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We were strongly reminded of these pathological facts bythe following case, in which no less than twenty years elapsedfrom the first inflammation causing thickening and perhapsadhesion of the coats of the jejunum and bladder, to thesecond inflammatory attack, which gave rise to a destructiveulceration and perforation, over a small area, of the texturescomposing the two organs. Here are a few particulars of thecase as obtained from the dresser, Mr. Edward Vernon:-Luke H-, aged sixty-four years, a farm servant, was

admitted into Forbes’ ward December 30, 1852, under thecare of Mr. Moore. The symptoms on admission are thusdescribed:-The patient has a sallow, cachectic appearance, anervous and irritable manner, and is considerably emaciated;the tongue is brown and furred, and the pulse 100. Pressureoil the hypogastrium gives considerable pain; the man alsocomplains of strange sensations about his head and spine, bothof which feel to him very cold. He passes urine every hour;the fluid is thick, ammoniacal, and very offensive, and anevacuation per anum takes place each time he attempts toiuictui-ate. This man has been very temperate all his life,and attributes his present illness to a large piece of woodfalling across the lower part of his abdomen some twenty yearsbefore his admission. The accident was followed by suppres-sion of urine, and subsequently hsematuria. The patient hadbaen ill six weeks when he was received in the hospital.Mr. Moore ordered mineral acids and tonics, besides an

opiate at night, and this line of treatment produced in a fewdays some amendment; the patient became more communica-tive and rational, and took his diet with an appetite.These favourable symptoms lasted about one week, when

the man relapsed into his former state: he became drowsyduring the day and moaned and started much at night. Thecatheter was several times passed without obstacle, andbrought away small quantities of urine presenting the pro-parties described above.Three weeks after admission the spasmodic action of the

bladder and rectum became more severe; the urine wasmuddy, offensive, and mixed with blood; the skin sallow,exsanguine, and always moist and clammy with an ill-smelliug perspiration. Warm baths and a soap-and-opiumsuppository were ordered, as well as quinine and the mineralacids.For the last fortnight of this patient’s life he lived upon

brandy and soda-water, with the occasional addition of alittle milk. The tongue was dry and brown: the countenancealternately suffused and dark-red, or ghastly and coveredwith a cold adherent sweat; and there was much pain andenderness on pressure around the lower half of the abdomen.During the day the man lay in a state of stupor, and whenthe nurse disturbed him to administer medicine or drink hewould attempt to bite and scratch her and rave incoherently.At night he was constantly tossing about or moaning andclasping his hands to his head. The pulse varied, but wasnever below 120, small and wiry. The urine and f2eces passedinvoluntarily for the last few days; both excretions were ofa black, pitchy colour and consistence, and streaked withblood. The patient about one month after admission becamecomatose, and died within twenty-four hours afterwards.Post-mortem examination, forty-eight hopirs after death.-Body

emaciated,witli sallow cachectic colour of skin; muscular tissuepale and wasted ; absence of adipose matter; omentum shrivelled,presenting red patches, and deprived of fat. Intestines in thelower part of the abdomen of a livid colour,distended, and large.The piincipal portion affected was the jejunum as it crossesthe bladder, to which viscus it was firmly adherent; and theperitoneum in this region was thickened and coated withlymph. On gently separating the jejunum from the bladdera communication was seen to exist between these organs, theperforation in the jejunum being large enough to admit aNo. 12 catheter. The bowel was full of thick grumousmatter; its walls dilated, thickened, and of a dark, lividcolour. No other ulcers were visible in its coats except theone which opened into the bladder; this foramen was roundwith thick puckered edges, and resembled a fever ulcer. Theopening into the bladder was ragged and depressed; its in-ternal margin very irregular and surrounded by effused blood.The peritoneal coat of that viscus was thickened and tough;its cavity very small and filled with reddish and very offensivesemi-fluid matter. The walls of the bladder were from halfan inch to an inch thick. The left kidney was healthy andsmall; the right lobulated, enlarged, and presenting granulardegeneration and congestion. The arachnoid membraneand pia mater separated easily from the brain sub-stance ; they were tough and much congested; no subarachnoidfluid was observed, and the sinuses were full of blood. On

the outer side of the left hemisphere was found a clot ofblood altered in character, evidently of old standing andpassing in deeply among the convolutions; the brain aroundit was softened and suppurating over a space " larger than acrown-piece." The cerebral substance was firm, and theusual sections presented but few red points. The ventricleswere found small; they contained no fluid; their walls werecovered with arborescent congestion, and the texture wasunusually tough. The choroid plexuses were large and gorged,with blood.

It is not a little strange that we find in this case, upon thesame patient, three possible causes of the stupor and comawhich were the principal symptoms of his malady — viz.,cerebral hsemorrhage, granular kidney, and the probableabsorption of some of the constituents of the urine whichpassed into the jejunum. It is very likely that the clot foundin the left hemisphere of the brain had a large share ofinfluence on the cerebral affection, though it is not improbablethat the two other pathological states contributed to give thesymptoms additional intensity.

