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Such is the principle which guides Dr. King. It has been remarked that when large calculi have broken in the forceps, previously to their extraction, the patient has recovered more frequently than when no such accident has happened. The breaking of a large calculus by the lithotomist appears to the inexperienced spectator a misfortune, yet it may be questioned if it be not the reverse. Dr. King's propositions are founded on the good effects, real or reputed, of this very accident. In short he proposes to break the calculus, after making an opening, a small opening, into the bladder in the usual manner from the perinæum.
"In order to meet the objection founded upon the inconvenience of scattering the bladder with fragments, I have endeavoured to devise means for enclosing the calculus in a bag, prior to breaking it to pieces. The instrument I use for the purpose is a light forceps, having the upper blade split into two branches, which are made to open and shut, and to which the end of a bag is adjusted for receiving the calculus. When the latter is pressed in the forceps, at the same time that the branches of the upper blade are gradually expanded, it necessarily passes between them into the orifice of the bag, in which, by continuing the pressure it becomes finally enveloped.
The next object was to find the best means of breaking the stone, in the quickest possible time. I tried several instruments, some constructed on the model of the forceps of Andreas à Cruce, with long strong branches, and wedgeshaped teeth in the blades; others having a contrivance for breaking the stone with a wedge or percussor; and one like that used by Baron Heurteloup for breaking calculi by percussion. Those of the first kind are the most simple, and give the least trouble in seizing the stone, and as they are extremely powerful, few calculi will resist their action. With the others, the hardest calculi may be broken, but they do not offer the same facility for grasping them.
The operation is performed in the following manner. The patient, who should be prepared as before submitting to Lithotomy, is to be placed upon Baron Heurteloup's bed. I introduce into the bladder a slightly curved staff, which is held by an assistant, nearly on the median line, whilst I make an incision up to it through the perinæum. This incision, about an inch and a half long and extending from a central point about an inch and a half below the inferior part of the symphysis pubis towards the left side of the anus, is made in two or three strokes with a straight, pointed knife; one serving to open the urethra from the left side of the bulb backwards, as in Lithotomy. I use Blizard's knife, or a sheathed instrument, to extend the opening to the anterior part of the prostate. A small conductor is then passed through the opening into the bladder, in the groove of the staff; and the latter being withdrawn, I exchange the conductor for the forceps. Thus far the operation differs from Lithotomy, only, in as much as the incision is made just sufficiently extensive to admit the forceps. In introducing the latter, the principal part of the bag, previously oiled, is kept close to the double or upper blade, which, when the stone is grasped, is to be gradually opened. As soon as the calculus is completely enclosed, the branches are to be shut and brought near the wound, in order that the end of the bag may be made secure and detached from them. The forceps is then to be withdrawn. It is through that part of the bag hanging out of the wound, that the instrument for breaking the stone is to be introduced, guided by the finger or a conductor; and, as the patient is placed in the position required for seizing the foreign body in Lithotrity, the stone, which cannot escape from the bag, will be easily grasped." 259.
To this proposal there may be some objections, but Dr. King believes that the chief will lie against the apparatus, and this may admit of improvement almost to an indefinite extent, at least that improvement can only be limited by human ingenuity. The risk of fragments remaining in the blad
der is an evil; yet supposing them not removed by the means in our power, they can leave but the necessity for future lithotrity. We must recollect that in this case we have only a choice of evils.
"The length of time required for the performance of the operation, and the necessary pain and irritation attending it, constitute another objection to perinæal Lithotrity. But, again, we ask, whether they endanger the life of the patient? What does reasoning upon analogy, what does experience teach us on this point? In Lithotomy, it is not the frequent introduction of instruments, or the time employed, that renders the operation dangerous, but the extent of the incision or the force employed to extract the stone; and, when hemorrhage is avoided, when we are secure from infiltration of urine, when the bladder has not been forced or the prostate lacerated, we may expect a successful result." 263.
In those desperate and deplorable cases, where the calculus is too large to admit of even this proposal being carried into effect, Dr. King recommends another plan. We are sorry that our exhausted space compels us to pass it over. Our own opinion is this, that in cases of such extremity, the result is but too probably unfortunate under any method of procedure, or any plan of treatment. Mankind will reap more benefit from the early discovery and removal of small stones, than from any inventions in the treatment of large ones. At the same time, we would not discourage attempts to mitigate the dangers of their extraction.
A chapter on calculus in the female bladder contains nothing of particular moment. The last division of the work consists of General Remarks on the Treatment of Calculi. In our full analysis of the able and practical lectures of Mr. Brodie on calculous disorders, their nature and treatment were so fully considered, as to render it unnecessary for us to dwell on them again. We may take the opportunity, however, of stating, that we think Dr. King's reflections indicative of judgment and reflection. But we do not quite agree with him on every point. He says, for instance, that the ammoniaco-magnesian diathesis certainly originates in a diet of too animal a nature, and, therefore, recommends the use of vegetables. That too much animal food, especially when conjoined with sedentary habits and late hours, will cause the deposition of the triple phosphate in the urine, we have the best means of knowing, having lately witnessed a well-marked instance of this description. But we doubt whether this be generally the case; indeed, we know that the triple phosphate is usually the deposition of debility-remedied by all that invigorates, augmented by all that weakens. In illustration of this principle, we refer to the excellent work of Dr. Prout. For this reason, general bleeding is seldom admissible in the triple-phosphate diathesis, and the surgeon should be cautious how he employs it.
