4 covery of the principle, but of the means by which it has been carried into practice. Envious men and rivals have endeavoured from time to time to attack the validity of this report; but if two of the most distinguished surgeons in France, totally disinterested, and having all the documents &c. at their command, arrived at a certain conclusion, I cannot see why others, deprived of the means of judging, should presume to overthrow it. structed in 1800, for the purpose of crushing cal culi. 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 M. Civiale, then, is to be regarded as the dis- account of his crushing forceps, to which I have coverer of lithotrity. I shall insist no further on already alluded. The first crushing instrument this point, nor on the different modifications which of any value-that is to say, one in which the his instruments have undergone; for although blades are placed one over the other, and have a lithotrity as a system was originally established gliding movement forwards-was, as far as I can with straight instruments, and on the principle of ascertain, manufactured by Mr. Weiss in the perforation, the system now almost universally year 1824. It is essentially the same as the imadopted rests on curved instruments and the proved percussor of Heurteloup, with this differprinciple of crushing. ence only, that it acts by crushing with a screw instead of percussion. 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. Fig. 26. Fig. 27. I should perhaps have observed to you that M. Civiale always used more or less crushing when the calculus was perforated and reduced into fragments; 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 for crushing. Mr. Hodgson tried this instrument upon a patient in the Birmingham Hospital in 1825. In the same year also a French instrument-maker, named Retoré, invented a sliding instrument, a description of which M. Leroy.gave Fig. 28. Fig. 29 FIG. 26.-M. Civiale's improved instruments, (1824.) FIG. 27.-Mr. Weiss's original instrument, (1824.) 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 con FIG. 28.-Dr. Haygarth's instrument for crushing stone, (1825.) FIG. 29.-Retore's instrument for measuring the diameter of calculi, (1825.) in 1827. The branches are similar to those of Weiss and Haygarth, but it would seem that the female branch was drawn backwards on the male The instrumental portion of the crushing system unquestionably originated in England, for we do not find crushing as a 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. FIG. 30-Mr. Weiss's catheter-forceps. In 1831 Professor Jacobson, of Copenhagen, presented his articulated crushing instrument to the Institute; 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. FIG. 32.-Professor Jacobson's instruments, (1831. As for percussion, Baron Heurteloup is un questionably 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 affirming, that, without the essential modification which it subsequently received, it could never have held its place, and the system of percussion must have been abandoned as impracticable. Indeed, true crushing does not seem to take Here is a drawing taken from the original indate as a complete system until after the produc-strument made by Weiss, and which Baron Heurtetion of Baron Heurteloup's percussor in 1832. loup presented to the Westminster Society. It On employing that instrument, surgeons soon is composed of two side pieces, with a thin central perceived that it might be applied to crush the plate of steel, representing the male branch. The stone. Some, as M. Tonsay in France, modified side pieces are curved at their extremities, and it, so as to render it available for percussion or are united to the central piece by the pressure of crushing; while others, especially our English a few screws. Near the curve of the male piece surgeons, returning to the principle of Mr. Weiss, is a short longitudinal slit, through which a rivet abandoned the percussor, and substituted in its passes from side to side, and this is the only solid place, crushing, either by pressure with the hand point of junction. This rivet limits the movement alone, or with a screw, or fly-screw, &c. of the branches. From the section of the instruThe intuitive genius of Dupuytren was one of ment you will perceive that the side-pieces, which the first to seize the advantages of pressure. Soon represent the female branch, do not meet either after the appearance of Baron Heurteloup's per-above or below, but are separated by the thick ness 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, produced by the way in which the branches slide laterally, and by the lever action of the connecting rivet. BARON HEURTELOUP'S ORIGINAL INSTRUMENT FOR PERCUSSION. These fatal defects were soon corrected by Dr. Fig.39 FIG. 39.-Dr. Costello's modification of the original percussor. 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 obviat: such an occurrence this surgeon suggested the additon of a saw. Fig.40 FIG. 40.