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operative dexterity, less of the "tactus eruditus," less of the indescribable something which makes the successful operator, than either median or perineal lithotomy.

Summary of Cases.-CASE I.-Oct. 16, 1886.--M. A., tinplateworker, 19 years, robust, symptoms for twelve months, blood at intervals during five weeks. Condition of urine not stated. Operation :-8 ounces of fluid in rectal bag and 10 in bladder; 21⁄2 inch incision. Peritoneum not seen; bleeding slight; bladder opened by puncture and tearing; stone broke during removal with forceps; bladder wound left open; superficial parts closed with silver stitches, drain tube inserted down to the bladder, and catheter tied in bladder for two days; wound healed on 22nd day. in smallest circumference, and few days ago, perfectly well.

urine per urethram on 11th day; Oxalate of lime calculus, 35%-in. weighing 285 grains. Saw him a

CASE 2.-July 29, 1887.-W. B. H., 4 years; rachitic and thin. Frequent micturition for two or three years. No blood noticed. Urine Alkaline. Operation: No rectal bag, 4 ounces of fluid in bladder; 11⁄2 inch incision; peritoneum not seen; bleeding slight; bladder opened by puncture, and torn; two stones removed with forceps; bladder wound closed with six silk sutures; superficial parts closed with silver, and drained; catheter tied in bladder twenty-four hours; urine from wound on the 3rd day, and continued for five days only. All passed per urethram on the 7th day. Wound not soundly healed until 38th day. Two symmetrical calculi of uric acid with. phosphatic coating, weighing 140 and 142 grains, and measuring 238 inches in shortest, and 33% inches in longest circumferences. Perfectly well at last visit.

CASE 3.-July 23rd, 1887.—G. H., 4 years; robust; frequent micturition for several months: blood?: urine not stated. Operation: No rectal bag; 4 ounces of fluid in bladder; 2 inch incision; peritoneum not seen; bleeding slight; bladder opened by puncture and stretching; stone broke in removal with forceps; bladder wound closed with five catgut sutures; superficial parts closed with silver, and drained; catheter per

urethram for twenty-four hours; urine from wound on 3rd day, and continued for nine days; all urine through urethra on 12th day; wound soundly healed by 24th day. Phosphate of lime calculus; soft and friable; weighing 61 grains. Quite Iwell at last visit.

CASE 4-Aug. 19, 1887.-H. B., 52 years, packing case maker. Healthy but thin. Frequent micturition, pain, and blood occasionally during three years. Urine acid, with trace of albumen. Operation :-rectal bag 10 ounces; bladder I2 ounces; 3 inch incision; peritoneum not seen: bleeding slight; bladder opened by puncture and tearing; stone removed with fingers; bladder closed with six Lembert silk sutures; superficial parts with four silver stitches, and drained; catheter through urethra for seven days Urine came per urethram almost at once, in part from wound on the 1st day, and not again until 8th day, since when it has continued till the present time (seven months). The wound is soundly healed, except for the small fistula. The man is in good health, but the urine contains muco-pus. Uric acid calculus measuring 434 inches in smallest and 7 inches in largest circumference, and weighing 910 grains.

CASE 5.-J. E. T., clerk, 21 years. Well nourished. Symptoms of ten months standing. No blood. Uric acid. Operation-rectal bag 10 ounces; bladder 10 ounces; 21⁄2 inch incision; peritoneum not seen; bleeding slight; bladder opened by puncture and stretching; stone removed with fingers; bladder wound closed with ten silk sutures; superficial parts with four silver ditto, and drained. Catheter per urethram for three days. No urine from wound at any time. Wound soundly healed in 5th week. Triple phosphate calculus measuring 3% inches in shortest and 434 in greatest circumference, and weighing 330 grains. Was shewn at the meeting;

well in every way.

CASE 6.-Feb. 5, 1888.-T. B., 24 years, carpenter; thick set man; frequent micturition and pain during three years; bloody urine occasionally eighteen months ago; urine alkaline with phosphate and few pus cells. Operation:-Rectal bag 10 ounces;

bladder 8 ounces; 21⁄2 inch incision; peritoneum not seen; bleeding slight; bladder opened by puncture and stretching; stone removed with fingers; bladder wound sutured with four silk sutures in its upper half only; superficial parts with three silver ditto and drained; urine through wound at once, and through urethra on following day; wound is still leaking freely. † Triple phosphate stone measuring 3 inches in shortest, and 5 inches in longest circumference, and weighing 412 grains.

