193

lesion of the medulla oblongata in the case we have made anote of. The case, however, deserves the brief mention wehave given it.

It would be well to examine the urine in recent cases of suddendeafness. Probably, in a few of these cases, the deafnesswould be owing to disease of, or near to, the auditory nucleus.This nucleus is, Dr. Lockhart Clarke says, continuous with thevagus nucleus, and disease of, or of parts near it would verylikely produce temporary glycosuria. But examinations ofurine for sugar should not be limited to these cases. AustinFlint, in his admirable work on the Practice of Medicine,says : ,It is to be borne in mind that the fact of sugarexisting in the urine is not sufficient evidence of the exist-ence of the disease under consideration [diabetes ]. Sugar,generally in a small quantity and for a transient period, isnot unfrequently found in the urine in the course of variousmaladies." For accounts of the very varied physiologicaland clinical import of the presence of sugar in the urine,the works of Harley, Pavy, Beale, and Roberts may be par-ticularly referred to.

KING’S COLLEGE HOSPITAL.

OLD TRAUMATIC STRICTURE, WITH PERINEAL FISTULÆ;THE OLD OPERATION OF PERINEAL SECTION.

(Under the care of Mr. HENRY SMITH.)THE subjoined case well illustrates the severe effects

which will result from a traumatic stricture, especially if itbe neglected. It is well known that, under ordinary circum-stances, the form of stricture which proceeds from an injuryto the perineum is the most rebellious to treatment ; but if,as in this case, it be neglected, the worst conditions will- obtain. Here, in reality, they were seen in their most aggra-vated form. The posterior part of the urethra was appa-rently quite obliterated, and the structures in the perineumwere so altered by the continuous passage of the urine

along the sinuses that no hopes of giving any relief exceptby a formidable operation could be held out. The old opera-tion of cutting down upon the point of a catheter or staff is,under any circumstances, most difficult; but when, as inthis instance, the point of the instrument could only bepassed a short distance along the canal, and the tissues infront were immensely thickened, the difficulties may be in-surmountable. Indeed, it is in such cases, as Mr. Smithremarked after the operation, that surgeons even of greatexperience have been compelled to abandon the proceeding.

Here, as was expected, the operation was found to bemost difficult, and at one time it seemed as though theoperator would have to desist, mainly in consequence ofthe great hæmorrhage which occurred, and which preventedhim from using a sharp-pointed knife until it was foundabsolutely impossible to find a passage along the obliteratedcanal without it. The gush of blood which followed theuse of this instrument showed how dangerous its employ-ment is without a guide to the deep parts of the perineum.The value of the treatment of drawing away the urine by

the use of a catheter every few hours is seen in this case.There is no doubt that, in some respects, it is superior tothe method by retaining the catheter in the urethra for anylength of time, as thereby irritation is produced, and someof the urine will of necessity escape by the side of the in-strument, and come in contact with the wound.John T-, aged thirty-five, admitted September 24th.

He states that eighteen years before he injured his perineumby falling on some spiked railings. Sixteen years ago hefirst suffered from symptoms of stricture, and became a pa-tient at Guy’s Hospital under Mr. Cock, who passed in-struments for him with great relief. Since that time he hadnot had any instrument passed into his bladder, but hasgradually got into the state he is in now. He has greatinduration and thickening in the perineum and lower partof scrotum, and there are several sinuses, through whichthe urine passes; he suffers very much from irritabilityof the bladder and pain, and has become very thin and ex-hausted. On examination, Mr. Henry Smith found that hecould not pass an instrument further than the middle ofthe scrotal portion of the urethra. He was determined totry to get the patient into a better state of health, andthen perform perineal section.

Oct. 16th.-The patient has been somewhat improved.He was therefore taken into the theatre, and placed underthe influence of chloroform. Mr. Smith introduced a No. 6grooved staff down to the stricture; and it was there heldby Sir William Fergusson. A free incision was now made

through the dense and indurated tissues in the middle lineof the perineum and scrotum, and an attempt made to findthe point of the staff ; but, in consequence of the depth atwhich it lay, and the free bleeding, it was not found pos-sible until after a very free dissection had been made, andwhen the point of the staff was found, great, difficulty wasexperienced in getting the instrument forwards in the

right direction. To effect this with as much safety as pos-sible, Mr. Smith used a long probe-pointed straight knifeto divide the deeper textures , but little progress was thusmade, and he was unwillingly compelled to make use of along sharp-pointed knife, by which means way was madequickly into the bladder. This step was accompanied bythe most profuse venous bleeding. A moderate-sizedsilver catheter was then tied in, and the patient was re-moved to bed, much exhausted.

19th.-Patient has complained of very little since the

operation. No further bleeding took place, and he soonbegan to rally well under the influence of careful nutri-ment and stimulation.

