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SOUTH DEVON AND EAST CORNWALL HOSPITAL, PLYMOUTH.
580 involvement." In this case the absence of evidence of pet up in the sac of the old hydronephrosis on the left side, growth of any kind, primary or secondary, until the post- For the notes of this case we are indebted to Mr. W. Gifford mortem revealed its presence, rendered diagnosis quite Nash, late house surgeon. A. S-, aged twenty-five, a school teacher, was admitted impossible. George T-,a coach trimmer, aged forty-eight, was into the South Devon Hospital on Nov. 18th, 1890, suffering, admitted into St. Pancras Infirmary on Dec. 7th in a semi- from a renal fistula, of which she wished to be relieved. unconscious state, with a history of having been seized with She stated that since the age of fourteen she suffered from. right-sided paralysis and loss of speech on Dec. 4th. On a dragging pain in the right loin and occasional attacks of examination of the heart the sounds were distant but dis- vomiting; she never had any hæmaturia or passed gravel. tinctly heard, fairly normal in quality and regular in For many years she passed very little urine by day, rhythm ; the impulse was weak but not displaced, and the but had to get up two or three times each night. area of cardiac dulness was not increased. The patient On Feb. 19th, 1890, she was admitted into the We&t until Dec. at 9 A.M. he sud- Kent General Hospital, Maidstone, where it was when improved slightly 12bh, denly became much worse ; his temperature rose in a few found that there was a large fluctuating swelling in the, hours to 107° F., and he died the same evening. right loin. The circumference of the abdomen varied Necropsy.-On examination of the brain no haemor- from thirty-two to thirty-four inches. The urine had a, rhages or emboli were found anywhere, but the lefoptic sp. gr. of 1010, and contained pus and phosphates. The, thalamus was decidedly softened as compared with that on daily quantity varied from sixty to 106 ounces, about two. the opposite side. On removal of the sternum several thirds of this being passed by night. This ratio was main. nodules were noticed on the surface of the heart showing tained whether she got up or remained in bed all day. through the pericardium, which, thoughcompletely Under chloroform no urine could be squeezed from the adherent, was not involved in the growth. The ventricular tumour into the bladder. Nephrotomy was performed and walls were slightly hypertrophied, but the valves appeared 100 ounces of alkaline fluid containing pus, sp. gr. 1012,. perfectly normal. The chief seat of the growth was in the evacuated. A urinary fistula has remained since then. On admission the patient was a florid and well-nourished auricles; there were also several small masses about the apex, mostly involving only the outer half of the thickness woman, with a urinary fistula in the right loin just above of the (ventricular) wall, and nowhere projecting into the the iliac crest. In the right loin and iliac region could becavity of the ventricle. The endocardium of the auricles felt a large firm tumour. A probe passed into the fistula. also was intact throughout; but outside this the walls of towards the umbilicus six inches, and upwards and downthe left auricle were almost entirely formed by new growth, wards four inches each. No kidney could be felt on. and attained a maximum thickness of one inch and the left side. During the first week in hospital the a half. There were two masses of growth in the urine from the loin averaged fifty ounces, but none inter,auricular septum about the size of small filberts. came from the bladder. On Nov. 26th chloroform was The anterior wall of the right auricle also was almost given and the bladder examined digitally, but nothing entirely replaced by new growth, which extended thence up abnormal was detected. The renal tumour was explored the adjacent wall of the pulmonary artery, embracing it so through the fistula, and the dilated kidney pelvis examined. closely that it could not be dissected off. Several of the The upper opening of the ureter could not be found. mediastinal glands were hard and enlarged. On examining On Dec. 16th the patient had a rigor and aching in the left, the lungs, the left bronchus was found to be all but loin; next day two ounces of purulent fluid came away from occluded by a mass of new growth close to its bifurcation, the bladder. The signs of suppuration continued until which was continuous with that in the walls of the auricle, operation. On Dec. 24th a swelling was first felt in the and extended for a short distance into the tissues of the position of the left kidney, and on the 27th a pyonepbrosie, lung at its root. There were also a few isolated nodules was opened in the leftloin, and thirty-one ounces of pu& of growth in the lower lobe of the lung. The masses of evacuated. The sac was well washed out, and its edges. growth were white, hard on section, cupped slightly, and stitched to the skin. After this there was no discharge of when scraped yielded a thin semi-transparent juice. On pus from the bladder, and the wound in the left loin rapidly microscopical examination they were seen to consist of a large contracted. On Feb. 13th, 1891, the wound in the left loin amount of fibrous tissue enclosing