66

pain, much worse when passing urine, not worse whenmoving about; that it was worse when the bladder hadbeen emptied. However, on examination she seemed tohave incontinence; there was continuous trickling fromthe urethra of slimy blood-stained urine. On May 28thMr. Sydney Jones examined with a sound. There was nocalculus, but there was a sensation of thickening in theposterior wall of the bladder. Microscopical examinationof the urine showed blood-corpuscles, pus-cells, crystals oftriple phosphate, amorphous phosphates, but no cell growthenabling one to arrive at a diagnosis of tumour.On June 3rd the patient was put under ether; the urethra

was dilated, and the bladder explored by the forefinger. Atumour was then felt, cauliflower-like, floating in thebladder, about the size of a Tangerine orange, and attachedby a pedicle about half or three-quarters of an inch in

length to the floor of the bladder, about an inch behind thevesical orifice of the urethra. The pedicle could be distinctlyfelt, and gave one the impression of being the thickness atleast of an ordinary goose quill.On June 8th the patient being again put under ether, Mr.

Sydney Jones operated. The forefinger was passed throughthe dilated urethra into the bladder so as to feel the pedicle.A catch forceps was then passed into the bladder so as tosecure the pedicle below the forefinger. The pedicle andtumour were then drawn forwards, and the noose of awire écraseur was passed over the tumour and forceps, and afew turns of the screw readily detached the tumour. Therewas no haemorrhage from the divided pedicle. The size ofthe removed tumour was less than when examined with itsnormal distension and vasculariry. When removed it wasthe size of a walnut, and in water presented a beautifullyvillous character. Mr. Shattock, who described it as acharming specimen, looks upon it as simple papilloma. Thespecimen is in St. Thomas’s Museum. The bladder waswashed out well with boracic lotion, and a large-sizedcatheter was left for some hours in the urethra.There is nothing to record in connexion with the after

symptoms. The patient went on continuously well. Onlyon the night of the operation did her temperature reach100° ; afterwards it was normal. She left the hospital onJune 27th, nineteen days after the second dilatation of theurethra and the removal of the tumour. On her dischargefrom the hospital there was no incontinence, no blood in theurine, and no pain.The patient was again seen on July 4th, and was in excel-

lent health.Remarks by Mr. SYDNEY JONEs.-The above cases are of

interest in that both presented the characteristic symptom,in the first place, of haemorrhage without any additionalsymptom. In the first case there was in the later stagessome frequency of micturition, but pain only during thepassage of clots. He was rapidly going to the bad from lossof blood. In the second case, that of the woman, there wasat first bsemorrhage; later on pain and incontinence, pro-bably due to the attachment of the tumour, the pedicle ofwhich was placed only a short distance behind the vesicalorifice of the urethra, so allowing the tumour to be washedforwards and to obstruct the exit of urine. In the firstease there could be no doubt of the existence of tumour.It was certainly the course to pursue to do a suprapubiccystotomy at once, without any preliminary perineal opera-tion ; and in any similar case I should at once follow thesame course. The suprapubic operation enables one toexpose the tumour in the best manner possible, and to usethose means best adapted for its perfect removal. Thebladder, too, is easily explored for any other growth. Ido not consider, with the peritoneum well out of theway, and with free drainage subsequently providedfor, that the suprapubic operation is a serious one.For tumours, I think, the suprapubic operation isthe one to be selected. For stone, in my opinion,this operation should be selected for large calculi.The same objection exists against operating for vesicaltumours through the perineum as for stone. In the case ofthe male above referred to, one month was occupied for thehealing of the suprapubic wound. Suppose the operationhad been done through the perineum, not less time in heal-ing would have been occupied, and one would have had more difficulty in exploring and thoroughly removing thetumour. In the case of the woman, the tumour was so

easily accessible through the dilated urethra, that no betteroperation could be suggested than that which was carriedout.

SAMARITAN HOSPITAL FOR WOMEN,N0TTINGHAM.

A CASE OF NEPHBECTOMY FOR HYDRONEPHROSIS ;REMARKS.

(Under the care of Dr. ELDER.)A. S-, aged twenty-three years, single, was admitted!’

on April 9th with a well-marked abdominal swelling on the.right side. The following history was elicited. It is nowseven years ago since first an aching pain in the right side,not constant but intermittent, was experienced by thepatient. Machining, which occasionally had to be done in,her occupation of dressmaking, or any unwonted and severeexertion, caused this discomfort, and its relief always.followed resting. For several months this state of matterswent on without affecting her general health, when.suddenly and spontaneously it ceased and caused no furthertrouble for the space of three years and a half. Thenan attack similar to the present came on and a" lump

" on the right side now was recognisable..

