and that since this beneficial change in practice, fewer patients have been lost there by peritonitis. This fact serves as a material confirmation of all that I have urged in the foregoing pages; because, the common fault of gorgets, particularly of those used some years ago, was to make too small an opening, and this sometimes not in the best direction. But, when a common scalpel, or beaked knife was preferred, the surgeon generally made the incision in the prostate gland and neck of the bladder, large enough for the easy passage of the stone, and always downwards and outwards in the most advantageous direction.

With respect to the degree of importance which ought to be attached to the fear of effusion of urine between the bladder and rectum, gangrene, fistulæ, &c. I can only repeat, that they are inconveniences, which are not commonly observed after lithotomy in this country. In two or three instances only, I have known the urine come through the wound longer than usual; but even these cases ended well. As for the extravasation of urine and sloughing, although there cannot be a doubt of their occasional occurrence, they cannot be fairly imputed to the method of operating in England, since they have not taken place after any of the numerous operations, with the results of which I have been acquainted.

All these facts and considerations, therefore, incline me to doubt, whether the apprehension of effusion of urine, fistulæ, &c. be sufficiently serious and well founded to render it adviseable for surgeons to relinquish the plan of making a complete divi sion of the side of the prostate gland, and part of the bladder in the operation of lithotomy. Nor is it at all clear to my mind, that effusion of urine and sloughing are likely to be the effect of practising a free opening. Indeed, when they do happen, I suspect that they generally proceed from a totally different cause, viz. from the incision in the skin being too small and too high up, and from the axis of the internal part of the incision not corresponding with that of the external wound. Hence, the urine does not readily find its way outward, and some of it passes into the neighbouring cellular membrane *.

*In noticing the faults of Hawkins's gorget, Desault has observed: "La methode de l'enfoncer horizontalement dans la vessie sur le cathéter tenu à angle droit avec le corps, a deux grands désavantages: d'un côté celui de pénétrer par l'endroit le plus rétréci du pubis, et par conséquent de ne faire que difficilement une ouverture suffisante; d'un autre côté, celui de ne pas établir de parallélisme entre l'incision extérieure des tégumens qui est oblique, et celle du col de la vessie et de la prostate qui se trouve alors horizontale. De-là la possibilité des infiltrations par les obstacles que les urines trouveront à s'écouler."

I have also no doubt, that some of the worst instances of extravasations of urine after lithotomy, have been owing to another cause, pointed out by the same excellent surgeon. "Imprudemment

"Imprudemment porté dans la vessie, le gorgeret peut aller, par le stylet beaucoup trop long qui le termine, heurter, dé. chirer, perforer même la membrane de la vessie, et donner lieu à des infiltrations d'autant plus dangereuses, que le lieu d'ou elles partent est plus inaccessible." (See Œuvres Chirurgicales de Desault, par Bichat, Tom. II. p. 460-461.

CASE

OF A

FATAL HÆMORRHAGE

FROM THE EXTRACTION OF A TOOTH.

BY RICHARD BLAGDEN, Esq.

SURGEON EXTRAORDINARY TO HIS ROYAL HIGHNESS THE
DUKE OF KENT.

Read Dec. 24, 1816.

JOSEPH LANCTON, while a boy, had a tooth extracted, in consequence of which an alarming hæmorrhage took place from the alveolus. The hæmorrhage continued twenty-one days and then ceased. It was observed afterwards, that whenever he cut himself accidentally, or received any other slight wound, hæmorrhage took place to a greater extent than in ordinary persons, and that it was more difficult to stop. In the summer of 1815, being then twenty-six years of age, he received a slight wound on the forehead. A profuse hæmorrhage took place from a wounded artery. Pressure and the ordinary styptics were employed for the purpose of suppressing it, but the bleeding constantly recurred. Mr. Gatcombe, who took

charge of the case, applied a ligature round each of the divided ends of the bleeding vessel, but it gave way behind the ligatures and the bleeding returned. Mr. Gatcombe observed the artery to be very thin in its coats, like a vein rather than an artery. The hæmorrhage was eventually stopped by the application of the kali purum, which produced an extensive slough of the soft parts, and even caused an exfoliation of a small portion of bone. In the spring of 1816 he suffered much from a caries of the second molaris of the upper jaw on the left side. Fearing that the extraction of it would occasion an hæmorrhage, such as had occurred formerly, he for a considerable time delayed having the tooth removed. At length, as he continued to suffer, he determined to submit to the operation, and the tooth was therefore extracted on the 30th of June. The jaw sustained no particular injury by the operation, but there was an abscess at the root of the tooth, which either was in, or communicated with, the maxillary sinus. A profuse hæmorrhage immediately took place from the alveolus. On the evening of the 1st July, as the bleeding still continued, I was desired to see him, and immediately applied the lunar caustic to the bottom of the alveolus, but without effect. I then carefully stopped the socket with sponge soaked in a solution of blue vitriol, and directed that the face should be kept moist with some cold application. The bleeding now ceased but returned in a few hours. On the following