OBSERVATIONS ON LITHOTRITY.

The selection of the remedies to fulfil these several indications is of more importance than may be at first apparent to the student. The reduction of the hydropic state of the blood and tissues can only be accomplished by purgatives ; but it is not every purgative which will equally effect this object. The mercurial and resinous purgatives must be carefully avoided; one single dose of calomel may produce severe salivation. Those purgatives which act powerfully, as hydragogues, must be selected. No remedy that I am acquainted with answers better or more effectively than the combination of jalap and cream of tartar, in the compound jalap powder of the LondonPharmacopoeia. This should be given in the morning fasting, in half-drachm or drachm doses in a wineglass of water. It may be repeated every or every other morning according to the effect produced. It possesses the great superiority over all other hydragogue cathartics, that it is not followed by any appreciable amount of prostration or exhaustion. In some constitutions it loses partially its effects by repetition, when more powerful remedies become necessary. To supply its place when this happens, the combination of gamboge, in the compound pill of that name, answers very well. It is very apt to gripe and produce some sense of exhaustion. I rarely find it necessary to resort to it, as the first-named powder is sufficient in the great majority of cases. Elaterium sometimes may be necessary. The action of these hydragogues drains away a large amount of fluid from the intestines, and at the same time saves the kidneys, which, in their state of inflammatory congestion, are unequal to the task of excreting the ordinary amount of urine, and are in a condition in which any increased labour thrown on them would aggravate their congested state. The use of warm baths, or the hot-air bath, and diaphoretics, will prove adjunctive to our efforts to save these organs from any increased excitation. The urine to the unaided eye contained blood; the microscope revealed that this blood came from the kidneys; escaping from the Malpighian tufts of capillaries, it coagulated in the renal tubes, was eventually swept out by the current, and appeared in the urine as fibrinous moulds of the tubes entangling blood-discs. There was thus present an unequivocal hæmorrhagic state of these organs, and it now became a question of the greatest practical importance to decide on the propriety of endeavouring to restrain the escape of blood, or to allow it to proceed, within certain limits, without unnecessary interferencerecognising it as a natural mode of relief to the overcharged vessels which, if imprudently or rashly obstructed, only precipitates the mischief which it is the physician’s aim to avert. I am very decidedly of opinion that, in these renal disorders, hæmaturia bears to their progress the same relation which haemoptysis does to some cases of tubercular deposit in the lungs-that is to say, that the disease is retarded by these natural methods of relief to the blood stasis of the parts. The use, therefore, of astringents-such as the ga,llic acid, or salts of lead, or alum-at the period of hæmaturia, is highly prejudicial. Even the taking of blood from the loins by cupping is an exceptionable practice, and only to be resorted to in exceptional cases. Dry cupping is far preferable. The only remedy having any direct influence on the hasmorrhagic state that should be employed is digitalis. The influence which this sedative exercises in many hasmorrhagio conditions is as remarkable as it is indisputable. It is not necessary here to discuss its modus operandi; it will be sufficient to say that daily experience convinces me that it is the most appropriate agent in the period of hasmaturia from renal engorgement. It may be given alone, or with some of the sudorific salines, such as the acetate of ammonia. It was continued in this case till the hæmorrhagic period had passed away. The microscope throughout this period, and even when it subsided, demonstrated that no evidence of ulterior organic change in the kidneys was present. The case therefore presented the most favourable indications for improvement, and the time had now arrived when the influence of chalybeates promised to be beneficial. Preparations of iron are of no use without the aid of a nutritious diet; so that when he was ordered the sesquichloride of iron his diet was advanced to the full allowance of the best kind. The sesquichloride was given in a form which appears to me to be peculiarly adapted for these renal cases: it is in combination with the acetate of ammonia and acetic acid; care being taken to add the sesquichloride to the previously acidulated acetate. It is remarkably efficacious, and is, moreover, not at all unpalatable-children taking it readily. It was not long before a manifest change for the better became apparent in the aspect of the patient; and by persevering in the plan laid down, at the end of four months his health appeared to be completely re-established, although the urine still contained traces of albumen,

