No. 3099.

JANUARY 20, 1883.

Clinical LectureON A

CASE OF TROPICAL ABSCESS OF THE LIVER.Delivered at the Middlesex Hospital,

BY J. KINGSTON FOWLER, B.A., M.B.,ASSISTANT-PHYSICIAN AND PATHOLOGIST TO THE HOSPITAL, AND

ASSISTANT-PHYSICIAN TO THE BROMPTON HOSPITALFOR CONSUMPTION.

GENTLEMEN,-The patient whose case will form the sub-ject of my remarks, and whom I shall presently show to you,is a man aged twenty-seven, well built, of good musculardevelopment, and by occupation a navvy. He was admittedinto the hospital on April llth, 1882, complaining of coughand pain in the right side; he came under my care about aweek later. He gave the following account of himself : Hehad enjoyed good health up to four years ago, when he waslaid up for six weeks with an attack of acute rheumatism

affecting the ankle, knee, and hip joints; since then, withthe exception of an occasional cold and cough, he has re-mained well. He stated distinctly on several occasions, inreply to questions, that he had never been out of England ;and it was not until we had been obliged to take the firstimportant step in treatment that we discovered that he hadenlisted in a cavalry regiment in 1869, and in February, 1870,had been sent to India. For the first year he was stationedat Bangalore, in the Madras Presidency, and whilst therewas quite well. The regiment was then moved to Secunde-rabad, and remained there five years, during which time hewas twice in hospital: in 1873 for six weeks with Indian

fever, the principal symptoms being fever, vertigo, weakness,and loss of weight; in 1874 for ten weeks with fever andpain in the right shoulder and hypochondrium. He remem-bers that on one occasion during this attack his temperaturerose to 106° F., but he had no diarrhoea, dysentery, or jaun-dice. There can, I think, be little doubt that this secondattack was one of acute hepatitis. After recovery he re-turned to duty, and remained two years longer in India.He left the army in 1877, and has since worked as a

navvy.We now come to his present illness. On April 2nd, whilst

working on a "night shift" in a tunnel, he felt sick andgiddy and shivered. He went to bed, but though wrappedin blankets the shivering continued more or less during thewhole of the following week. On April 6th sweating firstoccurred ; it was continuous, but most profuse during sleep.On the 9th he complained of pain of a sharp character,localised in the right loin and epigastrium. He vomit dseveral times, and suffered also -from cough, with expectora-tion of frothy, but not rusty, mucus. There was no pain inthe right shoulder, jaundice, or diarrhoea. On admission,the skin was of a saliow tint, and he was perspiring; thetongue wa coated and brown in the centre. Temperature101° F; pulse 84, soft and compressible. There was trouble-some cou9h; the expectoration frothy and of a slightlyyellow colour. On physical examination no adventitioussounds were heard in rhe 1’mgs. The cardiac apex was inthe normal position, and the sounds normal. The liver dul-ness was not increased, and the splenic dulness was normal.The urine deposited lithates on standing, and was free fromsugar and albumpn. On the following morning the

temperature was 103° F. He had passed a restless night,and had perspired profusely. On the 14th it was notedthat the breath sounds at the right base were weak,and accompan’ed on expiration by sibilant rhonchi. Thesesounds gave place soon after to fine crepitant rales. Thebowels were treely opened after taking five grains of calomel,the motion being of a dark-brown colour. For the next fewdays he rernained in much trze same condition. The tempe-rature fluctuated between 99° F. in the morning and 103 4°in the evening. The sweating was continuous and profuse,especially during s-leep. The cough was troublesome andexpectordti’m copious, but it was never rusty. At the rightbase, posteriorly, there was diminished vocal fremitus ; the

