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MANCHESTER ROYAL INFIRMARY.
215
opened and more fluid and a little air escaped; the latter had probably been sucked in by inspiratory effort. The finger, on being passed into this cavity, found that it was in front of the main mass of the tumour; the walls of the cavity were smooth and it reached forward nearly to the middle line and for some three inches upwards and downwards. The needle was now passed into the main mass at the posterior border of the cyst and more fluid, just like the previous
swelling. In the early stage there may be local swelling, pain, or tenderness ; indeed, the only pain may be epigastric in position. The protrusion of the gut in this case was into the canal of Nuck ; the opening was very mall but everything indicated the congenital nature of the sac. amount to cause a no
MANCHESTER ROYAL INFIRMARY.
one
A CASE OF RETRO-PERITONEAL CYST AND A CASE OF HYDRONEPHROSIS. care of Mr. WRIGHT and Dr. JUDSON BURY.) IN the former of the two succeeding cases the diagnosis was extremely difficult, not only before operation but even during the operation itself. The suggested explanation of the mode of origin of the retro-peritoneal cyst is possible. In the latter case the association of a duodenal ulcer with hydronephrosis may be looked upon as a mere coincidence, but the gastric symptoms caused much confusion as to the - exact cause of the renal swelling. For the notes of the cases we are indebted to Dr. Floyd, house surgeon, and to Mr. Bamber. CASE 1. Ret’l’o-pe’l’itoneal cyst the result of duodenalltlce’l’.. (Recorded by Dr. Ratcliff-Gaylard and Mr. Wright.)-A married woman, aged 25 years, the mother of two children, was admitted into the Manchester Royal Infirmary on Jan. 15th, 1899, under the care of Mr. Wright. For 11 weeks previously she had been a patient of Dr. RatcliffGaylard who has kindly supplied the notes of her illness prior to her admission to the infirmary. The illness began with a sudden attack of acute abdominal pain and faintness. The pain was at first in the region of the umbilicus. There were two slight attacks of vomiting and a rigor during the first few days. On the second day the pain was about the position of the pylorus. The temperature was at first about 101° F. and never rose above this point. There was constipation and the patient was apparently suffering from acute peritonitis. On the day after the onset the woman passed about half a chamber-pot of blood per rectum. No blood was passed on any other occasion. The attack gradually subsided and she was apparently convalescent in two or three weeks, when afresh acute attack occurred with pain in the region of the gall-bladder. This subsided but there were occasional slight attacks of pain in the same region. There was no jaundice or vomiting and the temperature did not rise above 995°. At this time a slight hardness began to be perceptible at the right side of the anterior border of the liver ; at this spot there was tenderness on pressure. No pain was caused by taking food. About Christmas a distinct tumour could be felt; it was uniform and circumscribed in outline, situated in the position of the gall-bladder and did not extend into the loin. Fluctuation was made out early in the history of the tumour. The patient was then going about the house suffering only slight discomfort and there was no vomiting. The tumour increased rather rapidly and extended downwards towards the groin and umbilicus ; the colon lay in front of it. (The above notes were taken from Dr. RatcliffGaylard’s report supplied to Dr. ]’loyd, house surgeon to the
(Under the
infirmary.) On admission into the infirmary a large rounded cystic swelling was found occupying the right hypochondriac and right lumbar regions. Above a depression could be felt between the tumour and the liver. Below the swelling extended into the right iliac region and anteriorly to the middle line, while behind it reached right back to the loin. There was dulness on percussion over the tumour except in front where it was crossed vertically by a band of tympanitic Behind the dulness extended back to the The pain was chiefly in the loin and sometimes radiated down the right leg and into the vulva. There was no history of any urinary trouble or sudden flushings of urine (no "flush-tank sign"). On Jan. 21st the urine was of specific gravity 1021. acid, contained a few leucocytes and a little mucus but no albumin or sugar. Mr. Wright’s opinion was that the case was one of hydronephrosis and resonance.
spine.
operation was recommended. On Jan. 23rd chloroform
given and an incision parallel made. After dividing the periTenal fat a layer of thick vascular membrane was On puncturing this with an exploring needle a clear amber’coloured, odourless fluid was drawn off. The cavity was to, and below, the last rib
was
was
exposed.
