- Email: [email protected]
Lectures ON LITHOTOMY AND LITHOTRITY.
JUNE
5, 1852.
quantity of phosphatic debris came away at
each introduction; the urine was alkaline. ON On the 26th, the bladder was very irritable. The patient obliged to introduce his catheter nearly every hour; LITHOTOMY AND LITHOTRITY. was the urine withdrawn contained mucus, clots of blood, and of the calculus. (Delivered at St. Mary’s Hospital.) On the 27th, the lithotrite was again introduced, and the By WILLIAM COULSON, ESQ., calculus crushed without any difficulty. This operation, howSURGEON TO THE HOSPITAL. ever, was soon followed by considerable local and constitutional disturbance. The pulse was now 120, the tongue very LECTURE I. brown and dry; there was great thirst, and he complained of pain GENTLEMEN,—Two cases which have recently been under and considerable swelling of the left knee-joint. The patient my care in this hospital afford me an opportunity of directing required the use of the catheter every half-hour, or oftener. your attention to one of the most important and interesting Diffusible stimuli, with opium, were administered at once, and subjects in the whole range of surgical science. I allude to the bladder was repeatedly washed out; but the patient began the various methods which have been devised for the relief or to sink, became rapidly worse, and expired on the 31st March. So vast a subject, gentlemen, His body was examined thirty hours after death. The cure of stone in the bladder. including such a number and variety of important points, pulmonary tissue was healthy, though gorged with dark blood. many of which are still matters of debate amongst the best The right pleura was universally adherent from old disease. surgeons, cannot be treated in anything like a satisfactory At the upper part of the pericardium, externally, and at the I therefore propose address- point where this membrane is covered by the pleura, there manner during a single lecture. ing to you a series of lectures on stone in the bladder, its was an encysted tumour, as large as a walnut, and containing treatment by the knife or by crushing instruments, and on brownish-green matter. Heart large and flabby; the right the indications, comparative advantages, and applicability of cavities filled with dark blood, staining the valves and lining lithotomy and lithotrity. The present lecture will be mainly membrane; the liver was soft, but otherwise healthy; the devoted to clinical remarks on one of the cases alluded to, kidneys presented externally a dark, mottled appearance, and may in some measure serve as a preface to those which and were considerably congested within. The other organs of the abdomen were healthy. The large veins were filled with are to follow. Two patients, as I observed, were recently under my care blood, and the lining membrane of both common and iliac for stone in the bladder. The one was young, the other old. veins was stained of a deep red colour. This staining extended In one I performed the operation of lithotomy : it lasted about into the external and internal iliac and femoral veins, but the walls of these vessels were not thickened. The external a minute, was unattended by the slightest accident; and the surface of the bladder presented a considerable degree of patient has recovered. In the other case, the patient was in his seventieth year: vascularity. It was contracted, and the muscular coat was the operation selected was lithotrity; the case to all appear- much thickened. It contained some small particles of the ances was not unfavourable; the operation of crushing the stone, but nearly the whole had come away. The mucous stone was effected without any difficulty; but on the day membrane was here and there coated with patches of phosafter the second sitting unfavourable symptoms set in, the man phatic deposit. No ulceration, breach of surface, or signs of began to sink, and died within a week from the first opera- !, inflammation, were discovered in any portion of the mucous tion. ’, membrane, but at one part a sacculated cavity, about the size The contrast between these two cases (and a similar one of a walnut, was observed, and this contained a quantity of will often present itself to you in practice) is striking. We very fœtid pus. There was a round projection at the orifice cannot avoid asking ourselves whence arose the difference in of the urethra, which also was coated with phosphates. The the results ? Why one patient died, while the other re- veins of the prostatic plexus were enlarged, thickened, and covered ? Why lithotomy was selected in the one instance, many of them filled with coagula. while lithotrity was employed in the other ? And these On opening the left knee-joint, some thin, chocolatequestions naturally lead to a consideration of two paramount coloured, purulent fluid escaped; the synovial membrane was points-viz. the indications which induce the surgeon to highly injected, and the articular cartilage covering the employ lithotomy in preference to lithotrity, or vice versâ; external condyle was softened and ulcerated in its centre, the and the different accidents which may supervene during or bone being laid bare at one point. The corresponding cartilaafter these operations, either retarding the cure, or involving ginous surface of the patella was superficially ulcerated. No the life of the patient. ulceration of the surface of the internal condyle or semilunar It would be impossible for me to comprise all that might cartilage could be discovered. On opening the right kneebe said on these points in a single lecture. I shall therefore joint, some pus escaped; the fluid was nearly healthy in at present dwell only on those which are most essential for appearance; the articular cartilages were ulcerated in the practice, and which bear on the case I am about to relate to same situation as on the left side, though in a less degree. The bone was not laid b re; the synovial membrane was highly you. The following is a short history of it :The patient, James F .was admitted into the hospital, injected. The head of the right femur was marked by fine under my care, on the 24th of March. He was seventy years red injection, and the synovial membrane round the neck of of age, yet appeared to have suffered little in his general the left femur was very vascular. The shoulder-joints appeared health, having principally complained, from time to time, of healthy. The examination did not extend further. There are many points in this case, gentlemen, worthy of heartburn. He had, however, laboured under an affection of the bladder for several years. The symptoms of stone were your attention; but I can only examine the most striking, and evident and characteristic, the principal being pain referred these are, the age of the patient, the nature of the calculus, to the region of the bladder, and brought on by any motion, the paralyzed state of the bladder, co-existing with hypersuch as that of riding in an omnibus; pain in the glans penis; trophy and contraction of this organ, the sacculus or cyst conhæmaturia, especially after walking; frequent and sudden taining pus, the enlarged prostate, and, lastly, the cause of desire to pass his urine, which, however, disturbed him little death, arising, as the post-mortem examination showed us, while lying down. For the last nine months he had experi- from what is called purulent absorption. enced a sensation of numbness down the thighs, and for ten On the symptoms of stone in the present case I need not years he had not been able to discharge his urine without the dwell: they offered nothing remarkable. The patient’s henlth aid of the catheter. The urine latterly was secreted in in- is stated not to have suffered much, though it is evident that creased quantities, and it contained a considerable proportion his disease had been of long duration. This is a circumstance of mucus, and some pus. which I have occasionally observed, and which has been The presence of a calculus in the bladder was readily de- noticed by all writers on diseases of the urinary organs. You tected in the usual manner. Though of large size, it was soft, should therefore remember that not only the constitutional and easily crushed between the blades of the lithotrite. On but the local signs of vesical calculus may be very slight, examining the fragments which came away, they were found or even so far absent as to lead the surgeon to overlook to consist of the triple phosphate, or ammoniaco-magnesian the existence of the disease altogether. I do not mention phosphate calculus. The patient was ordered to have twelve this as a means of affording you an excuse in certain cases, minims of Battley’s sedative three times a day, to allay any but to stimulate you to increased care and perseverance in irritation which might arise from the operation. the examination of all doubtful ones. On the 25th, the bladder had been emptied by the catheter Scarpa, Blanchard, Travers, and other writers mention cases seven or eight times since the operation. and a considerable in which the symptoms were so slight, that the nresence of a
Lectures
fragments
No. 1501.
