BRANCH SEAMEN'S HOSPITAL, ROYAL ALBERT DOCK.

30 character of the rash, I am inclined to believe that the case was one of abortive hEemorrhagic small-pox, the modification being due possibly to the primary vaccination. I shall be glad to know whether this condition is recognised, and if similar cases are recorded. Liverpool.

OF

HOSPITAL

PRACTICE,

BRITISH AND FOREIGN. Nulla autem est alia pro oerto noscendi via, nisi quamplurimas et morborum et dissectionum historias, turn aliorum turn proprias collectu De Sed. et Caua. Morb., habere, et inter se comparare.—Mon&AaNl Ub. iv. Proaerniurn. -

SEAMEN’S

HOSPITAL,

TWO CASES OF HEPATIC

GREENWICH.

regained their normal colour.

Eleven days after admission Mr. Johnson Smith resected two inches of the eighth rib immediately in front of the anterior axillary line. The layers of the pleura were not adherent, and as the pUH showed the presence of septic organisms, in addition to being offensive, these were stitched together to shut off the pleural cavity. Three days later an incision was made into the liver, and a considerable quantity (about one pint) of blood-stained pus was evacuated ; it had a slightly fsecul odour and was streaked with blood and bile. Repeated examinations failed to reveal any amoebas. The abscess cavity was a large one and had a ragged wall. The cavity was washed out once daily with a 1 in 60 carbolic solution and very rapidly closed. In two days the temperature became normal. A fortnight after the operation an alarming gush of blood from the interior of the cavity occurred while the wound was being syringed, but the haemorrhage was soon controlled by plugging with gauze. With this exception convalescence was uninterrupted, and the patient was dig.. charged recovered. CASE 2.-A man aged thirty-four was admitted to the Sea, men’s Hospital, Greenwich, on Oct. 21st, 1895. There was a slight family history of phthisis. He had had malaria and syphilis, but otherwise he had always been strong and healthy. There was a very inconclusive history of diarrhoea. The patient first noticed pain in his stomach one month before admission, while sailing home from Odessa ; the pain was of a sharp, shooting character, radiating between the shoulders, and was so severe as to prevent him from sleeping at night. He first observed a swelling over the stomach seventeen days before admission, and it had slowly increased in size. No history of colic or of jaundice was elicited. The bowels were very constipated. He had lost 2 st. in weight during the previous two months. On his admission the abdomen was found to be rather distended, particularly at its upper part. There was no oedema, and no enlarged veins were visible. There was a globular swelling lying very nearly in the middle line, immediately below the ensiform cartilage, its lower border being at the level of the umbilicus. Laterally the swelling approached close to the costal margin on each side, but especially to the right; but even here a finger could be laid between the margin of the swelling and the edge of the ribs when a deep inspiration was taken. The swelling measured eleven inches and a half transversely and six inches and a half from above downwards. It did not move perceptibly on respiration. It was rather fixed, and its right border either was connected with, or was in very close proximity to, the liver. There was no connexion with the right kidney. In consistence the mass was tense and elastic, fluctuation was obtainable, and the percussion note was dull. There was no fluid thrill, and there was no reddening of the skin. The liver dulness began at the sixth rib in the nipple line, and at the eighth rib in the mid-axillary line, and was continuous with that obtained over the swelling. The edge could not be felt in the axillary region, while anteriorly to this the swelling interfered with accurate palpation. There was no enlargement of the spleen. The bowels were constipated. The urine, which was normal in quantity and of specific gravity 1008, contained not albumin or sugar and no pus or blood. The patient’s appetite was fair, but he was slightly emaciated. In regard to the lungs nothing abnormal could be detected save a little emphysema. As for the heart the area of dulness was obliterated, the apex was normally placed, and the sounds The patient had an anmmic, sallow comwere healthy. plexion and an anxious expression. There was no cedema, nor were there any obvious nervous symptoms. Three days after admission Mr. Johnson Smith incised the abdominal swelling, and a large quantity of pus escaped; the pus was of a dark-red colour, containing abundant pus and blood cells, but no amcebas were found. The temperature, which had previously been slightly raised, fell to normal after the operation, and the patient made an uninterrupted recovery.

