she was unable to lie on the
of great the abdomen as far as the side with the knees drawn up ; in fact, there were symptoms of peritoneal inflammation. On examination, I found the belly extremely tympanitic, and generally tender on pressure, but more so in the hepatic region, and over the course of the transverse colon. She was unable to move ofF the left side without assistance, and even then the movement caused her most intense agony. At this period she suffered for about 72 hours from retention of urine, the catheter
pain in the right side, and umbilicus, and lay on the left
right side; complained
over
being required.
CASES PROM PRACTICE
On the oth January, the tympanitis was in a measure relieved, but the abdominal tenderness still continued ; the decubitus was still on the left side, with the legs drawn up; and. in addition, there was a remarkable and rapid increase in tho hepatic enlargement, which now extended to tho umbilicus, and nearly to tho crest of the right ilium; still, the surface of the tumour was perfectly smooth, and at time3 I fancied I couid distinguish indistinct and deep fluctuation.
?j
CASE OF HYDATID DISEASE OF THE LIVER; HYDATIDS (ACEPHALOCYSTES PROLIFER/E) DISCHARGED 13Y THE BOWELS.
At this time Mrs. S.
profuse night
Bv J. Browne, A.B. and
Surgeon,
Medical
in
F.E.C.S.I., charge, Mussoorie.
December.
Her husband told me that she had always been a most active person, and had generally enjoyed good health, though he noticed that for sometime past she was getting thin and her appetite had failed. Her friends too, who only saw her occasionally, remarked how very ill she was looking. Her husband also told me that Mrs. S. had an attack of jaundice some ten years ago, and he considers that she has not been the same since
On the morning of the 22nd December, 1868, Mrs. S. was attacked with violent vomiting, and told her husband she felt as if there was a bar of iron across her stomach. He thought she ?was suffering from a bilious attack, and immediately gave her an emetic, which, having acted freely, afforded her some relief. She, however, had to continue in bed, being sometimes better, sometimes worse, and I was asked to see her on the afternoon of the 24th December, as on the morning of that day she had drawn the attention of her husband to a tumour in the right hypochondrium, and which she considered to be an enlarged liver.
very considerably.
?
On the 29th of December there was effusion into the right pleura, and a few days afterwards there was some slight effusion in the left one. The pain in the hepatic region was persistent, and she was frequently troubled by sharp pains running, as she described them, through the liver to the back. She could lie, she said, with equal comfort and freedom on either side, or on the back ; but, as I generally found her at this stage of the disease lying on the right side, I have no doubt hut that she was most easy in this position. On the 2nd of January she was in some respects decidedly better ; she was free from fever, and the pulse was 96, but still there was the enlargement of the liver, and the tenderness on
pressure. On the morning of the 3rd. I was surprised to find my patient in a very dangerous condition: her countenance was pinched and anxious looking ; pulse very weak, and 120;
rapidly,
and had
On the morning of the 10th, her pulse was 128, and very feeble; she complained of extreme debility, and was perspiring profusely. In the afternoon of this day, her bowels were moved, and her husband was surprised to find that " more than half the motion consisted of globular gelatinous-looking substances, and varying in size from about that of a lien's egg to a gooseberry." After this motion she expressed herself as feeling great and immediate relief. During the night and next day, she had some nine motions ; tho few first containing hydatids, tho latter ones only containing tho empty memDranous sacs of others ; and Mr. S., a most accurate observer, conjectured that; altogether, I forgot some 500 of these entozoa must have been passed. to mention that on the 7th and 8th Mrs. S. uffered from dysenteric
then.
It is unnecessary, and "would tako up too much valuable space, to give a daily record of the case; but I shall briefly describe the most prominent and interesting events in connection with it, and which tended to complicate the diagnosis
to lose flesh
From the 5th to the 10th January, the abdominal tenderness had become less; tho tympanitis had disappeared; but still the hepatic enlargement was gradually increasing, and did not present any sensation of fluctuation more than I have before mentioned, nor was the surface of the tumour otherwise than smooth, though a marked fulness of the right side was visible. Altogether, at this stage, the ease looked most unpromising, and a fatal termination of it expected.