After a duration of three months this swelling dis-

appeared as suddenly as it came. It had caused notparticular symptom, but merely a sense of prostration.Again, six weeks prior to admission, the tumour rapidly re-appeared, accompanied this time by pain, sickness, andslight constitutional disturbance. During this last inva-sion the patient has lost flesh, but otherwise her health is.unaffected. When walking, standing, or lying on the leftside a dragging, sickening sensation is complained of.There has never been hasmaturia or other unhealthy con-dition of the urine, and menstruation has been uniformlynormal.The objective signs were as follows: On the right side

there was an irregularly-rounded, prominent swelling,.insensitive and fluctuant, which when the patient lay onher back naturally fell into the right renal position, butwhich was freely movable, either by changes of recum-bency on the part of the patient or in obedience to manipu-lation. It pretty well filled up the space between theileum and the lower border of the liver. Evidently over-lapped in front by the ascending colon, as manifestedby the percussion note, in other parts it was quite dull. Nopelvic or hepatic connexion could be made out, so thediagnosis lay between a floating kidney which had become,hydronephrotic, or renal hydatids-the former being lookedupon as the most probable one. The urinary secretion was,plentiful, normal, and with a 2’4 percentage of urea.On April 13th thi tumour was aspirated behind ther

peritoneal reflexion and eighteen ounces of straw-colouredfluid withdrawn. This had a specific gravity of 1004, was,very slightly albuminous, contained no hooklets, but showeda few crystals resembling urea nitrate. Within a few hoursthe swelling was as large as before and caused pain; st}

taking into account that renal extirpation in a patientotherwise healthy, and with the other kidney sound andable to perform the necessary compensatory function, is notso much more serious than a nephrotomy, this operation wa&decided upon and carried out on April 19th by the lumbarmethod. The comparative absence of peri-renal fat wasnoted at the time. The after progress of the case was oneof uneventful progress towards recovery, the temperature-only rising to 99° F. once, and this on the advent of amenstrual period. The patient left the hospital onJune 5th with part of the wound not quite healed. The

specimen removed showed the cyst to be composed of theupper part of the ureter and the pelvis and calices of thekidney, of which the greater part of the secreting tissuehad become absorbed.Remarks by Dr. ELDER.-The history of the above case

points pretty clearly to its being an instance of a movablekidney becoming cystic owing to interference with theurinary flow, by reason of kinking and impermeability of theureter. Intermittent hydronephrosis is thus explained-a condition which usually becomes permanent by virtue ofthe structural changes which take place in the walls of theureter from the alternations of extreme tension and evacua-tion. This doubtless happened in my own case, thusexplaining the repeated suddenness of the onset and dis-appearance of the swellings. Calculous impaction of theureter, pressure from without by ovarian or malignanttumours, and bands of cicatricial tissue in the pelvis,are well-recognised causes of this pathological condition..

67

With regard to the treatment of these cases, allow me todraw attention to a few statistics from Gross’s monographon Nephrectomy, published in 1885, and which includes allthe cases of extirpation and allied operations obtainable frompublic and private sources up to date. Of six cases of aspira-tion, three were cured, two improved, and one died from somecause unconnected with the operation. Five cases were in-

jected with tincture of iodine, of whom two were cured andthree died. Of fifteen cases of punctu) e, twelve died, one wascured, and two had temporary relief. Incision with drainagein twenty-five cases cured twenty-one, and there were fourdeaths. Of these the mortality was most by the ventraloperation. Of the twenty survivors (for some reason one isleft out by the author), eleven have urinary fistula, of whomtwo have been relieved of this discomfort by a nephrec-tomy. Extirpation has been performed twenty-one times,with a total mortality of 3809 per cent. Ten deathswere recorded out of seventeen ventral operations, andone of four lumbar. Gross, as the result of these in-vestigations, recommends in the first instance aspirationof hydronephrotic tumours, then, if necessary, incisionand drainage, in preference to the more serious operation ofremoval of the organ. It seems to me that, failing a cureby aspiration, a lumbar nephrectomy, in an otherwise goodand young subject, is very little more dangerous than anephrotomy, and is not followed by all the unpleasantnessof a primary fistula, which, as we have seen, follows themajority of cases of incision and drainage. The presentmakes my fifth nephrectomy, with one death-the remainingthree, previously reported in the pages of this journal, beingin good health.

_____

WOLVERHAMPTON GENERAL HOSPITAL.ANEURYSM OF CORONARY ARTERY; RUPTURE ;

NECROPSY; REMARKS.

(Under the care of Dr. MALET.)FOR the following notes we are indebted to Alr. Arnold

Evans, house-physician.J. D--, aged five, was admitted on Jan. 29th, 1887. He

was a pale, emaciated, and feeble child, with scarcelysufficient strength to walk ; he had three small unhealthy-looking sores, two on the face and one on the leg. His

father, who brought him, said that for three weeks thechild had suffered intensely from thirst and copious diuresis,the former being so distressing that he would even drinkdirty water from puddle-holes in the road. Enormousquantities of urine were passed after admission, and aspecimen examined was pale and clear; it had a specificgravity of 1002, and contained neither sugar nor albumen.The thoracic organs were examined, but nothing abnormaldetected. When attempting to sit up in bed on the morningof Feb. lst he complained of pain in the chest, then fellback and died almost instantaneously.At the post-mortem examination the pericardium was

