A CASE OF RUPTURE OF THE KIDNEY.

486

intractability of many functional disorders. It also answers to the description of the "primary lateral sclerosis" gives an explanation of the fact that under these circum- of Erb and Charcot, but differs from that disease, inasmuch stances the physical motor symptoms are sometimes such as as it is of common occurrence, it frequently recovers, and could not voluntarily be produced in health, as instanced by also because spasm of muscle with its consequences is not the the phenomena of hypnotism and hysterical malingering. leading feature of the affection. It is a condition which, In connexion with these reflexions it is a question of the when occurring in women, is almost invariably pronounced greatest practical importance to know whether repeated and to be hysterical; when in men, it is vaguely called paraplegia permanent functional over-activity or depression can lead or myelitis. For convenience I describe the group of to demonstrable structural changes in the tissues affected. symptoms under the term " hyper-tonic paresis," a symA priori reasoning would favour such a hypothesis, although ptomatic nomenclature which commits to no theory. This there is not a sufficient series of recorded facts to demonstrate in every respect answers to the hypothesis I have already it. At present brevity compels me to forego speculation on advanced concerning the nature of spastic paralysis. In conclusion, I venture to suggest the following points this interesting subject. Everything, however, seems to indicate that the causes which lead to hyper-excitability of for discussion:--I. Is the organic degeneration of the the ganglion motor cells, and consequently to the production lateral columns of the cord, so frequently associated with of spastic paralysis, are of an active or irritating rather than spastic symptoms, essential for their production; or may of a passive or inhibitory nature. This is supported by they be accounted for by functional derangement of the many facts; among others, that when one side of the body same regions, or of the psychical or motor centres? is primarily affected, there is invariably a tendency for the 2. Whether organic or functional, is the primary seat of other gradually to become involved; also, that all circum- disease in the cells of the brain or cord, or in the conducting stances which allay irritability, such as rest, sleep, tran- fibres, central or peripheral ? Are the symptoms the result, quillity, and sedatives, relieve the symptoms, while the of irritation or inhibition ? 3. May primary functional reverse conditions of emotion, exertion, injury, and ’, disorder eventually lead to secondary organic degeneration? 4. Regarding the cases described under the term hyperstimulants augment them. To sum up, it is suggested that spastic symptoms, from tonic paresis. What is the anatomical substratum of the whatever cause arising, are essentially due to abnormal affection? Where and in what manner does it originate? functional hyper-excitability of the motor ganglion cells of Is the condition one of organic or functional disease, the anterior cornua of the cord. The hyper-excitability and by what clinical criterion is the point to be determined may for various reasons be inherent in the cells themselves, during the life of the patient? What is the cause, proor may be induced therein by influences emanating from the gnosis, and treatment of the disorder? brain, the cord, or the peripheral nerves. These influences The irritation, when are probably of an irritating nature. it exists in the pyramidal tract, may be excited there either directly by organic disease or functional excitement, or A CASE OF RUPTURE OF THE KIDNEY. indirectly by changes in its nutrition as a result of severance BY G. Y. EALES, M.R.C.S., L.R.C.P. EDIN., from its trophic centres. These changes in nutrition may be LATE ASSISTANT-SURGEON, SIRHOWY AND EBBW VALE IRON AND either gross or dynamic. The gross changes usually follow STEEL WORKS, MON. gross disease of the cortical centres, while the dynamic changes may either follow their structural alterations or THE following interesting case is, I think, on account of their functional disorder. Finally, this functional disorder its comparative rarity worthy of record. of the motor tract may have its origin in psychical as well On April 10th, 1885, I was called to see S. G--, aged as in physical activity. These theoretical considerations a collier, who it was stated had been severely the of thirteen, pathology concerning