Reviews and notices of Books

3
267 Mr. C. BROOKE exhibited a specimen of ULCERAT10N OF ONE KIDNEY, SLOUGHING OF THE BLADDER, AND FISTULOUS OPENING FROM THE BLADDER INTO THE RECTUM. The subject of this disease, a middle-aged man, was admitted, under the care of Mr. Brooke, into the Westminster Hospital, with extensive extravasation of urine, which had existed for four days previously. The distention was freely relieved by incisions, and the scrotum was saved; but the integument of the perinæum appeared to have almost lost its vitality, and a large portion subsequently sloughed; after which the urine escaped freely from an orifice at the bottom of the wound. A small catheter was introduced and retained, through which the urine Rowed, and was occasionally ejected per saltum. Never- theless, the catheter could not be satisfactorily passed into the bladder; the point probably hitched in the vesical orifice of the fistulous canal, which appears to be of long standing. The patient stated that no instrument had been passed for four years, and for some years previously one of very small size only. The fistulous communication with the rectum was in- ferred from the passage of some apparently vesical mucus per anum. The patient sank from exhaustion. The slough con- tiguous to the neck of the bladder probably comprises the strictured portion of the urethra. There was also a very much constricted congenital phymosis. Dr. CocKLE showed a specimen of INTRA-THORACIC (VASCULAR) CANCER, occurring in a married female, aged twenty-eight. The mass was tripartite, exceeding in aggregate bulk an adult head, and of so semi-fluid a consistence that, in detaching it from its con- nexions, large quantities of grumous blood and encephaloid matter escaped. The portions of the mass were invested with a fine bounding membrane of glistening character. The larger rounded portion occupied nearly the entire left side of the chest, crushing the lung along the vertebral column, and ad- hering to its anterior face. Firm adhesions existed on this side throughout, particularly between the tumour, spine, and mid-portions of the fourth, fifth, and sixth ribs, which latter were markedly softened, and formed a medium of connexion between the tumour and an oblong swelling on the outer chest wall of some inches in area, corresponding to the left axillary line. The tumour, in its progress, gradually carried the heart before it as far as the right nipple, where, during life, it was seen and felt pulsating. The tumour itself did not extend but slightly beyond the right costal cartilages. By this encroach- ment, however, together with the displaced heart, the right lung also was greatly lessened in volume, to the extent of at least one-half, and bound down by adhesions. The second por- tion of the tumour, the size of an orange, nearly separate from the larger mass, lay behind the manubrium sterni, and a still smaller portion, of fig-shape form, was situated below the xiphoid cartilage. The heart was normal in size and structure. Considerable effusion existed in the peritoneum, as also exces- aive infiltration of the lower extremities. The symptoms and physical signs in this case, in its early and middle stages, were those of relapsing pleurisy, with copious, and, possibly, cir- cumscribed effusion. One important point, however, to be mentioned, was the increase, by measurement, over the left mammary region; but, since here tenderness and a markedly liquid impulse during cough existed, the case was, at this period, mistaken by him for empyema, and these signs re- garded as marking a tendency to the production of an empyema of necessity; and it was only after an exploratory puncture had been unsuccessfully made, together with the occurrence of the external tumour, that a suspicion was excited of malignant growth. Dr. BENNETT hoped that when the case was published, some fuller account of the physical signs during life would be given. The case had been in St. Thomas’s Hospital, and was at first regarded as one of empyema, but was eventually determined to be one of intra-thoracic tumour. The cardiac displacement was very great. The chest was punctured by a small trocar, and only a little blood followed; but the needle entered the ehest as if it contained fluid. CA98A.RIAN SECTION.-M. Alloin, in the " Journal de Médecine et de Chirurgie Pratique," publishes an account of an operation successfully performed both for mother and infant. The sides of the incision in the abdomen were kept in contact by means of compresses and bandages, the operator being opposed to sutures in these cases. Reviews and notices of Books. Second Memoir on Excision of the Knee-joint; to which is Ap- pended a Remarkable Example of the Power of Operative wfurgery in Saving the same Articulation. By RICHARD G.. H. BUTCHER, Esq., M. R. I.A., Surgeon to Mercers’ Hospital, and Lecturer on Clinical Surgery, Examiner on Surgery in the Royal College of Surgeons in Ireland, &c. With Illus- trations. Dublin: M’Glaahan and Gill. 1857. THE advocates of excision of the knee-joint will hail with satisfaction this second memoir of Mr. Butcher, and the entire profession will feel indebted to the author for having so honestly and carefully recorded the results of two years more experience of this very interesting operation. The course pursued by Mr. Butcher in this present memoir is the same that was adopted in the former one. A notice of each case that has come to his knowledge, either through the medium of the public journals, or through private information, has been carefully arranged. "The surgeon who operated; the hospital in which the patient was lodged; the sex and age of the person; the date of the operation; the result as to life; and the condition of the limb at the time the report closed." In this manner fifty-one operations are collected as having been performed in the interval between May 17th, 1854, and. October llth, 1856, and for many of these cases, says the author, . " I am indebted to the pages of the medical press; but for many more, which have not appeared in print, I am deeply indebted to the kindness of the operating surgeons in England and Scot- land, who have most courteously answered all my inquiries." Were it not, therefore, for the labours of the author in col- lecting all these cases of the operation, it is evident that much valuable experience in this department of surgery would be lost, and many interesting features that have been brought to. light would have remained still to have been learnt, perhaps to the disadvantage of the patient, and to the more limited success of the operation. The arrangement of the table at page 40 is admirable; but if the exact nature and origin of the disease for which the opera- tion was undertaken, in each particular instance, had been specially stated, we conceive it would materially increase the value of the statistics. In some of the cases, the records of which were sent to the author by the operators themselves, no strict allusion is made to the nature of the affection requiring the operation, which, perhaps, fails to cover a point upon which some disposed to deteriorate the value and objects of excision of the knee-joint might quibble. It is interesting to glance down the columns of this bold array of cases, and to see the names of those surgeons who counte- nance the operation. Many connected with the general im- provement of operative surgery will be found, men whose opinions carry immense weight, and whose example is imitated in every quarter of the globe where surgery is practised. There is, however, an almost total absence of names, ,familiar in our mouths as household words." The vast opportunities afforded by many of our large London hospitals have been allowed to pass, and an inertness to the value of this useful operation is sadly apparent. It is, however, to be hoped that the success which has attended the limited number of cases re- corded, will stimulate those whose duty it is to treat, to the best of their judgment, the afflictions of patients whose corn- forts and advantages are paramount to the adherence to ancient doctrines and prejudices. It is, on the other hand, gratifying to find men of less note testing the value of this important pro- ceeding for themselves, and departing in a somewhat disre- spectful, though wise, manner from the dictates and precepts of their elders. The results afforded by the table are criticised and investi- gated with fairness and impartiality. The author j’.!2tly ob. serves,-

