Lectures ON LITHOTOMY AND LITHOTRITY.

JULY

ON

LITHOTOMY Delivered

at

St.

BY WILLIAM

1852

perforated and reduced into fragments;

Lectures AND

10,

LITHOTRITY.

Mary’s Hospital.

COULSON, ESQ.,

SURGEON TO THE HOSPITAL.

LECTURE III.-(Concluded from page 4.) LITHOTRITY in its true sense is made up of two principal parts-seizing the stone in the bladder, and destroying the’stone. This latter part may be effected by perforation, by percussion, or by crushing; and the predominance of any of these three modes of attacking the stone constitutes a peculiar method, although in particular instances they may be combined together with advantage. I have already noticed the attempts made by the older surgeons to crush stone in the bladder. According to M. Bellinaye, an English surgeon named Stoddart had a sliding instrument constructed in 1800, for the purpose of crushing calculi. In 1813, Gruithuisen produced his forceps, but the blades, as I have before remarked, acted laterally, and all the urethral forceps previous to the year 1823 were constructed on the same defective principle. M. Civiale used a brise-pierre in 1821. It was worked with a rack and pinion, but the branches were moveable, and acted laterally. In 1822, M. Amussat published an account of his crushing forceps, to which I have already alluded. The first crushing instrument of any value-that is to say, one in which the blades ;are placed one over the other, and have a gliding movement for wards-was, as far as I can ascertain, manufactured by Mr. Weiss in the year 1824. It is essentially the same as the improved percussor of Heurteloup, with this difference only, that it acts by crushing with a screw instead of percussion.

he then crushed these with the blades of his three-branched forceps against the extremity of the canula. This was a very imperfect method. Dr. Haygarth comes next. In 1825 he invented a sliding instrument, for the purpose of extracting small calculi from the bladder, and, at the suggestion of Mr. Hodgson, a screw was attached to this instrument, that it might be employed Mr. Hodgson tried this instru!nent upon a for crushing. patient in the Birmingham Hospital in 1825. In the same year also a French instrument-maker, named Retord, invented a sliding instrument, a description of which M. Leroy gave in 1827. The branches are similar to those of Weiss Haygarth, but it would seem that the female branch was backwards on the male.

and drawn

Haygarth’s instrument for crushing stone, (1825.) FIG. 29. - Retoré’s instrument for measuring the diameter of calculi, (1825.) FIG. 28.-Dr.

The instrumental portion of the crushing system unquestionably originated in England, for we do not find crushing as

system alluded to in any of the French publications previous to 1829. To render this system available, the blades of the forceps must be placed in the same plane, one behind the other; the motion must be sliding from behind forwards, and the male piece should glide along a hollowed catheter. These three conditions were first obtained in the English instruments, and the system of crushing thus rendered capable of being executed. In 1831 Professor Jacobson, of Copenhagen, presented his articulated crushing instrument to the Institut; several successful operations were performed with it, but it is now abandoned. The principle was altogether different to that of the sliding instruments at present in use. Indeed, true crushing does not seem to take date as a complete system until after the production of Baron Heurteloup’s percussor in 1832. On employing that instrument, surgeons soon perceived that it might be applied to crush the stone. Some, as M. Tonsay in France, modified it, so as to render it available for percussion or crushing; while others, especially our English surgeons, returning to the principle of Mr. Weiss, abandoned the percussor, and substituted in its place, crushing, either by pressure with the hand alone, or with a screw, or fly-screw, &c. The intuitive genius of Dupuytren was one of the first to seize the advantages of pressure. Soon after the appearance of Baron Heurteloup’s percussor, we find Dupuytren writing Fic. 26.-M. Civiale’s improved instruments, (1824.) to him the following passage:-" If you could discover a mode FIG. 27.-Mr. Weiss’s origmal instrument, (1824.) of substituting for percussion a force of pressure which would I should perhaps have observed to you that M. Civiale, enable us to do away with your bed, &c., I should at once always used more or less crushing when the calculus was; advise the commission to award you the grand prize." a

