340 PATHOLOGY OF CATARACT.-MEDICAL NEWS. passed the meridian of life. Why, sir, my grocer, who stands hat in hand in my hall for orders, had two of these bastard M.D.'s at a tea-party last night. There seems to be a morbid desire among general practitioners just now to dub themselves M.D. A highly respectable gentleman of this class in my town has not long since thus added to his title. If he hopes to add to his position by so doing, how will he be mistaken! Still acting as an apothecary and union doctor, however his brass plate of "Dr., Surgeon Apothecary," may atonish the clod poles from his parishes, it will give him no importance in the eyes of the more intelligent. By thus decorating himself, the practitioner in pharmacy may degrade the status of the true physician, but he will not raise his own. I am, sir, your constant reader, Sept. 1852. M.D., BUT NOT M.R.C.S. AND L.R.A.C. PATHOLOGY OF CATARACT. To the Editor of THE LANCET. SIR,-In a paper on the development of Cataract (THE LANCET, vol. ii. 1852, p. 260), Mr. Dixon says, "Ophthalmic writers are, I believe, unanimous in describing it [cataract] as beginning at the centre of the lens, and gradually spreading towards the circumference." He then goes on to propound and defend the opposite opinion as an original one. A reference to Mackensie on "Diseases of the Eye," (p. 643, 3rd. edition, Lond., 1840) will show that a similar view was adopted by this author, to the one now published by Mr. Dixon. He says: "The process [by which cataract is formed] has been said to begin in the centre of the lens, where its nutrient vessels are smallest; but this is certainly incorrect. If we examine a cataractous lens immediately after it has been extracted, we shall find that the whitish opacity which constitutes cataract, and has impeded vision, affects principally its superficial lamina; the interior lamellæ being generally pretty transparent, although often presenting the amber or the reddish-brown hue of glaucoma. The superficial laminæ of a cataractous lens not only present a state of opacity, but appear to have undergone a peculiar change, which, by some, has been compared to a coagulation, and by others to a necrosis, and which is entirely wanting in the glaucomatous state of the lens." A similar view of the pathology of cataract was advanced some years ago in France, by Malgaigne, who says:-"L'opacité réside presque toujours dans les couches les plus superficielles du cristallin; elle ne commence jamais par le centre."-Ann. d'Oculistique, vol. vi. p. 70, Bruxelles, 1841. I am, Sir, your obedient servant, A STUDENT OF THE EYE. THE FACULTY OF PHYSICIANS AND SURGEONS OF GLASGOW, AND THE ARMY MEDICAL BOARD. THE following official communication has been forwarded to us for publication, at the request of the President of Faculty of the Physicians and Surgeons of Glasgow. 12885 4. a. 13, St. James's-place, St. James's, London. September 25, 1852. SIR, I have the honour to acknowledge the receipt of your note of the 14th instant, and, in reply, to state that I cannot, under existing circumstances, interfere with the course which the editors of medical journals observe; but you may rest assured that the diploma of the Faculty of Physicians and Surgeons of Glasgow will be recognised by this department. The Faculty may, if it sees proper, make the fact known—it might possibly have been done through this office had a representation been made when the late Director-General communicated his intention to receive the diploma of your College as a qualification. I have the honour to be, Sir, Dr. John Aitken, Registrar of Faculty of Physicians and Surgeons 21, Blythswood-square, Glasgow. DR. WOOD, who recently resigned his appointment of resident medical officer of Bethlehem Hospital, has been licensed by the Commissioners in Lunacy, and has entered upon the management of Kensington House Asylum, lately conducted by Dr. Philp. Saturday, October 2nd, 1852. ADAMS, JOSEPH DIXON, Martock, Somerset. FOOTNER, EDWARD, County Hospital, Winchester. LOWNDS, JAMES RICHARD, Newcastle-upon-Tyne SKINNER, WILLIAM ALFRED, Bath. WALKER, THOMAS S., Burslem. WATSON, WILLIAM SPENCER, Southampton-street. WOAKES, EDWARD, Luton, Bedfordshire. Monday, October 4th, 1852. ANDREWS, H. C., Chapel-street, Belgrave-square. ANSTIE, FRANCIS E., Devizes. BLAKER, N. P., Sussex County Hospital. BRIGHT, JOHN MEABURNE, Alvaston, near Derby. CARR, WILLIAM THOMAS, Newcastle-on-Tyne. CARTER, THOMAS, Newbury. DONNE, J. M., Bath. DOWLING, FRANCIS JOSEPH, Chew Magna, Somersetshire. FAWSSETT, F., Wisbeach. FOSTER, MICHAEL, Huntingdon. Fox, WILLIAM TILBURY, Broughton, Stockbridge. GUNDRY, HAMILTON DOWNE, Vernon-place, Bloomsbury. HUSBAND, JOHN, Wellington. JOHNSON, W. F., Colchester. JOLLYE, EDWARD WILLIAM, Hammersmith. KNAGGS, HENRY, Huddersfield. LEACH, HENRY, Wisbeach, Cambridgeshire. Piffard, BERNARD, White-hart-lane, Tottenham. PITMAN, E. H., Manchester. PIX, WILLIAM HOWELL, Tunbridge Wells. PUCKLE, WILLIAM, Sussex County Hospital. RICE, DAVID, Stratford-on-Avon. THOROWGOOD, JOHN CHARLES, Totteridge. TIDY, WILLIAM MEYMOTT, Cambridge-heath, Hackney. WALTON, B. M., Hampton, Middlesex. WARREN, JOHN, Worthing. WOODHOUSE, THOMAS JAMES, Philadelphia-place, Hackney. WORKMAN, FRANCIS, Reading. MEDICAL NEWS. ROYAL COLLEGE OF SURGEONS.