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plication of the deep cervical glands through the thoracicduct. Andral records a case in which, sequential to acancer of the uterus, the internal surface of the thoracicduct presented at irregular distances small whitish bodiesin great numbers and a little larger than a pea. Theyslightly projected into the interior, but were continuouswith the wall of the vessel. Their appearance resembled inevery respect, to the naked eye, the uterine growth.Similar nodules have been seen by Wagner in the pul-monary lymphatics in cases of cancer of the stomach.The lymphatics of the stomach arise from the mucous

membrane and from the muscular layers of the organ. Theyanastomose freely, and a network is formed of large andfrequently dilated vessels on the surface beneath the peri-toneum. The trunks pass from this in three directions: onegroup runs towards the cardiac orifice, accompanying thecoronary vessels in the gastro-hepatic omentum, and uniteswith some of the hepatic vessels before terminating in thecoeliae glands; the second group follows the right gastro-epiploic vessels to the back of the duodenum, and uniteswith the vessels from the first part of that viscus; whilstthe third group runs with the left gastro-epiploic vesselstowards the spleen, and, uniting with the splenic lymphatics,terminates in the same glands.The mesenteric and meso-colic glands.-These are from

100 to 200 for the small, and from 20 to 50 for the large,intestines, and are placed with the bloodvessels between thefolds of peritoneum enclosing the intestine. In the upperpart of the mesentery they are in three rows-one row ofsmall size near the intestine, another at some little distance,and the third (much the largest) near the origin of thesuperior mesenteric artery. Many glands in the last rowmay be fused together. The farther the intestine is fromthe root of the mesentery the more scattered are the glands ;the lower part of the ileum is not in relation with nearly somany glands as the commencement of the jejunum. Near thetermination of the ileum the glands are arranged in a singlerow, but along the large intestine a second small and in-significant set is placed at some distance from the bowel.The origin of the lymphatic vessels of the intestines wasfully described in my last lecture.

Clinical LectureON

CASES OF INTEREST OCCURRING DURINGTHE FIRST TERM OF THIS SESSION INSOME OF THE LOCAL HOSPITALS.

Delivered at the Cork South Infirmaryand County Hospital,

BY PROF. H. MACNAUGHTON JONES, M.D. &c.

GENTLEMEN,-At the commencement of the second terITof this session I have determined to address to you a fewwords on some cases of interest which have been treated irsome of the hospitals connected with this school, to whicbyou have had access, and which have been under my care.And here I must, in passing, express a regret that manyobstacles exist in this school which it is difficult for studentsto overcome in the pursuit of practical work. Of these, a1present I desire to refer to two prominent ones. In the first

instance, I cannot but regard the great division of surgicaland medical work in this city, through the existence of scmany small hospitals apart from each other, as most unfor-tunate. In a comparatively small city like Cork, it is muchto be deplored that the work is not more concentrated. Itis clearly impossible that a student can hope to practicallyeducate himself, midst a crowd of others, in a small hos-pital in a provincial town, with only from fifty to seventybeds on an average occupied, and without any special de-partments. It is essential for him to see, if possible, everycase of importance treated in any of the hospitals to whichhe has access. In all special departments I can testify tothe great ignorance of our students. Yet in our special

hospitals in this city cases of unusual interest are continuallyoccurring which are never brought under the notice of themajority of our pupils. Let me beg of you, then, to travela little out of the beaten track. There is no reason why astudent in our school should not make himself acquaintedwith several of the special branches. I refer to-day to thefollowing cases to bring this fact home to you. The secondmatter I wish to speak of is the interference with hospitalwork by the early attendance required at our local college.The college is nearly a mile from this hospital, and, as thephysicians and surgeons do not visit here till nine and half-past nine, and frequently later on in the mornings, thestudents have not time to do their practical work properlybefore starting for the college. Either the lectures anddemonstrations should begin later, or the staff here shouldattend earlier and very punctually. To prove to you, then,the importance of attending at all the hospitals as frequentlyas you can, I take this opportunity of reminding you of thesecases, occurring here and elsewhere during the past fewmonths. I limit my observations chiefly to cases treated bymyself, though there have been, as you are well aware,several others treated by my colleagues equally worthy ofyour attention and thought.

