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admitted that they rarely, if ever, pass spontaneously into astate of ulceration, they have none of the large and tortuousveins which surround a cancerous tumour, the adjacent skinis wholly unaffected, the lymphatic glands are not implicated,the tumours are extremely slow in their progress, oftenstationary for years, and sometimes they disappear entirely."

Let us now sketch the symptoms which are presented by Dr.Addison’s patient.

Eliza A-, aged twelve years, born in the country, a littlegirl of very prepossessing features, round and florid counte-nance, dark hair and eyes, and very intelligent, was admitted,Nov. 9, 1852, under the care of Dr. Addison. Her father, whois a shepherd, her mother, five brothers, and three sisters, areall in excellent health, and the patient herself has alwaysbeen well fed, and allowed to play about in the open air.The child now presents on the chest, dorsal region, and

along the left leg, discolorations, scars, ridges, and indurations,very similar to cicatrices after burns. The elbows and someof the fingers are strongly contracted, and the affection seemsto have principally involved the left side of the body. Nopain whatever is complained of, and none is given by pressureon the indurations, nodulations, and ridges which are observedon various parts of the patient’s frame.

It appears that six years before admission a white speckspontaneously formed just on the left side of the scrobiculuscordis; this gradually increased, the skin became of a darkerhue, and the cellular tissue formed adhesions with the osseoustextures beneath. The parts looked very much as if the bonehad been diseased, and the skin and cellular tissue hadcicatrized over, and had become adherent to, the bone. Oneportion just below the left clavicle presents a congeries ofwhite spots, having much the appearance of scars after leech-bites. This, the mother states, was the first part affected; itis now quite smooth, and not adherent to the subjacent tissue;whilst the cutaneous indurations observed a little to the leftof the scrobiculus cordis are now resisting, and giving offtough cords, as usually seen with cicatrices from burns. Theskin is, on the same spot, of a light-brown colour, resemblingthe ordinary tint of ephelis.From this congeries of keloid elevations, indurated lines

and scars run round towards the dorsal region, some towardsthe scapula, and others to the spinal column. The colorationof this offset is the same as that of the seemingly parenttumour; the tissues are hard, and more or less adherent to theparts beneath. In fact, this circle has all the appearance ofthe remains of a burn. Besides the cutaneous changes on thechest and back, the child presents, from the vertex down-wards, the following tegumentary alterations:-The head and neck are quite free from any external disease;

both shoulders are scarred, of a light brown colour, adherentto the parts beneath, and present numerous cicatrix-like spots,the adhesions and ridges running round into the axillm.These cutaneous phenomena have caused the movements ofthe shoulders to become limited, so that the arm cannot beraised higher than at a right angle with the trunk. The im-pediment seems to lie more towards the acromion, which pro-cess appears incorporated with the skin. On the chest nomorbid state of the integument is seen, except what has beendescribed above. A slight deepening of colour is, however,noticed just below the clavicles, with numerous white specks,but the skin is not adherent. On the back of the chest, andin the dorsal and lumbar regions, no alterations are perceived,saving the circular ridges above described, one running towardsthe scapula, the other to the spine.On the abdomen, there is, just below and on the left side of

the umbilicus, a deepening of colour, white scar-like indura.tions, and slight thickening of the abdominal muscles over aspace about three inches square. On the right inguinal regionthere is slight thickening of the skin. The left glutsealregion and thigh look as if they had been subjected to a severe eburn, with this difference, that the long streaks, cords, andridges running from the great trochanter to the knee, and thevariously-shaped cicatrix-like marks, present a light browncolour, whilst cicatrices from burns are in general white andpink. (The pink colour was the ordinary tint in the cases re-corded by Mr. Wilson.)The right glutmal region, trochanter, and thigh are quite

unaffected, whereas the skin over the left trochanter is quitefixed on the bone. The left thigh and leg are rather wasted,and the ham-strings very rigid, but the knee can be flexed.The right knee, ankle, and foot are sound; but on the dorsumof the left foot there is a large pustule, the great toe havinglately been highly inflamed on the same side.

