32

but all pain in the limb had quite disappeared. He finallyleft the hospital Dec. 22,1852, with the tumour quite solid,and the complete obliteration of the artery.

This is certainly a most satisfactory result of compressionin the treatment of aneurism, and likely to make a lastingimpression on all those surgeons who saw the case. Of coursethe patient may be looked upon as a very favourable subjectfor this kind of treatment; but it is very likely that, even withnervous and irritable patients, a course of sedative medicines,and proper warning that the success depends on perfectobedience and perseverance, would very probably have abeneficial effect, and facilitate the successful application ofcompression.Mr. Cock’s case was the more calculated to show the im-

portance and value of this method of practice, as a few bedsfrom his patient was the man whose case we reported lastweek. The latter, who had first been under the care of Mr.Poland, and afterwards under the charge of Mr. Hilton, was Ijust offering an example of speedy consolidation of the sac by I,,well-regulated compression, after a free communication be- ’,tween the sac and artery had been established by a strainupon the limb. It may from these cases (and especially fromMr. Critchett’s and Mr. Ward’s cases at the London Hospital,THE LANCET, vol. ii. 1851, p. 83, and vol. ii. 1852, p. 325) beinferred, that in all instances of aneurism of the extremities,compression should always be steadily and perseveringly triedbefore the deligation of the vessel is resorted to.

There is at this present time in Luke ward, Guy’s Hospital,another case of aneurism, under the care of Mr. Hilton. Thedisease is situated in the femoral artery, both at the middle ofthe thigh and near the groin. Compression is being tried,after a persevering use of ice, and we shall have much plea-sure in acquainting our readers with the result.

KING’S COLLEGE HOSPITAL.

Large Abscess of the Kidney.(Under the care of Dr. BUDD.)

PERCUSSION, palpation, mensuration, and auscultation, arecertainly of great service in the diagnosis of the diseases of thechest and abdomen. Affections of the latter cavity, especiallywhen of the chronic kind, are, nevertheless, now and then sur-rounded by the most complete obscurity. This fact becomes Imore and more obvious to those who, like ourselves, see a greatnumber of medical cases, and very frequently do we hear themost accomplished physicians declare themselves incompetent !,in deciding as to the actual nature of some abdominal tumours.An unfortunate circumstance connected with this state of ’’

things is, that patients affected with chronic affections of the ’’

abdomen, stay in general but a short time in hospitals; theycommonlv return home when told that treatment cannot beattempted with any prospect of success, and they disappearfrom this worldly scene without anything more being heard ofthem, the nature of their affection remaining unknown.The difficulties surrounding the diagnosis of abdominal

tumours are, however, very much diminished when the swellingis of an acute kind; for there are so many well-knownsymptoms of the formation of abscess, that it is hardly possibleto make a mistake. Still, in pelvic, lumbar, psoas, or anychronic abscess, the signs are sometimes ill calculated to leadto a correct diagnosis. An cect<<e abscess of the liver, of theemcum, or of the kidney is, however, detected without muchdifficulty; the more so as in the latter case the presence ofpus in the urine is in some degree a pathognomonic svmptom.But still, pus might have been generated in the bladder orprostate gland, and the tumour in the vicinity of the kidneybe quite unconnected with this viscus. On the other hand,it may happen, as will be seen by the case which shall pre-sently be put upon record, that abscess of the kidney mayassume some of the characters of an accumulation of pus inthe spleen, or considerable congestion of the same organ.Strange to say, a huge abscess destroyed, in this instance, thewhole of the inner portion of the kidney, transformed thelatter into a mere cyst filled with pus; and it was, neverthe-less, only by means of the microscope that purulent matterwas detected in the urine, because the ureter had becomepartially impervious. It may be supposed that the abscesswould soon have opened externally, had the patient livedsometime longer. Tiie following facts are, therefore, of greatimportance, as bearing upon the diagnosis of purulent col-lections in the kidney, and we hasten to offer the details ofthe case, as obtained from the notes of Mr. Pearl, one of Dr.Budd’s clinical clerks.William L-, a labourer, aged thirty-two years, was ad-

