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The conditions, productive of such great hepatic enlargement, are chronic mechanical congestion, abscess, cancer, fatty degeneration, both forms of hypertrophic cirrhosis, hydatids, and amyloid degeneration.
Mechanical Congestion of the liver, from mitral or tricuspid disease sometimes produces uniform and considerable enlargement of the liver, but never, in my experience to the extent present in this young man, in whom, moreover, no valvular affection exists.
Pycemic Abscess of the liver, consequent upon pleurisy might produce enlargement of the liver, but the entire absence of pain, and tenderness, which are always, and of jaundice, which is usually present in hepatic abscess; the absence of the general symptoms of pyæmia, viz. : irregularly recurring fever of intermittent type, rigors, profuse sweating, subcutaneous and articular suppuration, etc., and the short duration of pyæmic abscess which rarely outlasts three months, and generally ends fatally, will exclude that affection. I deem it unnecessary to discuss primary abscess of the liver, the result of hepatitis, a disease not infrequent in the tropics, but hardly known here.
Fatty Enlargement of the liver; so common in chronic phthisis, is rare in other wasting diseases, and in young and temperate persons. It is not attended with ascitis, and may be ignored in this instance. Moreover the enlargement appears to have existed before the protracted cough and expectoration set in.
Carcinoma of the liver, which might well explain the great size of the abdominal tumour, may be excluded, owing to the absence of the following symptoms : pain in and tenderness under pressure, of the liver ; tumour elsewhere; enlarged
; glands, and that profound alteration of health and nutrition necessarily consequent upon the existence of a malignant tumour for two years. Carcinoma steadily pursues the evil .tenor of its way towards cachexia, marasmus and death, and the last is not far off at the end of two years.
That form of Hypertrophic Cirrhosis, caused through obstruction of the bile duct by gall stones, cancerous glands, or pancreas, &c., and sometimes by malaria, and called Biliary cirrhosis may
be excluded, for the early and marked icterus of that affection has not existed in this patient. The presence of ascites in this case would also be opposed tothe idea of Biliary cirrhosis, according to Hanot, but other observers have met with that symptom at least in the advanced stages. This young man has not resided in a malarial region, nor had ague.
Simple Hypertrophic Cirrhosis, if I may so term it, to distinguish it from biliary cirrhosis, although not generally described in systematic works, is an affection of which I have seen several specimens.
It is not always due to obstruction of the bile ducts, nor is jaundice a necessary symptom. It may present all the clinical features of the ordinary atrophic form of cirrhosis, except that the liver is enlarged, sometimes very greatly, instead of being reduced in volume. In an interesting example which occurred in this Hospital, and is discussed in Dr. Osler's Pathological Report for 1876-77, p. 571, the liver was uniformly enlarged, and weighed 6lbs 11} oz. In some respects our patient's case conforms to cirrhosis with hypertrophy, viz. : in the uniform enlargement of the liver ; in the existence of ascites and of moderate enlargement; and visible anastomoses between the epigastric and mammary veins and the last two are amongst the most reliable evidences of cirrhosis.
But the absence of several other features incline me to exclude that affection. Thus, the patient has not used either strong alcoholic liquors or ale ; he is young; he has not had hæmorhage from stomach, bowels or elsewhere ; nor a sub-icteroid colour of skin.
Finally, a more probable cause of enlargement of the liver exists to explain the case.
Two other causes of the hepatic enlargement remain, neither of which can be certainly excluded, but I will take up the least probable first.
Hydatids of the liver, produce a slow but very considerable enlargement of the liver, unattended by pain or fever, or, in many cases, by jaundice or ascites, or enlarged superficial abdominal veins.
The enlargement, however, as a very general rule, does not involve the entire liver, but one or other part of it, producing, in this way a tumour not having the natural outline of the liver, and possessing an elastic or even distinctly fluctuating feel, and perhaps presenting one or more projections upon its surface.
The case, perhaps, corresponds in many respects with these characters ; but the hydatid disease is so rare in this country that I have never met with an example of it, and believe that the probabilities are in favour of another affection, now to be considered :
Amyloid degeneration of the liver resembles in many particulrs this young man's case. It produces a slow, and often painless and uniform enlargement of the entire organ, usually without jaundice or fever. Enlargement of the superficial abdominal veins, and ascites may occur, although they are not at all constant ; moderate ascites and cedema of the lower limbs are frequent. The spleen is also frequently enlarged as well as the liver, and it is so in this case, I believe ; although it is difficult to make out its limits accurately. The kidneys, too, are apt to undergo amyloid degeneration, and albuminuria results.
