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NOTES OF A CASE OF KERATITIS.
157 her to go to bed as soon as possible, which she appeared of the usual coma or convulsions, which usually take place loth to do ; also to take light farinaceous diet, with a little in about four or five days from the occuimence of complete brandy-and-water as a stimulant now and then. An effer- suppression of urine. The brain continued remarkably clear vescing diuretic mixture, containing a bitter, was sent, to during the whole course of her malady; she gave orders for be taken every four hours. In the evening she told me that the dinners to be served downstairs, and other directions she had not passed water since the day before, and com- for various household matters. No pain was ever complained plained of her limbs and back aching; in other respects she of in the region of the kidneys or over the bladder. Neither had not altered much since the morning. I advised her the stools nor the perspiration had any urinous smell, and again, and more strongly, to go to bed, told her to take she scarcely ever had any headache worth speaking of. some gin-and-water at bedtime, and prescribed a mercurial There was no organic disease of the heart. and rhubarb pill. Additional Notes, by J. 1’lANN, Esq. Sept. 14th.-The patient had passed a restless 1. As to in the much the duration of ischuria. On Tuesday morning’, same less and the state, tongue perhaps creamy brown surface more distinct; cough, which she had not the 15th, the patient told me she had passed no urine since complained of before, was rather troublesome, expectoration Thursday, the 10th. But I think her memory had failed, frothy. On percussion, there was no unusual dulness over and that her statement to Mr. Bryan on the evening of the the lungs. On auscultation, there was crepitation posteriorly 12th, that she had passed no urine since the day before, was and inferiorly on the right side; other parts of the chest the more correct one. The patient died on the evening of normal; breathing free, and respiratory movements not the 1 ith-i. e., the fifth day after the suppression of the hurried. Still complained of her limbs aching much; no urinary secretion. 2. to the presence of icterus. This was not due to any urine passed; no uneasy feelings or dulness on percussion obstruction to the passage of bile, which was present in the over the hypogastric region; pulse quick and weak, 105. A diuretic mixture, containing carbonate of ammonia, &c., was alvine excretions, apparently in the normal quantity. Was sent, to be taken every four hours. Also to take beef-tea, it not due to the same cause which produced the ischuria, ? A Dr. Abercrombie* remarks that there are some cases of small quantities of gin at stated intervals, grapes, &c. mustard poultice was ordered to the back of the chest, and icterus which are analogous to ischuria renalis ; the separathe steam from boiling water was diffused through the room. tion of bile from the blood being interrupted in the former I also recommended a warm hip-bath, which she had, and as the urinary secretion is in the latter. This was a case in felt more comfortable after.-Evening : Still no urine had which the two were combined, and probably from the same influence acting on the nerves of organic life. passed. I sent a podophyllin and colocynth pill, to be taken inhibitory 3. On the absence of lethargy, convulsions or coma, which at bedtime. 15th.-I met Mr. Mann, of Charterhouse-square, in con- usually terminate cases of ischuria renalis. The explanation sultation. The patient had a pulse of 88 to 100; no urine of this is to be sought in the concurrence of similar disease had passed; the bowels had acted slightly, the stool being in two important organs, in the presence of low pneumonia, of a brownish colour and tinged with bile, and rather liquid. and in the advanced age and previous decay of the patient, The crepitation had now spread to the middle, as well as to which caused her to sink before these symptoms had time the lower lobe of the right side. Sputa as before; slight to be developed. sickness; the conjunctiva and skin of a yellowish tint; abdomen resonant on percussion. We ordered her to take NOTES OF A CASE OF KERATITIS. beef-tea., milk, gin in larger quantities, and sent her a purto an be taken immediately; gative draught, effervescing BY M. CHARTERIS, M.D., diuretic mixture, to be taken every four hours; and a merASSISTANT-SURGEON, GLASGOW EYE INFIRMARY. curial and colocynth pill, to be taken every six hours ; mustard-and-linseed poultices to the chest.