Transcript of Reviews and notices of Books

267

Mr. C. BROOKE exhibited a specimen ofULCERAT10N OF ONE KIDNEY, SLOUGHING OF THE BLADDER,

AND FISTULOUS OPENING FROM THE BLADDER INTO THERECTUM.

The subject of this disease, a middle-aged man, was admitted,under the care of Mr. Brooke, into the Westminster Hospital,with extensive extravasation of urine, which had existed forfour days previously. The distention was freely relieved byincisions, and the scrotum was saved; but the integument ofthe perinæum appeared to have almost lost its vitality, and alarge portion subsequently sloughed; after which the urineescaped freely from an orifice at the bottom of the wound. Asmall catheter was introduced and retained, through which theurine Rowed, and was occasionally ejected per saltum. Never-theless, the catheter could not be satisfactorily passed into thebladder; the point probably hitched in the vesical orifice ofthe fistulous canal, which appears to be of long standing. The

patient stated that no instrument had been passed for fouryears, and for some years previously one of very small sizeonly. The fistulous communication with the rectum was in-ferred from the passage of some apparently vesical mucus peranum. The patient sank from exhaustion. The slough con-tiguous to the neck of the bladder probably comprises thestrictured portion of the urethra. There was also a very muchconstricted congenital phymosis.