No. 1506.

c

24 could

never

have held its place, and the system of abandoned as impracticable.

must have been

percussion

BARON HEURTELOUP’S

ORIGINAL INSTRUMENT FOR PERCUSSION. : FIG. 34.-The male and female branches, without handle and opened. The dotted lines show the slit in the male branch. FIG. 35.-The vesical extremity of the male branch; the slit in the blade enables it to be drawn back. Ffo. 36.-The handle and portion of instrument. FIG. 37.-Perpendicular section, showing the central or male branch, and the external or female side-pieces. .

)

drawing taken from the original instrument made and which Baron Heurteloup presented to the Westminster Society. It is composed of two side pieces, with a thin central plate of steel, representing the male branch. The side pieces are curved at their extremities, and are united to the central piece by the pressure of a few screws. Near the curve of the male piece is a short longitudinal slit, through which a rivet passes from side to side, and this is the only solid point of junction. This rivet limits the movement of the branches. From the section of the instrument you will perceive that the side-pieces, which represent the female branch, do not meet either above or below, but are separated by the thickness of the male branch. The sliding movement is altogether lateral. Now let us consider for a moment what takes place-nay, what actually did occur in Colonel Rankin’s case-with this instrument. When the blades embrace a calculus, and pressure or percussion is employed, at that part of the slit in the male branch which comes in contact with the rivet, a tilting effect is produced; the rivet acts as the point d’appui of a lever, and the extremity of the male forceps is more and more thrown up according to the force employed. In the case alluded to, it was bent upwards over the arch of the pubes. This is the inevitable effect of the want of solidity, proctuced by the way in which the branches slide laterally, and by the lever action of the connecting rivet. These fatal defects were soon corrected by Dr. Costello who modified the instrument in the way I now show you. Here is

a

by Weiss,

FIG. 32.-Professor Jacobson’s instruments, FiG. 33-Shows instrument closed.

(lS31.)

As for percussion, Baron Heurteloup is unquestionably entitled to the merit of having, if not discovered, at least introduced and subsequently established that system, which led to the still better one now adopted, of crushing with sliding instruments. And here I must enter into a few details which enable me to do justice to English surgery on a point that has been forgotten or intentionally overlooked. Baron Heurteloup’s original instrument was extremely imperfect ; and I have no hesitation in aflirming, that, without the essential modification which it subsequently received, it

FIG 39.-Dr. Costello’s modification of the original percussor. The female branch is a hollow catheter, with a slit of a triangular shape along the upper part; and the male branch is a solid catheter-shapedpiece of steel, fitting exactly into the former, with all the points of which it is in contact, except along the upper surface. Hence, from the solid manner in which the two branches are united while they slide, they admit of any degree of pressure being made, without danger of forcing the joints or branches of the instrument.

25 It is curious to observe how the progress of lithotrity in this direction was retarded by what we might call an accident. In the year 1824, Mr. Weiss demonstrated the power of his screw instrument to Sir Benjamin Brodie. The screw acted with so much power on a hard calculus, that it was feared the bladder might be injured by the force with which the fragments would be propelled against its walls; and to obviate such an occurrence this surgeon suggested the addition of a saw.

of Baron Henrteloup’s percussor, water having been previously injected, had refuted the theory of "danger from explosion of fragments," that Mr. Weiss’s principle began use

to attract attention, and his instrument became the starting point of all those subsequently employed. The position of the patient in this operation is a matter of importance, and Heurteloup used to place his patients on a