n

The left arm was affected first, the fore-arm on that sideforming now with the arm an angle a little less than ninety

degrees; on the right side the rigid right angle is complete.Neither articulation can be flexed or extended, and theyseem both anchylosed, though it is probable that the bonesare in both arms quite sound. No scar or change of colour isnoticed at either elbow; but the biceps muscles are ratherrigid and hard, cicatrix-like lines running down from theshoulder to near the elbow.Both wrists are quite stiff and rigid, without scars, seams,

or deepening of colour; on the right side the thumb is forciblyflexed, the index, middle, and little fingers are pretty free,but the ring finger is quite flexed, and almost adherent to thepalm of the hand. On the left side the thumb is comparativelyfree, but the four fingers are strongly and rigidly bent atright angles with the metacarpal bones.As stated above, the child has never experienced any pain ;

but it should not be overlooked that this cutaneous affectionbegan soon after an attack of measles. The fleshy tuberclesare very strongly marked on the chest, side, and left lowerextremity.We have been thus minute in the description of the cuta-

neous alterations presented by this child, because doubts havebeen thrown out as to the case being really and truly one ofkelis. Dr. Addison has prescribed iodine, cod-liver oil, andsteel, but no local applications have been attempted; the childhas now passed by clinical rotation under the care of Dr.Barlow, who is inclined to think that common inflammationof skin and cellular tissue may have had much influence onthe phenomena.As to the ultimate results of the treatment, we would just

mention that Mr. Wilson records a case in which the affectiondisappeared spontaneously. The steel, cod-liver oil, and iodineare likely to prove beneficial, as it is supposed that kelis hassome affinity with scrofula; except the disease be looked uponin the light in which Mr. Wilson regards it in his late workon Constitutional Syphilis, where the author says that kerisand lupus are perhaps offsets of syphilis.One striking difference between this case and some of those

recorded by Alibert, Devergie, and Wilson, is the absence ofpain and the deepening of colour in the parts affected; itshould, however, be mentioned that Alibert himself says thatthese tumours are sometimes indolent and merely give rise tostiffness of the skin; and Rayer remarks that the inconve-nience they occasion is in general so trifling, that he hasknown patients refuse to submit to curative means proposedfor their relief.

’

As to the resemblance of kelis with a cicatrix from burns,we shall just quote the description which Mr. Wilson 4vesof one of his cases. The patient was a robust man, agedforty-eight, with whom the cutaneous changes were situatedon the sternum; Mr. Wilson says: "On a first inspection themorbid excresence had the appearance of the cicatrix of aburn, and, upon closer examination, the only character atvariance with that idea was its elevation from the surround-ing skin, particularly at its borders. Its colour was pink,lighter in the centre than in the circumference, and it wasmarked on the surface by a coarse net-work of prominentwhite lines or ridges." ... "To the touch, the kelis gave theidea of a hard, resisting structure, like fibro-cartilage, investedby a soft velvety-seeming skin. The central portion washarder and more dense than the circumference, and the whitelines had all the rigidity of bands of fibrous tissue. Besidesthe kelis on the breast, the patient had a second on the outerside of the left leg, over the head and upper part of the shaftof the fibula."Saving the measles, which were alluded to above, no direct

case could, in Dr. Addison’s patient, be elicited; no blow,scratch, or accident of any kind, having preceded the tegu-mentary manifestations; nor is this circumstance to be won-dered at, as the cause of kelis is generally obscure, though ithas happened that irritating substances, slight abrasions,.wounds, cicatrices, or even a blister, were the origin of thedisease. We shall make a point of watching this little patient,.and acquainting our readers with the further progress of thecase.

ST. THOMAS’S HOSPITAL.

Ectropia Vesicæ; (Absence, of the Anterior Walls of the Bladderand Pubic Abdominal Parietes); Operation for Directing theOrifices of the Ureters into the Rectum; Temporary Success;Subsequent Death; Autopsy.

