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the occurrence of any fall or hurt, diarrhea, dysentery, or any other trouble, preceding or following the appearance of the swelling, which, according to her account, had been progressing for nine or ten months. An examination revealed a tense, elastic tumor in the epigastric region, which, judging from its situation, probably occupied the left lobe of the liver. The child cried so violently on our approaching or touching the tumor, that it was necessary to use ether in order to make an examination and an exploratory aspiration. Not having time on that day, I postponed this, owing to absence from the city, until June. In the mean time, Dr. W. T. Bull had also seen the child, and, at his request, it went to the New York Hospital, where I saw it with him at the time of the operation.
An exploratory aspiration revealed pus. The examination was followed by a free incision, the introduction of a drainage-tube, and washing out with bichloride solution, 1 to 5,000. The left lobe of the liver was found adherent to the anterior abdominal wall, and nearly a quart of pus was evacuated.
Dr. Bull informed me that the child subsequently made a good recovery.
In this case, from the history given by the mother, from the age of the child, and the presence of a slowly growing tumor markedly elastic to the feel, I had supposed it more likely to be an hydatid sac, although, as you all probably know, hydatids are extremely infrequent in this country, and they occur, almost if not quite exclusively, in those who have at some time lived abroad or are immigrants. I had, however, qualified this possibility by insisting on the necessity of an exploratory aspiration for diagnostic purposes.
Such a case is a very good illustration of an idiopathic abscess of the liver. The fact that the mother denied the occurrence of a fall or injury does not render it impossible that the child may have had one.
CASE III.—This case occurred in Bellevue Hospital, last August, while I was visiting for Dr. Smith during that month.
J. G., aged thirty-two, born in the United States, was admitted to the hospital, August 7, 1884. The patient said that, with the exception of an attack of Bright's disease, nine years ago, he had
been well up to the time of his present illness, three weeks before admission. He was then taken with severe pain in his left side, which was intensified by any movement of the body. His bowels had been regular, and his appetite good, but he had gradually been losing in flesh and strength. He denied having at any time had chilly sensations or a feeling of fever.
On admission, the patient was found weak and anæmic, complaining only of pain over his left side. An examination revealed the presence of a tumor in the median line, occupying the epigastric region. This tumor did not move with respiration. It was elastic to the touch, and, judging from its position, was situated in the left lobe of the liver, which, from its not moving with respiration, was probably adherent to the anterior abdominal wall. Moreover, there were no friction-sounds over it. The diagnosis was a probable abscess of the left lobe of the liver. The patient had, in addition, a faint presystolic mitral murmur, with slight enlargement of the heart. The urine contained a small quantity of albumen, but otherwise it was normal.
On the following day, a free incision was made into the abscess, under ether, and a large quantity of pus was evacuated. The abscess-cavity was washed out with bichloride solution, 1 to 5,000, a drainage-tube was introduced, and the wound was dressed antiseptically. An exploration at the time of the operation showed the abscess to be in the left lobe of the liver. After this, the cavity was washed out with a bichloride solution, 1 to 2,000. It discharged very little and was neither tender nor painful. On the 25th of August, the cavity was closed by healthy granulations, the patient having in the mean time gained in flesh and strength. He was discharged on October 3d, having made a good recovery.
Case IV.–This patient occupied a bed in the ward with Case III. He had been admitted and operated upon while Dr. Smith was attending to his service, but he passed under my supervision and observation during August.
C. B., aged thirty-five, porter, was admitted to Bellevue Hos. pital, July 23, 1884. With the exception of a stricture, he had been well until two months before admission, when he had intermittent fever for nine days. After this, he was well until five weeks before admission, when he had severe pain in his left side, which had continued without intermission.
Nine days before admission, he noticed a small lump just over the ensiform cartilage, wbich had gradually increased in size and was tender on pressure, but not otherwise painful. This, after a few days' stay in the hospital, was incised, washed with a carbolic-acid solution, dressed antiseptically, and allowed to discharge through a drainage-tube. Suffice it to say that the patient made a good recovery. This case properly belongs to Dr. Smith, and I am content to report it thus briefly.
