CASE OF CONGENITAL HARD CANCER OF THE LEG IN AN INFANT ;

766 a reason why cases of this class ought not to be allowed to Further confirmation of direct benefit derived from it. drift year after year into this broken-down condition, in this principle may be drawn from the fact that Mr. Syme which a comparatively trivial operation can extinguish the treated somewhat similar cases in the male by incising the feebly sustained vitality. It rather raises the question neck of the bladder as if for lithotomy, and from the suggested by Mr. Charles Smith, of Halifax, whether the rapidity with which the inflammation of the bladder prodisease of the kidney may not have been induced by the duced by a calculus subsides under the free drainage established by lateral lithotomy. prolonged vesical irritation. (2) Another objection may appear in the possibility that (To be continued.) the source of the irritation may not be in the bladder itself, but may be pus entering the bladder from the kidney or some other extraneous source. The fatal cases of my own, and CASE OF of Mr. Wheelhouse, already referred to, prove that the discomforts of the irritability of the neck of the bladder CONGENITAL HARD CANCER OF THE LEG may be suspended or relieved by the operation, although IN AN INFANT ; the irritability may have originated in a cause external to AMPUTATION DURING THE FOURTH MONTH; RECOVERY the bladder. AND PERMANENT CURE. (3) A third objection may be raised in the danger of profirst idea the incontinence urine. about ducing My of operaBY KELBURNE KING, F.R.C.S., tion was, that by producing temporary incontinence of urine SURGEON TO THE HULL GENERAL INFIRMARY. we might so set at rest the vesical structures that any ulcerated or abraded surface might heal, that morbidlyi ON the 28th of March, 1871, I was consulted regarding a irritable or hypertrophied sphincter-fibres might lose theirr excessive irritability, and that any unhealthy condition off male infant about two months old under the following urine resulting from an imperfectly emptied bladder (as circumstances. At its birth, on Jan. 31st, 1871, Dr. Robert occurs in the male from enlarged prostate) might, by its’ Savile, who attended its mother in her confinement, observed freedom of escape, regain its normal character. This was a tumour on the outer side of the right ankle, about the my original idea-namely, to producd incontinence. And I size of a filbert. It was not painful, nor did it seem to was induced to believe that any incontinence would be. temporary by what I had seen of the removal of large-sized cause any inconvenience, but it gradually increased in size. calculi in the female with rapid recovery of vesical compe- When I saw it it was about as large as a walnut, was closely tency. It has happened, however, that the operation was= connected with the lower end of the fibula, from which it rarely followed by any incontinence of urine, and many of seemed to spring. The skin covering it was quite healthy, the most rapid and most complete cases had not even temno appearance of vascular excitement. The tumour porary incontinence. On the contrary, instead of relieving having was lost in the the bladder every few minutes or every hour, they were able surrounding healthy parts, from gradually to retain their urine the greater part of the night imme- which it was not separated by any distinct boundary. By diately following the operation. Other cases, again, had its size and pressure the foot was forced inwards, and the incontinence of urine for a few weeks. One case for a few tumour occupied to some extent the position of the foot. It months had very little power of retaining urine and then was hard to the touch and adherent to the skin, which was recovered completely, the pain and irritability having been incorporated in the firm fibrous mass of which the tumour relieved from the first. Two cases that I know of have seemed to consist. It was firmly fixed, and could not be suffered from permanent incontinence of urine. It does not, detached from the surrounding parts. There was no feeling however, appear that the liability to permanent inconti- of softness or of elasticity; it was throughout firmer and nence depended upon the degree to which the dilatation harder than any natural tissue except cartilage and bone. was carried. The child was thin and delicate-looking. (4) Relapses.-In Mr. Wheelhouse’s case the cause of Although hard cancer is exceedingly rare in infants-in relapse-suppuration of the kidney-was revealed by the a tolerably extensive surgical experience I have never seen post-mortem. In one of my own cases the operation of it before,-I concluded from these physical signs that there dilatation had been performed by Dr. Bell, of Bradford, to was no doubt-firstly, of the malignant nature of the tumour; the extent recommended in my paper read at Leeds, but secondly, of the necessity of its removal ; and thirdly, of without relief. A few months after Dr. Bell and I dilated the impracticability of removing it by itself so as to save again more freely to the extent that would admit three the limb. Accordingly, but very reluctantly, I gave it as fingers. After some days of incontinence she recovered my opinion that no proceeding short of amputation of the power over the bladder. From passing urine every ten leg would meet the circumstances of the case; and, as the minutes or a quarter of an hour with groans, she was child had an anæmic appearance, I did not press this exable to relieve herself without pain, and though not cured, treme measure, and felt rather relieved to hear in a few days she is only disturbed five or six times each night. In two from Dr. Savile that the parents declined to submit their other cases the operation was repeated, and I believe both child to the chances of an operation. are comparatively well, having occasionally slight attacks In the first week of May I heard again from Dr. Savile of pain, with increased frequency in micturition. This, that the child had passed safely through an attack of however, may be said, that a relapse or the failure of a first whooping-cough, that its health was improved, but that the tumour was becoming larger, and the parents were anxious operation ought not to deter us from giving a second trial. to have something done for it. I saw it again on May 10th, D.-LITERATURE. and was much struck by the change in the child’s appearI have failed hitherto to find any authors who have pro- ance. He had grown much, was fat and well nourished. posed this or any similar treatment for affections of the But the tumour had doubled in size; the skin over a portion female bladder. The nearest approach to it is the proposal of its surface had ulcerated within the last few days, and of Sir James Simpson (mentioned shortly after his death there was a discharge of serous fluid mixed with blood. by Mr. Lawson Tait) to cure irritable ulcer of the bladder- Under these circumstances I had no hesitation in recomin other words, severe vesical irritation-in the female, by mending immediate amputation. With Dr. Savile’s kind and able assistance the following establishing a temporary vesico-vaginal fistula. His object was to obtain, what I aimed at by dilatation-physiological operation was performed :-The knife was enteredjust over rest for the distressed organ. In works on female diseases I the head of the fibula, and a semilunar incision was made the treatment of this distressing condition is generally dis- through the skin over the front of the leg. A similar inmissed in a few words. From the article referred to at the cision was made on the posterior aspect, the knife was passed beginning of this paper it is clear that the Americans are into the tibio-fibular articulation, so that the whole of the at work in the same direction, and the case quoted is a fibula was removed, and then the tibia was sawn across a strong confirmation of the correctness of the principle of£ little below its anterior spine. The popliteal artery was treatment here advocated. divided before its bifurcation, a ligature was placed upon No less a confirmation is the advocacy of Dr. Duncan of this vessel and two small arteries, and the operation-perdilatation of the neck of the female bladder as a means formed under the influence of chloroform-was completed of exploration, and the testimony of his patient to the in- without the loss of one teaspoonful of blood. ,

