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CLINICAL SOCIETY OF LONDON.
1219
mately become straight.-Mr. LANE, in reply, thought that a mechanical explanation was not a teleological one. Mr. BLAND SUTTON contributed a case of Neurotomy of
Dr. STEPHEN MACKENZIE knew of a case. The patient was young man of weakly health, but not really ill, since he attended a racecourse on the day of his sudden death, which the Third Division of the Fifth Nerve at the Foramen Ovale. resulted from an acute enlargement of the thyroid pressing This paper contained the details of a case in which a man, on the trachea; a recent haemorrhage into the thyroid severe attacks gland and large white kidneys were found at the necropsy.aged sixty-four, suffered from frequent and of the branches Mr. BERRY had seen a great number of such cases, and of epileptiform neuralgia, due to implication of the inferior maxillary division of the fifth nerve in a mass chiefly on the Continent-in Auvergne and in Switzerland. of epithelial cancer of the cheek. An operation was per- He had seen one in South Wales in a boy aged fourteen ; the formed, and the third division of the fifth nerve divided as enlargement was rapidly fatal. A second case occurred in it issues from the skull. The difficulties encountered in this Wiltshire, in the person of a young girl who died from procedure were detailed, which ended in the subsequent liga- dyspncea rather suddenly after a few weeks. In a similar ture of the common carotid artery. Notwithstanding this, case at Reading, also in a boy aged fourteen, he had secured and in spite of the man’s age, he recovered from the opera- the thyroid gland for the Royal College of Surgeons’ tion, was deprived of the neuralgic seizures, and lived in museum. The occurrence of these fatal cases at puberty comparative comfort until he succumbed to his cancerous was a noteworthy point. Of twenty-seven cases in which malady eight months later.-Mr. WALSHAM thought that the the acute enlargement caused death, and in which no operation should not be lightly undertaken. He had stretched opening except tracheotomy was attempted, twelve occurred many of the branches of the inferior maxillary division of between the ages of thirteen and sixteen. Enlargethe tifth nerve. The inferior dental, the gustatory, the ment of the thyroid, not fatal, could, of course, occur buccal, and the auriculo-temporal were the branches he had at any age, sometimes very early, and even congenitally. stretched, the first one six times. Stretching and not divi- The earliest age at which he had seen it was two years and sion should be employed; even in excision the nerve ends a half. The relationship of acute thyroid enlargement to might grow together again. Stretching, though efficacious rheumatism was interesting ; be had observed a case in the for some time, might in some cases not be permanent. He course of chorea ; treatment with arsenic was followed by a had removed Meckel’s ganglion on one occasion, but this cure. Although females were most frequently affected with proved ineffectual.-Mr. HOWARD MARSH asked what artery goitre, still these fatal cases were as common in males as was supposed to have been the source of the bleeding for females. Of thirty-two cases, seventeen occurred in girls which the common carotid artery was tied. In many cases and fifteen in men. He asked why Dr. Barlow had come to ligature of the external carotid would be sufficient.-Dr. T. the conclusion that in his case the enlargement was N. PEARSE asked what influence was exercised ultimately evidently not of the same nature as ordinary goitre; the on the malignant growth by the division of nerves.-Mr. microscopical changes were similar in all cases examined.BLAND SUTTON said occasion for such an operation would Dr. ANGEL MONEY considered that rheumatism was a rarely arise. The cancer had already implicated the muscles cause of acute thyroid enlargement running a similar of mastication, so there was no need to pay attention to the clinical course to the other manifestations of rheuHe related a case of a young lady in whom motor nerves. The lingual nerves were often divided for matism. carcinoma of the tongue. The internal maxillary artery was arthritis, erythema, and heart disease had occurred. He divided. Malignant growths possessed no nerves, and were contended that in the rapid onset and rapid subsidence, not under the domination of nerves. Perhaps the ligature with absence of chronic enlargement, we had characteristics which distinguished these idiopathic and rheumatic cases of the artery diminished the growth of the cancer. from ordinary goitre.-Dr. BARLOW, in reply, was interested in Mr. Berry’s information, but drew attention to the disCLINICAL SOCIETY OF LONDON. tinction between cases such as he had described, in which pyrexia occurred and the thyroid swelling ran through a Acute Enlargement of the Thyroid Gland in a Child.-The definite cycle and subsided completely, and ordinary cases of goitre in which more or less chronicity obtained. Surgery of Hydatid Disease of the Liver. Dr. COUPLAND read notes of a case of Hydatid Cyst of the THE last ordinary meeting of the year of this Society was Left Lobe of the Liver, which was radically cured by operaheld on the 9th inst., Dr. W. H. Broadbent, F.R.C.P., President, tion. The patient, a tall and pallid youth, aged seventeen, in the chair. was admitted into the Middlesex Hospital on Jan. 22nd, 1887. Dr. TnoM’AS BARLOW read a case of Acute Enlargement For two years he had been getting weak and suffering from of the Thyroid in a Child. The case was that of a boy aged constipation, and for three months had noticed in addition three, previously healthy, and just recovering from a a small and rather tender swelling in the upper part of the slight attack] of erythema nodosum. The day after he had abdomen. Beyond his lassitude and somewhat hypobeen taken out of doors he had a little nasal catarrh, and chondriacal tendency, there was nothing special in his complained of pain in the neck. A slight enlargement of general condition. In the epigastrium there presented a the thyroid gland was found. The whole gland was in- hard nodule, the size of a nut, slightly tender, apparently volved, but the