-5 P.M.: We again IN Mr. Hutchinson’s clinical record of cases of keratitis, met in consultation. The pulse was 110 to 120, and the heat of skin was increased; bowels unrelieved.-10 P.M.: which he ascribes to hereditary syphilis, only two cases are The patient seemed in much the same state. I sent her a mentioned in which the subjects of this peculiar malady are turpentine-and-camphor liniment, to be well rubbed over reported to have had children. Doubtless, this is in a great the loins and abdomen. measure due to the fact that keratitis occurs, as a rule, be16th.-I was suddenly called up at 2 A.M. Mrs. Rfore marriageable years, and that those who have been had, with assistance, got out of bed to use the enema appa- attacked by the disease are lost sight of after the affection ratus ; she was left for a moment sitting on a chair, and, whilst unsupported, fainted, and fell upon the floor. WhenI has been cured or palliated. Assuming the syphilitic origin I saw her she was in bed, but with a pulse scarcely to be of the disease to be a correct inference, I am somewhat at felt. Stimulants were administered. At 10 A.M., as no a loss to account for the non-transmissibility of the poison urine had passed, I introduced the catheter, and drew off to the children in the following case, which lately came barely 6 oz. of smoky-looking urine, the last few drops being under my observation. very thick. She expressed herself as relieved after the operaM. G-, aged thirty, has had keratitis for the last ten tion. Pulse very irregular, thready, fluttering, 130; heart’s action irregular and tumultuous ; sickness more urgent ; years, the affection being subject to various relapses. For six years she has been an out-patient of the Glasgow Eye tongue clearing at the tip, where it was red; hands very cold and clammy, and she was noticed to be restless with Infirmary, presenting herself at the institution at intervals, the disease appeared in any aggravated inflamthem, continually smoothing the bedclothes ; skin intensely or whenever form. At the time I first saw her, about two months matory and less and easier, sputa yellow, perspiring freely; cough in quantity. I ordered her to take brandy and soda water ago, both eyes presented the dim, ground-glass appearance keratitis. The two upper central incisor teeth were very (instead of gin), and stimulants at intervals were given, and of ice to be sucked; also a diuretic mixture ; and, later in the typical: they were peg-shaped, notched vertically, and set The bridge of the nose was to one another. day, calf’s-foot jelly. At 10 P.M. the sickness had abated angularly and the general contour of the face exhibited all sunken, I minims of nitric ether then added considerably. twenty the peculiarities which Mr. Hutchinson has so faithfully to each dose of her mixture. 17th.-The bowels had been opened four times during the delineated. She had no glandular enlargement, nor was She has been any evidence of hereditary struma. night, the stools being small in quantity, brownish, tinged there six years, and has had three children; the eldest married with bile, and chiefly liquid. Pulse very regular, about 98, being alive, and the youngest having died during dentiscarcely to be felt ; sickness much relieved. No urine having two me that her children were quite healthy, tion. passed, I again introduced the catheter, but found nothing. and a She assured personal visit to her house satisfied me of the truth of Skin and conjunctiva less yellow; great prostration. Omit the pills.-6 r.M.: The bowels had been opened three times her statement. The eldest, a boy, was a strong, well-made, little fellow. The second child, a girl aged during the day. Chlorodyne draught, with ammonia, to be rosy-cheeked taken directly.-9.20 P.M.: I was hastily summoned, and four years, had all the evidences of good health and a good found she had just breathed her last, without a struggle or constitution. The father and mother of M. G- were alive and well, and they assured me they had always enjoyed apparent pain. * This case is peculiar from the absence, towards the end, Diseases of the Abdomen, 3rd edition, p. 367.
night;
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158 excellent health, and had never had any eruptive or othei disease. They had had two children, M. G- being th( elder. The younger also was married, and was the mother of two healthy children. From the history of this case, thus briefly indicated, i1 may be seen that the cause of keratitis in the patient undei observation was as obscure as the non-transmissibility of the syphilitic poison (?) to her children was remarkable. G!asg’Mv, Nov. 9th, 1868.