534 calculus was never even suspected during life. Some time ago I saw a gentleman who had been sounded by an experienced surgeon, yet the latter was unable to say whether or not there was a stone in the bladder. The patient died sixteen months afterwards, and a calculus weighing four ounces and a half was discovered. The largest calculus in St. Bartholomew’s Hospital was taken from a patient who had been often sounded; and the museum of the College of Surgeons contains the bladder of a man who had committed suicide after long suffering from stone, though the late Mr. Abernethy and many other surgeons of the day had repeatedly sounded him, without having detected the presence of a calculus. In the case of F-, the local signs were evident, though, as I remarked, the constitutional disturbance never reached any considerable degree; and this is a point worthy of a moment’s attention, when we reflect, not only on the great duration of the disease, but on the nature of the calculus with which the patient was affected. It was the triple phosphate or ammoniaco-magnesian phosphate calculus. This concretion is formed by an admixture of the neutral phosphate of magnesia and ammonia with a bibasic phosphate. It might appear to you at first sight that the chemical nature of the calculus could exercise little influence on the operation performed for its extraction, or that a knowledge of its composition could be of little use beyond the domain of chemistry; but it is always useful to know beforehand the nature of the stone in the case on which we are about to operate: such knowledge furnishes several indications which should not be neglected. Thus we know that the phosphatic calculi are generally friable, so as to be more or less readily crushed, and, what is of much more importance, we know that the deposition of the phosphates from urine usually takes place in debilitated subjects, in persons of broken-down constitutions, and is mostly accompanied by considerable nervous irritation, lumbar pains, and great general debility. Indeed, it appears highly probable that the deposition of phosphatic calculi requires a certain degree of irritation or inflammation of the mucous membrane of the urinary organs, and their presence therefore indicates a highly disordered state of the urinary organs. They are readily deposited round any foreign body which irritates the bladder, or on such points of its mucous surface as have been most irritated by the calculus, or its fragments when broken up. This fact was illustrated by the post-mortem examination of my patient, and it is highly probable that the unfortunate complication which proved so suddenly fatal in his case, was connected with the irritative state of which the phosphatic secretion now alluded to was a result, and therefore an indication. The practical conclusion, then, that I would have you draw from this point, relative to the nature of the stone, is, that the triple phosphate and fusible calculi are, c2oteris paribus, less favourable subjects, if I may use the term, for operation than the other varieties of calculi; and this remark applies both to lithotomy and lithotrity-the indication, however, rather pointing to an election of the former in cases where an operation cannot be avoided. The next point, gentlemen, for consideration is the relative ages of our two patients. If you ask me why I selected lithotomy for the boy and lithotrity for the man, I will tell you that I was mainly influenced by the difference between their ages. My own experience has convinced me that, in an immense majority of cases, lithotomy is successful when performed on patients under twenty-five to thirty years of age. Success, in fact, is the rule, and failure the very rare exception. This fact alone should lead us to hesitate before we abandon a method, the success of which in the young subject is placed beyond doubt by the experience of nearly all surgeons in extensive practice. With old people the case is different. Here the proportion between deaths and cures from lithotomy is nearly balanced. Thus in Mr. Smith’s cases at the Bristol Hospital, we find that between the ages of sixty and seventy, two patients out of every three died; between seventy and eighty, one in two; and from the extensive researches of Mr. Crosse, of Norwich, we learn that from forty to eighty years the proportion of deaths is one in four. The statistics of the Parisian hospitals give 105 deaths for 297 operations in old people, or one in 24. We shall presently examine the different circumstances under which death takes place from both operations, the symptoms to which they may respectively give rise, and the reasons for selecting one in preference to the other; but I may now remark that there exists a strong reason why lithotomy is, as a general rule, the preferable operation for children under twelve years of age. At an early period of life the genito-uriuary organs are not sufficiently developed to permit
ready introduction and manoeuvring of the instruments employed for crushing stone in the bladder; but this and other questions of the same kind will be more conveniently examined by-and-by. Let us therefore return to the case of F——, simply remarking that his advanced age was an unfavourable circumstance under any method. The history of his case informs us that he laboured under paralysis-I should, perhaps, rather say atony-of the bladder, for a very considerable period previous to the operation. For ten years he had never been able to discharge his urine without the aid of a catheter, the
which he had learned to introduce himself. After death the muscular coat of the bladder was found much thickened, and its cavity was contracted. This you may at once remark to me is an extraordinary circumstance: the post-mortem appearances are inconsistent with the symptoms observed during life. How could paralysis of the bladder co-exist with the hypertrophy of the muscular coat and contraction of the cavity, observed in the present case ? The atony of the bladder, gentlemen, which accompanies vesical calculus, is a condition that has not been studied with the same care which has been bestowed on many other points; nor are the circumstances attending it yet very clearly made out. When you reflect on the constant irritation produced by stone on an organ, the chief function of which, like that of the heart, is to contract on its contents for the purpose of expelling them, you can readily understand that vesical calculus very often produces hypertrophy of the bladder, with diminution of its cavity. These