1327HOSPITAL MEDICINE AND SURGERY.

towards an explanation with a facility which brings themat once into prominence as a possible factor in etiology andbespeaks for them more than a passing consideration.In the outbreak at present under consideration it was

possible at once to exclude every other method of communi-cation, and to attach suspicion entirely to the water-supply,which for the time being was foully polluted. Further, thesource of the pollution was so manifestly local that the onlyother question requiring answer had reference to the specialelement in the pollution which could be regarded as causingthe outbreak. This outbreak was limited to three cases,each of them presenting well-marked and unmistakablesymptoms of enteric fever. Two of the patients werebrothers; the third belonged to a neighbouring family.This last, with the elder of the brothers, were miners ; the

younger of the brothers was at school. The elder brother,aged sixteen, sickened on June 29the ; the younger,aged nine, sickened on July 5th ; while the third lad,aged twenty, sickened on the 3rd of that month. Theselads were members of a detached population of miners,consisting of between thirty and forty families, and witha knowledge of their surroundings it was possible rapidlyto conclude that the more usual methods of transmittingthe disease were not in operation as a cause of theoutbreak. To this general statement there is, however,one exception, which I shall afterwards refer to. Butthe milk-supply of the infected families was from sepa-rate sources, both good. There was no system of sewers,provision for the disposal of refuse water being sup-plied by open channels. Further, the water-supply was, ashas been said, impure, and the circumstances from whichthis arose were at once simple and unusual. Until justprior to the time of the outbreak the water-supply of this

population was brought by hand-carriage from some littledistance ; but early in June this was superseded by a gravi-tation supply obtained through connexion with a systemwhich in other directions supplied over 20,000 of a popula-tion. This particular branch of the supply was an end-pipein that direction of the distribution, and the outbreak offever brought to light the fact that the water supplied by itwas foul. No analysis was made, but the smell of the waternewly drawn from the tap revealed the existence of sewage im-pregnation. The water supplied to other districts by the samesystem was unaffected, and a simple explanation made clearthe cause of the local impurity. As in all similar patches ofpopulation, surface pollution of the soil was the rule, and itwas consequently assumed that when the water-pipes werebeing laid this got access to them. The water first sentthrough them carried this impurity along with it, and onthis being discovered, the simple expedient was adopted ofallowing the water to run off till it had lost its smell. Sofar the connexion between the impure water and the casesof enteric fever is clear. There remains to be consideredthe question as to the active element in the impurity ; andby way of exclusion it may be stated that for at least fiveyears and a half before the cases in question, no other illnessoccurred in that particular section of the community pre-senting symptoms which supported for any time a suspicionef enteric fever.In previously stating that the more usual methods of

transmitting the disease could here be excluded, I purposelymade one exception. In every similar inquiry there alwaysfalls to be reckoned with that ubiquitous example of hisclass, the ambulant enteric patient; and here it may bethat he awaited his opportunity, and supplied the factor inthe impurity, which a free adoption of Rodet’s viewswould render unnecessary.Mossend.

CONFERENCE OF MEDICAL OFFICERS AT WOR-CESTER.-Last week, in compliance with a resolutionadopted by the County Council, the conference of districtmedical officers, with the county medical officer of health(Mr. Fosbroke), took place at the Shire Hall, Worcester.Sir Douglas Galton presided. In opening the proceedingshe pointed out (in view of several specified Acts of Par-liament passed during the last session) the necessity ofuniformity of statistical returns and classification of thesubjects included in the reports of the district medicalofficers. Mr. Fosbroke made several suggestions bearingapon the subjects before the meeting. Several proposi-tions were discussed and adopted, and the proceedingsterminated.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

WESTMINSTER HOSPITAL.DIFFUSED FEMORAL ANEURYSM ; LIGATURE OF EXTERNAL

ILIAC ARTERY; RECOVERY.

(Under the care of Mr. MACNAMARA.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionurn historias, tum aliorum tum proprias collectashabere, et inter se comparare.-MoRGAGNi De Sed. et Caus. Morb.,tib. iv. Proaerniurn. -

AKEURYSMAL swellings of the groin have not infrequentlybeen mistaken for abscesses, as this was before admissionto the hospital, and in some instances the diagnosis hasbeen acted upon and an incision made. All the cases onrecord where such treatment has been carried out have died.

Although this aneurysm presented signs of alteration in thecolour of the skin, careful examination elicited the factsdescribed in the report and led to the diagnosis of diffusedaneurysm, a rare condition in this region of the lower limb.The after extrusion of the blood-clot is an occurrence ofconsiderable rarity, and although so much came awaythrough the sinus the process does not appear to have beenattended with suppuration of the sac. We published acase of ligature of the external iliac artery for femoralaneurysm during the autumn of this year,l and in thatpatient recovery followed ; the aneurysm was not, however,diffused, nor was it producing so much pressure on sur-rounding vessels. Cases of successful ligature for femoralaneurysm have been published recently by Latimer,2 Bart-leet,3 Anderson4 Picque,5 Bryant,6 Maclean,7 and Stimson.8A patient suffering from cirsoid aneurysm in the groin, forwhom Trelat 9 first ligatured the external iliac artery, andthen dissected out the tumour, died from tetanus whichappeared on the tenth day. For the notes of this case weare indebted to Mr. J. C. King.