of the canula was at once occluded with the thumb, and the instrument withdrawn. During the latter part of the operation the patient complained of a deep sense of aching in the region of the liver. A flannel bandage was at once applied to fix the abdominal muscles, and a full opiate administered. About six hours later the patient had two sharp rigors, and lay with his knees drawn up in dorsal decubitus. The belly generally was tympanitic, and somewhat tender. The aspect was that of shock; the pulse had risen to 104, the temperature to 100°. An additional opiate A fair night followed; and the next morning was given. the temperature had fallen, and the abdominal tenderness On the was less ; his pulse, however, had risen to 120. second day from the operation the pulse ratio began to OF THE PRACTICE OF slacken, and from that time forth he had no unpleasant symptoms. On the fifth day a physical examination showed a diminution of 212 in. in the vertical dulness, and of in. MEDICINE AND SURGERY in the semicircumference. The man has continued under IN THE observation till the present time. The vertical dimension has since fallen an additional half inch; and he is comHOSPITALS OF LONDON. pletely comfortable. remarked upon this case: — ’ The only dianoseendi autem est alia certo nisi Nulla pro via, quamplurimas et morborum which we had to contend with consisted et dissectionum historias, tum aliorum, turn proprias colleetas habere, et gnostic difficulty inter se eompMai’e.—MoBGAMn: De S’ed, et Cans. o?-5., lib. iv. Procemium. in the deformity of the chest by the rickety softening and distortion of its walls. It served to bring out in strong relief the value to be attached to the great conKING’S COLLEGE HOSPITAL. vexity of the upper line of dulness. This, together with the great increase of the vertical dimensions of the liver, HYDATID TUMOUR OF THE LIVER TREATED BY SIMPLE the slight bulge below the costal cartilages, the almost PUNCTURE. character of the swelling, and the general good painless (Under the care of Dr. DUFFIN.) health of the patient, constituted the foundation of the THE following case aptly illustrates the value of the diagnosis. In determining the propriety of an operation, method of puncture with the small trocar in the treatment the probable absence of adhesions had to be borne in mind; but if puncture with a very fine trocar be resorted to, I of cases of hydatid tumour of the liver :believe that little importance need be attached to that cirS. R-,aged twenty-seven, a man of rickety build, but cumstance. With a few simple precautions, the chance of otherwise of a sound constitution, applied at King’s College any hydatid fluid escaping into the peritoneal sac may be almost to the vanishing point. One of the moments Hospital on October 13th, 1868, complaining of indigestion reduced and aching pains about the right side and shoulder. On of greatest danger is that of the withdrawal of the canula. As it quits the liver charged with hydatid fluid it should be examining the spot indicated the right inferior mammary occluded with the finger, and so brought out loaded with and hypochondriac regions were found to bulge consider- its contents. At the same moment the abdominal wall ably, and the hepatic dulness extended vertically downwards should be firmly pressed against the liver. The elasticity from the nipple over a space of nine inches and a quarter. of the hydatid exocyst is so great that only an extremely The possibility of a hydatid tumour was at once opened up, minute portion of fluid is likely to follow the canula. The smaller the instrument selected, the less will be the chance but the necessity of great caution in the diagnosis became of any hsemorrhage; and it is further remarkable how toleat the same time manifest, owing to the extreme deformity rant the peritoneum is of blood as contrasted with other the thorax had undergone during childhood from the process fluids. Another advantage of a very fine canula is, that the of rachitis, and from the existence of considerable lateral fluid leaves the hydatid cyst very gradually. This will be curvature of the spine. These rendered all transverse mea- obvious if we consider the vascularity of the organ implisurements next to worthless. Nevertheless a relative in- cated, and the changes in its relations that the withdrawal crease of half an inch in the right semicircmnference could of a considerable amount of fluid must necessarily occasion. be established. This proved to be half an inch below the Neither is it necessary to evacuate the cyst completely. line of the costal cartilages. Much more valuable informa- Even with a very partial emptying, it is probable that the tion was obtained on tracing the upper limit of the dull elasticity of the exocyst can peel off and fold the endocyst This was found to represent a curve, with its con- so as to interfere with its vascular supply, and ultimately axea. vexity directed upwards, and reaching its highest point at induce its degeneration. Next in importance to the method the fourth right rib a little outside the nipple. From this, of the operation stands the most complete rest of the abdoits greatest point of elevation, the line-trended sharply minal viscera which can be obtained. Hence I would downwards and backwards to the tenth rib, and downwards strongly recommend fixing the abdominal walls with a flanand