drawn off. The main cyst was opened and from half to two pints of liquid escaped. On passing the finger into the cyst the wall was found to be firm and parchment-like and in places slightly granular. The cavity reached upwards to the liver and downwards to the iliac crest, inwards to an inch beyond the middle line and backwards to the spine; its area was encroached upon by prominent ridges and bars, but was not subdivided or loculated. No kidney was felt behind the cyst. A large drainage tube was inserted and the wound was partly sutured and partly packed with gauze. The operation was borne fairly well. The dressings were changed the next morning as they were soaked through with a peculiar soursmelling discharge. The patient was very ill with acute bronchitis and had to be propped up in bed. In spite of free stimulation she gradually sank. On the third day after the operation it was noticed that there was food on the dressings-some milk curds, lemon pulp, and frothy mucus evidently expectoration. Food taken by the mouth appeared through the wound an hour or so later. Enemata were not retained after the second day and she died on the fifth day (Jan. 23th). There was never any vomiting or blood in the urine after the operation. Necropsy.-A post-mortem examination was made by Dr. Kelynack on Jan. 30th. His notes are as follows. There was no generalised peritonitis. Adhesions were present in the neighbourhood of the operation between the cyst, kidney, duodenum, small intestines, and retro-peritoneal structures. The stomach was normal in size ; its walls were normal and there was no lesion of the pylorus. The duodenum was adherent to the retro-peritoneal cyst. Three and a half inches beyond the pylorus there was a communication between the cyst and the duodenum. The aperture was situated on the convex side of the duodenal curve immediately below the level of the lower end of the right kidney. The mucous membrane round the opening was soft, swollen, and congested, but presented no evidence of growth or changes suggestive of old duodenal ulceration. The rest of the duodenum was fairly healthy. The intestines were congested and almost empty, but in places near the duodenum were somewhat adherent and of a greenish-black colour. The ascending colon and hepatic flexure lay in front of, but The head of the pancreas were not adherent to, the cyst. was adherent to the cyst, but did not apparently communicate with it; the tail was thin and anasmic. The right kidney, which was normal in size and shape, was a little elevated, being pushed up by the cyst. The rest of the abdominal organs were practically normal. As regards the cyst, examination revealed that a large cystic cavity had been opened into from the operation wound. The cyst was retro-peritoneal and extended beneath the lower end of the right kidney, passing behind the duodenum and reaching It over to the neighbourhood of the head of the pancreas. also extended downwards to about the level of the lower border of the curve of the duodenum but had not extended into the general peritoneal cavity. Posteriorly it reached the muscles in the posterior wall of the abdomen. The wall was in places somewhat thin and membranous. It was chiefly greyish or greenish-black in colour but in parts showed a considerable amount of yellowish-white, rather caseous-looking, shaggy, soft, necrotic tissue. The cavity contained little or no pus. There was no evidence of hydatids and the wall was not like that of a hydatid cyst. Bile and intestinal contents were present in the cavity. There was no evidence of malignant growth or of dermoid structures. The fluid withdrawn from the cyst’at the time of the operation was examined by the surgical registrar, Mr. Pomfret. It contained no urea but a moderate amount of albumin, not much more than would be accounted for by the blood mixed with it. There were no hydatid hooklets. CASE 2. An anomalous case of 7iydroneplirosis.-A man, aged 36 years, who had had good health nearly all hia life, was in November, 1898, seized with an attack of pain and vomiting. He was admitted to the Manchester Royal Infirmary on Jan. 5th, 1899, under the care ot
fluid,
°
was
and
a
216 Dr. Judscn Bary. From the first attack until the date of aperture admitting the forefinger which led into a hug his admission into hospital the patient bad had similar cavity lying external and posterior to the above-mentioned symptoms almost daily. Soon after his dinner he felt acute cyst. The walls of this cavity were thick, irregular, epigastric pain and this was followed in an hour or two by and presented evidence of calcification. Projecting masses vomiting. The vomited matter was sometimes clear but of yellowish-pink, soft, friable material were adherent usually thick and pultaceous; it contained no visible blood to the lining. There was no evidence of kidney substance and was never "coffee-ground." Vomiting always relieved anywhere. This second larger cyst was, it will be observed, He lost weight, as much as 181b. in three the one which was opened at the operation and described the pain. months, but had no other marked symptoms until his first, the order of description being reversed in the postadmission. On Jan. 5th the report described him as thin mortem record. The bladder was small and contracted. and looking as if he had lost much flesh. There was a The only other lesion worth noticing was a cheesy, apparlarge deep-seated swelling in the right hypochcndriac and ently tuberculous, deposit near the spleen. lumbar regions. This swelling was smooth and had Remarks by l4ir. IVRIG11T.-I have obtained a detailed rounded borders ; it reached to the iliac crest below, report of Case 1 as it seemed to me to be of sufficient interest to the middle line in front, posteriorly into the loin, and to be worthy of a complete record. After examining the upwards nearly but not quite to the liver ; the edge of the patient I felt fairly confident that in spite of certain liver could be felt above it. The tumour descended on anomalous features in the history the cyst was a hydroinspiration. The whole of the tamour except its inner border nephrosis. Almost the only symptom incompatible with this was the history of the passage of blood per rectum and this, was dull on percussion; a tympanitic area encroached on this margin. The stomach was markedly dilated. Soon after though it might have been a key to the case, does not his admission the patient vomited some yellowish pultaceous altogether fit in with the interpretation which I believe to be matter which microscopically was found to contain blood the correct one. The position and character of the swelling corpuscles and sarcinas. His appetite was good and his were quite compatible with hydronephrosis and the absence tongue was fairly clean. The urine was of specific gravity of all abnormal constituents in the urine did not negative this 1030 and acid ; it contained a small amount of albumin and diagnosis. The result proved that my opinion was entirely no sugar. No casts or blood were found in it but a few large wrong and that even a careful examination of the renal area He had no "flush tank" through a wound in the abdominal parietes will not always multi-nucleated corpuscles. symptom and no renal colic. His temperature was normal. enable one to say that a kidney exists at all. The sequence On Jan. 24th the patient was transferred to the surgical of events I take to be as follows. First a duodenal ulcer wards under the care of Mr. Wright, who thought that perforating by a minute opening and allowing the escape of the case was one either of hydatid or of hydronephrosis. On probably a little gas and fluid ; hence