Lectures ON LITHOTOMY AND LITHOTRITY.

NOVEMBER 6, 1852. Lectures ON

LITHOTOMY AND LITHOTRITY. Delivered at St. Mary’s Hospital.

BY WILLIAM

COULSON, ESQ.,

SURGEON TO THE HOSPITAL.

LECTURE XI.

GENTLEMEN,—In describing the obstacles which may present themselves in the performance of lithotomy, and the accidents that may occur during this operation, or follow it more or less rapidly, I shall pursue the same order that I adopted in speaking oflithotrity. The operation for the extraction of stone from the already informed you, of four partsbladder consists, as I have viz. the introduction of a grooved staff to guide your cutting instrument; the external incisions; the internal one ; and finally,

the extraction of the calculus. Now, any circumstance which may impede the due performance of one of these successive proceedings becomes an obstacle, and from the latter arise most of the accidents which accompany In the present lecture, I or succeed the operation of lithotomy. shall chiefly confine my remarks to what occurs during the lateral operation, for the accidents &c. connected with other methods will be noticed in the parallel which I shall draw between them. The introduction of a grooved staff into the bladder, through the urethra, being one of the conditions or parts of the lateral operation, anything which impedes this step is an obstacle ; but I shall not dwell on this circumstance, as it has been already noticed in my lectures on lithotrity. I shall only remark, that in cases where the calculus is impacted in the neck of the bladder, and cannot be pushed back into the cavity of that organ, it is evidently impossible to introduce the staff, and another method must be had recourse to. When the patient can be placed in the usual position, and the perinseum is not deformed by tumours, Bstulse, &c., or any irregularity in the bony structures, the operator experiences no difficulty in making the first incisions in a proper manner. On arriving at the membranous portion of the urethra, the point of the knife is generally guided to the groove of the staff without any difficulty ; but care must be taken, while we make the opening into this part, not to wound the rectum, which lies close upon it. Hence many operators advise us to open the membranous portion of the urethra from behind forwards; but this precaution has not been found necessary in the practice of English surgeons. When the internal incision is effected by the same instrument which was employed for the external incisions, there can of course exist no difficulty in hitting upon the small opening made into the membranous portion of the urethra, since the point of the knife has never quitted the groove of the staff. But in this mode of operating there is always some difficulty in making the point of the knife glide regularly and easily along the groove into the bladder. In the hands even of experienced operators, it has happened that the groove of the staff has been missed, or the knife has slipped out of the groove, making the incision irregularly, and to one side, in a dangerous manner. Moreau, frere Come, Scarpa, and many other writers on lithotomy, mention examples of this accident. On the other hand, when the beaked knife is substituted for the pointed one, there may be some little difficulty in hitting upon the exact point of the urethra, which you have already opened. This, however, is seldom any obstacle, and may be obviated by keeping the nail of the left forefinger well in contact with the groove of the staff, which the assistant takes care to hold perfectly steady. From what I have now said, you may perceive that there is little or no difficulty in making your way into the bladder; the great difficulty occurs in getting the stone out of that organ, and a great variety of obstacles may impede this important part of the operation. Let us examine them in succession. They may arise from certain conditions of the parts, or depend on the nature, position, and size of the calculus. The foreign body, as I have said in a former lecture, is extracted with a particular kind of forceps, which we pass along the finger through the external and internal incisions, expand in the cavity of the bladder, close over the stone, and then withdraw in the direction of the external wound. During each of these steps the operator may encounter unexpected obstacles. In the first place, I may observe that the best operators have occasionally found it difficult to seize the stone, although no impediment could be discovered. Mr. Crosse relates

No. 1523.

three-quarters of an hour were spent in efforts to larger than a pigeon’s egg. Generally speaking, however, the nature of the obstacle is

