following (the 21st), I was called in a great hurry, at 6, p.m., to attend him, as he had attempted suicide by plunging a knife into his abdomen. He had had one knife taken from him by his father, and another by a cottager, half a mile from his home, where he had run to on being interrupted at home; and it was with the third that he succeeded in producing the wound. I found him on his back, with an irregular, ragged wound, the direction of which was oblique, with the umbilicus for its centre. The extremity on the right side was the highest. There was a small tongue of integument and cellular substance at either end of the wound, presenting such an appearance, as induced me to imagine that the knife had been thrust in at the umbilical depression, drawn upward and outward, and then turned and pushed downward and to the left. My idea was confirmed in my own mind, by the appearance presented by the knife, which, when found, had a considerable quantity of fæces on its blade, near the point, and appearing to have been placed on it by a sort of turning or scooping action. This latter circumstance, coupled with the fetid odour emitted from the wound, amounted, I think, to almost the most direct evidence of a wound having been inflicted in an intestine. Lying on the abdomen, were portions of omentum and large and small intestines inflated, equal in contents to at least two quarts. The extreme extent of the wound was about three inches, which, from its nature and irregularity, possessed a capacity that it would not, had it been produced by a simple straight incision:-So much in favour of a replacement of the dislocated parts, though a larger portion had, of course, been protruded. Thanks to the jealousy which, I fear, actuates too many of our profession, having but recontly established my self in this neighbourhood, circumstances conspired to render it nessary for me to undertake the case alone, which I did, and which I have had no cause to regret. The dsiplaced intestines were but slightly if at all discoloured, and I contrived, without much delay, to return them in that order which I conceived necessary to securing a return of

function. I applied a light dressing, with numerous broad and long cross straps of adhesive plaister; and over all a roller of linen, four times round the abdomen. For some hours my patient was tranquil; yet aware that circumstances might arise which might tend to mischief, I remained all night, and it was fortunate that I did, for, about midnight, he struggled so violently with the abdominal muscles, that two knuckles of large intestine were thrown out between the sutures of the wound, of which I omitted to state I had applied three. The difficulty which I had now to contend with, was greater than that which was presented in returning the original mass. I first attempted to divide the sutures, but they were so imbedded beneath and among the convolutions, that the extreme risk of wounding the intestine induced me to desist. By dint of perseverance I at last succeeded, by gentle pressure, to return them again, though not until they (the intestinal convolutions) were more discoloured than I liked, they had also become perceptibly tender to the patient. After this all went on well.

Having learnt that his diet, for some days, had consisted of a small quantity of coarse bread daily, and that he had tasted nothing on the Monday, I would not bleed him, but determined to watch him closely, and do so should a shadow of excitement appear. On the second day the bowels acted four times, after taking two small doses of magn. sulph. and nothing occurred to excite my attention till the Sunday after the occurrence, when the patient complained of a slight tenderness in the region of the crest of the right ilium. The application of a dozen leeches quite removed this; and, as a measure of precaution, the leeches were re-applied in two days after. He has taken pulv. antim. gr. ij., c. ant. tart. gr. in a powder, and followed by tr. hyosc. 3ss., and liq. ammon acet. 3ij., in a draught every six hours.

The wound filled up early, and has now healed. It will be necessary, however, to remove him to an asylum, which will be

done on Monday next. There has been no recurrence of the tenderness.

LXXIII.

FATAL CASE OF COMPLETE CYSTOCELE, OR HERNIA OF THE BLADDER. By Mr. CLEMENT.*

THOUGH several authors of reputation have mentioned cases of hernia of the bladder and offered remarks on its origin and nature, they are still sufficiently obscure to make any additions to our knowledge of them desirable. The following case is related by Mr. Clement, and is equally interesting and instructive.

Case. Mr. Bowley, æt. 60, very corpulent, had been affected with scrotal hernia on the left side for five and twenty years. The hernia at first was very small, but had slowly increased until it attained a magnitude that will presently be described. The chief inconvenience experienced was from its great bulk and weight. He repeatedly, however, suffered from constipation of the bowels and slight attacks of hemiplegia. He could never make water without first raising the pendulous rupture from between his thighs towards his belly, when, after rolling it about for a short time, the urine would pass in a full stream, though never in considerable quantity at one time.