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The treatment of these cases requires patience and confidence the part of the physician: patience, because, from the very nature of the disease, it must be often months before the patient can be pronounced convalescent; and confidence in the remedies, or rather the principles on which he employs the remedies, so that a steady perseverance in one plan may not be interfered with, and a variety of agents tried, merely because the patient does not appear to advance more rapidly to recovery. In this, as in other forms of chronic disease, the principle upon which the treatment is to be conducted being first determined onand this resting, it is presumed, on a definite and correct dia. gnosis-will never be departed from; and the folly will thus be avoided of perpetually trying fresh remedies because those first selected do not appear to produce the effect desired, or to act so quickly as may be wished. It is thus that we may hope A steady to combat these otherwise intractable disorders. perseverance in the employment of ferruginous tonics (haematics), good diet, fresh air, moderate exercise, careful attention to clothing, and, as far as the station of life of the individual will permit, avoiding exposure to extremes of weather, particularly cold and wet; and a patient suffering, as this young man was, from symptoms of the gravest character, placing life in jeo. pardy, may escape a recurrence of the disorder, susceptible as these organs are to derangement when once they have been the seat -of disease, if ordinary precautions for regulating the health be prudently taken and strictly observed. on

OBSERVATIONS ON LITHOTRITY. BY WILLIAM SURGEON TO ST.

COULSON, ESQ., MARY’S

HOSPITAL.

(Continued from p. 30.) HAVING described the mode of conducting the preliminary examination of the bladder in lithotrity, I will now proceed to detail the various steps of the operation. Lithotrity presents some modifications as it is applied in simple or complicated cases. A case for lithotrity may be considered simple whenever it presents a combination of circumstances favourable to its easy performance, and calculated to render its result successful. Thus, the urinary organs are healthy, or at least not seriously disordered ; the bladder receives a certain quantity of water, and permits the instruments to be moved in it with some degree of ease, and the stone is of moderate size and density. In simple cases of this kind, the operation of lithotrity is easy, and, it cannot be too often repeated, eminently successful. It is a well-known fact, that Sir Benjamin Brodie operated in sixty consecutive cases, and with the loss of only one patient. The instruments required are few and simple, consisting of a catheter, syringe, and one or two lithotrites. The screw lithotrite is the instrument now universally employed, each operator adopting his favourite modification. Some prefer Weiss’s plain screw; some the rack and pinion, and others adhere to lil. Civiale’s modification, this being the instrument which I generally use, at least after the first operation. In my opinion, the choice of the instrument should be regulated by two considerations-the nature of the stone and the stage of the operation. The blades of M. Civiale’s lithotrite are sufficiently strong to crush soft stones, and those of moderate size; but it is difficult at the first sitting to develop the necessary force with this instrument, in cases where the calculus is large and hard. Hence, I generally use Wei-ss’s plain In the subsequent sitscrew lithotrite in the first instance. tings I employ M. Civiale’s lithotrite, which, in the majority of cases, can be used without irritating the bladder, or causing pain to the patient. Moreover, it admits of more free and rapid motion than the plain screw lithotrite. Whatever kind of instrument is used, the edges of the blades, near their extremity, should be well rounded, so as to be quite smooth, and not in any way to irritate the urethra in its passage, or the surface of the bladder when it is moved about in that organ. Care also should be taken that the hollow in the female branch of the lithotrite be not too deep, and that the male branch, when closed, fits evenly at the edges. The bottom of the excavation in the female branch should likewise be perfectly smooth and polished to prevent any detritus sticking to it. In several instruments which have recently been made for me, I have remarked that the two longitudinal slips of steel

