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of the Bath, which was not asked for, is nothing more than areiteration of the dogma, that military and naval surgeons areto continue to belong to the " civil" staff. To honourable

men, fetters and marks of injustice are not the less bitter orgalling because they may be gilded, and we cannot join in theopinion, that the best way of getting the rights of the militarysurgeons is for them tamely to subinit to the injustice involvedin their rigorous denial, if this be coupled with an attempt tosalve the sore by the offer of an honour which, upon principle,the most distinguished military surgeons will refuse to accept.We really advise our contemporary to find out some good"grievance," of which, unfortunately, there is an abundance

in the profession, and work it indefatigably and thoroughly toits reformation. He will find it much more satisfactory thanthe task of cavilling at his compeers, and, unless we are mis-

taken, far more conducive to the advancement of those pro-fessional interests which we take to be the highest objectof journalism to promote and protect.-

GULLIVER tells us, that the tailors of Laputa cut their coats

upon mathematical principles. The problem was worked outwith great accuracy, and the calculations were exact and

complete. Nevertheless, the coats were the most shockinglybad fits that the illustrious traveller had ever seen. Like the

Laputan tailors, many of the schemcrs of our own day work outtheir problems with mathematical accuracy. Nothing canlook better on paper; but let them be applied to practicalpurposes, and the coats of Laputa fitted not worse. The

provident or self-supporting dispensary scheme may fairly beclassed in this category, for no one can deny, that as a theorynothing can be better, and hold out brighter prospects ofdoing good to the great masses of the labouring population.But will it really work well ? We firmly believe not. On the

contrary, we are fully persuaded that a more suicidal schemewas never attempted to be carried cut, particularly as it

refers to large cities. One solitary instance, of questionablesuccess, may indeed be seen at Southam; at least, so saysMr. SMITH, to whose benevolence we would fain pay ourtribute. But what say medical men in his own neighbour-hood ? what say the great body of surgeons of this country onthe subject ? Where the penny-a-week system has been tried,a great number of the most regular payers were small farmersand tradesmen, well able to reward their medical attendantsmoderately and independently for their services. In manydistricts we know this to be the case, and the columns of this

journal for years past, and the number of private letters wereceive on the subject, would amply attest its truth. But

that which was an evil in the country would work withtenfold mischief in great cities and towns. None of those

checks which might be expected to operate in the countrywould be effective in large assemblies of people. No limit

could be placed on the admissions; no one could determine,even by common report, or inquire the means and stationof the parties applying to be members. Look at the way in

which the funds and other resources of some of our dispensa-ries are misapplied. We know of instances in which sub-scribers to dispensaries were themselves the patients, and wroteletters of admission for themselves! Carry out the system;let any one who presents himself be enrolled as a memberof the institution, by paying a penny a week, and where willthe mischief stop ? We know the advocates of the scheme

do not intend it to apply to those who are in circumstancesto pay fairly and honourably for medical attendance. But

let us ask these gentlemen what test they would apply ?How would they discover those who should and those whoshould not belong to such an institution? This is one difficultywhich there is no effectual means of surmounting. That" tyranny" it has been said, " is the greatest which workswith the machinery of freedom," and surely no "indepen-dence" is so abject as that which assumes a position on the" charity" of others. That such is the case in all so-called

"self-supporting dispensaries" an examination of their ac-

counts will fully testify, for the deficiency of the subscriptionof " independent" members is made up by the " donations" ofthe " charitable." Away, then, with the assertion that thesedispensaries are self-supporting—a greater delusion never ex-isted. They are dispensaries founded and carried on likeothers, with a most questionable, and, in our opinion, most in-jurious addition to their regulations. We caution those gen-tlemen who are agitating this question not to deceive them-selves. We believe their intentions to be most benevolent,but we believe them to be most mistaken. Should they wishfurther to see what the opinion of their medical brethren ison the subject, at about the only public meeting, we believe,held respecting it, we would refer them to THE LANCET, vol.ii. 1835 36, page 8T8. Mr. S.mTH will doubtless recollect

the signal and humiliating defeat this system met with, at a

large and influential meeting of the profession, held at theThree Tuns, Southwark. Amongst the gentlemen who at-tended that meeting were many who practised as parochialsurgeons. The dispensary system is no doubt fraught withevils, but the suggested plan is not the remedy. All thingsconsidered, we firmly believe that, so far as the profession is

concerned, it is even much worse than the disease.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. BARTHOLOMEW’S HOSPITAL.

