Inquirens. To the last question: Yes! The "Mirror" reflects the practice of all the leading general hospitals of the metropolis; and our correspondent may convince himself of the extent of the labour by glancing at any index of the six last volumes of THE LANCET. In the most recent volume (vol. i. 1852) he will find, under the head "Mirror of the Practice of Medicine and Surgery in the Hospitals of London," fourteen different hospitals, from which the most interesting and practically useful cases have been regularly reported, the details being clear and concise, and preceded by such introductory remarks as may direct the mind of the reader to the subject investigated.

J. B. F. M., and a Subscriber.-The diploma of either of the three Royal Colleges of Surgeons of England, Ireland, or Scotland, entitles the holder to practise in the United Kingdom.

Ir does not appear that the article in the penny publication that has been forwarded to us is entitled to a moment's consideration.

THE COLLEGE OF PHYSICIANS-THE SOIREES.

To the Editor of THE LANCET.

SIR, You state that your inquiries respecting the exclusion of "general practitioners" from the soirées given at this College have not been quite so satisfactory as you could wish. I should think not. My name has been put down twice by one of the fellows, but no card of invitation reached me. A friend tells me that the same thing has happened to him; others, I find, are making a similar complaint. This subject, in my opinion, demands a searching investigation. I feel that I have been either insulted by the College or grossly deceived and betrayed by my "friend," the fellow. If the "heads" of the College refuse to meet us in Pall-mall East, let them never again be invited to meet in the chamber of the sick, Paddington, June, 1852. A GENERAL PRACTITIONER.

** While publishing this note, we think it right to state that we have been informed, on unquestionable authority, that there were at least three GENERAL PRACTITIONERS at the last soirée. It appears, however, that there is something defective in the arrangements of the "committee of management."-ED. L.

A Country Surgeon.—In three letters under this signature Mr. Coulson is requested to favour the profession with the history of the hospital treatment in the case of Richard S-, on whom he performed the operation of the perinæal section. It appears he was admitted into St. Mary's Hospital, under the care of Mr. Coulson, on the 16th of April, and the perinæal section was performed on the 21st, when "Mr. Syme's smallest staff was passed into the bladder, and the stricture divided on it through the perinæum." Our correspondents wish to be favoured with "a statement of the treatment of the patient during the five days he was in the hospital before the operation was performed, what were the circumstances which appeared to render the operation necessary, and what were the post-mortem appearances which could have made such an operation justifiable." We feel confident that Mr. Coulson will be glad to have an opportunity of furnishing the required explanations.

Nauticus.-All the candidates for Lambeth are prepared, if elected, to assert the rights of the naval assistant-surgeons. Both of the present members are earnest and stanch friends of their cause.

THE subject mentioned by A Traveller will receive due attention.

MARISCHAL COLLEGE, ABERDEEN.

To the Editor of THE LANCET.

SIR,-Will you excuse me addressing a few lines to you for information on a subject, the truth of which I cannot arrive at ?

Some time since I received by post the enclosed, and thought I should like to graduate for the M.B., as I came under the regulations for so doing. Since I have been preparing for this object, however, I have seen it stated by advertisement that Marischal University has not the legal power and privilege of granting medical degrees; at least, this is the inference I draw from perusing the declaration set forth in the advertisements issued by King's College, Aberdeen.

In this dilemma, Sir, I know not to what higher or better authority than yourself I can appeal for a candid, impartial, and satisfactory statement of the matter, if you are cognizant of facts. Should such be the case, you would greatly oblige me by putting me in possession of the real truth, by a a simple reference to the subject in your Answers to Correspondents. I am, Sir, yours respectfully, Waverley-street, Hull, June, 1852. E. H. MILLIN, L.S.A. The constituted authorities of "MARISCHALCOLLEGE AND UNIVERSITY" will, in all probability, feel the propriety of noticing, in an official communication, the subject mentioned in this note.-ED. L. THE appeal to the profession by Mr. Daniel, in favour of the British Medical Fund, is an advertisement. Its great length would render it extremely inconvenient to publish it in the body of the journal. We highly appreciate the pure and admirable motives of Mr. Daniell, but we feel perfectly confident that the appeal, if published, although fervidly and eloquently written, would not succeed in resuscitating the moribund institution whose sad condition has brought it forth. Meetings of the Medical Societies.-In the last number of THE LANCET We stated that the medical societies of the metropolis had commenced their vacation. But we are reminded by a correspondent that the Epidemiological Society continues its monthly meetings until August. At the meeting of the Society on Monday next, July 5th, at the house of the Royal Medical and Chirurgical Society, the history of vaccination in India will come under discussion, and a paper will be read by Mr. Hunt on the prevailing Furunculoid Epidemic.