are the natural consequences of the repeated efforts of the organ to expel the foreign body, or of the repeated contractions excited by a permanent source of irritation. Indeed, one of the principal difficulties against which the surgeon has to contend, in the performance of lithotomy, or even lithotrity, is this hypertrophied, contracted, and irritable state of the organ, which gives it a tendency to contract still further on any additional irritation, and thus often renders it a matter of considerable difficulty, either to seize the stone with the forceps or extract it when laid hold of. It is not easy to understand how partial,, much less complete, paralysis of the bladder could exist with such a state of the bladder as the one now described; but the recent researches of M. Civiale have thrown much light on this obscure part of our subject. According to his experience, hypertrophy of the bladder may be of two kinds, the active or the passive. In the former we have contraction of the cavity of the bladder,. and in the latter dilatation. The active often changes inte the passive form, and that in a very sudden manner. Atony of the bladder, in calculous patients, generally coexists with atrophy and passive dilatation of that organ; but in some rare cases we have nearly total incapacity of expelling the urine, joined to active hypertrophy. A case of this kind occurred at the Clinical Hospital of the medical faculty at Paris, in the year 1839. A patient was admitted labouring under stone and debility of the bladder to such a degree, that only a few drops of urine were expelled at a time. He was cut, but died on the 6th day. The bladder was found much contracted and hypertrophical, exactly as occurred in my case. Atony, or partial paralysis of the bladder, is always an unfavourable complication of stone. When the inability to discharge the urine does not depend on some mechanical impediment in the urethra, or at the neck of the bladder, as enlargement of prostate, it generally is connected with chronic inflammation of the bladder, or a tendency to softening of the kidneys; and any operation may light up the latent malady, and give rise to a fatal result. In practice, therefore, you cannot watch these cases too carefully. The condition of the urinary organs may be very unfavourable, while the general symptoms are comparatively slight. If lithotrity be the mode which you have adopted, you must be alive to the first unfavourable appearances; and if signs of inflammation set in, if nervous or other symptoms acquire any degree of intensity, I would advise you to abandon the operation at once, and have recourse to lithotomy. It is the patient’s only chance. Any continuation of the attempt to break up the calculus would only hasten the development of the symptoms which have appeared, and seriously endanger the life of your patient-perhaps render death inevitable. Hypertrophy of the muscular fibres of the bladder is often attended by another deviation from the natural state, an example of which we find in the case now under our consideration. I allude to those sacculated prolongations of the mucous membrane, of which so much is said in relation to encysted calculi. These sacs or cysts are produced by protrusion of the mucous membrane between the hypertrophied muscular fibres, which have left interstices between them;
53 and hence, when the bladder contracts strongly while the flow of urine is prevented by any impediment, as a calculus, stricture of the urethra, &c., you can readily conceive how the mucous lining of the organ may form a kind of hernial sac through the muscular fibres. The existence of these sacculated cavities is unfavourable in several points of view, but I shall only notice those which bear on the present case. The urine and calculous deposits are, of course, apt to sojourn in them for a considerable time, and hence they are extremely apt to take on the suppurative inflammation. Besides this, they seem more subject to chronic inflammation than other portions of the mucous membrane; and these circumstances may explain an opinion of the late Mr. Liston, which was communicated to me at a recent meeting of the Pathological Society-viz., that the presence of these sacs in the bladder is a predisposing cause of purulent absorption. In fact, as I shall presently show, purulent absorption appears to require the presence of -pus in some tissue, or in an inflamed vein; and also the coincidence of some injury or operation by which the tendency to lay down the pus in a distant part is called into action. The cyst, then, may have been a predisposing cause to the disease which cut off my patient, by furnishing purulent matter; and the opinion of Mr. Liston thus receives a rational explanation. I have now, gentlemen, to direct your attention to the most interesting part of the case, both in a practical and pathological point of view. The operation to which my patient was submitted had been performed without any difficulty on the 25th of March, and repeated on the 27th. After the second sitting, constitutional disturbance occurred, and was followed, on the 29th, by pain and swelling of the knee-joint, with typhoid symptoms, under which the man sunk in forty-eight hours. The post-mortem appearances, as you must remember, were, deposits of pus on the pericardium and in the knee-joints, a sacculated cyst of the bladder filled with foetid pus, inflammation of the prostatic veins, and hypertrophy with contraction of the bladder. The immediate cause of death, then, in the present case, was that unfavourable complication which sometimes accompanies every kind of operation, and is known by the name of purulent infection. Upon this I now propose to make some remarks, bringing them to bear, as far as possible, on the connexion of this accident with diseases of, and operations on, the genito-