-Mr. Weiss's instrument for sawing stones in the bladder, (1825.) We now know that such fear is chimerical, though it was quite natural in 1824, for at this time the injection of the bladder with water, previous to operation, was not insisted upon; hence the fear of damaging the coats of the bladder. The French surgeons soon after this advised the injection of water prior to operating, since which this practice has been universally adopted. The principle of crushing by means of the screw, however, was rejected for the time; no trials were made on the living body, and it was not until 1832, when the use of Baron Heurteloup's percussor, water having been previously injected, had refuted the theory of "danger from explosion of fragments," that Mr. Weiss's principle began 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 cumbersome apparatus is never used at the present day, I must for history's sake say a few words about it. The drawing I now show you gives a good idea of all the main points of the bed, which is composed of M. Heurteloup calls his "fixed point," is a wedge a rectangular couch. On the upright rod, which 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 male branch shall take place. Anteriorly there are two pieces of wood, The female branch is a hollow catheter, with a having at their extremities two slippers for the slit of a triangular shape along the upper part; patient's feet. These can be lengthened or and the male branch is a solid catheter-shaped shortened at pleasure, to suit the height of the piece of steel, fitting exactly into the former, patient. In front there is a cross piece of wood, with all the points of which it is in contact, except very thick, uniting the two triangles together. In along the upper surface. Hence, from the solid this is seen a mortice for the small vice to play in, manner in which the two branches are united which holds the instrument during its action on while they slide, they admit of any degree of the stone. This bed can be lowered, if required, pressure being made, without danger of forcing to an angle of 45°, a strap being passed behind the joints or branches of the instrument. the neck and before the shoulders, and attached to a buckle on each side of the bed, so as to pre-justice to our Irish brethren, I cannot see on what vent the patient slipping off. this claim is founded. If Mr. L'Estrange's inEngland may, and you see, justly, claim the vention bears date from July, 1834, I have merely principal part in the crushing system. The oval to remark that the screw was employed by Weiss slit in the side or back of the female forceps, for in 1824, by Haygarth in 1825, again by Weiss the discharge of the detritus, was, I believe, in- in 1825, by Retoré in 1825, and by numerous vented by the late Mr. Oldham, a gentleman French surgeons in 1833. An English instruattached to the Bank of Ireland; while Mr. ment-maker on the Place de l'Ecole de Médecine, L'Estrange, of Dublin, claims the merit of having known as Sir Henry, (probably because he was a first applied a wire stilet, for the purpose of re- knight of the legion of honour,) had applied the moving the detritus. Mr. L'Estrange also claims screw for crushing long before 1834. It is but right, the honour of having been the first who applied however, to observe that the screw broke the blades, the principle of the screw as a means of crushing on the first trial made with it at the Hôtel Dieu, in calculi in the bladder: but with every desire to do 1828. FIG. 41.-Baron Heurteloup's bed. a. The percussor, fixed by a screw in explain to you in what cases lithotrity is to be 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 receive the detritus; the screw has been replaced by the rack and pinion: the latter furnished with a round handle, as in Charrière's instrument; or with a T-shaped one, as in the English, to give addi- Stone in the bladder, as you are fully aware, is tional force. To Mr. Fergusson we are indebted almost invariably attended by more or less severe for the application of the rack-and-pinion system, derangement of the genito-urinary organs or of which he introduced in 1834. It is unnecessary the general health. It is important, before profor me to notice all these improvements, as they ceeding to the operation, to remove these comhave been called, for almost every surgeon who plications as far as possible; and hence what has has occupied himself with lithotrity appears to been termed the preparatory treatment. I do have thought it incumbent on him to make some not now mean to say that you are to select your change in the apparatus-occasionally for the bet-patients in such a manner as to operate only on ter, often for the worse. 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 disorders as are likely to exercise any dangerous influence on the result of the operation. The instruments generally used at the present day for performing lithotrity are, the common screw one, the rack-and-pinion instrument described by Mr. Fergusson, and Charrière'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 41 VOL. II. 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 indicated; 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 eare, 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. |