Dr. King feels himself justified in stating, that the formation of the oxalate of lime gravel coincides with the use of coarse, indigestible food, in which animal matter does not preponderate. The causes of this diathesis have hitherto been a problem; but the deposition of the oxalate of lime in the urine appears to be connected with the formation of acid, rather than alkali, in the system, as is proved by its occasional alternation with the lithic acid in calculous concretions. Dr. King observes that in one case, in which he exhibited citric acid against oxalate of lime gravel, it succeeded perfectly. Dr. King very properly insists on dietetic rules and restrictions. It is worse than a farce to meet acid or alkali in the urine by alkaline or acid medicines, when the habits and the food which occasioned the morbid cha
racter of the secretion are allowed to be persisted in. For our own parts, we would infinitely rather throw physic into the Thames, and trust to regimen and general means only in the treatment of affections of the urinary organs, than appeal to pharmacy, to the exclusion of these most important agents. We speak advisedly; and we cannot but believe that the chemistry of the urine may possibly prove an ignis fatuus to some, and lure them from the high road of common experience and common sense.
We must now bring this article to a termination. We are not in the habit of pronouncing those oracular pieces of criticism, which seem to us of no use but to flatter or to hurt the feelings of authors. We do not wish to crucify an unfortunate writer, or exhibit him writhing under the lash of public ridicule or vituperation. We war with nothing but impudent assumption-want of principle-with doctrines or with practices calculated, in our opinion, to be mischievous to the community. If books are good, we endeavour to make the public fully acquainted with them; if indifferent, we usually pass them unnoticed. Silence is our censure-notice is our praise: by the former we lacerate no feelings-by the latter we accomplish a public good. We need say no more, then, to Dr. King than our review has told him; this is not a courtly compliment, but it is better-it is an honest one.
OBSERVATIONS IN SURGERY AND PATHOLOGY; ILLUSTRATED BY CASES, AND BY THE TREATMENT OF SOME OF THE MOST IMPORTANT SURGICAL AFFECTIONS. By William Jones Clement, · Surgeon. Octavo, pp. 230. London, 1832.
Mr. CLEMENT, the author of the volume before us, is a surgeon residing and practising at Shrewsbury. We believe that he has enjoyed a tolerably extensive private practice, and his object in publishing the present work is to communicate the results of his experience, to correct some errors which he imagines to be established, and to narrate some cases of surgical affections not commonly witnessed. Such objects cannot be otherwise than laudable, and we hope that others of our able and experienced provincial brethren will follow the example now set them by Mr. Fletcher, of Gloucester, and Mr. Clement, of Shrewsbury. The first portion of the volume consists of a critical inquiry into the different opinions respecting the structure of the urethra, and an attempt to refute the doctrines of Sir Everard Home; the second contains some cases of strangulated hernia; and the third is made up of several isolated cases-spina bifida, aneurysm by anastomosis, lithotomy in a female child, tumour attached to the biceps flexor cubiti, tumour attached to the lower jaw, and, finally, remarks on Sir Charles Bell's discovery of the functions of the facial nerves. Such are the many-coloured contents of the book, and it may be supposed that we do not pretend to offer an analytical review of them. In consequence of the narrowed limits of the review department, our notice here must be very brief; but we shall endeavour to supply, in the Periscope, an abstract of the most curious and interesting facts.
The first portion, that which treats of the urethra, need not detain us long. It is chiefly occupied with the refutation of Sir Everard Home's opi
nions on the muscularity of that canal. We believe that few surgeons now believe, or anatomists inculcate, such a doctrine, and it would be felling a man of straw to reiterate the arguments and proofs against it. The only part of the paper to which we think it necessary to direct attention, is one in which allusion is made to the nature and treatment of that difficulty in making water which not unfrequently succeeds gonorrhoea.
"The fears of patients are frequently excited, by the stream of urine appearing smaller than usual after their recovery from the acute symptoms of gonorrhoea; and they actually may experience some difficulty in voiding it; this they of course attribute to the formation of a stricture, whereas it more frequently depends upon the want of elasticity in the canal, produced by the previous inflammation; and some degree of thickening may probably exist as the consequence of it, but which will gradually subside, if the canal be not interfered with, or irritated, by the passing of instruments.