bed, a representation of which I

now give. Although this used at the present day, I must few words about it. The history’s sake drawing I now show you gives a good idea of all the main points of the bed, which is composed of a rectangular couch. On the upright rod, which M. Heurteloup calls his "fixed point," is a wedge to fix this branch solidly, and a grooved head, with a screw at the upper end of the branch, to fix the percussor. The object is to hold the percussor so steadily, that when the male branch is struck with the hammer, no movement of any other portion except the in stones the FIG. 40.-Mr. Weiss’s instrument for sawing branch shall take place. Anteriorly there are two bladder, (1825.) pieces of wood, having at their extremities two slippers We now know that such fear is chimerical, though it was for the patient’s feet. These can be lengthened or shortened quite natural in 1824, for at this time the injection of the at pleasure, to suit the height of the patient. In front there bladder with water, previous to operation, was not insisted is a cross piece of wood, very thick, uniting the two triangles upon; hence the fear of damaging the coats of the bladder. together. In this is seen a mortice for the small vice to play The French surgeons soon after this advised the injection of in, which holds the instrument during its action on the stone. water prior to operating, since which this practice has been This bed can be lowered, if required, to an angle of 450, a strap of being passed behind the neck and before the shoulders, and universally adopted. The principle of crushing by means attached to a buckle on each side of the bed, so as to prevent were trials no the the screw, however, was rejected for time; the the patient slipping off. made on the living body, and it was not until 1832, when

cumbersome apparatus is

for

never say a

male

fixed

in

by Fic. 41.-Baron Heurteloup’s bed. a. The percussor, 11 fixed point," which is itself the upright rod, b. b. the upright rod, or in. driven firmly fixed to the framework of the couch by a wedge, c,

England may, and you see, justly, claim the principal part in the crushing system. The oval slit in the side or back of the female forceps, for the discharge of detritus, was, I believe, invented by the late Mr. Oldham, a gentleman attached to the Bank of Ireland; while Mr. L’Estrange, of Dublin, claims the merit of having first applied a wire stilet, for the purpose of removing the detritus. Mr. L’Estrange also claims the honour of having been the first who applied the principle of the screw as a means of crushing calculi in the bladder: but with every desire to do justice to our Irish brethren, I cannot see on what this claim is founded. If Mr. L’Estrange’s invention bears date from July, 1834,I have merely to remark that the screw was employed by Weiss in 1824, by IIaygarth in 1825, again by Weiss in 1825, by Retoré m 1825, and by numerous French surgeons in 1833. An English instrumentmaker on the Place de 1’Ecole de Médecine, known as Sir Henry, (probably because he was a knight of the legion of honour,) had applied the screw for crushing long before 1834. It is but right, however, to observe that the screw broke the blades, on the first trial made with it at the Hotel Dieu, in 1828. Since 1834 many changes have been made in the details of various parts of lithotritic instruments, but none affect the principle on which they work. The blade of the female branch has been made wider and deeper, to receivethe detritus ; the screw has been replaced by the rack and pinion; the latter furnished with a round handle, as in Charriere’s instrument; or with a T-shaped one, as in the English, to

a screw

for give additional force. To Mr. Fergusson we are indebted the application of the rack-and-pinion system, which he

It is unnecessary for me to notice all these improvements, as they havebeen called, for almost every surgeon who has occupied himself with lithotrity appears to have thought it incumbent on him to make some change in the apparatus-occasionally for the better, often for the

introduced in 1834.

worse.

The instruments generally used at the present day for performing lithotrity are, the common screw one, the rack-andpinion instrument described by Mr. Fergusson, and Charriere’s last instrument, which likewise acts through a rack and pinion, but differs from the former in the shape of the handle. Having thus comprised, in as brief a space as possible, the principal facts connected with the history of lithotrity, I hasten to its practical application. I shall at another time endeavour to explain to you in what cases lithotrity is to be preferred to lithotomy, for you are not to conclude that all cases of calculus in the bladder admit of being cured by the new operation. For the present, let us suppose that a case of stone suitable for the employment of lithotrity presents itself. How are you to proceed ? What are the successive steps of the operationa Stone in the bladder, as you are fully aware, is almost in, variably attended by more or less severe derangement of the genito-urinary organs or of the general health. It is important, before proceeding to the operation, to remove these complications as far as possible; and hence what has been ..