Dr. Taylor's note has been received, and shall be answered shortly. Mr. R. T. H. B., (Bristol.)-The by-laws will not probably be so stringent as to prevent our correspondent doing as he wishes at a future period. A memorial presented to the authorities at the time would, no doubt, be successful.

Studens.-The question, "What is the necessary allowance of air in cub feet to sustain life in a man?" does not admit of an answer; but ▾ supply the following elements towards its solution. Pure atmospher air contains, on an average, 1 part in 2000 of carbonic acid; expir air contains 4 parts in 100 of carbonic acid; when the same air is expire again and again for a length of time, it contains 10 parts in 100 of Co Air containing 10 parts in 100 of CO2 causes asphyxia, and cannot su port life. A healthy man, 5 feet 10 high, weighing 12 stone, when sitting breathed 16 times in 1 minute, expired 24 cubic inches at each expir tion, at the rate of 313 cubic feet in 24 hours; when walking, breathed times in 1 minute, expired 60 cubic inches at each expiration, at the rate 1173 cubic feet in 24 hours; when running as fast as possible, he expire 16 times as much as when he sat still. The inspired air ought to be parethat is to say, ought not to contain more than 1 per 2000 of CO2. Now expired air contains 4 per 100 of CO2, and if not removed would speedil vitiate the surrounding air. It is therefore necessary for healthy respira tion, whatever be the number of cubic feet allotted to each person in room, that there be free ventila'ion; that the air tainted by the breath b continually removed, and its place supplied by pure air. The air of room containing 50 candles and 500 people held 1 part in 100 of CO2, 0 20 times as much as pure air; and that of one of the sleeping apartment of the Salpêtrière contained 8 parts in 1000 of CO2, or 16 times as much a it ought to have done. It is usually considered that 1000 cubic feet is a fair allotment in hospitals to each patient; some have more, some less In workhouses the quantity allotted is often exceedingly small-below 100 cubic feet to each in some instances. We repeat that whatever the quantity of cubic space allotted to each person, ventilation must be per fect, or the air will be vitiated by an excess of carbonic acid, of suspended animal matter, and of moisture in the air. The whole subject requires a close experimental investigation, and we trust that it will soon receive the practical attention that its importance so urgently demands.

THE SOCIETY OF APOTHECARIES And Their New REGULATIONS. To the Editor of THE LANCET.

SIR,-I am somewhat surprised to find that you are of opinion that the Society of Apothecaries ought to relax the stringency of their examination to those who have passed the middle period of life, and who have been regularly educated to the profession. A letter in your edition of the 26th June, signed "A Graduate," echoes the same desire. Now, I ask you, Mr. Editor, is it right or reasonable to the whole body of licentiates that any amnesty on the part of the examiners at Blackfriars should be granted towards those parties who are now in general practice, and who do not possess their certificate, inasmuch as those persons who hold "high medical certificates from other examining boards in the United Kingdom of high character" knew full well that they could not practise legally as general practitioners in England or Wales without the Society's licence? Therefore why not have, when the mind was stored with the necessary information, and fresh from the medical schools, undergone the examination, and not now come forward and say-" Oh! we must address the Court of Examiners at Black. friars, and get them to grant their licence to us middle-aged gentlemen; we have no objection to pay the fee, but we in toto object to the ordeal. We will convince them of our professional' as well as moral 'respec. tability.' On these two grounds we, the middle-aged, are of opinion that we ought to be enrolled as licentiates."

Should the Court of Examiners at Blackfriars grant the request of these middle-aged gentlemen, I fear none other than such will be presenting themselves for the Society's licence.

A LICENTIATE.

I have the honour to remain, Sir, your obedient servant, June, 1852. M.R.C.S. and an Assistant.—The subject will be treated of fully in an early number of THE LANCET.

One of the Ignorant Glasgow Folks.-Dr. Percival's work on Medical Ethics, and the more recent one of Dr. Hooker, of the United States. Chirurgicus.—Mr. Wade, in a letter published at page 19, has fully referred to the subject. We believe that caustics applied to the urethra have, in many instances, produced the worst and most inveterate forms of stricture that have fallen under the notice of hospital or of any other surgeons. We entirely agree with the writer (Chirurgicus) in his condemnation of the operation in question.

