HEPATIC ABSCESS, WITH THE REPORT OF A CLINICAL CASE BV / W. BLAIR STEWART, A.M., M.D., Instructor in Practice, Medico-Chirurgical College, Philadelphia. Reprinted from The Medical Bulletin. HEPATIC ABSCESS, WITH THE REPORT OF A CLINICAL CASE. By W. BLAIR STEWART, A M., M.D., Instructor in Practice, Medico-Chirurgical College, Philadelphia. HISTORY.-John C., gardener and day- laborer, was born in Ireland about 1859. His father, mother, brothers, and sis- ters always enjoyed good health, and had no history of chronic or specific diseases. He worked on a farm until he came to this coun- try, about 1884. When 14 years old, while driving through a stream, he had to get out of the wagon to lift one of the wheels from the mire. His own language is so expressive that it is appended : " I lifted and pulled very hard until there was a snap in my right side, which was followed by sharp pain and inability to lift or do hard work for several months." Some years later the same accident occurred, and since that time he has always felt that his right side was his weak point; that it always felt heavy and often interfered with active work; was subject to bilious attacks and suffered oc- casionally from piles; never had any swelling over liver that was recognizable to patient; is married and has three hearty, healthy children. During the month of March, 1892, he was seized with a sharp pain in the right hypochon- driac region and went to one of the Philadel- phia hospitals, where he placed himself under the care of a surgeon, March 15 th. The at- tending surgeon handed me the following re- port: "First visit, March 15, 1892; found two masses on the anterior surface of the liver about as large as duck-eggs, very hard and un- yielding ; no history of a blow or injury of any kind; was ordered iodide of potash. On the 19th was given Rochelle salt, 1 drachm each morning, and continued iodide. On April 21st and 2 7th,same treatment continued and growths apparently decreasing in size. He left the city about this time, as I supposed, apparently re- covered." April 27th he returned to his home in Bryn Mawr, and, in a few days, according to his own statement, began to pass mucus, pus, and blood, and continued this for several weeks before it ceased. No reliable medical examina- tion was made, but he held that the lumps in the side disappeared, and that the discharge came from an abscess that burst into the bowels. Whether this was the case is rather 2 dubious, as shown by future history. At any rate, the man resumed day-labor and worked very hard until July of the same year, when he took a severe cold ; had creepy, cold sensations, with pain and soreness over the liver. Was first called July 8, 1892. Temperature was 1020 F.; pulse, 100; tongue covered with white coating ; anorexia ; clammy skin ; eyes dull; great restlessness and bowels natural, with very slight tendency to diarrhoea. Objective Symptoms.-Slight swelling an- teriorly and posteriorly over right lobe of liver; hard to touch ; no fluctuation perceptible; ten- derness not marked on deep pressure; right rectus abdominis tense and prominent. Or- dered a pill containing 1 grain each of acetani- lide and bisulphate of quinine and grain cocaine hydrochlor, every hour, and a pill of cascara, aloin, and podophyllin night and morning ; strong counter-irritation over liver; diet of milk and animal broths. Slight im- provement for five or six days, when tempera- ture became normal. July 16th, pain returned; tumor was larger and gave slight sense of resistance, but no dis- tinct fluctuation. No distinct chill ever ap- peared. These symptoms justified me in diag- nosing the case as one of hepatic abscess of the right lobe. 3 July 19th, pain was quite severe and dis- tinct fluctuation was detected between the pos- terior and anterior tumor, showing some con- nection. Consent was given for an operation by aspiration, and on Wednesday, July 20th, at 1 p.m. , in consultation with Dr. Atlee, a medium-sized aspirating needle was introduced into the anterior tumor, at the junction of the epi- gastric and right hypochondriac regions at lower border of ribs and sternum. One quart of thin pus was withdrawn, followed by a subsidence of the tumors. A firm compress and bandage was adjusted and quietness enjoined. Pus was thin, dirty-yellow, and deposited a thick, creamy, yellow, laudable pus, without odor. Reaction decidedly alkaline; specific gravity, 1014; was markedly albuminous; no sugar nor phosphates; very slight trace of bile. Microscopically, - pus-cells, some disinte- grated ; mucus; a few particles of fibre, and no blood-cells. Soon after the operation the compress worked loose owing to too free motion, and, as a result, three hours later, peritonitis set in and pains were so severe that a hypodermic of morphine and atropine was administered ; ice- cold