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position, by strongly contracting the flexor muscles of the

fingers of the right hand, the male branch is driven forwardswith a kind of jerk on the stone, which, if not too hard, issoon crushed by a few movements of this kind. During thismanipulation, the right elbow should be firmly kept againstthe side. Should the calculus not yield to the action of thehand, nothing is easier than to bring the screw of M. Civiale’sinstrument into action. The catch-box is turned from right toleft; this allows the screw to play, the action of which is de-veloped by turning the fly-wheel attached to the extremity ofthe instrument.Even this manipulation will not always succeed, for any con-

siderable enlargement of the middle lobe of the prostate hasthe effect of creating a depression in the floor of the bladderimmediately behind the enlargement, in which depression thecalculus often lies concealed, and escapes the instrument. Incases of this kind, as I mentioned in the former paper, thelithotrite should be two or three inches longer than those inordinary use; its beak must be reversed, and carried down-wards till it reaches the stone.

Again, when the calculus is large and dense, the bladder con-tracted, and the instrument employed is the long beaked ilithotrite with narrow blades, we cannot adopt the manipula-tion applicable to simple cases. The various movements pre-viously described are unnecessary, and cannot safely be executedin the contracted and probably sensitive bladder. In cases ofthis kind there is little difficulty in finding the stone, becauseit is usually large; but, for the same reason, there may be con-siderable difficulty in seizing it. The instrument, slightlyopened, is laid sideways on the stone, and the two branchesare gradually separated until the edges of the foreign body aretouched, when the attempt is made to fix it.When, in simple cases, the stone has been broken by the

pressure of the hand or the screw, the surgeon may proceed tocrush some of the larger fragments, provided the whole opera-tion has not occupied more than five or six minutes. As a rule,however, little more should be done at the first operation thanto break the stone once.. Before withdrawing the instrumentfrom the bladder, it is absolutely necessary to ascertain thatthe branches are perfectly closed, and that no fragments of thestone or detritus are retained between them. I believe thatinjury to the neck of the bladder, chiefly produced by thedébl’is between the blades of the lithotrite, and in other casesby the shortness of the instruments employed, is a frequentcause of mischief after lithotrity. If any fragments or detritusremain, they must be got rid of, either by renewing the pressureuntil the female branch is completely emptied, or by giving afew turns backwards and forwards to the screw.The completion of these manipulations implies that a certain

portion of the stone has been sufficiently reduced to pass off bythe urethra without difficulty. The last step of the operation,therefore, consists in immediately freeing the bladder from thedetritus. If the operation has proceeded in a favourable man-ner, the patient is placed in the erect posture, and a full-sizedmetallic catheter, with a slit on the upper surface near its ex-tremity, is then introduced. The fluid which is in the bladderbeing withdrawn, some tepid water is repeatedly injected untilthe patient complains of fatigue or no detritus comes away. Ihave often been surprised, however, to find that the quantityof d6bris which comes away with this injection is small com-pared with what exists in the bladder, and comes away two orthree days afterwards by the natural efforts of micturition.In some complicated cases, where considerable enlargement ofthe prostate exists, it will be much easier to introduce thecatheter while the patient is in the recumbent posture, and inthis position wash out the bladder.

In ordinary cases, four or five operations will suffice for theremoval of the stone. The interval between the first andsecond should be longer than that between the other opera-tions. After the first crushing, even when performed with theutmost caution, febrile symptoms often supervene, togetherwith local irritation, which it may require one or more weeksto subdue before the crushing is repeated. Between the subse-quent operations an interval of only a few days may be neces-sary.Whether chloroform should be employed in lithotrity, is

a question which the surgeon will have to determine. Twohigh authorities, Sir B. Brodie and M. Civiale, have pronouncedagainst the use of chloroform, and in two cases only during thelast four years have I resorted to its use. Lithotrity is notnecessarily a painful operation, and the feelings of the patientmust be looked to as our guide in two important particulars.They serve to indicate whether any serious injury is inflictedon the soft parts by our manipulations, and they assist us indetermining whether the operation is carried on within those

limits which the bladder and constitution are capable of en-during. As a general rule, therefore, I advise that chloroformshould not be administered, and the chief exceptions which Iwould make are in nervous patients-females, for instance, andchildren.

