SUSSEX COUNTY HOSPITAL, BRIGHTON.
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125 plete loss of appetite. Chest-sounds normal; no cough. Urine clear; no albumen. He was ordered a mixture con- taining nitro-muriatic acid, opium, and logwood; and for diet, two pints of beef-tea, two pints of milk, egg, and six ounces of wine. May 15th.-Less flatus and pyrosis; the stools still average fourteen a day, and contain blood and slime. He was then put on a course of ipecacuanha, but this increased the vomiting, and was changed for a mixture containing carbonate of soda, dilute hydrocyanic acid, and bismuth. From the 18th to the 28th the average of stools decreased to nine daily, but the pyrosis had increased; accordingly salphite of soda was added to his mixture, which gave immediate relief. The vomiting and eructation almost ceased, and the average of stools was only five a day during the next week. June 5th.—Says he feels much better and stronger ; his appetite has improved. The stools are still loose, but very little slime; no blood. This improvement was, however, only temporary. The next week the stools averaged nine per diem, and the week following twenty-three. They contained some slime, but no blood, were of natural colour, but very loose. He had no pain or abdominal tenderness, and his temperature, which was taken repeatedly during his stay in hospital, never exceeded 997°, whilst the mean range was 98.6°. He never complained of rigors, neither was sweating observed, and there was no tenderness on pressure over the hepatic region, the only pain complained of being referred to the left hypochondrium and along the course of the descending colon. The patient died of exhaustion July 6th. Post-mortem examination.—The contents of the thorax, with the exception of four ounces of clear serum in the right pleura, were healthy. The right lobe of the liver was closely adherent to the diaphragm, and the under surfaee of the left lobe of the liver was adherent to the lesser curva- ture of the stomach. On opening the stomach an aperture with smooth edges, as large as a crown piece, existed at the point of adhesion, and led into a cavity on the under surface of the left lobe of the liver, large enough to hold four ounces of water, and bounded by ragged and apparently ulcerated liver-tissue. The upper surface of the right lobe of the liver posteriorly was adherent to the diaphragm. In endeavouring to remove it from the body by dissecting away from the ribs, the diaphragm was cut through, and about fourteen ounces of thick odourless pus were evacuated from an abscess existing in the upper portion of the right lobe of the liver. In addition several smaller abscesses were scat- tered through the hepatic substance, varying in size from a pea to a filbert. The liver, after the evacuation of the large abscess, weighed five pounds; spleen seven ounces, soft; kidneys thirteen ounces, healthy. The mucous mem- brane of the large intestine was thickly studded with ulcers (follicular), each about the size of the thumb-nail, and some- what transversely arranged, with floor and edges ragged. The walls of the intestine were thickened, and the sacculi obliterated. Remarks.-Dr. Ralfe observed that in this case two charac- teristic symptoms of abscess of the liver were wanting- pyrexia and regional pain. Dr. Murchison, in his Lectures on Diseases of the Liver, records two instances of absence of pyrexia in abscess of the liver, and in one (Case 83) the abscess at the time had attained an enormous sizp, and was rapidly increasing. Dr. Murchison finds it difficult to account for the absence of pyrexia in these exceptional cases except on the supposition that the morbid process here entails the destruction of an organ which contributes in part to the maintenance of animal heat"; and yet, as Dr. Murchison observes, " so far as we know, temperature is elevated in most large abscesses of the liver." It should be observed that in this case the diarrhoea was severe and per- sistent, which may in some measure have had effect in check- ing elevation of temperature. But if it is difficult to ac- count for the absence of pyrexia in this case, it is still more so to account for absence of pain. The patient up to the very last got readily in and out of bed, and allowed firm pressure to be made over the right hypochondrium. The absence of these two characteristic symptoms renders this case of clinical importance, as showing that extensive sup- puration may occur in the liver without giving rise to pyrexia or pain. SUSSEX COUNTY HOSPITAL, BRIGHTON. CASE OF CALCIFICATION OF THE THYROID GLAND. (Under the care of Dr. KEBBELL.) THE subject of this disease was a woman of about fifty years of age, who had had a bronchocele for twenty years, and had been out of health for some considerable time. When admitted into the hospital she was much reduced in strength and flesh, with a sallow cachectic appearance, and died in a few days. The whole surface of the gland was as hard as a bit of marble, and the abdomen was full of large hard tumours. These tumours were found after death to be situated in the mesentery, and contained a soft cheesy pultaceous fluid of about the consistence of thick cream, such as is seen in the tuberculous or strumous degenera- tion of the mesenterio glands of children, but without, as far as could be seen, any calcareous deposit. The thyroid gland, at least the surface of it, was so hard that the saw could hardly be got into it. The interior of the tumour consisted of a yellowish pultaceous matter, of various degrees of consistency, and was evidently undergoing the same pro- cess of degeneration. If this woman had lived long enough there is little doubt that the whole gland would have be- come an amorphous mass of calcareous matter. In explaining the difference between calcification and ossification Dr. Kebbell stated that in the latter there is an active change in the tissue tending to the formation of regular osseous structure ; while calcification, on the other hand, is a purely passive process-simply a deposit of cal- careous particles, without any change of structure. PROVIDENT INFIRMARY, BOSCOMBE, BOURNEMOUTH. POPLITEAL ANEURISM ; OPERATION ; RECOVERY. (Under the care of Mr. H. GUNTON TURNER.) THE subject of the above disease, a married man, a plas- terer, aged thirty-nine, but looking considerably older, was admitted on March 27th of the present year. He was pale and ansemic, and complained of