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was not then directed, as it might be now, by an accurate acquaintance with the chemistry of the urine and its concretions, or a just discrimination of what should or should not be attempted on the living body. These considerations, and such as these, must have influenced all judicious surgeons in withholding a positive opinion on the value of lithotrity when first proposed.

Ten years have elapsed since that epoch, and what is the state of lithotrity now? It has certainly gained ground, and every thinking man is convinced of its applicability and value. But we question if their real amount is ascertained, or if it will be ascertained till the operation is in more general use than at present. Many circumstances combine to render it difficult to determine the utility of any art, or branch of art, whilst practised by only a few individuals. Such was the case with the treatment of diseases of the eye, in the hands of the oculists. We therefore hail with pleasure the attempts of surgeons to make themselves acquainted with the practical application of lithotrity, and we are convinced that such attempts, if properly appreciated and encouraged, are certain, whatever be the immediate result, to end in ultimate benefit to the public.

Dr. King, the author of the volume before us, is calculated by his accurate anatomical knowledge, as well as by the opportunities which he enjoyed, and situation which he held at the Hôtel Dieu, to embark in such an undertaking. We shall put our readers in possession of the chief facts elicited by his researches, experiments, and experience.

The first twenty-seven pages of the volume are occupied by a sketch of the urinary apparatus, and it seems to us to be correctly, and cautiously drawn up. Perhaps it displays a little too much of the French mode of thinking respecting Nature's contrivances and mechanism, and scarcely evinces enough of that old fashioned English prejudice in favour of the admirable handicraft of the CREATOR, which we are neither afraid nor ashamed of avowing. There is only one passage on which we think any comment required. Dr. King observes that,

"In almost every case it (the urine) becomes acid soon after its expulsion, thus differing from all other animal fluids, which seem to be alkaline; whilst those of vegetables are acid." 4.

This is doubly incorrect. The urine in health is acid in the bladder, nay it is secreted acid. To prove this assertion, we have only to draw off the urine with a catheter, and, retaining the instrument in the bladder, to test the urine as it comes from the kidney. The urinary is not the only acid secretion. The perspiration is acid-free acid is frequently, if not generally, secreted by the stomach-the saliva is often decidedly acid, and probably it is always slightly so.

The next chapter or section contains a description of the bladder in the adult male subject. This anatomical description is precise and perspicuous. The following quotation is deserving of consideration.

"We now come to the relative position of the bladder. It is, however, of extreme importance that the Surgeon should first know that it is a fixed organ, not a floating one. There is one part of it as immoveably fixed as any soft parts in the body; yet, this fact seems to have escaped anatomists, or to have appeared to them either too evident or of too little consequence to demand particular notice. The bladder is fastened, at its neck, to the pelvis, nearly as

strongly as tendons are to the bones into which they are inserted; and, in this respect, it differs materially from every other organ in the abdomen. Its anterior and inferior part is fixed by those strong fibrous fasciculi described by authors as the anterior ligaments of the bladder; by the triangular ligament of the urethra, which is continuous along the membranous portion of the urethra with the capsule of the prostate gland; and, indeed, by the whole of the strong fascia of the pelvis. I do not mean to affirm that these parts are as strong as tendons, or ligaments but they certainly yield as little without laceration or injury; and as this is one of the most important facts connected with the treatment of stone, I particularly solicit attention to it.

The anterior region of the bladder corresponds to the symphysis pubis; to the pubic ligament, from which it is separated by its own anterior ligament and cellular tissue; and, in a small extent, to the triangular ligament of the urethra. Above the symphysis, this region corresponds, opposite the linea alba, to the fascia transversalis of Sir A. Cooper; but whenever the bladder rises fairly an inch and a half above the pubis, it is in contact with the peritonæum lining the wall of the abdomen, in addition to its own peritoneal covering. In other words, the shining surface of the peritoneal covering of the bladder is in contact with the same surface of the peritoneum lining the muscles of the abdomen; so that an instrument, to penetrate this part of the organ, must traverse the peritonæum twice.

I am induced to lay claim to the discovery of this fact; for all the authors I have read state, that when the bladder is distended so as to rise above the pubis, it passes to a considerable extent between the peritoneum and the abdominal muscles, or rather between it and the fascia transversalis. I was led to this discovery, from having seen the peritonæum wounded in the high operation for stone, by the best operators; which I could not explain, till I observed, on investigating the subject, that when the bladder is distended by insufflation, it rises in the proper cavity of the peritonæum. I do not pretend that a small part of the bladder, thus distended, may not be uncovered by the peritonæum above the pubis; but I positively assert that this organ (and in old persons more especially) expands in the abdomen, in some such manner as the uterus does in gestation, by a gradual yielding of its peritoneal as well as of its other coats; and not by detaching the peritoneum, as it has been hitherto supposed, from the abdominal parietes. It is remarkable that an acquaintance with the nature of serous membranes did not lead, á priori, to a knowledge of this fact. Why should not the serous membrane of the bladder yield as much as its mucous and muscular coats; when it is well known, that the susceptibility to yield to distension, is one of the characteristic properties of serous membranes? Indeed, they yield more promptly than other membranes, as we see in hydarthrus, hernia, ascites, and in a multitude of other circumstances." 33.