On the afternoon of the 24th December, 1868, I was asked to attend Mrs. S., who had been ill since the morning of the 22nd
On my first visit (24th December) I found my patient, a cachectic-looking subject, suffering from sharp fever, lying on the hack, and complaining of pain in the hepatic region. Her pulse was 110, and of rather small volume; conjunctiva) slightly jaundiced ; tongue thickly coated. On examining the liver I found it to be much enlarged, extending fully an inch below the cartilages of the ribs, and across nearly into the left hypochondrium. There was considerable tenderness of the enlarged liver on pressure, and its surface was perfectly smooth, quite free from any prominences or inequalities; its thin edge could also be distinctly felt. The urine was scanty, and contained a very copious lithatic deposit.
began
sweats.
symptoms. This case presents several features of unusual interest, the mo3t prominent amongst which are, perhaps, The apparently sudden and very rapid hepatic Mrs. S. assures me that she never had any idea of ment of liver until the 24th December, 1868.
lstly.
ment.
enlargeenlarge-
2ndiy. The double pleuritic effusion. 3rdly. The sudden symptoms of peritonitis. 4thly. The extreme tympanitis. 5thly. The dysenteric symptoms. Gthly. The rapid emaciation and profuse night sweats, symptoms which pointed to the probable formation of an abscess ?but then there had not been any rigor. 7thly. The channel selected by nature for the discharge of the hydatids, the rapid subsidence of the hepatic tumour, and tho general amendment of the patient after the discharge of tho hydatids. I did not see any of the hydatids tilL after the rupture of their cysts, as I thoughtlessly asked Mr. S. to keep them in
no doubt but that the cysts became their ovrr-distention by tho process of endosmose; however, I am of opinion, from tho examination of tho empty cysts, and from Mr. S.'s description of them, that tnev were acephalocy&t hydatids.
colli water; and I have
ruptured owing
I
was
very
to
glad
in
being
able to avail
myself
of tho ablo
advico and experience of Dr. Fogo, Iloyal Ilorso Artillery, from
almost the commencement of this best acknowledgments are due. A few remarks
on
some
lady's illness,
and to him my
of the mo^t prominent symptoms treatment pursued, cs also on tho form the subject of a second
already mentioned, and on the case geuerally, may perhaps paper.
to the present, January 20th, Mrs. S. has been and steadily improving, but is very weak. If all goes she will proceed to via the Cape in
T.S.?Up
gradually
on
well,
Kngland
February.
of great the abdomen as far as the side with the knees drawn up ; in fact, there were symptoms of peritoneal inflammation. On examination, I found the belly extremely tympanitic, and generally tender on pressure, but more so in the hepatic region, and over the course of the transverse colon. She was unable to move ofF the left side without assistance, and even then the movement caused her most intense agony. At this period she suffered for about 72 hours from retention of urine, the catheter
pain in the right side, and umbilicus, and lay on the left
right side; complained
over
being required.
CASES PROM PRACTICE
On the oth January, the tympanitis was in a measure relieved, but the abdominal tenderness still continued ; the decubitus was still on the left side, with the legs drawn up; and. in addition, there was a remarkable and rapid increase in tho hepatic enlargement, which now extended to tho umbilicus, and nearly to tho crest of the right ilium; still, the surface of the tumour was perfectly smooth, and at time3 I fancied I couid distinguish indistinct and deep fluctuation.
?j
CASE OF HYDATID DISEASE OF THE LIVER; HYDATIDS (ACEPHALOCYSTES PROLIFER/E) DISCHARGED 13Y THE BOWELS.
At this time Mrs. S.
profuse night
Bv J. Browne, A.B. and
Surgeon,
Medical
in
F.E.C.S.I., charge, Mussoorie.
December.
Her husband told me that she had always been a most active person, and had generally enjoyed good health, though he noticed that for sometime past she was getting thin and her appetite had failed. Her friends too, who only saw her occasionally, remarked how very ill she was looking. Her husband also told me that Mrs. S. had an attack of jaundice some ten years ago, and he considers that she has not been the same since
On the morning of the 22nd December, 1868, Mrs. S. was attacked with violent vomiting, and told her husband she felt as if there was a bar of iron across her stomach. He thought she ?was suffering from a bilious attack, and immediately gave her an emetic, which, having acted freely, afforded her some relief. She, however, had to continue in bed, being sometimes better, sometimes worse, and I was asked to see her on the afternoon of the 24th December, as on the morning of that day she had drawn the attention of her husband to a tumour in the right hypochondrium, and which she considered to be an enlarged liver.
very considerably.
?