considerable pain and swelling behind the right knee. Otherwise he was a fairly- nourished, well-formed man, and stated that he had always enjoyed good health, but had been intemperate from the age of twenty-five till within a month of his admission, when he became a total abstainer. His beverage was mostly beer, rarely spirits. His father died from some pulmonary affection, and his mother from morbus cordis. He had lost two sisters-one from burn, the other from some cause un- known. One brother and three sisters were living, and all healthy. There was no history of syphilis or rheumatic fever. Upon examination, a pulsating tumour with a decidedly marked thrill was found in the popliteal space of the right leg, attended by considerable oedema extending downwards to the foot. At the same time a loud diastolic aortic murmur was heard over the greater part of the chest, but most distinctly over the second sterno-costal articulation, while the first sound was remarkably muflled. The apex- beat was felt between the fifth and sixth ribs, and the arterial tension was very marked. The urine showed no trace of albumen. When questioned, he stated that he had first noticed shortness of breath, while taking ordinary exertion, about a year since. A month previous to admis- sion, he first became aware of a throbbing at the back of the knee when engaged in work, which necessitated kneeling. Subsequently, finding the throbbing continue, his attention was directed to a swelling in the popliteal space, and, a little more than a week before admission, on coming down a ladder, he was unaware that two of the rounds were missing, the result being that his leg slipped through the ladder and was violently jerked, after which the swelling increased rapidly. Until April 4th he was kept in bed with the leg flexed, and fed exclusively on milk, of which he consumed daily some six or seven pints. On that day, pressure by two tourniquets was applied, a horseshoe compressing the artery just below Poupart’s ligament, and a " Skey " at the apex
Transcript of SUSSEX COUNTY HOSPITAL, BRIGHTON.
125
plete loss of appetite. Chest-sounds normal; no cough.Urine clear; no albumen. He was ordered a mixture con-
taining nitro-muriatic acid, opium, and logwood; and fordiet, two pints of beef-tea, two pints of milk, egg, and sixounces of wine.May 15th.-Less flatus and pyrosis; the stools still
average fourteen a day, and contain blood and slime. Hewas then put on a course of ipecacuanha, but this increasedthe vomiting, and was changed for a mixture containingcarbonate of soda, dilute hydrocyanic acid, and bismuth.From the 18th to the 28th the average of stools decreased
to nine daily, but the pyrosis had increased; accordinglysalphite of soda was added to his mixture, which gaveimmediate relief. The vomiting and eructation almostceased, and the average of stools was only five a day duringthe next week.June 5th.—Says he feels much better and stronger ; his
appetite has improved. The stools are still loose, but verylittle slime; no blood.This improvement was, however, only temporary. The
next week the stools averaged nine per diem, andthe week following twenty-three. They contained someslime, but no blood, were of natural colour, but veryloose. He had no pain or abdominal tenderness, and his
temperature, which was taken repeatedly during his stayin hospital, never exceeded 997°, whilst the mean rangewas 98.6°. He never complained of rigors, neither wassweating observed, and there was no tenderness on pressureover the hepatic region, the only pain complained of beingreferred to the left hypochondrium and along the course ofthe descending colon.The patient died of exhaustion July 6th.Post-mortem examination.—The contents of the thorax,
with the exception of four ounces of clear serum in the rightpleura, were healthy. The right lobe of the liver was
closely adherent to the diaphragm, and the under surfaeeof the left lobe of the liver was adherent to the lesser curva-ture of the stomach. On opening the stomach an aperturewith smooth edges, as large as a crown piece, existed atthe point of adhesion, and led into a cavity on the undersurface of the left lobe of the liver, large enough to holdfour ounces of water, and bounded by ragged and apparentlyulcerated liver-tissue. The upper surface of the right lobeof the liver posteriorly was adherent to the diaphragm. In
endeavouring to remove it from the body by dissecting awayfrom the ribs, the diaphragm was cut through, and aboutfourteen ounces of thick odourless pus were evacuated froman abscess existing in the upper portion of the right lobe ofthe liver. In addition several smaller abscesses were scat-tered through the hepatic substance, varying in size froma pea to a filbert. The liver, after the evacuation of thelarge abscess, weighed five pounds; spleen seven ounces,soft; kidneys thirteen ounces, healthy. The mucous mem-brane of the large intestine was thickly studded with ulcers(follicular), each about the size of the thumb-nail, and some-what transversely arranged, with floor and edges ragged.The walls of the intestine were thickened, and the sacculiobliterated.Remarks.-Dr. Ralfe observed that in this case two charac-
teristic symptoms of abscess of the liver were wanting-pyrexia and regional pain. Dr. Murchison, in his Lectureson Diseases of the Liver, records two instances of absenceof pyrexia in abscess of the liver, and in one (Case 83) theabscess at the time had attained an enormous sizp, andwas rapidly increasing. Dr. Murchison finds it difficultto account for the absence of pyrexia in these exceptionalcases except on the supposition that the morbid processhere entails the destruction of an organ which contributesin part to the maintenance of animal heat"; and yet, as Dr.Murchison observes, " so far as we know, temperature iselevated in most large abscesses of the liver." It should beobserved that in this case the diarrhoea was severe and per-sistent, which may in some measure have had effect in check-ing elevation of temperature. But if it is difficult to ac-count for the absence of pyrexia in this case, it is still moreso to account for absence of pain. The patient up to thevery last got readily in and out of bed, and allowed firmpressure to be made over the right hypochondrium. Theabsence of these two characteristic symptoms renders thiscase of clinical importance, as showing that extensive sup-puration may occur in the liver without giving rise topyrexia or pain.
