% JifliilHoii of Hospital ?raojinc. NINE CASES OF LIVER ABSCESS

AND CASE OF HYDATID OF LIVER

TREATED IN THE BER1IAMPUR HOSPITAL

DURING THE YEAR, 1898.

By Major J. H. TULL-WALSH, i.m.s.

For the notes of these cases I am, in the main, indebted to Assistant-Surgeon Mrigendra Lai Mitra, the Medical Officer in charge of the Mu-

nicipal Hospital. Case I.?R. C., Hindu male, aged 67. General

health good. History of dysentery ; also addicted to alcohol. For two months had been suffering from " fever," pain and enlargement ot the liver. Admitted to hospital 011 3rd January. On the

same day, Assistant Surgeon Mrigendra Lai Mitra introduced three trocars into the liver in a line

over the most prominent part of the tumour. These trocars were left in situ. After an inter-

val of 48 hours, a free incision was made between two of the trocars. The pus was washed out

and a drainage tube introduced. The abscess was a large one and for the first two or three

days the dressings had to be changed two or three times daily. After a week there was little

discharge and the drainage tube was shortened from time to time. The patient left hospital cured after twenty-six days. The abscess was

in the right lobe of the liver, upper and anterior portion. Case II.?K. M. C., Hindu male, aged 60. Gene-

ral health bad ; much emaciated. The man was

addicted to drink,and had also had several attacks of dysentery during the previous six months. Two months before admission to hospital, he felt an acute pain in the region of the liver which

164 THE INDIAN MEDICAL GAZETTE. [May 1899.

pain increased daily. A swelling appeared in the right hypochondriac region. He suffered from " fever." Irritants had been applied to the skin over the liver by native quacks. He was admitted into the Berhampur Hospital on 18th Februaiy. Temperature, 103? F.* On the same clay, the Civil Surgeon introduced three trocars into the tumour

as in case I. Forty-eight hours after, a free inci- sion was made. The pu3 was thin and foetid, and the abscess cavity was washed out with boracic lotion. A tube was introduced. On the 19th

February, the temperature went up to 104? F., and against all advice the patient's friends re- moved him from the hospital. It was ascertained

that he died at home the day after his removal. The abscess was in the right lobe of the liver.

Case III.?Hindu male. The notes of this

case have been lost, but he was admitted early in the year and recovered after the operation. No further information can be found in the

hospital records. Case IV.?I., Hindu male, aged 38. General

condition good. Admitted to hospital on

27th March for a tumour in the hepatic region of eight years' standing. Addicted to

drinking alcohol. Complained of colicky pains, not always present, but coming cn now and

then. Temperature 100*2? F. on admission. The temperature remained between 100? F. and 101-2? F. until the night of the 28th, when it rose to 102? F. On the morning of the 29th March, Major Macdonald, I.M.S., introduced two trocars into the tumour and a thin

watery fluid escaped. The tumour was then

diagnosed as a hydatid tumour connected with

the?right lobe of the liver. On the 1st April, a free incision was made into the tumour, the cyst was stitched to the abdominal parietes and a drainage tube inserted. Although there was no suppuration, the temperature did not become normal until ten days after the operation after continued doses of quinine. It is probable therefore that the " fever" was of malarial origin and not connected with the presence of the cyst. A large number of " daughter cysts

" were dis-

charged and the cyst wall came away slowty. A fistula remained for some time, but the patient was ultimately discharged cured on the 10th July. Case V. R. C., Hindu male, aged 55. General

condition fair. The patient stated that for about one year he had suffered from a gnawing pain in the right hypochondrium. For a monthlhe pain had been severe, and he had been sufferino- from "fever." He was addicted to alcohol. No history of dysentery. The liver was much enlarged downwards, and the tissues of the abdominal wall over the tumour were oedeniatous. Admit- ted to hospital on 9th May 1898. On the 11th May, Assistant-Surgeon M. L. Mittra introduced three trocars into the tumour through which pus discharged freely. After forty-eight hours,

a free incision was made. The cavity was not washed out as the pus was not foetid. A drain-

age tube was inserted. The progress of the case was good and the patient left hospital cured 35 days after the operation. Case VI.?M., Hindu male, aged 35. In poor

health. Has been suffering from " fever," pain,

&c., for four months. There was a fluctuating swelling on the right side of the chest. Admit-

ted on 25th August 1898. I made a free opening between the 8th and 9th ribs. The cavity was washed out with boracic lotion, and a drainage tube inserted. There was considerable discharge, but the temperature became normal almost at once. The discharge decreased, but after about ten

days it suddenly increased and the temperature rose again. The patient also complained of pain in front just to the right side of the ensiform cartilage. On introducing a long probe, a sinus was found leading into a second abscess in the

right lobe, but nearer the middle line. As the

discharge appeared free, no further incision was made. The patient still did not improve very fast, and on the 7th November, another abscess

pointed just to the rightof the ensiform cartilage. With the pus from this abscess there came out a

piece of cartilage about one inch long by half an inch wide. On the 3 7th November, the first open- ing was enlarged to give free drainage both ways. The temperature again went down to normal, but was subject to occasional rises for which it was not easy to account. On the 5th Decem- ber the patient left the hospital not quite cured and against advice. When last heard of, he was

doing well. There is no distinct history in this

case of dysentery or any other likely cause.