mitted Nov. 20, 1852, under the care of Dr. Budd. Thepatient is a native of Kent, and has always lived about marshy

districts in the neighbourhood of Canterbury and Chatham;he is a sturdy, florid-looking countryman, and enjoyed goodhealth until eight years ago, when he had rheumatic fever.He never suffered from ague, nor did, as far as he knows, anymember of his family; but he has been frequently engaged inclearing ponds and ditches, and has known his fellow-labourersto suffer from intermittents.Two months before admission, the patient was digging a

deep hole, and, whilst throwing up the earth, strained his leftside; he was at the time very wet, and had been standing inwater all day. The poor man was now obliged to give upwork, and go to bed, as he could not sit up for any time froma dragging pain on the left side just below the ribs; he hadnever noticed any tumour in that locality. Ever since thattime the patient has had pain after eating, about two inchesbelow the ribs on the left side, but this pain never shiftedto the pit of the stomach. The uneasiness did not use tocome on directly after the ingestion of food, but only tenminutes or a quarter of an hour afterwards, when the work ofdigestion had begun.Fourteen days before admission, there was vomiting after

meals; this lasted for four days, and the patient had likewiserigors at night. There never has been vomiting of blood, norsanguineous alvine evacuations, and the bowels have beenmore or less confined since the above-mentioned accident. Itshould also be noticed that for three weeks previous to ad-mission the man had to get up five or six times in the night topass urine. There was pain across the loins, but it did notshoot down in the direction of the ureters, nor was any un.easiness in or retraction of the testicle or at the end of thepenis complained of.The parish surgeon had attended the patient for about a

month, and used blisters and sinapisms; but these remediesgave no relief, and the symptoms remained as above describeduntil the man was admitted into this hospital. The state ofthe patient on that day is given in the following terms:-He still has the pain in the left hypochondrium so severe

as to prevent his sitting up; he can only lie on his back, andif he ventures on his side acute pain is immediately felt. Theleft side is less tender than the right, and when the patientassumes the dorsal decubitus, and draws up his knees, he getsmuch relief. The spleen appears much enlarged, and extendsfour or five inches below the ribs; the notches on the anteriorsurface of the organ cannot be felt, and the organ is tender onpressure. There is pain across the loins; the lung sounds arefeebler than natural ; heart sounds healthy; tongue ratherwhite; pulse 96; appetite good, and sleep interrupted by pain;urine acid, specific gravity 1023. This fluid, examined by themicroscope, presented some pus globules.An opiate was ordered, which relieved the pain, and pro-

cured sleep; but three days after admission there was morepus in the urine, which latter became high-coloured, thoughnot albuminous.On the sixth day the man was taken very ill in the night.

As he was going to sleep, after taking a dose of morphia, hepartly turned on his right side, and was immediately seizedwith a violent pain, which extended all over the abdomen,beginning at the site of the tumour, on the left side. He hadviolent rigors soon afterwards, being at one time in a profuseperspiration, and afterwards feeling as if cold water wererunning down his back. He had retching, vomited a little,and the pulse was rapid and weak. Mr. Macnamara, thehouse physician, was called to the patient, and ordered tur-pentine fomentations, which measure gave great relief. Twoounces of brandy were likewise given, and at about half pastsix in the morning an enema of gruel and castor-oil was ad-ministered.Towards noon the man was very weak, could hardly speak,

and the pain between the crest of the ilium and the last ribextended towards the chest. There was much thirst; pulse120, small and feeble. On the day after this attack, the ten.derness over the abdomen had much diminished, but therewas still pain over the tumour. The patient lay on his back,with his legs extended; he had occasional twichings in his

I arms; the face was pale and listless, and the lips pallid, withI a bluish tinge; pulse not perceptible at the wrist; respiration26, entirely thoracic. The symptoms became more and moresevere, and the patient died, 48 hours after the sudden attackwhich was described above.Post-mortem Examination. opening the abdomen, the

peritoneum appeared healthy, and presented no marks of in-

flammation. When a portion of the small intestines had beenremoved, a huge tumour was seen, reaching from the seventh rib

