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CLINICAL LECTURE.
341
the same evening, suc- are two fractured ribs, a contusion ceeded in checking its -prbgress. of the thigh, and a case of rash His pulse got up to 100, and his from surfeit produced by oysters,
lancet, in
skin became very hot. About 10, which was removed by bleeding P.M. he was visited by the dresser, and purgatives. No operations of consequence and-bled to 3xiv. The pills -which he had taken in the.morning ope- have been performed here this. week. rated frequently. Has had 1st. a restless Sept. night, but does not complain of CLINICAL LECTURE. much pain in the head. His pulse furred. I is 80. Tongue Ordered, intend, Gentlemen, to-day, hydr. submur. gr. -ij. pulv. opii (said Mr. TYRRELL,) to make gr.½ nocte maneque; ; mist. ef some observations on stone, and to describe the different operations ferv. p. r. in. 2nd. Pu!se, this morning, 76, usually performed for its removal. and soft; slept several hours, and And first I shall mention, The symptoms of Stone in the the sleep refreshing ; skin cool; continues the former medicine, and Bladder.-These are somewhat the cold application to the head. similar to the symptoms of other 3rd. The wound was examined, complaints of the bladder, and, two of the adhesive straps were therefore, it is necessary distinctly removed, and the lower part of the to enumerate them. There is a wound had united ; a broad strap frequent desire to void the -urine, of plaster put across the middle of and, while doing so, the stream is it. A good discharge of pus from suddenly stopped ; there is great the upper part. Pulse 74, and pain felt near the extremity of the skin cool. Omitte cal. et opium. penis ; and the usual seat of the Persistat in usu misturce effer- pain is just opposite the frenum, ’Vescentis. extending down the urethra to the 4th. On the evening of this perinaeum. This pain is more se;day, the pulse :got up to 78, and veTe after the emptying of the ’were full. He complained, also, bladder, from the mucous mem’of some pain in the head, and the brane collapsing about the stone. ’8kin was hot; was bled to the ex- Sometimes the pain is very much tent of 5xij, after which he passed increased by walking or riding; ’a quiet night, and felt quite re- and sometimes there is a disposition to pass the -feces at the same Jieved on the following morning. 6th. Pulse 70; skin cool, and time with the urine. In children, sleeps well; has no pain in the there is a remarkable elongation of part, and the wound looks very the prepuce, from their nipping it healthy. He continues the use of between the finger and thumb, the cold application, and takes which is found very much to inf. rosce c. mag. sulph. 5j. ter deaden the pain. The urine is die. The case is proceeding very also bloody, and sometimes there favourably; and we shall give the are small coagula of blood passed result of the present treatment in a with it. In the more advanced future number. stage of the disease, it becomes The accidents received this week loaded with mucous and flaky
342
The number of stones varies very much: in the majority of cases eased there is the In a brane. only one; but as many as sounding patient, sound should be passed- in the 100 have been found in a patient. same way and with the same care When there are many present, as you would pass it in stricture, their surfaces are generally smooth, and which I explained in my lec- from friction. The surface of a ture on retention of urine. (Vide stone has been found smooth, even No. 8, Vol. iv.) This may be when there - has been but that one done very easily, except in cases in the bladder; but generally the of diseased prostate, -and in old surface of a stone is rough. The composition of stone is vapersons having stone, in whom the In Here are some sections of rious. prostate is generally enlarged. these cases,you have to introduce the stones, which have been analysed finger into the-rectum, and lift the by my friend Mr. Dorsler (passpoint of the sound over the en- ing them to the class). These are larged gland. Sometimes you composed of lithic acid, fusible cannot detect the stone on intro- calculus ; others having lithic acid ducingthe sound, although you for nuclei, surrounded by a demay feel the stone distinctly at posit of the triple phosphate. For other times, as was the case with a full account of the analysis of a boy on whom I lately operated. the different species of calculi, I I sounded him when he first came should advise you to consult Dr. into the Hospital, and was per- MARCET’S work. If a patient applies to you with satisfied of the existence, of a stone ; but I sounded him five or stone, and will not consent to have six times afterwards, and could not the operation performed; you must detect the stone ; and I found that relieve him as well as you can; this was owing to his voiding his and, for this purpose, the means ;urine whenever-he saw me coming. recommended- for the relief of irriTherefore, whenever you snspect table bladder will-be most likely to the existence of stone, and you are succeed, as opiates, the warm about to sound the patient, he bath, and the exhibition of alkalis should have retained his water for or acids, which you may know how to prescribe by testing the urine some little time previously. I believe stones found in the with litmus paper.’ -bladder either descend from the Although a patient may have kidnies, or are indebted to some stone in the bladder, there are many objections to the operation foreign matter getting into bladder for their formation ; this which it is very important to conmatter serving as a nucleus, on sider. He may have a diseased which the calculous precipitation state of the kidney; the mucous is deposited. A coagulum of blood membrane may be diseased; the has been found, sufficient for this prostate may be enlarged and irripurpose ; and numerous instances table; there may be a great dishave occurred in whichpieces of order of the. general health; and bougies, tobacco-pipes, and even the state of mind of the patient needles, have been found as the should also be very much attended nuclei of the stones. to ; and this will apply equally to