SUSSEX COUNTY HOSPITAL, BRIGHTON.CASE OF CALCIFICATION OF THE THYROID GLAND.
(Under the care of Dr. KEBBELL.)
THE subject of this disease was a woman of about fiftyyears of age, who had had a bronchocele for twenty years,and had been out of health for some considerable time.When admitted into the hospital she was much reduced instrength and flesh, with a sallow cachectic appearance, anddied in a few days. The whole surface of the gland was ashard as a bit of marble, and the abdomen was full of largehard tumours. These tumours were found after death to besituated in the mesentery, and contained a soft cheesypultaceous fluid of about the consistence of thick cream,such as is seen in the tuberculous or strumous degenera-tion of the mesenterio glands of children, but without, asfar as could be seen, any calcareous deposit. The thyroidgland, at least the surface of it, was so hard that the sawcould hardly be got into it. The interior of the tumourconsisted of a yellowish pultaceous matter, of various degreesof consistency, and was evidently undergoing the same pro-cess of degeneration. If this woman had lived long enoughthere is little doubt that the whole gland would have be-come an amorphous mass of calcareous matter.In explaining the difference between calcification andossification Dr. Kebbell stated that in the latter there is anactive change in the tissue tending to the formation of
regular osseous structure ; while calcification, on the otherhand, is a purely passive process-simply a deposit of cal-careous particles, without any change of structure.
PROVIDENT INFIRMARY, BOSCOMBE,BOURNEMOUTH.
POPLITEAL ANEURISM ; OPERATION ; RECOVERY.
(Under the care of Mr. H. GUNTON TURNER.)THE subject of the above disease, a married man, a plas-
terer, aged thirty-nine, but looking considerably older, wasadmitted on March 27th of the present year. He was paleand ansemic, and complained of considerable pain andswelling behind the right knee. Otherwise he was a fairly-nourished, well-formed man, and stated that he had alwaysenjoyed good health, but had been intemperate from theage of twenty-five till within a month of his admission,when he became a total abstainer. His beverage was mostlybeer, rarely spirits. His father died from some pulmonaryaffection, and his mother from morbus cordis. He had losttwo sisters-one from burn, the other from some cause un-known. One brother and three sisters were living, and allhealthy. There was no history of syphilis or rheumaticfever.Upon examination, a pulsating tumour with a decidedly
marked thrill was found in the popliteal space of the rightleg, attended by considerable oedema extending downwardsto the foot. At the same time a loud diastolic aorticmurmur was heard over the greater part of the chest, butmost distinctly over the second sterno-costal articulation,while the first sound was remarkably muflled. The apex-beat was felt between the fifth and sixth ribs, and thearterial tension was very marked. The urine showed notrace of albumen. When questioned, he stated that he hadfirst noticed shortness of breath, while taking ordinaryexertion, about a year since. A month previous to admis-sion, he first became aware of a throbbing at the back of theknee when engaged in work, which necessitated kneeling.Subsequently, finding the throbbing continue, his attentionwas directed to a swelling in the popliteal space, and, alittle more than a week before admission, on coming down aladder, he was unaware that two of the rounds were missing,the result being that his leg slipped through the ladder andwas violently jerked, after which the swelling increasedrapidly.
Until April 4th he was kept in bed with the leg flexed,and fed exclusively on milk, of which he consumed dailysome six or seven pints. On that day, pressure by twotourniquets was applied, a horseshoe compressing the arteryjust below Poupart’s ligament, and a " Skey " at the apex