On the 29th of December there was effusion into the right pleura, and a few days afterwards there was some slight effusion in the left one. The pain in the hepatic region was persistent, and she was frequently troubled by sharp pains running, as she described them, through the liver to the back. She could lie, she said, with equal comfort and freedom on either side, or on the back ; but, as I generally found her at this stage of the disease lying on the right side, I have no doubt hut that she was most easy in this position. On the 2nd of January she was in some respects decidedly better ; she was free from fever, and the pulse was 96, but still there was the enlargement of the liver, and the tenderness on
pressure. On the morning of the 3rd. I was surprised to find my patient in a very dangerous condition: her countenance was pinched and anxious looking ; pulse very weak, and 120;
rapidly,
and had
On the morning of the 10th, her pulse was 128, and very feeble; she complained of extreme debility, and was perspiring profusely. In the afternoon of this day, her bowels were moved, and her husband was surprised to find that " more than half the motion consisted of globular gelatinous-looking substances, and varying in size from about that of a lien's egg to a gooseberry." After this motion she expressed herself as feeling great and immediate relief. During the night and next day, she had some nine motions ; tho few first containing hydatids, tho latter ones only containing tho empty memDranous sacs of others ; and Mr. S., a most accurate observer, conjectured that; altogether, I forgot some 500 of these entozoa must have been passed. to mention that on the 7th and 8th Mrs. S. uffered from dysenteric
then.
It is unnecessary, and "would tako up too much valuable space, to give a daily record of the case; but I shall briefly describe the most prominent and interesting events in connection with it, and which tended to complicate the diagnosis
to lose flesh
From the 5th to the 10th January, the abdominal tenderness had become less; tho tympanitis had disappeared; but still the hepatic enlargement was gradually increasing, and did not present any sensation of fluctuation more than I have before mentioned, nor was the surface of the tumour otherwise than smooth, though a marked fulness of the right side was visible. Altogether, at this stage, the ease looked most unpromising, and a fatal termination of it expected.
On the afternoon of the 24th December, 1868, I was asked to attend Mrs. S., who had been ill since the morning of the 22nd
On my first visit (24th December) I found my patient, a cachectic-looking subject, suffering from sharp fever, lying on the hack, and complaining of pain in the hepatic region. Her pulse was 110, and of rather small volume; conjunctiva) slightly jaundiced ; tongue thickly coated. On examining the liver I found it to be much enlarged, extending fully an inch below the cartilages of the ribs, and across nearly into the left hypochondrium. There was considerable tenderness of the enlarged liver on pressure, and its surface was perfectly smooth, quite free from any prominences or inequalities; its thin edge could also be distinctly felt. The urine was scanty, and contained a very copious lithatic deposit.
began
sweats.
symptoms. This case presents several features of unusual interest, the mo3t prominent amongst which are, perhaps, The apparently sudden and very rapid hepatic Mrs. S. assures me that she never had any idea of ment of liver until the 24th December, 1868.
lstly.
ment.
enlargeenlarge-
2ndiy. The double pleuritic effusion. 3rdly. The sudden symptoms of peritonitis. 4thly. The extreme tympanitis. 5thly. The dysenteric symptoms. Gthly. The rapid emaciation and profuse night sweats, symptoms which pointed to the probable formation of an abscess ?but then there had not been any rigor. 7thly. The channel selected by nature for the discharge of the hydatids, the rapid subsidence of the hepatic tumour, and tho general amendment of the patient after the discharge of tho hydatids. I did not see any of the hydatids tilL after the rupture of their cysts, as I thoughtlessly asked Mr. S. to keep them in
no doubt but that the cysts became their ovrr-distention by tho process of endosmose; however, I am of opinion, from tho examination of tho empty cysts, and from Mr. S.'s description of them, that tnev were acephalocy&t hydatids.
colli water; and I have
ruptured owing
I
was
very
to
glad
in
being
able to avail
myself
of tho ablo
advico and experience of Dr. Fogo, Iloyal Ilorso Artillery, from
almost the commencement of this best acknowledgments are due. A few remarks
on
some
lady's illness,
and to him my
of the mo^t prominent symptoms treatment pursued, cs also on tho form the subject of a second
already mentioned, and on the case geuerally, may perhaps paper.
to the present, January 20th, Mrs. S. has been and steadily improving, but is very weak. If all goes she will proceed to via the Cape in
T.S.?Up
gradually
on
well,
Kngland
February.
