LONDON HOSPITAL.

the finger, and, if of moderate size, pcr,-3se8 readily into the ments would be more than it would be advisable to hazard. wound on zvithdrawiag the finger, the patient having power to The stone, before operation, could be perceived to be of immense strain upon, and thereby facilitate the extraction of the stone; size. Under these circumstances he preferred the urethrothis last-mentioned power being one of the great advantages of vaginal or vesico-vaginal section through the median line, when this operation." The author then goes on to observe, as re- a calculus the size of an average orange or apple was easily exmarked also by Mr. Erichsen, that, the incision being strictly tracted. Mr. Erichsen said he had not seen so large a calculus in the median line, no muscles are divided, and no gaping-open before from the female. A slight compress of lint, or tampon, wound is left, as in the lateral section, and as even in this to prevent haemorrhage, was now introduced, and the patient and Coulson both mention lithotrity very case before, for six months, The integrity of the removed to bed. bladder being preserved, and no chloroform given, the patient in the female as at one time somewhat common. The latter himself helps to expel the stone. surgeon does not see much force in the objection to lithotrity, It will be observed here that the prostate is not incised, but that the bladder will not hold the fluid injected. Where theredilated, and thus the chief evil of the lateral operation are small stones in the female bladder, it can be scarcely a merely is in some measure surmounted. It is worthy of remembrance, !, question as to their removal by dilatation or lithotrity. It is however, that Deschamps cut a nick in the prostate, and that doubtful whether Heurteloup’s plan by percussion has not been Mr. Syme finds it very difficult to dilate what he calls the ring too readily abandoned in breaking up large calculi. The faciof the prostate, even on the dead subject, to more than a circle lity of thus removing a calculus from the bladder of the female of an inch in diameter, and he states that if this annular sub- through the vagina must be obvious to every reader. Mery stance be torn the patient will die. For all stones of the size and Gooch are those who have described this operation with. of a large walnut, Allarton’s operation, therefore, would appear the greatest accuracy. The patient being placed in the usual to be very satisfactory. If the prostate be divided longitu- position, Mr. Erichsen passed a straight staff into the bladder,. dinally for larger calculi as far into its substance as this ring the groove directed towards the point of the coccyx, the end extends, or better still, perhaps, in the zig-zag manner of Mar- of the staff prominent against the vagina; the index finger of the tineau, of Norwich, so as to leave more room for the extraction left hand with or without a wooden gorget, is also passed the gland usually tears very readily, and without bad conse- into the vagina, the end of the staff resting against the conquences. Even the bistourie caclaee, cutting this ring from cavity of the gorget. These being held by an assistant, the within outwards for very large stones, is by many French sur- operator next directs the point of a straight bistoury along his geons conceived not so dangerous as too much dilatation or left forefinger until he meets the groove of the staff behind the laceration. Sir Astley Cooper, it will be remembered, in 1819, neck of the bladder, the incision forwards being then carried removed a somewhat large stone from the bladder by the to the extent necessary. As soon as this incision was made, operation now advocated by Allarton. Deschamps and Sir the stone, of very large size, camp forward. It weighed five Astley thought it, even in their time, not improbable we should ounces and three-quarters, and measured eight inches by six go back to the Marian plan, so much were they dissatisfied in circumference ! Mr. Erichsen stated that he apprehended. with Cheselden’s operation. It cannot be denied, however, as vagino-vesical fistula, which might be remedied by a subsequent objected to the apparatus major by Mr. Coulson and some operation, if the patient survived. other surgeons, that with it we run the risk that the whole of the canal, from the opening of the bulb to the body of the bladder-namely, the membranous portion" of the urethra and LONDON HOSPITAL. prostate and cervix-will be more or less contused, lacerated, and injured in a frightful manner;" but, we submit, only by USE OF THE GORGET IN LITHOTOMY; DANGER OF PYELITIS OR very large calculi. It is also equally clear that in every posNEPHRITIC DISEASE. sible form of lithotomy