distended with about five ounces of clotted blood, adherentto the walls of the heart. The ventricles were contractedand empty; valves competent and healthy. On removing theclots, a softened spot, surrounded by ecchymosis, was dis-covered in that part of the wall of the left ventricle whichis overlapped by the appendix of the left auricle, the auri-cular appendix itself being discoloured externally, but itsinternal surface quite healthy. A probe passed along theleft coronary artery from the aorta appeared at this sottenedpoint, and on dissecting out the artery it was found that itslumen at the above-mentioned point was increased and itswalls attenuated, the aneurysmal dilatation thus formedbeing about the size of a pea. It was clearly from a ruptureof this aneurysm that the haemorrhage had occurred.Remarks by Air. EVANs.-Attention having been called to

hasmo-pericardium in a recent issue of THE LANCET byMr. J. W. Batterham, I have been induced to report theabove case. Although haemorrhage into the pericardium isof frequent occurrence from a variety of causes, it rarelyhappens that rupture of an aneurysm of the coronaryartery occasions it. I have been able to find records ofnine similar cases, a resume of most of which by Dr. Crispwill be found in the twenty-second volume of the Transac-tions of the Pathological Society; in most of these cases,however, the subjects had reached an advanced age, andthe chief interest of the case just recorded is centred in theage of the patient.

Medical Societies.SOCIETY OF MEDICAL OFFICERS OF HEALTH.

An Improved System of Flush Closets for Small HouseProycrty.-Tlcc Powers and Responsibilities of LocalAuthorities in regard to Rabies.A MEETING of this Society was held at the Scottish Cor-

poration Hall, Crane-court, Fleet-street, on Friday, May 20th,Dr. Alfred Hill, President, in the chair.The Council presented the following report, which was

adopted :-1. That the annual meeting be held at a dateshortly preceding the October meeting, so as to enable theproposed amalgamation of the various societies to be com-pleted and the officers for the ensuing session chosen fromthe reconstituted society. 2. That the dairies, cowsheds,and milkahops regulations as amended be issued.The PRESIDENT referred to the loss the Society had sus-

tained by the death of Dr. Ihff, and it was unanimouslyresolved that a letter of condclence be sent to the bereavedfamily.The PRESIDENT read a paper on an Improved System of

Flush Closets for Small House Property. After referring tothe different methods of excremental refuse disposal andthe disadvantages attending each, Dr. Hill explained hismethod by which slop water was utilised, which, being ofhigher temperature than water supplied by the mains, pre-vented pipes from freezing. The amount of water thus madeavailable he estimated at fifteen gallons per day in a smallhouse, or 150 gallons for a court or row of ten houses, alarger amount than is used in connexion with an ordinarycloset supplied from a cistern. Slop water and surfacewater are conveyed to a tank which is constructed in twochambers, the first to arrest earthy and other solid matters,the second to constitute an automatic flushing tank,which, however, is only necessary in cases of one or twobouaes in which the quantity of water might prove insuffi-cient. From this second tank the water is discharged intoa horizontal glazed pipe, twelve by ten inches in diameter,in connexion with the sewer from which it is disconnectedby a syphon trap, to which access is given by means of aman-hole. The closets u,re placed over this pipe, andbeneath each seat is a perpendicular salt-glazed stonewarepipe connected with that below; the upper aperture of theperpendicular pipe is about seventeen by fifteen inches inits diameter, the lower twelve by ten inches. At the junc-tion of the two the lower opening is received into a collar;the vertical pipe is so shaped that its posterior wall isperfectly vertical, while its anterior wall towards the lowerend inclines in a straight line backwards and downwards,causing a narrowing of the lower aperture, to enable it toenter the collar or flange of the horizontal pipe; the latteris ventilated by a separate vertical pipe connected with itand running up the side of the house in a suitable position.Dr. Hill stated that this arrangement had the advantages ofcleanliness and cheapness, and was being largely adopted inBirmingham.

Dr. WHITELEGGE, medical officer of health for Notting-ham, read a paper on the Powers and Responsibilities ofLocal Authorities in regard to Rabies. In the first part ofthe paper the questions which present themselves to a localauthority in considering its action in regard to rabies wereexamined from the point of view of the medical officer ofhealth. These questions were stated thus :-1. Is rabieslikely to become prevalent in the district? 2. By whatmeans is it liable to be introduced and maintained ? 3. Whatevidence is there of the utility of the preventive measuresauthorised by the Rabies Order of 1887, and the Dogs Act-viz., compulsory muffling and the slaughter of stray dogs 24. What form should such regulations take? As bearingupon the first question, it was shown that before the numberof known cases was such as to excite alarm, the diseasemust be already widely spread. Rabies could be detectedwith certainty, both by its symptoms and by the evidenceattainable after death, but the great majority of cases doubt-less occurred among vagrant dogs and other animals nevercoming under observation; and, apart from the fact that eventhe most characteristic symptoms were frequently overlookedby the owners of dogs, it was common for an affected animal towander away from home in the earliest stage of the disease. Thesecond question was answered by pointing out that the bite