TRAUMATIC DISLOCATION OF THE HIP-JOINT.

1288 common

iliac artery

was

readily laid bare.

After

some

ureter was found ; it was the size of a coil of small intestine, and hence was overlooked several times in the search. It was then easily traced to the base of the bladder, the vas being seen as it crossed and hooked on one side. The ureter was opened .and a stricture found at its entry into the bladder. The catheter passed upwards, howIt was evident that the ever, for a distance of 20 inches. pelvis was much dilated. The ureter was therefore ligatured and divided close to the bladder, the upper end of the ureter being freed as far as possible in an upward direction. The wound was then closed and the kidney, which was in a condition of extreme hydronephrosis, removed together with the ureter by the ordinary incision in the loin.

difficulty the

2. A male aged 30 years. Six weeks before admission sudden onset of acute pain passing from right groin to loin, followed by hsematuria and frequency; one similar attack since. A radiograph showed an oval calculus in the position of the lower inch of the right ureter. On attempting to catheterise the right ureter the catheter was stopped 1 inch above the orifice. A 2-inch suprapubic incision was made 1 inch to the right of the mid-line. The ureter was readily found and traced down to the bladder, the stone being felt about half an inch above the bladder wall. The ureter was opened and the stone was easily extracted, a ureteric catheter then passing freely into the bladder. The opening in the ureter was stitched with three catgut sutures and a small tube inserted, the rest of the wound being closed. There was a slight discharge of urine for four days, after which the wound closed entirely, and the patient was discharged cured. 3. A male aged 42. Typical attack of renal colic two weeks before admission to hospital, followed by hæmaturia. The radiograph showed a typical shadow of a renal calculus about 2 inches above the vesical orifice on the left side. A catheter was obstructed at the corresponding point. An incision similar to that used in the last case was made to the left of the mid-line, and the stone easily extracted. There was a slight discharge of urine for nearly a week, after which the wound healed rapidly.

By the use of the lower rectus incision a very good view is obtained of the lower 6 inches of the ureter. Its point of entry into the bladder is laid bare and is rendered so accessible that operations upon it can be readily carried out, and the adjacent portions of the bladder are also exposed. The vas and vesiculae can be seen, as also the iliac arteries. The peritoneum being unopened no difficulty is experienced from the proximity of the intestines. The operation being wholly extraperitoneal the danger of infection is slight and the wound can be freely drained. The exposure is infinitely preferable to that given by a parasacral or iliac routes. I

am.

Sir.

vours

faithfullv.

ALBERT J. WALTON.

Weymouth-street, W., April 25th, 1914.

THE FATALITY OF MEASLES. To the Editor of THE LANCET.

SIR,—In Feb. 21st

with

a

on

leading article

in

THE

LANCET

of

"The Control of Measles" you quote

approval

Dr. James Kerr’s

statement

that

"the chief hope of combating measles lies in improvements in regard to habits of life, housing, No doubt this contains much and space to live." truth, but it does not quite hit the principal nail on the head. It is universally admitted that the fatality of measles is almost negligible among the educated and well-to-do classes, but considerable among the poor and ignorant. To a certain extent want of abundant fresh air and of comfortable accommodation is responsible ; but the chief cause, I have long been certain, is the scare of a " chill" on the part of

the poor and ignorant parents and friends; and in order to escape from this illusory Scylla they run into the real Charybdis of the opposite extreme. Thus the child is packed more or less tightly in a bundle of clothes-usually of flannel or flannelette - covered with a superabundance of impervious bedclothes, and sometimes (as I have seen in London) kept near a large fire, and, of course, in a badly ventilated room. To touch the skin with water would be looked upon as next door to murder, so that the child is not refreshed by washing or changing the clothes. This process of overheating is, I believe, far more prejudicial and dangerous than any chill that is likely to be sustained while the pyrexial period lasts. It intensifies the disease, and it is the intensity of the disease that mainly determines aggravation of bronchitis or the onset of pneumonia-the chief That this fact is recognised and causes of death. acted upon by most medical men I readily allow, but I do not remember having seen it expressly stated, especially in codes of instruction for

popular use. Small-pox used to be regarded and treated in the same way by popular and medical assent until Sydenham taught the beneficial effects of keeping the patient cool and giving him fresh air. It is, of course, useless, to expect any advantage from notification of the disease-the nostrum of The important desi. many health authorities. deratum is that cases of measles shall be attended by sensible medical men. If pneumonia should develop in the course of the disease, the most effectual treatment is blood-letting-not necessarily venesection as was always practised with good effect in old times, but, in the case of children, by the application of one or two leeches, which usually suffice -T

Cir

am

vours

faithfully

F. LUCAS BENHAM,

M.D., M.R.C.P.

Exeter, South Australia, March 25th, 1914.

TRAUMATIC

DISLOCATION

OF

THE

HIP-JOINT. To the Editor of THE LANCET.

SIR,—By an odd coincidence I read Mr. Harold Rischbieth’s account of the above injury in a boy aged 10, reported in THE LANCET of April 18th, a few hours after seeing a boy who was in the Children’s Hospital at Shadwell at the age of 7 for a similar accident. I had written to the boy asking him to come up to report himself. On referring to my notes I find that the boy was admitted on Oct. 23rd, 1910. He had fallen down in the street on the day of admission and the left femur had been dislocated dorsally. He had suffered from no previous injury to the limb. The femur was markedly flexed, adducted, and rotated inwards, the leftknee being in apposition with the lower end of the right thigh just above the right knee. The great trochanter was well above Nelaton’s line, and there was a deep pit in Scarpa’s triangle. Passive movements caused great pain. The boy was given chloroform and placed on a mattress on the floor. Reduction of the dislocation by flexion, adduction, and external rotation, associated with raising of the limb and sudden extension, was accomplished without great difficulty. A long sidesplint was applied for 24 hours, after which sandbags were substituted. Passive movements were commenced three days after the injury, and the boy was allowed to walk on Nov. 3rd. X rays showed

1289 no

injury

to

bone

or

epiphysis.