33

to the crest of the ilium, and pushing the spleen, which lay upon Iits upper end and partly overlapped its anterior surface, before iit. By further examination the tumour was found to be com-posed of the left kidney, this organ being greatly enlarged,the capsule, however, entire, and no external rupture visible.The kidney was then removed from the body, and submittedto a careful examination. The cortical substance was quitewasted, and the medullary portion unfolded, so that the kidneyformed one large cyst filled with pus. The cavity was partiallydivided into ten or twelve compartments, all opening into thedilated pelvis, and corresponding to the mammary bodies.Microscopically examined, the substance of the organ wasfound degenerated, presenting few if any indications of tubularstructure. The walls of the ureter were much hypertrophiedand cartilaginous, so as almost to render the passage imper.vious. The bladder appeared natural, and the viscus containedabout three-quarters of a pint of pure pus. The urethra washealthy in structure, the right kidney larger than usual andfatty, but the ureter was normal. Spleen healthy, thoughsomewhat enlarged; the surface of the liver was rough andnodulated, presenting the aspect of incipient cirrhosis; heartand lungs sound.The impression had been, as we stated above, that the spleen

had been damaged by the moisture to which the patient hadbeen so frequently exposed; still he stated that he had notsuffered from ague: but if the Professor of Clinical Medicineat the Paris Faculty, M. Piorry, is right, the spleen suffers firstfrom marshy exhalations, and ague is the consequence of con-gestion of the spleen. The affected kidney being the left one,it is no wonder that uncertainty should have prevailed as towhich of the organs-the kidney or spleen-was the seat ofabscess; the more so as the peculiar state of the ureter pre-vented the passage of a quantity of pus sufficient to build upa diagnosis. -

ST. GEORGE’S HOSPITAL.

Rupture of the Bladder; Death five days after the injury;Autopsy.

(Under the care of Mr. C&AElig;SAR HAWKINS.)RUPTURE of the bladder is not an accident of very rare occur-

I

rence, and it unfortunately is seen pretty frequently in the hospitalsof this metropolis. It is generally the result of a fall or blow onthe urinary receptacle when the latter is distended with urine;and the peritonitis consequent upon the effusion of the fluid intothe cavity of the abdomen is commonly fatal in a few days. Thepresent case offers these remarkable features, that the injury seemedto have been of but a trifling kind, and that the patient survivedfive days after the occurrence of a rent which must have allowedthe escape of almost the whole of the urine into the abdominalcavity. No doubt, however, but that there is a tendency, whilethe muscular coat of the bladder is contracting, towards theclosure of such solution of continuity ; and it is even probablethat an attempt at cicatrization would take place if the marginsof the wound were not constantly irritated by the urine, and theviscus kept semi-distended by the continual accession of fluid.As the symptoms of ruptured bladder are sometimes indistinct,we think we serve a useful end (besides the considerationsabove stated) in recording the following case from the notes ofMr. Holmes, surgical registrar to the hospital :-

Richard C aged fifty-five years, a navigator, of robustframe, was admitted August 25, 1852, under the care of Mr.Hawkins. It appears that the patient had been drinking duringthe whole of the two days which preceded the accident ; and

being much intoxicated, he became quarrelsome. Whilst attempt-ing to fight one of his companions, he fell heavily on his rightside, and this was the only injury he was known to have received,as it seems that his adversary never made any attempt to touchhim. The patient continued about the public-house for sometime, and was seen to make frequent attempts to pass water,(whether he succeeded or not, was not noticed,) and complainedsomewhat of pain in his side. Nothing more was known of hisstate till he was brought home, still complaining of pain in thesame region. The man was unable to pass any urine in thenight, and in the morning sent for a medical man, who drew offabout a quarter of a pint of bloody fluid. The same was doneagain in the evening, and next morning the patient applied at thehospital, complaining of much pain in the epigastrium, and reten-tion of urine.

to

He was put into a warm bath, and a catheter introduced, butonly a small quantity of bloody fluid came away. In the after-noon, a catheter was again passed without any difficulty, anda small quantity of clear urine, followed by a fluid tinged withblood, was drawn off. The patient’s complexion was natural, skin

cool, pulse regular; but he still complained of pain in the rightside, and winced much when pressure was made in that locality,yet no bruise was visible. The abdomen was distended to withina short distance of the pubes. Two full doses of laudanum weregiven, and the catheter was again introduced in the evening, withthe same result.