a case

seize

a

in which

stone not

obvious. The first one to which I shall direct your attention is unusual depth of the perinseam, occurring in fat perHere the distance from the external surface of the perisons. naeum to the cavity of the bladder is greatly increased; the operator is deprived of the great advantage arising from his being able to examine the interior of the bladder with his finger, and the young operator may be led astray, imagining that the forceps has gained the vesical cavity when it has hardly reached its entrance. This commonly occurs in old and fat persons; but the effect, though from a totally different cause, may be observed in the young subject. In children, from the great extensibility of parts, and other circumstances which I cannot now notice, the bladder is very apt to yield before the knife ; and when the incisions have been made, the bladder has also a tendency to recede before the finger. This receding of the organ upwards produces the same effect as if the perinseum were deep, and may become, though not in so great a degree, an obstacle to the easy extraction of the calculus. On the other hand, the neck of the bladder is often thick and unyielding in old persons, offering great impediment to the introduction of the forceps, and a still greater’obstacle to their withdrawal. Spasmodic contraction about the neck of the bladder may give rise to the same results ; indeed, Deschamps relates an interesting case, where spasmodic contraction rendered it impossible to pass even a catheter into the bladder through the internal incision, which had been freely made with a lithotome cache. Enlargement of the prostate presents a greater or less obstacle to the easy performance of lithotomy, as well as lithotrity. A moderate degree of enlargement may not embarrass the operator; but when this gland is considerably increased in size, it is always a cause of difficulty and annoyance. Anything approaching scirrhous induration will of course impede the action of the cutting instrument; and the lithotome cache has been broken in attempts to cut through indurated prostates. But the great obstacle which considerable enlargement of the prostate causes, is to seizing the stone. It places the calculus beyond the reach of the finger, and a sure guide to the position of the foreign body in the bladder is thus lost; while the distance of the vesical cavity from the external surface is greatly increased. Besides this, the enlarged gland raising up with it the neck of the bladder, leaves behind it a depression or artificial cavity, in which the stone becomes lodged, and easily escapes being detected by the sound, or seized with the forceps. The instrument slides over the calculus, and the only way of overcoming the difficulty is to employ a very long curved forceps, while, with the finger introduced into the rectum, we endeavour to raise up the stone from the depression behind the prostate in which it is lodged. But enlargement of the middle lobe, if carried to any excess, renders this latter proceeding generally impossible. The finger cannot reach beyond the enlarged lobe. Several morbid conditions of the bladder itself may impede the operator in his attempts to seize the stone. These I fully described in my lecture on the Pathological Effects of Vesical Calculi, and they readily explain the difficulties which are experienced. Thus I told you how, in old cases of vesical calculi, the bladder was often hypertrophied, and at the same time contracted firmly, embracing the stone, or leaving but a small interval between the foreign body and the walls of the containing cavity. The bladder also, in cases of this kind, is often extremely irritable. This condition of the bladder is a source of great embarrassment during the extraction of the stone. When the bladder is closely applied on the surface of a large calculus, it will require all the dexterity and patience of an experienced operator to pass the blades of the forceps between the bladder and calculus, without injuring or severely irritating the former; the operation thus becomes protracted, and its dangers proportionately increased. Mr. Samuel Cooper, and many other systematic writers, advise us, under such circumstances, to suspend our efforts for a short time, and wait until the contractions of the bladder have become less violent. This, perhaps, is more prudent than to go on irritating a diseased bladder with useless efforts; yet it is always a most undesirable thing to suspend such an operation as that of lithotomy. In some calculous patients the mucous coat of the bladder is relaxed and thrown into folds, behind one of which the calculus, if small, may be concealed, and escape the forceps. Here recourse may be had to the scoop, or the stone may perhaps be dislodged from its position by slowly expanding the blades of a broad forceps in a horizontal direction. It more often happens, however, that a small calculus gets entangled between the meshes of a columnar bladder, and quite

sufficiently

same

U

414

operation will turn out to have been useless; but when an opening has been made into the bladder, the surgeon is extremely unwilling to remove the patient from the operating table without having made every effort to complete the work which he has begun. Let us consider, then, the various ways in which operators have endeavoured to overcome the difficulty of encysted calculi. Two main points are to be borne in mind. The stone may be completely encysted, and the entrance into the sac may be narrow, or its orifice may be wide, and a portion of the stone proCases of encysted calculi, gentlemen, are fortunately very ject into the bladder. When the stone is completely encysted, I rare; but when they do occur, they present one of the most am decidedly of opinion that no attempt should be made to disembarrassing conditions with which the lithotomist can have to lodge it by incision of the neck of the sac. The operation of deal. Remember that the stone is more or less concealed in a lithotomy must be left unfinished. However disagreeable this sac, the entrance into which may be much narrower than the may be to the surgeon, it is better than to hasten the patient’s fundus. Couid it be ascertained with any certainty before an death by attempts which almost invariably prove fatal. On the other hand, when the calculus is only partially contained operation has been undertaken, that the stone is actually lodged in one of these sacs, I am decidedly of opinion that lithotomy in the cyst, and the orifice of the latter does not embrace it tightly, should not be had recourse to, because it is ten to one that the as in fig. 93, an attempt may be made to complete the operation.