left lobe more than the other parts. The ! connected with the left lobe of the liver, with which it enlargement increased, and gave rise to much pain and con- moved freely on inspiration. The cardiac pulsation was siderable dysphagia, and was attended with pyrexia as high also transmitted to it, especially during expiration. The as 103°. The acute phase lasted four days, and the total liver was not enlarged; there was no jaundice. The duration of the enlargement was about a fortnight. patient remained under observation for nearly two months, Great relief was obtained by the application of a single without any failing of his general health, or any apparent leech over the centre of the swelling. After the sub- change in the size or character of the small swelling. sidence of the fever there was very great anaemia and The diagnosis seemed to rest between a stationary insome tendency to collapse, but the boy made a complete nocuous growth or a shrivelled obsolete hydatid cyst, and recovery to health after three weeks stay at the seaside. A exploration was decided on, with the view as much of reliev summary of the literature of the subject was given in regard ing the patient’s anxiety as of clearing up the diagnosis. to acute enlargement of the gland as distinguished from Mr. Gould performed the operation on March 24th, and a goitre strictly so called. Besides the idiopathic, traumatic, hydatid cyst of the size of an orange was found embedded and metastatic forms described by Lucke, reference was in the left lobe of the liver, projecting mainly on the made to the epidemic variety recorded in connexion with posterior surface, but also to a slight extent on the anterior, French garrisons, and to thyroiditis occurring as a com- where it formed the nodule previously observed. The cyst plication or sequel of acute and subacute rheumatism, and was punctured, and clear bydatid fluid containing numerous also of ague. The present case, from the fact that it scolices evacuated. The cyst wall was then firmly stitched succeeded upon erythema nodosum, might be considered to to the peritoneum, the abdominal parietes freely incised, and belong to the rheumatic variety, but no other rheumatic a drainage tube inserted. The case did well, and on April 3rd phenomenon was observed, and its severity was greater the collapsed hydatid was extruded ; it contained two or than that of the recorded rheumatic cases, the duration of three small daughter cysts free within it, besides having its which in their acute phase was not longer than forty-eight endocyst thickly studded with scolices. Two days later hours. On the whole, it seemed best to place the present the tough and fibrous adventitious cyst wall was also case provisionally in Lucke’s idiopathic group, and to extruded. The cavity rapidly granulated, aDd the patient accentuate its association with slight nasal catarrh and left the hospital on the 28th for a convalescent home. When sequence on exposure to cold when in an anaemic condition.- seen a month later he was in excellent health. Thus the a
1220
- exploration
in this
- disease, the cystic
case
resulted in the radical
nature of which it was not
cure
of the
possible
to
determine by ordinary methods. The very solid nature of the presenting nodule prevented any recourse to the aspirator prior to the operation, whilst the lad has been saved the risks of rupture and suppuration by resorting to the exploratory incision in preference to leaving the case alone as one of " abdominal tumour of uncertain nature." Hydatid cysts are far less common in the left than in the right lobe of the liver, and it is rare for one to be treated by free incision in so early a stage. Although doubtless simple puncture might have sufficed to have lulled the parasite, there can be no question of the advantage of total eradication, if, as such a case seems to show. it can be made with
effusion from the space occurred, and the perinflammation fect manner in which the resumed it function after
lung long-continued compression and after operation, were important and cheering features in the case, and offered turther proof, were that needed, that the healthy pleura was as amenable to surgical trespass as was the synovial membrane of the knee joint or the peritoneum itself. 1I1r, TREVES read a case of Extra-peritoneal Rupture of a Hydatid Cyst of the Liver. The patient, a married woman aged twenty-one, was "hugged"by her husband, who
seized her round the waist and lifted her three times from the ground. She was immediately seized with intense abdominal pain, became very faint, and was sick. For thirty-six hours she was unable to lie down, and would not allow her clothes to be removed. Twenty-four hours after - almost equal impunity. Mr. EDMUND OWEN read a case of Hydatid Tumour on the the injury a swelling made its appearance under the ribs of Upper Surface of the Liver successfully Tapped and Drained the right side. This swelling in time extended to the left across the Pleural Space. A married woman, aged thirty- of the median line. It was dull on percussion, but did not four, who was born and had lived all her life in London, came fluctuate. It was not affected by posture, was evidently under Dr. Broadbent’s care in May, 1886, on account of pains below the subcutaneous tissues, and was not intra-muscular. in the region of the right hypochondrium, and constant The case was diagnosed to be one of subperitoneal htmorThere was great fulness in the region of rhage. No bruising was apparent, and no ribs were fractured. sickness. the liver, with dulness on percussion, which reached from The patient had enjoyed good health, had never had a day’s the fourth rib nearly to the umbilicus. The right lung was illness, had not suffered from jaundice, and had had no served to prove greatly elevated and compressed. The hepatic tumour was abdominal swelling. The tightness of herat stay smooth and hard, and gave no wave on impulse ; it did not the last point. The swelling diminished the end of a month. move with respiration, nor with any change of the patient’s It now was more deflned, was under the right ribs, and about position. Aspiration removed thirty ounces of clear fluid, the size of a child’s head. It fluctuated, and could° not