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HYDRONEPHROSIS OF HORSESHOE KIDNEY; NEPHRECTOMY; RECOVERY.
1151 curve given to the clavicle at the point where it arches over the first rib, making it no longer possible, after the callus leaves, for the clavicle to lever on the rib ; or is caused by the increased tension given to the rhomboid ligament by the new shape of the clavicle ; or, more likely, the good result is due to both causes combined. Owen Sound, Ontario.
increased
Clinical
na.tura.1 and necessary action." It is very evident that Hunter and others since his time believe that hypertrophy of the urinary bladder can only result from some obstruction at the neck of the bladder or in the urethra. In the case which I havejust recorded there was no evidence of any obstruction at the neck of the bladder or in the urethra. A No. 10 catheter was passed easily into the bladder. The resulting hypertrophy was no doubt connected with the way in which the bladder was incorporated with the anterior abdominal wall, and although the wall of the viscus was enormously thickened the expulsive power of the organ had not been correlatively increased. The association with an ovarian cyst was probably a mere coincidence and the cyst was probably not a?countable for the hypertrophy of the bladder. In some cases this disorder may, in my opinion, be due to disease of the viscus itself. Gordon-square, W.C.
some
Notes:
MEDICAL, SURGICAL, OBSTETRICAL,
AND
THERAPEUTICAL. HYPERTROPHY OF THE URINARY BLADDER IN A WOMAN WITH AN OVARIAN CYST. BY JAMES OLIVER, M D. EDIN., F.R.S. EDIN., PHYSICIAN TO
THE
HOSPITAL
FOR
HYDRONEPHROSIS OF HORSESHOE KIDNEY; NEPHRECTOMY; RECOVERY. BY W. GIFFORD NASH, F.R.C.S. ENG.
WOMEN, SOHO-SQUARE,
LONDON, W.
THE patient, aged 44 years, a widow, was the mother of two children, and the last child was born 23 years ago. Menstruation had recurred regularly and the
A FEMALE, aged 16 months, was admitted into Bedford County Hospital on Oct. 23rd, 19C6, with a history that six months previously her moher had noticed a lump of the size monthly discharge was of the usual amount. About five of a hen’s egg in the left half of the abdomen, which had months previously to seeking treatment the patient remarked gradually increased without in any way affecting the infant’s that she had some difficulty in passing urine and this diffi- health. On examination the child was found to be well culty had been noted more or less ever since. It. had never nourished and looked fairly healthy. In the left half of the been necessary for her to have the urine drawn off. For a abdomen a rounded swelling of about the size of a coccanut fortnight before I saw her she had observed that her abdomen could be felt. This fluctuated, felt elastic, and was moveable
increasing in size and it was on account of this that sought advice. She had complained of no pain practically. Physical signs.-The anterior abdominal wall was pushed markedly forward by a large globular and cystic swelling which was located centrally and extended out of the pelvis. The summit of this swelling was felt two inches above the It was not in the slightest degree tender to umbilicus. the touch. At this stage I passed the catheter and drew off 75 ounces of urine. The patient alleged that she had passed a good quantity of urine only half an hour before seeing me. After emptying the bladder by the catheter the following physical signs were noted. The abdominal swelling previously referred to had disappeared. Palpation detected a small globular swelling in the right iliac region and a small, somewhat flat and firm swelling in the left iliac region. Vaginal examination.-The posterior vaginal wall was thrust markedly forward by a firm swelling, the lower border of which was felt just within the entrance to the vagina. This swelling appeared to be continuous with the two iliac swellings. The cervix uteri was located high and was reached with difficulty. The body of the uterus could not be was
she
clearly defined. I came to the conclusion that the tumour was probably an anomalous fibroid of the uterus and advised
its removal.