,

26 termed the preparatory treatment. I do not now mean to say that you are to select your patients in such a manner as to operate only on those who are free from any complication. This would be impossible in hospital practice, and, moreover, would condemn many patients to perpetual suffering for the mere sake of enhancing your own reputation and appearing as a successful operator. What I mean is, that you must, by preparatory treatment, remove all such local or general

FIG. 42.-Welss’s latest improved lithotrite Fio. 43.-Fergusson’s rack and pinion. FIG. 44.-Charri’re’s rack and pinion.

disorders as are likely to exercise any dangerous influence on the result of the operation. Whenever the calculus is small, the bladder healthy, and the urinary passages show little or no signs of irritability, the patient is in the most favourable state, and preparatory treatment need not occupy your attention. But such cases are not very frequent. Patients seldom present themselves to you, especially with the idea of undergoing an operation for stone, until the urinary organs, and subsequently the general health, have more or less suffered. Here the patient must be carefully examined, and all unfavourable symptoms removed, or at least alleviated as far as possible, before you think of operating. The digestive organs often suffer in cases of stone. Endeavour to correct this derangement, and improve the condition of the intestinal secretions. Where the patient is much enfeebled, tonics should be administered; if, on the other hand, the circulation be much excited, general or local bleeding is indi. cated; but you must be cautious not to reduce your patient too much, nor to waste valuable time by continuing the preparatory system too long. If you relieve the most urgent symptoms, it is all you can expect to do in unfavourable cases. An excessive disposition of the bladder to contract on the stone should be combated by the use of opiates. The condition of the kidneys must be examined with the greatest care, for they are often diseased in long-standing cases of calculus. When the symptoms are uncertain and obscure, an examination of the urine will here be of great assistance. The state of the urethra, prostate, and bladder, must, I need hardly say, be ascertained, and, above all things, we must endeavour to determine whether disease of these parts has given rise to the secretion of pus. The existence of purulent deposit in the urethra, prostate, bladder, and kidneys, is, according to my experience, one of the most unfavourable complications which can present itself, not only with respect to lithotrity, but any other operation on the genito-urinary organs. The pre-existence of such abscess is a powerful determining cause of purulent infection, and hence I would lay down the rule that every effort should be made to remove such a complication before we think of operating for stone in the bladder; and this remark applies to lithotomy just as well as to lithotrity. As part of the local preparatory treatment, M. Civiale insists much on the propriety of introducing a soft bougie for a few days, and during a few minutes at each time, so as to accustom the urethra to the contact of a foreign body, and diminish its irritability. He never goes beyond the natural calibre of the urethra, and rejects dilatation of that canal. Other surgeons, however, employ flexible sounds, the calibre of which is gradually increased until a certain degree of dilatation ensues; but I am of opinion that you had better leave your patient as tranquil as possible until the appointed time for operating arrives. The urethra, like other parts, will bear irritation to a certain extent only, and it never can become habituated to much violence. The next step may be considered as preparatory also, for it consists in exploring the bladder. A great deal has been said, by the opponents of lithotrity, on the inutility and danger of these preliminary explorations; but they are indispensable, unless, indeed, you are content to go to work completely in the dark. They are somewhat analogous to the usual operation of sounding previous to lithotomy; the proceeding, however, is somewhat different, for more precise information is required; or, perhaps I should rather say, that lithotritists are more careful in ascertaining every particular connected with the state of the bladder, the size of the stone, &c., than lithotomists commonly are. Remember that you have to work for a considerable time with a steel instrument, on perhaps a hard body, in the interior of a small, contractile, and highly sensitive cavity. It is therefore indispensable to obtain some idea of the cavity and contractile power of the bladder before you proceed to break up a stone in this organ. A moderately sized sound, with a small curve, (this latter circumstance is essential,) is introduced into the bladder, and, being rotated, conveys a knowledge of its capacity, while the manner in which the urine escapes will enable you to form some estimate of the contractibility of the organ. Should the bladder be extremely irritable, or, on the contrary, in a state of atony, the opera-