-It may not perhaps be generally known, that by recent regulations of the Council, a Board of Examiners in Midwifery has been established, consisting of the senior Vice-President of the College, together with Dr. Arthur Farre, Dr. Henry Oldham, and Dr. James Reid. The conditions under which candidates are admitted have just been published, from which it appears that persons who are, or shall become fellows or members of the College prior to January, 1853, will be admitted to examination on production of their diploma; other gentlemen becoming members subsequently to the above date, will be admitted on producing, with their diploma, a certifi-¦ cate of having attended twenty labours. From the same regulations it appears that members or licentiates of any legally constituted College of Surgeons, or graduates in surgery of any University requiring residence to obtain degrees, will also be admitted to examination on producing, with their diploma, certificates of being 21 years of age, of having been occupied four years in the acquirement of professional knowledge, of having attended one course of lectures on midwifery, and of having attended not less than twenty labours. There are other regulations on the above important subject, which may be ascertained on reference to the Secretary at the College. THE CHOLERA.-Letters from Prussia, dated Sept. 20, 1852, state that the cholera is on the decrease, the mortality is not so great, and the number of cases has diminished. The whole of Poland, has, however, materially suffered. Three cholera hospitals were opened at Berlin, and at Posen there have been 2494 cases, and 1235 deaths, from the 20th of July to the 20th of September. All the schools were closed, and two members of the legislature have fallen victims to the epidemic.Intelligence has been received from Berlin, dated Sept. 24th, and it would appear that the progress of cholera is stayed by the mild weather which set in; the alarm is therefore greatly diminished. An official report has likewise contributed in tranquillizing the minds of the population, as it is stated, in that document, that the disease did not spread into the Brandeburgh province. Only three cases were reported on the 23rd of September, and the news from Poland and Eastern Prussia was more satisfactory. The favourable intelligence was, however, followed by less favourable news, dated Sept. 28th; for it now appears that seventy-one cases were returned at Berlin on the 26th, and further accounts give three more cases up to the 29th. Out of these seventy-four cases there have been forty-one deaths, fourteen recoveries, and nineteen patients are still under treatment. KING'S COLLEGE HOSPITAL. On Wednesday a meeting of the governors of the above hospital was held in the Board-room in Portugal-street, Lincoln's-inn-fields, for general business. The report of the committee regretted that the present state of the funds rendered it much to be feared that unless there be more liberality displayed, much of the blessings at present afforded to the poor in the hour of need must be denied, as demands on the hospital are so greatly on the increase that the resources are quite inadequate to meet them. During the past year, 30,607 in and out-patients have received relief, being an increase of more than 5000 over the preceding year, and a grand total of upwards of 220,000 patients since 1839. BRISTOL GENERAL HOSPITAL.-Messrs. Wyatts, Blackwell, and other architects and engineers, have sent in very elaborate plans for the new hospital at Bristol. DR. ANDERSON, chemist to the Highland Society, has been appointed by the Crown to the chemical chair in the Glasgow University.-Scotsman. SUSSEX COUNTY HOSPITAL.-The foundation-stone of two new wings to this hospital has been laid, which, when completed, will increase the accommodation from 50 to 123 beds. Since the opening of the hospital in 1828, the benefits which it has conferred upon the suffering poor are incalculable. A NEW SCHOOL OF MEDICINE IN FRANCE.-Our readers are aware that, besides the three faculties of medicine, viz., Paris, Montpellier, and Strasburg, there are seventeen preparatory schools of medicine in France, situated in the large provincial towns. To these a new one has just been added, which has its seat at Lille, in the north of France. APPOINTMENTS.-At a meeting of the Governors of the Leicester Dispensary on Thursday the 30th ult., Mr. George Simpson was elected resident medical officer.-Robert Briscoe Owen, Esq., M.D., has been appointed deputy-lieutenant of the county of Anglesey, and Harry William Carter, M.D., has been appointed deputy-lieutenant of the county of Kent. 341 THE LANCET'S ANALYTICAL SANITARY COMMISSION AND "BLACKWOOD'S MAGAZINE."