(To be continued,)

CLINICAL REMARKS, BY DR. BRINTON,AT THE ROYAL FREE HOSPITAL.

IT has repeatedly been suggested to me by professionalfriends, conversant with the number and importance of thecases constantly under my care at the Royal Free Hospital,that, in the absence of any such reports of them as might begiven by Clinical Lectures, a few brief remarks on some of theirmore characteristic features would often have sufficient interestto deserve publication in THE LANCET. For many years, how-

ever, I have not complied with these suggestions; in the hopeof being able to incorporate such experiences, either with vari.ous monographs, on the one hand, or with clinical instructionin a recognised Hospital, on the other.The circumstances which induce me now to modify this reso-

lution I need not detail; save to point out, that the contrastbetween the amount of an Hospital Physician’s practical duties,and of his literary leisure, soon forbids anyone who rightly ap-preciates the responsibilities of authorship from attempting towrite on many diseases, even in the sense of contributing merEssays on certain of their aspects. And since, for some timepast, I have rarely gone round the wards unaccompanied bysome student or practitioner, to whom explanation or illustra.tion has often been a matter of common professional courtesy,I have gradually found myself talking what, rather to my owasurprise, my auditors have sometimes challenged as being, forall practical purposes, clinical instruction.

It is not, however, in this light that I would offer the clinicalremarks of which the following form the first illustration. In-

struction in an art like that of Medicine should, doubtless, beby actual demonstration rather than by verbal description.And as examination at the bedside now seems likely to beadopted as a means of finally testing the student’s fitness forpractice, it may be hoped that, by-and-bye, the ExaminingBodies will dispense with the clumsy expedient of merely re-cognising the number of beds in an Hospital; and will acceptthe student who can detect and treat disease, without askingwhether he has learnt to do so by working sedulously in asmall Hospital or a large one. But however limited is now the

range of the private clinical instruction I have to give, andwhatever the difficulties and discouragements which balanceits usefulness, I cannot but think that brief casual remarks-"here a little, and there a little,"-such as form the staple ofthis bedside demonstration of disease, might sometimes convey,even to those of us who are more advanced in the study of ourprofession, a livelier idea of any ordinary case than systematicreports, which detail days and hours, and continuous symp-toms, with wearisome iteration.

‘

And here let me incidentally mention a plan by which Ihave long wished to see clinical instruction imparted in ourrecognised Hospitals. I dare not trust myself to point ott thedefects of our existing system, or to contrast the average ofinstruction of this kind given in London with the more carefuland conscientious efforts which seem to be made by our brethrenin Dublin and Edinburgh. But if our present system of teach-ing is to be maintained, I think it should be made to aim lessat the training of a few clinical clerks or dressers (often of

: superior diligence and capacity) to great excellence, than ataffording every pupil possessed of average ability and industry.

the opportunity of acquiring a fair practical skill. And justas it is by the number of pupils so taught how to benefit the; public that I should estimate the usefulness of the clinical; teaching at any given hospital, so I am sure it would be easy

to devise a plan by which every student in the course of hisl career should fall under the close personal supervision andL teaching of a clinical Demonstrator; to be either passed on tothe above valuable appointments as really qualified to hold

83

and to use them, or telegraphed to the Hospital authorities, oreven to the Examining Bodies, as having, perhaps from somesufficient reason, voluntarily put aside this most importantmeans of practical improvement, when pressed on his accept-ance.

I am aware of the difficulties which oppose such a plan, andthe obstacles it would assuredly meet with. But as I have thevery best means of knowing how much practical demonstra-tion can really do in clinical medicine-how much, namely, ithas done in the case of pupils of my own-I venture to think thatthis suggestion, of systematically carrying out what has casuallybeen long proposed and adopted by the most eminent teachersin Great Britain, is not unworthy of mention. In any case,what between the wide publication which this suggestion nowreceives in THE L--NCET, and the repeated attempts I havemade to secure for some such plan as the preceding a trial inone or two of our larger Hospitals, I may at least claim to haveuttered the conviction which fourteen years of teaching andlecturing have impressed upon me. Liberavi animam rneam.