remarkable part of the constitutional symptoms which accompany purulent infection are undoubtedly the rigors, followed by fever, which are extremely constant in their appearance, and have often led the surgeon to mistake the disease for agne. Several cases of this kind are on record: I shall relate one or two presently. It would appear as if each new deposit of pus in the tissues was announced by a rigor; but in many cases the rigors are absent, and the general symptoms confined to those of debility and rapid sinking. The pains in the joints may be mistaken for rheumatism, and when the skin over the articulation is at the same time red and inflamed, the error is more readily committed by those practitioners who are unaware how often and how unexpectedly the result I now speak of may complicate the most simple and slight operations. Purulent infection may succeed any operation or injury which has given rise to a secretion of pus in the part locally affected. This is the principal fact which may be deduced from the observations made up to the present time. The severity of the injury, and the quantity of pus secreted by the injured tissue, do not seem to have much influence in determining the secondary affection. It occurs after amputations, fractures, lithotomy, &c., but it may likewise supervene on trifling operations, or after the excision of piles, venesection, the application of a seton or cautery; from a boil or a pustule, or even after vaccination. Legalloie relates a case in which purulent infection followed the application of a seton to the neck for the cure of ophthalmia. Some time after the patient was seized with violent rigors, fell into a state of extreme debility, and died on the fourth day. Purulent collections were found in the liver, but all the other viscera were healthy. No pus could be discovered in the blood, nor were the veins inflamed at any point. Purulent infection may arise from phlebitis, and this form has been better studied by us than any other. Its connexion with puerperal fever and other affections of the generative organs in females, was long since pointed out by Doctors Fergusson, Davis, Lee, and others. In my work on 11 diseases of the Hip-joint" I have devoted a chapter to puerperal affections of the joints, in which the coincidence of purulent deposit into the articulations with a suppurative condition of the uterus is clearly established by several post-mortem examinations. In one of these cases the blood taken from the inferior vena cava just at its entrance into the auricle, was found to contain, besides the usual blood-corpuscles, pusglobules or true pus. These were special bodies, whitish and urinary organs. Purulent infection, gentlemen, may, perhaps be a new name granular on the surface, with a shell easily rendered pellucid to you, for it is not treated as a distinct affection in many of by sulphurous and acetic acids, and these showing three or four central molecules, these latter being unchanged by most acids, our standard works on surgery, but you will readily understand the disease to which I allude from the following brief descrip- and easily dissolved by caustic alkalies. The diameter of the tion :pus-globules was 300o to 240 of an inch. But admitting the existence of pus in the tissues or veins A patient has undergone an operation, say amputation of the leg, and everything appears to go on favourably for a short of the part primarily injured, it still remains a question in time, but without any appreciable cause the most serious what manner the secondary depositions of pus in the lungs, symptoms manifest themselves; the patient is seized with liver, joints, &c., take place. Various explanations have been severe rigors, followed by fever, and often by perspiration, offered; but I am still inclined to adhere to the one which I which bear a very close resemblance to those of intermittent published in the work just mentioned, and attribute them to a. fever; the rigors are obstinate and return every day; they are general contamination of the circulating fluid by the purulent matter absorbed into it. When this contamination has taken soon followed by a state of prostration, the complexion becomes yellowish and dull, the tongue dry and brown, the pulse place, after the manner of a poison, we can conceive that the quick and feeble; there is often delirium at intervals, and secondary deposits occur from metastasis, or that the vitiated diarrhma with tyrnpauitis. These general signs are, in a great blood circulating in the capillaries may, under certain conmany cases, accompanied by those of local inflammation in ditions of disordered health, or the impulse of an injury, excite low inflammation, and thus produce secondary abscess or purusome organ or tissue, very often in the chest, sometimes in the abdomen, but far most frequently in some of the joints or cel- lent infiltration. However this may be, it is certain that all lular tissue of the extremities; the joints swell, become red these forms of purulent infection constitute one and the same and painful, or purulent collections form in the cellular tissue affection, and that we take a limited view of the subject when between the muscles. After death,-for these cas?s are very we distinguish them, as has been too much the custom in often fatal,-we find abscesses in the lungs, liver, &c., in the this country, according to their immediate exciting cause. brain, heart, kidneys, uterus; or purulent infiltration of the The affection of the joints which I called puerperal, is extremities in which tumefaction was observed during life. identical with the affection of the same parts which occurs Even the suppurative inThe joints sometimes present traces of inflammation, as in after amputation, lithotomy, &c. F-’s case; but this is rare: more frequently they contain flammation of the eye which was thought to be peculiar to the purulent matter, without any trace of ulceration or inflamma- puerperal state, is now well known to form part and parcel of tion. The veins passing from the part which had been prima- purulent infection. (To be continued.) rily injured are very often inflamed, and sometimes contain pus globules, and hence many surgeons consider the disease as CHOLERA AND FEVER AT THE SEAT OF WAR.-The essentially connected with phlebitis; but it is certain that the most careful examination has failed to detect inflammation of troops in possession of the Great Pagoda, Rangoon, which was the veins in several instances. In some cases, I should ob- taken after a fearful slaughter, are suffering frightfully from serve, the symptoms are far from presenting the degree of fever and cholera, in consequence of the stench created by the seriousness just alluded to. There are no rigors ; no great heaps of dead bodies that were left by the enemy. Captain Hunt, fever; no local signs of inflammation in the organs or joints: 80th Regiment, has fallen a victim to cholera; and another officer yet the patient sinks rapidly into a typhoid state, and after was in a hopeless state at the time the dispatches left, which death the same purulent deposits are found in the lungs, joints, stated that an awful mortality prevailed among the troops gene&c., as are observed in the more severe cases. The most rally.