21st.-Catheter removed, and No. 9 silver reintroduced,and tied in. Patient progressing rapidly.27th.-No. 11 tied in. He bears the catheter very well,

and the wound is healing rapidly.This instrument was kept in for a week, when some irri-

tation was produced by it; accordingly, Mr. Smith directedthe house-surgeon to draw the water away three times aday. Great success followed this plan, as the irritation sub-sided, and the wound, which was very large, healed morerapidly. After this treatment had been adopted for a fort-night, a difficulty was one day experienced by the house-surgeon in passing the catheter, so the instrument was tiedin again for a few days, after which no further difficulty wasexperienced in passing a full-sized catheter thrice daily.The wound was long in healing, and it was not until theend of December that it had contracted to about the size ofa pea. The patient was then taught to pass a catheter forhimself, and was discharged, well able to do so, on January10th.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

TUESDAY, JAN. 18TH, 1870.DR. QUAIN, PRESIDENT, IN THE CHAIR.

MR. LAWSON exhibited a lad in whom an Elastic PulsatingTumour suddenly appeared over an opening in the frontalbone, which he had made with a trephine eighteen monthspreviously for the removal of depressed fragments of bonepressing into the substance of the brain. On April 17,1866,the lad, whilst cleaning some windows on the second-floor,fell, and sustained a compound stellated fracture of thefrontal bone, close to the hairy scalp. He was brought tothe Middlesex Hospital insensible, and Mr. Lawson at onceremoved a portion of the frontal bone with the trephine,and cut away, with a pair of bone forceps, pieces of bonewhich were sticking into the brain-substance, and raisedwith an elevator other portions of bone that were depressed.From this operation the boy made a rapid recovery, and insix weeks’ time left the hospital apparently well. After amonth the pain returned, accompanied by giddiness, andthere was some protrusion of the cicatrix in the forehead.By the next day the swelling had attained the size of a hen’segg, and was hot, and painful to the touch. A slightpuncture into the swelling with the point of a lancet wasmade, when a clear watery fluid escaped, and continuedafterwards to trickle from the wound. On the followingday a thick rash of herpes appeared by the side of themouth, and all the febrile symptoms at once began to sub-side. For three days following the outbreak of the herpeticeruption, the tumour continued to discharge, through theopening made with the lancet, the aame clear fluid, andgradually lessened in size, until, during sleep, the discharge

194

ceased and the swelling completely subside-1. The boy left;the hospital quite well, and has continued uninterruptedlyat his work, which is now in the stable, up to the presenttime. Some account was given of the case in THE LANCETof July 14, 1886.

Dr. FAGGE exhibited two o cases, a mother and child, in’which the nails were attacked by vegetable parasites. Thetwo inclivicluals belonged to a family of whom five memberswere aifeoted with ordinary ringworm. In the child thenails were discoloured, speckled white, in some placesbrownish, and soft. In tne mother certain nails weresoftened towards their roots, and of a dull aspect. In eachcase the change in the nails was preceded by an eczematousaffection of the fingers, and the disease in the nails seemedto take origin in the spread of the latter towards the end ofthe linger, and beneath the root of the nail. The sporeswere large-larger than in ordinary tinea tonsurans; therewere branched tubes also.

Dr. TILBURY Fox said he had long come to regard differ-ence of size in the fungus elements as of very little valueas a differential test of species. If we take the first half-dozen cases of tinea tonsurans that come before us, weshould often find a most striking difference in the size of thespores. Much depended on the presence or absence of heatand moisture. Such cases as those brought forward by Dr.Fagge were very much more common than is generally sup-posed.

Dr. PEACOCK showed a specimen of Malformation of theHeart, from a cyanotic girl, aged fifteen years, who died oftubercle, and in which the state of things present wassimilar to that which is normally found in the turtle’sheart.Dr. PEACOCK also sent round the room a second specimen,

representing a true Aneurism of the Apex of the Ventricle,from a man aged seventy-three, in its second stage. Theman met with an injury; this was followed by cardiacsymptoms, especially breathlessness; and after death theaneurismal condition was discovered.

Dr. PEACOCK had a third case for exhibition, showing anUlcer of the Stomach, which had led to perforation of thesplenic artery. The ulceration gave evidence of its presenceby profuse haemorrhage two years ago, with subsequentdyspeptic symptoms. In November last the hæmorrhagerecurred, to be arrested by ice and astringents, but it re-turned in three weeks in a profuse degree, and the patientrapidly died. In the lesser curvature of the stomach wasan ulcer, the size of a finger-nail, eroding the coats, andopening into the splenic artery.

