has occupied a great portion of the vesical cavity. In all the cases now alluded to, the effect of this extension of the middle lobe of the prostate backwards is to form a reservoir or sac behind the enlarged gland. The floor of the bladder is here greatly depressed; the urine remains as in a sac; and here a calculus may be lodged, the detection of which is often extremely difficult. I have, at the present time, under treatment, a patient who has a stone concealed behind an enlarged prostate, the existence of which had escaped the notice of those surgeons by whom he had been previously examined.

"The necessity of employing special sounds and catheters in cases of enlarged prostate is well known to all practitioners. The increased length of the urethra, and the encroachment of the enlarged lobe on the floor of the bladder, compel the surgeon to use a much longer catheter than usual. In prostatic enlargement the ordinary catheter will not penetrate into the bladder; and the experienced practitioner at once suspects the existence of the complaint from this circumstance. To enter the cavity of the bladder he takes a catheter from two to four inches longer than the one in ordinary use, and with an instrument of this kind he succeeds, after having passed it about twelve inches beyond the orifice of the urethra. The same holds good with regard to the sound. Thus the stem of the ordinary sound measures seven inches and a half; the stem of a moderately sized prostatic sound measures nine inches and a half. An ordinary catheter, now before me, measures nine inches and three-quarters to the point. A prostatic catheter measures thirteen inches and a half. From fourteen to sixteen inches is the length recommended in standard works.

"In cases of enlarged prostate, then, the surgeon requires a long catheter of peculiar shape to draw off the urine. For the same reason-viz., the increased length of the urethra, and the depression in the floor of the bladder—he will require a long lithotrite of peculiar shape, in order to catch and crush the stone with ease to himself and safety to his patient.

"If the long prostatic catheter be expedient, the long prostatic lithotrite is, à fortiori, indispensable. The necessity of employing a longer instrument than usual in such cases will, I imagine, be generally admitted; and if I insist on it here, it is because our standard works do not allude to the point-an omission of which I have been no less guilty than others, and which I would now repair. The ordinary lithotrite of Charrière measures ten inches from the root of the stem to the eye; the chord of the curve, from the eye to the point, is one inch and three-eighths. The long lithotrite, manufactured expressly for me by Charrière, measures twelve inches in the stem, and one inch and threeeighths in the curve. The stem of Weiss's ordinary lithotrite measures nine inches; the stem of the long instrument which he has made for me measures ten inches and a half; the beak is the same length in both, about an inch and a half.

"I need hardly occupy much space in dwelling on the necessity of the surgeon being provided with a long instrument of this kind, and of the many advantages which he will derive from its use. I can only say that I have had cases which, I feel convinced, I could never have conducted to a successful termination without it. It should be remembered that, with an elongated urethra, the distance between the external and internal orifices of the canal is increased by at least an inch. The enlarged prostate, again, occupies the front part of the floor of the bladder, on which it encroaches another inch or more. The calculus lies concealed in a sort of pouch behind the enlarged lobe, which rises like a barrier before it. Under these circumstances, it is evident that the surgeon will require an instrument longer than that in ordinary use by two or three inches; the common lithotrite will either not pass into the cavity of the bladder, or, if it does, after having been forced up to the handle, the motion of its curved part will still be greatly impeded by the prostate.

"In some of my cases the common instruments were not sufficiently long, and it became necessary to push them up to the shoulder before I could turn the point in the necessary direction. With the long lithotrite, on the other hand, the surgeon gets readily into the bladder; but to overcome the impediments likely to arise from an enlarged middle lobe, a peculiarly formed beak is necessary, and the pelvis must be raised.

"The beak or curved part of the lithotrite must be short, and the curve sharp. With an instrument of this kind the surgeon will often be able to fish up the stone from the depression behind the enlarged prostate,' in the manner described in the last edition of my work on the Bladder.' By turning the point down, and elevating the handle of the instrument, the stone will commonly be found in the position already mentioned. When the middle lobe of the prostate is much enlarged, and extends some way into the bladder, the point of the instrument cannot be turned downwards in such a way as to reach the stone. The plan from which I have derived most benefit in such cases is that of raising the pelvis of the patient in such a way that the calculus shall be displaced towards the posterior wall of the bladder. Especial care must be taken that the pelvis itself is raised, and not merely the lower extremities. By adopting this plan, I have, on several occasions, immediately caught the calculi, which lay concealed behind the prostate as long as the patient retained the ordinary position. Every lithotrity couch should be provided with some mechanical contrivance for executing this proceeding quickly. The sufferings occasioned by the attempt to seize a stone behind an enlarged prostate, in the ordinary way, and after strong elevation of the handle, are often of the most distressing kind, and cannot certainly contribute to the well-doing of the patient. On the other hand, the ease with which the reversed beak falls on the stone is remarkable; but the manipulation requires a cautious and practised hand."

