nity of examining after death a case where the entire urethra was taken away by this chronic ulceration, the opening of the bladder equalling a sixpence in circumference. No urine had been retained for months, the coats had thinned extremely. These cases furnish remarkable examples of the transition stages of the more chronic forms of this protean disease.

Transactions of Societies.

SURGICAL SOCIETY OF IRELAND.

THE Society met on Friday evening, the 22nd of January, in the Albert Hall, Royal College ofurgeons, Professor MAC NAMARA, Vice-President of the College, in the Chair.

Members present.-Messrs. C. Benson, Jameson, Wharton, Walsh, Elliott, Colles, Croly, sen., Croly, jun., Fleming, Jacob, Morgan, Murdock, Coulton, J. R. Kirkpatrick, Darby, Morrogh, Leech, W. D. Moore, Ferguson, H. Kennedy, Montgomery, Stoney, Roe, Stoker, Purcell, R. H. Moore, C. Moore, Willis, O'Grady, Grimshaw, J. Brady, Bookey, Kelly, D. White, Minchin, Swan, Wright, E. Hamilton, W. Stokes, jun., P. White, F. T. Porter, McSweeny, Croker, Butler, McClean, Skelton, J. K. Barton, Mapother, M. Ward.

CASE OF STONE IN THE BLADDER IN A BOY AGED SIX YEARS. LATERAL OPERATION-RECOVERY.

Mr. HENRY GRAY CROLY said :-The case I am about to bring under the notice of the Society is one in which I performed the lateral operation of lithotomy; and as the operation is not one that is usually adopted in Dublin, I thought it would be interesting to lay the specimen before the Society, and hear the opinions of the members on this mode of operating.

M. G., aged six years, a handsome and extremely healthylooking boy, was admitted under my care into the child's ward of the City of Dublin Hospital, in October, 1868.

History.-Three years previously his parents noticed that he had some difficulty in passing water, and pulled occasionally at the prepuce. He sometimes altered his position in bed when trying to pass water, and screamed from pain. The stream often stopped suddenly, and one day on which he suffered intense pain he passed a small calculus about the size and shape of a pea. The symptoms from that time disappeared, and the child enjoyed excellent health until April, 1868, when he again suffered from the same symptoms, which increased in severity. He was brought to me by his mother, and on hearing the history I placed the boy under the influence of chloroform, sounded him, and quickly detected the stone.

On his admission into hospital he was a perfect picture of health, and, except for the frequent micturition and startings in his sleep, he did not at first suffer much pain. For some days he fretted a good deal after his mother, but soon became accustomed to the ward and played about the yard with some convalescing children. A troublesome attack of diarrhoea (occasioned as I discovered by fruit and cakes injudiciously brought to him by his sister) obliged me to put off the operation for some days. His diet was nutritious, but unstimulating, and he got a tepid hip bath at night.

On the 9th of November I performed lithotomy. A small dose of castor oil was given to the patient the night previously to operation, and his rectum was emptied by an enema of warm water early in the morning. He was chloroformed in bed and carried to the theatre. The operation table was made of sufficient height (3 feet) by firm pillows and folded blankets. The following instruments and appliances were arranged on a tray: -lithotomy jupe-a staff grooved on the side-long-handled scalpel, probe-pointed knife, forceps, blunt gorget the tube with jupes and charpie-basin of warm water on floor for warming forceps and gorget-oil. The staff having been passed and the stone struck, the patient was firmly tied in the lithotomy position, and held steadily, with his buttocks projecting over the edge of the table. Before commencing, I introduced the forefinger of the left hand into the rectum to produce contraction of the bowel. Kneeling on one knee, and having fixed the integument of the perineum with fingers of left hand, I commenced the incision three-quarters of an inch in front of the anus and one line to the left of the raphè, and carried it downwards, backwards, and slightly outwards, well below the level

of the anus and tuber ischii. This incision divided the integu. ment fascia and fat. The second incision was commenced lower down, and having introduced the point of the forefinger of my left hand deeply into the wound, I quickly reached the shaft, and with the nail I pressed the membranous portion of the urethra into the groove, and divided the urethra, freely moving the knife from side to side to make sure of its being in the shaft. I next depressed my wrist, and elevated the point of the knife, keeping its point and back well up against the staff, and so passed it on into the bladder, the stop on the end of the staff telling me when it reached the bladder. Some urine now escaped. I laid down the knife and passed the left forefinger along the shaft into the bladder, the neck of which at this stage of the operation grasped my finger, and the stone fell against the finger's point. Standing up at this stage of the operation, the staff was withdrawn by Mr. Tufnell. I passed along my finger a small blunt gorget, and guided by it the forceps, which, acting as a sound, struck the stone. The gorget was withdrawn, the blades of forceps opened, the stone seized in long axis, and withdrawn with facility. Operation completed in two minutes and thirty seconds. I next passed in the tube, well oiled and plugged around with charpie. Canula was retained by means of tapes, legs and hands were loosed, and the child, who quickly recovered from the effects of the chloroform, was removed to bed, which was comfortably prepared with hot jar-mackintosh and cross sheet-knees tied together, and legs placed on a pillow.