which guard the screw have been omitted. This defect should point is suddenly stopped by the ridge near the neck of the not be overlooked, for on turning the fly-wheel in such an in- bladder. The operator now depresses his hand without adstrument a disagreeable grating sound, something like that of vancing the lithotrite, so as to tilt its point over the bar, and, friction on a calculus, is produced, and distracts the attention when this has been effected, the instrument passes on without further difficulty. of the surgeon, while it disquiets the patient. To lay hold of the stone in aproper manner is, undoubtedly, In proceeding to the operation, the patient is placed in a recumbent posture along the edge of his bed, or, if the surgeon the most difficult step in lithotrity. Two methods are emoperates at his own house, on a special couch. The thighs are ployed, differing essentially from each other. The one which bent, in order to relax the abdominal muscles, and the pelvis is is usually adopted in this country, consists in gently pressing raised by an unyielding pillow placed under the sacrum, it the convex part of the curved lithotrite against the floor of the being of great importance to throw back the calculus from the bladder, and then opening the blades of the lithotrite. The neck of the bladder. In the first sitting, and whenever I use effect of the pressure is to convert the lower surface of the the plain screw lithotrite, I usually avail myself of a sofa or bladder into a narrow cavity, into which the stone often falls couch without side or foot piece, so doubling the squab as to by its own weight between the blades of the instrument. The allow the sacrum to rest on its projecting folded extremity, the screw is then applied, and the stone crushed. head and shoulders being supported by pillows. The tendency In the other method, which I always adopt after the first to contraction of the bladder is thus avoided, and greater room sitting, the closed lithotrite is carried as nearly as can be for manipulating with the lithotrite is also obtained. In using judged to the centre of the bladder, and is lightly held between the French lithotrite, the operator places himself on the right the thumb and fingers of the left hand, which are applied to side of the patient, and not in front or between the legs. The the oblong portion immediately beyond the catch-box, the left hand is thus placed conveniently for steadying the instru- back of the hand being directed upwards. The fly-wheel ment, while the right is free for its easy working in the bladder. which drives the screw, and acts on the male branch, is held It is essentially necessary that the walls of the bladder be between the thumb and two first fingers of the right hand. If distended by a certain quantity of fluid, so that there may be the stone be not felt at once, the blades are separated from each other to the extent of half or three-quarters of an inch, room for the lithotrite to act without injury to the organ. Hence the first step of the operation consists in injecting the care being taken that the male branch is not broughttoo near bladder. The instruments employed for this purpose are, a the neck of the bladder. The open instrument is turned to full-sized silver catheter fitted with a stop-cock, and a metallic one side, and, if necessary, then to the other, in which situasyringe, having a graduated stem, capable of holding six ounces tions the stone is generally felt. If it is not speedily detected, of water and of being accurately fitted to the end of the cathe- the operator proceeds to a more methodical examination. The ter. The quantity of tepid water to be injected will depend instrument, being still lightly held, is made to revolve slowly in the bladder for a certain space at a time. The revolution is on the capacity of the bladder, but will usually vary from four to six ounces. Too much fluid is apt to provoke contraction of effected by movements of the thumb and two first fingers of the bladder, and thus defeat the object of the injection. The the left hand, as if we were turning a pencil between them. water should be thrown in by the operator himself, not by an The revolution is made first towards the right side of the assistant; and the fluid should be injected with slow, steady bladder, to the extent of one quarter of the circle; and during pressure, the bladder being encouraged, as it were, to receive this movement the male blade is gently moved forwards and and hold each successive quantity. As soon as the patient backwards several times, to the extent of three-quarters of an experiences a sense of fulness, the syringe is removed, the stop- inch. The object of these movements is, that the male branch cock turned, and the catheter carefully withdrawn. may come against the stone, which it usually does, whilst In complicated cases, even injection of the bladder cannot traversing these spaces. If the stone be not caught on the alwaysbe effected without difficulty. The bladder may be right side, the left must be examined in the same way. Lastly, contracted, thickened, and extremely irritable, and