767 Dr. Savile, who from that time took charge of the case man states that he first observed the right breast to be informed me that the sutures were all removed by the 19tti larger than the left about the age of sixteen and a half of May; the ligatures came away on the 22nd, and thE; years. Since that time it gradually increased in size until stump was almost healed on the 26th, at which date the, it attained its present dimensions. There has been no kind child was in vigorous health. of secretion from the nipple at any time. He has not expeI happened to be consulted the other day by a patient whc rienced any pain or uneasiness in the breast except, when lives close to this child’s parents, and who told me that the drilling aloft, it has come in contact with ropes, and necesboy has had no return of disease, but is a remarkably finei sitated his presenting himself as a candidate for the sickhealthy little fellow, and hops about most actively on his: list with a slight contusion. The genital organs are fully and well developed. one leg. On microscopical examination the tumour was found to The accompanying drawing, for which I am indebted to .consist of a mass of caudate cells of rather small size and Staff-surgeon Siccama, of H.M.S. Modeste, is a very accurate possessing but one nucleus. Histologists might refuse to and faithful representation of the case. call it by the name of cancer. But it was harder than any structure of the healthy body except bone and cartilage; it grew rapidly, encroaching on and displacing the normal parts; and it finally ulcerated and discharged bloody fluid. It possessed, therefore, all the usual physical signs of hard OF cancer of the most malignant kind, and would doubtless have soon led to the death of the patient. HOSPITAL ,

A Mirror

PRACTICE,

Hnh.

_______________

BRITISH

CASE OF ABNORMAL DEVELOPMENT OF THE RIGHT BREAST IN A SEAMAN AT THE AGE OF PUBERTY.

AND

FOREIGN.

inter

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum, turn proprias collectas habere, et se oomparare.—MORGAGNI De Sed. et Cau8. Morb., lib. iv. Prooemmm.

UNIVERSITY COLLEGE HOSPITAL. BY DEPUTY INSPECTOR-GENERAL ROYAL NAVAL

(Communicated by

MORGAN, C.B.,

TWO CASES OF COMPOUND FRACTURE OF THE LOWER END OF THE HUMERUS.

HOSPITAL, HONG-KONG.

the DIRECTOR-GENERAL

OF THE

MEDICAL DEPARTMENT

of Mr. CHRISTOPHER HEATH.) THE following cases of serious injury to the elbow-joint A. B., aged twenty-one, ordinary seaman, was admitted are favourable for comparison, since the accidents occurred into the Royal Naval Hospital, Hong-Kong, on May 14th, within a few hours of each other, and the patients lay side 1875, with what was said to be a chronic enlargement of side under precisely similar circumstances, and were the right breast. On examination, the right mamma pre- by treated in the same way, but with very different results. The first case appeared to be the more serious at first, both on account of the extent of injury and the age of the patient, yet he recovered without having any bad symptoms after the first few days. The second case ended in excision, from which the patient recovered. It is difficult to suppose that any better result could have followed the use of " antiseptic treatment" in the first case than occurred under the oldfashioned plan of applying a piece of lint dipped in blood; and the disorganisation of the joint in the second case seems to have been set up by a loose fragment of bone which no external treatment could have reached. The question of primary excision must necessarily arise in cases of injury to elbow-joint, and where the amount of damage is great there can be little doubt of its advisability; but where the injury is confined, as in this case, to a single bone, with no positive proof of the joint being involved, most surgeons would agree in waiting for more precise indications before submitting the patient to a serious operation. For the following notes we are indebted to Mr. A. P. Gould. On June 22nd, W. M-, aged fifty-two, was knocked down by a cab, the wheels of which passed over his right elbow. He was at once taken to the hospital. On examination, he was found to have a transverse fracture of the shaft of the humerus close to the lower end, and the lower fragment was evidently split, as the inner condyle could be moved apart from the outer, and this produced crepitus. There was a wound, about a quarter of an inch long, just above the inner condyle, leading down to the fracture, evidently produced by the projecting lower end of the shaft; from this there was a free escape of blood. The patient was at once admitted, and the arm was put upon an angular splint; a piece of lint dipped in the blood was applied over the wound, and an ice-bag was applied. 26th.-There is considerable swelling all round the elbow, with a good deal of tension; skin is marked with a slight red flush; not much pain in the part. From this date the sented, in size and conformation, the appearance of the redness, swelling, tension, and pain gradually decreased. well-developed breast of a full-grown woman, lobulated, 28th.-Swelling much less; no pain; suffers from conwith an enlarged brown-coloured areola. The nipple, how- stipation and flatulence, which are treated by the usual ever, corresponded in size with that of the left breast. The means. OF THE

NAVY.)

the

(Under the

care