Stone in the Bladder; Lithotomy.(Under the care of Mr. LAWRENCE.)

When the operation of lithotomy is followed by a fatalresult a short time after the extraction of the stone, death isgenerally attributed to haemorrhage or peritonitis, when thepatient is found to have been free from visceral disease. It

would, however, appear, from a case lately operated upon byMr. Lawrence, that, independently of inflammation, such anamount of irritation may be set up in certain subjects as tocarry off the patient, and disappoint the well-founded hopesof the surgeon.

It would certainly be a very difficult matter to decide, in agiven case, by observing the patient’s temperament, whetherhe was likely or not to bear the shock or irritation sometimesresulting from the operation. An approach to a correct viewon this head might, however, sometimes be made; and wherethere are other counter-indications, a nervous and irritabledisposition should be decidedly looked upon as giving themmore weight. But the question would of course be very diffi-cult of solution where no unfavourable symptoms existed ex-cept great nervous susceptibility, since the evils accompanyingthe presence of stone in the bladder are of a description likely

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to overrule apprehensions raised by the existence of greatnervousness and irritability.The patient in question was about forty years of age, and

had been suffering for the last two years from the usual syiilp-toms of stone in the bladder. The pain he was undergoingwas of a severe nature, and his distress very great ; Mr.Lawrence therefore determined to remove the calculus,which had been distinctly felt by the sound, and gave thepreference to the lateral operation.On the 2nd of March, the patient was brought into the

theatre, placed in the usual position for the operation of litho-tomy, and rendered insensible by the inhalation of chloroform.Mr. Lawrence, instead of taking his seat exactly opposite thepatient’s perinseum, sat down with his right side turnedtowards the pupils, and gave them, by this position, a fullview of the parts to be operated upon. The staff being heldby an assistant, Mr. Lawrence made the usual incision fromthe raphe to the left ischium with a common-sized scalpel,and when the muscles and fasciae had been successivelydivided, a double-edged gorget was introduced. When itspoint reached the groove of the staff, Mr. Lawrence broughtthe handle of the latter downwards towards the patient’sperincGum with his left hand, and allowed the gorget to cutits way into the bladder, by laterally dividing the neck of thatviscus. A gush of urine immediately testified that the instru-ment had penetrated the bladder; the gorget was withdrawn,the left forefinger passed into the wound, the forceps carefullyintroduced, and a stone about the size of a small plum ex-tracted.As this foreign body was found to be of a friable nature,

Mr. Lawrence proceeded to inject the bladder, through thewound, with lukewarm water, so as to wash away any particleswhich might have crumbled at the moment the stone wasseized. The patient, upon whom the chloroform had at firstacted in a suffocating manner, but who eventually was

thoroughly brought under its influence, was then untied, andremoved, without having experienced more than the usualamount of hcemorrhage.A slight amount of bleeding took place, however, when the

patient had been in bed for a little while; this was easilystopped by plugging, but it was found very difficult to controlthe nervous and irritable state into which the patient hadbeen thrown. Various means were used to counteract theseunfavourable symptoms, but they proved unavailing, thepatient became gradually weaker, and died three days afterthe operation. -

On a post-mortem examination, the bladder was foundtolerably healthy, no artery of any importance had beendivided, and no traces of peritonitis could be discovered. Urn-der such circumstances it seems that the fatal result mustbe attributed either to the extreme irritability and nervous-ness of the poor man, or to the effects of the chloroform. Itshould be mentioned, however, that hydatids were found inthe liver.

____

GUY’S HOSPITAL.

Disease of the Heart.(Under the care of Dr. HUGHES.)

Post-mortem appearances are allowed to be of great valuein cases where the diagnosis has necessarily been obscure, andthe symptoms unusually severe; we therefore hope that thefollowing case, recently under the care of Dr. Hughes, will beread with interest, and prove of practical utility. It is, un-fortunately, but too true, that in the majority of cardiac affec-tions, be they either primary or secondary, we can but palliateand keep off the evil hour: this temporary benefit is, however,in many instances, of sufficient importance to call for theexercise of our best energies to ward off the tendency to im-moderate action, or to flaccidity and debility in the centralorgan of circulation.On the 27th of March, a man, about thirty, was admitted