ART. 109.-A New Operation for Hydrocele.

By M. CARRON DU VILLARDS.

(Mon. des Hôp., No. 128, 1857; and Medico-Chir. Review, April, 1858.)

M. Carron du Villards, a French practitioner in the Antilles, has devised a modification of Larrey's operation for hydrocele, in consequence of the bad effects which result from injection in that part of the world. The accidents produced by it are tetanus, acute hematocele, suppuration, acute orchitis, easily passing into the condition of induration, gangrene, and, when only weak injections are employed, relapse. The author has himself never met with this consecutive tetanus, but practitioners settled at Cuba have assured him that it is of frequent occurrence there. He has, however, met with a great number of cases of hematocele consequent on injection, either with or without organic transformation of the tunica vaginalis. So frequent are these accidents, that a great number of persons repair to the United States for the purpose of having the injection performed. In such bad repute it is among the creole population and practitioners, that they content themselves with repeated palliative punctures by means of a lancet, the frequent repetition of which almost always leads to the degeneration of the tissues of the scrotum described by Larrey. The author has very frequently met with this form of elephantiasis of the scrotum in the Antilles, where it is known as the Barbadoes disease.

The operation which he has devised in lieu of injection, has now been performed by himself in 50 cases, producing 48 radical cures, and only 2 failures; and subsequently to the presentation of the memoir, M. Camilleri and others have operated 187 times, with but 7 relapses. It is attended with no accidents and but little pain, is adapted for all the complications and varieties of hydrocele, is of easy execution, and requires little confinement or after-treatment. The patient is placed on a high bed, with his buttocks well raised by means of a cushion, and the situation of the testis having been recognized, the operator, taking the lower part of the hydrocele in his hand, while an assistant presses it downwards, punctures the most dependent part of the tumor with a strong and narrow lancet, which he passes slowly in. As soon as the fluid escapes, he slides a long narrow trocar along the blade of the lancet, keeping the point of the instrument within the canula until the upper boundary of the tumor is reached. Having reached this point, the canula is pressed against the tissues, so as to project them somewhat externally, in order to be certain that neither the cord nor a pulsating vessel can be felt in front of it. A piece of cork is next placed against the projected tissues, and against this the trocar is forcibly

driven by the application of the palm of the hand to the handle of the instrument. A counter-opening is thus at once effected, just as the jewellers pierce the ears for ear-rings. The stiletto of the trocar is now withdrawn, and replaced by a grooved silver wire, which traverses the two apertures, and is left in situ on the removal of the canula. Spirit lotions are applied around the scrotum, and during twenty-four hours a slight discharge of fluid takes place. After this period inflammation is set up, and the secretion is no more reproduced. The scrotum becomes afterwards red, hard, and painful, as in acute orchitis, but it rarely requires treatment. More frequently it has been found necessary to encourage action by placing stimulant ointments in the groove of the wire. On the twelfth day (the patient being usually able to get up by the third) the wire is removed, the patient wearing a suspensory until the twentyfifth or thirtieth day, by which time he is usually radically cured.

(c) CONCERNING THE UPPER EXTREMITY.

ART. 110.-Case of Simultaneous Dislocation of both Shoulder joints. By Dr. W. H. VAN BUREN. Surgeon to the New York Hospital, &c.

(New York Journal of Medicine, Nov., 1857.)

CASE.-William Coy, a well-built, middle-aged man, was brought to the New York Hospital on April 21st, 1857. It was learned from his friends that he had fallen headlong down a flight of steps in a house in Pearl Street. He was perfectly insensible, with widely dilated and immovable pupils; pulse 84, rather full and soft; skin cool; respiration hurried and labored, and at each expiration bright arterial blood issued from nostrils and mouth, in small quantity; no bleeding from the ears. He sank rapidly, and died five hours after admission.