Dr. CocKLE showed a specimen ofINTRA-THORACIC (VASCULAR) CANCER,

occurring in a married female, aged twenty-eight. The masswas tripartite, exceeding in aggregate bulk an adult head, andof so semi-fluid a consistence that, in detaching it from its con-nexions, large quantities of grumous blood and encephaloidmatter escaped. The portions of the mass were invested witha fine bounding membrane of glistening character. The largerrounded portion occupied nearly the entire left side of thechest, crushing the lung along the vertebral column, and ad-hering to its anterior face. Firm adhesions existed on thisside throughout, particularly between the tumour, spine, andmid-portions of the fourth, fifth, and sixth ribs, which latterwere markedly softened, and formed a medium of connexionbetween the tumour and an oblong swelling on the outer chestwall of some inches in area, corresponding to the left axillaryline. The tumour, in its progress, gradually carried the heartbefore it as far as the right nipple, where, during life, it wasseen and felt pulsating. The tumour itself did not extend butslightly beyond the right costal cartilages. By this encroach-ment, however, together with the displaced heart, the rightlung also was greatly lessened in volume, to the extent of atleast one-half, and bound down by adhesions. The second por-tion of the tumour, the size of an orange, nearly separate fromthe larger mass, lay behind the manubrium sterni, and a stillsmaller portion, of fig-shape form, was situated below thexiphoid cartilage. The heart was normal in size and structure.Considerable effusion existed in the peritoneum, as also exces-aive infiltration of the lower extremities. The symptoms andphysical signs in this case, in its early and middle stages, werethose of relapsing pleurisy, with copious, and, possibly, cir-cumscribed effusion. One important point, however, to bementioned, was the increase, by measurement, over the leftmammary region; but, since here tenderness and a markedlyliquid impulse during cough existed, the case was, at thisperiod, mistaken by him for empyema, and these signs re-garded as marking a tendency to the production of an empyemaof necessity; and it was only after an exploratory puncturehad been unsuccessfully made, together with the occurrence ofthe external tumour, that a suspicion was excited of malignantgrowth. - _ -

Dr. BENNETT hoped that when the case was published, somefuller account of the physical signs during life would be given.The case had been in St. Thomas’s Hospital, and was at firstregarded as one of empyema, but was eventually determinedto be one of intra-thoracic tumour. The cardiac displacementwas very great. The chest was punctured by a small trocar,and only a little blood followed; but the needle entered theehest as if it contained fluid.

CA98A.RIAN SECTION.-M. Alloin, in the " Journal deMédecine et de Chirurgie Pratique," publishes an account ofan operation successfully performed both for mother and infant.The sides of the incision in the abdomen were kept in contactby means of compresses and bandages, the operator beingopposed to sutures in these cases.

Reviews and notices of Books.Second Memoir on Excision of the Knee-joint; to which is Ap-

pended a Remarkable Example of the Power of Operativewfurgery in Saving the same Articulation. By RICHARD G..

H. BUTCHER, Esq., M. R. I.A., Surgeon to Mercers’ Hospital,and Lecturer on Clinical Surgery, Examiner on Surgery inthe Royal College of Surgeons in Ireland, &c. With Illus-trations. Dublin: M’Glaahan and Gill. 1857.THE advocates of excision of the knee-joint will hail with

satisfaction this second memoir of Mr. Butcher, and the entireprofession will feel indebted to the author for having so honestlyand carefully recorded the results of two years more experienceof this very interesting operation. The course pursued by Mr.Butcher in this present memoir is the same that was adoptedin the former one. A notice of each case that has come to his

knowledge, either through the medium of the public journals,or through private information, has been carefully arranged."The surgeon who operated; the hospital in which the

patient was lodged; the sex and age of the person; the date ofthe operation; the result as to life; and the condition of thelimb at the time the report closed."