No. 3099. ’

percussion note was flat ; the breath sounds feeble, and somefine crepitant râles were hrard. The cardiac apex was notdisplaced. The pulse rose on the 19th to 120, and was softand dicrotic, and he was evidently losing strength rapidly.I was struck when I rust saw this patient with profuseperspiration, and remarked thd.t the case reminded me oftwo which I had seen at Adde[i bro4)ke’s Hospital, Cambridge,which proved to be cases of hepatic abscess. I have sincethen been strongly impressed with the fact that when obscuredisease-e.g., pleurisy with doubtfic pneunzonia-at the baseof the right lung is associated with pmjuse sweating, the

formation of an hepatic abscess should be suspected. OnApril 21st I carefully examined the liver, with the followingresult: the lower ribs on the right side were slightlybulged ; there was slight fulness and increased resistance inthe epigastrium and some terdernss on pressure there; theliver dulne’Js commenced at the fi’th rib, and measured sixinches in the right mammary line, and five inches and a half inthe mid-sternat line ; there was no hydatid thrill or fremitus ;the right rectus abdominis was tense. Dr. Cayley kindly sawthe case in consultation with me, and agreed that it was quitejustifiable to make an exploratory puncture into the liver.I therefore thrust an aspirator needle, oue-eighth of an inchin diameter, into the liver one inch below and the samedistance to the right of the tip of the ensiform cartilage, andwith the point at a depth of about two inches pus began toflow through the tube. After about an ounce had escapedthe tube became blocked, and as the object of the puncturehad been attained I withdrew the needle. The pus wasthick, curdy, blood-stained, and contained Folid flakes ; onmicroscopical examination no booklets of echinococci werefound. On the following morning, at my request, Mr.Andrew Clark plunged a large trocar into the same spotand drew off twelve ounces of pus having the same

characters as that previously obtained. The cannula wasallowed to remain in and a large poultice applied over it,some carbolic tow being placed immediately over the orifice.At 2 P.M. on the same day the temperature had fallen to 99°;but it rose again in the evening to 102’8°. On the 24th, he wasordered sulphate of atropia, Thth grain in pill every night,with the view of checking the sweating ; this it did veryeffectually for a time. For the next few da) s the tempe-rature ranged lower than before the operation ; there wasa free discharge of healthy pus from i he cannula; the abscesssac was washed out thuce daily with a 2 per cent. solutionof carbolic acid ; and be took ’h’ee-grain doses of quininethree times a day. On the 26th the cannula was removedand a drainage-tube insert-d. On the 29th the drainage-tube accidentally slipped out of its place, and could not bereinserted into the absce*s san; I found it lying in the sinus,and removed it altogether. Tne discharge still continued,but was not free. The range of temperature was between99° in the morning and 103° in the evening. For thenext fortnight he continued in much the same condition ; thetemperature maintained the hectic type; the sweating, thoughless profuse, was still continuous, and the discharge was notfree. The lower margin of the liver could now be felt twoinches below the ensiform cartilage, and it was clear thatpus had again accumulated and fhled the abscess sac. OnMay 14th I determined to tap the liver again, and plungedin a trocar, having a diameter of three-eihths of an inch,just above, and internal to, the first opening. Pus flowedfreely through the cannula, and in all rather more thantwenty ounces were withdrawn. It had not altered incharacter since the first tapping. Towards the end of theoperation, when it was thought that the greater part of thepus had bepn evacuated, he began to retch, probably as aresult of the ether he had ihald, and the compression ofthe liver between the abdomii-at muscles Mud the diaphragmforced out a large quantity of pus. Coughing and retchingare useful, though posi-ibly rather dangerous, aids to the

emptying of an hepatic abs,’e.s. Tie cannula was now with-drawn, and a laminaria tent inserted in order to dilate theopening. This was removed in four hours, and replaed bya drainage-tube. The effects of the second tapdng wereextremely favourable. The lower edge of the liver recpded aninch and a half. The temper.t’ure fell to the iormal at once,and for nearly three weks did not rise above 99°. Thetongue cleaned, the appetite improved rapidly, the sweatingalmost ceased, and there was a iiiodt-rate discharge ofhealthy puq. His progress towards convalescence, however,received a sudden check ; for during the night of June 3rd,whilst the dressings were being changed, the tu be was acci.dentally withdrawn, and was not at once replaced. This