J. B-, aged forty, painter, came to Mr. Spencer’s out-patient department at the Westminster Hospital, complainingof what he had been told was an abscess in the right groin.He had always been in good health, had never had syphilis,nor was there any other circumstance in his previoushistory which threw light on the causation of the disease.He had noticed a swelling about the size of a pigeon’s egg inthe situation of the present one for from six to eightweeks, but gave it no further attention. About a weekbefore the swelling had begun to increase rapidly. Hewas ordered to poultice it by a doctor, and as the sup-posed abscess appeared to be about to burst he appliedat the hospital. The right Scarpa’s triangle was occupiedby a dome-shaped swelling about four inches in diameter,and on the apex of the tumour the skin for about half aninch square was of a dusky colour. The thigh was swollenalong the inner side down to its lower third, but the rest ofthe limb was of normal colour. On palpation, expansilepulsation was easily detected, and then disappeared whenthe external iliac was compressed. The wall of theaneurysm was extremely thin where the skin was dis-coloured, indicating clearly that at this point skin aloneformed the wall. The rest of the wall of the aneurysm wasthicker, and it did not collapse when the artery was com-pressed, suggesting the presence of clot in the sac. Nopulsation could be felt in the superficial femoral artery,but there was a hard swelling along its course, pointingto the diffusion around the vessel of blood from theaneurysm. The leg and foot were colder than on the

opposite side, aud there was slight oedema. The pulse inthe posterior tibial and dorsalis pedis arteries could befelt, but more weakly than on the opposite side. Hewas admitted to the wards of the hospital, and on the

1 Lawson, THE LANCET, vol. ii. 1890, p. 2812 THE LANCET, 1887.

3 Ibid., vol ii. 1887, p. 521. 4 Ibid., vol. ii. 1887, p. 4145 Revue de Chirurgie, 1888, April.

6 Medical Press and Circular, Jan., 1888.7 Journal of Amer. Med. Assoc., June, 1888.

8 Med. Jour., N.Y., Aug., 1889.9 Sajous, 1889, vol. iii., f. 10.

1328 HOSPITAL MEDICINE AND SURGERY.

day following the signs of diffusion had become moremarked. A bulla had formed on the patch of discolouredskin, the leg was colder and more oedematous, but thepulse in the arteries about the ankle could still be felt.Mr. Macnamara exposed the right external iliac in theusual way, and found it perfectly healthy. He ligaturedit through a minimal opening in the sheath by a single silkligature tied lightly. The silk ligature had been kept ina 5 per cent. solution of carbolic acid, and was boiled ina test-tube half filled with the same fluid before beingused. The wound was washed out with perchloride ofmercury (1 in 2000), the deeper layers united by catgutsutures and the skin by silk. No drainage-tube wasused. The antiseptic dressings were removed on the nintliday, when the wound was found to be quite united. Theleg and foot, which were well wrapped in wool, main-tained full warmth, and the pulse about the anklecould be felt on the day following the operation. Thebulla over the surface of the tumour was also dressed mostcarefully. The epidermis separated, and left a chroniculcer in the skin, which continued stationary, neither heal-ing nor extending, for about two months, during which theaneurysmal tumour became reduced in size and firmer. OnJuly 21st the patch of skin finally sloughed, and somedarkly stained fluid discharged daily. The ulcer healedgradually to a sinus, which then closed. The patient got upone week after the sinus had closed-viz., three months afterthe ligature, but this was attended by a swelling of thetumour and redness down the course of the femoral artery.He returned to bed, and from the sinus blood-clot wasslowly pushed out day by day until the tumour in Scarpa’striangle and the swelling along the femoral artery had gone.The greatest care was taken by antiseptic dressings to pre-vent further inflammation, and the blood-clot was not pulledfrom the wound, but only cut off as it was extruded. Bythe end of September the sinus had finally closed.The patient was seen on Dec. 4th; he had been at work

for some time, and said that his right leg was as useful asever, except that on walking fast for a long time he feltslight pains in his knee and calf as of " pins and needles."The scar at the site of the aneurysm had become small, nopulse could be felt in the thigh from Poupart’s ligamentdownwards.Remccrks.-However certain the diagnosis when the

patient came to the hospital, the case shows that, eitherthrough the ignorance of the patient or through a superficialinspection by a medical man, an aneurysm in the groin waspoulticed until on the verge of external rupture. It is pos-sible that an equally superficial palpation might have de-tected fluctuation on the surface of the tumour, and havebeen followed by a hurried incision. The aneurysm probablybegan at the bifurcation of the common femoral, and at firstremained small and sacculated. On diffusion, extensiontook place forwards to the skin, and downwards in theloose connective around the superficial femoral. The pres-sure had so far diminished the nutrition of the skin that ithad undergone septic changes before the ligature. Itwas, therefore, the careful dressing alone which preventedsuppuration from involving the whole sac before the latterhad become shut off from the arteries communicating withit. But a considerable amount of unorganised blood-clotstill remained when he first got up, and the consequentmovement or slightly increased congestion was sufficient toset up inflammation around the blood clot, and to push itout as a foreign body. This happened three months afterthe ligature, and so there was little risk of haemorrhage.The method of ligaturing large arteries has formed thesubject of much experimental work and discussion. As

applied above, the points of importance appear to be thestrictly antiseptic method, and the slight separation of thesheath from the vessel.