matter; and this indicates state
of the
a
dis-
mucous mem-
fectly
the
343
all operations of importance. ;I It is very easy, if symptoms should have -seen many operations per- afterwards arise, to use blood-letformed in this Hospital, whilst the ting, and you thus avoid the danpatients have been labouring under ger of the patient’s losing too much. .feelings -of the greatest anxiety ; I It is an important point in old perand I have observed that very few sons previously to make an accurate of them did well. As to the suf- examination by the rectum ; for if ferings of the patient from the dis- the lateral lobes only are much eneaseitself, it is rather favourable to larged, and not the other parts of his safety than otherwise; as, for the gland, that enlargement would example, his complaining of great form no material objection to the pain after voiding his urine, unac- operation, because the stone might companied by any disease of the be extracted without much diffikidnies. culty. The patient’s bowels having When you have made up your been freely emptied, and having mind to perform the operation, been kept on a low diet, the general the patient should be well prepared health being good, and having exfor it; and I believe that the cause amined the state of the prostate by of our success at this Hospital de- the rectum, I should proceed to the pends mainly on this circumstance, operation. and the care that is taken in the The mode of securing the paafter-treatment. They are all put tient previous to the operation.(as you are aware) under the ma- This is a point of great importance, nagement of one Sister, who has and I shall, therefore, now speak of been many years in the house, and the application of the bandage. who was for a long time with ano- The bandage used at this hospital, ther female, who had the care of is a broad worsted tape; a noose is first made, which is passed over such patients for many years. The plan which I usually adopt the wrist, and pulled tight, the ends is, to give the patient an opiate, if are then brought down the palm of he is irritable,’taliing care to keep the hand, and the patient is dithe bowels open, and the morning rected to lay hold of the sole of his previous to ’the operation empty foot: the tapes are then crossed It over the foot, and carried alterthe rectum by an injection. has been recommended to irritate nately round the ancle and hand, the patient by frequent sounding, so that it is impossible for him to but I- oppose this practice ; and it draw the one from the other; and has also been advised to bleed the the tape is lastly carried over the person previous to the operation, shoulder, and fastened to the tape but I object to this; because, if the coming from the opposite side. The - man should lose much blood during next material point is to have the the operation, the effect which this patient firmly held in this position, hemorrhage would produce on the with his shoulder and back raised, system, aided by the previous and the thighs widely separated, so bleeding, would be that of lowering as to bring the external incision and the constitution too much, and you the opening into the bladder into. as would not -have such an attempt straight a line as possible : by attentowards a healthy restoration of tion to which circumstances you the injured parts as is necessary. may convey any instrument into
344 rea-arch of the pubes,-and continue it downwards and outwards to oppodiness. The staff should be now intro-site the middle of the anus, between duced,’or if you are not much iniit and the tuberosity of the ischium. the habit of introducing the staff,, Ifyou begin your incision above the or seeing it frequently done, youplace I have mentioned, it cannot may introduce it before the patientt be of any service to you in extractis bandaged. It is, however, justing the stone. I next make an inas well done after as before, by at-cision into the groove of the staff, tending to the rules which I haveas near as possible to its medium before mentioned. line, because I think the danger of ’There has been lately introduced hemorrhage from the transverse ara straight staff, (but I always usetery of the perinaeum or any other the cu-rved staff,) and I will men- artery is less in proportion to the tion some of my objections to it. Indistance you are from its origin; as the first place, there is great diffi- soon as I have laid open the ureculty in introducing it’ in the en- thra, and carried the knife into the larged state of the prostate gland ; groove, I introduce the nail of the you would not be able to detect the fore-finger of my left hand, and sasituation of the stone so well with.. tisfy myself that the knife is proit; and, in the after steps of the perly within the groove, although operation, there is a further objec- you may feel pretty confident of it, tion to it, which I shall describe by the sensation produced in rubbing the knife in the staff; then presently. I shall now explain the operation, incline the edge of the knifealittle as I usually perform it, and after- outwards, and carry it on nearly to wards point out the other plans the prostate gland, then I carry it which are adopted. The instru- down deeply into the perinaeum, in ments are, a grooved staff, a dou- the direction of the first incision, to ble-edged scalpel, a straight nar- divide the deep muscles there as I row knife, with a probe point, and withdraw the knife. 