eludes your efforts

to seize it with the forceps. Here, unless succeed in dislodging the stone from its position, either with the finger, the scoop, or some analogous instrument, I cannot see what i& to be done. If you attempt to extract the foreign body without regard to the position which it occupies, you must inevitably lacerate the coats of the bladder. The position of the calculus in a regular sac or cyst formed by the mucous coat which has been forced outwards between the muscular fibres, is a still greater obstacle, and one, in my judgment, that is all but insurmountable.

you

can

Various

have been resorted to by different surgeons. Collot succeeded in dislodging the stone by changing the position of his patient; but this must be regarded as a lucky chance on which others cannot count. In another case, where the orifice of the cyst was wide, Moreau succeeded in grasping and dislodging the stone with the forceps. The best practice is to endeavour to dislodge the calculus with the finger; but unless the cyst be seated near the neck of the bladder, the finger does not penetrate far enough to be of much use. A long probe, or other blunt instrument, may be substituted for it, and careful efforts made to enlarge the orifice of the cyst. In one case, Sir B. Brodie succeeded in dilating the neck of the sack ith a probepointed bistoury; after which he separated the calculus from the cyst with his nnger, and was fortunate enough to be able to grasp the stone with a forceps. Other surgeons recommend us to divide the neck of the sac with a bistoury, or with the lithotome cache, but I need hardlysay that so dangerous a proceeding should never be employed unle"s the finger can be made to guide the cutting instrument ; and if the finger can reach the cyst, I should much prefer dilating its orifice, if practicable, to cutting ir. Desault invented a peculiar kind of knife, somewhat l’ke a pharyngotome, for this operation ; but he can cite only a single case of success ; and Deschamps also met bat one case ofsac.cuhtted stone in his extensive practice. The stone was only partly engaged in the s.’tc. and was extracted with the forceps, though with considerable dinicuhy. After many failures, Vesc11amps contrived to seize the projecting part of the stone, and to disengage it from the cyst by gentle rotation with the forceps. If you trust whar you will find in books relative to encvsted calculi, the operative proceeding seems easy and sirnple. Thus, to quote a standard work, we are told—"’When there is reason to believe that the stone is encysted, it is advisable to introduce the finger into the bladder, aid to rupture the c) st with the nail; or where this is impracticable on account of its great strength and thickness, to divide it with a probe-poiuted bistoury, or a knife fashioned like a gum lancet, and furnished with a long handle." In

expedients

one case

oS-hand way of describing one of the most delicate in surgery is well calculated to mislead the young It is easy enough to say, divide the neck of the sac with a knife, but the difficulty is to do so without danger; and I have little hesitation in affirming, that it would be a most hazardous proceeding to divide the tissues of the. bladder at any point which is beyond the reach of the finger; and the latter can seldom penetrate more than half-an-inch beyond the neck of the bladder in the adult. What I now say applies to the lateral Sach

an

proceedings : practitioner.

operation. An

irregular posi tion of the stone in the bladder may cause difficulty in seizing it, and thus protract the operation. The natural position, ifI may use the term, is in the most depending part of the floor of the bladder, behind the prostate. In some cases, however, the calculus has been found suspended,

some

above the prostate and behind the shown in the annexed drawing. Pressure on the abdomen, just above the pubes, may perhaps dislodge it; if not, an (’fT01’t must be made with a forceps strongly ! curved. In other case’s—bu*t these also are extremely rarethe stone appea"s to be retained in an anomalous position, by some irregular action of the muscular fibres of the bladder, analogous to the hour-glass contraction of the uterus. A case or this kind occurring during the lateral operation, would be the cause of almost nsunuountable difficulty. The action of the finger or knife is here out of the question ; and, even if the nature of the c,:se rrere understood, the efforts to pass the blades of the to; ceps between the stone and contracted cavity must be extremity injurious. Perhaps the only thing left under untoward circumstances is the high operation. I The numbers, form, size, and physical nature of the calcul may very much influence the proceedings necessary for their extraction, and render this part of the operation difficult or or

hooked

as

it

symphysis pubis,

were

as

such

protracted.