Operation.-On opening the abdomen mesially the bladder found to be incorporated with the anterior abdominal wall from the pelvis to the level of a spot located midway was
between the pubes and the umbilicus. The summit of the bladder was located two inches higher. The bladder was so enormously thickened that grasped between the fingers it felt like a uterus and altogether it was rather larger than a normal adult uterus. On exploring the pelvis I detected a swelling of the size of a large cocoanut firmly fixed in Douglas’s pouch. On separating the adhesions the tumour, which proved to be a cyst of the left ovary, burst. On account of the bladder it was awkward to transfix and ligature the left mesovarium. The right ovary was healthy. The uterus, which was of a normal size, could not be dragged higher than a spot about the level of the middle of the bladder. On referring to hypertrophy of the bladder Hunter states that "in consequence of obstruction to the passage of urine, the bladder having more to do’ than common is almost in a constant state of irritation and action ; by which, according to a property in all muscles, it becomes stronger and stronger
in all directions. It appeared to be attached to the left kidney by a sort of neck and had no pelvic connexions. It was not tender on manipulation. The right kidney could not be felt. Micturition was normal. The urine had a specific gravity of 1020, was faintly acid, and did not contain any albumin. Operation.-On Oct. 30th a vertical incision was made over the front of the swelling and then it was seen to be a retro-peritoneal cyst arising from the left renal region. The peritoneum was closed and another incision was made at right angles to the first. A trocar was inserted and about half a pint of clear fluid was evacuated. The cyst was drawn up and with it the kidney, which was found to be the left half of a horseshoe kidney. The ureter was first tied and divided. At the junction of the two halves of the horseshoe kidney a white band could be seen. An incision was made through this and the cut capsule of the right kidney was united with catgut sutures. Lastly, the renal vessels which were abnormal were tied and the left half of the kidney was removed. The hydronephrosis chiefly consisted of a dilatation of the renal pelvis. The ureter was not dilated. A drain was inserted and the wound was closed. The fluid from the hydronephrosis had a specific gravity of 1010, was alkaline, and contained 0’ 1 per cent. of urea. The child made a good recovery, but owing to an attack of varicella remained in hospital until Dec. 8th. She has remained in good health. Remarks.-This case is of interest for the following reasons : 1. The two kidneys were fused in the form of a horseshoe. Morris states that this malformation was found in 19 out of 18 244 cases-i.e., about once in a thousand. 2. The fused kidneys lay at a lower level than the normal kidneys. 3. The left half was hydronephrotic. The dilatation was confined to the pelvis of the kidney and appeared to be due to the angle at which the ureter it. 4. Nephrectomy of the left half of the horseshoe kidney was performed. Morris mentions the fact that a horseshoe kidney may be hydronephrotic but does not mention any case of nephrectomy for this cause. 5. The age of the infant was only 16 months.
entered
Bedford.
NOTES ON A CASE OF RUPTURED UTERUS. BY JOHN H. TONKING, M.B. LOND.
THE rarity of rupture of the uterus in general practice muscular coat; and I suspect that this disposition to induces me to publish this case. Out of over 2000 labours become stronger from repeated action is greater in the this is the first case that I have seen. It therefore follows involuntary muscles than the voluntary ; and the reason why that the experience of the individual practitioner in such it should be so is, I think, very evident ; for, in the The want of definite rules by caaes must be limited. tary muscles the power should be in all cases capable of authorities places a large margin of responsibility on the overcoming the resistance, as the power is always performing medical attendant. In this case the uterus was removed
in its
involnn-
I
increased
Clinical
na.tura.1 and necessary action." It is very evident that Hunter and others since his time believe that hypertrophy of the urinary bladder can only result from some obstruction at the neck of the bladder or in the urethra. In the case which I havejust recorded there was no evidence of any obstruction at the neck of the bladder or in the urethra. A No. 10 catheter was passed easily into the bladder. The resulting hypertrophy was no doubt connected with the way in which the bladder was incorporated with the anterior abdominal wall, and although the wall of the viscus was enormously thickened the expulsive power of the organ had not been correlatively increased. The association with an ovarian cyst was probably a mere coincidence and the cyst was probably not a?countable for the hypertrophy of the bladder. In some cases this disorder may, in my opinion, be due to disease of the viscus itself. Gordon-square, W.C.
some
Notes:
MEDICAL, SURGICAL, OBSTETRICAL,
AND
THERAPEUTICAL. HYPERTROPHY OF THE URINARY BLADDER IN A WOMAN WITH AN OVARIAN CYST. BY JAMES OLIVER, M D. EDIN., F.R.S. EDIN., PHYSICIAN TO
THE
HOSPITAL
FOR
HYDRONEPHROSIS OF HORSESHOE KIDNEY; NEPHRECTOMY; RECOVERY. BY W. GIFFORD NASH, F.R.C.S. ENG.
WOMEN, SOHO-SQUARE,
LONDON, W.
