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A CASE OF

ABSCESS OF THE LIVER; RECOVERY AFTERTHE ABSTRACTION, BY DIEULAFOY’S

ASPIRATOR, OF 106 OZ. OF PUS.WITH REMARKS ON THE EFFECTS OF THE DIRECT ABSTRAC-

TION OF BLOOD FROM THE LIVER BY THE SAME

INSTRUMENT.

BY PROFESSOR MACLEAN, C.B.

BERNARD P-, aged forty-one, private 107th Regiment,served in the German Legion at the Cape of Good Hope,and for fourteen years in India, at Kurrachee, PoonaDelhi, and Roorkee; unmarried. Was a labourer previousto enlistment. Always temperate, beer, not spirits, by hisown account, having been his only beverage in India. No

syphilitic history. Had, on the whole, good health in

India, having only been in hospital for a slight attack ofbronchitis, and one of ague. For three months in 1872 hewas in attendance on an officer labouring under phagedeniculceration and urinary extravasation. Patient attributeshis illness to the pestilential effluvia of the discharges towhich he was exposed during his attendance. He was firstattacked by diarrhoea; after suffering from this for ten orfourteen days, he reports that he,, fell down insensible,"and suffered from severe and constant vomiting, with occa-sional sharp shooting pains in his right side. After suffer-

ing more or less from the above symptoms, he began to passthe characteristic stools of dysentery, which yielded to treat-ment ; but he remained in hospital with hepatic symptoms,and was finally invalided home in January, 1873. On the

voyage home in H.M.S. Serapis he was occasionally undertreatment for dysenteric and hepatic symptoms, withoutany permanent improvement.

Condition on adinission at Netley on April 10th, 1873.-Much emaciated; chest-walls expand imperfectly; rightintercostal spaces are full and prominent, especially thelower ones. Heart displaced over to left side; soundsnormal. Pulse 110, feeble; respiration 22 or 24 per minute,Constant cough ; expectoration muco-purulent, scanty, andslightly offensive. Complains of chilliness in legs and ab-domen. Moist rales are heard over both lungs, especiallyin their upper portion. The right infra-clavicular region istender on percussion, flattened, and bronchial breathing,with increased resonance, are noticed. Tongue furred;breath offensive; bad taste in the mouth; no appetite, butmuch thirst. The whole region of the liver is visibly pro-minent and enlarged, and acutely tender. The dulness ex-tends far over into the left hypochondrium and down intothe right lumbar and umbilical regions, also encroaching agood deal upwards on the right lung. Gastralgia and con-stant acid eructations. Very weak and irritable; counte-nance sallow, presenting almost the aspect of the cachexiaof malignant disease, with an appearance of intense anxiety,almost amounting to horror. Hardly sleeps at all, beingharassed by cough, and a constant boring pain always inthe right and sometimes in the left shoulder.The case was diagnosed as one of abscess of the liver, and

the prognosis was unfavourable.On April 14th I saw the patient for the first time, and at

once made an exploratory puncture with one of the smallhollow needles of Dieulafoy’s aspirator near the tip of theeighth costal cartilage. This yielded about an ounce and ahalf of bloody fluid, but no pus. A second plunge of theneedle a little further from the middle line had no betterfortune, as the aspirator brought away only the same quan-tity of blood. Dr. Battersby, the gentleman in charge ofthe ward, who kept the above-quoted record of the case,noted that " the effect of this operation was very marked,giving the man great relief from the excruciating pain hewas in all the morning." Chloride of ammonium in fifteen-grain doses was ordered three times a day, with poulticesto the side, suitable support, and a sedative at night. Aboutan hour after the operation he,passed a semi-solid stool con-taining about two ounces of purulent matter. He perspiredexcessively during the day, and was very weak towardsevening.

April 15th.-Slept fairly; bowels opened three times, but

)o more pus was noticed in the evacuations; temperature)90; respiration 36, very shallow.l6th.-Prominence on right side very marked a couple of

.nchea posterior to last puncture. Into this I plunged a.

small trocar and canula, and the aspirator drew off twelveounces of rather fetid pus and some blood. As this wasdrawn off the canula could be moved freely in a large cavity.Great relief was afforded, but the patient was extremelyweak and his condition precarious. The cough continued’urgent and the sweating profuse, and he complained of painin both shoulders.On the 17th, towards evening, he became flushed and’

restless, his temperature rose from 99° to 999°, and thecough was very troublesome. He was ordered small dosesof solution of hydrochlorate of morphia, and milk with lime-water, iced ; claret was substituted for brandy.On the 18th he was in great pain and looked anxious and

ghastly ; his temperature had fallen more than 2° ; his

pulse and respiration were quickened. Much increase of

swelling was noticed, especially behind the last puncture,and the area of hepatic dulness was much increased; someflorid blood was coughed up before the morning visit. Dr.Fyffe at once introduced the largest trocar and canula be-longing to the aspirator into the most prominent part ofthe swelling, and drew off the enormous quantity of ninety-six ounces of pus, of a reddish-brown colour and creamyconsistence. Towards the close of the operation he becamevery weak, but the relief of all the most urgent symptomswas immense and immediate. A full dose of morphia wasgiven, and the patient passed a tranquil night.From this day, indeed from the hour of the last operation,

