its beginning to its end: it must not have any bridges, the angles must not be cut more shallow than the middle, and the edges must not be jagged." "The mode of holding the knife has an important influence on its use. In this respect, four postures or positions may be distinguished. 1. It is held like a pen, the handle being taken hold of with the thumb and middle-finger near the blade, and the fore-finger laid on its back. Herewith the knife can be used with ease, and employed in every direction. It is especially suitable where small cuts are to be made with great care. 2. The knife is held with the thumb on one, and the middle and ring-finger on the other side of its handle, and the fore-finger laid on the back of its blade, as in holding a violin-bow. 3. The handle is placed on the inside of the ball of the thumb, with the thumb on one side, and the middle, ring, and little finger on the other, whilst the fore-finger is extended upon the back of the blade. 4. The knife is grasped with the whole hand, the thumb on one and the fingers on the other side of the handle. This is only applicable to large or amputating knives. "Scissors effect the division of parts, like the bistoury, by drawing and pressure; but the pressure is greater, and therefore the scissor edge is generally not so fine as that of the knife; neither are the edges set directly opposite, but lie beside each other, so that ordinarily a cut with scissors is not so clean as that with a bistoury; the part too must also be pressed and squeezed before they are divided. On this account, the use of scissors is by many entirely rejected. The objections, however, to their use may be done away with by the proper fineness of their edge, and by the greater power with which they can be employed. It has been hitherto supposed that the due degree of fineness, like that of a bistoury, cannot be given to scissors without impairing their strength. I, however, possess scissors, made by our clever instrument-maker Görck, which have the perfect edge of a bistoury, and with proper strength." P. 859. Mr. South has most injudiciously committed himself in a postscript to an unfavourable and somewhat sneering opinion upon the employment of Ether as a means of preventing pain during operations. Writing in Feb. 1847, he was not called upon in a systematic work to even notice a remedy only introduced to the profession a few weeks; but, having determined to do so, it is matter of congratulation that his opinion has not been fortified by subsequent experience, and that it will only disfigure his book as a specimen of over-hasty conclusion. Speaking of the propriety of preliminary trials, he says-" With this opinion I fully concur, and I should certainly adopt it, if I made up my mind to try inhalation at all; but upon that point I am not decided, for I have considerable doubt of the propriety of putting a patient into so unnatural a condition as results from inhaling ether, which seems scarcely different from severe intoxication (!)—a state in which no surgeon would be desirous of having a patient who was about to be submitted to a serious operation." Of one thing we are certain, that if some surgeons have not made up their minds upon this matter, most patients have, and that the services of those who, upon mere speculative grounds, decline availing themselves of this means of mitigating dreadful suffering, will very properly be but rarely put into requisition. This is a matter the public must and will decide for itself. General Treatment of Lithotomy Patients.-Mr. South observes that lithotomy cases may prove fatal, however dexterously an operation may have been performed, and he is disposed to refer this to some error in the 1847] Management of Lithotomy Patients. 365 prior or after-treatment. Upon this subject he offers some very judicious directions, going into minutiæ not to be found in our works on surgery, and for the want of being acquainted with which practitioners may lose patients upon whom the operative procedures have been conducted with skill. He deprecates the placing of patients with stone in the ordinary wards, where they are not quiet enough, and the sisters of which are not habituated to watch various circumstances it is important for the surgeon to be made acquainted with. The following is a brief abstract of the account he furnishes of the practice which has been long followed at St. Thomas's Hospital. The patient is placed in a small ward containing only half-a-dozen beds, and which, after the operation, is kept very private and quiet; and here he remains under the watchful eye of an experienced sister for ten days or a fortnight, to get accustomed to place and attendants. If in tolerable health his diet and habits only demand ordinary attention, occasionally resorting to a hip-bath when his suffering is great, especially after sounding. Rarely is bloodletting or other depleting means practised. The bowels are however to be kept clear; and if the patient have been accustomed to take gin and water to increase the action of the kidneys a practice very prevalent among such persons-this is to be only discontinued gradually, or even not at all. Temperate weather should if possible be selected, for great heat exercises a very depressing effect on these patients; while, if it be very cold, he may easily become chilled while exposed at intervals during the after-treatment. The day prior to the operation a dose of castor-oil is given, and the diet restricted to rice-pudding and milk, with plenty of barley-water or gruel, especially the former. If the motions are hard and lumpy, an injection of castor-oil and gruel is to be thrown up on the morning, but if not, the gruel alone suffices. After the operation the patient is put to bed with his legs straight and close together, for the purpose of gently maintaining the edges of the wound in contact, and checking slight hæmorrhage. A napkin is passed around the pelvis just as it is put on an infant, and throughout the treatment this is carefully changed when wet by the urine passing from the wound. In the evening, or next morning, if there be no bleeding, a piece of lint folded on the end of the finger is introduced into the wound, and pressed up the depth of the perineum. It is changed each time the patient wets, and is continued until the healing is accomplished, with the intention of securing