THE patient, aged 44 years, a widow, was the mother of two children, and the last child was born 23 years ago. Menstruation had recurred regularly and the
A FEMALE, aged 16 months, was admitted into Bedford County Hospital on Oct. 23rd, 19C6, with a history that six months previously her moher had noticed a lump of the size monthly discharge was of the usual amount. About five of a hen’s egg in the left half of the abdomen, which had months previously to seeking treatment the patient remarked gradually increased without in any way affecting the infant’s that she had some difficulty in passing urine and this diffi- health. On examination the child was found to be well culty had been noted more or less ever since. It. had never nourished and looked fairly healthy. In the left half of the been necessary for her to have the urine drawn off. For a abdomen a rounded swelling of about the size of a coccanut fortnight before I saw her she had observed that her abdomen could be felt. This fluctuated, felt elastic, and was moveable
increasing in size and it was on account of this that sought advice. She had complained of no pain practically. Physical signs.-The anterior abdominal wall was pushed markedly forward by a large globular and cystic swelling which was located centrally and extended out of the pelvis. The summit of this swelling was felt two inches above the It was not in the slightest degree tender to umbilicus. the touch. At this stage I passed the catheter and drew off 75 ounces of urine. The patient alleged that she had passed a good quantity of urine only half an hour before seeing me. After emptying the bladder by the catheter the following physical signs were noted. The abdominal swelling previously referred to had disappeared. Palpation detected a small globular swelling in the right iliac region and a small, somewhat flat and firm swelling in the left iliac region. Vaginal examination.-The posterior vaginal wall was thrust markedly forward by a firm swelling, the lower border of which was felt just within the entrance to the vagina. This swelling appeared to be continuous with the two iliac swellings. The cervix uteri was located high and was reached with difficulty. The body of the uterus could not be was
she
clearly defined. I came to the conclusion that the tumour was probably an anomalous fibroid of the uterus and advised
its removal.
Operation.-On opening the abdomen mesially the bladder found to be incorporated with the anterior abdominal wall from the pelvis to the level of a spot located midway was
between the pubes and the umbilicus. The summit of the bladder was located two inches higher. The bladder was so enormously thickened that grasped between the fingers it felt like a uterus and altogether it was rather larger than a normal adult uterus. On exploring the pelvis I detected a swelling of the size of a large cocoanut firmly fixed in Douglas’s pouch. On separating the adhesions the tumour, which proved to be a cyst of the left ovary, burst. On account of the bladder it was awkward to transfix and ligature the left mesovarium. The right ovary was healthy. The uterus, which was of a normal size, could not be dragged higher than a spot about the level of the middle of the bladder. On referring to hypertrophy of the bladder Hunter states that "in consequence of obstruction to the passage of urine, the bladder having more to do’ than common is almost in a constant state of irritation and action ; by which, according to a property in all muscles, it becomes stronger and stronger
in all directions. It appeared to be attached to the left kidney by a sort of neck and had no pelvic connexions. It was not tender on manipulation. The right kidney could not be felt. Micturition was normal. The urine had a specific gravity of 1020, was faintly acid, and did not contain any albumin. Operation.-On Oct. 30th a vertical incision was made over the front of the swelling and then it was seen to be a retro-peritoneal cyst arising from the left renal region. The peritoneum was closed and another incision was made at right angles to the first. A trocar was inserted and about half a pint of clear fluid was evacuated. The cyst was drawn up and with it the kidney, which was found to be the left half of a horseshoe kidney. The ureter was first tied and divided. At the junction of the two halves of the horseshoe kidney a white band could be seen. An incision was made through this and the cut capsule of the right kidney was united with catgut sutures. Lastly, the renal vessels which were abnormal were tied and the left half of the kidney was removed. The hydronephrosis chiefly consisted of a dilatation of the renal pelvis. The ureter was not dilated. A drain was inserted and the wound was closed. The fluid from the hydronephrosis had a specific gravity of 1010, was alkaline, and contained 0’ 1 per cent. of urea. The child made a good recovery, but owing to an attack of varicella remained in hospital until Dec. 8th. She has remained in good health. Remarks.-This case is of interest for the following reasons : 1. The two kidneys were fused in the form of a horseshoe. Morris states that this malformation was found in 19 out of 18 244 cases-i.e., about once in a thousand. 2. The fused kidneys lay at a lower level than the normal kidneys. 3. The left half was hydronephrotic. The dilatation was confined to the pelvis of the kidney and appeared to be due to the angle at which the ureter it. 4. Nephrectomy of the left half of the horseshoe kidney was performed. Morris mentions the fact that a horseshoe kidney may be hydronephrotic but does not mention any case of nephrectomy for this cause. 5. The age of the infant was only 16 months.
entered
Bedford.
NOTES ON A CASE OF RUPTURED UTERUS. BY JOHN H. TONKING, M.B. LOND.
THE rarity of rupture of the uterus in general practice muscular coat; and I suspect that this disposition to induces me to publish this case. Out of over 2000 labours become stronger from repeated action is greater in the this is the first case that I have seen. It therefore follows involuntary muscles than the voluntary ; and the reason why that the experience of the individual practitioner in such it should be so is, I think, very evident ; for, in the The want of definite rules by caaes must be limited. tary muscles the power should be in all cases capable of authorities places a large margin of responsibility on the overcoming the resistance, as the power is always performing medical attendant. In this case the uterus was removed
in its
involnn-
I