So convinced am I of the impropriety of, and the bad effects which arise from, the use of bougies, in what are supposed to be cases of recently-formed strictures, that whenever I am consulted by patients who have some difficulty in making water, and express their fear of the formation of a stricture, I invariably object to the introduction of the bougie, if, upon enquiry, I find that they have only recently recovered from gonorrhoea. My practice, in such cases, is to direct a small quantity of the Linim. Hydr. Camphor to be rubbed along the line of the urethra every night and morning; and it has always happened that those patients, who have had confidence to pursue this plan and give it a fair trial, have returned to me in the course of a short period, declaring themselves perfectly free from any obstruction, or difficulty in making water." 39.
If obliged to sound the patient, our author has generally found one tender point in the urethra, about three or four inches from the orifice. Both the bougie within, and pressure from without, produce a sensation of soreness and pain here, and Mr. Clement imagines that a slight degree of inflammatory action, lurking in the part, is the cause. In some examinations after death, which he has had an opportunity of making, he has found redness, vascularity, and a degree of firmness in the membrane of the urethra at this spot. In such cases, Mr. Clement avoids the bougie, although it is too frequently employed in them, under the supposition of the existence of a spasmodic stricture. Mr. Clement's plan of treatment is, to direct the application of leeches as near as possible to the part affected, and repeat them once a week for a month, or longer if circumstances require it, giving, at the same time, full doses of the liquor potassæ. When the sensation of soreness is removed, he advises the application of the linimentum hydrargyri camphoratum. After the diligent employment of this method for some time, he has been enabled to pass a full-sized bougie into the bladder without difficulty or the production of pain. We have drawn attention to this mode of practice, because we know, from experience, that it is successful. We have seen many instances of diminished stream of urine after gonorrhoea, which by mild and unirritating treatment has been removed, and has not subsequently terminated in stricture. We agree with Mr. Clement, that the bougie is not only not required in such cases, but must prove absolutely prejudicial in many.
We pass to the subject of hernia, or rather to the cases of this disease; for the remarks are only in the form of notes upon these, as they are detailed.
CASE 1.-Strangulated Inguinal Hernia-Operation-subsequent Protrusion and Mortification of Omentum.
Mrs. B. æt. 49, who had long been subject to reducible inguinal hernia, but worn no truss, was seized with the symptoms of strangulation in the night of the 5th of November, 1823. The operation was not performed till the evening of the 6th, two large bleedings, with the warm bath and taxis, having been ineffectually employed in the interim. The contents of the hernial sac were found to be a considerable portion of omentum, and below this, three or four inches of small intestine, firmly strictured and exceedingly livid. The stricture was formed by the neck of the sac. The principal symptoms subsequent to the operation were, retention of urine for a day or two, and, on the 8th, some fever, with shooting pains in the loins and bowels. On the 9th she was better, and in two or three days the wound was, to all appearance, closed, and the patient in a very favourable condition. In straining to evacuate the bowels on the 13th, the wound opened, and a considerable piece of omentum was protruded. When the patient was visited it was impossible to reduce the omentum, now as large as a billiard-ball. It became strangulated, sloughed, and separated, without the occurrence of an unpleasant symptom. The wound was perfectly healed on the 2d of December.
Mr. Clement, like all judicious surgeons, is a warm advocate for an early operation in cases of strangulated hernia. The operation is rarely dangerous-delay almost always is so. He is also inimical to the use of the tobacco enema, because he has seen it prove fatal, because he has never seen it beneficial, because its good effects may be obtained by the warm bath and bleeding without the risk of its bad ones, and because it not only protracts the performance of the operation, but probably renders the patient worse calculated to bear it and less willing to submit to it. Mr. Clement objects to active purgatives before or after the operation. If aperients are necessary after it, they should be mild ones, and enemata are usually to be preferred.
CASE 2.-Strangulated direct, or Ventro-Inguinal Hernia-OperationEpilepsy afterwards.
Wm. Giles, æt. 29, iron-founder, robust and temperate, had been subject, for six years, to a small hernia, for which he wore no truss. In the morning of the 19th January, he felt the hernia descend lower, and was attacked with symptoms of strangulation. At 7, a.m. Mr. Clement saw him. He was suffering great pain. The hernial tumour was of the size of a common lemon, and, on examination, Mr. C. discovered that it was of the direct, or ventroinguinal description. Mr. C. bled him to syncope, employed the taxis, produced syncope again in the warm bath, and again employed the taxis without Six hours had now elapsed since the commencement of symptoms of strangulation, and at 1, p.m. the operation was performed.
"After the integument and superficial fascia were freely divided, the spermatic cord was seen running obliquely across the lower part of the wound. I pushed it gently downwards, and directed my assistant to place his finger upon it. The layers of fascia covering the hernial sac were very thin, and it was difficult to distinguish the difference between the true peritoneal covering and the intestine which was seen through it, presenting a very livid colour.
The sac was cautiously pinched up, taking care to avoid including any portion of the intestine; then, holding the knife horizontally, I made a small opening into it, which was afterwards enlarged by the bistoury. It was not until the sac had been freely opened, that any serum escaped, and then only a very small quantity. About three inches of the jejunum was exposed, in colour more resembling