In concluding this brief introduction, I have but to warnthe reader not to expect in the following "remarks" any-thing more than such a term strictly implies. But I hopethat their fragmentary character will not seriously diminishtheir usefulness. I believe that it need not prevent me fromoccasionally making them the vehicle of some novel detailsof practice, suggested to me by many years of arduous hos-pital work. They will be illustrated neither more nor lesscopiously than it is my custom to make sketches or diagramshelp verbal descriptions in the wards. And lastly, while I i

can only promise their careful revision, I can at least guarantee Ithat, whether as remarks or Lectures, they will faithfully reportthe particulars to which they refer.

IRREGULAR AGUE.

In this bed is an Italian, suffering from an ague, extra-ordinary only in the length (five days) its intermissions havefor some time offered. His spleen is enlarged (here its outlineswere marked out), though so moderately, that unless Mr. -(a student present) will kindly permit me to tap at the out-side of his coat, as a sort of exea°inzentum c1’ucis, I can hardlyhope you will fully realize this fact. Measured thus accurately,by anyone thoroughly versed in auscultation, scarcely one spleenin a hundred fails to show some abnormal enlargement during(often long after) an ague. Our patient, whose next paroxysmfalls due to-morrow, will probably never have another fit, andmay go out well in a fortnight. (He has since done so.)

’’ His case recalls a very good illustration of the Proteanaspects of ague, in a countryman of his, who, a few weeks ago,- occupied the same bed. A Piedmontese, of forty-five or fiftyyears old, came in with great general anasarca. The heart wasweak, but otherwise healthy; the urine, though scanty andconcentrated, was also otherwise healthy, both chemically andmicroscopically. His face, and a peculiar booming first soundof the heart, thin almost to a blowing character, suggestedaguish poisoning. But if you know the privations, the toil,and the filthy crowded dwellings of some of these poorforeigners in London, you will see that his pallor and debilitymight well have been due to other than malarious causes.Of course I eagerly searched his history. But he spoke

nothing save a Piedmontese pcäoÍ’5, not easy for me to compre-hend. However, our dialogue soon made me quite sure thathe had never had anything akin to ordinary ague. His brain,however, was enfeebled. His story, poor fellow, always tookme b:1c1;: to his wife’s death in Italy, from typhoid fever, somethree years ago, and the suffering he endured in watching andnursing, to finally lose her.

" The spleen was a trifle larger, but scarcely duller to per-cussion, than it should have been. Remember the differencebetween these two points. A thin, flat, solid cake, over a cavitylike the cardiac end of the stomach, gives you quite a tympaniticsound. It is the tone sype2-acided to thifs which, at the thinedge of the spleen, marks its widened outline; a fact which Ijust now demonstrated, though I cannot well describe it inwords. Dullness to percussion means thickening.

"Here, then, I was left to make a diagnosis. A spleen,which might mean little; a face and heart, which might meanmany things. A dropsy, utterly disproportionate to every-thing else, and very rare as the chief or sole symptom, even inregular ague. And a history which suggested nothing at all.I trusted to that professional instinct which had mentally

Hashed into an opinion the moment I saw the patient’s face,and before I even reached his bed-side. Under quinine andiron, and a generous diet, he recovered from his dropsy in little’more th&.n a fortnight; and went out of hospital comparativelyruddy, fat, and strong, in little more than a month."

NOTES ON

ATROPHY AND DEGENERATION OF THE

ARTERIES, ETC.

BY EDWIN CANTON, ESQ., F.R.C.S.,SURGEON TO THE CHARING-CROSS HOSPITAL, AND LECTURER ON

SURGICAL ANATOMY.

PART III.