be which contained no hooklets. In June another tapping was separated from the liver. The application of pressure, in made, but with no result. In July, as the tumour was the form of Martin’s elastic bandage, caused a rise of temincreasing, it was again tapped in the seventh space, perature on each occasion of its employmen’. At the end .sixty-eight ounces of bile-stained fluid coming away. of the second month the patient had become emaciated, and This contained an abundance of hooklets. In the beginning the swelling was very prominent. The tumour was incised ,of 1887 the patient was again admitted into the close to the margin of the ribs. Hydatid fluid escaped, hospital. The tumour had increased, and there was suppuration supervened, and the patient died, greatly danger of the cyst bursting into the thorax. Several emaciated, three months from the time of the injury. The aspirations were performed, with fairly satisfactory re- necropsy showed that a hydatid cyst had formed in the sults. It was decided that the hydatid cyst, which was posterior part of the right lobe of the linea close to the completely hidden behind the lower ribs on the right side, diaphragm. This had been ruptured by violence. The fluid and was probably occupying the upper surface of the right had found its way into the subperitoneal tissues of the lobe of the liver, must be incised and drained. On Feb. 14th anterior abdominal wall. On the development of a second this was done by making an incision in the eighth inter- cyst-the one incised-the extravasated fluid had receded. costal space, opening the pleural cavity. Air rushed freely The hepatic tissue of the right lobe was almost wholly in; the faryer, introduced, readily felt the diaphragm, which destroyed. The case affords an example of extra-peritoneal was bulging up along the inner surface of the chest wall, rupture of a hydatid cyst of the liver. but the lung itself, completely collapsed, could not be Dr. ANGEL MONEY related a case of empyema due to reached. The phrenic pleura was then incised, and with hydatids that had been under his care at the Chest Hospital, it the The finger, passed through the dia- Victoria-park. The patient spat up a translucent, jelly-like phragm, came at once upon the tense cyst, from which substance and laminated membrane with a great quantity of pus. Mr. Macready was called in, and excised a portion a considerable amount of fluid was withdrawn by aspiration, so that some of its surface might be dragged of the ninth rib; a large cavity was found in which through the opening in the diaphragm and up to the abundance of hydatids existed, and were discharged at the skin wound. There it was fixed by four hare-lip pins, operation to the amount of two large basinfuls. The hole so that the wounded phrenic pleura might become in the diaphragm leading into the hydatid cyst in the .glued to the wounded costal pleura, and that the cyst right lobe of the liver was easily felt. A perfect recovery might be subsequently incised and drained without risk of ensued. - Mr. GODLEE drew attention to the difference leakage into the pleural space. The wound was dressed in the doctrine of treatment in this country and In the latter country surgeons found with wood-wool pads. On the fourth day (the patient’s in Australia. temperature never having reached 100°) the dressings were aspiration to be sufficient, whereas in England subsequent removed, and the cyst was incised. Bile-stained fluid operation was often necessary. He described various escaped, and with it pieces of cyst wall, like rotten wash- methods of procedure which could be employed, and ex leather. A large flanged drainage tube was inserted, and pressed an opinion in favour of drawing the sac out, aspiradaily the cyst was washed out with warm iodine water, ting, and then extirpating it.-Mr. HARRISON CRipps had large pieces of cyst wall escaping. The woman made a treated three cases. The first one by simple aspiration, complete and uninterrupted recovery. The pneumothorax which had to be repeated in a few months when pus was gradually disappeared, as did also a slight effusion of fluid found, but the patient did well. Trocar and drainage were into the chest, and when Dr. Broadbent saw the patient a employed for the second case, and with success. The third short time since she was well and fairly strong, whilst the case was explored as an obscure abdominal tumour; the lung had descended to its proper level. He alluded to a case hydatid was found, and its sac opened, a pint of pus escapin which Mr. Godlee a few months later had traversed a ing, after which the sac was removed entirely. Another healthy pleural space to evacuate a lung abscess. In the cyst was discovered opening into the first; this was also latter case sutures had been employed to stitch the margins opened up and removed, with a good result. In suppuraof the wound in the phrenic pleura to those of the wound ting cysts it was best to open and remove the cyst wall.in the costal pleura, but Mr. Owen was of opinion that Dr. DUFFIN had had two cases of hydatid in the left lobe of hare-lip pins were more handy than sutures, and quite as the liver. He did not believe in removing much fluid by effective for the purpose, and he would prefer them to the aspirator, but only enough to lessen the tension of the sutures if ever he had to fix the lung to the chest wall, sac. In the first case, which happened in a girl, aspiration before proceeding to deal with a suppurating pulmonary alone was successful. In the second, in a woman, the cyst cavity. It would be an interesting question as to how long suppurated and a free incision had to be made, when the it would take for the wounded and approxima,ted pleural numerous daughter cysts gave rise to some difficulty, but surfaces to become securely fixed by adhesive inflammation ; ultimately the case did well. In ordinary cases he would perhaps it would be an affair of hours rather than of days. draw off only half an ounce if the cyst contained about The tolerance with which the pleura submitted to the in- thirty ounces. A secondary enlargement often followed, trusion, the rapidity with which absorption of air and and then the fluid became albuminous. Really nothing
diaphragm.