unable at should we fail to meet the stone on either side, the revolution first to receive the necessary quantity of fluid. In cases of this of the instrument is continued until the whole of the floor of kind, thepelvis should be still more raised, and an attempt the bladder has been traversed, the back and forward moveagain made to repeat the injection in a slow and cautious man- ments of the male blade being continued all the while. As ner, a small quantity being first thrown in, the patient allowed soon as the stone is felt, the beak of the lithotrite is laid to repose a little, and then a fresh quantity injected. With gently and sideways on the stone, and the male branch is patience and caution we may often succeed; but should the cautiously advanced or withdrawn (according to circumstances), irritable condition of the bladder continue, the operation must until we feel that the foreign body is fairly grasped between be postponed. According to Sir B. Brodie’s experience, the the blades of the instrument. While thus fixing the calculus, quietude of the bladder may generally be restored by keeping it is important to remember that the female branch should be the patient in the recumbent position for seven or fourteen kept as steady as possible while the male branch is brought forward to close on the stone. If this precaution be neglected, days, and daily injecting a small quantity of fluid. Next as to the introduction of the lithotrite. The lithotrite, we run the risk of constantly displacing the stone whilst closing having been warmed and well oiled, is passed into the bladder the instrument. somewhat after the manner of a catheter. It is necessary, This description applies to cases where the small short-beaked however, to bear in mind that the curve of the instrument is instrument is used, and no unusual difficulties present them. more abrupt and its beak much shorter than the corresponding selves. When these exist, they must be met by a change in parts of an ordinary catheter. The main point to be attended the mode of operating. Thus, it may happen that, from ento, as I have elsewhere described, is that the beak of the litho- largement of the prostate or other causes, the calculus remains trite should follow the natural curves of the urethra, so that lodged in a depression behind the neck of the bladder, and, if when the point has arrived at the bulb of the urethra, its small, it may easily escape the lithotrite. In a case of this handle should be slowly lowered to a right angle with the body kind, an attempt should be made to dislodge the stone by sud. of the patient. The extremity of the lithotrite is thus brought denly elevating the pelvis, for the mere change of position may into the direction of the canal under the arch of the pubes, displace the calculus, and enable us to seize it. If this mode after which the instrument is still further lowered, and gently fail, the following proceeding should be adopted:-The revopushed on until it enters the bladder. A slight rotatory move- lution of the lithotrite is continued until the end of its beak is ment at once determines that the beak has entered this organ. directed immediately downwards, the handle of the instrument The steps just described are conducted in a cautious and being now elevated so as to bring the point into the hollow gradual manner, and force must never be employed. In cases just behind the prostate. The male branch is moved to and where certain deviations from the normal structure or func- fro as before, and it rarely happens that the stone is not thus tions exist, the manipulations may be required to be modified detected. With proper care, this manipulation may be safely according to the degree or nature of the obstacle. Commonly effected; and, according to my own experience, it is often the the obstruction arises from some enlargement of the prostate, only effectual mode that can be employed. or the bar-like ridge described by Mr. Guthrie. An increase When once detected and firmly fixed between the blades of in the size of the prostate necessarily raises the floor of the the lithotrite, the stone is crushed into fragments, either by urethra; hence, on arriving at the prostatic portion, the handle the pressure of the hand or with the aid of the screw. of the lithotrite must be slowly lowered between the thighs of Little change takes place in the position of the instrument. the patient, so as to elevate its beak, and allow it to pass be- The stone is carried rather towards the posterior wall of the yond the obstruction. The amount of depression required bladder, and then the handle of the instrument is firmly will depend on the extent of the enlargement of the prostate, grasped with the left hand. The palm of the right hand, and on the length of the beak of the instrument employed. In turned upwards, is placed against the extremity of the male cases where the bar-like ridge exists, a different manipulation branch; while the index and middle fingers are hooked on the is required. Here the instrument is passed with ease until its catch-box, which they use as their point d’appui. In this