During the night, a few ounces of bloody urine were passedwith much straining; he seemed in much pain, and was veryrestless, frequently getting out of bed and walking about. Thecatheter was passed, and the same kind of urine evacuated. The

patient was rather delirious, but answered rationally when roused.Examination by the rectum detected some fulness behind theprostate gland ; bowels open, the motions were scanty, but therewas no blood in them.Next day, the man was perceptibly weaker ; he complained of

constant pain in the umbilical region; was ever straining to passurine, without effect, and seemed to derive relief from walkingabout. The catheter drew off about four ounces of clear urine.Percussion elicited a dull sound over the whole of the dependingpart of the abdomen as high as the umbilicus; when the positionwas varied, the dulness changed its position also. The pulseretained some strength, and the rate was natural. Bowels notopen. Manner stupid and confused.On the third day the weakness had increased, and before noon

the patient had become comatose. In this state he continued: most of the day, and, as far as was observed, till his death. His

wife, however, who was with him, declared that he recoveredconsciousness, a short time before his decease, sufficiently to tellher that the injury he had received was a kick on the abdomen,but did not acquaint her with any circumstances connected withthe infliction of the injury. She made several other statements,which appeared to be wanting in truth. He died quite comatoseon the third day after admission, and the fifth after the accident.

Post-rnort6m Examination.-No marks of external violencewere visible. The thoracic viscera were healthy; but on openingthe peritonseal cavity, a large quantity of fluid escaped-in all,between two and three quarts-of a turbid yellow colour, with ahighly urinous odour. This fluid displayed some of the salts ofthe urine under the microscope-viz. oxalate of lime, and afterit had been allowed to stand and become putrid, many crystals oftriple phosphate. A great many flakes, resembling those oflymph, were swimming about the effused liquid. The perito-naeurn was everywhere smooth, and its opposed surfaces un-adherent ; but in many places, especially where this membranelines the posterior parietes of the abdomen, it was very vascular.The cavity of the peritonaeum communicated freely with that ofthe bladder by means of a rent in the upper and posterior partof the latter viscus, of more than an inch in length. The lacera-tion extended further through the peritonseal covering than thesubjacent tissues ; its edges were dark and ragged, without anytraces of an attempt at union. The bladder seemed to be ofnatural thickness, and its lining membrane appeared healthy.The other abdominal viscera were quite sound, and none of themshowed any traces of injury. The pelvic bones were carefullyexamined, and found in a perfectly normal state.

Reviews and Notices of Books.

Practical Remarks on the Treatment of Anezcrisoa by Compression;with Plates of the Instruments hitherto eairptoyed in Dublin,and the recent In?.prove-ments by Elastic Pressure. By JOLLIFFETUFNELL, M.R.I.A. &c. 8vo, pp. 154. Dublin: Fannin.

THE treatment of certain cases of aneurism by compressionmay now be said to constitute an established proceeding in sur-gery. It is unnecessary, after the many articles which have

appeared in THE LANCET upon the subject, to enter at anylength upon the advantages of the system. It must, however,be admitted, that the profession is much indebted to the Dublin

surgeons, not only for carrying out compression in many cases,but also for several improvements in the mode of applyingpressure. Mr. Tufnell’s work is an excellent epitome of ourknowledge on the subject, and may be usefully referred to forinformation. After contrasting the results of treatment by liga-ture and compression, from published tables and other data, thefollowing remarks are the result of the author’s expeiience :&mdash;

" Is there, in an ordinary case of aneurism, any difference be-tween the mode of cure by the ligature and that exercised bycompression ? I believe not. I consider both as being ident1’callyI the same. In each instance the direct current is arrested, and