(Under the care of Mr. SIMON.)SUCH of the readers of THE LANCET who take interest in

the hebdomadal account given in the " Mirror" of the prac-tically useful facts which may be observed in the hospitals of

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London, will perhaps remember that about twelve months s

ago we brought under their notice a valuable case of ectropia tvesicse, treated by Mr. Lloyd at St. Bartholomew’s Hospital, a

(THE LANCET, vol. ii. 1851, p. 370.) It was then attempted to t

remedy the inconvenience resulting from the malformation 1by passing a skein of silk through the rectum and the pro- ttruded posterior walls of the bladder, in the hope that a per- 1

manent communication between the two organs might be t

established, and the urine take its course into the bowel in- istead of constantly trickling over the pubes. The operation I

did not prove successful, as the patient died seven days after ’the passing of the skein. IIn some introductory remarks which we then prefixed to

the account of the case, we mentioned that there were at thatperiod two cases of ectropia vesim in the hospitals of London; -,one, under the care of Mr. Thomas Wakley, at the RoyalFree Hospital; the other under the charge of Mr. Simon, at St.Thomas’s Hospital. The first of these patients has returnedinto the country, with an ingenious apparatus which removesto a great degree the distressing consequences of theimperfection of the bladder, abdominal walls, and penis, (videTHE LANCET, vol. ii. 1851, p. 3’two.) The second remainedabout ten months in the hospital, giving at one time the besthopes as to the success of the operation which we shall presently describe; but after the recovery had for some time beenreckoned upon, the boy sunk from exhaustion at a time whenthe untoward symptoms seemed to be one by one disappearing.We said in the above-cited number of THE LANCET, that

the case had undergone an operation, for which instrumentsof a very ingenious construction were contrived, by means ofwhich the urine would ultimately take its course per rectum."Mr. Simon did indeed succeed in implanting the orifices of theureters upon the coats of the rectum, and the communication iwas soon so far established that the urine was voided per anum.

I

The treatment was of necessity protracted, and the boy at lastsunk into a state of great exhaustion and debility. The caseis highly important, for it will show how well-directed surgicalefforts may effectually change and modify the natural relationand functions of parts. We therefore beg this day to offer afew details concerning the history of the patient, the operationwhich he underwent, the temporary success, and the eventualdeath of the boy.John H--, aged thirteen years, was admitted into Abra-

ham’s ward, under the care of Mr. Simon, February 18, 1851.The patient presented a deficiency of the anterior walls of thebladder and the pubic portion of the abdominal walls, and epis-palrias. The posterior walls of the bladder were, as is usualin this malformation, pushed forwards by the small intestines,and formed just above the pubes a globuiar tumour, coveredwith mucous membrane. The orifices of the ureters werevisible, and from them constantly trickled the urine, whichhad a tendency to irritate the parts situated beneath.Rest in bed, and attention to cleanliness, greatly diminished

-the inconvenience resulting from this state of things; but Mr.Simon, being anxious to relieve the patient entirely from the Imisery to which he was subjected, resolved to employ suchmeans as would permanently direct the urine into the rectum,do away with the continuous trickling of that fluid upon thepatient’s thighs, and make the protruded bladder finallyassume, like the mucous membrane of the prolapsed uterus,all the characteristics of the skin.

]B’[1’. Simon bestowed a considerable amount of attention,reflection, and constant consideration to the discovery of themeans by which he might accomplish this end. Before settlingupon the plan which was eventually carried out, Mr. Simonhad given a thought to an autoplastic operation, so as to bringthe skin from either side over the protruded viscus, treatingthe separation of the pubic bones pretty well as the analogouscongenital defect in the lip and hard palate. But it was evi-dent that measures of this kind would but very imperfectlyremedy the evil, for the flow of urine, even were such anoperation followed by complete cicatrization, would then beattended, not only with inconvenience, but actual danger.