the sudden and painful the 27th an incision was made parallel to, and below, the onset of the illness. I have met with another almost exactly last rib on the right side. On exposing the tumour it was similar case. On the next day hemorrhage took place from, tapped and some fluid was drawn off for examination. The the ulcer and the blood was so rapidly poured out that it The duodenal cyst was then incised and about one and a half pints of clear escaped almost unaltered per rectum. yellow, slightly viscid fluid, free from any odour of urine, contents set up inflammation in the retro-peritoneal cellular escaped. A finger passed into the cyst made out that the tissue, but this was not sufficiently severe to produce walls were parchment-like and in places slightly gritty. An suppuration, though a localised eff asion of serum took place. opening just admitting the forefinger led from the first cyst Repeated leakages of a similar kind led to further outinto a second one which had smoother and thinner walls. pourings of fluid and the formation of adhesions to various No trace of kidney cnnld be felt. A drainage-tube was parts around, and so the cysts gradually developed just as fastened in the cyst. The patient recovered well from the solid tumours of the abdomen do in the manner described by operation and his progress was quite satisfactory till Greig Smith. At the operation the superficial cavity was Feb. 5th. There was a free discharge of odourless probably intra-peritoneal and localised by adhesions. The fluid from the wound. The urine still contained a trace of cyst proper was retro-peritoneal. The failure to feel the albumin and a slight trace of blood, and after the first 24 kidney may be charitably explained by supposing that hours the patient passed from 42 to 44 ounces daily. After pressure of the cyst somewhat displaced and a good deal the first day the urine was free from albumin. On Feb. 5th flattened the organ and that it recovered itself after it was noticed for the first time that the discharge had a the cyst was emptied. After, or perhaps as a result urinous odour. The patient passed 24 ounces of urine and this of the operation, the opening in the duodenal wall was alkaline and phosphatic. The case, then, He was sick for the first time enlarged and the contents escaped. since the operation. On the 6th he was still sick and passed is apparently one of serous cyst in the retro-peri28 ounces of urine ; the vomiting continued on the 7th, and toneal cellular tissue the result of perforation of a small ulcer ot°the duodenum, with repeated leakages of material on the 8th though there was less vomiting the amount of urine fell to 12 ounces, and the same evening he became con- of such character as to cause inflammation around but not vulsed and died in a few hours. Examination of the fluid sufficient to set up suppuration. The question of pancreatic drawn off at the time of the operation showed that its cyst was considered, but neither the fluid in the cyst nor specific gravity was 1020 ; the fluid was acid, contained one- the condition found after death supports this view. I desire fourth albumin, no sugar, some urea, and an amylolytic to thank all those who have contributed to the record of this remarkable case. ferment. Nec’l’opsy.-Dr. Kelynack made a post-mortem examina- There are two main points of interest in Case 2. First, the tion and his report has been abstracted. The stomach was gastric symptoms which proved to be due to an independent dilated and contained much mucus, its walls were thickened, lesion and to be unconnected with the large cystic tumour and the mucous membrane in parts was granular. At which was found during life; and secondly, the condition the pylorus there was a chronic simple ulcer on the posterior of the kidneys. The absolute conversion of the right kidney wall, vertical in position, and one and a quarter inches into a cyst with no visible remains of kidney structure without in length by three-fifths of an inch in width ;its borders any recognisable mechanical obstruction is remarkable.’ Some secreting structure must no doubt have been left as a were smooth and the edges were somewhat undermined ; its floor was thickened, irregular, and presented several vessels certain amount of urinous fluid escaped from the wound, from which blood was oozing. There was no evidence of unless it is supposed that this regurgitated from the bladder, which is suggested by the appearance of the urinous odour. new growth. The small intestines were displaced downwards, but with the exception of the stomach and the condition It is possible that the tuberculous mass in the neighbourthere was no other noteworthy hood of the spleen may be the clue to the cause of the now to be described lesion. The left kidney weighed seven and a half ounces destruction of the kidney, though it was quite unlike am and presented the usual characters of compensatory ordinary tuberculous organ. Why the left kidney ceased bypertrophy. The right kidney was converted into an work and the man died from urasmia ("reflex suppresextensive cyst which, with adjacent adhesions, weighed 17t sion ") I am unable to suggest. Such a termination of ounces. On slitting np the ureter into the pelvis the latter the case was quite unexpected until the amount of urine was found to be dilated into an irregular cavity across coming away began to lessen. Apart from these questions which ran several fibrous septa. The cavity was thus some- the case was of special interest to me as both before what loculated, but everywhere was lined with membrane and during operation there was a very close resemblance which was mostly smooth, though in places roughened. No between this case and that of the woman with the retrocause of mechanical obstruction to the ureter was found. peritoneal cyst (Case 1) ; indeed, I felt much more sure that At the lower part of the cyst described there was an her cyst was renal than I did that the man’s was so. In
217 the appearance of the fluid withdrawn and in the nature of the lining of the cysts, there The was the closest resemblance between the two cases. duration of the illness, the sudden onset, and the presence of symptoms pointing to a lesion in the upper part of the digestive tract were somewhat alike in both cases ; yet in the light of after knowledge it was easy to see the essential differences. In one the gastric symptoms were likely to lead us astray as regards the recognition of the nature of the tumour; in the other the intestinal hoemorrhage was the key to the whole problem. Remarks by Dr. BURY.-The prominent features in Case 2namely, pain and vomiting after food, emaciation, and the physical signs of dilatation of the stomach-pointed to pyloric obstruction, and the presence of a tumour on the rig-bt side of the abdomen suggested that the obstruction might be due to cancer. The shape and consistence of the swelling, however, indicated that it was more likely to be fluid than solid; hence it seemed possible that the gastric phenomena were the indirect result of pressure on the py7oras, while the presence of albumin in the urine, together with the situation of the tumour, suggested that the latter either directly involved the kidney or pressed upon it. The post-mortem examination showed that the gastric symptoms were due to an independent lesion-namely, an ulcer of the pylorus. One important lesson to be learned from the case is that when symptoms are manifold and are not readily explained by a tumour or other obvious lesion it is necessary to consider how far some of the symptoms may be dependent on another lesion, even in the absence of any direct physical evidence.