alveoli of various sizes. was enlarged, and the pyonephrotic sac peeled off the surThe alveoli contained many epithelial cells, some of which rounding tissues, and as much as possible removed. The sac were distinctly columnar in form. A careful examination extended high up under the ribs, so that its upper part could of every other organ of the body was made, and in none was not be got at. Nothing was seen of the remains of ureter or any trace of growth found. Hence it was thought that the renal vessels. On July 24th, as there was still some discharge growth might have originated in the epithelial lining of some from a sinus running up under the ribs, chloroform was mucous gland in the left bronchus and have affected the given and the cavity scraped out. A few days later thereheart and mediastinal glands secondarily. The case is of was a discharge of pus from the wound resembling softened interest on account of the rare occurrence of the disease spleen. This lasted three or four days, and then the disand the total absence of any symptoms pointing to so charge gradually diminished, so that when the patient left the hospital at the beginning of October there was only a, serious an affection of the heart and lungs. small sinus remaining. The urine from the right loin contained about one-twelfth albumen, and was collected in a, Maw’s urinal. SOUTH DEVON AND EAST CORNWALL Remarks by Mr. W. GIFFORD NASH. -The points in favour of the obstruction being a congenital stricture HOSPITAL, PLYMOUTH. of both ureters, either at their origin from the pelvis of HYDRONEPHROSIS OF RIGHT KIDNEY ; NEPHROTOMY; the kidney or at their entrance into the bladder, are the PYONEPHROSIS OF LEFT KIDNEY ; NEPHRECTOMY. facts-(1) That the majority of hydronephroses in children (Under the care of Mr. WHIPPLE.) are due to congenital narrowing at cne or other of the THE explanation of this case seems to be as follows : The spots mentioned, as shown by the examination of museum girl was the subject of some congenital stricture of both specimens ; (2) the absence of any urethral obstruction or’ ureters. The left kidney first became dilated, and eventually tumour of the bladder blocking the urethra, or involving the all its eecreting tissue was completely absorbed. Whilst the apertures of the ureters ; (3) the absence of any history orsigns of a previous attack of pelvic cellulitis ; (4) the absence of left kidney was undergoing atrophy the right kidney was any pelvic tumour; (5) the absence of history of renal calculi, undergoing compensatory hypertrophy, and at the same time or any other known cause of hydronephrosis. The other its pelvis and calyces were dilating. At the age of fourteen points of interest in the case are: (a) The increased flow of the right hydronephrosis had become apparent. Ten years urine by night, which cannot be explained on mechanical later the right loin being drained and all the urine grounds, as it occurred if the patient was up all day, or if escaping from it, it became evident that the left kept in bed. (b) The large quantity and low specific gravity kidney was destroyed. The patient being very anxious of the urine and albuminuria are no doubt due to the chronic to get rid of the fistula, an attempt was made, by interstitial nephritis which accompanies the hydronephrosis. exploring the bladder and the right kidney, to find (c) The escape of splenic pus, which is easily explained by the cause of the obstruction, which at that time was the fact that the spleen is in contact with the left kidney. unexplained. Either owing to the examination of the (d) The fact that the absence of the left kidney could not bladder or the palpation of the left loin, suppuration was have been diagnosed, so that if the hydronephrotic kidney ,
581 9iad been removed without previous drainage, as recom- fever. Through a supra-pubic incision a phosphatic stone mended by Barker, the only working kidney would have weighing 300 grains was removed. Three large worms were
It is, therefore, advisable to drain a hydro- expelled during convalescence. Wound healed; patient April 7th. The boy continues quite well. nephrotic kidney before removing it so as to find out what discharged -M. CASE 5 is the working capability of the other kidney. (e) The U-, aged fifty-nine, was admitted on obstruction which caused the hydronephrosis was incom- Nov. 2nd, 1890, with a history of stone for four years. He plete on both sides. (f) The renal vessels on the left side had severe cystitis, a large prostate, and much pus in the had atrophied pari passu with the kidney which they urine. Lithotrity performed a year ago gave little relief. supplied, the pyonephrotic sac receiving its blood-supply I Seven stones (phosphatic) were removed through a suprafrom the vessels in the fatty capsule. pubic incision ; the largest was the size of a pigeon’s egg. A wide glass-tube was inserted, and replaced at the end of twenty.four hours by one of smaller calibre. The bladder was drained for two weeks. The wound then healed, and RIO TINTO HOSPITAL, HUELVA, SPAIN. the urine was normal. The patient was discharged cured CASES OF PERINEAL AND SUPRA-PUBIC DRAINAGE OF THE on Nov. 24th. A year later he reported himself in perfect health. BLADDER, ILLUSTRATING THE USE OF GLASS-TUBES CASE 6.