All the above cases recovered from the operation without difficulty. Four are absolutely well in every way, and one was operated on only twelve days ago. One has an urinary fistula seven months afterwards. The youngest was 4, and the eldest 52 years. The stones varied in weight from 61 to 910 grains. Symptoms had existed before operation from several months to three years. The rectal bag was employed in all except the four-year-old boys. The peritoneum was never seen. The bleeding was trivial. In five out of the six the bladder wound was sutured: only one healed by primary union. Urine leaked from the others for 7 days, 12 days, 12 days, and 16 days, and 7 months.

I would conclude by stating my opinion that the above six cases, taken collectively, will bear favourable comparison, either as regards risk and suffering to the patient, labour and anxiety to the surgeon, completeness and rapidity of recovery with a similar half-dozen treated by any other cutting operation.

† Urine ceased to flow through wound about the 24th day. He is now quite well.





THE Canton of Grisons is the most eastern portion of Switzerland: on the east and north it is bounded by the Austrian Tyrol and on the south by Italy. Through the whole of this Canton runs, from south-west to north-east, the valley of the Engadine, which is seldom much over a mile in breadth, and often, as between Süs and Zernetz, not half this width. It is divided into two portions, Upper and Lower; the exact point of division is variously stated: Baedeker in his letter-press makes the Upper Engadine cease at Samaden, but in his map it extends to Zernetz. For our purpose to-night we shall include in the Upper Engadine only that most south-west district which lies between Samaden and the Maloja; and it is to this Upper Engadine, so delineated, to which alone reference will be made.

The whole valley is some 60 miles in length, but the Upper Engadine measures only 15. This narrow tract of 15 miles is one of great and striking beauty: its floor is chiefly occupied by a string of pale green lakes-those of St. Moritz, Campfer, Silvaplana, and Sils-the last and largest of which is four and a half miles in length. Linking these together flows the baby Inn, rapidly growing by means of its many glacier tributaries, till it falls, a tumbling torrent, over the escarpment which so strangely separates St. Moritz from Celerina and Samaden. The edges of these lakes are clad with grass and bordered by charming walks beneath the shade of pines. On each side the valley the mountains rise steeply; on the north-west to end in the frozen peaks of the Piz Julier and Piz d'Err; while on the south-east lie massed the mighty glaciers of the Bernina range. But the charm of the Upper Engadine chiefly exists in the grand forms

* Paper read before the Midland Medical Society, April, 1888.

in which these mountainous ramparts are outlined: there is such striking diversity and boldness in their shapes that one can gaze long without perception of monotony.

Its places suitable for winter residence are—the Maloja Kursaal, Sils Maria, Campfer, St. Moritz, Samaden, and Pontresina.

The Maloja Kursaal is not very happy in its situation; it is nearly on the summit of the pass leading down into Italy: this is a very low one, and allows the south-west wind to rush up the Val Bregaglia with a good deal of its unpleasant moisture still in it. The Lake of Sils too lies very near the hotel and is practically on the same level as this; hence one would think, as indeed I was told—I confess, at St. Moritz the Kursaal is apt to share in the mists which hang over the lakes. Certainly the night I spent there in October last the whole place resembled a veritable cave of winds with all the winds let loose and a swirling snow storm added. But Dr. Wise asserts that the Föhn (south-west wind) is rarely perceived here. The Kursaal itself is a magnificent structure and far the most complete in its appointments of all the Hotels in the two valleys.

Sils Maria and Campfer are two charming hamlets on the south and north sides of the valley respectively; they are both well protected from the wind, quiet and sunshiny: as yet they are scarcely to be called winter residences though Campfer is said to have an admirably-conducted hotel.

Samaden has one good hotel which is kept open during the winter and is fitted up most completely as invalid winter quarters. Samaden is blessed with much sunshine and is the Engadine capital, but the scenery will not compare with that of either of the other hamlets.

Pontresina is too bustling in summer, and in winter too exposed, to be suitable for any but very robust invalids; for it is at the meeting of three valleys. For those who can stand such exposure however its large amount of sunshine would prove most exhilarating. It is scarcely as yet prepared to receive winter visitors.

St. Moritz Dorf is at present the place for invalids in winter,

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