When Ithan one

due care is exercised, the circumstance that more carcuius is present in the bladder can seldom have

415

any other unfavourable effect than that of prolonging the opera- tion when it has unfortunately been seized by one of its large A tolerablv healthy bladder bears the contact of instru- diameters. There is a great difference between extracting a no violence be used. The number of body which measures two inches, and a body which measures ments well, calculi which have been sometimes extracted from the bladder, only half an inch, through the same wound of the prostate. by the lateral operation, is surprising ; but we must remember You must, then, always bear in mind the possibility of your that in such cases the calculi are usually small in proportion to having seized an irregularly-shaped stone by one of its long their number. As many as 200 of these small calculi have been diameters; and hence, whenever you find any difficulty in removed by M. Roux and Dupnytren. My friend, Professor extracting the stone, your very first care must be to let go the Eve, of the United States, removed 117 calculi by the lateral calculus without withdrawing the forceps from the bladde r, and operation, about three years ago, and the patient did well. The endeavour to seize the stone in a more favourable manner. This, I say, must be done before you think of enlarging the internal case of a woman whose bladder contained 214 is recorded in the Philosophical TTansactions/ and even a still greater number wound, of breaking up the foreign body, or having recourse to another mode of extraction. it may be that the calculus is really has been discovered in the bladder after death. It is difficult to form any exact estimate of the proportion of a large one, and that it has been seized in the best way ; but give cases in which a number of calculi may exist, but it is certain your patient the benefit of the doubt, and before you push dilatathat in a vast majority, I might say ten times to one, the calculus tion as far as it can go, see if nothing is to be gained by a change is single. In twenty-seven cases the late Mr. Liston met with of position. On the other hand you are not to let go the stone without sufficient reason, and because of slight resistance to exseven in which more than one calculus existed; Mr. Klein, the celebrated German lithotomist, met with twelve cases (two to six traction. A great point is always gained when the calculus is calculi) in seventy-nine operations of lithotomy. We are once within the grasp of the forceps, and it may not be so easy to indebted, however, for the best table which we possess to the late catch it the next time you try. Whenever the finger can be Mr. Crosse, of Norwich, who gives a list of 100 fatal cases, in made to penetrate sufficiently far into the bladder, it will be of eighty-four of which the calculi were single ; in seven, two great assistance in determining the shape of the stone, and in calculi were found ; in six, three; in two, four calculi; and in placing the latter in a more favourable manner between the blades the forceps. only one, five. A month ago, I extracted four calculi from a patient. Two of these were round and large, measuring more Although fracture of the calculus during extraction belongs than an inch and a quarter in the smallest diameter. The other more properly to accidents, it may be conveniently noticed here, it likewise presents an obstacle to the rapid completion of the two calculi presented at one part flattened surfaces, as if a portion of the sphere had been cut off. They weighed three ounces and I operation. It is a curious fact, that the fracture of the stone may This case did extremely well; and I may here notice, be spontaneous, or, at all events, may occur some time anterior a half. that the sensation communicated by the sound passing over to the operation. the four calculi, led me to believe that I had to deal with a Mr. Crosse has published a case placing this fact beyond doubt. single large one. A number of small calculi may be extracted In the bladder of a man seventy years of age, Mr. Crosse found with the forceps; but when the foreign bodies are very small twenty-two calculi, weighing three ounces and a half. These and numerous, the scoop seems the better instrument. It has calculi, however, were evidently fragments, and could be ut often been said that the roughness of the stone, on its surface, is together so as to form three different bodies, one comprising a sure sign that the bladder contains no other calculi ; this, fragments, a second eight, and the last nine fragments. The however, is an error which Deschamps pointed out long ago. primitive calculi were about the size of a pigeon’s egg, and comThe first stone extracted may present no sign whatever of the posed of uric acid with a small proportion of oxalate oflime. effects of friction, yet the bladder may contain several calculi. M. Civiale endeavours to explain spontaneous fracture of calculi Hence the practical rule never to remove your patient until you by the violent contractions of an hypertrophied bladder. It have convinced yourself, by careful examination, that no other would seem that rough exercise on horseback has also been a foreign bodies are left behind in the bladder. determining cause of the fracture ; while the admirers of mineral When the stone is single, and at the same time small, the waters will not fail to attribute the disintegration which someoperator may experience some difficulty in grasping it with the times occurs during their use to the solvent virtues of the spring. forceps, on account of the smallness of the body which he seeks ! However this may be, we find that calculi may spontaneously to lay hold of, or, when seized, it may easily escape from the break up in the bladder, or be fractured by the forceps; and in forceps. Many operators are in the habit of having recourse to either case the operation of extraction is necessarily prolonged; the scoop under such circumstances ; for my own part I prefer in the latter, indeed, the lithotomist has performed a kind of employing the forceps whenever it is possible : it is not easy to lithotrity, without intending it. find a very small calculus with the scoop, and repeated scraping The surgeon should always endeavour to extract the calculus of the bladder is apt to excite great irritation, if not inflammation for two reasons especially. The first is, that a single calof the organ. culus is more quickly extracted than a number of fragments; and The shape of the stone may occasionally be an obstacle to its however writers may insist on the necessity of caution, prudence, it is no less certain, that to perform lithotomy well, it must easy extraction. The commonest form of vesical calculi is the &c., oval, but sometimes they are more or less flattened ; thus, one of be performed in the shortest space of time compatible with the the calculi extracted by Vacca was two inches long, one inch and safety of the patient. The use of chloroform may perhaps render two-thirds broad, and not half an inch thick. M. Civiale has it less necessary than formerly for the operator to be a quick one; seen calculi almost as flat as a crown-piece, and our own museums but even with the aid of this valuable agent, I believe that the contain many specimens of the same kind. Now you can easilyi old rule holds good-the shorter your patient is under the knife understand that there may be some difficulty in laying hold of a the better. I do not say that you are to sacrifice safety to brilflat stone with the forceps ;but the great obstacle is to its extrac- liancy, but that the acme of perfection in the lithotomist is, to do