1 then lay a forceps. The staff is first intro- aside the scalpel, and take the long duced, and it should well fill the straight knife, used by Sir ASTLEY urethra, the larger the staff is, the CooPmt, in my right hand; and better, as you have the advantage take hold of the staff firmly with of a deeper groove. The staff is my left, introduce the beak fairly then firmly held by an assistant, within the groove, and keep it and the bulb is made to project a well against the staff, and carry it very little toward the left side. I onwards, following the curve of the now take the double-edged scalpel, staff, into the bladder. The knife make an incision through the in- having entered the bladder, I give teguments and fascia of the peri- the staff to an assistant to hold steanæum on the left side of the raphe, dily in the same position, and inthe it troduce at my finger on the surface of commencing point just beneath the lower edge of the sym- the rectum, under the point of the physis, at the place where the ure- knife, which I can then feel in the thra begins to - curve under the bladder, and divide the prostate as I withdraw the knife in the di* This is Mr. KEY’S instrument. rection of the former incision, let-
’the bladder with the greatest
345
ting its probe point press on my this operation-(these were placed finger, which is at this time protect- on the table and shown to the class.) This knife was used by Sir ASTLEY ing the rectum from injury. the a where when I was an apprentice with him, I on If operate child, I introduce and he has told me that he has been is shallow, perinaeum the and feel as successful with it as any other into bladder, my finger
the stone, and then withdraw the instrument which he has used, but and introduce the forceps on you know he is fond of variety, and the finger: But if the perinaeum therefore has used many others. It is deep, I introduce the forceps is the knife which I always employ. with the blades a little open, and Here is another knife, the only blade one the of difference between this and the groove glide along the staff, and it very readily finds former, is, that the beak is placed a its way into the bladder, and let it little on one side of the point, rest firmly on the stone, which you whereas in the other, it is placed then grasp, by deliberately opening directly in the middle line of the the blades of the forceps, and point. It is called BLIzARD’s knife. .cautiously withdraw it. Points of importance to be atAs far as regards the operation tended to in the operation, are,- the by the gorget, the division of the position of the patient, a steady deep muscles, and the first incision, assistant to hold the staff, for if the are exactly the same as in the opeperson be nervous, his hand shakes, ration for the knife. The gorget and you have great difficulty to find used in this Hospital, is what is the opening you have made into the called Mr. CLINE’S gorget ; a little urethra, or in introducing the point alteration was made in it by Sir of the knife, or the beak of the gor- AsTLEY; he advised the cutting get. When you make your incision edge at the shoulder to be removed. Another form of gorget is that through the urethra into the groove, carry the incision onwards to as used by Mr. MARTINEAU, of Nornear the prostate as you can, espe- wich, who, I believe, has been the cially when the gorget is to be used, most successful operator for stone you introduce the gorget as near the in this country. The gorget which prostate as possible, and carry it he uses has two edges, but these onwards in the way I have described edges are blunt, so that, when he when operating with the knife, pushes it through the prostate, he and make a free division of the rather tears it asunder than cuts it. neck of . the bladder through the This, I believe, generally happens prostate; as it is better to havee even when the cutting gorget is an opening of sufficient size to allow employed, and is a great objection the stone to be extracted with to its use, as it does not allow of readiness, and the section of a your getting out a large’stone without quarter or even of half of an inch considerable violence. The gorget of the gland more than might ap- should be passed exactly in the same pear at first to be absolutely neces- direction as you would pass the sary is not of such great conse- knife, inclining- its edge a little quence. obliquely downwards in the line of I will now show you the different the first incision ; and keep the instruments which are used for point up so as to bear well against
staff,
346