In this manner fifty-one operations are collected as havingbeen performed in the interval between May 17th, 1854, and.October llth, 1856, and for many of these cases, says the

author, .

" I am indebted to the pages of the medical press; but for manymore, which have not appeared in print, I am deeply indebtedto the kindness of the operating surgeons in England and Scot-land, who have most courteously answered all my inquiries."Were it not, therefore, for the labours of the author in col-

lecting all these cases of the operation, it is evident that muchvaluable experience in this department of surgery would belost, and many interesting features that have been brought to.light would have remained still to have been learnt, perhaps tothe disadvantage of the patient, and to the more limited successof the operation.The arrangement of the table at page 40 is admirable; but if

the exact nature and origin of the disease for which the opera-tion was undertaken, in each particular instance, had beenspecially stated, we conceive it would materially increase thevalue of the statistics. In some of the cases, the records ofwhich were sent to the author by the operators themselves, nostrict allusion is made to the nature of the affection requiringthe operation, which, perhaps, fails to cover a point upon whichsome disposed to deteriorate the value and objects of excisionof the knee-joint might quibble.

It is interesting to glance down the columns of this bold arrayof cases, and to see the names of those surgeons who counte-nance the operation. Many connected with the general im-provement of operative surgery will be found, men whoseopinions carry immense weight, and whose example is imitatedin every quarter of the globe where surgery is practised.There is, however, an almost total absence of names, ,familiarin our mouths as household words." The vast opportunitiesafforded by many of our large London hospitals have beenallowed to pass, and an inertness to the value of this useful

operation is sadly apparent. It is, however, to be hoped thatthe success which has attended the limited number of cases re-

corded, will stimulate those whose duty it is to treat, to thebest of their judgment, the afflictions of patients whose corn-forts and advantages are paramount to the adherence to ancientdoctrines and prejudices. It is, on the other hand, gratifyingto find men of less note testing the value of this important pro-ceeding for themselves, and departing in a somewhat disre-spectful, though wise, manner from the dictates and preceptsof their elders.The results afforded by the table are criticised and investi-

gated with fairness and impartiality. The author j’.!2tly ob.serves,-

268

The review demands grave and serious consideration. The for excision, debar the patient from a likelihood of cure by am-’Cause of death in each instance must be strictly investigated, as putation ?" One very interesting case, under the care of Mr.well as the reason of failure in others, demandmg, as a dernier Hutchinson, is quoted at some length, to show that such anressort, amputation of the limb. Uut of fifty operations, death error does not debar the patient from the chance of ultimatefollowed in nine instances, from which number one must be

error does not debar the Patient from the chance of ultimate

subtracted, Case XXIII., partial excision. Seven were sub- cure by amputation.jected to amputation, and only one died. One case is said to A very important question, " Is amputation likely to be suc-be in a precarious way, and all the rest are either cured with cessful when performed some days after excision, owing to someuseful limbs, or progressing rapidly towards the same result." unfortunate circumstance having arisen ?" is discussed at some

It is interesting to trace the cause of death in each of these length. From the details of the seven cases in which it wasfatal cases, and by doing so, a just appreciation of the value of expedient to resort to amputation of the thigh, owing to variousthe operation may be obtained, circumstances, it would appear that the success is greater thanThe cases after excision, requiring amputation of the thigh, could be expected. Six out of the seven instances made an

seven in number, are analyzed with the same impartiality. excellent recovery.The author then "turns from the dark side of the picture to Mr. Butcher naturally looks with satisfaction to this return

investigate those cases which have been successfully cured, "and as contrasted with the result of the wholesale lopping off ofgratifying is it to find such encouraging success, limbs for " abscess, and " ulceration of the cartilages."