We believe that Dr. King is perfectly correct in this description. We have seen the peritonæum reflected on itself by the distended bladder in the dead body. We remember a case in which this occurred to a very remarkable degree. A female was under the care of a physician for an abdominal tumour, supposed to be an enlarged ovarium, or a gravid uterus, or something else not very obvious. Many consultations were held on the subject, but the only point on which all appeared unanimous, was in steering clear of an operation. The woman died, and was examined. On reflecting the abdominal integuments, a tumour was seen, of considerable size, lying loosely, as it seemed, in the cavity of the abdomen. The physician chuckled -"I told you the lady was enceinte," said he : but the Doctor was premature-it was a bladder so enormously distended, that it held, at the least, half a gallon of urine. On emptying the viscus, a malignant polypus was

found in the uterus, growing from its fundus. We mention this case, because the loaded bladder lay loosely in the peritonæum, like another abdominal organ, and the instrument which punctured it would have penetrated two folds of the serous membrane. At the same time we must not forget that, when the urinary bladder is distended, there certainly is a cellular interspace of some dimensions between the peritoneum, reflected from the abdominal parietes to the organ, and the upper margin of the symphysis pubis. Dr. King very properly points out the laxity of expression respecting the "neck of the bladder," and "prostatic part of the urethra." In point of fact, these are one and the same, for the prostate forms the whole floor, and a portion of the sides of the neck, and if this be deemed a part of the urethra, then the bladder can have no neck whatever. The urethra should be considered as commencing at the anterior extremity of the prostate.

The following dimensions of the apertures of the pelvis, in reference to lithotomy, are deserving of attention. We seldom see so much accuracy displayed in anatomical description as is done by Dr. King.

"The margin of the inferior aperture of the pelvis is formed superiorly and anteriorly by the symphysis pubis; laterally, by the branches of the ossa pubis and of the ischia; behind, by the summit of the coccyx; and on the sides, posteriorly, by the sacro-sciatic ligaments and ischiatic tuberosities. The plane of the aperture is inclined forwards, as its axis indicates.

The best mode of measuring the opening, and of appreciating its form and direction is to remove the bladder, rectum, and all the soft parts of the perinæum and pelvis, except the obturators and pyriformes muscles, and their fascia. It will then be seen, that the distance from the bottom of the symphysis pubis to the tip of the coccyx, is about four inches and an eighth. The greatest transverse diameter is that taken from the back part of one tuber ischii, where the larger sacro-sciatic ligament is attached, to the same point of the opposite side; it passes immediately behind the anus and measures three inches.*

The extent of a line drawn across, along the inferior edge of the pubic ligament, from one side of the pubic arch to the other, is one inch and an eighth ; lower down, opposite the posterior margin of the prostate, (and by opposite, I mean in a line intersecting another drawn parallel to the axis of the outlet, from this margin forwards,) the distance across, which has been tremendously overrated, is only one inch and three quarters. Finally, the extent of a line drawn from one ramus ischii to the other immediately in front of the anus, is two inches and a half. This last line circumscribes what is generally called the perinæum; all that is posterior to it belonging to the region of the anus.

The length of one side of the pubic arch, taken from the back part of the tuber ischii to the bottom of the symphysis pubis, is about three inches and a half. We have given the average admeasurement, but these dimensions vary much more in the male than in the female pelvis; and almost always, what is lost in one diameter is gained in another; if the distance is augmented from the symphysis pubis to the coccyx, the transverse diameter will be found proportionably diminished; and when the latter is excessive, the antero-posterior diameter is lessened."-77.

"The direction in which a stone should be extracted by the pelvic outlet is indicated by a line drawn from the incision in the prostate, towards the part of the pelvis where this diameter is taken; but, as the prostate is turned forwards and near the bones, the extraneous body and blades of the forceps must first be made to revolve on an axis formed at the posterior extremity of the incision in this gland."

Here we must take leave of the anatomy of the pelvis, though we cannot do so without bestowing a well-earned compliment on Dr. King, for the care with which he appears to have studied, and the precision with which he certainly has described it. Dr. K. next proceeds to the consideration of lithotomy in the perinæum. We shall select such passages as seem to convey new views, or contain important criticisms on old methods. Our readers are aware that many surgeons employ the bistoire cachée of Frere Cosme; indeed, the most dexterous lithotomist whom we know most commonly uses it. There may be objections, in point of principle, to the instrument, but we cannot avoid thinking it a very convenient one. However, what we wish to advert to at present, is Dr. King's alteration of this lithotome caché.

" I shall first explain what alterations I have made in the lithotome caché, and then briefly describe the operation as I prefer performing it. The original instrument consists of a sheathed knife four inches long, curved so as to be convex on its cutting edge; and of a handle with a spring for unsheathing and sheathing the knife, which passes from and into the sheath edgewise. The sheathed knife which I use, opens in like manner; but it is straight, wider than the original one, cutting in its whole extent, and only two inches long in the blade. Where the blade joins the handle, there is a sort of stop or hilt to prevent this part of the instrument going beyond the prostate; the handle is thin and six inches in length." 98.