-J. C-, aged seventy-five, was admitted on IN THE SURGERY OF THE URINARY ORGANS. Dec. 30bh, 1891. There was a history of stone in the (Under the care of Dr. W. A. MACKAY.) bladder for eight years. Four years ago Dr. Mackay reTHIS series of cases illustrates the advantages of pro- moved with the lithotrite a large quantity of phosphatic longed drainage in some conditions of disease of the urinary matter, but the relief was only temporary. On admission the tract. The results cannot be ascribed to the fact that glass patient was suffering from severe cystitis; much pus in the urine, which was ammoniacal ; a large prostate; there was was the material used to form the drainage-tubes, but it is no stone. The catheter no longer relieved him. He was desired to draw attention to the value of that material in worn out by pain and want of sleep. Sapra-pubic cystotomy the after treatment of such patients. We are in receipt of gave immediate relief. The pulse before the operation was a communication from Mr. Haydon Brown with reference to constantly over 100. After the operation it never reached .glass tubes for drainage of other than abdominal wounds, 90, and was seldom over 80. A wide glass-tube was used and he has forwarded us specimens of tubes which may be for the first twenty-four hours. This patient was in his more safely used than those at present at our disposal, less chair at the end of the first week. The bladder is to be liable to break or cause damage to parts. We have tried drained until the urine is normal, and free from pus. Bemarks by Dr. W. A. MACKAY.-Far from imagining them, and find them very useful in many cases where at present the ordinary rubber tube causes pain in introduc. that there is anything new in the idea of employing glass tion, readily becomes foul, or where it is necessary to con- in the surgery of the urinary organs, I am rather anxious to tinue the drainage for a long time. learn whether we have any other substance which ought to CASE 1.—M. B--, aged thirty-seven, was admitted be preferred. After a trial of all kinds of lithotomy and ,on May 28th, 1886, much emaciated and confined to other drainage-tubes, I have found that the general wellbed. He was suffering from urinary abscess in the being and comfort of the patient are best attained with glass. anterior abdominal wall, seven fistulae in the perineum, Why abdominal surgery should have such a monopoly of .a tight stricture, cystitis of a year’s standing, with this commodity I have never been able to understand ; but much pus in the urine. The patient was unable to it is certain that abdominal surgeons through attention bear thepresence of a catheter when tied in. The to such simple details have reached a position of ,abscess was opened and drained. The catheter was again security from which neither the fear of a germ nor the .passed four days later. A staff was also passed down beautiful colouring of an antiseptic dressing can allure to the stricture, and an incision made through the perineum, them. I do not attempt to enumerate the advantages of .dividing the stricture; the finger was passed along the a glass-tube in the drainage of the urinary bladder, but have catheter into the bladder. A glass-tube was then tied in. simply given details of a few cases where glass was used. ’The bladder was drained for six weeks. The patient has There has been an entire absence of any grave symptoms been seen lately (five years after the operation), and is in after operation in all cases in which I have either opened or drained the bladder. Sufficient time has now elapsed in perfect health and never passes an instrument. CASE 2.-R. M-, aged forty-one, was admitted on most of the cases cited to ensure a trustworthy result. The Dec. 5th, 1889, with a history of ten years’ suffering from bladder was in some instances drained for a very long time.
’been removed.
stricture of the urethra and urinary fistulae. The urine a large quantity of thick, ropy, tenacious mucoThe bladder, which was contracted and extremely pus. irritable, was drained through the perineum for three months, and gradually but forcibly dilated with boracic acid solution. The patient continues in perfect health, and does act require to pass an instrument. CASE 3.-J. C-, aged thirty-two, was admitted on Aug. 15ch, 1891, suffering from gangrene of the skin of the penis and scrotum caused by extravasation of urine, which followed the bursting of a deep perineal abscess into the urethra; no external opening. On admission the pulse was 130, the scrotum was the size of a foetal head, with gangrenous patches, and the anterior abdominal wall was dusky red and hard up to the umbilicus. The case was considered hopeless. Carbolic acid and - mercury were powerless against the stench arising on incising the gangrenous patches. No urine had been voided for thirty hours. A staff was passed as far as .,possible. Incision through the perineum on the point of the staff enabled a large solid slough to be turned out, and after clearing a fetid cavity in the deep perineum a glass tube was passed through the wound into the bladder, and fastened in. Beside the gangrenous patches a large piece ,of the skin of the anterior abdominal wall sloughed, and the penis was left almost denuded. Twenty-four hours after the operation the pulse was under 100. The patient made
,contained
a
rapid recovery.