A fortnight prior to his death the bowels became obstinately constipated, and he was attacked with paralysis of the left side of the body. The more urgent symptoms of strangulation of intestine were absent, but there was constant stillicidium urinæ. The cathether was used several times by two surgeons in attendance, who believed that it passed into the bladder; not more than a tea-cup full of urine followed each introduction of the instrument. Strong purgatives and enemata were employed; the stillicidium

urinæ was supposed to be dependent on the paralytic affection. No alvine evacuation was procured, yet the patient laboured under symptoms of retention of urine rather than strangulated gut. There was great pain about the pubes and in the rupture, which became more distended-articulation became indistinct, and the patient expressed his feelings only in a low muttering tonehe became delirious-and died. Such is the imperfect but correct outline of the case. Mr. Clement was first present at the examination of the body.

Cadaveric examination 24 hours after death. "The circumference of the rupture was two feet five inches; its greatest length, measuring in a direction over the pubes to the apex of the tumour, one foot two inches and three quarters. The whole of the penis was retracted within the integument covering the rupture; the opening through which the urine flowed very much resembled the navel, and this gave to the tumour the appearance of an immense umbilical hernia, extending over the pubes and falling down between the thighs. One of the testicles could be distinctly felt near the surface, about the middle of the tumour, but the other was not discoverable before the parts were dissected.

Although the rupture was so large as to extend generally over the pubes, and occupy both inguinal regions, it was easily ascertained, without making any incision, that the protruded parts came down through the left abdominal ring.

The examination was commenced by dissecting for the left inguinal canal, which was exposed, and part of the colon found passing through it greatly distended with feculent matter, but exhibiting no marks of inflammation or strangulation: the latter could not have taken place, the passage being so much dilated as to give the whole hand free admission into the cavity of the abdomen.

A semicircular cut was next made through the integument, following the course which the colon had taken downwards in the sac:

posed, and we were surprised by the sight of another distinct sac, very tense and containing fluid. By this we were led to suppose, that some portion of the intestine must also have protruded through the abdominal ring on the right side, forming a double kind of hernia. This part was again carefully examined, but no intestine could be traced to that side: besides, the surface of this second or supposed sac was too regular to contain either omentum or intestine; it formed the greatest bulk of the whole tumour, and more resembled a hydrocele, if it was possible to conceive one to attain a size so immense. By dissecting the integument from the surface, the apex of this second sac was found to be very thin, red, and pointed-in fact, appearing ready to burst: this inflamed part was accidentally ruptured, and about two quarts of very fetid urine was evacuated, which removed all doubt and previous uncertainty as to its

nature.

By following down the course of the urethra, which was wonderfully displaced from its natural situation, we discovered that the bladder of urine had protruded through the abdominal ring. Owing to the prejudices of the patient's friends, all the parts could not be brought away, so as to make a complete preparation shewing the relative situation which they observed to each other. The bladder was however removed from the body, and, upon examination of the prostate gland, which was much enlarged, I found that it had been perforated by the catheter, in the ineffectual attempts made to draw off the urine. The diameter of the ureters was so much enlarged as to admit my fore finger with great facility.

The abdomen presented no marks of acute inflammation having recently taken place: the omentum was much loaded with fat, and the whole length of the colon was greatly distended with feculent matter.

In the pelvis there was nothing remarkable, excepting the want of the urinary bladder; the natural connexion which exists between that viscus and the inner sur

face of the pubes, was not to be discovered."