The

history

since the accident has been uneventful. I am, Sir, yours faithfully, Harley-street, W., April 24th, 1914. HILDRED B. CARLILL.

THE

STATE,

THE MOTHER, AND THE CHILD.

To the Editor of THE LANCET.

SIR,-The leading article with this title in April 25th approves " the efforts which are now being made to extend State action in all that relates to maternity and infant welfare," THE LANCET of "

and says that individualists, if any such remain," and "the eugenist," may argue against these efforts. Then you remark that " such arguments, however, usually appear to be pleas for inaction." This is very true; for few individualists and eugenists have the courage to advocate the extension of the knowledge of family limitation to the poor, which is the only alternative to State action So we are progressing towards on their behalf. married couples with more a stage when the than 30s. a week will be having an average of only one child per family in order to help to maintain the large families of those with less than 30s. a week! I earnestly hope, however, that there are many colleagues who share my view that if people were encouraged to have no more than one child for every 20s. or so a week poverty would soon cease to exist, the race would quickly improve, and a welcome freedom from meddlesome and costly legislation and officialism would ensue.-I am, Sir, vours faithfullv. BINNIE DUNLOP, M.B., Ch.B. Alexandra Court, S,W.,

April 25th, 1914.

THE NATIONAL INSURANCE ACT. LONDON INSURANCE COMMITTEE

AND THE SURPLUS FUNDS. THE London Insurance Committee by a majority of four votes has decided to draw up a scheme for the distribution among the medical men on the panel of the surplus funds arising in respect of unallotted patients. At a meeting of the Committee held to consider the matter, Mr. Kingsley Wood first moved that having regard to the opinion of Mr. Danckwerts, K.C., whose death is recorded this week, the Committee should inform the Commissioners that it could not proceed with the distribution. Mr. Kingsley Wood argued that there should be either judicial or Parliamentary authority before dealing with the fund, but he pointed out that no action had been instituted by the medical practitioners which would have facilitated the obtaining of a judicial decision. Mrs. Handel Booth moved an amendment to the effect that a scheme for the distribution of the money should be prepared and submitted to the Commissioners, who would have the opinion referred to before them and whose decision would absolve the committee. After discussion this amendment was carried by 27 votes to 23. With regard to the risks suggested in the opinion of Mr. Danckwerts, it may be pointed out that even though a distribution were to take place which in law were wrong, it might still be difficult to find anyone having such an alternative interest in the money as would entitle him to raise any question in the courts with regard to it.

SANATORIUM BENEFIT IN LONDON. The London Sanatorium Benefit Subcommittee in a report on arrangements for the present year estimates the income to be dealt with at £100,000, and the required expenditure to include JE40,000 to medical practitioners for domiciliary treatment, JB7620 for drugs, £5000 for dispensary treatment, and £54,600 to cover the cost of 700 beds for institutional treatment. In an explanatory memorandum the Sanatorium Benefit Subcommittee quoted the Chancellor of the Exchequer as having stated that at first the payment of 6d. for domiciliary treatment might be very much too high. At present the amount of the payment under this head could not be varied, but the subcommittee noted that before the end of 1915 there would be a reconsideration of If it were not for money the whole position. accumulated during the first six months’ working of the Act, when applications for sanatorium benefit were few, there would be a deficit of £10,000 this year in respect of institutional treatment. LONDON PRACTITIONER VINDICATED. The Medical Service Subcommittee communicated to the London Insurance Committee on April 23rd the results of its inquiries into a case in which a practitioner on the panel had been censured (in his absence) by a coroner’s jury, it being suggested that he did not properly examine a patient. Treatment had been given for dyspepsia and rheumatism ; the post-mortem examination showed advanced tuberA curious feature of the case culous disease. to be the reticence of the patient as to appeared his symptoms. He never mentioned that he had night sweats, and definitely denied that he had cough or expectoration ; he only mentioned diarrhoea, stomachic pains, and rheumatic pains in the knee. The practitioner had examined the patient a year earlier and had found him to be organically sound. The medical members of the subcommittee advised that there was no evidence to show that the tuberculous disease of the lungs was in any way active at the time of death, or that it was an active agent in causing death. The conclusion arrived at was that the practitioner exercised proper professional care and was not negligent in any way. At the request of the practioner-Dr. D. J. F. Bennett, of Walworth, S.E.-his name was publicly announced. ARBITRATION UNDER THE INSURANCE ACT. The Scottish Insurance Commissioners were recently invited for the first time to arbitrate between an insured patient and an Approved Society on the question of the refusal of the latter to pay sickness benefit. The applicant was Mrs. M’Cartney, a member of the Scottish Catholic Society, which had refused her the benefit claimed on the ground that she was not incapacitated. Mrs. M’Cartney, in accordance with the rules of the society, applied to the Commissioners to appoint an arbitrator to decide the question, and Mr. R. D. M’Ewen, chairman of the Glasgow Insurance Com. mittee, being duly appointed by the Commissioners, held an inquiry and found in her favour. The society appealed to the Commissioners against this decision, and the Commissioners have now issued their award upholding that of the arbitrator, and finding that the insured person was incapacitated for the period for which she claimed. The Commissioners further found the society liable for £3 3s. as costs. Congratulations are due to the