Certain statements were made by the author in his former We have reviewed this very admirable memoir at some

memoir in favour of excision, and now again he has been enabled length, and in so doing it is hoped that many surgeons who,to adduce additional evidence to prove the correctness of those perhaps, would not otherwise have become acquainted with its:assertions. pages, will be induced to study its valuable details. The pro-

Firstly.-It is satisfactorily proved "that the danger of ex- fession is deeply indebted to Mr. Butcher for this excellent- cision of the knee-joint is considerably less than that attending addition to other papers on conservative surgery. The time

- amputation of the thigh." has now arrived, as is seen by the table of names attached to

Secondly.-By numerous examples it is again demonstrated tho operation, when the dictates of teachers on many pointsthat " the after utility and ceemliness of the limb are vastly must cease to be blindly received. It will not now-a-dayssuperior to any artificial substitute, no matter how beautifully suffice for a new operation to be condemned from a lecture-contrived. " table. Experience and facts must soon overturn empty asser-

It is unfortunate to observe that the author is obliged to tions and deep-rooted prejudices, no matter how strongly sup-regret thati n all instances due care has not been taken in the ported.selection of suitable cases for resorting to the operation. The remarks and criticisms must be valued as emanating" fear the panting after éclât has charmed away some from

from one who is in every respect an admirable authority onthe stern dictates of judgment; yet I trust this may never be many points connected with conservative surgery. It is to be

the case, infinite mischief is done by such rashness. Not only hoped that Mr. Butcher will, before long, again record futureis the life of the patient jeopardized by an operation which experience, and be rewarded for his labours in this departmentcannot secure a useful limb for the purposes of life, but the of surgery, by the more general adoption and success of theoperation itself is brought into disrepute, and open to the sar- operation. <castic criticism of those who know but little about It." opera tion. .,Wastic criticism of those who know but little about it." . The case of the cripple, Hugh Brady, operated upon by the The evidence of several surgeons, who have seen their various author, in Mercers’ Hospital, offers another illustration of theeases some considerable time after they have discontinued at- judicious application of surgery.

ano er us ra iOn 0 6

tendance, proves that the condition of the repaired limb keeps jud icious app licat ion of surgery.

pace with its fellow, and its growth is not checked by excision .

,of the joint. The Change of Life in Health and Disease : a Practical TreatiseThe vast importance of the subsequent treatment of the limb on the Nervous and other Affections incidental to Women at ,

,being properly attended to is very forcibly insisted upon; for the Decline of Life. By EDWARD JOHN TILT, M.D. Second"amongst the foregoing cases there are lamentable instances Edition. London: Churchill. pp. 307.

where it was not adhered to, and which, I trust, will appeal THE volume before us is an expansion of a much smaller one,forcibly to the mind of every thinking man." which made its appearance some years ago. Dr. Tilt has now

" Excision of the knee-joint," says the author, has been fairly occupied the field with a work, which, if it does not in-objected to by some, owing to the tediousness of the convales- clude all that is known upon the diseases of the climactericcence." Some cases of very rapid recovery are adduced, which period, is at all events a repertory of information upon a sub-’very considerably modify these objections. The remarks of jeot not very generally understood. The work is divided intoMr. Fergusson on this point, in a letter to the author, are much twelve chapters : the first five are, an introductory, one on theto the purpose. Mr. Fergusson writes,- physiology of the change of life, one on its pathology, one on

" No doubt the recovery has been very slow in some in- its therapeutics, and one on its hygienics. Then follow chaptersstances; but the same may be said of amputations. It is well which treat consecutively of the diseases of the reproductiveknown that stumps occasionally do not heal for six or twelve organs at this period of life, of the diseases of the digestivemonths, or even a longer date. Such, also, is the occasional organs, and of the skin; the tenth treats of the diseases of thehistory of resection of the elbow. Such, also, seems likely to ’ . ’

, ,, . , - ,

be the case in certain instances of resection of the knee. I ganglionic nervous system, and the eleventh of the cerebro-Tiave, however, seen a patient, after this latter operation, stand spinal affections; and the concluding chapter is miscellaneous.&laquo;on his own leg within three months, and within six months Thus as far as arrangement is concerned the subject ofwalk in a more efficient manner than I ever saw any one in the climacteric derangements is pretty nearly exhausted. Addi-same time make use of an artificial limb. The wound is a very tional value is given to the volume by numerous interestingdinicult one to heal, and I believe, from what I have heard, .... ..., . , .-.., -.,."that the unfortunate and I believe, from cases has have heard, tables, which exhibit various physiological and pathologicalthat the unfortunate resnlt of some of the cases has arisen fromdefective after-treatment. When better surgery prevails in facts in a clear and definite manner.

