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tem. A blow on the epigastrium will produce death; contusion of any of the viscera may do the same, and if not immediately, almost invariably at a subsequent period. Why then should we feel surprised that tugging at the bladder and lacerating its coats, with its many tissues, its organic and animal sympathies, its large hypogastric plexus, should likewise prove a cause of speedy destruction? Secondly, contusion and laceration of the bladder and contiguous cellular membrane may occasion diffuse cellular inflammation, with its sequelæ, abscesses or sloughing, or depôts in other parts. Thirdly, the same conditions may ensue from infiltration of urine. Such are the effects, not hypothetical, but real, melancholy, practical effects of laceration. Those of too free an incision, are-infiltration of urine, and, we believe, diffuse inflammation of the cellular tissue independent of urinary effusion. Besides these, we are inclined to conceive, from cases which we have witnessed, that a circumscribed abscess in the deep cellular membrane of the pelvis is another consequence of too free an incision, though it may probably arise without it. The observations of our author on this head are so sensible, so consistent with the conclusions of practical surgeons that we feel regret at being unable, from want of space, to give insertion to them. We refer our readers to the work itself, and this we do more readily, as we have pointed out in a few words the real dangers, the roads and shoals in the way of the lithotomist.
"It would be difficult to say geometrically how long the incision may be made without danger; and I certainly have not the presumption to draw precisely the line, on one side of which is safety, and on the other death; but, I am convinced from meditation on the anatomical facts connected with this subject, and from the painful experience of seeing many die, that the danger of a wound in the prostate is in the direct ratio of its extent, and that an incision necessary for the extraction of a stone measuring an inch and a half in its two lesser diameters, puts life in imminent peril.
Of the two evils-the use of force, or a long incision-there can be no doubt which is the minor; since the latter subjects the patient to only one serious danger, whilst by the former he is exposed to many fatal consequences." 119.
The fact is that no incision into the bladder, be it ever so inconsiderable, is free from the risk of cellular inflammation. Wherever there is loose cellular tissue, the most trifling wound of it will, under circumstances which we cannot well determine, and in some individuals, give rise to that inflammatory effusion which runs like wild-fire through the tissue, killing it, or occasioning secondary inflammations and deposites elsewhere. Yet this danger is incalculably increased by contusion, or too extensive incision. Several highly interesting cases are detailed by Dr. King: we shall notice two or three.
Case 1. (3.) "Protot François, aged 22 years, of a good constitution and sanguiferous temperament, had been subject to derangement in the urinary apparatus for fifteen years, and had frequently passed small calculi by the urethra. On the 15th of April, 1822, he entered the Hotel-Dieu, complaining of the usual symptoms of stone in the bladder; he suffered intensely in voiding his urine, which contained no blood, but a great deal of mucus. A spare diet and baths were ordered. On the 12th the patient was sounded and the stone recognised. On the 15th, the operation was performed according to the plan of Frére Cosme or (méthode lateralisée.) Incisions were first made through the soft parts of the perinæum up to the membranous portion of the urethra; this canal was then
opened to admit the sheathed knife, which was passed into the bladder, opened, and then withdrawn unsheathed, so as to divide the prostate to the extent of a little more than an inch. The stone which appeared to be very large, was extracted with great difficulty; after several attempts to remove it, which lasted eight or ten minutes, its external layers at length gave way and were crushed; it was then withdrawn without further violence. As several of the fragments escaped from the forceps, a few minutes were occupied in clearing and washing out the bladder.
The patient was carefully put to bed, and an antispasmodic tisane was ordered. He passed the day tolerably well, although he seemed much depressed; towards evening some uneasiness was felt at the lower part of the abdomen; it seemed however, to be occasioned by the passage of gaz in the intestines. On the 17th, there came on vomiting with increasing uneasiness in the abdomen. Forty leeches were applied to the abdomen, and diluent drinks given plentifully. There was some abatement in the symptoms in the night, but no distinct remission. On the 18th, twenty more leeches were applied to the abdomen, and twenty to the perinæum. The patient was also placed in a bath. On the 19th the vomiting had disappeared, but the features were much changed; the pulse was wiry, the skin hot and dry, the tongue somewhat parched. More leeches, purgatives, baths and fomentations were had recourse to, but without effect: the patient died on the 21st.
Necropsy. The parts in the vicinity of the wound, were macerated in a brown purulent fluid. The whole of the cellular tissue of the pelvis was infiltrated with thick pus; this infiltration extended into the lumbar regions and filled the iliac fossæ.
The peritonæum presented, to the extent corresponding to the suppuration beneath it, abundant pseudo-membranous productions uniting the small intestines to one another and to the bladder. The other parts of the body were healthy; the tissue of the kidneys seemed, however, to contain a little more black blood than usual." 127.
Here it is obvious that the mischief was primarily and essentially in the cellular tissue, and that the peritoneum was secondarily affected. The period at which the symptoms superveued, and their character, are deserving of attention.
