}iiEBRUAU, 1 95. OUTH AFRICA MEDICAL JOUR AL. 2 1
were pigmented yellow, blanched, and bloodle . The A CA E OF HEP TIC AB CE
liver weighed 6 oz. 6 drahms; the bile-duct, though mall, CO~fPLICATl!lD WITH PUL::\fONARY HER lA;
was patent; there were no signs of obstruction. pleen
weighed 3i grs. 30 dark red, and he pulp wa diffluent. By WALTER H. HAW, B. ., LR.C. ., Ru tenburg,
The adrenals were congested and red tained; no throm- .A.R.
bosis. 0 hlEmorrhaO'es. The stomach contained a
large quantity of yellow mucou. The spleen contained Female, age 60, married, rather tout. Ha lived in
curious large nucleated cell filled with patches of yellow Africa about 30 year. General health good, until 1 90,
pigment. Injections of the spleen into guinea pig gave when he came under my care for an affection of the
a negative re ul t. liver, which wa diagnosed as an acute locali ed hepatiti
The econd ca e is that of a econd female child, born at situated in the left lobe of the liver. The illne la ted
term, well developed, after a natural labour. The nearly three week, and re ulted in apparently complete
parent were healthy. The fir child died in the ame recovery, ,vith the exception of attack of pain in riO'ht
manner on the fifth day. '£he child showed a light houlder and liver region, after lea t exce s in diet, and
icteric tinge of skin and conjunctivlE on the second day, inaptitude for exertion. On eptember 12th, 1 91, I
which gradually deep nea, accompanied by great pallor, wa very unexpectedly ummoned to see her, for he had
the body becoming apparently bloodless and of a golden pent the previou evening but one at my house, and wa
yellow colour. The umbilicu uppurated lightly. The in her u ual health and excellent pirit. My notes are:
child after the fir t day became apathetic and did not -Hepatalgia ince la t ni ht; back aud right hypochon-
take the breast wcll. The anlEmia and yellowne s drium affected; vomiting; faintne s; no pyrexia;
increa ed, and death en ued on the third daY. The pul e 4. The pa age of a gall- tone wa diaO'no ed,
meconium was normal, 301 0 the urine. and treatment given. At 11 a.m. she had slept after
Post Mortem.-Bodyyellow, no extrava ation of blood. the morphia which had been g1.ven. The morphia was
On opening abdomen alar e dark clot was found in the repeated on account of pain. omiting very severe.
peritoneal cavity; the actual ource wa not evident. September 13th.-Pain be n again at 1 a.m, and h
mbilical cord wa normal in ide abdomen. Liver and continued ince in paroxy m. Tongue furred; breath
gall bla
rately full of green bile. Bile-duct patent. Liver con- September 15th.-A ri or la t night, and again thi
gested, mottled brown and dark green in colour, loaded morning; vomiting continue.
with bile which exude on ection. pleen weiO'hed eptember 17th.-A catch on deep in piration is felt
1 oz., wa engorged with blood and very friable. Pan- over the region of the liver. Pain in the back.
crea pale and yellow. Inte tine normal. Kidneys September 1 th.-The catch felt by patient on deep
pale and yellow tained, adrenal oftened and yellow. in piration is gone. In the evening there wa great
Lung extremely anlEmic, Cl' pitant, light yellow colour. pain, but no tenderne in the back over liver region.
Heart normal, foramen ovale clo ed. Brain pale and Breath foul; tongue tends to dryne ii: motions clayey.
yellow. 0 extrava ation of blood in the vi cera.