1221 should be done for this secondary swelling, at least fo: symptoms, consisting of emotional excitement, erythema time, because gradual absorption was the usua fugax, extreme physical prostration, with short cough and consequence. If the swelling persisted for a long time little expectoration. The mind is impressed with the then turther interference would become necessary. Tht idea of impending death, but is neither alarmed nor second puncture was more dangerous and apt to set ul anxious. There is no acute pain at any stage. The phythe very thing which it was our object to avoid.- sical signs are dulness, commencing, as a rule, in tne Mr. BABEEB pointed out that in Russia, where cases oj bases ot the lungs, but sometimes in patches or Contrds, was with fine crepitation at first, soon becoming moist, and in hydatid cysts were comparatively common, inopinion two the later stages bronchial rales. The symptoms run a rapid of the in favour stages operation performing greatly He mentioned one surgeon who had not had a death ir, course, and one that is usually fatal. If the organic nerves operations so carried out, whereas he had lost two patient, entering by the root of the lung could be divided, the emptying the sac at once. He suggested that corrobora- phenomena witnessed would be those of pneumoparesis. by tive evidence on this point would be very useful.—Mr Some years ago, by synthetical research, the author produced RowABD MARSH related the case of a boy where hE an artificial pneumoparesis in one of the lower animals, the had cut down on the cyst and sutured it to the margin oi rabbit, by placing it in an atmosphere charged with vapour the abdominal wound. Some weeks later he opened the of amyl nitrite, and he showed coloured drawings taken at cyst, and the lad had done remarkably well. In anothet the time of the condition of the lungs in different stages of case at St. Bartholomew’s Hospital he had sutured the sac the induced disease. In these cases the pulmonary paresis to the wound and left it for five or six days, and he felt was caused by the action of a chemical substance on the very strongly that that was the better course to pursue, organic nervous structures, and recovery followed upon the He said that it really did not amount to making two opera- withdrawal of the cause, but the effects while they lasted tions of it, for opening the sac was a painless proceeding. He were identical physically with those which had been deadded that the general opinion of English surgeons was in scribed from the disease in the human subject. Pneumofavour of the two-stage operation. He had aspirated in paresis in the human subject, according to the author’;3 children several times, and in one or two cases no recurrence view, is a disease having its seat in the organic nervous had taken place, but recurrence did sometimes take place.- centres which in health regulate and control the pulmonary Dr. BROADBENT said that in a considerable proportion of circulations. It is as yet an open point whether the the cases he had seen, simple aspiration had been sufficient failure commences in the nutritive circulation derived to effect a cure. He could recollect at least half-a-dozen from the bronchial arteries rising from the thoracic aorta, cases in which he had subsequently seen the patients. He or in the respiratory circulation of the pulmonary mentioned that cysts varied in character, and said that he artery. This was a subject very rarely, if ever, studied, had remarked that when there were quantities of daughter in relation to pulmonic affections, but it called for the cysts suppuration was very likely to take place; whenever the minutest attention, especially in the disease now under confluid came away easily, retrogression might be expected. In sideration. On the whole, Dr. Richardson thought that in one case the struggles of the child caused laceration of the this instance the failure was first developed in the nutritive walls of the cyst and escape of the fluid into the abdomen. pulmonary vessels, and that the embarrassment in the This, however, was absorbed, and the child got well. He was respiratory circulation was secondary. Leaving this question unable to reconcile this case with that related by Mr. Treves.- as sub judice, he next spoke on the nature of the nervous Dr. COUPLA.ND, in reply, said that most of the cases he bad lesion which led to the primary failure. This might be due (a) to mechanical injury, pressure or shock to the seen in which aspiration was employed, either suppurated or refilled. He suggested that one advantage of a free in- nervous-supplying centre or its plexuses; (b) to the generacision was that the presence of other cysts might be detected. tion within the body of some chemical product, which, like —Mr. EDMUND OWEN, in reply, said he was disappointed amyl nitrite, reduces to paresis the organic nervous supply ; that the discussion had not turned more on the extension of (c) to hereditary failure or premature exhaustion of the the cysts into the thoracic cage. As to the best operation nervous-supplying centre under exhausting or depressing to be performed, he said that in abscess of the liver it might influences. The last-named view was that most favoured be advisable to open the sac directly, but, on the whole, he bv the author. and we have onlv to let the mind become preferred the method of doing the operation in two steps. accustomed to the thought of the possible arrest of nervous He thought that there was no necessity for waiting so long stimulus in the pulmonary circulations as we do to other or even for a few days, seeing that a few hours probably organs, and the fact of pneumoparesis is one of the most sufficed to obviate any danger of the fluid escaping into the simple and clear forms of nervous failure and resultant abdomen.-Mr. TREVJ
,
.