JAMES P-, aged fifty-three, a cabman of well-hnown in-temperate habits, was admitted into the Charing-cross Hos-pital, under my care, on the 8th of May, 1858, with a com-pound fracture of the lower third of the tibia and fibula. The

external wound was not an inch in length. The bones were

readily adjusted, and the edges of the opening over them easilybrought together. A small quantity of blood only had beenlost. No other injury had been received, and the recoveryfrom shock was apparently speedy. It was soon to be per-ceived, however, that the reparative powers were in abeyance;the man’s spirits were always depressed; his countenance, atfirst plump, soon became jaded, and the listless expression ofthe eyes spoke of gloomy forebodings ; there was no rallyingsmile betokening force. In twenty days from his admission hedied from pyaemia, without having displayed a single hopefulsymptom.At the autopsy, the body was seen to be moderately well

stored with fat, and though the age was but fifty-three, thereexisted in each cornea a broad circle of fatty degeneration.Thorax well formed. Cartilages of the ribs to a great extentossified, and presented under the microscope fatty degenerationwhere calcification had not yet taken place. There was a largequantity of pus in the right pleural cavity. Lungs healthy.The trunk of the left coronary artery of the heart presented,here and there, calcareous scales, and its branches were speckledby fatty deposits between their coats. The heart itself was

tolerably firm in substance/but its fibres were, in many parts,in an advanced stage of fatty degeneration. All the valveswere normal.* Abdomen : Liver large, pale, and fatty, con-taining abscesses of various sizes. Spleen quite pulpy, and insome parts almost diffluent. Kidneys pale, and the middleportion of each showed fatty degeneration.! The aorta, in itsentire length, presented atheromatous patches and calcareousplates. This condition pervaded also the iliac and femoralarteries. The larynx was almost completely ossified, --inclusiveof nearly the whole of the arytenoid cartilages; those portionswhich were as yet unaffected by bony change were involvedby fibrous and fatty degeneration.

P—— was a well-built man, of only fifty-three YCW’S of age,though coiistitittionally much older; in "living on his forces"he had lived too fast, and undermined their integrity. He wasin constant exposure to all states of weather, and the habitualexcitement of dram-drinking and cab-driving. Gradually in-creasing impairment of nutrition resulted, eventuating inatrophy and degeneration. The great extent to which the

* " In the course of some investigations made in the year 1649, I was led toobserve, that fatty disease of the heart and disease ot the valves were notusually found together. This was at first an impression; but as these maysometimes be erroneous, I set about collecting data on which to found solidconclusions, and in a short time had collected some 53 eases. Of these, Ifound the valves were healthy in 43, which left only 10 of an opposite character.Here, then, was a fact of some consequence, and which I have taken everyopportunity of testing since, and with no other result thsn still further con-firming the point. I have noted 152 additional cases, so that the entire, now,amount to 205. These numbers, I thin]:, speak for themselves, and appear tomyself to prove that valvular disease and fatty heart are rarely eo-existent."—H. Kennedy, M.D.: "Edinbmgh Medical Journal," No. xlix., p. 15, July, 1S59.t The following interesting case is extracted from Dr. Todd’s " Clinical

Lectures on certain Diseases of the Uiinary Organs and Drupies" (p. 83,London, 1857):-" A copper-plate printer, and by the nature of his avocationsubject to great vicissitudes of temperature. His age is hfty-flve years. Hedenies being an intemperate man, but admits that his habit h1s been to drinkabout two quarts of porter and a quartern of gin daily. He never had rheu-matism or gout, nor have any of his family suffered either of these complaints.On examining the eyes, each cornea exhibits a well-marked arcus senilis." This patient was under treatment for many months, suj’er;:ig’ from renal

dropsy, of which he eventually died."A post-mortem examination was made of the abdomen only, when the

kidneys were found to be larger than natural, and presented exceedingly goodspecimens of fatty degeneration of these oigans, exhibiting under the micro-scope the usual characters of this form of renal disease."

’

Dr. Christison, in speaking of intemperance, in its different degrees, as acause of granular degeneration of the kidneys, observes : "I am not preparedto state the exact proportion of cases referable to one variety or another of in-temperance, but I certainly am within the mark in stating it at three-fourths,or even four-fifths, of the whole:’-" Oa Granular Declaration of theKidnevs." n. 110. Edin1mr2’1->. 1R39.

c