his recovery commenced, and his history was one of steadyimprovement; his cough subsided, his breathing became.tranquil, the sweats disappeared, his temperature becamenormal, his appetite returned, and he gained flesh with sur-prising quickness. So rapidly did the abscess contract thata needle passed near the last puncture some days after theoperation did not enter a cavity, but encountered only thesolid substance of the gland. After spending in all eightweeks in hospital the patient was found 11 fit for duty," anddischarged on June 6th, and, I regret to add, celebrated hisrestoration to health and freedom from hospital restraintby getting- drunk and spending the night in the guard-room.

This case presents some points of great practical interest.lst. The case was clearly of pyaemic origin, secondary todysentery. 2nd. As is usual in such cases, the foregoinghistory clearly establishes the fact that there were moreabscesses than one. Even if it be assumed that the puru-lent matter passed by stool was not of hepatic origin, it ishardly possible to believe that a cavity which was completelyemptied by the aspirator on the 16th could have filled tosuch a prodigious extent as by the 18th to contain ninety-six ounces of pus. It is more probable that between theabscess opened on the former date and that evacuated on thelast occasion there was a more or less thin wall of separa-tion, which, under the pressure of the larger abscess, hadgiven way, converting the two excavations into one. 3rd.The fall of temperature on the 18th (the date of the lastoperation), amounting to 2° F., was very remarkable, and atrue indication of the extreme depression and consequentperil of the patient; for, as I have had many opportunitiesof observing and recording, the thermometer rises a degreeor more when an abscess in the liver, which has beenemptied, fills again-thus giving a most reliable indicationof the fact, apart from all other signs. 4th. The rapiditywith which this great cavity closed, and never again filled,was most remarkable; and, as a consequence, the speedyamendment, convalescence, and final complete recovery of’the patient-an event, under the apparently hopeless cir-cumstances of the case, I did not for a moment anticipate.-5th. A most noteworthy point in this case was the reliefafforded by the abstraction of blood directly from the liver,by the aspirator, in my first search for the site of the ab-scess on the 14th. This was carefully noted by the youngmedical officer in charge, and was apparent to all who-

: watched the case. If this were a solitary example I would. not be disposed to dwell much on the fact. But on the

same day, in ward 27A of the medical division, I found a! soldier, private H- of the 109th Regt., just arrived from,

India, with all the symptoms of acute inflammation of the’ liver-enlargement of the gland (quite apparent to the eye-

40

and confirmed by palpation and percussion), a temperatureof 1014°, a pulse of 120, extreme hepatic tenderness, dorsaldecubitus, and a very anxious countenance. The symptomswere such as to warrant the suspicion that an abscess wasmaking its way to the surface. Without hesitation I plungedone of Dieulafoy’s perforated needles in succession into themost prominent parts of the liver, applying the aspirator.I failed to find an abscess, but brought away about fourounces of blood. The result was most striking. The pa-tient experienced immediate and marked relief; the tem-perature fell; the excessive swelling of the liver subsidedin a manner out of all proportion to the quantity of bloodextracted ; and, under the use of chloride of ammonium,the patient made a very good recovery. It cannot be saidthat the result was due to the operation of the medicinealone, as the relief experienced was gratefully acknowledgedat the time in the presence of the medical officers doingduty in my wards. In yet a third case-one of chronicdysentery, complicated with hepatic symptoms so acute asto lead me to suspect that pus had formed-I pursued thesame plan, not for the purpose of withdrawing blood, butin search of a supposed abscess, which was not found; butthe withdrawing of about the same quantity of blood bythe aspirator was, in like manner, followed by the imme-diate subsidence of the hepatic symptoms.Without wishing to draw large conclusions based on a

small number of cases, I think the facts given above arevery suggestive, and worth the consideration of those whohave to deal with acute inflammation of the liver in hotclimates, and who, like myself, know how futile it is to

expect much benefit from the abstraction of blood from theexternal tissues over the inflamed organ. I think it themore necessary to be explicit on the high opinion I enter-tain of the benefit likely to be derived from the use ofaspirators in the treatment of inflammation of the liver andits consequence, suppuration, because my name is oftenquoted as a determined opponent of " exploration" of theliver. And with justice; for so long as the operationwas performed in the unsurgical method, and with thecoarse and unsuitable instruments, then in use, I con-

demned the practice. From the hour that finer instruments,such as those of Dieulafoy and Bowditch, were available, Ihave, by precept and example, urged their use. Indeed,it was in my wards at Netley that the instruments justnamed were first used in hepatic cases.

I am still as ardent an advocate as ever for the exclusionof air from a suppurating cavity in the liver, and believeit to be the duty of all who have to do with such cases,whether they be acute or chronic, to give the sufferers thechance of an issue such as was obtained in P-’s case,by so conducting the operation as to exclude air; but whenthe cavity, after being once or twice evacuated in this way,fills again, I believe the patient’s best chance of recoverywill be to make a free opening after Mr. Lister’s method,which gives the advantage of a free drain, without the ad-mission of air unfiltered through an antiseptic medium.