mately become straight.-Mr. LANE, in reply, thought that a mechanical explanation was not a teleological one. Mr. BLAND SUTTON contributed a case of Neurotomy of
Dr. STEPHEN MACKENZIE knew of a case. The patient was young man of weakly health, but not really ill, since he attended a racecourse on the day of his sudden death, which the Third Division of the Fifth Nerve at the Foramen Ovale. resulted from an acute enlargement of the thyroid pressing This paper contained the details of a case in which a man, on the trachea; a recent haemorrhage into the thyroid severe attacks gland and large white kidneys were found at the necropsy.aged sixty-four, suffered from frequent and of the branches Mr. BERRY had seen a great number of such cases, and of epileptiform neuralgia, due to implication of the inferior maxillary division of the fifth nerve in a mass chiefly on the Continent-in Auvergne and in Switzerland. of epithelial cancer of the cheek. An operation was per- He had seen one in South Wales in a boy aged fourteen ; the formed, and the third division of the fifth nerve divided as enlargement was rapidly fatal. A second case occurred in it issues from the skull. The difficulties encountered in this Wiltshire, in the person of a young girl who died from procedure were detailed, which ended in the subsequent liga- dyspncea rather suddenly after a few weeks. In a similar ture of the common carotid artery. Notwithstanding this, case at Reading, also in a boy aged fourteen, he had secured and in spite of the man’s age, he recovered from the opera- the thyroid gland for the Royal College of Surgeons’ tion, was deprived of the neuralgic seizures, and lived in museum. The occurrence of these fatal cases at puberty comparative comfort until he succumbed to his cancerous was a noteworthy point. Of twenty-seven cases in which malady eight months later.-Mr. WALSHAM thought that the the acute enlargement caused death, and in which no operation should not be lightly undertaken. He had stretched opening except tracheotomy was attempted, twelve occurred many of the branches of the inferior maxillary division of between the ages of thirteen and sixteen. Enlargethe tifth nerve. The inferior dental, the gustatory, the ment of the thyroid, not fatal, could, of course, occur buccal, and the auriculo-temporal were the branches he had at any age, sometimes very early, and even congenitally. stretched, the first one six times. Stretching and not divi- The earliest age at which he had seen it was two years and sion should be employed; even in excision the nerve ends a half. The relationship of acute thyroid enlargement to might grow together again. Stretching, though efficacious rheumatism was interesting ; be had observed a case in the for some time, might in some cases not be permanent. He course of chorea ; treatment with arsenic was followed by a had removed Meckel’s ganglion on one occasion, but this cure. Although females were most frequently affected with proved ineffectual.-Mr. HOWARD MARSH asked what artery goitre, still these fatal cases were as common in males as was supposed to have been the source of the bleeding for females. Of thirty-two cases, seventeen occurred in girls which the common carotid artery was tied. In many cases and fifteen in men. He asked why Dr. Barlow had come to ligature of the external carotid would be sufficient.-Dr. T. the conclusion that in his case the enlargement was N. PEARSE asked what influence was exercised ultimately evidently not of the same nature as ordinary goitre; the on the malignant growth by the division of nerves.-Mr. microscopical changes were similar in all cases examined.BLAND SUTTON said occasion for such an operation would Dr. ANGEL MONEY considered that rheumatism was a rarely arise. The cancer had already implicated the muscles cause of acute thyroid enlargement running a similar of mastication, so there was no need to pay attention to the clinical course to the other manifestations of rheuHe related a case of a young lady in whom motor nerves. The lingual nerves were often divided for matism. carcinoma of the tongue. The internal maxillary artery was arthritis, erythema, and heart disease had occurred. He divided. Malignant growths possessed no nerves, and were contended that in the rapid onset and rapid subsidence, not under the domination of nerves. Perhaps the ligature with absence of chronic enlargement, we had characteristics which distinguished these idiopathic and rheumatic cases of the artery diminished the growth of the cancer. from ordinary goitre.-Dr. BARLOW, in reply, was interested in Mr. Berry’s information, but drew attention to the disCLINICAL SOCIETY OF LONDON. tinction between cases such as he had described, in which pyrexia occurred and the thyroid swelling ran through a Acute Enlargement of the Thyroid Gland in a Child.-The definite cycle and subsided completely, and ordinary cases of goitre in which more or less chronicity obtained. Surgery of Hydatid Disease of the Liver. Dr. COUPLAND read notes of a case of Hydatid Cyst of the THE last ordinary meeting of the year of this Society was Left Lobe of the Liver, which was radically cured by operaheld on the 9th inst., Dr. W. H. Broadbent, F.R.C.P., President, tion. The patient, a tall and pallid youth, aged seventeen, in the chair. was admitted into the Middlesex Hospital on Jan. 22nd, 1887. Dr. TnoM’AS BARLOW read a case of Acute Enlargement For two years he had been getting weak and suffering from of the Thyroid in a Child. The case was that of a boy aged constipation, and for three months had noticed in addition three, previously healthy, and just recovering from a a small and rather tender swelling in the upper part of the slight attack] of erythema nodosum. The day after he had abdomen. Beyond his lassitude and somewhat hypobeen taken out of doors he had a little nasal catarrh, and chondriacal tendency, there was nothing special in his complained of pain in the neck. A slight enlargement of general condition. In the epigastrium there presented a the thyroid gland was found. The whole gland was in- hard nodule, the size of a nut, slightly tender, apparently volved, but the left lobe more than the other parts. The ! connected with