1348 HOSPITAL MEDICINE AND SURGERY.-MEDICAL SOCIETY OF LONDON.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas etmorborum et disseetionum historias, tum aliorum turn propriascollectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus.Morb., lib. iv., Proœmium.

BEDFORD COUNTY HOSPITAL.A CASE OF RUPTURE OF THE URETER ; DRAINAGE ; RECOVERY.

(Under the care of Mr. W. GIFFORD NASH.)A MAN, aged 44 years, was admitted to the Bedford

County Hospital on July llth last, complaining of abdo-minal pain. He was dull and stupid and there was greatdifficulty in obtaining any history from him, but the follow-ing history of his case was afterwards given by Dr. C. H.Nicholson of Silsoe, Bedfordshire, under whose care he hadbeen. " The man had never been robust but did not rememberhaving any serious illness-in fact, he had not been on hisclub for 15 years previously to February, 1906. On Feb. 22ndhe suffered from pain in his lower abdomen, slight vomiting,and obstinate constipation. There was some bleeding fromthe rectum which was too tender to admit of digital examina-tion. He returned to work on April 14th relieved of painand not passing blood. On May 16th he had a severe attackof vomiting and pain in the left hypochondrium. His

temperature was 1000 F. These attacks continued atintervals of about a week until June 22nd. On July 5thhe had an attack of a similar nature on the right side andon July 8th he first noticed a swelling on this side whichcame with pain and subsided when the pain was relieved.The attacks of pain were attributed to renal colic."On admission nothing could be felt in the abdomen. The

right flank was tender. Per rectum nothing abnormal wasdetected. His temperature was 100°. On July 14th a

swelling was felt on the right side of the abdomen outsidethe caecum. This rapidly increased during the two followingdays, so that at the date of operation-July 16th-itextended from the right costal margin downwards acrossthe iliac fossa as far as the external abdominal ring.An incision was made into the swelling with its centre two

inches internal to the anterior superior spine of the ilium.A large cavity was found containing about 30 ounces of clearurinous fluid. At the upper part of the cavity the right kidneyof about normal size could be felt lying loose, as if dissectedout by the fluid. The caecum was displaced inwards. The

cavity was mopped dry and then it was seen that clearfluid kept dribbling in from the position of the ureter on alevel with the crest of the ilium. The fluid was ejected inspurts at intervals of a few seconds, just as urine enters thebladder from the ureter. It was evident that this fluid wasescaping from the ureter about three or four inches belowthe pelvis of the kidney. At the time of operation very littlewas known of the patient’s history, so that no search wasmade for calculus. Mr. Gifford Nash did not feel justified inremoving a healthy-looking kidney, so he decided to drainthe cavity The urine ceased to flow from the wound onJuly 20th and on the 24th the tube was left out. OnAugust 12th the patient was out of bed and left the hospitalon the 22nd. For four days after the operation the urinepassed naturally, averaged about 30 ounces, for the nextweek 40 ounces, and after that about 50 ounces. Dr.Nicholson reported on Oct. 24th that the man was gettingabout and was quite free from any pain or swelling.Remarks by Mr. GIFFORD NASH.-Subcutaneous injuries

of the ureter are very rare. Morris 1 gives a list of 24 casesdescribed as " rupture of the ureter," and of these says thatonly 12 can be considered injuries of the ureter proper, andof the 12 only three were actually proved to be rupture ofthe ureter. In most of the cases the patient died or

underwent nephrectomy. In six of the cases a retroperi-toneal collection of fluid appeared.The ideal treatment is immediate suture or anastomosis of

the ureter (Morris). Other methods are puncture of thecyst and lumbar incision. Puncture of the retroperitoneal

1 Surgical Diseases of the Kidney and Ureter, vol. ii., p. 330.

cyst has given uncertain results. Stanley’s case was

punctured six times without effecting a cure. In a caseunder the care of Mr. Paul Swain which I recorded inTHE LANCET,2 one aspiration cured a large retroperitonealextravasation of urine due to injury, but this may have beena rupture of the kidney or its pelvis.