-The adulterators of Cayenne pepper, the falsifiers of milk, and the employers o light weights and deceitful balances, have much which they may be justly called upon to answer for. They have undermined the reputation and demolished the character of the age in which we live. Some choleric old gentleman, to whom Cayenne pepper, notwithstanding the quantity of it which his temper appears to have assimilated, is evidently one of the first necessaries of life, stung to fury by the dreadful revelations of THE LANCET, and writhing under the horrible suspicion that he has been for years seasoning his viands with red-lead, sulphuret of mercury, and vermilion, has poured forth his wrongs and his griefs into the confiding ear of Blackwood's Magazine, on which no sounds fall so sweetly as those which tell of the abjectness and degeneracy of the present time. Warmed with this titillating subject, and becoming more peppery the more he discoursed of pepper, the indignant lover of capsicum widens the sphere of his inquiry and lengthens the lash of his censure till the original grievance-the adulteration of pepper-sinks into utter insignificance in presence of the storm which it has raised, and becomes merely a type of the trickery and dishonesty of the age. We are a nation of humthe press, our best institutions, our noblest achievements, are so bugs, impostors, braggarts, and liars. The people, the Parliament, many vehicles of enormous lying. We boast, says Mr. Cayenne, of a prosperity from which millions are running away; of a representative system which represents not much of the sense, but a very large proportion of the nonsense of the people; of trial by jury, of which he has a very bad opinion; and are not aware, it seems, that the same lying spirit which carried the Reform Bill and repealed the Corn Law is adulterating coffee with chicory. Nothing escapes this spicy critic. Our coats are made of devil'sdust, our silk handkerchiefs are half cotton, our shirts are thickened with flour, our mustard-plasters are made of turmeric, our houses are full of vermin, our literature is reduced to puffing, our culture of the fine arts to pillaging and forging. Not only are we vicious, but are actually acquiring a passion for vice in the abstract. From Leading Article in the Times of Tuesday, Oct. 5. GODFREY'S CORDIAL.-At Lincoln, a child was lately poisoned through the nurse administering a dose of Godfrey's Cordial intended for the mother. The medical evidence proved that a tea-spoonful of it was sufficient to cause death, EAST INDIA COMPANY'S SERVICE.-The following new regulation has lately been adopted by this company with respect to assistant-surgeons. "It is also expected that the assistantsurgeon shall produce a certificate of having diligently attended, for at least three months, the practical instruction given at one of the asylums for the treatment of the insane, and at one of the institutions or wards of a hospital especially dedicated to the treatment of ophthalmic disease. He will also be required to attend a course of lectures on the principles and practice of military surgery, if such a course shall be given at the place at which he has been educated." THE LEGION OF HONOUR GIVEN TO QUACKS.We are grieved to find that the Cross of the Legion of Honour has been given to the veriest quack whom France ever produced. The man had been for years selling and advertizing a wonderful medicine for syphilitic disease, and has now, probably by dint of granted only to men of high attainments, or who had rendered money, obtained a distinction, which in former times used to be some signal service to their country. HEALTH OF LONDON DURING THE WEEK ENDING Saturday, October 2.-In the week ending last Saturday, 1251 deaths were registered in the metropolitan districts. It is necessary to state that the increase which this return exhibits over previous weeks is not the effect of an increased rate of mortality, but is produced by an accumulation of cases, principally violent and sudden deaths, on which inquests have been previously held, but which have not been formally registered till the close of the quarter. In the ten corresponding weeks of the years 1842-51, of a tenth for increase of population, and for the sake of the average number of deaths was 1000, which, with the addition comparison with last week's return, would be 1100. The follow ing are the fatal cases, as enumerated in this week's table, under the several kinds of zymotic disease: only 6 cases, two of which were in the Small-pox Hospital, occurred from small-pox, 5 from measles, 13 from hooping-cough, 8 from croup, 2 from thrush, 2 from influenza, 4 from purpura, 1 from ague, 2 from remittent fever, 1 from rheumatic fever, 4 from puerperal fever, 51 from typhus, 6 from erysipelas, 2 from syphilis, 72 from diarrhea and dysentery, 2 from cholera, while 81 were caused by scarlatina. The fatal effects of this last complaint in particular instances are noticed both by registrars and medical men. Last week the births of 807 boys and 797 girls, in all 1604 children, were registered in London. The average number of seven corresponding weeks in the years 1845-51 was 1335. At the Royal Observatory, Greenwich, the mean height of the barometer in the week was 29-403 in. The mean temperature was 52.20. The wind blew from the north-east on the first three days, and from the south-west afterwards. TO CORRESPONDENTS. THE BRITISH MEDICAL DIRECTORY. THE Editors of this work have requested us to insert in THE LANCET the names and addresses of those members of the profession who have made the requisite authentic "returns." As the names