Strangulated Inguinal Heritia operation ; recovery.Somehow the operation for strangulated hernia is not often

performed in our wards or theatre ; nor is strangulationrequiring operative interference a frequent occurrence here.Why this is so I cannot explain. But the inference is clear,that you should see every case presenting itself, and carefullyfollow it to its termination. This one I now refer to was aninstructive example of life saved by operation. Severallectures might be devoted to the study of this subject. Imust be content with pointing out the particular features ofthis case which teach us a few lessons not to be forgotten.A respectable woman, aged sixty years, was brought into

the Women’s Hospital on Nov. 29th. She had had previouslyobstinate constipation, notwithstanding enemata, salinepurgatives, and a dose of calomel. The costive state wasfollowed by the characteristic gulping vomiting of strangu-lated hernia, a general tenderness over the abdomen, andcolicky pain. The patient never had noticed any swelling inhealth, and the illness commenced with a violent cough,which still continued. I saw her at her own house the dayof admission. She then directed my attention to a swellingwhich she stated she noticed for the first time the nightprevious in the right inguinal region. On examining herclosely this small tumour was barely perceptible, save bythe feel ; hard, tense, non-fluctuating, fixed, very painful tothe touch ; in fact, like a large marble stuck in the inguinalcanal, and forcing its way through the external ring. As hercountenance was then becoming anxious, and the vomitedmatter dark-coloured, her temperature being 99°, and herpulse 110, rapid and wiry, I advised immediate removal tothe Women’s Hospital. I at once saw that this was one ofthose cases where delay in operation would be culpable, andin which the constitutional symptoms following on the ob-struction clearly pointed to a strangulated portion of bowel asthe cause. When I got to the hospital at 4 o’clock I found herstill worse, constantly vomiting, moaning with pair, whichwas increased by the violent cough. With my colleague Dr.Grattan I decided to operate at once. He had, however,some misgivings as to the swelling being actually a portionof bowel. After an enema was administered, I placed herunder the influence of ether, and operated in the usualmanner. I found immediately the sac, not much congested,strictured in the ring and the short fibres of the inter-columnar fascia, here acting on the constricting band; thesewere divided with the hernia knife as usual, and on passingup my finger, the bowel not returning, I found a secondconstriction at the internal ring; this I also divided byturning the edge of the knife carefully against it, in a direc-tion upwards and outwards. Immediately the bowel re-turned with a gurgle. I did not open the sac. Passing myfinger then in through the internal abdominal ring, I sweptit round to ascertain that all was right. I then closed thewound with a few silver sutures, dressed it antiseptically,and had the patient carried to bed. The entire steps wereconducted antiseptically under the steam spray. Immediaterelief followed. She never vomited subsequently to theoperation. The after-treatment consisted mainly in keepingthe bowels quiet for some days, the administration of opiates,antiseptic dressings to the wound, attention to the cough,which was very severe, and the administration of an enema.

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on the third day after the operation. Some slight peri-tonitis threatened with tympanites about the fourth day,but it all subsided, and she has perfectly recovered. Severalof you saw the operation, and to others I pointed out thesite of the hernia, now completely obliterated, before sheleft the hospital. Before dismissing this case let me remindyou that it was early operation saved this woman, that thesac was not opened, that the internal ring was thoroughlyexplored, and that the entire operation and the subsequentsteps were carried out in a thoroughly antiseptic method.Surgeons have laid down golden rules for your guidance inrespect to early operation; remember that one specially," When in doubt, operate." You may, indeed, often regretoperating too late, whereas the symptoms which demandearly operation are so clearly defined that you can hardlyconceive a case in which you will operate too soon. Let merecommend for your perusal, besides the admirable articlesin your text-books, Erichsen, Bryant, Druitt, and Holmes, thechapters on hernia in those clinical lectures, unsurpassed inthe literature of British surgery, by Sir James Paget.Transplantation Operation for Defor2izity of Eye and Face.Many of you saw a man who gave us as his history that