ERUPTIVE DISEASES.

To the Editor of THE LANCET. SIR,-Has anyone of your readers lately noticed, amongst children, pustules over the body, especially on the hands and feet, resembling the vesicle of small-pox, and as they die away others are reproduced. The health does not seem to suffer, but still the irritation from the sores is troublesome. Can any of your correspondents suggest an appropriate treatment? Hyd. c. cretâ has been tried, also hyd. chlorid. et pulv. antimon.; also absorbents, and lotio ox. zinci. Nothing has been of any use. Yours truly, CHIRURGUS. COMMUNICATIONS, LETTERS, &c., have been received from-Mr. J. Stokes, (Wednesbury ;) Mr. J. M. Blizard, (Belfast, with enclosure;) Mr. Low, (Solihull;) A Country Surgeon; Chirurgus; Viator; Mr. Baker, (Mirfield ;) Mr. T. S. Guppy, (Falmouth ;) Mr. Daniell, (Newport Pagnell ;) Mr. Brooke; Dr. E. Moore; Mr. T. Atkinson, (Brading;) A Sufferer; Mr. J. Peter, (Callington;) Dr. Ward, (Huntingdon, with enclosure;) Mr. T. Bentley; Messrs. A. and D. Dalrymple, (Norwich, with enclosure ;) Mr. A. Arden, (Hull ;) Mr. J. A. Marston; Mr. W. T. Greaves, (Penrith;) Dr. Taylor, (Bradford;) Mr. A. Cook; Mr. C. Mingaye, (Dedham, with enclosure;) Dr. J. Bailey, (with enclosure;) Nauticus; Twenty Years a Surgeon's Assistant; W. W.; Mr. R. T. H. B., (Bristol;) M.R.C.S. and an Assistant; One of the Ignorant Glasgow Folks; Nemo; Inquirens; Dr. Taylor; Studens; Mr. E. H. Millin; A General Practitioner; Viator; A Licentiate; J. B. F. M., and a Subscriber; Mr. E. Summers, (Roth. bury, with enclosure;) Mr. G. Garson, (Stromness, with enclosure;) A Traveller; &c. &c.

Lectures

ON

LITHOTOMY AND LITHOTRITY.

Delivered at St. Mary's Hospital.

BY WILLIAM COULSON, Esq.,

SURGEON TO THE HOSPITAL.

LECTURE III.-(Concluded from page 4.) LITHOTRITY in its true sense is made up of two principal parts-seizing the stone in the bladder, and destroying the stone. This latter part may be effected by perforation, by percussion, or by crushing; and the predominance of any of these three modes of attacking the stone constitutes a peculiar method, although in particular instances they may be combined together with advantage.

I have already noticed the attempts made by the older surgeons to crush stone in the bladder. According to M. Bellinaye, an English surgeon named Stoddart had a sliding instrument constructed in 1800, for the purpose of crushing calculi. In 1813, Gruithuisen produced his forceps, but the blades, as I have before remarked, acted laterally, and all the urethral forceps previous to the year 1823 were constructed on the same defective principle. M. Civiale used a brise-pierre in 1821. It was worked with a rack and pinion, but the branches were moveable, and acted laterally. In 1822, M. Amussat published an account of his crushing forceps, to which I have already alluded. The first crushing instrument of any value-that is to say, one in which the blades are placed one over the other, and have a gliding movement forwards-was, as far as I can ascertain, manufactured by Mr. Weiss in the year 1824. It is essentially the same as the improved percussor of Heurteloup, with this difference only, that it acts by crushing with a screw instead of percussion.

perforated and reduced into fragments; he then crushed these with the blades of his three-branched forceps against the extremity of the canula. This was a very imperfect method.

Dr. Haygarth comes next. In 1825 he invented a sliding instrument, for the purpose of extracting small calculi from the bladder, and, at the suggestion of Mr. Hodgson, a screw was attached to this instrument, that it might be employed for crushing. Mr. Hodgson tried this instrument upon a patient in the Birmingham Hospital in 1825. In the same year also a French instrument-maker, named Retoré, invented a sliding instrument, a description of which M. Leroy gave in 1827. The branches are similar to those of Weiss and Haygarth, but it would seem that the female branch was drawn backwards on the male.

F10, 26.-M. Civiale's improved instruments, (1824.)
FIG. 27. Mr. Weiss's original instrument, (1824.)

I should perhaps have observed to you that M. Civiale always used more or less crushing when the calculus was No. 1506..