12 noon (two hours after operation). —No hæmorrhage; urine passing through canula, but not very freely.

2 p.m.-Muslin of plug saturated with urine; not much urine passing through catheter; plug removed, as it seemed to act as a foreign body; urine then passed freely through incision.

5 p.m.-Patient was restless through the day, and complained of pain in incision; got an anodyne, which was rejected. 10th (day after operation).-Patient slept well; took ice, chicken broth, and milk; urine passing freely through incision; cross-sheet drawn regularly; pulse 130.

11th. Slept well last night; skin cool; countenance cheerful; buttocks well dried and dusted with flour to prevent irritation from urine.

13th.-Wound commencing to granulate.

15th.-Small quantity of urine passed by urethra. 16th. Urine passed by urethra.

18th.-Nearly all the urine passed by urethra. Dec. 1st.-Patient allowed to get up.

Discharged perfectly well on the 6th of December-twenty. seven days.

The subject of lithotomy in early life is one of great interest to the surgeon, and the operation is one that requires considerable care. It is of great importance to remember the difference of position which the bladder presents in a child and in an adult. In this case, as I have already stated, I used a staff grooved on its side, and completed the operation with one knife, thus adopting the London mode of operating instead of using the second knife for the purpose of enlarging the neck of the bladder, as was generally adopted in Dublin. The chief danger in operating on a child appears to be the chance of the surgeon missing the bladder and getting into the recto-vesical space; secondly, not opening the urethra and neck of the bladder sufficiently with the knife, but pushing these parts before the finger and so tearing across the urethra, and thus necessarily being unable to complete the operation; and thirdly, running the knife too far along the groove of the shaft into the bladder, and thus wounding the posterior part of that organ. In this case I had the probe-pointed knife on the tray, and before commencing the operation I determined, if I found it necessary, to use the second knife; but I confess when I had got the knife into the groove of the staff and fixed it there, I thought it better to go into the bladder with that knife, especially as I knew from sounding that the stone was not a large one.

Mr. CROLY then exhibited a section of the stone, which was chiefly composed of lithic acid with a nucleus of oxalate of lime. He expressed a wish to hear the opinions of the members on these points; first, as to the use of one knife; second, as to the use of a staff grooved on the side; and third, as to the use of a chemisette plug-whether it was of use in any case except where hæmorrhage was expected.

The CHAIRMAN observed that these cases possessed great interest. The questions submitted by Mr. Croly for discussion were well worthy of consideration-the employment of one knife only, the side-grooved staff, and the canule a chemise.

Mr. CROKER said that about two years ago he operated for

stone on a child eleven years of age, who had been sent up from the Curragh. He used but one knife, and the stone was one of considerable size. He used the side-grooved staff, and did not find the chemisette tube at all necessary.

Mr. FLEMING observed that he had operated in a good many instances for stone, and had always used the lateral grooved staff because he supposed he was accustomed to it. With respect to the knife, he had often employed a single knife, and more frequently he had used the lithotome with the knife. He must acknowledge that, in the case of children especially, he should be doubtful as to the safety of the single knife, except under particular circumstances. He should be apprehensive that without precaution a single knife might be sent further than was desirable. As to the canule a chemise, he had constantly used it. He had experienced in three or four instances the necessity of its early removal, as remarked by Mr. Croly, but that might possibly arise from their own fault. Surgeons were sometimes not sufficiently careful, when using the chemisette, to bear in mind the age of the individual. If too long a canula were used in the case of a child, they ran the risk of driving it in further than was desirable, and causing a portion of it to come into contact with the lining membrane of the bladder. In such instances he had seen the flow of urine prevented from coming through the canula, but he was favourable to its use generally speaking, and he would refer the Society to some remarks by the late Dr. O'Ferrall on the use of the chemisette after the operation for lithotomy. He did not mean to insinuate for a moment that in the hands of Mr. Croly the accident would occur to which he had alluded; but he certainly thought the lithotome was a safeguard to the operation, and an especially valuable assistant in the operation on a child.

The CHAIRMAN said he remembered an interesting lecture on lithotomy by Sir Philip Crampton, in 1847, in which he says that Mr. Dease, a celebrated surgeon in this city, latterly used but one knife only in operating for stone, and Sir Philip went on to pay a very high tribute indeed to the reputation of Mr. Dease, "the greatest surgeon," he called him, that this country had ever produced. So that what was originated some seventy or eighty years ago in Ireland was found worthy of imitation in London, and at last received the name of the London method of operating; whereas it was in reality the Irish method. Mr. WHITE said he had assisted the late Mr. Smyly on four occasions in operating for stone, and that gentleman only used one knife, and was always an advocate for that mode of operating. Mr. Smyly spoke to him on several occasions of its being a satisfactory method, and one to which the surgeon coull easily train himself. He was rather surprised to hear Mr. Fleming speak so strongly in favour of the canule & chemise. The experience in the Meath Hospital was that it was unnecessary. He did not remember more than one case out of a considerable number of operations which he saw performed there, in which the canula was used, and in that case the reason for using it was that there was a tendency to hæmorrhage.

