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10th. Remaining stitches removed, and bladder washed out through a small catheter.
13th. Openings from the cutting through of stitches, through which the urine escaped, have entirely closed. Eats and sleeps well; suffers no pain. Flaps cicatrizing at edges.
25th. Large quantities of mucus collect in the bladder causing distension, and have to be removed with a syringe. Is sitting up to-day for the first time.
June 17. Has been walking about the ward since May 27. Flap has nearly cicatrized over the whole extent.
25th. Flaps and perineum completely cicatrized, the cicatrix in the perineum being quite small. By pressing the fold of skin above the penis against the latter, he can retain his urine for two and a half hours. The greatest difficulty in the treatment of the case was caused by the very free secretion of vesical mucus, which distended the bladder and prevented the free escape of urine. No pain or inflammation was caused by the urine, which was allowed to flow over the exposed testicles and raw surface of the perineum, but it appeared to hasten cicatrization.
The boy at this date (April 25, 1875) is doing well. He is able to walk erect; he runs and jumps with ease; and by the use of a shield, the urine is collected in a bottle fastened to the inside of his boot, thus preventing bis clothing from becoming soiled.
HYDRO-NEPHRITIS CAUSED BY THE FORMATION OF
STONES IN THE PELVIS OF THE KIDNEYS.
BY LEON J. WILIEN, M.D.,
Wm. McM., aged 26 years, medium size, nervoso-bilious temperament, delicately constituted, puddler by profession, could give no information as to his family history regarding scrofulous, tuberculous, or cancerous diathesis. Engaged in the military service for two years in the late war, in a cavalry regiment, during the latter part of which he was thrown from a horse, the latter falling on him with its full weight.
Although severely hurt for a time, he entirely recovered from the injury, with the exception of a dull and deep pain in the left lumbar region, and some slight touches of hæmaturia, the latter disappearing entirely for the space of four years. In 1866, he resumed his profession, without ever complaining of the soreness in his side, and a gradual enlargement of the abdomen, which he says never caused him
distress w batever. In July, 1874, he received a severe shock and contusion of his back and left side, while standing on a platform of a railroad car. This accident caused much pain, and, micturating a few minutes afterwards, he noticed a rather large quantity of blood discharged with the urine, this occurring repeatedly for about two weeks. At that time, he stated that he felt a tumor the size of a large goose egg, very painful on pressure and more or less movable, in the left side. He returned to Terre Haute, and continued working until Saturday, the 20th day of February, 1875, when he suddenly fell against a sheet of iron, which caused momentary loss of consciousness. From that time his sufferings increased, and on Monday, the 24th of February, we were called to see him, and found the following symptoms: Decubitus dorsal, body emaciated, features pinched, eyes sunken, skin hot and dry, pulse small and depressible, 120 a minute, tongue red and dry, vomiting of bile and frequent eructations of gas, breathing short, a painful sensation of tension of the abdomen, bowels constipated, urine scant, lightly tinged with blood, and of a very strong ammoniacal odor. Abdomen greatly distended, especially on the left side, where a tumor could be discerned by the eye; this one could be easily limited by palpation and percussion, appearing semi-solid on pressure, with evident fluctuation.
The shape of the tumor was similar to that of a kidney, with a very smooth surface, extending longitudinally from the pubis to the sixth intercostal space, measuring 15 in. Its lower transverse diameter measured 101 in. from the left crest of the ilium to within 3 in. to the right of the median line; its upper transverse diameter from the ensiform cartilage to its external limit 7} in.
The antecedents and general symptoms, the shape of the tumor, and absence of any malarial disease gave us to suppose that this could not be the spleen; while, on the other hand, the rapid increase of the tumor, its shape, and the existence of blood in the urine led us to suspect a cystic degeneration of the kidney--its nature and cause being not easily ascertained.
Dr. J. D. Mitchell, being sent for, endorsed our diagnosis, and approved of the decision we had arrived at, to relieve the patient by an immediate puncture with a trocar about two inches to the right of the crest of the ilium. The cyst was gradually emptied, discharging eight pints of a chocolate-colored liquid, rather thin, inodorous, and of alkaline reaction, depositing, after standing a few minutes, a bloody sediment. After this the patient seemed to improve, the tumor having receded, leaving the abdomen still dis. tended by intestinal tympanites; a castor oil emulsion with spirits of turpentine was then given, a tablespoonful every three hours until the bowels were evacuated. This took place during the night of the 24th of February, after which the patient went to sleep, having taken 1 of a grain of sulphate of morphine, with free administration of beef-tea and brandy. To remove pain in abdo. men, we ordered the following liniment: B. Spts. turpentine, tr. belladonna, tr. opium, comp. spts. lavander, and tr. camph., of each
To be applied freely over the abdomen every three hours.
The pain which the patient felt in the bowels was not from any apparent local irritation or circumscribed peritoneal inflammation, but a mere malaise. The apparent improvement in the general
symptoms, for a few days after the puncture, did in no way retard the rapid refilling of the emptied cyst. On the 10th day of March, we again found ourselves obliged to endeavor to procure relief for our sufferer by making a second puncture, near the spot where the first was made; but not with the same satisfactory results. After about three quarts of a light-colored fluid, very thin and inodorous, had escaped, it was immediately followed by a thick grumous (or, rather, gelatinous) substance, there being about one pint of it evacuated. The sufferings of the patient were in no manner relieved, excepting the discomfort arising from the enormous distension caused by the cyst. On the 14th of March the cyst bad refilled, and the patient kept on sinking rapidly. On the 18th of March we made the last puncture, which resulted in the discharge of blood and pus-one quart in all.
The patient gradually grew worse, with all the symptoms of circumscribed peritonitis, with general emaciation, and he expired on the morning of the 22d of March, at five o'clock.
Autopsy, twenty-four hours after.---Body greatly emaciated, skin yellow, cadaveric rigidity complete. The opening of the abdominal cavity disclosed a tumor, as already described, situated in the left side, and extending from the ileo-pectineal eminence upwards to the sixth and seventh intercostal space, transversely from the crest of the ileum to three inches to the right of the linea alba, 10 inches in all. In the centre near the hilum 7 inches, and its upper and transverse diameter 8 inches. Our diagnosis proved correct, for we had an enormous kidney before us, with a portion of the ureter, which had acquired its vast size on account of the formation of stone in the pelvis of the kidney, and a smaller one which obstructed the flow of urine into the bladder near its cystic connection with the ureter. The stones therein found we here exhibit, the larger one weighing over one ounce, and the smaller about three drachms.
This tumor had formed complete adhesions with the whole peritoneal surface, anteriorly, laterally, and posteriorly; internally to a portion of the omentum, pancreas, and more so with the colon descendens in its whole length down to its sigmoid flexure, being nearly imbedded in the tissues. The spleen was partly adherent, but of normal size, pushed against the diaphragm; the lower part forming in fact but one continuation to the bladder. The ureter measured about 1 in. in transverse diameter, and was of a cartilaginous formation. The renal artery and veins were greatly