5, 1852.
quantity of phosphatic debris came away at
each introduction; the urine was alkaline. ON On the 26th, the bladder was very irritable. The patient obliged to introduce his catheter nearly every hour; LITHOTOMY AND LITHOTRITY. was the urine withdrawn contained mucus, clots of blood, and of the calculus. (Delivered at St. Mary’s Hospital.) On the 27th, the lithotrite was again introduced, and the By WILLIAM COULSON, ESQ., calculus crushed without any difficulty. This operation, howSURGEON TO THE HOSPITAL. ever, was soon followed by considerable local and constitutional disturbance. The pulse was now 120, the tongue very LECTURE I. brown and dry; there was great thirst, and he complained of pain GENTLEMEN,—Two cases which have recently been under and considerable swelling of the left knee-joint. The patient my care in this hospital afford me an opportunity of directing required the use of the catheter every half-hour, or oftener. your attention to one of the most important and interesting Diffusible stimuli, with opium, were administered at once, and subjects in the whole range of surgical science. I allude to the bladder was repeatedly washed out; but the patient began the various methods which have been devised for the relief or to sink, became rapidly worse, and expired on the 31st March. So vast a subject, gentlemen, His body was examined thirty hours after death. The cure of stone in the bladder. including such a number and variety of important points, pulmonary tissue was healthy, though gorged with dark blood. many of which are still matters of debate amongst the best The right pleura was universally adherent from old disease. surgeons, cannot be treated in anything like a satisfactory At the upper part of the pericardium, externally, and at the I therefore propose address- point where this membrane is covered by the pleura, there manner during a single lecture. ing to you a series of lectures on stone in the bladder, its was an encysted tumour, as large as a walnut, and containing treatment by the knife or by crushing instruments, and on brownish-green matter. Heart large and flabby; the right the indications, comparative advantages, and applicability of cavities filled with dark blood, staining the valves and lining lithotomy and lithotrity. The present lecture will be mainly membrane; the liver was soft, but otherwise healthy; the devoted to clinical remarks on one of the cases alluded to, kidneys presented externally a dark, mottled appearance, and may in some measure serve as a preface to those which and were considerably congested within. The other organs of the abdomen were healthy. The large veins were filled with are to follow. Two patients, as I observed, were recently under my care blood, and the lining membrane of both common and iliac for stone in the bladder. The one was young, the other old. veins was stained of a deep red colour. This staining extended In one I performed the operation of lithotomy : it lasted about into the external and internal iliac and femoral veins, but the walls of these vessels were not thickened. The external a minute, was unattended by the slightest accident; and the surface of the bladder presented a considerable degree of patient has recovered. In the other case, the patient was in his seventieth year: vascularity. It was contracted, and the muscular coat was the operation selected was lithotrity; the case to all appear- much thickened. It contained some small particles of the ances was not unfavourable; the operation of crushing the stone, but nearly the whole had come away. The mucous stone was effected without any difficulty; but on the day membrane was here and there coated with patches of phosafter the second sitting unfavourable symptoms set in, the man phatic deposit. No ulceration, breach of surface, or signs of began to sink, and died within a week from the first opera- !, inflammation, were discovered in any portion of the mucous tion. ’, membrane, but at one part a sacculated cavity, about the size The contrast between these two cases (and a similar one of a walnut, was observed, and this contained a quantity of will often present itself to you in practice) is striking. We very fœtid pus. There was a round projection at the orifice cannot avoid asking ourselves whence arose the difference in of the urethra, which also was coated with phosphates. The the results ? Why one patient died, while the other re- veins of the prostatic plexus were enlarged, thickened, and covered ? Why lithotomy was selected in the one instance, many of them filled with coagula. while lithotrity was employed in the other ? And these On opening the left knee-joint, some thin, chocolatequestions naturally lead to a consideration of two paramount coloured, purulent fluid escaped; the synovial membrane was points-viz. the indications which induce the surgeon to highly injected, and the articular cartilage covering the employ lithotomy in preference to lithotrity, or vice versâ; external condyle was softened and ulcerated in its centre, the and the different accidents which may supervene during or bone being laid bare at one point. The corresponding cartilaafter these operations, either retarding the cure, or involving ginous surface of the patella was superficially ulcerated. No the life of the patient. ulceration of the surface of the internal condyle or semilunar It would be impossible for me to comprise all that might cartilage could be discovered. On opening the right kneebe said on these points in a single lecture. I shall therefore joint, some pus escaped; the fluid was nearly healthy in at present dwell only on those which are most essential for appearance; the articular cartilages were ulcerated in the practice, and which bear on the case I am about to relate to same situation as on the left side, though in a less degree. The bone was not laid b re; the synovial membrane was highly you. The following is a short history of it :The patient, James F .was admitted into the hospital, injected. The head of the right femur was marked by fine under my care, on the 24th of March. He was seventy years red injection, and the synovial membrane round the neck of of age, yet appeared to have suffered little in his general the left femur was very vascular. The shoulder-joints appeared health, having principally complained, from time to time, of healthy. The examination did not extend further. There are many points in this case, gentlemen, worthy of heartburn. He had, however, laboured under an affection of the bladder for several years. The symptoms of stone were your attention; but I can only examine the most striking, and evident and characteristic, the principal being pain referred these are, the age of the patient, the nature of the calculus, to the region of the bladder, and brought on by any motion, the paralyzed state of the bladder, co-existing with hypersuch as that of riding in an omnibus; pain in the glans penis; trophy and contraction of this organ, the sacculus or cyst conhæmaturia, especially after walking; frequent and sudden taining pus, the enlarged prostate, and, lastly, the cause of desire to pass his urine, which, however, disturbed him little death, arising, as the post-mortem examination showed us, while lying down. For the last nine months he had experi- from what is called purulent absorption. enced a sensation of numbness down the thighs, and for ten On the symptoms of stone in the present case I need not years he had not been able to discharge his urine without the dwell: they offered nothing remarkable. The patient’s henlth aid of the catheter. The urine latterly was secreted in in- is stated not to have suffered much, though it is evident that creased quantities, and it contained a considerable proportion his disease had been of long duration. This is a circumstance of mucus, and some pus. which I have occasionally observed, and which has been The presence of a calculus in the bladder was readily de- noticed by all writers on diseases of the urinary organs. You tected in the usual manner. Though of large size, it was soft, should therefore remember that not only the constitutional and easily crushed between the blades of the lithotrite. On but the local signs of vesical calculus may be very slight, examining the fragments which came away, they were found or even so far absent as to lead the surgeon to overlook to consist of the triple phosphate, or ammoniaco-magnesian the existence of the disease altogether. I do not mention phosphate calculus. The patient was ordered to have twelve this as a means of affording you an excuse in certain cases, minims of Battley’s sedative three times a day, to allay any but to stimulate you to increased care and perseverance in irritation which might arise from the operation. the examination of all doubtful ones. On the 25th, the bladder had been emptied by the catheter Scarpa, Blanchard, Travers, and other writers mention cases seven or eight times since the operation. and a considerable in which the symptoms were so slight, that the nresence of a
Lectures
fragments
No. 1501.
