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intensity, or by provoking disease in some organ whose integrity is necessary to life. I should think that one half of these cases of fistula terminate fatally. In a very small proportion of them, where the patients happen to be placed under the influence of the most propitious circumstances, a cure may be obtained; but by far the greater portion of those whose general health remains unimpaired by the local injury, must submit to a deformity, which renders life almost unendurable. I have seen, at least, five or six operations by this method, and in only one case was the cicatrisation of the wound obtained, although they were per formed with consummate skill, and great care was taken to make only a mere notch in the rectum." 160.

Infiltration of urine is perhaps less likely to follow this than the lateral operation. The ejaculatory ducts may be wounded. In the only instance in which we have seen the recto-vesical operation performed, the patient died of abscess in the pelvis. Dr. King relates a case in which the operation was performed by M. Sanson. The patient died of suppuration and sloughing in the cellular membrane, extending into the peritoneal cavity.

HIGH OPERATION, OR LITHOTOMY ABOVE THE PUBES.

As Dr. King very justly observes, this operation is not only more liable than the lateral operation to be succeeded by infiltration of urine into the cellular tissue, but also by peritonitis, the two chief dangers of the latter. When we add that the operation is one of extreme difficulty, we pronounce its condemnation in the most emphatic terms. A very large stone has been supposed to be its only justification, yet we venture to say that if a calculus is too large to admit of extraction by any operation but that above the pubes, it were better not extracted at all. The patient must almost surely die.

LITHOTRITY.

The following enumeration of the gentlemen who have invented lithotrity, for really there appears to have been half-a-dozen, will prove what we have frequently asserted, that in medicine, as in the arts, discovery is always gradual. The man who first strikes out an idea is seldom if ever successful in its practical application.

"Lithotrity consists in the reduction of calculi to powder, or fragments sufficiently small to pass through the urethra, by means of instruments introduced down this canal into the bladder. To accomplish this or some very similar ob ject, instruments have been invented and recommended by Messrs. Elderton, Amussat, Leroy d'Etiolles, and Heurteloup. These gentlemen were preceded by Mr. Gruithuisen in the invention of an instrument for drilling a hole in calculi, but with a view, it is believed, of dissolving them by some chemical agents; and it is well worthy of remark, that long before their praiseworthy attempts, two non-medical persons, a monk of Citeaux and Col. Martin, not only devised but actually cured themselves of stone by means somewhat similar to those now adopted in Lithotrity. The idea of breaking and pulverizing a stone in the bladder seems first to have originated with the monk, but it is not likely Col. Martin borrowed it from him, since he employed different means. I think there is no probability of plagiarism, either on his part or that of the practitioners we have just named. It would be a difficult task to assign to each of these the degree of merit due to him; suffice it to say, they have all well deserved of mankind. Mr. Gruithuisen, who published in 1813, appears to have been the first

to devise any thing like scientific or methodical means for acting upon a stone in the bladder by trituration. In 1819, our countryman, Mr. Elderton, conceived the idea of Lithotrity, and invented ingenious instruments for the operation; but here he stopped. Mons. Leroy had the same idea in 1822; he constructed and made known instruments which are now in use. About the same time, Mons. Civiale succeeded in the same object; and to him was reserved the good fortune and high privilege of first employing Lithotrity with method and success upon the living subject: he is still a very successful operator. Baron Heurteloup is now quite as successful and scientific a lithotritist, and to him the world is indebted for the invention of instruments more ingenious, and in many respects, more perfect than those known before his valuable labours. The merit of laying down the principles of Lithotrity more comprehensively and more perfectly than any other person, belongs also to him; and he shares likewise the honour of its introduction into Great Britain, to which, with my skilful friend Mr. Costello, I hope I have endeavoured to contribute." 183.

The instruments most in use at present are, the three-branched forceps of Messrs Leroy and Civiale, and the four-branched forceps, the assisting forceps, and the shell-breaker of Baron Heurteloup. We lately gave an extended review of the able Baron's work, and, as many descriptions of the process of lithotrity and of the instruments employed are before the public, we shall refrain from touching on these topics again. Our object is rather to point out the comparative advantages of lithotrity and lithotomy, and to put our readers in possession of the sentiments of Dr. King, which appear to us both impartial and judicious, on this important subject. It seems to be generally acknowledged that, in the present state of science, lithotrity is scarcely applicable when the foreign body exceeds an inch and a half in two of its diameters. Thus large stones must still be left for the lithotomist; that is, the worst and most fatal cases must continue to be confided to him. Information, however, is spreading both in the profession and out of it, and we entertain no doubt that patients will now learn to appreciate the early symptoms of this complaint, and apply in the first instance for surgical assistance. Surgeons, again, will not only be better acquainted with the initiative of calculous disorders, with the chemical alterations of the urine, and the most scientific means of obviating them; but they are in possession of mechanical methods of destroying or removing small stones when formed -methods which, in such circumstances, are comparatively devoid of risk, and fail to inspire the horror which the prospect of lithotomy must create in the minds of unfortunate patients. The invention of Sir Astley Cooper's urethra-forceps and of lithotrity must, in this point of view, form an era in the history of surgery, and, if mitigation of human sufferings and preservation of human life deserve well of mankind, in the history of the world.