"Some time ago, Baron Dupuytren, deeply impressed with the difficulty and danger of extracting a large stone, and imagining that they might be partially obviated by an incision occupying the whole breadth of the perinæum, revived and improved the operation of Celsus. In this method the prostate is divided by a semilunar incision, or almost horizontally, on a level with its junction with the urethra; therefore, the incision extends very near, if it does not interest the margin of the gland, where its capsule splits and becomes continuous with the different layers of the fascia of the pelvis. One of the evils belonging to this plan is, of course, the facility with which the urine makes its way between these layers; and as the consequences are precisely those which are observed when, in the lateral operation, the incision is made too horizontally, I shall insert one or two cases to illustrate this point, and farther to exemplify what has been stated generally respecting the effects of lithotomy when the stone is large. First, however, it may be right to remark here, that a still greater objection to the horizontal method is the impossibility of withdrawing the stone in the direction we have so much insisted upon, as the only one offering any chance of safety." 129.
Two cases in which the Baron performed this operation are related by Dr. King. We shall take the second, not only because it is the shortest, but because it comprises several circumstances worthy of attention.
Case 2 (5.) Ternisien Victor, æt. 22, admitted into the Hôtel Dieu, March 12th, 1825.
"He declared, that from his infancy he had experienced pain and difficulty in voiding his urine, although, during certain intervals, the symptoms had been intermittent. He had been sounded in 1815, when a stone was recognized in the bladder but as the symptoms were not very urgent, no curative means were then employed.
On the 12th of March, the patient's sufferings were truly distressing; the most acute pains returned at very short intervals; the fæces were involuntarily excreted by the violent contraction of the abdominal and perinæal muscles, which took place to expel the urine whenever the fluid was accumulated in the quantity of two or three ounces; and all the usual symptoms of stone existed, to an intense degree. Being of rather a plethoric habit, he was prepared by purgatives and a spare and regular diet, till the 29th, when the operation was performed by the horizontal method.
The stone which, as was afterwards seen, was equal in size to a large walnut and of a globular form, could not be extracted without considerable force exercised amidst the patient's shrieks, and the violent convulsive contraction of his abdominal muscles.
As little blood had been lost during the operation, the patient was bled shortly after it a large, soft, hot poultice was applied to the abdomen and an antispasmodic mixture administered. Notwithstanding these means, he passed a restless night, and in the morning of the 30th another bleeding was performed. After this he seemed better, but on the 2nd of April, he complained of uneasiness in the gluteal region: his pulse was frequent, the skin hot. April 3rd, fifteen leeches were applied to the painful part. April 5th. Shivering and increase of fever, with great restlessness. (Seven leeches; Mixture containing an ounce of the Syrup. Papaver.)
The following days, the same symptoms prevailed, although the urine flowed freely from the wound and leeches were applied in abundance.
The 10th instant. It was ascertained that pus had formed in the cellular tissue of the left gluteal region; and a large opening was made which gave issue to a great quantity of it, of a fetid nature, and mixed with gas. The countenance was anxious and dejected, the pulse soft but rapid, the tongue white, the skin covered with copious perspiration. A little soup was now allowed. The 11th and 12th instant. The symptoms became alarming; the small pulse, dry tongue and general depression indicated a fatal issue. A little claret was administered, but on the 13th the patient expired.
Post-mortem Examination, Thirty-six hours after Death. The skin of the whole of the posterior region of the trunk had a livid aspect, and under it, communicating with an opening in the left gluteal region, the cellular tissue was every where infiltrated by a layer of thick, concrete, yellowish pus. The latissimus dorsi and gluteus maximus of the left side were equally drenched in pus, which extended under them as far as the pyriformis, but no farther. The kidneys were rather pale, but healthy; the right and its ureter were a little larger than those of the left side.
The bladder was contracted and empty; its mucous membrane had rather a brown aspect, and appeared somewhat thickened. Its prostatic portion presented a horizontal opening, the lips of which appeared evidently contused. The soft parts of the perinæum were divided by a semilunar incision half an inch before the anterior wall of the rectum. Some of the lymphatic glands in the pelvis were in a state of suppuration; there was also some pus in the cellular tissue between the muscles of the upper part of the right thigh.
The brain and its membranes were in the state usually observed after death by similar causes; there was a good deal of serum, infiltrated as it were, in the substance of the pia mater. The organs of circulation and digestion were healthy. No. XXXIII, D
The anterior border of the right lung presented a circumscribed abscess one inch in diameter; this appeared to me to be a true vomica. In no part of the body could a tubercle be found." 141.
