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Echinococcus of the Liver

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ECHINOCOCCUS OF THE LIVER.

is a woman, thirty-nine years old, who was admitted to the Presbyterian Hospital on June 8, i9oo. She stated that fifteen months before she began to suffer from abdominal pain, with loss of flesh and strength. A year ago she was admitted to the hospital, and her case was diagnosed as one of cyst of the liver, but she refused treatment. Five weeks ago she began to develop very severe pain in the right side of the abdomen ; this pain was constant, and increased upon lying down or deep inspiration. When in the recumbent position there was some dyspncea. There was marked loss of flesh and strength. The patient at times suffered from nausea, with occasional vomit ing, particularly upon lying down.

When the patient entered the hospital, her chief complaint was the pain. She was extremely emaciated and very weak. There was marked bulging of the lower right chest anteriorly and in both axillae, more pronounced on the right side. There was also distinct tenderness in the right axilla anteriorly and over the lower region. Percussion showed flatness over the right lung anteriorly, from the third rib to the base, with absence of breathing sounds over same area. Posteriorly, there was flatness from the angle of the scapula to the base, and on the left side from a point just below the angle to the base. Vocal fremitus and breathing sounds were absent on the right side, and much impaired on the left side. The right chest, just below the nipple, measured one and three-quarters inches more than the circumference of the corresponding portion of the left chest.

Palpation of the abdomen revealed a tumor, the lower border of which was at a level with the umbilicus. This area was dull on percussion and elastic to the touch. The corresponding por tion of the abdomen was rigid, especially the upper half. There was some cedema of the lower extremities. The urine contained 3 per cent. of albumen (by volume), with many granular casts. These disappeared after the operation.

Operation, June 8, 19oo. A vertical incision, two and one half inches long, was made over the right lobe of the liver, from the upper border of the ninth costal cartilage downward. The surface of the liver was found to be firmly adherent to the parietal peritoneum. An exploring-needle was inserted, and revealed the presence of turbid fluid. The opening along the needle was en larged, and several quarts of fluid containing many spherical trans parent globules were slowly evacuated without any appreciable effect on the pulse. The cavity, when emptied, was eleven inches in anteroposterior diameter. It was washed out with hot saline solution and drained with a large rubber tube.

Subsequent to the operation, the patient's temperature never went above 101.5° F., and reached normal in three weeks. The pulse ranged between 8o and mo. There was no nausea or vomit ing. The patient felt disinclined to take any nourishment for some time after the operation. The dressing was changed daily, the cavity being irrigated with saline solution and creolin. In the intervals, siphon drainage was employed, and the bed was raised so as to favor free drainage.

Notwithstanding a very copious discharge, the patient's gen eral condition gradually improved and she made an excellent re covery, which was retarded only slightly by a collection of fluid in the right side of the chest ; this was aspirated on July 26, twenty-five ounces being removed.

A microscopic examination of the cyst contents revealed pus, leucocytes, and echinococcus hooklets.

A TRAUMATIC TORTICOLLIS.

Dr. Royal Whitman presented a boy who, he said, was the same case which had been presented for diagnosis by Dr. Daw barn at the meeting of the Surgical Society on December 26 last The boy, last October, received a blow from a stick upon the side of the jaw, producing a small wound, which was dressed by the family physician. At this time the boy's mother noticed that his head was strongly deviated towards the left. Six weeks later the patient was seen by Dr. Dawbarn, who, on account of this marked lateral deviation of the head and the presence of a bony pro tuberance posteriorly, was inclined to regard the case as one of fracture or dislocation of the atlas.

In the discussion of the case when it was first presented, Dr. Whitman said he did not think the case was one of fracture or dislocation of the atlas, but rather that it was a case of trau matic or spasmodic torticollis, and Dr. Dawbarn thereupon re ferred the patient to him for treatment. This consisted in the application of a plaster jacket and jury-mast to support the head, combined with manual stretching of the contracted muscles and exercises. Under this treatment there has been marked improve ment in position and control of the head, and complete relief from the pain. There is still some spasm of the posterior group of muscles on the right side, but motion is free and painless in other directions. The bony prominence posteriorly, which was proba bly due to a twisting of the atlas, has almost entirely disappeared. There was also some enlargement of the thyroid, which has also improved ; this was probably the result of congestion caused by the malposition of the head.

patient, pain, head, left, lower, operation and marked