I venture to hope that the good effects indisputably ob-tained, in the examples above related, by the direct abstrac-tion of blood by means of aspirators, may induce a moreextended trial of them by medical officers in India, incases of acute suppurative inflammation of the liver.Netley.

________________

THE TREATMENT OF SMALL-POX BYVACCINATION.

BY R. C. FURLEY, L.R.C.S.

IN THE LANCET of February lst there is an article on theabove subject by Dr. Matthew Taylor, in which he makescertain statements to combat my views, and states proposi-tions to refute them. I hail with pleasure his appearanceas champion of the older views on this subject, because Ithink that Burke never uttered a truer sentiment than that"our antagonist is our helper. This amiable conflict with

difficulty obliges us to an intimate acquaintance with ourobject, and compels us to consider it in all its relations."In the opening part of his article Dr. Taylor expresses

himself as of opinion that so much has already been written

on the subject 11 that little room is left for anyone to makeoriginal observations." Were I of a similar opinion I wouldnot trouble the profession with any views I might entertain ;but I am convinced that some good, even though little, willaccrue from an interchange of thought and deductions fromfacts and observations on the subject. Anyone who endeavoursto shake belief in doctrines long entertained and foundedon the observations of acute, accurate, and respected mem-bers of our profession, may expect, and rightly too, to en-counter opposition of a somewhat stringent kind. This noone seeking truth as his end and aim has any right to objectto, because, whether the old doctrine or the new criticismbe in error, it will the sooner be rectified; and if the latterbe found wrong, the former will rest on a surer foundation,as having withstood the attacks made upon it. This is thespirit in which I hope the discussion will be carried on.When, therefore, Dr. Taylor says I scout the opinions ofMr. Marson and others he uses too strong a term ; I onlydissent from them, and give my reasons for my dissent.Dr. Taylor, speaking for himself, Mr. Marson, Dr. Grieve,and "most medical men," says: "Anyone who has giventhe subject careful consideration knows that the preventiveaction of the vaccine virus does not come into operation tillthe constitutional effect is produced, or, in other words,till the maturation of the vesicle, which occurs in ninedays." This, I think, is the generally received opinionand fairly stated, although it implies that anyone dif-

fering from it has not given the subject "careful con-sideration." In endeavouring to show the fallacy of it,Dr. Taylor can the less find fault if he is confronted withhis own words and statements. According to him, "fromthe time of exposure to the variolous virus till the appear-ance of the eruption is fourteen days." We shall say aperson named C. D. is so exposed, and vaccination not per-formed ; the eruption will then make its appearance on thefourteenth day. Dr. Taylor says, " Suppose A. B., an un-vaccinated person, is exposed to tho variolous poison onMonday; if he is vaccinated on the Tuesday he is safe, orthe Wednesday, Thursday, or even up to the Friday."Say that A. B. is vaccinated on Friday-that is, four daysafter exposure, and add the nine days till the maturation ofthe vesicle, which makes thirteen days in all, and yet " heis safe"; while the eruption appears on the following dayon C. D., who was exposed to the virus at the same time.Now, the preventive action of the vaccine virus came intooperation on A. B. before the maturation of the vesicle, orthe variolous virus lay dormant in C. D. for thirteen days,and then suddenly broke out into activity during the nextday, which we know, as a matter of fact, is not the case.Dr. Taylor says, 11 If the effect of introducing vaccine lymphwere instantaneous, then Mr. Furley might be right." Ithink I have shown from these two assumed cases it isnearly so. For what is the nature of the disease ? Variolaconsists of the introduction of corpuscles into the blood,their multiplication there, and their subsequent extrusionthrough the cutis vera, between which and the epidermisthey accumulate, till the epidermis yields, and the diseaseexhausts itself. Now, vaccination checks the increase ofthese corpuscles either wholly or partially ; wholly if vaccinelymph be introduced sufficiently early, and partially, I main-tain, through the whole period of the multiplication of thecorpuscles. If not, when will the vaccine lymph cease tocheck the increase ? When they have multiplied to theextent of one thousand, or two or three, or what number ?Even a million seems a small quantity in this disease, soenormous is the increase. Looking thus at the disease, itappears to me not so much a question of time when vac-cination ceases to be beneficial, but a question of condition.When the corpuscles have multiplied till they can multiplyno longer, then, and then only, will vaccination be of nouse; and this does not appear to be the case until the erup-tion is complete.From what I have said, the indications for treatment

consist of two parts: first, to check the reproduction ofthe corpuscles in the blood ; and, secondly, to destroy themas soon as they make their appearance through the cutisvera. The first indication is best fulfilled by vaccination,or the hypodermic injection of lymph, no other substancebeing known-or at all events sufficiently tested-capableof producing that effect. As regards the second indication-i. e., the destruction of the corpuscles after their extrusion-many things have been proposed to effect that object, such