now amount to thousands in number, it is utterly impossible for us to appropriate space for their publication in our columns. The Editors have also requested us to acknowledge, with the warmest expression of their gratitude, the prompt and effective manner in which their applications have been treated and answered by their professional brethren. The Editors emphatically call for a continuance of the active exertions of the profession in promoting the success of their labours; and they fervently hope that all qualified members of the profession, who have omitted to make their "returns," will send them in without delay, and that those gentlemen who have already performed that duty will exert themselves individually amongst their professional brethren to procure the necessary "returns" from other practitioners who have not been similarly active. When it is stated that the object of the Editors in undertaking the publication of this important DIRECTORY is not commercial, but strictly profes sional, and with a view to withhold from quackish impostors the titles and distinctions which are so profusely attached to their names in the Medical Directories already published, there cannot be a single respectable member of the profession who would withhold any assistance he can render to make such an undertaking completely successful. In conclusion, the Editors have requested us to announce that all the requisite arrangements for publishing the work have been made, and they feel confident that THE BRITISH MEDICAL DIRECTORY will be ready for delivery on the first day of January next. We need scarcely remark, that the efforts which these gentlemen are making to uphold the character and dignity of the profession, by excluding from the names of the quacks in a Medical Guide (which must be a work of universal reference) the titles and distinctions which are appended to them in the existing Directories, entitle the Editors to the gratitude and zealous co-operation of all legally-qualified and regular practitioners belonging to the profession. ** Blank forms for making the "official returns" may be obtained on applying for them, either personally or by letter, at the Office of THE LANCET, 423, Strand. Mr. Leonard Birskell, (Chichester.)-The fee, though miserably inadequate, is, we fear, all that can be legally claimed. The entire subject of payment of medical witnesses in courts of law and justice, requires amendment, and is likely soon to receive attention in the proper quarter. MANY thanks to Mr. Wraith for his polite communication. MOPPING OUT THE AIR-PASSAGES. To the Editor of THE LANCET. SIR. In the last number of THE LANCET, Mr. Beavan, with reference to the following paragraph,-"The sponges used by Dr. Green are about half an inch (generally less) in diameter. The one I actually removed was more than fourteen times as large as one of these; and the whole mass at first was at least fifteen or sixteen times as large."-inquires whether any unintentional error is contained in these figures, or whether it is seriously meant that a foreign body, eight inches in diameter, found its own way into the human trachea. Allow me to suggest to Mr. Beavan the possibility that the "unintentional error" may have been committed by himself, and not by Professor Peaslee. If he will examine the paragraph again, he will see that it is not stated that the diameter of the sponge extracted was sixteen times as great as that of those used by Dr. Green, but simply that the whole body was sixteen times as large. Now, here is a wide" difference; for we know that solid bodies do not increase in the same ratio as their diameters, but in the ratio of the cubes of their diameters; conse. quently the diameter of the sponge extracted by Professor Peaslee, instead of being eight inches, would only be an inch and a quarter, or two and a half (the cube root of sixteen nearly) times half an inch, the diameter of the sponges used by Dr. Green. Of course I cannot be certain that this is what is meant by Professor Peaslce, but merely give the above as a probable explanation. I am, Sir, your obedient servant, Mortimer, Oct. 1852. W. ORANGE. Mr. L. Rieder.-Medical gentlemen, being duly qualified to practise, are the only witnesses who can legally claim payment for giving evidence, and these only when specially summoned according to the provisions of the Medical Witnesses' Act. Exceptions are also made under special circumstances in the case of witnesses who are called to give their opinion on matters of art, science, &c. Remuneration also is given in some instances to poor persons, at the discretion of the coroner, for loss of time, &c. G. C. G.-Many "remedies" for cholera have been recommended. If the medicine alluded to by G. C. G. have any real efficacy, we advise him to make it public. We repudiate all secret remedies, and he is no friend to his profession or to his fellow-beings who withholds from them the knowledge of a "remedy" in so fatal a disease as cholera. If G. C. G. be determined to wait until Government or some public body promise to remunerate him for his secret, it is probable that he will take it out of the world with him. A NAP AFTER DINNER. To the Editor of THE LANCET. SIR.