Our patient's history corresponds very closely with this description, although albumen was not present in the single sample of his urine examined by me; but he says it was found when his dropsy first appeared.
There is one important difficulty, however, in accepting amyloid disease as an explanation of this case ; viz. : the fact that the enlargement of the liver was noticed six months before the winter cough and expectoration set in—the only symptom in. addition to the enlargement observed by the patient being gradually increasing dyspnoea.
The usual cause of amyloid disease is chronic suppuration from disease of bone, tuberculous affections of the lungs and other organs, constitutional syphilis and the like, none of which can be said to have preceded the enlargement of the liver in our patient. The pleural sero-purulent, or purulent effusion, which I have inferred to have obtained at the beginning, however, may have occasioned, and would account for the amyloid degeneration, But, inasmuch as it sometimes appears to originate in persons of a scrofulous diathesis, without suppuration, and sometimes cannot be traced to any cause whatever, the absence of a wellestablised cause in this case does not, in my opinion, justify us saying that amyloid disease is not present. It best meets all the requirements of the case. You
see, then, how many difficulties surround the formation of a reliable diagnosis in this instance. Yet, I venture to believe the most probable view is, that chronic pleurisy with retraction and amyloid degeneration of the liver, are the conditions present. I admit the possibility of some rare form of cystoma, or sarcoma, in the liver; or of a tumour or aneurism, or collection of pus between the diaphragm and the liver, but have not time to discuss these clinical curiosities, some of which are beyond the power of diagnosis.
MEDICAL AND SURGICAL CASES OCCURRING IN THE PRACTICE OF THE
MONTREAL GENERAL HOSPITAL,
Case of Gunshot Wound of the Brain.—Recovery.–Subse
quent Death from Phthisis.-Autopsy.—Under the care of G. E. FENWICK, M. D. Reported by Mr. H. W.
LLOYD. C. G., aged 19, a sickly-looking lad, was admitted into the Montreal General Hospital on the 8th day of March, 1878, suffering from the effects of a small pistol wound situated a little above and in front of the right ear. This wound had been accidentally received the day before his admission to the hospital. The account he gives of the occurrence is as follows:While sitting on the edge of his bed, and examining the barrel of a small-sized revolver, which he did not suspect to be loaded, an explosion took place, and the ball entered the skull through the upper segment of the right temporal fossa, piercing the muscle, bone and membranes, and passing into the substance. of the brain. The barrel of the revolver was not more than a few inches from his head, and he believed it to be almost at a right angle to it. The receipt of the wound was followed by a sharp pain at or about the point of entrance, accompanied by a ringing noise in the ears, slight dizziness, or a feeling as if he was floating in the air. Shortly after receiving the wound, vomiting set in, and continued at intervals for the ensuing 36 hours. During the straining while vomiting, a little blood would ooze from the wound. There was no bleeding in quantity from it at any time, but there trickled away an abundance of bloody serosity, in all likelihood from the arachnoid cavity. He was perfectly sensible, and continued so throughout, during his stay in the hospital. There was no sign of paralysis. The pupils were dilated, but equally so, and respond to a strong light. No pain complained of, except in the vicinity of the wound, which was lightly puffy and red. The wound itself was half an inch in diameter. The bullet was lodged in the substance of brain, possibly in the anterior lobe of the cerebrum, as the point of entrance was on a line with, but above, the junction of the anterior and middle fossæ, close to the situation of the fissure of Sylvius, one inch and a half above the external auditory foramen, and one inch and a quarter in front. Has not slept since the accident; is silent, perfectly quiet; has dozed, but sleep is uneasy and short; awaking with a sudden start, he fancies he hears an explosion, which arouses him. The second day after his admission he complained of frontal pain, not however severe, his pulse was 60 per minute. There was no rise in temperature; pupils were still dilated, but equal in size, and responded to light, contracting, however, rather slowly. There is no vomiting nor tendency thereto, and he takes nourishment, which, however, was restricted to milk. An ice cap was ordered to the head, a pledget of lint wet with water, and covered with oil silk, to be applied over the wound, and the following mixture was given. R Potassii Bromd.