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from cystitis is more frequent after lithotomy than after lithotrity.

It is a pity that surgeons who have examined hospital registers have left us no account of the causes of death in a given number of cases; so that each is now forced, according to his individual experience, to say hæmorrhage is frequent or rare, infiltration of urine is the most frequent cause of death, &c. Dupuytren, indeed, has attempted to supply this deficiency, but his table applies to so limited a number of cases, that it is of little or no value. In eighty-five cases operated on, in the Parisian hospitals, nineteen deaths occurred from the following causes:

In seven, from inflammation of the bladder and cellular tissue.

In two, from hæmorrhage.

In one, from laceration of the prostate.

In one, from the calculus being encysted.

In one, from calculus of the prostate.

In one, from shock of the operation.

In four, from obstacles, consisting, in two cases, of the size of the calculus; in one, narrowness of perinæum ; and in the other, excessive depth of perinæum.

In one, from cancer of the bladder.

In one, from gastro-entritis.

I should remark, besides, that this table applies to the bilateral operation.

There is, finally, another cause of death after lithotomy, and a frequent one likewise; but, in fairness, we should rather say that, in the cases to which I now allude, the operation has only hastened death, not been its actual cause.

I have already explained how vesical calculus seldom exists for any considerable time without affecting the general health, and either producing latent disease of the kidneys, ureters, &c., or at least producing a tendency towards disease in these organs, which the slightest exciting cause may light up.

I have also said that the lithotritist is very careful not to meddle with these cases, whenever he is fortunate enough to discover their nature, knowing full well the great chance which exists that they will terminate unfavourably. The lithotomist is perfectly aware of the same fact; yet, whether it be that he is more bold in his practice, or from other causes, it is certain that many patients labouring under incipient disease of the kidneys, or with suspicious symptoms, are submitted to the knife, whereas the lithotritist would decline interfering with them. In the majority of these cases, the operation hastens death by giving a spur to the organic disease already existing, or by lighting up an affection to which a strong tendency already exists. The patient would probably fall a victim to the disease sooner or later, but there can be no question about the fact that lithotomy, especially if there be the least obstacle to the extraction of the calculus, often hastens the fatal result in a remarkable manner.

We may, however, have a case in which the symptoms of renal disease are obscure, while the patient earnestly entreats to be relieved from his more pressing and palpable malady. Here it may be asked, supposing an operation to be decided on, whether we should select lithotomy or lithotrity. This comes to the same as if we asked which of the two operations is the more likely to de

velope the renal disease already existing. I confess that my mind is not quite made up on this difficult point. Some authorities boldly assert, that lithotrity is less dangerous than lithotomy, whenever disease of the kidneys exists. I cannot go so far as this; our safest course, perhaps, will be to consider, in the most careful manner, all the circumstances of the case, and then, according to these, select the operation which seems less likely to irritate the bladder.

CHAPTER XIV.

LITHOTOMY AND LITHOTRITY IN THE FEMALE.

THE operations performed for the removal of calculi from the female bladder, require a separate notice, and I shall therefore devote a chapter to them.

Women are not very subject to stone in the bladder, at least not so much so as men. Every one is acquainted with this fact, but I believe that vesical calculus exists in the female oftener than is generally supposed. We possess few documents which throw any light on this point. The following are the principal that have fallen under my observation, and they are very imperfect, for they only show the relative proportions of males and females in a given number of persons operated on, instead of showing the proportion of females in a given number of calculous patients; however, they furnish something less vague than the unsatisfactory expressions, rare and frequent.

In Mr. South's translation of "Chelius's Surgery," I find a list of all the operations of lithotomy performed in St. Thomas's Hospital from 1822 to 1845, that is, during a period of twenty-three years; 144 males were

operated on and only two females. A surgeon, we see, may remain attached to one of our large hospitals all his life without being called upon to operate on the female. Mr. South's table gives a proportion of one female for seventy-one males; this is greatly below the average. In Mr. Crosse's tables formed from the cases in the Norwich Hospital, we find that out of 704 patients operated on, 669 were males and thirty-five females, giving a proportion of one female to nineteen males.

This agrees pretty closely with the proportions observed at the Hôtel Dieu of Paris. From 1808 to 1830, 284 calculous patients were admitted into that hospital, of whom seventeen were females, which gives a proportion of one female to sixteen males. From the tables collected by M. Civiale, I find that of 1104 operated on in the Lombardo-Venetian States, 1047 were males, fifty-seven females, or one in eighteen; and of 2834 in France, 2711 were males, 123 females, or one in twenty-two.

All these tables agree very closely, and show that for about twenty males operated on for stone, there will be one female. It is, however, very probable that the proportion of calculous affections in the female is still higher, because we all know that delicacy prevents numbers of females labouring under urinary disorders from applying for hospital relief. The same holds good in private practice; of 307 patients operated on by M. Civiale, only seven were females. Dupuytren collected 356 cases of lithotomy which occurred in Paris during a period of ten years; 312 of the patients were males and forty-four were females, which gives a proportion of one female to eight males.

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