But, as we stated above, the case derives great interestfrom the perforation of the intestine and the bladder follow-ing so many years after the falling of a heavy body upon thehypogastrium. It might perhaps be doubted that these twocircumstances were connected as distant cause and effect; butas this opinion is not in opposition with the generally re-ceived pathological notions, it may, without straining,be believed, that a chronic thickening and adhesion of the twoorgans over a small area had existed for a long time, and that

L an attack of inflammation (subsequent on fever !) had speedily’ been followed by destructive ulceration or sloughing of im-

perfectly organized parts.l There is, at the present moment, in this hospital, a patient,- under the care of Mr. Shaw, who suffers very severely from a

communication of the same kind as the one described above,with this difference only, that the portion of bowel affected is

3the rectum instead of the jejunum. This distressing state of, things is the consequence of a scrofulous abscess which formed. between the bladder and lower bowel, and burst through the] coats of both organs. The patient has now been suffering1 for many months, and is on the eve of leaving for Margate.

The case offers several points worthy of record, and we shall1 seize the first opportunity of presenting it to our readers.

ST. MARY’S HOSPITAL

Stone in the Bladder; Second Operation; Removal of theCalculus; Recovery.

(Under the care of Mr. URE.)IT is certainly very annoying and painful for a surgeon to

lay open the neck of the bladder and to search the latter invain for the stone, whilst the sound had left no doubt as tothe presence of a calculus. And yet such an accident mayhappen to the most accomplished operator when the stone islodged in a cyst with a narrow neck. Let us see what Mr.Coulson says on this subject.

" It more often happens, however, that a small calculusgets entangled between the meshes of a columnar bladder,and quite eludes our efforts to seize it with the forceps.Here, unless we can succeed in dislodging the stone from itsposition, either with the Roger, the scoop, or some analogousinstrument, I cannot see what is to be done. If we attemptto extract the foreign body without regard to the positionwhich it occupies, the coats of the bladder must be inevitablylacerated. The position of the calculus in a regular sac orcyst formed by the mucous coat, which has been forcedoutwards between the muscular fibres, is a still greaterobstacle, and one, in my judgment, that is all but insurmount-able. Cases of encysted calculi are fortunately very rare,but when they do occur they present one of the most em-barassing conditions with which the lithotomist can have todeal, for the stone is more or less concealed in the sac, theentrance into which may be narrower than the fundus.Could it be made out with any certainty, before an operationhas been undertaken, that the stone is actually lodged in oneof these sacs, I am decidedly of opinion that lithotomy should

not be had recourse to, because it is ten to one that the opera-tion will turn out to have been useless."

It should not be forgotten that the stone may also be. lodged above the prostate gland or behind the pubis, and thus. elude the forceps by this irregular position.l As to the grasping of the calculus by a cyst, we would referLto a case treated at University College Hospital, and lately

386

reported in the "Mirror," (see THE LANCET, vol. i. 1853,p. 56.)Now, it is very likely that Mr. Ure’s patient, who was

operated on for stone, in the country, without a calculus beingfound, presented the peculiarity of a cyst containing thestone; and as Mr. Ure, on performing the same operation fivemonths after the first, succeeded in extracting a calculus, itmay be supposed that the stone, by growing larger, had fallenout of the cyst. The following case presents therefore greatpractical interest as to the difficulties that the lithotomist mayencounter, and the changes which may render a second opera-tion less unfavourable than the one performed in the first in-stance. The case runs as follows:-Septimus N-, aged five years and a half, was admitted

November 19,1852, under the care of Mr. Ure. The patientis a healthy-looking child, of fair complexion, who resides atHull, and has generally drank water from a spring. Abouttwo years ago he first complained of pain about the neck ofthe bladder, was worse after running, and constantly wettedhimself in bed. The pain usually began just before the boypassed urine, and became worse afterwards; micturition wasvery frequent; the water would stop suddenly, and the patientwas in the habit of frequently pulling his prepuce.An operation was undertaken in the country five months

before admission; but after the usual incisions no stone couldbe found.Mr. Ure sounded the little patient soon after his admission,

and readily felt and heard the stone, which however seemedto be encysted. The operation was performed in the usualway on the 24th of November, and with the aid of the scoopa calculus was extracted of about the size of a nutmeg, stalkedlike an almond, and weighing sixty-four grains, (see theannexed engraving.)

The boy progressed very favourably; in about eleven daysalmost all the urine came by the urethra, and he was dis-charged one month after the operation, the principal symptomshaving been the plugging of the wound by clots, and the con-sequent obstruction to the flow of urine.In glancing at the shape of this stone, it might be supposed

that the body of the calculus lay originally in a cyst, thenarrow portion being grasped by the neck of the sac. Theunpleasant clogging of the wound in this case shows how ad-vantageous it may sometimes be found to leave an elasticcatheter in the perinaeal opening.