CASE 4. -M. D-, aged eleven, was admitted on ileb. 24:’jh, 1888, with a history of stone extending over a period of six years. There was severe prolapse of the .anus ;the patient was weak, and suffering from malarial
This, I believe,
has a marked influence on the permanency of the result. A patient can wear with little inconvenience a properly fitting tube, and it seems to me unwise to let the wound close before the condition for which it was made is radically relieved. In all the cases a glass-tube was employed, like that used in abdominal surgery, only of smaller calibre. To this is attached a small piece of indiarubber tubing, which con. veys the urine to a vessel in the bed, and the patient is kept quite dry and undisturbed. No dressing is used except a T-bandage in a perineal case, and a piece of fine sticking plaster and thread to fix the tube when it is inserted above the pubes. A rectal bag and warm solution of boracic acid were employed at the operation in all the supra-pubic cases. In none of these was there any appearance of extravasation of urine or abscess formation about the wound. In the case of old men the stone is often not the most important factor in the pathological condition of the patient. It may be got rid of by means of a lithotrite, and yet no rest is given to the prostate and bladder. Such cases can only be cured by prolonged drainage, which I venture to suggest might well supersede prostatectomy in many cases.
DEATH
OF
DR. IMMISCH.—A well-known
figure in
Heidelberg has just passed away in the person of Dr. Immisch, the Heidelberg "duel" doctor. Dr. Immisch had occupied for over forty years the post of doctor to the
students who were wounded in duels. All the students of the Heidelberg University attended the doctor’s funeral, each corps bearing its banners and devices.
581 9iad been removed without previous drainage, as recom- fever. Through a supra-pubic incision a phosphatic stone mended by Barker, the only working kidney would have weighing 300 grains was removed. Three large worms were
It is, therefore, advisable to drain a hydro- expelled during convalescence. Wound healed; patient April 7th. The boy continues quite well. nephrotic kidney before removing it so as to find out what discharged -M. CASE 5 is the working capability of the other kidney. (e) The U-, aged fifty-nine, was admitted on obstruction which caused the hydronephrosis was incom- Nov. 2nd, 1890, with a history of stone for four years. He plete on both sides. (f) The renal vessels on the left side had severe cystitis, a large prostate, and much pus in the had atrophied pari passu with the kidney which they urine. Lithotrity performed a year ago gave little relief. supplied, the pyonephrotic sac receiving its blood-supply I Seven stones (phosphatic) were removed through a suprafrom the vessels in the fatty capsule. pubic incision ; the largest was the size of a pigeon’s egg. A wide glass-tube was inserted, and replaced at the end of twenty.four hours by one of smaller calibre. The bladder was drained for two weeks. The wound then healed, and RIO TINTO HOSPITAL, HUELVA, SPAIN. the urine was normal. The patient was discharged cured CASES OF PERINEAL AND SUPRA-PUBIC DRAINAGE OF THE on Nov. 24th. A year later he reported himself in perfect health. BLADDER, ILLUSTRATING THE USE OF GLASS-TUBES CASE 6.-J. C-, aged seventy-five, was admitted on IN THE SURGERY OF THE URINARY ORGANS. Dec. 30bh, 1891. There was a history of stone in the (Under the care of Dr. W. A. MACKAY.) bladder for eight years. Four years ago Dr. Mackay reTHIS series of cases illustrates the advantages of pro- moved with the lithotrite a large quantity of phosphatic longed drainage in some conditions of disease of the urinary matter, but the relief was only temporary. On admission the tract. The results cannot be ascribed to the fact that glass patient was suffering from severe cystitis; much pus in the urine, which was ammoniacal ; a large prostate; there was was the material used to form the drainage-tubes, but it is no stone. The catheter no longer relieved him. He was desired to draw attention to the value of that material in worn out by pain and want of sleep. Sapra-pubic cystotomy the after treatment of such patients. We are in receipt of gave immediate relief. The pulse before the operation was a communication from Mr. Haydon Brown with reference to constantly over 100. After the operation it never reached .glass tubes for drainage of other than abdominal wounds, 90, and was seldom over 80. A wide glass-tube was used and he has forwarded us specimens of tubes which may be for the first twenty-four hours. This patient was in his more safely used than those at present at our disposal, less chair at the end of the first week. The bladder is to be liable to break or cause damage to parts. We have tried drained until the urine is normal, and free from pus. Bemarks by Dr. W. A. MACKAY.-Far from imagining them, and find them very useful in many cases where at present the ordinary rubber tube causes pain in introduc. that there is anything new in the idea of employing glass tion, readily becomes foul, or where it is necessary to con- in the surgery of the urinary organs, I am rather anxious to tinue the drainage for a long time. learn whether we have any other substance which ought to CASE 1.