In the case under notice there was an absence of a historyof injury. The cause might have been ulceration of a

calculus through the wall of the ureter and the previoushistory rather pointed to this. No sign of a stone was seen.Other causes which suggest themselves are rupture of a

dilated ureter above a stricture or perforation of an ulcer,but if either of these was the cause one would not haveexpected such rapid healing to take place. The cause, Ifear, must remain unexplained.With reference to the treatment adopted, the incision was

an extensive one so as freely to expose the csecum and thekidney. The site of oozing from the ureter was easily seen.I did not think it possible to sew up the opening in theureter and before performing nephrectomy I determined togive the fistula a chance of granulating up. By adoptingthis method Morris’s surmise came true, " that if the ureterwere not completely torn across and free drainage were pro-vided he would expect cicatrisation of the wound and re-establishment of the ureteral channel to take place."

Medical Societies.MEDICAL SOCIETY OF LONDON.

Exhibition of Cases.A MEETING of this society was held on Nov. 12th, Mr. C. A.

BALLANCE, the President, being in the chair.Dr. E. G. GRAHAM LITTLE exhibited four cases of Urticaria

Pigmentosa in children. The disease had started in earlylife, as usual in this complaint. It was characterised by anappearance of successive crops of urticaria, followed bypigmentation ; the former stage might be so evanescent asto escape notice. The condition was rare, occurring only aboutonce in 4000 instances of skin disease. Sketches of the histo-logical features were exhibited. In many cases the eruptionsubsided as adolescence became established. No treatmenthad much influence.

31r. C. GORDON WATSON exhibited a case of Ileo-

Sigmoidostomy after Excision of Carcinoma of the SigmoidFlexure, the colotomy wound being still open, in a man, aged33 years. The chief question raised was how best to closethe wound.-Mr. CUTHBERT S. WALLACE suggested divisionof the large bowel below the wound and anastomosing thiswith part of the bowel above.-Mr. A. E. J. BARKERendorsed this suggestion.-The PRESIDENT remarked thatwhen portions of the bowel were thrown out of use theyatrophied, disappeared, and could not be identified. He tooka more favourable view than previous speakers of theprognosis in this case.

Mr. EDRED M. CORNER showed a case of MultipleSwellings on the Bones of One Lower Extremity in a girl,aged seven years. The swellings existed on the upper andlower ends of the right femur and tibia, the upper end ofthe right fibula, the right ramus of the os pubis, and possiblyon the right ilium. There was nothing to be found in therest of the skeleton. Attention was drawn to the extra-

ordinary distribution of the tumours-namely, in one limband the corresponding half of the limb girdle. Theseswellings had interfered with the growth of the bones inwhich they were situated, so that the right leg was twoand a half inches shorter than the left, causing the girl tofall about. Otherwise the patient was perfectly well. Inskiagrams the swelling presented a vacuolated appearance.When shown at the Clinical Society on Oct. 26th the casewas regarded as possibly syphilitic in origin on account ofthe history and the depressed bridge of the nose. But sincethen sections had been cut of part of one of the swellingswhich revealed them to be enchondromata undergoingirregular ossification in the form of a network. Therewere at least seven well-marked tumours in the one limb.-The PRESIDENT discussed the origin of such tumours andthought they might quite well be termed enchondromata.

2 THE LANCET, Sept. 12th, 1891, p. 612.

1349CLINICAL SOCIETY OF LONDON.