534 calculus was never even suspected during life. Some time ago I saw a gentleman who had been sounded by an experienced surgeon, yet the latter was unable to say whether or not there was a stone in the bladder. The patient died sixteen months afterwards, and a calculus weighing four ounces and a half was discovered. The largest calculus in St. Bartholomew’s Hospital was taken from a patient who had been often sounded; and the museum of the College of Surgeons contains the bladder of a man who had committed suicide after long suffering from stone, though the late Mr. Abernethy and many other surgeons of the day had repeatedly sounded him, without having detected the presence of a calculus. In the case of F-, the local signs were evident, though, as I remarked, the constitutional disturbance never reached any considerable degree; and this is a point worthy of a moment’s attention, when we reflect, not only on the great duration of the disease, but on the nature of the calculus with which the patient was affected. It was the triple phosphate or ammoniaco-magnesian phosphate calculus. This concretion is formed by an admixture of the neutral phosphate of magnesia and ammonia with a bibasic phosphate. It might appear to you at first sight that the chemical nature of the calculus could exercise little influence on the operation performed for its extraction, or that a knowledge of its composition could be of little use beyond the domain of chemistry; but it is always useful to know beforehand the nature of the stone in the case on which we are about to operate: such knowledge furnishes several indications which should not be neglected. Thus we know that the phosphatic calculi are generally friable, so as to be more or less readily crushed, and, what is of much more importance, we know that the deposition of the phosphates from urine usually takes place in debilitated subjects, in persons of broken-down constitutions, and is mostly accompanied by considerable nervous irritation, lumbar pains, and great general debility. Indeed, it appears highly probable that the deposition of phosphatic calculi requires a certain degree of irritation or inflammation of the mucous membrane of the urinary organs, and their presence therefore indicates a highly disordered state of the urinary organs. They are readily deposited round any foreign body which irritates the bladder, or on such points of its mucous surface as have been most irritated by the calculus, or its fragments when broken up. This fact was illustrated by the post-mortem examination of my patient, and it is highly probable that the unfortunate complication which proved so suddenly fatal in his case, was connected with the irritative state of which the phosphatic secretion now alluded to was a result, and therefore an indication. The practical conclusion, then, that I would have you draw from this point, relative to the nature of the stone, is, that the triple phosphate and fusible calculi are, c2oteris paribus, less favourable subjects, if I may use the term, for operation than the other varieties of calculi; and this remark applies both to lithotomy and lithotrity-the indication, however, rather pointing to an election of the former in cases where an operation cannot be avoided. The next point, gentlemen, for consideration is the relative ages of our two patients. If you ask me why I selected lithotomy for the boy and lithotrity for the man, I will tell you that I was mainly influenced by the difference between their ages. My own experience has convinced me that, in an immense majority of cases, lithotomy is successful when performed on patients under twenty-five to thirty years of age. Success, in fact, is the rule, and failure the very rare exception. This fact alone should lead us to hesitate before we abandon a method, the success of which in the young subject is placed beyond doubt by the experience of nearly all surgeons in extensive practice. With old people the case is different. Here the proportion between deaths and cures from lithotomy is nearly balanced. Thus in Mr. Smith’s cases at the Bristol Hospital, we find that between the ages of sixty and seventy, two patients out of every three died; between seventy and eighty, one in two; and from the extensive researches of Mr. Crosse, of Norwich, we learn that from forty to eighty years the proportion of deaths is one in four. The statistics of the Parisian hospitals give 105 deaths for 297 operations in old people, or one in 24. We shall presently examine the different circumstances under which death takes place from both operations, the symptoms to which they may respectively give rise, and the reasons for selecting one in preference to the other; but I may now remark that there exists a strong reason why lithotomy is, as a general rule, the preferable operation for children under twelve years of age. At an early period of life the genito-uriuary organs are not sufficiently developed to permit
ready introduction and manoeuvring of the instruments employed for crushing stone in the bladder; but this and other questions of the same kind will be more conveniently examined by-and-by. Let us therefore return to the case of F——, simply remarking that his advanced age was an unfavourable circumstance under any method. The history of his case informs us that he laboured under paralysis-I should, perhaps, rather say atony-of the bladder, for a very considerable period previous to the operation. For ten years he had never been able to discharge his urine without the aid of a catheter, the
which he had learned to introduce himself. After death the muscular coat of the bladder was found much thickened, and its cavity was contracted. This you may at once remark to me is an extraordinary circumstance: the post-mortem appearances are inconsistent with the symptoms observed during life. How could paralysis of the bladder co-exist with the hypertrophy of the muscular coat and contraction of the cavity, observed in the present case ? The atony of the bladder, gentlemen, which accompanies vesical calculus, is a condition that has not been studied with the same care which has been bestowed on many other points; nor are the circumstances attending it yet very clearly made out. When you reflect on the constant irritation produced by stone on an organ, the chief function of which, like that of the heart, is to contract on its contents for the purpose of expelling them, you can readily understand that vesical calculus very often produces hypertrophy of the bladder, with diminution of its cavity. These