Dr. King very properly insists on the care which should be taken to prepare the patient for lithotrity, as for all great surgical operations, care which we regret to say we have not seen on too many occasions. The following are Dr. King's opinions on the three-branched instrument of M. Civiale, and the four-branched instrument of Baron Heurteloup.

"A few remarks will now be necessary upon the preference to be given to

"To this gentleman, who resides at Northampton, we are also indebted for other inventions of great importance in surgical operations.”

any particular plan of Lithotrity, or to any particular instruments, in the treat ment of the principal varieties of stone. We have no hesitation in stating, that there is only one case in which the four-branched instrument ought to be preferred, namely, that where the calculus is composed chiefly of oxalate of lime, and very hard. In all other cases, which form by far the greatest number, we prefer the three-branched instrument and drill, that is, the treatment by succes sive perforation, which, in the present state of science, appears much more safe than any other. The instrument with which it has been proposed to destroy the stone by excavation, is much more liable to break than the three-branched forceps; and that invented to act by concentric pulverization is open to the same objection, besides being inadequate to the purpose for which it was intended. Most assuredly we should recommend the four-branched instrument for the treatment of all large round stones, of whatever composition, if excavation, or still more, if concentric pulverization could be employed with efficacy and safety; but we contend they cannot the excavator has not yet been, and we fear, can never be made of sufficient strength; and even barring this difficulty, it is almost impossible to reduce a stone, in the manner proposed, to so thin a shell that it may be broken by percussion, unless it can be seized with the percussor-forceps. When an excavator shall be made so strong that there be but very little risk of its breaking, and so well as to reduce a stone to a mere shell, it will deserve to be adopted with the four-branched forceps, in preference to the drill and the three-branched instrument, wherever the calculus is large and round. But, we are of opinion that the most rational and safe plan of all for destroying calculi, would be that of concentric pulverization, were the saw sufficiently perfect to carry it into effect. Some of the strongest objections to Lithotrity would then be obviated: there would be no rough fragments left to irritate the bladder; and as the instrument would leave the surface of the stone smooth, the operation, every step of which would bring relief to the patient, might be interrupted and deferred, at any time, with impunity. Had we such a saw it would be right to use it with the four-branched forceps, in all cases where the stone is not flat, but more particularly in those in which it is voluminous. It will appear from what precedes, that we consider the four-branched forceps better adapted, than any other, to overcome the difficulty of seizing the stone, without pinching the bladder." 216.

In general, several applications of the instrument are necessary, the number varying with the size and consistence of the stone, the state of the bladder, and condition of the patient. The time between the sittings must of course vary under similar, or nearly similar circumstances. The surgeon should always be prepared to perform lithotomy, and should never be without the necessary instruments. Of the propriety of this advice, we have ourselves seen a remarkable instance. For many judicious directions and reflections respecting the operation, and matters connected with it, we refer the surgeon to Dr. King's work. After relating two interesting cases of li, thotrity, he proceeds to consider, seriatim, the objections which have been advanced against it.

1. "A great deal has been said about the difficulty of seizing the stone; many considering it so great as to prevent the general adoption of the operation. The ablest Surgeons, say they, have been foiled in their attempts to lay hold of the calculus, and those who style themselves Lithotritists, nearly as often. But the answer to this is, that the difficulty, however great, (and certainly it is the greatest attending the operation) is to be overcome by patience and that dexterity which practice gives. Besides, it has been, in a great measure, obviated by Baron Heurteloup. With his bed, the stone can almost always be made to roll to

the back part of the floor of the bladder, where a Surgeon who has practised on the dead subject, will seldom fail to grasp it.

2. The liability to contuse and pinch the bladder is certainly a serious objection; and it cannot be denied that these injuries are sometimes inflicted. But, although the coats of the bladder may, by chance, be caught in the forceps by an expert operator, he will discover the accident early enough to avoid doing them any fatal or serious violence. We are inclined to believe, that except on very rare occasions, he must be rather inexpert who could pinch or strike the bladder so severely as to produce contusion, laceration, or violent inflammation. 3. Another strong objection, founded upon the occurrence of the accident to some of the best Lithotritists, is, that the instruments are liable to break in the bladder. Now, admitting this may have happened once in twenty or thirty operations, when we consider that it is to be attributed to defects in the instruments, which are rendered every day more perfect and less fragile, is it too much to expect, that the time will come when such an occurrence shall be unheard of? When it does take place, the patient must generally undergo Lithotomy; but even then, he is not in a worse condition than he would have been before the invention of Lithotrity. He may possibly be in less favourable circumstances, from the irritation already produced by the Lithotritic process; in most cases, however, he will not. In a very unirritable patient, the detached piece of instrument might, perhaps, be attracted and drawn through the urethra with a magnetized rod, it might even find its way out spontaneously; but, since in most cases of this kind, Lithotomy must be performed without delay, the Surgeon should always have the requisite instruments at hand, as well as a magnet.