Cases like these are only useful when they afford a profitable lesson or serve to inspire future caution. There are several circumstances in the history of the case which might perchance have afforded a clue to its nature, if presented to a well-informed and reflecting surgeon. The long continuance of a large hernia unaccompanied with much disturbance of the intestinal functions, the occasional attacks of retention of urine, the mode in which the bladder was most easily emptied, the character of the final and fatal attack, might possibly have led an acute observer to suspect the real nature of the hernia, or will serve to do so to those who read the present particulars, and chance to meet with a similar case hereafter. We are not informed that the size of the hernia was diminished after the passage of urine, a circumstance generally, we believe, remarked in the recorded cases of hernia of the bladder. Mr. Clement adds some reflections on the mode in which hernia of the bladder takes place, but this is a topic on which we need not dwell. It is of more importance for our readers to be aware that the bladder having passed wholly or in part into the inguinal canal, a pouch is formed above by the peritoneum accompanying the viscus, into which pouch omentum or intestine, or both may descend, or even be accidentally strangulated. We have noticed this case to put practitioners on their guard, for although the knowledge of rare cases is of less importance than that of diseases of common occurrence, yet a surgeon from ignorance of the former may lose his patient and endanger his professional character.

LXXIV.

MR. LIZARS' LETTER ON Cholera,

To those acquainted with the professional zeal and professional acquirements of Mr. Lizars, any mention of them would be superfluous, and we need not therefore say

that the letter before us is both instructive in a practical, and interesting in a physiological point of view. The letter also derives an additional degree of interest, from its having been the occasion of a personal attack on Mr. Lizars by some individuals in the Edinburgh Board of Health. An attack so ungentlemanly, so uncalled for, has seldom been witnessed of late years, and the general feeling of indignation which it aroused will prove we hope an ample guarantee, against the repetition of similar outrages from authority on common decency and common sense. Mr. Lizars may be persuaded that however galling such a scene may be to his feelings as a private individual, he has gained, not lost, in his public character. The spirit which could dictate in these days wanton insult on account of a professional opinion, is a lineal descendant of that which in darker ages could raise the Smithfield fire for religion, and persecute Galileo for science.

The first part of the paper contains a letter to Mr. Lizars from the able Professor of Montpellier, M. Delpech. Our readers are probably aware that M. Delpech conceives the semilunar ganglia, and abdominal plexus to be the principal and essential seat of the morbid action of cholera, and that he has found his ideas confirmed by numerous dissections. To establish this point is the main object of the present letter. We have already dedicated so much space to cholera, that we cannot enter into it again. Mr. Lizars is an anti-contagionist, and portrays in a manner equally argumentative and eloquent the absurdities into which contagion has led both Boards and individuals. That doctrine is now so generally abandoned that we need not discuss it here. Yet we cannot refrain from mentioning one instance of the cruel folly to which it has given birth in Scotland. While cholera was at its acmé at Fisherrow, and when the most unrestricted intercourse by land and by foot passengers was allowed, a solitary boat with two men from the place touched at Leith harbour. The poor fishermen had no sooner landed than they were hurried away under guidance of a guard-boat to perform

quarantine at St. Margaret's Hope! We can scarcely believe that men in the possession of their senses could be guilty of such absurd injustice. We will not say with Fouché that such conduct is "worse than a crime-it is a blunder;" but assuredly it is both a crime and a blunder. As a matter of rational argument it cannot admit of defence, but when the injurious consequences upon a population already pauperized and ruined are considered, we shudder at the levity of men who can rashly deal abroad destruction, with such indifference and indiscretion. The following quotation is the only one we shall make from Mr. Lizars' pamphlet. It is obviously insusceptible of abbreviation, and yet contains a very valuable digest of the morbid anatomy of cholera. It is a summary of twenty dissections."

"BRAIN.

แ

Of this number twelve had this organ examined, and, in all, the arteries and veins of the integuments and muscles covering the cranium were distended with the dark blood, which, in some flowed like tar.

In ten, the blood-vessels of the dura mater were turgid with this blood; and in three, there were fibrinous coagula.

In seven, there was serous effusion under the arachnoid membrane.

In four, the pia mater was congested with blood-vessels.

In seven, the cerebrum was highly vascular; and in one, slightly softened.

In seven, the cerebellum was very vascular; and in three, its substance was slightly softened.

SPINE EXAMINED IN TEN.

In six, scrous effusion between theca vertebralis and arachnoid membrane, and, in one of these, the fluid was bloody.

In two, serous effusion between arachnoid and pia mater.

In six, blood-vessels of spinal chord highly injected with the dark blood; and one with evidence of inflammation between dorsal and lumbar regions.

In six, the spinal or rachidian veins turgid with dark blood.