are the natural consequences of the repeated efforts of the organ to expel the foreign body, or of the repeated contractions excited by a permanent source of irritation. Indeed, one of the principal difficulties against which the surgeon has to contend, in the performance of lithotomy, or even lithotrity, is this hypertrophied, contracted, and irritable state of the organ, which gives it a tendency to contract still further on any additional irritation, and thus often renders it a matter of considerable difficulty, either to seize the stone with the forceps or extract it when laid hold of. It is not easy to understand how partial,, much less complete, paralysis of the bladder could exist with such a state of the bladder as the one now described; but the recent researches of M. Civiale have thrown much light on this obscure part of our subject. According to his experience, hypertrophy of the bladder may be of two kinds, the active or the passive. In the former we have contraction of the cavity of the bladder,. and in the latter dilatation. The active often changes inte the passive form, and that in a very sudden manner. Atony of the bladder, in calculous patients, generally coexists with atrophy and passive dilatation of that organ; but in some rare cases we have nearly total incapacity of expelling the urine, joined to active hypertrophy. A case of this kind occurred at the Clinical Hospital of the medical faculty at Paris, in the year 1839. A patient was admitted labouring under stone and debility of the bladder to such a degree, that only a few drops of urine were expelled at a time. He was cut, but died on the 6th day. The bladder was found much contracted and hypertrophical, exactly as occurred in my case. Atony, or partial paralysis of the bladder, is always an unfavourable complication of stone. When the inability to discharge the urine does not depend on some mechanical impediment in the urethra, or at the neck of the bladder, as enlargement of prostate, it generally is connected with chronic inflammation of the bladder, or a tendency to softening of the kidneys; and any operation may light up the latent malady, and give rise to a fatal result. In practice, therefore, you cannot watch these cases too carefully. The condition of the urinary organs may be very unfavourable, while the general symptoms are comparatively slight. If lithotrity be the mode which you have adopted, you must be alive to the first unfavourable appearances; and if signs of inflammation set in, if nervous or other symptoms acquire any degree of intensity, I would advise you to abandon the operation at once, and have recourse to lithotomy. It is the patient’s only chance. Any continuation of the attempt to break up the calculus would only hasten the development of the symptoms which have appeared, and seriously endanger the life of your patient-perhaps render death inevitable. Hypertrophy of the muscular fibres of the bladder is often attended by another deviation from the natural state, an example of which we find in the case now under our consideration. I allude to those sacculated prolongations of the mucous membrane, of which so much is said in relation to encysted calculi. These sacs or cysts are produced by protrusion of the mucous membrane between the hypertrophied muscular fibres, which have left interstices between them;
53 and hence, when the bladder contracts strongly while the flow of urine is prevented by any impediment, as a calculus, stricture of the urethra, &c., you can readily conceive how the mucous lining of the organ may form a kind of hernial sac through the muscular fibres. The existence of these sacculated cavities is unfavourable in several points of view, but I shall only notice those which bear on the present case. The urine and calculous deposits are, of course, apt to sojourn in them for a considerable time, and hence they are extremely apt to take on the suppurative inflammation. Besides this, they seem more subject to chronic inflammation than other portions of the mucous membrane; and these circumstances may explain an opinion of the late Mr. Liston, which was communicated to me at a recent meeting of the Pathological Society-viz., that the presence of these sacs in the bladder is a predisposing cause of purulent absorption. In fact, as I shall presently show, purulent absorption appears to require the presence of -pus in some tissue, or in an inflamed vein; and also the coincidence of some injury or operation by which the tendency to lay down the pus in a distant part is called into action. The cyst, then, may have been a predisposing cause to the disease which cut off my patient, by furnishing purulent matter; and the opinion of Mr. Liston thus receives a rational explanation. I have now, gentlemen, to direct your attention to the most interesting part of the case, both in a practical and pathological point of view. The operation to which my patient was submitted had been performed without any difficulty on the 25th of March, and repeated on the 27th. After the second sitting, constitutional disturbance occurred, and was followed, on the 29th, by pain and swelling of the knee-joint, with typhoid symptoms, under which the man sunk in forty-eight hours. The post-mortem appearances, as you must remember, were, deposits of pus on the pericardium and in the knee-joints, a sacculated cyst of the bladder filled with foetid pus, inflammation of the prostatic veins, and hypertrophy with contraction of the bladder. The immediate cause of death, then, in the present case, was that unfavourable complication which sometimes accompanies every kind of operation, and is known by the name of purulent infection. Upon this I now propose to make some remarks, bringing them to bear, as far as possible, on the connexion of this accident with diseases of, and operations on, the genito-
