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¶ 1 Leave a comment on paragraph 1 0 344

¶ 2 Leave a comment on paragraph 2 0 THE LONDON PRACTICE OF MEDICINE AND SURGERY.

¶ 3 Leave a comment on paragraph 3 1 should be deferred until, after the free action of a purgative, a second examination has been instituted..

¶ 4 Leave a comment on paragraph 4 1 We have introduced the above remarks in this part of the series, among the examples of tumours resulting from accumulation of inflammatory products, because it is for such that these fictitious enlargements will generally be mistaken. Cases of typhlitis are perhaps those with which, more especially, they are likely to be confounded, and, next to them, tumours springing from the kidney or abscesses in that organ. We shall now proceed with the series in order, taking next cases in which the suppuration was connected with the liver.

0. ¶ 5 Leave a comment on paragraph 5 0
1. Case 15. —LARGE CHRONIC ABSCESS IN THE LIVER, IN A MAN WHO HAD BEEN THE SUBJECT OF CANCER OF THE PENIS.—DEATH.—AUTOPSY.

¶ 6 Leave a comment on paragraph 6 0 [Under the care of Dr. BARLOW.]

¶ 7 Leave a comment on paragraph 7 3 Henry Andrews, aged 34, a tall, dark-complexioned man, was admitted on August 10, 1853. His aspect was that of a man suffering from an advanced stage of malignant disease, and he was, in addition, somewhat jaundiced. The abdomen was much distended, and the legs were also slightly oedematous; but the upper extremities and thorax were extremely emaciated. It appeared that he had formerly been a private in the army, and had served in India; his habits had been very intemperate, and he had suffered much from illness. A year ago he had been an inmate of St. Mary’s Hospital, and had there submitted to amputation of the penis on account of cancerous disease of the glans.(a) At the same time, he suffered from the swelling of the abdomen, and, after recovery from the operation, had been an inmate of the Physicians’ ward on account of it. Since the operation, he had had no trouble with the urinary apparatus, and there had been no signs of return of the disease, either in the remaining portion of the penis or in the glands. He had, however, continued to lose flesh, and distension of the belly had increased. Dr. Barlow examined the abdomen very carefully. It was so much distended with fluid that it was difficult to ascertain the exact position of the viscera; but it was evident, either that the liver was much displaced, or that there was a large solid tumour in the right hypochondriac region. An accurate diagnosis could not be formed: but, judging from the account of his having already suffered from cancer, and from the state of his general health, the inference of malignant disease seemed not improbable. The conjecture was also supported by the circumstance, that his left testis contained a firmish tumour, about the size of a half walnut.

¶ 8 Leave a comment on paragraph 8 1 This man remained under cate, without material change, excepting that he got weaker and weaker, from August 10 to October 11, on which last date death rather suddenly took place. It had been evident from the first that the case was a hopeless one, and the treatment had consisted mainly in the administra tion of remedies for the relief of cough and of the violent abdominal pain from which he suffered. The condition of his abdomen remained as at first; and, indeed, from the increase of the ascites it became towards the end additionally difficult to form an opinion as to the exact nature of the tumour.

¶ 9 Leave a comment on paragraph 9 1 The autopsy was performed on October 12, by Dr. Habershon, and Dr. Wilkes was kind enough to furnish us with the following brief particulars respecting it:—The peritoneal sac was distended with clear serum. The liver adhered closely to the diaphragm, and was in all parts cirrhosed to a slight degree. In its right lobe was a mass the size of an infant’s head, which proved to be a dense, almost cartilaginous cyst, containing stuff which appeared like a mixture of concrete tubercle and pus. This tumour had involved the diaphragm, and partly destroyed it, the lung above being closely adherent. The first thought suggested was, that the cyst and its contents were the remains of a degenerated hydatid; but on further examination this view was not supported. The fibrinous walls of the cyst were very firm, and gradually merged into the liver tissue. In the left testis was a circumscribed collection of precisely similar deposit.

¶ 10 Leave a comment on paragraph 10 1 Remarks.—In the above case, the primary cancer had been of a kind (the epithelial) which with extreme rarity is deposited in the internal organs; there was not, therefore, much ground for supposing the abdominal tumour to have had any connexion with it. That another form of cancer was also present did not seem so improbable, and the tumour in the left testis was naturally suggestive of secondary growth from the lumbar glands, and very possibly from the liver also. The real nature of the disease had probably

¶ 11 Leave a comment on paragraph 11 1 been an abscess in the first place, the contents of which had been inspissated to a certain degree by absorption. The man had resided in hot climates, and had most likely there acquired a proclivity to hepatic disorder. The duration of the ascites, which was known to have been more than a-year, favoured the idea that the abscess had been of long standing. No doubt but that both the ascites and the jaundice had been occasioned by the compression of the ascending cava by the tumour.

