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Abscess of Liver.—Shuttee.
tion was justified. This case has been and will be a tardy one in giving a complete recovery, but such recovery I am satisfied will follow. Occasionally six months is required for the establishment of good health.
NOTE.—May 7, Dr. McClintock writes that the patient has recovered from the operation.-ED. INDEX.
A CASE OF ABSCESS OF THE LIVER.*
BY H. C. SHUTTEE, M. D., WEST PLAINS, MO.
On September 29, 1889, I was called to see Mrs. D— widow' æt. 45 years, who four weeks previously, while climbing over a fence, slipped and fell on her right side, a rail striking her in the hepatic region. She had had more or less pain in the region of the liver ever since, and the past week slight fever, anorexia and occasional nausea, but no voming. She was very sparely built, anæmic, sallow, and considerably ema
. ciated. Temperature 100°, pulse 90 and weak. Had had no chills and perspired but little.
The liver was very much enlarged in downward direction, the lower . border reaching some two and a half inches below the ribs, of uniform firmness and tender to the touch. No particular spot at this time was more tender than another, nor was there any bulging. Bowels were opened, and quinine, with opium to relieve pain when necessary, were given, and poultices applied. Plenty of nourishment and stimulants. were ordered.
October 8. About the same. Swelling not increased, no bulging, but the lower part of the liver is more sensitive to pressure.
Oct. 16. For the past two days has had severe pain over the lower part of swelling, due to peritonitis; and an obscure sense of deep fluctuation is made out, at a point a little below and three inches to the right of the umbilicus, also between crest of the ilium and the ribs.
With a hypodermic syringe pus is found at a depth of two inches in the former, and at one and a half in the latter region.
I determined the next morning, with Dr. N. C. Berry to assist me. to make a free incision; but, upon a close examination, it was considered doubtful if firm adhesions had formed between the liver and parietal peritoneum ; and as the surroundings were as unsanitary as could well be imagined and the patient could not be seen often, we decided instead to aspirate. A medium-sized needle was passed to a depth of two inches, about three inches above the center of crest of the ilium, and six ounces of pus withdrawn. The abscess cavity was not washed out. Search was made in several places, with a hypodermic needle, but
*Read before the South West Missouri Medical Society, April 21, 1890, at Springfield, Mo.
no more pus was found. She was given iron, quinine, whisky and plenty of nourishment.
The case after this improved rapidly, however not decreasing much in size. Improvement continued up to the 24th, when she had a chill, followed by high fever, and when seen again on the 27th the abscess cavity had re-filled and there was visible bulging an inch below and two and a half inches to the right of the umbilicus. A free incision was made at this point, about eight ounces of pus evacuated, the cavity washed out with bichloride solution, a drainage-tube introduced, and over this was placed bichloride gauze and borated cotton.
Oct. 29. Abscess discharging freely. No fever or pain. Attendants were instructed to wash out the abscess, which they did very imperfectly.
Nov. 3. Discharge rapidly decreasing, and patient gaining strength. After this, discharge almost entirely stopped, and the patient was able to walk about the yard. The liver had very much decreased in size.
Nov. 14. Yesterday there was a sudden free discharge of pus, doubtless from rupture of a secondary abscess into the pimary one ; but to-day the discharge has nearly stopped again. A close search was made, but no indications of another abscess could be discovered. She improved again rapidly, being able to be up.
Nov. 30 she had another chill, severe pain in the abdomen set up, and she died before I could see her, probably from rupture of an abscess into the peritoneal cavity. For several days before this there had been an increase of swelling and pain, but this was not reported to me until after her death. I report this case not because there is anything unusual about it, but to get the opinion of those whose experience has been greater than mine in the operative treatment of hepatic abscess. All the text-books to which I have access advise aspiration, unless there is clear evidence that the liver is adherent to the abdominal wall. Wyeth says:
In the choice of methods the character of the abscess must determine the employment of the aspirator or drainage by incision. Aspiration is advisable when the abscess is deeply located, and especially so when strong inflammatory adhesions have not been formed between the walls of the abscess and the abdominal or thoracic parieties." "When, after repeated use of the aspirator, a cure is not effected, and when the tissues between the most superficial portion of the abscess and the integument have become so solidified by adhesions that infiltration of pus cannot occur, the abscess should be opened by direct incision, its contents allowed to escape, the sac thoroughly irrigated with i to 5,000 sublimate, and a drainage-tube inserted. If, after cutting down to the walls of the abscess, it is discovered that adhesions have not occurred, the sac should not be opened. The wound should be packed with sublimate gauze, and in four or five days, after adhesions have been established, it may be incised."