, It was clear that the pubic bones were separated to the ex-tent of an inch and a half or two inches, and Mr. Simonconsidered that they were held together by a strong fibrouscontinuation or exaggeration of the triangular ligament.Setting, therefore, the above-mentioned plastic operationaside, Mr. Simon’s ideas were now directed to the best meansto be used for directing the flow of urine into the rectum,the attempt being based upon the following facts :-Many of the animal creation excrete the urine in this

manner, and it is found that patients whose bladder, after theoperation of lithotomy, opens into the rectum,acquire a certaincontrol over the fluid contents of that bowel, by means of both

;phincters ani. Resting upon this analogy, it was reasonable;0 think that the congenital defect of the patient might be in1 great measure remedied by such direction being given to theurine. To accomplish this by operation, it was important tobear in mind the relations existing between the ureters andthe rectum. These anatomical relations are well known, theureter on each side coursing downwards and in a slantingmanner upon the rectum. The next point of importance was,to ascertain the actual reflections of the peritonaeum in theabnormal arrangement of parts manifested by this patient.This information was the more necessary, as Mr. Simon hadfirst thought that it might be advisable to dissect off the visibleextremities of the ureters, and, were no peritonaeum in theway, to fix them into the rectum. Experiments were madeupon dogs, to ascertain the feasibility and safety of this pro-cedure. It was found that great difficulties would have to beovercome; the result was almost always fatal, and it was plainthat the peritonaeum would be exposed to much hazard.Mr. Simon had endeavoured, by examining preparations in

the museums, to discover how low down the peritonaeumreached in cases of absence of the anterior walls of the bladder;but this could not be satisfactorily made out. The planwhich was ultimately adhered to, was to bring the canal of theureter in close and intimate contact with the walls of therectum, below the point of reflection of the peritonaeum ; thetwo canals were to be transfixed by two points of suture, be-tween which the loop of a thread was to extend, the two endsof the latter coming out through the anal orifice.

It was clear that great difficulties must attend merely thepassing of one thread through the visible aperture of theureter, then through its walls as well as those of the rectum,one end hanging out in front of the bladder, and the other atthe anus. But this, though not easy, would have been of noavail, the intention being, to effect two perforations, givingeach entrance to one end of a thread, and the interval betweenthem to be fixed and drawn down by the loop.

For this purpose Mr. Simon had a silver catheter con-structed, the bore of which was separated by a septum; in thetwo canals thus formed two stilets were placed, the terminalthird of which was made of watch-spring ending in a sharppoint, close to which was an eye for the thread. Thus wasthe catheter provided with two stilets, each armed with athread, and ready, on the pressure at their handle, to emergefrom an eye placed opposite its point in the catheter, and’per-forate the walls of the ureter and rectum, these lying in con-tact. The operator would then be able to seize within thebowel, with the forceps, the end of either thread, draw themboth down, and make, by bead or otherwise, the loop thusobtained either more or less tight.On Saturday, July 5, 1851, the patient was brought into the

theatre, and placed under the influence of chloroform, whenMr. Simon introduced the catheter just mentioned into theorifice of the ureter; and having carried it on for the properand previously-ascertained distance, while the instrument waskindly held by Mr. Green, he endeavoured, by gently press-ing and working the handles of the spring stilets, to effectthe above-described perforation. But the difficulty of accom-plishing this had been foreseen, and Mr. Simon had had anothercatheter constructed without a septum, and with one stiletonly, in case the double one did not act satisfactorily.The cause of the inefficiency of the first instrument lay in

the fact, that being limited as to the size of the catheter bythe calibre of the ureter, the spring stilets must of course bemade thin, and thus they proved too weak to overcome theresistance of the coats of the ureters, when the points emergedfrom the aperture of the catheter. The peculiarity of thesestilets was, that when they passed through the eyes, beingmade of spring material, they at once formed a decided curvedownwards, just in the direction of the rectum.Mr. Simon, though aware of the obstacles to be overcome by

using but one thread only, now passed the catheter with asingle stilet up the ureter, and succeeded in perforating itscoats and those of the rectum, and by means of the forcepspassed up the rectum, he brought down one thread. The in-strument was now removed, and so managed that one end ofthe thread remained hanging out of the orifice of the ureter,and the other from the anus. A fresh thread was now adaptedto the instrument, and a second thread passed about half aninch lower down in the ureter than the first; there were thentwo ends emerging from the anus, and two from the entranceof the ureter. Now to obtain a loop bearing upon the coats ofthe ureter and rectum, and dependent on a single thread, andwithout a knot, A’tr. Simon tied the two anal ends together,and pulling upon the second thread, effected his purpose.