In cases related in the foregoing manner, abbreviation, at least useful abbreviation, is impossible. They are already abbreviated to the utmost degree, consistent with the preservation of features of importance. The preceding is an instance of the purulent deposites in the cellular membrane and in the lung, following the operation of lithotomy. One point appears to merit notice. M. Dupuytren performed the Celsian operation, or a modification of it, that is, he made a semilunar incision between the rectum and urethra, in order to gain space for the extraction of the stone. Now we are told that the latter was equal in size to a large walnut, and that considerable force was exerted in effecting its extraction. We do not hesitate to say, that a stone of this bulk could have been extracted without the employment of more violence by the lateral operation. It appears to us that it is not in the external incision, or in the wound between the integuments and the bladder, that space is required. It is the opening into the bladder itself that is insufficient for the safe removal of a large stone. It may be said that, by the Celsian operation, we divide both sides of the prostate, and so gain room. The fact is, that both sides of the prostate may be divided, independently of the Celsian operation, by a broad-shouldered, double-edged knife or gorget, with a beak inclined at an angle to the plane surface of the blade. By the Celsian operation we are liable to wound both ejaculatory ducts; nay, it is not impossible that the urethra might be severed from the bladder. These are objections; and the foregoing case is sufficient, of itself, to prove that the freedom with which a large stone can be removed by it is ideal.
The next subject adverted to by Dr. King is hæmorrhage, an important one. This is usually furnished by the perinæal artery, or the artery of the bulb, occasionally, as in the case of the late Mr. Shaw, by irregular branches which no knowledge can anticipate-no dexterity avoid. Dr. King observes, and we think well, that profuse and dangerous hæmorrhage may be furnished by small deep-seated vessels about the neck of the bladder. There is a plexus of veins in this situation, and we have good reason for thinking that, in advanced age, when the vital contractility of the bloodvessels is diminished, and the natural means of arresting hæmorrhage inefficient, bleeding to a dangerous amount may occur from this source. We also agree with Dr. King that the best, because the least injurious, means of stopping this bleeding, is pressure by the finger of an assistant. This is irksome enough, God knows; but the life of the patient is at stake.
"At the Hotel Dieu, plugging to arrest hemorrhage after perinæal lithotomy, is performed thus :-a kind of linen purse, five or six inches in length, which the French call shemise, a straight metallic tube or catheter not quite so long, of three eighths of an inch diameter, and a certain quantity of lint for stuffing (bourdonnets de charpie) are necessary for the purpose. The purse is fixed tight round the canula in a notch at about three quarters of an inch from that end of it which is to be passed into the bladder, and open at the opposite extremity. By this contrivance the canula is placed in the centre of the bag, and protrudes through it at one end. The Surgeon, after anointing the exterior of the linen with cerate, passes the canula with the purse drawn close upon it through the wound into the bladder, his left index serving as a conductor; he then introduces
the bullets of lint into the bag, one by one, with a common dressing-forceps, pressing them down with sufficient force to stop the bleeding. Pressure is thus exercised between the lips of the wound, in their whole extent, and the canula which secures an issue to the urine, and which is fixed by means of two rings it presents to a T bandage adjusted to the patient." 145.
Hæmorrhage after lithotomy is a great evil on several accounts. Independent of the immediate risk from loss of blood, and subsequent exhaustion or reaction, we believe that the pressure and the plugging of the wound increase in a very material degree the hazard of the formation of matter or of diffuse inflammation in the cellular tissue of the pelvis. It is certain that in two instances which we have lately seen, of abscess in the cellular texture of the pelvis after this operation, hæmorrhage occurred, and required long and tedious pressure to restrain it, much exposure of the parts and much disturbance of them. A fatal case of hæmorrhage is related by Dr. King. The symptoms in that case are so perfectly analogous to those which we have witnessed in cases of internal suppuration, that we cannot but suspect the existence of such, although Dr. King declares that none was discovered on the examination after death.
LITHOTOMY BY THE RECTUM.
We know how this operation has been lauded in modern times. Bellinghieri, we think, in Italy, has been said to have met with we know not what success, but something almost surpassing belief. M. Sanson, at the Hôtel Dieu, has also been said to be very successful. It is fortunate that Dr. King has had an opportunity of seeing many of M. Sanson's and M. Breschet's cases, and can therefore tell us what he saw. We shall find that his remarks are not calculated to encourage English surgeons to adopt this operation.
"Recto-vesical fistula and infiltration of urine render it dangerous, and the former attends it in so consequent a manner, that it is as disastrous, if not so immediately dangerous, as the lateral method. Those who have watched cases in which this plan was adopted must allow that it leaves a fistula as an almost certain consequence of the operation. The incision will not close; it appears that its lower part constituted by the anterior wall of the rectum, is kept open by the passage of the fæces and irregular motions of the sphincter, and its upper by the flowing of the urine; there is no support for granulations: the cicatrix has nothing to build upon.
This result is so constant, that the recto-vesical section must be viewed rather as the substitution of one disease for another, than as the means of restoring health; and it then becomes a question whether the one substituted, is of such inconsiderable inconvenience as to warrant its introduction into practice? If this kind of fistula only amounted to an inconvenient and temporary deformity, the project might be entertained; but, unfortunately it is of a very serious nature, and depending as it does entirely upon the physical disposition of the parts concerned, is almost always beyond the reach of art. In general it is not immediately destructive, but it seldom persists long without impairing even the most robust and vigorous constitution. The continual contact of the urine produces inflammation in the mucous membrane, which, as it creeps along the intestine, occasions great disturbance; giving rise to diarrhoea, which cannot be subdued, since the cause cannot be removed, and which, although the patient may resist it for months, or even years, finally exhausts him, either by its own