4. It has been stated, that, if the branches of the forceps cross each other, or become entangled in a hole of the stone, there is no possibility of withdrawing the instrument, without lacerating the urethra. This would certainly be a very embarrassing accident, and, although there is no evidence that it ever occurred, its bare possibility should induce the Surgeon to provide against it. If unable to put things right with a steel rod, he would be obliged to have recourse to an opening in the bladder, by the perinæum, through which he might disentangle the end of the instrument with his finger, or in case of this failing, cut it off with a pair of curved nippers I have had constructed for the purpose, and with which he should always be furnished. But, the best provision against such an accident, would be to have the branches of the forceps separate throughout, as recommended by Messrs. Costello and Guthrie, so that, by withdrawing the external tube, they might be removed one at a time.

5. Several eminent practitioners contend that the principle of reducing a stone in the bladder to fragments, is bad and untenable; they are of opinion, that the presence of these fragments, in so delicate an organ, is sufficient to produce dangerous inflammation; that the frequent application of the instrument required to destroy them, very often occasions the same result, and finally, that, in spite of the greatest skill and attention, one may remain unpulverized, and become the nucleus of a new calculus." 237.

Now, in answer to the last objection, or rather string of objections, Dr. King replies, that experience has proved that the fragments left after the lithotritic process do not give rise to inflammation, in the great majority of cases. Several applications of the lithotritic instruments can hardly be looked on as a serious objection, provided the risk is not materially increased, which it certainly is not. Lithotomy, it is true, is usually completed at once; but is the patient's convalescence accomplished in a day? If safety is increased by the sacrifice of time, that sacrifice should be cheerfully and unhesitatingly made. In fact, we cannot look upon this as an objection to lithotrity at all-it is merely a circumstance which diminishes its éclat, and derogates from its rapidity of cure and quantum of inconvenience. Are relapses more

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frequent after lithotrity than lithotomy? Probably they are so, although the cutting operation is well known not to be devoid of them. But if a relapse does occur after lithotrity, it is but, as Dr. King supposes a patient to exclaim, "only a little more grinding."

"The opponents of Lithotrity have not failed to enumerate, at full length, the cases to which it is inapplicable: those where the stone is very hard, or very voluminous, or encysted; diseases of the prostate; urethræ originally very small, or contracted from strictures, have been much dwelt upon. In considering these dispassionately, it will be found, that they do not constitute any thing like a foundation for hostility to the general adoption of the operation. In some adults, where the urethra is naturally very narrow, it may sometimes be impossible to introduce the smallest instrument; but this is very rare indeed. And, in children, Lithotomy, well performed, loses three-fourths of its dangers, differing by its lenity, nearly as much as Lithotrity does, from the same operation performed on grown persons." 244.

This is the true state of the case. Take away these cases, and you have a great number to which lithotrity is applicable, and in which it may, and in all human likelihood will, become a means of safety. With respect to encysted calculi, the remark appears absurd. We would wish to know on how many cases of encysted calculi would the surgeon operate, knowing them to be such, or in how many would an operation be required! Such frivolous objections as these are like nibbling at the operation in committee; they come from the waverers.

"After this enquiry into the principal circumstances connected with the treatment of stone, by Lithotomy and Lithotrity-in which we have attempted to place side by side, their respective dangers and advantages, by an appeal to facts, and thus to establish the degree of estimation in which each ought to be holden in practice, our conviction is, that wherever Lithotrity can be employed, Lithotomy should never be thought of." 249.

PROPOSALS FOR THE TREATMENT OF CALCULI OF GREAT MAGNITUDE AND DENSITY.

The surgeon whose genius could devise or dexterity accomplish means of removing large calculi from the bladder with little, or even with less than the present risk, would unquestionably deserve well of his kind. Large calculi are the opprobrium of surgery. Lithotomy for them brings nothing but danger; to them lithotrity is confessedly inapplicable. Dr. King makes some proposals for their treatment which we shall lay before our readers.

We need not repeat that a great, perhaps the greatest danger in the operation of lithotomy is a large incision. Yet, whenever the calculus is of great dimension we must either make an incision fatally extensive, or commit a laceration yet more destructive. We are on the horns of a dilemma, and, do what we will, experience has proved that lithotomy for large calculi is too generally unfortunate.

"The principle of Lithotomy-Lithotomy of the safest and best kind—is, then, to have the incision proportionate to the size of the stone. Now, what I would suggest is, that this principle be reversed, and that the stone be reduced to the limits of a tolerably safe incision. In Lithotomy, the rule is, to adapt the wound to the calculus; whereas, I propose, adapting the calculus to the wound. This new plan may be called perinæal Lithotrity.' 252.

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