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are not however agreed as to the propriety of bleeding in the cases in question. Some looking only to the loss of the elasticity of the brain, and the stupor resulting from it, consider bleeding injurious, and prefer the use of remedies calculated to relieve the brain from its torpid state. But experience has shown that when the injury has not been severe enough to destroy entirely the functions of the brain, and to cause sudden death, there is no further danger except from extravasation of blood, inflammation and suppuration. Now bleeding is the best remedy to prevent these consequences. The number of bleedings, the quantity to be drawn, and the part from which it is to be taken, must be determined by the ability of the patient to bear them, his strength and temperament.'
In the same chapter, Boyer says, emetics are sometimes useful but generally dangerous remedies. He advises purgatives, warm drinks, even cordials, when the stupor continues and the weakness is very great.'
The difficulty of treating these cases properly, arises from the uncertainty of the diagnosis. In simple stupor of the brain, exciting remedies are indicated; in extravasation they are injurious. The indications are clear when the nature of the case can be ascertained-the obscurity is in the symptoms by which the condition of the brain is manifested.'—Boyer Traité des Maladies Chirurgicales. Vol. 4th."
In the first place we may remark that these observations of Boyer's apply to injuries of the head. They do not refer to cases of shock in general. What weight they may have must therefore be materially diminished in the case of simple shock.
Dr. Stevens remarks:
"I have seen many recoveries from a state of extreme prostration where either nothing was done except leaving the patient quiet, or where rest was combined with stimulating remedies; and having carefully compared the result of this treatment with that of an opposite character, I confidently recommend it to you in all cases of injury attended with great prostration, except internal hemorrhages; as in the head from apoplexy or injury, and in any of the cavities of the chest or abdomen from wounds. In these cases it is better to incur the dangers of extreme depression of the powers of life, while a clot is forming at the mouths of the bleeding vessels, than to re-excite the bleeding by giving force to the action of the heart and arteries. These remarks are especially applicable to gun-shot wounds of the lungs."
It appears to us that nothing can be more absurd than to bleed a man furiously again and again, merely because he has been knocked down or run over. Yet in a case of severe shock, particularly in injuries of the head, the consequent reaction is so likely to be severe, that a moderate abstraction of blood is not objectionable in theory, nor, we think, in practice. We say a moderate abstraction of blood, for we do consider that recommended by Boyer, decidedly immoderate.
In a slight case of concussion we have always found the do-nothing system answer very well. Quiet, cold lotions to the head, and purgatives, have answered very well in most cases. But in severe concussion, if the symptoms do not yield, those of compression or inflammatory action must be apprehended, and depletion ought to be resorted to.
Dr. Stevens notices particular symptoms. We shall insert his observations on a few.
Jactitation. This occurs in various degrees as a symptom of fever of two forms: First, the fever with strong, full pulse, moderately accelerated. Second, with a very rapid thrilling pulse, easily compressed. Bleeding is applicable to the former state; the latter demands the application of cold to the head, tepid ablutions to the extremities, opium and extreme quiet of mind and body. But the sort of jactitation more immediately under consideration, occurs in connexion with coldness of the surface, a lustreless eye, and disturbed sensorium; this is a common effect of hemorrhage. Warm stimulants, external heat, sinap
isms to the epigastrium, together with mechanical confinement in a draft of cool air, and frequent sponging of the face with cold water, are here indicated. When the skin has become hot, sponging with cold water, or spirits and water, or ice to the head is also useful. In many instances, confinement by bandages, pressure upon the knees so as to keep the legs extended, and at rest, will induce sleep; even the weight of a pillow in slight cases is attended with benefit. Of the internal remedies more particularly indicated by this symptom, opium and camphor stand in the foremost rank.