positive physical characters, in
accurate. These researches were continued and became generally known through a supplement to the Oomptes Rendus in 1856. The publication of this memoir caused men of science in all lands to be awarethat a young physiological inquirer
of striking powers had arisen in Paris. Yet the merits of the research on the pancreas were soon to be eclipsed by results of a still higher order and of far more commanding influence." These were of course his researches on glycogeny, which showed that the liver did not produce bile alone, as had been universally accepted, but that it had a hidden function which was of equal iE not of greater importance in the economy--to wit, the production cf a saccharine substance which was taken up by the blood traversing the This discovery he followed up with wonderM liver. He showed the constancy of its occurrence not acumen. but in carnivorous animals ; he demonin herbivorous only of the nervous system upon it ; he the influence strated out to diabetes, and finally isolated the relation its pointed The history of name of glycogen. it the substance and gave Foster who Michael is told Sir all this by graphically remark that 11 in the it with the concludes his account of first stone but the left a matter of glycogen he not only laid able to men have been house so nearly finished that other title of Claude add but little." But this was not the only Bernard to fame. He made important observations on the vaso-motor nerves, on the temperature of the blood in different parts of the system, on the absorption of oxygen, on curara, and on the opium alkaloids. The life of Claude Bernard was that of a man entirely wrapped up in his work. The whole bent of his mind was towards physiology. Jousset de Bellesme, who knew him well, tells us that, seated by the fireside of his little C?a?tde Bernard. By Sir MICHAEL FOSTER, K.C.B., M.A., bedroom, trimly kept by his trusty old servant, and with a M.D. Cantab., Secretary of the Royal Society, Professor dressing-gown on his ample shoulders, the conversation of Physiology in the University of Cambridge. London : would begin with the striking events of the day, but speedily T. Fisher Unwin. 1899. Pp. 245. Price 3s. 6d. turned to physiology. About this he would wax eloquent 1’xIS volume is one of a series-"Masters of Medicine "-- and quickly entered on the higher regions of the science which includes Harvey, Hunter, Simpson, Stokes, Brodie, when time would pass rapidly away. The same writer states Helmholtz, Vesalius, and Sydenham, and amongst these that Bernard was pasEionately fond of Descartes’ I I Discours remarkable men Claude Bernard holds a not inconspicuous de la Methode" and strongly recommended its perusal, attention to its rules many scientific position. that maintaining by Claude Bernard was a native of the south-east of France, was a brilliant experibe Bernard could solved. problems having been born on July 12tb, 1813, at St. Julien, in the menter and very dexterous in the performance of operations. department of the Rhone, a few miles from Lyons, which As a rule his deductions from the observations he made were preserves his name by a noble quay on the side of the Rhone. sound and have stood the test of controversy, and he was a He died on Feb. 10th, 1878, at Paris, from nephritis, con- lucid expositor of the views which he held not only in sequent on exposure to cold. Sir Michael Foster tells us scientific but in popular assemblies. We have to thank Sir that he arrived in Paris with the manuscript of a comedy in Michael Foster for a very readable and instructive his pocket, intending to apply himself to literature. On biography of a brilliant Frenchman. submitting it to Girardin, then Professor at the Sorbonne, he was recommended to study medicine as affording better prospects than letters to an impecunious student. He took J9e/ecM’e Eyesightthe Principles of its Relief by Glasses. Girardin’s advice and with characteristic energy threw By D. B. ST. JOHN ROOSA, M.D., LL.D., Surgeon to the himself heart and soul into medical studies, and at the close Manhattan Eye and Ear Hospital. London: Macmillan I and Co. 1899. Pp. 186. Price 4s. 6d. of his studentship was appointed interne to Magendie, then the chief physiologist in France, who quickly recognised his CONSIDERING the large number of treatises that are now merit and made him his prosector. Sir Michael Foster gives extant which are intended to teach the student and practian appreciative account of his earlier work, which com- tioner how to detect, diagnose, and treat impairment of menced with a communication to the Annales Meclico- vision due to errors of refraction that subject ought to be one Psychologiqlles in 1843 entitled" Recherches Anatomiques of the best known in the whole range of medicine. As a et Physiologiques sur la Corde du Tympane," immediately rule, however, some preliminary knowledge of mathematics followed by his thesis for his degree of Doctor in Medicine, is demanded of the reader and the result is, we fear, that, as which was upon the gastric juice and its function in Dr. Johnson said of Milton’s "Paradise Lost," the reader digestion. He then investigated the function of the spinal lays down the book that is to instruct him and-forgets to accessory nerve and soon after examined the colouring take it up again. No fears need be entertained on this matters in the body, which last was the subject of his thesis score in regard to the present volume. It is written in a at the " Concours pour l’Agrégation." The observation that style which is intended to be understood by beginners. fats and oils underwent changes at different parts of the The first chapter deals with the means of determining intestine in dogs and rabbits was the starting-point of his the sharpness of vision by means of test types. This mode researches on the functions of the pancreas, an observation of testing leaves something to be desired, for the author which, as Sir Michael Foster remarks, was not entirely relates a case in which a collision took place on the Hudson
Reviews
and
Notices of Books.