remarkable part of the constitutional symptoms which accompany purulent infection are undoubtedly the rigors, followed by fever, which are extremely constant in their appearance, and have often led the surgeon to mistake the disease for agne. Several cases of this kind are on record: I shall relate one or two presently. It would appear as if each new deposit of pus in the tissues was announced by a rigor; but in many cases the rigors are absent, and the general symptoms confined to those of debility and rapid sinking. The pains in the joints may be mistaken for rheumatism, and when the skin over the articulation is at the same time red and inflamed, the error is more readily committed by those practitioners who are unaware how often and how unexpectedly the result I now speak of may complicate the most simple and slight operations. Purulent infection may succeed any operation or injury which has given rise to a secretion of pus in the part locally affected. This is the principal fact which may be deduced from the observations made up to the present time. The severity of the injury, and the quantity of pus secreted by the injured tissue, do not seem to have much influence in determining the secondary affection. It occurs after amputations, fractures, lithotomy, &c., but it may likewise supervene on trifling operations, or after the excision of piles, venesection, the application of a seton or cautery; from a boil or a pustule, or even after vaccination. Legalloie relates a case in which purulent infection followed the application of a seton to the neck for the cure of ophthalmia. Some time after the patient was seized with violent rigors, fell into a state of extreme debility, and died on the fourth day. Purulent collections were found in the liver, but all the other viscera were healthy. No pus could be discovered in the blood, nor were the veins inflamed at any point. Purulent infection may arise from phlebitis, and this form has been better studied by us than any other. Its connexion with puerperal fever and other affections of the generative organs in females, was long since pointed out by Doctors Fergusson, Davis, Lee, and others. In my work on 11 diseases of the Hip-joint" I have devoted a chapter to puerperal affections of the joints, in which the coincidence of purulent deposit into the articulations with a suppurative condition of the uterus is clearly established by several post-mortem examinations. In one of these cases the blood taken from the inferior vena cava just at its entrance into the auricle, was found to contain, besides the usual blood-corpuscles, pusglobules or true pus. These were special bodies, whitish and urinary organs. Purulent infection, gentlemen, may, perhaps be a new name granular on the surface, with a shell easily rendered pellucid to you, for it is not treated as a distinct affection in many of by sulphurous and acetic acids, and these showing three or four central molecules, these latter being unchanged by most acids, our standard works on surgery, but you will readily understand the disease to which I allude from the following brief descrip- and easily dissolved by caustic alkalies. The diameter of the tion :pus-globules was 300o to 240 of an inch. But admitting the existence of pus in the tissues or veins A patient has undergone an operation, say amputation of the leg, and everything appears to go on favourably for a short of the part primarily injured, it still remains a question in time, but without any appreciable cause the most serious what manner the secondary depositions of pus in the lungs, symptoms manifest themselves; the patient is seized with liver, joints, &c., take place. Various explanations have been severe rigors, followed by fever, and often by perspiration, offered; but I am still inclined to adhere to the one which I which bear a very close resemblance to those of intermittent published in the work just mentioned, and attribute them to a. fever; the rigors are obstinate and return every day; they are general contamination of the circulating fluid by the purulent matter absorbed into it. When this contamination has taken soon followed by a state of prostration, the complexion becomes yellowish and dull, the tongue dry and brown, the pulse place, after the manner of a poison, we can conceive that the quick and feeble; there is often delirium at intervals, and secondary deposits occur from metastasis, or that the vitiated diarrhma with tyrnpauitis. These general signs are, in a great blood circulating in the capillaries may, under certain conmany cases, accompanied by those of local inflammation in ditions of disordered health, or the impulse of an injury, excite low inflammation, and thus produce secondary abscess or purusome organ or tissue, very often in the chest, sometimes in the abdomen, but far most frequently in some of the joints or cel- lent infiltration. However this may be, it is certain that all lular tissue of the extremities; the joints swell, become red these forms of purulent infection constitute one and the same and painful, or purulent collections form in the cellular tissue affection, and that we take a limited view of the subject when between the muscles. After death,-for these cas?s are very we distinguish them, as has been too much the custom in often fatal,-we find abscesses in the lungs, liver, &c., in the this country, according to their immediate exciting cause. brain, heart, kidneys, uterus; or purulent infiltration of the The affection of the joints which I called puerperal, is extremities in which tumefaction was observed during life. identical with the affection of the same parts which occurs Even the suppurative inThe joints sometimes present traces of inflammation, as in after amputation, lithotomy, &c. F-’s case; but this is rare: more frequently they contain flammation of the eye which was thought to be peculiar to the purulent matter, without any trace of ulceration or inflamma- puerperal state, is now well known to form part and parcel of tion. The veins passing from the part which had been prima- purulent infection. (To be continued.) rily injured are very often inflamed, and sometimes contain pus globules, and hence many surgeons consider the disease as CHOLERA AND FEVER AT THE SEAT OF WAR.-The essentially connected with phlebitis; but it is certain that the most careful examination has failed to detect inflammation of troops in possession of the Great Pagoda, Rangoon, which was the veins in several instances. In some cases, I should ob- taken after a fearful slaughter, are suffering frightfully from serve, the symptoms are far from presenting the degree of fever and cholera, in consequence of the stench created by the seriousness just alluded to. There are no rigors ; no great heaps of dead bodies that were left by the enemy. Captain Hunt, fever; no local signs of inflammation in the organs or joints: 80th Regiment, has fallen a victim to cholera; and another officer yet the patient sinks rapidly into a typhoid state, and after was in a hopeless state at the time the dispatches left, which death the same purulent deposits are found in the lungs, joints, stated that an awful mortality prevailed among the troops gene&c., as are observed in the more severe cases. The most rally.