—M. B--, aged thirty-seven, was admitted be preferred. After a trial of all kinds of lithotomy and ,on May 28th, 1886, much emaciated and confined to other drainage-tubes, I have found that the general wellbed. He was suffering from urinary abscess in the being and comfort of the patient are best attained with glass. anterior abdominal wall, seven fistulae in the perineum, Why abdominal surgery should have such a monopoly of .a tight stricture, cystitis of a year’s standing, with this commodity I have never been able to understand ; but much pus in the urine. The patient was unable to it is certain that abdominal surgeons through attention bear thepresence of a catheter when tied in. The to such simple details have reached a position of ,abscess was opened and drained. The catheter was again security from which neither the fear of a germ nor the .passed four days later. A staff was also passed down beautiful colouring of an antiseptic dressing can allure to the stricture, and an incision made through the perineum, them. I do not attempt to enumerate the advantages of .dividing the stricture; the finger was passed along the a glass-tube in the drainage of the urinary bladder, but have catheter into the bladder. A glass-tube was then tied in. simply given details of a few cases where glass was used. ’The bladder was drained for six weeks. The patient has There has been an entire absence of any grave symptoms been seen lately (five years after the operation), and is in after operation in all cases in which I have either opened or drained the bladder. Sufficient time has now elapsed in perfect health and never passes an instrument. CASE 2.-R. M-, aged forty-one, was admitted on most of the cases cited to ensure a trustworthy result. The Dec. 5th, 1889, with a history of ten years’ suffering from bladder was in some instances drained for a very long time.
’been removed.
stricture of the urethra and urinary fistulae. The urine a large quantity of thick, ropy, tenacious mucoThe bladder, which was contracted and extremely pus. irritable, was drained through the perineum for three months, and gradually but forcibly dilated with boracic acid solution. The patient continues in perfect health, and does act require to pass an instrument. CASE 3.-J. C-, aged thirty-two, was admitted on Aug. 15ch, 1891, suffering from gangrene of the skin of the penis and scrotum caused by extravasation of urine, which followed the bursting of a deep perineal abscess into the urethra; no external opening. On admission the pulse was 130, the scrotum was the size of a foetal head, with gangrenous patches, and the anterior abdominal wall was dusky red and hard up to the umbilicus. The case was considered hopeless. Carbolic acid and - mercury were powerless against the stench arising on incising the gangrenous patches. No urine had been voided for thirty hours. A staff was passed as far as .,possible. Incision through the perineum on the point of the staff enabled a large solid slough to be turned out, and after clearing a fetid cavity in the deep perineum a glass tube was passed through the wound into the bladder, and fastened in. Beside the gangrenous patches a large piece ,of the skin of the anterior abdominal wall sloughed, and the penis was left almost denuded. Twenty-four hours after the operation the pulse was under 100. The patient made
,contained
a
rapid recovery.
CASE 4. -M. D-, aged eleven, was admitted on ileb. 24:’jh, 1888, with a history of stone extending over a period of six years. There was severe prolapse of the .anus ;the patient was weak, and suffering from malarial
This, I believe,
has a marked influence on the permanency of the result. A patient can wear with little inconvenience a properly fitting tube, and it seems to me unwise to let the wound close before the condition for which it was made is radically relieved. In all the cases a glass-tube was employed, like that used in abdominal surgery, only of smaller calibre. To this is attached a small piece of indiarubber tubing, which con. veys the urine to a vessel in the bed, and the patient is kept quite dry and undisturbed. No dressing is used except a T-bandage in a perineal case, and a piece of fine sticking plaster and thread to fix the tube when it is inserted above the pubes. A rectal bag and warm solution of boracic acid were employed at the operation in all the supra-pubic cases. In none of these was there any appearance of extravasation of urine or abscess formation about the wound. In the case of old men the stone is often not the most important factor in the pathological condition of the patient. It may be got rid of by means of a lithotrite, and yet no rest is given to the prostate and bladder. Such cases can only be cured by prolonged drainage, which I venture to suggest might well supersede prostatectomy in many cases.
DEATH
OF
DR. IMMISCH.—A well-known
figure in
Heidelberg has just passed away in the person of Dr. Immisch, the Heidelberg "duel" doctor. Dr. Immisch had occupied for over forty years the post of doctor to the
students who were wounded in duels. All the students of the Heidelberg University attended the doctor’s funeral, each corps bearing its banners and devices.