On examination of the body thirteen hours and a half after death, extravasated blood was found beneath the scalp over the left parietal bone and in the temporal fossa of the same side, and a fissure commencing about the centre of the parietal bone and tending obliquely downward and forward to the base of the skull. On removing the calvarium, a large amount of fluid blood was found between the dura mater and bone, covering the surface corresponding to both hemispheres of the brain. The brain proper was apparently uninjured, but an extensive laceration occupied the substance of the right hemisphere of the cerebellum. After removal of the brain, the fracture was found to extend through the petrous portion of the left temporal, and across the body of the sphenoid bones; splitting off the sella turcica completely.

Both shoulders were observed to present the usual physiognomy of dislocation into the axilla, and distinct crepitus could be felt on both sides when the humeri were rotated. On dissection of the right shoulder, the head of the humerus was found in the subscapular fossa, lying between the surface of the bone and subscapular muscle, which had been lacerated and torn up from its attachments to make a bed for it. Its exact position was about one inch and a half below, and one inch nearer the median line of the body than the base of the coracoid process. The greater tuberosity of the humerus was broken off, and retained in its normal relation to the glenoid cavity of the scapula by the capsular ligament and the muscles to which it gives attachment. The capsular ligament, extensively lacerated in front and on its inner aspect, presented an elongated shred stretching from the upper margin of the glenoid cavity downward and inward to the dislocated head of the humerus, to which it was still attached. The long tendon of the biceps was found occupying its normal relation to the greater tuberosity, having been dragged out of the bicipital groove, which was empty. The coracoid process of the scapula was fractured through its base, and dragged forward and downward by the action of the coraco-brachialis muscle and the short head of the biceps.

On dissection of the left shoulder, a condition of parts was found similar to that described as existing upon the right side, with the following exceptions: the head of the humerus was displaced more directly downward, resting upon the anterior margin of the lower border of the scapula, just below the glenoid

cavity; the capsular ligament was lacerated on its inner aspect, and less extensively; and the coracoid process was uninjured. The greater tuberosity, however, was fractured off almost exactly in the same manner as on the right side, and retained its natural position in relation to the glenoid cavity, and the long tendon of the biceps.

Apart from its rarity as an example of simultaneous luxation of both humeri, the case just related is remarkable from the similarity of the fracture of the greater tuberosity of the humerus on both sides. The detached fragments were circular in outline, little more than an inch in diameter, and each represented the section of a sphere in its shape, comprising, in fact, little more than the outer shell or cortical layer of the humerus, into which the supra-spinatus, infra-spinatus, and teres-minor muscles are inserted; and they were evidently torn off by the sudden and violent action of these muscles.

This complication of dislocation of the shoulder, with tearing off of the greater tuberosity of the humerus, if we are to credit Malgaigne, occurs much more frequently than is generally supposed, and its presence explains, according to this surgeon, the sensation of crepitus which Velpeau asserts is so often felt in cases of luxation when the shoulder is firmly grasped by the left hand, and the dislocated limb rotated forcibly by the right. Malgaigne also asserts that this lesion is accompanied by the appearance of ecchymosis upon the inner side of the arm within a few days after the accident ("Traité des Fractures et des Luxation," t. ii. p. 512). In two out of the six dissections, which he had made of cases of what he classifies as intra-coracoid luxations of the shoulder (according to him the most frequent variety), the greater tuberosity of the humerus was found torn off, and occupying the same position and relation to the glenoid cavity as in the case which I have described.

ART. 111.-A new Splint for cases in which the Elbow-joint has been excised. By Mr. HEATH, Demonstrator of Anatomy in the Westminster Hospital.

(Lancet, Nov. 28, 1857.)

The three following cases, occurring in the practice of Mr. Fergusson, in King's College Hospital, and related by Mr. Swain, house-surgeon to the hospital, show how advantageously Mr. Heath's splint may be used in cases of this kind, in effecting passive motion after the process of healing is nearly completed. The instrument prevents the bones from coming into close contact, and permits of flexion and extension. It is now in general use in King's College Hospital.