about a year since, when away at sea, he was struck in astorm by the wheel in the face, and horribly mutilated.He had cicatrices in different parts of his head, and onelarge scar, which ran down his forehead, a second passingacross this at right angles. He had the entire lower eyelidcut clean away, leaving a broad red surface of mucous mem-brane, which, with the white scars on his face, gave himquite a ghastly look. So much was this the case that hestated he would not be taken on board any vessel, and im-nlored me to do something to assist him to earn his bread-

Though, as I pointed out to you at the time, a most un-promising case, I determined to give him the benefit of atransplantation operation. Below the red surface was asecond cicatricial band. I made a V-shaped incision, in-cluding a portion of skin, the base of which was equal tothe lower eyelid, the wings of the V running down fromeither end of the raw surface, and meeting about an inchbelow. I dissected this triangular flap up, and with it theraw surface, turning it in to form a lower eyelid. I fixedthis new lid with sutures. I took now a good-sized portionof skin from the temple, brought it round, laid it on the

exposed surface, attaching it by sutures to the healthy skin,and to the eyelid I had just formed. Finally, I brought themargins of the temple-wound together. Many of you sawhim at the Ophthalmic Hospital. There is now but a veryslight ectropion, and the man cannot be refused employ-ment, as there is no longer deformity. I show him to youhere to-day, and you can for yourselves see the improve-ment.

Enucleation of the Eye.There were three cases of enucleation of the eyeball-one

for injury and destruction of the globe; the other two I shallbriefly refer to.

Mrs. ——, aged sixty, consulted me privately in October.She was then suffering from a formidable warty-lookinggrowth of the inner surface of the eyeball. It was of a deep-blue colour, evidently highly vascular, being subject tooccasional attacks of bleeding, but movable. The con-

junctiva all round the wart was considerably thickened andhighly vascular. It encroached on the cornea, which it par-tially concealed. The entire eyeball was congested, and hada dark and angry appearance. I furnish you with a sketch ofthe eye as I took it at the time (Fig. 2). My first impulse on

seeing the eye was to enucleate. On carefully examining thewart, however, I determined to remove it by ligature. ThisI did subsequently, with fine silk, transfixing the base ofthe wart, and strangling it with a small figure-of-eight liga-

ture. There was some haemorrhage at the time, which waseasily controlled. The wart fell off on the third day, and Ihoped all would go well ; but the general congestion con.tinued, and by degrees, first necrosis, and secondarily sup.puration of the cornea set in. Every means, such as eserine,leeches, vesication, seton, kerototomy, &c., was used toarrest this latter without effect. The eyeball suddenlybecame much swollen, intensely livid and dark-looking, andthere were a few attacks of haemorrhage. I enucleated theeye, and found the interior of the ball full of blood. I had,not long since, a similar case, in which, with a ligature, Iremoved a like wart with a perfect result. I cite this case,as it grievously disappointed me, and resisted my utmostefforts to insure success. I dreaded implication of the othereye, and also the advent of malignant disease. I did notconsider the wart itself, in the first instance, malignant;but the ugly appearance assumed after removal alarmed me,I am happy to say without just grounds, as the patient hasperfectly recovered the operation. There was some severehaemorrhage from the eyeball before the operation, and afterenucleation the vitreous was found full of blood.The other case was one of considerable interest, and, as I

had a few students present, although occurring in private,I allude to the case here. In December, 1877, Mr. - con-sulted me for a cystic tumour of the eyeball. The sight ofthe right eye had been lost for four years, and he dated thecommencement of the mischief in or about the year 1872.He then got a stroke of a bramble-bush. There was littlepain save at times. His general health was good. The eyepresented the appearance shown in