Mr. CROLY, in reply, said, when he spoke of using one knife as a London mode of operation, he merely alluded to the general system adopted there, whilst he believed the majority of surgeons in Dublin used the second knife for the purpose of enlarging the neck of the bladder. As to the danger of using only one knife, he knew when he had got the knife as far as the stop, that he had got to the neck of the bladder, and he then used his finger. The chemisette plug which he used was a small female catheter suited for a child's urethra, and with a small piece of cambric upon it, so that it could not get further into the bladder than was necessary. He thought, however, when there was no danger of hemorrhage, that bringing the child's legs together was better than using the

canula.

Mr. MORGAN detailed a case of

SUBCLAVIAN ANEURISM OF THE RIGHT SIDE, and exhibited a preparation of the parts. The aneurism occupied the second and third stages of the artery, and partly engaged the first also; it was the size of a goose's egg, and had eroded the first rib, which formed a part of its wall; the brachial plexus was expanded over the tumour, and seemed to grow out of it, so intricate was the union; the branches were spread over the posterior part, the fascia over the artery, in its first stage, and the sac was very greatly condensed, thickened, and adherent; the internal jugular vein was very small, and both it and the pneumogastric nerve were also in timately adherent, and expanded over the vessel; the accomanying subclavian vein was also contracted, and adherent.

The artery itself was obliterated to one-third its ordinary size, hardly admitting a No. 4 catheter; the opening into the sac was of a curious triangular shape, owing to the adherence and compression of the thickened tissues around. The interior contained a good deal of laminated fibrine in parts, but not regularly deposited over the interior; some of this appeared of a recent date, judging from its density and adherence.

The left carotid arose close to the innominata arteria, lying in front of the trachea in its course upwards. The tumour had drawn over to itself the right carotid.

The collateral vessels were greatly enlarged. The aorta, when opened, showed a large deposit of atheromatous and ossific deposit, the degeneration extending into the arteria innominata itself, which was affected irregularly over half its interior.

The heart was normal in size and condition. Several of the bronchial glands contained_calcareous matter. The lungs were hypostatically congested to an excessive amount, and a quantity of bloody serum had been effused in the pleural cavities, especially on the right side.

The preparation showed the impossibility of exposing the artery itself, owing both to the adherence of the tissues around, and to the contracted and semi-obliterated state of the vessel, and the right carotid artery at its origin.

The history of the case was interesting, as showing the influence of position on the aneurism and on the parts in its vicinity.

1868.

Thomas McC aged thirty-five, of stout build, rather below average height, first came under Drs. Little and Barton's observation at the Adelaide Hospital on January 22, About seven years before, he was troubled with pains, and stiffness all through the arms and shoulders, which he at tributed to working as a dyer. The pain, &c., in the left arm soon after abated, but increased in the right, his occupation being now chiefly cutting bread with a large knife in a union. He felt this very trying and fatiguing, and finally gave it up. Previous to this date, nine months ago, he felt a "kernel" above his collar-bone, which "went ticking like a watch"-that is, twenty-one months before the operation, he first noticed the tumour by its pulsation and size, and for seven years had suffered from pain. He states that he was never affected by syphilis in any form, has healthy children, and has always been a hard-working man.

On examination (22nd January, 1868), the tumour was about the size of a large hen's egg, pulsating visibly and centrifugally, extending from a level of cricoid cartilage to the clavicle and below it; there was a bruit over the tumour, and the hand and arm were somewhat numb; he could not discern a shilling when held between the finger and thumb; the pain was rather severe at times. On making an examination of the tumour at this date, it would appear that pulsation from the axillary downwards was suddenly arrested, as supposed, from the disengagement of a plug of coagulum, as in the "manipulation" method of treatment. This condition lasted till the 3rd of February, when pulsation again returned in the vessels of his arm, and continued till the 18th of February, a period of fifteen days, when again the stream was interrupted. During this period he had been taking ten-drop doses of digi talis tincture, and then three grains of acetate of lead every four hours. On the 24th he was put up in a constrained posi tion, with his hand on the back of his head, as this stopped the pulsation. The transversalis humeri and other vessels were now enlarging considerably.

disappeared nearly, and from this to the 15th of April reMarch 28. Tumour solid; pulse disappeared; pulsation mained stationary. He went to see the Prince of Wales's entrance, took some drink, and got excited. From that day the tumour became more active; the pulse, in brachial, radial, and ulnar, however, did not return; the anastomosing vessels were enlarged. Up to this date the treatment had been carried out of keeping the arm in the peculiar position above alluded to, and so restraining the pulsation in the tumour; indeed, the patient preferred this position as far as practicable.

On the 28th of September he came under my care at Mercer's Hospital. He had the appearance of a man who had suffered much. He was spare, but not emaciated. His chief sufferance now was from paroxysms of pain. The pulse at the wrist and large vessels had totally disappeared; the tumour was pulsating softer above than below the clavicle; there was a slight bruit also over the clavicle, not below. The