In the rare cases where jaundice and ascites are produced by a hydatid cyst placed near the concavity of the liver, no localised swelling can be de tected, and a diagnosis is hardly possible unless we can satisfy ourselves by puncture or otherwise of the presence of a similar cyst in other organs.
the child is seen before injury has been inflicted upon neighbouring organs by bursting of a hydatid sac into them, the prog nosis is favourable ; for the slight operative procedure necessary for the evacuation of the fluid and destruction of the cyst and its contents is usually well borne. If the sac has been evacuated into a neighbouring organ, the situation is a very serious one, and most of these cases prove fatal.
Treatment.—Although many internal remedies have been administered in the hope that the drug might pass from the blood to the interior of the cyst, and so destroy the life of the hydatid, it is now admitted that such an object is not to be attained by physic. Our only means of curing the patient is to puncture the cyst and evacuate its contents. If this be done with a fine trocar and canula, there is little risk of escape of the fluid into the peritoneum, and consequent peritonitis. It is best to employ the pneumatic aspirator, so as to prevent the entrance of air into the sac. After the withdrawal of its fluid contents, the hydatid cyst collapses and its membrane shrinks away from the investing capsule. The resulting space is rapidly filled by exuded serum, and the hydatid quickly dies. Sometimes the operation requires to be repeated. It is usually unneces sary to employ irritating injections after emptying the sac, but if the cyst continually refills, it may be desirable to do so.
A healthy-looking, well-nourished girl, aged twelve years, was under my care in the Victoria Park Hospital, for a swelling in the right side of the belly which had been first noticed two months previously.
On examination it was seen that the lower ribs on the right side were distinctly prominent, and that the intercostal spaces at that part were wi dened. The liver dulness began at the lower border of the fourth rib, and the inferior edge of the organ could be felt just below the level of the Immediately below the ribs, a solid-feeling tumour was dis covered. This gave no elastic sensation to the finger, and was not at all tender when pressed upon. It descended somewhat on deep inspiration. Below it the substance of the liver could be felt of normal density, convey ing to the finger a very different sensation to the solid resistance of the tumour. Posteriorly, the hepatic dulness began at the lower angle of the
scapula, and complete dulness one interspace lower down. The respira tory sounds were weak at the right base behind, and some friction was heard in the infra-axillary region and at the base in front (the child had had pleurisy eighteen months before). There was no jaundice or ascites, and the superficial veins, although more visible than natural over the front of the chest, were not dilated in the epigastrium or on the abdominal wall. The heart's apex was in the fifth interspace in the nipple line. Its sounds were healthy.
Au exploratory puncture was made in the tumour with a hypodermic in jection syringe, and some colourless fluid containing chlorides but no albu men was withdrawn. No hydatids could be discovered in the fluid by the microscope. Some days afterwards the tumour was again punctured with the aspirator through the eighth interspace, and twenty ounces of a clear, straw-coloured fluid were withdrawn, having the characters above men tioned. Its specific gravity was 1.008. No hooklets could be seen under the microscope. A solution of iodine (half a drachm of the tincture to half an ounce of water) was then injected into the cyst, and the child took a draught containing five drops of laudanum.
The operation was followed by no rigors, sickness, or other sign of dis comfort; but the temperature rose every night to between 101° and 102°, sinking in the morning to nearly the normal level. A fortnight after the first operation, the tumour being rather more prominent than on the child's admission, the cyst was again punctnred, and twenty-three ounces of thick greenish pus were drawn oft. In another fortnight the operation was repeated for the third time, removing eleven ounces of greenish pus. This was quite sweet, and under the microscope showed hooklets and signs of hydatid debris. On each of these occasions the cyst had been tapped through the chest-wall ; but ten days after the last operation, the cyst hav ing again refilled, the needle of the aspirator was introduced through the abdominal parietes and twenty-three ounces of pus were evacuated. The operation set up some local peritonitis ; but this was quickly reduced by poulticing and the administration of six drops of laudanum three times a day.