Reviews and Notices of Books.

A Text-Book of Physiology. By Dr. VALENTIN. Translatedand edited by WILLIAM BRINTON, M.D., Physician to theRoyal Free Hospital. Part I., pp. 320. Renshaw.

THE great work entitled " Lehrbuch der Physiologie" hasalready acquired a world-wide reputation. This must be

acknowledged from the fact that it is universally quoted inall text-books upon the subject. That the work of Dr.Valentin will always exercise a fascinating influence over theminds of true physiologists is certain, because the facts of thescience were not recorded until their existence had beenverified and demonstrated by experiments, chemical and

microscopical, and by mathematical calculations, performedand worked out by the author himself. Completeness andbrevity appear to have been the author’s principal objects.The numerous physico-chemical and microscopical researches,which have done so much towards unravelling many of

nature’s secrets, hitherto unrevealed, are fully detailed, toge-ther with a succinct account of those portions of the physicalsciences on which the facts are established and the theoriesfounded. In the preface the editor observes that-"The advanced student of physiology may use this book as

a convenient summary of many experiments hitherto imper-fectly known in this country. While the beginner will cer-tainly find that, in addition to a full, though condensed treat-

ment of the first principles of this science, it comprehends somuch of various kindred subjects as may either obviate, orwhat is better, fructify, a reference to the ordinary text-booksof each. And in this respect it seems peculiarly adapted tothat increasing number of the educated public, who, althoughunable to devote themselves to an extended course of study,still desire some insight into the natural laws which regulatetheir own life and welfare."-p. iii.

The first part of the English translation now before us con.tains thirteen chapters, treating respectively of Organizationand Life-Organic Animal Functions-Independence of VitalManifestations in Animals-Physical Properties of the Body-Chemical Composition of Organized Beings-Digestion-Absorption — Circulation—Respiration—Evaporation—Secre-tion-The Vascular Glands-Nutrition. Weightsand measuresare described throughout the work in conformity with Englishstandards. Notes have been added by the editor wheneverhe thought a further elucidation of the meaning of the text tobe necessary.The work is most elegantly and elaborately illustrated by

engravings on copper, stone, and wood; many of them arecoloured. The entire number of engravings will exceed fivehundred; those in the part before us are beautifully executed.As a specimen of Dr. Brinton’s translation, as well as of the

terse style in which Dr. Valentin has abridged his great sys.tematic treatise, we quote the following paragraph from

chap. ii., on the organic animal functions:-"ion the series of functions met with in man and the more

highly organized animals, that of digestion elaborates the food,while the useless remainder, mixed with excretory matters,is rejected in the fæces. That of absorption provides for thetransmission of whatever is to be added to the blood-themother-fluid of nutrition. The circulation sends this in closedcanals throughout the body, in order both to the maintenanceof the particular parts and to the renovation of the fluiditself. The respiration effects the greater part of the exchangeof its gases, while the cutaneous transpiration repeats the sameoccurrence on a smaller scale. Besides this, watery vapourand other matters are thrown off both by the lungs and theskin. The organs of excretion offer certain secretions, whichare either destined to leave the body immediately, or mayserve other purposes, and then be discharged, or may, whenwanted, be returned into the mass of the blood. Finally,nutrition maintains, increases, or diminishes the mass of theconstituents of which the entire organism is composed, andforms in this manner the result of the general organic func-tions of the animal being. ,

" While the senses receive the impressions of the externalworld, the phenomena of motion lead to the change in space ofparticular parts, or of the entire mass of the creature. Theorgan of voice results from a suitable connexion of the organsof respiration and movement. The nervous system, whichreceives and elaborates excitements, coerces the musclarfibres to contraction, and constitutes the immediate instrumentof the mental functions, while it at the same time exercises amediate control over most other organs of the body, since itcan alter their movable pieces within certain limits."-p. 6,7.

In concluding a short notice of Dr. Brinton’s excellenttranslation of this admirable work, we congratulate himupon the good taste he has shown, as well as on his talentand accuracy. In a most honourable manner he has con-nected his name with that of Valentin, and with the vastlyimportant science of physiology. Dr. Brinton has not assumeda false character while discharging the duties of translatorand editor. He is in no instance guilty of strutting in plumesthat do not belong to him. He has displayed the modesty oftrue ability, and will receive his reward.Part II. is already nearly in type, and will be published in

a few weeks. It will complete the work. This promptaction is highly creditable both to Dr. Brinton and his

publisher.

EPIDEMIOLOGICAL SOCIETY. - At the ordinarymeeting of this society, to be held on Monday, May 2nd, apaper by Dr. Snow, "On the Comparative Mortality of LargeTowns and Rural Districts, and the Causes by which it isInfluenced," will be read.