-I would suggest as a curative agent for post-prandial drowsiness to "A Constant Reader," (vide THE LANCET of Sept. 18th,) who is at a loss how to combat this influence, the sitting in a hard, uncomfortable chair. I was myself for some time the victim of this habit; but having become the resident house-surgeon to an eleemosynary institution, the governors of which have been as usual not at all solicitous about furnishing with an eye to the comfort of their medical officer, I find no difficulty at all in keeping staring wide awake, as there is not a chair in the establishment that might not have been used by the Inquisition as an instrument of torture. I strongly suspect that the fautenil of "A Constant Reader" is too luxuriously padded to act as an anti-soporific. If he finds a difficulty in procuring a chair sufficiently hard and angular, I shall be particularly happy to effect an exchange with him. September, 1852. I am, Sir, your obedient servant, J. E. N. Mr. Alexander Broden.-We shall be happy to supply Mr. Broden with any information he may require relating to the use of the microscope. 4 Subscriber is referred for information respecting the manufacture of vinegar to the Reports of the Analytical Sanitary Commission, recently published in THE LANCET, on "Vinegar and its Adulterations." Mr. Winter.-Mr. Acland, of Hatton-garden, has recently brought out a microscope specially adapted for the examination of urinary deposits, and suited for most medical purposes, as well as for the detection of adulteration in articles of diet. We have compared one of these instruments with Oberhauser's microscope, and find it to be in every way superior. The price is, we believe, very moderate. Mr. R. H. James.-1. Yes.-2. Certainly not.. A Constant Reader, (Oct. 4.)—He is entitled to the fellowship under the regulations of the new Charter. J. O. P.-There is little to choose between the schools named. PROPER COMPLIMENT TO THE MEDICAL PROFESSION. SIR,-Allow me to call to your observation, that in addition to W. S. Cox, Esq., the honour of Deputy-Lientenancy has been conferred upon John Sutton, Esq., who practised for fifty years at Greenwich, but who is now retired to Lee, Kent; it was gazetted in the Times of Sept. 24th. The reason I call your attention to it is, because up to the present time he is the only general practitioner that has had that honour conferred upon him. I remain, Sir, yours obliged, King's-road, Chelsea, Oct. 1852. JOHN ALLEN. Messrs. Hill, Evans, and Co. (Worcester) will receive a private answer to their letter of the 5th instant. A Surgeon who has Retired from Practice wishes to know if there would be a chance for him to be elected a member of Parliament for any borough requiring a representative. He is neither Whig nor Tory, but his principles strongly incline to Radicalism. As Peterborough is in an agricultural district, he desires us to state that he is ready to vote for total repeal of the malt tax. J. C. The paper shall be perused, and our correspondent shall receive an answer next week. A. B., (Vernon-place.) — We cannot insert any communications which have a tendency to uphold quackery. J. B.-Mr. George Hind is an able teacher. His name was accidentally omitted in the Students' Number. His class-room is 25, Newman-street, Oxford-street; private residence, 9, South-crescent, Bedford-square. Mr. Alfred Hill, (Birmingham.)-If our correspondent will take the trouble to turn to page 304 of our impression of October 2, he will find the prospectus of the school in question. COMMUNICATIONS, LETTERS, &c., have been received from Dr. Marshall Hall; Dr. Chambers; Mr. Collins; Mr. Nugent; Dr. Jones; Dr. Crisp; Mr. Hurlston; Vindex; Dr. Howard; Dr. Jenner; Mr. Leslie Paterson, (Norfolk ;) M.R.C.S. Eng., (Darlington;) Mr. Lester; Mr. G. Lowther, (Hull;) Mr. John Allen; B.; An Army Surgeon; Dr. J. A. Vyle; A Lover of Justice; M.D.; Mr. L. Rieder; Mr. W. Rackell; Mr. J. Webb; Mr. H. S. Wharton; A Medical Pupil; Mr. A. Clarke; F. R. A.; A Student of the Eye; G. C. G.; Mr. A. Shaw; Dr. Black; Mr. Grainger; Dr. Taylor; B. T. S.; Mr. F. S. Garlick, (with enclosure ;) Rev. F. Lathes, (with enclosure ;) Mr. J. A. Tucker; Mr. Alfred Hill, (Birmingham;) Dr. Aldis; Veritas; Dr. J. Aitken, (Glasgow ;) Messrs. Curliss and Simmonds; Mr. Richard Morris, (Wigan;) Mr. R. H. James; Mr. F. H. Warren, (Exeter ;) One of Many; A Constant Reader; Phear; Mr. T. W. Nunn; Wide-Awake; Y. O. P.; Mr. E. Fortnum; T. G., (Manchester;) Mr. W. Orange, (Mortimer ;) Messrs. Hill, Evans, and Co., (Worcester ;) J. C., (Whitehaven;) Mr. Leonard Birskell, (Chichester,) J. E. N.; Mr. Alex. Broden; A Subscriber; Mr. Winter; A Surgeon who has Retired from Practice; J. C.; A. B., (Vernon-place;) J. B.; Mr. Wraith; &c. &c. THE LANCET, OCTOBER 16, 1852. Clinical Lectures, Delivered at Guy's Hospital, BY JOHN HILTON, Esq., F.R.S., SURGEON TO THE HOSPITAL. LECTURE VI. be felt extending upwards nearly to the umbilicus; it felt tense and distended with urine." You hear it stated in the report that the bladder was dull on percussion; pray give your attention to this symptom, and bear in mind, on the other hand, that accounts given by patients of no water having been passed must not be fully relied