The condition of the 1i ver found in the e cases was September 19th.-Pain ha di appeared; bowels
very different; in the one case it was anlEmic with no have acted very freely; flEce white.
signs of conge tion of the biliary duct ; in the other the September, 20th.-There is jaundice. Patient feels
liver was:much congested, and bile exuded on section. better. Urine yellow, containing bile. (Play of colours
In neither was there any ob truction to the pa sage of with nitric acid, and turn green on tanding in conical
bile into the inte tine, nor any sign of septiclEmia, nor la s in bright unliO'ht).
any history or ·jO'ns of yphili . eptember 21 t.-Vomiting rather troublesome. The
It is noteworthy that the di ea e occurred in more than ymptoms O'radually improved until 6.30 p.m. on
one member of same family, but howednohereditary ign . eptember 27th, when very severe pain in the back
The patholo y of the e ca e i very ob cure. 'l'hat came on, which wa de cribed as "back breaking."
great de truction of the red blood corpu de take place There were cold weat ; he hand and feet were cold;
seem obviou, and that the ieteru re ults from thi i he expre ion wa pinched, and the pul e weak. he
probable; but of the cau e and real nature of the di ea e vomited once, the vomit being de cribed a being like
we are entirely ignorant. coffee-ground. I did not see it, for the nul' e in charO'e
In connection with the e caiie it i intere in to note at the time had inadvertently thrown it away. 0
the researche of Buhl in acute fatty degenllration of the tenderne s over liver or other abnormal phy ical ign
newly born-a rare disea e, characterised by a phyxia or in front.
cyano i , internal hlEmorrhage, and frequently jalUldice ; eptember 2 th.-Jaundic more marked; bile in
and of ~ inckel' di ea e characteri ed by its occurrinO' urine (it had been ab_cnt); pain not so great; friction
a. an.epidemic, and by cyano is, jaunJice, and hcemoglo- heard over liver; re piration hallow and frcquent (4 ).
bmuna. But both the e di ea e have characters di '- J u the evening four tarry tools were passed. Abdomen
tinqtive from the case I have described. di tcnded, no great pain; drow incss.
2 2 OUTH AFRICAN MEDICAL JOUR AL. FEBRUA..RY, 1895.
September 29th.-Had a quiet night; jaundice not ide of the right nipple, and passing through to the
increased; one tarry stool; abdomen less distended; back. To be exact, the attack was described as consist-
borborygmi; tongue red with brown fur. Fed on ing more of a deep-seated tenderness than of pain (the
nutrient enemata containing pep i11e and HCl. patient' own word). There were collapse, cold clammy
September 30th.-Purplish flush on the cheeks, sweats, and great difficulty of breathing, the patient
especially on the right one; very small gall-stone saying that she felt as though she was breathinO' with
obtained after straining the freces, which no longer lung belonging to omebody else. The dulness in
contain blood. front i half an inch higher than it was this morning.
October 1 t.-Very weak. Loss of tone in levator Pulse fair.
palpebra, dicrotic pulse, tongue dry and black, sordes, October 1 th.-After a sleepless night, in pite of
hands and feet cool, temperature ubnormal. I expected morphia, i. very collapsed thi morning, and the pulse
speedy death, but, after free admini tration of brandy, is failinO'. Death took place quietly at 1.15 p.m., with
ether, and ammonia, with a siduous feeding, the pulse no further symptoms beyond a complaint of coldne s.
lost its dicrotism, and a change for the better set in. Remarks.-The diagnosis, to which I wa led after a
October 2nd.-Appears tronger. Pul e fair. From careful con ideration of the symptoms, was as follows :-
this time there was continuous improvement, although 1. Po ibly an old latent ab cess of the liver.
the temperature remained irregular, and the puJ e never 2. Pa age of a11- tone.
fell below 90, except once, when it beat 4 after a five- 3. Hepatic ab ce or ab ce es, pos ibly one large one,
grain dose of quinine. On October 5th, I fir t had an situated in the upper and back part of the liver,
opportunity of examining the po terior bases of the which has burst into the pleural cavity.
lungs (eight days after the attack of back-breakinO' 4. Liver dragged upwards by adhesions.
pain). Dulness and friction present, but, on account of 5. Empyema with pleuritic adhesions in front and
the exces ive physical weakne s of the patient, no behind.