’ The very same succession of measures were taken on the

570

other side, and with the same success, the whole operationhaving of course been protracted, but the boy suffering nopain by the beneficent assistance of chloroform.Mr. Simon ordered thirty drops of laudanum, both as a seda-

tive and a constipating agent. The bowels remained boundfor six days, a very slight amount of peritonitis and fits of

vomiting occurred, for which the patient was ordered smalldoses of calomel, and leeches to the lumbar regions; he tookalso iced soda water, as well as hydrocyanic acid and opium.On the tenth day, some urine already passed by the anus,

the quantity went on increasing, it being only voided by anexpulsive effort of the patient. Castor-oil was given on theSeventh day, and procured a copious evacuation.Three weeks after the operation, only a slight trickling

through the apertures of the ureters was taking place, most ofthe urine passing into the rectum, and being expelled withthe faeculent matter. The threads were not at that timedetached, though it might be supposed that they were ulce-rating through, and that an aperture already existed.Mr. Simon considered that a fibrinous exudation would

gradually take place round the opening in the walls of theureters and rectum, throwing out a regular circle in thevicinity of the artificial fistulous tract, and preventing theeffusion of urine.The patient continued to improve, experiencing slight occa-

sional pain; he was regaining his appetite, and said he felt aswell as before the operation. The ligatures, however, notseeming to make any progress, the boy was, on the fourteenthday after the operation, placed under the influence of chloro-form, and carefully examined by Mr. Simon. It was nowfound that the threads had still a considerable thickness toulcerate through, and on slightly tightening them a smallquantity of pus escaped. Pain and feverishness were, on thenext day, relieved by leeches to the abdomen.

Twenty-six days after the operation, the ligatures wereagain tightened, after the patient had been narcotized withchloroform; the communication between the ureters andrectum was found quite free, and admitted a middle-sizedcatheter. The urine at this time escaped principally through Ithe rectum, and the patient could retain about a cup-full fornearly two hours.On the thirtieth day, one of the ligatures being found loose,

was removed by the patient himself, the escape of some pusbeing thus occasioned. It was now found advisable to placesmall compresses over the orifices of the ureters, so as to pre-vent the urine from passing anteriorly.On the forty-first day, the second ligature came away, and

with it a considerable quantity of pus.On the fiftieth day, there was much feverishness, the abdo-

minal pain had increased, and pus was continuing to escapeper anum. The pulse was at the same time feeble, and thetongue white and dry. Mr. Simon ordered six leeches to beapplied to the painful part, a gentle purge, and four ounces ofwine daily.Two months after the operation, the urine was still passing

per rectum, the patient’s health was improving, and thoughpale and emaciated, he had a good appetite. Sometimes hecould say when the urine was on the point of escaping, and atother times he could not foretell; the warning consisted in alittle pain running over the extruded bladder. The latterlooked smaller and not so red as before. There was no pain,no pus was escaping per anum, and the boy slept well.Three weeks after this it was noticed that the urine was

partly escaping anteriorly, and the compresses against theorifices of the ureters which had been omitted, were re-applied.

Three months after the operation these untoward symptomshad given way, the boy was improving, and Mr. Simon pur-posed, when the patient’s general health had been sufficientlyrestored, to close permanently the orifices of the ureters by asystem of ligatures. He ordered, at the same time, cod-liveroil to be administered. Soon after this period an attemptwas made to close the mouths of the ureters by needles andthe twisted suture, as practised for hare-lip. But union didnot occur, and the threads ulcerated through after two suchoperations.On January 29, 1852, seven months after the operation,

