Vol. 60, 1909 - University of North Carolina at Chapel Hill

,iS4 THE CHARLOTTE MEDICAL JOURNAL. []
badly mottled. She was unable to climb ment of the bony structures and fatty and ij
stairs or to lie down at night. Her liver muscular tissues." n
was hard and extended down to the um- The abdomen, after tapping: The liver
bilicus. There was no ascites, no swelling is seen to extend down almost to the umof
the feet and legs nor any detectable les- bilicus. The left lobe is plainly palpable
ion of the heart. well below the costal margin. The liver !
Under treatment, the dyspnea and cya- feels hard and smooth. Its lower border is
nosis disappeared. She could lie down at sharp and clearly defined. The spleen can- •
night and, for a short time, was enabled to not be felt. Measurements: Around the ;
return to her work in the factory. The im- iliac crest, 28/^ inches; around the umbili- '
provement did not last long, however, for cus, 27/2 inches; around the liver, one inch J
her symptoms returned and fluid began to below the xyphoid, 29/'2 inches. The veins 4
accumulate in her abdomen. of the abdominal wall are not much en- .
I saw her some three or four months later, larged. f
in the spring of 1908. She was enormously Negative History.—She has never had \
distended. Her face, hands, arms and body nausea, spitting or vomiting of blood, hem-
were deeply cyanosed with a peculiar orrhoids or jaundice. There is no history
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blotched or mottled appearance. She suf- of tuberculosis or malaria; no history or \
fered greatly with dyspnea, and had been signs of specific trouble. She has never
unable to lie down for some time. There suffered much pain except after tapping,
was no swelling of the feet nor edema any- when it is acute and of a cramping characj
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where, nor could I detect any heart murmur, ter and in the pit of the stomach. Her i
First, 1 tapped her, removing four or five bowels have moved fairly regularly, and i
gallons of fluid. Second. In the fall. Dr. the kidneys are normally active.
M. E. Nuckols tapped her, getting about Diagnosis.—Hypertrophic cirrhosis of the «
three gallons. Third. In December, I re- liver.
moved four gallons. Fourth. In February, Operation (two days after tapping): .
1909, just prior to operating, I removed two Under chloroform anesthesia, a right rectus i
gallons. incision was made a half-inch to the right >
Examination.—A small, poorly developed of the median line from the costal margin c
girl of quick mentality and bright and to the umbilicus. A half-gallon of fluid \
cheerful mien. Though actually 18, she was evacuated and the abdomen mopped 1
does not look to be over 13 or 14. Her as dry as possible. Palpation of the viscera a
figure is slight and singularly girlish. She revealed an infantile uterus with diminutive J
is 4 feet, 10^4 inches in height and weighs ovaries; normal kidneys and spleen enlarg- -j
90 pounds. The breasts and vulva are ed probably one-third. The intestines were J
small, undeveloped and child-like. There normal in color, their vessels not engorged;
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is absence of pubic and axillary hair. The omentum very small, very thin and scanty ;
two lobes of the thyroid are somewhat en- of fat; the vessels did not seem to be en- i
larged and rather harder than normal, larged. There are no adhesions, no tuber- ;
There is no exophthalmos. Temperature, cles nor evidence of peritonitis. :
97 1-5° to 98 3-5°; pulse, 60 to 72; respira- The liver is of a dark, purplish color, not '<
tions, IS to 20. Urine normal, except a much harder than normal to the touch. I
trace of albumen. Blood, red cells 6,000,- There are no nodules upon it nor hard areas I
000; white, 4,400; hemoglobin, 85; color within its substance. The margin presents !
index, 70. Differential count shows noth- a peculiar fringy appearance like a mina- <
ing abnormal. ture cockscomb. A small wedge was ex- \
The heart, examined by Dr. W. -S. Gor- cised from the margin, which I present i
don before tapping: Right heart enlarged, mounted for microscopic inspection. The j
left but sligntly; no murmur can be detect- anterior surface of the liver was now rubbed •)
ed; examined by Dr. J. G. Nelson after lightly with gauze, which readily provoked '.
tapping, "shows general hypertrophy, es- a free oozing of blood. On account of the i
pecially the right ventricle. The valves very small size of the omentum, it was de- i
are in excellent condition. The muscle is cided to make the liver anastomosis as broad i
normal except for hypertrophy. The heart as possible. Turning back the abdominal (
sounds are slightly accentuated, especially wall, a matter easy of accomplishment in
the pulmonary second sound. The condi- its relaxed condition, the parietal perito-
tion of the heart may be accounted for by neum was stitched to the oozing surface of \
the liver from the upper angle of the wound j
prolonged increase of resistance in the gen-
eral circulation due to accumulation of ^^ the lower margin of the liver 1 -3 inches ^
. ,, from the incision on either side. I he pen- :
toneum was next closed from above down-
The lungs: "Slight general hyper-reson- ward, the stitches including liver tissue,
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anceof breath sounds due to lack of develop- thus making an attachment by three rows _
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