the left lobe of the liver, with which it enlargement increased, and gave rise to much pain and con- moved freely on inspiration. The cardiac pulsation was siderable dysphagia, and was attended with pyrexia as high also transmitted to it, especially during expiration. The as 103°. The acute phase lasted four days, and the total liver was not enlarged; there was no jaundice. The duration of the enlargement was about a fortnight. patient remained under observation for nearly two months, Great relief was obtained by the application of a single without any failing of his general health, or any apparent leech over the centre of the swelling. After the sub- change in the size or character of the small swelling. sidence of the fever there was very great anaemia and The diagnosis seemed to rest between a stationary insome tendency to collapse, but the boy made a complete nocuous growth or a shrivelled obsolete hydatid cyst, and recovery to health after three weeks stay at the seaside. A exploration was decided on, with the view as much of reliev summary of the literature of the subject was given in regard ing the patient’s anxiety as of clearing up the diagnosis. to acute enlargement of the gland as distinguished from Mr. Gould performed the operation on March 24th, and a goitre strictly so called. Besides the idiopathic, traumatic, hydatid cyst of the size of an orange was found embedded and metastatic forms described by Lucke, reference was in the left lobe of the liver, projecting mainly on the made to the epidemic variety recorded in connexion with posterior surface, but also to a slight extent on the anterior, French garrisons, and to thyroiditis occurring as a com- where it formed the nodule previously observed. The cyst plication or sequel of acute and subacute rheumatism, and was punctured, and clear bydatid fluid containing numerous also of ague. The present case, from the fact that it scolices evacuated. The cyst wall was then firmly stitched succeeded upon erythema nodosum, might be considered to to the peritoneum, the abdominal parietes freely incised, and belong to the rheumatic variety, but no other rheumatic a drainage tube inserted. The case did well, and on April 3rd phenomenon was observed, and its severity was greater the collapsed hydatid was extruded ; it contained two or than that of the recorded rheumatic cases, the duration of three small daughter cysts free within it, besides having its which in their acute phase was not longer than forty-eight endocyst thickly studded with scolices. Two days later hours. On the whole, it seemed best to place the present the tough and fibrous adventitious cyst wall was also case provisionally in Lucke’s idiopathic group, and to extruded. The cavity rapidly granulated, aDd the patient accentuate its association with slight nasal catarrh and left the hospital on the 28th for a convalescent home. When sequence on exposure to cold when in an anaemic condition.- seen a month later he was in excellent health. Thus the a
1220
- exploration
in this
- disease, the cystic
case
resulted in the radical
nature of which it was not
cure
of the
possible
to
determine by ordinary methods. The very solid nature of the presenting nodule prevented any recourse to the aspirator prior to the operation, whilst the lad has been saved the risks of rupture and suppuration by resorting to the exploratory incision in preference to leaving the case alone as one of " abdominal tumour of uncertain nature." Hydatid cysts are far less common in the left than in the right lobe of the liver, and it is rare for one to be treated by free incision in so early a stage. Although doubtless simple puncture might have sufficed to have lulled the parasite, there can be no question of the advantage of total eradication, if, as such a case seems to show. it can be made with
effusion from the space occurred, and the perinflammation fect manner in which the resumed it function after
lung long-continued compression and after operation, were important and cheering features in the case, and offered turther proof, were that needed, that the healthy pleura was as amenable to surgical trespass as was the synovial membrane of the knee joint or the peritoneum itself. 1I1r, TREVES read a case of Extra-peritoneal Rupture of a Hydatid Cyst of the Liver. The patient, a married woman aged twenty-one, was "hugged"by her husband, who
seized her round the waist and lifted her three times from the ground. She was immediately seized with intense abdominal pain, became very faint, and was sick. For thirty-six hours she was unable to lie down, and would not allow her clothes to be removed. Twenty-four hours after - almost equal impunity. Mr. EDMUND OWEN read a case of Hydatid Tumour on the the injury a swelling made its appearance under the ribs of Upper Surface of the Liver successfully Tapped and Drained the right side. This swelling in time extended to the left across the Pleural Space. A married woman, aged thirty- of the median line. It was dull on percussion, but did not four, who was born and had lived all her life in London, came fluctuate. It was not affected by posture, was evidently under Dr. Broadbent’s care in May, 1886, on account of pains below the subcutaneous tissues, and was not intra-muscular. in the region of the right hypochondrium, and constant The case was diagnosed to be one of subperitoneal htmorThere was great fulness in the region of rhage. No bruising was apparent, and no ribs were fractured. sickness. the liver, with dulness on percussion, which reached from The patient had enjoyed good health, had never had a day’s the fourth rib nearly to the umbilicus. The right lung was illness, had not suffered from jaundice, and had had no served to prove greatly elevated and compressed. The hepatic tumour was abdominal swelling. The tightness of herat stay smooth and hard, and gave no wave on impulse ; it did not the last point. The swelling diminished the end of a month. move with respiration, nor with any change of the patient’s It now was more deflned, was under the right ribs, and about position. Aspiration removed thirty ounces of clear fluid, the size of a child’s head. It fluctuated, and could° not be which contained no