attempt at localised diagnosi wa made. The jaundice The ground on which I ba ed the diagno is were
disappeared, the tongue became clean and moist, but the the e:-
bowels always required an enema. .Latent Abscess.-A previou acute inflammation of the
October 13th.-Rigor at 4.30 a.m. Pul e small. 0 liver, followed by general malaise, with symptoms of
complaint except of cold and hivering. It pa sed off pain after the lea t exce s in diet.
during my presence, and the pulse became full and Gall lones.-The character of the first attack Qf
boundin ,while the temperature, which had been sub- pain, ubsequent jaundice, and the di covery of a stone
normal, ro e to normal. At 9'30 a.m., there was profuse in the motionil.
sweating with development of miliary ve icle over chest Hepatic Abscess or Abscesses.-The occurrence of
and abdomen. The course of the rigor re-called an rigor, irregular as to time. Friction heard over liver.
ague fit. The localisation of the one ab ce depended upon pain
October 14th.-Looks better. Tender spot com- referred to the right ide of the back, and the po ition
plained of on thi and succeeding days over the dull area of a tender spot in that region during the last few days
at the back of the chest. of life. From the position of the lower marO'in of the
October 17th.-Rigor lasting twenty minutes. liver dulne it wa evident that the liver wa dragged
Result of chest examination this momillg:- upward by some force, and thi force was most proba-
Inspection.-Right side of chest flatter, and moves bly the contraction of pleuritic adhe ions.
less on inspiration than the left. Right hypochondrium The re ult of physical examination pointed clearly
retracted on in piration. enough to the pre ence of empyema with adhe ions, or
Palpatiolt.-Partial los of vocal re onance at the rather to the pre ence of fluid with adhe ions. The
lower part of the che t (back and front), and absolute quality of the fluid was determined by the previous
10 in axillary re ion. Hand applied to chest raised diagno is of an abscess, which had bur t into the pleural
less during inspiration on the ri ht ide than on the left. cavity. Of cour e, the employment of the hypodermic
Percussion.-Dulne s over ba e of right lung, not syringe would have ettled any doubt. At this distance
absolute at the front and back, but ab olute in axillary of time I cannot recall why I did not employ it, but I
region. Lower margin of liver dulness very high .p. think it wa on account of the certainty in my own mind of
Heart not displaced. the purulent nature of the fluid, combined with the
Auscllltatio1t.-Over the dulness at the hack and front evident complication of events in the chest and abdomen.
distant respiratory murmur is heard, and vocal I connected the hrematemesis and melrena which
re onance can be appreciated; neither murmur nor vocal occurred on September 27th and 2 th with the atta{lk
resonance in axillary region. of back-breaking pain, and thought that perhaps another
Mens1tration.-Right measurement of che~t less by gall-stone had passed, especially as jaundice came on on
one inch than left. the following day. Had the patient not been in so
In the evening of thi day I wo. hurriedly called, on weak and pro trate a condition as to preclude physical
account of a sudden attack of pain referred to the inner examination of the back, I am inclined to think that the
FEBRUARY, 1 95. SOUTH AFRICAN MEDICAL JOURNAt.
probably sudden or rapid appearance of igns of pleural and, without doubt, when empyema nom rupture of an
effu ion would have sugge ted he rupture at that time hepatic ab cess occur in the future, this terrible danger
of a fluid containing cavity into the pleura. My view will have to be very carefully guarded against.
on di covering the fluid wa that it had lowly oozed Rustenburg, ovember 29th, 1 94.
into the pleural cavity, and that on October 17th a ---0----
further udden ru h of pu had taken place. In favour
of thi , the upper limit of dnlne ro~e about half-an-inch, APPEAL FOR AKE VENOM FROM PROF.
and no doubt more pu was forced into the chest, but T. R. FRA ER, EDI B RGH.