There is an important objection. tire staff as you carry it onwards. And it is of the greatest importancethat strikes me to the use of a knife that the staff skould be held forci- which is pointed,* which is, that bly against the pubes. In the ope- the urinepasses by its side, while ration, as it is performed by the the instrument is in the staff, and gorget, you have not the same op- you may go farther with it than portunity of introducing your finger- you.might wish; but.you cannot do to : feel the stone as in the knife so with a probe-pointed knife; for, when such knife ’is within the operation. Here is another form of the knife, bladder, you could not go beyond used by the French, it is called the it without very great violence.’ bistouri cache ; it is a slender knife When your knife is slender, also; which is fixed, within a steel case, there is little danger of doing any and you regulate the extent, which injury to the neighbouring strucyou may wish the knife to reach by tures, and you use the finger to proa.screw in the handle. After you tect the deeper. parts, have introduced the knife, you touch 1 Deneve tms (Sir A. L’. s first a spring at the end, which imme- described) to be- the best shaped diately throws the blade out to the knife you can employ;and next to extent you had before set it, and it is, I consider, the bistouri caehe. then divide the prostate as you I have operated with it in nine withdraw it. It is, on the whole, cases, and all of them have done I think. a srood instrument. well. One of the cases was even What induces me principally to very unfavourable, for the patient prefer the use of the knife to any. was 70 years of age, with a-great other instrument, was the frequent enlargement of the- prostate, and opportunities which I had at Brus- the stone was very, large. My, sels, after the battle of Waterloo, reasons, then, for using this instruof operating on the dead sub- ment are, that I do not go farther: jects. I used- all- the instruments with it than I intended ;that it is which are generally recommended, introduced with facility ; that it and afterwards examined, by dis- makes a clean section of the gland;. section, the division which I had and that you regulate the-extent of made of the parts. I found that its course with precision. the wound made in. the perinæum operation may be performed was not so large in diameter as the with the str-aight staff, as.well as instrument- which had been intro- any other, in -cases where the periduced, owing to the elasticity of næum is shallow, as in- children; the structure of the part; and I but in persons more advanced in was so satisfied of the superiority of life you would not find the sme the knife to every other instrument, to apply. In the first place;, when both in expedition and safety,. that you commence the operation, the I determined to adopt it in, any staff is- held firmly up against the operations which I might, in after- symphysis- pubes; and, in adults, its extremity must certainly, very life, have to perform. There, is great violence neces- much depress the prostate; and if sary to be used in the introduction of the gorget, but not so with, the This is the case with Mr. KEY’S ,
The
knife,
knife.
’
347
enlargement of the should occur after the operation,, must it separate that part do not try to stop it by forcing up a gland, from the neck of the bladder. Then, plug of lint into the wound, but put when you have made your first in- your finger over the vessel for about cision, you have to depress the ten or fifteen minutes, and the handle of the staff, and bring the bleeding will stop ; but if you plug scrotum and penis into a right line up the external wound, the blood with the perinæum, and, I think, in will find its way into the bladder, the way of the operator. Nearly and the patient die. I have seen all operators, and C ii E- a case of this kind, therefore I wish used the curved SELDEN, staff, to put you on your guard. I think, and he does not describe any diffi- in all operations of importance, culty in introducing it: because it where there is a difference of opihas been said, in favour of the nion, the surgeon should ask himstraight one, that it is easier to in- self how he would have the operatroduce. But I believe the curved tion performed, provided he had staff affords every facility which to submit to it himself. can be gained during the operaMr. T. concluded by announction, and-is more out of the way of ing, that he should describe the
there be any
especially
the operator,
independently ’of the operation for stone in the female in ’
much greater ease with which it his next lecture. may be introduced in cases of en-
larged-prostate.
MIDDLESEX HOSPITAL. The after-treatment of the patient consists merely in keeping him perfectly quiet ; the knees -Continuation of the case of’ should be tied together and raised, Martha Hollizvell. and the scrotum should also be Sept. 8th. To this case, which supported, and the patient kept on has been recorded in most of the his back. The diet should be low, volumes of our journal,* we have and opiates should be given ifne- at present but little addition to cessary. Apply fomentations, im- make, and that happily by the way mediately after the operation, to of conclusion. Such unfavourable the belly, and continue them several symptoms as presented themselves days. This is done, in these Hos- a- few days subsequent to the operapitals, by applying a bag of heated tion were gradually mitigated, and chamomile flowers, with a little soon entirely removed. At present spirit sprinkled over it, and which her general health is tolerably good, is generally productive of great and her appetite is equal to a percomfort to the patient. We do not son’s in perfect health; her nights make any application to the peri- are comfortable, and her dayss nseum after the operation, but now spent agreeably. The stump looks and then a bit of lint dipped in oil. i remarkably well; the lower edges The urine is received on sponges, of the flap are now consolidated the parts kept constantly clear ; by healthy granulations, and the and in about six days the urine is * Admitted Dec. 8th. The case discharged by the natural outlet. be found in Vol. i. pp. 380, 411, may 438. It generally happens in from five to Vol. ii. pp. 27, 68, 102, 193, 263, 264. If any hemorrhage Vol. iv. pp. 121 and 285. seven days. ’