adjourned. be tion must ascertained that the bladder is in condition to thus Having bear further continue examination. a

exploration,

Fio. 45.-M. Civiale’s latest instrument for crushing with the hand or the screw, or for employing percussion. Fie. 40.-The jointed catch, which is shown in situ on the

instrument, fig..5

a.

you now your When the bladder is contracted the flow of urine must be prevented, and the point of the sound should be directed at once downwards towards the rectum, where the stone is most likely to be found, and the conditions of which part of the bladder,

from its relation to the prostate, are most

important to be known

27 The most experienced surgeons have, from time to time, early ones, as I remarked before, were all perfectly failed to detect the presence of a stone in the bladder by the straight, for curved instruments were not introduced into use usual method of sounding. In doubtful cases of this kind until 1831 or 1832. Still you must remember that the curve M. Civiale advises us to inject some fluid into the bladder, of the lithotrite differs considerably from that of the ordinary and to repeat the injections at short intervals, so as to vary The elbow, as you see, is very abrupt, the ascendthe capacity, keeping it at one time full and the next moment ing part is much shorter, and in many instruments the forceps is much flattened, to give solidity to the branches. In empty; and in this way the bladder is excited to contract, its form and capacity are made to change, and it rarely happens introducing the instrument the abruptness of the curve not be forgotten; and the principal point you have to that, as the walls of the bladder close round the end of the instrument and the calculus, the latter is not placed in con- attend to is to keep this curved portion constantly in the tact with the former. of the canal, especially while the instrument is Certain diseases of the prostate may cause such a depresunder the arch of the pubes and through the neck sion of the bladder behind the gland, as to render it impos-: of the bladder. Proceed, therefore, with the utmost gentlesible to discover the stone by the ordinary method of sound- ness, feeling your way as you go along. When you arrive at ing ; and the same result may arise from fungous tumours, the bulbous portion of the urethra, the penis and handle of &c., at the neck of the bladder. In these difficult cases the the instrument should be brought to a right angle with the curve of the sound must be increased, and if this fail, you body of the patient, by which you bring the curve of the must have recourse to the lithotrite, which you are to use as a instrument under the pubic arch. This done, you slowly sound. The small size of the calculus has always been an depress the handle, advancing it at the same time until the obstacle to its detection with the common sound. If you bladder is reached. The amount of depression will depend meet with a case of this kind you must inject two or three on the curve of the instrument you use; the shorter the ounces of fluid; next introduce the lithotrite, and open curve, the less you need depress, but the principle to be folits blades from time to time, when the calculus is usually lowed must guide you; that is to say, you must endeavour to seized. Having seized it between the blades of the instru- make the curve of the lithotrite follow the natural curve of ment, you next endeavour to ascertain its size: but this can be the urethra. There is seldom any difficulty in passing the instrument, at done only approximatively, for when the calculus is large, or of an oval form, it is quite impossible to measure its size with least in ordinary cases. When the prostatic portion of the urethra is healthy, the lithotrite, such as we now use, passes anv degree of accuracv. These various gentlemen, will be of great assistance readily enough, but if there be any tumefaction of this to you in the operation which is subsequently to be performed. gland, you must depress the handle of the instrument proIf we examine the practice of the most