Abscess of Liver.—Shuttee.
The Medical News of October 29, 1889, says:
The ideas of surgeons have, in the last few years, become fairly crystallized in regard to the treatment of abscess affecting the liver. Although a great variety of measures for relief are to be found in the standard text-books, the writings of more modern investigators point to the earliest posssble incision as being, beyond all others, the most successful treatment.” Where typical signs are present, or where there is suspicion that liver abscess has formed or is forming, the surgeon should at once perform an exploratory laparotomy; if swelling is present, the incision should be made over its most prominent part. If this important guide is absent, the incision should begin at the costo-chondral articulation of the tenth rib, and be carried directly downward in the long axis of the body. If the surgeon fears that his antiseptic precautions or his manual skill are not sufficient to prevent the entrance of microorganisms or blood into the peritoneal cavity, he can satisfactorily explore the liver surface by Bradenheuer's or the so-called peritoneal incision—that is, the knife may be carried down to, but not through, the peritoneum. The latter may be stripped from the parietes, and the fingers may be carried over nearly the entire surface of the liver, with the interposition of only a thin membrane. In this way swellings, irregularities of surface or fluctuation can be readily discovered.
" If adhesions have not formed between the liver and peritoneum, the surgeon should suture these two surfaces together, and then, having so placed his thread that the peritoneal cavity is absolutely protected against the entrance of pus, should freely incise the abscess cavity, and should make ample provision for drainage.
“At the time of the operation the surgeon should carefully explore for secondary abscesses, and, if found, should, by means of his finger or the end of a blunt instrument, break through the wall separating them from the major cavity.
“There have been many cases successfully treated by means of aspiration, but both statistics and anatomical reasoning would strongly indicate exploratory laparotomy. We can never be sure, unless superficial signs of inflammation are present, that the liver is adherent to the parietes. Any puncture into the organ would, if such adhesions had not taken place, expose the prtient to the risks of septic peritonitis. Thor- . ough evacuation, either through the canula or aspirating needle, is absolutely impossible, and the surgeon is left in ignorance as to the existence or non-existence of more than a single abscess.”
Now this is doubtless good practice for hospital surgeons, but for the country surgeon, who is probably not possessed of the maximum operative dexterity, and who often is altogether unable to control the surroundings of his patient, it is, in my opinion, not justifiable; and I submit that, for him, the operative treatment of hepatic abscess must continue to be aspiration in the early stage, and later, when adhesions be
tween the liver and mural peritoneum are sufficiently firm to insure against the entrance of pus into the abdominal cavity, incision and drainage.
It seems to me that the dangers incident to aspiration, above quoted, are overdrawn; and that where there is considerable liver substance intervening between the abscess and the surface of the organ, as there must be where the abscess is deeply seated, and in all cases before it has approached sufficiently near the surface to set up peritonitis, the use of a small aspirating needle would be almost, if not quite, absolutely safe.
In regard to the early diagnosis of adhesions, I cannot refrain from quoting from an article by Dr. Deaver in the Medical News of February 12, 1890, which, if true, will enable a surgeon to incise a liver abscess several days sooner than has heretofore been considered safe.
* Accompanying the pains of peritonitis, there is tenderness on pressure over the seat of the pain, usually very extreme, but perhaps over an area so small that it may be covered with the end of a finger. As the swelling of the underlying organ increases, the area of contact between it and the abdominal wall extends, and the inflammation of the parietal peritoneum, being dependent upon contact of the opposing surfaces, spreads accordingly. The portion of the peritoneum which is first inflamed becomes adherent to the opposite surface first, and as soon as the adhesion is firm enough to prevent movement and friction, the extreme pain and tenderness over its extent, be it ever so small, disappears.