90

unfortunate occurrence was immediately followed by a severe 1rigor, in which the temperature rose to 103’4°. He sweated pro- Ifusely, the tongue quickly became brown and dry, and when fI saw him in the afternoon his condition appeared extremelycritical. A long laminaria bougie was inserted and allowedto remain in three hours, and he was ordered quinine in Ififteen-grain doses three times a day. When the tent was Iwithdrawn the drainage-tube was replaced without difficulty, Iand, the discharge being re-established, all the bad symptomsat once disappeared. On the following day he was quite aswell as before, and the large doses of quinine were discon-tinued. Since then he has made steady progress towardsrecovery. On June 23th, the discharge having almostceased, I withdrew the tube, as the sinus was evidentlygranulating upwards, and the sac appeared to have becomeobliterated. It is quite possible that the tube might havebeen safely dispensed with earlier, but, warned by our pre-vious experience, I was anxious not to close the woundbefore it appeared certain that the abscess had healed. Thephysical signs noted at the right base gradually cleared up,and the lung symptoms ceased to give trouble after the firsttapping. The edge of the liver cannot now be felt beneaththe ribs, and the sinuses have completely closed. The dietat first was liquid, and suited to his feverish state, but assoon as the appetite returned I allowed him as liberal a dietas he desired.

I should like now to direct your attention to some of thechief points of interest in this case. First, as to its nature.It was soon clear that this was not an ordinary case ofpleurisy with effusion or an empyema depressing the liver.The normal position of the cardiac apex alone negatived suchan hypothesis. The physical signs, so far as the lung alonewas concered, were consistent with a rare form of inflamma-tion, of which some of you have lately seen an example, inwhich the bronchi, even the primary branches in the affectedarea, are filled with fibrinous coagula. This condition hasbeen named " massive pneumonia." This would not, how-ever, have accounted for the profuse sweating, a symptomalmost constantly met with in abscess of the liver, andwhich formed one of the most marked features in this case.I think there can be little doubt that we have been dealingwith a tropical abscess of the liver, the result of the attack ofhepatitis, from which the patient suffered whilst stationed atSecunderabad in 1874. It is quite possible that a small collec-tion of pus may have remained encysted in the liver during theeight years which have since elapsed, and during which ourpatient has enjoyed good health. From some cause, whichwe can only guess at, possibly a strain whilst at work, thesac may have ruptured and set up an acute inflammation inits neighbourhood. Or it may be that without actual pushaving been encysted there were residues of the old in-flammation lying quiescent in the liver, and around thesesuppuration occurred. Sir James Paget-has shown howthis may take place in other parts of the body, andDr. Murchison suggested this explanation of those cases

of hepatic abscess occasionally met with in persons longresident in this country who have suffered from hepatitis inthe tropics.Another point of interest is the prompt relief to all the

symptoms which followed on the evacuation of the pus, andcontinued so long as the discharge was free, notwithstandingthat a large portion of the liver must have been destroyed.In some other cases of the same kind which I have seenrecovery has taken place with equal rapidity when once afree exit has been given to the pus.The most common causes of hepatic abscess as it occurs in

this country are either pysemia or suppuration of an hydatidcyst. We may exclude the former, because the abscess waslarge and single, whereas pyaemic abscesses are usuallysmall and numerous, and almost invariably have a fataltermination. That we had not to deal with a suppuratinghydatid cyst is, I think, clear from the fact that frequentcareful examination of the pus failed to detect any booklets ’,of echinococci. You will have noticed that the patient isstated never to have had dysentery.The connexion between dystentery and tropical abscess is

a point which has been much discussed, and is still un-decided. Sir Joseph Fayrer, in common with many otherdistinguished Indian pathologists, holds the opinion that!"the two affections are independent though often coexistentand due to the same climatic causes; that hepatic abscessdoes occasionally result secondarily by absorption from the