the same evening, suc- are two fractured ribs, a contusion ceeded in checking its -prbgress. of the thigh, and a case of rash His pulse got up to 100, and his from surfeit produced by oysters,
lancet, in
skin became very hot. About 10, which was removed by bleeding P.M. he was visited by the dresser, and purgatives. No operations of consequence and-bled to 3xiv. The pills -which he had taken in the.morning ope- have been performed here this. week. rated frequently. Has had 1st. a restless Sept. night, but does not complain of CLINICAL LECTURE. much pain in the head. His pulse furred. I is 80. Tongue Ordered, intend, Gentlemen, to-day, hydr. submur. gr. -ij. pulv. opii (said Mr. TYRRELL,) to make gr.½ nocte maneque; ; mist. ef some observations on stone, and to describe the different operations ferv. p. r. in. 2nd. Pu!se, this morning, 76, usually performed for its removal. and soft; slept several hours, and And first I shall mention, The symptoms of Stone in the the sleep refreshing ; skin cool; continues the former medicine, and Bladder.-These are somewhat the cold application to the head. similar to the symptoms of other 3rd. The wound was examined, complaints of the bladder, and, two of the adhesive straps were therefore, it is necessary distinctly removed, and the lower part of the to enumerate them. There is a wound had united ; a broad strap frequent desire to void the -urine, of plaster put across the middle of and, while doing so, the stream is it. A good discharge of pus from suddenly stopped ; there is great the upper part. Pulse 74, and pain felt near the extremity of the skin cool. Omitte cal. et opium. penis ; and the usual seat of the Persistat in usu misturce effer- pain is just opposite the frenum, ’Vescentis. extending down the urethra to the 4th. On the evening of this perinaeum. This pain is more se;day, the pulse :got up to 78, and veTe after the emptying of the ’were full. He complained, also, bladder, from the mucous mem’of some pain in the head, and the brane collapsing about the stone. ’8kin was hot; was bled to the ex- Sometimes the pain is very much tent of 5xij, after which he passed increased by walking or riding; ’a quiet night, and felt quite re- and sometimes there is a disposition to pass the -feces at the same Jieved on the following morning. 6th. Pulse 70; skin cool, and time with the urine. In children, sleeps well; has no pain in the there is a remarkable elongation of part, and the wound looks very the prepuce, from their nipping it healthy. He continues the use of between the finger and thumb, the cold application, and takes which is found very much to inf. rosce c. mag. sulph. 5j. ter deaden the pain. The urine is die. The case is proceeding very also bloody, and sometimes there favourably; and we shall give the are small coagula of blood passed result of the present treatment in a with it. In the more advanced future number. stage of the disease, it becomes The accidents received this week loaded with mucous and flaky
342
The number of stones varies very much: in the majority of cases eased there is the In a brane. only one; but as many as sounding patient, sound should be passed- in the 100 have been found in a patient. same way and with the same care When there are many present, as you would pass it in stricture, their surfaces are generally smooth, and which I explained in my lec- from friction. The surface of a ture on retention of urine. (Vide stone has been found smooth, even No. 8, Vol. iv.) This may be when there - has been but that one done very easily, except in cases in the bladder; but generally the of diseased prostate, -and in old surface of a stone is rough. The composition of stone is vapersons having stone, in whom the In Here are some sections of rious. prostate is generally enlarged. these cases,you have to introduce the stones, which have been analysed finger into the-rectum, and lift the by my friend Mr. Dorsler (passpoint of the sound over the en- ing them to the class). These are larged gland. Sometimes you composed of lithic acid, fusible cannot detect the stone on intro- calculus ; others having lithic acid ducingthe sound, although you for nuclei, surrounded by a demay feel the stone distinctly at posit of the triple phosphate. For other times, as was the case with a full account of the analysis of a boy on whom I lately operated. the different species of calculi, I I sounded him when he first came should advise you to consult Dr. into the Hospital, and was per- MARCET’S work. If a patient applies to you with satisfied of the existence, of a stone ; but I sounded him five or stone, and will not consent to have six times afterwards, and could not the operation performed; you must detect the stone ; and I found that relieve him as well as you can; this was owing to his voiding his and, for this purpose, the means ;urine whenever-he saw me coming. recommended- for the relief of irriTherefore, whenever you snspect table bladder will-be most likely to the existence of stone, and you are succeed, as opiates, the warm about to sound the patient, he bath, and the exhibition of alkalis should have retained his water for or acids, which you may know how to prescribe by testing the urine some little time previously. I believe stones found in the with litmus paper.’ -bladder either descend from the Although a patient may have kidnies, or are indebted to some stone in the bladder, there are many objections to the operation foreign matter getting into bladder for their formation ; this which it is very important to conmatter serving as a nucleus, on sider. He may have a diseased which the calculous precipitation state of the kidney; the mucous is deposited. A coagulum of blood membrane may be diseased; the has been found, sufficient for this prostate may be enlarged and irripurpose ; and numerous instances table; there may be a great dishave occurred in whichpieces of order of the. general health; and bougies, tobacco-pipes, and even the state of mind of the patient needles, have been found as the should also be very much attended nuclei of the stones. to ; and this will apply equally to