tion.

provided

offor

ve

entire,

IJ

416

I

his work safely, and at the same time rapidly. The second reason for avoiding fracture of the calculus is, the possibility of relapsei from retention of some fragment in the bladder. After lithotrity, you have the natural passages open for the discharge of detritus; but after lithotomy, we cannot keep the external wound open too long without inconvenience and danger. The chemical nature of the stone will of course mainly influence its tendency to give way under the pressure of the forceps. Hence it is of much importance to ascertain beforehand, as nearly as possible, the composition of the calculus which you are about to extract. Uric-acid concretions are the hardest, and the ringing sound which they emit, when struck, often suffices to indicate their nature. On the other hand, the triple phosphate is easily broken ; but the most fragile of all is the fusible calculus, which sometimes crumbles into fragments on the slightest pressure. It is necessary to bear these points in mind, for when you know that the calculus is friable, you will of course be more careful during its extraction. The forceps employed should be broadbladed, with the teeth not very long, and the stone must be seized as lightly as possible, care being taken not to increase the pressure as the forceps are being withdrawn through the neck of the bladder and prostate, where the greatest resistance is usually

been retained in leaden cisterns, have been at intervals recorded. Dr. Wall’s case,* at Worcester, has been so often quoted, that it would be tedious to repeat it; and in the present state of chemical science, I think it would be to go back to cases the data of which we can hardly depend upon, and many of the explanations of which, as given by contemporaries, are, to say the least, not quite phi-

or

unwise

’ ,

experienced.

-

In spite of our caution, the calculus, however, may give way,and either throw off several fragments or even break up into a mass resembling mortar. This is an unfavourable accident, for it compels us to introduce instruments frequently into the bladder, and the irritation thus produced has excited such violent contraction of the organ as to render it impossible to finish the operation. When it does occur, any large fragments must be extracted with the forceps, and the smaller ones with the scoop; some will inevitably remain behind, and, to remove these, injections with tepid water are to be employed and repeated before the wound in the perinseum closes. I once had a case in which more than an hour was employed in removing, with a scoop, the matter of a fusible calculus ; still a considerable portion remained, and as I was unwilling to protract the operation any longer, I had the patient removed to bed. At the end of a fortnight I introduced a large catheter through the urethra, and washed out the bladder thoroughly; this brought away a good deal of the friable matter through the wound in the perinaeum. The same process was repeated every second day until no more calculous matter came away-that is, for about a fortnight. The patient recovered, and has had no relapse. .When. the prostate is much enlarged, this plan may not succeed, as the fluid thrown in by the urethra does not find a ready exit through the incision in the neck of the bladder. In cases of this kind, the best practice is to employ the large-eyed . catheter, and wash out the bladder in the way I have already described when speaking of the removal of detritus after lithotrity. The last obstacle, gentlemen, which we have to consider, is one arising from the size of the stone ; but the extraction of a large calculus is a point of such great importance, and is attended by so many accidents of a dangerous nature, that I shall include what I have to say on this subject with the accidents of lithotomy.