upon as final in determining the case to be one of retention, for the patient's kidneys might have secreted no urine, the case being then one of suppression rather than retention. Dulness on percussion, and the definite form of the swelling, will quickly show you that the Continuation of the case of retention of urine in which the bladder bladder is filled with fluid. I must, however, not omit to say for was punctured through the rectum. Fruitless attempts at passing a catheter; discharge of pus through the meatus urinarius. The use of opium in cases of retention. The surgeon should endeavour to give relief without an operation. Symptoms of a full and distended bladder; distinction between suppression and retention. Anatomical reasons why the bladder distends in a particular direction. Parallel between the urinary apparatus and the hydraulic press. Operation of puncturing the bladder through the rectum. Description of the operation. Precautions to be taken when the patient returns to his bed. Progress of the case after the operation. Great improvement. Blood in the urine; removal of the canula. Severe constitutional symptoms, death. Remarks upon the likelihood of peritonitis having taken place; safety of the operation. Post-mortem examination. Anatomical preparation showing the course of the trocar. Pathological peculiarity of this patient's bladder. Considerations about the cause of death in this case. Reasons achy this patient's bladder was punctured through the rectum. Review of the several methods of puncturing or relieving the bladder distended with urine:-1. By forcing a catheter into the bladder. 2. By puncturing above the pubis. 3. By punc turing through the perinæum. 4. By puncturing through the rectum. Recapitulation of the reasons which support the operation of puncturing the bladder through the rectum. Analogy with tracheotomy in disease of the larynx, and rest to the strictured œsophagus in giving nourishment by the lower bowel. Case of patient nourished by enemata for thirty-four days. We now resume, gentlemen, the consideration of the case of stricture which formed the subject of the last lecture. Recollect that we are following the phenomena presented by a case wherein stricture of the urethra was the root of the evil; abscess, fistula in perinæo, and retention of urine had followed; and the contents of the bladder had eventually been evacuated, by puncturing that viscus through the walls of the rectum. Let us proceed with the details of the case. “The following day, November 19th, the patient was brought to the hospital; and as complete retention had existed or thirty hours, Mr. Poland and Mr. Puckle, the dresser, endeavoured sedulously to introduce a catheter; they failed, however, in their object. The instrument, instead of entering the bladder, readily glided into a false passage, nearly three inches in length, along the anterior walls of the rectum, and immediately behind the prostate gland. Soon afterwards, nearly two tablespoonfuls of pus and urine escaped through the meatus." You at once surmise that the pus here evacuated, proceeded from one of the abscesses, which, during the manipulations just described, had been punctured. "The patient was now ordered a warm bath, and two grains of opium. Two hours afterwards he was seen by Mr. Hilton, who likewise tried to pass an instrument, but, not having succeeded, prescribed two more grains of opium." What was my object in giving opium so freely? To endeavour to overcome the spasmodic state of the parts surrounding the urethra, and bring about relief to the urgent symptoms without having recourse to an operation. It is, indeed, a great triumph in surgery when we succeed in affording relief, and eventually curing an affection of a serious kind, without the use of the knife. There is always some éclat connected with surgical operations, but I would strongly advise you ever to prefer doing good to your patient, to merely trying to attract upon yourself the attention of your professional brethren, and make a public display of your dexterity. By giving the opium largely, I was endeavouring to overcome muscular spasm, which latter is so often the sole cause of the retention. Patients thus treated by opium, generally fall into a profound sleep, the spasm gives way, and they succeed in emptying their bladder by vias naturales, in small quantities at a time. "At half past seven P.M., Mr. Hilton saw the patient again, and found him evidently affected by the opium; he had been sleeping, was drowsy, the pupils contracted, and he was aww in scarcely any pain. But the bladder, dull on percussion, might No. 1520. your instruction, that a gaseous tumour has been, and perhaps will be again, mistaken for a full bladder; the case being one of suppression of urine, and the intestines distended with gas occuPying the site of the bladder. You should inquire the anatomical reason why the latter viscus does not distend sidewards, nor distressingly backwards, when filled with urine. The course and adhesions to the anterior parietes of the abdomen, it being there direction of the distended bladder are determined forwards by its attached by cellular tissue, and the remains of the urachus fixes it to