedly predispose to the affeed
Hospital
1
'
?
374
THE INDIAN MEDICAL GAZETTE.
botli cases, to the drain, on the patient's already enfeebled constitution from the suppurating area beneath the parietes. This would appear to me a not improbable complication, f As an abscess of the liver of any dimensions heals, a considerable amount of contraction must follow, and the parietes being fixed, the contracted organ naturally recedes, having a space certainly potentially, if not actually, dangerous at the time : a space which may become filled with pus and from which it is with difficulty drained. jjC Dr. Hatch does not make it quite clear whether all his fatal cases were subjected to postmortem examinations. If they were and the conditions similar to those just described were never found, they would, perhaps, account for those phenomenally protracted convalescences (out of all proportion to the size of the abscess) which doubtless others, like myself, have experienced in the treatment of this affection. That I should take the precaution, after the experience just recorded, of suturing the edges of the liver wound to the parietes, in the next case I operated upon, is not surprising, j s~ The question remains would such suturing lessen the risk of complications such as I have described ? In my opinion it would./ At any rate the extra time spent upon the operation need not militate against its trial, 011 account of any increased risk or inconvenience to the patient. >
[Oct.
1898.