Passing over the steps of the operation, as performed by Dr. King, in which there is more that is judicious than new, and merely noticing his antipathy to the operation by the gorget, which he denominates "stabbing in the dark," we pause at a subject of the utmost consequence the incision of the prostate. On this point there is much discrepancy of opinion, and probably, therefore, much error. Mr. Brodie, in his lectures on calculous diseases, which were published in this Journal, particularly cautions the surgeon against carrying his incision through the prostate, so as to injure its capsule. If the latter be torn, there is nothing to protect the loose texture of the bladder from laceration, the cellular tissue in the neighbourhood is extensively injured, and the risk of infiltration of urine immeasurably augmented. Such is the doctrine of Mr. Brodie, deduced from no inconsiderable experience. It will now be shewn that Dr. King maintains opinions in all respects similar, nay, identical.

"Of the patients who submit to the lateral operation, one in seven or eight dies; and, in almost all those cases which have a fatal issue, death is produced either by the force used to extract the calculus, or by too extensive an incision in the prostate. If the incision is small in comparison with the stone, death will follow from the violence done to the bladder and surrounding parts, in the extraction; and if the incision is made sufficiently extensive to admit of the fair extraction of a stone one inch and a half in each of its two lesser diameters, death will follow from infiltration of urine.

In criticising the lateral operation, the first thing to be attended to is, then, the volume of the stone; success or failure depends upon it. If the foreign body never exceeded three inches in its lesser circumference, so that the incision in the prostate might be limited to three quarters of an inch or a few lines more, the operation, when well performed, would seldom or never be followed by fatal consequences. When it measures four inches and a half in its lesser circumference, or that the sum of its two lesser diameters amounts to three inches, the patient may recover, but the chances are very much against him; and when it exceeds this volume, death is almost sure to be the result of the operation.

The Surgeon is in this dilemma,—he must either use force, or make a long incision; the former lacerates the prostate and cellular tissue, bruizes the bladder and stretches its membranes, and shocks the nervous system: the latter prepares the way for infiltration of urine: both are fatal nearly to the same degree." 105.

This is a subject deserving, nay, demanding, the most anxious and careful consideration of lithotomists. The largest transverse diameter of the pelvic outlet is three inches; opposite the prostate it is only one inch and three quarters, of which one inch and a half is all that can be obtained by moderate pressure.

"But, the great obstacle to the extraction of a stone measuring an inch and a half in its lesser diameters is the situation of the prostate. The calculus must pass between the inner surface of the rami of the ossa pubis, and the posterior boundary of the incision in this gland; and, as the distance between these, when the incision in the prostate is not dangerously extensive, is only an inch and a quarter, it necessarily presses the anterior wall of the bladder against the bones, on the one hand, and tends to tear the back part of the prostate, on the other. As the prostate is firmly fixed, it cannot be drawn backwards, or pushed farther from the bones towards the cavity of the pelvis, without the ligaments yield or break; yield they may, perhaps, a quarter of an inch without laceration, and then a stone of the above size may be extracted, possibly without mortal injury.

But when the foreign body is larger, something must give way: the bones cannot yield, and if the calculus be not crushed, the prostate and bladder must be torn; and the effects of this laceration is almost certain death." 107.

We do believe that this is true, true at least in the main. Who that sees many great operations, but can generally predict too truly, which of them will be followed by disastrous consequences. The surgeon may find an excuse in unavoidable embarrassments, well-disposed spectators may allow of such, but their judgment whispers that the issue will be fatal, and very rarely indeed is that judgment false. For instances of the disastrous consequences of the violence in lithotomy, we may refer our readers to our review of Mr. Fletcher's Medico-Chirurgical Notes and Illustrations. The following expressions of Dr. King are strong, yet not more so than the circumstances warrant.

"The use of force to extract a stone is so surely followed by death, that I shudder to think how often Surgeons have recourse to it. It has so generally occurred to me, to foretel the issue of a case simply by the degree of force employed, that, if I witness it now, I do not hesitate in indicating to those near me when the operator has arrived at the point beyond which recovery is impossible. I shall shew presently, that a large opening in the prostate, made scientifically with the knife, is too dangerous a lesion to be aliowed much longer to belong to surgery; but dangerous as it is, one would almost call it a safe and simple wound, when compared to the injury inflicted by a surgeon, who, placing his foot against the table, employs all the strength he possesses, to stretch and tear the bladder, lacerate its connecting tissues, bruise the surrounding parts, and shake, mortally shake, the whole nervous system! This anti-physiological process, this absurd and horrid practice, is so cruel, so fatal and yet so common, that there is nothing in which, as a surgeon, a man might more justly pride himself, than having contributed to abolish it.” 111.

Laceration may prove fatal-first, from the immediate shock to the sys

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