we must have the same dilatation of the care of Mr. LUKE.) (Under parts to extract the same sized stone; in fact, cceteris paribus, we must have a certain aperture through which we extract the THE dangers of an average case of large stone, such as we calculus, whether in the lateral or median operation; the real see in numerous instances in the through the year, question seeming to be where the opening is to be, and the sur- were unhappily too well shown inhospitals a case operated on, during geon will content himself with an aperture such as we have just the past month, at the London Hospital. The calculus, when described in Allarton’s own words, with or without incising appeared to be broken in two, and about the size of the prostate, and thus extracting the stone by slow and gentle removed, half a closed fist, with something of a funnel-shaped form, as dilatation, or the more striking and showy operation in the side one can perceivethe thumb side of a closed hand tapering of the prostate, to make room for large forceps, with chances of towards the wrist. The was performed on the 19th. bursting the left side of the gland, and tearing the neck of the of October, by Mr. Luke, operation with his usual skill, by the ordinary bladder-that ring of gland structure so well described by lateral operation, and did not present any peculiarity. Mr.Liston and Syme. Sixteen patients were operated on also by we perceived, used the cutting gorget; the calculus, Luke, Le Dran about 100 years since by the Allarton method, withbroke in the extraction. out a single death, the chief secret being slow and gentle dila- however, On the 26th of October, we found the man doing well. He tation. had not had a bad symptom. The calculus, by its peculiarNov. 21st.-A week has now elapsed, and the man has seemed as if it had lain in a cyst, at the back of the not shown a single bad symptom. It seems the rectum was shape, its immense size led us yet to fear danger. adherent to the membranous portion of the urethra, attached prostate; Nov. 2nd.-This day the case was reported to us as well. by the cicatrix of the former operation and the old fistula. The The man seemed in health. His age, he told us, was bladder, also, has been unusually irritable before and after the sixty-four, and that hegood had suffered from symptoms of stone so the case not even the most fortunate that was operation; for twenty-five years. for the new operation, as was suspected when he first came 7th.-Not satisfied with our own prognosis, we made under observation. The patient, however, may be considered inquiries again, and found the man, as we feared from the cured. beginning, was sinking, and died that day, death occurrring soLITHOTRITY IN THE FEMALE; GOOCH’S OPERATION. late as the nineteenth day. A second very remarkable case was operated on by Mr. At the post-mortem examination, as we were informed by Mr . Erichsen on Nov. 7th. The patient was a young woman sent Ward, it was found that the capsule of the prostate had escaped. up from the country. It appeared, from the history of the The kidneys, however, were found very much diseased, as one case, that she had been suffering from several obscure but not might have been led to expect, from the man suffering from. uncertain signs of stone for some time. Having recently got symptoms of stone for twenty-five years. The ureters were married, it was found, in giving birth to her first child, that a dilated, and much inflamed. The bladder was hypertrophiedsingular obstruction opposed itself to the passage of the head and thickened, in the state so familiar to surgeons in theseof the child, more particularly at the anterior part of the cases,-the cause of death being, however, purulent deposit ill vagina, about the region of the neck of the bladder. This ob- the recto-vesical septum and cellular tissue of this part. The stone appeared to us peculiarly soft, and somewhat struction, which even obliged the surgeon in attendance to lessen the head of the child before delivery, proved to be a tapering or bevelled at one extremity, (not two separate large calculus in the bladder. Mr. Erichsen said he was afraid stones,) as if it had been moulded in some rude fashion, more to have recourse to lithotrity, as the mucous membrane of the at one side than another, to the neck of the bladder, or some bladder had already suffered so much from the pressure of the pouch at the back of the prostate. No doubt the irritation child’s head in parturition, as well as from the presence of such kept up so long here, with the consequent thickening of the a large stone, that the mechanical irritation of the large fragbladder, led to the fatal result.

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