spastic paralysis, like other hypotheses, are open to criticism. I admit they are some- injured by a fall of coal while at work in one of the comwhat involved, but this is scarcely to be avoided in attempt- pany’s pits. I found him lying on his back with the ing to account for the complicated circumstances connected shoulders raised up, thighs flexed (especially the right one), with this group of symptoms. pale and of anxious appearance, surface cold and bathed If, gentlemen, the doctrinal speculations on the subject face in sweat, pulse rapid and feeble, and respiration shallow and we are discussing are uncertain, the practical difficulties met with at the bedside are none the less perplexing. As of intercostal type, there being but slight diaphragmatic their clinical features are now well recognised, I pass over movement. A deep breath caused intense pain in the right those forms of spastic paralysis associated on the one hand lumbar region. He had vomited several times, and was, in with secondary changes from gross disease of the nerve fact, in a state of collapse. On examination I found an excentres, and on the other with obvious functional disorder. tensive contusion in the right lumbar region, and slight I limit myself to directing attention to a condition in con- abrasion of skin over the eleventh and twelfth ribs. The nexion with this subject, which has always seemed to me patient complained of such intense pain on pressure that I most obscure, and which I cannot find anywhere accurately was unable to ascertain if any ribs were fractured. There differentiated or satisfactorily explained. It is a group of was also a slight contusion on the right shoulder, another symptoms which everyone must have met with, and of which in the hypogastrium, and another on the posterior aspect of there are in the other room several illustrative examples. the right thigh. There was no tenderness on pressure in the In the evening he passed a large quantity In my own limited experience it is of frequent occurrence; and I find in my note-books of the last two or three years of bright arterial blood, mixed with urine, and vomited the detailed account of twenty-four typical examples. several times. An individual, either male or female, in otherwise good April llth.—11.30 A.M.: Very weak and anasmic. Pulse health, without obvious cause, gradually experiences slight hardly perceptible at the wrist. Had vomited constantly weakness in a limb-say, the leg. This, as a rule, very during the night, and had passed urine tinged with blood. insidiously increases, and, after a year or more, extends Some fulness in the right iliac region, with dulness on perto the arm of the same side, sometimes to the opposite leg, cussion. Complained of great pain all over the right half of and subsequently to all the extremities. On examination the abdomen, and tenderness on pressure. motor weakness is detected without incoordination; there 12th.--Yesterday, about 9 he passed some urine are clumsy and feeble actions of the upper, and a weak, slightly tinged with blood. To-day he has voided nothing shuffling, stiff, gait with the lower, extremities. At an early from the bladder. There has been no vomiting. Complained stage there is great exaggeration of the tendon phenomena, of pain all over the abdomen. Thighs strongly flexed on the cutaneous reflexes remaining normal. Afterwards ankle- abdomen, and abdominal walls rigid. Died in the night clonus is developed, and later slight stiffness of the muscles from a combination of anaemia and shock, having lived and trepidation of the limbs. The general health remains sixty hours since the accident. robust, and all the organs and functions of the body are Necropsy.-I made a post-mortem examination in connormal. Sensibility and nutrition continue unimpaired. junction with Dr. Coates (chief surgeon to the works) and Occasionally, but very rarely, in my experience this Dr. Henderson (senior assistant-surgeon; Tredegar Iron abnormal condition is acute, and reaches its full develop- Works). Body short for the age, and thin. The right side ment with great rapidity. The affection may entirely re- of the abdomen showed extensive bruising. On opening cover, but as often it persists for many years without change, the abdomen we found a large quantity of blood in the The disorder is one peritoneal cavity. No injury to the diaphragm or liver and or slowly increases in severity. evidently limited to the motor apparatus. It imperfectly no fracture of any ribs could be detected. There was no and