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position, by strongly contracting the flexor muscles of the limits which the bladder and constitution are capable of enfingers of the right hand, the male branch is driven forwards during. As a general rule, therefore, I advise that chloroform with a kind of jerk on the stone, which, if not too hard, is should not be administered, and the chief exceptions which I soon crushed by a few movements of this kind. During this would make are in nervous patients-females, for instance, and manipulation, the right elbow should be firmly kept against children. the side. Should the calculus not yield to the action of the (To be continued,) hand, nothing is easier than to bring the screw of M. Civiale’s instrument into action. The catch-box is turned from right to left; this allows the screw to play, the action of which is de- CLINICAL REMARKS, BY DR. BRINTON, veloped by turning the fly-wheel attached to the extremity of the instrument. AT THE ROYAL FREE HOSPITAL. Even this manipulation will not always succeed, for any considerable enlargement of the middle lobe of the prostate has IT has repeatedly been suggested to me by professional the effect of creating a depression in the floor of the bladder conversant with the number and importance of the friends, immediately behind the enlargement, in which depression the cases constantly under my care at the Royal Free Hospital, calculus often lies concealed, and escapes the instrument. In cases of this kind, as I mentioned in the former paper, the that, in the absence of any such reports of them as might be lithotrite should be two or three inches longer than those in given by Clinical Lectures, a few brief remarks on some of their ordinary use; its beak must be reversed, and carried down- more characteristic features would often have sufficient interest wards till it reaches the stone. to deservepublication in THE LANCET. For many years, howAgain, when the calculus is large and dense, the bladder con- ever, I have not complied with these suggestions; in the hope is the tracted, and the instrument employed long beakedi lithotrite with narrow blades, we cannot adopt the manipula- of being able to incorporate such experiences, either with vari. tion applicable to simple cases. The various movements pre- ous monographs, on the one hand, or with clinical instruction viously described are unnecessary, and cannot safely be executed in a recognised Hospital, on the other. in the contracted and probably sensitive bladder. In cases of The circumstances which induce me now to modify this resothis kind there is little difficulty in finding the stone, because I need not detail; save to point out, that the contrast lution it is usually large; but, for the same reason, there may be considerable difficulty in seizing it. The instrument, slightly between the amount of an Hospital Physician’s practical duties, opened, is laid sideways on the stone, and the two branches and of his literary leisure, soon forbids anyone who rightly apare gradually separated until the edges of the foreign body are preciates the responsibilities of authorship from attempting to touched, when the attempt is made to fix it. write on many diseases, even in the sense of contributing mer When, in simple cases, the stone has been broken by the Essays on certain of their aspects. And since, for some time pressure of the hand or the screw, the surgeon may proceed to crush some of the larger fragments, provided the whole opera- past, I have rarely gone round the wards unaccompanied by tion has not occupied more than five or six minutes. As a rule, some student or practitioner, to whom explanation or illustra. however, little more should be done at the first operation than tion has often been a matter of common professional courtesy, to break the stone once.. Before withdrawing the instrument I have gradually found myself talking what, rather to my owa from the bladder, it is absolutely necessary to ascertain that auditors have sometimes challenged as being, for the branches are perfectly closed, and that no fragments of the surprise, my all practical purposes, clinical instruction. stone or detritus are retained between them. I believe that is not, however, in this light that I would offer the clinical It to of the the neck the injury bladder, chiefly produced by débl’is between the blades of the lithotrite, and in other cases remarks of which the following form the first illustration. Inby the shortness of the instruments employed, is a frequent struction in an art like that of Medicine should, doubtless, be cause of mischief after lithotrity. If any fragments or detritus actual demonstration rather than by verbal description. remain, they must be got rid of, either by renewing the pressure by And as examination at the bedside now seems likely to be until the female branch is completely emptied, or by giving a few turns backwards and forwards to the screw. adopted as a means of finally testing the student’s fitness for The completion of these manipulations implies that a certain practice, it may be hoped that, by-and-bye, the Examining portion of the stone has been sufficiently reduced to pass off by Bodies will dispense with the clumsy expedient of merely rethe urethra without difficulty. The last step of the operation, the number of beds in an Hospital; and will accept therefore, consists in immediately freeing the bladder from the cognising the student who can detect and treat disease, without asking detritus. If the operation has proceeded in a favourable manwhether he has learnt to do so by working sedulously in a ner, the patient is placed in the erect posture, and a full-sized metallic catheter, with a slit on the upper surface near its ex- small Hospital or a large one. But however limited is now the tremity, is then introduced. The fluid which is in the bladder range of the private clinical instruction I have to give, and being withdrawn, some tepid water is repeatedly injected until whatever the difficulties and discouragements which balance the patient complains of fatigue or no detritus comes away. I its usefulness, I cannot but think that brief casual remarkshave often been surprised, however, to find that the quantity of d6bris which comes away with this injection is small com- "here a little, and there a little,"-such as form the staple of pared with what exists in the bladder, and comes away two or this bedside demonstration of disease, might sometimes convey, three days afterwards by the natural efforts of micturition. even to those of us who are more advanced in the study of our In some complicated cases, where considerable enlargement of profession, a livelier idea of any ordinary case than systematic the prostate exists, it will be much easier to introduce the detail days and hours, and continuous sympcatheter while the patient is in the recumbent posture, and in reports, which toms, with wearisome iteration. this position wash out the bladder. And here let me incidentally mention a plan by which I In ordinary cases, four or five operations will suffice for the removal of the stone. The interval between the first and have long wished to see clinical instruction imparted in our second should be longer than that between the other opera- recognised Hospitals. I dare not trust myself to point ott the tions. After the first crushing, even when performed with the defects of our existing system, or to contrast the average of utmost caution, febrile symptoms often supervene, together instruction of this kind given in London with the more careful with local irritation, which it may require one or more weeks and conscientious efforts which seem to be made by our brethren to subdue before the crushing is repeated. Between the subse- in Dublin and Edinburgh. But if our present system of teachquent operations an interval of only a few days may be neces- ing is to be maintained, I think it should be made to aim less at the training of a few clinical clerks or dressers (often of sary. Whether chloroform should be employed in lithotrity, is: superior diligence and capacity) to great excellence, than at a question which the surgeon will have to determine. Twoaffording every pupil possessed of average ability and industry high authorities, Sir B. Brodie and M. Civiale, have pronounced the opportunity of acquiring a fair practical skill. And just against the use of chloroform, and in two cases only during theas it is by the number of pupils so taught how to benefit the last four years have I resorted to its use. Lithotrity is not; public that I should estimate the usefulness of the clinical necessarily a painful operation, and the feelings of the patient; teaching at any given hospital, so I am sure it would be easy must be looked to as our guide in two important particulars. to devise a plan by which every student in the course of his They serve to indicate whether any serious injury is inflictedl career should fall under the close personal supervision and on the soft parts by our manipulations, and they assist us inL teaching of a clinical Demonstrator; to be either passed on to determining whether the operation is carried on within thosethe above valuable appointments as really qualified to hold 82 ‘

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