matter; and this indicates state
of the
a
dis-
mucous mem-
fectly
the
343
all operations of importance. ;I It is very easy, if symptoms should have -seen many operations per- afterwards arise, to use blood-letformed in this Hospital, whilst the ting, and you thus avoid the danpatients have been labouring under ger of the patient’s losing too much. .feelings -of the greatest anxiety ; I It is an important point in old perand I have observed that very few sons previously to make an accurate of them did well. As to the suf- examination by the rectum ; for if ferings of the patient from the dis- the lateral lobes only are much eneaseitself, it is rather favourable to larged, and not the other parts of his safety than otherwise; as, for the gland, that enlargement would example, his complaining of great form no material objection to the pain after voiding his urine, unac- operation, because the stone might companied by any disease of the be extracted without much diffikidnies. culty. The patient’s bowels having When you have made up your been freely emptied, and having mind to perform the operation, been kept on a low diet, the general the patient should be well prepared health being good, and having exfor it; and I believe that the cause amined the state of the prostate by of our success at this Hospital de- the rectum, I should proceed to the pends mainly on this circumstance, operation. and the care that is taken in the The mode of securing the paafter-treatment. They are all put tient previous to the operation.(as you are aware) under the ma- This is a point of great importance, nagement of one Sister, who has and I shall, therefore, now speak of been many years in the house, and the application of the bandage. who was for a long time with ano- The bandage used at this hospital, ther female, who had the care of is a broad worsted tape; a noose is first made, which is passed over such patients for many years. The plan which I usually adopt the wrist, and pulled tight, the ends is, to give the patient an opiate, if are then brought down the palm of he is irritable,’taliing care to keep the hand, and the patient is dithe bowels open, and the morning rected to lay hold of the sole of his previous to ’the operation empty foot: the tapes are then crossed It over the foot, and carried alterthe rectum by an injection. has been recommended to irritate nately round the ancle and hand, the patient by frequent sounding, so that it is impossible for him to but I- oppose this practice ; and it draw the one from the other; and has also been advised to bleed the the tape is lastly carried over the person previous to the operation, shoulder, and fastened to the tape but I object to this; because, if the coming from the opposite side. The - man should lose much blood during next material point is to have the the operation, the effect which this patient firmly held in this position, hemorrhage would produce on the with his shoulder and back raised, system, aided by the previous and the thighs widely separated, so bleeding, would be that of lowering as to bring the external incision and the constitution too much, and you the opening into the bladder into. as would not -have such an attempt straight a line as possible : by attentowards a healthy restoration of tion to which circumstances you the injured parts as is necessary. may convey any instrument into
344 rea-arch of the pubes,-and continue it downwards and outwards to oppodiness. The staff should be now intro-site the middle of the anus, between duced,’or if you are not much iniit and the tuberosity of the ischium. the habit of introducing the staff,, Ifyou begin your incision above the or seeing it frequently done, youplace I have mentioned, it cannot may introduce it before the patientt be of any service to you in extractis bandaged. It is, however, justing the stone. I next make an inas well done after as before, by at-cision into the groove of the staff, tending to the rules which I haveas near as possible to its medium before mentioned. line, because I think the danger of ’There has been lately introduced hemorrhage from the transverse ara straight staff, (but I always usetery of the perinaeum or any other the cu-rved staff,) and I will men- artery is less in proportion to the tion some of my objections to it. Indistance you are from its origin; as the first place, there is great diffi- soon as I have laid open the ureculty in introducing it’ in the en- thra, and carried the knife into the larged state of the prostate gland ; groove, I introduce the nail of the you would not be able to detect the fore-finger of my left hand, and sasituation of the stone so well with.. tisfy myself that the knife is proit; and, in the after steps of the perly within the groove, although operation, there is a further objec- you may feel pretty confident of it, tion to it, which I shall describe by the sensation produced in rubbing the knife in the staff; then presently. I shall now explain the operation, incline the edge of the knifealittle as I usually perform it, and after- outwards, and carry it on nearly to wards point out the other plans the prostate gland, then I carry it which are adopted. The instru- down deeply into the perinaeum, in ments are, a grooved staff, a dou- the direction of the first incision, to ble-edged scalpel, a straight nar- divide the deep muscles there as I row knife, with a probe point, and withdraw the knife. 