Vomiting in the Intemperate.-" Sometimes vomiting or retching occurs in those habituated to spirituous liquors, from withholding the accustomed stimulus: here the customary dram is required. In all cases where it continues after the stomach is emptied, it should be met by sinapisms to the epigastrium, or to the whole abdomen, applied hot, and not so strong as not to be tolerated for two or three hours. If the surgeon be not attentive and rigid in the enforcement of the proper administration of remedies, vomiting will be reinduced by an undue quantity of stimulants, or of the vehicles in which they are administered. On this point it is difficult to fix upon doses and quantities that will not require great variation in particular cases. Yet as a medium dose that can be administered in any case, I would state about two quarts in twenty-four hours and of brandy half a pint; carbonate of ammonia one dram; the vehicle two quarts. As regards the intervals of exhibiting these remedies, once in fifteen minutes is sufficiently often for the worst period, and the quantity half an ounce. After the patient has rallied, he will be more benefited by giving larger quantities at longer intervals, and permitting him to sleep. Alternations of nourishment and sleep, are Nature's best restoratives. If you have a very careful and intelligent assistant at the bedside, the patient may be suffered to sleep until the pulse begins to flag; but after injuries, as in low fevers, patients may sleep away their strength, and relapse into coma and prostration, for want of due stimulation. The timidity of nurses not unfrequently leaves patients to sink for want of stimulus, when in fact they are able to swallow. The surgeon placing himself at the patient's right side, should gently elevate his head with the left hand, and rubbing the half-filled spoon against the lower lip of the patient, endeavour to arouse him by a decided exhortation to swallow; and at the first indication of consciousness he should pour the liquid on the back part of the tongue, and wait a few moments to see if it is swallowed, which he will know by seeing the larynx to be slightly elevated. If this does not take place, these efforts should be repeated, and the patient be again exhorted to swallow. If the attempt does not succeed, the liquid should be permitted to run out of the mouth, otherwise it may produce strangulation."
Stimulants ought not generally to be given long after a rigor has set in.—When a person, says Dr. Stevens, has been travelling with the thermometer at zero, and approaches the bar-room fire, he shakes and trembles, and feels cold, although he may have been comfortable on the road. The rigor is the harbinger of returning warmth. If he sits by a hot fire and takes stimulants, brandy in lieu of warm tea, a feverish condition of the system is induced. It is in this way that colds are taken. Therefore, we should be careful, lest the operation of the stimulants be carried into the state of excitement, and cause undue rapidity of circulation, and undue determinations of blood to particular organs. The serous tissues of the head, the mucous membranes of the alimentary canal, and of the lungs, are most often the seat of such local determinations.
Another bad effect of giving too much stimulus is, that vomiting is excited. "Ah, Doctor," said a shrewd bye-stander, when a medical man attempted to bleed, and the blood would not flow, "nature knows more than the physician." So she does, also, when she rejects by vomiting, the excessive doses to which the stomach is often subjected.
A third evil consequence of excessive stimulation is, that it exhausts the ex
citability and leaves the patient in a state of depression very difficult to manage. To stop with the stimulants is difficult; to go on with them impossible. The giving of powerful stimulants, is like borrowing money at high interest; it may do in a special emergency, but if long continued, it is sure to be followed by loss of excitability, which is the capital by which life is supported. This lecture contains many excellent observations.
NEW YORK HOSPITAL.
LECTURES ON LITHOTOMY, DELIVERED AT THE NEW YORK HOSPITAL, December, 1837. By ALEX. H. STEVENS, M.D. Surgeon of the New York Hospital, and Emeritus Professor of Clinical Surgery. 8vo. Stitched, pp. 93. New York, 1838.
We shall extract a few passages from this Lecture. Dr. Stevens appears to be a zealous and an able surgeon.
1. On the Causes of Death from Lithotomy.
After quoting the observation of Dupuytren, that "about three-fifths die of inflammation; the most frequent seat of which is the bladder, the cellular tissue of the pelvis, the rectum, the peritonæum, the kidneys, the lungs, the pleura, or the liver."
"About one fourth die of hemorrhage, or the means used to arrest it; of the rest some perish from accidental or concomitant diseases: as verminous affections, measles, convulsions, small-pox, disorders of the digestive system, rheumatism, catarrhs, &c."-Dr. Stevens adds:
"Without sufficient personal experience to offer an opinion on these most interesting and important statistical statements, I would yet remark that too little stress appears to me to be laid upon those complications of affections of the kidneys, which are found upon dissection to co-exist with stone in the bladder, and render operations improper and fatal; and secondly, that no mention is made of those nervous symptoms, the sinking and prostration, from which it is not unusual for patients to perish; and finally, nothing is said of phlebitis, or of diffuse inflammation, depending either upon infection, or a disordered state of the constitution."