CASE 1-Margaret W, æt. 21, admitted into No. 3 Ward, May 9th, 1857, with disease of the right elbow-joint. The patient is a native of Maidstone, where she had been in service; has never been very strong; and about twelve months ago had a glandular abscess in the neck, which is still open. About six months ago, without any previous injury, the right elbow began to swell, and became so painful that she was unable to move the joint. Fomentations and liniments were used without any relief. The joint became more tender; and in the month of April, an abscess burst a little below the external condyle of the humerus, where an ulcer still remains. The arm continuing swollen and immovable, she was advised to come to King's College Hospital. On admission: she is a pale, delicate-looking young woman. On the neck are the scars of some scrofulous ulcers; there is considerable enlargement of the right elbow; the arm is bent at a very oblique angle, and requires to be supported; there is some slight movement in the joint; the ulna can be pushed up against the humerus, and slightly moved from side to side. About two inches below the outer condyle of the humerus is a small ulcer, the size of a fourpenny piece, which discharges a serous-looking fluid; the skin covering the joint is red and shining. She complains of considerable pain in the joint, aggravated by move

ment.

May 13th. Mr. Fergusson detected fluctuation above the inner condyle, and made a puncture which gave exit to an ounce of pus.

16th. The patient being placed under the influence of chloroform, Mr. Fergusson proceeded to excise the joint. He made a single longitudinal incision

at the back of the joint, about four inches in length, and then dissecting back the integuments on either side, he was enabled to remove the olecranon and articular surface of the ulna by means of a saw and cutting forceps. He then proceeded to remove about an inch of the end of the humerus with the saw, steadying the bone by the use of the lion forceps. The end of the radius was then removed, and the wound brought together with four sutures. Little bleeding occurred. In the evening, the elbow being extended, and the forearm placed in a position midway between pronation and supination, a bandage was placed above and below the wound, and a splint, contrived by Mr. Christopher Heath, the late house-surgeon, was applied, the principle of which it is to make extension between the cut surfaces of bone, it being possible at the same time to flex and extend the arm so as to lead to the formation of a movable joint. The accompanying engraving (from a photograph by Mr. Mason, of King's College Hospital) represents the apparatus as applied to the patient's arm. It consists of four iron plates (well padded) with projecting portions, each of which is perforated by a female screw. Two iron rods, with hinges in their centres, and a male screw at each extremity, work in the projecting eyes, and the screws at the two ends being cut in opposite directions, the hinge necessarily remains central, while the plates may be separated to any extent. The arm having been bandaged above and below the wound, the plates are attached firmly by means of straps and buckles (additional strips of plaster being used if necessary), when by turning the iron rods, the extremities of the bones are separated to the required distance, while by means of the hinges in the centres of the rods, motion can be made with the greatest facility.

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By means of this splint, the arm was kept in position, and flexed daily. On the 23d the splint was readjusted, and the wound reported healthy.

On June 15th the patient is reported as being in much better health. The wound was granulating healthily, and she was beginning to obtain some power of flexion and extension. The splint was now entirely left off.

On August 5th the patient was discharged, with the wound quite healed, and possessing some little power over the limb.

A few days ago the patient presented herself at the hospital. Her general appearance was much improved, and she has now almost perfect power of flexion, extension, and rotation.

CASE 2.-Jane P—, æt. 14, a slight girl, with florid complexion, was admitted on the 16th of June, 1857, with disease of the left elbow-joint. When a month old, abscesses formed in the neck and both elbow-joints; that in the right subsided, and perfect motion was obtained after a short period; but the abscess in the left joint led to complete anchylosis. The joint remained in a quiescent state up to five years ago, when an abscess formed in its neighborhood; this, however, subsided, and she experienced no inconvenience until a month before admission, when another abscess formed on the inner side of the joint, which burst, and has continued to discharge ever since. The forearm is slightly flexed on the humerus; the elbow is perfectly locked, very tender, and slightly enlarged. Just over the internal condyle there is an ulcer about the size of a sixpence, through which a probe can be passed down to the bare bone. On the posterior surface of the joint, and on the outer side of the forearm, there are old cicatrices.

June 27th.-Dr. Snow having administered amylene, Mr. Fergusson proceeded to excise the joint. Having made a vertical incision about six inches