1 then lay a forceps. The staff is first intro- aside the scalpel, and take the long duced, and it should well fill the straight knife, used by Sir ASTLEY urethra, the larger the staff is, the CooPmt, in my right hand; and better, as you have the advantage take hold of the staff firmly with of a deeper groove. The staff is my left, introduce the beak fairly then firmly held by an assistant, within the groove, and keep it and the bulb is made to project a well against the staff, and carry it very little toward the left side. I onwards, following the curve of the now take the double-edged scalpel, staff, into the bladder. The knife make an incision through the in- having entered the bladder, I give teguments and fascia of the peri- the staff to an assistant to hold steanæum on the left side of the raphe, dily in the same position, and inthe it troduce at my finger on the surface of commencing point just beneath the lower edge of the sym- the rectum, under the point of the physis, at the place where the ure- knife, which I can then feel in the thra begins to - curve under the bladder, and divide the prostate as I withdraw the knife in the di* This is Mr. KEY’S instrument. rection of the former incision, let-
’the bladder with the greatest
345
ting its probe point press on my this operation-(these were placed finger, which is at this time protect- on the table and shown to the class.) This knife was used by Sir ASTLEY ing the rectum from injury. the a where when I was an apprentice with him, I on If operate child, I introduce and he has told me that he has been is shallow, perinaeum the and feel as successful with it as any other into bladder, my finger
the stone, and then withdraw the instrument which he has used, but and introduce the forceps on you know he is fond of variety, and the finger: But if the perinaeum therefore has used many others. It is deep, I introduce the forceps is the knife which I always employ. with the blades a little open, and Here is another knife, the only blade one the of difference between this and the groove glide along the staff, and it very readily finds former, is, that the beak is placed a its way into the bladder, and let it little on one side of the point, rest firmly on the stone, which you whereas in the other, it is placed then grasp, by deliberately opening directly in the middle line of the the blades of the forceps, and point. It is called BLIzARD’s knife. .cautiously withdraw it. Points of importance to be atAs far as regards the operation tended to in the operation, are,- the by the gorget, the division of the position of the patient, a steady deep muscles, and the first incision, assistant to hold the staff, for if the are exactly the same as in the opeperson be nervous, his hand shakes, ration for the knife. The gorget and you have great difficulty to find used in this Hospital, is what is the opening you have made into the called Mr. CLINE’S gorget ; a little urethra, or in introducing the point alteration was made in it by Sir of the knife, or the beak of the gor- AsTLEY; he advised the cutting get. When you make your incision edge at the shoulder to be removed. Another form of gorget is that through the urethra into the groove, carry the incision onwards to as used by Mr. MARTINEAU, of Nornear the prostate as you can, espe- wich, who, I believe, has been the cially when the gorget is to be used, most successful operator for stone you introduce the gorget as near the in this country. The gorget which prostate as possible, and carry it he uses has two edges, but these onwards in the way I have described edges are blunt, so that, when he when operating with the knife, pushes it through the prostate, he and make a free division of the rather tears it asunder than cuts it. neck of . the bladder through the This, I believe, generally happens prostate; as it is better to havee even when the cutting gorget is an opening of sufficient size to allow employed, and is a great objection the stone to be extracted with to its use, as it does not allow of readiness, and the section of a your getting out a large’stone without quarter or even of half of an inch considerable violence. The gorget of the gland more than might ap- should be passed exactly in the same pear at first to be absolutely neces- direction as you would pass the sary is not of such great conse- knife, inclining- its edge a little quence. obliquely downwards in the line of I will now show you the different the first incision ; and keep the instruments which are used for point up so as to bear well against
staff,
346