ABSCESS ; OPERATION ; RECOVERY. of Dr. J. ANDERSON and Mr. W. (Under JOHNSON SMITH.) THHSE cases are examples of some of the methods of treating hepatic abscess at the present day. The larger number of cases of this disease are met with at hospitals such as the Seamen’s, which collect patients chiefly from foreign parts. Sometimes, however, a case of acute abscess with dysentery may be admitted into a general hospital in the summer time, although the patient has never visited the tropics. Two methods of treatment are shown, both of which proved successful: (1) free incision in Case 2, where the structures overlying the liver were adherent from extension of the inflammation to the abdominal parietes; and (2) operation in two stages across the pleural cavity in Case 1-viz., resection of rib and suture of the healthy layers of the pleura to each other in the first stage, and then, three days later, incision through the diaphragm into the abscess, with drainage. For the notes of these two cases we are indebted to Dr. C. W. Windsor. CASE l.-A native of Zanzibar aged twenty-seven years was admitted to the Seamen’s Hospital, Greenwich, on Aug. 17th, 1895. He complained of pain in the right side of the abdomen and chest, from which he had suffered for one month. Four months before admission he had an attack of diarrhoea lasting one month, with very frequent small stools containing a good deal of mucus, but no blood. For three weeks previously to admission he bad a similar attack of diarrhoea and tenesmus, but no blood was passed. He had never had malaria. He had not suffered from vomiting or jaundice, but he had lost flesh during the previous few months. On admission he was found to be a fairly nourished man suffering from pain in the right side. The abdomen was not distended ; there was no marked prominence, oedema, or obliteration of the intercostal spaces. The liver dulness began at the sixth rib in the nipple line, at the eighth rib in the mid-axillary line, and at the ninth rib in the scapular line; it was continued downwards two inches below the costal margin. The edge of the liver could be felt mid-way between the costal margin and the umbilicus. Considerable tenderness was felt over the hepatic area, especially just below the ribs. The spleen was enlarged ; its edge could be felt below the border of the ribs. Nothing else abnormal was detected in the abdomen. The patient had slight diarrhcea ; the bowels were opened four times in the first twenty-four hours, the stools being clay-coloured, but The urine was of specific without blood or mucus. gravity 1026 and contained no albumin or sugar, but a quantity of bile pigment. The temperature was high and remittent, reaching 103° F. The lungs were clear, except at the right base behind, where there was some impairment of resonance; slight feebleness of the breath sounds was noted, and vocal resonance and vocal fremitus were diminished. No adventitious sounds were audible. There was no differBRANCH SEAMEN’S HOSPITAL, ROYAL ence in the measurements of the two sides of the chest. The ALBERT DOCK. heart was normal. No nervous symptoms were observed. Two days after admission an exploring needle was inserted TWO CASES OF HEPATIC ABSCESS; OPERATION; RECOVERY. into the liver directly backwards through the eighth the care of Dr. PATRICK MANSON and Mr. W. intercostal space ; a small quantity of dark-red, rather (Under JOHNSON SMITH.) offensive pus was withdrawn, showing under the microscope readers in the account of two cases our Wn before bring abundant blood and pus cells, degenerated liver tissue, and treated at the Seamen’s numerous streptococci, but no amoeba coli was seen. Hospital two methods of operation In a few days the urine became free from bile, and the stools The abscess. hepatic following cases present two other the

care

for

31

methods, which were also followed by recovery of the patients. The first of these patients was operated on by Dr. Manson’s method, the insertion of a drainage-tube through a largesized cannula after tapping the abscess. In the second case peritoneal adhesions did not cover the whole surface of the abscess, and the incision opened the peritoneal cavity in the lower part. Hence special precautions were required, which

drainage-tube were then inserted, and the opening was carefully packed round. Sutures were inserted into tt e peritoneum, and the lower part of the wound was closed. The upper part through the swelling looked so unhealthy that it was considered advisable to pack it with