Mr. Simon examined the ureters, and found that the openingsinto the rectum were still patent, although very much con-tracted ; he also discovered the incipient formation of acalculus in each ureter, a portion of which came away at theend of the catheter. The openings of the ureters in front hadcontracted somewhat, but had not formed a complete cicatrixso as to block up the orifices.From this time the patient’s health gave way, and though

he did not suffer much, stimulants, good diet, and constantcare and attention, failed in combating exhaustion, and hedied of debility and low peritonitis about twelve months afterthe operation.The openings into the rectum corresponding to the perfora-

tions of the ureters were, on inspection, found clear and patent,these artificial orifices being situated at about two inches abovethe anus. In the ureters, calculi of about the size of peas andbeans were found, and they lay in the vicinity of the foraminamade by operation. Signs of peritonaeal inflammation beingnoticed in this locality, it is supposed that slight infiltrationof urine may have occurred.The facts of the above case will no doubt make a deep im-

pression upon the readers of this journal, and a train of thoughtwill naturally arise in reviewing the nature of the malforma-tion, the misery thereby entailed upon the patient, the per-severing investigations of the surgeon, the attempt to remedya distressing inconvenience, the complicated and well-devisedmeans for changing the course of the urine, the obstacles tobe overcome, the successful operation, the good results at firstobtained, and the unfavourable termination of the case. Allthese circumstances might give rise to remarks and reflexionsinto which our space does not permit us to enter. Every onewill judge for himself; we would merely beg permission to ob-serve that this novel operation, as well as that performed byMr. Lloyd, at St. Bartholomew’s Hospital, in a case of thesame kind, testify to the ardent wish of the surgeon to benefithis patient, but that the risks are perhaps disproportionatewith the annoyance of a malformation which improved appa-ratuses may render bearable.

Foreign Department.

Chancre of the -3featits-Death, probably caused by Catheterism.M. VIDAL (de Cassis) lately brought the following very in-

structive fact before the Surgical Society of Paris. A man,twenty-six years of age, strong and healthy, was admitted atthe Hospital for Venereal Diseases, for retention of urine, themeatus urinarius being blocked up by an indurated chancre.The house-surgeon passed a gum-elastic catheter without sti.lette, and evacuated some urine. M. Vidal saw the patientthe next day, and also passed a catheter, after having enlargedthe meatus by two incisions. The wound thus made assumeda chancrous ulceration, but no catheters were left in thebladder. Four days after his admission, the patient wasseized with peritonitis, and rapidly died. On a post-mortemexamination, an ulcerated spot about one-third of an inch indiameter was discovered on the right side of the body of thebladder, and at the bottom of the ulcerated surface werethree perforations, which allowed the urine to pass into thecellular tissue of the pelvis. There were scattered about thefundus of the bladder several tuberosities formed by calcareousdeposits, similar to those seen in the coats of arteries. M.Vidal stated that this perforation of the bladder might beexplained in various ways. It may be supposed, first, that itwas caused by the extremity of the catheter, though it shouldbe noticed that the instrument was not left in the bladder,and was used without stilette. Second. That the first catheterthat was passed carried from the meatus some virulent pus, andinoculated the mucous membrane of the bladder, giving riseto a perforating chancre. Or, third, it might be surmised thatthe bladder could not dilate over the spot where the ulcera-tion was found, owing to a calcareous concretion, and that thecoats of the viscus were ruptured in the same way as happenswith the coats of arteries which present calcareous deposits.We leave this important case to the consideration of ourreaders; it is well worth a few moments’ attention.

Hydatid Cyst of the Ovary>" Tapping of the Tumour). Injectionof Tincture of Iodine; Recovery.

M. 130INET has lately attracted much attention in Paris bythe success he has met with in treating congestive and chronicabscess by injections of equal parts of tincture of iodine andwater, after the evacuation of the pus. This practice has beenextended to ovarian cysts, and success is said to havebeen obtained in several cases. L’Union Medicale, in thenumber of Sept. Il,1852, has just published another successfulcase in the hands of M. Boinet, at the St. Lazare Hospital.The facts are these :-A woman, fifty-one years of age, was admitted March 17,

1852, into the St. Lazare Hospital, under the care of M. Boys