flannel cloths (dipped in iced-water) were applied and changed every minute for four hours, when pain had become bearable and 4 had almost ceased. This was followed by short naps, free from dreams. Pulse 90, and temperature 1010 F. Free vomiting of mucus, but no bile. Cold applications were continued, and Rochelle salt was given every two hours (tablespoonful to a goblet of water, and dessert- spoonful to dose). Peritonitis became general; marked tym- pany ; pain; constipation, and peculiar wan, sunken expression. Second morning after operation bilious vomiting began, and was deep-green and almost wholly bile; bowels freely moved. On the evening of the 2 2d, was called and found him bordering on col- lapse. Eyes set and sunken; skin pale, cold, and clammy; pulse weak, and scarcely per- ceptible ; abdomen tense and tympanitic; res- pirations very shallow and pain severe. Ad- ministered 1 ounce of whisky in hot milk, and 10 drops of essence of peppermint in hot water; rubbed the extremities toward the centre. Reaction began in about one-half hour, and enormous quantities of wind were passed and belched. Whisky and milk con- tinued at intervals of one to three hours. Zinc sulpho-carbolate, gr. iiss, was given every hour for sixteen consecutive hours, which reduced tympany, stopped vomiting, and checked the obstinate diarrhoea. Was then placed on an 5 emulsion of oil of turpentine, gtt. v, and sulpho-carbolate of zinc, each alternate two hours for five days. Improvement continued, and August 5 th he went down-stairs for the first time, and in a few days was walking around. His diet consisted of milk, rich broths, toast, crackers, and a small quantity of chicken, rice, orange- juice, and a dessertspoonful of best brandy four times daily. During the fall and winter he did light work, and rapidly grew stronger. In the spring of 1893 he resumed his duties as a gardener and day-laborer, and has continued at this hard work until the present, July 6, 1893. He enjoys the best of health, weighs about one hundred and seventy pounds, and rarely complains of his side. There is a small amount of fullness over the right lobe of the liver anteriorly, but no sense of fluctuation. Area of percussion dullness is slightly increased. This case is one of unusual interest, as it can be classed with those affections which are rather rare in this climate. The origin of this abscess is not at all certain, even though the previous history would couple it with an accident which occurred nearly ten years before its diag- nosis. Another question of doubt arises at the time when he had these muco-purulent and bloody discharges from the bowels. Was this 6 dependent on a dysentery or an abscess? No reliable data can be obtained to confirm this view. Diagnosis of hepatic abscess is never certain unless the presence of pus can be dem- onstrated by aspiration, operation, or rupture, for pysemic fever and its symptoms are rarely present. Here is a case in which there never were chills and fever, such as would be ex- pected in pysemic conditions. One must con- sider the possibility of hydatids, cancer, and syphilis. Surgeons are divided in their opinion as to the propriety of aspiration or section, and it will not be my purpose to advocate one method or the other. In this case it was as- piration, as under no circumstances would the family allow section. To leave the man alone meant death at an uncertain time. If it should prove a hydatid, aspiration would be bene- ficial and, possibly, curative. If a cancer, death might be hastened. The aspirating needle readily penetrated the skin, muscles, and peritoneal layers, but then met with a tough, hard membrane (?) which was penetrated with difficulty, leaving the point of the needle free to move in a large cavity, from which one quart of pus was drawn. The size of the cavity and the connection be- tween the anterior and posterior tumors were so apparent that, after aspiration, they pre- 7 sented a depressed appearance. It would have been wise to cleanse the cavity with a solution of boric acid, pyoctanin, or other antiseptic, but this was not done. A natural question: Will this abscess reform? There is not the least doubt that a small amount of pus will form, but whether it will assume its original proportions or become encysted remains to be decided by time. Peritonitis was probably caused by septic matter from the abscess. It is my opinion that there is a distinct adhesion between the visceral and parietal layers of the peritoneum and its reflections at the point of aspiration, due to peritonitis, and that future aspiration would not probably result in peri- tonitis. This case will be closely watched, and, should an opportunity for an autopsy be presented (it looks as if age would cause death before this trouble), further report will be given. Bryn Mawr, Pa.