tively to watch its future effects. On the appearance of the erythema or salivation, it is time to interrupt altogether, for a while, the exhibition of arsenic; if necessary, it may be resumed when these symptoms have vanished.

If pain of the stomach, nausea or vomiting supervene; if the head be affected with pain or vertigo; or should a cough, with any signs of irritation of the pulmonary organs, be observed, the use of arsenic should be totally and for ever abandoned. Leith, February 15. 1808.

IX.

Case of Jaundice, occasioned by the pressure of a large Hydatid in the Liver, situated in the region of the Vena Portarum. BY ANDREW DUNCAN, sen. M. D. Professor of the Institutes of Medicine in the University of Edinburgh.

MARCH

ARCH 18th 1807.-John Brown, a labourer, aged 38. The whole abdomen is very much enlarged, and affords to the touch a distinct sense of fluctuation. When in the erect posture, there is observed, about the upper part of the right hypochondriac, and extending over the greater part of the epigastric region, a large circumscribed tumour, possessing evident fluctuation, which subsides immediately on his assuming the horizontal posture, when an uniform tense swelling occupies the whole abdomen. Pressure applied under the margin of the false ribs, on the right side, excites so considerable a degree of pain as to cause him to wince under it.

The skin over the whole body, and the tunica adnata of both eyes, are of a deep yellow colour. The urine also is observed to have a very dark yellow appearance, and linen, when immersed in it, is very deeply tinged. The alvine excretion is said to be of a white colour, and rather thick consistence.

He is affected with occasional sickness, and inclination to vomit; but he has never complained of pain in the epigastrium. He complains of great dyspnoea, which is always most severe in the morning, and is induced on stooping forward or making any exertion. He is also much affected in the evening, particularly at first lying down, with a severe cough, which, by his account, is extremely urgent, except when lying on the left side; and is accompanied

companied by a difficult, though copious viscid expectoration, having a bad taste and smell. It excites the dyspnoea to a great degree, which then requires the erect posture.

Pulse 100; tongue white; great thirst; heat moderate; urine very scanty; belly costive; and he is distressed with frequent tenesmus; appetite much impaired; sleep disturbed by frequent startings.

About six months ago, the period from which he dates the origin of his complaints, he was affected with an obtuse gnawing pain in the right hypochondrium, which was much aggravated on pressure or motion, and stretched to the shoulder of the same side; at which time, the yellowness of his skin and eyes, and deep colour of his urine, were also first perceived, but they are since much increased. He says, however, that the pain of the hypochondrium and shoulder ceased six weeks ago to be constant, and that now it only returns occasionally. The tumefaction of the abdomen was first observed eight weeks ago; but for a fortnight this was noticed only in the morning, and disappeared during the day. During the last six weeks it has been constant, and for the same time the quantity of his urine has been daily diminishing. He also says, that about a fortnight ago, for three days his legs and feet became edematous towards evening, but that he cannot now perceive this. The dyspnoea and cough have continued to increase in proportion to the increasing tumefaction in the abdomen.

He does not assign any cause for the symptoms with which he was first attacked, but it appears that, as a labourer in a distillery, he has had a pretty liberal allowance of ardent spirits for three years. He attributes his swelling of his abdomen, and conse quent dyspnoea and cough, to very hard labour, after which he was exposed to cold while in a state of profuse perspiration, when he swallowed a large quantity of very strong spirituous liquor. He has taken a few purgative pills, but no other medicines. Sumat vespere pil. scil. 1. gr. x.

19th.-Has had two stools since he took the pills at bed-time, and thinks the tension of his abdomen somewhat diminished. Yellowness nearly as before; urine still very scanty, and very high coloured. Continuentur pilule scilitica, et inunguetur abdomini unguentum hydrargyri ad 3ij vespere.

20th. Used the ointment last night as directed; has had one stool since last visit, of a whiter colour than natural; swelling and tension of the abdomen nearly as before, and there is no change in the yellowness of his skin and eyes; urine lib. i. of a very high colour, and turbid; pulse 80; heat natural. Continuentur pilulæ et unguentum.

21st. Complains much to-day of gripes; urine about lib. i. and very high-coloured; yellowness nearly as before; belly rather bound. Continuentur medicamenta, et capiat statim infusi tamarindorum cum senna 3ij. et repetatur omni horâ ad quartam vicem, nisi prius supervenerit catharsis.

22d.-Has had three stools from his purgative; the fæces discharged are still of a white colour; urine as high coloured as before; the swelling of his abdomen is rather increased, with a considerable sense of tension, but less obvious fluctuation than before. Continuentur unguentum hydrargyri. Intermittantur infusum tamarindorum, et

B. Submuriatis hydrargyri

Pulveris radicis scillæ exsiccati utriusque grana xij.
Extracti gentianæ

Saponis Hispani utriusque ij.

Syrupi simplicis q. s. fiat massa dividenda in pilulas

xxiv.

Capiat duas omni mane et vespere.

27th. Urine lib. iij. he has had two stools since last visit, of the same apearance as before; his legs are observed to be much swelled in the evening; pulse 88; heat natural. Continuentur medicamenta.

31st. Urine and stools as before; he complains much to-day of pain of his back. Continuentur medicamenta, et illinatur pars dolens dorsi tincturâ saponis cum opio.

April 1st.-Pain of back rather easier since it was rubbed with the anodyne balsam; urine and stools as before; pulse 86; heat natural. He complains of some soreness in his gums, but has no spitting. Continuentur medicamenta, ut antea.