¶ 12 Leave a comment on paragraph 12 0 (a) The operator, Mr. James Lane, was subsequently kind enough to inform us, in answer to inquiries respecting the disease for which the penis Was in this case removed, that it was a well characterised epithelial cancer.

¶ 13 Leave a comment on paragraph 13 0 ST. BARTHOLOMEW’S HOSPITAL.

0. ¶ 14 Leave a comment on paragraph 14 0
1. Case 16. —LARGE FLUCTUATING TUMOUR IN THE LEFT HYPOCHONDRIUM.— PUNCTURE.-FAVOURABLE PROGRESS. — DEATH FROM PLEURISY. — AUTOPSY.

¶ 15 Leave a comment on paragraph 15 0 [Under the care of Mr. LLOYD.]

¶ 16 Leave a comment on paragraph 16 5 A man of dark complexion, aged 45, was admitted in June, 1853, into Pitcairn Ward, suffering from a large and prominent tumour in the left hypochondrium. He had originally been of a powerful frame, and had mostly enjoyed good health; but his illness having then lasted several months, he had become much emaciated. His aspect was sallow and almost icteroid. It appeared, that about three months before, he had, while at work on board a vessel at the London Docks, been injured by the fall of a chest of tea, which struck him below the edge of the ribs on the left side. Much pain followed the injury, and within a few weeks afterwards he became subject to slight rigors. Subsequent to this a tumour gradually formed, and became perceptible externally; he also lost his flesh and strength. At the time of admission there was a distinct projection of the margins of the ribs on the left side, and beneath them a prominent swelling about the size of the extended hand might be seen. Percussion over this part gave a dull note, and the area of dulness was continued upwards without any interval until it joined that of the heart. Over the most prominent part of the swelling obscure fluctuation, as of fluid in a very tense, thick-walled cyst, might be felt. No abnormal sounds were heard on auscultation of the chest, but the lung on the left side appeared to be considerably pushed upwards. The man suffered from some dyspnoea, and had an anxious expression ; his tongue was moist and almost clean; pulse feeble and soft, 100 in the minute. About three weeks after admission, the tumour having meanwhile much increased in size and fluctuation, having become much more distinct, Mr. Lloyd determined not to defer the making of a puncture into it. The man had decidedly lost ground, and appeared, indeed, to be fast sinking. Mr. Lloyd selected the most prominent part of the swelling, about an inch below the margin of the ribs, and two inches to the left of the median line. A lancet puncture was first made, and considerably more than a pint of thin, gruel-like fluid having escaped, the operator then enlarged the opening with a bistoury, and examined the cavity by means of the finger, which could be passed freely in to its full length. The upper boundary of the cavity was, as afterwards proved, formed by the diaphragm, and so thin was this structure that a gentleman present, who, at Mr. Lloyd’s request, made an examination with his finger, believed that he had passed it directly into the pericardium, and that he had touched the heart itself. The man was rendered a little faint by the operation, but soon afterwards recovered, and appeared relieved. It had been thought not improbable before the puncture that the tumour might prove to be an hydatid cyst, which, in consequence of the injury received had suppurated, and the appearance of the fluid evacuated, although not containing any acephalo-cysts, rather tended to support that view. A very careful microscopic examination of the fluid was accordingly instituted by Mr. Lloyd, Mr. Paget, and several others, all of whom, however, failed to discover any either of the echinococci or their booklets. The fluid appeared to consist of thin serous pus, in which were mixed many little masses of adherent yellow globules, which could only be supposed to be derived from the bile. The inference, therefore, seemed unavoidable, that the case was one of hepatic abscess.

¶ 17 Leave a comment on paragraph 17 1 For several weeks after the operation the man continued in a very precarious state; profuse suppuration ensued, and oh several occasions there were symptoms as if of general peritonitis. By degrees, however, the discharge diminished in quantity, the tumour quite disappeared, and the greatest improvement in his general condition resulted. About two months after the puncture, at a time when he appeared to be making steady progress, symptoms of acute pleurisy on both sides set in, and from this disease, in the course of a few days, death resulted.