this respect, it is probable that we shall have more satisfactory Although, as a whole, Dr. Tilt has produced a work whichresults. we can recommend to the perusal of the profession, there areThe author endeavours to prove that a more general adoption some few points in which we feel compelled to differ from him.

of the operation in military surgery will be awarded with suc- In the treatment of the flushes, or " ardor volaticus" of women’ce,,4s; but sufficient data is wanting to enable a positive opinion at the transitional age, no mention is made of a class of agentsto be expressed on this point. which we are disposed to place great reliance upon-viz., anti.

" Does an error in diagnosis,- as to the suitableness of a case spasmodics. Valerian and ammonia, assafcetlda and musk, are

269

not included in the therapeutics of this condition ; and thebloodletting recommended appears to us to be a rather doubtfulremedy, unless the "flushes" are coincident with evidence ofother temporary local congestions of a grave character. Neithercan we give our assent to the distinction drawn between syn-cope and fainting. The cases of sudden death quoted from SirGilbert Blane, and adduced from the experience of the writeras occurring after pernicious fever and delivery, would appearto us to be quite explicable by reference to the damage inflictedupon the heart by any serious cause of debilitation. The ex-

planation given by Dr. Tilt of the manner in which a violentblow on the epigastrium produces death, does not appear incon-trovertible ; for the intimate connexion of the semilunar gangliawith the vagus nerve, and of the vagus with the heart, would

appear to make it quite as likely that death, under the influenceof a violent blow in this region, may be the result of a veritablesyncope, as of the somewhat obscure " leipothymia. "

The condition of women during the " dodging time" is oftenvery complex, and includes a great number of morbid states.We have seen cases in which the hysterical diathesis of thisperiod has been combined with epilepsy, hypochondriasis,pseudo-narcotism, and oxaluria. Such cases derive benefitfrom the use of mineral acids and strychnia. There is a familiarcategory of cases met with in hospital and dispensary practice,to which the name " charwoman’s disease" might be applied;they occur about the climacteric peaiod, but are the result of along course of gin, and they benefit by morphia and other narcotics, which are not generally well borne by women at thecritical period.There is, however, a fund of practical matter in Dr. Tilt’s

book, and no small share of theory also, which is very clearlyenunciated. As the best work on the subject of which it

treats, we can cordially recommend it to the profession.

InventionsIN AID OF THE

PRACTICE OF MEDICINE AND SURGERY.

ARNOTT’S SMOKE-CONSUMING GRATE.

IN an age when the progress of sanitary science is beingmarked by many valuable sanitary inventions, we know ofnone that more justly deserves universal adoption than the in-genious and effective " Smokeless Grate" of Dr. Arnott. Wehave no alternative, at least at present, than to trust to coalsfor our supply of artificial warmth. An Englishman’s fire-side is one of the most cherished of his Lares and Penates. He

loves to see the cheering blaze as well as to feel its warmth.The dreary, ugly, stuffy, close stove of the German and Russianmight parch his body, but would never give a glow to hisheart. He clings to the open fire-place around which he hasso often seen his friends and children gather; it is to him the

focus of his social and domestic enjoyments, and’serves for acompanion when alone. Every Englishman will therefore ap-preciate an invention which tends to perpetuate the open fire-place, by removing those objections which undoubtedly attachto the forms in common use.

If a bright fire be so intimately connected with our ideas ofdomestic happiness, an expressive proverb has also linked inunpleasant association a smoky fire with connubial discord.But smoke, although a visible, tangible, dirty and destructivenuisance, is not the only evil result of burning coal in fire-placesunscientifically constructed. Every kind of coal in common useis largely impregnated with sulphur ; this, under the influenceof heat is thrown off into our rooms in various offensive andnoxious compounds. By the use of Dr. Arnott’s stove all theseinconveniences are avoided, an immense economy attending.From observations of our own we are fully persuaded of thetruth of the estimate put forward by Dr. Arnott and Messrs.