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opened and more fluid and a little air escaped; the latter had probably been sucked in by inspiratory effort. The finger, on being passed into this cavity, found that it was in front of the main mass of the tumour; the walls of the cavity were smooth and it reached forward nearly to the middle line and for some three inches upwards and downwards. The needle was now passed into the main mass at the posterior border of the cyst and more fluid, just like the previous
swelling. In the early stage there may be local swelling, pain, or tenderness ; indeed, the only pain may be epigastric in position. The protrusion of the gut in this case was into the canal of Nuck ; the opening was very mall but everything indicated the congenital nature of the sac. amount to cause a no
MANCHESTER ROYAL INFIRMARY.
one
A CASE OF RETRO-PERITONEAL CYST AND A CASE OF HYDRONEPHROSIS. care of Mr. WRIGHT and Dr. JUDSON BURY.) IN the former of the two succeeding cases the diagnosis was extremely difficult, not only before operation but even during the operation itself. The suggested explanation of the mode of origin of the retro-peritoneal cyst is possible. In the latter case the association of a duodenal ulcer with hydronephrosis may be looked upon as a mere coincidence, but the gastric symptoms caused much confusion as to the - exact cause of the renal swelling. For the notes of the cases we are indebted to Dr. Floyd, house surgeon, and to Mr. Bamber. CASE 1. Ret’l’o-pe’l’itoneal cyst the result of duodenalltlce’l’.. (Recorded by Dr. Ratcliff-Gaylard and Mr. Wright.)-A married woman, aged 25 years, the mother of two children, was admitted into the Manchester Royal Infirmary on Jan. 15th, 1899, under the care of Mr. Wright. For 11 weeks previously she had been a patient of Dr. RatcliffGaylard who has kindly supplied the notes of her illness prior to her admission to the infirmary. The illness began with a sudden attack of acute abdominal pain and faintness. The pain was at first in the region of the umbilicus. There were two slight attacks of vomiting and a rigor during the first few days. On the second day the pain was about the position of the pylorus. The temperature was at first about 101° F. and never rose above this point. There was constipation and the patient was apparently suffering from acute peritonitis. On the day after the onset the woman passed about half a chamber-pot of blood per rectum. No blood was passed on any other occasion. The attack gradually subsided and she was apparently convalescent in two or three weeks, when afresh acute attack occurred with pain in the region of the gall-bladder. This subsided but there were occasional slight attacks of pain in the same region. There was no jaundice or vomiting and the temperature did not rise above 995°. At this time a slight hardness began to be perceptible at the right side of the anterior border of the liver ; at this spot there was tenderness on pressure. No pain was caused by taking food. About Christmas a distinct tumour could be felt; it was uniform and circumscribed in outline, situated in the position of the gall-bladder and did not extend into the loin. Fluctuation was made out early in the history of the tumour. The patient was then going about the house suffering only slight discomfort and there was no vomiting. The tumour increased rather rapidly and extended downwards towards the groin and umbilicus ; the colon lay in front of it. (The above notes were taken from Dr. RatcliffGaylard’s report supplied to Dr. ]’loyd, house surgeon to the
(Under the
infirmary.) On admission into the infirmary a large rounded cystic swelling was found occupying the right hypochondriac and right lumbar regions. Above a depression could be felt between the tumour and the liver. Below the swelling extended into the right iliac region and anteriorly to the middle line, while behind it reached right back to the loin. There was dulness on percussion over the tumour except in front where it was crossed vertically by a band of tympanitic Behind the dulness extended back to the The pain was chiefly in the loin and sometimes radiated down the right leg and into the vulva. There was no history of any urinary trouble or sudden flushings of urine (no "flush-tank sign"). On Jan. 21st the urine was of specific gravity 1021. acid, contained a few leucocytes and a little mucus but no albumin or sugar. Mr. Wright’s opinion was that the case was one of hydronephrosis and resonance.
spine.
operation was recommended. On Jan. 23rd chloroform
given and an incision parallel made. After dividing the periTenal fat a layer of thick vascular membrane was On puncturing this with an exploring needle a clear amber’coloured, odourless fluid was drawn off. The cavity was to, and below, the last rib
was
was
exposed.