successful lithotritist portionately, so as to throw up the point and clear the obstacle. of the present day-one who has performed more than 600 I must again caution you against using the slightest force operations-we can hardly attribute his unexampled success during any of these proceedings. The young operator should to any other cause than the great attention lie bestows on never forget that it is very possible to lacerate the lining these preparatory arrangements. Many surgeons exceed him membrane of the urethra, and that this accident may occur in manual dexterity, but none bestow so much care on the without any great amount of force, especially while the instrumedical and accessory points of each case; and hence, I ment is traversing the membranous portion of the canal. You have now the instrument in the bladder. The next believe, the success of his practice. On the position of the patient a few words only need be step is to seize the stone. This is easily done when the calculus said. The patient is placed on a bed or couch with the pelvis is small and the blades of the lithotrite large. The blades first, kept closed, and moved in a sweeping direction, slightly raised, so as to bring the most depending part of are, atthe the bladder on a line with the internal orifice of the urethra. convexity downwards, from before backwards, along The legs are to be separated; the thighs slightly flexed; the the bas-fond and posterior surface of the bladder; it is then a little, and the convexity directed to the right surgeon stands on the right side of the patient. Having drawn drawn off the urine with a catheter, he next proceeds to or left side, each of which is explored in its turn; lastly, point of the instrument is directed upwards, and downinject slowly some tepid water, continuing until the patient the The experiences a desire to evacuate it; the quantity required wards to the space immediately behind the prostate. in should order then be to rotated, varies from five to ten ounces. If the fluid be carefully generally expelled the injection must be repeated, for you should never comein contact with the foreign body. This found, the think of attempting to operate when the bladder is empty. blades of the lithotrite are cautiously opened, and the inIn some cases the bladder, as M. Civiale observes, is thick- strument is pressed on the stone laterally; after which, the ened and extremely irritable, tending to eject the smallest blades are closed with the same caution, every effort being the stone as much towards its centre as is quantities of the fluid introduced. Here the injection must made to seize conducted with extreme slowness-a small quantity at a possible. This is an affair of dexterity which practice and time only being thrown in-and the patient allowed to repose great tact alone can attain. It is of importance to remembetween each injection; or the urine may be allowed to accu- ber that the female branch should be kept perfectly immovemulate naturally in the bladder. If the irritability continues, able while you are closing the instrument, otherwise you run the risk of displacing the stone, which generally lies you must cease your attempts for the moment, and adopt against its ascending branch. other means, as leeching, hip-baths, opiate clysters, &c. Having seized the stone, the surgeon must next satify himChloroform has been tried in some cases of this kind, but without effect, the contractions of the bladder remaining self that nothing besides the stone is included between the branches of the instrument. At an early period of lithotrity, undiminished, though the patient was completely insensible. The instruments employed for injecting the bladder are the mucous membrane of the bladder was more than once catheter with a stop-cock, and a pinched up, and ground together with the stone; but such an a large-sized silver metallic syringe, capable of holding half a pint and of being accident, which mainly depended on the imperfect nature of the instruments then employed, is, I believe, unknown at the accurately fitted to the catheter.