FIG. 28.-Dr. Haygarth's instrument for crushing stone, (1825.)
FIG. 29. Retoré's instrument for measuring the diameter of
calculi, (1825.)

The instrumental portion of the crushing system unquestionably originated in England, for we do not find crushing as a system alluded to in any of the French publications previous to 1829. To render this system available, the blades of the forceps must be placed in the same plane, one behind the other; the motion must be sliding from behind forwards, and the male piece should glide along a hollowed catheter. These three conditions were first obtained in the English instruments, and the system of crushing thus rendered capable of being executed.

In 1831 Professor Jacobson, of Copenhagen, presented his articulated crushing instrument to the Institut; several successful operations were performed with it, but it is now abandoned. The principle was altogether different to that of the sliding instruments at present in use.

Indeed, true crushing does not seem to take date as a complete system until after the production of Baron Heurteloup's percussor in 1832. On employing that instrument, surgeons soon perceived that it might be applied to crush the stone. Some, as M. Tonsay in France, modified it, so as to render it available for percussion or crushing; while others, especially our English surgeons, returning to the principle of Mr. Weiss, abandoned the percussor, and substituted in its place, crushing, either by pressure with the hand alone, or with a screw, or fly-screw, &c.

The intuitive genius of Dupuytren was one of the first to seize the advantages of pressure. Soon after the appearance of Baron Heurteloup's percussor, we find Dupuytren writing to him the following passage:-"If you could discover a mode of substituting for percussion a force of pressure which would enable us to do away with your bed, &c., I should at once advise the commission to award you the grand prize.”

с

BARON HEURTELOUP'S ORIGINal Instrument for PercussION.】 FIG. 34.-The male and female branches, without handle and opened. The dotted lines show the slit in the male branch. FIG. 35.-The vesical extremity of the male branch; the slit in the blade enables it to be drawn back.

FIG. 36.-The handle and portion of instrument.

FIG. 37.-Perpendicular section, showing the central or male branch, and the external or female side-pieces.

Here is a drawing taken from the original instrument made by Weiss, and which Baron Heurteloup presented to the Westminster Society. It is composed of two side pieces, with a thin central plate of steel, representing the male branch. The side pieces are curved at their extremities, and are united to the central piece by the pressure of a few screws. Near the curve of the male piece is a short longitudinal slit, through which a rivet passes from side to side, and this is the only solid point of junction. This rivet limits the movement of the branches. From the section of the instrument you will perceive that the side-pieces, which represent the female branch, do not meet either above or below, but are separated by the thickness of the male branch. The sliding movement is altogether lateral. Now let us consider for a moment what takes place-nay, what actually did occur in Colonel Rankin's case-with this instrument. When the blades embrace a calculus, and pressure or percussion is employed, at that part of the slit in the male branch which comes in contact with the rivet, a tilting effect is produced; the rivet acts as the point d'appui of a lever, and the extremity of the male forceps is more and more thrown up according to the force employed. In the case alluded to, it was bent upwards over the arch of the pubes. This is the inevitable effect of the want of solidity, produced by the way in which the branches slide laterally, and by the lever action of the connecting rivet.

These fatal defects were soon corrected by Dr. Costello who modified the instrument in the way I now show you.

Fig. 39.

FIG. 32.-Professor Jacobson's instruments, (1831.)
FIG. 33-Shows instrument closed.

As for percussion, Baron Heurteloup is unquestionably entitled to the merit of having, if not discovered, at least introduced and subsequently established that system, which led to the still better one now adopted, of crushing with sliding instruments. And here I must enter into a few details which enable me to do justice to English surgery on a point that has been forgotten or intentionally overlooked.

Baron Heurteloup's original instrument was extremely imperfect; and I have no hesitation in affirming, that, without the essential modification which it subsequently received, it

FIG 39.-Dr. Costello's modification of the original percussor. The female branch is a hollow catheter, with a slit of a triangular shape along the upper part; and the male branch is a solid catheter-shaped piece of steel, fitting exactly into the former, with all the points of which it is in contact, except along the upper surface. Hence, from the solid manner in which the two branches are united while they slide, they admit of any degree of pressure being made, without danger of forcing the joints or branches of the instrument.

It is curious to observe how the progress of lithotrity in this direction was retarded by what we might call an accident. In the year 1824, Mr. Weiss demonstrated the power of his screw instrument to Sir Benjamin Brodie. The screw acted with so much power on a hard calculus, that it was feared the bladder might be injured by the force with which the fragments would be propelled against its walls; and to obviate such an occurrence this surgeon suggested the addition of a saw.

