fatal result within a few days; on the other, the excruciating agony without hope of mitigation by any other course of treatment. It is not surprising to know that frequently the patient himself prefers the greater danger with the hope of relief to the unending torment with no prospect of abatement. It seems the duty of the surgeon to state the case as fairly as he can, and leave the decision in the hands of his patient, biassing him in one way or the other according to the gravity of the case. Of course there are some instances where no one would agree to operate at all; but these must be very few and exceptional. In many examples on record, the surgeon has undertaken the case as a last resource at the urgent request of the patient, and has had good reason to congratulate himself on the result. This applies equally to both operations, but I refer to it just now in connexion with the question as to what circumstances should deter us from operating at all. In a case which I had lately, where the stone had been in existence, and of considerable size, for many months, and where there was enlarged prostate, atony of the bladder, chronic cystitis, and enfeebled health,-I felt bound to give a very guarded opinion; but as I could not exclude the hope of recovery, the patient himself elected to have the operation, lithotomy, performed, saying the agony was too great to be endured any longer. In similar instances we are, I think, bound to give the patient the chance of recovery unless in exceptionally bad cases.

I think I have now touched briefly on most of the points of interest which assist us in determining the question of lithotomy or lithotrity in particular examples. I am aware that the discussion of these topics might be extended to almost any length, and I know that they are treated systematically in the standard works on the subject. But I have thought that they might be introduced here in a concise form, so that they may be looked on as the ground on which I believe in many instances in the adult, calculi may be removed with more safety by the crushing than by the cutting operation.

With regard to the pain and suffering during the period of treatment, so much depends on individual constitution that no general conclusion can be drawn. Lately I had two typical cases which made a great impression on many of the students who witnessed the treatment in each case. One was a boy two and a half years of age, from whom I removed a calculus weighing ten grains by the rectangular lithotomy. He made a very perfect recovery, being discharged with the wound completely healed in three weeks after the operation. During the time the wound was open he screamed with pain each time the urine was evacuated, but no untoward symptoms arose. The other case was that of an adult who had a small hard stone. I crushed it on four occasions, at intervals of two days, and he was dismissed perfectly cured, after a fortnight's residence, having been confined to bed only one day during the whole time. Of course this is an unusually fortunate example; still, in most that I have seen, the pain or suffering, where there was any, was limited to the time when the operation was performed, and when excessive, could easily be mitigated by chloroform.

There is one objection to lithotrity frequently urged, which I must notice. It is stated that there is a greater frequency of a return of the disease after the crushing than after the cutting operation. This assumed consequence is attributed to the retention in the bladder of some small fragments that may have eluded the final search of the surgeon, or to an alteration in the lining membrane of the bladder produced by the use of the instruments, which tends to cause phosphatic deposit. But I know of no evidence to support this assumption. I am very unwilling to quote my own experience in this matter, but in the absence of any other, I can do nothing else. I know of two cases in which lithotrity was followed by the formation of another calculus some time after; just such cases as would be quoted in evidence of the above assumption; but in each case the new formation was clearly to be attributed to the constitutional tendency, and not to faulty operation. In one case the stone was formed many years after a small one of a similar nature had been crushed and removed by Sir Benjamin Brodie; and after the second was removed, a third made its appearance two or three years subsequently.

In the other case, a uric calculus was formed two years after the operation of lithotomy, in which two stones were removed. The third one was crushed, and was followed in a year by another; that was followed by another, which was detected when so small that a single manipulation removed it; since which time the patient has not had a symptom. In the May number of the Edinburgh Medical Journal, there is an account of a case in which lithotomy was performed three times at intervals of some years; the calculus being reproduced after complete removal. Until I find evidence to the contrary, I am justified in believing that relapse is not more frequent after well-performed lithotrity than after lithotomy.

me.