There is an important objection. tire staff as you carry it onwards. And it is of the greatest importancethat strikes me to the use of a knife that the staff skould be held forci- which is pointed,* which is, that bly against the pubes. In the ope- the urinepasses by its side, while ration, as it is performed by the the instrument is in the staff, and gorget, you have not the same op- you may go farther with it than portunity of introducing your finger- you.might wish; but.you cannot do to : feel the stone as in the knife so with a probe-pointed knife; for, when such knife ’is within the operation. Here is another form of the knife, bladder, you could not go beyond used by the French, it is called the it without very great violence.’ bistouri cache ; it is a slender knife When your knife is slender, also; which is fixed, within a steel case, there is little danger of doing any and you regulate the extent, which injury to the neighbouring strucyou may wish the knife to reach by tures, and you use the finger to proa.screw in the handle. After you tect the deeper. parts, have introduced the knife, you touch 1 Deneve tms (Sir A. L’. s first a spring at the end, which imme- described) to be- the best shaped diately throws the blade out to the knife you can employ;and next to extent you had before set it, and it is, I consider, the bistouri caehe. then divide the prostate as you I have operated with it in nine withdraw it. It is, on the whole, cases, and all of them have done I think. a srood instrument. well. One of the cases was even What induces me principally to very unfavourable, for the patient prefer the use of the knife to any. was 70 years of age, with a-great other instrument, was the frequent enlargement of the- prostate, and opportunities which I had at Brus- the stone was very, large. My, sels, after the battle of Waterloo, reasons, then, for using this instruof operating on the dead sub- ment are, that I do not go farther: jects. I used- all- the instruments with it than I intended ;that it is which are generally recommended, introduced with facility ; that it and afterwards examined, by dis- makes a clean section of the gland;. section, the division which I had and that you regulate the-extent of made of the parts. I found that its course with precision. the wound made in. the perinæum operation may be performed was not so large in diameter as the with the str-aight staff, as.well as instrument- which had been intro- any other, in -cases where the periduced, owing to the elasticity of næum is shallow, as in- children; the structure of the part; and I but in persons more advanced in was so satisfied of the superiority of life you would not find the sme the knife to every other instrument, to apply. In the first place;, when both in expedition and safety,. that you commence the operation, the I determined to adopt it in, any staff is- held firmly up against the operations which I might, in after- symphysis- pubes; and, in adults, its extremity must certainly, very life, have to perform. There, is great violence neces- much depress the prostate; and if sary to be used in the introduction of the gorget, but not so with, the This is the case with Mr. KEY’S ,
The
knife,
knife.
’
347
enlargement of the should occur after the operation,, must it separate that part do not try to stop it by forcing up a gland, from the neck of the bladder. Then, plug of lint into the wound, but put when you have made your first in- your finger over the vessel for about cision, you have to depress the ten or fifteen minutes, and the handle of the staff, and bring the bleeding will stop ; but if you plug scrotum and penis into a right line up the external wound, the blood with the perinæum, and, I think, in will find its way into the bladder, the way of the operator. Nearly and the patient die. I have seen all operators, and C ii E- a case of this kind, therefore I wish used the curved SELDEN, staff, to put you on your guard. I think, and he does not describe any diffi- in all operations of importance, culty in introducing it: because it where there is a difference of opihas been said, in favour of the nion, the surgeon should ask himstraight one, that it is easier to in- self how he would have the operatroduce. But I believe the curved tion performed, provided he had staff affords every facility which to submit to it himself. can be gained during the operaMr. T. concluded by announction, and-is more out of the way of ing, that he should describe the
there be any
especially
the operator,
independently ’of the operation for stone in the female in ’
much greater ease with which it his next lecture. may be introduced in cases of en-
larged-prostate.
MIDDLESEX HOSPITAL. The after-treatment of the patient consists merely in keeping him perfectly quiet ; the knees -Continuation of the case of’ should be tied together and raised, Martha Hollizvell. and the scrotum should also be Sept. 8th. To this case, which supported, and the patient kept on has been recorded in most of the his back. The diet should be low, volumes of our journal,* we have and opiates should be given ifne- at present but little addition to cessary. Apply fomentations, im- make, and that happily by the way mediately after the operation, to of conclusion. Such unfavourable the belly, and continue them several symptoms as presented themselves days. This is done, in these Hos- a- few days subsequent to the operapitals, by applying a bag of heated tion were gradually mitigated, and chamomile flowers, with a little soon entirely removed. At present spirit sprinkled over it, and which her general health is tolerably good, is generally productive of great and her appetite is equal to a percomfort to the patient. We do not son’s in perfect health; her nights make any application to the peri- are comfortable, and her dayss nseum after the operation, but now spent agreeably. The stump looks and then a bit of lint dipped in oil. i remarkably well; the lower edges The urine is received on sponges, of the flap are now consolidated the parts kept constantly clear ; by healthy granulations, and the and in about six days the urine is * Admitted Dec. 8th. The case discharged by the natural outlet. be found in Vol. i. pp. 380, 411, may 438. It generally happens in from five to Vol. ii. pp. 27, 68, 102, 193, 263, 264. If any hemorrhage Vol. iv. pp. 121 and 285. seven days. ’