this taking place from the bottom, under which plan the formation of fistulous passages is a matter of very rare occurrence. "A handful or two of chamomile flowers thrown into a basin, are sprinkled with spirits of wine, well mixed, so as to be equally moistened, and then put into a thin flannel bag, and having been well heated on a warmingpan, are applied over the belly as hot as the patient can bear, on the evening of the operation-day, if there be no bleeding; and this is continued for a week or ten days." If the wound on the second day is swollen and no urine flows, no lint is introduced, but a bread-and-water poultice is applied until the swelling subsides and the water increases. Cold is not applied, and an opiate is rarely given. The diet for the first two or three days consists of farinaceous food and free libations of barley-water; and a little castor-oil is given on the third day. If there is pain in the belly or sickness, however, these may usually be relieved by giving the oil a little NEW SERIES, NO. XII.-VI. CC earlier. About the third or fourth day urine usually passes by the urethra as well as through the wound, and in a week or ten days it flows through the natural passage alone, and then the wound is dressed with wax and oil spread on the lint, introduced as before. If the urine does not flow through the wound at first, and the patient becomes irritable and uneasy, the finger should be passed in to remove any obstruction which may be offered by a coagulum. If the patient flag, the resumption of his gin and water may be advisable. He should be kept in bed for some days after the urine has ceased flowing from the wound; and if the formation of a small sinus retard cicatrization, a piece of lint of corresponding size should be twisted up, dipped in a solution of sulph. cupr., and screwed up to its bottom; but generally the wax and oil-dressing suffices. In from three to four weeks the cure is completed, the diet having been in the mean time gradually improved, and porter or wine added if deemed necessary. Comparison of Lithotomy and Lithotrity.-This question has lost none of its interest and importance, and from recent discussions at the French Academy, seems as little settled among our brethren across the Channel as heretofore. Lithotrity is there as warmly espoused by the specialists as the preferable operation, as its eligibility is stoutly denied by some of the best surgeons in that country; and the discovery of Etherization, which seems likely to be a valuable adjuvant in the one operation, and a most questionable means in the other, where the retention of sensibility often affords most useful guidance for the operator, will doubtless render the substitution of lithotrity less common. In our own country, some of our best surgeons, as Brodie, Liston, Key, &c. &c., have shewn that, in many cases, it is the preferable procedure; and we now have to give an account of the opinion entertained by Chelius. He observes that many of the objections which were tenable at first have lost their validity by reason of the subsequent perfection of instruments and procedures; but that we have not even yet data upon which any positive opinion can be delivered. The statistics are eminently defective to this end, constructed, as they are, on a faulty basis, while their accuracy and good faith have been warmly and effectually contested at Paris. "If the possible evils which may occur on and after lithotomy and lithotrity be compared, they are found to have a certain degree of equality as to their number and danger; only that in lithotomy the wound especially gives rise to symptoms which in lithotrity are absent, whilst the latter occasions considerable irritation of the bladder, and dangerous symptoms resulting therefrom." After enumerating the various untoward circumstances which may attend either operation, Chelius goes on to say "If these various circumstances in lithotomy and lithotrity be compared in regard to their cause; to wit, the wound in lithotomy, and the injury of the bladder in lithotrity, it must be presumed that pain and nervous symptoms may be equally present in both, but their frequent repetition in lithotrity is of impor tance; that bleeding, wound of the rectum, injury to the peritoneum, which are very much to be dreaded in lithotomy, cannot happen in the modern practice of lithotrity; that infiltration of urine, so frequently fatal after lithotomy, is almost impossible in lithotrity; that phlebitis and peritonitis are observed not unfiequently after lithotomy, but very rarely after lithotrity, which also applies in like manner to the continuance of fistula; that, on the other hand, inflammation of the bladder, inflammation and abscess of the prostate, are more common after 1847] Comparison of Lithotomy and Lithotrity. 367 lithotrity. Bruising or tearing of the mucous membrane of the bladder, as also breaking of the instruments in the bladder, is at the present time scarcely possible with the improved instruments. "Further, if lithotrity be considered in reference to the condition of the urinary organs, the age, sex, and constitution of the patient, and the nature of the stone, it follows, that a diseased change and swelling of the prostate, purulent catarrh, great sensibility and contraction of the bladder, render lithotrity quite impossible, or considerably increase its danger. Although lithotrity was formerly considered inapplicable to children, and numerous experiments by Civiale, Amussat, Leroy, and others have proved its practicability in little children; yet, however, the result of lithotomy at this age is so favourable, and the employment of lithotrity so difficult, that lithotomy should undoubtedly be preferred. In advanced age, on the contrary, the results of lithotomy are far more unfavourable than those of lithotrity. (How does the author reconcile this with his statement, that an enlarged prostate contra-indicates lithotrity?) In females, the less difficulty in the introduction of instruments is compensated by the difficulty of keeping the bladder distended; but lithotrity, although lithotomy in woman is much more rarely fatal than in man, has this great advantage, that no incontinence of urine remains after it, an infirmity the importance of which in woman cannot be too seriously thought of. It must finally be remembered that, for very stout persons, who are