hooklets. In June another tapping was separated from the liver. The application of pressure, in made, but with no result. In July, as the tumour was the form of Martin’s elastic bandage, caused a rise of temincreasing, it was again tapped in the seventh space, perature on each occasion of its employmen’. At the end .sixty-eight ounces of bile-stained fluid coming away. of the second month the patient had become emaciated, and This contained an abundance of hooklets. In the beginning the swelling was very prominent. The tumour was incised ,of 1887 the patient was again admitted into the close to the margin of the ribs. Hydatid fluid escaped, hospital. The tumour had increased, and there was suppuration supervened, and the patient died, greatly danger of the cyst bursting into the thorax. Several emaciated, three months from the time of the injury. The aspirations were performed, with fairly satisfactory re- necropsy showed that a hydatid cyst had formed in the sults. It was decided that the hydatid cyst, which was posterior part of the right lobe of the linea close to the completely hidden behind the lower ribs on the right side, diaphragm. This had been ruptured by violence. The fluid and was probably occupying the upper surface of the right had found its way into the subperitoneal tissues of the lobe of the liver, must be incised and drained. On Feb. 14th anterior abdominal wall. On the development of a second this was done by making an incision in the eighth inter- cyst-the one incised-the extravasated fluid had receded. costal space, opening the pleural cavity. Air rushed freely The hepatic tissue of the right lobe was almost wholly in; the faryer, introduced, readily felt the diaphragm, which destroyed. The case affords an example of extra-peritoneal was bulging up along the inner surface of the chest wall, rupture of a hydatid cyst of the liver. but the lung itself, completely collapsed, could not be Dr. ANGEL MONEY related a case of empyema due to reached. The phrenic pleura was then incised, and with hydatids that had been under his care at the Chest Hospital, it the The finger, passed through the dia- Victoria-park. The patient spat up a translucent, jelly-like phragm, came at once upon the tense cyst, from which substance and laminated membrane with a great quantity of pus. Mr. Macready was called in, and excised a portion a considerable amount of fluid was withdrawn by aspiration, so that some of its surface might be dragged of the ninth rib; a large cavity was found in which through the opening in the diaphragm and up to the abundance of hydatids existed, and were discharged at the skin wound. There it was fixed by four hare-lip pins, operation to the amount of two large basinfuls. The hole so that the wounded phrenic pleura might become in the diaphragm leading into the hydatid cyst in the .glued to the wounded costal pleura, and that the cyst right lobe of the liver was easily felt. A perfect recovery might be subsequently incised and drained without risk of ensued. - Mr. GODLEE drew attention to the difference leakage into the pleural space. The wound was dressed in the doctrine of treatment in this country and In the latter country surgeons found with wood-wool pads. On the fourth day (the patient’s in Australia. temperature never having reached 100°) the dressings were aspiration to be sufficient, whereas in England subsequent removed, and the cyst was incised. Bile-stained fluid operation was often necessary. He described various escaped, and with it pieces of cyst wall, like rotten wash- methods of procedure which could be employed, and ex leather. A large flanged drainage tube was inserted, and pressed an opinion in favour of drawing the sac out, aspiradaily the cyst was washed out with warm iodine water, ting, and then extirpating it.-Mr. HARRISON CRipps had large pieces of cyst wall escaping. The woman made a treated three cases. The first one by simple aspiration, complete and uninterrupted recovery. The pneumothorax which had to be repeated in a few months when pus was gradually disappeared, as did also a slight effusion of fluid found, but the patient did well. Trocar and drainage were into the chest, and when Dr. Broadbent saw the patient a employed for the second case, and with success. The third short time since she was well and fairly strong, whilst the case was explored as an obscure abdominal tumour; the lung had descended to its proper level. He alluded to a case hydatid was found, and its sac opened, a pint of pus escapin which Mr. Godlee a few months later had traversed a ing, after which the sac was removed entirely. Another healthy pleural space to evacuate a lung abscess. In the cyst was discovered opening into the first; this was also latter case sutures had been employed to stitch the margins opened up and removed, with a good result. In suppuraof the wound in the phrenic pleura to those of the wound ting cysts it was best to open and remove the cyst wall.in the costal pleura, but Mr. Owen was of opinion that Dr. DUFFIN had had two cases of hydatid in the left lobe of hare-lip pins were more handy than sutures, and quite as the liver. He did not believe in removing much fluid by effective for the purpose, and he would prefer them to the aspirator, but only enough to lessen the tension of the sutures if ever he had to fix the lung to the chest wall, sac. In the first case, which happened in a girl, aspiration before proceeding to deal with a suppurating pulmonary alone was successful. In the second, in a woman, the cyst cavity. It would be an interesting question as to how long suppurated and a free incision had to be made, when the it would take for the wounded and approxima,ted pleural numerous daughter cysts gave rise to some difficulty, but surfaces to become securely fixed by adhesive inflammation ; ultimately the case did well. In ordinary cases he would perhaps it would be an affair of hours rather than of days. draw off only half an ounce if the cyst contained about The tolerance with which the pleura submitted to the in- thirty ounces. A secondary enlargement often followed, trusion, the rapidity with which absorption of air and and then the fluid became albuminous. Really nothing
diaphragm.