the umbilicus. The lateral distention of the bladder is happily limited; if it were not so, the increased size of the viscus in that direction would cause compression of the the round ligaments or remains of the umbilical arteries iliac veins, and then edema of the lower extremities; in fact, prevent the distention in the direction just mentioned. When recollected, it is really surprising that, in cases like the present, the position and relation of the ureters and bladder are the latter does not burst, or become forcibly rent from the pelvis; is the receptacle, and the ureters the tubes; and as these pass for these organs resemble much an hydraulic press-the bladder obliquely into the bladder, there is no necessity for the valves attached to the real hydraulic press. The neck of the bladder will become much elongated by distention. You may easily convince yourself of this by passing your finger into the rectum, and feeling at intervals of time the condition of the part whilst the The ligamentous tissue exbladder is filling from the ureters. isting in the vicinity of the pubis, and around the neck of the bladder, is intended to resist over-distention or forced separation, notwithstanding the extreme stretching force to which it must be sometimes subjected; this is very probably the use of that tissue, clse it would hardly be so strong and so abundant. "Mr. Hilton having tried again, but without success, to pass a catheter, determined upon operating by puncturing the bladder through the rectum, by means of a trocar and canula. The patient was brought to the edge of the bed, and placed as for the operation of lithotomy, but with his head and chest much lower than the pelvis. Very nearly three pints of turbid, ammoniacal urine were drawn off, and the canula (consisting of three tubes, one within the other) was secured in the bladder by means of tapes fastened to a band round the waist. There was no blood lost; the patient was conveyed to his bed, which was previously carefully arranged, and he was allowed wine and porter." I must here point out to you that the position of the patient for this operation is not exactly that usually assumed for lithotomy, as you will be able to see by this diagram; the head and chest ought, in fact, to be lower than the pelvis, and the rectum and bladder should be brought on a line. I will now attempt to describe the operation with the assistance of this drawing. (See the following page.) The sketch represents a section of the pelvis, with a part of the rectum opened, to show the course of the finger and instrument within the bowel. You pass the index-finger of the left hand into the rectum until you feel the prostate gland, and push your finger, if possible, behind that part, which is generally very high up in distended bladders. You then seek for fluctuation, and endeavour to ascertain this symptom, which, however, is not always easy to do. Desire now your assistant to make pressure upon the bladder over the pubis, and to press the viscus down towards the rectum, in which the finger is placed. Having recognised the posterior part of the prostate gland, and maintaining with all possible care the median line, glide the instrument along the palmar surface of the left index-finger until it is in contact with the distended bladder resting on the rectum; take out the director, introduce the trocar, and push it upwards and forwards one or two inches into the bladder, or till you lose the resistance which the coats of the gut and bladder offer to the trocar. I have never before used the canula which I am showing you; but I think it certainly very useful, for it admits a sort of sound, the smooth and convex end of which protects the rectum from injury during its passage along the gut. Upon the trocar being introduced into the bladder, the urine will flow easily; great care should, however, be taken that the prostate gland be not transfixed, for such a mistake would very likely be fatal to the patient. R I show you here a canula which has been designed by Mr. whole of his urine through the proper channel; a very little of it Cock; it is composed of a hollow tube, provided with three is occasionally evacuated through the rectum; he sleeps well, and cranks on one end, which are made to expand by the introduc- is entirely free from pain. The nodular masses in the perinæum tion of a canula within it, and which latter is prevented by the have disappeared.-12th. The patient again experiences difficulty cranks from slipping out of the bladder. I consider this as a in micturition, accompanied by great scalding and pain; the urine very good instrument. You should, when the patient is in bed, contains some dark venous blood.-14th. The bladder is very place one pillow under his thighs, one under the pelvis, and the irritable, and the man thinks that a little water passes through utensil between them, so that the urine may drip guttatim into it the rectum; the perinæum is hot and painful; the pulse small without wetting the bed. The details of the case proceed as and rapid; the tongue brown and dry; there is frequent vomiting follows:and great thirst. Ordered soda water.