CASE V.-Mr. O., a resident of Brooklyn, called at my ofice with his physician, Dr. Peer, on Monday, October 27, 1884. He was forty-three years of age, and had been well, with the exception of his present disease. He was a man of good habits. At this time, he denied that he had suffered any injury or strain at the beginning of his trouble ; but later, on inquiry from his wife, the following history was obtained :
In December, 1881, having a gun in his left hand, he ran to catch a car, and seized it expecting it to stop ; but in this effort, he received a severe wrench in his right shoulder and was dragged for some distance without losing his feet. He was laid up by the sprain of his shoulder, and, while under treatment for this, began to have pain in his right side over the region of the liver, which was accompanied with marked enlargement. At this time he lost flesh and strength and had some fever. He made a journey to Cuba, and returned without improvement, but shortly afterward suddenly began to improve after taking taraxacum, and apparently recovered completely. During this time, he lost thirty pounds in weight. About a year and a half later, he had an attack of . pain over the liver, with some swelling, lasting for three weeks, and he again improved. The attack for which I saw him began in August, and it came on after running to the cars while in the country for the summer. He had been driving, and the breaking of an axle threw the other occupants out of the vehicle, while be remained seated. Ile says that he experienced no jar, and that his run afterward to the train involved no great effort.
He was soon affected with enlargement of the liver, pain in his right side, a slight evening-rise of temperature, and a gradual failure in flesh and strength. His weight had decreased twentyfive pounds at the time of his visit to me.
For a short time before this, he had suffered intense pain over the
liver and in his right shoulder. At the time of his visit, the most notable symptoms were the hepatic tenderness and enlargement. The enlargement was such that the line of hepatic flatness was increased in an upward direction for an inch and a half, and downward for two inches. The diagnosis was abscess of the right lobe of the liver in the convexity of the diaphragm, which seemed, in view of the severe pain, to be producing perihepatitis. Neither fluctuation nor any evidence by which the abscess could be located absolutely was obtained. A blister over the right side was advised, a careful record of temperature was made, and Warburg's tincture was used for the fever.
The pain disappeared very soon after the application of the blister. The evening-temperature rose to 102° Fahr. After three days, a cough occurred, accompanied with slight expectoration, and followed, on the sixth day, by a more severe cough and an expectoration which amounted to a chamberful in twenty-four hours.
The expectoration was of a brownish color, thick, and somewhat tenacious. Under the microscope, it showed fatty pus-cells, granular matter, and blood-globules, but no distinct evidence of bile-pigment. A physical examination, made on the 3d of November at his house, showed marked dullness over the greater part of the lower lobe of the right lung, feeble respiratory murmur over this area, attended with numerous coarse, moist râles, with normal respiratory murmur and absence of râles over the rest of the right and over the left lung. Moreover, his respiration was not markedly hurried, and the area of hepatic flatness had considerably decreased since my former examination. In view of the quantity of the discharge, the slight effect upon the lungs, the improvement in his general condition, and the diminished size of the liver, it was decided that it would be wiser to wait for a few days than to explore the liver with a view of removing the pus by aspiration. On Tuesday, November 4th, two days after the marked discharge from his lungs, he had colicky pains in the abdomen, followed by several movements and a discharge of pus with blood in clots. On the next day, his bowels were quiet ; but on the 6th he again had smaller passages, accompanied with some blood. A re-examination on this day showed that the respiratory murmur had returned over the right lower lobe, that the râles had disappeared, and that, beyond a diminished resonance over this portion, there was nothing to indicate that the abscess had discharged through the lung. The area of hepatic flatness had still further decreased, the temperature was normal, and the patient felt himself markedly improved. The treatment adopted was symptomatic and supporting from the time of his first visit. I have heard that he is progressing favorably, although I bave not seen him since.
This case illustrates the advantage of a counter-opening. A careful review of the case makes it seem probable to me that he had an abscess of the liver during the time of his first illness, two years and eight months before the discharge spoken of above ; that this became latent, and that in his efforts, without his knowledge, when the axle broke, or during the subsequent running, he received injury sufficient to revive the former trouble, possibly around the wall of an old abscess.
Since writing the above, a second discharge has occurred through the lung, and at this time the discharge by the bowels ceased. The patient's general health has improved.
CASE VI.-W. R., male, aged twenty-two years, was admitted to Mount Sinai Hospital, March 8, 1884. His past record was of no importance, and there was nothing marked about his family history. His illness began, three months before admission to the hospital, with chills, repeated every afternoon, lasting a quarter of an hour, and not followed by perceptible fever but by sweating during the night. These continued until three weeks before his admission, since which time the chills had ceased, but the sweating at night continued. He had suffered severe pain in the left hypochondriac region and across the back, which came and went. He had lost flesh, strength, and color. Two weeks before entering the hospital, he had lost some blood at stool. He had been up and about until two weeks before admission, and his bowels had been regular until three days before, since which time he stated that he had three or four thin stools daily. On admission, he was emaciated, pale, of a sallow complexion, having loose movements from the bowels, and complaining of pain in the back and in the left hypochondriac region. His pulse was feeble and frequent. After a short stay in the hospital, he was found to have a psoas abscess on the left side, and at different times friction-sounds were heard over the lower part of each lung.
The peculiar points in his history were the following : Three