drawn off. The main cyst was opened and from half to two pints of liquid escaped. On passing the finger into the cyst the wall was found to be firm and parchment-like and in places slightly granular. The cavity reached upwards to the liver and downwards to the iliac crest, inwards to an inch beyond the middle line and backwards to the spine; its area was encroached upon by prominent ridges and bars, but was not subdivided or loculated. No kidney was felt behind the cyst. A large drainage tube was inserted and the wound was partly sutured and partly packed with gauze. The operation was borne fairly well. The dressings were changed the next morning as they were soaked through with a peculiar soursmelling discharge. The patient was very ill with acute bronchitis and had to be propped up in bed. In spite of free stimulation she gradually sank. On the third day after the operation it was noticed that there was food on the dressings-some milk curds, lemon pulp, and frothy mucus evidently expectoration. Food taken by the mouth appeared through the wound an hour or so later. Enemata were not retained after the second day and she died on the fifth day (Jan. 23th). There was never any vomiting or blood in the urine after the operation. Necropsy.-A post-mortem examination was made by Dr. Kelynack on Jan. 30th. His notes are as follows. There was no generalised peritonitis. Adhesions were present in the neighbourhood of the operation between the cyst, kidney, duodenum, small intestines, and retro-peritoneal structures. The stomach was normal in size ; its walls were normal and there was no lesion of the pylorus. The duodenum was adherent to the retro-peritoneal cyst. Three and a half inches beyond the pylorus there was a communication between the cyst and the duodenum. The aperture was situated on the convex side of the duodenal curve immediately below the level of the lower end of the right kidney. The mucous membrane round the opening was soft, swollen, and congested, but presented no evidence of growth or changes suggestive of old duodenal ulceration. The rest of the duodenum was fairly healthy. The intestines were congested and almost empty, but in places near the duodenum were somewhat adherent and of a greenish-black colour. The ascending colon and hepatic flexure lay in front of, but The head of the pancreas were not adherent to, the cyst. was adherent to the cyst, but did not apparently communicate with it; the tail was thin and anasmic. The right kidney, which was normal in size and shape, was a little elevated, being pushed up by the cyst. The rest of the abdominal organs were practically normal. As regards the cyst, examination revealed that a large cystic cavity had been opened into from the operation wound. The cyst was retro-peritoneal and extended beneath the lower end of the right kidney, passing behind the duodenum and reaching It over to the neighbourhood of the head of the pancreas. also extended downwards to about the level of the lower border of the curve of the duodenum but had not extended into the general peritoneal cavity. Posteriorly it reached the muscles in the posterior wall of the abdomen. The wall was in places somewhat thin and membranous. It was chiefly greyish or greenish-black in colour but in parts showed a considerable amount of yellowish-white, rather caseous-looking, shaggy, soft, necrotic tissue. The cavity contained little or no pus. There was no evidence of hydatids and the wall was not like that of a hydatid cyst. Bile and intestinal contents were present in the cavity. There was no evidence of malignant growth or of dermoid structures. The fluid withdrawn from the cyst’at the time of the operation was examined by the surgical registrar, Mr. Pomfret. It contained no urea but a moderate amount of albumin, not much more than would be accounted for by the blood mixed with it. There were no hydatid hooklets. CASE 2. An anomalous case of 7iydroneplirosis.-A man, aged 36 years, who had had good health nearly all hia life, was in November, 1898, seized with an attack of pain and vomiting. He was admitted to the Manchester Royal Infirmary on Jan. 5th, 1899, under the care ot
fluid,
°
was
and
a
216 Dr. Judscn Bary. From the first attack until the date of aperture admitting the forefinger which led into a hug his admission into hospital the patient bad had similar cavity lying external and posterior to the above-mentioned symptoms almost daily. Soon after his dinner he felt acute cyst. The walls of this cavity were thick, irregular, epigastric pain and this was followed in an hour or two by and presented evidence of calcification. Projecting masses vomiting. The vomited matter was sometimes clear but of yellowish-pink, soft, friable material were adherent usually thick and pultaceous; it contained no visible blood to the lining. There was no evidence of kidney substance and was never "coffee-ground." Vomiting always relieved anywhere. This second larger cyst was, it will be observed, He lost weight, as much as 181b. in three the one which was opened at the operation and described the pain. months, but had no other marked symptoms until his first, the order of description being reversed in the postadmission. On Jan. 5th the report described him as thin mortem record. The bladder was small and contracted. and looking as if he had lost much flesh. There was a The only other lesion worth noticing was a cheesy, apparlarge deep-seated swelling in the right hypochcndriac and ently tuberculous, deposit near the spleen. lumbar regions. This swelling was smooth and had Remarks by l4ir. IVRIG11T.-I have obtained a detailed rounded borders ; it reached to the iliac crest below, report of Case 1 as it seemed to me to be of sufficient interest to the middle line in front, posteriorly into the loin, and to be worthy of a complete record. After examining the upwards nearly but not quite to the liver ; the edge of the patient I felt fairly confident that in spite of certain liver could be felt above it. The tumour descended on anomalous features in the history the cyst was a hydroinspiration. The whole of the tamour except its inner border nephrosis. Almost the only symptom incompatible with this was the history of the passage of blood per rectum and this, was dull on percussion; a tympanitic area encroached on this margin. The stomach was markedly dilated. Soon after though it might have been a key to the case, does not his admission the patient vomited some yellowish pultaceous altogether fit in with the interpretation which I believe to be matter which microscopically was found to contain blood the correct one. The position and character of the swelling corpuscles and sarcinas. His appetite was good and his were quite compatible with hydronephrosis and the absence tongue was fairly clean. The urine was of specific gravity of all abnormal constituents in the urine did not negative this 1030 and acid ; it contained a small amount of albumin and diagnosis. The result proved that my opinion was entirely no sugar. No casts or blood were found in it but a few large wrong and that even a careful examination of the renal area He had no "flush tank" through a wound in the abdominal parietes will not always multi-nucleated corpuscles. symptom and no renal colic. His temperature was normal. enable one to say that a kidney exists at all. The sequence On Jan. 24th the patient was transferred to the surgical of events I take to be as follows. First a duodenal ulcer wards under the care of Mr. Wright, who thought that perforating by a minute opening and allowing the escape of the case was one either of hydatid or of hydronephrosis. On probably a little gas and fluid ; hence