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H. LUDWIG, PRINTER, Nos. 70 & 72, Vesey-street.

MEDICO-CHIRURGICAL

REVIEW.

JANUARY, 1845.

MEDICO-CHIRURGICAL TRANSACTIONS, PUBLISHED BY THE ROYAL MEDICAL AND CHIRURGICAL SOCIETY OF LONDON. Volume the Twenty-seventh (the Ninth of the Second Series), 1844.

IN the present dearth of medical works of sterling merit and original views, the appearance of the annual volume of the Royal Medical and Chirurgical Society is an event of some importance in medical literature. There have been few men of eminence in the profession in the present century who have not been contributors to these transactions. Those long established in practice have enriched the pages of this work with the results of their matured views of disease, and with the curiosities of their medical experience, whilst the young and enterprising have made them a record of original inquiries and interesting observations in the ample field of pathological science. It must be confessed that the novelty of the volume, though not its substantial value, is in some degree lessened by the authorized publication in the weekly periodicals of an abstract of the papers read at the Society's meetings, and even of papers of which the titles only had been announced, owing to the press of communications sent in at the close of the season. For this reason, we think that the publication of the present volume should not have been delayed to so late a period as the month of November. The papers are communicated to the Society in a state ready for the press, and the task of selection-of winnowing the grain from the chaff, may be said to commence at the beginning of the session. We are aware of one alleged cause of delay, viz. the time occupied in colouring the plates. They are, however, too few in number (only three) to account for the late period at which the volume has this year been delivered to the members. We are glad, however, to see some coloured illustrations. Pathological appearances cannot always be satisfactorily represented by plain lithographs, and the Society is sufficiently prosperous to afford the additional expense of colouring them. The present number is thicker than any of the later volumes, having no less than five hundred pages, and as usual contains many valuable communications to which we shall now direct the attention of our readers.*

The Council have done well in placing round the Meeting-room the busts of No. 99. 1

1. AN ACCOUNT OF TWO CASES OF RUPTURE of the URETER, OR PELVIS OF THE KIDNEY, FROM EXTERNAL VIOLENCE, FOLLOWED BY LARGE EFFUSION OF URINE INTO THE ABDOMEN. By Edward Stanley, F.R.S.

Cases of rupture of the urinary bladder by external violence are by no means of rare occurrence, and as the laceration usually involves that portion of the viscus which is invested with serous membrane, the urine escapes into the sac of the peritoneum and gives rise to fatal peritonitis. But the pelves of the kidneys and the ureters are differently situated, so that a rupture of their walls would only permit the escape of the secretion of the kidneys into the surrounding cellular tissue, where we can easily understand that actions might be set up to limit the diffusion of the fluid and to avert the dangerous consequences of the injury. It may also be observed, that these parts are by their position well protected from injuries, and being channels for the transmission of the urine, and not organs for its retention, they are less liable to be ruptured by external violence than a distended urinary bladder, which sufficiently explains the rarity of the accident described by the President in the two interesting cases which he has com municated to the Society.

A boy, aged 9 years, was brought to St. Bartholomew's Hospital, having been squeezed between the wheel of a cart and a curb-stone.

"The immediate consequences were, severe contusion of the soft parts around the pelvis, inability to walk, and great pain in the lower part of the abdomen; he lay helpless, apparently suffering from severe internal injury. Much ecchymosis ensued in the integuments around the pelvis, and extensive suppuration in the subcutaneous cellular tissue, from which several ounces of matter were discharged by puncture near the left sacro-iliac symphysis. By the end of the sixth week, recovery of the injured soft parts around the pelvis had considerably advanced. At this period, my attention was directed to a fulness not before observed on the right side of the abdomen, and on further examination, a circumscribed, oblong swelling was recognised through the abdominal parietes, extending from the base of the chest downwards to within a short distance of Poupart's ligament; anteriorly, it terminated abruptly at the linea alba; posteriorly, it could be traced into the lumbar region, but it here presented no distinct boundary; the liver appeared to be pressed upwards by the swelling, so that the right lung did not extend below the sixth rib, the admission of air into it here ceasing in a defined line. Pressure on the swelling gave no pain, but a deep fluctuation in it could be recognised. The urine passed naturally, as it had done throughout, and that there was no distention of the bladder was ascertained by the introduction of a catheter. I could but suppose the swelling to be an abscess, but there was difficulty in adopting this opinion of it from the absence of pain and constitutional derangement. To discover the nature of the swelling, I made a small puncture in it with a lancet, from which a little clear yellow fluid escaped; this was followed by much pain in the abdomen, which yielded to the application of leeches. By this exploratory proceeding, I learned that the fluid was situated immediately beneath the abdominal muscles, and that it was not pus. Three

some of the more distinguished Members and former Presidents of the Society. They form elegant and appropriate ornaments to the walls, and Halford, Cline, Babington, Cooper, Abernethy, Travers, Earle and Brodie have well deserved the honour awarded them.