inwards to the xiphoid cartilage. The lower edge of nel bandage, and the immediate administration of a free the liver was sharp and supple, and convex in the opposite opiate. In the instance before us some rigors, general abdirection. The summit of the bulge thus corresponded to dominal tenderness, and slight febrile signs, ensued a few the centre of the organ, and at this point an obscure sense hours subsequent to the operation. Within twenty-four of fluctuation could be detected. Beyond the pushing up- hours, however, all threat of danger had passed away. wards of the right leaf of the diaphragm, no notable visceral Something similar to this has been so frequently noted after displacement existed. Vesicular breathing could be traced this method of interference that it may be considered almost to the upper edge of the dulness. The only annoyance com- as the rule. Provided the temperature does not exceed 101°, plained of was an indistinct sense of aching in the hepatic I believe it need not alarm us. I am inclined to ascribe it to region. The inferior edge of the dull space was found to the great change in the relations of the portal system which vary its position slightly with the movements of respiration the decrease of pressure within the liver must necessarily and the changes of posture of the patient, giving presump- entail. It is too transient and too frequently observed to tive evidence of the absence of adhesions. The rest of the be attributable to aborted peritonitis. According to the evidence was mainly negative. Neither ascites, jaundice, statistics collected by Dr. Murchison, a first puncture is also a final one six times out of seven. Should a second be nor evidence of infection existed. After a consultation with Mr. Henry Smith, Dr. Duffin requisite, no additional risk is involved in a repetition of requested that gentleman to make an exploratory puncture the first process. If suppuration of the cyst supervene, with a long, fine trocar and canula. Twenty-eight ounces free evacuation should of course be at once resorted to. The of a clear, transparent, watery fluid were readily withdrawn. accident happened, according to Dr. Murchison’s statistics, This proved to contain numerous echinococci and free hook- ten times out of forty-six, but even in seven of these free lets. As soon as the jet of liquid began to slacken, the end emptying of the cyst was followed by a favourable result." ,
A Mirror
Dr. Dunin
subsequent
night;
I
As
158 excellent health, and had never had any eruptive or othei disease. They had had two children, M. G- being th( elder. The younger also was married, and was the mother of two healthy children. From the history of this case, thus briefly indicated, i1 may be seen that the cause of keratitis in the patient undei observation was as obscure as the non-transmissibility of the syphilitic poison (?) to her children was remarkable. G!asg’Mv, Nov. 9th, 1868.
of the canula was at once occluded with the thumb, and the instrument withdrawn. During the latter part of the operation the patient complained of a deep sense of aching in the region of the liver. A flannel bandage was at once applied to fix the abdominal muscles, and a full opiate administered. About six hours later the patient had two sharp rigors, and lay with his knees drawn up in dorsal decubitus. The belly generally was tympanitic, and somewhat tender. The aspect was that of shock; the pulse had risen to 104, the temperature to 100°. An additional opiate A fair night followed; and the next morning was given. the temperature had fallen, and the abdominal tenderness On the was less ; his pulse, however, had risen to 120. second day from the operation the pulse ratio began to OF THE PRACTICE OF slacken, and from that time forth he had no unpleasant symptoms. On the fifth day a physical examination showed a diminution of 212 in. in the vertical dulness, and of in. MEDICINE AND SURGERY in the semicircumference. The man has continued under IN THE observation till the present time. The vertical dimension has since fallen an additional half inch; and he is comHOSPITALS OF LONDON. pletely comfortable. remarked upon this case: — ’ The only dianoseendi autem est alia certo nisi Nulla pro via, quamplurimas et morborum which we had to contend with consisted et dissectionum historias, tum aliorum, turn proprias colleetas habere, et gnostic difficulty inter se eompMai’e.—MoBGAMn: De S’ed, et Cans. o?-5., lib. iv. Procemium. in the deformity of the chest by the rickety softening and distortion of its walls. It served to bring out in strong relief the value to be attached to the great conKING’S COLLEGE HOSPITAL. vexity of the upper line of dulness. This, together with the great increase of the vertical dimensions of the liver, HYDATID TUMOUR OF THE LIVER TREATED BY SIMPLE the slight bulge below the costal cartilages, the almost PUNCTURE. character of the swelling, and the general good painless (Under the care of Dr. DUFFIN.) health of the patient, constituted the foundation of the THE following case aptly illustrates the value of the diagnosis. In determining the propriety of an operation, method of puncture with the small trocar in the treatment the probable absence of adhesions had to be borne in mind; but if puncture with a very fine trocar be resorted to, I of cases of hydatid tumour of the liver :believe that little importance need