Dr. CRISP exhibited a Diseased Brain, taken from thebody of a girl under the care of Dr. Henry Davis, of Put-ney. The patient was a strong girl, aged fourteen, whohad enjoyed excellent health till recently. Two monthssince she was seized with severe pain in the nape of theneck, and had a somewhat unsteady gait, accompaniedwith giddiness. Six days before she died she went to aparty, and was obliged to leave from an increase of hersymptoms. She was compelled, when she stooped, to steadyher head " to get up." Dr. Davis saw her accidentally,and recognised the grave nature of the case. On the third

day after his seeing her, she was being got out of bed, andin the act of bending forward she became paralysed, anddied. At the post-mortem, the lateral ventricles were founddistended with twenty ounces of fluid. The brain-substancewas normal, but in the fourth ventricle, just behind theuvula, was a small, prominent, hard, red foreign body, thesize of a pea. The brain weighed three pounds. Dr. Crispreferred to a similar case recorded by Dr. Ogle.Dr. THOROwGOOD regretted that the spine had not been

fully examined. The case seemed to point to disease aboutthe atlas.

Dr. CRISP said that the uppermost parts of the spine andcord had been examined, and they were healthy.

Dr. BROADBENT suggested whether the case might notbe a hydrocephalic one.

Dr. FERGUS (of Marlboro’) exhibited a specimen of fatalPerforation of the Appendix Vermiformis, taken from a boyaged seventeen, who complained at the outset of his illnessof pain in the stomach, followed by acuter pain in theright iliac fossa and upwards, this being accompanied bydistinct retraction of the abiominal wall over the formerregion and peritonitis. Two days afterwards the boy died.He ha1 I been playing at football the day before the attack,

and fancied he had eaten something which had disagreedwith him. At the post-mortem there were found the evi-dences of peritonitis, with ulceration from impaction by ahard body, and perforation of the appendix.

Dr. FAGGE thought these causes not so fatal as generallysupposed, judging from experience at Guy’s.Dr. MARTIN related a case in which the ulceration was

tubercular in character.The PRESIDENT drew attention to the distinction to be

made between cæcal and vermiform disease, in relation toDr. Fag-ge’s remarks.

Dr. i2logov exhibited a specimen of Hydatid Disease ofthe Heart, blocking up the coronary vein and the greatcoronary sinuses. He wanted to know by what channel theblood was returned from the heart-substance itself.The specimen was referred to Drs. Greenhow and

Cayley.Dr. MOXON also brought forward a second case, one of

Tubercle of the Spine and Dura Mater, taken from a girladmitted into hospital with all the symptoms of tubercular-meningitis, and, in addition, great pains over the body.The membranes were covered with deposits having theappearance of sand. He had found it in other cases.

Dr. DotraLAs POWELL had met with a like appearancerecently.

Dr. BASTIAN had brought forward a case of the kindthree years ago. The small growths were projecting fromthe inner side of the dura mater, over an inflamed patch ofthe brain. He had regarded them as irritative outgrowths,fibro-nuclear in character.

Dr. MoxoN had never found any change in the cranialdura mater. In Dr. Bastian’s case the granules were in theparietal portion of the cranial dura mater.

Dr. DICKINSON asked if any microscopical examinationhad been made of the granules, and Dr. Moxon replied inthe negative.

Dr. MOXON exhibited next an example of Thrombosis.of the Renal Vein, in connexion with chronic disease ofthe femur.

Dr. WILSON Fox mentioned that Virchow had describedthis state as the result of any cause that retards the renalcirculation.Dr. DICKINSON said it was minutely discussed in a certain

manuscript in St. George’s Museum, bearing the date 1842,by Mr. Hewett when curator.Mr. T. SMITH exhibited 31 largish stones, removed from

the bladder of a Hindoo by lithotomy, by Dr. Wise ofBengal. The patient after operation absconded on the tenthday, and was found travelling to his home to look after hisbusiness, having gone 100 miles on foot. The stones werephosphatic.

Dr. WILSON Fox showed the last specimen of the evening ;and a very interesting case it was-viz., that of a Heartremoved from the body of a man in whom during life a well-marked tricuspid regurgitant murmur, together with othersigns of tricuspid disease, were present. The man had beenadmitted to hospital about a fortnight before his death..He was cyanotic-looking. His jugulars were markedlydistended, and in size about that of the little finger; theypulsated strongly and filled from below. The urine wasalbuminous and contained granular casts. During life therewas over an area of about half an inch at the ensiform

cartilage a systolic murmur, which was lost as the stetho-scope was moved away from this spot. There was no othermurmur, no accentuation of other sounds, and no thrill.The lungs were emphysematous. At the post-mortem, therewas great distension of the superior cava and its mainbranches. The tricuspid valve measured in eircumferenc&4% inch by cone. The chordae tendinese were shortened, thevalve slightly thickened. The heart was, otherwise thangreatly hypertropied, healthy.

CLINICAL SOCIETY OF LONDON.FRIDAY, JAN. 28TH.

MR. PAGET, PRESIDENT, IN THE CHAIR.

DR. OPPERT read particulars of a case of SyphiliticLaryngitis, treated -with the hypodermic injection of mer-cury. The patient, a young’ woman, aged 24, came underhis care at the Margaret-street Infirmary, on January Sth,