2d.-Pain of back easier; urine lib. ij. of the same appearance as before; pulse 86. Continuentur medicamenta, ut antea.

3d. Complains of soreness of his mouth and gums, but there is little obvious affection; pulse 86; belly bound; urine and skin as formerly. Continuentur medicamenta, et capiat statim, olei ricini 3j.

4th.-Has had two stools from the purgative; mouth rather more affected; urine lib. iij. Intermittantur oleum ricini, et unguentum hydrargyri. Continuentur alia.

5th. Still complains much of his mouth, but his spitting is not considerable; urine lib. ij. and rather less high coloured than formerly, but the appearance of his stools is not changed; pulse 86; belly regular. Continuentur pilula calomelanos cum

scilla.

6th.-Has still considerable pain in his mouth; urine less high

coloured;

coloured; pulse 90; heat moderate. Continuentur pilulæ, ut

antea.

7th.-Mouth nearly as yesterday; urine lib. ij. of a less deep tint; his stools have now somewhat more of a yellow appear ance; pulse 80; belly natural. Continuentur pilula calomel

anos ut antea.

8th.-Has slept ill, and complains much to-day of weakness; urine and stools as yesterday. Continuentur pilule ut antea. 9th. Urine lib. iij. and less high coloured, but still tinging linen of a deep yellow; his stools have a more natural appearance, but he still complains of great weakness; mouth as before; pulse 80; heat natural. Continuentur pilulæ ut antea.

10th. Urine lib. iij. and he has had three stools; pulse 80; heat natural. Continuentur pilulæ, ut antea.

11th.—Urine lib. iiss. and of a less deep colour than before, but his skin is still very yellow, and his stools have not obtained the natural appearance; he has had, during the night, a considerable hemorrhage, which, he thinks, proceeds entirely from his mouth; he is very weak, and much emaciated; pulse 70; heat moderate. Intermittantur pilule scilliticæ.

Habeat indies vini rubri Lusitanici, viij.

12th. There has been little discharge of blood, and he feels somewhat renovated by the wine. Coninuentur vinum, et repetantur pilulæ, ut antea.

18th.-Has had one stool since last visit; urine lib. iij.; pulse 86; heat moderate, weakness rather increased. Continuentur vinum et pilulæ, ut antea.

14th. Urine about lib. iij. and he still complains of very great weakness. Continuentur pilulæ et vinum, ut antea.

15th.-Has had three stools since last visit; urine lib. iij. and rather of a lighter colour; he still complains of great weakness, and of much soreness of his mouth. Continuentur medicamen

ta.

16th.-There is no return of the hemorrhage, but he complains of a great sense of coldness, and his weakness is nothing diminished. Continuentur pilulæ et vinum.

17th.-Has had three stools; urine lib. iiss. still very dark coloured weakness daily increasing. Continuentur vinum. Intermittantur pilulæ scilliticæ.

Capiat horâ somni pilularum Thebaicarum grana x. Let him have a bason of beef-tea daily.

18th. Slept well after the pills; urine lib. ij. and he has had two stools since the last visit; weakness nearly as yesterday. Pulse 86. Continuentur vinum et pilule thebaicæ, ut antea. 19th. Takes his wine and beef-tea freely, but his weakness is

rather

rather increased; he is now free from the looseness; urine not above lib. i. yellowness as before; pulse 60, and very small. Continuentur pilule thebaicæ, vinum et diæta. 20th.-Died last night about eight o'clock.

The history of this man's case, which occurred in the clinical ward, was drawn up by my clinical assistant Mr Wightman, and is in some respects singular and highly worthy of notice. At his admission he evidently laboured under a complication of jaundice and dropsy; and although these appeared to be the most alarming of his complaints, the tumour in the right hypochondrium attracted much attention on account of its unusual phenomena, disappearing in the horizontal position, and evidently containing a fluctuating fluid. It was thought to be water contained in a sac, but, to this opinion, its disappearance immediately on his lying down, when there was nothing to be discovered but the uniform swelling of the abdomen, was a strong objection. Hence I concluded, that it had some communication with the cavity of the abdomen; and it appeared to be somewhat similar to a case which I had not long before attended with Mr Dewar.

A gentleman from the West Indies put himself under our care for a complication of affections. Among these, there was a considerable degree of ascites, and a considerable projecting tumour at the umbilicus, which was evidently not hernia, but water. It had distinct fluctuation and communication with the abdomen, for although it did not disappear in a horizontal position, it could be emptied by pressure. From different circumstances, particularly from the habit of the patient, we did not think artificial evacuation of the water advisable in this case, but we often suspected that spontaneous rupture would have taken place. This, however, did not occur; and, by the use of powerful diuretics, a large urinary discharge was obtained. Both the general ascites and the tumour at the umbilicus disappeared, and the patient returned to the West Indies in tolerable health.

The analogy of these two cases led me to suppose that, in the erect posture, the water of the dropsy escaped through some rupture of the peritoneum, out of the proper cavity of the abdomen, into a sac, probably formed of condensed cellular membrane.

I ascribed the dropsy in the present instance to a diseased state of the liver, from excess in spirituous liquors, and accordingly directed the treatment to its removal. I had, however, very slight hopes of success, and expressed my opinion, that if the death of the patient should afford us an opportunity of ex

amining