hypogastrium.

487 but portions of the ileum she was deliriously insane, howling, laughing, incessantly kidney showed commencing talking, struggling, and trying to bite. She spat out peritonitis. The right kidney was displaced downwards food and saliva, and urine and faeces were passed into and forwards, and lay in the iliac fossa ; behind it was an the bed, which had been made up on the floor. enormous amount of blood-clots and effused blood, the Morphia, given hypodermically, increased the excitelatter extending along the cellular tissue almost to the middle ment ; but chloral-administered with much difficultyline of the abdomen in front. There was also a quantity somewhat lessened it. On the 21st she was seen with me of blood-clots immediately in front of and on the right side of by Dr. Blandford of London, who confirmed the diagnosis. the lumbar vertebrae, overlying the solar plexus and semi- As the heart had begun to intermit, the chloral was lunar ganglion; this had apparently spread along the renal abandoned, and paraldehyde ordered instead. The food was plexus of vessels ; it did not extend over to the left side of limited to eggs and milk. From this time slight improvethe vertebrae. The peritoneum anterior to the kidney was ment took place until the 24th, when swelling of the left - severely lacerated, and so allowed escape of blood into its parotid gland was observed. The swelling had taken place cavity. The upper half of the kidney was literally smashed rapidly during the night, and extended to the malar into a pulp, but more so on the anterior surface than the bone and behind the angle of the jaw; it was hard and posterior, extending down to the pelvis of the kidney. very tender, but free from redness. Two days afterwards There were several large branches of the renal artery laid open. the right parotid took on the same action, giving the We could detect no wound of the trunk artery or vein. patient the characteristic aspect of mumps. During gleams There was also a small deep jagged wound in the lower half of consciousness much complaint was made of pain; and of the kidney on the posterior surface, which looked as if a attempts at swallowing were virtually abandoned. Feeding Tough object had been driven into it. The ureter appeared by the nares was impracticable, whilst haemorrhoids that to be completely blocked by a blood-clot. Bladder empty bled copiously at every touch precluded the use of nutrient ’and healthy; left kidney and ureter healthy. There was no enemata. No suppuration took place in the parotids, but evidence of the lower ribs having been driven through the from this time the strength swiftly declined. Exhaustion abdominal walls. passed into coma, and death took place on the 29th, which Remarks.-The noteworthy feature of this case is how was the sixteenth day of the illness. such an extensive injury to the kidney should have been -Remarks.-It is to the occurrence of the parotitis in this - caused without fracture of any ribs. The sudden cessation case that attention is drawn, and it is worth noting of hasmaturia was apparently due to clots in the ureter. because it really turned the balance against the patient at ’The rapidly-increasing anasmia, together with the haema- the critical point in her illness. Without referring to the turia and fulness of the iliac region, pointed presumably to difficulties it threw in the way of treatment, the question haemorrhage from the kidney; accordingly, astringents were of causation is full of interest. It was clearly not a case of given. Mr. H. A. Reeves, F.R.C.S., in a case published by idiopathic parotitis. Anyone who had for the first time seen him in THE LANCET of Oct. 4th, 1884, says that as soon as the patient when both parotids were swollen would it is found that haemorrhage is not controllable after trial of assuredly have thought of mumps and meningitis; but even every known means, a lumbar incision should be made over had there been no history the delirium could not have been the kidney, and all clots and blood removed, and the kidney mistaken for that of meningitis. The condition was sym also, if necessary. It occurred to me, if it would have been ptomatic, and not idiopathic. A great deal is heard now of justifiable to cut down and remove the kidney as soon as it the sympathy between the parotids and affections of the became evident that haemorrhage was profuse, obviously in generative organs; in this case, however, although the such cases to wait the effect of a lengthy trial of astringents approaching menopause may have had some share in inI do not feel competent to give ducing the maniacal attack, so far as could be ascertained means waiting till too late. an opinion as to the actual cause of this injury ; but rememthere was nothing wrong with the external or internal organs bering the fact that the boy was crushed beneath a great of generation, or with the mammae. The case ranks with those similar affections of the parotid which have long been mass of coal, it occurred to me that the kidney may have been suddenly dislocated, as it were, by the force of the known to occur towards the termination of fevers. Some have ’blow, and at the same time caught between the vertebral held that in these circumstances the parotitis result from a and the suddenly compressed ribs; and what makes this spread of the specific poison of the fever. Since the condition idea more tenable is the fact that the boy was small and has been seen in pneumonia, however, others have ascribed it very thin for his age, and that the anterior portion of the to the extension of oral inflammation. The present instance confirms the latter view. The mucous membrane of the kidney was the most severely damaged. mouth was dry and parched and covered with dead epitheKettering. lium ; possibly the milk that was retained in the mouth helped to increase the oral inflammation; but no aphthae ON A The incessant action of the jaw and the retenwere seen. FATAL CASE OF ACUTE DELIRIOUS MANIA tion of saliva in the parotid may have been contributing agents. So far as 1 can gather, this parotid complication, COMPLICATED WITH PAROTITIS.

apparent injury to the intestines, in the

neighbourhood

BY JAMES M.

of the

WILLIAMSON, M.D. EDIN.,

HONORARY SURGEON TO THE ROYAL NATIONAL HOSPITAL FOR CONSUMP-

TION, VENTNOR,

patient in this case forty, but looking older. THE

well-known in some severe diseases, does not appear to have been much recognised in connexion with acute delirious mania. Ventnor, Isle of Wight.

ETC.

American

ON SOME OF THE PROPOSED CHANGES IN

lady, aged THE LUNACY ACTS. She was a highly educated and talented woman, and was the principal of a large BY JAMES A D A M, M.D., RESIDENT PHYSICIAN, &C., WEST MAILING ASYLUM ; LATE MEDICAL educational establishment. Overwork had brought on SUPERINTENDENT, CRICHTON ROYAL INSTITUTION, SOUTHERN nervous prostration and insomnia, for which Dr. Ilammond, COUNTIES ASYLUM, AND CATERHAM ASYLUM, SURREY. of New York, ordered rest from work and change of scene. For twelve months the patient followed this advice, THE measure introduced by Lord Selborne ia already in but without much benefit. During familiarly known to the public and the medical profession. It travelling England, April, 188.5, while at Bournemouth, she had a throat attack, was presented to the House of Lords during the last session suspected to have been diphtheritic, and accompanied by of the last Parliament, and was ordered to be printed on what she called " delirium." The patient came to Ventnor early in the next month (May), and consulted me on March 26th, 1885. It met with by no means unanimous the 10th for insomnia. Her catamenia, regular as yet, approval, and some of its provisions were so much objected to began on the 12th, and brought on increased restlessness that they led to the resignation of Lord Shaftesbury as chair:and irritability, upon which chloral and the bromides made man of the Board of Commissioners in Lunacy; but it was no impression. On the 14th she was in bed, her mind with satisfaction hailed and it came at last to be by others, excited and wandering. The pulse was rapid, but the on the belief that it was to do something accepted not elevated. The was the breath necessary ’temperature tongue dry ; absent; but the bowels were not con- to allay the public agitation and suspicion which had been tined, and the urine was freely voided. In two days more strongly aroused on the subject. The Bill passed through

tensive;appetite

was an