always the most unfavourable subjects for lithotomy, lithotrity is far less dangerous. "If now, after the consideration, founded on experience, of the advantages and disadvantages of lithotomy and lithotrity, the particular cases in which the one or the other practice is specially indicated, be reviewed, it follows that lithotrity appears preferable-1, in small stones, or those of no great size; 2, where there are two or several little stones; 3, in stones of moderate size, and when they can be easily broken, and if in all these cases the bladder be healthy, or only in a trivial degree affected. These indications are important, when such cases occur in old persons, in females, or in very stout people. On the other hand, lithotomy is decidedly to be preferred; 1, in childhood; 2, with large and hard, and especially mulberry stones; 3, when there are several large stones; 4, when large stones entirely fill, or are completely locked in by a contracted and unextensible bladder; 5, in diseased prostate, or great affection of the bladder; 6, in very great sensibility of the bladder, so that the patient can bear neither its distension, nor the motion of the instruments; 7, with stones of which the nucleus, as for example, when it is a bullet or the like, cannot be destroyed by the lithotriptor. It is also not to be overlooked that, in the general employment of lithotrity, the patient should be subjected to it early, by which its results are more certain, and its use will become more easy and general. On the other hand, however, it must not be unnoticed, that under directly the same circumstances which are favourable for crushing, does cutting for the stone, if performed with ability, lose much of its danger. Vol. II., p. 623—5. After detailing the opinions entertained by some of our best surgeons favorable to lithotrity, Mr. South goes on to say: "I do not propose to offer any opinion of my own as to the preference which should be awarded to lithotrity or lithotomy, as I have had little practical experience in regard to the former, and am therefore not qualified to give one. But I may be permitted to say that the results of the practice of lithotomy, both with gorget and knife, and by various operators on patients of all ages and under various circumstances, during the course of a long series of years at our hospital, have been so favourable, as to afford little cause for making it give place to lithotrity. I think it is proved that lithotomy, when properly conducted, is not the dangerous operation it is too commonly held to be; and it is no trifling advantage it possesses, that the patient is relieved at once, with a few minutes' suf C C * fering, sharp indeed it must be acknowleged to be, instead of being subjected to several operations, which the more frequent in their repetition, become, as generally admitted, greater in severity, and occasionally leave the necessity for resorting to the cure by lithotomy. I may here also add the testimony of some patients who have undergone both operations, that the suffering during lithotomy was less than in lithotrity, and that knowing both, they would, if needful, prefer undergoing the former. It is well, however, that we have the opportunity of employing lithotrity in cases where patients are too fearful to submit to the knife; but I am by no means sure that, under all circumstances, lithotomy is not at least as free from danger as lithotrity, and certainly more speedy as regards cure." P. 629. A tolerably strong opinion this for one who professes his inability to offer any; and one which we will venture to say will not receive general assent. Although the operations at St. Thomas's may have proved as successful as stated, and we have heard of individual operators, both in this and other countries boasting of their never, or hardly ever, losing a case; yet the untoward events which attend lithotomy are of too frequent occurrence to be disposed of in this way. So too the few minutes sharp suffering, here so quietly spoken of, is too often prolonged, and that sometimes under the best hands, to a far more protracted period of intense agony. Mr. South limits his preference to the operation to examples of it " properly conducted;" but it is but just to mete out a similar restriction to the rival proceedure, which most certainly could never have embraced the cases he alludes to. Nor do we see how this is ever to be the case if suitable instruction be not given to the students of our hospitals in the use of lithotripic instruments-the more dashing results of lithotomy even yet almost exclusively occupying their attention. It seems to us certain enough that if we were restricted to the one operation, lithotomy would necessarily be the one preferred, as embracing many cases lithotrity is not competent to cope with but, enabled as we now are to adapt each procedure to appropriate cases, it is surely but reasonable to select the least painful and least formidable one for such as satisfactorily admit of its being put into force. The grounds of the selection may yet occasion some difference of opinion; and we certainly cannot agree with Chelius, who prefers lithotrity in the aged, or with other surgeons who employ it in the cases of children. Perhaps the greatest benefit which lithotrity has conferred is the inducement it offers for patients to submit and surgeons to undertake the curative treatment of stone-cases at a far earlier stage of the case than was formerly the practice-thereby preventing much of that secondary disease of the urinary organs which rendered the results of operations more doubtful and the recurrence of the disease more probable. Mr. South furnishes us with a table of the 295 operations performed at St. Thomas's Hospital from 1800 to 1846; and a second table containing the dates and results of most of those which have occurred since 1822: the table being compiled from various sources and yet confessedly very imperfect, owing to the disgraceful negligence which has prevailed, until quite a recent period, at this and our other hospitals in the keeping minute and accurate records of the cases treated within their walls. It is singular enough to find one of the surgeons of that hospital now acknowledging the assistance he has derived from the "Lancet," in rescuing several of these from oblivion. With all its early faults, who can doubt the great |