be attached to that cirS. R-,aged twenty-seven, a man of rickety build, but cumstance. With a few simple precautions, the chance of otherwise of a sound constitution, applied at King’s College any hydatid fluid escaping into the peritoneal sac may be almost to the vanishing point. One of the moments Hospital on October 13th, 1868, complaining of indigestion reduced and aching pains about the right side and shoulder. On of greatest danger is that of the withdrawal of the canula. As it quits the liver charged with hydatid fluid it should be examining the spot indicated the right inferior mammary occluded with the finger, and so brought out loaded with and hypochondriac regions were found to bulge consider- its contents. At the same moment the abdominal wall ably, and the hepatic dulness extended vertically downwards should be firmly pressed against the liver. The elasticity from the nipple over a space of nine inches and a quarter. of the hydatid exocyst is so great that only an extremely The possibility of a hydatid tumour was at once opened up, minute portion of fluid is likely to follow the canula. The smaller the instrument selected, the less will be the chance but the necessity of great caution in the diagnosis became of any hsemorrhage; and it is further remarkable how toleat the same time manifest, owing to the extreme deformity rant the peritoneum is of blood as contrasted with other the thorax had undergone during childhood from the process fluids. Another advantage of a very fine canula is, that the of rachitis, and from the existence of considerable lateral fluid leaves the hydatid cyst very gradually. This will be curvature of the spine. These rendered all transverse mea- obvious if we consider the vascularity of the organ implisurements next to worthless. Nevertheless a relative in- cated, and the changes in its relations that the withdrawal crease of half an inch in the right semicircmnference could of a considerable amount of fluid must necessarily occasion. be established. This proved to be half an inch below the Neither is it necessary to evacuate the cyst completely. line of the costal cartilages. Much more valuable informa- Even with a very partial emptying, it is probable that the tion was obtained on tracing the upper limit of the dull elasticity of the exocyst can peel off and fold the endocyst This was found to represent a curve, with its con- so as to interfere with its vascular supply, and ultimately axea. vexity directed upwards, and reaching its highest point at induce its degeneration. Next in importance to the method the fourth right rib a little outside the nipple. From this, of the operation stands the most complete rest of the abdoits greatest point of elevation, the line-trended sharply minal viscera which can be obtained. Hence I would downwards and backwards to the tenth rib, and downwards strongly recommend fixing the abdominal walls with a flanand inwards to the xiphoid cartilage. The lower edge of nel bandage, and the immediate administration of a free the liver was sharp and supple, and convex in the opposite opiate. In the instance before us some rigors, general abdirection. The summit of the bulge thus corresponded to dominal tenderness, and slight febrile signs, ensued a few the centre of the organ, and at this point an obscure sense hours subsequent to the operation. Within twenty-four of fluctuation could be detected. Beyond the pushing up- hours, however, all threat of danger had passed away. wards of the right leaf of the diaphragm, no notable visceral Something similar to this has been so frequently noted after displacement existed. Vesicular breathing could be traced this method of interference that it may be considered almost to the upper edge of the dulness. The only annoyance com- as the rule. Provided the temperature does not exceed 101°, plained of was an indistinct sense of aching in the hepatic I believe it need not alarm us. I am inclined to ascribe it to region. The inferior edge of the dull space was found to the great change in the relations of the portal system which vary its position slightly with the movements of respiration the decrease of pressure within the liver must necessarily and the changes of posture of the patient, giving presump- entail. It is too transient and too frequently observed to tive evidence of the absence of adhesions. The rest of the be attributable to aborted peritonitis. According to the evidence was mainly negative. Neither ascites, jaundice, statistics collected by Dr. Murchison, a first puncture is also a final one six times out of seven. Should a second be nor evidence of infection existed. After a consultation with Mr. Henry Smith, Dr. Duffin requisite, no additional risk is involved in a repetition of requested that gentleman to make an exploratory puncture the first process. If suppuration of the cyst supervene, with a long, fine trocar and canula. Twenty-eight ounces free evacuation should of course be at once resorted to. The of a clear, transparent, watery fluid were readily withdrawn. accident happened, according to Dr. Murchison’s statistics, This proved to contain numerous echinococci and free hook- ten times out of forty-six, but even in seven of these free lets. As soon as the jet of liquid began to slacken, the end emptying of the cyst was followed by a favourable result." ,
A Mirror
Dr. Dunin
subsequent