Edwards, who have carried out his views in the construction ofhis stove, that a saving of at least thirty per cent. in coals iseffected. If we reflect for a moment upon the aggregate resultsof diminishing the expenditure of coal in this metropolis by one-third, we shall form some idea of the great importance of thisinvention, if the question, " Will this stove be generally used?"’so pertinently put by the manufacturer, be answered in theaffirmative. It means, beyond cavil, the burning, by one-thirdat least, of that thick, palpable cloud of smoke which contami-nates the London atmosphere. But it means far more thanthat. At present a large proportion of smoke in domesticgrates escapes into the air unburnt-that is, as smoke. Butin this stove all the smoke is burnt; it is converted into heat;and the gases which escape up the chimney are of a nature to.mingle instantly with the general mass of the atmosphere-Already the atmosphere of London is sensibly improved by theoperation of the Smoke Act, which has compelled the propri-etors of factories to consume their own smoke. But this ame-lioration is as nothing compared with the beneficial results thatwould follow the general adoption of Dr. Arnott’s stove. Everyman who substitutes one of these admirable stoves for the rude-and unscientific grates now in use will not only benefit himselfdirectly in health and purse, but will contribute in an impor-tant measure to the general health and economy. We believethat the stove, as manufactured by Messrs. Edwards, of Poland-street, fully comes up to the designs of the accomplished in-ventor. Many of the forms of designs are exceedingly elegant.The prime cost necessarily somewhat exceeds that of thecommon stove; but we see no reason why a plain stove should.not be made on this principle at such a cost as would render it,accessible to every-one

THE RECTANGULAR CATHETER STAFF FORLITHOTOMY.

To the Editor of THE LANCET.SIR,- Will you allow me to correct an important typical error

which occurred in your report of my paper at the Medico-Chi-rurgical Society (THE LANCET, Feb. 28th) ? In the explanatorynote to the woodcut it is stated, that the groove, as shown, issufficiently large," whilst it should have been " is not suffi-ciently large." In the instrument itself the groove comes backquite to the angle, and is there widened out so as to becomeposterior as well as lateral. This is of importance, in orderthat it may be easily found by the knife. Another, but moretrivial misprint occurs in the same note, the concluding wordof which should have been " found" not " formed."

Whilst on this subject, permit me also to reply to some in-quiries which have been made respecting the instrument. With,one in which the foot is of good length, (much longer than inthe one I have been shown as Dr. Buchanan’s,) it is difficult,unless the bladder be very capacious, to push it so far that theangle is in the viscus, and for this reason, as well as the limitedmobility which its shape permits of, it is awkward as a sound.As to the objection made by Mr. Wells, that the angle is liableto slip into the bladder, and that the surgeon may be inducedto cut upon it through, instead of anterior to, the prostate, itwill be apparent to all that such could only happen with a rec-tangular instrument, when its stem was brought low down to-wards the patient’s thighs. Held in the usual way, its shape.makes it absolutely impossible that its angle can be anywhereelse than tolerably superficial in the perin&aelig;um. I can easilyimagine that the accident might happen to any one attemptingto imitate Dr. Buchanan’s practice-i. e., pressing the staffdown upon the rectum, and endeavouring to bring the prostate;as near the surface as possible. It is very desirable that the:merits of the rectangular staff should be discussed as quite dis-tinct from Dr. Buchanan’s peculiar method of lithotomy. Of’the advantages of the staff when used in the usual way I amvery certain, and cannot doubt that it will soon come intogeneral employment. It is important that its details as tolength of foot, width, groove, &c., should be attended to cor-rectly by the instrument-maker. Fergusson, of Giltspur-street,will, I believe, shortly have on hand some, made after themodel of my own, and I shall be most happy to allow any onean opportunity of having it copied who may wish to do so.

I am, Sir, &c.,- Finsbury-circus, March, 1857. JONATHAN HUTCHINSONJONATHAN HUTCHINSON.