But an important method of preventing the re-formation of calculus remains to be mentioned, which has been recommended as a part of the aftertreatment of lithotrity. I allude to the practice of washing out the bladder with a stream of tepid water. This can be done very effectually by the patient himself, by means of a gum-elastic catheter and india-rubber bag. The water may be made astringent or slightly acid, or alkaline if desired, according to the nature of the case. My experience is too limited to entitle me to give any opinion as to its effects after lithotrity, but in an analogous case the benefit was very striking. A young man with urinary symptoms consulted Dr. J. B. Cowan, who, finding some of the indications of stone, sent him to A very careful examination with the sound satisfied Dr. Cowan and myself that there were no calculi. There were occasional slight discharges of blood, just enough to tinge the urine. There was a considerable quantity of mucus and phosphatic sand in the urine; the latter occurring in bits the size of a small pin's head. The patient was ordered a tonic regimen, and advised to wash out his bladder daily with a solution of acetate of lead, one grain to two ounces of water. This he continued for a month with manifest improvement; then the injections were made weekly, and at the end of three months every trace of the former affection had disappeared. I have no doubt that if the precaution referred to had not been adopted, he would have become the subject of a phosphatic calculus in the bladder. The same treatment, I am informed, has been effectual in preventing re-accumulation after phosphatic calculi have been removed by lithotrity; a well known example of which was the case of the late King of the Belgians.-Edinburgh Medical Journal, July, 1868, p. 6.

66.-ON LITHOTOMY.

By Sir HENRY THOMPSON, Bart.

I now come to the mode of performing the lateral and the medio-bilateral operations, and will give a few general hints which will apply equally to either. As I have said before, when we have to do with many details, let us try to revert to first principles, and define clearly the object we aim at. I told you that the object of lithotrity is to remove the stone without injury to the patient either from the stone or the instrument. In lithotomy you must have a wound, and the object is to make it in such parts as shall least endanger the blood-vessels, the viscera, or the neck of the bladder, and to remove the stone through the lower outlet of the pelvis with as little mischief as possible to any of those parts. When that problem is best solved we shall have the best form of lithotomy.

Now, in order to aid you to solve the problem for yourselves, I have placed before you a diagram drawn accurately from the preparation, showing the bones and ligaments of the pelvis, in the position for lithotomy. The lower outlet is opposite to us; it is in the patient filled by soft parts, and it is the opening into which you have to cut, and through which you must remove the stone, and in all that you do, you must be limited by its boundaries of bone. I like to have that in my mind's eye when the patient is tied up and I take my seat to operate. Here also are diagrams, showing two stages of the dissection of the perineum. I take it for granted that you know your

anatomy too well to require any detailed account here of the important parts involved in the operation. I shall simply name those which concern us. First, there is the pudic artery, safely sheltered under the pubic ramus; but it gives a branch to the bulb, a vessel to be avoided at the upper part of the space. Then in the same part is the bulb of the urethra, which is not to be thought too lightly of; indeed it is the source of some of the chief dangers; it is a vascular expansion from the vessel named. and cutting into it is as bad as cutting into the vessel itself, if not worse. Next there is the rectum in the middle and lower part, which it is also important to avoid. The other diagram shows the position of the prostate, which must be divided in the deep incision.

I will now briefly touch on the principal steps of the operation. The patient's bowels are to be thoroughly emptied by an enema a few hours before. Do not trouble yourself about the quantity of urine in the bladder. Some think it very important that it should be full. Cheselden, on the other hand, preferred it to be empty, saying that in this condition the stone was easily found close to the neck of the bladder.

The first thing the operator does is to pass the staff into the bladder and find the stone. Never think of cutting a man if you are not perfectly satisfied that the staff is in contact with it. Frightful blunders have been made through indifference to this rule. Suppose for example, the staff is in a false passage, and is not in the bladder at all: one shudders at the idea of an operation performed on a staff so placed-an exhibition distressing to all concerned never to be forgotten either by the operator or the bystander, and probably fatal to the patient. The "click," then, is to be distinctly audible to yourself and to a witness, and the staff is to be put into the hand of your best friend, who is to attend implicitly to your instructions, and to no others, whatever they may be. The patient is then to be tied up firmly; better still if secured by these leather anklets and wristbands, devised by Mr. Pritchard, of Bristol, because they truly realise the proverb "fast bind, safe find," which our old friends the garters often did not.