by a mechani m totally different from mere rupture,
viz., hernia of the lung into the ab ce cavity. Po ibly Prof. Fr&ser iR at preBent conducting a valuable inves·
the sen ation de cribed by the patient of apparently tigation into the nature of snake poison, and for the
breathing with omebody else' lung may in future purpo es of this work he is most anxious to have sent to
in tance of like complication throw some light upon the him some specimen of: the poison of South African
nature of the ca e. snakes. We subjoin a portion of·a letter recently received
The diagnosis arrived at was borne out in every par- from him by a correspondent ;-
ticular by the post-mortem, with this exception, viz.,
My dear Sir,
hernia of the lung. The cour e of events was, I am now
assured, not interpreted correctly. The attack of back- • • • • • •
breaking pain wa probably due to rupture of the If you should have an opportunity, it would be a great
pleural cavity, the hrematemesis being either accidental, favour if you would end me ome nake poison. I am
doing some work at presen with Indian nake-venom.
connected with the icteru , or due to udden and tem- The poison may be got by pres ing it out of the glands
porary increase of tension in the portal vein. Probably or by causing the serpent to bite through a leaf, or piece
a gall-stone also passed at the time, and may have been of kid, stretched over a spoon. In either case, the poison
the immediate eau e of the rupture. The final and fatal should be dried by expo ure to a very moderate heat not
attack of pain and collap e on October 17th, with the above 90F., putting the dry scaly substance into a.
deep- eated tenderness, dy pnma, and trange re piratory perfectly dry small bottle or tube. .
sen ations, was no doubt the outcome of the pas age of There are many venemou serpents in Africa about
a portion of lung tis ue into the abscess cavity. which little is known.
The po t-mortem revealed the ubjoined state of affairs. When the venom i taken, if the name of the serpent is
The pleural (parietal and visceral) of the right lung were not known, a de cription of it, with the head preserved in
adherent in front, ne h bands of lymph were thrown out spirit, should be sent.-I remain, &c.,
THOMAS R. FBASER.
but not yet adherent in the axillary region, and firm
adhesions at the back. About 10 ounces of pus were After the poison has been obtained in the bowl of the
taken from the right pleural cavity. Close and strong spoon and dried, we would ugge t that the handle be
adhesions existed between the ba e of the right lung and nipped off with a pair of pliers or cut with a file, the
diaphraO'm, nece itating separation with the knife, and bowl with the poi on undi turbed placed in a wide-
this expo ed an ab e cavity in the upper and back mouthed bottle, carefully labelled, and sent by parcel
post t{)
part of the liver, which contained a piece of lung of the Prof. T. R. Fraser, M.D., F.R. .,
size of a Tanjerine orange or omewhat larger. A New Buildings, University of Edinburgh.
smaller ab cess (walnut ize) containing light :yellow pus
wa found to the riO'ht of the large one. 0 others
It will be as well, perhap , to offer the spoon to the
serpent at the end of a long tick, as it is within the range
exi ted. The left lobe, the diagno ed eat of he acute of possibility that the reptile migh prefer the offerer to
inflammatory attack in 1 90, wa harder than the the thing offered. Verb. ap.
right, both to t{)uch and the knife. We publish this appeal confident in the hope that there
The gall-bladder was contracted, and contained seven are many of the Profe sor's old students scattered through
faeetted stones, but no bile. The structures in the South Africa who will be grateful for the chance of
region of Glisson's cap ule were tightly matted together. rendering him this small service.
There was no le ion of the tomach to account for the
occurrence of hremateme is. The left lung was deeply
conge ted. The heart wa small, but otherwise normal. m:be .soutlJ S!ftican ~£l:Jical journal,
The pericardium and endocardium healthy. The right FEBRUARY, 1 95.
lung wa partially collap ed. The whole liver wa
drawn upwards by the adhe ion.
[COMMUNICATED.]
The advi ability of drainage was being considered
when the hernia occurred and precipitated death. It is THE extent to which life in urance business has of late
very probable that an early opening into the pleural years been pushed throughout the lenO'th and breadth of
cavity would have prevented the hernia by relieving South Africa makes it perhaps worth while to direct the
tension there, with consequent pressure upon the lung, attention of medica.l men to some features connected.