weeks afterwards, the abdominal swelling having become more tense and pointed, I punctured it with a small trochar midway between the last rib and crista of the ilium, and discharged from the opening fifty-one ounces of a clear yellow fluid. Pain in the abdomen followed this puncture, but it yielded as before to the application of leeches. Eleven days afterwards, the swelling having again enlarged, I discharged from it by puncture fifty-eight ounces of a clear yellow fluid. In sixteen days from this puncture, the swelling having again greatly increased, I removed from it sixty-four ounces of fluid. The swelling returned, and having acquired a certain size, it remained stationary, on which account it was not interfered with for nearly three months, when I again punctured it, and discharged seventy-two ounces of fluid of the same characters as before. Three weeks afterwards, I punctured the swelling the sixth and last time, but discharged only six ounces of fluid, and it appeared to me that a larger quantity was not obtained from the existence of some obstacle to the canula fairly entering the cavity in which the fluid was contained. The other parts of the treatment consisted in the repeated application of leeches, in the application, on one occasion, of a large blister to the swelling, and in the use for a considerable time of the ointment of iodide of potassium : but, with the exception of the leeches, which relieved the pain in the abdomen recurring more or less after each puncture, it is doubtful whether the other measures were of any service. Throughout, the general health had been good, and all the functions of the body appeared to be perfectly performed. From this period the swelling continued without increase or obvious diminution: it still extended from the linea alba into the right lumbar region, and as any further interference by operation or otherwise, was now considered inexpedient, I discharged the boy from the hospital nine months after the occurrence of the accident. At several subsequent periods I have seen him in good health, with the abdominal swelling still distinct, but, as we have thought, slowly diminishing, and with less evident fluctuation." 5.

Mr. Stanley remarks that three questions of interest here arise-what was the nature of the fluid so largely accumulated in the abdomen; where was it situated; and, if it was urine, from what part of the urinary apparatus was it derived? The first question is answered by the chemical examination of the fluid evacuated made by Mr. Edward Ormerod and Mr. Taylor, who detected, in addition to a large quantity of urea, the other ordinary ingredients of urine. Mr. Taylor further observed, that from the absence of mucus in the fluid, the probable source was high in the urinary apparatus, as at the commencement of the ureter. With respect to the situation of the fluid, Mr. Stanley discusses the question, whether it was lodged within the peritoneal sac, or had formed for itself a cavity by detaching the peritoneum from the abdominal and lumbar muscles, and from the circumscribed character of the swelling, and especially its abrupt termination at the linea alba, where its further progress would be impeded by the firm connection of the peritoneum with the abdominal aponeuroses, as well as from the absence of peritoneal inflammation, and the formation of the tumour without pain or constitutional derangement, we think justly concludes the latter to be the situation where the fluid had accumulated.

The second case also occurred in St. Bartholomew's Hospital, under the care of Mr. Vincent. A woman was admitted immediately after having been knocked down, and, as it was stated, pushed some way before the wheel of a cart. The left femur was broken and she was much hurt in the left hypochondrium. On the following day there was much febrile disorder, and severe pain and distention of the abdomen. After bleeding

from the arm, the application of leeches to the abdomen, and the administration of calomel and antimony, the general distention and pain subsided, but there remained a circumscribed and painful swelling in the right hypochondrium. It increased and formed a fluctuating tumour, which was supposed to be an abscess probably connected with the liver. Mr. Vincent punctured the swelling with a small trocar and discharged between two and three pints of a straw-coloured urinous-smelling fluid. The patient was much relieved; but in about ten days the fluid had again accumulated so as to occasion much distress. Six pints of a similar fluid were again removed, with temporary relief. But the swelling returned and she gradually sunk and died in the tenth week from the receipt of the injury. The fluid obtained from the abdomen was found to be albuminous, and to contain a small quantity of urea.

"Upon examination of the body, a large cyst was found on the right side of the abdomen behind the peritoneum extending upwards to the diaphragm, and downwards to the pelvis. The boundaries of this cyst were formed by lymph and thickened cellular tissue; within it was a large quantity of fluid presenting the characters of a mixture of pus and fetid urine. A passage was found extending from the upper part of the cyst into the pelvis of the right kidney. The aperture in the pelvis of the kidney was large and irregular; the appearances were such as might be expected to result from laceration of the membranous structure composing it. The liver presented in its anterior border, the marks of a slight laceration of its tissue, which was in progress of healing. The kidneys were slightly granular." 10.

Mr. Stanley notices a circumstance exhibited by these cases which may be of importance in practice, viz. the absence of any symptom of imme. diate occurrence leading to a suspicion of injury to any part of the urinary apparatus, and concludes by suggesting the question, whether the best proceeding would be gradually to withdraw the fluid by repeated punctures of the cyst, and thus to favour the collapse and adhesion of its sides upon the plan recommended by Mr. Abernethy for the treatment of lumbar abscess, or whether the urinary cyst should be punctured at its lowest part, in the view of maintaining the aperture free for some time, that the fluid may drain from it, upon the plan which has been adopted in cases of empyema for the discharge of fluid from the chest. We should be inclined to give the preference to the plan adopted by Mr. Stanley and Mr. Vincent in these cases, because we conceive that a large cyst containing urine mixed with morbid secretions would, if left with an open com. munication, be as liable to inflame and to give rise to severe constitutional derangement and hectic symptoms as the cyst of a large lumbar abscess.

II. ACCOUNT OF A CASE OF CYSTICERCUS CELLULOSE OF THE BRAIN. By Drewry Ottley, Esq.

This is a form of hydatid which sometimes occurs in large numbers in the brain, especially of persons dying at an advanced age. Cruveilhier observed in the brain of an epileptic patient who died in the Bicêtre at Paris at least a hundred of these parasites. Some were seated in the subarachnoid cellular tissue of the brain and cerebellum; others occupied the

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