the sudden and painful the 27th an incision was made parallel to, and below, the onset of the illness. I have met with another almost exactly last rib on the right side. On exposing the tumour it was similar case. On the next day hemorrhage took place from, tapped and some fluid was drawn off for examination. The the ulcer and the blood was so rapidly poured out that it The duodenal cyst was then incised and about one and a half pints of clear escaped almost unaltered per rectum. yellow, slightly viscid fluid, free from any odour of urine, contents set up inflammation in the retro-peritoneal cellular escaped. A finger passed into the cyst made out that the tissue, but this was not sufficiently severe to produce walls were parchment-like and in places slightly gritty. An suppuration, though a localised eff asion of serum took place. opening just admitting the forefinger led from the first cyst Repeated leakages of a similar kind led to further outinto a second one which had smoother and thinner walls. pourings of fluid and the formation of adhesions to various No trace of kidney cnnld be felt. A drainage-tube was parts around, and so the cysts gradually developed just as fastened in the cyst. The patient recovered well from the solid tumours of the abdomen do in the manner described by operation and his progress was quite satisfactory till Greig Smith. At the operation the superficial cavity was Feb. 5th. There was a free discharge of odourless probably intra-peritoneal and localised by adhesions. The fluid from the wound. The urine still contained a trace of cyst proper was retro-peritoneal. The failure to feel the albumin and a slight trace of blood, and after the first 24 kidney may be charitably explained by supposing that hours the patient passed from 42 to 44 ounces daily. After pressure of the cyst somewhat displaced and a good deal the first day the urine was free from albumin. On Feb. 5th flattened the organ and that it recovered itself after it was noticed for the first time that the discharge had a the cyst was emptied. After, or perhaps as a result urinous odour. The patient passed 24 ounces of urine and this of the operation, the opening in the duodenal wall was alkaline and phosphatic. The case, then, He was sick for the first time enlarged and the contents escaped. since the operation. On the 6th he was still sick and passed is apparently one of serous cyst in the retro-peri28 ounces of urine ; the vomiting continued on the 7th, and toneal cellular tissue the result of perforation of a small ulcer ot°the duodenum, with repeated leakages of material on the 8th though there was less vomiting the amount of urine fell to 12 ounces, and the same evening he became con- of such character as to cause inflammation around but not vulsed and died in a few hours. Examination of the fluid sufficient to set up suppuration. The question of pancreatic drawn off at the time of the operation showed that its cyst was considered, but neither the fluid in the cyst nor specific gravity was 1020 ; the fluid was acid, contained one- the condition found after death supports this view. I desire fourth albumin, no sugar, some urea, and an amylolytic to thank all those who have contributed to the record of this remarkable case. ferment. Nec’l’opsy.-Dr. Kelynack made a post-mortem examina- There are two main points of interest in Case 2. First, the tion and his report has been abstracted. The stomach was gastric symptoms which proved to be due to an independent dilated and contained much mucus, its walls were thickened, lesion and to be unconnected with the large cystic tumour and the mucous membrane in parts was granular. At which was found during life; and secondly, the condition the pylorus there was a chronic simple ulcer on the posterior of the kidneys. The absolute conversion of the right kidney wall, vertical in position, and one and a quarter inches into a cyst with no visible remains of kidney structure without in length by three-fifths of an inch in width ;its borders any recognisable mechanical obstruction is remarkable.’ Some secreting structure must no doubt have been left as a were smooth and the edges were somewhat undermined ; its floor was thickened, irregular, and presented several vessels certain amount of urinous fluid escaped from the wound, from which blood was oozing. There was no evidence of unless it is supposed that this regurgitated from the bladder, which is suggested by the appearance of the urinous odour. new growth. The small intestines were displaced downwards, but with the exception of the stomach and the condition It is possible that the tuberculous mass in the neighbourthere was no other noteworthy hood of the spleen may be the clue to the cause of the now to be described lesion. The left kidney weighed seven and a half ounces destruction of the kidney, though it was quite unlike am and presented the usual characters of compensatory ordinary tuberculous organ. Why the left kidney ceased bypertrophy. The right kidney was converted into an work and the man died from urasmia ("reflex suppresextensive cyst which, with adjacent adhesions, weighed 17t sion ") I am unable to suggest. Such a termination of ounces. On slitting np the ureter into the pelvis the latter the case was quite unexpected until the amount of urine was found to be dilated into an irregular cavity across coming away began to lessen. Apart from these questions which ran several fibrous septa. The cavity was thus some- the case was of special interest to me as both before what loculated, but everywhere was lined with membrane and during operation there was a very close resemblance which was mostly smooth, though in places roughened. No between this case and that of the woman with the retrocause of mechanical obstruction to the ureter was found. peritoneal cyst (Case 1) ; indeed, I felt much more sure that At the lower part of the cyst described there was an her cyst was renal than I did that the man’s was so. In
217 the appearance of the fluid withdrawn and in the nature of the lining of the cysts, there The was the closest resemblance between the two cases. duration of the illness, the sudden onset, and the presence of symptoms pointing to a lesion in the upper part of the digestive tract were somewhat alike in both cases ; yet in the light of after knowledge it was easy to see the essential differences. In one the gastric symptoms were likely to lead us astray as regards the recognition of the nature of the tumour; in the other the intestinal hoemorrhage was the key to the whole problem. Remarks by Dr. BURY.-The prominent features in Case 2namely, pain and vomiting after food, emaciation, and the physical signs of dilatation of the stomach-pointed to pyloric obstruction, and the presence of a tumour on the rig-bt side of the abdomen suggested that the obstruction might be due to cancer. The shape and consistence of the swelling, however, indicated that it was more likely to be fluid than solid; hence it seemed possible that the gastric phenomena were the indirect result of pressure on the py7oras, while the presence of albumin in the urine, together with the situation of the tumour, suggested that the latter either directly involved the kidney or pressed upon it. The post-mortem examination showed that the gastric symptoms were due to an independent lesion-namely, an ulcer of the pylorus. One important lesson to be learned from the case is that when symptoms are manifold and are not readily explained by a tumour or other obvious lesion it is necessary to consider how far some of the symptoms may be dependent on another lesion, even in the absence of any direct physical evidence.
