494

intemperate habits, forty-six years of age. When admittedunder the care of Mr. Cock, the fragment in the bladder wasbelieved, from the piece bi oken away, to be about five inchesin length. The patient, except an attack of inflammation ofthe testis, has since gone on very well, and was dismissed curedthis week.

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ST. BARTHOLOMEW’S HOSPITAL.

RECTO-VESICAL ABSCESS; DIFFICULT CATHETERISM ; DEATH.

(Under the care of Mr. SKEY.)Mr. Cock recently directed the attention of his class to a

singular case, at Guy’s Hospital, where a large hydatid hadgrown between the rectum andbladder, exactly like a distendedbladder, and simulating in some measure the pain of calculus.A catheter was passed, but no urine flowed out ; it seemed asif the instrument had pierced or injured the parent hydatid, forseveral small hydatids passed out after the instrument waswithdrawn. We were strongly reminded of this case, by apatient recently under the care of Mr. Skey, where a large ab-scess in precisely the same situation as this hydatid had beenfollowed by very difficult catheterism and death. The disease,in Mr. Skey’s case, arose without any well-defined cause exceptunskilful catheterism before the patient came to the hospital.This poor man was admitted on October 15th, into St. Bartho-lomew’s, suffering from severe retention of urine ; he appearedin a state of partial insensibility, possibly from urasmic poison-ing ; he was evidently very ill. He had suffered from completeinability to pass urine, and had had previously very suspiciousrigours. A No. 10 catheter was found for some days to passeasily into the bladder, when it was followed by a flow ofurine and great temporary relief; at other times it passed inthe same way the whole length up to the end, but no urinecould be obtained, the instrument having evidently gone intosome other cavity. Blood sometimes flowed, mixed with

quantities of pus. It was too clear that we had here an abscessbetween the bladder and rectum. The poor man lingered fora fortnight, when he expired. Very extensive disease of thekidneys was found, and false passages in the prostatic urethra,behind the veru montanum, with an abscess in the situationalready indicated.

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UNIVERSITY COLLEGE HOSPITAL.

ALLARTON’S OPERATION: CALCULUS REMOVED BY SECTION INTHE MEDIAN LINE, AND DILATATION.

(Under the care of Mr. ERICHSEN.)

A YOUNG- MAN—a favourable subject for lithotrity, or for thenew operation by dilatation of the prostate and incision in themedian line brought recently into notice by Allarton-havingpresented himself this month at University College Hospital,Mr. Erichsen decided to give the patient the chance of thisimproved operative proceeding, in preference to either litho-trity or the lateral section. Amongst the more prominentadvantages of Allarton’s operation, it is said it results in a

perfect cure in a few days, while in lithotrity cases, and toooften also in common lithotomy, we need hardly remark, thecure is lengthened out to as many weeks or months; andamongst the artizan or working classes this is a matter of pri-mary importance. This man had lithotomy performed be-fore, for instance, and was ill with fistula for six monthsafter. The average rate of mortality amongst old and

young patients, from the lateral section, is something liketwenty per cent., if not higher; while the new method holdsout the gratifying prospect of reducing this terrifying evil to’one per cent. For these several reasons alone the young manwished for the new operation, which was accordingly per-formed last Wednesday week.Very marked differences of surgical opinion, we may remark,

,exist as to the originality or value of this operation. The ques-tion of originality is one of entirely secondary moment, andmay very well merge in that of the safety and value of thepatient’s life, and the avoidance of the " lateral section." In-deed, as any single idle objection always lessens the weight ofan objection better founded, it may be that the fault foundwith the proceeding of the Italian surgeons, De Borsa andManzoni-viz., that dilatation of the prostate is more danger-ous than incision, may be quite as groundless as that otherobjection, that the operation ought not to be undertaken be-cause it is not original, but the old Marian proceeding, appa-- ratu8 major, and some other things long since given up. It issaid of two great chemists, one of these our own Wollaston,,that they made all their discoveries by resolving to examine

nothing but the refuse materials of other chemists, long thrownaway as useless. We have now chloroform; we have also abetter knowledge of anatomy, better means of checking in-flammation, &c., than Marianus, in 1520; and all the tendencyof conversation in hospitals amongst the best surgeons leads toacknowledge the necessity of some surgical Wollaston, so to