The Lumleian Lectures, Delivered at the Royal College of Physicians for the Session 1852. BY JAMES ALDERSON, M.D., F.R.S.

losophical. The symptoms in all the racter.

Some years ago

cases are

nearly

uniform in cha-

striking instance occurred in my own practice, including a whole family. Every individual in the house had been previously attacked by colic, and one had already died paralytic, (the exciting cause not having been suspected.) I found the head of the family paralysed and epileptic, and it was then ascertained that the water a

used for domestic purposes was rain-water, and was received into a leaden cistern. On examination of the water by a clever chemist, Mr. Pearsall, lead was found in large quantity, separable by filtration. The cistern contained a considerable amount of carbonaceous matter, which no doubt had assisted in detaching the lead. The angles of the cistern were found studded with crystals of carbonate of lead, espeeially where the joinings by solder occurred, and the solder had probably favoured the deposit. The paralysis in this case was of the form which I am of opinion is the true chronic form of paralysis from lead. The arms hung from the shoulder-joiut, pendulous and powerless, and all the symptoms described as belonging to this form were strongly marked. One of the latest and most interesting cases occurred at Claremont, in which no less than thirteen persons, including the heads of the royal family of France, as well as members of the household, were attacked with colic, many of the cases being in the severest form. The symptoms, besides those usually observed, included a peculiar, exquisitely painful sensitiveness of the surface of the body in an intense of the palace exhibited some of the earlier degree. Other inmates signs, such as the " slate-coloured line in the glims" and " the spots in the mucous lining of the mouth," without furthe? disease having been developed. In this case the water at the spring had been confined in a large iron cylinder, in order to keep it free from surrounding impurities, and was afterwards conveyed by a leaden pipe into a leaden reservoir. No lead was detected in the water of the cylinder, but in that contained in the cistern, one grain of lead was found in every gallon, by Professor HoffThe history of these cases is graphically described by man. Dr. Do Mussy, the accomplished physician of the royal family of France. The water at Claremont was a very pure water, giving, upon examination by the late Mr. Phillips,—

In seeking to explain the action of the Claremont water upon lead. by galvanic action, Dr. de Mussy was surprised at not finding lead in the water contained in the iron cylinder,

as iron is negative to lead under the action of acids, he expected to find the current set up from the lead to the iron. The pipe had been cut with a view to prevent a further influx of lead into the cistern; the symptoms of colic, however, reON THE EFFECTS OF LEAD UPON THE SYSTEM. curred with greater violence, and then, on examining the cistern, it was found to contain the poisoned water. (Concluded from p. 393.) A case illustrative of the same change is alluded to by our President in his "Life of Sir Humphry Davy," in which the Contamination of rain-water kept in leaden cisterns; of water water became impregrtated with lead in consequence of an containing lead at Cla2-ei;zont; the Royal Family of France" iron pump in the cistern which the water. Dr. Paris analytical examination of the water, and its mode of contami- mentions also another case at supplied Islington, in which the prenation explained; " similar cases explaiazed by Dr. Paris in sence of an iron bar in a leaden cistern had caused a his Life of Sir Hurnplcry Davy. Galvanic agency estasimilar effect. The change in the water in these cases is blished " other sources Qf’co2ztai7tination erzzcnzerated. Supply attributed by him to the galvanic action of themetals, in conof water to London by the Government. Plan of the Board sequence of which the acid was taken to the iron, and the Health. ’The Government Commission Filtraof Qf CIle7nists. alkali to the lead, and the lead became dissolved. water tion of anl disturbance of sediment remove the lead. Dr. Paris proved, by experiment, and laid down very Real cause of poisoning. Leaden pipes and cisterns. A cc’ithat lead, when rendered negative by iron, and placed clental causes of contamination of water. Galvanic agency. clearly, in contact with weak saline solutions-such, for instance, Abelnclonment of lead in the distribution ofwate1’for domestic as common spring-water-became dissolved. Brande takes pzcrposes. Conclusion. up this view, and states that danger may occur when A MORE general source of danger, to which all are liable, is lead is thrown into an electro-negative as well as into to be recognised in the contaii-iination of water. Since the an electro-positive state, for lead, which is soluble in alkalies time of Sir George Baker, instances of severe disease arising Medical Transactions, College of Physicians. fron) the use of water which has passed through leaden pipes,

for