We quite agree with Dr. Stevens in the preceding observations. We are sure that the state of the kidneys is insufficiently ascertained or weighed, previously to the performance of the operation of lithotomy.
Dr. Stevens goes on to remark that, in post-mortem examinations we find, according to Dupuytren, the neck of the bladder, and the left half of the prostate gland, freely and smoothly divided by the cutting instrument as far as the cellular tissue which surrounds the bas fond, and the lateral portions of the bladder; and we see inflammation of this tissue spreading to all the soft parts within the pelvis, the rectum, and the peritonæum. In other cases the neck of the bladder and the left half of the prostate are found scarcely divided by the incision, but exhibiting a wound of which the lips are contused, torn, stretched, and the surface soft and gangrenous. In this case, also, the inflammation extends into the pelvis, to the rectum, and to the peritoneum; but from different causes.
The bladder itself may become inflamed by being pinched, stretched, bruised, or lacerated with the forceps. This instrument, passed between the bladder and rectum, may seize the stone between the coats of the bladder; or the posterior wall alone of the bladder may be embraced by the instrument.
The cellular tissue of the rectum may become inflamed from the violence done to it; or its mucous membrane may be inflamed by the contact of urine arising from an opening through the gut.
Estimate of the principal Instruments employed.—Speaking of the various instruments in common use, Dr. Stevens observes :
"In the lateral operation, the preference of one or other of these instruments is more or less a matter of taste, about which no one should dispute. But as regards the bistouri cachè of Frêre Côme, I consider it a dangerous instrument; liable to wound the fundus of the bladder, and by no means necessarily making, in the withdrawal of it, the definite incision claimed as one of its advantages. The incision must be larger or smaller, not only according to the graduation of the instrument, but according as it is withdrawn straight, or pushed to one side or the other; or as its handle is elevated or depressed. The knife of Langenbeck, and the straight staff of Mr. Key, appear to me very awkward instruments : after one trial of each of them, I fully resolved not to employ either of them again. The blunt bistoury seems to me a very convenient instrument; but considering that the incision of the prostate is to be made with one sweep of the knife, it must happen that this incision is more or less extensive than the operator may desire, according as that gland is harder or softer, or larger or smaller. The desideratum is to make an incision of a definite extent; this object is not precisely attained by the bistoury.”
Dr. Stevens refers to the observations of Mr. Stanley on the subject. They are, like all the remarks of that gentleman, judicious.
An exclusive preference is not to be given to the gorget, or to the knife for the incision of the prostate. With either instrument, skilfully used, the operation may be well done. With a gorget, properly constructed, there is no risk of wounding the internal pudic artery or the rectum, because the limits of the incision are determined by the dimension and form of the instrument. With a knife in an experienced hand, there is not so much certainty of confining the incision within its proper limits.
A comparison of the gorget with the knife, so far as instituted, is favourable to the former; but to the narrow-bladed and beaked knife, first used by Mr. Blizard, an advantage belongs, which a gorget, from the width of its blade, cannot possess. The knife enters the bladder, as Mr. Blizard was accustomed to remark, as easily as a probe. The gorget, on the other hand, must meet resistance in passing through the prostate; very much less, however, will this resistance be, than it has been usually represented, when the gorget has been properly made, and it is guided with skill.
For the young subject, or for a thin adult, the knife is especially suited. It is also to be preferred for any case in which the bladder is closely contracted upon the stone. But for a very fat, or for an old subject, in whom, by the enlargement of the prostate, or the dilatation of the rectum, the bladder is raised much above its natural situation, the gorget is better adapted, on account of the great distance from the perineum, at which the prostate and neck of the bladder are in such instance situated.