1 THE LANCET, Jan. 1880, p. 674.

ulcerated bowel, and is then of the nature of pysemic sup.puration, in which case it is apt to be multiple and moreserious in character than ordinary tropical abscess." It is,I believe, now generally recommended that the single largeabscess, from whatever cause arising, should be opened asearly as possible; but considerable difference of opinion stillexists as to the best method of operating, whether by in.cision or with a trocar. If the abscess be distinctly pointing,it may be opened by incision, but even then I should preferto use a trocar, and if it is at all deeply seated, there aredecided advantages in adopting that course-viz. :

1. The risk from bsemorrage is much less; for when theliver is incised there is often a violent gush of blood. This,it is true, soon ceases ; but these patients are usually not ina condition to bear a loss of blood which a distinguishedsurgeon, Mr. Lister, describes as "alarming." "

2. There is less danger from septic absorption along thetrack of the wound, as the pus flows through a cannula ordrainage-tube.

3. As a trocar of any diameter may be used, the openinginto the sac may be of any size that is considered desirable.For an exploratory puncture I prefer one having a diameterof one-eighth of an inch; but if there is certain evidence ofthe presence of pus, it is very important to employ an instru-ment of at least three-eighths of an inch or half an inch indiameter. If a smaller one be used, it is liable to get blockedby the solid shreds of liver tissue which these abscesses sofrequently contain.The site to be chosen for the puncture must be determined

in each case by the physical signs, but it is better, if pos-sible, to avoid going between the ribs or cartilages, as thetrocar must then pierce the diaphragm, and may wound thepleura and lung; also if the cannula, or tube, be retainedfor a long time necrosis of the rib is very likely to occur. In

inserting the trocar it is desirable to follow the directions ofthe bulging-that is, if the abscess is pointing upwards, thetrocar should be directed from below upwards, and vicevers; thus as contraction usually takes place towards thecentre of the liver, the sac is brought as nearly as possiblebeneath the opening in the skin, pressure upon the tube isavoided, and drainage facilitated.

I did not in this case use the carbolic spray at the time ofthe operation, but by carefully washing out the sac withcarbolic lotion and surrounding the opening with carbolisedtow, the discharges throughout remained aseptic. As it isnot possible in the time at our disposal to discuss fully thewhole subject of the treatment of hepatic abscess, I havecontented myself with drawing your attention to those

points which appear to me of the greatest practical import-ance.

LATERAL CURVATURE OF THE SPINE.1

BY E. NOBLE SMITH, F.R.C.S. ED.,SENIOR SURGEON AND SURGEON TO THE ORTROYÆDIC DEPARTMENT OF

THE FARRINGDON DISPENSARY.

THE following paper contains a short account of the nature,causes, and treatment of lateral curvature of the spine. Fromthe great variety of views which have been expressed uponthis subject I have selected those which have seemed to mefrom observation and from practical experience to be mostworthy of acceptance. I believe that the views which I have

adopted cannot be considered in any sense extreme, andthat the plan of treatment which I shall describe is basedupon sound surgical principles, and is free from the objec-tions which have been justly raised against many othermethods.In lateral curvature of the spine there are usually two

curves, because when one is produced from some specialcause in one direction; another, as a rule, forms in theopposite direction to allow the equilibrium of the body to bemaintained. The manner of formation of the secondary orcompensatory curve is shown in the following diagrams,which represent a case in which obliquity of the pelvis actsas the cause of the primary curve.

Fig. 1 shows the position of the spine when the pelvis isoblique. Fig. 2 indicates the position the spine would assume(if the lumbar curve remained fixed) when the pelvis was

1 A paper read before the Harveian Society, January 4th, 1883.