The

catheter. portion

,

-

must direction passing

points,

with

back

instrument

be

present day. Once firmly fixed between the blades of the lithotrite, the calculus is generally broken down without any difficulty. Many surgeons employ pressure with the hand only; and this answers well enough when the stone is not too large or hard.

In other cases the use of the screw becomes necessary. Its slow propulsion soon causes the calculus to yield; and if

employ the rack-and pinion system, a rapid succession of slight jerks may be communicated, which produce many of the effects of percussion. Should the stone, from its hardness, resist pressure, we must have recourse to percussion as an auxiliary, and Charricre’s instrument admits of our employing this mode without withdrawing the lithotrite from the bladder.

we

is, in fact, both a percussor and a crusher at the same time. Before withdrawing the instrument from the bladder, it is essentially necessary to ascertain that the branches are perfectly closed, and that no detritus has accumulated in the forceps portion. If this be not done, vou may encounter an unexpected obstacle when you arriveat the urethra. A few

It

Wenow arrive at the introduction of the instrument

,

28 turns of the screw backwards and forwards will usually suffice to clear the instrument, or Mr. L’Estrange’s stilet may be used, if the male branch be grooved to allow of its passage. It is only in exceptional cases, and when the stone is both mnall and very friable, that you expect to break it up at a single operation. The first proceeding should always be short, and when the passage becomes accustomed to the instruments, or less irritable, the operation may be prolonged for ten minutes at a time. This is a rule from which M. Civiale never deviates, and his opinion in this matter deserves the deepest attention. From three to eight days should elapse between each operation, to allow the fragments to pass away with the urine, and any irritation which the operation may have excited to subside. Such fragments of the calculus as are too large to come away with the urine must, of course, be treated as distinct calculi, and crushed separately. I shall refer to this point again. In my next lecture, gentlemen, I shall consider the difficulties which may be encountered in the performance of lithotrity, and the accidents which may accompany or follow it. ERRATA.-In the last number, page 1, col. i., the following corrections should be made in the explanations attached to the drawings : Fig. 1 is the quadrupulus vesicle of Franco.-Figs. 2 and 3 represent the forceps of Hildanus, for the extraction of urethral calculi. Fig. 2 shows the instrument embracing a small calculus ; fig. 3, the forceps.-Figs. 4 and 5 represent the ball-extractor of Alphonso Ferri. Fig. 4 shows the extremity of the three-bladed forceps; fig. 5, the instrument closed within the canula.

Clinical Lecture, ON A CASE OF

GONORRHŒAL BY

OPHTHALMIA. JOHN ADAMS, ESQ.,

SURGEON TO LONDON HOSPITAL.

CHAS. M’C-,wire-worker, aged nineteen, was admitted, under the care of Mr. Adams, suffering from gonorrhosal oph. thalmia, on March 5th, 1852. About six weeks before, lie had contracted gonorrhoea, and he thinks it probable that he had infected his eye with the purulent discharge through the medium of his finger. He had discovered the existence of the disease the day before, by feeling as if he had something gritty, like sand, in his right eye, and had requested others to examine it for the purpose of removing the obnoxious particles. The disease had progressed for thirty-two hours previous to his admission, and had then assumed the following aspect: Considerable purulent discharge, with eye completely closed from the excessive inflammation of eyelids; tears running freely down the cheeks; cornea quite clear; considerable chemosis of conjunctiva, forming a complete bed for the cornea, and in two parts overlapping it. This was accompanied with great pain in the right eye, forehead, and temples; pulse quick, with strong feverish symptoms and great depression of spirits; the left eye very slightly inflamed; tongue clean. The following was the course of treatment adopted: Venesection to twelve ounces; calomel and jalap, one scruple, immediately, and afterwards, calomel, one grain; tartar-emetic, one-eighth of a grain, every fourth hour. Lotion: nitrate of silver, eight grains; distilled water one ounce; two drops to be instilled into the external canthus hourly.-Seven P.M.: Pain still great in the temples and head, with increased inilammation of the eye. Ordered, twelve leeches to the eyelids. Pulse 78.-Nine P.M.: Greatly relieved by the leeches; bowels freely relieved. March 6th.-Pulse 84; pain in the head not so great; bowels Open; discharge much diminished; tongue clean; iilflamiliation gradually subsiding. Lotion ordered to be applied every two hours. 7th.-Going on favourably, though the conjunctiva still remains considerably injected; the cornea quite clear, and sight very good. The effects of the calomel being apparent, the pill is ordered to be taken every six hours; the lotion every three hours. 8th.—Rapidly mending; mouth being sore, the pill is discontinued. 19th.-After this the eyeresumed gradually a more healthy appearance, but still for a considerable time a pink blush was visible over the surface of the sclerotica, and its aspect was not unlike that presented in rheumatic selerotitis. This, howThe urethral discharge has ever, has almost disappeared. nearly ceased; but he was ordered copaiba mixture. The above case affords an excellent illustration of one of the most formidable affections of the eye. The disease is one