Histories as given by natives are unfortunately not very clear or valuable. Cask VII.?U., Hindu male, aged 14 years.

General condition good. History of a blow

some time ago, but he felt nothing particular until fifteen days ago. He then suffered from " fever," and a pain in the right hypochondrium. Admitted on 7th September. There was a

small fluctuating swelling just below the ribs

on the right front. The tumour was explored, and pus being found, an incision was made at once. About four ounces of pus came out. The

highest temperature was 101?F. on the day of operation. The next day the temperature was normal. The abscess filled up rapidly, and the patient left hospital on 14th September. There

was a small sinus which has since closed. The

boy is now quite well. Cask VIII.?S., Hindu male, 40 years of age.

Very weak and thin. About 3 months previ- ously, the man was struck on the right sido by a cart. Shortly after the accident he felt pain over the liver, and had an attack of

" fever."

There was no " fever" at the time of admission to hospital. There was a hard swelling over

the front of the liver on the right side, and the

May 1899.] KASHMIR MISSION HOSPITAL?NEVE. 165

skin over the tumour was tender and (Edematous.

I lie swelling reached down to the level of the

umbilicus. Admitted to Hospital on 11th No-

vember. Under chloroform, the liver was ex-

pored with a needle and a large abscess found.

An incision was at once made into it and a very

large quantity of thin pus came out. As the

cavity was very large and there was some bleed-

ing, it was packed with sal-alembroth gauze. I lie man was in a very feeble state when ad-

mitted, and he gradually sank and died 011 the

morning of the 14th November. The abscess

?occupied nearly the whole of the right lobe of

the liver.

.

Case IX.?P. H., Hindu male, aged 45. Suffer-

ing from pain in the region of the liver and

?swelling for the past six months. Has been in

the habit of taking alcohol. Had an attack of

dysentery with fever four months ago. Has had

other attacks. Admitted to hospital on 29th

September. The liver was much enlarged

downwards, two inches below the costal margin.

The intercostal spaces on the right side bulged.

Distinct fluctuation in the 8th intercostal space.

Temperature on admission, 99'8?F. Tempera-

ture on the evening of the 30th, 100?F. after

operation. On the morning of the 30th Sep-

tember, I made a free incision into the liver

at

the point of fluctuation, washed out the abscess

cavity and packed it with antiseptic gauze,

-fhe temperature was normal 011 the 4th October,

and a drainage tube was inserted in place of the

gauze packing. The temperature remained nor-

mal and the man made a good recovery. He was

discharged cured 011 the 20th November.

Case X.?Hindu male, aged 88. In very bad

condition, thin and emaciated. No history of

alcohol or dysentery, but had a blow 011 the right

side about three months ago. Shortly after-

wards felt pain in the right side and had

" fever."

Admitted to hospital 011 11th December. The

same day, an incision was made into the most

prominent part of the swelling in front just

below the ribs on the right side. More than a

quart of pus came out. The cavity was packed

with antiseptic gauze. The next day, the gauze

was removed and a drainage tube inserted. The

temperature was generally normal, but reached

99? to 99'8? F. in the evenings. The tongue

was red and glazed, and the man very feeble.

Diarrhoea set in on the 21st December, and blood

was seen in the stools on the 22nd. The patient

continued to suffer from dysenteric diarrhoea and

died on the 26th of December.

Of the nine cases of liver abscess, six recovered

?and three died. The cases in which the patients

died were Nos. I J, VIII and V and in all three,

the patients were in a very feeble condition

on

admission to hospital, and the prognosis was not

favourable from the outset. In all nine cases,

the abscess (in case VI, two abscesses) was in

?the right lobe of the liver.

As regards causation, known or probable :? ! Case I " dysentery ; also addicted to alcohol:" Case II " was addicted to drink and had also

had several attacks of dy sentery du- ring the previous six months:"

Case III unknown: Case V" addicted to alcohol; no history of

dysentery:" Case VI "no history of dysentery; not addict-

ed to alcohol:" Case YII "a blow

"

(age 14 years): Case VIII " a blow Case IX " in the habit of taking alcohol; had

an attack of dysentery with fever

four months ago :" Case X " a blow." As regards the abuse of alcohol such abuse is

very common among the lower classes in this

district, and by itself may predispose to conges- tion of the liver. Indulgence in alcohol alone, however, can hardly be a cause of liver abscess. Dj'sentery will, I think, be found present in the majority of cases of abscess of the liver. As

regards treatment, immediate free incision is the best. The previous introduction of trocars offers no advantages, and the aspirator should only be regarded as an instrument for diagnosis.