under the care of Dr. Hughes, with intense dyspnoea; his dis-tress in this respect was very great; he could not lie down,and his breathing was so hurried and noisy that it was quiteimpossible to judge accurately either of the pulmonary orcardiac sounds. The pulse could not be counted, but it was be-lieved, from examination of the heart, that its pulsations wereno less than 240 in a minute, or even more; the countenancewas suffused and bluish; the cough comparatively trifling;but the patient was tormented by frequent vomiting. Theonly history which could be obtained from him was, that hehad always enjoyed good health, and followed the occupationof a fisherman, until three weeks ago, when, in hauling nets,

he was suddenly seized with great pain in the chest, anddyspnoea, which latter had since been constant, and indeedcontinually increasing up to his admission.The patient lived in much pain and anxious panting for

three days, and was found dead only a very few minutes afterthe physician had seen him, subsequently to one of the severeparoxysms of vomiting, after which it is supposed he fell backexhausted.The autopsy, which excited a great deal of interest, from the

violent symptoms, and uncertain diagnosis of the case, wasconducted by Dr. Lloyd. The venous system of the thoracicand abdominal cavities was found very highly congested; theheart was hypertrophied in every respect, the walls of bothventricles being remarkably thickened, and the capacity ofthe ventricles materially increased. As far as could bejudged by the eye, the organ was almost double the ordinarysize. In following the walls, from the base to the apex in theleft ventricle, their thickness was observed to diminish sud-denly very near the apex, which was bifid; the thinning ex-tended in that region over a space the size of a crown piece,the walls being of about the thinness of the sterno-hyoidmuscle. A fibrinous concretion, which had softened down inthe centre, occupied the thinned apex, and being partially if’.-terlaced with the musculi pectinati, caused it to bulge, thusincreasing, if not producing, its bifid extremity. There was sno trace of ulceration, nor actual perforation, nor, of course,haemorrhage into the pericardium. Dr. Lloyd carefully re-moved part of the fibrinous mass, and followed the course ofthe carnece columnse, in order to discover whether actual rup-ture had taken place in any of them, but none of these fleshybands was found torn across.The lungs presented a very unusual form of tubercular de-

posit. This abnormal substance was so firmly and evenlyspread upon the pleura that at first sight it looked like anordinary fibrinous deposit, and accurately resembled some ofthe vegetable lichens; but on cutting through the substanceof the lung, thick arborescent clusters of tubercular depositwere found pervading the whole thickness of both organs,many parts of which were completely solidified, both by thecongestion resulting from the cardiac affection, and the pre-sence of tubercular matter arranged in remarkably minutepoints.

It was supposed by some that the constant vomiting, withwhich the patient was troubled, was caused by the pressure ofthe heart and lungs upon the pneumogastric nerve; the mucousmembrane of the stomach was, however, very much congested,presenting here and there patches of a deep colour. The liverwas in the condition known by the name of cirrhosis, and theremaining organs tolerably healthy, though greatly congested,as mentioned above.From the autopsy a certain amount of light is thrown upon

the phenomena exhibited in this case. Without indulgingtoo much in suppositions, it might be maintained, that thetubercular affection, which had fixed upon the lungs, wasthe primary disease, which may have taken many years toarriye at the development found after death. This is again aninstance of disorganization and spoiling of the lung going onfor a long period, without exciting much cough, or any hæmo-ptysis, or creating (if the patient’s statements can be entirelyrelied upon) any great degree of inconvenience. Still theman’s occupation was one of frequent and violent exertion,and the circulation through the lungs being necessarily imperfect, the hydraulic machine receiving and driving away theblood, had evidently to contend against obstacles which itovercame by more powerful contractions, which led to hyper-trophy. Now, it may be inquired, what pathological con-

dition gave rise to the sudden seizure which the man

experienced ? Was the aneurismal thinning of a small spaceof the left ventricle caused by rupture of some of the carneæcolumnse, a certain amount of haemorrhage, and consequentabsorption ? or was the fibrinous mass found in the apex andattached thereto, a result of inflammation which led to theattenuation of the walls, and to less energetical contrac-tions ?

It is very likely that cases of this description may be greatlybenefited, when seen in time, by the observance of greatquiet of mind and body, and small bleedings. Great good canbe done, for a time, as mentioned by Dr. Watson, by wardingoff all cause of agitation and hurry. When, however, a

laborious occupation, and perhaps intemperate habits, (asmight be inferred from the cirrhosed liver,) step in the placeof caution and perfect tranquillity, it is hardly possible thatsuch a state of organs should end otherwise than in a fit ofdyspnoea, more or less sudden, according to the amount ofexertion used at the time. ’