On the 30th the temperature rose to. iodoform gauze. 99 8° F., but fell again after dressing. It rose again on the For the notes 31st, but from that date continued normal. On Sept. 13th are described in the account of the case. of Case 1 we are indebted to Dr. J. Rust, senior resident there was no discharge, and the drainage-tube was removed. This was followed by no rise of temperature. On the 21st the medical officer. CASE l.-A man aged twenty-six years, a native of patient, who had been steadily gaining flesh after the operaBombay, was admitted to the hospital on April 29th, 1895. He tion, was transferred as a convalescent to Greenwich. The had been ill for fifteen or sixteen days, suffering from diarrhoea, wound had almost, but not quite, granulated over. He was and the motions sometimes contained blood. He complained discharged recovered from Greenwich on Oct. 2nd. of pain in the right hypochondrium and in the right shoulder. After admission the bowels were opened three times in twelve hours ; the motions were dysenteric. Amoebae coli BRISTOL ROYAL INFIRMARY. were present in the faaces. The liver was extremely tender RESECTION OF INTESTINE FOR TUMOUR WITH INTUSSUSon pressure on the epigastrium and also posteriorly, but the CEPTION BY MEANS OF MURPHY’S BUTTON. liver dulness was not increased in the epigastrium or right nipple line. Posteriorly, however, a dull percussion note (Under the care of Mr. J. GRETG SMITH.) was obtained from the angle of the right scapula downwards. SIMPLE tumours of the bowel very rarely cause intestinal Over the dull area the breath sounds were very distant, and vocal resonance was diminished. The spleen was not enlarged. obstruction, either as a primary result of their presence or "Tubular The urine was normal. The other organs were likewise secondarily to an induced intussusception. normal. An attack of bronchitis continued from May 2nd till adenomata and papillomata are the most common simple the 10th. On that date there was a distinct bulging over the tumours of the intestines, but if we exclude those growing liver, this organ being enlarged in the epigastrium and in the rectum they are extremely rare. Fibromata, extending two inches below the costal margin in the right springing from the submucous tissue, fibro-myomata, liponipple line. The patient had no rigors or night sweats. On mata, and angeiomata have also been described, but they are the 13th an aspirating needle, introduced in the eighth intermerely pathological curiosities."1 This is one of those cases space in the right anterior axillary line, withdrew one ounce of resection in which the rapidity of operation bears such an of liver pus. This pus did not contain amoeba?. On the 16th important influence on the result, and there can be little part of the seventh right rib between the nipple and anterior doubt that the use of the Murphy button helped greatly in axillary lines was excised. A trocar was pushed into theI the success, the account of which we are pleased to place abscess, and a large drainage-tube was inserted into it. About ’i before our readers. The case is worthy of record from the eighteen ounces of liver pus escaped. On the 23rd there was z, interest of the pathological condition and the gratifying considerable retention of pus; a longer drainage-tube was ’, of the patient after operation. For the notes of the inserted. On June lst there had been a slight rise of tempera- I progress case we are indebted to Mr. T. Carwardine, house surgeon. ture during the previous two days. Amoebae coli were found I An emaciated woman aged thirty-one years was admitted in the discharge from the liver. The dysentery continued. to the Bristol Royal Infirmary on Oct. 30th last under the On the 25th the diarrhoea had ceased. On July 15th the care of Mr. Smith. She complained of sickness and conGreig discharge had gradually diminished in amount ; it still con- stipation, together with severe griping pains in the abdomen. tained amoebse. The patient had gained flesh considerably. She was very collapsed ; the eyes were dull, the tongue was On Aug. 23rd the sinus was washed out with a solution of and furred, and she lay on her side vomiting repeatedly, dry sulphate of quinine (1 in 1000). The sinus was four and a whilst every few minutes she moaned on account of abdominal half inches long. On Sept. 10th the drainage-tube was The abdomen was tense, distended, and tympanitic, removed, and the sinus was washed out with a solution of pain. with prominent umbilicus. Palpation brought on visible zinc chloride. On the 17th the opening had closed, and on by pain, large distended coils of gut the 20th the patient was well. He was transferred to the peristalsis accompaniedacross the lower part of the abdomen. transversely appearing Seamen’s Hospital, Greenwich, for a few days, and was dis- The wave passed from left to right, peristaltic gurgling there on the 24th. charged recovered from to cease at the right iliac fossa, where a tender CASE 2 (under the care of Dr. Tom R. Taylor, whilst appearing intra -abdominal mass could be felt. Constipation was acting as visiting surgeon to the hospital in the autumn of absolute and enemata were of no avail. She passed no

1895).-A native of Bombay was admitted to the hospital blood or mucus per anum, and her urine, though small in Aug. 28th, 1895. He had been suffering from loss quantity, was normal in reaction. She stated that two years. of flesh and general malaise for eight months. His she had had severe bearing-down pains in the illness began with pain in the sixth right interspace. previously lower part of the abdomen, which usually began in the night, There was no history of dysentery. Upon examination lasted for about twenty-four hours, and recurred about once the chest was found to be normal. Liver dulness a each attack being associated with sickness. Laterfortnight, extended from the fifth rib in the middle line, the fifth the attacks became more and severe, and during rib in the axilla, and the eighth rib behind down to the last midsummer she had frequent herself under medical care placed costal margin. Towards the middle line it extended down for some ten weeks, from which she derived temporary to a rounded tumour situated in the epigastrium. The benefit. At the end of September she became worse; the swelling reached down to about two inches above the pains increased in severity and recurred every two umbilicus and was so situated that two and a half inches or three minutes, and she needed an enema every day. of its transverse diameter lay on the right and one and a half The pains were always accompanied by nausea and usually inches on the left of the middle line. It was elastic and by vomiting. There was nothing striking in her family or painful on pressure, and the skin over it was thin and dis- previous history, except that as a girl she was subject coloured. On Aug. 29th the following operation was performed. to constipation and often went a week without defecating. A vertical incision was made over the centre of the tumour, On admission to the infirmary, brandy and gastric sedatives which was exceedingly tough and made up of indurated and were given and the vomiting became less, but collapse infiltrated muscular tissue. The lower part of the wound increased for a time, and it was feared that she opened up the peritoneal cavity. This opening was carefully would not alarmingly be able to undergo an operation. On Nov. 1st she packed with a carbolic compress. Upon digital examination had rallied somewhat, and the operatk n was performed under a sinus was found reaching down into a large cavity in the minutes’ anaesthesia with chloroform. The abdominal liver. Upon dilatation there was a gush of grumous pus. forty was entered by an incision on the right side, starting cavity On the left side the liver was firmly adherent, but it was the anterior superior iliac spine and following the above found necessary to attach the right side of the opening into direction of the fibres of the external oblique muscle the liver to the edge of the parietal wound by a suture. The and backwards for three inches. An intussuscepupwards pus evacuated amounted to about twenty ounces and came tion of the small into the large bowel was at once discoveied away very freely. After evacuation the cavity was wiped The intussusception formed a mass about as large as t] e: No oat with a carbolic plug on a long sponge-holder. 1 Erichsen: Science and Art of Surgery, vol. i., 1895, p. 904. washing out was attempted. Eight inches of a large sized on