“If the inflammation continues and extends after a point of adhesion has formed, the area of tenderness will move with it; and if it spreads in all directions the tender area will become ring-shaped. As the inflammation advances, the ring becomes larger, all the time preserving the excessive tenderness to pressure, which is characteristic to inflamed peritoneum ; and the central area under which adhesions have formed, and which consequently has lost its tenderness, increases in size correspondingly."
When the central area has lost its tenderness, he says that the adhesions are sufficiently, firm to make a free incision perfectly safe, and that it is altogether unnecessary to wait for the classical signs of adhesions, such as sub-cutaneous ædema and swelling, fluctuation and inflammation of the skin.
BLINDNESS FROM QUININE, OR QUINININE AMAUROSIS.*
BY FLAVEL B. TIFFANY. M. D., KANSAS CITY, MO. Professor of Ophthalmology, Otology, Histology and Microscopy in the University Medical College of Kansas City, Mo.; Oculist and Aurist to the All Saints Hospital, Gervian Hos
pital, Missouri. Pacific Railroad Hospital, the East Side Free Dispensary, etc.
February 18, 1890, I was called to see U. S. Commissioner W'm. 1'. Rend before the Missouri State Medical Association, May 18. 1890.
Quinine Amaurosis.— Tiffany.
Childs, who, the brother said, had gone blind the night previous. On my reaching the residence of the patient I obtained the following history:
Mr. Childs is a lawyer by profession; is 34 years of age and in usual health, excepting that for a few weeks previous he had been a little indisposed from a slight attack of la grippe. He is a man of good habits, uses a slight amount of tobacco, not more than three cigars, on an average, per day. Does not use alcoholic liquors as a beverage. He had been in the habit of taking quinine, but only in small doses, as he had always noticed that even in small doses the effect was invariably prompt and marked, producing ringing in the ears and dizziness. February 17, 1890, he got the following prescription from Dr. W.:
Misce, et ft. capsul. No. viij. Sig.: Two capsules
every three hours. H. B. W." He says that he took one capsule at 8 P. M., the evening of the 17th, two at 11 P. M., one at i A. M., and two more at 4 A. M. “ After taking the sixth," he said, “ I looked at my watch, and it was then 4:30.
I noticed nothing wrong with my sight, could see as well as ever I could : I felt sleepy, lay back, went to sleep and slept until morning. When I awoke I found it was very dark-I couldn't see a thing. I then found my way to the window, opened the window-blinds, and found that I was totally blind. I groped my way to my brother's room where I found it was 8:30, a bright morning; but I was unable to distinguish day from night, all was inky blackness; and only a few hours since I could see perfectly well, and now at this hour (10:30, A. M.) I can only see a halo of light, with a spot in the center which appears bright and the size of a silver dime."
Examination revealed pupils dilated ad maximum, not responsive to the stimulus of light; and total blindness, he not being able to recognize even a pencil of light when flashed upon the eyes by the ophthalmoscope. The optic nerve and retina were blanched and anæmic. The optic nerve appeared swollen and partially atrophied. My diagnosis was quinine amaurosis. I ordered an aperient of mineral water to be taken immediately, and to be followed in the evening by a hydrogogue cathartic, and a 12 per cent. solution of eserine dropped into the eyes every four hours.
The following evening I found the pupils contracted to a pin's point, but not a particle of vision in either eye. The patient was allowed a bandage over the eyes, as he said they felt better bandaged. The following morning I began the use of sulphuric ether by inhalations, and kept the patient in a recumbent position. The pupils now were about the normal size, but did not respond to the stimulus of light, and the tension still above the normal. I ordered the eserine to be used twice a day, and the patient to scrupulously keep the recumbent position. The following day (February 20 ) I telegraphed to Dr. John Green, of St.