Now, what are the instructions to your friend the staff-holder? You want it held firmly, and, of all things not to leave the bladder. I don't think you will gain much by cultivating a fancy for any particular spot, such as right or left, or projecting in the perineum. If it is to be steady and in one spot, which is the main thing, there must be a point of support for it to rest against and there is but one such spot in the whole region. Rely upon it, then, you had better tell him to keep it close to the arch of the pubes, well hooked up, with the handle pretty nearly vertical. Your fingers now traverse the region and find the lines of the rami, also the condition of the bowel, whether empty and contracted, or the reverse.

Now, relative to the first incision, different authorities advise different places at which to enter the scalpel and commence. Without discussing these, let me say that as a rule, the usual spot should be, for an adult, an inch or an inch and a quarter in front of the anus, a little on the left side of the raphé. Go in boldly, slightly pointing upwards, near to or into the staff, and then gradually less deeply till you come out about three inches lower down towards the inner side of the tuber ischii. It is very pleasant to feel that you touch the staff in that first incision, and it saves trouble and uncertainty to have gone close to it, which you always ought to do; never let it be a timid, shallow cut, merely dividing the skin. The left index-finger follows, and should feel the staff easily through the tissues. Fixing the finger-nail upon it, the point of the knife is fixed firmly in the groove, and is run steadily on in contact with the staff. Keep the point up and you will be safe; let it down and you may slip out and get into the rectum, or nobody knows where. Simply go on, letting the blade be a little more horizontal as it proceeds. Go on till you are well into the bladder, not letting the point leave the staff. The depth of the incision will depend upon the angle which the knife makes with the staff; if you withdraw with the knife close to the staff, of course you will only make a wound the width of the knife; and if the edge is directed outwards and downwards against the soft parts, with a light

hand as you come out, you will make a freer and cleaner opening. It is better to be rather free in cutting than otherwise [the presence of a large stone is assumed], but you must not make the incision too wide. There has been a great deal of good advice expended about this subject, the depth of the incision, but it is manifestly impossible for one man to make another understand what he means or what he does by any amount of talk. My belief is, however, that the result of our anxious care about this matter is, practically, that we are apt to cut rather too niggardly than too freely, and the neck of the bladder, in consequence, receives severer injury from the stone and forceps than it otherwise would receive from the knife. This relates of course to adults; for in children you can scarcely find the prostate —it weighs but a few grains, and does not come in for a moment's consideration, and your knife goes far beyond its limits; yet these little patients are the safest to cut. Of course there is a very great difference in the two ages, due to the different conditions of puberty and childhood. To return. The incision being completed, your left index finger immediately follows close along the staff into the bladder, where you will probably just touch the stone. The finger goes firmly and deeply in, stopping the urine perhaps to some extent in its outflow, and accomplishing some dilatation of the parts. Then you slide the forceps closely along the palmar surface of the finger, and insinuate them into the bladder, which makes dilatation No. 2. Then, generally speaking, you have but to open the instrument carefully, yet widely, one blade flat at the bottom of the bladder, the other towards the top, and, closing the blades, the stone is probably between them. If it seems that you have a good hold, draw gradually outwards and downwards, easing or adjusting, if you can, with the left index; and so you make the third and last dilatation. Remember not to pull out horizontally and bruise the parts against the pubic arch, but downwards into the widest part of the lower pelvic aperture. [Diagram.] And don't be hurried for the sake of anybody else. You and your patient are to be, for you, at this moment, the only persons present, and your responsibility to him must never be forgotten for an instant through the influence of bystanders and lookers on.

I must now briefly add that you will search for a second stone, tie any vessel spouting within sight, insert the tube into the bladder, and stuff the wound round it if the hemorrhage is free. The patient is placed in bed on his back, with one or two pillows under each ham, and the parts involved exposed to air and light, so that you see how the urine flows. The less meddling afterwards generally the better.