Mr. PERCY W. G. SARGENT exhibited two cases of Sym-metrical Myeloid Sarcomata. One was a male, aged 14 years,in whom enlargement of both sides of the mandible had beennoticed for two years. When admitted to St. Thomas’sHospital in August, 1904, there were hard swellings on eachside in the region of the bicuspid teeth, the second lowerbicuspids being absent. No enlarged glands were felt.Operation was performed on the left side; the tumour wasnot encapsuled. Microscopically it proved to be a giant-celled sarcoma with much fibrous tissue. The sister of the ilast patient, a year or two younger, was also shown, with anexactly similar condition of the lower jaw. In this casethere were some enlarged lymphatic glands.Mr. BARKER exhibited a case of Lymphangiectasis of

the Left Thigh in a man, aged 22 years. The conditionhad existed for six or seven years. At certain periods of theday, e.g., after food, the contents of the swollen lymphaticswere chyle-like. This seemed to indicate some communica-tion with the lacteals. When the swelling of the leg becameintolerable the patient pricked the swollen lymphatics andlet out the fluid. Discussing the possible operative measuresfor relief Mr. Barker deprecated anastomosis between theenlarged lymphatics and a vein as not being free from thedangers of thrombosis and embolism.

Dr. F. J. POYNTON exhibited a case of Enlargement of theLower Limb in a child, aged seven years. The child’s leftleg was said to have been always larger than the right,there being at the present time from three to four inchesdifference in the circumference of the two limbs. The skinof the affected part had a peculiar consistency and, togetherwith the subcutaneous tissues, appeared thickened and feltresistant. There was no pitting on pressure. The bones ofthe affected side could be felt to be bigger than those of theright side and this difference was confirmed by x rays. Thethickening of the skin and subcutaneous tissues could beappreciated over the lower abdominal, gluteal, and lumbarregions of the left side up to about the level of the umbilicus.Dr. Poynton suggested the possibility of his case resemblingthe case just shown by Mr. Barker in an earlier stage.-Dr.A. F. VOELCKER believed there was some enlargement of thebones on the affected side ; but it could not be regarded asa case of true gigantism.

Dr. F. PARKES WEBER exhibited a case of Multiple FibrousNodules about each Olecranon with a Rheumatoid Condition ofOne Foot, in a man, aged 37 years. The nodules were notspecially tender to pressure, but of a tough fibrous-likeconsistence, situated in the neighbourhood of the bursas. Onone of the fingers there was also a small fibrous nodule. Twoyears ago the patient developed rheumatism which affectedhis hands and feet, and since that time he has never beenquite free from active symptoms. The nodules appearedabout one year ago. Dr. Weber, in commenting on this case,expressed the view that there was no hard-and-fast linewhich distinguished many conditions clinically termed rheu-matoid arthritis from conditions termed chronic or subacuterheumatism, or even from conditions supposed to be gouty.Dr. WEBER also exhibited a case of Myelopathic Spleno-

megalic Polycythsemia.Dr. J. F. H. BROADBENT exhibited an Early Case of

Paralysis Agitans without Tremor in a female patient, aged54 years. For upwards of a year she had noticed increasingdifficulty in writing, sewing, and finer movements of theright hand on account of stiffness and weakness. She alsostated that the right leg was weaker than the left. Thefingers of the right hand were held in an "interosseal"position. There was no tremor anywhere. There were noalteration in voice and no marked loss of emotionalexpression.-Dr. J. WALTER CARR expressed some doubt asto the validity of the diagnosis.-Dr. BROADBENT replied.Dr. R. A. YourtG exhibited a case of Multiple Neuritis

following Enteritis. The patient was a boy who at the ageof two years and nine months was in a hospital at Maltafrom June 15th to August 5th with acute enteritis followedby a febrile illness associated with symmetrical weaknessand wasting of the muscles of both legs and to a less degreeof both arms. When seen at the Middlesex Hospital at theage of three and a half years there was a partial reaction ofdegeneration in the muscles of the legs, which were cold andblue. The reflexes in the lower extremities were lost and thechild could not walk without assistance. No particular group yof muscles had specially suffered and recovery was takingplace symmetrically.Mr. WALLACE showed a case of Myeloid Sarcoma

of the Upper End of the Right Fibula in a female

child, aged five years. The history was only of 14 days’duration. The growth lay in the diaphysis under the epi-physeal cartilage and evenly expanded the bone. The caseseemed, Mr. Wallace thought, to be a suitable one for a localexcision ; the upper end of the cut fibula might be fastenedto the tibia.