1221 should be done for this secondary swelling, at least fo: symptoms, consisting of emotional excitement, erythema time, because gradual absorption was the usua fugax, extreme physical prostration, with short cough and consequence. If the swelling persisted for a long time little expectoration. The mind is impressed with the then turther interference would become necessary. Tht idea of impending death, but is neither alarmed nor second puncture was more dangerous and apt to set ul anxious. There is no acute pain at any stage. The phythe very thing which it was our object to avoid.- sical signs are dulness, commencing, as a rule, in tne Mr. BABEEB pointed out that in Russia, where cases oj bases ot the lungs, but sometimes in patches or Contrds, was with fine crepitation at first, soon becoming moist, and in hydatid cysts were comparatively common, inopinion two the later stages bronchial rales. The symptoms run a rapid of the in favour stages operation performing greatly He mentioned one surgeon who had not had a death ir, course, and one that is usually fatal. If the organic nerves operations so carried out, whereas he had lost two patient, entering by the root of the lung could be divided, the emptying the sac at once. He suggested that corrobora- phenomena witnessed would be those of pneumoparesis. by tive evidence on this point would be very useful.—Mr Some years ago, by synthetical research, the author produced RowABD MARSH related the case of a boy where hE an artificial pneumoparesis in one of the lower animals, the had cut down on the cyst and sutured it to the margin oi rabbit, by placing it in an atmosphere charged with vapour the abdominal wound. Some weeks later he opened the of amyl nitrite, and he showed coloured drawings taken at cyst, and the lad had done remarkably well. In anothet the time of the condition of the lungs in different stages of case at St. Bartholomew’s Hospital he had sutured the sac the induced disease. In these cases the pulmonary paresis to the wound and left it for five or six days, and he felt was caused by the action of a chemical substance on the very strongly that that was the better course to pursue, organic nervous structures, and recovery followed upon the He said that it really did not amount to making two opera- withdrawal of the cause, but the effects while they lasted tions of it, for opening the sac was a painless proceeding. He were identical physically with those which had been deadded that the general opinion of English surgeons was in scribed from the disease in the human subject. Pneumofavour of the two-stage operation. He had aspirated in paresis in the human subject, according to the author’;3 children several times, and in one or two cases no recurrence view, is a disease having its seat in the organic nervous had taken place, but recurrence did sometimes take place.- centres which in health regulate and control the pulmonary Dr. BROADBENT said that in a considerable proportion of circulations. It is as yet an open point whether the the cases he had seen, simple aspiration had been sufficient failure commences in the nutritive circulation derived to effect a cure. He could recollect at least half-a-dozen from the bronchial arteries rising from the thoracic aorta, cases in which he had subsequently seen the patients. He or in the respiratory circulation of the pulmonary mentioned that cysts varied in character, and said that he artery. This was a subject very rarely, if ever, studied, had remarked that when there were quantities of daughter in relation to pulmonic affections, but it called for the cysts suppuration was very likely to take place; whenever the minutest attention, especially in the disease now under confluid came away easily, retrogression might be expected. In sideration. On the whole, Dr. Richardson thought that in one case the struggles of the child caused laceration of the this instance the failure was first developed in the nutritive walls of the cyst and escape of the fluid into the abdomen. pulmonary vessels, and that the embarrassment in the This, however, was absorbed, and the child got well. He was respiratory circulation was secondary. Leaving this question unable to reconcile this case with that related by Mr. Treves.- as sub judice, he next spoke on the nature of the nervous Dr. COUPLA.ND, in reply, said that most of the cases he bad lesion which led to the primary failure. This might be due (a) to mechanical injury, pressure or shock to the seen in which aspiration was employed, either suppurated or refilled. He suggested that one advantage of a free in- nervous-supplying centre or its plexuses; (b) to the generacision was that the presence of other cysts might be detected. tion within the body of some chemical product, which, like —Mr. EDMUND OWEN, in reply, said he was disappointed amyl nitrite, reduces to paresis the organic nervous supply ; that the discussion had not turned more on the extension of (c) to hereditary failure or premature exhaustion of the the cysts into the thoracic cage. As to the best operation nervous-supplying centre under exhausting or depressing to be performed, he said that in abscess of the liver it might influences. The last-named view was that most favoured be advisable to open the sac directly, but, on the whole, he bv the author. and we have onlv to let the mind become preferred the method of doing the operation in two steps. accustomed to the thought of the possible arrest of nervous He thought that there was no necessity for waiting so long stimulus in the pulmonary circulations as we do to other or even for a few days, seeing that a few hours probably organs, and the fact of pneumoparesis is one of the most sufficed to obviate any danger of the fluid escaping into the simple and clear forms of nervous failure and resultant abdomen.-Mr. TREVJ
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