I have only time to say a word or two about the median and medio-bilateral operations. For the median, an incision is made in the line of the raphé from about two inches and a half above the anus, downwards or near to its margin as is safe, for you want all the space you can get. Dissecting down to the staff, with a finger in the rectum, and opening the urethra in the membranous portion or thereabout, you carry a director on into the bladder; your finger follows, and dilates, and then the forceps on that. Manifestly this will not do for large stones, which mainly, thanks to lithotrity, are what we have to deal with now. Hence the applicability of the “median" is extended by making it "medio-bilateral," and in this manner. Having performed the median, as just described, up to the joint of opening the urethra, instead of introducing a director, you introduce the two-bladed lithotome, and when it is in the bladder you open the blades, and two moderate incisions are made, one right, the other left, as you draw the opened instrument outwards in the groove of the staff. These two operations I have now performed about thirty tines, and I do not know, after all, that there is much to choose between them and the old lateral." To make an accurate estimate, one requires at least 100 cases of each operation by the same hand. Nevertheless, I may say a word, finally, on the principle which essentially distinguishes these operations. They are the result of opposite convictions respecting the hazard of the knife. There is a set of men to whom anatomy is a bugbear, and who are afraid of cutting as much as is absolutely necessary; and there are other men less timid-mind, I don't say less cautious,-who regard the

larger, freer style of operating as better than the small or fearful style. All surgeons, of course, tend more or less to fall into one of these two classes. The anatomical school have devised a variety of median operations in order to avoid certain blood-vessels, &c., and they sacrifice space in doing so. They answer excellently well for small and medium-sized stones; but these are or should be crushed now, and we do not want any operation for such stones. The perineal operation which offers the most room, the recto-vesical excepted, is the lateral operation. All the others named are essentially median operations. Now I am bound to say that formerly, judging theoretically, I had a leaning to the median method, being disposed to think that it would be attended with less hemorrhage than the others. But I do not find this so in practice, and I have arrived at the conclusion that there is quite as much bleeding as in the lateral operation. I attribute this to the bulb. I regard the bulb as a large artery to all intents and purposes. You cut into that spongy tissue-not in all cases but in some.-and there is as much bleeding as if you cut the artery of the bulb, and more difficulty in controlling it. The bulb must be cut more or less in the median operation. The problem is how to get into the bladder without wounding the bulb, its artery, and the rectum; and I believe that a well-performed lateral operation accomplishes this, where a free opening for a large stone is required, better than any other.-Lancet, June 6, 1868, p. 709.

67.-ON SOME RECENT IMPROVEMENTS IN THE OPERATION OF LITHOTOMY.

By Dr. ANDREW BUCHANAN, Glasgow.

[The following article which was published as a letter addressed to the editor of the Lancet, was elicited by that of Mr. Hutchinson, contained in our last volume of the Retrospect, p. 236.]

The idea of confining the section both of the external parts and of the prostate gland to the mesial plane in front of the rectumn was shown by Dupuytren more than half a century ago to be utterly impracticable for all stones of ordinary magnitude; and yet this operation, under the ambiguous generic name of median" (proper specific name, medio-vertical), has been for some years past occupying simple minds in this country as something quite novel, and big with vast results.

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The mesial plane enables us to penetrate by the best road into the bladder, and this constitutes the distinctive character of the "mesial " or " median operations in contradistinction to the lateral, where the knife penetrates inward from the side of the perineum. But to extract a stone of ordinary size we must also make a lateral section both of the prostate gland and of the external parts on one or both sides (medio-lateral and medio-bilateral operations). Now comes the most important question of all. Which of all these operations is the safest, or that attended with the least average mortality? Is it one of the median operations: the medio-lateral, the medio bilateral, or the medio-vertical; or does the advantage lie with the old lateral operation? The question can only be answered by referring to the recorded results of these different operations. We may put out of the competition the medio-vertical as too restricted in its range. The medio-bilateral was, as I stated in my last letter, in the hands of its author, an unfortunate operation in its results. It only remains, therefore, to compare the medio-lateral and the old lateral operations. With respect to the latter I referred in my last in an especial manner to Sir William Fergusson, in the hope of drawing from him the most recent statistics of the lateral operation, which he seems never weary of extolling to his applauding students as superior to every other. Having failed in my object, I refer to Sir William's published work on Surgery, in which he states that the highest average of success in the hands of Cheselden and other great operators whom he enumerates, has been one death in five, six, seven, or eight. Now in the medio-lateral operation, which I recommend, there is ample evidence to show that the average mor