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CLINICAL SOCIETY OF LONDON.

Treatment of I’raatures.-Multvple Strictures of the Ileumatreated by Operation.—Rotatory Subluxation of the Spine.-Congenital Deformity of the Cervioal Spine treated byOperation.A MEETING of this society was held on Nov. 9th, Mr. H. H.

CLUTTON, the President, being in the chair.Dr. E. DIVER read a paper oia the Treatment of Fractures

in which difficulty was experienced in bringing the ends ofthe bone together. The suggested treatment applied to thosecases in which good apposition of the two ends was notattainable. Efforts should be directed to gain contactmerely of some portion of the broken ends of the bone,regardless of the contour of the limb until callus wasbeginning to fix the fracture. Subsequently the norma)outline of the limb could be restored by movements alter-nating with periods of rest much as in a case of tenotomy.The callus as it hardened would yield to the surgeon’smanipulations until the limb was as far as possible insymmetry with the other. In some cases the effect of mus-cular action would aid in maintaining the fragments in goodposition. The principle of the treatment was similar to that.governing the treatment of clubfoot and at first sight seemedto promise results similarly good. An opportunity for tryingthe treatment had not hitherto presented itself.Mr. CHARTERS J. SYMONDS read the notes of a case of

Multiple Strictures of the Small Intestine, probably of Tuber-culous Origin. The patient was a man, aged 43 years, who-was admitted into Guy’s Hospital in September, 1899. Sincea boy he had been subject to abdominal pain. Since theage of 20 years he had had one or two attacks of pain eachyear, generally at night. He was first seen on August 30th,1899, and he said that the attacks had been more frequentduring the last three years and the pain had been almostconstant for the last three months. During the last week hehad been frequently sick, bringing up much brown fluid. Onexamination the abdomen was swollen, coils of small gutcould be seen, there was loud gurgling, and a marked soundof fluid passing a narrow orifice was heard at a point below,and to the left of, the umbilicus. On Sept. 5th, 1899,the abdomen was opened and resection with end-to-endanastomosis was carried out. The portion removed was 15inches long and showed a thickened and dilated length ofbowel with a stricture at either end. The dilated portion wasof the size and shape of a small stomach and about 12 inchesin length. The patient had had no return of symptoms andwas at present in perfect health. Reference was made to asimilar case in a child and another in a male adult patient.-Mr. F. J. STEWARD referred to a similar case in a man, aged37 years, admitted to Guy’s Hospital. Abdominal pain wasthe leading symptom. There was nothing to suggest thecause of the stricture in this case.-Dr. W. H. B. BROOKasked whether there were any signs of tubercle in the lungsor elsewhere.-Mr. A. E. J. BARKER suggested that thestricture might have been the result of typhoid fever.Another case he referred to had been the result of strangu-lated hernia. He advocated the freer removal of the intestine-in the operation of resection, cutting always into thoroughlysound tissue.Mr. EDRED M. CORNER read a paper upon Rotatory

Subluxation of the Atlas. He drew attention to those casesin which, as the result of violence such as a sudden twist,’he head became fixed in a rotated position. This he con-cluded was the result of the locking together of the forwardlylisplaced side of the atlas on the axis by muscular action.rhe position and fixation of the atlas could be discoveredclinically by the position of its transverse processes and byshe loss of certain movements of the head and neck. Caseswere quoted and diagrams were exhibited in support of these;tatements. Skiagrams were shown from a case exhibited’vt the society on Oct. 20th, 1905. A skiagram was mainly)f use to demonstrate the absence of complicating injuries,tuch as a fracture of the odontoid process or of the anteriorLrch of the atlas. If such additional fractures were excludedm ansesthetic should be slowly and carefully administered.