if not very speedily arrested, leads to the entire destruction of vision in many instances, or, its destructive effects being checked by appropriate treatment, it still leaves behind vestiges of its ravages, in the form of partial opacities of the cornea, and much consequent impairment of the function of the eye. Can we, therefore, occupy ourselves better than by briefly referring to the circumstances of this case, and dwelling on the means which in this instance have been successfully put in requisition ? I am induced to direct your attention to this case, because we have had lately three similar instances treated in an analogous manner, with slight modification, and all ending satisfactorily. If you consult authorities on this subject, you will find that all who have written from experience on this disease, as Lawrence, Middlemore, and Mackenzie, agree in the great fatality of the affection: I use the term, of course, as applicable to vision. I believe I am right in asserting that in nearly one half of the cases mentioned has the issue been destructive of vision by sloughing cornea. The characters of this disease can scarcely be mistaken; there is great chemosis of the conjunctiva, so as to encroach upon the cornea to a greater or less extent; the eyelids are swollen, so that it is difficult to get a view of the surface of the eye; profuse lacrymation and a constant escape of pus or muco-pus from the eye over the cheek, are also present; and all these symptoms are accompanied with constitutional irritation, intolerance of light, pain in the head. One of the prominent signs of the disease,

which,

although not a diagnostic symptom, is, at its commencement, the sensation of a foreign body, as grains of sand or dust, in

the eye. The patient is usually the subject of gonorrhoea; but I believe there is no doubt that the disease may be conveyed by the contact of gonorrhœal matter from one person to another; indeed, some deny that an individual can infect himself. In this respect, however, I may tell you that experio ments have been made by surgeons themselves, which lead to this conclusion; but I do not think they are to be depended on, for it is well known that some individuals are altogether proof against thegonorrheeal poison. In the case before us, there is good ground for believing that the patient infected his own eye with the discharge from his own urethra; and my opinion is, that the disease is usually induced in this manner. In the case of a little boy under my care some few months back, there was reason for believing that he became infected from the gonorrlioeal matter of another person with whom he

slept. The diagnosis of the disease in its acute stage is easy, but in its modified form it may be confounded with common purulent ophthalmia, which prevails occasionally in an epidemic form, and is itself highly contagious. The history of the case will, in a great measure, assist us in the diagnosis. In the latter form of disease, for instance, the inflammation is more confined to the palpebral conjunctiva at its commencement, and is slow in its progress, although frequently destructive in its effects; it also usually attacks both eyes, and this is not common in gonorrhoeal ophthalmia. The prognosis in these cases is, as I have already stated, unfavourable; but if the disease be understood, and active measures be commenced and well carried out, many eyes may, even under the most unfavourable circumstances, be saved from destruction. The treatment must be modified according to the existing condition of the eye; for where the cornea has commenced to slough, active antiphlogistic means are to be discontinued. The treatment pursued in the case just detailed has been successful; it presents nothing new, but we cannot do wrong in reviewing it; and although my own experience is limited, I should have no hesitation in adopting it if another similar case came under my observation. First, then, if the patient be young, you must take away sixteen or eighteen ounces of blood from the arm, pleno vivo. Of course this is inadmissible in old subjects, or where the constitution is much impaired. Invigorous person you may bleed ad deliquium. You are then to apply leeches to the eye, and purge your patient briskly. It is desirable that he should speedily be put under the influence of mercury-not that mercury will of itself cure the patient, for it has over and over again been found to fail. You are also freely to scarify the conjunctiva, to unload the blood-vessels-and not with the view to get rid of the venereal matter, which the old surgeons thought was distending the conjunctiva-or you may snip out pieces of the overhanging conjunctiva. The late Mr. Tyrrell (a very good authority in such cases) advised that the scarifications should be made so as to radiate from the margin of the cornea. He thought that the cornea perished from the strangulation of its vessels, and he adopted this plan to pre-