positive physical characters, in
accurate. These researches were continued and became generally known through a supplement to the Oomptes Rendus in 1856. The publication of this memoir caused men of science in all lands to be awarethat a young physiological inquirer
of striking powers had arisen in Paris. Yet the merits of the research on the pancreas were soon to be eclipsed by results of a still higher order and of far more commanding influence." These were of course his researches on glycogeny, which showed that the liver did not produce bile alone, as had been universally accepted, but that it had a hidden function which was of equal iE not of greater importance in the economy--to wit, the production cf a saccharine substance which was taken up by the blood traversing the This discovery he followed up with wonderM liver. He showed the constancy of its occurrence not acumen. but in carnivorous animals ; he demonin herbivorous only of the nervous system upon it ; he the influence strated out to diabetes, and finally isolated the relation its pointed The history of name of glycogen. it the substance and gave Foster who Michael is told Sir all this by graphically remark that 11 in the it with the concludes his account of first stone but the left a matter of glycogen he not only laid able to men have been house so nearly finished that other title of Claude add but little." But this was not the only Bernard to fame. He made important observations on the vaso-motor nerves, on the temperature of the blood in different parts of the system, on the absorption of oxygen, on curara, and on the opium alkaloids. The life of Claude Bernard was that of a man entirely wrapped up in his work. The whole bent of his mind was towards physiology. Jousset de Bellesme, who knew him well, tells us that, seated by the fireside of his little C?a?tde Bernard. By Sir MICHAEL FOSTER, K.C.B., M.A., bedroom, trimly kept by his trusty old servant, and with a M.D. Cantab., Secretary of the Royal Society, Professor dressing-gown on his ample shoulders, the conversation of Physiology in the University of Cambridge. London : would begin with the striking events of the day, but speedily T. Fisher Unwin. 1899. Pp. 245. Price 3s. 6d. turned to physiology. About this he would wax eloquent 1’xIS volume is one of a series-"Masters of Medicine "-- and quickly entered on the higher regions of the science which includes Harvey, Hunter, Simpson, Stokes, Brodie, when time would pass rapidly away. The same writer states Helmholtz, Vesalius, and Sydenham, and amongst these that Bernard was pasEionately fond of Descartes’ I I Discours remarkable men Claude Bernard holds a not inconspicuous de la Methode" and strongly recommended its perusal, attention to its rules many scientific position. that maintaining by Claude Bernard was a native of the south-east of France, was a brilliant experibe Bernard could solved. problems having been born on July 12tb, 1813, at St. Julien, in the menter and very dexterous in the performance of operations. department of the Rhone, a few miles from Lyons, which As a rule his deductions from the observations he made were preserves his name by a noble quay on the side of the Rhone. sound and have stood the test of controversy, and he was a He died on Feb. 10th, 1878, at Paris, from nephritis, con- lucid expositor of the views which he held not only in sequent on exposure to cold. Sir Michael Foster tells us scientific but in popular assemblies. We have to thank Sir that he arrived in Paris with the manuscript of a comedy in Michael Foster for a very readable and instructive his pocket, intending to apply himself to literature. On biography of a brilliant Frenchman. submitting it to Girardin, then Professor at the Sorbonne, he was recommended to study medicine as affording better prospects than letters to an impecunious student. He took J9e/ecM’e Eyesightthe Principles of its Relief by Glasses. Girardin’s advice and with characteristic energy threw By D. B. ST. JOHN ROOSA, M.D., LL.D., Surgeon to the himself heart and soul into medical studies, and at the close Manhattan Eye and Ear Hospital. London: Macmillan I and Co. 1899. Pp. 186. Price 4s. 6d. of his studentship was appointed interne to Magendie, then the chief physiologist in France, who quickly recognised his CONSIDERING the large number of treatises that are now merit and made him his prosector. Sir Michael Foster gives extant which are intended to teach the student and practian appreciative account of his earlier work, which com- tioner how to detect, diagnose, and treat impairment of menced with a communication to the Annales Meclico- vision due to errors of refraction that subject ought to be one Psychologiqlles in 1843 entitled" Recherches Anatomiques of the best known in the whole range of medicine. As a et Physiologiques sur la Corde du Tympane," immediately rule, however, some preliminary knowledge of mathematics followed by his thesis for his degree of Doctor in Medicine, is demanded of the reader and the result is, we fear, that, as which was upon the gastric juice and its function in Dr. Johnson said of Milton’s "Paradise Lost," the reader digestion. He then investigated the function of the spinal lays down the book that is to instruct him and-forgets to accessory nerve and soon after examined the colouring take it up again. No fears need be entertained on this matters in the body, which last was the subject of his thesis score in regard to the present volume. It is written in a at the " Concours pour l’Agrégation." The observation that style which is intended to be understood by beginners. fats and oils underwent changes at different parts of the The first chapter deals with the means of determining intestine in dogs and rabbits was the starting-point of his the sharpness of vision by means of test types. This mode researches on the functions of the pancreas, an observation of testing leaves something to be desired, for the author which, as Sir Michael Foster remarks, was not entirely relates a case in which a collision took place on the Hudson
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