The growth projected upwards under the upper eyelid inthe direction and to the extent of the dotted lines. Of latethe fellow-eye, he said, was not as strong as formerly. Therewas no reflection from the fandus. I advised enucleation.The patent went away, and I did not see him until lastOctober, when he came with the eye as depicted in Fig. 4.The tumour had assumed a livid appearance ; the deformitythen was extreme. I enucleated the eye on the 21st ofOctober, under ether. He recovered rapidly. The tumourfortunately did not involve any of the parts in the orbit, andthe optic nerve was quite healthy. He now wears an arti-ficial eye. Dr. Atkins, who assisted me at the operation,took the tumour away for microscopical examination, butas yet it has not sufficiently hardened for the purpose.1In the hospital also there has been an interesting case of

Congenital Ccstc!racttreated by solution, in a boy aged fourteen. I thought thelenses of too solid a nature to attempt suction. He left to goout at Christmas with the lenses almost completely removed.There has been also a case of cataract removed successfully

1 Vide Dublin Journal of Medical Science.

729

after fifteen years’ duration; and an anxious case of traumaticcataract, with wound traversing the entire cornea, where lfeared sympathetic mischief, but in which there has been amost successful issue after iridectomy, followed by evacuation

of the lens matter. You have seen the value of eserine invarious cases of corneitis, suppuration of the cornea, marginalulcers, &c., many times proved. We have had an unusualnumber of cases of optic neuritis, one of which you saw dis-charged able to read S. with the affected eye ; whenadmitted she was barely able to count her fingers. Thetreatment consisted of a mild mercurial course, followed bylarge doses of iodide of potassium, and, locally, atropia,setons in the temples, and the use of smoke-preservers ;alternately a course of strychnine in doses of the thirty-second of a grain, completed the cure. An interesting caseof congenital luxation of both lenses upwards in a girl, anda case of corectopia, or eccentric pupil, with displacementof the lens, have also occurred.

Aitral Polypi.Nothing of special interest has occurred in the aural depart-

ment. There have been several cases of aural polypi. Onemorning I removed the three typical forms of polypi fromthree individuals in the extern department-fibroid, fibro-gelatinous, and the vascular, using Wilde’s snare for thefirst two, and the lever ring forceps of Toynbee for the latter.Chloro-acetic acid I almost entirely employ to destroy whatremains of those troublesome tenants of the auditory canalor tympanum. I find my aural probe, which I show you,armed with cotton wool in this fashion, the most perfectmeans of applying this acid, or any other agent, to thetympanum. I contrived this probe about a year since,finding the wire too troublesome and tedious a method.With this I work quickly, screw on or off as many pieces ofwool as I want, and make the point of the wool as fine as Iwish to touch minute growths. There is no chance, withcare, of the wool remaining in, as you can make it as firmas you like to the probe. In a few minutes with this instru-ment you can cleanse an ear thoroughly of all discharge,dry it, and touch the part with any agent you desire toemploy. (To be concluded.) )

ON INCONTINENCE AND RETENTION OFURINE IN CHILDREN.1

BY W. F. TEEVAN, B.A., F.R.C.S.,SURGEON TO THE WEST LONDON AND ST. PETER’S HOSPITALS.

Incontinence of urine embraces a wide field, affecting as itdoes, not only male, but female children. Its causation isoften difficult to elucidate, and its treatment unsatisfactory.The great point is to make out the diagnosis, for unless thisbe done all treatment is simply empirical. It is not myintention to investigate the medical phenomena of the com-plaint, which are often inscrutable, but to impress stronglyon my hearers the necessity of a physical examination in all

Read before the Harveian Society on Feb. 6th, 1879.

cases ; for if the cause of the malady be surgical, we mayusually effect a cure without delay. If, on the other hand,a surgical origin cannot be elicited, a long period of un-satisfactory treatment is too often in store for the patient.The surgical causes that may give rise to incontinence are:

1. Rectal complaints, such as piles, fistula, excoriations.2. Ascarides. 3. A tight foreskin. 4. Congenital in-

sufficiency of the external urethral orifice. 5. A calculusimpacted in the urethra. The above are fertile causes of thecomplaint, and all remediable. All of them set up and keepup irritation, and produce incontinence by reflex action.Probably of all the above causes the fourth and fifth are butlittle suspected of giving rise to trouble. A tight foreskin isa common cause of complaint, and I always advocate itsremoval, as it is usually followed by the best results. It iswell known that the meatus externus is the narrowest partof the urethra, but the relation of its size to the rest of thecanal is perhaps not so much attended to as it ought to be.There is a general belief to the effect that so long as there isa hole it suffices for micturition. This, however, iserroneous. If the relation of the calibre of the externalorifice to the general urethra be disproportionate, theresult is that the urine cannot escape as fast as it oughtto do, and irritation is set up in the peripheral ex-

tremity of the nerve, which disturbs the vesical centres.For instance, if a boy of twelve or fourteen years of agehave a meatus that will only admit a No. 3 catheter,and be suffering from incontinence, we ought at once tosuspect that the local obstruction is the cause. I haveso often seen this to be the case that I invariably lookfor it. A well-marked instance of how such a cause canact and how it can be removed was well seen in a younggentleman put under my care by my friend Dr. Fothergill.The unfortunate patient had suffered from incontinencefrom birth, and had been physicked by many eminentphysicians for years. Tonics and sea-bathing were all invain. On examining the patient I found that, although hewas fifteen years old, his meatus externus was not largerthan a new-born babe’s. I incised the orifice, enlargingthe calibre to a No. 12 English catheter. By this simpleoperation the boy was cured of his incontinence, which wasnocturnal. The profession has long recognised the con-genital contractions of the anal orifice, but no attentionhas been paid to similar defects of the urethral aperture.I would therefore very strongly urge the necessity of anexamination of the calibre of the meatus externus todetermine its sufficiency or not for the purpose it wasdesigned. Now as regards the last cause of incontinence-a stone impacted in the urethra. If I could not discoveranything wrong with the rectum or urethral orifice, Iwould pass a very slender sound, having a beak only halfan inch long, to ascertain if there were any stone impactedin the urethra. It is not generally known that a stonein the urethra may give rise to incontinence or retention,according to where it may be situated. If the calculus hasonly just entered the meatus internus, it will be firmly andaccurately embraced by the sphincter, so that no urine canescape along the sinuosities in the stone. If, however, thestone advance half an inch further, incontinence will be theresult, for the calculus will then act as a gag, and preventthe sphincter from closing, and the urine will dribble awayalong the sinuosities of the stone. For a knowledge of thisfact I am indebted to Civiale’s works, and in several casesof incontinence it has enabled me to detect a stone impactedin the urethra. It might be at first sight imagined that if acalculus be impacted in a boy’s urethra, it would give riseto great pain and discomfort, but this is not so. As theurine dribbles away, the stone may cause but little annoy-ance ; indeed, I have known patients who have had calculiimpacted in their urethrse for years without being aware ofit, so little discomfort was there caused. Therefore it wouldbe well not to be misled by the quiescence of the parts. Incases of incontinence where a surgical cause cannot be eluci-

, dated, I have found belladonna most useful where the com-: plaint was only nocturnal, as also Sir D. Corrigan’s plan of

sealing the meatus externus with collodion at bedtime.Strychnia is indicated where the incontinence is diurnal as

’ well as nocturnal. Blistering and an exclusively milk dietmust not be lost sight of. If all means fail, the applicationof a mild solution of nitrate of silver to the neck of thebladder is justifiable.Retention of urine in children is usually due to one of

three causes : (1) congenital contraction of the meatus ex-ternus ; (2) phimosis; (3) stone. The first two cames can