We must say that we think a good gorget not so bad an instrument as it is now generally represented to be. One great advantage attending it, is the obliquity of its handle, in reference to its blade. When the scalpel is introduced into the groove of the staff, a clumsy manœuvre is requisite to accommodate the operator's hand to the subsequent stage of the incision.
Best Method of Performing the Operation.-Dr. Stevens revives, but he believes, improves the Celsian operation. The form of incision is much the same as that of the "cutting on the gripe," but it is the staff, not the gripe that he cuts on.
He offers to the profession a new instrument for the bi-lateral section of the prostate; in form it resembles a large olive, with a beak at the extremity, with cutting edges at the sides, parallel to its longest axis, and with a straight handle. The instrument, of which there are three sizes, and the manner of employing it, will be readily understood by the annexed engravings. The grooved staff employed in connexion with this instrument, is as wide as the urethra will
admit, and the groove gradually terminates as it approaches the end of the staff. The advantages in the use of this instrument are, first, that the circular form of a transverse section, gives an opening through the gland of three diameters instead of two, as when a flat instrument is employed; thus it is not necessary to carry the incision so far laterally to obtain an opening of given dimensions; and hence there is less likelihood of hemorrhage from injuring the plexus of vessels that surrounds the prostate.
Second. The prostate is cut horizontally, and though not absolutely, yet for all practical purposes in its greatest diameter.
Third. The rectum is pushed back by by the convexity of the posterior part of the instrument.
Fourth. As the prostate is stretched transversely across the instrument, the section is made by a clean cut, and with so little resistance that the instrument does not, like ordinary gorgets, require to be thrust in with force, but may be passed lightly along until the section is completed. Thus there is less danger of wounding the fundus of the bladder by a sudden cessation of resistance from the parts divided; they are, in fact, divided without force.
Fifth. The easy division of the prostate obviates the danger of tearing the cellular tissue which connects the anterior surface of the bladder to the posterior wall of the ossa pubis.
Mode of Operating." The following is the method I have adopted, and the one I would recommend for performing the operation.
Let the patient be secured in the usual manner, but with the pelvis rather higher than the trunk, on a firm flat table, with only two or three thicknesses of blanket under him. The rectum should have been previously emptied by a dose of oil given on the night preceding the operation, and the urine should be retained for a short time previous. The patient secured, let the assistant who is to hold the staff be placed on the patient's left, and a second assistant on his right, to support the rectum with a cloth, in case of prolapsus. The staff is then to be introduced. If you are quite certain of the existence of a stone, I would advise you not to delay the operation because you do not feel it when the patient is on the table; and much less would I advise you to ask all the assistant surgeons to satisfy themselves of the presence of the calculus. During these painful and protracted manoeuvres, the urine is often discharged, and you lose the advantage of its presence in the bladder. Let only one of the assistants sound, and in doing so press the urethra against the groove of the staff to prevent the escape of urine. Exhort your patient not to strain; and while you are encouraging him with the hope of speedy relief, mark with your eye, but more especially by feeling with your finger, the exact situation of the two tuberosities of the ischia; the divergence of these two bones, the lower border of the triangular ligament, and the bulb of the urethra. The bulb is situated directly at the lower border of the ligaments, which to pretty firm pressure will impart a greater degree of resistance than the parts between it and the anus. In a deep pelvis and with enlarged prostate, you may expect to find a deep perinæum, and should be prepared to find the bladder more than usually out of reach. Plan for yourself an incision of a crescentic shape, posterior to the bulb, but near it-nearest it when the pouch of the rectum, as in old men, is much enlarged, and in those whose pelvis is naturally narrow at the inferior strait. Let its convex side be next the bulb, its horns between the anus and the tuberosities of the ischia, not below the centre of the anus, for here are the hemorrhoidal vessels; not within a quarter of an inch of the ischia, for by approaching the bone too closely, the incision might reach the internal pudic artery. Now, covering the anus with three fingers of the left hand, press the rectum backward and tighten the skin of the perinæum. As a general rule, make your incision one inch and a quarter anterior to the anus, and in length about one inch and three quarters, with slight convexity forwards. When the incision through the skin is completed, pass the fingers of