-17th. Nearly all the "The day after the operation, Nov. 20, the patient felt much urine passes through the two large openings in the perinæum.better and quite free from pain; has passed a considerable quan- 19th. The patient lies in a half-conscious state; his sleep is distity of urine through the tube.-21st. Has slept well, tongue turbed with constant moaning; respiration impeded; pulse interclean, skin warm and moist; the bowels not having acted since mitting and very weak; tongue dry and thickly coated with a the operation, the patient was ordered one ounce of castor oil.- brown fur; teeth covered with sordes; and fæces passed involun22nd. Passed very dark motions. Ordered to repeat the castor tarily.-20th. He is fast sinking; pulse imperceptible at the wrist. oil, with twenty minims of tincture of opium; six ounces of wine-21st. The patient was supported by beef-tea, eggs, brandy, and and one pint of porter daily.-23rd. The oil has acted very wine, but he expired at two A.M." powerfully; the patient has a troublesome cough, and was ordered a sedative expectorant mixture.-24th. To-day the two inner tubes were withdrawn for the purpose of cleaning them, and the bladder syringed out with warm water at 98°. As the bowels continued very loose, the porter was omitted, and ammonia, in a tonic and aromatic mixture, was prescribed.-25th, being the sixth day from the operation. For the first time nearly an ounce of urine was evacuated through the penis, and caused very great smarting pain along the whole course of the urethra, which pain was more particularly referred to the end of the penis.-27th. Passes as much urine through the penis as through the tube; he can retain a considerable quantity of urine in his bladder, nearly half a pint being evacuated at will by the meatus." I will just remark here that this was evidence of great improvement, as the patient was able on the seventh day to pass as much urine through the urethra as through the tube in the rectum. This circumstance points to a favourable change in the walls of the urethra. "29th. Very profuse diarrhoea has come on during the night, without any assignable cause. Mr. Hilton prescribed chalk mixture, with aromatic confection and syrup of poppies; the two inner tubes were to be removed and cleaned, and the bladder to be syringed with warm water.-Dec. 3. The urine passed through the urethra, besides a large quantity of pus, to day also contains blood; there is great constitutional as well as local irritation. The presence of the canula in the bladder being considered in some measure the cause of these symptoms, the instrument was removed. Ordered half a grain of morphia at night." What was the cause of this bleeding from the man's urethra? Probably from some sloughing in the perineum; the blood is very likely to have come from that region, and not from any part about the canula. "Dec. 6th.-Better: the urine is more healthy, and does not contain any blood; cough troublesome. To take a conium mixture three times a day. As the diarrhea continued, a starch-andopium enema was ordered.-9th. The patient passes almost the Ever since this man had had untoward symptoms, the mischief really lay in the perinæum. He had for some time been in a very unhealthy condition; he was aged, and had been living upon poorhouse fare. Though some suspicion of peritonitis might have existed, I found on examination that no such inflammation had taken place. The latter is the bugbear of surgeons in cases of this kind, but it should be recollected, that when the bladder is distended there is but little, if any, probability of wounding the peritoneum, by puncturing that viscus through the rectum. Mr. Cock has now operated upon between twenty and thirty cases of this kind, and is confident that, with care, there is not much danger of injuring the peritoneum; the more so as it is lifted away from the vesiculæ seminales when the bladder is distended, though these parts are close to each other in the undistended state. I do not mean to maintain that there is no danger whatever of the peritoneum or vesiculæ seminales being wounded, but I repeat that, with care, this objection is no obstacle to the operation. Post-mortem examination.-The peritoneum did not present the slightest evidence of any inflammation. The abdominal viscera were all in their normal position, but pale, flabby, and badly nourished. The urinary bladder contained a small quantity of turbid, brownish, and highly offensive urine; its muscular parietes were thickened to nearly half an inch; the mucous membrane was inflamed, having upon it patches of recently effused lymph. Prostate gland but little enlarged, and the strictured portion of the urethra, which was about one inch in length, and more free than during life, occupied the bulbous division of the canal, the walls of the urethra being thickened, and the mucous surface raised, uneven, and corrugated. Two false passages were found communicating with the urethra-one in front of the urethral obstruction, the other near the prostate gland. Both of these false passages were traceable into the large perineal sinuses, through the medium of a sloughing cavity occupying the perinæum, and extending for a short distance between the bladder and rectum. The opening from the latter |