SOUTH DEVON AND EAST CORNWALLHOSPITAL, PLYMOUTH.

A SERIES OF RENAL CASES IN WHICH OPERATIVE PRO-CEDURES WERE REQUIRED ; REMARKS.

THE cases of this series which were published in our issueof last week (p. 1268) were: (1) Recovery after nephro-lithotomy for an oxalate of lime calculus which weighedsix grains; (2) relief of pain after ineikion down to andpuncture of a kidney, in the case of a man aged forty ninesuffering from nephralgic oxaluria and pyuria ; (3) recovery

after nepliro-litliotoniy and the removal of an oxalate oflime calculus which weighed 275 grains. The important.features presented by these cases are indicated by Mr. Nash(to whom we are indebted for the report of them) in his.remarks.CASE 4. Renal calculus; nep7tro-litlioto2ny; peri-nephric

abscess involving the liver death. (Under the care ofMr. Whipple. )-E. H-, aged thirty-two, a gasworker,was admitted on July 22nd, 1890. He stated that fiveyears ago, when in Egypt, he was wounded at the battleof Tamai by a spear thrust in the right loin. Thewound remained open for six months, and then healed.He was then discharged from the military hospital. As hecontinued to have pain in the region of the old wound, hewent into another hospital at Plymouth, where an abscesswas opened and drained, healing in three or four months.There still continued some pain in this region, and henoticed a deposit in his urine. This was not bad untilthree months ago. The patient is a fairly well-nourishedman, complaining of slight pain over the right kidney,some difficulty of breathing, and deposit in his urine. Hehas not passed any gravel. The pain in his kidney hasbeen of a throbbing character ; it has not radiated to thetesticle. He passes urine every two hours; this is slightlyacid, and contains pus cells and oxalate of lime crystals.The right kidney could not be felt. There was dulness atthe base of the right lung behind, with impairment of vocahfremitus and loss of breath sounds.July 27th.-Since admission his temperature has been

continually high. He has had no more pain than before.The right kidney is more tender than the left.Aug. lst.-Under methylene an incision was made in

the right loin parallel to and half an inch below the lastrib. The muscles were divided, and the kidney exposed.It was punctured, and pus found. It was then incised, andseveral calculous masses were extracted from the pelvis ofthe kidney. The cavity was syringed out, a drainage-tubeinserted, and the wound partly closed with sutures. Theweight of stones removed was 124 grains. They consistedof three main pieces, which fitted into the calyces, andfour smaller rounded masses.2nd.-Wound dressed; it looks well. Has passed thirty

i ounces of urine since the operation. Later in the day hehad retention of urine. Catheterisation was attemptedunsuccessfully owing to the presence of stricture. A rigoroccurred shortly afterwards. Quinine and brandy weregiven, but he gradually became worse, and died at 10.30 P.M.4th.-At a post-mortem examination the lungs showed old

pleurisy on both sides, and a recent effusion at the right,base. Fibrous nodules in each apex. Liver: About halfof the right lobe and a third of the left was destroyed by a.huge peri-nephric abscess, which, on removing the rightlung, burst into the right pleural cavity. Kidneys: Left-large and congested ; right, pelvis and calyces muchdilated ; cortical tissue much thinned and atrophied. Thekidney was surrounded by a large peri-nephric abscess.Ureters and bladder healthy. Urethra: A bridle-shapedstricture existed five inches from the meatus.CASE 5. Renal caLczsL2cs; nephro-lithotomy,’ wound of

plenra.>’ recovery. (Under the care of Mr. Whipple.)-M. A. J-, a domestic servant aged thirty-six, was sentto the hospital by Mr. Permewan on Aug. 27th, 1890. Shestated that two years ago she had a severe attack of painin the right loin, during which she vomited. She had asecond attack of pain four or five months later, and two orthree others in quick succession. In February, 1890, shehad influenza, and after this had constant pain in the rightloin, radiating at times towards the groin. In April shehad a bad attack of renal colic, accompanied by vomiting,and since then has had several attacks, the last being a.fortnight ago. She has noticed a sediment in her urine,.but nothing like gravel. She does not know that she hasever passed blood. Has been passing urine four or fivetimes by day, but not at all by night. Micturition attimes has been painful. She has suffered much from in-digestion, and has lost a little flesh. The patient is a.

fairly well-nourished woman with grey hair, complainingof occasional attacks of pain, lasting a few hours, in theright loin, radiating down to the groin and pubes, and outerside of thigh. During these attacks she vomits, but has no<frequency of micturition. Abdomen: There is more re-sistance in the right lumbar region than left, probably dueto muscular resistance. There is a little tenderness onmaking deep pressure over the front of the right kidney,