Fig. 40

FIG. 40.-Mr. Weiss's instrument for sawing stones in the
bladder, (1825.)

We now know that such fear is chimerical, though it was quite natural in 1824, for at this time the injection of the bladder with water, previous to operation, was not insisted upon; hence the fear of damaging the coats of the bladder. The French surgeons soon after this advised the injection of water prior to operating, since which this practice has been universally adopted. The principle of crushing by means of the screw, however, was rejected for the time; no trials were made on the living body, and it was not until 1832, when the

$25

use of Baron Heurteloup's percussor, water having been previously injected, had refuted the theory of "danger from explosion of fragments," that Mr. Weiss's principle began to attract attention, and his instrument became the starting point of all those subsequently employed.

The position of the patient in this operation is a matter of importance, and Heurteloup used to place his patients on a bed, a representation of which I now give. Although this cumbersome apparatus is never used at the present day, I must for history's sake say a few words about it. The drawing I now show you gives a good idea of all the main points of the bed, which is composed of a rectangular couch. On the upright rod, which M. Heurteloup calls his "fixed point," is a wedge to fix this branch solidly, and a grooved head, with a screw at the upper end of the branch, to fix the percussor. The object is to hold the percussor so steadily, that when the male branch is struck with the hammer, no movement of any other portion except the male branch shall take place. Anteriorly there are two pieces of wood, having at their extremities two slippers for the patient's feet. These can be lengthened or shortened at pleasure, to suit the height of the patient. In front there is a cross piece of wood, very thick, uniting the two triangles together. In this is seen a mortice for the small vice to play in, which holds the instrument during its action on the stone. This bed can be lowered, if required, to an angle of 45°, a strap being passed behind the neck and before the shoulders, and attached to a buckle on each side of the bed, so as to prevent the patient slipping off.

England may, and you see, justly, claim the principal part in the crushing system. The oval slit in the side or back of the female forceps, for the discharge of detritus, was, I believe, invented by the late Mr. Oldham, a gentleman attached to the Bank of Ireland; while Mr. L'Estrange, of Dublin, claims the merit of having first applied a wire stilet, for the purpose of removing the detritus. Mr. L'Estrange also claims the honour of having been the first who applied the principle of the screw as a means of crushing calculi in the bladder: but with every desire to do justice to our Irish brethren, I cannot see on what this claim is founded. If Mr. L'Estrange's invention bears date from July, 1834, I have merely to remark that the screw was employed by Weiss in 1824, by Haygarth in 1825, again by Weiss in 1825, by Retoré in 1825, and by numerous French surgeons in 1833. An English instrumentmaker on the Place de l'Ecole de Médecine, known as Sir Henry, (probably because he was a knight of the legion of honour,) had applied the screw for crushing long before 1834. It is but right, however, to observe that the screw broke the blades, on the first trial made with it at the Hôtel Dieu, in 1828.

Since 1834 many changes have been made in the details of various parts of lithotritic instruments, but none affect the principle on which they work. The blade of the female branch has been made wider and deeper, to receive the detritus; the screw has been replaced by the rack and pinion; the latter furnished with a round handle, as in Charrière's instrument; or with a T-shaped one, as in the English, to

give additional force. To Mr. Fergusson we are indebted for the application of the rack-and-pinion system, which he introduced in 1834. It is unnecessary for me to notice all these improvements, as they have been called, for almost every surgeon who has occupied himself with lithotrity appears to have thought it incumbent on him to make some change in the apparatus-occasionally for the better, often for the worse.

The instruments generally used at the present day for performing lithotrity are, the common screw one, the rack-andpinion instrument described by Mr. Fergusson, and Charrière's last instrument, which likewise acts through a rack and pinion, but differs from the former in the shape of the handle.

Having thus comprised, in as brief a space as possible, the principal facts connected with the history of lithotrity, I hasten to its practical application. I shall at another time endeavour to explain to you in what cases lithotrity is to be preferred to lithotomy, for you are not to conclude that all cases of calculus in the bladder admit of being cured by the new operation. For the present, let us suppose that a case of stone suitable for the employment of lithotrity presents itself. How are you to proceed? What are the successive steps of the operation?

Stone in the bladder, as you are fully aware, is almost invariably attended by more or less severe derangement of the genito-urinary organs or of the general health. It is important, before proceeding to the operation, to remove these complications as far as possible; and hence what has been