NORTH-EASTERN HOSPITAL FOR CHILDREN
line on a level with -the fourth rib. It was quite fixed, was adherent to the chest-wall, and had ulcerated through the skin ; at this time it appeared to be quite unconnected with the breast itself. The age and general condition of the patient rendered operation inadvisable, so that the course of the growth has been watched. It extended during the following months along the lower border of the pectoralis major into the breast which became extensively involved. Retraction of the nipple took
... the nipple took place and oedema of the skin, showing blocking of the lymphatics, and now the case has the appearance of a typical slow-growing scirrhus with the addition of the process extending into the axilla and the ulcer where the growth commenced. There is no glandular enlargement to be felt as yet. In this case the tumour apparently extends by continuity into the breast and does not start in an outlying and free nodule of glandular tissne. Highbury, N. (Under the care of Dr. ARTHUR DAVIES and Mr. STEPHEN PAGET.) Nulla antem est aiia pro certo noscendf via, nisi quamplnrimas et morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.-MORGAGNI De Sed. et Caus. Morb., lib. iv. Prooemium. I As Dr. Davies points out in his remarks the pain felt in the loin radiating round the abdomen in cases of renal calculus is often attributed to attempts made by the stone to pass into the ureter; but it is explicable rather as due to irritation of some of the nerves with which the kidney is so fully supplied. The pain of ureteral colic is different in character and different in its position for it passes definitely downwards towards the testis and thigh. The case illustrates the ease with which a stone can sometimes be found in a kidney by needling ; yet numerous cases have been recorded in which stones quite as large as that found by Mr. Paget have entirely escaped discovery even after the very thorough use of an exploring needle. A man, aged twenty-three years, was admitted into the Metropolitan Hospital on March 30th, 1896, complaining of great pain of a lancinating character in the left side. The first attack occurred two years previously and lasted for two hours; a year afterwards he experienced a similar attack which was of short duration only; and a month before admission to the hospital he had another attack which lasted for some hours. He described the attacks as coming on quite suddenly. The pain was intense, radiating round the loin to the middle line of the abdomen and not descending down the thigh or to the testis. The pain ceased as suddenly as it came on. The patient had not noticed any alteration in the colour of his urine during or after an attack. As regards the previous history of the case he had an attack of left pleurisy in 1887. He said that taking beer always increased the ter dency to pain in the left side. His father passed a stone two years previously. When the patient was admitted he was doubled up with pain which caused vomiting. There was less expansion on the left side of the chest than on the right and the note was impaired. No pain was felt over the left kidney on deep palpation. The urine was of specific gravity 1018 and contained a cloud of albumin. When the urine was examined under the microscope blood corpuscles, granular casts with oxalate of lime crystals, and pus cells were seen to be present in great number. As the symptoms continued Dr. Davies requested his surgical colleague, Mr. Stephen Paget, to explore the left kidney with a view to ascertain whether there was a calculus. This he did on April 16th. The kidney was exposed by a suitable incision and was found to be uniform in shape with no bulging. A harelip needle was passed into it and on the first occasion grated against some hard substance. An incision was made into the kidney following the course of the needle with a tenotome and on a finger being introduced it came immediately upon a calculus which was found lying in the pelvis of the kidney and was removed by a scoop. The calculus was composed of oxalate of lime and uric acid and weighed forty-nine grains. It was an irregular triangle in shape and was about an inch in its longest diameter. The patient made a perfect recovery. Remarks by Dr. DAVIES,-It is noted in the above case that no pain was present on deep palpation. This is a point strongly emphasised by Sir Henry Thompson, who also insisted upon the fact that the majority of the cases of nephralgia are not calculous in origin. There was no pain radiating down to the inner side of the thigh or to the testicle. There seems to be no doubt but that the attacks of pain were due to the calculus irritating the renal pelvis and not to the passage of the stone into the ureter, though these attacks were formerly considered as a proof of such an occurrence. Similar attacks of pain are seen in cases of hepatic colic where the gallstones never leave the gallbladder. IN the following case the much greater degree to which the left side of the chest was affected pointed to pressureon the left bronchus as the cause of the spasmodic cough, even though the spasms so closely resembled whoopingcough. The case is one of great interest. A female child, aged six years, was admitted into the North-Eastern Hospital for Children under the care of Dr. J. P. Parkinson on Jan. 6th, 1898. The child had been healthy till she had an attack of whooping-cough when she was two years old, but had since suffered from a chronic cough. Fourteen days before admission shortness of breath came on, together with pains between the shoulders ;. a week later there occurred spasmodic attacks of coughing: followed by vomiting, with occasionally slight traces of blood in the sputum. On admission the child was paleand thin and had clubbed fingers and toes ; she was short of breath, breathing 40 to the minute. There were infrequent attacks of coughing resembling whooping-cough, with a, definite whoop and causing much blueness and distress.. The left side of the chest was smaller than the right and its movement was limited, the percussion note was dull both in front and at the back, and the breathing generally was obscured by numerous moist sounds, except about the lower angle of the scapula, where the breathing was cavernous in character. On the right side there was much impairment to percussion over the posterior base and there was also slight. impairment at the apex and in the axilla. The breathing was harsh and numerous moist râles were heard all over.-The pulse was 120 to the minute and compressible. The heart's apex beat was visible in the fifth space in the nipple line ; the heart sounds were normal. The abdominal organs= appeared to be normal and there was no albumin in the urine.. The mucoid sputum was examined for tubercle bacilli but nobacilli were found. The temperature varied-between 99° and 1030 F. and the child got more dyspnceic and died on Jan. 12th.