speak, who would review all the old operations of Raw andothers, and give us something better than an operation whichallows one death in three cases in old patients. This Allartonhas tried to do.We recently directed attention to a modification of Allarton’s

operation, as practised by Mr. Lloyd, (THE LANCET, vol. i.1855, p. 512,) an operation also in the case of a young man, inwhich Mr. Lloyd intentionally divided the sphincter, butotherwise followed Allarton’s directions. That case, and someothers by the same surgeon, succeeded very well, at St. Bar-tholomew’s. The operation, as performed by Mr. Erichsen, onthe 14th inst., is perhaps tedious, and to those looking on nota little irksome; yet if the cure be so rapid as to be effected ina few days, and the average rate of mortality be anything likewhat is represented, we may soon disregard the tediousness,and hope to dispense with large cutting gorgets, and somethingnot unlike obstetric forceps, which we occasionally see thrustinto the bladder in the Chesclden proceeding, too often, it is tobe feared, lacerating the neck of the bladder and capsule ofthe prostate, or, as we have recently observed, unavoidablytearing through cervix, prostate, and rectum. It is quite trueand obvious that very large calculi could not be removed bythe dilatation process of Allarton, yet the very apprehensionof danger of the lateral operation, it is observed in the ope-rating-theatre, increases the danger, as patients put it offtill it becomes a last and fatal resource; whereas, if the rate ofmortality were changed from twenty per cent. to one per cent.,patients would be less fearful, and small stones would be foundas the rule in our operating-theatres, and not, as now, the ex-ceptions. The conscientious surgeon would also, as in litho-trity, teach his pupils to disregard the irksomeness of suchoperations in the satisfaction of saving his patient. We wouldadvise our winter students to try the operation for themselveson the dead body. The innovation, it must not be concealed,is one of very great seriousness, but there are few things webreak away from so reluctantly as old and venerable prejudices.

There was nothing unusual in the previous history of thecase operated on by Mr. Erichsen on the 14th instant, ex-

cept its being an instance of recurrent calculus. The pointswe have just lightly touched on were fairly and broadlystated to his class, with that anxiety for their improve-ment which always distinguishes the prelections and clinicalobservations of this surgeon. Experience alone can decide asto the value of the " dilatation" method. We have had ex-

perience on a large scale of the Cheselden operation; yet whenit is remembered that Raw had 3000 (!) cases by a lithotomyoperation not now understood, but a modification of the Marianmethod, and not one death, and then call to mind one death inthree, five, or seven, it must appear that there is ample roomfor improvement upon the operation by the "lateral section."The directions given by Mr. Allarton are so concise that we

are tempted to give them in his own words. " I introduce agrooved staff," he says, " of the usual size, and confide it to anassistant, with directions to keep it perpendicular and hookedup against the pubes; I then introduce the index finger of myleft hand into the rectum, placing its extremity in contactwith the staff, as it occupies the prostate, and press it firmlyagainst the staff so as to steady it; then, with a sharp-pointed,straight knife, with a tolerably long and rough handle, I piercethe perinaeum in the middle line, about half an inch above theanus, or at such a distance as may appear necessary to avoid.

dividing the fibres of the external sphincter. I carry the knifesteadily and firmly on till it strikes the groove of the staff, thedeep sphincter lying between the knife and the directing finger,which latter enables me to judge of the distance as the knifepasses along. Having struck the groove of the staff, I movethe point of the knife along the groove towards the bladder afew lines, and then withdraw it, cutting upwards, so as toleave an external incision of from three quarters of an inch toan inch and a half, according to the presumed size of the stone.The escape of urine indicates the entrance to the urethra. Ithen introduce a long, ball-pointed probe, or wire, through theexternal opening into the groove of the staff, and slide it intothe bladder, to sufficient depth to insure its safe lodgment inthat viscus, and withdraw the staff. I then well grease theindex finger of the left hand, and pass it along the probe, witha semi-rotatory motion, through the prostate into the bladder; .and whenthe stone is free it comes at once into contact with