A clinical lecture on exophthalmic goître (Graves's or Basedow's disease) / by James K. Crook.

  • Crook, James K. (James King), 1859-1908.
Date:
1894
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Licence: Public Domain Mark

Credit: A clinical lecture on exophthalmic goître (Graves's or Basedow's disease) / by James K. Crook. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    great majority of cases suppuration, either abscess or pylephle- bitis. Here in a woman the onset with pains and the early ■chills suggest, even in the absence of jaundice, that the whole trouble may depend upon gallstones, and that the chills may be associated with suppurative cholangeitis. Chills and fever may, however, occur in cancer of the liver, and in this case the emaciation, the enlargement of the organ; and particularly the nodular masses, suggest the presence of a neoplasm. The chills and fever may be associated with the rapid growth of cancer, but in the liver the suppuration may be in some of the large bile ducts, blocked with the neoplasm. Dr. Norris wrote that subsequently jaundice developed. The fever persisted, and before her death the emaciation was ex- treme. Case XXXIII. Large Nodular Tumors at the Edge and Surface of the Liver.—Mrs. S., aged about fifty years, consulted me January 24th, complaining of cough, loss of flesh, fever, and shortness of breath on exertion. There was slightly defi- cient expansion at the left apex, and a few rales in the supra- scapular region. An examination of the sputum showed tuber- cle bacilli. I did not see the patient again until October 18th in consultation with Dr. Aaronsohn. She had had pleurisy on the left side, with some effusion, which had almost completely disappeared. She had become progressively weaker; had had some loss of appetite, but no marked gastric symptoms. On examination of the abdomen, however, there was felt a remark- able ridgelike tumor extending just below the level of the navel, with a very hard, everted, and irregular edge, above which was a sort of shallow groove. The abdomen was much relaxed and the intestines lay between the abdominal wall and this ridgelike mass. At first I thought it possibly might be the omentum curled up and indurated, but on more careful pal- pation it was evident that the indurated, irregular edge was continuous with the liver. The extreme hardness and irregu- larity were, of course, very suggestive of cancer, in favor of which also were the enlargement and the pain on pressure. I saw this patient again in consultation on the 30th and 31st, and the two weeks which had elapsed had made a very striking change in the condition of the liver. It was considerably be- low the level of the navel. The irregularity was very much more pronounced, and definite nodular masses could be felt both at the edge and on the surface. One of these, a little to the left of the middle line, was at least six centimetres in diameter, with a rounded edge and a depressed center. The condition was still a little peculiar and unusual from the fact that the abdominal walls were extremely relaxed and the intes- tines lay in front of the liver, so that there was resonance as high as the costal margin. The growths in the liver were, from their local character, evidently secondary, and though the pa- tient had profound anorexia, there was no evidence as to the seat of the primary disease. She died a few days after my last visit. Case XXXIY.—Enlargement of the Liver ; Prominent Mass in the Upper Umbilical Region; Latent Cancer of the Stom- ach.—Henry T., aged fifty-nine years, admitted October 4th, complaining of pain in the abdomen and back. Family history is good. Has been a temperate man and has had no serious illnesses. Three months ago he says he was quite well. About eight weeks ago noticed that he had occasional pain in the abdomen, which for the past four weeks has been constant and of a dull aching character. He only stopped work three weeks ago; has lost, he says, thirty pounds in weight in two months. His appetite is poor ; has never had any vomiting; has no nausea. Food makes no difference in the pain. Two days ago his feet began to swell. Patient is a tall man, much emaciated. The skin has every- where a sallow tint, and the conjunctivas are slightly tinged. Tongue moist, covered with a white fur. Condition of tho- racic organs is negative. Abdomen much distended in epigas- tric and hypochondriac regions, especially on the right side. In the upper part of the umbilical region there is a prominent mass which is to be seen readily, and which moves up and down with respiration. On palpation, it is felt to be separated by a distinct groove from the swelling in the right hypochon- driac and epigastric regions. The surface is smooth, painless ; no nodules are to be felt, but on the lower margin which ex- tends to the navel it is distinctly irregular. The percussion dullness does not correspond to the edge of the mass, but is fully a hand’s breadth above it. The upper limit of dullness is at the fifth rib in the nipple line, and at the seventh in the midaxillary. The splenic dullness is not increased ; the edge is not palpable. The urine was dark brownish-yellow and contained a faint trace of albumin. There seemed no question at all that this was a liver en- larged by cancer, but at first the prominent mass in the umbili- cal region, which seemed separated from the upper part by a distinct groove, raised a slight doubt; but the profound ca- chexia, the rapid growth, and the irregular, nodular edge seemed conclusive. The primary trouble was not evident. The examination of the rectum was negative. A test breakfast, withdrawn fifty minutes after, gave fifty cubic centimetres of a dirty reddish-brown fluid consisting of undigested food, and showed a great many blood-cells. Free hydrochloric acid was not present. On the 10th he had been suffering a great deal ot pain, and following three injections of a sixth of a grain of morphine at 9 a. m., 3 p. m., and 10 p. m., he became profoundly comatose, and died at 2 a. m. on the 11th. The autopsy showed the primary carcinoma to be in the stomach, at the greater curvature, just eight centimetres from the cardiac orifice. The liver was enormously enlarged and weighed five kilogrammes and a half. The prominent tumor in the upper umbilical region felt during life corresponded to a new growth in the left lobe of the liver, which formed a pro- jecting knob ten by ten centimetres in extent. The entire organ was occupied with small and large secondary nodules, very little liver substance remaining. The bile ducts were not affected. There were secondary nodules of cancer in the pancreas. The following case is of great interest from the local character of the tumor masses, which in the epigastric re- gion were so prominent, soft, and fluctuating that the con- dition of abscess of the liver was suspected. It illustrates, too, the importance of obtaining a thorough history. Case XXXV. Sarcoma of the Liver ; Two Prominent Tumor Masses in the Epigastric Region; Diagnosis of Abscess; Explora- tory Laparotomy.—E. K., aged nineteen years, seen September 6, 1892, with Dr. McGill. Condition on visit was as follows: The most extreme grade of emaciation, particularly of the face. The skin was bathed in perspiration; pulse, 104, of fair vol- ume and good tension ; respirations quiet; no fever. On exposing the abdomen, the upper zone is distinctly full, and two tumor masses are visible in the middle line, the smaller and less prominent just below the ensiform, and the other, a larger hemispherical mass, bulges the thin, tense skin between the ensiform cartilage and the navel. Both rose and fell with the respiratory movements. No glandular enlargements were visible. On palpation, the superficial tumor masses were not tender,